2 Minute Medicine Rewind August 9 – August 16, 2015

Patients With Ankylosing Spondylitis Have Increased Cardiovascular and Cerebrovascular Mortality

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis that affects, primarily, the axial skeleton.  AS is a seronegative spondyloarthropathy with a strong genetic predisposition that typically presents as back pain in young adults between the ages of 20-30.  In this population-based retrospective cohort study, researchers analyzed the administrative health data of 21,473 patients over the age of 14 with AS and compared it to the data of 86,606 similar individuals without AS to assess whether or not patients with AS are at an increased risk of cardiovascular and cerebrovascula mortality.  Adjusted hazard ratios for vascular death in individuals with AS were calculated and found to be 1.36 (95% CI, 1.13 to 1.65) overall, suggesting that AS is associated with an increased risk of vascular mortality.  More research is needed to assess how this increased risk may change the ways in which practitioners should screen and treat individuals with AS.

Elotuzumab Therapy for Relapsed or Refractory Multiple Myeloma

Elotuzumab is an immunostimulatory monoclonal antibody used in combination with lenalidomide and dexamethasone in the treatment of patients with relapsed or refractory multiple myeloma.  In this phase 3 randomized controlled trial, investigators assigned 321 participants to receive elotuzumab, lenalidomide, and dexamethasone (experimental group), and 325 participants to receive lenalidomide and dexamethasone alone (control group) in order to assess effect of elotuzumab on progression-free survival in relapsed or refractory multiple myeloma.  The rate of progression-free survival at 1 year was 68% in the elotuzumab group compared to 57% in the control group; at 2 years, the rates were 41% in the elotuzumab group and 27% in the control group.  Median progression-free survival in the elotuzumab group was 19.4 months, whereas median progression-free survival in the control group was only 14.9 months (HR 0.70; 95% CI 0.57 to 0.85; p<0.001).  Finally, the overall response rate was 13% higher in the elotuzumab group compared to the control group (79% in elotuzumab group, 66% in control group; p<0.001).  This study shows promise for the use of adjunctive elotuzumab when treating patients with relapsed or refractory multiple myeloma.    

Association Between Household Food Insecurity and Annual Health Care Costs

As healthcare providers become increasingly aware of the negative impact poverty has on health status, more time is being spent investigating how the social determinants of health relate to health care utilization and costs.  Along these same lines, food insecurity has become increasingly recognized as a serious public health concern for many Canadians.  In this study, researchers drew data from 67,033 individuals between the ages of 18 and 64, who participated in the Canadian Community Health Survey in 2005, 2007/08, or 2009/10, in order to assess their household food security status.  This data was then linked to administrative health care data and two-part regression models were used to determine whether or not household food security had any effect on direct health care costs over a 12-month period.  Health care costs were found to be 16% higher in households with marginal food insecurity (95% CI 10-23%), 32% higher in households with moderate food insecurity (95% CI 25-39%), and 76% higher in households with severe food insecurity (95% CI 65-88%).  These findings are consistent with the previously held adage that food insecurity is associated with higher health care costs.  Future research is needed to identify exactly how food insecurity affects adults’ health and their use of the health care system.  

Corticosteroid Therapy for Patients Hospitalized With Community Acquired Pneumonia

Community acquired pneumonia (CAP) is a common reason for admission into hospital across North America.  Recent literature has suggested a potential benefit to the concomitant use of antibiotics and corticosteroids for the treatment of individuals hospitalized with CAP.  In this systemic review and meta-analysis, investigators extracted data from 13 randomized controlled trials assessing the effectiveness of corticosteroids in hospitalized adults with CAP in order to determine whether or not adjunctive corticosteroid therapy had an effect on mortality, morbidity, and duration of hospitalization in patients with CAP.  The findings suggest that adjunctive corticosteroids may decrease all-cause mortality by 2.8% (RR 0.67, 95% CI 0.45 to 1.01; moderate certainty), need for mechanical ventilation by 5% (RR 0.45, CI 0.26 to 0.79; moderate certainty), progress to acute respiratory distress syndrome by 6.2% (RR 0.24, CI 0.10 to 0.56; moderate certainty), time to clinical stability by 1.22 days (CI 0.10 to 0.56; high certainty), and hospital stay by 1 day (CI, -1.79 to -0.21 days; high certainty).  Although compelling, the trials used in this study frequently excluded individuals with co-morbidities thus greatly affecting generalizability of the study.  There was also very little consistency amongst the trials with respect to type, dosage and duration of corticosteroid therapy. Future research is needed to assess the effectiveness of corticosteroid use and to guide use in CAP. 

A Study of the First Year of the End-of-Life Clinic for Physician-Assisted Dying in the Netherlands

There has been a great social and legal shift in the laws governing physician-assisted suicide over the last several years.  Many healthcare providers oppose the passing of legislation allowing physician assisted suicide whereas others feel as though it is a valuable service to offer to patients.  In this retrospective cohort study, researchers analyzed application forms and registration files of 645 patients who applied for euthanasia or physician-assisted suicide at the End-of-Life Clinic in the Netherlands.  Researchers were interested in investigating outcomes of requests for euthanasia or physician-assisted suicide as well as factors associated with granting or rejecting such requests.  It was found that patients with a somatic condition or with cognitive decline had the highest percentage of granted requests (32.8% and 37.5% respectively.  Patients with a psychological condition had the smallest percentage of granted requests.  Factors associated with granted requests were found to be older age (p < 0.001), having multiple children (OR 2.35, 95% CI 1.31 to 4.23; p = 0.004), fatigue (OR 3.62, 95% CI 1.88 to 6.97; p < 0.001), and loss of autonomy (OR 3.41, 95% CI 1.86 to 6.16; p < 0.001).  This type of research is important in guiding the ways in which we adopt standards of care for physicians willing to provide care to individuals requesting physician assisted suicide. 

Image: PD

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