2 Minute Medicine Rewind February 19, 2024

Traumatic Brain Injury and Subsequent Risk of Brain Cancer in US Veterans of the Iraq and Afghanistan Wars

1. Among United States veterans of the Iraq and Afghanistan wars, the experience of a moderate, severe, or penetrating traumatic brain injury was associated with a greater risk of developing brain cancer. 

Evidence Rating Level: 2 (Good)

Primary brain cancer is uncommon, affecting 7.02 per 100,000 persons in the United States. Little is known about the risk factors for primary brain cancer. In this retrospective cohort study, researchers aimed to determine whether traumatic brain injury (TBI) is associated with the development of primary brain cancer. Data were collected from United States veterans of the Iraq and Afghanistan wars via the Long-Term Impact of Military-Relevant Brain Injury Consortium–Chronic Effects of Neurotrauma Consortium. 1,919,740 participants were included in the study, 80.25% male, 63.11% non-Hispanic White, median age 31 (IQR, 25-42 years). 449,880 of the participants had suffered from a TBI. 385 848 were mild, 46 859 were moderate to severe, and 17,173 were penetrating TBIs. There was an increased risk of developing brain cancer for those with moderate to severe TBIs (adjusted hazard ratio [AHR], 1.90; 95% CI, 1.16-3.12) and penetrating TBIs (AHR, 3.33; 95% CI, 1.71-6.49). Mild TBIs were not associated with brain cancer. A strength of this study is the large cohort size. A limitation is that only veterans were included, therefore the results may not be generalizable to the average population with traumatic brain injuries. Further research is needed to assess whether there is an association between TBIs and brain cancer in other populations. Overall, this study demonstrates that among United States veterans, the experience of a moderate, severe, or penetrating traumatic brain injury was associated with a greater risk of developing primary brain cancer. 

Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trial

1. In this post-hoc analysis of the CHANCE-2 trial, ticagrelor-acetylsalicylic acid was more beneficial compared to clopidogrel-acetylsalicylic acid for preventing recurrent stroke among those with elevated levels of homocysteine and CYP2C19 LOF mutations. 

Evidence Rating Level: 2 (Good) 

Elevated homocysteine levels are associated with increased hemostasis, progression of atherosclerosis, and greater risk of initial or recurrent stroke. Little is known about whether homocysteine levels impact the effectiveness of dual antiplatelet treatments for preventing stroke. Researchers aimed to assess the association between homocysteine levels and the efficacy of ticagrelor-acetylsalicylic acid (ASA) vs. clopidogrel-ASA for patients with prior minor stroke or transient ischemic attack (TIA) and CYP2C19 loss-of-function (LOF) alleles. 2740 participants from the Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events–II (CHANCE-2) Trial were included in this analysis. The participants were randomly assigned to treatment with ticagrelor-ASA or clopidogrel-ASA. In addition, the participants were categorized as having elevated or non-elevated levels of homocysteine. Among those with elevated homocysteine, ticagrelor-ASA compared to clopidogrel-ASA was associated with a reduced risk of recurrent stroke (74 [5.3%] v. 119 [8.5%]; hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.45–0.81). This association was not found for those without elevated homocysteine levels. The benefit of ticagrelor-ASA for reducing the risk of recurrent stroke increased as the homocysteine level increased (p = 0.04 for interaction). No association was found between the homocysteine level and the risk of bleeding while on dual antiplatelet therapy. A limitation of this study is that there was a very low incidence of bleeding during the trial period, which reduces the statistical power for assessing the safety risks of different medication regimens. Overall, this study demonstrates that ticagrelor-ASA was more beneficial compared to clopidogrel-ASA for preventing recurrent stroke among those with elevated levels of homocysteine and the CYP2C19 LOF mutation. 

Unmet Social Needs and Breast Cancer Screening Utilization and Stage at Presentation

1. Having a greater number of unmet social needs was associated with lower utilization of screening mammography services, as well as a later stage of breast cancer at the time of diagnosis. 

Evidence Rating Level: 1 (Excellent)

Social determinants of health (SDOH) are important drivers of health inequities. Unmet social needs, such as housing and food insecurity, are known to be associated with worse health outcomes. In this study, researchers aimed to determine whether unmet social needs are associated with the use of screening mammography programs and the stage of breast cancer diagnosis. This prospective cohort study included 322 adult women with stage I-IV invasive ductal or lobular carcinoma. Participants were recruited between 2020 and 2023 from two sites: an underserved safety-net hospital (SNH) and a National Cancer Institute-designated academic cancer center (ACC) in Southern Florida. All participants completed the Health Leads Social Needs Screening Toolkit. Those who presented to the SNH were more likely to be diagnosed with late-stage compared to early-stage disease (15 of 48 [31%] vs 50 of 274 [18%]; P = .04). Having a greater number of unmet social needs was associated with decreased use of screening mammography programs (OR, 0.74; 95% CI, 0.55-0.99; P = .047), as well as a later stage at diagnosis (OR, 0.92; 95% CI, 0.89-0.96; P < .001). Having unmet social needs was still associated with decreased use of mammography even after controlling for access to city-funded mammography programs. A limitation of this study is that participants were only recruited from Southern Florida, and the results may not be generalizable to other populations. Overall, this study demonstrates that greater unmet social needs are associated with lower utilization of screening mammography services, as well as a later stage of breast cancer at the time of diagnosis. Future work may focus on collaboration between healthcare providers, social workers, and policymakers to overcome barriers to screening uptake and facilitate earlier diagnoses for those with unmet social needs.

Association of non-alcoholic fatty liver disease with cardiovascular disease and all-cause death in patients with type 2 diabetes mellitus: nationwide population-based study

1. The risk of CVD and all-cause death for individuals with T2DM is increased for those with NAFLD compared to those without NAFLD. 

Evidence Rating Level: 2 (Good)

Non-alcoholic fatty liver disease (NAFLD) is increasing in prevalence globally. Patients with NAFLD are at an increased risk for developing cirrhosis, as well as cardiovascular disease (CVD). CVD is the leading cause of death for individuals with NAFLD. In this longitudinal cohort study, researchers aimed to assess the risk of NAFLD on CVD and all-cause mortality among participants with and without type 2 diabetes mellitus (T2DM). Data were collected on 7,796,763 participants via the National Health Screening Program in Korea starting in 2009. The median follow-up period was 8.13 years. Participants were categorized as having no NAFLD, grade 1 NAFLD, or grade 2 NAFLD. 6.49% of participants had T2DM. The incidence rate of CVD and all-cause mortality increased with the grade of NAFLD, and the incidence rates among those with T2DM were greater compared to those without T2DM. In addition, the 5-year absolute risk of CVD and all-cause mortality increased with the grade of NAFLD for patients with and without T2DM but was greater for those with T2DM. A limitation of this study is that NAFLD was defined by the fatty liver index, as opposed to biopsy or ultrasound. Additionally, the study was only conducted among a Korean population; as such, further research is needed to confirm these results among other populations. Overall, this study demonstrates an association between NAFLD and the risk of CVD and all-cause mortality for patients with T2DM. 

Point-of-care ultrasound (POCUS): Assessing patient satisfaction and socioemotional benefits in the hospital setting

1. The use of POCUS in an adult inpatient setting improved patient satisfaction with their overall care and perceived 

Evidence Rating Level: 3 (Average)

Point-of-care ultrasound (POCUS) is a tool used to aid in decision-making at the bedside. While POCUS is used frequently in emergency departments, with increasing use in inpatient settings. Aside from the known diagnostic benefits, recent studies have shown that POCUS has socioemotional benefits as well. There is thought to be a placebo-like “POCUS positive care effect” (PPCE). In this cross-sectional study, 30 adult participants were recruited from an inpatient medical center, median age of 63.0 years. Researchers made observations during routine POCUS encounters. Certain factors were observed to be associated with greater PPCE, such as trusting and respectful relationships between patients and care providers. Severe illness and pathological findings were observed to reduce PPCE. In addition, 27 patients completed post-pocus surveys. The median patient-rated magnitude of PPCE on a 1-5 scale was 5/5 for the extent to which POCUS improved the patient’s satisfaction with their care and perceived efficiency of care. This study demonstrates that POCUS is useful not only for diagnostic purposes but also for positive socioemotional effects and increased patient satisfaction. A limitation of this study is the small sample size. Additionally, surveys were only administered to patients after POCUS was completed, so no comparison can be made to patient satisfaction before they received POCUS. Future work may build on this study by administering surveys to patients both before and after POCUS to more clearly assess the impact of POCUS on the overall patient experience. 

Image: PD

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