Bottom line: Prasugrel therapy was significantly better than clopidogrel but with an increased risk of major bleeding.
Citation: Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357:2001-2015.
Can the Rate of New Hip Fracture Be Reduced with Zoledronic Acid?
Background: Mortality is markedly increased following hip fractures, and medical interventions exist to improve clinical outcomes.
Study design: Randomized, double-blind, placebo-controlled trial.
Setting: International, multicenter trial involving patients with recent hip fracture.
Synopsis: This study, know as the HORIZON trial, involved 2,127 patients. Of those, 1,065 (mean age of 74.5) were assigned to receive yearly infusions of 5 mg IV zoledronic acid within 90 days after surgical hip fracture repair. Meantime, 1,062 were assigned to receive placebo.
All patients received supplemental vitamin D and calcium. The median follow-up was 1.9 years, and the primary end point was a new clinical fracture. The rate of any new clinical fracture was 8.6% in the zoledronic acid group and 13.9% in the placebo group. This represents a 35% relative risk reduction with zoledronic acid.
Limitations of the study included a slightly younger and healthier patient population with hip fracture than the general population.
Bottom line: An annual infusion of zoledronic acid within 90 days after repair of hip fracture was associated with reduced new fractures and improved survival.
Citation: Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
Does Peri-operative Consultation Improve Post-operative Outcome, Reduce Hospital Cost?
Background: Hospitalist-surgical co-management of the surgical inpatient is a model of care enjoying increasing interest. However, there is little published evidence of the effectiveness of this model.
Study design: Retrospective chart review.
Setting: Surgical service of academic teaching hospital.
Synopsis: Of 1,282 surgical patients, 9.1% underwent perioperative medical consultation in a retrospective review. Based on a number of measurement variables (post-operative serum glucose, venous thromboembolism [VTE] prophylaxis, use of perioperative beta-blockers), consulted patients had the same outcome, length of stay and cost as did non-consulted patients. This was, however, a retrospective observational study, using chart abstraction and administrative techniques. This introduces considerable weakness to the validity of the findings.
Bottom line:: In a retrospective study, no value was found to the use of peri-operative medical consultation of surgical patients in a large academic teaching hospital. Because of the weakness in study design, no conclusion can be drawn regarding the true effectiveness of perioperative medical consultation of the surgical patient.
Citation: Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007 Nov 26;167(21):2338-2344.
Does an RRT Save Children Outside the ICU?
Background: The Institute for Healthcare Improvement initiative known as the 100,000 lives campaign recommended six strategies to decrease preventable inpatient deaths. Implementation of a rapid response team (RRT) was one such strategy.
Study design: Cohort study design.
Setting: A 264-bed academic children’s hospital, between Jan. 1, 2001, and March 31, 2007.
Synopsis:
A total of 22,037 patient admissions and 102,537 patient days were evaluated pre-intervention, and 7,257 admissions and 34,420 patient days were evaluated post-intervention. Once the RRT was implemented, the mean morality rate decreased by 18% and the mean monthly code rate per 1,000 patient days were decreased by 71.2%. Study limitations included small differences in gender and race between pre-intervention and post-intervention populations.