Healthy user and related biases in observational studies of preventive interventions: a primer for physicians

Association Between Xanthelasma Palpebrarum with Cardiovascular Risk and Dyslipidemia: A Case Control Study

PURPOSE

To determine whether xanthelasma palpebrarum (XP) is associated with dyslipidemia, cardiovascular disease (CVD), and other systemic conditions in a large population.

DESIGN

Case-control study conducted at a single tertiary care center.

PARTICIPANTS

Individuals who were examined at a medical screening institute from 2001 through 2020.

METHODS

Medical records were reviewed to extract data on ophthalmic evaluations, blood test results, and systemic diagnoses. Patients identified with XP in at least 1 eye constituted the study group. A control group without XP was established matched by age and sex at a 10:1 ratio to allow robust statistical analysis.

MAIN OUTCOME MEASURES

Associations between XP and dyslipidemia and CVD were determined. Lipid profiles and diagnoses of dyslipidemia and CVD were compared between the case and control groups.

RESULTS

The database included 35 452 individuals, 24 287 of whom were male (69%), with a mean ± standard deviation age of 52.2 ± 12.2 years. The study population included 203 patients with XP (0.6%) and 2030 matched control participants. The prevalence of dyslipidemia diagnosis was similar between the two groups (42% XP vs. 46% controls, P = 0.29), as were the use rates of statins, fibrates, or other cholesterol-lowering medications (48% XP vs. 47% controls, P = 0.88). Lipid profiles were similar between the groups, including total cholesterol (controls median 187 [IQR, 163-211] vs. XP 192 [166-215], P = 0.093), high-density lipoprotein (controls median 48 [IQR, 41-57] vs. XP 47 [42-57], P = 0.65), low-density lipoprotein (controls median 120 [101-141] vs. XP 125 [104-145], P = 0.17), and triglyceride levels (controls median 111 [81-152] vs. XP 105 [81-139], P = 0.16). The rate of CVD was similar as well (10% control group vs. 8.9% XP group; P = 0.56). The prevalences of related conditions, including hypertension, diabetes mellitus, and history of cerebrovascular accident, were similar between groups (24% control group vs. 23% XP group, 14% control group vs. 10% XP group, and 1.3% control group vs. 1% XP group, respectively; P > 0.05).

CONCLUSIONS

Xanthelasma palpebrarum was not associated with increased rates of dyslipidemia or CVD. This questions the extent to which XP serves as an indicative marker for heightened systemic risk.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Comparison of the incidence of proteinuria and changes in eGFR among febuxostat and topiroxostat users

BACKGROUND

Febuxostat and topiroxostat are non-purine selective xanthine oxidoreductase inhibitors commonly used for hyperuricaemia treatment in Japan. However, comparative data on the effects of febuxostat and topiroxostat on renal function and proteinuria are limited. This study compared proteinuria incidence and changes in the estimated glomerular filtration rate (eGFR) among prevalent febuxostat and topiroxostat users.

METHODS

We conducted a retrospective cohort study using databases provided by DeSC Healthcare, Inc. (Tokyo, Japan). We identified 17,446 individuals (11.8% women; mean age 67.4 years) with eGFR ≥ 30 mL/min/1.73 m2 and no history of cardiovascular disease or proteinuria at baseline. Separate analyses were performed for individuals with eGFR < 60 mL/min/1.73 m2 and those with eGFR ≥ 60 mL/min/1.73 m2. The adjusted hazard ratio (HR) for proteinuria incidence in topiroxostat users compared with febuxostat users was assessed using the Cox model. Changes in eGFR were compared between the two groups using multiple regression analysis.

RESULTS

During the mean follow-up period of 1.79 years, 1,433 participants developed proteinuria. In non-diabetic individuals with eGFR ≥ 60 mL/min/1.73 m2, the adjusted HR for proteinuria incidence in topiroxostat users compared with febuxostat users was 0.60 (95% confidence interval, 0.40-0.91; p = 0.016). No significant differences were observed in eGFR changes between the two groups with eGFR < 60 and ≥ 60 mL/min/1.73 m2.

CONCLUSION

Topiroxostat prevalent users had a lower risk of proteinuria than febuxostat prevalent users in non-diabetic individuals with eGFR ≥ 60 mL/min/1.73 m2. Our findings suggest that topiroxostat might be more effective than febuxostat in preventing proteinuria in non-diabetic individuals with eGFR ≥ 60 mL/min/1.73 m2.

Objective study validity diagnostics: a framework requiring pre-specified, empirical verification to increase trust in the reliability of real-world evidence

OBJECTIVE

Propose a framework to empirically evaluate and report validity of findings from observational studies using pre-specified objective diagnostics, increasing trust in real-world evidence (RWE).

MATERIALS AND METHODS

The framework employs objective diagnostic measures to assess the appropriateness of study designs, analytic assumptions, and threats to validity in generating reliable evidence addressing causal questions. Diagnostic evaluations should be interpreted before the unblinding of study results or, alternatively, only unblind results from analyses that pass pre-specified thresholds. We provide a conceptual overview of objective diagnostic measures and demonstrate their impact on the validity of RWE from a large-scale comparative new-user study of various antihypertensive medications. We evaluated expected absolute systematic error (EASE) before and after applying diagnostic thresholds, using a large set of negative control outcomes.

RESULTS

Applying objective diagnostics reduces bias and improves evidence reliability in observational studies. Among 11 716 analyses (EASE = 0.38), 13.9% met pre-specified diagnostic thresholds which reduced EASE to zero. Objective diagnostics provide a comprehensive and empirical set of tests that increase confidence when passed and raise doubts when failed.

DISCUSSION

The increasing use of real-world data presents a scientific opportunity; however, the complexity of the evidence generation process poses challenges for understanding study validity and trusting RWE. Deploying objective diagnostics is crucial to reducing bias and improving reliability in RWE generation. Under ideal conditions, multiple study designs pass diagnostics and generate consistent results, deepening understanding of causal relationships. Open-source, standardized programs can facilitate implementation of diagnostic analyses.

CONCLUSION

Objective diagnostics are a valuable addition to the RWE generation process.

Reduced healthcare costs for patients with screen-detected colorectal cancer: A Danish nationwide cohort study

OBJECTIVES

This Danish nationwide retrospective register-based cohort study investigated healthcare costs for patients with screen-detected colorectal cancer (SD-CRC) compared to non-screen-detected CRC (NSD-CRC).

STUDY DESIGN

Nationwide cohort study.

METHODS

Quarterly healthcare costs including costs of hospital care, out-of-hospital medication, and primary sector contacts were compared between the two groups from two years before diagnosis of CRC until two years after. A quasi-experimental difference-in-differences analysis was performed to estimate the differences per patient in total quarterly healthcare costs between the groups.

RESULTS

A total of 13,852 patients were included, 4703 with SD-CRC, 7420 with NSD-CRC, and 1,729 with interval- or post-colonoscopy CRC (I-PC-CRC). The total quarterly healthcare costs per patient were significantly higher in the NSD-CRC group than in SD-CRC. This was consistent across the total period and in 6-month analyses, accruing additional €16,600 of costs for patients with NSD-CRC over two years after diagnosis. Total healthcare costs were significantly higher for patients with NSD-CRC as compared to patients with SD-CRC across all Union for International Cancer Control (UICC) stages, except for UICC stage I. Correspondingly, total costs associated with I-PC-CRC were significantly higher than for SD-CRC.

CONCLUSIONS

Apart from improving post-treatment outcomes, higher participation rates in the CRC screening programmes present an opportunity for reducing healthcare costs related to patients diagnosed with CRC.

Survival and longevity among male Australian elite athletes: A retrospective cohort study

OBJECTIVES

To quantify and compare survival and longevity in three populations of male Australian elite athletes, relative to sex- and age-matched referents from the general population.

DESIGN

Retrospective cohort study.

METHODS

This study comprised a census of three populations of male Australian elite athletes (i.e. N = 10,502 Australian Football League players, N = 803 national team rugby union players, and N = 1527 Olympic athletes) who debuted from 1-JAN-1921 to 31-DEC-2023. Nonparametric relative survival analysis was conducted using the Kaplan-Meier estimator to generate survival curves, the Pohar Perme method and a log-rank type test to estimate and compare net survival, and the life years difference measure to estimate longevity gains or losses.

RESULTS

Olympic athletes had a continuous gain in net survival post-debut, with an average life years difference of 3.40 (95 % confidence interval 2.30 to 4.49) years at the maximum follow-up time. Australian football and rugby union players initially had modest gains in net survival post-debut, followed by a gradual decline in net survival, with average life years differences of 0.31 (95 % confidence interval -0.03 to 0.65) and -0.67 (95 % confidence interval -1.87 to 0.53) years at the maximum follow-up time, respectively. Net survival was significantly different across the three cohorts (test statistic 21.8; degrees of freedom = 2; p < 0.001).

CONCLUSIONS

Expected survival benefits were offset in elite male Australian football and rugby union players. Further research examining cause-specific mortality is warranted to elucidate the underlying reasons for the observed lack of expected survival benefit in Australian football and rugby union players.

Markers of optimal medical therapy are associated with improved limb outcomes after elective revascularization for intermittent claudication

BACKGROUND

Optimal medical therapy (OMT) is a modifiable factor that decreases mortality and cardiovascular events in patients with severe peripheral arterial disease. We hypothesized that preintervention OMT would be associated with improved 1-year reintervention and major adverse limb event (MALE) rates after elective endovascular revascularization for intermittent claudication (IC).

METHODS

Using the Vascular Quality Initiative (2010-2020), we identified patients with IC undergoing elective endovascular, hybrid, and open surgical interventions. Preoperative antiplatelet, statin, and nonsmoking status defined OMT components and created three groups: complete (all components), partial (1-2 components), and no OMT. The primary outcome was 1-year reintervention. Secondary outcomes included MALE and factors associated with OMT usage. Multivariable logistic regression generated adjusted odds ratios (aOR).

RESULTS

There were 39,088 patients (14,907 [38.1%] complete, 22,054 [56.4%)] partial, 2127 [5.4%] no OMT) who met our criteria. Patients with any OMT were more frequently older with more cardiovascular diseases and diabetes (P < .0001). Patients without OMT were more likely to be Black or with Medicare or Medicaid (P < .05). Observed 1-year reintervention (5.3% complete OMT, 6.1% partial OMT, 8.3% no OMT; P < .001) and MALE (5.6% complete OMT, 6.3% partial OMT, 8.8% no OMT; P < .001) were decreased by partial or complete OMT compared with no OMT. Complete OMT significantly decreased the adjusted odds of reintervention and MALE by 28% (aOR, 0.72, 95% confidence interval [95% CI], 0.59-0.88) and 30% (aOR, 0.70; 95% CI, 0.58-0.85), respectively, compared with no OMT. Partial OMT decrease the adjusted odds of reintervention and MALE by 24% (aOR, 0.76; 95% CI, 0.63-0.92) and 26% (aOR, 0.74; 95% CI, 0.62-0.89), respectively.

CONCLUSIONS

Preintervention OMT is an underused, modifiable risk factor associated with improved 1-year reintervention and MALE. Vascular surgeons are uniquely positioned to initiate and maintain OMT in patients with IC before revascularization to optimize patient outcomes.

Statin use after cancer diagnosis and survival among patients with cancer

PURPOSE

The association between statin use and cancer survival has been investigated in previous studies with conflicting findings. This study aimed to assess the association between statin use following cancer diagnosis and survival in six common cancers using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

METHODS

Individuals aged ≥ 66 years diagnosed with prostate cancer, colorectal cancer, lung cancer, bladder cancer, pancreatic cancer, or non-Hodgkin lymphoma (NHL) from 2008 through 2017 were identified. Statin use was defined as two or more statin prescription fills after cancer diagnosis. Time-dependent Cox proportional hazard regression models were used to estimate the association between statin use and cancer-specific mortality for each cancer.

RESULTS

This study included 34,618 patients with prostate cancer (median follow-up 4.0 years), 20,579 with colorectal cancer (2.9 years), 20,133 with lung cancer (1.7 years), 6,163 with bladder cancer (2.1 years), 4,538 with pancreatic cancer (0.8 years), and 3,270 with NHL (2.9 years). Statin use post-diagnosis was associated with a reduced risk of cancer-specific mortality in lung cancer (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.74-0.88) and pancreatic cancer (HR, 0.72; 95% CI, 0.59-0.87). The association was not statistically significant for prostate cancer, colorectal cancer, bladder cancer, or NHL. A dose-response relationship by duration of statin use was observed in lung cancer and pancreatic cancer.

CONCLUSION

Statin use after cancer diagnosis appears associated with improved survival in lung cancer and pancreatic cancer. Clinical trials of statin therapy in lung and pancreatic cancer patients are warranted to confirm these findings.

COVID-19 Vaccine Safety in Pregnancy, A Nested Case-Control Study in Births From April 2021 to March 2022, England

OBJECTIVE

Assessment of COVID-19 vaccine safety in pregnancy using population-based data.

DESIGN

Matched case-control study nested in a retrospective cohort.

SETTING

April 2021-March 2022, England.

POPULATION OR SAMPLE

All pregnant individuals aged between 18 and 50 years with valid health records.

METHODS

Individuals identified from the national Maternity Services Data Set (MSDS) had their records linked to hospital admission, national COVID-19 vaccine and COVID-19 testing databases. Matching included participant's age and estimated week of conception. We compared outcomes across multiple COVID-19 vaccine exposures using conditional multivariable logistic regression, adjusting for demographic and health characteristics.

MAIN OUTCOME MEASURES

Adverse pregnancy, maternal and neonatal outcomes.

RESULTS

514 013 individuals were included. We found lower odds of giving birth to a baby who was low birthweight (aOR = 0.86, 95% CI: 0.79-0.93), preterm (aOR = 0.89, 95% CI: 0.85-0.92) or who had an Apgar score < 7 at 5 min of age (aOR = 0.89, 95% CI: 0.80-0.98) for individuals who received at least one dose of COVID-19 vaccine during pregnancy. The odds of admission to intensive care unit during pregnancy were lower in those vaccinated (aOR = 0.85, 95% CI: 0.76-0.95). There was no association between vaccination in pregnancy and stillbirth, neonatal death, perinatal death and maternal venous thromboembolism in pregnancy.

CONCLUSIONS

COVID-19 vaccines are safe to use in pregnancy. Our findings generated important information to communicate to pregnant individuals and health professionals to support COVID-19 maternal vaccination programmes.

Vaginal estrogen use in breast cancer survivors: a systematic review and meta-analysis of recurrence and mortality risks

OBJECTIVE

To assess the risk of breast cancer recurrence, breast cancer-specific mortality, and overall mortality for breast cancer survivors receiving vaginal estrogen therapy for genitourinary syndrome of menopause.

DATA SOURCES

From the inception of each database to April 6th, 2024, a systematic literature search was conducted in Google Scholar, PubMed, EMBASE, CINAHL, NCBI, and Science Direct. A secondary search was conducted on September 26th, 2024 utilizing Google Scholar, PubMed, EMBASE, CINAHL, and Science Direct.

STUDY ELIGIBILITY CRITERIA

We identified studies that reported on breast cancer recurrence defined per individual review criteria and considered both local and distant recurrence.

STUDY APPRAISAL AND SYNTHESIS METHODS

Three reviewers evaluated studies with eligibility criteria in mind. Breast cancer recurrence was the primary outcome. The secondary outcomes included: breast cancer mortality and overall mortality. Pooled unadjusted odds ratios with 95% confidence intervals were calculated using a random-effects model. We assessed the 95% prediction intervals to calculate the likely range within which we can expect to observe future individual values, based on a current model or dataset. We calculated the fragility index to evaluate the robustness of the pooled estimates.

RESULTS

Of 5522 articles identified, 8 observational studies were included in this meta-analysis. The use of vaginal estrogen in patients with a history of breast cancer was not associated with an increased risk of breast cancer recurrence (6 articles, 24,060 patients, odds ratio, 0.48; 95% confidence interval, 0.23-0.98). There was no increase in the risk of breast cancer mortality (4 articles, 61,695 patients, odds ratio 0.60; 95% confidence interval 0.18-1.95). Lastly, there was no increase in overall mortality with use of vaginal estrogen in breast cancer survivors (5 articles 59,724, odds ratio 0.46; 95% confidence interval 0.42-0.49).

CONCLUSION

The use of vaginal estrogen in patients with a history of breast cancer does not appear to be associated with an increased risk of breast cancer recurrence, breast cancer-specific mortality, or overall mortality.

Methodological Considerations in Evaluating Breast Cancer Screening Studies

In evidence-based medicine frameworks, the highest level of evidence is derived from quantitative synthesis of double-masked, high-quality, randomly assigned controlled trials. Meta-analyses of randomly assigned controlled trials have demonstrated that screening mammography reduces breast cancer deaths. In the United States, every major guideline-producing organization has recommended screening mammography in average-risk women; however, there are controversies about age and frequency. Carefully controlled observational research studies and statistical modeling studies can address evidence gaps and inform evidence-based, contemporary screening practices. As breast imaging radiologists develop and evaluate existing and new screening tests and technologies, they will need to understand the key methodological considerations and scientific criteria used by policy makers and health service researchers to support dissemination and implementation of evidence-based screening tests. The Wilson and Jungner principles and the U.S. Preventive Services Task Force general analytic framework provide structured evaluations of the effectiveness of screening tests. Key considerations in both frameworks include public health significance, natural history of disease, cost-effectiveness, and characteristics of screening tests and treatments. Rigorous evaluation of screening tests using analytic frameworks can maximize the benefits of screening tests while reducing potential harms. The purpose of this article is to review key methodological considerations and analytic frameworks used to evaluate screening studies and develop evidence-based recommendations.

Correspondence: Cancer incidence and mortality after a first-ever venous thrombosis in northern Sweden

We congratulate Hägg et al. on their study investigating cancer incidence and mortality following first-ever venous thromboembolism (VTE), which provides valuable insights into VTE as a potential marker for underlying malignancies. However, we highlight concerns regarding healthy user bias, the unclear follow-up duration, and inconsistent adjustment in the statistical analysis. We also suggest the use of the Fine-Gray subdistribution hazard model to address competing risks, and the accurate reporting of sex-gender terminology. Lastly, we advise caution in concluding a high incidence of cancer following first-ever VTE without pre-VTE data for comparison and recommend acknowledging potential surveillance bias when interpreting the higher cancer detection rate within 6 months of VTE diagnosis.

Plasma lipids and glycaemic indices in australians following plant-based diets versus a meat-eating diet

BACKGROUND

Vegan and vegetarian dietary patterns are known to beneficially modulate risk factors for cardiovascular disease; however, the current literature does not differentiate between various plant-based diets. This study aimed to examine the association between various plant-based diets and plasma lipids and glycaemic indices compared to a regular meat-eating diet.

METHODS

A cross-sectional study of Australian adults (n = 230) aged 30-75yrs habitually consuming the following were recruited: vegan, lacto-vegetarian, pesco-vegetarian, semi-vegetarian, or regular meat-eater. Multivariable regression analysis was used to adjust for covariates.

RESULTS

Compared to regular meat-eaters, vegans had significantly lower total cholesterol (-0.77mmol/L,95% CI -1.15, -0.39, P < 0.001), low-density lipoprotein cholesterol (LDL-C, -0.71mmol/L, 95% CI -1.05, -0.38, P < 0.001), non-high-density lipoprotein cholesterol (non-HDL-C, -0.75mmol/L, 95% CI -1.11, -0.39, P < 0.001), total cholesterol/HDL-C-ratio (-0.49mmol/L, 95% CI -0.87, -0.11, P = 0.012), fasting blood glucose (FBG, -0.29mmol/L, 95% CI -0.53, -0.06, P = 0.014), haemoglobin A1C (-1.85mmol/mol, 95% CI -3.00, -0.71, P = 0.002) and insulin (-1.76mU/L, 95% CI -3.26, -0.26, P = 0.021) concentrations. Semi-vegetarians had significantly lower LDL-C (-0.41mmol/L, 95% CI -0.74, -0.08, P = 0.041) and non-HDL-C (-0.40mmol/L, 95% CI -0.76, -0.05, P = 0.026) and lacto-ovo vegetarians had significantly lower FBG (-0.34mmol/L, 95% CI -0.56, -0.11, P = 0.003) compared to regular meat-eaters. There were no differences in HDL-C and triglycerides between plant-based and regular-meat diets.

CONCLUSIONS

Plasma lipaemic and glycaemic measures as a collective were more favourable among vegans, whereas among lacto-ovo vegetarians and semi-vegetarians, only some measures were favourable.

TRIAL REGISTRATION

ACTRN12621000743864. Date 6/11/2021.

Challenges around diagnosis of early onset colorectal cancer, and the case for screening

BACKGROUND

Colorectal cancer (CRC) is the third most diagnosed cancer in the world, with an estimated 1.93 million cases diagnosed in 2020. While the overall CRC incidence in many countries is falling there has been a dramatic increase in CRC in those aged under 50 (early onset colorectal cancer, EOCRC). The reason for this increase in EOCRC is unknown. As the best predictor of survival is stage at diagnosis, early diagnosis is likely to be beneficial and population screening may facilitate this.

METHODS

A narrative review of the literature was undertaken.

RESULTS

Improving time to diagnosis in symptomatic patients is beneficial. However, by the time symptoms develop, over a third of patients already have metastatic disease. Screening asymptomatic patients (with Faecal Immunochemical test (FIT) and colonoscopy) has been proved to be effective in older patients (>60 years). In younger populations, the decreasing incidence rates of CRC previously made cost effectiveness, compliance and therefore benefit questionable. Now, with the increasing incidence of CRC in those under 50 years of age, modelling suggests screening with FIT and colonoscopy is cost effective from 40 years of age. There is evidence that some countries screening below 50 have prevented the rise in EOCRC incidence. Additionally the use of new and novel non-invasive biomarkers may also be able to improve the accuracy of screening asymptomatic patients.

CONCLUSION

Diagnosis of EOCRC once symptoms develop is often too late, and screening patients from age 40 is the best way to improve outcomes in this group.

Improved medication adherence in COPD patients using tiotropium or tiotropium olodaterol with the HealthPrize digital behavior change program

OBJECTIVE

To assess the impact of the HealthPrize RespiPoints™ program on treatment adherence and persistence in adults with chronic obstructive pulmonary disease (COPD).

METHODS

In this retrospective cohort study, program participants and nonparticipants receiving tiotropium bromide (TIO) or TIO and olodaterol between 1 January 2015-31 March 2020 were propensity score matched (PSM), from the linked database of the HealthPrize patient list and IQVIA PharMetrics® Plus. Treatment adherence, persistence, healthcare resource utilization, and costs were compared. Multivariable logistic regression models assessed the odds of adherence (≥80% proportion of days covered [PDC]), adjusted risk of discontinuation, and adjusted total healthcare costs.

RESULTS

Program participants (n = 262) demonstrated a 44% greater adherence during followup than nonparticipants (n = 262) (mean [standard deviation] PDC: 0.72 [0.27] vs 0.50 [0.36], p < 0.0001). Participants had higher odds of adherence vs nonparticipants (adjusted odds ratio: 2.51; 95% confidence interval: 1.72-3.66, p < 0.0001) and a lower percentage of participants discontinued their index medication (19.85% vs 33.59%, p = 0.0004). Fewer participants were hospitalized during follow-up (13.74% vs 17.56%, p = 0.23); adjusted total medical costs were 24% lower (p = 0.08). Higher pharmacy costs partially offset lower healthcare costs.

CONCLUSIONS

Program participants showed improved COPD medication adherence and persistence compared to nonparticipants.

The potential impact of a vegetarian diet on glaucoma

Treatment of primary open-angle glaucoma has centered on the lowering of intraocular pressure that damages the optic nerve; however, this strategy is not uniformly successful, especially in normal tension glaucoma, and there is interest in antioxidant, anti-inflammatory, and other neuroprotective strategies. Vegetarian diets are known to be rich in antioxidant and anti-inflammatory components and have a number of established health benefits. Thus, it would be reasonable to assume that vegetarian diets would be beneficial in glaucoma, but this approach has not been well studied. We examine the possible role of vegetarian diets and their components in the incidence and progression of glaucoma.

Risk of Dementia and Alzheimer's Disease Associated With Antidiabetics: A Bayesian Network Meta-Analysis

INTRODUCTION

Dementia risk is substantially elevated in patients with diabetes. However, evidence on dementia risk associated with various antidiabetic regimens is still limited. This study aims to comprehensively investigate the risk of dementia and Alzheimer's disease (AD) associated with various antidiabetic classes.

METHODS

Cochrane Central Register of Controlled Trials, Embase, MEDLINE (PubMed), and Scopus were searched from inception to March 2024 (PROSPERO CRD 42022365927). Observational studies investigating dementia and AD incidences after antidiabetic initiation were identified. Bayesian network meta-analysis was performed to determine dementia and AD risks associated with antidiabetics. Preferred Reporting Items for Systematic Reviews-Network Meta-Analyses (PRISMA-NMA) guidelines were followed. Statistical analysis was performed and updated in November 2023 and March 2024, respectively.

RESULTS

A total of 1,565,245 patients from 16 studies were included. Dementia and AD risks were significantly lower with metformin and sodium glucose co-transporter-2 inhibitors (SGLT2i). Metformin displayed the lowest risk of dementia across diverse antidiabetics, whereas α-glucosidase inhibitors demonstrated the highest risk. SGLT2i exhibited the lowest dementia risk across second-line antidiabetics. Dementia risk was significantly higher with dipeptidyl peptidase-4 inhibitor (DPP4i), metformin, sulfonylureas, and thiazolidinediones (TZD) compared to SGLT2i in the elderly (≥75 years). Dementia risk associated with metformin was substantially lower, regardless of diabetic complication status or baseline A1C.

DISCUSSION

Metformin and SGLT2i demonstrated lower dementia risk than other antidiabetic classes. Patient-specific factors may affect this relationship and cautious interpretation is warranted as metformin is typically initiated at an earlier stage with fewer complications. Hence, further large-scaled clinical trials are required.

Effect of screening mammography on the risk of breast cancer deaths and of all-cause deaths: a systematic review with meta-analysis of cohort studies

OBJECTIVES

Observational cohort studies are used to evaluate the effectiveness of screening mammography in women offered screening. Because screening mammography has no effect on causes of death other than breast cancer (BC), cohort studies should show reductions in the risk of BC death substantially greater than possible reductions in the risk of all-cause death. We assessed the risk of BC deaths and of all-cause (or of nonBC) deaths associated with screening mammography attendance reported in cohort studies.

STUDY DESIGN AND SETTING

Cohort studies published from 2002 to 2022 on women invited to screening mammography were searched in PubMed, Web of Sciences, Scopus, and in review articles. Random effect meta-analyses were performed using relative risks (RRs) of death between women who attended screening compared to women who did not attend screening.

RESULTS

Eighteen cohort studies were identified, nine that reported RRs of BC deaths only, five that reported RRs of all-cause deaths only, and four that reported RRs for both BC deaths and all-cause deaths. The latter four cohort studies reported 12-76 times more all-cause deaths than BC deaths. The random-effect summary of RR for BC mortality in screening attendees vs nonattendees was 0.55 (95% CI: 0.50-0.60) in 13 cohort studies. The summary of RR for all-cause mortality was 0.54 (0.50-0.58) in 10 cohort studies. In the four cohort studies that evaluated both outcomes, the summary of RRs were 0.63 (0.43-0.83) for BC mortality and of 0.54 (0.44-0.64) for all-cause mortality.

CONCLUSION

The similar relative reductions in breast- and all-cause (or nonBC) mortality indicates that screening mammography attendance is an indicator of characteristics associated with a lower risk of dying from any cause, including from BC, which observational studies have falsely interpreted as a screening effect.

Perioperative Primary Care Utilization and Postoperative Readmission, Emergency Department Use, and Mortality in Older Surgical Patients

BACKGROUND

Postdischarge primary care follow-up is associated with lower readmission rates after medical hospitalizations. However, the effect of primary care utilization on readmission has not been studied in surgical patients.

METHODS

Retrospective cohort study of Medicare beneficiaries aged 65 and older undergoing major inpatient diagnostic or therapeutic procedures (n = 3,552,906) from 2017 through 2018, examining the association between postdischarge primary care visits within 14 days of discharge (primary exposure), and Annual Wellness Visits in the year prior (secondary exposure), with 30-day unplanned readmission (primary outcome), emergency department visits, and mortality (secondary outcomes).

RESULTS

Overall, 9.5% (n = 336,837) had postdischarge visits within 14 days, 2.9% (n = 104,571) had Annual Wellness Visits in the year preceding the procedure, 9.5% (n = 336,401) were readmitted, 9% (n = 319,054) had emergency department visits, and 0.6% (n = 22,103) of the cohort died within 30 days. Our fully adjusted propensity-matched proportional hazards Cox regression analysis showed that postdischarge visits were associated with a 5% lower risk of readmission (hazard ratio [HR], 0.95, 95% confidence interval [CI], 0.93-0.97), 43% higher risk of emergency department use (HR, 1.43, 95% CI, 1.40-1.46) and no difference in mortality risk (HR, 0.98, 95% CI, 0.90-1.06), compared with not having a visit within 14 days of discharge. In a separate set of regression models, Annual Wellness Visits were associated with a 9% lower risk of readmission (HR, 0.91, 95% CI, 0.88-0.95), 45% higher risk of emergency department utilization (HR, 1.45, 95% CI, 1.40-1.49) and an 18% lower mortality risk (HR, 0.82, 95% CI, 0.75-0.89) compared with no Annual Wellness Visit in the year before the procedure.

CONCLUSIONS

Both postdischarge visits and the Medicare Annual Wellness Visit appear to be extremely underutilized among the older surgical population. In those patients who do utilize primary care, compared with propensity-matched patients who do not, our study suggests primary care use is associated with modestly lower readmission rates. Prospective studies are needed to determine whether targeted primary care involvement can reduce readmission.

The impact of statin use on sepsis mortality

BACKGROUND

Statins exert pleiotropic anti-inflammatory and antioxidant effects in addition to their cholesterol-lowering properties. This study aimed to investigate whether statin use is associated with improved outcomes of sepsis.

METHODS

Data from sepsis patients were extracted from the Medical Information Mart for Intensive Care IV database. Patients with a history of receiving prescriptions for statins (i.e. atorvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, or simvastatin) were matched with non-users using propensity-score matching, to balance confounding factors between the groups. Mendelian Randomization (MR) analyses were performed using information from the UK Biobank dataset to explore the potential causal link between low-density lipoprotein cholesterol (LDL-C) levels and LDL-C lowering effects via genetically inhibiting β‑hydroxy β-methylglutaryl-coenzyme A reductase and the susceptibility to sepsis, and the sepsis-related 28-day mortality.

MAIN RESULTS

90-day mortality rate was lower among the 10,323 statin users when compared to matched non-users [hazard ratio (HR): 0.612, 95 % CI: 0.571 to 0.655]. In-hospital mortality was also lower for statin users compared to non-users (11.3% vs. 17.8 %, p < 0.0001, HR: 0.590, 95 % CI: 0.548 to 0.634). Statin use was associated with better outcome in all investigated subpopulations apart from patients with severe liver disease. MR analyses further pointed toward pleiotropic effects beyond lipid-lowering effects of statins on sepsis-related outcomes.

CONCLUSIONS

Statin use is associated with improved outcomes following sepsis-related ICU admission, most likely from its pleiotropic properties, characterized by lower 90-day and in-hospital mortality among statin users.

Longitudinal associations of polypharmacy and frailty with major cardiovascular events and mortality among more than half a million middle-aged participants of the UK Biobank

BACKGROUND

Studies of the associations of polypharmacy and frailty with adverse health outcomes in middle-aged adults are limited. Furthermore, a potentially stronger association of polypharmacy with adverse health outcomes in frail than in non-frail adults is of interest.

OBJECTIVE

To evaluate associations of frailty (assessed using a frailty index) and polypharmacy (defined as taking five or more drugs) with major cardiovascular events, cancer incidence, all-cause, cardiovascular disease-specific, and cancer-specific mortality.

METHODS

Cox proportional hazards regression models were used to analyze 501,548 participants of the UK Biobank cohort study aged 40-69 years who were followed up for an average of 12 years.

RESULTS

The prevalence of pre-frailty and frailty were 43.2 % and 2.3 %, respectively, and that of polypharmacy was 18.3 %. Although strongly associated with each other, frailty and polypharmacy were independently, statistically significantly associated with major cardiovascular events, cardiovascular disease-specific, and all-cause mortality. In addition, the hazard ratios of polypharmacy were stronger among (pre-)frail than non-frail study participants. No profound associations with cancer incidence and cancer mortality were observed. No sex and age differences were observed.

CONCLUSIONS

This large cohort study showed that polypharmacy and frailty are independent risk factors for major cardiovascular events, cardiovascular disease-specific and all-cause mortality in both middle-aged (40-64 years) and older people (≥ 65 years). In addition, the hazard ratios of polypharmacy were stronger among (pre-)frail than non-frail study participants. This underlines the need to avoid polypharmacy as far as possible not only in older but also in middle-aged subjects (40-64 years), especially if they are pre-frail or frail.

Gene-vegetarianism interactions in calcium, estimated glomerular filtration rate, and testosterone identified in genome-wide analysis across 30 biomarkers

We examined the associations of vegetarianism with metabolic biomarkers using traditional and genetic epidemiology. First, we addressed inconsistencies in self-reported vegetarianism among UK Biobank participants by utilizing data from two dietary surveys to find a cohort of strict European vegetarians (N = 2,312). Vegetarians were matched 1:4 with nonvegetarians for non-genetic association analyses, revealing significant effects of vegetarianism in 15 of 30 biomarkers. Cholesterol measures plus vitamin D were significantly lower in vegetarians, while triglycerides were higher. A genome-wide association study revealed no genome-wide significant (GWS; 5×10-8) associations with vegetarian behavior. We performed genome-wide gene-vegetarianism interaction analyses for the biomarkers, and detected a GWS interaction impacting calcium at rs72952628 (P = 4.47×10-8). rs72952628 is in MMAA, a B12 metabolic pathway gene; B12 has major deficiency potential in vegetarians. Gene-based interaction tests revealed two significant genes, RNF168 in testosterone (P = 1.45×10-6) and DOCK4 in estimated glomerular filtration rate (eGFR) (P = 6.76×10-7), which have previously been associated with testicular and renal traits, respectively. These nutrigenetic findings indicate genotype can modify the associations between vegetarianism and health outcomes.

Correlation between positive airway pressure and medication adherence: the healthy user effect

STUDY OBJECTIVES

Despite the efficacy of positive airway pressure (PAP) for the treatment of obstructive sleep apnea, adherence remains challenging and negatively affects assessments of effectiveness. It is unclear whether low adherence is due to intolerance of PAP or whether this reflects overall adherence with medical therapy. We sought to correlate PAP use with medication adherence to determine whether poor adherence with PAP was specific to this treatment or represented global compliance with medical therapy.

METHODS

A total of 600 consecutive patients with obstructive sleep apnea were treated with PAP. Objective measures of PAP use were correlated with medication adherence. We included all chronically used medications, defined as medications used daily for at least 90 days prior to PAP initiation. Medication use was verified using an electronic health record. PAP adherence ("regular use") was defined as PAP use for ≥ 4 hours/night on ≥ 70% of nights. Medication adherence was defined as > 70% of pills taken as prescribed.

RESULTS

Complete records were available for 566 patients; 361 (63.8%) used chronic medications. The cohort was primarily men (90.3%, age 44.6 ± 10.2 years) with moderate obstructive sleep apnea (apnea-hypopnea index, 18.1 ± 13.9 events/h). In patients on chronic medications, PAP was used 55.8% of nights and 37.7% were regular users. Patients who were adherent with medications used PAP more hours/night (5.4 vs 4.6, P < .001) and were more likely to have regular PAP use compared with those nonadherent with medications (P = .04).

CONCLUSIONS

Adherence with PAP correlated with adherence to chronic medications. Low PAP adherence may reflect an individual's global adherence to medical care. This association may lead to better identification of patients who benefit from targeted therapy to improve overall health care adherence.

CITATION

Lettieri MJ, Warren WA, Walter RJ, Lettieri CJ. Correlation between positive airway pressure and medication adherence: the healthy user effect. J Clin Sleep Med. 2024;20(7):1087-1092.

Participation and engagement in online cognitive testing

Web-based testing of cognitive abilities allows for large-scale assessments without geographical constraints. Yet, the extent to which it can reach populations beyond the typical demographic groups recruited for cognitive studies is unclear. This study focused on comparing the characteristics of individuals from a general population study (HUNT4) who chose to participate in a cognitive study (HUNT4-Hjernetrim) with those who did not. Additionally, we investigated participants' engagement and user experience. We obtained data on socio-demographics, health conditions (both physical and mental), self-reported cognitive or learning difficulties, and lifestyle factors of Hjernetrim participants and non-participants from the HUNT4 database. Hjernetrim involved 13 cognitive tests, administered through the online platform Memoro. We used logistic regressions to assess participation biases and linear regressions to assess participants' engagement and user experience. Of 65,851 HUNT4 participants invited via regular mail to Hjernetrim, 5634 (9.4%, aged 13-97, 54% women) participated. The best represented in the sample were 50-79-year-olds, women, tertiary educated, living alone, from urban areas, not occupationally active, and reporting memory complaints. Individuals who were aged 80+, had motor or vision impairments, and teenagers with learning disabilities, were underrepresented. Participants were more likely to have mental health problems, have or survived cancer and less likely to have cardiovascular disease. Participants logged on mainly during weekdays, the preferred time of day varied by age. On average, participants used 42 min and completed 78% of the tasks. Using PCs provided the most complete data. In terms of user experiences, 65% were positive while 14% were negative or reported technical difficulties. Overall, the study demonstrated that web-based methodology allowed for a relatively well-represented sample that included groups typically difficult to reach. The presence of somatic and mental diseases had a variable influence on participation. Participants finished most tests and reported positive experiences overall.

Exploring the Pathophysiology of Long COVID: The Central Role of Low-Grade Inflammation and Multisystem Involvement

Long COVID (LC), also referred to as Post COVID-19 Condition, Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), and other terms, represents a complex multisystem disease persisting after the acute phase of COVID-19. Characterized by a myriad of symptoms across different organ systems, LC presents significant diagnostic and management challenges. Central to the disorder is the role of low-grade inflammation, a non-classical inflammatory response that contributes to the chronicity and diversity of symptoms observed. This review explores the pathophysiological underpinnings of LC, emphasizing the importance of low-grade inflammation as a core component. By delineating the pathogenetic relationships and clinical manifestations of LC, this article highlights the necessity for an integrated approach that employs both personalized medicine and standardized protocols aimed at mitigating long-term consequences. The insights gained not only enhance our understanding of LC but also inform the development of therapeutic strategies that could be applicable to other chronic conditions with similar pathophysiological features.

Multivitamin Use and Mortality Risk in 3 Prospective US Cohorts

Importance

One in 3 US adults uses multivitamins (MV), with a primary motivation being disease prevention. In 2022, the US Preventive Services Task Force reviewed data on MV supplementation and mortality from randomized clinical trials and found insufficient evidence for determining benefits or harms owing, in part, to limited follow-up time and external validity.

Objective

To estimate the association of MV use with mortality risk, accounting for confounding by healthy lifestyle and reverse causation whereby individuals in poor health initiate MV use.

Design, Setting, and Participants

This cohort study used data from 3 prospective cohort studies in the US, each with baseline MV use (assessed from 1993 to 2001), and follow-up MV use (assessed from 1998 to 2004), extended duration of follow-up up to 27 years, and extensive characterization of potential confounders. Participants were adults, without a history of cancer or other chronic diseases, who participated in National Institutes of Health-AARP Diet and Health Study (327 732 participants); Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (42 732 participants); or Agricultural Health Study (19 660 participants). Data were analyzed from June 2022 to April 2024.

Exposure

Self-reported MV use.

Main Outcomes and Measures

The main outcome was mortality. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% CIs.

Results

Among 390 124 participants (median [IQR] age, 61.5 [56.7-66.0] years; 216 202 [55.4%] male), 164 762 deaths occurred during follow-up; 159 692 participants (40.9%) were never smokers, and 157 319 participants (40.3%) were college educated. Among daily MV users, 49.3% and 42.0% were female and college educated, compared with 39.3% and 37.9% among nonusers, respectively. In contrast, 11.0% of daily users, compared with 13.0% of nonusers, were current smokers. MV use was not associated with lower all-cause mortality risk in the first (multivariable-adjusted HR, 1.04; 95% CI, 1.02-1.07) or second (multivariable-adjusted HR, 1.04; 95% CI, 0.99-1.08) halves of follow-up. HRs were similar for major causes of death and time-varying analyses.

Conclusions and Relevance

In this cohort study of US adults, MV use was not associated with a mortality benefit. Still, many US adults report using MV to maintain or improve health.

Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review

STUDY OBJECTIVES

We performed a systematic review of long-term health outcomes of continuous positive airway pressure (CPAP) use in adults with obstructive sleep apnea.

METHODS

We updated prior systematic reviews with searches in multiple databases through January 3, 2023. We included randomized controlled trials (RCTs) and adjusted nonrandomized comparative studies that reported prespecified long-term (mostly > 1 year) health outcomes. We assessed risk of bias, conducted meta-analyses, and evaluated strength of evidence.

RESULTS

We found 38 eligible studies (16 trials, 22 observational). All conclusions were of low strength of evidence given study and data limitations. RCTs found no evidence of effect of CPAP on mortality (summary effect size [ES] 0.89; 95% confidence interval [CI] 0.66, 1.21); inclusion of adjusted nonrandomized comparative studies yields an association with reduced risk of death (ES 0.57; 95% CI 0.44, 0.73). RCTs found no evidence of effects of CPAP for cardiovascular death (ES 0.99; 95% CI 0.64, 1.53), stroke (ES 0.99; 95% CI 0.73, 1.35), myocardial infarction (ES 1.05; 95% CI 0.78, 1.41), incident atrial fibrillation (ES 0.89; 95% CI 0.48, 1.63), or composite cardiovascular outcomes (all statistically nonsignificant). RCTs found no evidence of effects for incident diabetes (ES 1.02; 95% CI 0.69, 1.51) or accidents (all nonsignificant) and no clinically significant effects on depressive symptoms, anxiety symptoms, or cognitive function.

CONCLUSIONS

Whether CPAP use for obstructive sleep apnea affects long-term health outcomes remains largely unanswered. RCTs and nonrandomized comparative studies are inconsistent regarding the effect of CPAP on mortality. Current studies are underpowered, with relatively short duration follow-up and methodological limitations.

CITATION

Balk EM, Adam GP, Cao W, Bhuma MR, D'Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. J Clin Sleep Med. 2024;20(6):895-909.

Association between trajectories of adherence to endocrine therapy and risk of treated breast cancer recurrence among US nonmetastatic breast cancer survivors

BACKGROUND

Endocrine therapy is the mainstay treatment for breast cancer (BC) to reduce BC recurrence risk. During the first year of endocrine therapy use, nearly 30% of BC survivors are nonadherent, which may increase BC recurrence risk. This study is to examine the association between endocrine therapy adherence trajectories and BC recurrence risk in nonmetastatic BC survivors.

METHODS

This retrospective cohort study included Medicare beneficiaries in the United States (US) with incident nonmetastatic BC followed by endocrine therapy initiation in 2010-2019 US Surveillance, Epidemiology, and End Results linked Medicare data. We calculated monthly fill-based proportion of days covered in the first year of endocrine therapy. We applied group-based trajectory models to identify distinct endocrine therapy adherence patterns. After the end of the first-year endocrine therapy trajectory measurement period, we estimated the risk of time to first treated BC recurrence within 4 years using Cox proportional hazards models.

RESULTS

We identified 5 trajectories of adherence to endocrine therapy in BC Stages 0-I subgroup (n = 28,042) and in Stages II-III subgroup (n = 7781). A trajectory of discontinuation before 6 months accounted for 7.0% in Stages 0-I and 5.8% in Stages II-III subgroups, and this trajectory was associated with an increased treated BC recurrence risk compared to nearly perfect adherence (Stages 0-I: adjusted hazard [aHR] = 1.84, 95% CI = 1.46-2.33; Stages II-III: aHR = 1.38, 95% CI = 1.07-1.77).

CONCLUSIONS

Nearly 7% of BC survivors who discontinued before completing 6 months of treatment was associated with an increased treated BC recurrence risk compared to those with nearly perfect adherence among Medicare nonmetastatic BC survivors.

Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation

BACKGROUND

Obstructive sleep apnea (OSA) contributes to the generation, recurrence, and perpetuation of atrial fibrillation, and it is associated with worse outcomes. Little is known about the economic impact of OSA therapy in atrial fibrillation. This retrospective cohort study assessed the impact of positive airway pressure (PAP) therapy adherence on health care resource use and costs in patients with OSA and atrial fibrillation.

METHODS AND RESULTS

Insurance claims data for ≥1 year before sleep testing and 2 years after device setup were linked with objective PAP therapy use data. PAP adherence was defined from an extension of the US Medicare 90-day definition. Inverse probability of treatment weighting was used to create covariate-balanced PAP adherence groups to mitigate confounding. Of 5867 patients (32% women; mean age, 62.7 years), 41% were adherent, 38% were intermediate, and 21% were nonadherent. Mean±SD number of all-cause emergency department visits (0.61±1.21 versus 0.77±1.55 [P=0.023] versus 0.95±1.90 [P<0.001]), all-cause hospitalizations (0.19±0.69 versus 0.24±0.72 [P=0.002] versus 0.34±1.16 [P<0.001]), and cardiac-related hospitalizations (0.06±0.26 versus 0.09±0.41 [P=0.023] versus 0.10±0.44 [P=0.004]) were significantly lower in adherent versus intermediate and nonadherent patients, as were all-cause inpatient costs ($2200±$8054 versus $3274±$12 065 [P=0.002] versus $4483±$16 499 [P<0.001]). All-cause emergency department costs were significantly lower in adherent and intermediate versus nonadherent patients ($499±$1229 and $563±$1292 versus $691±$1652 [P<0.001 and P=0.002], respectively).

CONCLUSIONS

These data suggest clinical and economic benefits of PAP therapy in patients with concomitant OSA and atrial fibrillation. This supports the value of diagnosing and managing OSA and highlights the need for strategies to enhance PAP adherence in this population.

Work-Related Mental Health Problems in Switzerland

OBJECTIVE

The study identifies work-related risk factors that are relevant to mental health and quantifies their influence. This allows estimation of risk levels for individual workplaces and of the proportion of occupational causation in the emergence of mental health problems.

METHODS

Swiss Health Survey data, containing information on several potential risk factors and health indicators that cover aspects of mental health, were used in multiple multivariate logistic regression analyses.

RESULTS

Stress was the predominant risk factor, followed by exposure to violence, unergonomic work processes, and work that conflicted with family life. Hotel and restaurant industries and health and social services had high exposure to risk factors. One of 20 workplaces was deemed high-risk based on an odds ratio >4.

CONCLUSIONS

Up to one-third of mental health problems within the active workforce may have highly predominant occupational causation.

Association of Tumor Necrosis Factor-α Inhibitors with Incident Dementia: Analysis Based on Population-Based Cohort Studies

BACKGROUND AND OBJECTIVE

Preliminary evidence suggests a possible preventive effect of tumor necrosis factor-α inhibitors (TNFi) on incident dementia. The objective of the analysis was to investigate the association between TNFi and the risk of incident dementia in a population undergoing treatment for rheumatological disorders.

METHODS

We followed patients aged ≥ 65 years with dementia and rheumatological conditions in two cohort studies, DANBIO (N = 21,538), a Danish clinical database, and AOK PLUS (N = 7112), a German health insurance database. We defined incident dementia using diagnostic codes and/or medication use and used Cox regression to compare the associations of TNFi with other rheumatological therapies on the risk of dementia. To ensure that the patients were receiving long-term medication, we included patients with rheumatic diseases and systemic therapies.

RESULTS

We observed similar trends towards a lower risk of dementia associated with TNFi versus other anti-inflammatory agents in both cohorts (hazard ratios were 0.92 [95% confidence interval 0.76, 1.10] in DANBIO and 0.89 [95% confidence interval 0.63, 1.24] in AOK PLUS, respectively).

CONCLUSIONS

Tumor necrosis factor-α inhibitors may decrease the risk of incident dementia although the association did not reach statistical significance in this analysis. Further research, ideally with randomization, is needed to gauge the potential of repurposing TNFi for dementia prevention and/or treatment.

Chronic disease prevention and screening outcomes for patients with and without financial difficulty: a secondary analysis of the BETTER WISE cluster randomised controlled trial

OBJECTIVE

Building on Existing Tools To improvE chronic disease pRevention and screening in primary care Wellness of cancer survIvorS and patiEnts (BETTER WISE) was designed to assess the effectiveness of a cancer and chronic disease prevention and screening (CCDPS) programme. Here, we compare outcomes in participants living with and without financial difficulty.

DESIGN

Secondary analysis of a cluster-randomised controlled trial.

SETTING

Patients of 59 physicians from 13 clinics enrolled between September 2018 and August 2019.

PARTICIPANTS

596 of 1005 trial participants who responded to a financial difficulty screening question at enrolment.

INTERVENTION

1-hour CCDPS visit versus usual care.

OUTCOME MEASURES

Eligibility for a possible 24 CCDPS actions was assessed at baseline and the primary outcome was the percentage of eligible items that were completed at 12-month follow-up. We also compared the change in response to the financial difficulty screening question between baseline and follow-up.

RESULTS

55 of 265 participants (20.7%) in the control group and 69 of 331 participants (20.8%) in the intervention group reported living with financial difficulty. The primary outcome was 29% (95% CI 26% to 33%) for intervention and 23% (95% CI 21% to 26%) for control participants without financial difficulty (p=0.01). Intervention and control participants with financial difficulty scored 28% (95% CI 24% to 32%) and 32% (95% CI 27% to 38%), respectively (p=0.14). In participants who responded to the financial difficulty question at both time points (n=302), there was a net decrease in the percentage of participants who reported financial difficulty between baseline (21%) and follow-up (12%, p<0.001) which was similar in the control and intervention groups. The response rate to this question was only 51% at follow-up.

CONCLUSION

The BETTER intervention improved uptake of CCDPS manoeuvres in participants without financial difficulty, but not in those living with financial difficulty. Improving CCDPS for people living with financial difficulty may require a different clinical approach or that social determinants be addressed concurrently with clinical and lifestyle needs or both.

TRIAL REGISTRATION NUMBER

ISRCTN21333761.

Effect of periodontal therapy on glycaemic control in type 2 diabetes

AIM

This study aimed to elucidate the impact of periodontal therapy on glycaemic control in individuals with type 2 diabetes and various baseline blood glucose levels using a large-scale claims database from Japan.

MATERIALS AND METHODS

Using the JMDC Claims Database, we identified individuals with type 2 diabetes who underwent health check-ups in the fiscal years 2018 or 2019 and were followed up until the next year's health check-up. We conducted a weighted cohort analysis using stabilized inverse probability weights for treatment and censoring to estimate the effect of periodontal therapy on changes in haemoglobin A1c levels within a year. Analysis was done for different baseline haemoglobin A1c categories: 6.5%-6.9%, 7.0%-7.9% and ≥8.0%.

RESULTS

Of the 4279 insured persons included in the study, 957 received periodontal therapy. Overall, there was a tendency towards improved glycaemic control among those who received periodontal therapy. Participants with baseline haemoglobin A1c levels of 7.0%-7.9% who received periodontal therapy exhibited significantly better glycaemic control compared with those without dental visits (difference; -0.094 [95% confidence interval: -0.181 to -0.007]).

CONCLUSIONS

Periodontal therapy may improve glycaemic control in individuals with diabetes, especially in those with haemoglobin A1c levels ≥7.0%.

Hypertension, Cardiovascular Risk Factors, and Uterine Fibroid Diagnosis in Midlife

Importance

Fibroids are benign neoplasms associated with severe gynecologic morbidity. There are no strategies to prevent fibroid development.

Objective

To examine associations of hypertension, antihypertensive treatment, anthropometry, and blood biomarkers with incidence of reported fibroid diagnosis in midlife.

Design, Setting, and Participants

The Study of Women's Health Across the Nation is a prospective, multisite cohort study in the US. Participants were followed-up from enrollment (1996-1997) through 13 semiannual visits (1998-2013). Participants had a menstrual period in the last 3 months, were not pregnant or lactating, were aged 42 to 52 years, were not using hormones, and had a uterus and at least 1 ovary. Participants with prior fibroid diagnoses were excluded. Data analysis was performed from November 2022 to February 2024.

Exposures

Blood pressure, anthropometry, biomarkers (cholesterol, triglycerides, and C-reactive protein), and self-reported antihypertensive treatment at baseline and follow-up visits were measured. Hypertension status (new-onset, preexisting, or never [reference]) and hypertension treatment (untreated, treated, or no hypertension [reference]) were categorized.

Main Outcomes and Measures

Participants reported fibroid diagnosis at each visit. Discrete-time survival models estimated hazard ratios (HRs) and 95% CIs for associations of time-varying hypertension status, antihypertensive treatment, anthropometry, and biomarkers with incident reported fibroid diagnoses.

Results

Among 2570 participants without a history of diagnosed fibroids (median [IQR] age at screening, 45 [43-48] years; 1079 [42.1%] college educated), 526 (20%) reported a new fibroid diagnosis during follow-up. Risk varied by category of hypertension treatment: compared with those with no hypertension, participants with untreated hypertension had a 19% greater risk of newly diagnosed fibroids (HR, 1.19; 95% CI, 0.91-1.57), whereas those with treated hypertension had a 20% lower risk (HR, 0.80; 95% CI, 0.56-1.15). Among eligible participants with hypertension, those taking antihypertensive treatment had a 37% lower risk of newly diagnosed fibroids (HR, 0.63; 95% CI, 0.38-1.05). Risk also varied by hypertension status: compared with never-hypertensive participants, participants with new-onset hypertension had 45% greater risk of newly diagnosed fibroids (HR, 1.45; 95% CI, 0.96-2.20). Anthropometric factors and blood biomarkers were not associated with fibroid risk.

Conclusions and Relevance

Participants with untreated and new-onset hypertension had increased risk of newly diagnosed fibroids, whereas those taking antihypertensive treatment had lower risk, suggesting that blood pressure control may provide new strategies for fibroid prevention.

Weight loss response to semaglutide in postmenopausal women with and without hormone therapy use

OBJECTIVE

To compare weight loss response and changes in cardiometabolic risk markers in postmenopausal women using semaglutide with and without menopause hormone therapy (HT) use.

METHODS

Retrospective cohort study of postmenopausal women treated with semaglutide for overweight or obesity for ≥3 months. Endpoints: total body weight loss percentage (TBWL%) at 3, 6, 9, and 12 months after semaglutide initiation; and percentage of women achieving ≥5% and ≥10% TBWL and changes in cardiometabolic risk markers (glucose, blood pressure, and lipids) at 12 months.

RESULTS

There were 16 women on HT and 90 on no-HT; mean age 56 ± 8 vs 59 ± 8 yr, P = 0.2 and mean BMI 36 ± 5 vs 39 ± 8 kg/m 2 , P = 0.1; respectively. Among women on no-HT, White race, dyslipidemia, and depression were more prevalent. Women on HT had a higher TBWL% at 3, 6, 9, and 12 months: 7 ± 3% vs 5 ± 4%, P = 0.01; 13 ± 6% vs 9 ± 5%, P = 0.01; 15 ± 6% vs 10 ± 6%, P = 0.02; and 16 ± 6% vs 12 ± 8%, P = 0.04; respectively. After adjusting for potential confounders, this association remained significant across time. At 12 months, a greater percentage of women on HT achieved ≥5% and ≥10% TBWL. Both groups experienced an improvement in cardiometabolic risk markers.

CONCLUSION

In postmenopausal women with overweight or obesity treated with semaglutide, HT use was associated with an improved weight loss response. This association was maintained when adjusted for confounders. Larger studies should be conducted to confirm these results.

Impact of dental visiting patterns on oral health: A systematic review of longitudinal studies

AIM

To systematically review longitudinal studies investigating the impact of dental visiting patterns on oral health across the life course.

METHODS

Five databases (MEDLINE, Embase, Scopus, Web of Science, CINAHL) were searched up to March 2023. Results were screened based on eligibility criteria in a two-stage process: title and abstract, and full-text review. A backward search of reference lists and a forward search of citations of the included papers was also conducted. The quality of the included papers was assessed using the Newcastle-Ottawa Scale. Key study information was extracted and a narrative synthesis of the findings was performed.

RESULTS

Eleven papers from five longitudinal studies in five countries (Australia, Brazil, China, New Zealand, Sweden) met the inclusion criteria. Studies of moderate to high quality consistently reported that regular dental attendance was associated with having less dental caries experience, fewer missing teeth and better oral health-related quality of life. Inconsistent findings were observed for decayed teeth, and no association was found for periodontal condition.

CONCLUSIONS

This review highlights an association between regular dental visiting pattern and improved oral health, notably less dental caries experience and better oral health-related quality of life. Dental attendance emerges as an important predictor of oral health across the life course, underscoring the importance of routine dental care.

REGISTRATION INFORMATION

The PROSPERO registration number is CRD42023396380.

Intensity of and adherence to lipid-lowering therapy as predictors of goal attainment and major adverse cardiovascular events in primary prevention

BACKGROUND

The effectiveness of lipid-lowering therapy (LLT) for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in routine care may depend on treatment intensity and adherence.

METHODS

Observational study of adults with newly initiated LLT for primary prevention of ASCVD in Stockholm, Sweden, during 2017-2021. Study exposures were LLT adherence [proportion of days covered (PDC)], LLT intensity (expected reduction of LDL cholesterol), and the combined measure of adherence and intensity. At each LLT fill, adherence and intensity were calculated during the previous 12 months, and the patients estimated ASCVD risk was categorized. Study outcomes were major adverse cardiovascular events (MACE) and LDL-C goal attainment.

RESULTS

Thirty-six thousand two hundred eighty-three individuals (mean age 63 years, 47% women, median follow-up 2 years), with a baseline low-moderate (40%), high (49%), and very-high (11%) ASCVD risk started LLT. Increases in LLT adherence, intensity, or adherence-adjusted intensity of 10% over 1 year were associated with lower risks of MACE (with hazard ratios of 0.95 [95% CI, 0.93-0.98]; 0.93 [0.86-1.00]; and 0.90 [0.85-0.95], respectively) and higher odds of attaining LDL goals. Patients with good adherence (≥80%) had similar risks of MACE and similar odds ratios for LDL-C goal attainment with low-moderate and high-intensity LLT. Treatment discontinuation was associated with increased MACE risk. The relative and absolute benefits of good adherence were greatest in patients with very high ASCVD risk.

CONCLUSION

In routine-care primary prevention, better adherence to LLT was associated with a lower risk of MACE across all treatment intensities. Improving adherence is especially important among patients with very high ASCVD risk.

Interventions and contextual factors to improve retention in care for patients with hypertension in primary care: Hermeneutic systematic review

BACKGROUND

Regular engagement over time in hypertension care, or retention, is a crucial but understudied step in optimizing patient outcomes. This systematic review leverages a hermeneutic methodology to identify, evaluate, and quantify the effects of interventions and contextual factors for improving retention for patients with hypertension.

METHODS

We searched for articles that were published between 2000 and 2022 from multiple electronic databases, including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, and WHO International Trials Registry. We followed the latest version of the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline to report the findings for this review. We also synthesized the findings using a hermeneutic methodology for systematic reviews, which used an iterative process to review, integrate, analyze, and interpret evidence.

RESULTS

From 4686 screened titles and abstracts, 18 unique studies from 9 countries were identified, including 10 (56%) randomized controlled trials (RCTs), 3 (17%) cluster RCTs, and 5 (28%) non-RCT studies. The number of participants ranged from 76 to 1562. The overall mean age range was 41-67 years, and the proportion of female participants ranged from 0% to 100%. Most (n = 17, 94%) studies used non-physician personnel to implement the proposed interventions. Fourteen studies (78%) implemented multilevel combinations of interventions. Education and training, team-based care, consultation, and Short Message Service reminders were the most common interventions tested.

CONCLUSIONS

This review presents the most comprehensive findings on retention in hypertension care to date and fills the gaps in the literature, including the effectiveness of interventions, their components, and contextual factors. Adaptation of and implementing HIV care models, such differentiated service delivery, may be more effective and merit further study.

REGISTRATION

CRD42021291368.

PROTOCOL REGISTRATION

PROSPERO 2021 CRD42021291368. Available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=291368.

Effect of colorectal cancer screening on colorectal cancer surgery outcomes: nationwide cohort study

BACKGROUND

National colorectal cancer screening commenced in Denmark in 2014. Little is known about the effects of organized colorectal cancer screening on intraoperative and postoperative events. The aim of this nationwide cohort study was to evaluate the difference in intraoperative and postoperative outcomes between patients with screen-detected colorectal cancer and non-screen-detected colorectal cancer within the first 90 days after surgery.

METHODS

National register data were collected for Danish residents diagnosed with colorectal cancer between January 2014 and March 2018. Outcomes for the two cohorts were reported as relative risk or weighted mean difference. Intraoperative outcomes were blood loss, blood transfusion, tumour perforation, and organ lesion. Postoperative outcomes were complications (surgical and non-surgical) and 90-day mortality. Discrete data estimates were calculated from a general linear model. Analyses were adjusted for potential healthy user bias with respect to sex, age, location of the cancer (colon/rectum), and Charlson co-morbidity index.

RESULTS

In total, 10 606 patients were included. Compared with patients in the non-screen-detected colorectal cancer group (4497 patients), patients in the screen-detected colorectal cancer group (6109 patients) had reduced intraoperative blood loss (-52 mL, 95% c.i. -67 to -37, P < 0.001), a shorter duration of hospitalization (-2.3 days, 95% c.i. -2.8 to -1.8, P < 0.001), and reduced rates of intraoperative organ lesion (0.76, 95% c.i. 0.59 to 0.99, P = 0.042), surgical complications (0.79, 95% c.i. 0.73 to 0.87, P < 0.001), non-surgical complications (0.68, 95% c.i. 0.60 to 0.78, P < 0.001), and 90-day mortality (0.29, 95% c.i. 0.21 to 0.39, P < 0.001).

CONCLUSION

In comparison with non-screen-detected colorectal cancer, surgery for screen-detected colorectal cancer remains associated with improvement in several intraoperative and early postoperative outcomes after considering healthy user bias.

Prevalence of common and rare ophthalmic findings in adults attending a medical survey institute

PURPOSE

To examine the ophthalmic data from a large database of people attending a general medical survey institute, and to investigate ophthalmic findings of the eye and its adnexa, including differences in age and sex.

METHODS

Retrospective analysis including medical data of all consecutive individuals whose ophthalmic data and the prevalences of ocular pathologies were extracted from a very large database of subjects examined at a single general medical survey institute.

RESULTS

Data were derived from 184,589 visits of 3676 patients (mean age 52 years, 68% males). The prevalence of the following eye pathologies were extracted. Eyelids: blepharitis (n = 4885, 13.3%), dermatochalasis (n = 4666, 12.7%), ptosis (n = 677, 1.8%), ectropion (n = 73, 0.2%), and xanthelasma (n = 160, 0.4%). Anterior segment: pinguecula (n = 3368, 9.2%), pterygium (n = 852, 2.3%), and cataract or pseudophakia (n = 9381, 27.1%). Cataract type (percentage of all phakic patients): nuclear sclerosis (n = 8908, 24.2%), posterior subcapsular (n = 846, 2.3%), and capsular anterior (n = 781, 2.1%). Pseudophakia was recorded for 697 patients (4.6%), and posterior subcapsular opacification for 229 (0.6%) patients. Optic nerve head (ONH): peripapillary atrophy (n = 4947, 13.5%), tilted disc (n = 3344, 9.1%), temporal slope (n = 410, 1.1%), ONH notch (n = 61, 0.2%), myelinated nerve fiber layer (n = 94, 0.3%), ONH drusen (n = 37, 0.1%), optic pit (n = 3, 0.0%), and ON coloboma (n = 4, 0.0%). Most pathologies were more common in males except for ONH, and most pathologies demonstrated a higher prevalence with increasing age.

CONCLUSIONS

Normal ophthalmic data and the prevalences of ocular pathologies were extracted from a very large database of subjects seen at a single medical survey institute.

Helicobacter pylori Treatment and Gastric Cancer Risk After Endoscopic Resection of Dysplasia: A Nationwide Cohort Study

BACKGROUND & AIMS

The study investigated the association between Helicobacter pylori treatment and the risk of gastric cancer after endoscopic resection of gastric dysplasia.

METHODS

Patients who received endoscopic resection for gastric dysplasia between 2010 and 2020 from Korean nationwide insurance data were included. We verified the occurrence of new-onset gastric cancer and metachronous gastric neoplasm, which encompasses both cancer and dysplasia, >1 year after the index endoscopic resection. Newly diagnosed gastric cancer ≥3 years and ≥5 years was regarded as late-onset gastric cancer. A multivariable Cox regression model with H pylori treatment status as a time-dependent covariate was used to determine the risk of gastric cancer and metachronous gastric neoplasms.

RESULTS

Gastric dysplasia in 69,722 patients was treated with endoscopy, and 49.5% were administered H pylori therapy. During the median 5.6 years of follow-up, gastric cancer developed in 2406 patients and metachronous gastric neoplasms developed in 3342 patients. Receiving H pylori therapy was closely related to lower gastric cancer risk (adjusted hazard ratio [aHR], 0.88; 95% confidence interval [CI], 0.80-0.96). H pylori treatment also significantly decreased metachronous gastric neoplasm development (aHR, 0.76; 95% CI, 0.70-0.82). Furthermore, H pylori therapy showed a prominent protective effect for late-onset gastric cancer development at ≥3 years (aHR, 0.84; 95% CI, 0.75-0.94) and ≥5 years (aHR, 0.80; 95% CI, 0.68-0.95).

CONCLUSIONS

In this nationwide cohort, H pylori therapy after endoscopic resection of gastric dysplasia was associated with a reduced risk of gastric cancer and metachronous gastric neoplasm occurrence.

Treatment of patients with screen-detected colorectal cancer is less strenuous: a nationwide cohort study with long-term follow-up

OBJECTIVE

During the last two decades, organised colorectal cancer (CRC) screening has been widely implemented. It remains to be established if screen-detected CRC (SD-CRC) is associated with reduced long-term requirements for treatment as compared with patients with non-screen-detected CRC (NSD-CRC).

STUDY DESIGN AND METHODS

This nationwide cohort study evaluated differences in treatment and healthcare contacts from the date of diagnosis to two years after comparing patients with SD-CRC and NSD-CRC. Data were collected from national healthcare registers, including patients aged 50-75 years and diagnosed with CRC between January 1st 2014 and March 31st 2018. Analyses were stratified into UICC stages and adjusted for sex, 5-year age groups, type of cancer (colonic/rectal), and Charlson comorbidity index score to address healthy user bias.

RESULTS

In total, 12,040 patients were included, 4708 with SD-CRC and 7332 with NSD-CRC. In patients with SD-CRC, the duration of hospitalisation and rate of emergency surgery were reduced by 38 % (relative risk [RR] = 0.62) and 66 % (RR = 0.34), respectively. Moreover, this group was characterised by a 75 % reduction in oncological outpatient visits (RR = 0.35) and a reduced number of treatments with chemotherapy (RR = 0.57) and radiotherapy (RR = 0.50). There were no significant differences between the two populations in the rates of metastasectomy and the number of contacts with primary healthcare providers.

CONCLUSION

Compared to patients with NSD-CRC, patients with SD-CRC experience less hospitalisation and treatment within the first two years after diagnosis.

Oral Contraceptives and the Risk of Psychiatric Side Effects: A Review

Background

Oral contraceptives (OCs) are an essential medicine used by millions of people every day. Given the widespread usage of these medicines, even a small increase in psychiatric risk could be of clinical significance. Although mood-related side effects are a common reason for OC hesitancy and discontinuation, studies investigating psychiatric responses to OC treatment have had inconsistent results.

Summary

While OCs are beneficial for most users, there is evidence that a subgroup of users is susceptible to mood side effects. Randomized controlled trials have generally failed to find differences in mood symptoms between OC and placebo users, but observational studies comparing OC users to non-users have reported increases in symptoms of depression, anxiety, and eating disorders. Additionally, observational evidence suggests that OC users may be more likely to use prescription psychotropic medications and to attempt or die by suicide. However, responses to OC treatment are highly heterogeneous, and some users report mood improvement. A variety of factors may increase the likelihood of negative psychiatric side effects, including younger age, previous experience of side effects from OCs, and preexisting psychiatric disorders. Progestin-only pills may confer a higher psychiatric risk than combination pills.

Key Messages

Further research investigating factors that contribute to susceptibility to the mood-related side effects of OCs is clearly warranted. Genomic approaches may provide insight as to why some users experience side effects while others do not. Research elucidating who is most at risk and why will be essential to addressing prevalent concerns about the psychiatric risk of OCs.

Vaccination against influenza viruses reduces infection, not hospitalization or death, from respiratory COVID-19: A systematic review and meta-analysis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and has brought a huge burden in terms of human lives. Strict social distance and influenza vaccination have been recommended to avoid co-infections between influenza viruses and SARS-CoV-2. Scattered reports suggested a protective effect of influenza vaccine on COVID-19 development and severity. We analyzed 51 studies on the capacity of influenza vaccination to affect infection with SARS-CoV-2, hospitalization, admission to Intensive Care Units (ICU), and mortality. All subjects taken into consideration did not receive any anti-SARS-CoV-2 vaccine, although their status with respect to previous infections with SARS-CoV-2 is not known. Comparison between vaccinated and not-vaccinated subjects for each of the four endpoints was expressed as odds ratio (OR), with 95% confidence intervals (CIs); all analyses were performed by DerSimonian and Laird model, and Hartung-Knapp model when studies were less than 10. In a total of 61 029 936 subjects from 33 studies, influenza vaccination reduced frequency of SARS-CoV-2 infection [OR plus 95% CI = 0.70 (0.65-0.77)]. The effect was significant in all studies together, in health care workers and in the general population; distance from influenza vaccination and the type of vaccine were also of importance. In 98 174 subjects from 11 studies, frequency of ICU admission was reduced with influenza vaccination [OR (95% CI) = 0.71 (0.54-0.94)]; the effect was significant in all studies together, in pregnant women and in hospitalized subjects. In contrast, in 4 737 328 subjects from 14 studies hospitalization was not modified [OR (95% CI) = 1.05 (0.82-1.35)], and in 4 139 660 subjects from 19 studies, mortality was not modified [OR (95% CI) = 0.76 (0.26-2.20)]. Our study emphasizes the importance of influenza vaccination in the protection against SARS-CoV-2 infection.

Effects of SGLT2 inhibitors on clinical cancer survival in patients with type 2 diabetes

PURPOSE

According to the preclinical data, sodium-glucose cotransporter 2 (SGLT2) inhibitors (SGLT2is) may exert anticancer effects. Here, we clarified the cancer-specific mortality (primary outcome) and all-cause mortality (secondary outcome) of SGLT2is and their dose-dependency in patients with cancer undergoing standard curative treatments.

METHODS

We analyzed data from patients with type 2 diabetes mellitus (T2DM) diagnosed with cancer between January 1, 2016, and December 31, 2018, enrolled from the Taiwan Cancer Registry database. Kaplan-Meier method was used to estimate all-cause mortality and cancer-specific mortality, comparing survival curves between SGLT2i users and nonusers using the stratified log-rank test. Cox proportional hazards regression was conducted to identify independent predictors for all-cause and cancer-specific mortality among the covariates.

RESULTS

We performed 1:2 propensity score matching of our data, which yielded a final cohort of 50,133 patients with cancer; of them, 16,711 and 33,422 were in the SGLT2i user and nonuser groups, respectively. The adjusted hazard ratio (aHR) for cancer-specific and all-cause mortality in SGLT2i users compared with nonusers was 0.21 (95 % confidence interval [CI]: 0.20-0.22) and 0.22 (95 % CI: 0.21-0.23). We divided the patients into four subgroups stratified by quartiles (Q) of cumulative defined daily doses per year (cDDDs), and all-cause and cancer-specific mortality was noted to significantly decrease with increases in dosage (from Q1 to Q4 cDDDs) in SGLT2i users compared with in nonusers (P < 0.001).

CONCLUSION

SGLT2is increase overall survival and cancer-specific survival in patients with cancer in a dose-dependent manner.