2 Minute Medicine Rewind December 12, 2022

Eczema Care Online behavioural interventions to support self-care for children and young people: two independent, pragmatic, randomised controlled trials

1. Parents or carers of eczema patients and young patients randomized to receive online behavioural interventions reported greater decreases in eczema symptom severity over 52 weeks, compared to care as usual.

Evidence Rating Level: 1 (Excellent)

Eczema can impact quality of life for patients lifelong, making eczema education important for self-management of this condition. However, there have been few online educational interventions developed for eczema, none of which have been studied in a trial with adequate sample size. Therefore, this randomized controlled trial compared eczema symptoms reported by young patients and parents or carers of patients, half of which underwent an online behavioural intervention for eczema. The study population consisted of 524 parents and carers for eczema patients aged 0-12 years, and 411 young patients aged 13-25 years with eczema. Within each demographic, participants were randomized 1:1 to receive the online intervention plus eczema care as usual, or care as usual without intervention. The intervention evaluated was the Eczema Care Online website, which were self-guided curriculum that provided education on decreasing eczema symptoms through evidence-based and expert-endorsed behavioural and lifestyle modifications. Two different interventions were created, one specific to parents and carers, and the other specific to young patients. The primary outcome was severity of eczema every 4 weeks for 24 weeks, measured by the Patient-Oriented Eczema Measure (POEM), with a change of 2.1 to 2.9 points indicating a change likely not attributable to measurement error. The secondary outcome included severity of eczema every 4 weeks for 52 weeks. After adjustments, the mean difference in POEM score between groups for patients and carers was -1.5 over 24 weeks (95% CI -2.5 to -0.6, p = 0.002), indicating a small significant effect from the online behavioural intervention. As well, 39% of the usual care and 58% of the intervention participants had a POEM score improvement of 2.5 points (OR 2.1., 95% CI 1.2-3.6 and NNT of 6, 95% CI 3-13). Over 52 weeks, the mean difference was -1.4 (95% CI -2.3 to -0.4), with 48% in the usual care and 60% in the intervention improving at least 2.5 points (OR 1.4, 95% CI 0.8-2.4). For the young people cohort, the mean difference over 24 weeks was -1.9 (95% CI -3.0 to -0.8, p < 0.001), with 39% of usual care and 56% of intervention patients improving at least 2.5 points (OR 2.0, 955 CI 1.2-3.5 and NNT of 6, 95% CI 4-18). Over 52 weeks, the mean difference was -1.4 (95% CI -2.4 to -0.4), with 47% of usual care and 62% of intervention patients improving 2.5 points (OR 1.6, 95% CI 0.9-2.8). Overall, this study demonstrated that online behavioural interventions for both parents or carers and young patients can be linked to sustained decreases in eczema symptoms severity.

Association of In Utero Antipsychotic Medication Exposure With Risk of Congenital Malformations in Nordic Countries and the US

1. Generally, 1^st trimester exposure to antipsychotic medication was not found to be significantly associated with congenital malformations.

2. Specific exposure-outcome combinations require further investigation, including olanzapine exposure and cleft conditions, chlorprothixene with cardiovascular malformations, and atypical antipsychotic exposure with gastroschisis and non-hydrocephalus brain anomalies.

Evidence Rating Level: 2 (Good)

Although antipsychotic medication is standard treatment for individuals with schizophrenia and bipolar disorders, the research surrounding the teratogenicity of these medications is conflicting. While the general consensus is that they are not major teratogens, alerts have also been raised about potential links to congenital cardiovascular conditions and cleft conditions. Therefore, this multinational cohort study aimed to determine the risk of major congenital defects from first-trimester exposure to antipsychotic medications. This study spanned from 1996 to 2018, and included all pregnancies of singleton live-born infants in Norway, Sweden, Finland, Denmark, and Iceland, as well as pregnancies resulting in live-born infants from publicly insured mothers in the USA. Additionally, pregnancies with known chromosomal conditions or teratogenic medication exposures were excluded. In total, there were 6,455,324 pregnancies included without first-trimester exposure to antipsychotics, 21,751 with atypical antipsychotic exposure, and 6,371 with typical antipsychotic exposure. The results showed that the risk for a major congenital malformation was 2.7% amongst unexposed women, 3.7% (95% CI 3.6-3.7%) amongst unexposed women with a mental health condition, 4.3% (95% CI 4.1-4.6%) amongst women exposed to atypical antipsychotics, and 3.1% (95% CI 2.7-3.5%) amongst women exposed to typical antipsychotics. Furthermore, the risk varied from 1.8% to 5.5% depending on the specific medication used. When linking exposures to specific congenital outcomes, most exposures were not found to carry significant relative risk, apart from olanzapine exposure and cleft conditions (adjusted RR 2.1, 95% CI 1.1-4.3. As well, higher risks were observed for exposure-outcome combinations that were supported with a moderate amount of information, including atypical antipsychotic exposure and gastroschisis (aRR 1.5, 95% CI 0.8-2.6), non-hydrocephalus brain anomalies (aRR 1.9, 95% CI 1.1-3.0), and also chlorprothixene exposure with cardiac anomalies (aRR 1.6, 95% CI 1.0-2.7). Overall, this study found that for the most part, there were no significantly elevated risks of congenital malformations associated with 1^st trimester exposure to antipsychotics, except for a few potential exposure-outcome combinations listed that warrant further investigation.

Association Between Consumption of Ultraprocessed Foods and Cognitive Decline

1. At 8 years follow-up, a higher percentage of daily caloric intake from ultraprocessed foods (UPFs) was associated with quicker global cognitive decline and executive function decline, but not associated with memory decline.

Evidence Rating Level: 2 (Good)

While dementia is a leading cause of disability worldwide, the paucity of treatments available turns the focus to preventative measures and lifestyle factors. Research has shown that healthy eating, not smoking, and physical activity are linked to prevention of dementia. However, despite research linking ultraprocessed foods (UPFs), defined as food products that contain minimal to no whole foods, to metabolic syndrome and associated diseases, there is little data examining the connection between UPFs and cognitive decline. This prospective cohort study investigated this association through a longitudinal study of adults based in Brazil. The study population consisted of public servants ranging from 35 to 74 years old, in 6 Brazilian cities, with data collected in three 3-year increments between 2008 and 2019. Diet was assessed through the Food Frequency Questionnaire (FFQ), and cognitive assessments were done up to 3 times every 4 years, which included tests for memory and executive function. In total, there were 10,775 study participants. Those with the highest quartile of UPF consumption were more likely to be non-smokers, less likely to be alcohol consumers, and more likely to have higher income and education. The results showed that after a median 8-year follow-up, there was a 28% more rapid rate of global cognitive decline in individuals reporting greater than 19.9% of daily caloric consumption from UPFs, compared to those reporting less than 19.9% (β = −0.004, 95% CI −0.006 to −0.001, p = 0.003). There was also a 25% quicker rate of decline in executive function (β = -0.003, 95% CI -0.005 to 0.000, p = 0.01), but no association with UPF consumption and memory. Overall, this study demonstrated that higher percentages of daily caloric intake from UPFs were associated with greater global cognitive decline and execution function decline at 8 years follow-up.

A digital application and augmented physician rounds reduce postoperative pain and opioid consumption after primary total knee replacement (TKR): a randomized clinical trial

1. Total knee replacement (TKR) patients randomized to receive education on analgesia through a digital app and augmented physician rounds had improved self-reported postoperative pain, decreased oxycodone consumption, and improved patient satisfaction.

Evidence Rating Level: 1 (Excellent)

Presently, postoperative opioids are the mainstay for managing severe postoperative pain, when lower potency analgesics are not sufficient. However, it is also pertinent to avoid opioid overuse when possible, to minimize costs and potential for addiction. One proposed method for improving pain outcomes is the use of “open medication”: This means making the administration of analgesics more obvious to the patient, such as through sight and smell, or by using technical aids that educate a patient on what, when, and how much of an analgesic they are being administered. Another proposed method is improving interpersonal relationships between patient and doctor, such as through augmented physician rounds, where physicians make time to listen to and address concerns elicited from the patient. Therefore, this single-centre randomized controlled trial based in Germany compared postoperative pain relief outcomes for total knee replacement (TKR) patients in four arms: The “application” arm (APP) with information about medication administration displayed on an iPad, the “doctor” arm (DOC) with augmented physician rounds, the “combined” arm (APP+DOC) with both the iPad and augmented rounds, and “treatment as usual” (TAU) with standard postop pain management, including analgesics, physiotherapy, and typical physician rounds. Compared to the TAU arm, the remaining arms provided information to patients about expected pain progression after receiving analgesics, including demonstration of a prognostic graph of pain levels based on pharmacockinetic properties. This information was delivered by an iPad in the APP arm, by a doctor during augmented rounds in the DOC arm, and by both in the APP+DOC arm. In total, there were 96 patients randomized equally to the 4 arms. The results showed that on a 10-point pain scale, the APP+DOC arm had a 2.3 reduction in pain, and the APP, DOC, and TAU arms had a 1.7, 0.7, and 0.1-point reduction in pain respectively. APP+DOC had a significantly greater reduction in pain compared to DOC (95% CI 0.08-3.09, p = 0.04) and TAU arm (p = 0.005, 95% CI 0.69-3.71), whereas APP also had a significantly greater reduction compared to TAU (95% CI 0.09-3.10, p = 0.04). As well, oxycodone consumption was significantly higher for TAU and APP patients compared to DOC and APP+DOC patients, and APP+DOC patients had significantly lower consumption than DOC patients. Furthermore, APP+DOC patients were more satisfied than TAU patients (p = 0.03). Overall, this study demonstrated that supplementing postoperative opioid prescription, alongside patient education facilitated by physician communication and a digital app, improved postoperative pain outcomes, decreased oxycodone consumption, and improved patient satisfaction.

Carotid and femoral bruits as cardiovascular risk indicators in a middle-aged Finnish population: A 20-year prospective study

1. Patients with auscultated carotid and femoral bruits were found to have an elevated risk for cardiovascular (CV) mortality, but after excluding patients with a history of CV events, no association was found between bruits and CV events or all-cause mortality.

Evidence Rating Level: 2 (Good)

As the leading cause of death globally, predicting the risk of cardiovascular (CV) disease-related adverse events is pertinent. While there are risk calculators available and complex measurements such as carotid intima-media thickness, the utility of less complex clinical tests, such as assessing for carotid or femoral bruits, has not been rigorously studied. Therefore, this 20-year prospective study examined the association between carotid and femoral bruits and mortality from CV disease and all causes. The study population consisted of participants randomly chosen from the Social Insurance Institute of Finland: This included 600 patients with hypertension who were matched by age and sex to 600 other subjects. The auscultation for bruits was done in the early 1990s, and patients were followed for 20 years until 2014. In total, there were 1045 subjects, 49.8% of whom were male, and with a mean (SD) age of 51.3 (5.97) years at the beginning of the study. Also, 4.0% had carotid bruits, 11.9% had femoral bruits, 1.1% had both, and 85.2% had neither. The results found that 23.1% of participants died, and 34.0% of those deaths were CV related. Both carotid and femoral bruits were associated with higher risk of CV-related death (hazards ratio 4.15, 95% CI 2.39-8.52, p < 0.001; HR 2.55, 95% CI 1.54-4.22, p < 0.001 respectively). The incidence of mortality from CV events was 1.48% per person-year for those with carotid bruits, 0.81% per person-year for those with femoral bruits, and 0.82% per person-year for those with either. After adjustments for CV risk factors such as blood pressure, smoking, cholesterol levels, and history of coronary disease or stroke, the risk for CV deaths was increased by 69% for patients with a carotid or femoral bruit, compared to those without. However, when excluding patients with prior CV events, there was no association between carotid and femoral bruits with future CV event or all-cause mortality. Overall, this study found that there is an elevated risk of CV-related death for middle-age patients with carotid and femoral bruits, but without a history of a prior CV event, bruits were not associated with future CV events or all-cause mortality.

Image: PD

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