In This Edition
Literature At A Glance
A guide to this month’s studies
- Early treatment with intravenous tPA for acute stroke
- Perioperative morbidity, mortality for current smokers
- Statins associated with musculoskeletal conditions
- Antithrombotic medications in patients with history of stroke
- Extended prophylaxis with aspirin for patients after total hip arthroplasty
- Prognosis for symptomatic subsegmental pulmonary embolism
- Video-based educational workshops for academic hospitalists
- Increased mortality for elective surgeries on Fridays, weekends
- Basal plus correction insulin regimen and Type 2 diabetes
- Capnography to diagnose diabetic ketoacidosis in the ED
- How publicly reported mortality rates correlate with hospitals’ overall mortality
- Cost savings and preventable acute-care visits for Medicare patients
Early tPA in Acute Stroke Is Associated with Better Short-Term Outcomes in Routine Clinical Practice
Clinical question: Does early treatment with intravenous (IV) tissue plasminogen activator (tPA) result in better outcomes among patients with acute ischemic stroke in routine clinical practice?
Background: IV tPA for acute ischemic stroke is beneficial if given in the first 4.5 hours after symptom onset. However, pooled data from clinical trials have been limited in characterizing the extent to which onset-to-treatment (OTT) with IV tPA influences outcomes and how effective tPA is in routine clinical practice.
Study design: Data analysis from a stroke registry.
Setting: One thousand three hundred ninety-five U.S. hospitals participating in the Get with the Guidelines—Stroke Program.
Synopsis: Data were analyzed from 58,353 tPA-treated patients within 4.5 hours of symptom onset. Clinical outcomes were compared among patients treated in the 0-90-, 91-180-, and 181-270-minute OTT windows. Patient factors strongly associated with shorter OTT were greater stroke severity (odds ratio [OR] 2.8; 95% confidence interval [CI], 2.5-3.1 per five-point increase), arrival by ambulance (OR 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR 4.6; 95% CI, 3.8-5.4). Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR 0.96; 95% CI, 0.95-0.98; P<.001), reduced symptomatic intracranial hemorrhage (OR 0.96; 95% CI, 0.95-0.98; P<.001), increased achievement of independent ambulation at discharge (OR 1.04; 95% CI, 1.03-1.05; P<.001), and increased discharge to home (OR 1.03; 95% CI, 1.02-1.04; P<.001).
Data collected were dependent on the accuracy and completeness of the chart abstraction, and only short-term outcomes were reported. Although no post-discharge outcomes were reported, previous studies have shown that functional status at discharge strongly correlates with three-month disability outcomes.
Bottom line: In routine clinical practice, earlier tPA for acute ischemic strokes results in better short-term clinical outcomes.
Citation: Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480-2488.
Current Smokers Have Higher Perioperative Morbidity and Mortality Compared to Past Smokers
Clinical question: Is there an association between current and past smoking on outcomes among patients having major surgery?
Background: Smoking is associated with adverse postoperative outcomes, but it is not known whether the associations are dose-dependent or limited to patients with smoking-related diseases. Smoking-related effects on postoperative events among patients having major surgery are also not well established.
Study design: Retrospective cohort study.
Setting: Four hundred forty-eight non-VA hospitals across the U.S., Canada, Lebanon, and the United Arab Emirates.
Synopsis: Data from 607,558 adult patients undergoing major surgery were obtained from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. After adjusting for confounders (cardiopulmonary diseases and cancer), the effects of current and past smoking (quit >1 year prior) on 30-day post-operative outcomes were measured.
There were 125,192 (21%) current smokers and 78,763 (13%) past smokers. Increased odds of post-op mortality were noted in current smokers only (odds ratio [OR] 1.17; 95% CI, 1.10-1.24). The adjusted odds ratios were higher for arterial and respiratory events among current smokers compared with past smokers (OR 1.65; 95% CI, 1.51-1.81 vs. OR 1.20; CI, 1.09-1.31 for arterial events, respectively) and (OR, 1.45; CI, 1.40-1.51 vs. OR, 1.13; CI, 1.08-1.18, for respiratory events, respectively). No significant effects on venous events were observed.