2 Minute Medicine Rewind June 19, 2023
1. Intraoperative and postoperative dexmedetomidine significantly decreased the incidence of post-traumatic stress disorder (PTSD) in patients with trauma undergoing emergency surgery.
Evidence Rating Level: 1 (Excellent)
The incidence of PTSD after trauma hospitalization is reported to be as high as 23%. Once PTSD develops, it is highly debilitating, difficult to manage, and associated with increased suicide risk. Dexemedotimidne, widely used to optimize anesthesia and analgesia effects, has been hypothesized to mitigate the formation and consolidation of conditioned fear memories in early trauma. This randomized control trial aimed to examine the impact of dexemedotimidne on the incidence of postoperative PTSD in patients with trauma in the emergency department. From four hospitals in China between January and October 2022, the trial enrolled 350 eligible patients (mean (SD) age 40.2 (10.3), 57.7% men, 42.3% women) undergoing emergency surgery. Patients were randomized in a 1:1 ratio to the normal saline placebo group or the dexmedtomidine. All the participants, surgeons, and research staff were blinded to the treatment group. Those in the dexmedetomidine group were less likely to screen for PTSD (OR, 0.52; 95% CI, 0.29-0.93; P = .03) and had a significantly lower PTSD incidence (14.1% versus 24.0%; adjusted OR, 0.51; 95% CI, 0.27-0.94; P = .03) compared to placebo. Furthermore, when looking at the CAPS-5, a tool to assess the severity of PTSD, the dexmedetomidine group had significantly lower scores as compared to the placebo group (mean difference, 1.65; 95% CI, 0.31-2.99; P = .02). Overall, this trial demonstrated that perioperative administration of dexmedetomidine reduced the incidence of PTSD compared with the placebo, with no significant differences in postoperative delirium, nausea, pruritus, sleep quality, anxiety, and adverse events.
1. In this randomized controlled trial, patients with adenomyosis that received mifepristone were found to have decreased adenomyosis-associated dysmenorrhea intensity at 12 weeks.
Evidence Rating Level: 1 (Excellent)
Adenomyosis, characterized by the presence of ectopic endometrial glands and stroma in the myometrium, is diagnosed in approximately 20% of reproductive-aged people with a uterus. Mifepristone, a selective progesterone receptor modulator found to have applications for endometriosis and uterine fibroids, has shown promise in preclinical and small sample studies as a potential therapy for adenomyosis. This double-blind, multicenter, and placebo-controlled randomized clinical trial was conducted to evaluate the efficacy of mifepristone for adenomyosis compared to traditional treatment. 134 eligible patients aged 18 to 50 years diagnosed with adenomyosis were enrolled from 10 hospitals in China between May 2018 and April 2019. Patients were randomized in a 1:1 ratio, with 66 patients assigned to the mifepristone group (mean [SD] age, 40.2 [4.6] years) and 68 patients assigned to the placebo group (41.7 [5.0] years). After 12 weeks of treatment the mean (SD) change in visual analog scale (VAS) scores, a tool used to evaluate adenomyosis-associated dysmenorrhea intensity, was significantly lower in the mifepristone group (between-group difference, −5.68; 95% CI, −6.37 to −4.99; P < .001). Furthermore, the remission rates for dysmenorrhea in the mifepristone group were significantly better than those in the placebo group (effective remission: 91.8% vs 23.1% of patients; complete remission: 88.5% vs 6.2% of patients; P < .001). Compared to the placebo group, patients in the mifepristone group showed significant improvements in all secondary outcomes (P < .001) — menstrual blood loss, hemoglobin levels, CA125 levels, platelet counts, and uterine volume — with no significant difference in adverse outcomes. Overall, these findings suggest that administering a daily dose of 10 mg of mifepristone over a period of 12 weeks proved to be both safe and effective in managing adenomyosis.
1. For patients with IgA nephropathy (IgAN), long-term use of hydroxychloroquine demonstrated similar antiproteinuric effects compared to corticosteroids at 24 months.
Evidence Rating Level: 3 (Average)
IgAN is the most common form of primary glomerulonephritis, occurring in 1 in 100 people worldwide, and can lead to end-stage renal disease. No specific treatment currently exists for IgAN, but corticosteroids (CS) are widely used as supportive treatment to maintain renal function in patients, despite their significant side effects. This retrospective case-control study aimed to evaluate the long-term antiproteinuric and reno-protective efficacy of HCQ compared to systemic CS. From a single center in China, 39 eligible patients with IgAN who received HCQ treatment for 24 months were identified and propensity score-matched to 39 controls who received systemic CS. In both the CS and HCQ group, the level of proteinuria significantly decreased from baseline at 12 and 24 months (P <0.001). At 12 months, there was no significant difference in proteinuria levels between groups (0.85 [0.50, 1.41] vs. 0.54 [0.19, 0.89] g/d, P = 0.099). However, the HCQ group exhibited a smaller percentage of proteinuria reduction at 12 months compared to the CS group (-47.8% [-66.9%, -33.1%] vs. -73.5% [-89.5%, -57.0%], P = 0.005), indicating that initially, the antiproteinuric effect of HCQ was less pronounced than the systemic CS treatment. With more prolonged follow-up at 24 months, no significant differences were found between the HCQ group and CS group in the levels of proteinuria or the percentage of reduction. Both groups maintained a stable estimated glomerular filtration rate over the 24-month study period. Overall, these findings suggest that the long-term application of HCQ has significant antiproteinuric effects and can maintain stable renal function, similar to CS. HCQ is a well-tolerated supportive treatment for IgAN patients and should be considered as an alternative for patients intolerant to CS.
Risk factors for depression in asthmatic individuals: Findings from NHANES (2005–2018)
1. In this cross-sectional study, hypertension, smoking, and arthritis were identified as risk factors for depression in asthmatic individuals.
2. Higher education and increased age were associated with decreased depression risk.
Evidence Rating Level: 2 (Good)
Asthma, a chronic inflammatory disorder of the airways, affects over 300 million individuals worldwide. It accounts for 1 in every 250 deaths in the world and imposes a substantial economic and social burden. Asthmatic individuals often experience comorbidities, with depression being particularly prevalent and linked to decreased asthma control and quality of life. This study aims to identify the risk factors associated with depression among asthmatic individuals using a nationally representative sample from the National Health and Nutrition Examination Survey (NHANES). Among the 5,379 asthmatic participants identified between 2005 to 2018, 767 had depression and 4,612 did not. In the univariable logistic analyses, multiple factors were associated with a higher likelihood of depression in asthmatic individuals, including female gender, “Other Hispanic” ethnicity, older age, obesity, lower education level, current smoking, hypertension, diabetes, stroke, arthritis, and other comorbid heart or lung conditions. Multivariable analysis confirmed that smoking (OR 1.98, 95% CI 1.19–3.29), hypertension (OR 2.73, 95% CI 1.48–5.04), and arthritis (OR 2.83, 95% CI 1.53–5.22) were independent risk factors for depression in asthmatic individuals. Additionally, having more than a high school education (OR 0.55, 95% CI 0.30–0.99) and increasing age (OR 0.97, 95% CI 0.95–0.99) were associated with a decreased risk of depression in asthmatic individuals. While smoking, hypertension, arthritis, education level, and age were implicated in the development of depression in asthmatic individuals, the directionality of these relationships cannot be determined given the cross-sectional design of the study.
Impact of the COVID-19 pandemic on cancer diagnoses, stage and survival in Alberta
1. This study found that healthcare disruption during the COVID-19 pandemic led to significant reductions in diagnoses and increased mortality of various cancers compared to the period before the pandemic.
Evidence Rating Level: 2 (Good)
The COVID-19 pandemic that started in Canada in January 2020, involved minimizing in-person care for healthcare services not related to COVID-19 in efforts to reduce the strain on the healthcare system. In doing so, there were delays and disruptions in cancer care services including nonemergency surgeries and screening programs. This study aimed to evaluate the impact of COVID-19 on the number of cancer diagnoses, the cancer stage at diagnosis, and cancer survival rates in Alberta. The Alberta Cancer Registry was used to identify 42 862 cancer diagnoses between January 2018 and December 2022. Breast, colorectal, and prostate cancers, and melanoma experienced significant reductions in diagnoses during the state of emergency (SOE) period (Mar 16 to June 15, 2020). New diagnoses of breast, colorectal, prostate, and melanoma cancers were 33%, 36%, 36%, and 43% lower during the SOE than before it, respectively, and monthly diagnoses recovered at a rate of 10%, 8%, 8%, and 9% per month, respectively. In terms of cancer stage, the SOE led to statistically significant decreases in the detection of stage I and III breast cancers, stage I and unstaged colorectal cancers and melanoma, and stage I to III prostate cancers. After accounting for confounding variables, there was an increased risk of mortality for patients diagnosed with colorectal cancer (hazard ratio [HR] 1.21, 95% CI 1.05–1.40), non-Hodgkin lymphoma (HR 1.43, 95% CI 1.14–1.79), and uterine cancer (HR 1.57, 95% CI 1.06–2.33) from March to December 2020 compared those who received the diagnosis in 2018. Overall, these findings suggest that the pandemic-related state of emergency in Alberta corresponded with decreased diagnoses of earlier stage breast, colorectal, and prostate cancers, and melanoma, and increased mortality for colorectal cancer, non-Hodgkin lymphoma, and uterine cancer.
Image: PD
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