2 Minute Medicine Rewind August 9, 2021

Association between self-reported importance of religious or spiritual beliefs and end-of-life care preferences among people receiving dialysis

1. Religious and spiritual beliefs of dialysis patients had an impact on their end-of-life care planning and resuscitation preferences.

2. An integrative approach to end-of-life care that takes into consideration patients’ religious and spiritual beliefs may be beneficial. 

Evidence Rating Level: 2 (Good)

Patients with kidney disease, chronic kidney failure, or those on dialysis have a lower life expectancy and a higher risk of comorbidity compared to people with normal kidney function. Often, these patients are faced with choices regarding their care planning, palliative care directives, and life extending interventions. However, little is known about how spiritual and religious beliefs play into these decisions. This cross-sectional survey study aimed  further explore this topic and better understand the association between dialysis patients’ religious and spiritual beliefs and their care preferences. The United States Renal Data System Study of Treatment Preferences (USTATE) survey was administered between April 2015-October 2018 at 31 dialysis facilities across Washington and Tennessee.  A total of 937 dialysis patients completed the survey, answering questions regarding their understanding, preferences, values, and expectations regarding end-of-life care. Additionally, to assess the importance of religious and spiritual beliefs, participants were asked to respond to a statement with their level of agreement or disagreement. Specifically, the statement declared that religious and spiritual beliefs were guiding decision making and the patient’s approach to their lives. The survey revealed that 46.4% (n=435) of participants believed this to be definitely true with an additional 24.6% (n=230) agreeing that it tends to be true for them as well. Additionally, when assessing the care planning of these participants who had self-reported the high importance of their beliefs, the cohort was found to be more likely to request cardiopulmonary resuscitation (CPR) and mechanical ventilation. This information can be useful in offering individualized care adapted for patients based on their beliefs. A strength of this study was that it included several analyses to adjust and account for patients’ age, sex, race, ethnicity, dialysis timeline, and level of education. These analyses allowed for a better understanding of the results and can help with personalized care.  A potential limitation of the study was that it did not differentiate between religion and spirituality. Future studies may wish to separate these distinct concepts as well as to further stratify specific religions. Overall, this study had clinical relevance as it highlighted the need for individualized care based on a patient’s religion and spiritual beliefs. Furthermore, understanding a patient’s beliefs can help in the planning process for chronic conditions, dialysis treatments, and end-of-life care.


Preterm birth and stillbirth rates during the COVID-19 pandemic: a population-based cohort study

1. Rates of preterm birth and stillbirths in Ontario remained the same in the first 12 months of the COVID-19 pandemic compared to previous years.

Evidence Rating Level: 2 (Good)

Globally, several studies have assessed the impacts of the COVID-19 pandemic on preterm birth rates and stillbirth rates with inconsistent findings. Regardless of these conflicting analyses, it is clear that preterm birth, defined as birth before 37 weeks’ gestation, and stillbirths are incredibly emotional burdens for families. It is also well understood that causes of preterm birth and stillbirth are multifaceted and are commonly associated with stress, infection, and genetic predisposition. This retrospective cohort study assessed 2 465 387 pregnancies in Ontario, Canada between June 2002 and December 2020. Among this cohort, the mean birth rates were reported as 7.96% for preterm births and a stillbirth rate of 0.56%. This data was extrapolated from population health administrative databases over the past 17.5 years. Specifically, from the Canadian Institute for Health Information’s Discharge Abstract database (CIHI-DAD) as well as the Ontario Mother-Baby data set. From these, pandemic period rates were calculated between January-December 2020. No significant differences were found between time periods with a preterm birth rate of 7.87% and stillbirth rate of 0.53%.  A strength of this study was its analysis and inclusion of data from the past 2 decades prior to the pandemic. This allowed for a solid baseline rate of preterm births and stillbirths to be established. On the other hand, a limitation of the data was that it was only analyzing Ontario and it is clear from previous studies that rates vary drastically geographically. Expanding to a larger scale Canadian study may be beneficial to allow for more generalizable results as well as to better understand the factors associated with preterm birth and stillbirths. Overall, no special cause variations were found within the study’s specific Ontarian cohort of pregnancies. However, it is abundantly clear that other studies on the pandemic’s impact have not reflected the same insignificant results and future research is thus still required.


Adverse childhood experiences and child mental health: an electronic birth cohort study

1. Adverse childhood experiences such as victimization, alcoholism, and previous mental health diagnoses in the household were associated with increased risk of mental health diagnosis among children. 

Evidence Rating Level: 2 (Good)

Mental health diagnoses in children are unfortunately not rare. In fact, approximately 10% of children receive a diagnosis between the ages of 5 and 16. These mental health concerns are often caused by adverse childhood experiences (ACEs) which can include neglect, exposure to physical or substance abuse, and violence. Previous studies have confirmed the association between ACEs and childhood mental health problems, however there are still limitations and gaps in the research. In order to address these gaps, this study assessed the association between individual ACEs on child mental health (as opposed to cumulative ACEs) as well as analyzed the impacts of sociodemographic factors on these associations.  Data was collected from the Wales Electronic Cohort for Children (WECC) between January 1998 and October 2012 accounting for 191,035 children. Additional data was derived from primary care data, hospital admissions, and death records. These sources yielded information regarding ACEs such as childhood victimization, mental illness, alcohol abuse in the home, or death of a household member. Children with mental health diagnoses were further divided into categories including those with stress, anxiety, depression, learning disabilities, eating disorders, and/or antisocial behaviours. All of these outcomes were entered into Cox proportional hazards regression models. These models revealed a prevalence rate of 4% (n=836) of children with a mental health diagnosis between ages 12-14. Furthermore, rates of mental health diagnosis were higher among children living in socially deprived quintiles and those with younger mothers. When assessing the specific ACEs, the experience of victimization increased risk of mental health diagnosis with a conditional hazard ratio (cHR) of 1.90, CI 95%. Similarly, living with a household member with a mental health disorder also significantly increased risk (cHR 1.63). A strength of this study was the fact that data was assessed over 14 years and therefore took into account the entirety of the childhood period. However, a limitation is that certainly not all ACEs were recorded in the databases. For example, families who did not visit health care services to seek aid does not exclude them from having ACEs occurring in their household. Overall, the need for a healthy, nurturing, environment for children is paramount. Mental health support could be beneficial for parents in order to remove ACEs for their children. Targeted health care resources for substance abuse, violence prevention, and accessibility to health care services for lower socioeconomic demographics may prove to help improve the mental health of children.


Effect of vasoactive intestinal polypeptide on development of migraine headaches

1. Vasoactive intestinal polypeptide may play a key role in the mechanism of migraine pathogenesis.

2. Drug therapies targeting vasoactive intestinal polypeptide receptors may be beneficial for treating migraines.

Evidence Rating Level:  1 (Excellent)

The pathophysiology of migraines is an intricate and complex process that is not yet fully understood. However, it is known that when the trigeminovascular system is activated, vasoactive peptides are released by afferent and efferent nerve fibres. In simplistic terms, these vasoactive peptides play a role in the signalling cascade leading to migraines. Additionally, these migraines are often associated with dilation of the superficial temporal artery (STA) and the middle meningeal artery (MMA). This study aimed to investigate the role of vasoactive intestinal polypeptides (VIP) as they are currently the only peptide known to cause arterial dilation without inducing migraines. In order to test the effects of VIP, a randomized, double-blind, placebo controlled, crossover study was conducted in Denmark.  Participants (n=21) between the ages of 18-40 with a diagnosis of migraines without aura were recruited. Participants were then randomly assigned either a sterile saline placebo or VIP 8pmol/kg/min to be infused over the course of 2 hours. Participants were monitored for signs of headaches, migraines, diameter of the STA, cranial autonomic parasympathetic symptoms (CAPS), blood pressure, and asked to keep a diary of all symptoms over 12 hours. Out of the total cohort, n=15 (71%; 95% CI) developed migraine attacks after VIP treatment. This was compared to the placebo where only 1 patient (5%; 95% CI) experienced a migraine (P < .001). Participants who received the VIP also experienced more nausea, photophobia, increase in STA diameter, and increased heart rate compared to placebo. The study concluded that among participants with migraine without aura, a 2-hour infusion of VIP induced migraines at a rate of 71%. Previous studies have investigated the impacts of VIP but with smaller doses and time intervals. In contrast, a strength of this study was the long duration of the infusion. The two hours of infusion allowed for long-term dilation of the STA which may be key in understanding the pathogenesis of migraine attacks. On the other hand, the study’s cohort size was relatively small and future studies may wish to expand the trial to include more participants including those without prior diagnoses of migraines. Overall, the results of this study may have important treatment impacts as VIP antagonists may be a potential drug therapy for migraine attacks.


Plant‐centered diet and risk of incident cardiovascular disease during young to middle adulthood

1. Long term consumption of a nutritionally rich, plant-centered diet starting in young adulthood was associated with a reduced risk of cardiovascular disease.

Evidence Rating Level: 1 (Excellent)

The leading cause of death in the United States is heart disease and therefore, cardiovascular health is a topic that is continuously being studied.  One key factor in these studies is diet with the goal of finding a preventative approach to reduce cardiovascular disease (CVD). CVD can include myocardial infarction, stroke, heart failure, atherosclerotic disease, and hypertension. This prospective cohort study aimed to investigate the long-term impacts of plant-centered diets on incidence of CVD. In order to do so, participants (n= 5115) aged 18-30 were enrolled in the study. Participants were interviewed using the Coronary Artery Risk Development in Young Adults (CARDIA) diet history questionnaire. Specifically, the A Priori Diet Quality Score (APDQS) was used at year 0, 7, and 20 to assess participants’ diets. This scale allows for classification of flood groups into ‘beneficial’, ‘adverse’, and ‘neutral’ with regards to their impacts on CVD. The APDQS ‘beneficial’ category does not only include plant foods but also nutritionally rich animal products such as fish and low-fat yogurts. The flexibility of this scale allows for maintenance and ease of long-term healthy consumption in participants who do not intend to eat fully vegan diets. Over the course of 32 years, participants, who were enrolled with no prior CVD, were monitored for CVD. Overall, there were 289 CVD incidents throughout the study timeline. Participants with higher scores of APDQS (healthier diets in the ‘beneficial’ category) were found to have a 52% lower risk of CVD. These participants were more often women, higher education levels, and more physically active than their counterparts with lower APDQS scores. A strength of this study was that its participants were a younger cohort, allowing for a better analysis of the transition from young to middle adulthood. Previous studies have focused on middle age and older adults when assessing CVD but the younger cohort allows for better follow-up as well as insight into prevention strategies.  Overall, the findings of this study are clinically relevant as healthcare professionals can encourage patients to begin introducing nutritionally rich plant-centered foods into their diets. Cardiovascular disease is omnipresent and prevention at a young age is key. By introducing these healthy diet changes in early adulthood, the devastating impacts of cardiovascular disease may be reduced along with the clinical burden on the healthcare system.

Image: PD

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