Long-term excess mortality associated with diabetes following acute myocardial infarction: a population-based cohort study

BACKGROUND

The long-term excess risk of death associated with diabetes following acute myocardial infarction is unknown. We determined the excess risk of death associated with diabetes among patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) after adjustment for comorbidity, risk factors and cardiovascular treatments.

METHODS

Nationwide population-based cohort (STEMI n=281 259 and NSTEMI n=422 661) using data from the UK acute myocardial infarction registry, MINAP, between 1 January 2003 and 30 June 2013. Age, sex, calendar year and country-specific mortality rates for the populace of England and Wales (n=56.9 million) were matched to cases of STEMI and NSTEMI. Flexible parametric survival models were used to calculate excess mortality rate ratios (EMRR) after multivariable adjustment. This study is registered at ClinicalTrials.gov (NCT02591576).

RESULTS

Over 1.94 million person-years follow-up including 120 568 (17.1%) patients with diabetes, there were 187 875 (26.7%) deaths. Overall, unadjusted (all cause) mortality was higher among patients with than without diabetes (35.8% vs 25.3%). After adjustment for age, sex and year of acute myocardial infarction, diabetes was associated with a 72% and 67% excess risk of death following STEMI (EMRR 1.72, 95% CI 1.66 to 1.79) and NSTEMI (1.67, 1.63 to 1.71). Diabetes remained significantly associated with substantial excess mortality despite cumulative adjustment for comorbidity (EMRR 1.52, 95% CI 1.46 to 1.58 vs 1.45, 1.42 to 1.49), risk factors (1.50, 1.44 to 1.57 vs 1.33, 1.30 to 1.36) and cardiovascular treatments (1.56, 1.49 to 1.63 vs 1.39, 1.36 to 1.43).

CONCLUSIONS

At index acute myocardial infarction, diabetes was common and associated with significant long-term excess mortality, over and above the effects of comorbidities, risk factors and cardiovascular treatments.

The knee adduction moment and knee osteoarthritis symptoms: relationships according to radiographic disease severity

OBJECTIVE

To investigate relationships between external knee adduction moment parameters (KAM) and osteoarthritis (OA) symptoms according to disease severity.

DESIGN

164 participants with symptomatic medial knee OA were included. Radiographic severity was graded by (1) Kellgren & Lawrence (KL) scale (Grade 2, n = 49; Grade, n = 52; Grade 4, n = 63) and; (2) medial tibiofemoral joint space narrowing (JSN) (Grade 1, n = 47; Grade 2, n = 50; Grade 3, n = 67). KAM-related parameters (peak KAM, KAM impulse and cumulative load) were determined from three-dimensional gait analysis and pedometry. Cumulative load was determined by multiplying KAM impulse by the average number of steps/day recorded over at least 5 days. Symptoms were assessed via numeric rating scale ((NRS), pain) and Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (pain and physical function). Relationships between KAM parameters (independent variables) and symptoms (dependent variables) were evaluated by radiographic severity using linear models, adjusting for covariates.

RESULTS

In mild disease (either KL Grade 2 or JSN Grade 1), there were no associations between KAM and symptoms. In moderate disease of KL Grade 3, higher KAM impulse was associated with greater WOMAC pain. In severe disease (KL Grade 4), higher KAM impulse was associated with less WOMAC pain (KL Grade 4), while higher peak KAM was associated with better function (KL Grade 4). Higher cumulative knee adduction load was associated with less pain on both NRS and WOMAC (JSN Grade 3) as well as better function (both JSN Grade 3 and KL Grade 4).

CONCLUSIONS

Relationships between KAM-related parameters and symptoms differ according to underlying radiographic OA severity.

Cost consciousness among physicians in the neonatal intensive care unit

OBJECTIVE

The objectives of this study were (1) to describe the prevalence and correlates of cost consciousness among physician providers in neonatology and (2) to describe knowledge of cost of common medications, laboratory/imaging evaluations, hospitalization costs and reimbursements.

STUDY DESIGN

A 54-item survey was administered to members of the Section on Neonatal-Perinatal Medicine of the American Academy of Pediatrics.

RESULTS

Of the 602 participants, 37% reported cost consciousness in decision making. Adjusting for years in practice, gender, training level, type of practice setting and region of practice, formalized education about costs was associated with increased cost consciousness in practice (adjusted odds ratio (AOR): 3.4; 95% confidence interval (CI): 1.2 to 9.8). Working in a private practice setting was also associated with increased cost consciousness when ordering laboratory (AOR: 3.0; (95% CI: 1.2 to 7.6)) or imaging tests (AOR: 2.0; 95% CI: 1.0 to 4.8).

CONCLUSIONS

We found variation in knowledge of cost. Formal education about costs and working in a private practice setting were associated with increased cost consciousness.

Geographic variation in the treatment of non-ST-segment myocardial infarction in the English National Health Service: a cohort study

OBJECTIVES

To investigate geographic variation in guideline-indicated treatments for non-ST-elevation myocardial infarction (NSTEMI) in the English National Health Service (NHS).

DESIGN

Cohort study using registry data from the Myocardial Ischaemia National Audit Project.

SETTING

All Clinical Commissioning Groups (CCGs) (n=211) in the English NHS.

PARTICIPANTS

357 228 patients with NSTEMI between 1 January 2003 and 30 June 2013.

MAIN OUTCOME MEASURE

Proportion of eligible NSTEMI who received all eligible guideline-indicated treatments (optimal care) according to the date of guideline publication.

RESULTS

The proportion of NSTEMI who received optimal care was low (48 257/357 228; 13.5%) and varied between CCGs (median 12.8%, IQR 0.7-18.1%). The greatest geographic variation was for aldosterone antagonists (16.7%, 0.0-40.0%) and least for use of an ECG (96.7%, 92.5-98.7%). The highest rates of care were for acute aspirin (median 92.8%, IQR 88.6-97.1%), and aspirin (90.1%, 85.1-93.3%) and statins (86.4%, 82.3-91.2%) at hospital discharge. The lowest rates were for smoking cessation advice (median 11.6%, IQR 8.7-16.6%), dietary advice (32.4%, 23.9-41.7%) and the prescription of P2Y12 inhibitors (39.7%, 32.4-46.9%). After adjustment for case mix, nearly all (99.6%) of the variation was due to between-hospital differences (median 64.7%, IQR 57.4-70.0%; between-hospital variance: 1.92, 95% CI 1.51 to 2.44; interclass correlation 0.996, 95% CI 0.976 to 0.999).

CONCLUSIONS

Across the English NHS, the optimal use of guideline-indicated treatments for NSTEMI was low. Variation in the use of specific treatments for NSTEMI was mostly explained by between-hospital differences in care. Performance-based commissioning may increase the use of NSTEMI treatments and, therefore, reduce premature cardiovascular deaths.

TRIAL REGISTRATION NUMBER

NCT02436187.

A survey of factors affecting the capacity to work in patients with rheumatoid arthritis in South Wales

A survey was undertaken during 1992-93 to identify factors associated with the severity of rheumatoid arthritis and its management which might be modified to improve the patient's ability to continue to work. Two hundred and twenty patients taking part in a trial of second-line therapy were sent a postal questionnaire. Seventy-four per cent returned valid forms and these patients were subsequently medically examined. The unemployment rate in males was 71 % and in females 69%, compared to the average for the whole of Wales of 27% and 42% respectively in the same age range for the year in question. The data obtained suggested that improvements could be made with respect to disease control, organization of medical care and better use of rehabilitation services to optimize ability to work.

A new top-loading venous bag provides vacuum-assisted venous drainage

A new venous bag has been developed, prototyped, and tested. The new bag has its inlet, outlet purge, and infusion tubes extending upward from the top of the bag, and are threaded through, bonded to, and sealed within a flat rigid top plate. This design allows the bag to be hung from its top plate by its tubes. It also allows the bag to be: 1) dropped into or removed from its holder, as is done with existing hard-shell reservoirs so that its weight pulls it into the holder without the need for eyelets and hooks and 2) placed closer to the floor so that gravity drainage is facilitated. The V-Bag® (VB) is easily sealed within an accompanying rigid housing. Once sealed, vacuum applied to the housing is transmitted across the flexible walls of the bag to the venous blood. Thus, vacuum-assisted venous drainage (VAVD) is obtained as it is with a hard-shell reservoir, but without any contact of air with the blood. Bench tests, using a circuit that simulated the venous side of the cardiopulmonary bypass (CPB) circuit, showed that applying suction to the housing increased venous flow, and the fractional increase in flow was not a function of the venous cannula, but of the level of vacuum applied. In the gravity drainage mode, the bubble counts at the outlet of the V-Bag compared to two other bags were lower at any pumping condition. When used in the VAVD mode, bubble counts were two orders of magnitude lower than when using kinetically assisted venous drainage (KAVD) with a centrifugal pump. Results obtained with the VB suggest its clinical usefulness.

'I felt weird and wobbly.' Child-reported impacts associated with a dental general anaesthetic

AIM

This qualitative study sought to obtain children's accounts of having dental extractions under general anaesthesia (GA). The aim was to gain greater understanding of the physical and psychological impacts from a child's perspective.

METHOD

Ten children, aged 6-11 years, maintained a video diary to document their feelings and experiences before, and following their hospital admission. Two semi-structured home interviews supplemented the video diary data and analysis was guided by narrative approaches.

RESULTS

This research revealed new insights into children's experiences of having teeth removed under GA. Several of the post-operative impacts correlated with those previously reported by parents/carers. These were notably nausea, bleeding and tiredness, although children used different terminology. However, additional physical and psychological outcomes, both positive and negative, emerged from the children's narratives. Negative aspects included hunger, disturbed eating, being scared/worried and experiencing discomfort from the IV cannula. Interestingly, pain was not a strong theme. Positive outcomes were also reported, such as satisfaction with the resolution of their dental problem and receipt of rewards and attention from family members.

CONCLUSION

These accounts have implications for improving patient experiences and outcomes throughout the dental GA care pathway. A review of pre-operative fasting protocols should be a priority.

Oxaliplatin and 5-FU/folinic acid (modified FOLFOX6) with or without aflibercept in first-line treatment of patients with metastatic colorectal cancer: the AFFIRM study

BACKGROUND

The combination of aflibercept with FOLFIRI has been shown to significantly prolong overall survival in patients with metastatic colorectal cancer (mCRC) after progression on oxaliplatin-based therapy. This trial evaluated the addition of aflibercept to oxaliplatin-based first-line treatment of patients with mCRC.

PATIENTS AND METHODS

Patients with mCRC were randomized to receive first-line therapy with mFOLFOX6 plus aflibercept (4 mg/kg) or mFOLFOX6 alone. The primary end point of this phase II study was the progression-free survival (PFS) rate at 12 months in each arm. The analysis of efficacy between the arms was a pre-planned secondary analysis.

RESULTS

Of 236 randomized patients, 227 and 235 patients were evaluable for the primary efficacy analysis and safety, respectively. The probabilities of being progression-free at 12 months were 25.8% [95% confidence interval (CI) 17.2-34.4] for the aflibercept/mFOLFOX6 arm and 21.2% (95% CI 12.2-30.3) for the mFOLFOX6 arm. The median PFS was 8.48 months (95% CI 7.89-9.92) for the aflibercept/mFOLFOX6 arm and 8.77 months (95% CI 7.62-9.27) for the mFOLFOX6 arm; the hazard ratio of aflibercept/mFOLFOX6 versus mFOLFOX6 was 1.00 (95% CI 0.74-1.36). The response rates were 49.1% (95% CI 39.7-58.6) and 45.9% (95% CI 36.4-55.7) for patients treated with and without aflibercept, respectively. The most frequent treatment-emergent grade 3/4 adverse events (AEs) excluding laboratory abnormalities reported for aflibercept/mFOLFOX6 versus mFOLFOX6 were neuropathy (16.8% versus 17.2%) and diarrhea (13.4% versus 5.2%). Neutropenia grade 3/4 occurred in 36.1% versus 29.3%. The most common vascular endothelial growth factor inhibition class-effect grade 3/4 AEs for aflibercept/mFOLFOX6 versus mFOLFOX6 were hypertension (35.3% versus 1.7%), proteinuria (9.2% versus 0%), deep vein thrombosis (5.9% versus 0.9%) and pulmonary embolism (5.9% versus 5.2%).

CONCLUSION

No difference in PFS rate was observed between treatment groups. Adding aflibercept to first-line mFOLFOX6 did not increase efficacy but was associated with higher toxicity.

CLINICAL TRIAL NUMBER

NCT00851084, www.clinicaltrials.gov, EudraCT 2008-004178-41.

Determinants of excess mortality following unprotected left main stem percutaneous coronary intervention

OBJECTIVE

For percutaneous coronary intervention (PCI) to the unprotected left main stem (UPLMS), there are limited long-term outcome data. We evaluated 5-year survival for UPLMS PCI cases taking into account background population mortality.

METHODS

A population-based registry of 10 682 cases of chronic stable angina (CSA), non-ST-segment elevation acute coronary syndrome (NSTEACS), ST-segment elevation myocardial infarction with (STEMI+CS) and without cardiogenic shock (STEMI-CS) who received UPLMS PCI from 2005 to 2014 were matched by age, sex, year of procedure and country to death data for the UK populace of 56.6 million people. Relative survival and excess mortality were estimated.

RESULTS

Over 26 105 person-years follow-up, crude 5-year relative survival was 93.8% for CSA, 73.1% for NSTEACS, 77.5% for STEMI-CS and 28.5% for STEMI+CS. The strongest predictor of excess mortality among CSA was renal failure (EMRR 6.73, 95% CI 4.06 to 11.15), and for NSTEACS and STEMI-CS was preprocedural ventilation (6.25, 5.05 to 7.75 and 6.92, 4.25 to 11.26, respectively). For STEMI+CS, the strongest predictor of excess mortality was preprocedural thrombolysis in myocardial infarction (TIMI) 0 flow (2.78, 1.87 to 4.13), whereas multivessel PCI was associated with improved survival (0.74, 0.61 to 0.90).

CONCLUSIONS

Long-term survival following UPLMS PCI for CSA was high, approached that of the background populace and was significantly predicted by co-morbidity. For NSTEACS and STEMI-CS, the requirement for preprocedural ventilation was the strongest determinant of excess mortality. By contrast, among STEMI+CS, in whom survival was poor, the strongest determinant was preprocedural TIMI flow. Future cardiovascular cohort studies of long-term mortality should consider the impact of non-cardiovascular deaths.

Assessment of the impact of scheduled postmarketing safety summary analyses on regulatory actions

In addition to standard postmarketing drug safety monitoring, Section 915 of the Food and Drug Administration Amendments Act of 2007 (FDAAA) requires the US Food and Drug Administration (FDA) to conduct a summary analysis of adverse event reports to identify risks of a drug or biologic product 18 months after product approval, or after 10,000 patients have used the product, whichever is later. We assessed the extent to which these analyses identified new safety signals and resultant safety-related label changes. Among 458 newly approved products, 300 were the subjects of a scheduled analysis; a new safety signal that resulted in a safety-related label change was found for 11 of these products. Less than 2% of 713 safety-related label changes were based on the scheduled analyses. Our study suggests that the safety summary analyses provide only marginal value over other pharmacovigilance activities.

Abstract P1-16-03: Quantitative versus semi-quantitative assessments of radiation-induced pulmonary fibrosis post adjuvant breast radiotherapy

Objective

To evaluate the quantitative versus semi-quantitative assessments of radiation induced pulmonary fibrosis (RIPF) post adjuvant breast radiotherapy (RT).

Methods

High resolution computed tomography (HRCT) assessed lung physical density changes (CTD) and physician identified HRCT visual grading scores (CTS) were analysed at the minimum of 12 months post RT at one institution. The treated side in-portal lung regions for CTD and CTS assessments were: central-axis (CA) + regions 5cm superior & inferior to CA and the corresponding mid anterolateral region respectively. Respiratory motion was accounted for by subtracting the untreated side lung density from the treated side. Mean lung densities correspond to each voxels were automatically calculated by Pinnacle software (Phillips, Eindhoven, The-Netherlands). Grading of CTS was according to the RTOG/EORTC (grade 0, 1, 2, and 3 defined as none, slight, patchy, and dense HRCT appearance respectively) and analysed by a radiologist (JL) and re-checked a radiation oncologist (PG).

Results

Total numbers of 403 patients were analysed. A substantial association was verified between CTD and CTS assessment. An increase of ∼0.01 g/ml (95% CI 0.003-0.02) in CTD with each CTS score increase of 1 was observed (Table-1a). The RIPF can be categorised quantitatively into three groups of CTS 0 vs. 1-2 vs. 3 based on the mean CTD (Table-1b).

Table-1a. Correlation between CTD and CTS method. Table-1b. Grouping of CTS based on CTD methodTable-1a. Correlation between CTD and CTS methodCTSTreated side mean CTD - LeftTreated side mean CTD - RightMean Total00.055 (119)-0.011 (136)0.020 (255)10.065 (60)0.005 (56)0.036 (116)20.083 (15)0.012 (13)0.050 (28)30.108 (4)00.108 (4)Total0.061 (198)-0.005 (205)0.028 (403)Table-1b. Grouping of CTS based on CTD methodCTSTreated side mean CTD - LeftTreated side mean CTD - RightMean Total95% Confidence interval00.055 (119)-0.011 (136)0.020 (255)0.012-0.0271-20.069 (75)0.006 (69)0.039 (144)0.029-0.04830.108 (4)00.108 (4)0.079-0.137

A cut off CTD of 0.089 g/ml exemplified the best compromise between sensitivity (100%) and specificity (88.2%) for dense HRCT appearance. However, there was no good compromise of CTD cut off for slight and patchy HRCT score possibly due to intra observer variation and the scale of the CTD measure (small increase in CTD may not be detected visually by the observer). Multivariable analysis revealed increasing age, current smoker, V20 ≥ 10% (the volume of lung that was covered by the 20Gy isodose line), central lung distance ≥ 2cm (the distance between posterior RT tangents and the chest wall), combined endocrine & chemotherapy, and treated side mean CTD to be significantly associated with development of grade ≥1 RIPF.

Conclusions

There was a good correlation between quantitative (CTD) and semi-quantitative (CTS) assessment of RIPF post adjuvant breast RT. The CTD method could be advantageous for both routine clinical practice and future clinical trials that require more detailed quantification of dense RIPF.

Citation Format: Pramana A, Browne L, Cox H, Saba A, Pham K, Trakis S, Crawford K, Hall M, Batchelor N, Lim J, Graham P. Quantitative versus semi-quantitative assessments of radiation-induced pulmonary fibrosis post adjuvant breast radiotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-16-03.

Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003-2013

OBJECTIVE

Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is insufficiently implemented in many countries. We investigated patient and hospital characteristics associated with PPCI utilisation.

METHODS

Whole country registry data (MINAP, Myocardial Ischaemia National Audit Project) comprising PPCI-capable National Health Service trusts in England (84 hospital trusts; 92 350 hospitalisations; 90 489 patients), 2003-2013. Multilevel Poisson regression modelled the relationship between incidence rate ratios (IRR) of PPCI and patient and trust-level factors.

RESULTS

Overall, standardised rates of PPCI increased from 0.01% to 86.3% (2003-2013). While, on average, there was a yearly increase in PPCI utilisation of 30% (adjusted IRR 1.30, 95% CI 1.23 to 1.36), it varied substantially between trusts. PPCI rates were lower for patients with previous myocardial infarction (0.95, 0.93 to 0.98), heart failure (0.86, 0.81 to 0.92), angina (0.96, 0.94 to 0.98), diabetes (0.97, 0.95 to 0.99), chronic renal failure (0.89, 0.85 to 0.90), cerebrovascular disease (0.96, 0.93 to 0.99), age >80 years (0.87, 0.85 to 0.90), and travel distances >30 km (0.95, 0.93 to 0.98). PPCI rates were higher for patients with previous percutaneous coronary intervention (1.09, 1.05 to 1.12) and among trusts with >5 interventional cardiologists (1.30, 1.25 to 1.34), more visiting interventional cardiologists (1-5: 1.31, 1.26 to 1.36; ≥6: 1.42, 1.35 to 1.49), and a 24 h, 7-days-a-week PPCI service (2.69, 2.58 to 2.81). Half of the unexplained variation in PPCI rates was due to between-trust differences.

CONCLUSIONS

Following an 8 year implementation phase, PPCI utilisation rates stabilised at 85%. However, older and sicker patients were less likely to receive PPCI and there remained between-trust variation in PPCI rates not attributable to differences in staffing levels. Compliance with clinical pathways for STEMI is needed to ensure more equitable quality of care.

Generic medicines and generic substitution: contrasting perspectives of stakeholders in Ireland

BACKGROUND

The Health (Pricing and Supply of Medical Goods) Act 2013 passed into law in July 2013 and legislated for generic substitution in Ireland. The aim of the study was to ascertain the knowledge and perceptions of stakeholders i.e. patients, pharmacists and prescribers, of generic medicines and to generic substitution with the passing of legislation.

METHODS

Three stakeholder specific questionnaires were developed to assess knowledge of and perceptions to generic medicines and generic substitution. Purposive samples of patients, prescribers and pharmacists were analysed. Descriptive quantitative and qualitative analyses were undertaken.

RESULTS AND DISCUSSION

A total of 762 healthcare professionals and 353 patients were recruited. The study highlighted that over 84% of patients were familiar with generic medicines and are supportive of the concept of generic substitution. Approximately 74% of prescribers and 84% of pharmacists were supportive of generic substitution in most cases. The main areas of concern highlighted by the healthcare professionals that might impact on the successful implementation of the policy, were the issue of bioequivalence with generic medicines, the computer software systems used at present in general practitioner (GP) surgeries and the availability of branded generics. The findings from this study identify a high baseline rate of acceptance to generic medicines and generic substitution among patients, prescribers and pharmacists in the Irish setting. The concerns of the main stakeholders provide a valuable insight into the potential difficulties that may arise in its implementation, and the need for on-going reassurance and proactive dissemination of the impact of the generic substitution policy.

CONCLUSION

The existing positive attitude to generic medicines and generic substitution among key stakeholders in Ireland to generic substitution, combined with appropriate support and collaboration should result in the desired increase in rates of prescribing, dispensing and use of generic medicines.