Cocaine is a consistent contributor to overdose deaths, especially among blacks

1. Cocaine is a consistent contributor to overdose deaths, especially among blacks

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1812

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Drug overdose deaths due to cocaine occur in the non-Hispanic black population at a similar rate to heroin and prescription opioid-related deaths in the non-Hispanic white population. While strategies to address prescription opioid and heroin overdoses remain critical for all racial/ethnic groups, prevention efforts focused on reducing cocaine-related deaths among the non-Hispanic black population are also needed. The findings of a brief research report are published in Annals of Internal Medicine.

Rates of drug overdose deaths increased by 5.5 percent per year between 1999 and 2015, with most of these deaths being attributed to opioid use among non-Hispanic white persons. However, increases in rates of drug overdose deaths were also recently reported for non-Hispanic black and Hispanic persons. Whether these deaths were due to opioids or other drugs has been unclear.

Researchers at the National Institute on Drug Abuse and the National Cancer Institute, both part of the National Institutes of Health, studied complete U.S. death certificate data between 2000 and 2015 to compare trends in rates and types of drug overdose deaths among non-Hispanic black and Hispanic persons and non-Hispanic white persons. They found that drug overdose deaths were a significant problem for non-Hispanic black and non-Hispanic white persons and a rarer but increasing problem among Hispanic persons. Cocaine-related overdose deaths in non-Hispanic black persons were on par with heroin- and prescription opioid-related deaths in non-Hispanic white women and men and was also an important contributor to deaths in Hispanic and non-Hispanic white persons.

Media contacts: For an embargoed PDF, please contact Cara Graeff. For more information or interview requests, contact the NIDA press office at media@nida.nih.gov or 301-443-6245.

2. New ACC/AHA hypertension guidelines may lack clarity, especially with regard to younger patients

Abstract: http://annals.org/aim/article/doi/10.7326/M17-3103

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New 2017 hypertension guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) may lack clarity, especially with regard to younger patients. A commentary from the Hypertension Division, Perelman School of Medicine, University of Pennsylvania is published in Annals of Internal Medicine.

The ACC/AHA guidelines stand out among the proliferation of hypertension guidelines because of their size and scope - 481 pages, 106 recommendations, 23 tables, and 11 figures representing countless hours of systematic literature review. With a lower diagnosis threshold of >/= 130/80 mmHg, the population-wide burden of hypertension will increase dramatically.

For patients under the age of 45, the prevalence of hypertension will triple for men and nearly double for women. However, these low-risk patients are not well-represented in existing trials of aggressive blood pressure lowering and the new recommendations lack clear guidance on how to treat them in specific situations.

According to the editorialists, the potential benefits of any guidelines must be considered along with their consequences, as guidelines are frequently used to inform policy and insurance reimbursement and may impact the physician-patient relationship. The most valuable conclusion clinicians can convey to their patients is that a guideline can never serve as a substitute for clinical judgment.

Media contacts: For an embargoed PDF, please contact Cara Graeff. To speak with the lead author, Jordana B. Cohen, MD, MSCE, please contact Abbey Anderson at abbey.anderson@uphs.upenn.edu.

3. DNA sequencing may inform diagnosis and management of kidney disease

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1319

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Whole-exome sequencing - a technique used to analyze DNA from the protein-coding portion of the genome - was found to be useful in identifying the genetic cause of kidney disease and informing treatment during a pilot study. These findings suggest that DNA sequencing could become part of the routine diagnostic workup for patients with chronic kidney disease (CKD), potentially replacing time-consuming clinical tests. The findings are published in Annals of Internal Medicine.

An estimated 14 percent of people in the United States have CKD, and between 10 and 25 percent of these individuals have a family history of kidney problems. Diagnosis typically relies on clinical tests. Even with a kidney biopsy, it can be difficult to identify different subtypes of the disease. As a result, the precise cause of kidney failure often remains unknown.

Researchers from Columbia University Medical Center performed whole exome sequencing in 92 adults with kidney disease to determine its utility. More than half of the participants had a family history of kidney problems. Most had been given a clinical diagnosis, but 16 individuals did not know the cause of their disease. DNA sequencing yielded a diagnosis in 22 of the participants, encompassing 13 different genetic disorders syndromes. In 13 individuals, including 9 in whom the cause of kidney failure was unknown, the genetic data either explained the original clinical diagnosis or prompted frank reclassification of the patient's disease. The researchers also identified three patients who harbored a mutation in a gene not previously associated with kidney failure, thereby defining a new genetic cause of kidney disease.

The authors conclude that whole exome sequencing may offer real clinical value in diagnosing and managing patients with kidney disease.

Media contacts: For an embargoed PDF, please contact Angela Collom. To interview the lead author, Ali Gharavi, MD, please contact Helen Garvey at hbg3@cumc.columbia.edu or 917-514-1317.

4. More than one in six patients readmitted to the hospital within 30 days of revascularization for peripheral arterial disease

Readmissions primarily related to procedural complications and patient characteristics, whereas differences in hospital quality had only a modest impact

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1058

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More than one in six patients is readmitted to the hospital within 30 days of a revascularization procedure for peripheral arterial disease (PAD). Procedure- and patient-related factors were the most common reasons for rehospitalization, whereas variations in hospital quality had only a modest influence on the need for readmission. Findings from a nationwide cohort study are published in Annals of Internal Medicine.

More than 200 million persons worldwide are affected by peripheral arterial disease (PAD). These patients typically are older, have a high burden of comorbidities, and have lower projected life expectancy. Although surgical and endovascular revascularization procedures are shown to improve outcomes in these patients, little is known regarding the need for readmission following these procedures. Understanding the national burden of rehospitalization risk among recently revascularized PAD patients is of importance in the context of the success of the Centers for Medicare & Medicaid Services' (CMS) Hospital Readmissions Reduction Program (HRRP), which financially penalizes hospitals on the basis of higher-than-predicted 30-day readmission rates for select clinical conditions. Although the HRRP does not currently include PAD revascularization procedures, this program has considered expanding to include such treatments, and understanding the reasons for readmission can assist in determining whether interventions such as the HRRP may reduce these events.

Researchers from Beth Israel Deaconess Medical Center used a national readmissions database to determine rates, causes, and associated costs of nonelective 30-day readmissions among patients who underwent in-hospital PAD revascularization. They also standardized rates of readmission by patient characteristics for each institution in order to understand whether readmission risk varied between hospitals, a marker of hospital quality. The investigators found that more than 17 percent of patients were readmitted to the hospital within 30 days. Readmissions were associated with high mortality risk and costs. Procedural complications were the most frequent cause of rehospitalization, particularly among patients who underwent surgical revascularization. After standardization for hospital case mix, there was only modest variation in readmission rates between institutions, suggesting that patient characteristics may be stronger drivers of readmission than differences in hospital quality. The authors conclude that clinicians need to recognize the special needs of the PAD patient population and that future investigation should focus on the development and implementation of programs to help better manage these patients outside the hospital.

Media contacts: For an embargoed PDF, please contact Cara Graeff. For more information or to interview the lead author, Robert Yeh, MD, please contact Teresa M. Herbert at therbert@bidmc.harvard.edu or 617-667-7305.

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