2 Minute Medicine Rewind August 26, 2024

Incidence of Medication-Related Osteonecrosis of the Jaw in Patients With Breast Cancer During a 20-Year Follow-Up: A Population-Based Multicenter Retrospective Study

1. The cumulative incidence of medication-related osteonecrosis of the jaw (MRONJ) in patients with breast cancer bone metastases was much higher compared to the available data reported in the literature thus far.

Evidence Rating Level: 2 (Good)

MRONJ is a common side effect of antiresorptive therapeutics such as bisphosphonates and denosumab which are used in the setting of metastatic breast cancer to manage bone metastases. While data has been reported on the risk of developing MRONJ, reports are highly variable and range between 1% and 17%. This multicentre retrospective study therefore sought to provide a precise investigation of the population-based incidence of MRONJ in breast cancer patients with bone metastases. 639 participants (median age = 61.8 years) from several centres in the Austrian state of Tyrol were included in this study. Individuals must have been diagnosed with breast cancer and bone metastases and received antiresorptive therapy to have been included. The cumulative incidence of MRONJ overall was 8.8% (95% CI, 6.6 to 11.0). It was found to be 11.6% (95% CI, 8.0 to 15.3) for patients receiving denosumab only, 2.8% (95% CI, 0.7 to 4.7) with bisphosphonates only and 16.3% (95% CI, 8.8 to 23.9) in patients who received bisphosphonates followed by denosumab. A significant difference in overall survival (OS) was observed between patients receiving different management options (log-rank test; P < .001), with the median OS being 7.9 years for patients receiving denosumab only, 5.6 years for patients receiving bisphosphonates only and 10.7 years for patients receiving bisphosphonates and then denosumab sequentially. However, as the use of denosumab became the standard of care during a period where significant changes were made to the management strategies of breast cancer, these results should be taken with caution. Overall, this study showed that the cumulative incidence of MRONJ was considerably higher than the data currently reported in the literature.

Sarcopenia Is a Risk Factor for Postoperative Complications Among Older Adults With Inflammatory Bowel Disease

1. Sarcopenia is associated with an increased risk of adverse postoperative outcomes in older adults with inflammatory bowel disease (IBD).

Evidence Rating Level: 2 (Good)

A considerable fraction of individuals living with IBD will undergo IBD-related surgery soon after diagnosis, presenting a point of concern for older adults living with IBD who are at a greater risk of postoperative complications. In many studies of populations of non-IBD older adults, sarcopenia has been shown to be an important risk factor for adverse postoperative outcomes. This single-institution, multi-hospital retrospective study therefore sought to investigate the relationship between skeletal muscle mass and postoperative outcomes in a population of older adults with IBD undergoing IBD-related surgery. 120 individuals (median age = 70 years) aged 60 years or older who underwent intestinal resection for IBD between 2012 and 2022 within the NYU Langone Health System were included in this study. The Total Psoas Index (TPI) and Skeletal Muscle Index (SMI) were obtained for each patient. Overall, 48 (40.0%) patients experienced an adverse 30-day postoperative outcome. Using receiver operating characteristic curves, SMI had a significantly higher area under the curve (AUC) than TPI (0.66 [95% CI, 0.56-0.76] versus 0.58 [95% CI, 0.48-0.69], P = 0.02). Lower SMI was found to be significantly associated with a greater risk of an adverse 30-day postoperative outcome, as the median SMI for patients experiencing an adverse outcome was 37.1 cm2/m2 versus 41.8 cm2/m2 for patients who did not experience an adverse outcome (P < 0.01). Overall, this study found that sarcopenia, as measured by SMI, is associated with increased risks of adverse postoperative outcomes in older adults living with IBD.

Sex, atrial fibrillation, and long-term mortality after cardiac surgery

1.In a cohort of adults who underwent cardiac surgery, men were more likely to develop postoperative atrial fibrillation (poAF) than women, but among those women, there was an increased risk of long-term mortality compared to men who developed poAF.

Evidence Rating Level: 2 (Good) 

Women are at a higher risk of postoperative complications and mortality after open heart surgery compared to men. However, it is unclear if there is an association between sex and postoperative atrial fibrillation (poAF), the most common complication after cardiac surgery. To address this gap in knowledge, this retrospective cohort study enrolled adults over 20 years of age who underwent a coronary artery bypass graft (CABG), an open aortic valve replacement or repair (AVR), open mitral valve replacement or repair (MVR), or combined procedures, with the use of cardiopulmonary bypass (CPB). The study measured the incidence of poAF, and all-cause mortality as the primary outcomes. PoAF was defined as any atrial fibrillation that occurred on an electrocardiogram (EKG) during the hospitalization in patients who originally presented with a normal sinus rhythm. A total of 21,568 patients (14,967 were men (69.4%) and 6,601 (30.6%) were women) participated in the study. Of these individuals, 8,499 (39.4%) developed poAF after open heart surgery, and women had a higher incidence of poAF compared to men (2694 [40.8%] vs 5805 [38.8%], however, according to the multivariable logistics regression model, women had a lower risk of poAF (odds ratio [OR], 0.85; 95% CI, 0.79-0.91; P<.001). In women who developed poAF, there was a higher mortality rate compared to women who did not develop poAF (HR, 1.31; 95% CI, 1.21-1.42, P<.001). The same pattern applied to men (HR, 1.17; 95% CI, 1.11-1.25, P<.001), however, this difference was not as extreme. The findings indicate that men had a higher incidence of poAF, however, women who developed poAF were at a higher risk for mortality. The study was limited since only patients who underwent a CABG, AVR, MVR, or combined procedures were included, thus making it difficult to generalize the results to patients who underwent other procedures. Overall, in this retrospective cohort study of patients undergoing cardiac surgery, women had a lower risk of developing poAF compared to men, but the women who developed poAF had a higher risk of mortality.

Early Occupational Therapy Intervention post-stroke (EOTIPS): A randomized controlled trial

1. Early occupational therapy in stroke patients significantly improves recovery of functional independence, quality of life, cognition skills, and level of depression 3 months post-discharge

Evidence Rating Level: 1 (Excellent)

Strokes incur significant changes in patients’ lives causing health, social, and economic problems that can cause disability. Additionally, there is an increasing incidence of stroke in the younger population leading to long-term health problems including mental health, cognitive impairment, and difficulties in activities of daily living (ADLs). Post-stroke rehabilitation provides an opportunity for functional improvements in patients’ lives. This prospective, randomized, controlled trial aimed to look at the effect of an Early Occupational Therapy Intervention Post-Stroke (EOTIPS) on hospital discharge post-stroke and quality of life for patients seen in the Spanish healthcare system. The EOTIPS intervention involved a personalized approach where individualized objectives were established. Sessions were an initial evaluation at the hospital, a post-discharge home visit, a follow-up home visit one month later, and a final evaluation 3 months post-discharge. The most common individual goal was related to performing ADLs, social participations, and activities related to self- and occupational identity. The control group only received the typical care and rehabilitation within the healthcare system. The primary outcomes were quality of life (Stroke and Aphasia Quality of Life Scale). Other outcomes included functional independence (Barthel Index, Modified Rankin Scale, and Stroke Impact Scale-16), sensory-motor skills (Fugl Meyer Assessment, Berg Balance Scale, and Timed Up & Go), communication skills (Communicative Activity Log), and mood disorders (Beck Depression Inventory-II and Hamilton Anxiety Scale). The EOTIPS group showed significantly better recovery of functional independence, quality of life, cognition skills, and level of depression relative to the control group. However, it is important to note that regardless of the rehabilitation program, all patients significantly improved in all forms of evaluation. 

Biomarker guided antibiotic stewardship in community acquired pneumonia: A randomized controlled trial

1. Using either procalcitonin or c-reactive protein as a biomarker to guide antibiotic treatment in patients with community-acquired pneumonia reduce the length of treatment course with no effect to time to reach stability or new antibiotic prescriptions

Evidence Rating Level: 1 (Excellent) 

20-50% of the 3.3 million people who develop community-acquired pneumonia (CAP) need to be hospitalized every year. Treatment of CAP is recommended to be a 5-21 day course of antibiotics yet in practice, patients are treated for longer than recommended. Biomarkers have been proposed to be an objective measure of when to start and stop antibiotic treatment in patients with CAP. These biomarkers include procalcitonin (PCT) and C-reactive protein (CRP). PCT is used as a marker of bacterial infection and CRP is a marker of inflammation. This randomized controlled trial aimed to look at the effects of a treatment algorithm based on PCR or CRP on the duration of antibiotic treatment in patients hospitalized with CAP. The control group’s treatment endpoint was determined by the attending physician. In either of the experimental groups, CRP or PCT respectively were determined on day 1 of admission and day 4. If on day 4, the level was below the threshold values (100 mg/L and a reduction to below 50% of the initial value for CRP and below 0.25 μg/L or a reduction to below 10% of the initial value for PCT), antibiotics were discontinued. If not, daily CRP and PCT were taken until the threshold was reached or until day 7 at the latest. The primary outcome was the total number of days on antibiotic treatment (IV and oral) until day 30. Secondary outcomes were new prescriptions, hospital stay length, clinical stability time, and all-cause mortality. In both experimental groups, the length of antibiotic course was reduced. The control group had an average treatment course of 7 days. There was a 30% reduction to a median of 4 days in the CRP group (pp<0.001) and by 22% to a median of 5.5 days in the PCT group (p<0.001). No significant changes were seen in time to reach clinical stability or new antibiotic prescriptions. Therefore, using either the CRP or PCT biomarkers reduced the duration of antibiotics used in patients hospitalized with CAP while having no change in the time needed to reach clinical stability or receive a new antibiotic prescription. The key limitation of this study is that it was underpowered to exclude harm due to the reduced duration of antibiotic treatment.  

Image: PD

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