Tom Nolan’s research reviews—8 June 2023

How do DOs do?

How important are qualifications in modern day healthcare? Regardless of how good you are at your job, whether you’re a consultant, staff grade, registrar, nurse specialist, physician's associate, or GP, it still puts you in a pecking order. In the US there’s the extra factor of whether doctors have a medical doctor (MD) or doctor of osteopathic medicine (DO) qualification. Allopathic (MD) and osteopathic (DO) physicians can prescribe, operate, and train in primary or secondary care. Those who are trained the osteopathic way learn a whole person approach that considers the connection of body, mind, and spirit in delivering healthcare, and receive osteopathic manipulation training on top of their medical training. There are far fewer DOs than MDs, with less competitive medical school entry requirements, and, when it comes to status, apparently the MDs rule the roost.

But are you any more likely to get better if your doctor has an MD after their name? A retrospective observational study found no difference in 30 day mortality, length of hospital stay, or healthcare spending among over 300 000 patients who received inpatient care from MDs or DOs.

Ann Intern Med doi:10.7326/M22-3723

Tirofiban versus aspirin in acute ischaemic stroke

Lots of people with an acute stroke don’t get to hospital in time for intravenous thrombolysis (<10% do in China, where this study is based) or don’t have large vessel occlusions that are amenable to endovascular thrombectomy. Then there are those who do have these treatments but who deteriorate anyway. In these scenarios might the glycoprotein IIb/IIIa receptor inhibitor tirofiban be a more effective and safer treatment than aspirin? Previous randomised trials did not find any additional benefit from tirofiban, but this larger study, which recruited patients with more severe symptoms, has found a greater number of patients who received tirofiban making an excellent recovery compared with those who received aspirin (29.1% v 22.2%). One per cent had a symptomatic intracranial haemorrhage with tirofiban versus none with aspirin.

N Engl J Med doi:10.1056/NEJMoa2214299

Whittling down opioid use

On the face of it, that a group based educational intervention significantly reduced opioid use in people with non-malignant pain sounds quite promising. The intervention included three days of educational group sessions followed by 1-to-1 support from a nurse and lay person for a year with usual care. Of the 225 people in the intervention group, 65 (29%) reported having stopped taking opioids when followed up after 12 months—compared with only 15 (7%) in the control group.

But how feasible would it be to roll this out? Over 20 000 people were identified from GP records and invited to the study: 2220 replied, of whom 1612 couldn’t be contacted, lost interest, stopped responding, didn’t give consent, were ineligible, or weren't randomised for other reasons. Of the 608 who were randomised, 96% were white British. Then only 206 of the 305 people in the intervention group attended the first session. Further limitations of the study—the authors reel off 11 in total, including that it was unblinded, relied on self reported outcomes, and that many participants were taking relatively low doses of opioids—mean that it’s hard to say whether the intervention was effective at all.

JAMA doi:10.1001/jama.2023.6454

The pressure not to fail

A promotional video for the CardioMEMS-HF system describes how a sensor the size of a paper clip is inserted into the pulmonary artery and transmits pulmonary artery pressure measurements to an external unit that’s the size of “a queen sized pillow.” The readings get sent to the patient’s medical team, who can advise on early signs of deterioration of heart failure. There are stylish graphics to showcase all the benefits (and an overloaded PowerPoint slide at the end listing the potential harms).

The latest study of the device tested it in the Netherlands in people with symptomatic heart failure (NYHA class III) and a previous hospital admission with heart failure. Twelve months after the device insertion, those with the device had improved quality of life scores and fewer hospital admissions than those who received standard care.

Lancet doi:10.1016/S0140-6736(23)00923-6

Medication errors during drug shortages

Thanks to the shortage of antibiotics at the height of the strep B panic last winter, I can now name you every pharmacy within a 20 mile radius of my house—and rank them in order of how helpful they were to a stressed-out parent.

In Canada they also had shortages of paediatric medicines, with paediatric paracetamol and ibuprofen in short supply between August and December 2022. In correspondence to the New England Journal of Medicine, researchers looked at calls to a poisons centre in Ontario between 2018 and 2023 and found a big spike in calls about paracetamol and ibuprofen dosing errors for people under 18 years old during the drug shortage. The spike was higher even than the authors would have expected given the high levels of viral illness and errors due to parents and carers having to use adult tablets. Sourcing stock from other countries might have contributed. Either way, autumn will be here before we know it, so I might just head down to the pharmacy now to stock up.

N Engl J Med doi:10.1056/NEJMc2300561