Antiplatelet strategies in acute coronary syndromes: design and methodology of an international collaborative network meta-analysis of randomized controlled trials.

INTRODUCTION: The optimal choice of oral P2Y12 receptor inhibitors has the potential to significantly influence outcomes. We seek to compare the safety and efficacy of the three most commonly used oral P2Y12 receptor inhibitors (clopidogrel, prasugrel, and ticagrelor) in acute coronary syndromes (ACS) via a comprehensive systematic review and network meta-analysis. EVIDENCE ACQUISITION: In line with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines, we performed a comprehensive search for RCTs which compared cardiovascular and hemorrhagic outcomes after use of at least two of the distinct oral P2Y12 receptor inhibitors (i.e. clopidogrel, prasugrel, and ticagrelor). A search strategy has been designed to systematically search multiple databases, including MEDLINE with PubMed interface, The Cochrane Central Register of Controlled Trials, and Embase. In addition, key inclusion criteria will be trial size of at least 100 patients and at least 1 month of follow-up time. Several prespecified subgroups will be explored, including Asian patients, patients presenting with ST-elevation myocardial infarction, patients of advanced age, and others. EVIDENCE SYNTHESIS: Exploratory frequentist pairwise meta-analyses will be based primarily on a random-effects method, relying on relative risks (RR) for short-term outcomes and incidence rate ratios (IRR) for long-term outcomes. Inferential frequentist network meta-analysis will be based primarily on a random-effects method, relying on RR and IRR as specified above. Results will be reported as point summary of effect, 95% CI, and P values for effect, and graphically represented using forest plots. CONCLUSIONS: An international collaborative network meta-analysis has begun to comprehensively analyze the safety and efficacy of prasugrel, ticagrelor and clopidogrel, each on a background of aspirin, for management of patients with ACS. It is our hope that the rigor and breadth of the undertaking described herein will provide novel insights that will inform optimal patient care for patients with ACS treated conservatively, or undergoing revascularization.

Rule Out Acute Kidney Injury in the Emergency Department With a Urinary Dipstick.

INTRODUCTION: The identification of acute injury of the kidney relies on serum creatinine (SCr), a functional marker with poor temporal resolution as well as limited sensitivity and specificity for cellular injury. In contrast, urinary biomarkers of kidney injury have the potential to detect cellular stress and damage in real time. METHODS: To detect the response of the kidney to injury, we have tested a lateral flow dipstick that measures a urinary protein called neutrophil gelatinase-associated lipocalin (NGAL). Analysis of urine was performed in a prospective cohort of 479 patients (final cohort N = 426) entering an emergency department in New York City and subsequently admitted for inpatient care. RESULTS: Colorimetric development had high interrater reliability (88% concordance rate) and correlated with traditional enzyme-linked immunosorbent assay (ELISA) measurements (ρ = 0.732, P < .0001). Of the 14% of the cohort who met Acute Kidney Injury Network (AKIN) SCr criteria for acute kidney injury (AKI), 67% demonstrated transient (<2 days) and 33% demonstrated sustained (>2 days) elevation of SCr. Comparing the outcomes of patients with sustained versus transient or undetectable changes in SCr revealed that the urinary NGAL (uNGAL) dipstick had high specificity and negative predictive value (NPV) (high- vs. low-intermediate readings, sensitivity = 0.55, specificity = 0.91, positive predictive value = 0.24, NPV = 0.97, χ2 = 20.39, P < 0.001). CONCLUSION: We show that the introduction of a bedside uNGAL dipstick permits accurate triage by identifying individuals who do not have tubular injury. In an era of shortening length of stay and rapid decisions based on isolated SCr measurements, real-time exclusion of kidney injury by a dipstick will be particularly useful to overcome the retrospective, insensitive, and nonspecific attributes of SCr.

Pharmacological Agents Targeting Thromboinflammation in COVID-19: Review and Implications for Future Research.

Coronavirus disease 2019 (COVID-19), currently a worldwide pandemic, is a viral illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The suspected contribution of thrombotic events to morbidity and mortality in COVID-19 patients has prompted a search for novel potential options for preventing COVID-19-associated thrombotic disease. In this article by the Global COVID-19 Thrombosis Collaborative Group, we describe novel dosing approaches for commonly used antithrombotic agents (especially heparin-based regimens) and the potential use of less widely used antithrombotic drugs in the absence of confirmed thrombosis. Although these therapies may have direct antithrombotic effects, other mechanisms of action, including anti-inflammatory or antiviral effects, have been postulated. Based on survey results from this group of authors, we suggest research priorities for specific agents and subgroups of patients with COVID-19. Further, we review other agents, including immunomodulators, that may have antithrombotic properties. It is our hope that the present document will encourage and stimulate future prospective studies and randomized trials to study the safety, efficacy, and optimal use of these agents for prevention or management of thrombosis in COVID-19.

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review.

Coronavirus disease-2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, because of excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, the authors review the current understanding of the pathogenesis, epidemiology, management, and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, of those with pre-existing thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.

Impact of Jahnigen/GEMSSTAR Scholarships on Careers of Recipients in Emergency Medicine and on Development of Geriatric Emergency Medicine.

BACKGROUND: The Jahnigen Career Development Awards program was launched in 2002 with private funding and transformed into the Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) program in 2011 through support from the National Institute on Aging and medical specialty professional societies. The Jahnigen/GEMSSTAR program has provided grants to early career physician-scientists from 10 surgical and related medical specialties to initiate and sustain research careers in the geriatric aspect of their discipline. From 2002 to 2016, there were 20 Jahnigen/GEMSSTAR recipients in emergency medicine (EM). The goal of this investigation was to examine the impact of Jahnigen/GEMSSTAR awards on careers of EM recipients and on development of academic geriatric EM. METHODS: We conducted an online survey of the 20 EM recipients from 2002 to 2016 and analyzed their academic productivity, research impact, career trajectory, and contributions to geriatric EM since receiving the award. RESULTS: All 20 Jahnigen/GEMSSTAR scholars completed the survey. Scholars have published a median of 33 peer-reviewed articles (interquartile range [IQR] = 10-97) since the award, with median annual publication rates of 4.5 (IQR = 1.6-7.0). All scholars had h-indices of 6 or more, with a median of 18 (IQR = 9-28). Jahnigen/GEMSSTAR scholars have served as principal investigator (PI) or co-PI on 126 grants since their award, with 90% having served as PI on at least one additional grant and 30% having received National Institutes of Health Career Development Awards. All scholars reported believing that the Jahnigen/GEMSSTAR was very helpful or helpful for career progress. Most (85%) reported ongoing contributions to geriatric EM in research, education, or administration. CONCLUSIONS: After the Jahnigen/GEMSSTAR award, EM scholars have been highly academically productive and successful, and the award has been instrumental in their career development. Awardees have been critical to the development of geriatric EM.

Surgical Guidelines for Perioperative Management of Older Adults: What Geriatricians Need to Know.

A multidisciplinary panel of experts representing surgery, anesthesia, and geriatrics recently published guidelines for surgeons on the optimal perioperative management of older adults, including recommendations on postoperative recovery and posthospital transitions of care. Geriatricians have an important role in the care for older adults in the preoperative period as older adults consider surgical options and prepare for surgical procedures, during the perioperative period as inpatient consultants, and in the postoperative period as older adults transition to rehabilitation facilities or to home. This article outlines the perioperative surgical guidelines and describes how they apply to the role of the geriatrician in the care of older adults during the perioperative period.

Comparison of stress experienced by family members of patients treated in hospital at home with that of those receiving traditional acute hospital care.

OBJECTIVES: To compare differences in the stress experienced by family members of patients cared for in a physician-led substitutive Hospital at Home (HaH) and those receiving traditional acute hospital care. DESIGN: Survey questionnaire completed as a component of a prospective, nonrandomized clinical trial of a substitutive HaH care model. SETTING: Three Medicare managed care health systems and a Veterans Affairs Medical Center. PARTICIPANTS: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. INTERVENTION: Treatment in a substitutive HaH model. MEASUREMENTS: Fifteen-question survey questionnaire asking family members whether they experienced a potentially stressful situation and, if so, whether stress was associated with the situation while the patient received care. RESULTS: The mean and median number of experiences, of a possible 15, that caused stress for family members of HaH patients was significantly lower than for family members of acute care hospital patients (mean +/- standard deviation 1.7 +/- 1.8 vs 4.3 +/- 3.1, P<.001; median 1 vs 4, P<.001). HaH care was associated with lower odds of developing mean levels of family member stress (adjusted odds ratio=0.12, 95% confidence interval=0.05-0.30). CONCLUSION: HaH is associated with lower levels of family member stress than traditional acute hospital care and does not appear to shift the burden of care from hospital staff to family members.

Satisfaction with hospital at home care.

OBJECTIVES: To examine differences in satisfaction with acute care between patients who received treatment in a physician-led substitutive Hospital at Home program and those who received usual acute hospital care. DESIGN: Survey questionnaire of participants in prospective, nonrandomized clinical trial. SETTING: Three Medicare-managed care health systems and a Department of Veterans Affairs Medical Center. PARTICIPANTS: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in Hospital at Home and 130 in the acute care hospital. INTERVENTION: Treatment in a Hospital at Home model of care that substitutes for treatment in an acute care hospital. MEASUREMENTS: A 40-question survey measuring nine domains of care for patients and a 37-question survey measuring eight domains of care for family members. RESULTS: A higher proportion of patients were satisfied with treatment in Hospital at Home than with the acute care hospital in eight of nine domains, and this difference was statistically different in four domains. Hospital at Home patients were more likely than acute hospital patients to be satisfied with their physician (adjusted odds ratio (AOR) = 3.84, 95% confidence interval (CI) = 1.32-11.19), comfort and convenience of care (AOR = 6.52, 95% CI = 1.97-21.56), admission processes (AOR = 5.90, 95% CI = 2.21-5.76), and the overall care experience (AOR = 2.98, 95% CI = 1.08-8.21). Family members of patients treated in Hospital at Home were also more likely to be satisfied with multiple domains of care. CONCLUSION: Hospital at Home care was associated with greater satisfaction than acute hospital inpatient care for patients and their family members. These findings support further dissemination of the Hospital at Home care model.

Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients.

BACKGROUND: Acutely ill older persons often experience adverse events when cared for in the acute care hospital. OBJECTIVE: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home. DESIGN: Prospective quasi-experiment. SETTING: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center. PARTICIPANTS: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. INTERVENTION: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital. MEASUREMENTS: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care. RESULTS: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001). LIMITATIONS: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences. CONCLUSIONS: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.

Geriatrics for residents in the surgical and medical specialties: implementation of curricula and training experiences.

In 1994, under the leadership of the late Dennis Jahnigen, the American Geriatrics Society, with support of the John A. Hartford Foundation, began a project to improve the amount and quality of geriatrics education that surgical and related medical specialty residents receive. The targeted disciplines initially were general surgery, emergency medicine, gynecology, orthopedic surgery, and urology and, later, anesthesiology, ophthalmology, otolaryngology, physical medicine and rehabilitation, and thoracic surgery. A key element of this project was to develop model programs within surgical and related specialty residency education. The Geriatrics Education for Specialty Residents (GESR) program has supported 29 residencies to pilot methods for integration of geriatrics within residency programs, encouraged and inspired development of curricular content, and helped to develop faculty leaders to support these efforts in the long term and at a national level. This paper describes the GESR program, the status of curriculum development, steps for other programs to use in developing a geriatrics education program, and some of the common barriers likely to be encountered during implementation along with solutions to those barriers.

Geriatrics and physical medicine and rehabilitation: common principles, complementary approaches, and 21st century demographics.

The demographic changes occurring in the United States transcend the capabilities of any specific medical specialty to provide optimum care for the elderly. This commentary discusses a statement of principles drafted by representatives of the American Academy of Physical Medicine and Rehabilitation who collaborated with members of 9 other medical and surgical specialties. In this commentary, we argue that geriatrics and physical medicine and rehabilitation (PM&R) share common principles and complementary approaches. We urge physiatrists and other rehabilitation professionals to address the needs of elderly patients and recommend that these principles be incorporated into PM&R practice.