Highlights for Monday, May 2

2016-05-02

We are starting Monday with 3 publications chosen as suggested reading by McMaster editors.

Prognosis and management in patients with TIA or minor stroke

Amarenco P, Lavallée PC, Labreuche J, et al; TIAregistry.org Investigators. One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke. N Engl J Med. 2016 Apr 21;374(16):1533-42. doi: 10.1056/NEJMoa1412981. PubMed PMID: 27096581.

In this cohort study, over 4,000 patients who suffered a transient ischemic attack (TIA) or minor stroke within previous 7 days and who were managed in systems dedicated to urgent evaluation were followed for 1 year. About three-quarters of patients were seen by a stroke specialist within 24 hours of symptom onset and were admitted to the hospital for an average of 4 days. The study run from 2009 to 2011 and provided information on such issues as patient prognosis and management.

The risk of stroke (re)occurrence was 1.5% at day 2, 2.1% at day 7, 2.8% at day 30, and 5.1% at 1 year (about half of what was reported in the past). A higher risk was associated with an age over 60 years, a blood pressure level of 140/90 mm Hg or higher, the presence of unilateral weakness or speech disturbance, diabetes mellitus, and duration of symptoms over 60 minutes.

At entry to the study, about 70% of patients had history of hypertension, and a similar proportion had hyperlipidemia. Diabetes was present in 20% of patients. Five percent of patients had a new diagnosis of atrial fibrillation, in addition to about 10% who had had it before. A carotid stenosis of over 50% was found in 15% of patients, and about 25% of them underwent revascularization prior to discharge.

At discharge, 70% of patients were treated with at least 1 antihypertensive drug and a similar proportion with a lipid-lowering medication (mostly statin). Over 90% of patients were on an antiplatelet drug (two-thirds received acetylsalicylic acid) and 17% were anticoagulated.

Diabetes medications: monotherapy or metformin-based combination therapy for type 2 diabetes

Maruthur NM, Tseng E, Hutfless S, et al. Diabetes Medications as Monotherapy or Metformin-Based Combination Therapy for Type 2 Diabetes: A Systematic Review and Meta-analysis. Ann Intern Med. 2016 Apr 19. doi: 10.7326/M15-2650. [Epub ahead of print] PubMed PMID: 27088241.

In this systematic review, the authors compared different medications used as monotherapy or part of metformin-based combination treatment for type 2 diabetes mellitus.

The authors observed that metformin was associated with reduced cardiovascular mortality in comparison to sulfonylureas. Reduction in the hemoglobin A1c level was similar across different drugs, except for the smaller effect of dipeptidyl peptidase-4 (DPP-4) inhibitors. Patients’ body weight was increased with the use of insulin and sulfonylureas but maintained or decreased with the use of metformin, DPP-4 inhibitors, glucagon-like peptide-1 (GLP-1) receptor antagonists, and sodium-glucose cotransporter 2 (SGLT-2) inhibitors.

The effect of adding an additional drug to metformin was similar to that achieved with that drug used as monotherapy.

A simple outcome score in patients with ARDS

J, Ambrós A, Soler JA, et al; Stratification and Outcome of Acute Respiratory Distress Syndrome (STANDARDS) Network. Age, PaO2/FIO2, and Plateau Pressure Score: A Proposal for a Simple Outcome Score in Patients With the Acute Respiratory Distress Syndrome. Crit Care Med. 2016 Mar 31. [Epub ahead of print] PubMed PMID: 27035239.

An ICU-based study examined over 600 patients with moderate to severe acute respiratory distress syndrome (ARDS). It classified patients according to age (<47 years, 1 point; 47-66 years, 2 points; >66 years, 3 points), the PaO2/FiO2 ratio (>158, 1 point; 105-158, 2 points; <105, 3 points), and plateau pressure (<27 cm H2O, 1 point; 27-30 cm H2O, 2 points; >30 cm H2O, 3 points).

The overall hospital mortality was over 40%, with major differences depending on the above score (range, 3-9 points). One-month mortality in those with scores 3-4 was less than 10%; in those with 5-6 points, 30%; and in those with 7-8 points, 70%. Respective mortality at 2 months ranged from 15% through 40% to 80%. Those observations may help clinicians and patients as well as families in prognostication and decision-making.

In this observational study, a lower tidal volume (<6.7 mL/kg of predicted weight vs >7.8 mL/kg) was associated with lower mortality (42% vs 54%), as was ventilation with a higher respiratory rate (RR) (38% mortality among those with a RR >26 vs 53% among those with a RR <21), providing additional support for lung-protective ventilation.

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