2 Minute Medicine Rewind August 3rd, 2026
1. The antithrombotic agents aspirin, clopidogrel, and rivaroxaban were non-inferior to metoprolol for responder rate in participants with patent foramen ovale and migraine.
Evidence Rating Level: 1 (Excellent)
Patent foramen ovale (PFO) has been associated with migraine and has been suggested to involve a microembolic mechanism. Antithrombotic treatment has been proposed for migraine prevention by suppressing thrombus formation and microemboli. However, the efficacy of antithrombotic agents in preventing migraine among patients with PFO is unclear. This study thus examined the efficacy and safety of antithrombotic treatment for migraine prevention in patients with PFO. This randomised clinical trial included adults in China aged 18-64 years between October 2022 and December 2024 who were diagnosed with migraine for >1 year, experiencing at least four migraine days per month, and with PFO. Participants were randomised 1:1:1:1 to receive aspirin (300 mg once daily), clopidogrel (75 mg once daily), or rivaroxaban (20 mg once daily), or the first-line preventive agent metoprolol (25 mg twice daily; active control) for 12 weeks. The primary outcome was the proportion of participants achieving a ≥50% reduction in monthly migraine days or attacks from baseline to weeks 9-12 after randomisation. Safety outcomes included bleeding and other adverse events. Among the 984 participants analyzed (mean [IQR] age =38.5 [31.0-47.3], female [%] = 739 [75.1%]), 247 were in the aspirin group, 244 in the clopidogrel group, 245 in the rivaroxaban group, and 248 in the metoprolol group. All three antithrombotic agents were non-inferior to metoprolol, with responder rates of 61.7% with aspirin, 66.8% with clopidogrel, 78.4% with rivaroxaban, and 61.8% with metoprolol. Only rivaroxaban showed a higher responder rate than metoprolol, with an absolute difference of 16.2% (98.33% CI 6.0 to 26.4). Overall, the antithrombotic agents aspirin, clopidogrel, and rivaroxaban were non-inferior to metoprolol for responder rate in patients with PFO and migraine. These findings support a potential microembolic mechanism contributing to migraine in patients with PFO.
1. Active surveillance was cost-effective over 5 years compared with standard surgery.
Evidence Rating Level: 1 (Excellent)
Active surveillance for patients with esophageal cancer and a complete clinical response (CCR) after neoadjuvant chemoradiotherapy (nCRT) is noninferior to standard surgery for 2-year survival. It is unclear whether active surveillance is cost-effective compared with standard surgery among these patients. This study thus examined the cost-effectiveness of active surveillance vs standard surgery after nCRT. This was a secondary analysis of a randomized clinical trial in the Netherlands that enrolled patients with esophageal cancer who achieved a CCR after nCRT between November 8, 2017, and January 17, 2021, with follow-up for up to 5 years. Patients underwent either active surveillance or standard esophagectomy, according to cluster randomization. Active surveillance involved repeated clinical response evaluations and surgery as needed when locoregional regrowth occurred. Standard surgery involved immediate surgery after determination of CCR. The primary outcome was incremental cost-effectiveness of active surveillance vs standard surgery and quality-adjusted life-years (QALYs) up to 5 years. Among 309 patients in the study cohort, 198 were in the active surveillance group (median age, 69 years [IQR, 63-74 years]; 156 men [79%]) and 111 were in the standard surgery group (median age, 68 years [IQR, 61-73 years]; 86 men [77%]). At 5 years, patients in the active surveillance group had a mean of 2.99 QALYs (95% CI, 2.73-3.26) vs 2.88 QALYs (95% CI 2.69-3.06) in the standard surgery group. Active surveillance resulted in a 0.11 QALY gain (95% CI, −0.10 to 0.33), although the difference was not significant. The mean costs for active surveillance were €8374 lower (95% CI, €1792-€15 355) compared with standard surgery. Active surveillance was found to be cost-effective, with the mean incremental net monetary benefit (iNMB) being €17 568 (95% CI, −€725 to €37 497) at a willingness-to-pay threshold of €80 000 per QALY. Overall, this study found that among patients with esophageal cancer achieving a CCR after nCRT, active surveillance was cost-effective over 5-years compared with standard surgery. These findings support broader implementation of active surveillance to reduce health care costs while maintaining comparable health outcomes.
1. Intraarterial dexamethasone was associated with greater pain relief after uterine fibroid embolization compared with placebo.
Evidence Rating Level: 1 (Excellent)
Uterine fibroid embolization (UFE) is a minimally invasive treatment for symptomatic uterine fibroids, which are most common tumor of the female reproductive tract. However, a major limitation of UFE is acute postprocedural pain. Intravenous (IV) dexamethasone administered prior to UFE has previously been associated with reductions in pain severity. It is unknown whether intraarterial dexamethasone administration during UFE would further reduce postprocedural pain after UFE. This study thus examined whether intraarterial dexamethasone reduced postprocedural pain after UFE compared with placebo. This randomized clinical trial included women aged 20 to 50 years in the US undergoing UFE between July 2020 and December 2023. Participants were randomized 1:1 to receive either intraarterial dexamethasone (10 mg) or saline placebo during embolization. The primary outcome was postprocedural pain through 168 hours (7 days). Among the 42 women randomized (mean [SD] age, 44.7 [4.7] years), 40 women were analyzed with 20 in the dexamethasone group and 20 in the placebo group. Compared with placebo, intraarterial dexamethasone was associated with lower mean (SD) pain scores immediately after the procedure (4.0 [3.3] vs 6.1 [3.1]; mean difference, −2.1 [95% CI, −4.14 to −0.06]) and at 96 hours (2.4 [2.4] vs 4.5 [3.2]; mean difference, −2.1 [95% CI, −3.90 to −0.30]). The mean (SE) pain score over 168 hours was lower in the dexamethasone group vs placebo (2.63 [2.28] vs 4.28 [2.27] visual analog scale units), with a mean difference of −1.64 (95% CI, −3.10 to −0.19). Overall, this study found that intraarterial dexamethasone was associated with lower postprocedural pain compared with placebo among women undergoing UFE, highlighting its potential as a low-cost strategy to reduce analgesic burden in this population.
1. Hematologic inflammatory indices in emergency department patients with COVID-19 showed an age-dependent prognostic performance for 30-day mortality, with systemic immune-inflammation index showing good discriminatory performance in patients <65 years and poorer performance in patients >65 years.
Evidence Rating Level: 2 (Good)
Hematologic markers derived from the complete blood count (CBC) including systemic immune-inflammation index (SII), systemic inflammatory response index (SIRI), and pan-immune-inflammation value (PIV) and have shown prognostic value in COVID-19 cohorts. While some hematologic markers have shown age-dependent predictive performance in hospitalized COVID-19 patients, it is unclear whether similar trends exist in the emergency department (ED) setting. This study thus examined the predictive accuracy of CBC-derived inflammatory indices for all-cause mortality and ICU admission across age groups in ED patients with COVID-19 during the pre-vaccination pandemic period. This retrospective cohort study included adults (>18 years) presenting to the ED with confirmed SARS-CoV-2 infection between March 1 and May 31, 2020. Patients were categorized into younger (<65 years) and elderly (≥65 years) groups. The primary outcome was 30-day mortality, and secondary outcome was ICU admission. The discriminative ability of SII, SIRI, and PIV (calculated at admission) for predicting ICU admission and mortality was evaluated. Among the 2,778 patients in the study (mean age 47.8 ± 16.2; 58.7% male), 2,269 (81.6%) were <65 years and 509 (18.3%) were >65 years. ICU admission occurred in 2.9% of all patients, and there was no significant difference between age groups (2.6% vs 4.1%, p = 0.108). The overall 30-day mortality rate was 6.2% (n = 171), with a higher rate among elderly patients (21.0%) than younger patients (2.8%) (p < 0.001). In patients <65 years, the area under the curve (AUC) for SII, SIRI, and PIV was modest at 0.727, 0.676, and 0.677, respectively. In patients ≥65 years, discrimination was lower, with AUCs for SII, SIRI, and PIV at 0.570, 0.604, and 0.588. The predictive ability of SII decreased as patient age increased (ΔAUC = 0.159; P = 0.0055), whereas similar trends for SIRI and PIV were not significant. All indices demonstrated high negative predictive values in younger patients (>95%). Overall, this study found that inflammatory indices in emergency department patients with COVID-19 showed an age-dependent prognostic performance for 30-day mortality, with SII showing good discriminatory performance in patients <65 years and poorer performance in patients >65 years. These findings highlight the potential for hematologic markers as cost-effective parameters to support rule-out decisions for younger adults in emergency settings but not for elderly patients.
Choroidal metastasis: Impact of primary tumors and age on survival – a single center analysis
1. Younger age (<59.6 years) and systemic metastases (>1) were independent predictors of survival among patients with choroidal metastases.
Evidence Rating Level: 2 (Good)
Around 1–2% of all cancer patients develop intraocular metastases, with the choroid representing the primary site of metastatic involvement (90%). It is unclear how age and primary tumor type impact survival in choroidal metastasis. This study investigated the association of patient’s age and primary tumor type with survival following choroidal metastasis diagnosis. This retrospective study included patients diagnosed with choroidal metastases between August 2013 and July 2025. Patients were grouped according to primary tumor origin (lung, breast, or other primaries) and age at time of choroidal metastasis diagnosis (<59.6 vs ≥59.6 years). In total, 70 patients and 70 eyes were included in the study (mean [SD] age = 57.54 [13.02], female [%] = 43 [61.4%]). The median overall survival was 71.6 weeks. Patients <59.6 years survived significantly longer than patients ≥59.6 years (median 88.3 vs 41.9 weeks; estimated 3-year survival 33.2% vs 16.8%; p = 0.037). The median survival based on primary tumor group was 94.4 weeks for breast cancer (estimated 3-year survival 38.3%), 52.7 weeks for lung cancer (9.5%), and 40.6 weeks for other primaries (19.7%), but these differences were not statistically significant (p = 0.269). Patients aged ≥59.6 years had a 2.1-fold higher hazard of death compared with those < 59.6 years (HR = 2.10; p = 0.016). Patients with >1 metastasis elsewhere in the body had a 2.53-fold higher risk for mortality compared to those with one or no metastases (HR = 2.53; p = 0.029). Primary tumor classification (lung, breast, others) was not significantly associated with survival (p = 0.088). Overall, this study found that younger age (<59.6 years) and systemic metastases (>1) were independent predictors of survival among patients with choroidal metastases, supporting their use as reliable indicators for a more favourable prognosis.
Image: PD
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