2 Minute Medicine Rewind February 7, 2022

Outcomes in patients with and without disability admitted to hospital with COVID-19: a retrospective cohort study

1. Patients with disabilities who are hospitalized with COVID-19 have higher rates of unplanned 30-day readmissions and have longer hospital stays, compared to patients without disabilities, but not significantly higher in-hospital mortality or ICmU admission rates, after adjustment.

Evidence Rating Level: 2 (Good)

Currently, the COVID-19 response in Canada has not taken into account the impact of disabilities on accessing healthcare and risk for contracting COVID-19. For instance, the vaccine rollout eligibility was stratified by age and medical comorbidity, and data on individuals with disabilities has typically not been tracked. Disabilities can create physiologic challenges that make patients more susceptible to respiratory disease, whereas other disabilities may affect access to healthcare if barriers are not addressed, such as masks impeding communication for individuals with hearing challenges. The current retrospective cohort study compared patients with disabilities and without, who were hospitalized with COVID-19, with outcomes including in-hospital mortality, admission to the intensive care unit (ICU), length of stay, and unplanned 30-day readmission. This study included 1279 hospital admissions across 7 hospitals: 58.0% were male, and the median (IQR) age was 66 (54-79). Among those with a disability, 74.4% had a physical disability, 6.3% had vision or hearing impairments, 8.4% had an intellectual/developmental disability or traumatic brain injury, and 10.9% had more than one disability. After adjustments to separate disability from associated socioeconomic and chronic disease factors, there was no significant difference for in-hospital mortality (28.1% for disabilities vs. 17.6% for no disabilities, relative risk 1.09, 95% CI 0.82-1.45). Prior to adjustment, the risk was higher for those with disabilities (RR 1.57, 95% CI 1.19-2.06). There was also no significant difference in ICU admissions after adjustment (28.3% for those with disabilities vs 22.5% for those without, RR 1.00, 95% CI 0.75-1.33). However, those with disabilities had significantly longer hospital stays, with a median (IQR) stay of 13.9 (5.8-30.1) days compared to 7.8 (3.6-16.8) days (adjusted rate ratio 1.36, 95% CI 1.19-1.56). As well, those with disabilities had significantly more unplanned 30-day readmissions (17.6% vs. 7.9%, adjusted RR 1.77,95% CI 1.14-2.75). Overall, this study demonstrated that patients with disabilities in the hospital for COVID-19 are at higher risk for poor clinical outcomes, underlying the need for better supports to address patients with physical, sensory, and intellectual/developmental disabilities.

Association Between Screen Time Exposure in Children at 1 Year of Age and Autism Spectrum Disorder at 3 Years of Age: The Japan Environment and Children’s Study

1. Longer daily screen time at 1 year of age was associated with higher odds of autism spectrum disorder (ASD) diagnosis at 3 years of age, in boys only.

Evidence Rating Level: 2 (Good)

Risk factors thought to be associated with autism spectrum disorder (ASD) include genetic mutations, and both pre- and post-natal risk factors. For instance, some studies have found Limiting screen time is recommended by the World Health Organization and the American Academy of Pediatrics, suggesting no screen exposure before 1 year of age and 18 months respectively. Therefore, the current retrospective cohort study examined the association between screen time at 1 year of age and subsequent ASD diagnosis at 3 years of age. Data from this study came from the Japan Environment and Children’s Study, a birth cohort involving 15 regional centres. In total, there were 84,030 children participants, 76.0% of whom were boys. After adjustment, there was an association between more screen time and subsequent ASD diagnosis: Compared to no screen time, the odds ratios (95% confidence intervals) were 1.16 (0.66-2.03) for less than 1 hour daily screen time, 1.81 (1.05-3.10) for 1-2 hrs, 2.87 (1.68-4.91) for 2-4 hours, and 2.64 (1.42-4.91) for greater than 4 hours (p-value for trend < 0.001). When stratifying based on gender, an association was found between longer screen time and ASD diagnosis for boys, but not for girls. Furthermore, screen time at 3 years of age was not associated with ASD diagnosis at 3 years of age. Overall, this study found evidence that increased screen time for boys at 1 year of age was associated with a diagnosis of ASD at 3 years of age.

Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers

1. Injured children treated at trauma centres with greater emergency department (ED) pediatric readiness had lower mortality at 1-year follow-up, compared to centres with lower pediatric readiness.

Evidence Rating Level: 2 (Good)

Emergency department (ED) pediatric readiness broadly refers to equipment, resources, and protocols needed to care for acutely injured children. When children are treated at pediatric trauma centres or at centres with high ED pediatric readiness, the in-hospital short-term survival is higher. However, long-term outcomes comparing centres of varying pediatric readiness have not been researched. This retrospective cohort study evaluated the association between ED pediatric readiness and days to death for pediatric trauma patients, with up to 1-year follow-up. This involved 146 level 1-4 trauma centres, with the study population consisting of 88,071 children under the age of 18, 34.8% female, and with a median (IQR) age of 11 (5-15) years. ED pediatric readiness was measured using the weighted Pediatric Readiness Score (wPRS), based on an assessment of EDs according to national guidelines. Overall, the study found that 2.2% of patients died in 1 year following the initial admission to the ED. Children treated at EDs in the highest quartile of readiness had increased 1-year survival than those in the lowest quartile (hazards ratio 0.73, 95% CI 0.57-0.94). This association remained when examining the highest-risk subgroups, such as children with an injury severity score (ISS) of 16 or greater (adjusted HR 0.69, 9% CI 0.54-0.88), an abbreviated injury score (AIS) of 3 or greater (aH 0.70, 95% CI 0.56-0.88), and those with a head AIS of 3 or greater (aHR 0.69, 95% CI 0.52-0.90), but not for those needing early critical resources (aHR 0.79, 95% CI 0.60-1.04). In conclusion, this study found that greater ED pediatric readiness was associated with increased survival at 1-year follow-up for pediatric trauma patients.

Interactions Between Atrial Fibrillation and Natriuretic Peptide in Predicting Heart Failure Hospitalization or Cardiovascular Death

1. Elevated NT-proBNP concentrations predicted heart failure (HF) hospitalization and cardiovascular mortality at 2.5 years follow-up, including for patients with atrial fibrillation (AF), regardless of their HF status.

Evidence Rating Level: 2 (Good)

Heart failure (HF) and atrial fibrillation (AF) are both prevalent conditions that contribute significantly to cardiovascular morbidity and mortality. Both conditions are associated with each other, with 50% of AF patients having HF as well, and higher mortality is observed among patients with both HF and AF. Currently, N-terminal pro-B-type natriuretic peptide (NT-proBNP) is measured to diagnose a patient with HF, but natriuretic peptides can also be higher in AF patients, although guidelines do not adjust the NT-proBNP cut-offs for patients with comorbid HF and AF. As well, NT-proBNP is not yet used as a prognostic indicator for cardiovascular morbidity and mortality. Therefore, the current study aimed to explore whether NT-proBNP levels can predict risk of HF hospitalization and cardiovascular mortality at 2.5 year follow-up, in patients with neither AF nor HF, with AF only, with HF only, and with both HF and AF. The study population consisted of 1616 patients taken from the Birmingham and Black Country Atrial Fibrillation registry: The median (IQR) age was 70 (60-78) years, 40% were female, and 77% were White. 30.2% had neither AF nor HF, 21.9% had AF only, 22.8% had HF only, and 25.1% had both AF and HF. Median NT-proBNP levels were lowest in the group with neither AF nor HF, followed by the AF only, HF only, and both AF and HF groups. Following the same trend, the composite outcome of HF hospitalization and cardiovascular mortality occurred in 7.4% of patients with neither (3.2/100 person-years), 15.5% of patients with AF only (7.1/100 person-years), 24.9% of patients with HF only (12.1/100 person-years), and 31.6% (17.7/100 person-years) with both. Furthermore, NT-proBNP levels predicted the composite outcome in all phenotype groups, particularly in those with no HF, such as the AF only group (C-statistic 0.82, 95% CI 0.77-0.87, p < 0.001) and the group with neither AF nor HF (C-statistic 0.73, 95% CI 0.65-0.81, p < 0.001). Overall, this study demonstrated that NT-proBNP levels can be prognostic indicator for HF hospitalization and cardiovascular mortality, even in patients without HF.

Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial

1. 72 hours after administration, full remission of suicidal ideas was achieved at a higher rate following two infusions of ketamine compared to placebo, with the greatest difference observed among patients with bipolar disorder.

Evidence Rating Level: 1 (Excellent)

Currently, suicide is the second leading cause of death in young adults and adolescents. However, there are scant evidence-based options to treat suicidality acutely. For instance, antidepressants can reduce suicide risk, but will often take weeks for benefits to be observed. Commonly, hospital admissions and anxiolytics are used, but suicide rates remain high in psychiatric wards and also after discharge. Intravenous ketamine has been found to rapidly diminish symptoms of depression and suicidal ideation, with a meta-analysis demonstrating improvements in suicidal ideation scores persisting for 72 hours after infusion. The current double-blind, randomized controlled trial based in France assessed the full remission of suicidal ideas 72 hours after two ketamine infusions or placebo, and the persistence of the effect over a 6-week period. The study population consisted of 156 patients admitted to hospital, having a suicidal ideation (SSI) score of greater than 3. 73 were randomized to ketamine (83 to placebo), and were stratified into three groups: Bipolar disorder, depressive disorder, and other diagnoses. The results found that after 72 hours, 63.0% of patients in the ketamine group and 31.6% in placebo had full remission of suicidal ideas, or an SSI score of less than 3 (odds ratio 3.7, 95% CI 1.9-7.3, p < 0.001). This difference was significant in the bipolar disorder group, with 84.6% in the ketamine group versus 28.0% in placebo (OR 14.1, 95% CI 3.0-92.2, p < 0.001), and not significant in the depressive disorder (42.3% vs. 35.7%, OR 1.3, 95% CI 0.3-5.2, p = 0.6) and other diagnoses groups (61.9% vs. 30.8%, OR 3.7, 95% CI 0.9-17.3, p = 0.07). At 6 weeks, 8.2% of those in the ketamine group and 9.8% in placebo had attempted suicide (0 vs 2 patients respectively in the bipolar disorder group, 5 vs 1 patients in the depressive disorder group, and 1 vs 5 patients in the other diagnoses group). As well, there was no significantly higher rate of suicidal remission in the ketamine compared to placebo groups (69.5% vs. 56.3%, OR 0.8, 95% CI 0.3-2.5, p = 0.7), although this may be attributed to diminished suicidality across both groups by week 6. Overall, this study showed that ketamine is a rapid and effective intervention in lowering suicidal ideation within 72 hours, and psychiatric disorders may mediate this relationship, with bipolar disorder having the largest improvement in suicidal ideation with ketamine compared to placebo.

Image: PD

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