2 Minute Medicine Rewind April 17, 2023

Low-Value Prostate-Specific Antigen Screening in Older Males

1. This retrospective cohort study demonstrated that males over the age of 70 are overscreened for prostate cancer, despite current guidelines advising against screening in this population. 

Evidence Rating Level: 2 (Good)

PSA screening may reduce mortality associated with prostate cancer, though it is also associated with overtreatment, and invasive testing, and often leads to excessive worry for patients. PSA screening is not currently recommended for patients over age 70. Patients in this age group are unlikely to receive mortality benefits from interventions for prostate cancer. For patients aged 55-69, the decision to undergo PSA testing should be made via shared decision-making between the patient and their physician. This study aimed to assess rates of PSA screening for males over age 70, estimating that this population is over-screened despite the current guidelines. Researchers collected data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS), including 32,306 males over age 70 who had never been diagnosed with prostate cancer. Despite current guidelines, they found that 55.3% of males aged 70-74, 52.1% of males aged 75-79, and 39.4% of males aged 80+ had PSA screening completed in the previous two years. Discussing the benefits of PSA screening with their primary care physician increased the likelihood of having completed PSA screening (OR 9.09, 95% CI 7.60-11.40, p <0.01). Conversely, discussing the risks of PSA screening did not reduce the likelihood of screening (OR 0.95, 95% CI 0.77-1.17, p = 0.60). Other factors that were significantly associated with a greater likelihood of recent screening included annual income >$25,000, having no financial barrier to accessing health care, and post-high school education. This study demonstrates that men over age 70 in the US are over-screened for prostate cancer, despite evidence that this age group is more likely to experience harm than benefits from screening. This study has important clinical implications, demonstrating that primary care providers can play an important role in reducing the overscreening of older males for prostate cancer. 

Adverse birth outcomes and early-life infections after in utero exposure to corticosteroids for inflammatory bowel disease: a Danish nationwide cohort study

1. In this retrospective cohort study, maternal steroid use for the treatment of IBD flares was associated with an increased risk of pre-term birth, though no other adverse effects on fetal development were observed. 

Evidence Rating Level: 2 (Good)

Systemic corticosteroids are frequently administered to treat inflammatory bowel disease flares, including during pregnancy, though it is unknown whether maternal steroid use in early pregnancy has an impact on fetal development. This cohort study used the Danish national registries to collect data on the live births of 6,968 pregnant patients with IBD between 1995 and 2015. The researchers divided patients into three groups: Those with IBD who were treated with corticosteroids during pregnancy and those with IBD who were unexposed to corticosteroids during pregnancy. They compared the rates of congenital malformations, pre-term births, small for gestational age infants, and low 5-minute Apgar scores. There was no association found between steroid use and small for gestational age infants, low 5-min Apgar scores, congenital malformations, or hospital-diagnosed infections in the first year of life, though the likelihood of pre-term birth was greater for the steroid-exposed group (adjusted OR 2.45, 95% CI 2.45-3.13). It is important to acknowledge that the differing rates of IBD flares between these two groups may be a confounding variable. Future research in this area should address whether there are other aspects of fetal development impacted by steroid use, including rates of neonatal ICU admissions and neonatal hypoglycemia. 

Nirmatrelvir and risk of hospital admission or death in adults with covid-19: emulation of a randomized target trial using electronic health records

1. Oral nirmatrelivir, started within 5 days of SARS0-CoV-2, reduces the risk of hospitalization and death at 30 days for individuals at risk for severe SARS0-CoV-2 illness. 

Evidence Rating Level: 2 (Good)

Nirmatrelivir, an antiviral agent given in combination with ritonavir, has been previously shown to reduce hospital admission or death at 28 days when given within 5 days of a SARS0-CoV-2 diagnosis to individuals at high risk for progression to severe illness. This data was previously collected from a randomized control trial published in 2022, prior to the spread of omicron, and did not include patients who had received any covid vaccines or were previously infected with SARS0-CoV-2 . The current study aimed to assess the effectiveness of starting oral nirmatrelivir versus no treatment within 5 days of a SARS0-CoV-2 positive result for reducing the risk of hospitalization or death at 30 days, accounting for vaccination status and previous SARS-CoV-2 infection. Researchers used healthcare databases from the US Department of Veteran Affairs to collect data on 256,288 participants who tested positive for SARS0-CoV-2 between January 3rd and November 30, 2022, with at least one risk factor for severe covid-19 illness, including age >60 years, body mass index >25, current smoking, chronic lung disease, cardiovascular disease, kidney disease, immune dysfunction, hypertension, diabetes, and cancer, and had not received any other covid treatments. Of this cohort, 31,524 individuals received nirmatrelivir within 5 days of diagnosis and 224,764 did not. Nirmatrelvir compared to no treatment was associated with a reduced risk of hospitalization or death, for unvaccinated individuals (RR 0.60, 0.5-0.71, absolute RR 1.83%, 1.29-2.49%), patients with 1-2 doses of a covid vaccine (RR 0.65, 0.57-0.74, absolute RR 1.27%, 0.90%-1.61%), a booster-dose of covid vaccine (RR 0.64, 0.58-0.71, absolute RR 1.05%, 0.85%-1.27%), first SARS-CoV-2 infection (RR 0.61, 0.57-0.65, absolute RR 1.36%, 1.19%-1.53%), and those who were re-infected with SARS-CoV-2 (RR 0.74, 0.63-0.87, and absolute RR 0.79%, 0.36%-1.18%). This demonstrates the effectiveness of nirmatevir for reducing the risk of hospitalization and death at 30 days for individuals at risk of severe SARS0-CoV-2, confirming that this medication is beneficial for those of varying vaccination status and previous SARS0-CoV-2 infections. Future research may re-assess the effectiveness of nirmatrelivir as further SARS0-CoV-2 variants emerge and with the distribution of future booster vaccines. 

Association of State Supplemental Nutrition Assistance Program Eligibility Policies With Adult Mental Health and Suicidality

1. Expansion of the Supplemental Nutrition Assistance Program (SNAP) eligibility criteria is associated with decreased mental illness and suicidality. 

Evidence Rating Level: 2 (Good)

Food insecurity, the limited or unsteady access to food due to a lack of sufficient resources, is related to poor mental health and suicidality. In the United States, approximately 25 million adults report food insecurity annually.  The Supplemental Nutrition Assistance Program (SNAP) is a program that provides over 21 million low-income households with assistance with the cost of food. Federal eligibility criteria include household assets not exceeding $2250, with household income not exceeding 130% of the federal poverty level (FPL), though states are able to expand income to 200% FPL and eliminate the asset test, increasing the number of eligible households. The purpose of this retrospective cohort study was to examine whether the adoption of broader SNAP inclusion criteria at the state level reduces mental illness and suicidality among adults. Researchers included data from the National Vital Statistics System between 2014 and 2017, as well as data from the National Survey on Drug Use and Health between 2015 and 2019. State elimination of the asset test only was associated with decreased rates of past-year major depressive episodes (RR 0.92, 087-0.98) and mental illness (RR 0.91, 0.87-0.97). State elimination of both the asset test and increasing the income limit was associated with decreased rates of past year major depressive episodes (RR 0.92, 0.86-0.99), mental illness (0.92, 0.87-0.98), serious mental illness (RR 0.91, 0.84-0.99), and suicidal ideation (RR 0.89, 0.82-0.96). There was no statistically significant reduction in suicide deaths. Food insecurity is a known risk factor for mental illness and suicidality, with this study emphasizing the importance of reducing food insecurity as an important public health and psychiatric intervention. Policymakers may use the results of this study to encourage greater expansion of programs addressing food insecurity. 

Previous BCG vaccination is associated with less severe clinical progression of COVID-19

1. In this case-control study, previous BCG vaccination was associated with a reduced risk of developing severe covid illness for those who are not vaccinated against COVID-19. 

Evidence rating level: 3 (Average)

The Bacillus Calmette-Guerin (BCG) vaccine for tuberculosis is known to have non-specific effects, including protection against respiratory viruses such as RSV. Recommendations for BCG vaccination are made based on the regional incidence of TB. This case-control study aimed to assess whether previous BCG vaccination offers protection against severe covid illness. The study included individuals who presented to COVID-19 referral care units in Salvador, Sao Paulo, and Recife in Brazil, excluding those vaccinated for COVID-19. Individuals who were hospitalized in ICU with severe COVID-19 (497 cases) were compared to those, who were individuals with COVID-19 who presented to the same health units and were not hospitalized or were hospitalized in general wards (670 controls). Data collection occurred from 2020 to 2021. Compared to controls, those with severe COVID-19 were significantly more likely to be above 60 years of age, have higher education, and have at least one comorbidity, with p <0.000. The control group was significantly more likely to have previous BCG vaccination (58.7% of the severe COVID-19 group, compared to 92.1% of controls), with p <0.000. After adjusting for race, education level, sex, age, municipality, and presence of comorbidity, the odds ratio was 0.27 (95% CI 0.17–0.44), demonstrating a protective effect from BCG vaccination of 73% (95% CI: 56.0–83.0%). The protective effect conferred by BCG vaccination was reduced in the 60+ age group, at 35% (95% CI 33-71%). This research suggests that the non-specific effects of BCG vaccination offer protection against severe COVID-19 illness. Future research may examine whether the BCG vaccine confers a benefit to those who are also immunized for COVID-19. 

Image: PD

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