2 Minute Medicine May 6th, 2024

Plant-based diets and disease progression in men with prostate cancer

1. In a cohort of men with prostate cancer, disease progression was lower in men who had a higher intake of plant-based foods.

Evidence Rating Level: 2 (Good)

Plant-based diets have been increasing in popularity and have shown benefits among individuals living with chronic diseases such as prostate cancer, one of the most prevalent cancers among men in the United States. As there is not much known about the associations between a plant-based diet and prostate cancer, this cohort study focused on the relation between clinical outcomes in patients with prostate cancer and plant-based food intake postdiagnosis. The focus was on two plant-based diet indices, those being the overall plant-based diet index (PDI) and the healthful plant-based index (hPDI). A total of 18 groups were created to compute food intake to plant-based diets based on nutritional commonalities. These groups were then split into 3 larger groups which consisted of 7 healthy foods, 5 unhealthy foods, and 6 animal foods. The primary outcome assessed was the progression of prostate cancer, which took into account bone metastases, recurrence, and secondary treatment. Death from prostate cancer was assessed as the secondary outcome. To understand the correlation between the PDI and hPDI, the Pearson correlation coefficient was used. Multiple surveys were administered over the years, with 2891 participants completing at least 1, and 2062 of them (mean [IQR] age at diagnosis, 65.0 [59.0-70.0] years) met the inclusion criteria. PDI scores were between 27 and 76, while hPDI scores were between 29 and 84, with the two indices being moderately positively correlated (r=0.34; P<.001). When compared to the lowest quintile, those in the highest quintile had a 47% decreased risk of prostate cancer progression (HR, 0.53; 95% CI, 0.37-0.74; P for trend=.003). There was a 55% decrease in risk of cancer progression in the highest quintile compared to the lowest quintile (HR 0.45; 95% CI, 0.25-0.81; P for trend=.01) for 680 participants with a Gleason grade of 7 or higher at diagnosis. Overall, of the men with prostate cancer, those who had a higher intake of plant-based foods postdiagnosis were associated with a lower cancer progression risk. 

Weight-bearing physical activity, lower-limb muscle mass, and risk of knee osteoarthritis

1. Increased incidence of radiographic knee osteoarthritis was associated with high amounts of weight-bearing activity only in those with a low lower-limb muscle mass index (LMI).

2. There was no association identified between symptomatic knee osteoarthritis and weight-bearing activity, total physical activity, or non-weight-bearing activity. 

Evidence Rating Level: 1 (Excellent) 

Osteoarthritis is an inflammatory joint disease involving the degeneration of joints along with chronic pain and limited mobility. These additive effects combined with the high prevalence lead to a burden on the health care system and a high socioeconomic cost. It is essential to identify modifiable risk factors in patients with osteoarthritis and to create and implement new prevention strategies. To assess the association between weight-bearing versus non-weight-bearing activities on incident knee osteoarthritis, this study was embedded in the Rotterdam Study (RS), a prospective cohort. From the RS, three subcohorts (RS-I, RS-II, and RS-III) with data for baseline physical activity, baseline knee pain, and baseline knee radiographs along with 1 additional follow-up radiograph, were analyzed. The Zutphen Physical Activity Questionnaire was adapted and used alongside the Longitudinal Aging Study Amsterdam questionnaire, to collect data for weight-bearing, and non-weight-bearing physical activity. X-ray knee osteoarthritis was assessed as the primary outcome, while symptomatic knee osteoarthritis was the secondary outcome. A total of 5003 individuals (2804 women [56.0%]; mean [SD] age, 64.5 [7.9] years) were included in the study as they had complete data. Over a mean (SD) follow-up time of 6.33 (2.46) years, there was an 8.4% (793 of 9483 knees) incident rate of knee osteoarthritis. Weight-bearing activity was associated with osteoarthritis found on x-ray (odds ratio [OR], 1.22; 95% CI, 1.10-1.35; P<.001) whereas non-weight-bearing activity had no association with new cases of radiographic osteoarthritis (OR. 1.04; 95% CI, 0.95-1.15; P=.37). The groups were also stratified based on lower-limb muscle mass index (LMI) which was assessed using a DXA scan. Weight-bearing activity and incident knee osteoarthritis (as seen on an x-ray) had a significant association among 431 participants in the lowest LMI tertile that did not have baseline knee pain (model 1, OR, 1.53; 95% CI, 1.15-2.04; P=.003).  Overall, increased weight-bearing activity was associated with an increased incidence of radiographic knee osteoarthritis in the low LMI subgroup.

Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population based cohort study using data from the national joint registry and hospital episode statistics for England 

1. Reverse total shoulder replacement (RTSR) was examined as a potential treatment for end-stage shoulder arthritis.

2. After analysing the risk factors, RTSR was shown as a potential alternative treatment to total shoulder replacement for those with an intact rotator cuff.

Evidence Rating Level: 1 (Excellent)

One treatment for end-stage shoulder arthritis that is increasingly popular is shoulder replacement therapy. Reverse total shoulder replacement (RTSR) has previously been used for rotator cuff arthropathy but has expanded its use for other indications despite a lack of supporting evidence. To better understand the effectiveness and economic implications of RSTR, a population-based prospective cohort study was conducted on shoulder replacement patients. Since the study focused on RTSR, patients aged 60 years or older who had an intact rotator cuff and a total shoulder replacement (TSR) or an RTSR were eligible to participate. The study’s main outcome was revision surgery at any time as this represented survival of the implant. Serious adverse events within 3 months of surgery, lengthened stay in the hospital, reoperations within 1 year of surgery and a change in the Oxford shoulder score were examined as the secondary outcomes. Logistic regression was used to generate propensity scores representing the likelihood of a patient receiving an RSTR as opposed to a TSR and was based on several covariates such as age, previous shoulder surgery, and past medical history. After excluding missing data for 175 procedures (1.3%) and for 7903 (61%) preoperative and 6448 (50%) postoperative Oxford Shoulder Scores, 11 961 patients were included with 12 986 elective shoulder replacement surgeries. The covariates were balanced after one-to-one propensity score matching (n=7124; TSR: 3562, RTSR: 3562) and adjustment of inverse probability (n=12 968; TSR: 9393, RTSR: 3575). Of the matched cohort, there were 126 revisions (1.8%; TSR: 85 RTSR: 41) that had a maximum follow-up time of 8.75 years with an observation period of 24 353 years (TSR: 14 332, RTSR: 10 021). Whereas in the weighted cohort, there were 294 revisions (2.3%; TSR: 253, RTSR: 41) that had 8.75 years of maximum follow-up, and 47 886 years of observation (TSR: 37 842, RTSR: 10 044). After three years, the observed risk for a TSR was shown to (hazard ratio local minimum 0.33, 95% confidence interval (CI) 0.18 to 0.59) compared to an RTSR revision which showed a non-significant postoperative hazard ratio (1.39 [95% CI 0.61 to 3.17]). The relative risk of reoperations decreased by half (odd ratio 0.45, 95% CI 0.25 to 0.83) within one year after RTSR. Further, there was an absolute risk difference of -0.51% (95% CI -0.89 to -0.13). After comparing the benefits and risks, RTSR was an appropriate treatment for individuals aged 60 years or older with osteoarthritis.

First-trimester fetal size, accelerated growth in utero, and child neurodevelopment in a cohort study  

1. Restricted growth of a fetus during early pregnancy was examined as a risk factor for impaired neurodevelopment.

2. Decreased crown-to-rump length was shown to impact neurodevelopment at 2 years of age.

Restricted fetal growth in the uterus is an important risk factor to consider for impaired development in the child. Early pregnancy is a crucial time for growth of a fetus, as it allows for the development of the neural tube, along with an increasing number of fetal brain cells. There is a lack of research studying the association between first-trimester fetal size and childhood neurodevelopment. To address this gap, a prospective birth cohort study investigated the associations between fetus size during the first trimester and accelerated intrauterine growth with brain development in childhood. 2058 fetuses were examined for the study. During the first trimester, their crown to rump length (CRL) was measured and used to estimate fetal size. Once the children reached 2 years of age, the Bayley Scaled of Infant Development (BSID) of China Revision was used to measure the brain development of the children. This scoring system produced a mean development index (MDI), representing language and social development along with a psychomotor development index (PDI), representing motor ability. The maternal age at the time of delivery had a mean (SD) of 29.0 (3.5) years, while the mean (SD) gestation time was around 39.34 (1.12) weeks. There was a significant association between neurodevelopment at 2 years and first-trimester CRL. With every increase in Z score for CRL, there was an associated increase in score for MDI (adjusted beta estimate = 1.19, (95% CI: 0.13, 2.25), P=0.03) and PDI (adjusted beta estimate = 1.36, (95% CI: 0.46, 2.26), P < 0.01) at 2 years of age. Furthermore, a linear trend was observed in the quartile CRL models (MDI: P for trend = 0.03; PDI: P for trend < 0.01).  The MDI and PDI scores were higher amongst children in the highest quartile compared to those in the lowest quartile (adjusted beta estimate = 2.88, (95% CI: 0.27, 5.49), P = 0.03), (adjusted beta estimate = 3.88, (95% CI: 1.68, 6.08), P < 0.01). In summary, restricted fetus growth in utero during the first trimester was associated with neurodevelopmental delays at the beginning of childhood. Improved mental development was associated with accelerated intrauterine growth after the first trimester, however, psychomotor development had no such association. 

A randomized controlled trial of an app-based intervention on physical activity and glycemic control in people with type 2 diabetes

1. A personal health record (PHR) app that used inspirational notifications was not effective in reducing HbA1c levels and daily step count in patients with diabetes compared to control. 

Evidence Rating Level: 1 (Excellent) 

There is an anticipation that the global prevalence of diabetes along with diabetes-related macrovascular and microvascular complications will increase by the year 2045. Diabetes currently affects 10% of the population, a number that is expected to rise. With the prevalence of the disease, it is important to find ways to mitigate the cost of treatment. One well-studied treatment is regular exercise, which has been shown to decrease mortality in people afflicted. For this study, physical activity was assessed by measuring the step count by using a personal health record (PHR) app. While all participants used the application, the intervention group would further receive text messages encouraging more steps based on baseline activity levels. To assess the effectiveness of the PHR, a randomized controlled trial divided participants into the control group who used the app, and the intervention group that used the app and received text messages. The trial began with a run-in period of one week, which was then followed by a 12-week randomized treatment period, and then a 12-week extension period. To best understand the impact of physical activity on type 2 diabetes, the change in daily step count in both groups was assessed as the primary outcome. The secondary outcomes measured mean daily step count, mean HbA1c levels, fasting glucose levels, body weight, physical activity, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides, all of which were measured at weeks 12 and 24. A total of 200 participants were split into two groups, with 62 (93.9%) assigned to the control and 118 (88.1%) assigned to the intervention group. There was no significant change in the daily step count between the two groups (P = 0.365). For participants that had a baseline step count < 7500 steps per day, the change in step count at the 12-week mark was larger in the intervention group (1319 ± 3020) than in the control group (-139 ± 2309) (P = 0.009). At the same 12-week mark, the HbA1c was significantly lower in the intervention group (6.7 ± 0.5% compared to the control group (6.9 ± 0.6%, P = 0.041). However, when the groups were compared at the 24-week mark, the changes were significant but comparable between the groups. In the intervention group, a decrease of HbA1c was greater for the patients with baseline HbA1c ≥ 7.5% (-0.81 ± 0.84%) compared to those with a baseline HbA1c < 7.5% (-0.22 ± 0.39%) (P for interaction = 0.014). Participants in the intervention group experienced significant weight loss at weeks 12 and 24 compared to baseline (-1.07 kg and -1.46 kg, all P < 0.001). Whereas participants in the control group only had significant weight loss at week 24 (-1.05 kg, P = 0.03). Overall, the inspirational notifications did not increase step count, and when compared to the control group saw similar changes in HbA1c levels.

Image: PD

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