1. Among older adults with atrial fibrillation with no cognitive compromise at baseline, there was no statistical difference between warfarin or dabigatran groups in cognitive outcomes.
Evidence Rating Level: 1 (Excellent)
Atrial fibrillation has been shown to be associated with an increased risk of cognitive decline and dementia, which is concerning given its higher prevalence and incidence among older adults. Certain theories surrounding this presentation may be related to silent brain infarctions, cerebral microbleeds, and hypoperfusion. Effective therapeutic strategies for atrial fibrillation in this population are needed; however, there remains a paucity of information on this topic and its potential relation to cognitive function. In this randomized clinical trial, 200 participants were randomized to receiving either dabigatran or warfarin. A thorough and comprehensive cognitive evaluation was performed at baseline and at 24 months assessing various cognitive domains. These tests included the Mini-Mental Status Examination (MMSE), the Montreal Cognitive Assessment (MoCA), a neuropsychological test battery (NTB), and computer-generated neuropsychological tests (CGNT). The results showed that after controlling for age, education, and raw baseline score, the difference in mean change of cognitive function was not statistically significant between the two groups with respect to MMSE, MoCA, NTB, and CGNT scores (mean difference -0.12, 95%CI -0.88-0.86; mean difference -0.96, 95%CI -1.80-0.13; mean difference -0.05, 95%CI -0.07-0.18; mean difference -0.15; 95%CI -0.30-0.006, respectively). In conclusion, this randomized clinical trial confirms that in older adults with atrial fibrillation without cognitive impairment at baseline, no difference in cognitive outcomes was identified between dabigatran and warfarin groups. However, there are some limitations in this study to note. For instance, given the small sample size of this study, its power is limited, and these findings cannot be generalized to the broader population. Additionally, this paper examined cognitive outcomes after 24 months, although an extended follow-up period may be needed to assess the long-term impacts of these anticoagulants. Nevertheless, this randomized clinical trial was the first of its kind to compare anticoagulants in older adults and assess for cognitive outcomes and further studies with larger population sizes should be conducted to confirm these results.
1. In pregnant patients undergoing non-elective cesarean section, the use of glycopyrrolate does not significantly reduce vasopressor requirements and prevent hypotension compared to placebo.
Evidence Rating Level: 1 (Excellent)
In cesarean sections, spinal anesthesia is a frequently used anesthetic technique; however, hypotension is a common adverse event which has negative implications on both maternal health and neonatal outcomes. Recent studies have explored the use of glycopyrrolate during spinal anesthesia as it increases maternal heart rate and consequently maintains cardiac output, while having a minimal effect on the fetus due to its inability to cross the placental barrier. In this randomized double-blind clinical trial, 258 pregnant participants undergoing non-elective cesarean section were randomized to the glycopyrrolate group or the normal saline group to assess hemodynamic parameters throughout the surgery at specific time points. Following the spinal injection, a phenylephrine infusion was initiated and additional vasopressor could be used to maintain maternal systolic blood pressure (SBP) within 20% of baseline. The results of this study show that the incidence of hypotension was 30% in the glycopyrrolate group and 39% in the saline group (mean difference of lowest SBP 4.57, 95%CI 1.7-7.4). The phenylephrine volume for maintaining intraoperative maternal hemodynamics was additionally similar between both groups (mean difference 5 micrograms). Maternal adverse events such as nausea, vomiting, and dry mouth were similar in quantity between the two groups. In conclusion, among patients undergoing non-elective cesarean sections, the use of glycopyrrolate did not improve maternal hemodynamics or decrease phenylephrine use, compared to the use of normal saline. The double-blinded nature of this study with participants, investigators, and anesthesiologists blinded to allocation, reduces bias. However, thresholds between the anesthesiologists for maintaining maternal SBP and amount of phenylephrine used may vary, which is a potential limitation of this study. Further studies exploring the use of glycopyrrolate and other similar agents in cesarean sections could be valuable to assess for differences in vasopressor requirements and optimize maternal-fetal outcomes.
1. Among patients discharged from the emergency department, individuals with telehealth follow-up visits were more likely to return to the emergency department compared to individuals with in-person follow-ups.
Evidence Rating Level: 2 (Good)
Many patients who present to the emergency department are frequently discharged home without requiring admission to hospital. However, outpatient follow-up in these individuals may be essential in reducing mortality rates as this often guides decisions on future hospitalizations. The recent integration of telehealth into healthcare may increase availability of follow-up appointments but patient outcomes with this modality is not known. In this retrospective cohort study, 12 848 adult participants discharged home from the emergency department were examined for return to emergency department within 30 days of follow-up appointment. Rate of inpatient hospitalization and observation stays were also assessed. The results of this study showed that after adjusting for sociodemographic factors, acuity of illness, and medical complexity, telehealth follow-ups resulted in 28.3 more emergency department returns (95%CI 11.3-45.3) compared to in-person visits (aOR 1.23, 95%CI 1.09-1.39). Additionally, individuals with telehealth follow-up also had increased hospitalizations compared to in-person follow-ups. In conclusion, among patients discharged from the emergency department, individuals with a telehealth follow-up visit were more likely to return to the emergency department compared to those with in-person follow-ups. However, this study has several limitations to note. For instance, this paper only assessed whether patients returned to a hospital setting after their follow-up, but many individuals may have also visited other health care providers outside of the emergency department, which is not accounted for by this study. Additionally, this study was only conducted at a single academic medical center in one country and as such, these findings cannot be generalized to a broader population. Nevertheless, with new advancements in technology and telehealth, further studies and randomized clinical trials assessing the impact of online visits on patient outcomes could be quite informative.
1. In patients with acute ischemic stroke due to distal medium vessel occlusions, endovascular therapy was associated with a higher rate of excellent outcomes compared to medical management.
Evidence Rating Level: 2 (Good)
In patients with acute large-vessel occlusion of proximal anterior circulation, endovascular therapy (EVT) for cerebral reperfusion has been considered the gold standard. However, the safety and efficacy of EVT in primary distal, medium vessel occlusions (DMVO) have not been well discussed in external literature. This may be because of the smaller size of these distal cerebral arteries and longer distances to traverse for EVT which may present several challenges for successful reperfusions. In this multicenter, retrospective cohort study, 286 adult patients with acute ischemic stroke and DMVO were examined for 3-month functional independence as defined as prestroke modified Rankin Scale (mRS) scores of 0 to 2 at 90 days and successful reperfusion following EVT or medical management. The results of this study showed that there was no difference between the EVT and medical management groups in terms of 3-month functional independence (51.7% vs 50%, respectively) and rate of symptomatic intracranial hemorrhage (4% vs 3.1%, respectively). However, EVT was associated with a slightly higher 3-month excellent outcome score compared to medical management (aOR 1.71, 95%CI 1.02-2.87). In conclusion, these findings suggest that with more modernized and advancing endovascular technologies, EVT procedures may be conducted in more distal arteries safely. However, there remain several limitations to note. The observational and non-randomized nature of this study may introduce bias as baseline deficit and baseline risk of developing worse outcomes could not be accounted for. Additionally, the sample size of this paper remains small which limits the power and generalizability of this study to a broader population. Further large-scale investigations and randomized controlled trials comparing EVT and medical management in acute ischemic stroke with DMVO could yield beneficial findings.
1. Among adults older than 50 years of age, vitamin D3 supplementation did not have significant effects on cardiac structure and function after two years.
Evidence Rating Level: 1 (Excellent)
Vitamin D deficiency has been increasingly prevalent globally, especially with more time spent indoors in recent years. Research investigating animal models suggests that vitamin D may exert direct antihypertrophic effects on the heart, ultimately leading to regression of left ventricular hypertrophy (LVH) and subsequent improvements in both systolic and diastolic left ventricular function. However, there is a paucity of evidence regarding the effect of vitamin D on the cardiac structure of humans. In this randomized controlled trial, 25871 adult participants were randomized to either receiving vitamin D3 or placebo. After enrollment, all participants underwent transthoracic echocardiography at baseline and then two years after. The results of this study showed that the change in left ventricular mass, intraventricular septal thickness, posterior wall thickness, and relative wall thickness did not significantly differ between the vitamin D and placebo groups. Compared to the placebo group, there was a slight increase in left ventricular end-diastolic diameter in participants belonging to the vitamin D group. In conclusion, the results of this study showed that supplementation with vitamin D3 did not significantly contribute to changes in cardiac structure, systolic function, or diastolic function over a 2-year period. These findings do not support the role of vitamin D3 supplementation in changing cardiac structure and function among adults older than the age of 50. The large sample size of this paper increases the validity of these results. However important limitations to note include the limited follow-up duration of this study. It is uncertain whether an extended follow-up period greater than two years could reveal cardiac structure changes with vitamin D3 use. More research and randomized controlled trials with a longer follow-up period should be conducted to thoroughly assess for long-term cardiac changes after vitamin D3 supplementation.
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