2 Minute Medicine Rewind January 15, 2018
Long-Term Effects of Inhaled Budesonide for Bronchopulmonary Dysplasia
Among extremely pre-term infants, bronchopulmonary dysplasia is the most common chronic complication, associated with high mortality and other sequelae, including growth failure, chronic cardiovascular deficits and neurodevelopmental delay. Inhaled glucocorticoids, such as budesonide, are used in the prevention and treatment of this disease. In this randomized controlled trial, 863 infants born extremely preterm (gestational age 23 weeks 0 days to 27 weeks 6 days) were randomly assigned to receive either budesonide or placebo within 24 hours of birth to investigate the long-term effects of inhaled budesonide on the neurodevelopment of children. Infants were followed up for neurodevelopmental disability, a composite measure that included cerebral palsy, deafness, blindness, and cerebral palsy, all measured at a corrected age of 18-24 months. Researchers found that the incidence of neurodevelopmental disability was not significantly different between the two groups (RR 0.93, 95% CI 0.80 to 1.09, p=0.40). The mortality rate, however, was higher in the budesonide group, where death occurred in 19.9% of the infants compared to 14.5% of infants in the control group (RR 1.37, 95% CI 1.01 to 1.86, p=0.04). Investigators therefore concluded that there was no difference in the long-term neurodevelopmental outcomes of infants treated with budesonide, as compared to placebo. However, the mortality rate was greater in infants that received budesonide.
Patients requiring mechanical ventilation in the setting of critical illness incur the risk of malnutrition and, therefore, early feeding is recommended. However, it is currently unknown whether the route of feeding, enteral or parenteral, affects patient outcomes. This randomized controlled trial enrolled 2,410 adults receiving mechanical ventilation and vasopressor support and assigned them to receive either parenteral or enteral nutrition, both with normal caloric goals. Patients were followed up for mortality within 28 days of randomization. Researchers found no significant difference in mortality rate at 28 days, as 37% of those in the enteral group and 35% of those in the parenteral group had reached the primary end point (absolute difference 2%, 95% CI -1.9 to 5.8, p=0.33; HR 0.89, 95% CI 0.72 to 1.09, p=0.25). Infection rates in the intensive care unit (ICU) were also not significantly different between groups. However, individuals fed with enteral nutrition were at a higher risk of experience gastrointestinal complications, including diarrhea (HR 1.20, 95% CI 1.05 to 1.37, p=0.009), vomiting (HR 1.89, 95% CI 1.62 to 2.20, p<0.0001), and bowel ischemia (HR 3.84, 95% CI 1.43 to 10.3, p=0.007). Investigators concluded that early enteral feeding in this patient population did not improve mortality rate, but was associated with more gastrointestinal complications.
Weight loss has been associated with increased adherence to healthy dietary patterns. However, the effects of a healthy diet on genetic predisposition to obesity are currently unknown. In this prospective cohort study, a genetic predisposition score based on 77 genetic factors associated with body mass index (BMI) was measured in 5,218 men and 8,828 women who were then assessed for adherence to a healthy diet by the Alternate Healthy Eating Index 2010 (AHEI-2010) and followed up for body mass index (BMI) and body weight change, measured in 4-year intervals over 20 years. Results showed that, in both men and women, the effects of genetic predisposition on body mass index were significantly diminished by adherence to healthy dietary patterns. The 4-year change in BMI per 10 risk allele increment was -0.01 for those with increased AHEI-2010 score and 0.07 (SE 0.02) with a decreased AHEI-200 score (p<0.001 for interaction). Additionally, for low, intermediate, and high genetic risk of obesity, the changes in BMI per 1 standard deviation increase in AHEI were -0.35, -0.36, and -0.50, respectively. Investigators therefore concluded that healthy diet has a profound effect on weight management in those with a strong predisposition for obesity and can help mediate the effects of genetic predisposition in the population as a whole.
Anesthesiologists frequently hand over care intraoperatively. The effects of intraoperative handover on outcomes, however, are currently unknown. This retrospective study aimed to investigate the effects of complete handover of anesthesia care on patient outcomes. The cohort included 313,066 patients that were undergoing major surgery expected to last at least 2 hours and require at least one night in the hospital. A composite of major post-operative complications, hospital re-admission, and all-cause mortality was selected as the primary outcome. Of the 5,941 patients whose anesthesia care was completely handed over (1.9%), the primary outcome was met in 44%. This was significantly greater than the 29% of patients meeting the primary outcome in the group where handover did not occur (adjusted risk difference 6.8%, 95% CI 4.5% to 9.1%, p<0.001). The risk of major complications (adjusted risk difference 5.8%, 95% CI 3.6% to 7.9%, p<0.001) and all-cause death (adjusted risk difference 1.2%, 95% CI 0.5% to 2%, p=0.002), when analyzed individually, were also significantly increased in the group with a complete anesthesia care handoff. Investigators concluded that completely handing over anesthesia care intraoperatively is associated with higher rates of complications, such as all-cause death.
Transfer of Fresh Versus Frozen Embryos in Ovulatory Women
Using frozen embryos for in vitro fertilization (IVF) in women with polycystic ovarian syndrome (PCOS) has previously been shown to improve pregnancy rates and outcomes perinatally. However, outcomes in infertile women who are ovulatory are currently unknown. This randomized controlled trial enrolled 2,157 infertile, ovulatory women without PCOS and assigned them to receive either fresh embryo transfer or transfer after cryopreservation to investigate the effects of fresh versus frozen embryo transfer on a primary outcome of live birth after the first transfer. Researchers found that there was not a significant difference between the two groups, as 48.7% of women with frozen embryos and 50.2% of women with fresh embryos experienced live birth on the first transfer (RR 0.97, 95% CI 0.89 to 1.06, p=0.50). However, ovarian hyperstimulation syndrome was significantly lower in the frozen embryo group, occurring in 0.6% of women versus 2% in the fresh embryo group (RR 0.32, 95% CI 0.14 to 0.74, p=0.005). The risks of obstetrical and neonatal complications and other adverse outcomes did not differ significantly between groups. Investigators therefore concluded that, among women with ovulatory infertility, frozen embryos led to a similar live-birth rate as fresh embryos, but a significantly lower risk of ovarian hyperstimulation.
Image: PD
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