Loading with a statin in ACS

Thursday, May 9th, 2019 | Rory | No Comments

  1. Berwanger O, Santucci EV, Silva PGM de B e, Jesuíno I de A, Damiani LP, Barbosa LM, et al. Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial. JAMA. 2018 Apr 3;319(13):1331–40. EZProxy link

Some of you may have seen this before but recently heard about this trial published in JAMA last year. This was a RCT trial where patients with ACS and going on to have angiography were given a loading dose (80mg) of Atorvastatin or placebo i) NSTEMI – 2–12hrs prior to angiography/PCI or ii) STEMI – ASAP. This was reported as a negative trial with no reduction in 30 day major adverse cardiac events (MACE) in the ACS population. However, in post-hoc subgroup analysis (read what you will into this) the group that had a STEMI and received Atorvastatin had a >40% reduction in 30-day MACE.

Patients with STEMI (MACE over first 30d)

This is a therapy that they will end up on anyway and is unlikely to do harm if the definitive treatment is not delayed. 80mg of Atorvastatin could be given whilst drawing up the lytics!

Note these were patients that went onto have PCI (which would hopefully be the majority of STEMI in NZ now) and it is unclear if re-perfusion by any means (lysis v primary PCI) will yield the same results but it is a big effect size.

Abstract

Importance The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain.

Objective To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management.

Design, Setting, and Participants Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017.

Interventions Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication.

Main Outcomes and Measures The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days.

Results Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, −0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69–1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group.

Conclusions and Relevance Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management.

POC testing changes practice in rural hospitals

Tuesday, April 30th, 2019 | Rory | No Comments

Blattner K, Beazley CJ, Nixon G, Herd G, Wigglesworth J, Rogers-Koroheke MG. The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory. Rural and Remote Health 2019; 19: 4934. https://doi.org/10.22605/RRH4934 Open Access link

Mixed methods study from the team at Rawene in the Far North showing the, sometimes significant, impact of having a point-of-care FBC analyser in their small rural hospital. Knowledge is power and cost saving… Interesting that the largest cost saving is for the base hospital – something that seems like is missed in funding discussions.

Kati is a senior member of the rural section and convenes GENA 724 – The context of rural hospital medicine.

Abstract

Introduction:

Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital.

Methods:

This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost–benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted.

Results:

Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to ‘make it work’. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost–benefit analysis showed a clear cost saving to the health system as a whole.

Conclusions:

This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

Most rural hospitals reliant on POC troponin

Wednesday, April 17th, 2019 | Rory | No Comments

Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.

Not a great surprise: most rural hospitals do not have timely access to the same troponin assays that metropolitan hospitals rely on, instead reliant on less sensitive point-of-care troponin. A significant number of NSTEMI maybe missed using POC troponin at the manufacturer’s cut-off and we have an observational study underway evaluating a pathway that will limit these missed AMI.(1,2) This pathway has been shown to be effective in a pilot run in a low-risk primary care population.(3) There is also hope as discussed previously that a new high precision point-of-care assay will bring rural chest pain assessment in line with urban hospitals.(4)

“The results of this survey reinforce the importance of considering the context and resources of all New Zealand hospitals when making recommendations at a national level, such as the adoption of ADPs. Failure to do so can confuse clinical practice in our small rural hospitals that have access to fewer resources and risks exacerbating existing inequities.”

Abstract

AIMS: Accelerated diagnostic chest pain pathways (ADP) have become standard of care in urban emergency departments. It is, however, unknown how widely they are used in New Zealand’s rural hospitals because ADP require immediate access to contemporary or high-sensitivity troponin (hs-Tn). We aimed to determine for rural hospitals the troponin assay being used, if they were using an ADP and if they had access to on-site exercise tolerance testing (ETT).

METHODS: An online survey was sent to 27 rural hospitals providing acute care in New Zealand.

RESULTS: Most rural hospitals (23/27, 85%) responded to the survey. Most (17/23, 74%) used point-of- care cardiac troponin (POC-cTn) and the majority of these hospitals (15/17, 88%) were reliant on this assay 24-hours per day. All hospitals that had timely access to hs-Tn (8/23, 35%) used an ADP but only a minority (4/17, 24%) of hospitals using POC-cTn used an ADP. Only a minority of the larger rural hospitals (7/23, 30%) had access to on-site ETT.

CONCLUSIONS: Most New Zealand rural hospitals rely on POC-cTn to assess chest pain and are not using an ADP. There are limited data available to support this approach in rural settings especially with patients who are not low-risk.

References

1. Miller R, Nixon G. The assessment of acute chest pain in New Zealand rural hospitals utilising point-of-care troponin. Journal of Primary Health Care. 2018;10(1):90–2.

2. Schneider HG, Ablitt P, Taylor J. Improved sensitivity of point of care troponin I values using reporting to below the 99th percentile of normals. Clinical Biochemistry. 2013 Aug;46(12):979–82.

3. Norman T, Devlin G, Than M, George P, Young J, Egan G, et al. Measured Implementation of an Accelerated Chest Pain Diagnostic Pathway in Primary Care. Heart, Lung and Circulation. 2018 Jan;27:S4–5.

4. Pickering JW, Young JM, George PM, Watson AS, Aldous SJ, Troughton RW, et al. Validity of a Novel Point-of-Care Troponin Assay for Single-Test Rule-Out of Acute Myocardial Infarction. JAMA Cardiology. 2018 Oct;

Research networks in Aotearoa

Monday, April 15th, 2019 | Rory | No Comments

Editorial from the latest edition of the NZMJ from two members of the Rural post-graduate programme; Marc and Sampsa.

Gutenstein M, Kiuru S. Building collaborative research networks across rural and provincial Aotearoa. New Zealand Medical Journal. 2019;132(1493):3.

“Rural and provincial research faces many of the same obstacles that clinical teams face, with fragmented and dispersed rural hospitals lacking a formal research network. Research networking is essential for disseminating and sharing knowledge, meeting local population health needs and promoting appropriate non-urban health policies.”

“Greater involvement of rural and provincial providers in health research will increase visibility of these journeys, build collaborative academic, educational and clinical networks, and allow research data to be translated back into clinical practice for all.”

Reflections on rural medical schools

Thursday, April 11th, 2019 | Rory | No Comments

Two articles in the latest edition of the Journal of Primary Care on rural medical schools for New Zealand. Dr. John Burton writes a piece on his time at the Northern Ontario Medical School and reflects what that experience means in the NZ context.

Burton John (2019) Experiencing a rural medical school. Journal of Primary Health Care 11, 6-11.

https://doi.org/10.1071/HC18096

Open access

The other is a guest editorial by Dr. Garry Nixon and Dr. Ross Lawrenson contextualising this in the current political climate. Hopefully the health minister has a read (and he might of given the comments at the National Rural Health Conference). Fingers crossed

Nixon Garry, Lawrenson Ross (2019) Failing to thrive: academic rural health in New Zealand. Journal of Primary Health Care 11, 4-5.

https://doi.org/10.1071/HCv11n1_ED2

Open access

Breathing reduces hypoxia!

Friday, March 8th, 2019 | Rory | No Comments

BMV during RSI

Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine. 2019 Feb 28;380(9):811–21.

EZProxy link

An American multi-centre study that shows that delivering breaths via bag-valve-mask during rapid sequence induction (after induction and paralysis) was associated with higher oxygen saturations than withholding breaths, without any increase in (clinically apparent) aspiration events. These were medically unwell patients in an ICU setting. While this paper suggests that breathing for a patient who you have stopped breathing (without protecting their airway first) is beneficial – caution must be recommended applying the findings of this paper to rural or pre-hospital settings, given these patients were enrolled in an ICU.

https://www-nejm-org.ezproxy.otago.ac.nz/doi/full/10.1056/NEJMoa1812405?query=emergency-medicine

What is the practice out there? comment below.

Abstract

Background

Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial.

Methods

In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy. The primary outcome was the lowest oxygen saturation observed during the interval between induction and 2 minutes after tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as an oxygen saturation of less than 80%.

Results

Among the 401 patients enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87 to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to 99) in the no-ventilation group (P=0.01). A total of 21 patients (10.9%) in the bag-mask ventilation group had severe hypoxemia, as compared with 45 patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95% confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in the no-ventilation group (P=0.41). The incidence of new opacity on chest radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%, respectively (P=0.73).

Conclusions

Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.)

Some sense from Australia

Thursday, February 28th, 2019 | Rory | No Comments

Better Health in the Bush

Wakerman, J. and Humphreys, J. S. (2019), “Better health in the bush”: why we urgently need a national rural and remote health strategy. Med. J. Aust.. doi:10.5694/mja2.50041

EZProxy link

“The five key questions are:

  • How do we get health professionals to work in rural areas and retain them?
  • How do we ensure that high quality, comprehensive primary health care (PHC) services are accessible locally?
  • How do we ensure that these services are sustainable?
  • How much should these services cost?
  • How do we ensure that these services meet community needs?"

“In summary, using available evidence, a national strategy can improve access to high quality, comprehensive PHC in a way that results in greater efficiency, improved equity and more effective service provision that will bring about improved health outcomes in rural and remote areas, which has been the quest of the Australian Government for the past 25 years.”

A nice summary of the issues and some solutions from the two Johns in Aussie.

Understanding and reacting to health inequalities

Thursday, February 14th, 2019 | Rory | No Comments

How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care

Breannon Babbel, Mhairi Mackenzie, Annette Hastings & Graham Watt (2019) How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care, Critical Public Health, 29:2, 168–180, DOI: 10.1080/09581596.2017.1418499

Link to abstract

EZProxy link

from Garry Nixon:

This is a helpful way of understanding the world that is for patients from disadvantaged communities – but also for understanding the world on those healthcare providers working for those communities.

Abstract:

Scotland is faced with pernicious health inequalities, which stem from inequalities in living conditions and the societal structures that create them. While action is needed to address the wider structural causes of health inequalities, the role of general practitioners (GPs) merits attention due to health care’s potential to mitigate or exacerbate health inequalities.

Minimal research, however, has explored how GPs understand the fundamental causes of health inequalities nor how they conceptualise their role in mitigating these. This paper aims to fill this gap using in-depth qualitative interviews with 24 GPs working in some of Scotland’s most socio-economically disadvantaged, urban areas.

Using Raphael’s SDH discourse framework, this paper found clear linkages between GPs’ perceptions of their patients, how they defined the ‘problem’ of health inequalities, and what they thought could be done to tackle them in disadvantaged areas.

In general, there was convergence on how interviewees viewed their role in mitigating health inequalities through their work with individual patients. However, greater variation was found when describing the boundaries of their role and how far these extended beyond individual encounters. Specifically, only those GPs fluent in discussing structural causes of health inequalities discussed obligations to change local systems via strengthening community linkages and to influence higher level policies related to the SDH.

This suggests that while there is a degree of what Metzl and Hansen deem ‘structural competency’ amongst some GPs working in disadvantaged areas, the scope remains to deepen this competency more broadly.

link to the open access paper on ‘structural competency’

Fluid therapy: A review

Friday, January 18th, 2019 | Rory | No Comments

Fluid therapy in the emergency department: an expert practice review

Harris T, Coats TJ, Elwan MH Fluid therapy in the emergency department: an expert practice review Emerg Med J 2018;35:511–515.

Open Access

Comment:

Take homes: Not sure anything too new here – read the article, it’s free

  • Crystalloid > colloid
  • Balanced (Hartmann, PlasmaLyte) may be > unbalanced (0.9% NaCl)
  • Don’t assume ED patient same as ICU patient – i.e. don’t apply same guidelines – this goes for patients in Rural NZ!
  • Not too much, not too little: guideline driven therapy (e.g. Surviving sepsis) may be detrimental.
  • Assessment of fluid status difficult – need some ED / Rural studies
  • PO safer than IV

Abstract

Intravenous fluid therapy is one of the most common therapeutic interventions performed in the ED and is a long-established treatment. The potential benefits of fluid therapy were initially described by Dr W B O’Shaughnessy in 1831 and first administered to an elderly woman with cholera by Dr Thomas Latta in 1832, with a marked initial clinical response. However, it was not until the end of the 19th century that medicine had gained understanding of infection risk that practice became safer and that the practice gained acceptance. The majority of fluid research has been performed on patients with critical illness, most commonly sepsis as this accounts for around two-thirds of shocked patients treated in the ED. However, there are few data to guide clinicians on fluid therapy choices in the non-critically unwell, by far our largest patient group. In this paper, we will discuss the best evidence and controversies for fluid therapy in medically ill patients.

DOI link

POCUS: another wee paper from GN et al.

Sunday, December 16th, 2018 | Rory | No Comments

Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management

Nixon Garry, Blattner Katharina, Muirhead Jill, Kerse Ngaire (2018) Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management. Journal of Primary Health Care , -.

Open access.

http://www.publish.csiro.au/hc/Fulltext/HC18034

POCUS really is a incredible tool that makes a large difference to clinicians and patients. No suprise here to see bladder and kidney scans having high sens and spec for urinary retention and hydronephrosis amongst rural hospital doctors. There needs to be a national credentialling service for rural clinicians to tap into.

Abstract

INTRODUCTION: Point-of-care ultrasound (POCUS) of the kidney and bladder are among the most commonly performed POCUS scans in rural New Zealand (NZ).AIM: To determine the quality, safety and effect on patient care of POCUS of the kidney and bladder in rural NZ.METHODS: Overall, 28 doctors in six NZ rural hospitals completed a questionnaire both before and after undertaking a POCUS scan over a 9-month period. The clinical records and saved ultrasound images were reviewed by a specialist panel.

RESULTS: The 28 participating doctors undertook 138 kidney and 60 bladder scans during the study. POCUS of the bladder as a test for urinary retention had a sensitivity of 100% (95% CI 88–100) and specificity of 100% (95% CI 93–100). POCUS of the kidney as a test for hydronephrosis had a sensitivity 90% (95% CI 74–96) and specificity of 96% (95% CI 89–98). The accuracy of other findings such as renal stones and bladder clot was lower. POCUS of the bladder appeared to have made a positive contribution to patient care in 92% of cases without evidence of harm. POCUS of the kidney benefited 93% of cases, although in three cases (2%), it may have had a negative effect on patient care.

DISCUSSION: POCUS as a test for urinary retention and hydronephrosis in the hands of rural doctors was technically straightforward, improved diagnostic certainty, increased discharges and overall had a positive effect on patient care.

excuse the pun...