Survivors of firearm injury carry long term physical and mental burdens that are poorly understood

1. Survivors of firearm injury carry long term physical and mental burdens that are poorly understood 

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0309  

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A timely research report evaluating firearm injury survivors has found that despite medical advancements that improve survival from firearm injuries, many survivors experience long-term post-traumatic stress disorder (PTSD) and poor physical quality of life. The report is published in Annals of Internal Medicine.  

Firearm injury is a public health crisis in the United States. Organizations including the American College of Physicians and Annals of Internal Medicine have called for the consideration of long-term consequences of firearm violence. Interpersonal firearm violence survivors report significantly worse physical health and functioning compared with the general population and other mechanisms of traumatic injury. Yet, there is limited work examining self-reported mental and physical health consequences of firearm violence for survivors acutely after injury, thwarting health care systems’ ability to comprehensively intervene. 

Researchers from Medical College of Wisconsin studied 87 survivors of firearm injury between 2014 to 2016 and 2017 to 2021 to describe the mental health symptoms and health-related quality of life of firearm injury survivors. Participants were evaluated at baseline and at 6 months after injury. The authors found that participants experienced chronic PTSD symptoms across time and worsened symptoms of depression, anxiety, and stress. Participants also reported poor health-related quality of life at both baseline and 6 months from injury, but their quality of life did not worsen during this period. According to the authors, this preliminary study highlights the need to better understand and manage the mental health consequences of firearm injury. They suggest that early screening and comprehensive care may improve outcomes in this at-risk population.  

Note: Annals of Internal Medicine offers a resource hub for firearms-related content to help internal medicine physicians address firearm injury and violence as a public health issue and to provide strategies to help keep patients and their loved ones safe. This article and others are available for free at https://www.acponline.org/firearms.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Sydney Timmer-Murillo, PhD, please contact the Medical College of Wisconsin media office at media@mcw.edu. 

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2. Screening all U.S. adults aged 35 and older for chronic kidney disease could be cost effective 

Chronic kidney disease currently affects 15% of U.S. adults 

Abstract: https://www.acpjournals.org/doi/10.7326/M22-3228   

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A cost-effectiveness analysis of screening for chronic kidney disease (CKD) has found that screening all adults in the United States starting at age 35 could be cost-effective for the quality of life-years (QALY) gained. The analysis is published in Annals of Internal Medicine.  

CKD is a common, costly cause of morbidity and mortality, affecting approximately 15 percent of U.S. adults. It is often a clinically silent disease until it progresses to advanced stages or kidney failure. Currently, Medicare spends $87 billion annually on care for CKD and an additional $37 billion for care of patients with kidney failure requiring kidney transplant therapy. The characteristics of disease progression and costs associated with late-stage kidney disease make screening for early-stage CKD a high priority.  

While experts have been unable to agree whether screening for early-stage CKD improves clinical outcomes, sodium-glucose cotransporter-2 (SGLT2) inhibitors are changing the discussion. Researchers from Stanford University conducted a cost-effectiveness analysis of adults aged 35 years and older who were screened for albuminuria with and without SGLT2 inhibitors to the current standard of care for CKD. The authors assessed costs, QALYs, and incremental cost-effectiveness ratios (ICERs). The authors found that screening U.S. adults once and adding SGLT2 inhibitors between ages 35 and 75 prevented dialysis or transplant in 398,000 people and screening every 10 years until age 75 years cost less than $100,000 per QALY gained. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Marika M. Cusick, MS, please email Beth Duff Brown at bethduff@stanford.edu. 

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3. Despite new decision rules, angiography still frequently used to diagnose low risk pulmonary embolism in the ED 

Findings are contrary to prior studies of CTPAs, raising questions about use in routine practice 

Abstract: https://www.acpjournals.org/doi/10.7326/M22-3116   

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An analysis of persons admitted to the emergency department (ED) for suspected pulmonary embolism (PE) and evaluated using computed tomographic pulmonary angiography (CTPA) has found that despite recent rules to limit its use, clinicians have instead increased the use of CPTA as well as increasing diagnoses of PEs and especially low-risk PEs. The analysis is published in Annals of Internal Medicine. 

The recommended diagnostic strategy for patients with suspected PE in the ED follows 3 steps: evaluation of clinical probability, followed if needed by D-dimer measurement, followed if positive by chest imaging including CTPA. The use of CTPA and subsequent diagnosis of PE have increased substantially since the 1990s, raising concerns about the risk of CTPA overuse and overdiagnosis of PE. Overdiagnosis is associated with complications including kidney injury, anaphylactic reaction, long-term complication from radiation exposure, and unnecessary anticoagulant treatment. Since 2010, several decision rules have been developed to reduce the need for chest imaging either by alleviating the need for D-dimer testing to rule out PE or by raising the D-dimer threshold for chest imaging. 

Researchers from Sorbonne Universite, Assistance Publique–Hôpitaux de Paris, and Royal London Hospital conducted an analysis of persons with CTPA performed for suspected PE in the ED in intervals between January 2015 and December 2019. The authors included 8970 CTPAs in their analysis. They observed that EDs were using CTPAs more often and more frequently diagnosing PE, including low-risk PE. The authors also observed an increase in ambulatory management and a lower proportion of intensive care unit admissions. The authors highlight that their findings do not suggest increasing overuse of CTPA, but instead suggest a trend towards more diagnosing of mild PEs.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Yonathan Freund, M.D., PhD, please email yonathan.freund@aphp.fr.  

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4. Amiodarone used with anticoagulant therapy associated with more bleeding-related hospitalizations compared with flecainide or sotalol 

Abstract: https://www.acpjournals.org/doi/10.7326/M22-3238   

URL goes live when the embargo lifts 

A cohort study of more than 90,000 older adults diagnosed with atrial fibrillation (Afib) who were treated with anticoagulants found that treatment with amiodarone during apixaban or rivaroxaban use was associated with greater risk for bleeding-related hospitalizations compared to flecainide or sotalol. The findings are published in Annals of Internal Medicine.  

Apixaban and rivaroxaban are the most prescribed anticoagulants to prevent ischemic strokes in patients with Afib. However, amiodarone, the most prescribed medication to maintain sinus rhythm in patients with Afib, inhibits apixaban and rivaroxaban elimination, possibly increasing anticoagulant-related risk for bleeding.   

Researchers from Vanderbilt University School of Medicine conducted a retrospective cohort study of 91,590 Medicare beneficiaries aged 65 years and older with Afib who were treated with anticoagulants and anti-arrhythmic drugs. 54,977 participants were treated with amiodarone and 36,613 with flecainide or sotalol. The authors found that patients treated with amiodarone experienced a 44 percent increased risk for bleeding-related hospitalizations compared to patients using flecainide or sotalol. However, they found that these patients had no increased risk for ischemic stroke or systemic embolism. The authors note that the risk was most pronounced in patients taking rivaroxaban or with known risk factors for hemorrhagic complications of anticoagulant treatment.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Wayne A. Ray, PhD, please email wayne.ray@vumc.org.  

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