2 Minute Medicine Rewind April 26, 2021

Association of oral corticosteroid bursts with severe adverse events in children

1. Among a large cohort of children in Taiwan, oral corticosteroids prescribed for <14 days were associated with an increased risk of gastrointestinal (GI) bleeds, sepsis, and pneumonia during the first month of therapy initiation.

Evidence level rating: 2 (Good)

Oral corticosteroids are commonly prescribed to children for various inflammatory conditions, including asthma, inflammatory bowel disease, and bronchitis. Though the adverse effects of long-term corticosteroid use have been thoroughly explored in scientific literature, the short-term risks of therapies are not as well characterized. In this population-based cohort study, data from medical claims records and prescription data from the National Health Insurance Research Database from January, 2013 to December, 2017 was used to further explore the adverse events and potential risks of corticosteroid bursts, defined as treatment courses of 14 or fewer days. 1,064,587 participants younger than 18 years who received one burst of corticosteroid therapy were included in this self-controlled case series. Each participant’s risk of severe adverse events within the pre-treatment period (5-90 days prior to initiation of therapy) was compared to the risk within each of the two post-treatment periods (5-30 days and 31-90 days after initiation of therapy). The adverse events examined were GI bleeds, sepsis, pneumonia, and glaucoma. The study calculated incident rate ratios (IRR) by comparing the incident rates of severe events within each post-treatment period to the incident rates of severe events in the reference period (pre-treatment). During the first post-treatment period (5-30 days after therapy), the IRR was 1.41 (95% CI, 1.27-1.57) for GI bleeds, 2.02 (95% CI, 1.55-2.64) for sepsis, 2.19 (95% CI, 2.13-2.25) for pneumonia, and 0.98 (95% CI, 0.85-1.13) for glaucoma. During the second post-treatment period (31-90 days after therapy), the IRR was 1.10 (95% CI, 1.02-1.19) for GI bleeds, 1.08 (95% CI, 0.88-1.32) for sepsis, 1.09 (95% CI, 1.07-1.11) for pneumonia, and 0.95 (95% CI, 0.85-1.06) for glaucoma. Overall, the study demonstrates that corticosteroid bursts prescribed to children are associated with a 1.4 to 2.2-fold increased risk of GI bleeds, sepsis, and pneumonia, and provides data to further inform shared decisioned making between practitioners and patients.


Sex-related disparities in cardiovascular health care among patients with premature atherosclerotic cardiovascular disease

1. In this cross-sectional study, women with premature atherosclerotic cardiovascular disease (ASCVD) and extremely premature ASCVD were less likely to receive antiplatelet agents or statins than men.

Evidence level rating: 2 (Good)

Secondary prevention guidelines highlight the importance of initiation antiplatelet and statin therapy in patients with ASCVD, especially in younger patients. In this nationwide cross-sectional study, data from patients enrolled in the Veterans with Premature Atherosclerosis (VITAL) registry was used to evaluate the disparities in secondary prevention in women with premature ASCVD (ASCVD event at 55 years or younger) and extremely premature ASCVD (ASCVD event at 40 years or younger). The primary outcomes evaluated were antiplatelet use, any statin therapy, high-intensity statin (HIS) therapy, and statin adherence. Statin adherence was assessed using a validated measurement of proportion of days covered (PDC), calculated by dividing the prescription’s covered days supply by total days in the given period. There were 147,600 patients (10,413 women and 137,187 men) with premature ASCVD (<55 years) involved in the study. In this group, adjusted regression analysis demonstrated that women were significantly less likely to receive antiplatelets (odds ratio [OR], 0.59; 95% CI, 0.56-0.61), any statin (OR, 0.66; 95% CI, 0.63-0.69) or HIS therapy (OR, 0.64; 95% CI, 0.60-0.67). Women were also less statin adherent than men (mean [SD], 0.67 [0.35] vs 0.72 [0.32]; coefficient, -0.01; 95% CI, -0.02 – -0.01). The study identified 9485 patients (1,340 women and 8,145 men) with extremely premature ASCVD (<55 years). In this group, an adjusted analysis showed that female sex was independently associated with lower odds of antiplatelet use (OR, 0.61; 95% CI, 0.53-0.70), any statin use (OR, 0.51; 95% CI, 0.44-0.58), and HIS use (OR, 0.45; 95% CI, 0.37-0.54). However, there were no significant sex-associated differences in statin adherence. Overall, this study revealed that women veterans with premature and extremely premature ASCVD receive less optimal secondary cardiovascular treatment compared to men.


Costs and effects of comprehensive geriatric assessment in primary care for older adults with high risk for hospitalisation

1. Amongst older adults with high risk of hospitalisations in Sweden, a comprehensive geriatric assessment (CGA) in primary care reduced the need for hospital care days.

Evidence level rating: 1 (Excellent)

Increased healthcare needs amongst the aging population is recognized as major challenge across developed countries in the world. In this prospective match-controlled trial, data from 1,604 individuals aged 75 years or older from 19 different primary care practices in Sweden were used to evaluate the effectiveness of comprehensive geriatric assessment of older adults with a high risk of hospitalisation. Calculation of a risk score for unplanned hospitalisation admissions used a validated prediction model, which extracted data from the preceding 12 months of electronic medical records. Using various factors such as age, healthcare use, diagnoses from inpatient care and outpatient visits, the participants were risk stratified and the top 11% with the highest risk were included. The participants were equally distributed to an intervention and control group. During the run of the study, there were 17% (control) and 19% (intervention) dropouts caused by death. The mean age of the group was 83.2 years and 51% were female. By the end of the study, there were 451 participants in the intervention group and 470 in the control group with no significant differences in participant demographics. The intervention, CGA, was three-fold, the first of which included a thorough health and frailty assessment and medication review by a nurse. The second part was a team meeting with the nurse and physician where they grade frailty using the Clinical Frailty Scale. Finally, the third part involved creating a care plan for the participant based on the assessment and their individual needs. The control group received care as usual. The primary outcome measured a significant reduction in hospital care days in the intervention group (8.5 days vs 10.3 days) during the 2 years of follow-up. The relative risk reduction (RRR) was -22% (-35% to -4%, p=0.02). The number of outpatient visits to primary or secondary care did not differ significantly and mortality was similar between the two groups. Finally, a cost analysis found a reduction of healthcare cost in the intervention group as a result of decreased hospital care days. Overall, the study helped demonstrate that CGA performed in primary care can significantly reduce the need for hospital care amongst high risk older adults.


Long term follow-up of endometriosis surgery in Ontario: A population-based cohort Study

1. Amongst large cohort of women in Ontario who underwent endometriosis surgery, women who undergo major conservative surgery are less likely to seek medical attention for pain and have repeat surgical intervention compared to those undergoing minor conservative surgery.

Evidence level rating: 2 (Good)

Endometriosis is a chronic inflammatory condition that presents a significant burden on a patient’s quality of life and the healthcare system. In this population-based retrospective cohort study conducted on women aged 18 – 50 who underwent endometriosis surgery between April 1, 2002 and March 31, 2018 in Ontario, researchers sought to characterize the long term outcomes for patients undergoing surgical management of endometriosis. The surgical interventions were classified into diagnostic laparoscopy, minor conservative surgery, major conservative surgery (with and without bilateral salpingo-oopherectomy [BSO]), and hysterectomy (with and without BSO). The primary outcome was the occurrence of repeat surgery, whilst the secondary outcomes were consultation for infertility and subsequent births. Of the 84,885 participants who underwent endometriosis surgery, 3.2% were diagnostic laparoscopy, 25.4% were minor conservative surgery, 33.6% were major conservative without BSO, 2.5% were major conservative with BSO, 25.5% were hysterectomy without BSO and 9.9% were hysterectomy with BSO. The average age of the participants at surgery was 37.5 years + 7.7 and they were followed for a median of 10 years to examine whether they had repeat surgery. The study concluded that the risk of repeat surgery was low for those who underwent a hysterectomy (0.4% for hysterectomy with BSO and 1.9% for hysterectomy without BSO). For those who underwent diagnostic laparoscopy, 26.5% had repeat surgery. Additionally, 25.3% of patients having minor conservative surgery, 18.8% of major conservative surgery without BSO and 2.1% of major surgery with BSO went on to have repeat surgery. Infertility assessments after diagnostic laparoscopy, minor conservative surgery, and major conservative surgery (without BSO) were 50.8%, 41.5%, and 38.4% of patients <44 years, respectively. Five years after index surgery, 28.5% participants who underwent diagnostic laparoscopy, 29.4% of those who had minor conservative surgery, and 20.7% of major conservative surgery without BSO had given birth. Overall, women undergoing major surgery were less likely to require a repeat surgery when compared to those undergoing minor conservative procedures, providing valuable data that can be used to further guide discussion between care teams and patients in the preoperative phase.


Epidemiological and virological characteristics of respiratory tract infections in children during COVID-19 outbreak

1. In a large cohort of children from China, there was a significant decrease in outpatient visits and respiratory tract infections during the COVID-19 outbreak.

Evidence level rating: 2 (Good)

Children are commonly affected by respiratory tract infections and it has been confirmed that a majority of them are due to viruses such as Adenovirus (ADV), influenza A (FluA), influenza B (FluB), and respiratory syncytial virus. Over the past year, stay-at-home orders, reducing non-essential activities, and wearing of masks amongst other measures have been used to reduce the transmission potential of the novel coronavirus (COVID-19). Interestingly, there is evidence suggesting that these measures have additionally significantly reduced the transmission of other respiratory tract infections. To further investigate this, this cohort study extracted data on outpatient visits, respiratory infection visits, number of completed tests for respiratory viruses, and tested positive cases from electronic health records. The data extracted from January to April, 2020 was compared to the same time period in 2018 and 2019. It found that outpatient visits in January, 2020 were comparable with those in 2019 and 2018 (241,251 vs. 266,190 vs. 315,685 respectively). However, outpatient visits reduced significantly during the period of February-April, 2020 when compared to the same period in 2018 and 2019. Specifically, it reduced by 57.4% (288,003 vs. 676,704) from 2019 and by 59.9% (288,003 vs. 717,983) from 2018. The total number of pediatric respiratory infections from January to April, 2020 was lower than the number in 2018 and 2019. It decreased by 59.0% (119,532 vs. 291,557) when compared to 2019 and by 65.7% (119,532 vs. 348,762) from 2018. The number respiratory tests completed declined significantly from 33,037 in 2018 and 55,103 in 2019 to 7,005 in 2020. Finally, the study also reported that cases positive for ADV, FluA, FluB, and RSV were significantly lower in 2020 when compared to 2018 and 2019. Overall, the study demonstrated a decrease in respiratory infections amongst children during the COVID-19 outbreak. It predicted that this was likely due to blocking transmission routes via frequent handwashing, wearing masks, and isolating by staying at home, and provide interesting insight into how health protective behaviours for COVID-19 have impacted the transmission dynamics of other diseases.

Image: PD

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