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PAs can effectively serve as leader of an RRT

Clinical question Does a rapid response team (RRT) led by a PA reduce the rates of in-hospital cardiac arrest, unplanned transfers to the intensive care unit, and in-hospital mortality?

Bottom line A RRT led by a trained PA in a community hospital lowered rates of in-hospital cardiac arrest, unplanned ICU admissions, and in-hospital mortality. (Level of evidence = 1b)

Synopsis This 350-bed community hospital developed a rapid response system (RRS) using a team consisting of a PA leader, a critical care nurse, and a respiratory therapist. All PAs received intensive training in airway management and ICU skills. Those responsible for activating the RRS were staff nurses, physicians, PAs, and respiratory therapists who also had undergone RRS training. The rates of in-hospital cardiac arrest, unplanned ICU transfers, and in-hospital mortality using the RRS were compared with a 5-month period prior to implementation. Over the 13-month study period, the RRT was activated 344 times. The rate of cardiac arrest decreased during the study period from 7.6 to 3.0 arrests per 1,000 discharges per month, and unplanned ICU admissions were reduced from 45% to 29%. Overall in-hospital mortality decreased from 2.8% in the year prior to implementing the RRS to 2.3% after the RRS was in place. The RRT was also responsible for changing the resuscitation status in 35 patients. Although the hospital hired two additional PAs and dedicated one ICU nurse per shift to the team, a cost savings of approximately $5,000 per arrest was estimated, and they avoided 94 cardiac arrests per year. Although limited by lack of randomization, this study suggests that trained PAs can effectively serve in the role of RRT leader.

Dacey MJ, Mirza ER, Wilcox V, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076-2082.

Warfarin is better than aspirin in preventing strokes in older patients

Clinical question In patients older than 75 years with atrial fibrillation, is warfarin more effective than aspirin at preventing strokes?

Bottom line This study confirms that warfarin titrated to a target international normalized ratio (INR) of 2.0 to 3.0 is more effective than 75 mg aspirin in preventing strokes without significantly increasing the risk of bleeding complications. (Level of evidence = 1b–)

Synopsis This was an open-label trial with masked assessment of the outcomes. The patients, who were aged 75 years and older with atrial fibrillation or atrial flutter, were recruited from primary care practice. They were randomly assigned to receive aspirin (75 mg daily; n = 485) or warfarin (target INR = 2.0-3.0; n = 488). Patients with rheumatic heart disease, major hemorrhage within the previous 5 years, intracranial hemorrhage, proven peptic ulcer disease in the previous year, esophageal varices, allergy, terminal illness, recent surgery, or BP higher than 180/110 mm Hg were excluded. The researchers used an intention-to-treat analysis to assess the outcomes. The two groups were similar at baseline and were evaluated for an average of 2.7 years. The annual rate of strokes in the warfarin group was 1.6%, compared with 3.4% in the aspirin group (number needed to treat [NNT] = 56 per year; 95% CI, 40-294). The annual rate of total events (stroke, systemic emboli, intracranial hemorrhage including subdural hematoma) in each group was 1.8% and 3.8%, respectively (NNT = 51; 95% CI, 37-290). There was no significant difference between the two groups in the rate of extracranial hemorrhage (1.4% and 1.6%).

Mant J, Hobbs FD, Fletcher K, et al; for the BAFTA investigators; Midland Research Practices Network (MidReC). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007;370(9586):493-503.

Apolipoprotein levels are useful for evaluating CHD risk

Clinical question Are apolipoprotein levels and ratios useful in predicting the risk of coronary heart disease (CHD)?

Bottom line Measurement of the apolipoprotein B:apolipoprotein A-I ratio is comparable with, but does not offer any incremental utility to, standard lipid level ratios in predicting CHD. Routine measurement of apolipoprotein levels in clinical practice should be discouraged. (Level of evidence = 1b)

Synopsis As part of the Framingham Offspring Study, these investigators prospectively followed 3,322 white adults (53% female), aged 30 to 74 years, initially attending an examination cycle from 1987 to 1991. Baseline evaluation included measuring standard lipid levels (total cholesterol, HDL cholesterol, and LDL cholesterol), as well as non-HDL cholesterol, apolipoprotein A-I, and apolipoprotein B. None of the participants had cardiovascular disease at the beginning of the study. Three individuals assessed outcomes after review of hospital and physician office visit records; the authors do not specifically state if they were masked to baseline lipid levels. After a median of 15 years of follow-up, 291 subjects (198 men) developed CHD. Using multivariate prediction models adjusting for nonlipid risk factors, the apolipoprotein B:apolipoprotein A-I ratio was comparable with, without any incremental utility to, other standard lipid level ratios (eg, total cholesterol:HDL cholesterol ratio) in predicting CHD.

Ingelsson E, Schaefer EJ, Contois JH, et al. Clinical utility of different lipid measures for prediction of coronary heart disease in men and women. JAMA. 2007;298(7):776-785.

Clinical rule diagnoses PCOS more accurately

Clinical question What are the key signs and symptoms for the diagnosis of polycystic ovarian syndrome (PCOS)?

Bottom line A simple questionnaire completed by patients before they see the physician can assist in the diagnosis of PCOS. It is limited by the fact that it has only been validated in a referral setting. (Level of evidence = 1a)

Synopsis These authors recruited patients referred to an endocrinology clinic for evaluation. Patients completed a detailed questionnaire, and then were evaluated by an endocrinologist who made the final diagnosis of PCOS using standard National Institutes of Health (NIH) criteria. Fifty patients had PCOS, 50 did not. The best predictors of PCOS were identified, and the survey was then applied prospectively to a second group of 117 patients, 41 of whom had PCOS using the NIH criteria. The four best predictors were: (1) average duration of menstrual cycle greater than 34 days or totally variable; (2) three or more sites of dark, coarse hair; (3) obesity between ages 16 years and 40 years; and (4) no history of galactorrhea outside of pregnancy or recent childbirth. In the validation cohort, patients with two or more factors were likely to have PCOS (positive likelihood ratio = 13), whereas those with fewer than two factors were unlikely to have the syndrome (negative likelihood ratio = 0.16).

Pedersen SD, Brar S, Faris P, Corenblum B. Polycystic ovary syndrome: validated questionnaire for use in diagnosis. Can Fam Physician. 2007;53(6):1042-1047, 1041.

Pregnancy outcomes are similar after medical and surgical abortions

Clinical question What are the long-term health consequences of medical abortion?

Bottom line Subsequent pregnancy outcomes after medical abortion using prostaglandins are similar to the outcomes after surgical abortion. (Level of evidence = 2b)

Synopsis These researchers used a Danish registry that tracked all women who had an elective abortion for nonmedical reasons. They identified women who had a medical abortion using mifepristone, misoprostol, or other prostaglandins between 1999 and 2004. These data were linked to other registries to determine the outcome of future pregnancies, ectopic pregnancies, and other potential complications. Data from a separate cohort study were compared with the registry data and the researchers found excellent agreement. A total of 30,349 women had an abortion for nonmedical reasons, of whom 11,682 had 11,814 pregnancies (women whose abortion was induced after 9 weeks or who had missing data were excluded). In that group, 2,710 had a medical abortion and 9,104 had a surgical abortion. The incidence of ectopic pregnancy was the same in both groups (2.4% vs 2.3%). There also was no difference in the subsequent risks of live birth, spontaneous abortion, mean gestational age, preterm birth, birth weight, and stillbirth between the medical and surgical abortion groups. There was a trend favoring medical abortion with regard to preterm birth and low birth weight.

Virk J, Zhang J, Olsen J. Medical abortion and the risk of subsequent adverse pregnancy outcomes. N Engl J Med. 2007; 357(7):648-653.

Bariatric surgery reduces all-cause mortality in morbidly obese

Clinical question Does bariatric surgery reduce all-cause mortality?

Bottom line This nonrandomized controlled trial showed that bariatric surgery results in sustained weight loss of 14% to 25% after 10 years and also reduces all-cause mortality. (Level of evidence = 2b)

Synopsis This study reports 10-year outcomes for the largest prospective study of bariatric surgery. This is not a randomized controlled trial—patients were recruited from the general public, and if they chose surgery, a matching control patient was selected from the group that refused surgery. Case patients and control patients were matched on 18 factors, including age, body mass index (BMI), smoking status, comorbidities, and body measurements. All men had a BMI of at least 34 kg/m² and all women had a BMI of at least 38 kg/m². Patients were recruited between 1987 and 2001, and were followed up for 4 to 18 years (mean = 10.9 years). There were statistical differences between groups on the matching variables, but these differences were small and not likely to be clinically important. Deaths were determined from the Swedish population and address registry, and emigrants were successfully tracked by contacting relatives and embassies around the world. In the surgery group, 376 had banding, 1,369 had vertical-banded gastroplasty (VBG), and 265 had gastric bypass. Initial weight loss differed by procedure: 20% for banding, 25% for VBG, and 32% for gastric bypass. After 10 years, patients had regained some of the weight but the weight gain stabilized at approximately 8 years. Weight loss at 10 years was 14% for banding, 16% for VBG, and 25% for gastric bypass. All-cause mortality was lower in the bariatric surgery group (5.0% vs 6.3%; P = .04; number needed to treat to prevent 1 death at 10 years = 77). A multivariate analysis also showed that bariatric surgery was an independent predictor of lower all-cause mortality (hazard ratio = 0.73; 95% CI, 0.56-0.95). The difference in death rates was largely due to fewer MIs and deaths due to cancer in the bariatric surgery group.

Sjöström L, Narbro K, Sjöström CD, et al; for the Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741-752.

Levels of evidence in Bottom line are explained at www.infopoems.com/levels.html.