2 Minute Medicine Rewind September 28, 2020

Identification of Modifiable Social and Behavioral Factors Associated With Childhood Cognitive Performance

1. Moderate increases in positive exposures were associated with improved cognitive performance in children.

2. Black children experienced fewer cognitively beneficial exposures than other racial groups.

Evidence Rating Level: 2 (Good)

Racial disparities in all aspects of healthcare are at least partially consequences of inequitable social environments. Identifying and modifying these risk factors associated with racial disparities can serve to reduce or prevent these disparities in long-term health outcomes. This longitudinal pregnancy cohort study sought to identify these modifiable risk factors associated with childhood cognitive performance. A total of 1,503 mother-child dyads were enrolled in the University of Tennessee Health Science Center-Conditions Affecting Neurodevelopment and Learning in Early Life study between December 1, 2006 and July 31, 2011. Women were recruited between 16 and 28 weeks’ gestation from four hospitals in one Tennessee county (M [SD] age = 26.0 [5.6] years, 64.1% Black). These individuals were evaluated annually until children reached four to six years of age. Of these dyads, 1,055 were used in subsequent analyses with 155 prenatal, perinatal, and postnatal exposures, involving socioeconomic position, family structure, maternal mental health, nutrition, parenting behaviours, and other factors. Approximately 50.4% of the children were female and 59.0% of the women had a high school education or lower. Following the least absolute shrinkage and selection operator regression analysis, 24 factors were retained. Child cognitive performance, as measured by the Stanford-Binet Intelligence Scales, Fifth Edition (SB-5), was associated with parental education and breastfeeding. For every one standard deviation increase in exposure, positive associations were discovered with cognitive growth fostering from dyad interactions (β = 1.12, 95% CI 0.24 to 2.0) and maternal reading ability (β = 1.42, 95% CI 0.16 to 2.68). A negative association was found between cognitive performance and parenting stress (β = -1.04, 95% CI -1.86 to -0.21). Moderate increases in the positive exposures were associated with improvement in estimated cognitive performance using marginal means (0.5% of 1 SD). Black children were exposed to fewer beneficial cognitive performance measures than other racial groups, though no significant racial disparities were noted in cognitive performance. Overall, this study suggests that individuals can capitalize on positive exposures through increasing their frequency, which seems to improve cognitive development in early childhood.


Antibiotic Prescribing for Lower UTI in Elderly Patients in Primary Care and Risk of Bloodstream Infection: A Cohort Study Using Electronic Health Records in England

1. Delaying antibiotic treatment for UTI in older adults did not increase risk of bloodstream infection compared to immediate antibiotic treatment.

2. Delayed treatment may have contributed to increased risk of mortality in this group.

Evidence Rating Level: 3 (Average)

Urinary tract infection (UTIs) is one of the most common reasons for antibiotic prescription, which is frequently caused by the Escherichia coli (E. coli) pathogen. The rate of E. coli bloodstream infection (BSI) is highest in older adults. Clinically, the safety of delaying treatment among this population with suspected UTI has been questioned. This retrospective study aimed to investigate the relationship between antibiotic timing for UTI treatment and risk of BSI using the nationally representative, United Kingdom Clinical Practice Research Datalink database. Included participants were aged 65 years or older between April 1, 2007 and March 31, 2015, with a minimum of 60 days of follow-up. A total of 280,562 people were included in the final dataset (Med [IQR] age = 77.3 [71.1 to 83.9] years, 77.5% female). This study discovered that delaying antibiotic treatment for UTI did not increase risk of BSI but there was some evidence that it may result in increased mortality. Compared to men, women were more likely to develop BSI (adjusted OR 0.49, 9% CI 0.43 to 0.55, p<0.001). BSI was independently associated with both social deprivation (adjusted OR 1.45, 95% CI 1.19 to 1.76, p<0.001) and increasing age (adjusted OR 1.22, 95% CI 1.18 to 1.27 per 5 years, p<0.001). Analyses suggested that there were differences between those who received immediate antibiotic treatment and those whose treatment was delayed, which are likely due to confounding. Overall, this study suggests that delaying antibiotic treatment for suspected UTI in older adults may increase the risk of mortality without demonstrating sufficient advantages over immediate treatment.


Cardiac Abnormalities Seen in Pediatric Patients During the SARS-CoV2 Pandemic: An International Experience

1. Pediatric patients during the COVID-19 pandemic present with a wide range of cardiac manifestations that require early detection and treatment.

Evidence Rating Level: 2 (Good)

The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) has resulted in increased hyperinflammatory presentations in otherwise healthy children. This international, multi-center, retrospective chart review examined cardiac manifestations in a pediatric cohort with multi-system inflammatory syndrome (MIS-C) occurring during the SARS-CoV2 pandemic. A total of 55 children from five countries met inclusion criteria (M [SD] age = 7.0 [5.2] years). A total of 27 patients (49%) required ICU admission, 35 patients (64%) had evidence of myocardial dysfunction (left ventricular ejection fraction [LVEF] < 60%), 24 patients (44%) had evidence of shock, and 2 patients (4%) did not survive. A total of 11 patients (20% met full criteria for Kawasaki disease and had lower NT pro-BNP (M [SD] = 1,606 [1,089], p = 0.007), ferritin (M [SD] = 171 [57], p = 0.008), and D-dimer (M [SD] = 1.4 [0.7], p = 0.025) levels compared to those not meeting full diagnostic criteria. Patients with full Kawasaki criteria, compared to others, were also younger (M [SD] age = 5.4 [5.7] years, p = 0.01), experienced longer fevers (M [SD] length = 6.3 [1.3] days, p = 0.07), and better LVEF (LVEF 58 [9%], p = 0.05). Overall, this study highlights the spectrum of cardiac manifestations among pediatric patients during the SARS-CoV2 pandemic, allowing for better detection and preparation for treatment in clinical settings.


Association of Sarcopenia and Body Composition With Short-Term Outcomes After Liver Resection for Malignant Tumor

1. Sarcopenia was an independent risk factor for reduced muscle mass and strength following liver resection for malignant neoplasms.

Evidence Rating Level: 2 (Good)

Sarcopenia is an involuntary, age-related loss of skeletal muscle mass and strength. This condition is known to drastically impact postoperative and oncological outcomes following liver resection for malignant neoplasms, yet evidence is limited to retrospective studies. This cohort study investigated the relationship between sarcopenia and 90-day morbidity after liver resection in this population.  A total of 234 patients undergoing liver resection for malignant neoplasms at one hospital in Rome, Italy between June 1, 2018 and December 15, 2019 were included in this study (median age [interquartile range, IQR] = 66.50 [58.00 to 74.25] years, 32.5% female). Variables of interest were skeletal muscle index (SMI) on preoperative computed tomography (CT) scans and grip strength. These patients were divided into Group A (normal muscle mass+strength), Group B (reduced muscle strength), Group C (reduced muscle mass), and Group D (reduced muscle mass+strength). One-hundred seventy minor and 64 major hepatectomies were performed among the patients. Group D comprised a subset of patients who had significantly higher rate of 90-day morbidity than patients in Group A (difference 45.1%, p<0.001), Group B (difference 28.4%, p<0.001), and Group C (difference 12.8%, p<0.001). Group D also exhibited longer hospital stays (p<0.001) and more readmissions (p = 0.02) than all other groups. Several independent risk factors were associated with 90-day morbidity: sarcopenia, portal hypertension, liver cirrhosis, biliary reconstruction. Overall, this study demonstrated that sarcopenia is associated with negative outcomes following liver resection for malignant neoplasms. Muscle mass via CT scans and muscle strength via grip test can adequately evaluate these outcomes.


Arterial Calcification at Multiple Sites: Sex-Specific Cardiovascular Risk Profiles and Mortality Risk – the Rotterdam Study

1. Sex- and location-specific differences among three cardiovascular risk factors were found to be associated with cardiovascular mortality.

Evidence Rating Level: 3 (Average)

Converging evidence suggests that sex and location are associated with the burden of arteriosclerosis. Most studies, however, focus on individual risk factors rather than sex-specific cardiovascular risk profiles. A cohort of 2,357 participants (M age = 69.0 years, 53% female) from the population-based Rotterdam Study underwent non-contrast computed tomography (CT) scans to quantify calcification, which is a proxy measure for arteriosclerosis. The coronary arteries (CAC), aortic arch (AAC), intracranial (ICAC) and extracranial carotid arteries (ECAC), vertebrobasilar arteries (VBAC), and aortic valve (AVC) were the locations of focus. This study used principal component analysis (PCA) of eight sex-specific cardiovascular risk factors to establish risk profiles based on shared between-factor variance. The associations between severe calcification in regions of interest and PCA risk profiles were determined using a sex-stratified multivariable logistic regression. A total of three cardiovascular risk profiles in both sexes emerged: 1) anthropometry, glucose, and HDL cholesterol; 2) blood pressure; and, 3) smoking and total cholesterol. The strongest associations among women were found in profile 2 with severe ICAC and ECAC (adjusted OR [95% CI] = 1.32 [1.14 to 1.53]) and profile 3 with severe calcification in all areas except AVC. Among men, profile 2 possessed the strongest associations with VBAC (adjusted OR [95% CI] = 1.31 [1.12 to 1.52]) and profile 3 with ACC (adjusted OR [95% CI] = 1.28 [1.09 to 1.51]). The strongest, independent associations with cardiovascular mortality were found with ECAC (HR [95% CI] = 2.11 [1.22 to 3.66]) and AVC in women (HR [95% CI] = 2.05 [1.21 to 3.49]) and with the CAC in men (HR [95% CI] = 2.24 [1.21 to 3.78]). Overall, this study suggests that there are sex- and location-specific differences in arteriosclerosis etiology. Further, this study provides a foundation for future research on these differences across risk profiles.

Image: PD

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