Suchita Shah Sata, MD

Clinical question: Are oral steroids as effective as NSAIDs in treating acute gout?

Background: Two small trials have suggested that oral steroids are as effective as NSAIDs in treating acute gout. Wider acceptance of steroids as first-line agents for acute gout may require more robust evidence supporting their safety and efficacy.

Study design: Multicenter, double-blind, randomized equivalence trial.

Setting: Four EDs in Hong Kong.

Synopsis: The study included 416 patients presenting to the ED with clinically suspected acute gout who were randomized to treatment with either oral indomethacin or oral prednisolone for five days. A research investigator assessed response to therapy in the ED at 30, 60, 90, and 120 minutes after administration of the initial dose of medication. Patients then kept pain-assessment diaries for 14 days after discharge from the ED.

Pain scores were assessed using a visual analog scale of 0 mm (no pain) to 100 mm (worst pain the patient had experienced). Clinically significant changes in pain scores were defined as decreases of >13 mm on the visual analog scale.

The number of patients with clinically significant decreases in pain scores did not differ statistically between groups. Both groups had similar reductions in mean pain scores over the course of the study. Patients in the indomethacin group had a statistically significant increase in minor adverse events. No patients in either group had major adverse events.

Bottom line: Oral prednisolone appears to be a safe and effective first-line agent for the treatment of acute gout.

Citation: Rainer TH, Chen CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout. Ann Intern Med. 2016;164(7):464-471.

Short Take

Rate Control as Effective as Rhythm Control in Postoperative Atrial Fibrillation

This study randomized patients with postoperative atrial fibrillation to rhythm control (using amiodarone and/or direct current cardioversion) or rate control and found neither treatment strategy has a clinical benefit over the other.

Citation: Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med. 2016;374(20):1911-1921.

Clinical question: Are oral steroids as effective as NSAIDs in treating acute gout?

Background: Two small trials have suggested that oral steroids are as effective as NSAIDs in treating acute gout. Wider acceptance of steroids as first-line agents for acute gout may require more robust evidence supporting their safety and efficacy.

Study design: Multicenter, double-blind, randomized equivalence trial.

Setting: Four EDs in Hong Kong.

Synopsis: The study included 416 patients presenting to the ED with clinically suspected acute gout who were randomized to treatment with either oral indomethacin or oral prednisolone for five days. A research investigator assessed response to therapy in the ED at 30, 60, 90, and 120 minutes after administration of the initial dose of medication. Patients then kept pain-assessment diaries for 14 days after discharge from the ED.

Pain scores were assessed using a visual analog scale of 0 mm (no pain) to 100 mm (worst pain the patient had experienced). Clinically significant changes in pain scores were defined as decreases of >13 mm on the visual analog scale.

The number of patients with clinically significant decreases in pain scores did not differ statistically between groups. Both groups had similar reductions in mean pain scores over the course of the study. Patients in the indomethacin group had a statistically significant increase in minor adverse events. No patients in either group had major adverse events.

Bottom line: Oral prednisolone appears to be a safe and effective first-line agent for the treatment of acute gout.

Citation: Rainer TH, Chen CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout. Ann Intern Med. 2016;164(7):464-471.

Short Take

Rate Control as Effective as Rhythm Control in Postoperative Atrial Fibrillation

This study randomized patients with postoperative atrial fibrillation to rhythm control (using amiodarone and/or direct current cardioversion) or rate control and found neither treatment strategy has a clinical benefit over the other.

Citation: Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med. 2016;374(20):1911-1921.

Clinical question: Are oral steroids as effective as NSAIDs in treating acute gout?

Background: Two small trials have suggested that oral steroids are as effective as NSAIDs in treating acute gout. Wider acceptance of steroids as first-line agents for acute gout may require more robust evidence supporting their safety and efficacy.

Study design: Multicenter, double-blind, randomized equivalence trial.

Setting: Four EDs in Hong Kong.

Synopsis: The study included 416 patients presenting to the ED with clinically suspected acute gout who were randomized to treatment with either oral indomethacin or oral prednisolone for five days. A research investigator assessed response to therapy in the ED at 30, 60, 90, and 120 minutes after administration of the initial dose of medication. Patients then kept pain-assessment diaries for 14 days after discharge from the ED.

Pain scores were assessed using a visual analog scale of 0 mm (no pain) to 100 mm (worst pain the patient had experienced). Clinically significant changes in pain scores were defined as decreases of >13 mm on the visual analog scale.

The number of patients with clinically significant decreases in pain scores did not differ statistically between groups. Both groups had similar reductions in mean pain scores over the course of the study. Patients in the indomethacin group had a statistically significant increase in minor adverse events. No patients in either group had major adverse events.

Bottom line: Oral prednisolone appears to be a safe and effective first-line agent for the treatment of acute gout.

Citation: Rainer TH, Chen CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout. Ann Intern Med. 2016;164(7):464-471.

Short Take

Rate Control as Effective as Rhythm Control in Postoperative Atrial Fibrillation

This study randomized patients with postoperative atrial fibrillation to rhythm control (using amiodarone and/or direct current cardioversion) or rate control and found neither treatment strategy has a clinical benefit over the other.

Citation: Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med. 2016;374(20):1911-1921.

Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?

Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.

Study design: Analysis of existing literature on medical errors.

Setting: U.S. hospitals.

Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.

Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.

Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.

Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.

Short Take

Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections

In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.

Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.

Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?

Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.

Study design: Analysis of existing literature on medical errors.

Setting: U.S. hospitals.

Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.

Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.

Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.

Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.

Short Take

Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections

In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.

Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.

Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?

Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.

Study design: Analysis of existing literature on medical errors.

Setting: U.S. hospitals.

Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.

Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.

Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.

Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.

Short Take

Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections

In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.

Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.

Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?

Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.

Study design: Retrospective cohort study.

Setting: EDs of acute-care hospitals in Ontario, Canada.

Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).

Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.

Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.

Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.

Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?

Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.

Study design: Retrospective cohort study.

Setting: EDs of acute-care hospitals in Ontario, Canada.

Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).

Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.

Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.

Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.

Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?

Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.

Study design: Retrospective cohort study.

Setting: EDs of acute-care hospitals in Ontario, Canada.

Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).

Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.

Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.

Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.