Big drop in ICU sepsis deaths
MORTALITY from severe sepsis, with or without shock, in Australian and New Zealand intensive care units (ICUs) has decreased steadily since 2000, from 35.0% of cases then to 18.4% in 2012, according to research involving more than one million patients published in JAMA. The researchers found that the decrease in sepsis-related mortality occurred even after adjustments for illness severity, centre and regional effects, hospital size, baseline risk of becoming septic and other key variables. “Of 1 037 115 patients treated in 171 ICUs during the study period, 101 064 (9.7%) had severe sepsis, and 15 471 (15.3%) [of these] were of younger age (≤44 years)”, the researchers wrote. “In 2012 and in the absence of comorbidities and older age, the mortality rate of severe sepsis or septic shock in Australia and New Zealand was 4.6%.” During the same study period the researchers found an annual increase in rates of discharge to home, which was significantly greater in patients with severe sepsis compared with all other diagnoses. There was also an annual increase in the rate of patients discharged to rehabilitation facilities but this was significantly less in severe sepsis compared with all other diagnoses. “It is unclear whether any improvements in diagnostic procedures, earlier and broader-spectrum antibiotic treatment, or more aggressive supportive therapy according to severity of the disease contributed to this change”, the researchers wrote. “The observation that an equivalent improvement occurred in nonseptic patients supports the view that overall changes in ICU practice rather than in the management of sepsis explain most of our findings.” An accompanying editorial said that although the reduction in sepsis-related mortality was welcome, “it makes the need for data on morbidity and longer-term outcomes all the more pressing”.
Guidelines could make millions more eligible for statins
RESEARCHERS have estimated that the number of US adults eligible for statin therapy could increase by almost 13 million under new guidelines for the management of cholesterol. The research, published in the New England Journal of Medicine, found the increase would be seen mostly among older adults without cardiovascular disease. The research was based on the 2013 guideline on the treatment of blood cholesterol from the American College of Cardiology and the American Heart Association and used data from National Health and Nutrition Examination Surveys (NHANES) to estimate the number and summarise the risk profile of people who would, under the guidelines, be recommended for statin therapy compared with the guidelines of the Third Adult Treatment Panel of the National Cholesterol Education Program. The results based on 3773 participants of NHANES were extrapolated to 115.4 million US adults aged 40–75 years. The researchers wrote that the big increase in the number of people eligible for statin therapy would be mainly due to more adults being classified solely on the basis of their 10-year risk of a cardiovascular event. “These new treatment recommendations have a larger effect in the older age group (60 to 75 years) than in the younger age group (40 to 59 years)”, they wrote. “Although up to 30% of adults in the younger age group without cardiovascular disease would be eligible for statin therapy for primary prevention, more than 77% of those in the older age group would be eligible.” The researchers did acknowledge several limitations in the study.
Too much imaging for headache
NEUROIMAGING is ordered in about 12% of outpatient visits for headache in the US and costs nearly $1 billion annually, according to a research letter published in JAMA Internal Medicine. The researchers analysed all headache visits for patients 18 years or older from the National Ambulatory Medical Care Survey, a nationally representative survey that characterises all outpatient office-based care in the US. They found most headache-associated visits were to primary care physicians (54.8%), followed by neurologists (20%), other specialists (12.9%) and non-primary care generalists (12.4%). Of 51.1 million headache visits over 4 years, including 25.4 million for migraine, neuroimaging was carried out in 12.4% of all visits and 9.8% of migraine visits. The researchers said multiple guidelines recommended against routine neuroimaging in patients with headaches as serious intracranial conditions were an uncommon cause, so the magnitude of neuroimaging suggested considerable overuse. “Perhaps guidelines have not curbed utilization because patients, as opposed to health care providers, may be the primary drivers of utilization”, they wrote. “If so, efforts such as the Choosing Wisely campaign, which seeks to empower patients with knowledge regarding unwarranted testing, may be more effective than guidelines alone.” They said optimising headache neuroimaging practices “should be a major national priority”.
Hemicraniectomy increases stroke survival
EARLY hemicraniectomy in older patients who have had a large ischaemic stroke with brain swelling significantly increased the probability of survival, although most survivors had substantial disability, according to research published in the New England Journal of Medicine. The trial, which was stopped for efficacy reasons after reductions in deaths and severe disability at 6 months had become significant, showed that the treatment effect remained stable after 12 months of follow-up. The research involved 112 patients aged 61 years or older with malignant (space occupying) middle cerebral artery infarction who were randomly assigned within 48 hours of the onset of symptoms to either conservative treatment in the intensive care unit (control) or hemicraniectomy (surgery). In the surgery group 38% survived without severe disability compared with 18% in the control group, although there was much lower mortality in the surgery group (33% v 70%). In the surgery group moderately severe disability affected 32% of survivors compared with 15% in the control group, and severe disability affected 28% and 13%, respectively. An accompanying editorial said that hemicraniectomy “tests the fortitude of patients and their families who, in the moment, must make a decision about survival”. The research provided numerical values for the likelihood of severe disability which could be discussed with the patient or a surrogate decisionmaker. “However, the choice must be made early and quickly, just as the brain begins to swell …”, the editorial said.
“Dramatic” reduction in colorectal cancer deaths
A COMPREHENSIVE overview of current US colorectal cancer (CRC) statistics, published in CA: A Cancer Journal for Clinicians, has found CRC incidence rates have decreased by about 3% per year in the past decade (2001–2010), with the largest drops in those aged 65 years and older. The researchers also found substantial variation in tumour location by age, eg, 26% of colorectal cancers in women aged younger than 50 years occurred in the proximal colon, compared with 56% in women aged 80 years and older. The researchers estimated numbers of expected new cases and deaths in 2014, finding 71 830 men and 65 000 women would be diagnosed with colorectal cancer and 26 270 men and 24 040 women would die of the disease. More than a third of all deaths (29% in men and 43% in women) would occur in those aged 80 years and older. The researchers said that although there had been dramatic progress in reducing colorectal cancer incidence and mortality rates in the past decade, striking racial and socioeconomic disparities remained, for example, “incidence and death rates are highest in blacks and lowest in Asians/Pacific Islanders”. “Further reductions in the burden of colorectal cancer will require comprehensive implementation of known cancer control interventions across the nation and to all segments of the population, with a particular emphasis on those individuals who are economically disenfranchised”, they wrote.
No benefit from androgen-deprivation therapy
A RETROSPECTIVE cohort study, published in the Journal of Clinical Oncology, has found no mortality benefit from primary androgen-deprivation therapy (PADT) for most men with clinically localised prostate cancer who are not being treated with curative intent therapy. The research included 15 170 men newly diagnosed with clinically localised prostate cancer between 1995 and 2008 and not treated with curative intent who were able to be followed up to the end of 2010. The primary outcomes were all-cause and prostate cancer-specific mortality. The researchers found that 23% of the men had PADT initiated within the first year after diagnosis. Men with higher PSA levels were more likely than not to receive PADT (42% v 10% for PSA > 20) as were those with higher Gleason scores (26% v 7% for Gleason score ≥ 8). There were 4921 deaths in the cohort — of which 1049 related to prostate cancer. Compared with those not receiving PADT, men who received PADT experienced a nearly twofold increase in all-cause mortality (49% v 28%) and a nearly threefold increase in prostate cancer-specific mortality (13% v 5%), without adjustments for other variables. PADT was associated with decreased all-cause mortality only among the subgroup of men with the highest risk of cancer progression (PSA < 20 ng/mL, or Gleason score 8 to > 10, or tumour stage T2c-T3a). “We found no significant difference in the risk of all-cause mortality, prostate cancer-specific mortality, cancer mortality, or cardiovascular mortality between the PADT and no-PADT groups”, the researchers wrote. “Our main conclusion is that PADT does not seem to be an effective strategy as an alternative to no therapy among men diagnosed with clinically localized PCa who are not receiving curative-intent therapy. The risks of serious adverse events and the high costs associated with its use mitigate against any clinical or policy rationale for PADT use in these men.” However the authors included a caution about the limitations of their study design saying “the most significant concern in treatment outcome studies is the possibility of residual confounding, particularly for factors that have implications for treatment choice and are related to the outcome”.