Bottom line: Elderly adults had lower in-hospital mortality after implementation of the Keystone QI project in ICUs.
Citation: Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
Serious Long-Term Risks with Acute Kidney Injury after Coronary Angiography
Clinical question: Does postcoronary angiography acute kidney injury (AKI) increase the risk of poor long-term clinical outcomes?
Background: Previous studies have shown that AKI following coronary angiography increases the risk of poor short-term clinical outcomes, such as in-hospital myocardial infarction, prolonged hospital stay, and early mortality. Little is known about the long-term cardiovascular and renal outcomes following post-coronary angiography AKI.
Study design: Retrospective cohort study.
Setting: All coronary angiography centers in Alberta, Canada.
Synopsis: The study included 14,782 adults who were ≥18 years of age, underwent coronary angiography, had a baseline creatinine measurement, did not have end-stage renal disease (ESRD), and had a creatinine measurement within seven days after coronary angiography.
During a median follow-up period of 19.7 months, 1,099 (7.4%) patients developed stage 1 AKI and 321 (2.2%) developed stage 2 or 3 AKI. Mortality increased twofold with stage 1 AKI and >3-fold with stage 2 or 3 AKI. Risk of ESRD increased substantially by >11-fold in patients with stage 2 or 3 AKI. Risk of hospitalization for subsequent AKI, myocardial infarction, and heart failure also increased significantly following post-coronary angiography AKI.
Patients who experienced AKI were older, had more severe CAD, were more likely to have such comorbidities as DM, HTN, and heart failure, and had lower baseline GFRs. However, the underlying comorbidities do not completely explain the increased risk of poor long-term outcomes in the adjusted analysis.
Limitations include missing or underestimating mild cases of AKI, residual confounding from unmeasured variables, and inability of retrospective comparative studies to establish causality.
Bottom line: Adults with post-coronary angiography AKI are at increased risk of poor long-term cardiovascular and renal outcomes.
Citation: James MT, Ghali WA, Knudtson ML, et al. Associations between acute kidney injury and cardiovascular and renal outcomes after coronary angiography. Circulation. 2011;123(4):409-416. TH
Pediatric HM Literature
Proton-Pump Inhibitors Ineffective for Gastroesophageal Reflux Disease in Children
Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Clinical question: What is the efficacy of proton-pump inhibitors (PPIs) in children with gastroesophageal reflux disease (GERD)?
Background: Gastroesophageal reflux is both a common and normal phenomenon in infants. GERD refers to the presence of abnormal symptoms ascribed to the reflux and frequently is treated in children in a manner similar to adults with reflux esophagitis. PPIs often are prescribed as front-line treatment, and their use has increased dramatically in recent years, though their effectiveness in children remains unclear.
Study design: Systematic review of the literature.
Setting: Hawaii’s largest health insurer.
Synopsis: Medline, Embase, and the Cochrane Database of Systematic Reviews were searched for randomized controlled trials (RCTs) and crossover studies performed to evaluate the efficacy of PPIs in children 0-17 years with GERD and no complicating diseases. Ten RCTs and two crossover studies were analyzed and rated independently by two reviewers.
Due to significant heterogeneity between the studies, a meta-analysis was not possible; studies were discussed separately. PPIs offered no advantage when compared with controls (alginates, ranitidine, different dosages of PPIs), and similar rates of adverse events were reported between treatment groups.
This study is hampered by notable heterogeneity of patient type, symptoms, and study design in many of the trials. However, the results are in line with discussions at a recent FDA Gastrointestinal Drugs Advisory Committee meeting, which reviewed the lack of efficacy of PPIs in infants in four recent Phase 3 clinical trials.
Bottom line: Little evidence supports the widespread use of PPIs in children.
Citation: Van der Pol RJ, Smits MJ, van Wijk MP, Omari TI, Tabbers MM, Benninga MA. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011;127:925-935.