2 Minute Medicine Rewind June 14, 2021

Postpartum mental illness during the COVID-19 pandemic: a population-based, repeated cross-sectional study

1. Clinical visits for postpartum mental health illness increased in the first 9 months of the COVID-19 pandemic comparatively to pre-pandemic rates, peaking between 0 and 90 days after birth. 

2. In Ontario, Canada, postpartum people living in low income neighbourhoods had less significant visit increases compared to higher income neighbourhoods. 

Evidence Rating Level: 2 (Good)

Postpartum mental illness affects approximately 1 in 5 mothers, and can present as anxiety, depression, bipolar disorder, psychotic disorders, alcohol and or substance abuse. This emotional burden on mothers also represents a clinical burden on the health care system with increasing rates due to the COVID-19 pandemic. This study aimed to better understand the extent of this exasperation by comparing pre and current pandemic data.  In this population-based, repeated cross-sectional study, patient records (n=137 609) were extracted from health care data from Ontario, Canada to assess rate changes of postpartum mental illness visits before and after the start of the COVID-19 pandemic. This data was combined, and a negative binomial regression was employed to contrast expected visit rates per 1000 postpartum people from March–November 2020 compared to pre-pandemic data, January 2016–February 2020.  The study outcome measured was a mental health visit to a primary care physician or a psychiatrist. Incidence ratio was calculated and a stratified analysis, using sociodemographic characteristics such as ethnicity groups (specifically Chinese and South Asian individuals based on surnames), was completed. Elevated rate differences in postpartum mental health visits peaked between 0-90 days after birth, with the highest rate difference being in April 2020 [(RD = 11.7; 95% CI 10.0–13.5) (IRR = 1.30; 95% CI 1.24–1.36)]. Postpartum people living in lower income neighbourhoods had less significant increases in visit rates. However, individuals who did not seek out postpartum mental health support did not necessarily indicate a lack of mental illness. Furthermore, visit rates of postpartum people with Chinese surnames increased in April, whereas rates for those with South Asian surnames became elevated later into the pandemic, peaking in June. South Asian and Chinese postpartum people do not fully represent Ontarian postpartum people and therefore cannot be generalizable to the entire Canadian population. Overall, this study revealed the impacts of the COVID-19 pandemic on postpartum mental health, and highlighted the need for further support. Accessibility to resources such as support groups, breastfeeding clinics, mental health check-ins from health care professionals are imperative to meet the constantly evolving needs of postpartum people.


Caregiver-reported health-related quality of life of New Zealand children born very and extremely preterm

1. Caregivers reported good health related quality of life of New Zealand children despite their shorter gestational periods

2. Neurodevelopmental impairment and socio-economic deprivation were found to be associated with lower health related quality of life (HRQoL). 

Evidence Rating Level: 2 (Good) 

Children born with shorter gestational periods have been found to have greater morbidity and mortality risk factors. Specifically, preterm births can lead to higher risk of neurodevelopmental impairments (NDI) such as cerebral palsy, visual or hearing impairments, and motor function delays. Children born very or extremely preterm represent approximately 16% of preterm births, however, health related quality of life (HRQoL) of these children have not been extensively studied. This retrospective cohort study aimed to not only address this gap in the research but also to better understand the factors influencing HRQoL as well as long term impacts later in life. In order to do this, data was collected on a cohort of children (n=127) born preterm and very preterm (mean gestational age of 26.7 weeks). This cohort was composed of children born <30 weeks’ gestation or <1500 g birthweight in Auckland, New Zealand between 2005-2008.  Of these children 6% had a diagnosed neurological impairment during their neonatal period and at 7 years, 47% were categorized as having one. The effects of these NDIs lead to reduced individual functioning, socio-economic deprivation, and worse psychosocial HRQoL. The assessment of HRQoL took a holistic approach in order to consider all domains of the children’s health. Specifically, The Wechsler Intelligence Scale for Children 4th Edition (WISC-IV) and the Movement Assessment Battery for Children 2nd Edition (MABC-2) were used to assess the IQ and physical abilities of the children. Visual acuity, neurological examinations, and Gross Motor Function Classification Score (GMFCS) were also utilized. Furthermore, the caregivers completed the Child Health Questionnaire Parent Form 50 Questions (CHQ-PF50) and the modified Health Utilities Index Mark 2 (HUI-2) to assess the children’s perceived physical, social, and emotional wellbeing. Overall, participants reported good HRQoL across all assessed domains. Factors potentially influencing caregiver’s responses may have included their family dynamic and social environments. Caregiver stress and low socioeconomic status may have also impacted their perception of their child’s quality of life. Additionally, for the children themselves, accessibility of social opportunities, anxiety, depression, and cognitive difficulties may all have an impact on their HRQoL. The study results revealed NDI, lower gestational age, and greater socio-economic deprivation have varying levels of association with HRQoL. However, the children’s IQ as well as their motor function were the only independent predictors. Ultimately, this study can help guide strategies to improve HRQoL in preterm children by improving and preventing NDIs as well as improving socio-economic situations of children and their caregivers. The lifelong implications for individuals with NDIs are more significant than the impacts of their shorter gestation periods.


Association between well-being and compliance with COVID-19 preventive measures by healthcare professionals: A cross-sectional study

1. Healthcare providers were found to have higher compliance with COVID-19 preventative measures and had more positive attitudes towards their well-being compared to non healthcare workers.

2. Healthcare providers were more knowledgeable with regards to personal hygiene, personal protective equipment, and COVID-19 transmission than non health care providers.

Evidence Rating Level:  2 (Good)

The COVID-19 pandemic is omnipresent and an international priority in 2021. While studies focus on understanding, controlling the virus, and vaccine distribution, prevention is of the utmost importance to limit propagation of the disease. Certain public health measures and preventative strategies have proven to be effective such as social distancing, wearing masks, and disinfecting surfaces. However, compliance and factors effecting adherence with these health measures had not been previously extensively studied. This multicentre cross-sectional study collected information regarding knowledge, attitudes, and practises (KAP) of COVID-19 preventative measures and respondents’ perceived risk and well being. More specifically, this cross-sectional study consisted of a multinational survey with 2703 respondents across 36 counties between May and June, 2020. The survey was disseminated on various social media platforms and reached individuals over 21 years of age working in healthcare (40.5%) or elsewhere (59.5%). Health care professionals (HCPs) were found to have significantly more knowledge on personal hygiene and COVID-19 risk transmission compared to non-HCPs ((mean knowledge score—1.88, SD– 0.35 vs. mean knowledge score—1.80, SD– 0.44 (p-value—<0.001)). In other words, HCPs were 1.21 times more likely to have a positive attitude towards personal hygiene such as hand washing compared to non-HCPs. HCPs were also more compliant with personal protective equipment such as face masks and 1.46 times more likely to use a contract tracing app to prevent future spread compared to non-HCPs (80.6% vs. 73.9%, p-value—<0.01). Additional factors leading to compliance may have included societal pressure, social media, and interpersonal relationships. Attitudes and compliance towards social distancing were not significantly different between the two groups but knowledge of the safe distancing measures was higher in HCPs. Individuals with higher job satisfaction had better perceived well being and higher perceived health status. HCPs were found to have significantly higher rates of good well-being compared to non-HCP (74.8% vs. 68. 6%, p-value—<0.001).  A limitation of this study was that wellbeing was evaluated with a continuous score that did not account for severity. The threshold created a dichotomous score of low or high compliance and low or high wellbeing with a cut-off score of 75%. Therefore, individuals with 74% would be classified as having poor or low well being. This study highlights the importance of targeting public health measures to individuals and communities with lower compliance through platforms such as social media. It is imperative for risk mitigation to target awareness and education towards these more at-risk and vulnerable individuals.  Additionally, efforts should be made to increase mental health services in order to promote wellbeing and ultimately compliance. It also emphasized the importance of prevention and adherence to public health guidelines, such as good hand hygiene and social distancing, as protective measures from COVID-19. Finally, preventive strategies should rely on attitudes, perceptions, and responsiveness of the public in order to increase compliance.


Cognitive outcomes in children of pregnant women with epilepsy

Evidence Rating Level: 1 (Excellent) 

1. There were no language ability differences among 2-year-old children of women taking epileptic medication during pregnancy compared to children of healthy women not taking medication. 

2. Anti-seizure medications taken in the third trimester of pregnancy had insignificant teratogenic effects on the developing fetal brain and subsequent cognitive abilities. 

While it is generally a well-known fact that teratogens are to be avoided during pregnancy to reduce risk of fetal development abnormalities, the most commonly prescribed teratogens are anti-seizure medications (ASMs). Unfortunately, there remains a lack of knowledge surrounding risks, dosage, and long-term effects of these medications taken during the 3rd trimester. Furthermore, due to ethical reasons, randomization of participants and experimental research is prohibited when studying vulnerable populations such as pregnant women and their fetuses. Risks associated with teratogens such as ASMs are dose dependent and this study aimed to better understand cognitive effects on children at 2 years of age in order to adjust dose management and future treatment plans. This prospective study began at birth, continued with an assessment at 2 years old, and will also continue for an assessment at 6 years old. The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study involved 20 epilepsy centers in the United States. This multicenter, observational cohort study included 292 children of women with epilepsy (WWE) and 90 children of healthy women (without epilepsy). The MONEAD study looked specifically at the impacts of women taking anti-seizure medications (ASM) during their 3rd trimester of pregnancy. The goal of the primary analysis was focused on assessing language domain scores in order to understand effects on cognitive abilities in children at 2 years of age. The secondary analysis investigated the other 4 domains of the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) including; motor control, cognitive, social-emotional and general adaptive. Overall, the study found there were no significant differences between children of both cohorts in all domains. Differences in cognitive abilities were attributable to confounding factors of the mother and child, but none were significantly associated with the ASMs themselves. This study highlights the lack of understanding and unknown effects of teratogens during pregnancy such as anti-seizure medications. Finally, dose management during pregnancy is challenging as the long-term effects are often unclear and further research is required including the follow up study at 6 years of age.


Ibrutinib plus Venetoclax for first-line treatment of chronic lymphocytic leukemia: nonrandomized phase 2 trial

Evidence Rating Level: 2 (Good) 

1. Combination therapy of Ibrutinib and Venetoclax may be successful first-line treatments for patients with Chronic Lymphocytic Leukemia (CLL) who are currently not undergoing treatment 

2. This combination therapy had a 3-year progression free survival (PFS) of 93% in first line treatment of CLL 

The evolution and treatment of chronic lymphocytic leukemia (CLL) presents a clinical burden on the healthcare system causing a need for treatment plans to rapidly evolve in order to control the condition. The main form of treatment has shifted away from chemoimmunotherapy and towards oral targeted medications. However, success rates and durability of CLL treatment requires further research, particularly when comparing monotherapy to combined therapies. This study looked specifically at Ibrutinib, a Bruton tyrosine kinase (BTK) inhibitor as well as Venetoclax, a Bcl-2 inhibitor. These drugs have been used primarily in monotherapy leading to partial but not full remission of CLL. This nonrandomized phase 2 trial aimed to better understand the synergy of the two drugs by assessing remission and durability of CLL when combining the two medications. The study did this by assessing the measurable residual disease (MRD) in patients taking these medications together. While patients underwent cycles of treatment, this MRD was monitored in the bone marrow using peripheral blood samples taken every 6 months. More specifically, the study was a phase 2, non randomized trial conducted with patients currently not undergoing CLL treatment. The participants in the study had either del(17p), TP53-mutated CLL, del(11q), unmutated immunoglobulin heavy chain variable gene, or were aged 65 or older. In total, 75 patients taking combination therapy of Ibrutinib and Venetoclax were included in the study between August 2016 and June 2018. Serial assessments of their bone marrow were performed to achieve undetectable MRD remission (U-MRD).  Overall, 75% of the baseline cohort (n=60) reached U-MRD remission during the study period. Furthermore, the estimated 3-year progression free survival (PFS) rate was 93% (95% CI, 88%-99%) with an overall survival rate of 96% (95% CI, 92%-100%). While patients had variable outcomes, remission rates and PFS rates, the study found that no participants had CLL progression while taking the combined therapy. The study results focused on the impact of the combined therapy on CLL, however it is worth noting that participants had side effects, adverse events, complications, and one possible treatment-associated death was reported.  Overall, this study reveals that further research is required to better understand the long-term effects of combined treatment with Ibrutinib and Venetoclax as this study had a relatively short follow up period of only 38.5 months.

Image: PD

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