2 Minute Medicine Rewind August 21, 2023
1. For women with infertility on assisted reproductive technologies (ART), higher preconception adherence to dietary patterns for prevention of chronic disease were associated with lower probability of pregnancy loss, but no difference for clinical pregnancy or live birth.
Evidence Rating Level: 2 (Good)
The prevalence of infertility has been increasing over time, turning attention towards research into the use of assisted reproductive technologies (ART). Several studies have demonstrated associations between maternal dietary patterns and probability of pregnancy or live birth from using ART, including the Mediterranean diet. However, there have been inconsistent results due to disparities in how adherence to a diet is measured, and lack of comparison amongst different dietary patterns. Therefore, this current cohort study aimed to examine the correlation between 8 common dietary patterns and ART-related outcomes. The population included 612 women between 18 and 45 years of age, enrolled between 2007 and 2019, with 804 intrauterine insemination (IUI) cycles and 768 in-vitro fertilization (IVF) cycles. The women completed a validated questionnaire to evaluate their preconception diet’s adherence to the 8 dietary pattern, which included 3 Mediterranean diet indexes, the Healthy Eating Index (HEI) and Alternate Healthy Eating Index (AHEI), the American Heart Association (AHA) 2020 dietary goals Index, the DASH diet, and the plant-based diet (PBD). Outcomes evaluated included clinical pregnancy, live birth, clinical pregnancy loss, and total pregnancy loss (which included biochemical and clinical loss). The results showed no association between adherence to the 8 patterns and the outcomes of clinical pregnancy or live birth after either ART method. However, there was a lower risk of total and clinical pregnancy loss for women with higher adherence to the AHA dietary pattern: The probability of total pregnancy loss was 0.41 (95% CI 0.33-0.50) vs 0.28 (95% CI 0.21-0.36, p for trend = 0.02) for the lowest vs highest quartile adherence to the AHA diet, whereas the probability of clinical pregnancy loss was 0.30 (95% CI 0.22-0.39) vs 0.15 (95% CI 0.10-0.23, p for trend = 0.007) for the lowest vs highest quartiles. A similar but weaker association was found for other patterns, including the HEI, AHEI, and 3 Mediterranean diet scores, but not the PBD. Overall, this study demonstrated the association between higher preconception adherence to specific dietary patterns for prevention of chronic disease and lower probability of pregnancy loss on ART, but not clinical pregnancy or live birth.
1. For patients with acute venous thromboembolism (VTE) requiring extended anticoagulation therapy past 6 months, direct anticoagulants (DOACs) are associated with lower rates of recurrent VTE compared to warfarin.
2. There were no significant differences in hemorrhage events requiring hospitalization or all-cause death between VTE patients on extended DOAC versus warfarin treatments.
Evidence Rating Level: 2 (Good)
Anticoagulation therapy for venous thromboembolism (VTE) generally lasts for 3-6 months, but an extended course may be warranted depending on clinical indications, such as in cases of unprovoked VTEs. Warfarin and direct oral anticoagulants (DOACs) are options for extended VTE treatment, though the comparative efficacy and safety outcomes for both options are not well-studied. Therefore, this retrospective cohort study aimed to compare the outcomes of warfarin and DOACs for extended VTE treatment. The study population consisted of patients with a newly diagnosed acute VTE in California between 2010 and 2018, who completed at least 6 months of continuous anticoagulation after the VTE diagnosis. The outcomes measured included rates of recurrent VTE, hemorrhage event with hospitalization, or death from any cause: Patients were excluded if these events occurred within the initial 6 months of treatment. Multivariable adjustment was performed with confounders including risk factors for recurrent VTE, risk factors for bleeding events, comorbid medical conditions and medications, and patient demographics. In total, there were 18,495 patients, 88.5% of whom were prescribed warfarin. The results showed that DOAC patients compared to warfarin patients had lower adjusted rates of recurrent VTE, with an adjusted hazard ratio of 0.66 (95% CI 0.52-0.82). However, the risk of hemorrhage events with hospitalizations and all-cause death was not significantly different for DOAC patients compared to warfarin patients (aHR 0.79, 95% CI 0.54-1.17 and aHR 0.96, 95% CI 0.78-1.19 respectively). There was heterogeneity in the subgroup analysis for kidney function: For patients with eGFR >60, the aHR for hemorrhage events requiring hospitalization for DOACs vs warfarin was 0.59 (95% CI 0.35-1.00), whereas the aHR for patients eGFR < 60 was 1.30 (95% CI 0.71-2.39, p for interaction = 0.03). There was no significant heterogeneity in the subgroup analysis for age and any of the 3 clinical outcomes. Overall, this study demonstrated that patients on DOACs for extended anticoagulation have lower recurrent VTEs compared to warfarin, with no significant difference in hemorrhage events requiring hospitalization and all-cause death.
1. The risk of mortality from solid cancer, lagged by 10 years, is estimated to be increased by 52% per Gy of radiation exposure, an association that is doubled when limiting to the low cumulative dose range of 0-100 mGy.
2. There is an approximate relationship between cumulative dose radiation exposure and mortality from solid cancer.
3. Excluding cancers commonly associated with smoking and asbestos exposure did not alter the association between radiation exposure and solid cancer mortality substantially.
Evidence Rating Level: 2 (Good)
Although there is a known association between exposure to high dose radiation and cancer, the long-term risk from low dose and low dose rate radiation exposure is not well-studied. Therefore, the International Nuclear Workers Study (INWORKS) aimed to assess the mortality risk amongst nuclear workers to better elucidate the relationship between radiation dose and solid cancer mortality. The study population included workers from France, the UK, and the USA, employed in the nuclear industry for at least 1 year and who wear dosimeter monitors. Estimates were made of the individual annual exposure to radiation, converted to the absorbed dose of radiation to the colon, in gray (Gy) units. The primary outcome evaluated was mortality from solid cancers. As well, separate analyses were done excluding specific types of cancer, such as lung or pleura, to address confounding factors such as smoking or asbestos exposure. In this study, cumulative doses were lagged by 10 years to allow for a minimum period between radiation exposure and death, consistent with previous work done on this study and others. The study is ongoing, with the earliest data from the year 1955, including 309,932 workers with 10.7 million person-years of follow-up. In total, there were 31,009 deaths from cancer, with 28,089 being from solid cancer. The excess relative rate for any cancer mortality was 0.53 per Gy (90% CI 0.30-0.77) and for solid cancer mortality was 0.52 per Gy (90% CI 0.27-0.77). When examining lower cumulative dose ranges, the excess relative rates for solid cancer mortality were 0.63 per Gy (90% CI 0.34-0.92) for 0-400 mGy cumulative dose, 0.97 per Gy (90% CI 0.55-1.39) for 0-200 mGy cumulative dose, 1.12 per Gy (90% CI 0.45-1.80) for 0-100 mGy cumulative dose, and 1.30 per Gy (90% CI -1.33 to 4.06) for 0-20 mGy cumulative dose. Furthermore, a linear model was found to best depict the overall relationship between cumulative dose and solid cancer mortality, lagged by 10 years, including the low 0-200 mGy cumulative dose range. In addition, the excess relative rates for solid cancers excluding smoking-related cancers was 0.52 per Gy (90% CI 0.10-0.99), and when excluding lung and pleura cancers to control for asbestos exposure, it was 0.43 per Gy (90% CI 0.15-0.73), both of which were similar to the overall relative rate. Overall, this study found a linear dose-response association between radiation exposure and mortality from solid cancer, with the strength of the association being twice as great in the lower cumulative dose range, and with no clear changes when adjusting for smoking and asbestos exposure.
1. Patients with inappropriate hospital admission (IHA) experience twice more adverse events (AEs) on average than appropriately admitted patients.
2. IHA is associated with longer ICU stays resulting from AEs compared to AEs experienced by non-IHA patients.
Evidence Rating Level: 2 (Good)
The concept of health overuse refers to when the harm outweighs the benefit to a patient when health services are provided, such as with inappropriate hospital admissions (IHA). Health overuse can result in adverse events (AEs), such as healthcare-associated infections. This current cross-sectional study aimed to examine the association between IHA and AEs, as well as its downstream implications. The setting of this study was a hospital in Madrid, Spain during one week in May 2019. To measure IHA, the study used versions of the validated Appropriateness Evaluation Protocol (AEP): IHA was thus defined as an admission that did not meet any one appropriateness criterion from the AEP. As well, validated tools from the Harvard Medical Practice Study (HMPS) and the European Point Prevalence Survey of Healthcare-associated Infections were used to measure AEs: The avoidability of AEs was scored from 1 to 6 using the HMPS tools. The study population included 558 eligible patients hospitalized during the week, 12.7% of which were deemed as IHA. 15.5% of the IHA patients experienced 1 or more AEs, compared to 10.7% of patients who were not IHA (p = 0.231). As well, IHA patients had twice more AEs per person than those who were not IHA (0.27 vs 0.12, p = 0.015). The odds ratio of an IHA patient experiencing an AE compared to a non-IHA patient was 2.26 (95% CI 1.26-4.04). The most frequent AEs were healthcare-associated infections (38.8%), procedural-related AEs (26.3%), and nursing care AEs (26.3%). AEs experienced by IHA patients were associated with more ICU days (mean 3.3 vs 0.9, p = 0.037), and incurred an average €12,600.40 for each extra day of hospitalization (€166,324.90 total for all extra days in the study). Overall, this study showed that IHA patients experience AEs more often than appropriately admitted patients, and can lead to longer ICU stays and additional financial costs.
Safety and efficacy of precision hepatectomy in the treatment of primary liver cancer
1. Patients with primary hepatocellular carcinoma randomized to receive primary hepatectomy versus conventional hepatectomy had less operation time, fewer complications, higher immune function post-op, and lower rates of recurrence at 3 years, amongst other advantages.
Evidence Rating Level: 1 (Excellent)
For patients with primary liver cancer, precision hepatectomy is a novel surgical approach that aims to decrease invasiveness and improve hepatic protection: This is done by creating a virtual 3D reconstruction of an individual patient’s liver to guide the surgical plan. This current randomized controlled trial compared the outcomes of patients undergoing conventional versus precision hepatectomy for primary hepatocellular carcinoma. This was a single-centre trial based in China, with 49 patients in the conventional hepatectomy (control) group and 49 in the precision hepatectomy (study) group. In the study group, CT scans were used to virtually reconstruct each patients’ livers, and various surgical options were analyzed using these reconstructions, to inform the surgical plan prior to surgery. The outcomes measured included operation time, complications, liver and immune function 1 week post-op, and recurrence or metastasis, with follow-up done up to 3 years after surgery. The results showed that in the study group compared to the control, there was significantly less operation time (91.29 vs 98.47 min), less intraoperative bleeding (220.71 vs 248.91 mL), less anal venting time (72.19 vs 81.23 h), and fewer hospital days stayed (9.27 vs 11.38; all p < 0.001). There were significantly higher levels of CD4+, CD3+, and CD4+/CD8+ in the study compared to control 1-week post-op (p < 0.001). In the study group, there were also higher levels of ALT (32.81 vs 26.98), AST (41.38 vs 43.98), total bilirubin (17.47 vs 14.39), and albumin (55.39 vs 46.19) 1-week post-op. As well, there was a lower incidence of complications in the study versus control group (2.04% vs 14.29%, p = 0.027). Lastly, there was a significantly lower incidence of relapse (2.04% vs 14.29%, p = 0.027) and death (2.04% vs 14.29%, p = 0.027) in the study compared to control group, with no difference in metastasis (2.04% vs 8.16%, p = 0.168). Overall, this randomized trial demonstrated that precision hepatectomy is effective and safe compared to conventional hepatectomy, and may have several intraop and post-op advantages compared to the conventional method as well.
Image: PD
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