2 Minute Medicine Rewind May 31, 2021

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits

1. Emergency department visits for common medical emergencies dropped at the start of the COVID-19 pandemic, but with no changes in complication or mortality rates from these emergencies.

Evidence Rating Level: 2 (Good)

Due to the COVID-19 pandemic, there were concerns that patients in medical emergencies may be hesitant to visit the hospital, potentially leading to adverse complications. For instance, some data has shown that individuals with appendicitis and cholecystitis during the pandemic have presented with more severe illness, and in Italy, there was higher rate of ectopic pregnancy rupture early in the lockdown. The current repeat cross-sectional study based in Ontario, Canada compared the rates of emergency department visits prior to and during the pandemic, for 4 common medical emergencies: Appendicitis, cholecystitis, ectopic pregnancy, and miscarriage. The clinical outcomes and management strategies were also examined. Three time periods were compared: January to July 2019 served as the historical control, January to March 10th 2020 served as the pre-COVID-19 period, and March 11th to June 30th 2020 served as COVID-19 period. In total, 36,691 emergency room visits were included, 40.2% of which were for appendicitis. The results showed that there was a decrease in all visits at the start of the pandemic, but 5 weeks in, the visits for cholecystitis were returning to normal. The incident rate ratio (IRR) ranged from 0.60-0.76 for the first 3 weeks. For ectopic pregnancy, visits were below the historical volume for 3 weeks during the COVID-19 period, with an IRR of 0.53-0.60. However, visits for appendicitis and miscarriage remained lower in the COVID-19 period, with an IRR ranging from 0.61 to 0.80, indicating a decrease of 20-39% compared to the same weeks the year before. Furthermore, there were no differences found in rehospitalization rates, frequency/type of interventions, complications, or mortality rate. Overall, although emergency visits experienced a sudden decrease at the start of the pandemic, there were no changes in the rate of complications or severity of presentations arising from common medical emergencies.


Long‐term cardiovascular outcomes after pregnancy in women with heart disease

1. Women with heart disease had were at greater risk of cardiovascular events postpregnancy, compared to women without heart disease.

2. Tools that assess cardiovascular risk in pregnant women were able to identify higher risk individuals who later experienced adverse cardiovascular events.

Evidence Rating Level: 2 (Good)

The number of women with heart disease undergoing pregnancy is growing, which is currently at 1-4% of pregnancies. Having heart disease in pregnancy is associated with greater risk of cardiac and pregnancy complications, due to the increased hemodynamic stress. However, the long-term cardiac outcomes postpregnancy for this population has not been systematically studied. This retrospective cohort study based in Ontario, Canada compared the long-term cardiovascular outcomes of pregnancy between women with and without heart disease, and also examined the utility of pregnancy risk prediction tools to identify women at risk of adverse cardiac outcomes. The study population consisted of 1014 women with heart disease that had given birth between 1994 and 2015, each matched to two women without heart disease, but with a similar cardiovascular risk score based on demographics. The primary outcomes were all-cause mortality, myocardial infarction, stroke, heart failure, arrhythmia, or atrial fibrillation. Secondary outcomes included cardiovascular death, cardiac procedures, diabetes, or hypertension. The results found that there were 25.3 events per 1000-person years in the heart disease group, compared to 1.1 events in the group without heart disease. This translated to a hazards ratio of 19.6 (95% CI 13.8-29.0, p < 0.0001). The incidence of a primary outcome was 20.1% at 10 years and 33.1% at 20 years in the heart disease group, compared to 2.1% in the control group. There was also a higher rate of secondary outcomes at 20 years, such as cardiovascular death (1.0 versus 0.04 per 1000 person-years), cardiac procedures (30.6% versus 0.5%), and hypertension or diabetes mellitus (27.2% versus 18.4%). Furthermore, tools that estimate cardiovascular risk for pregnant women (such as CARPREG and WHO) were useful in predicting the primary outcomes: For example, heart disease patients in WHO classes III and IV had an incidence of 52.8% and 54.2% respectively, compared to just 12.% for WHO class I patients. Overall, the study demonstrated that pregnant women with heart disease are at elevated risk for cardiovascular events in the long-term, demonstrating the need for risk assessment and continued surveillance of this population postpregnancy.


Clinical indications of premenstrual disorders and subsequent risk of injury: a population-based cohort study in Sweden

1. Women with premenstrual disorders (PMD) were found to be at higher risk for accidents and suicidal behaviours compared to their biological sisters and the general female population.

Evidence Rating Level: 2 (Good)

Premenstrual disorders (PMD) refer to the physical and emotional symptoms associated with the week preceding menstruation. This includes premenstrual syndrome (PMS), which affects around 20-40% of menstruating individuals, and premenstrual dysphoric disorder (PMDD), which affects 2-6% and is diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM). In general, PMD is thought to elevate suicide risk, as it can manifest as depressive and anxiety symptoms. As well, individuals with PMD may be more at risk of accidents, due to feeling irritated or tired. However, these associations have only been shown through retrospective studies, and so the current study based in Sweden prospectively investigated the risk of intentional or unintentional injury in women diagnosed with PMD, comparing their risk to the general population and to their full biological sisters. The study cohort consisted of 1.5 million women born in Sweden between 1960 and 1990, with 18,628 women diagnosed with PMD, and 7,674 of them having full sisters. Injuries or deaths from accidents and suicides were identified through healthcare visit records. The study found that, following a PMD diagnosis, the cumulative incidences for suicidal behaviours and accidents were at 1.6% and 17% respectively, after 12 years follow-up, compared to approximately 0.75% and 14% in the general female population. This translated to a hazards ratio of 1.65 (95% CI 1.43-1.89, p < 0.01) for suicidal behaviours and 1.28 (95% CI 1.23-1.34, p < 0.01) for accidents. Similar results were found in the sibling analysis, although the risk for suicidal behaviours was higher, and had less precision (HR 1.86, 95% CI 1.21-2.87, p < 0.01). However, when controlling for psychiatric comorbidities, no difference in risk for suicidal behaviours was found in the siblings analysis (HR 1.44, 95% CI 0.87-2.40, p = 0.16), suggesting these comorbidities may contribute significantly to this association. In conclusion, women with PMD were found to be at higher risk of injury, particularly accidents, illustrating the importance for healthcare professionals to monitor and be aware of these risks for this population.


Dexamethasone vs methylprednisolone high dose for COVID-19 pneumonia

1. Hospitalized COVID-19 patients receiving high-dose methylprednisolone followed by oral prednisone had improved clinical outcomes compared to patients receiving dexamethasone.

Evidence Rating Level: 2 (Good)

In June 2020, a preliminary report of a study was published comparing hospitalized COVID-19 patients receiving dexamethasone (DXM) 6 mg daily (for 10 days) to patients who didn’t receive corticosteroids. The study found an 11% decrease in mortality for mechanically ventilated patients, and a 2.8% decrease in global mortality. However, it is unknown whether this effect is specific to dexamethasone, or if other corticosteroids would be effective. The current ambispective cohort study compared outcomes of patients on high-dose methylprednisolone (MTP) with those on DXM. This study was conducted at a centre in Colombia, where up until September 14, 2020, the protocol was to treat patients with DXM 6 mg daily for a maximum of 10 days (or until discharge). From September 15 onwards, the protocol changed to MTP 250-500 mg daily for 3 days, then oral prednisone 50 mg daily for 14 days. The cohort consisted of 216 patients, 111 of whom received DXM, and 105 receiving MTP. The results showed that 26.1% of patients in the DXM group developed severe acute respiratory distress syndrome (ARDS), compared to 17.1% in the MTP group. As well, there were lower rates of transfer to the ICU and mortality in the MTP group (4.8% versus 14.4% and 9.5% versus 17.1% respectively). Finally, clinical markers of COVID-19 severity were significantly lower in MTP patients, such as C-reactive protein (2.85, [95% CI 2.3-3.8] versus 7.2 [5.4-9.8], p < 0.0001), and D-dimer (691 [612-874] versus 1083 [740-1565], p = 0.04). Overall, the study found that patients receiving the high-dose methylprednisolone and prednisone treatments had better clinical outcomes than those receiving dexamethasone. However, randomized controlled trials would be needed to provide more robust evidence for this finding.


Racial/ethnic, social, and geographic trends in overdose-associated cardiac arrests during the COVID-19 pandemic

1. Overdose-associated cardiac arrests during the COVID-19 pandemic increased to 98.3% above baseline in May 2020, before declining to 21.4% above baseline in December.

2. Communities that tend to experience fewer cardiac arrests from overdose also experienced the greatest increases in cardiac arrests during the pandemic, including the Latinx and Black communities, and Pacific states.

Evidence Rating Level: 2 (Good)

The United States has been experiencing an overdose crisis for years, and it was predicted that the pandemic would exacerbate the crisis due to heightened isolation and drug supply shifts. The Centers for Disease Control provided preliminary data demonstrating this, with 81,684 deaths from April 2019 to May 2020. However, this data has limitations due to only capturing the first 2-3 months of the lockdown, not separating data by month, and not stratifying by race or other demographics. In recent years, the appearance of toxic fentanyl in the heroin supply has disproportionately affected communities in which overdose cardiac arrests have been lower, such as Black and Latinx communities, and Western states. Therefore, the current study used data from emergency medical services (EMS) to analyze mortality trends from overdose-associated cardiac arrests in the US, taking into account race, geography, urbanicity, and neighbourhood poverty level. This study used data from 11,000 EMS agencies across 49 states, encompassing 33.4 million patient encounters in 2020, and 19,957 cardiac arrests from overdose. Baseline statistics were taken from the years 2018 and 2019. The results showed that they increased in April 2020 and reached 2,112 cardiac arrests in May, the highest ever recorded. Patient encounters decreased overall by 17.7% between March and April 2020. However, overdose cardiac arrests rose to 78.9 per 100,000 EMS activations in May, which was 98.3% higher than baseline (39.8 per 100,000). Over the course of the year, the rate decreased to 56.7 per 100,000 by December (21.4% above the baseline of 46.7 per 100,000). Additionally, although cardiac arrests were more prevalent in White individuals prior to and during the pandemic, larger increases were observed for Latinx and Black patients in 2020, with increases of 49.7% and 50.3% respectively, compared to an increase of 38.3% in White patients. Those living in impoverished neighbourhoods and Pacific states also experienced large increases (46.4% and 63.8% respectively). In conclusion, there was an enormous increase in overdose-associated cardiac arrests in the United States during the pandemic months of 2020, demonstrating the need for prioritizing overdose prevention measures, especially in communities that experienced larger increases in deaths compared to pre-pandemic era.

Image: PD

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