2 Minute Medicine Rewind October 4, 2021

Health care costs associated with hepatitis C virus infection in First Nations populations in Ontario: a retrospective matched cohort study

1. Health care costs associated with with hepatitis C virus in Status First Nations people increased with disease progression

2. Net costs were higher among females in the initial stages of the infection, whereas males had higher costs associated with the terminal phase. 

Evidence Rating Level: 2 (Good) 

Hepatitis C virus (HCV) is a prevalent infection across Canada that places a significant burden on the healthcare system. When left untreated, HCV can have detrimental health consequences including chronic hepatic inflammation, cirrhosis, liver cancer, and death. Previous studies have found that First Nations people in Canada are disproportionately affected by HCV infection. This retrospective matched cohort study aimed to calculate total and net costs per 30 days of HCV infection in First Nations communities. Health administrative databases were used to gather  information from 2004-2014 on Status First Nation people having tested positive for HCV antibodies or RNA. The study also identified non HCV status participants, or those who had no HCV testing records as the control group. A total of 2197 participants were diagnosed with HCV between 2004 and 2014. Next, the costs were analyzed among four stages including pre-diagnosis, initial, late, and terminal until death. Finally, costs were compared inside and outside of First Nations communities. The net cost per 30 days for the pre-diagnosis, initial, late, and terminal stages were $637, $875, $2786, and $8896 respectively. Net costs were higher among males with the exception of the terminal phase and in general the majority of the costs were associated with the antiviral drug treatment for HCV. When comparing inside and outside the communities, costs were higher outside of the First Nations communities however, this may be due to lack of access to services. Barriers to care include mistrust in the healthcare system due to systemic racism, the effects of colonization, and a history of generational trauma inflicted on First Nations people. A limitation of this study was that it solely focused on status First Nations people registered under the Indian Act. Therefore it excluded Non-status First Nations, Inuit, and Métis people. On the other hand, a strength of this study was the collaboration between the First Nations community partners, organizations, and researchers. Overall, this study not only highlighted the high costs of HCV but the need for culturally specific services to target high risk populations such as First Nations people. Additional research, planning, and resources should be utilized in order to prevent HCV progression before it reaches terminal stages. 

Young people’s romantic relationships and sexual activity before and during the COVID-19 pandemic

1. Youth have continued to engage in romantic relationships and sexual activity throughout the COVID-19 pandemic 

2. Access to sexual health educations, services, and resources are required to meet the  needs of young adults and adolescents 

Evidence Rating Level: 2 (Good) 

The COVID-19 pandemic has led to school closures and stay-at-home orders within The United States, impacting the social lives of adolescents (13-17), young adults (18-21), and their relationships. Previous studies have examined the effects of social distancing on peer acceptance, social connection, and mental health. However, there has been limited data on young people’s romantic and sexual relationships during the pandemic. This study aimed to address this gap and assess the impact of COVID-19 social distancing guidelines on romantic and sexual relationships of young people in Fresno County, California. Fresno County was disproportionately impacted by COVID-19 with higher rates of the virus than the state average and their schools closed for the 2020-2021 year. Participants aged 13-19 were recruited from a larger sample of participants enrolled in a 5 year, randomized controlled trial for sexual health education. Students were invited to complete an online survey about the impacts of COVID-19 on their living arrangements, their sexual and reproductive health, and the use of technology in their relationships. Furthermore, participants were asked questions regarding the impacts of physical distancing from intimate partners, sexual activities, online relationships, and baseline attitudes towards COVID-19.The use of the Chi-square test of independence allowed comparison between age groups (adolescents vs young adults), gender identity, and sexual orientation. A total of n=351 youth responded to the survey with the majority being females (72%), Hispanic (75%), and heterosexual (83%). Over one third (37%) of respondents were in a romantic relationship during the pandemic. Among these participants 34% were unable to spend time with their partner during the lockdown restrictions. This social distancing was mainly due to parental restrictions among adolescents compared to young adults (44% vs 20%). The stay-at-home orders lead to increased parental monitoring, less independence, and reduced privacy. However, the percentage of participants who had sex monthly declined by only 1% with similarly insignificant reductions among weekly and daily rates. Further studies are required to analyze the lasting impacts on mental health among youth with regards to their relationships. Relationships differed between adolescents and young adults due to their living situations and the influence of parents and caregivers. A limitation of the study was the relatively small sample size in only one county in California which may not be generalizable to the larger population. However, a strength of the small sample size was that it included primarily Hispanic participants, a demographic often underrepresented in research studies and in past surveys. Overall, the study reinforced the need for continued access to sexual and reproductive health services and education for youth even during pandemic lockdowns. Health care providers, schools, and community organizations should have resources available for youth during the COVID-19 pandemic in order to keep adolescents and young adults safe and healthy. 

Use of menopausal hormone therapy and risk of dementia: nested case-control studies using QResearch and CPRD databases

1. The use of menopausal hormone therapy was not associated with an increased risk of developing dementia or Alzheimer’s disease 

2. Estrogen-only therapy for 10 years or more was associated with a decreased risk of dementia 

Evidence Rating Level: 3 (Average) 

Approximately 80% of women experiencing menopause report symptoms including hot flashes, sleep disturbances, depression, cognitive and concentration decline, and even development of neurodegenerative diseases. Biological studies have found that estrogen has a neuroprotective role and therefore prescribing estrogen to ease menopausal symptoms is often warranted. However, hormone replacement therapy studies have been inconclusive with certain research suggesting higher risks of cognitive harm. This study aimed to assess and understand the impacts of hormone therapy and the risk of developing dementia. Specifically, it conducted two nested case-control studies using primary care databases; QResearch and CPRD GOLD. These databases offered information between 1998 and 2020 of all prescriptions used for menopausal treatment including estrogen and progestogens as well as topical hormonal preparations such as vaginal creams for menopausal women. Time intervals were also used to calculate durations of exposure for each prescription. Furthermore, analyses were performed separately for Alzheimer’s disease and vascular dementia. In total, n= 118 501 cases of women over the age of 55 with a diagnosis of dementia were identified and matched to n= 497 416 controls (women over 55 without dementia). 16 291 (14%) of the cases and 68 726 (14%) of controls had used menopausal hormone therapy for more than three years prior to the study index date. Additional findings revealed that 34% of patients with dementia were diagnosed with Alzheimer’s whereas 21% had a diagnosis of vascular dementia, and 3% having both. Overall, no significant association between the use of menopausal hormone therapy and dementia risks was found. There was however, a decreased risk of dementia for participants younger than 80, taking estrogen-only therapy for 10 years or more. A strength of the study was that it took into account the age of the participants, the dosage and type of medications, various methods of applications of therapy, as well as duration of therapy. However, a limitation was the lack of available data recording specific dates of menopause as well as differentiating women who may have experienced neurocognitive decline without an official diagnosis of dementia. Overall, the study can offer some reassurance to women and  health care professionals that there were no increased risks of developing dementia associated with the continued use of their estrogen-only hormone therapies. 

Is duration of passive second stage associated with a risk of hysterotomy extension during cesarean?

1. Prolonging passive second stage beyond 2 hours did not increase the risk of hysterotomy extension during cesareans 

2. Surgeon’s level of experience and forceps use during cesarean were associated with hysterotomy extensions

Evidence Rating Level: 2 (Good)

Approximately 3-8% of cesareans result in hysterotomy extension which can result in increased postpartum hemorrhage and subsequent pregnancy complications. Previous studies have suggested that during the second stage of labour, at full dilation, women are at a higher risk of extension of the incision. The goal of this study was to better understand the factors associated with second-stage labour and hysterotomy extensions. This 5-year retrospective cohort study included 747 women at the Port Royal maternity hospital in Paris. Women were included if they had a cesarean delivery during the second stage of labor at term (37 weeks gestation or later). Data were collected on all hysterotomies requiring a suture including lateral, inferior, and superior extensions.  Analyses were included for operative time, hemorrhage, maternal, and neonatal complications. Of the 747 second-stage cesareans, there were 83 (11.1%) hysterotomy extensions, with only 2 being intentional in order to extract the fetus. Overall, the occurrence of hysterotomy extension was more frequent among obese women, those with hypertensive conditions, and multiparous women. However, the rate of extensions did not change based on duration of the passive second-stage, the position of the fetal head, nor fetal station. Additionally, birth weight and head circumference did not make a significant difference in hysterotomy extension either. Factors that were found to be associated with hysterotomy  extension included the supervising surgeon’s experience and the use of forceps. Therefore, a limitation of the study is that it may suggest that forceps use is dangerous. However, situations when forceps are used are typically higher risk regardless and they are required in order to safely and efficiently deliver the fetus. Conversely, a strength of this study was the large amount of data analyzed covering a large cohort of births in their many stages and the factors associated with varying cesarean experiences. Overall, this study can give reassurance to women in labour and obstetrical health care providers that prolonged second stage and delayed pushing does not lead to greater risk of extended hysterotomy when cesarean delivery is performed. 

Associations Between Historically Redlined Districts and Racial Disparities in Current Obstetric Outcomes

1. Historically redlined districts and racial discriminatory policies were associated with worse obstetrical outcomes including preterm birth 

2. Structural inequities and racial disparities had detrimental health effects, increased obstetric related morbidity, and mortality 

Evidence Rating Level: 2 (Good) 

Racial and ethnic disparities are prevalent in the United States with pregnancy related morbidity and mortality at a significantly higher rate among Black women. Preterm birth is no exception with Black women experiencing a preterm birth rate 50% higher than non-Hispanic white women. Previous studies have revealed socioeconomic factors, stress, and structural systemic racism contribute to these findings. One aspect that has not yet been studied extensively was the practise of redlining by the federal government’s Home Owners’ Loan Corporation (HOLC). This redlining, beginning in the 1930s was a form of overt racism where mortgages and properties were classified as either  « desirable » or « hazardous » based on the demographic living in the area. In these HOLC maps, «safety » was synonymous with « white » neighborhoods. This led to declining conditions in certain black communities while intergenerational wealth was perpetuated among white families. These historical inequities have influenced modern day home ownership and further exasperated health disparities. This study aimed to better understand the impacts of structural racism in the housing market and specifically modern obstetric outcomes. In order to do so, a retrospective cohort study was conducted with n= 199 088 live births between 2005-2017 in 15 historically redlined zip codes. These zip code regions were previously categorized by racially discriminatory criteria according to the 1940’s (HOLC) map. Within these regions, specifically in Finger Lakes, live births were analyzed from obstetric data systems to assess for preterm birth (gestation less than 37 weeks), neonatal morbidity, and mortality. Overall, the association of racially  discriminatory home loan practise continues to have detrimental effects on modern obstetric outcomes.  A total of n=64 804 live births occurred within 15 zip codes redlined by the HOLC grading map. Rates of preterm birth increased as the HOLC grades worsened, with the « hazardous » zip code having the highest overall rate of preterm births 427/3449 (12.38%). This was in stark contrast with historically defined « Best/Desirable » zip codes resulting in the lowest overall preterm birth rates at 217/2873 (7%) of births.  Furthermore, rates of periviable birth were 3-fold higher in the “Hazardous” zip codes compared to the “Desirable” ones (26 births [0.75%] vs 7 births [0.24%]). Naturally, this study was limited by potential confounding factors leading to preterm and periviable births. However, a strength of the study is that it did include a relatively large sample size, covering several cities, counties and HOLC zip codes. Overall, this study highlights that historic inequities are not as far in the past as we may have hoped. Rather, their intergenerational effects continue to impact obstetric outcomes today. The legacy of inequities and discrimination continue in the 21st century. 

Image: PD

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