Geriatrics Abstracts: Abstracts from Medical Literature for the Geriatrics Practitioner

Dressings for Acute and Chronic Wounds

The objective of this systematic review was to critically review the literature on the efficacy of modern dressings in healing chronic and acute wounds by secondary intention. The authors conducted a search of 3 databases (MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials Register) from January 1990 to June 2006, completed by manual research, for articles in English and in French. The end points for selecting studies were the rate of complete healing, time to complete healing, rate of change in wound area, and general performance criteria (eg, pain, ease of use, avoidance of wound trauma on dressing removal, ability to absorb and contain exudates).

Studies were selected by a single reviewer. Overall, 99 studies met the selection criteria (89 randomized controlled trials [RCTs], 3 meta-analyses [1 of which came from 1 of the selected systematic reviews], 7 systematic reviews, and 1 cost-effectiveness study). The RCTs, meta-analyses, and cost-effectiveness studies were critically appraised by 2 reviewers to assess the clinical evidence level according to a modification of Sackett's 1989 criteria. Ninety-three articles were finally graded.

The authors found no level A studies, 14 level B studies (11 RCTs and 3 meta-analyses), and 79 level C studies. Hydrocolloid dressings proved superior to saline gauze or paraffin gauze dressings for the complete healing of chronic wounds, and alginates were better than other modern dressings for debriding necrotic wounds. Hydrofiber and foam dressings, when compared with other traditional dressings or a silver-coated dressing, respectively, reduced time to healing of acute wounds.

This systematic review provided only weak levels of evidence on the clinical efficacy of modern dressings as compared with saline or paraffin gauze in terms of healing, with the exception of hydrocolloids. There was no evidence that any of the modern dressings was better than another, or better than saline or paraffin gauze, in terms of general performance criteria. More wound care research, providing level A evidence is needed.

Chaby G, Senet P, Vaneau M, et al. Dressings for acute and chronic wounds. Arch Dermatol 2007;143(10):1297-1304.
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Thiazolidinediones and Cardiovascular Outcomes in Older Patients With Diabetes

Thiazolidinediones (TZDs), used to treat type 2 diabetes, are associated with an excess risk of congestive heart failure, and possibly acute myocardial infarction. However, the association between TZD use and cardiovascular events has not been adequately evaluated on a population level. The objective of this study was to explore the association between TZD therapy and congestive heart failure, acute myocardial infarction, and mortality as compared with treatment with other oral hypoglycemic agents. The investigators used nested case-control analysis of a retrospective cohort study using healthcare databases in Ontario, Canada. They included diabetes patients age 66 years or older treated with at least 1 oral hypoglycemic agent between 2002 and 2005 (N = 159,026) and followed them up until March 31, 2006. The primary outcome consisted of an emergency department visit or hospitalization for congestive heart failure; secondary outcomes were an emergency department visit or hospitalization for acute myocardial infarction and all-cause mortality. The risks of these events were compared between persons treated with TZDs (rosiglitazone and pioglitazone) and other oral hypoglycemic agent combinations, after matching and adjusting for prognostic factors. During a median follow-up of 3.8 years, 12,491 patients (7.9%) had a hospital visit for congestive heart failure, 12,578 (7.9%) had a visit for acute myocardial infarction, and 30,265 (19%) died. Current treatment with TZD monotherapy was associated with a significantly increased risk of congestive heart failure (78 cases; adjusted rate ratio [RR], 1.60; 95% confidence interval [CI], 1.21-2.10; P < .001), acute myocardial infarction (65 cases; RR, 1.40; 95% CI, 1.05-1.86; P = .02), and death (102 cases; RR, 1.29; 95% CI, 1.02-1.62; P = .03) as compared with other oral hypoglycemic agent combination therapies (3478 congestive heart failure cases, 3695 acute myocardial infarction cases, and 5529 deaths). The increased risk of congestive heart failure, acute myocardial infarction, and mortality associated with TZD use appeared limited to rosiglitazone.

The authors concluded that in this population-based study of older patients with diabetes, TZD treatment, primarily with rosiglitazone, was associated with an increased risk of congestive heart failure, acute myocardial infarction, and mortality when compared with other combination oral hypoglycemic agent treatments.

Lorraine L. Lipscombe, MD, MSc; Tara Gomes, MHSc; Linda E. Lévesque, BScPhm, MSc; Janet E. Hux, MD, MSc; David N. Juurlink, BPhm, MD, PhD; David A. Alter, MD, PhD. JAMA 2007;298(22):2634-2643.
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A 4-Year Trial of Tiotropium in Chronic Obstructive Pulmonary Disease

Previous studies showing that tiotropium improves multiple end points in patients with chronic obstructive pulmonary disease (COPD) led the investigators to examine the long-term effects of tiotropium therapy. In this randomized, double-blind trial, they compared 4 years of therapy with either tiotropium or placebo in patients with COPD who were permitted to use all respiratory medications except inhaled anticholinergic drugs. The patients were at least 40 years of age, with a forced expiratory volume in 1 second (FEV1) of 70% or less after bronchodilation and a ratio of FEV1 to forced vital capacity (FVC) of 70% or less. Coprimary end points were the rate of decline in the mean FEV1 before and after bronchodilation beginning on day 30. Secondary end points included measures of FVC, changes in response on St. George's Respiratory Questionnaire (SGRQ), exacerbations of COPD, and mortality. Of a total of 5993 patients (mean age, 65±8 years) with a mean FEV1 of 1.32±0.44 liters after bronchodilation (48% of predicted value), the investigators randomly assigned 2987 to the tiotropium group and 3006 to the placebo group. Mean absolute improvements in FEV1 in the tiotropium group were maintained throughout the trial (ranging from 87 to 103 ml before bronchodilation and from 47 to 65 ml after bronchodilation), as compared with the placebo group (P<0.001). After day 30, the differences between the two groups in the rate of decline in the mean FEV1 before and after bronchodilation were not significant. The mean absolute total score on the SGRQ was improved (lower) in the tiotropium group, as compared with the placebo group, at each time point throughout the 4-year period (ranging from 2.3 to 3.3 units, P<0.001). At 4 years and 30 days, tiotropium was associated with a reduction in the risks of exacerbations, related hospitalizations, and respiratory failure.

The authors concluded that in patients with COPD, therapy with tiotropium was associated with improvements in lung function, quality of life, and exacerbations during a 4-year period but did not significantly reduce the rate of decline in FEV1. (ClinicalTrials.gov number, NCT00144339.)

Donald P. Tashkin, MD, Bartolome Celli, MD, Stephen Senn, Ph.D., Deborah Burkhart, BSN, Steven Kesten, M.D., Shailendra Menjoge, PhD, Marc Decramer, MD, PhD, for the UPLIFT Study Investigators. N Engl J Med 2008;359(15):1543-1554.
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Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians

The American College of Physicians (ACP) developed this guideline to present the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis. Published literature on this topic was identified by using MEDLINE (1966 to December 2006), the ACP Journal Club database, the Cochrane Central Register of Controlled Trials (no date limits), the Cochrane Database of Systematic Reviews (no date limits), websites of the United Kingdom National Institute of Health and Clinical Excellence (no date limits), and the United Kingdom Health Technology Assessment Program (January 1998 to December 2006). Searches were limited to English-language publications and human studies. Keywords for search included terms for osteoporosis, osteopenia, low bone density, and the drugs listed in the key questions. This guideline grades the evidence and recommendations according to the ACP's clinical practice guidelines grading system.

Recommendation 1: ACP recommends that clinicians offer pharmacologic treatment to men and women who have known osteoporosis and to those who have experienced fragility fractures (Grade: strong recommendation; high-quality evidence).

Recommendation 2: ACP recommends that clinicians consider pharmacologic treatment for men and women who are at risk for developing osteoporosis (Grade: weak recommendation; moderate-quality evidence).

Recommendation 3: ACP recommends that clinicians choose among pharmacologic treatment options for osteoporosis in men and women on the basis of an assessment of risk and benefits in individual patients (Grade: strong recommendation; moderate-quality evidence).

Recommendation 4: ACP recommends further research to evaluate treatment of osteoporosis in men and women.

Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Paul Shekelle, MD, PhD; Robert Hopkins, Jr., MD; Mary Ann Forciea, MD; and Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Ann Intern Med 2008;149(6):404-415.