1. Exposure to opioid analgesics during the first trimester was associated with a small increased risk of congenital anomalies
Evidence Rating Level: 2 (Good)
Approximately 2-4% of pregnancies are exposed to prescribed opioids for pain management. Opioid analgesics cross the placenta and may cause fetal harm, presenting a significant public health concern. Some studies have suggested an association between prenatal exposure to opioid analgesics and increases in anomalies. Other studies have reported no association with any minor or major anomalies. To further add to the literature, this population-based cohort study aimed to estimate associations between opioid analgesic exposure during the first trimester of pregnancy and congenital anomalies. Using administrative health data from Ontario, 599,579 gestational parent-infant pairs from singleton pregnancies without opioid use disorder were followed. Exposure was captured using records of prescribed prenatal opioid analgesics and classified as exposure to any opioid analgesic and specific agents. Congenital anomalies diagnosed within the first year of life were identified using diagnosis codes from various databases. Propensity score-adjusted risk ratios (RRs) between first trimester exposure and congenital anomalies were estimated. Of the 599,579 pregnancies, 11,903 (2.0%) were exposed to opioid analgesics. The prevalence of congenital anomalies was 2.8% in exposed infants and 2.0% in unexposed infants. Relative to unexposed infants, exposed infants were found to be at a higher risk for some anomaly groups, including gastrointestinal anomalies (any opioid analgesic: adjusted RR 1.46, 95% confidence interval [CI] 1.15–1.85; codeine: adjusted RR 1.53, 95% CI 1.12–2.09; tramadol: adjusted RR 2.69, 95% CI 1.34–5.38) and several specific anomalies, including ankyloglossia (any opioid: adjusted RR 1.88, 95% CI 1.30–2.72; codeine: adjusted RR 2.14, 95% CI 1.35–3.40). These findings further quantify the potential risks of prenatal opioid use, helping inform treatment options for pain in pregnancy.
1. An app-based education program delivered through primary schools in China was effective in lowering salt intake and systolic blood pressure in adults, although effects were insignificant in children
Evidence Rating Level: 1 (Excellent)
High salt intake in a major dietary risk factor responsible for significant morbidity and mortality. Previous research has demonstrated that salt reduction lowers blood pressure and reduces cardiovascular disease risk. Salt intake in China is among the highest in the world. Unlike other developed countries where 80% of salt is added by the food industry to processed and fast foods, in China, approximately 80% of salt is added by consumers during cooking. Consequently, reducing salt intake in China is largely reliant on changing individuals’ dietary behaviours. Mobile technology may be a tool for tracking health behaviours and improving health knowledge of consumers in China. Consequently, the authors of this study developed a new smartphone application (AppSalt) focused on salt reduction and evaluated its effectiveness through a cluster randomized trial run in 54 primary schools from September 15, 2018 to December 27, 2019. A total of 592 Grade 3 children (308 (52.0%) boys; mean age 8.58 (SD 0.41) years) and 1184 adult family members (551 (46.5%) men; mean age 45.80 (SD 12.87) years) were included. Children were randomly assigned to either the intervention or control group. Those in the intervention group were taught about salt reduction with the support of the app. Additionally, they were assigned homework to encourage their families to participate in activities to reduce salt consumption. Children in the control group did not receive the intervention. The primary outcome measure was the difference in salt intake change, measured by 24 hour urinary sodium excretion, at 12 month follow-up. A total of 297 children and 594 adult family members were allocated to the intervention group. A total of 295 children and 590 adult family members were allocated to the control group. At baseline, mean salt intake was 5.5 g/day (SD 1.9) in children and 10.0 g/day (SD 3.5) in adults in the intervention group, and 5.6 g/day (SD 2.1) in children and 10.0 g/day (SD 3.6) in adults in the control group. During the study, salt intake of children increased in both intervention and control groups, but to a lesser extent in the intervention group (mean effect of intervention after adjusting for confounding factors −0.25 g/day, 95% confidence interval −0.61 to 0.12, P=0.18). In adults, salt intake decreased in both intervention and control groups, but to a greater extent in the intervention group (mean effect −0.82 g/day, −1.24 to −0.40, P<0.001). The mean effect on systolic blood pressure was −0.76 mm Hg (−2.37 to 0.86, P=0.36) in children and −1.64 mm Hg (−3.01 to −0.27, P=0.02) in adults. App-based education may be an effective tool for changing health behaviours of individuals in China.
1. In a large cohort of Americans with hypertension, Black patients were least likely to achieve blood pressure (BP) control while Asian patients were most likely to achieve BP control.
2. Poor BP control in Black populations appeared to be at least partially attributable to lower treatment intensification and greater missed visits when compared to other racial groups.
Evidence Rating: 2 (Good)
Hypertension is one of the most prevalent conditions in North America, and is a major risk factor for cardiovascular events such as myocardial infarction and stroke. In prior literature, it has been well documented that hypertension is disproportionately prevalent in black populations. Less known however, are the underlying healthcare processes contributing to these statistics. In this retrospective cohort study, researchers included 16,114 adults with hypertension, consisting of populations from various racial backgrounds to address this gap in literature. They collected data from nephrology, primary care, and cardiology clinics ranging from January, 2015 to November, 2017 with successful blood pressure (BP) control as the primary outcome. Sociodemographic factors, and underlying healthcare processes, including treatment intensification (essentially measuring number of antihypertensive medication changes relative to number of visits with an elevated BP measurement), and scheduled follow-up intervals and missed visits were recorded. Over a mean observation period of 25 months, Black patients had the lowest rate of BP control (66.1%) compared to the general population mean of 71.9%, while Asians had the highest rate of BP control (75.8%). Black patients also had lower treatment intensification scores (mean [SD], −0.33 [0.26] vs −0.29 [0.25]; β = −0.03, P < .001) and missed more visits (mean [SD], 0.8 [1.5] visits vs 0.4 [1.1] visits; β = 0.35; P < .001) than the general population, while Asian patients had higher scores and fewer less visits. Further data analysis determined that the lower treatment intensification scores and greater missed visits accounted for 21% and 14% of the decreased likelihood of the population to achieve BP control, respectively. Interestingly, these findings existed despite Black patients having a higher mean number of total visits (13.1) compared to the general population (12.3). Overall, study findings not only reinforce already known findings in which Black patients are disproportionately affected by hypertension, but also provide insight into the underlying healthcare processes that contribute to them.
1. For overweight adults with habitual sleep duration of less than 6.5 hours per night, a sleep extension intervention was found to be effective in decreasing daily energy intake, and may be a viable intervention for weight loss and obesity prevention.
Evidence Rating: 1 (Excellent)
Obesity is highly prevalent in the North American population, and has known association with a myriad of adverse health outcomes. There is past literature to suggest that chronic sleep deprivation may be at least partially associated with obesity. Specifically, there appears to be an association between insufficient sleep duration with increased energy intake. To investigate this further, researchers enrolled adult men and women aged 21 to 40 years in this single centre, parallel-group randomized controlled trial between November 1st 2014 to October 30th 2020. 80 adults with a BMI between 25.0 to 29.9 with a mean habitual sleep duration of less than 6.5 hours were randomized to receive either a two-week sleep extension intervention or 2 weeks of continued habitual sleep as a control. Those randomized to the intervention group received individualized sleep hygiene counselling with the goal of increasing sleep duration to a mean duration of 8.5 hours. Researchers monitored energy intake, expenditure, and body weight composition over a two-week period, with the primary outcome being a change in energy intake. At a 22 day follow-up appointment, there was an increase in sleep duration by 1.2 hours per night in the treatment group, which was found to be associated with a significant decrease in energy intake in intention-to-treat analysis (−270 kcal/d; 95%CI, −393 to −147 kcal/d; P < .001). In concordance with these findings, change in sleep duration appeared to be inversely correlated by change in energy intake. Though the sample size was small, study findings suggest that improved sleep habits, even over a short time span, can have significant impacts on dietary behaviours. With further investigation, this may support a role for optimization of sleep duration as an easy an accessible means of treating and preventing obesity in adults.
1. In patients with first-time ischemic stroke, underlying atrial fibrillation was associated with greater stroke severity, as well as increased rates of 30-day and 1-year mortality.
Evidence Rating: 2 (Good)
It is well known that atrial fibrillation (AF) significantly increases risk of ischemic stroke. This knowledge has long been used to guide risk stratification of patients and consideration and initiation of anticoagulation. Less is known however, regarding the relative severity and disease burden of strokes in patients with AF compared to the general population, In this nationwide contemporary nationwide cohort study, researchers compiled data between January 2005 to December 2016 from 84,458 first-time adult ischemic stroke patients from the Danish Stroke Registry. Information including, sex, age, CHA2DS2‐VASc score were used to match AF (including patients with atrial flutter) with non-AF patients. Stroke severity, as measured by the Scandinavian Stroke Scale (SSS), 30-day mortality, and 1-year mortality, were additionally gathered using the registry. In univariable and multivariable logistic models, it was found that a greater proportion of AF patients had very severe strokes than patients without AF (13.7% versus 7.9%, P<0.01). Additionally, 30-day mortality rates were higher (12.1% versus 8.7%), as well as 1-year mortality (28.4% versus 21.8%). These findings provide novel insight into the association between AF and stroke, as AF appears to not only increase stroke incidence, but also severity, morbidity, and mortality. With further investigation, study findings may be used to further guide risk stratification discussions, and there may be a continued trend in which practitioners become more aggressive with anticoagulation in patients with AF.
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