Mr. Susman is a freelance medical writer based in Florida, USA. He travels worldwide to report from medical conferences, writing regularly for wire services, internet websites, and medical journals such as the Journal of the National Cancer Institute and AIDS.
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Despite never having been recommended in evidence-based guidelines, about 1 in 8 patients who hobble into an emergency department with a sprained ankle limp out with a prescription for opioids – a situation that may be fueling narcotic epidemics, researchers reported in a brief research report in the journal, Annals of Internal Medicine.
Fred Finney, MD, an orthopedic surgeon at the University of Michigan Hospitals and Health Center, Ann Arbor, and colleagues, determined that of 591,663 patients who were treated for ankle sprains from 2008 to 2016, practitioners prescribed opioids for pain relief to 70,692 individuals (11.9 percent).
Drilling deeper into the Optum Clinformatics Data Mart, Dr. Finney found that of 454,813 of these ankle sprain patients who were naive to opioids, 37,603 of these patients’ filled opioid prescriptions within 7 days of the trip to the emergency room (8.3 percent).
In addition, the researchers found that 91 days to 180 days, 8.4 percent of the patients in the study re-filled an opioid prescription.
“The opioid epidemic is a result of over-prescribing by practitioners and misuse and diversion of opioids,” Dr. Finney noted in his research.
“Evidence-based guidelines for ankle sprains have never recommended opioid therapy,” he reported. “However, a recent study showed that approximately 25 percent of persons with ankle sprains presenting to hospital emergency departments received an opioid prescription. In the current study, 11.9 percent of patients diagnosed with an ankle sprain filled an opioid prescription within 7 days of diagnosis. Among opioidnaive patients, 8.4 percent of those who filled an initial opioid prescription continued to use opioids more than 90 days after diagnosis.”
The researchers noted that evidence-based treatment guidelines include cryotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and functional support and exercise. “Although the role of opioids in the treatment of ankle sprains has been discussed, these drugs have never been included in treatment recommendations.” Dr. Finney reported.
He urged his colleagues to take the findings to heart. “This study identified a large cohort of opioid-naive patients who received nonsurgical treatment of ankle sprain and showed a relatively high rate of opioid prescription and persistent use,” he wrote. “It is imperative that clinicians identify which injuries are appropriate for opioid therapy and develop and adhere to appropriate evidence-based prescribing guidelines.”
In another article in the journals, researchers found that pneumonia patients are frequently over-prescribed antibiotics on hospital discharge despite evidence that longer-course therapy does not reduce mortality or hospital readmission.
In a study that encompassed nearly 6,500 patients at 43 Michigan hospitals, two-thirds of the patients were prescribed antibiotics that exceeded the shortest time to effective treatment for their infection, reported Valerie Vaughan, MD, assistant professor of medicine at the University of Michigan’s Institute for Healthcare Policy & Innovation, Ann Arbor.
“Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection,” Dr. Vaughan reported. “Each excess day of treatment was associated with a 5 percent increase in the odds of antibiotic-associated adverse events reported by patients after discharge. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes.”
More than 93 percent of patients were prescribed excessive antibiotics at hospital discharge, the researchers reported. The researchers reported that patients with community acquired pneumonia were expected to have a treatment duration of at least 5 days, with longer courses expected only if time to clinical stability was longer. Patients with healthcare acquired pneumonia, Staphylococcus aureus, or a non-fermenting Gram-negative bacillus such as Pseudomonas aeruginosa were expected to have a treatment duration of at least 7 days.
Dr. Vaughan and colleagues in the Michigan Hospital Medicine Safety Consortium suggested in their paper that long courses of antibiotics are prescribed for pneumonia patients because of concerns that shorter courses could result in relapse or disease progression – even though recent clinical trials have demonstrated that shorter courses of treatment are safe and equally effective.
That notion was borne out in the study.
–Mortality after 30 days following discharge was 1.9 percent among the 2,090 patients given appropriate antibiotic therapy compared with a rate of 2 percent among the 4.391 patients who were given longer than necessary courses of antibiotic therapy (adjusted P=0.60).
–The readmission rate for patients given short-course antibiotics was 14.1 percent in the 30-day period, compared to 11.3 percent of the patients who were given extended antibiotic prescriptions (adjusted (P=0.92).
–The emergency department visits for patients given short-course antibiotic therapy was 11.4 percent compared with 10.9 percent for patients who received extended antibiotic prescriptions (adjusted P=0.166).
–Patient reported adverse events were noted by 2.3 percent of the patients who received appropriate duration antibiotic therapy compared with 4.6 percent of the patients with extended duration therapy (adjusted P=0.001).
–Overall adverse events were observed among 23.9 percent of the patients given appropriate antibiotic therapy and by 20.4 percent of the patients on extended therapy (adjusted P=0.40).
“Our findings have implications for policy and research efforts,” Dr. Vaughan and colleagues suggested. “First, we found that excess antibiotic treatment duration was not associated with improved patient outcomes, which should increase comfort with prescribing shorter-course treatment. Specifically, the next iteration of [pneumonia] guidelines should explicitly recommend (rather than imply) that providers prescribe the shortest effective duration, similar to recommendations made in the hospital-acquired and ventilator-associated pneumonia guidelines.
“We also found that excess antibiotic prescribing continues despite national efforts to contain it. Future improvement may be more effective by focusing on discharge stewardship, including antibiotic documentation at discharge, and on patients with high rates of overuse, such as those with community acquired pneumonia.”
Some help from supplements
A meta-analysis of studies that scrutinized multiple studies of dietary interventions and use of nutritional supplements suggest that a low-salt diet, the use of fish oils and supplementation with folate may decrease the risks of cardiovascular disease, researchers also reported in the journal.
Although the level of evidence to support the findings was considered to be low to moderate, Safi Khan, MD, a hospitalist in internal medicine at J.W. Ruby Memorial Hospital/West Virginia University, Morgantown, and colleagues found that: reduced salt intake decreased the risk for all-cause mortality in normotensive participants (P=0.01) and cardiovascular mortality in hypertensive participants (P=0.04);.
Omega-3 long-chain polyunsaturated fatty acid was associated with reduced risk for myocardial infarction (P=0.03) and coronary heart disease (P=0.01); and folic acid was associated with lower risk for stroke (P=0.02).
On the other hand, Dr. Khan reported that intake of calcium plus vitamin D increased the risk for stroke (P=0.01]. “Other nutritional supplements, such as vitamin B6, vitamin A, multivitamins, antioxidants, and iron and dietary interventions, such as reduced fat intake, had no significant effect on mortality or cardiovascular disease outcomes,” he reported.
The analysis included 9 articles, 105 meta-analyses, 24 interventions, 277 randomized clinical trials and included 992,129 participants, the researchers stated.
“In summary, this overview of the efficacy of nutritional supplements and dietary interventions on mortality and cardiovascular outcomes found evidence that supports reduced salt intake, omega-3 intake, and folate supplementation for CVD risk reduction,” Dr. Khan suggested. “Conversely, combined calcium plus vitamin D showed an increased risk for stroke. Other vitamins, minerals, dietary supplements, and dietary interventions were not associated with survival or cardiovascular benefits.
“Overall, these findings are limited by suboptimal quality of the evidence. This study can help those who create professional cardiovascular and dietary guidelines modify their recommendations, provide the evidence base for clinicians to discuss dietary supplements with their patients, and guide new studies to fulfill the evidence gap.”