2 Minute Medicine Rewind September 19, 2022

Anticoagulant use and associated outcomes in older patients receiving home palliative care: a retrospective cohort study

1. The decision to discontinue anticoagulation in palliative care patients was not strongly associated with patient factors and comorbidities, except recent knee or hip arthroplasty.

2. Discontinuation was associated with lower rates of bleeding, similar rates of thrombosis, and increased rates of mortality.

Evidence Rating Level: 2 (Good)

Patients in palliative care are often on anticoagulation medication due to a medical history that increases the risk of stroke and venous thromboembolism. However, it is a goal in palliative care to minimize medication burden, only taking those that are compatible with patient goals. As such, the use of anticoagulants in palliative care has not been well-studied. This current retrospective cohort study examined the rates of anticoagulation discontinuation in palliative care, as well as compared factors and outcomes for discontinued and continued anticoagulation patients. The study population consisted of all individuals in Ontario, Canada 66 years and older, who had their first physician home palliative care visit (index date) between 2010 and 2018. Discontinuation was primarily defined as not having a claim within 1.5 times the day’s supply, or within 7 days of the previous supply’s expiry. In total, 8687 patients were on anticoagulation at the index date, 24.4% of whom discontinued therapy by the study’s primary definition. The only patient factors and comorbidities that strongly predicted discontinuation were recent knee or hip arthroplasty (odds ratio 13.71, 95% CI 5.69-33.03). After adjusting for patient and physician factors, the use of a direct oral anticoagulant (DOAC) and low molecular weight heparin (LMWH) were less likely to be discontinued (OR 0.49, 95% CI 0.43-0.56 and OR 0.56, 95% CI 0.47-0.66 respectively). Furthermore, at a median follow-up of 111 (IQR 32-400) days, discontinuation was associated with decreased bleeding rates (adjusted hazards ratio 0.75, 95% CI 0.62-0.90), comparable rates of thrombosis (adjusted HR 1.06, 95% CI 0.81-1.39), and increased mortality (adjusted HR 1.35, 95% CI 1.28-1.42). Overall, this study demonstrated that the decision to continue anticoagulation in palliative care is not necessarily associated with patient factors and that there are risks and benefits when it comes to the outcomes of continuing or discontinuing anticoagulation.

Same-Day Home Recovery for Benign Foregut Surgery

1. A program to promote same-day home recovery (SHR) for patients after benign foregut surgery improved SHR rates from 11.5% to 72.6% gradually over 3 years.

Evidence Rating Level: 2 (Good)

Same-day home recovery (SHR) has become a care standard for many surgical procedures, including minimally invasive general surgery and orthopedic surgery. As such, a benign foregut surgery group based out of Northern California developed a program to increase the rates of SHR for these procedures. This current study evaluates the rates of SHR and adverse events before and after this implementation. The SHR program was created by foregut surgeons with patient education at the centre, including patient-family involvement by outlining how to prepare for surgery, expectations for the patient’s condition after surgery, and how to promote recovery at home. Other aspects included promoting early oral intake, early physical activity, and an opioid-sparing analgesic plan post-operatively. In total, 1248 patients underwent the 3 most common benign foregut surgery procedures (hiatal hernia repair, fundoplication, and Heller myotomy) in the study period, with 558 occurring prior to the SHR program, and 690 occurring after. The results showed that the SHR rate was 11.5% in 2018 prior to the program and increased gradually to 26.9% in 2019, 49.3% in 2020, and 72.6% in 2021 (p < 0.001). Additionally, there were comparable rates of mortality (1 death in both groups), postoperative ED visits at 7 and 30 days, hospital readmissions, and reoperations. Overall, this study showed that an SHR program centred on patient education and early recovery increased the rate of SHR amongst benign foregut surgery patients, without differences in adverse events or complications.

Association of Mental Health Burden With Prenatal Cannabis Exposure From Childhood to Early Adolescence: Longitudinal Findings From the Adolescent Brain Cognitive Development (ABCD) Study

1. Prenatal cannabis exposure was associated with increased rates of psychopathology, including rule-breaking and aggressive behaviour, at middle childhood and at early adolescence.

Evidence Rating Level: 2 (Good)

The Adolescent Brain Cognitive Development (ABCD) study is a longitudinal cohort study based in the United States, enrolling 11,880 children between the ages of 9 and 10, to follow their cognitive and behavioural development into adolescence and adulthood. This study had previously found an association at baseline with prenatal cannabis exposure (PCE) and psychopathologies, such as rule-breaking behaviour and conduct problems. The current study examined whether these associations remained in the early adolescent years, at 1 and 2 years follow-up. In the ABCD cohort, maternal cannabis consumption was reported retrospectively, either as before knowledge of pregnancy (BK-PCE), before and after knowledge (BAK-PCE), or as no exposure (NE). In total, there were 391 participants in the BK-PCE group, 208 in the BAK-PCE, and 10,032 in the NE group. The results showed that the associations with PCE and psychopathology persisted into early adolescence, not changing with age, and being driven mostly by PCE after knowledge of pregnancy. For instance, the rates for total problems on the child behavioural check list (CBCL) were 23.41% for the BAK-PCE group, 19.66% for the BK-PCE group, and 15.55% for the NE group, leading to p < 0.001 when comparing BAK-PCE to NE and comparing BAK-PCE to BK-PCE, but leaving no significant difference (p = 0.29) when comparing BK-PCE to NE. This pattern was also seen for externalizing factors, rule-breaking behaviour, aggressive behaviour, and social problems. Overall, this study demonstrated that associations between PCE and psychopathology are present in middle childhood and can persist to early adolescence as well.

Impact of Socioeconomic Status on Mortality and Readmission in Patients With Heart Failure With Reduced Ejection Fraction: The ARIC Study

1. Amongst patients with HFrEF, lower socioeconomic status was associated with increased rates of HFrEF readmission and all-cause mortality, even when adjusting for usage of guideline-directed medical therapies (GDMTs).

Evidence Rating Level: 2 (Good)

Heart failure (HF) affects over 6.5 million people in the USA, but advancements in guideline-directed medical therapies (GDMTs) have improved rates for mortality and readmission in those with reduced ejection fraction (HFrEF). While lower socioeconomic status (SES) is associated with higher rates of incident HF, there is not as much known about SES and HFrEF prognosis, where uptake of GDMTs has a profound effect on outcomes. Therefore, this current study examined the association between SES and the risk of HFrEF readmission and all-cause mortality. SES was measured in several different ways, including income, education level, and area deprivation index (ADI) quartile. The cohort was taken from the Atherosclerosis Risk in Communities (ARIC) study, which has 15,792 participants based out of communities in 3 states, and between 2005 and 2018, there were 728 eligible patients who had HFrEF events. The results showed that low income <$12,000 compared to income >$50,000 was associated with increased mortality (hazards ratio 1.52, 95% CI 1.14-2.04), and low income also increased the risk of HFrEF readmission (HR 1.45, 95% CI 1.04-2.03). Additionally, having below a high school education level was associated with increased mortality (HR 1.27, 95% CI 1.01-1.59) and readmission (HR 1.62, 95% CI 1.24-2.12), whereas ADI had no mortality association, but an increased readmission risk (HR 1.69, 95% CI 1.11-1.28). Finally, even after adjusting for uptake of GDMT, there still remained associations between low SES and poorer HFrEF prognosis. Overall, this study demonstrated that numerous metrics of lower SES were associated with increased HFrEF readmission and all-cause mortality, regardless of GDMT status.

Impact of ultrasonographic blind spots for early-stage hepatocellular carcinoma during surveillance

1. Hepatocellular carcinoma (HCC) tumours located in ultrasound (US) blind spots were associated with poorer overall survival if not detected by US, larger tumour size, and greater likelihood of treatment with hepatectomy as opposed to radiofrequency ablation, compared to tumours in non-blind spots.

Evidence Rating Level: 2 (Good)

Hepatocellular carcinoma (HCC) relies on early detection for patient survival, with high-risk populations receiving half-yearly abdominal ultrasound (US), with or without serum alpha-fetoprotein (AFP), based on worldwide guidelines. However, US-based surveillance is controversial due to its substandard accuracy, in part due to inherent blind spots. These are areas with poor acoustic penetration due to anatomical limitations. Because varying tumour locations impact liver function differently, identifying lesions in blind spot areas could influence the treatments offered. Currently, there have been no studies examining the effects of US blind spot tumours on HCC prognosis. Therefore, this retrospective study based in China evaluated the characteristics of blind spot location tumours and their impact on prognosis and treatment selection. The study population consisted of 1289 participants with single-nodular BCLC stage 0-A HCC. Patients were divided into two groups: The US-detected group (n=1062) consisted of those with malignancies detected on US with or without an AFP increase, whereas the US-missed group (n=227) included those with no US lesions but an increased AFP. The ultrasounds were re-evaluated manually by researchers with greater than 5 years of US experience, and blind spots were defined as the hepatic dome, caudate lobe around the IVC, <1 cm beneath the ribs, and the left lateral segment surface. The results showed that more HCC blind spot tumours were found in the US-missed group than the US-detected group (64.3% vs 44.6%, p < 0.001). As well, a significant proportion of tumours >2 cm were within blind spot regions compared to non-blind spot regions (60.3% vs 47.1%, p = 0.001). After adjustment, factors associated with blind spot lesions include male sex, HCC size > 2 cm, cirrhosis signs, and US-missed HCC. Furthermore, there was no difference between blind spot and non-blind spot lesions in the proportion of those receiving curative treatment, even after adjusting for size. However, a greater proportion of blind spot tumours were treated with hepatectomy (60.0% vs 46.0%, p < 0.001) whereas non-blind spot tumours were more likely treated with radiofrequency ablation (30.5% vs 16.95%, p < 0.001). In terms of survival, the US-missed group had a significantly lower overall survival than the US-detected group when an HCC tumour was in a blind spot (p = 0.008), but was not different when the tumour was not in a blind spot. Overall, this study showed how blind spot location was associated with differences in tumour size, treatment type, and overall survival if not detected by US.

Image: PD

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