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2 Minute Medicine Rewind February 10, 2025
1. After cannabis policy legalization, incident cases of schizophrenia linked to cannabis use disorder nearly tripled.
Evidence Rating Level: 2 (Good)
The use of cannabis has been associated with the development of psychosis and schizophrenia. However, the association between cannabis legalization and psychosis is unclear. This retrospective cohort study thus examined how population-attributable risk fraction (PARF) for cannabis use disorder (CUD) associated with schizophrenia changed over time after medical cannabis liberalization and nonmedical cannabis legalization in Canada. Using routinely collected health administrative data of residents aged 14-65 from the province of Ontario, Canada, this study examined annual changes in the PARF of schizophrenia associated with CUD between January 1, 2006, and December 31, 2022. Three policy periods were analyzed: prelegalization (Jan 2006–Nov 2015), cannabis liberalization (Dec 2015–Sep 2018), and nonmedical legalization (Oct 2018–Dec 2022). The primary outcome was diagnosis of schizophrenia and the secondary outcome was diagnosis of psychosis not otherwise specified (NOS). This study included a total of 13,588,681 individuals (mean [SD] age, 39.3 [16.1] years; 6,804,906 males [50.1%]), of whom 118,650 (0.9%) had CUD. In total, 91,106 individuals (0.7%) developed schizophrenia (10,583 of 118,650 [8.9%] with CUD vs 80,523 of 13,470,031 [0.6%] without CUD). The PARF of CUD associated with schizophrenia nearly tripled from 3.7% (95% CI, 2.7%-4.7%) prelegalization to 10.3% (95% CI, 8.9%-11.7%) postlegalization. The overall incidence of schizophrenia per 100,000 individuals remained stable between the prelegalization (53.5) and postlegalization (53.3) periods, while the incidence of psychosis NOS increased by 60.2%, from 33.9 to 54.3. The largest absolute increase in PARF occurred among individuals aged 19 to 24 years, which increased in males from 8.5% (95% CI, 6.7%-10.3%) to 18.9% (95% CI, 16.8%-21.0%) and in females from 4.8% (95% CI, 3.3%-6.3%) to 12.0% (95% CI, 9.5%-14.6%). Overall, this study found that during a period of cannabis policy liberalization, incident cases of schizophrenia linked to CUD nearly tripled. Future research is needed to examine the long-term impact of cannabis policy changes on the incidence of psychotic disorders.
1. Higher dietary niacin intake was associated with lower all-cause mortality risk in patients with chronic kidney disease.
Evidence Rating Level: 2 (Good)
Chronic kidney disease (CKD), characterized by a progressive decline in renal function, involves chronic inflammation and is associated with an increased risk of cardiovascular disease. Previous research suggests that dietary niacin (vitamin B3) intake contains anti-inflammatory properties and may help improve cardiovascular outcomes. However, the relationship between niacin intake and CKD prognosis remains unclear. This retrospective cohort study thus examined the association between dietary niacin intake and all-cause mortality in CKD patients. Data was obtained from the National Health and Nutrition Examinations Survey (NHANES) and included US adults aged >18 years with CKD. Dietary niacin intake data were based on the 24-hour dietary recall interviews. In total, 4,659 CKD patients were included in the study (mean [SD] age, 58.03 [0.42] years; 2,502 females [58.45%]), of whom 1,325 (28.44%) died during a mean (SD) follow-up of 73.92 (1.14) months. Compared to lower niacin intake (≤19mg), higher niacin intake (>33 mg) was associated with lower all-cause mortality risk (Hazard ratio (HR) = 0.74, 95%CI: 0.59–0.93), even after adjusting for covariates. Subgroup analyses also found higher niacin intake to be associated with lower all-cause mortality risk in those age ≥65 years old (HR = 0.68, 95%CI: 0.53–0.88), males (HR = 0.68, 95%CI: 0.51–0.92), BMI < 25 kg/m2 (HR = 0.70, 95%CI: 0.39–0.99), smoking (HR = 0.68, 95%CI: 0.49–0.94), dyslipidemia (HR = 0.71, 95%CI: 0.56–0.91), and non-hyperphosphatemia (HR = 0.73, 95%CI: 0.58–0.91). Overall, this study found higher dietary niacin intake to be associated with lower all-cause mortality risk in CKD patients, suggesting a potentially beneficial role of niacin in the CKD prognosis. Future studies are needed to confirm these findings.
The impact of polypharmacy on health outcomes in the aged: A retrospective cohort study
1. Polypharmacy was associated with a greater risk of mortality and hospitalizations at one and five years.
Evidence Rating Level: 2 (Good)
Polypharmacy, commonly defined as the use of five or more medicines, has been associated with a greater risk of adverse drug reactions (ADRs), particularly among the older population. Studies on polypharmacy and its association with sociodemographic and clinical factors have been inconsistent. This retrospective cohort study thus aimed to determine the association of polypharmacy with mortality, hospitalization, ADRs, and falls among community-dwelling adults in the UK at one and five years. This study used a random sample of patients >75 years from the Clinical Practice Research Datalink (CPRD). In total, 977 patients were analyzed (mean [SD] age, 83 [5.5] years; 351 males [36%]) and polypharmacy was present in 457 (47%) patients. At one year and five years, adjusted hazard ratios [95% confidence intervals] indicated polypharmacy was positively associated with mortality (one year: 2.37 [1.40–3.90]; five years: 1.60 [1.30–2.00]) and hospitalization (one year: 2.47 [1.40–4.30]; five years: 1.49 [1.30–1.70]). Polypharmacy was not associated with falls or ADRs, and this was attributed to inadequate recordings of these events in the CPRD database. Adjusted odds ratio (OR) found mortality risk associated with polypharmacy to be higher in women than men (OR 1.89 vs 1.73), in participants aged 75–85 years than 86 years and above (OR 1.77 vs 1.73), in those with ≥ 6 Potentially Inappropriate Medicines (PIMs) than those with less (OR 1.79 vs 1.64), and in those with 3-6 morbidities than 1–2 morbidities (OR 3.55 vs 1.67) (p < 0.05 for all). Hospitalization risk associated with polypharmacy was higher in patients aged 86 years and above than 75–85 years group (OR 3.08 vs 1.69) and in those with ≥ 6 PIMs than in those with less (OR 2.35 vs 2.19) (p < 0.05 for both). Overall, this study found polypharmacy to be a risk factor for mortality and hospitalizations in the short and long term. Future studies are needed to confirm these results.
Cognitive Processing Therapy for Posttraumatic Stress Disorder in Japan: A Randomized Clinical Trial
1. Cognitive processing therapy combined with treatment as usual (TAU) was superior to TAU alone in reducing the severity of post-traumatic stress disorder (PTSD) symptoms from baseline to 17 weeks.
Evidence Rating Level: 2 (Good)
Cognitive behavioral therapy, specifically cognitive processing therapy (CPT), is an evidence-based treatment for post-traumatic stress disorder (PTSD). However, the efficacy of CPT among the East Asia population is unclear. This randomized clinical trial thus examined the efficacy of CPT for PTSD in a Japanese population. This study used a 16-week, single-center, assessor-blinded, parallel-group superiority design to examine the efficacy of CPT in conjunction with treatment as usual (CPT-TAU) vs TAU alone while wait-listed for CPT (WL-TAU) from April 2016 through December 2022. Adult patients aged 18-70 years with PTSD at a national psychiatric referral hospital in Tokyo, Japan were included and randomized 1:1 to CPT-TAU (n = 29) or WL-TAU (n = 31). TAU included pharmacotherapy, clinical monitoring, psychoeducation, and supportive counseling. The primary outcome was the Clinician-Administered PTSD Scale (CAPS-5) score (higher scores indicating more severe PTSD symptoms), and secondary outcomes included self-reported PTSD symptoms assessed by the PTSD Checklist–5, and responder status. Due to attrition, of the 60 participants included in the intention-to-treat analysis (mean [SD] age, 36.9 [9.9] years; 54 women [90.0%]), 27 completed CPT-TAU intervention, and 24 completed the WL-TAU condition. The mean (SD) number of completed sessions for the CPT-TAU group was 13.19 (1.25). At 17 weeks, the CPT-TAU group showed a greater mean (SE) reduction in CAPS-5 scores of 14.00 (1.92) compared to 0.15 (1.91) in the WL-TAU group. CPT-TAU group also showed superiority in all secondary and other outcomes. Mean change differences were found in depression (8.83; 95% CI, 6.00-11.66), suicidal ideation (6.73; 95% CI, 1.25-12.22), disability (8.16; 95% CI, 3.90-12.43), clinical global impression (0.84; 95% CI, 0.41-1.26), and loss of principal PTSD diagnosis (59.09; 95% CI, 37.19-81.00). Improvements for the CPT-TAU group were maintained in all outcomes from 17 to 34 weeks. No serious adverse events were observed in the CPT-TAU group, while 3 serious adverse events in the WL-TAU group during the intervention period. Overall, combining CPT with TAU was superior to TAU alone in reducing PTSD symptoms in a Japanese population, suggesting that incorporating CPT to TAU may be beneficial for patients with PTSD in East Asian populations.
1. Increased blood–urea–nitrogen-to-albumin ratio was associated with increased risk of in-hospital mortality among patients with COVID-19.
Evidence Rating Level: 2 (Good)
Blood–urea–nitrogen-to-albumin ratio (BAR) is recognized as a novel short-term prognostic index, and elevated BAR has been linked to worse prognosis among patients hospitalized for coronavirus disease 2019 (COVID-19). However, research on the relationship between BAR and in-hospital mortality associated with COVID-19 is limited. This retrospective cohort study thus examined the association between BAR and in-hospital mortality in patients with COVID-19 in China. This study included patients over 18 years old who were hospitalized with COVID-19 from December 2022 to March 2023. In-hospital mortality was characterized as any death occurring during patient hospitalization or within 24 hours of discharge from the hospital. BAR (mg/g) was calculated using the initial serum blood–urea–nitrogen (mg/dL) divided by serum albumin (g/dL). Patients were divided into tertiles based on BAR values: tertile I (BAR, 1.134–3.932 [n = 341]); tertile II (BAR, 3.944–5.793 [n = 343]); and tertile III (BAR, 5.811–48.3 [n = 343]). In total, 1,027 patients were included in this study (mean [SD] age, 72.1 [13] years; 569 males [55.4%]), of whom 117 patients (11.4%) died from various causes during hospitalization. Patients in the highest BAR tertile had a higher risk of in-hospital mortality (adjusted hazard ratio [HR] 2.44 [95% confidence interval CI 1.24–4.79]) compared to those in the lowest tertile. Additionally, for every 1-unit increase in BAR, the risk of in-hospital mortality increased by 6% (adjusted HR 1.06 [95% CI 1.03–1.08]). Stratified and interaction analyses found that the association between BAR and in-hospital mortality due to COVID-19 remained consistent across various subgroups, including age, sex, COVID-19 severity, hypertension, coronary heart disease, and diabetes mellitus. Overall, this study found increased BAR to be associated with an increased risk of in-hospital mortality among patients with COVID-19. As this study mainly focused on patients with the Omicron variant of SARS-CoV-2, future studies are needed to confirm study findings.
Image: PD
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