Have You Read? March 2021

By: Daniel A. Shoskes, MD | Posted on: 01 Mar 2021

Rastogi R, Sheehan MM, Hu B et al: Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Intern Med 2020; doi:10.1001/jamainternmed.2020.7501.

How many calls in the middle of the night do we get for asymptomatic patients with a spike in blood pressure (BP)? How many acute doses of medications do we order to treat the call rather than treating the patient? How often do we raise the dose of an existing antihypertensive based on 1 call? I was skeptical about this decades ago as an intern, and now finally we have a proper study.

The authors wanted to characterize clinician response to BP in the hospital and at discharge and to compare short-term and long-term outcomes associated with antihypertensive treatment intensification. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching. The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year.

Among 22,834 adults hospitalized for noncardiovascular diagnoses, 17,821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5,904 (33.1%) were treated. A total of 8,692 of 106,097 cases (8.2%) of hypertensive systolic BPs were treated. Of these, 5,747 (66%) were treated with oral medications. In a propensity matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4,520 [10.3%] vs 357 of 4,520 [7.9%]; p <0.001) and myocardial injury (53 of 4,520 [1.2%] vs 26 of 4,520 [0.6%]; p=0.003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1,645 of 17,821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year.

The authors conclude that in this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.

Rapp DE, Tuong M, Zillioux J et al: Publication of positive studies in the urologic literature. Urology 2020; 146: 90.

Negative clinical trials are vitally important to be published for all the obvious reasons including preventing unnecessary duplication of effort and bias towards small positive studies that might have been negative if adequately powered. Are we making progress against this bias? The authors’ goal was to assess rates of positive publications within the urological literature, comparing the years 2012 and 2017. All studies published in The Journal of Urology, Neurourology and Urodynamics, Urologic Oncology, Journal of Endourology and Urology in 2012 and 2017 were reviewed. The primary study outcome was proportion of positive studies. Additional article characteristics, including associated citations and subspecialty focus, were recorded and statistical analyses used to assess for differences in negative publication rates were based on these variables.

A total of 1,796 articles meeting inclusion criteria were analyzed. The overall proportion of positive studies decreased in comparison of 2012 and 2017 (90% to 86%, p=0.01). A statistically significant decrease was seen in 2 of 5 journals: Neurourology and Urodynamics (97% to 87%, p=0.01) and Journal of Endourology (93% to 83%, p <0.01). There were no significant differences in associated citations for positive vs negative studies in either year. Logistic regression focused on year and journal revealed that studies published in 2017 and Urology were more likely to be negative.

The authors conclude that the vast majority of studies within the urological literature are positive, with only a small increase in negative study publication comparing 2012 vs 2017. Continued efforts are needed to identify publication bias and promote dissemination of negative research findings.

Whitley JA, Holt SK, Nelson D et al: Gender differences in authorship in urology: a five-year review of publications in five high-impact journals. Urology 2020; doi:10.1016/j.urology.2020.07.080.

Moving from content to gender, do articles in the current urological literature reflect current gender proportions among trainees and staff? The authors wished to describe the proportions of peer reviewed manuscripts authored by women in 5 high impact, widely available urology journals, and to compare these to the proportion of women in urology. About 9% of attending urologists and 25% of urology residents are women. They hypothesized that women comprised fewer than 25% of first authors and fewer than 10% of last/senior authors.

They searched peer reviewed original manuscripts in The Journal of Urology, Journal of Pediatric Urology, Neurourology and Urodynamics, Urology and Urologic Oncology from January 2014 to June 2019. First and last author gender identity was recorded. Observed and expected proportions and temporal trends were compared. Of 8,653 multiple author papers, 2,275 (26.3%) had women as first authors, paralleling the current proportion of women in training. Women were senior/last authors in 1,255 (14.5%) papers; this was higher than the current proportion of female urologists in practice (p <0.0001) for all journals but Neurourology and Urodynamics (p=0.59). Only 527 (6.1%) of multiple author papers had both female first and last authors, whereas 5,640 (65.3%) of papers had both male first and last authors. The first author was more likely female when the senior author was female (OR 2.34, 95% CI 2.06–2.65); most female first and last authored manuscripts were published in subspecialty journals and those utilizing double blind peer review.

The authors conclude that the proportion of female first and senior authored manuscripts is significantly higher than the proportion of women in urology and may reflect differential subspecialty choices and mentorship opportunities for women.

Top 300x250:
Bottom 300x250: