2 Minute Medicine Rewind December 23, 2019

Association of prehospital plasma transfusion with survival in trauma patients with hemorrhagic shock when transport times are longer than 20 minutes: A post-hoc analysis of the PAMPer and COMBAT clinical trials

1. Prehospital plasma transfusion is associated with increased survival in the setting of hemorrhagic shock, particularly with longer transport times

Evidence Rating Level: 1 (Excellent)

It has been well established that the early transfusion of blood products in the setting of hemorrhagic shock reduces associated morbidity and mortality. Only recently, however, have a number of trauma systems begun to incorporate red blood cell, plasma or whole blood transfusion in the pre-hospital setting. The PAMPer and COMBAT clinical trials were two prospective randomized studies of prehospital administration of plasma, the results of which were contradictory. In the current study, the authors conducted a post-analysis using combined data from both studies (n=626) to determine whether prehospital plasma administration is more beneficial when patient transport times are longer. As part of both original trials, patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 units of thawed plasma in the prehospital environment. Of the 626 patients included in the study, 74.6% were male and the median age was 42 years (IQR 27 to 57 years). Based on an adjusted survival analysis, researchers found a significant overall survival benefit with prehospital plasma administration (HR 0.65, 95% CI 0.47 to 0.90, p=0.01). Importantly, researchers noted that survival was influenced by pre-hospital transport time in patients who received standard care, where the rate and likelihood of mortality were increased 2-fold with transport times in excess of 20 minutes (HR 2.12, 95% CI 1.05 to 4.30, p=0.04). This was not observed in patients who received prehospital plasma (HR 0.78, 95% CI 0.40 to 1.51, p=0.46). Furthermore, although there was no significant difference in survival for patients with short transport times (<20 minutes), survival was improved in the plasma group when transport times were longer (HR 0.56, 95% CI 0.40 to 0.80, p=0.001). This study therefore shows that prehospital plasma transfusion is associated with increased survival in the setting of hemorrhagic shock, particularly with longer transport times.

Association between use of multiple classes of antibiotic in infancy an allergic disease in childhood: Findings from the Suffolk County Mental Health Project

1. Commonly prescribed antibiotics in infancy are associated with later diagnosis of allergic disease in childhood

Evidence Rating Level: 2 (Good)

The use of antibiotics negatively impacts the human microbiome, decreasing bacterial diversity. These kinds of changes to the microbiome have been previously found to be associated with allergic disease. In this retrospective cohort study, 798,426 children (Department of Defense Tricare beneficiaries) were followed up for the presence of any allergic disease and/or related conditions (i.e. anaphylaxis, asthma, atopic dermatitis) to determine whether exposure to multiple antibiotic classes in infancy is associated with a higher risk of developing allergic disease in early childhood. Researchers found that all the antibiotic types assessed were associated with an increased risk of allergic disease in childhood, including penicillin (HR 1.30, 95% CI 1.28 to 1.31), penicillin with a β-lactamase inhibitor (HR 1.21, 95% CI 1.18 to 1.23), cephalosporins (HR 1.19, 95% CI 1.17 to 1.21), sulphonamides (HR 1.06, 95% ci 1.03 to 1.10) and macrolides (HR 1.28, 95% CI 1.26 to 1.30). Children prescribed an additional class of antibiotic demonstrated a further increased likelihood of later developing allergic disease. This study therefore shows that commonly prescribed antibiotics used in infancy are associated with later diagnosis of allergic disease in childhood.

Expanding heart transplant in the era of direct-acting antiviral therapy for hepatitis C

1. The rate of hepatitis C virus (HCV) transmission from nucleic acid amplification testing (NAT)-negative donor hearts is low, and survival rates in patients with donor-derived HCV are high.

Evidence Rating Level: 2 (Good)

While there have been considerable advances in heart transplantation, more and more patients are becoming reliant on mechanical circulatory support (MCS) and are subject to increasing morbidity and mortality due to long wait times and a shortage of donor hearts. Studies examining the use of hepatitis C virus (HCV)-positive donors had previously demonstrated a high rate of HCV infection and poor outcomes in recipients. With the introduction of direct-acting antivirals (DAAs), however, there is renewed interest in using organs from HCV-positive donors. In this prospective cohort study, 80 patients that received a heart transplant from an HCV-positive donor (September 2016-April 2019) at a large academic center were followed up to determine whether the inclusion of HCV-positive donors increased the donor pool, impacted waitlist duration, and to better understand the transmission and cure of donor-derived hepatitis C, morbidity and mortality at 1 year post-transplant. Researchers found that the median active waitlist time from the time of consenting to accept a HCV-positive donor heart was 4 days (IQR 1 to 18 days). Of the patients that had accrued active waitlist time before being consented to receive an HCV-positive donor heart, the median waitlist time was 28 days (IQR 6 to 168 days). The transmission rate of HCV in patients that received a nucleic acid amplification testing (NAT)-positive donor heart was 95.7%. None of the 10 recipients of hearts from NAT-negative donors developed infection. Among the recipients with donor-derived HCV (dd-HCV), 30-day and 1-year survival rates were 92.5% and 90.4%, respectively. This study therefore shows that with the availability of DAAs, the use of HCV-positive donor hearts may serve to expand the donor pool, reducing waitlist times and cardiac-related mortality.

Mental disorders and intimate partner violence perpetrated by men towards women: A Swedish population-based longitudinal study

1. Numerous mental health disorders are associated with an increased risk of perpetrating intimate partner violence (IPV) towards women

Evidence Rating Level: 2 (Good)

Previous studies have demonstrated a link between mental health disorders and the risk of perpetrating intimate partner violence (IPV) against women; the direction and magnitude of this association, however, has not been well established. In this retrospective cohort study (1998 to 2013), researchers used Swedish nationwide registries to study individuals of 9 different diagnostic groups (schizophrenia spectrum disorders, bipolar disorder, depressive disorder, anxiety disorder, alcohol use disorder, drug use disorder, ADHD, autism, personality disorders), matched to individuals in the general population, to examine the association between mental health disorders and IPV perpetrated by men towards women. The sample size for each diagnostic group ranged from 9,529 for individuals with autism, to 88,182 for individuals with depressive disorder. Researchers found that compared to general population controls, all psychiatric diagnoses studied except autism were associated with an increased risk of IPV against women in men. Based on sibling analyses, researchers also found that men with depressive disorder (HR 2.9, 95% CI 2.7 to 3.2), anxiety disorder (HR 2.5, 95% CI 2.2 to 2.7), alcohol use disorder (HR 7.0, 95% CI 6.6 to 7.5), drug use disorder (HR 7.7, 95% CI 7.2 to 8.3), attention deficit hyperactivity disorder (HR 6.4, 95% CI 5.5 to 7.4), and personality disorders (HR 4.3, 95% CI 3.8 to 4.9) had a higher risk of IPV against women when compared to their unaffected siblings. One limitation of this study is the fact that analyses were restricted to IPV leading to arrest, and as such, the applicability of these results may be limited to more severe forms of IPV. This study therefore shows that a number of mental disorders are associated with an increased risk of perpetrating IPV towards women. These findings have important implications for IPV risk identification and prevention among individuals with certain mental health conditions.

Dietary supplement use during chemotherapy and survival outcomes of patients with breast cancer enrolled in a cooperative group clinical trial (SWOG S0221)

1. Certain dietary supplements, including vitamin B12, iron and omega-3 fatty acids, may negatively impact disease-free survival and overall survival in breast cancer patients undergoing chemotherapy

Evidence Rating Level: 2 (Good)

While the use of dietary supplements during cancer treatment is not uncommon, there is little data available to support current recommendations for use during chemotherapy. While supplements could reduce treatment-related adverse effects, concerns have been raised surrounding the generation of reactive oxygen species (ROS), which could affect treatment efficacy. In this observational study, 1134 patients with breast cancer that had been randomly assigned to an intergroup metronomic trial of cyclophosphamide, doxorubicin, and paclitaxel, were queried on their use of supplements at the initiation and during treatment. Researchers found that patients who used any antioxidant both before and during treatment had an increased risk of disease recurrence (HR 1.41, 95% CI 0.98 to 2.04, p=0.06) and death (HR 1.40, 95% CI 0.90 to 2.18), though these findings were not statistically significant. In examining the use of specific supplements, researchers found that the use of vitamin B12 before and during treatment was associated with poorer disease-free survival (HR 1.85, 95% CI 1.15 to 2.92) and overall survival (HR 2.04, 95% CI 1.22 to 3.40). The analysis yielded similar findings with respect to recurrence for the use of iron supplementation. The use of omega-3 fatty acids before and during treatment was associated with poorer disease-free survival (HR 1.67, 95% CI 1.12 to 2.49) but not overall survival. This study therefore shows that certain dietary supplements may negatively impact disease-free survival and overall survival. Clinicians should exercise caution in recommending particular supplements, including vitamin B12, iron and omega-3 fatty acids, to patients undergoing chemotherapy.

Image: PD

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