2 Minute Medicine Rewind January 15, 2024
1. This multicentre, randomized, comparative effectiveness study found that the short-stay unit (SSU) was often as effective as hospitalization in patients with new onset of acute heart failure (AHF) and otherwise low-risk profiles.
2. There was no difference in 30- and 90-day mortality between the SSU and hospitalized patients.
Evidence Rating Level: 1 (Excellent)
Patients in acute heart failure (AHF) account for a great deal of healthcare spending, particularly due to hospitalizations that often originate from emergency department (ED) visits. Hospitalizations are also not entirely benign with the possibility for in-hospital adverse events and data to suggest a multi-fold increase in 1-year all-cause mortality in patients who are hospitalized for heart failure compared to non-hospitalized counterparts. A model for brief observation (also coined short-stay units [SSU]) is supported in some literature, particularly in AHF patients with otherwise favourable risk profiles. The current study is the first randomized trial to evaluate the efficacy of SSUs for AHF compared to hospitalization. A total of 193 patients across 12 sites (mean [SD] age, 64.8 [14.8] years) were randomized to either the SSU arm (n = 93) or the hospitalization arm (n = 100). There were no differences in the proportions of patients in either arm receiving furosemide treatment, nor were there differences in initial ED therapies received by either arm. At discharge and at 30 days, scores on a questionnaire assessing quality of life in cardiac patients did not differ significantly between the groups (ps = .47 and .19, respectively). While a proportion of patients in the SSU arm required hospitalization, over 60% were sufficiently treated in the SSU environment. SSU patients had 1.6 more days alive and out of hospital (DAOOH) at 30 day follow-up than hospitalized counterparts (p = .02). The total number of deaths at 90 days was comparable at 3 for the SSU arm and 4 for the hospitalization arm. While patients randomized to the SSU arm had slightly lower left ventricular ejection fractions (LVEF) on assessment, this did not appear to impact end-results of the study. This study should be replicated due to limitations in enrollment caused by the COVID-19 pandemic to ascertain the true statistical power of the results. However, the results do indicate that SSUs could be a reasonable alternative to hospitalization for lower-risk patients presenting with symptoms consistent with AHF.
Perinatal Depression and Risk of Suicidal Behavior
1. Perinatal depression (PND) was found to be associated with a 3-fold increased risk for suicidal behaviours compared to a non-PND cohort at 18-year follow-up.
2. PND most significantly increased risk for suicidal behaviours for 1 year after diagnosis, with certain suicide methods being much more common than in the general population.
Evidence Rating Level: 2 (Good)
Among several important public health issues is that of maternal mental health. Up to one-third of postnatal mortality has been attributed to maternal suicide, and thus, identifying at-risk groups for maternal suicide is thought to be a priority in prevention. At-risk groups may involve mothers with a psychiatric history prior to pregnancy, lower socioeconomic status, and those with perinatal depression (PND). The current matched cohort study and analysis included 86,551 women with PND (55% affected in the antenatal period, and the rest affected postnatally; mean [SD] age 30,67 [5.23] years) and 1,029,215 matched cohorts without PND. Women with PND were more likely to be primiparous, smoked within the 3 months prior to pregnancy, had greater BMIs, and psychiatric histories. At 18-year follow-up, women who were identified to have PND were 3 times more at-risk for suicidal behaviour (HR, 3.15; 95% CI, 2.97-3.35), and this risk was even higher for women without a previous history of psychiatric disorders. Risk was greatest in the first year following PND diagnosis (HR, 7.20; 95% CI, 6.07-8.54), lasting up to 5 years later (HR, 2.34; 95% CI, 2.12-2.57). With respect to suicidal behaviours, women in the PND group were over 7 times more likely to use the method of hanging (HR, 7.29; 95% CI, 4.42-12.03) and within the first year, risk was highest for self-poisoning (HR, 11.76; 95% CI, 9.86-14.02). A sibling-matched cohort also revealed similar results in that those with PND were at higher risk for suicidal behaviours than non-PND counterparts. This study has strengths in that the lengthy follow-up period of 18 years allowed for a longitudinal approach to assessing maternal suicide risk, which remained elevated if one had been diagnosed with PND. However, results are somewhat limited in that they may be underestimating the impact of suicidal behaviour; of those who attempt suicide or experience suicidal ideation, a large proportion never seek medical help. Future studies should also assess the impact of PND on psychiatric hospitalizations, and control for other environmental factors that may be at play in the development of PND (e.g., domestic violence, birth trauma, etc.).
1. This cross-sectional study is the first to identify the monocyte-to-HDL ratio (MHR) as an indicator of poor endothelial dysfunction in a sample of diabetic patients.
Evidence Rating Level: 2 (Good)
Endothelial disruption and damage are common sequelae of diabetes, leading to downstream microvascular and macrovascular complications that are often devastating and contribute to a great deal of morbidity and mortality for diabetic patients. Flow-mediated dilation (FMD) is a tool that assesses the extent of damage to endothelial cells, and has been used to monitor the progression of endothelial dysfunction in diabetic patients. Literature indicates that endothelial function is impacted by glucose presence in the blood due to its effects on the inflammatory response (which is largely mediated by monocytes and macrophages). On the other hand, there is also literature to suggest that the presence of high-density lipoproteins (HDLs) in the blood can improve endothelial function by decreasing the expression of adhesion molecules that are active in inflammation and atherosclerosis. Thus, the monocyte-to-HDL Cholesterol ratio (MHR) was studied to ascertain whether it could be used as a biomarker for vascular endothelial dysfunction. The current cross-sectional study included 193 diabetic patients with endothelial dysfunction (FMD scores above the cutoff of 6.4%; mean age 66.6 years). They were found to be older than their non-dysfunctional counterparts (with a mean age of 63.0 years), and displayed higher rates of systolic and diastolic hypertension (ps < .05). The MHR in the group with endothelial dysfunction was significantly higher than their non-dysfunctional counterparts (p = .009). The difference was not found in HDL-C levels, but rather in the monocyte levels, which were significantly higher in those with endothelial dysfunction (p = .002). After adjusting for sex, age, BMI, disease course, hypertension, smoking, alcohol consumption, hemoglobin-A1C, C-reactive protein, and triglyceride levels, each 10% increase in MHR resulted in a 35% increase in endothelial dysfunction (OR 1.35, 95% CI 1.02-1.77). This study should be replicated in a larger sample across several centers to verify its effectiveness as a biomarker for endothelial dysfunction, but provides a promising and potentially convenient measure to be used to risk-stratify diabetic patients.
1. This longitudinal prospective cohort study found that older adults with trajectories involving impairments to instrumental activities of daily living, higher comorbidity, and increasing depressive symptoms were particularly at risk for developing cognitive impairment.
Evidence Rating Level: 2 (Good)
The global population is rapidly aging, and with this comes an increased incidence of morbidity and disease burden. In particular, cognitive impairment – marked by difficulties with memory, learning, concentration, and decision-making – will continue to burden the aging population. Thus, a preventative approach aimed towards identifying risk factors for dementia and cognitive impairment are of great importance. Previous literature has pointed to factors including sleep disorders, depression, functional limitations, and multimorbidity as correlates for cognitive impairment, but their trajectories through the lifespan are often neglected in the reporting of results. The current study made use of 8 years worth of measurement data from the Health and Retirement Study (HRS) to identify correlations between long-term health status and cognitive impairment. After implementing exclusion criteria, over 4319 adults older than 60 (mean [SD] age, 75.5 (5.55); 61.4% female) had demographic and health data analyzed, including several measures for sleep disturbance, functional status, and depressive symptoms over the course of 8 years. Those who reported sleep disturbances, increasing limitations on activities of daily living (ADLs/IADLs), and increasing scores on depression inventories over the years were more likely to be older, female, less educated, overweight, and sedentary. On an assessment of those participants that developed cognitive impairment, high multimorbidity status (HR = 1.89; 95% CI = 1.49–2.39), worsening depressive symptoms (HR = 1.80; 95% CI = 1.53–2.12), limitations in ADLs (HR = 1.88; 95% CI = 1.54–2.31), and IADLs (HR = 2.98; 95% CI = 2.34–3.78) presented heightened risk for cognitive impairment. Interestingly, the effects of increasing difficulty with IADLs (e.g., using the telephone, managing money, taking medications, shopping for groceries, and preparing hot meals) were more strongly correlated with cognitive impairment for older adults living in urban areas (HR = 2.30; 95% CI = 1.65–3.21; P for interaction = 0.049) compared to rural areas. The interaction of IADL impairment and cognitive impairment was also stronger in those with a history of smoking (HR = 2.77; 95% CI = 1.91–4.02; P for interaction = 0.033). For every point increase in the total score of risk trajectories, risk for cognitive impairment increased by 49%. Overall, the results of this study indicate that there exists a co-occurrence between physical, psychological, and neurocognitive disorders. A randomized trial should be implemented in the future to explore the effects of early intervention for these conditions, particularly for patients in the identified at-risk groups.
Predictive value of SIRI and SII for metastases in RCC: a prospective clinical study
1. This prospective study found that the Systematic Inflammatory Response Index (SIRI) and Systemic Immune-Inflammation Index (SII), as well as high platelet and low lymphocyte counts, were independent predictors of metastasis in patients with renal cell cancer (RCC).
Evidence Rating Level: 2 (Good)
Cancer is a major contributing cause of mortality and morbidity worldwide, and survival rates vary greatly based on the type of cancer as well as the rate of spread. Renal cell cancer (RCC) in particular has varying survival rates which are drastically impacted in the case of distant metastases. There is also emerging literature to suggest the role of inflammatory-mediated pathways in the development of cancer. The Systemic Inflammatory Response Index (SIRI) and Systemic Immune-Inflammation Index (SII) are used as markers of an inflammatory environment, and take into account several blood cell line counts (including neutrophils, monocytes, platelets, and lymphocytes). The predictive value of the SII and SIRI in RCC was investigated in the current study. Seventy-two patients (51 male, 21 female; 22 with metastatic RCC and 50 with non-metastatic RCC diagnosed through surgery, biopsy, lymph node dissection, and imaging) were identified. Their medical records for laboratory results, histopathological findings, and tumor staging/grading were used. Inflammatory indices for the SII and SIRI were calculated based on lab results. There were statistically significant differences in SIRI and SII scores (collected at time of admission for RCC diagnosis) between the metastatic and non-metastatic patients (ps < .05 and < .001, respectively), indicating the presence of predictive value for metastasis based on these inflammatory markers. High platelet and low lymphocyte counts were also found to be independently predictive of metastasis in this sample. These results align with other studies pointing to the potential predictive and prognostic value of these tools and present a potentially cost-effective method of screening and risk stratification for patients with RCC and risk of metastatic progression. However, the power of these results would be bolstered if replicated with a larger sample size and standardized diagnostic methods (e.g., biopsy).
Image: PD
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