Calculating the "number needed to be exposed" with adjustment for confounding variables in epidemiological studies

The prognostic role of cardiopulmonary exercise testing in obesity

AIM

Poor cardiorespiratory fitness has been suggested to increase the risk of chronic diseases in obesity. We investigated the ability of key variables from cardiopulmonary exercise testing (CPET) to predict all-cause mortality in an obese cohort.

METHODS

The sample included 469 participants of both sexes (mean age 40 ± 13 years) who underwent a CPET for clinical reasons between 1 March 2009 and 1 December 2023. All-cause mortality was the prognostic endpoint. A receiver operating characteristic analysis was performed to establish optimal cut-points for CPET variables. Kaplan-Meier and Cox regression analyses were used to determine the association between CPET variables and all-cause mortality.

RESULTS

There were 46 deaths during a mean follow-up period of 69 ± 48 months, resulting in an annual mortality rate of 2%. Despite the sample being made up of mostly women (70%), there were more deaths in men (18 vs. 6%, p < 0.001).The optimal thresholds for discrimination of survival were as follows: (a) peak oxygen uptake (pVO2) ≤16 mL/kg/min; (b) minute ventilation/carbon dioxide production (VE/VCO2) slope ≥31; (c) ventilatory power ≤5.8 mmHg; and (d) circulatory power ≤2980 mmHg/mL O2/min. Kaplan-Meier survival plots revealed a significant positive association between lower pVO2, circulatory power and ventilatory power values and survival (log-rank, p < 0.001) and higher mortality for men than women. Adjusted Cox regression models showed that a pVO2 ≤16 mL/kg/min had a 20-fold higher risk of mortality when compared with >16 mL/kg/min.

CONCLUSION

Given the strong association of VO2, ventilatory efficiency, circulatory and ventilatory power with all-cause mortality, our findings support the notion that poorer cardiorespiratory fitness is associated with a poor prognosis in patients with obesity.

Association of statins with nonalcoholic fatty liver disease in patients with diabetes

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in patients with diabetes; limited data suggested that statins may reduce the risk of NAFLD progression. This study aimed to examine the association between statins and the development or progression of NAFLD in veterans with diabetes. In a new-user negative control design, we conducted a retrospective propensity score (PS)-matched cohort study of patients with diabetes between 2003 and 2015. After excluding patients with other causes of liver disease, we formed PS using 85 characteristics. The primary outcome was a composite NAFLD progression outcome. Primary analysis examined odds of outcome in PS-matched cohort. Post-hoc analysis included a PS-matched cohort of statin users with intensive lowering of low-density lipoprotein-cholesterol (LDL-C) vs low-intensity lowering. We matched 34,102 pairs from 300,739 statin users and 38,038 non-users. The composite outcome occurred in 8.8% of statin users and 8.6% of non-users (odds ratio (OR) 1.02, 95% confidence interval (95% CI) 0.97-1.08). In the post-hoc analysis, intensive lowering of LDL-C compared to low-intensity showed increased NAFLD progression (OR 1.21, 95% CI 1.13-1.30). This study showed that statin use in patients with diabetes was not associated with decreased or increased risk of NAFLD progression. Intensive LDL-C lowering, compared to low-intensity LDL-C lowering, was associated with an increased risk of NAFLD progression.

Statistical significance, clinical importance and effect sizes: Enhancing understanding of a study's results

BACKGROUND

The proper interpretation of a study's results requires both excellent understanding of good methodological practices and deep knowledge of prior results, aided by the availability of effect sizes.

METHODS

This review takes the form of an expository essay exploring the complex and nuanced relationships among statistical significance, clinical importance, and effect sizes.

RESULTS

Careful attention to study design and methodology will increase the likelihood of obtaining statistical significance and may enhance the ability of investigators/readers to accurately interpret results. Measures of effect size show how well the variables used in a study account for/explain the variability in the data. Studies reporting strong effects may have greater practical value/utility than studies reporting weak effects. Effect sizes need to be interpreted in context. Verbal summary characterizations of effect sizes (e.g., "weak", "strong") are fundamentally flawed and can lead to inappropriate characterization of results. Common language effect size (CLES) indicators are a relatively new approach to effect sizes that may offer a more accessible interpretation of results that can benefit providers, patients, and the public at large.

CONCLUSIONS

It is important to convey research findings in ways that are clear to both the research community and to the public. At a minimum, this requires inclusion of standard effect size data in research reports. Proper selection of measures and careful design of studies are foundational to the interpretation of a study's results. The ability to draw useful conclusions from a study is increased when investigators enhance the methodological quality of their work.

Evaluating the Effect of Rotator Cuff Repair With Concomitant Distal Claviculectomy on 2 and 4 Year Reoperation Rates

BACKGROUND

The current literature has differing views on the efficacy of concomitant distal claviculectomy (DC) during rotator cuff repair (RCR) in preventing revision surgery. Our aim was to investigate the revision surgery rate between RCR with DC and RCR without DC.

METHODS

A retrospective cohort analysis was conducted using a national claims database. Patients undergoing open or arthroscopic primary RCR with or without concomitant DC were identified. The primary outcome was 4-year revision surgery rates. Univariate analysis was conducted using chi-square or Student t tests. Multivariable analysis was conducted using logistic regression, and an adjusted number needed to harm was calculated.

RESULTS

A total of 131,232 patients met inclusion criteria. After logistic regression, patients undergoing RCR with DC had higher odds of requiring a subsequent DC procedure [OR; 95% CI; P-value (1.49; 1.35-1.64; P < 0.001)] but lower odds of any revision surgery (0.87; 0.80-0.91; P < 0.001) within 4 years than those who underwent RCR without DC.

CONCLUSION

Although associated with a lower rate of overall revision surgeries within 2 and 4 years of RCR, those who underwent RCR with DC were 85% more likely at 2 years and 49% more likely at 4 years to undergo revision surgery of the distal clavicle than those without concomitant DC.

Post-exposure prophylaxis in leprosy (PEOPLE): a cluster randomised trial

BACKGROUND

Post-exposure prophylaxis (PEP) using single-dose rifampicin reduces progression from infection with Mycobacterium leprae to leprosy disease. We compared effectiveness of different administration modalities, using a higher (20 mg/kg) dose of rifampicin-single double-dose rifampicin (SDDR)-PEP.

METHODS

We did a cluster randomised study in 16 villages in Madagascar and 48 villages in Comoros. Villages were randomly assigned to four study arms and inhabitants were screened once a year for leprosy, for 4 consecutive years. All permanent residents (no age restriction) were eligible to participate and all identified patients with leprosy were treated with multidrug therapy (SDDR-PEP was provided to asymptomatic contacts aged ≥2 years). Arm 1 was the comparator arm, in which no PEP was provided. In arm 2, SDDR-PEP was provided to household contacts of patients with leprosy, whereas arm 3 extended SDDR-PEP to anyone living within 100 m. In arm 4, SDDR-PEP was offered to household contacts and to anyone living within 100 m and testing positive to anti-phenolic glycolipid-I. The main outcome was the incidence rate ratio (IRR) of leprosy between the comparator arm and each of the intervention arms. We also assessed the individual protective effect of SDDR-PEP and explored spatial associations. This trial is registered with ClinicalTrials.gov, NCT03662022, and is completed.

FINDINGS

Between Jan 11, 2019, and Jan 16, 2023, we enrolled 109 436 individuals, of whom 95 762 had evaluable follow-up data. Our primary analysis showed a non-significant reduction in leprosy incidence in arm 2 (IRR 0·95), arm 3 (IRR 0·80), and arm 4 (IRR 0·58). After controlling for baseline prevalence, the reduction in arm 3 became stronger and significant (IRR 0·56, p=0·0030). At an individual level SDDR-PEP was also protective with an IRR of 0·55 (p=0·0050). Risk of leprosy was two to four times higher for those living within 75 m of an index patient at baseline.

INTERPRETATION

SDDR-PEP appears to protect against leprosy but less than anticipated. Strong spatial associations were observed within 75 m of index patients. Targeted door-to-door screening around index patients complemented by a blanket SDDR-PEP approach will probably have a substantial effect on transmission.

FUNDING

European and Developing Countries Clinical Trials Partnership.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Infertility treatment is associated with increased risk of postpartum hospitalization due to heart disease

BACKGROUND

Cardiovascular disease is a major cause of maternal mortality, but the extent to which infertility treatment is implicated in heart disease remains unclear.

OBJECTIVE

To evaluate the association between infertility treatment and postpartum heart disease.

METHODS

We designed a retrospective cohort study of patients who delivered in the United States between 2010 and 2018. The primary outcome was hospitalization within 12-month post-delivery due to heart disease (including ischemic heart disease, atherosclerotic heart disease, cardiomyopathy, hypertensive disease, heart failure, and cardiac dysrhythmias). We estimated the rate difference (RD) of hospitalizations among patients who conceived with infertility treatment and those who conceived spontaneously. Associations were expressed as hazard ratios (HRs) and 95% confidence intervals (CIs), derived from Cox proportional hazards regression after adjustment for potential confounders.

RESULTS

Infertility treatment was recorded in 0.9% (n = 287,813) of 31,339,991 deliveries. Rates of heart disease hospitalizations with infertility treatment and with spontaneous conception were 550 and 355 per 100,000, respectively (RD 195, 95% CI: 143-247; adjusted HR 1.99, 95% CI: 1.80-2.20). The most important increase in risk was observed for hypertensive disease (adjusted HR 2.16, 95% CI: 1.92-2.42). This increased risk was apparent as early as 30-day post-delivery (HR 1.61, 95% CI: 1.39-1.86), with progressively increasing risk up to a year.

CONCLUSIONS

Although the absolute risk of postpartum heart disease hospitalization is low, infertility treatment is associated with an increased risk, especially for hypertensive disease. These findings highlight the importance of timely postpartum follow-ups in patients who received infertility treatment.

Adverse perinatal events and maternal interpregnancy weight change: A population-based observational study

OBJECTIVE

Mothers whose newborn experiences adversity may neglect their own health to care for their affected infant or following a perinatal death. Weight gain after pregnancy is one measure of maternal self-care. We measured interpregnancy weight gain among women whose child had an adverse perinatal event.

METHODS

This population-based observational study included 192 154 primigravid women with two consecutive singleton births in Ontario, Canada. Outcomes included net weight gain, and adjusted odds ratios (aOR) of moving to a higher body mass index (BMI) category between pregnancies, comparing women whose child did versus did not experience either a perinatal death, prematurity, severe neonatal morbidity, major congenital anomaly, or severe neurologic impairment.

RESULTS

Perinatal death was associated with a +3.5 kg (95% confidence interval [CI]: 2.1-4.9) net higher maternal weight gain in the subsequent pregnancy. Relative to term births, preterm birth <32 weeks (+3.2 kg, 95% CI: 1.9-4.6), 32-33 weeks (+1.8 kg, 95% CI: 0.7-2.8) and 34-36 weeks (+0.9 kg, 95% CI: 0.6-1.3) were associated with higher net weight gain. Having an infant with severe neonatal morbidity was associated with a +1.2 kg (95% CI: 0.3-2.1) weight gain. Likewise, the aOR of moving to a higher BMI category was 1.27 (95% CI, 1.14-1.42) following a perinatal death, 1.21 (95% CI: 1.04-1.41) after a preterm birth <32 weeks, and 1.11 (95% CI: 1.02-1.22) with severe neonatal morbidity.

CONCLUSION

Greater interpregnancy weight gain, and movement to a higher BMI category, are each more likely in a woman whose first-born was affected by certain major adverse perinatal events.

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes

BACKGROUND

Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics.

RESULTS

Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients.

CONCLUSION

Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

Gestational diabetes mellitus in pregnancies conceived after infertility treatment: a population-based study in the United States, 2015-2020

Objective

To evaluate the risk of gestational diabetes mellitus (GDM) in singleton pregnancies conceived using infertility treatment and examine the influence of race and ethnicity as well as prepregnancy body mass index (BMI).

Design

Cross-sectional study using the US vital records data of women that delivered singleton births.

Setting

United States, 2015-2020.

Interventions

Any infertility treatment was divided into two groups: those that used fertility-enhancing drugs, artificial insemination, or intrauterine insemination, and those that used assisted reproductive technology (ART).

Main Outcome Measuress

Gestational diabetes mellitus, defined as a diagnosis of diabetes mellitus during pregnancy, includes both diet-controlled GDM and medication-controlled GDM in singleton pregnancies conceived with infertility treatment or spontaneously and delivered between 20- and 44-weeks' gestation. We also examined whether the infertility treatment-GDM association was modified by maternal race and ethnicity as well as prepregnancy BMI. Associations were expressed as a rate ratio (RR) and 95% confidence interval (CI), derived from log-linear models after adjustment for potential confounders.

Results

A total of 21,943,384 singleton births were included, with 1.5% (n = 318,086) undergoing infertility treatment. Rates of GDM among women undergoing infertility treatment and those who conceived spontaneously were 11.0% (n = 34,946) and 6.5% (n = 1,398,613), respectively (adjusted RR 1.24, 95% CI 1.23, 1.26). The RRs were adjusted for maternal age, parity, education, race and ethnicity, smoking, BMI, chronic hypertension, and year of delivery. The risk of GDM was modestly increased for those using fertility-enhancing drugs (adjusted RR 1.28, 95% CI 1.27, 1.30) compared with ART (adjusted RR 1.18, 95% CI 1.17, 1.20), and this risk was especially apparent for non-Hispanic White women (adjusted RR 1.29, 95% CI 1.26, 1.31) and Hispanic women (adjusted RR 1.35, 95% CI 1.29, 1.41). The number of women who needed to be exposed to infertility treatment to diagnose one case of GDM was 46. Prepregnancy BMI did not modify the infertility treatment-GDM association overall and within strata of race and ethnicity. These general patterns were stronger after potential corrections for misclassification of infertility treatment and unmeasured confounding.

Conclusions

Infertility treatment, among those who received fertility-enhancing drugs, is associated with an increased GDM risk. The persistently higher risk of GDM among women who seek infertility treatment, irrespective of prepregnancy weight classification, deserves attention. Infertility specialists must be vigilant with preconception counseling and ensure that all patients, regardless of race and ethnicity or BMI, are adequately tested for GDM early in pregnancy using a fasting blood glucose level or a traditional 50-g oral glucose tolerance test. Testing may be completed by the infertility specialist or deferred to the primary prenatal care provider at the first prenatal visit.

Efficacy and safety of adjunctive oral therapy in Parkinson's disease with motor complications: a systematic review and network meta-analysis

Background

The aim of this manuscript is to review the evidence and compare the efficacy and safety of catechol-O-methyltransferase inhibitors (COMT-Is), dopamine receptor agonists (DRAs) and monoamine-oxidase B inhibitors (MAOB-Is) as adjunctive treatment to levodopa in patients with Parkinson's disease (PD) experiencing motor complications.

Methods

In this systematic review and network meta-analysis, literature searches were performed in MEDLINE and Embase to identify eligible randomised controlled trials (RCTs) with a minimal follow-up of at least 4 weeks published in English between 1980 and 2021. RCTs were included if either a COMT-I, DRA or MAOB-I was evaluated as an adjunctive therapy to levodopa in patients with PD experiencing motor complications and dyskinesia. The main outcomes included daily off-medication time, motor and non-motor examination scales, and adverse events including dyskinesia.

Results

74 RCTs reporting on 18 693 patients were included. All three studied drug classes decreased daily off-medication time compared with placebo (COMT-Is mean -0.8 hours (95% CI -1.0 to -0.6), DRAs -1.1 hours (95% CI -1.4 to -0.8), MAOB-Is -0.9 hours (95% CI -1.2 to -0.6)). Safety analysis showed an increased risk of dyskinesia for all three drug classes (COMT-Is OR 3.3 (95% CI 2.7 to 4.0), DRAs 3.0 (95% CI 2.5 to 3.5), MAOB-Is 1.6 (95% CI 1.2 to 2.2)). According to surface under the cumulative ranking curve scores, pramipexole IR was associated with the most favourable benefit-risk profile.

Conclusions

COMT-Is, DRAs and MAOB-Is effectively reduce motor complications and increase incidence of dyskinesia. In the network meta-analysis, adjunctive use of DRAs appeared most effective.

The impact of previous conservative treatment of atypical hyperplasia on pregnancy outcomes after IVF/ICSI-embryo transfer: a propensity score-matched retrospective cohort study

STUDY QUESTION

Do women have worse pregnancy and neonatal outcomes of IVF/ICSI-fresh embryo transfer (ET) after conservative treatment of atypical hyperplasia (AH)?

SUMMARY ANSWER

AH has no impact on live birth but is associated with increased risks of pregnancy loss and preterm delivery (PTD).

WHAT IS KNOWN ALREADY

AH is a precancerous lesion of endometrial cancer. Several recognized AH risk factors include nulliparity, increased body mass index, ovulation disorders, diabetes mellitus, and others. As such, patients are suggested to attempt conception upon achieving AH regression. Recently, successful pregnancies with IVF/ICSI have been increasingly reported.

STUDY DESIGN, SIZE, DURATION

Forty-two patients with AH regression and 18 700 women with no evidence of endometrial abnormality, who underwent their first autologous oocytes' retrieval and fresh ET cycles of IVF/ICSI in the Center for Reproductive Medicine, Shandong University, from May 2008 to July 2021, were retrospectively enrolled.

PARTICIPANTS/MATERIALS, SETTING, METHODS

First, 42 AH patients were propensity score matched with control women (n = 168) at a 1:4 ratio. Reproductive outcomes and maternal/neonatal complications were compared between the matched pairs. Binary logistic regression analyses were conducted to assess odds ratios (ORs) of AH for live birth, pregnancy loss, and PTD from AH women and all 18 700 eligible controls.

MAIN RESULT AND THE ROLE OF CHANCE

Patients with AH achieved a numerically lower live birth rate (LBR) as compared to the matched controls, but without significant difference (26% versus 37%, P = 0.192). However, compared with the matched controls, AH patients showed significantly higher rates of pregnancy loss (52% versus 21%, P = 0.003) and PTD (45% versus 16%, P = 0.041). Further analyses revealed a statistically significantly increased rate of late pregnancy loss (17% versus 3%, P = 0.023), but not early miscarriage (35% versus 18%, P = 0.086), in the AH group. Furthermore, after correcting for potential confounders, the likelihood of a live birth in AH patients narrowly failed to be statistically significantly different from controls (adjusted OR [aOR]: 0.51, 95% CI: 0.25-1.04, P = 0.064). Nonetheless, the logistic regression reconfirmed that AH was an independent risk factor for pregnancy loss (aOR: 3.62, 95% CI: 1.55-8.46, P = 0.003), late pregnancy loss (aOR: 9.33, 95% CI: 3.00-29.02, P < 0.001), and PTD (aOR: 5.70, 95% CI: 1.45-22.38, P = 0.013).

LIMITATIONS, REASONS FOR CAUTION

Selection bias was an inherent drawback of this study. First, because of the low AH prevalence among women receiving IVF/ICSI treatment, and consequently, limited sample size, the relationship between AH with LBR and adverse complications might be concealed and underestimated. Hence, the results should be interpreted cautiously. Similarly, the impacts of diverse clinical features of AH patients on the pregnancy outcomes need further studies in a larger population. Second, although most data used in this study were obtained by reviewing the medical records, missing data did exist and so did the recall bias. Third, although the propensity score matching and multivariable logistic models were performed collectively in order to minimize potential confounders between AH and controls, the intrinsic disadvantages of the retrospective nature of this study could not be avoided completely, and additional confirmation bias might be induced with reduplication of statistical analyses.

WIDER IMPLICATION OF THE FINDINGS

Our results highlight the necessity of adequate counseling and intensive pregnancy monitoring for AH individuals and their families.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by grants from the National Key Research & Developmental Program of China (2022YFC2703800), the Natural Science Foundation of Shandong Province (ZR2022MH009), and Projects of Medical and Health Technology Development Program in Shandong Province (202005010520, 202005010523). There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Social Determinants of Health Disparities Increase the Rate of Complications After Total Knee Arthroplasty

BACKGROUND

Few studies have investigated whether social determinants of health disparities (SDHD), which include economic, social, education, health care, and environmental factors, identified through International Classification of Diseases (ICD) codes are associated with increased odds for poor health outcomes. We aimed to investigate the association between SDHD, identified through this novel methodology, as well as postoperative complications following total knee arthroplasty (TKA).

METHODS

Using a national insurance claims database, a retrospective cohort analysis was performed. Patients were selected using Current Procedural Terminology and ICD codes for primary TKA between 2010 and 2019. Patients were stratified into 2 groups using ICD codes, those who had SDHD and those who did not, and propensity matched 1:1 for age, sex, a comorbidity score, and other comorbidities. After matching, 207,844 patients were included, with 103,922 patients in each cohort. Odds ratios (ORs) for 90-day medical and 2-year surgical complications were obtained using multivariable logistical regressions.

RESULTS

In patients who have SDHD, multivariable analysis demonstrated higher odds of readmission (OR): 1.12; P = .013) and major and minor medical complications (OR: 2.09; P < .001) within 90-days as well as higher odds of revision surgery (OR: 1.77; P < .001) and periprosthetic joint infection (OR: 1.30; P < .001) within 2-years.

CONCLUSION

The SDHD are an independent risk factor for revision surgery and periprosthetic joint infection after TKA. In addition, SDHD is also an independent risk factor for all-cause hospital readmissions and both minor and major complications.

LEVEL OF EVIDENCE

III.

Higher revision rates in patients with preoperative contralateral pes planovalgus deformity following total knee arthroplasty

PURPOSE

The purpose of this study was to compare the incidence of revision in those with pes planovalgus deformity to those without using a large national database. Given the reciprocal changes in lower extremity alignment associated with planovalgus foot deformity, it has been suggested that patients with this deformity has worse outcomes following total knee arthroplasty (TKA).

METHODS

A retrospective cohort analysis of patients undergoing elective TKA was conducted using the PearlDiver database. Patients were stratified into three cohorts: those without pes planovalgus, patients with ipsilateral or bilateral pes planovalgus relative to the TKA, and patients with contralateral pes planovalgus. Patients with prior foot reconstructive surgery were excluded. The cohorts were each matched to those without pes planovalgus. Bivariate analysis was performed comparing 90-day medical complications and 2- and 4-year revisions following TKA. An adjusted number needed to be exposed for one additional person to be harmed (NNEH) was calculated using the adjusted odds ratio (OR) and unexposed event rate.

RESULTS

Following matched analysis, those with contralateral pes planovalgus had similar odds (OR 3.41; 95% CI 0.93-12.54; p = n.s.) for aseptic revision within 2 years but significantly higher odds (OR 3.35; 95% CI 1.08-10.41; p = 0.03) within 4 years when compared to those without a pes planovalgus deformity. Within 4 years, there was no significant difference in the incidence of aseptic revision (p = n.s.) in patients with ipsilateral/bilateral pes planovalgus. No patients in any cohort underwent septic revision within 4 years of TKA.

CONCLUSION

This study found that patients with contralateral pes planovalgus deformity had higher odds of aseptic revision within 4 years following primary TKA in a national database, suggesting that the change in gait kinematics associated with this deformity could possibly be associated with increased revision rates.

LEVEL OF EVIDENCE

Level III.

Postoperative oxygenation assessed by SpO2/FiO2 ratio and respiratory complications after reversal of neuromuscular block with Sugammadex or neostigmine: A retrospective cohort study

STUDY OBJECTIVE

Residual neuromuscular block may lead to postoperative muscle weakness, inadequate oxygenation, and other pulmonary complications. Sugammadex may provide more rapid and effective restoration of neuromuscular function than neostigmine. We therefore tested the primary hypothesis that noncardiac surgical patients given sugammadex oxygenate better during initial recovery than those given neostigmine. Secondarily, we tested the hypothesis that patients given sugammadex have fewer pulmonary complications during hospitalization.

DESIGN

Retrospective cohort analysis.

SETTING

Postoperative recovery area of a tertiary care hospital.

PATIENTS

Adults who had non-cardiothoracic surgery and were given either neostigmine or sugammadex.

INTERVENTIONS

None.

MEASUREMENTS

The primary outcome was the lowest SpO₂/FiO₂ ratio in the post-anesthesia care unit. The secondary outcome was a composite of pulmonary complications.

MAIN RESULTS

Among 71,457 cases, 10,708 (15%) were given sugammadex and 60,749 (85%) received neostigmine. After propensity weighting, the mean minimum SpO₂/FiO₂ ratio was 301 ± 77 (SD) in patients given sugammadex and 303 ± 71 in those given neostigmine, yielding an estimated difference in means of -3.5 (95% confidence interval: -5.3, -1.7; P = 0.0002). 4.4% of patients given sugammadex and 3.6% of patients given neostigmine had postoperative pulmonary complications (P = 0.0005, number-needed-to-be-exposed =136; 95% CI: 83, 330), with the main contributing components being new bronchospasm or exacerbation of obstructive pulmonary disease.

CONCLUSIONS

Postoperative minimum SpO₂/FiO₂ ratio during PACU admission was similar after reversal of neuromuscular block by sugammadex and neostigmine. Reversal with sugammadex was associated with more pulmonary complications, but most were minor and of little consequence.

Outdoor light at night in relation to glucose homoeostasis and diabetes in Chinese adults: a national and cross-sectional study of 98,658 participants from 162 study sites

AIMS/HYPOTHESIS

Exposure to artificial light at night (LAN) disrupts the circadian timing system and might be a risk factor for diabetes. Our aim was to estimate the associations of chronic exposure to outdoor LAN with glucose homoeostasis markers and diabetes prevalence based on a national and cross-sectional survey of the general population in China.

METHODS

The China Noncommunicable Disease Surveillance Study was a nationally representative study of 98,658 participants aged ≥18 years who had been living in their current residence for at least 6 months recruited from 162 study sites across mainland China in 2010. Diabetes was defined according to ADA criteria. Outdoor LAN exposure in 2010 was estimated from satellite data and the participants attending each study site were assigned the same mean radiance of the outdoor LAN at the study site. The linear regression incorporating a restricted cubic spline function was used to explore the relationships between LAN exposure and markers of glucose homoeostasis. Cox regression with a constant for the time variable assigned to all individuals and with robust variance estimates was used to assess the associations between the levels of outdoor LAN exposure and the presence of diabetes by calculating the prevalence ratios (PRs) with adjustment for age, sex, education, smoking status, drinking status, physical activity, family history of diabetes, household income, urban/rural areas, taking antihypertensive medications, taking lipid-lowering medications, and BMI.

RESULTS

The mean age of the study population was 42.7 years and 53,515 (weighted proportion 49.2%) participants were women. Outdoor LAN exposure levels were positively associated with HbA_1c, fasting and 2 h glucose concentrations and HOMA-IR and negatively associated with HOMA-B. Diabetes prevalence was significantly associated with per-quintile LAN exposure (PR 1.07 [95% CI 1.02, 1.12]). The highest quintile of LAN exposure (median 69.1 nW cm^-2 sr^-1) was significantly associated with an increased prevalence of diabetes (PR 1.28 [95% CI 1.03, 1.60]) compared with the lowest quintile of exposure (median 1.0 nW cm^-2 sr^-1).

CONCLUSIONS/INTERPRETATION

There were significant associations between chronic exposure to higher intensity of outdoor LAN with increased risk of impaired glucose homoeostasis and diabetes prevalence. Our findings contribute to the growing evidence that LAN is detrimental to health and point to outdoor LAN as a potential novel risk factor for diabetes.

Identifying Risk Factors for Complication and Readmission with Same-Day Discharge Arthroplasty

BACKGROUND

The COVID-19 pandemic caused a surge of same-day discharge (SDD) for total joint arthroplasty. However, SDD may not be beneficial for all patients. Therefore, continued investigation into the safety of SDD is necessary as well as risk stratification for improved patient outcomes.

METHODS

This retrospective cohort study examined 31,851 elective SDD hip and knee arthroplasties from 2016 to 2020 in a large national database. Logistic regression models were used to identify patient variables and preoperative comorbidities that contribute to postoperative complication or readmission with SDD. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated.

RESULTS

SDD increased from 1.4% in 2016 to 14.6% in 2020. SDD is associated with lower odds of readmission (AOR: 0.994, CI: 0.992-0.996) and postoperative complications (AOR: 0.998, CI: 0.997-1.000). Patients who have preoperative dyspnea (AOR: 1.03, CI: 1.02-1.04, P < .001), chronic obstructive pulmonary disease (AOR: 1.02, CI: 1.01-1.03, P = .002), and hypoalbuminemia (AOR: 1.02, CI: 1.00-1.03, P < .001), had higher odds of postoperative complications. Patients who had preoperative dyspnea (AOR: 1.02, CI: 1.01-1.03), hypertension (AOR: 1.01, CI: 1.01-1.03, P = .003), chronic corticosteroid use (AOR: 1.02, CI: 1.01-1.03, P < .001), bleeding disorder (AOR: 1.02; CI: 1.01-1.03, P < .001), and hypoalbuminemia (AOR: 1.01, CI: 1.00-1.02, P = .038), had higher odds of readmission.

CONCLUSION

SDD is safe with certain comorbidities. Preoperative screening for cardiopulmonary comorbidities (eg, dyspnea, hypertension, and chronic obstructive pulmonary disease), chronic corticosteroid use, bleeding disorder, and hypoalbuminemia may improve SDD outcomes.

Postpartum severe acute maternal morbidity according to gestational age at delivery in twin pregnancies: A prospective cohort study

OBJECTIVE

To assess the association between gestational age at delivery and postpartum severe acute maternal morbidity (SAMM) in twin pregnancies.

METHODS

Secondary analysis of the JUMODA cohort, a national, prospective, population-based study of twin pregnancies in France. We excluded women with delivery before 32 weeks of pregnancy, with a fetal death or medical termination, with antepartum SAMM, or with antepartum conditions responsible for postpartum SAMM. The primary outcome was a composite of postpartum SAMM. We assessed the association between gestational age at delivery and SAMM by using multivariable multilevel modified Poisson regression modeling.

RESULTS

Among the 7713 women included, 410 (5.3%) developed postpartum SAMM. Compared with the reference category of 37 weeks of pregnancy, the risk of postpartum SAMM was significantly lower for all categories of earlier gestational age at delivery (from an adjusted relative risk [RR] of 0.34, 95% confidence interval [CI] 0.17-0.68 at 32 weeks to an adjusted RR of 0.71, 95% CI 0.54-0.94 at 36 weeks), and did not differ for later gestational ages.

CONCLUSION

In twin pregnancies, compared with delivery at 37 weeks of pregnancy, delivery at earlier gestational ages was associated with a lower risk of postpartum SAMM. Continuing pregnancy beyond 37 weeks of pregnancy is not associated with an increased risk of postpartum SAMM.

Palliative Care and Documented Suicide: Association Among Veterans With High Mortality Risk

CONTEXT

Palliative care consultations (PCCs) are associated with reduced physical and psychological symptoms that are related to suicide risk. Little is known, however, about the association between PCCs and death from suicide among patients at high risk of short-term mortality.

OBJECTIVE

To examine the association between the number of PCCs and documentation of suicide in a cohort of Veterans at high risk of short-term mortality, before and after accounting for Veterans' sociodemographic characteristics and clinical conditions.

METHODS

An observational cohort study was conducted using linked Veterans Affairs clinical and administrative databases for 580,620 decedents with high risk of one-year mortality. Logistic regression models were used to examine the association between number of PCCs and documentation of suicide.

RESULTS

Higher percentages of Veterans who died by suicide were diagnosed with chronic pulmonary disease as well as mental health/substance use conditions compared with Veterans who died from other causes. In adjusted models, one PCC in the 90 days prior to death was significantly associated with a 71% decrease in the odds of suicide (OR = 0.29, 95% CI = 0.23-0.37, P < 0.001) and two or more PCCs were associated with a 78% decrease (OR = 0.22, 95% CI = 0.15-0.33, P < 0.001). Associated "number needed to be exposed" estimates suggest that 421 Veterans in this population would need to receive at least one PCC to prevent one suicide.

CONCLUSION

While acknowledging the importance of specialized mental health care in reducing suicide among high-risk patients, interventions delivered in the context of PCCs may also play a role.

Statins and renal disease progression, ophthalmic manifestations, and neurological manifestations in veterans with diabetes: A retrospective cohort study

Background

Statins increase insulin resistance, which may increase risk of diabetic microvascular complications. Little is known about the impact of statins on renal, ophthalmologic, and neurologic complications of diabetes in practice. The objective of this study was to examine the association of statins with renal disease progression, ophthalmic manifestations, and neurological manifestations in diabetes.

Methods

This is a retrospective cohort study, new-user active comparator design, that included a national Veterans Health Administration (VA) patients with diabetes from 2003 to 2015. Patients were age 30 years or older and were regular users of the VA with data encompassing clinical encounters, demographics, vital signs, laboratory tests, and medications. Patients were divided into statin users or nonusers (active comparators). Statin users initiated statins and nonusers initiated H2-blockers or proton pump-inhibitors (H2-PPI) as an active comparator. Study outcomes were: 1) Composite renal disease progression outcome; 2) Incident diabetes with ophthalmic manifestations; and 3) Incident diabetes with neurological manifestations.

Results

Out of 705,774 eligible patients, we propensity score matched 81,146 pairs of statin users and active comparators. Over a mean (standard deviation) of follow up duration of 4.8 (3) years, renal disease progression occurred in 9.5% of statin users vs 8.3% of nonusers (odds ratio [OR]: 1.16; 95% confidence interval [95%CI]: 1.12–1.20), incident ophthalmic manifestations in 2.7% of statin users vs 2.0% of nonusers (OR: 1.35, 95%CI:1.27–1.44), and incident neurological manifestations in 6.7% of statin users vs 5.7% of nonusers (OR: 1.19, 95%CI:1.15–1.25). Secondary, sensitivity, and post-hoc analyses were consistent and demonstrated highest risks among the healthier subgroup and those with intensive lowering of LDL-cholesterol.

Conclusions

Statin use in patients with diabetes was associated with modestly higher risk of renal disease progression, incident ophthalmic, and neurological manifestations. More research is needed to assess the overall harm/benefit balance for statins in the lower risk populations with diabetes and those who receive intensive statin therapy.

The number needed to treat adjusted for explanatory variables in regression and survival analysis: Theory and application

The number needed to treat (NNT) is an efficacy index commonly used in randomized clinical trials. The NNT is the average number of treated patients for each undesirable patient outcome, for example, death, prevented by the treatment. We introduce a systematic theoretically-based framework to model and estimate the conditional and the harmonic mean NNT in the presence of explanatory variables, in various models with dichotomous and nondichotomous outcomes. The conditional NNT is illustrated in a series of four primary examples; logistic regression, linear regression, Kaplan-Meier estimation, and Cox regression models. Also, we establish and prove mathematically the exact relationship between the conditional and the harmonic mean NNT in the presence of explanatory variables. We introduce four different methods to calculate asymptotically-correct confidence intervals for both indices. Finally, we implemented a simulation study to provide numerical demonstrations of the aforementioned theoretical results and the four examples. Numerical analysis showed that the parametric estimators of the NNT with nonparametric bootstrap-based confidence intervals outperformed other examined combinations in most settings. An R package and a web application have been developed and made available online to calculate the conditional and the harmonic mean NNTs with their corresponding confidence intervals.

Gastrointestinal and eating problems in women with Ehlers-Danlos syndromes

PURPOSE

Ehlers-Danlos syndromes (EDS) are a group of heritable conditions in which abnormal collagen synthesis leads to features such as joint hypermobility, skin abnormalities, and tissue fragility. Gastrointestinal (GI) symptoms are common among those affected. These may negatively impact eating behaviors, leading to weight/nutritional problems. We aimed to compare GI symptoms, disordered eating, and body mass index (BMI) between EDS patients and healthy controls, and to explore the link between these variables in EDS patients.

METHOD

In this cross-sectional study, women with EDS and healthy controls responded to an online survey assessing GI symptoms (heartburn/regurgitations, early satiety, nausea/vomiting, bloating, abdominal pain, dysphagia), food allergies/intolerances, disordered eating, history of eating disorders (ED), and BMI. We performed intergroup comparisons as well as multivariate analyses to explore the associations between disordered eating, GI symptoms, and BMI in the EDS group.

RESULTS

Sixty-six women with EDS and 39 healthy controls were included in the study. The EDS patients showed significantly more GI symptoms and food allergies/intolerances, increased prevalence of ED history, higher risk of current ED, and lower BMI than the controls. In the EDS group, the risk for ED was associated with GI symptoms; restricted eating was associated with GI symptoms, food allergies/intolerances, and dysphagia; uncontrolled eating was associated with GI symptoms; and BMI was associated with GI symptoms and food allergies/intolerances.

DISCUSSION

Our results are concordant with that of previous reports highlighting the high level of GI problems and disordered eating in women with EDS. In addition, and for the first-time, the association between both is evidenced in this specific population.

LEVEL OF EVIDENCE III

Case-control analytic study.

Association of Statin Therapy Initiation With Diabetes Progression: A Retrospective Matched-Cohort Study

IMPORTANCE

Statin therapy has been associated with increased insulin resistance; however, its clinical implications for diabetes control among patients with diabetes is unknown.

OBJECTIVE

To assess diabetes progression after initiation of statin use in patients with diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective matched-cohort study using new-user and active-comparator designs to assess associations between statin initiation and diabetes progression in a national cohort of patients covered by the US Department of Veterans Affairs from fiscal years 2003-2015. Patients included were 30 years or older; had been diagnosed with diabetes during the study period; and were regular users of the Veterans Affairs health system, with records of demographic information, clinical encounters, vital signs, laboratory data, and medication usage.

INTERVENTIONS

Treatment initiation with statins (statin users) or with H2-blockers or proton pump inhibitors (active comparators).

MAIN OUTCOMES AND MEASURES

Diabetes progression composite outcome comprised the following: new insulin initiation, increase in the number of glucose-lowering medication classes, incidence of 5 or more measurements of blood glucose of 200 mg/dL or greater, or a new diagnosis of ketoacidosis or uncontrolled diabetes.

RESULTS

From the 705 774 eligible patients, we matched 83 022 pairs of statin users and active comparators; the matched cohort had a mean (SD) age of 60.1 (11.6) years; 78 712 (94.9%) were men; 1715 (2.1%) were American Indian/Pacific Islander/Alaska Native, 570 (0.8%) were Asian, 17 890 (21.5%) were Black, and 56 633 (68.2 %) were White individuals. Diabetes progression outcome occurred in 55.9% of statin users vs 48.0% of active comparators (odds ratio, 1.37; 95% CI, 1.35-1.40; P < .001). Each individual component of the composite outcome was significantly higher among statin users. Secondary analysis demonstrated a dose-response relationship with a higher intensity of low-density lipoprotein-cholesterol lowering associated with greater diabetes progression.

CONCLUSIONS AND RELEVANCE

This retrospective matched-cohort study found that statin use was associated with diabetes progression, including greater likelihood of insulin treatment initiation, significant hyperglycemia, acute glycemic complications, and an increased number of prescriptions for glucose-lowering medication classes. The risk-benefit ratio of statin use in patients with diabetes should take into consideration its metabolic effects.

Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry

Background and Purpose

 In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors.

Methods

 Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score ≤2) and survival at 3 months was studied using inverse probability of treatment weighting (IPTW) analysis in three pre-defined baseline prognostic groups: poor (if pre-stroke disability, age >85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score <6, proximal vertebrobasilar occlusion, supratherapeutic international normalized ratio >3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups’ criteria).

Results

 Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3).

Conclusions

 Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors.

Physical Activity, Cardiorespiratory Fitness, and Population-Attributable Risk

OBJECTIVE

To determine population-attributable risk (PAR) and exposure impact number (EIN) for mortality associated with impaired cardiorespiratory fitness (CRF), physical inactivity, and other risk markers among veteran subjects.

METHODS

The sample included 5890 male subjects (mean age 58±15) who underwent a maximal exercise test for clinical reasons between January 1, 1992, and December 31, 2014. All-cause mortality was the end point. Cox multivariable hazard models were performed to determine clinical, demographic, and exercise-test determinants of mortality. Population-attributable risks and EIN for the lowest quartile of CRF and for inactive behavior were analyzed, accounting for competing events.

RESULTS

There were 2728 deaths during a mean ± standard deviation follow-up period of 9.9±5.8 years. Having low CRF (<5.0 metabolic equivalents [METs]) was associated with an approximate 3-fold higher risk of mortality and a PAR of 12.9%. Each higher MET achieved on the treadmill was associated with a 15% reduction in mortality (hazard ratio [HR]=0.85; 95% confidence interval [CI], 0.83 to 0.88; P<.001). Nearly half the sample was inactive, and these subjects had a 23% higher mortality risk and a PAR of 8.8%. The least fit quartile (<5.0 METs) had relative risks of ≈6.0 compared with the most-fit group (HR=5.99; 95% CI, 4.9 to 7.3). The least-active tertile had ≈2-fold higher risks of mortality vs the most active subjects (HR=1.9; 95% CI, 0.91 to 4.1). The lowest EIN was observed for low fitness (3.8; 95% CI, 3.4 to 4.3, P<.001), followed by diabetes, smoking, hypertension, and physical inactivity (all P<.001 except for diabetes, P=.008).

CONCLUSION

Both higher CRF and physical activity provide protection against all-cause mortality in subjects referred for exercise testing for clinical reasons. Encouraging physical activity with the aim of increasing CRF would have a significant impact on reducing mortality.

Intraincisional medical grade honey decreases the prevalence of incisional infection in horses undergoing colic surgery: A prospective randomised controlled study

BACKGROUND

Medical grade honey has previously been described as a prophylactic treatment for wounds. Local prophylactic treatment may be valuable in preventing post-operative incisional infections in horses undergoing colic surgery but has not been evaluated.

OBJECTIVES

To establish whether medical grade honey gel, applied on the linea alba intraoperatively, decreases the prevalence of incisional infections in horses undergoing colic surgery with no associated adverse effects.

STUDY DESIGN

Prospective blinded randomised controlled clinical study.

METHODS

Horses older than 4 months that underwent colic surgery between May 2017 and December 2018 and survived for >2 weeks were included in the study. Horses were allocated 1:1 to treatment or control by block randomisation. In the treatment group, following closure of the linea alba, medical grade honey gel (L-Mesitran Soft^® ) was placed in the incision followed by apposition of subcutaneous tissue and skin. Information regarding the incision and post-operative complications was obtained at five time points (24 hours, 48 hours, 5 days, 14 days and 3 months).

RESULTS

Eighty-nine horses were included in the study. No adverse effects associated with treatment were observed. Horses in the treatment group had a lower rate of incisional infection compared with the control group (8.2% vs. 32.5%, P = .02). The protective effect of MGH had a calculated adjusted odds ratio (OR) of 0.2 (95% CI:0.07-0.8, P = .03). The number of patients required to receive treatment to prevent one case of incisional infection (NNEB) was 4.7. Risk factors associated with infection included: younger age (OR = 27, 95% CI: 2.3 to 306, P = .008) and diarrhoea 48 hours post-operatively (OR = 20, 95% CI: 1.5 to 277, P = .02).

MAIN LIMITATIONS

Follow-up was performed by different veterinary surgeons, hence not completely uniform.

CONCLUSION

Local prophylactic treatment with medical grade honey gel in the abdominal incision during surgery is safe and may significantly decrease the prevalence of incisional infections in horses undergoing colic surgery.

Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis

STUDY DESIGN

Longitudinal analysis of prospectively collected data.

OBJECTIVE

Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection.

METHODS

We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability).

RESULTS

Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination.

CONCLUSION

Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS.

LEVEL OF EVIDENCE

2.

Risk of severe hypoglycemic events from amiodarone-sulfonylureas interactions: A population-based nested case-control study

PURPOSE

To evaluate whether concomitant use of amiodarone and sulfonylureas is associated with an increased risk of serious hypoglycemia.

METHODS

We conducted two nested case-control studies by analyzing the Taiwan National Health Insurance Research Database from 2008 to 2013 among diabetic patients continuously receiving sulfonylureas. Cases were defined as patients with severe hypoglycemia and those with a composite outcome of severe hypoglycemia, altered consciousness, and fall-related fracture in the first and second study, respectively. In both studies, each case was individually matched up to 10 randomly-selected controls. Conditional logistic regressions were employed to estimate odds ratios (ORs).

RESULTS

We identified 1343 cases and 11 597 controls as well as 2848 cases of composite events and 24 808 controls among 46 317 sulfonylurea users. Concurrent use of amiodarone with sulfonylureas was associated with a 1.56-fold (95% CI: 0.98-2.46) increased risk of severe hypoglycemia, despite not statistically significant. Notably, an approximately 2-fold increased risk of severe hypoglycemia was observed with amiodarone therapy lasting for >180 days (adjusted OR: 2.08; 95% CI: 1.01-4.30) or at a daily dose greater than 1 defined daily dose (adjusted OR: 2.21; 95% CI: 1.25-3.91) when concurrently administrating sulfonylureas. A significantly increased risk of hypoglycemia-related composite events was also found with amiodarone concurrently used with sulfonylureas (adjusted OR: 1.59; 95% CI: 1.13-2.24).

CONCLUSIONS

Concurrent use of amiodarone and sulfonylureas is associated with an increased risk of serious hypoglycemia among diabetic patients, with an elevated risk for amiodarone used in a long-term or at a high daily dose.

Having a baby in your 40s with assisted reproductive technology: The reproductive dilemma of autologous versus donor oocytes

BACKGROUND

Increasing numbers of women ≥40 years old are accessing assisted reproductive technology (ART) due to age-related infertility. There is limited population-based evidence about the impact on the cumulative live birth rate (CLBR) of women aged ≥40 years using their own oocytes, compared to women of a similar age, using donor oocytes.

AIMS

To compare the CLBR for women ≥40 years undergoing ART using autologous oocytes and women of similar age using donor oocytes.

MATERIALS AND METHODS

This population-based retrospective cohort study used data from all women aged ≥40 years undergoing ART with donated (n = 987) or autologous oocytes (n = 19 170) in Victoria, Australia between 2009 and 2016. A discrete-time survival model was used to evaluate the CLBR following ART with donor or autologous oocytes. The odds ratio, adjusted for woman's age; male age; parity; cause of infertility; and the associated 95% confidence intervals (CI), were calculated. The numbers needed to be exposed (NNEs) were calculated from the adjusted odds ratio (aOR) and the CLBR in the autologous group.

RESULTS

The CLBR ranged from 28.6 to 42.5% in the donor group and from 12.5% to 1.4% in the autologous group. The discrete-time survival analysis with 95% CI demonstrated significant aOR on CLBR across all ages (range aOR: 2.56, 95% CI: 1.62-4.01 to aOR: 15.40, 95% CI: 9.10-26.04).

CONCLUSIONS

Women aged ≥40 years, using donor oocytes had a significantly higher CLBR than women using autologous oocytes. The findings can be used when counselling women ≥40 years about their ART treatment options and to inform public policy.

Cardiorespiratory fitness and cancer in men with cardiovascular disease: Analysis from the Veterans Exercise Testing Study

Background

Cardiovascular disease and cancer share similar risk factors and are the leading causes of death worldwide. This study aimed to assess the association between cardiorespiratory fitness, cancer incidence and cancer mortality in men with cardiovascular disease.

Methods

Baseline cardiorespiratory fitness (treadmill exercise test) was assessed in 565 men aged 58.9 ± 17 with documented cardiovascular disease and free from any malignancy. Cox multivariable hazard models, population attributable fraction and exposure impact number were analyzed in model accounting for competing events for cancer outcomes.

Results

Mean cardiorespiratory fitness was 7.6 ± 3.4 metabolic equivalents. During a 12.0 ± 7.5 year follow-up, 147 participants developed any type of cancer, 70 died from cancer, and five died from causes other than cancer as competing events. Compared to low cardiorespiratory fitness (&lt;5 metabolic equivalents), moderate (5–10 metabolic equivalents) and high cardiorespiratory fitness (&gt;10 metabolic equivalents) were associated with 50% (0.50, 95% confidence interval (0.27–0.91)) and 68% (0.32 (0.11–0.88)) reduced risks for cancer mortality (p trend = 0.026), respectively. Survival time was longer among individuals with moderate (20.8 (19.7–22) years) and high (24.9 (23–26.7) years) compared to low cardiorespiratory fitness (17.2 (15.1–19.3) years), p &lt; 0.001. Population attributable fraction and exposure impact number for cancer mortality were 13% (4.1–17.7) and 10.8 (5.1–56.4), p = 0.01, respectively. Cardiorespiratory fitness was not associated with cancer incidence.

Conclusion

Higher cardiorespiratory fitness was independently associated with lower risk of cancer mortality and extended survival time in men with cardiovascular disease, although it was not associated with cancer incidence. Improving cardiorespiratory fitness through supervised exercise rehabilitation programs could potentially serve as a cost-effective public-health strategy for secondary prevention and survivorship in men with cardiovascular disease.

Prognostic significance of early urinary catheterization after acute stroke: Secondary analyses of the international HeadPoST trial

BACKGROUND

An indwelling urinary catheter (IUC) is often inserted to manage bladder dysfunction, but its impact on prognosis is uncertain. We aimed to determine the association of IUC use on clinical outcomes after acute stroke in the international, multi-center, cluster crossover, Head Positioning in Acute Stroke Trial (HeadPoST).

METHODS

Data were analyzed on HeadPoST participants (n = 11,093) randomly allocated to the lying-flat or sitting-up head position. Binomial, logistic regression, hierarchical mixed models were used to determine associations of early insertion of IUC within seven days post-randomization and outcomes of death or disability (defined as "poor outcome," scores 3-6 on the modified Rankin scale) and any urinary tract infection at 90 days with adjustment of baseline and post-randomization management covariates.

RESULTS

Overall, 1167 (12%) patients had an IUC, but the frequency and duration of use varied widely across patients in different regions. IUC use was more frequent in older patients, and those with vascular comorbidity, greater initial neurological impairment (on the National Institutes of Health Stroke Scale), and intracerebral hemorrhage as the underlying stroke type. IUC use was independently associated with poor outcome (adjusted odds ratio (aOR): 1.40, 95% confidence interval (CI): 1.13-1.74), but not with urinary tract infection after adjustment for antibiotic treatment and stroke severity at hospital separation (aOR: 1.13, 95% CI: 0.59-2.18). The number exposed to IUC for poor outcome was 13.

CONCLUSIONS

IUC use is associated with a poor outcome after acute stroke. Further studies are required to inform appropriate use of IUC.

Cardiorespiratory fitness and cancer in women: A prospective pilot study

PURPOSE

To assess the association between cardiorespiratory fitness (CRF) and the incidence and mortality from cancer in women, and to evaluate the potential public health implications for cancer prevention.

METHODS

Maximal exercise testing was performed in a pilot cohort of 184 women (59.3 ± 15.2 years) who were followed for 12.0 ± 6.9 years. Cox hazard models adjusted for established cancer risk factors and accounting for competing events were analyzed for all-type cancer incidence and mortality from cancer. Population-attributable risks and exposure impact number were determined for low CRF (<5 metabolic equivalents (METs)) as a risk factor.

RESULTS

During the follow-up, 11.4% of the participants were diagnosed with cancer and 3.2% died from cancer. CRF was inversely and independently associated with cancer outcomes. For every 1-metabolic equivalent increase in CRF, there was a 20% decrease in the risk of cancer incidence (hazard ratio (HR) = 0.80, 95% confidence interval (CI): 0.69-0.92; p = 0.001) and a 26% reduction in risk of cancer mortality (HR = 0.74, 95%CI: 0.61-0.90; p = 0.002). The population-attributable risks of low CRF were 11.6% and 14% for incidence and mortality of cancer, respectively, and the respective exposure impact numbers were 8 and 20.

CONCLUSION

Greater CRF was independently associated with a lower risk of incidence and mortality from cancer in women. Screening for low CRF as a cancer risk factor and referring unfit individuals to a supervised exercise program could be a public health strategy for cancer prevention in middle-age women.

Association of Maternal Age With Severe Maternal Morbidity and Mortality in Canada

IMPORTANCE

Over the past 2 decades, there has been a trend toward increasing maternal age in many high-income countries. Maternal age may lead to greater attendant morbidity and mortality for Canadian mothers.

OBJECTIVE

To investigate the association of maternal age, adjusting for patient-level and hospital-level factors, with severe maternal morbidity (SMM) and maternal death in Canada.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide population-based cohort study of all antepartum, peripartum, and postpartum women and adolescents seen at Canadian acute care hospitals from April 1, 2004, to March 31, 2015. All analyses were completed on September 13, 2018.

EXPOSURES

Maternal age at the index delivery.

MAIN OUTCOMES AND MEASURES

Severe maternal morbidity and maternal death during pregnancy and within 6 weeks after termination of pregnancy.

RESULTS

During the study period, there were 3 162 303 new pregnancies (mean [SD] maternal age, 29.5 [5.6] years) and 3 533 259 related hospital admissions. There were 54 219 episodes of SMM (17.7 cases per 1000 deliveries) in the entire study period, with a 9.8% relative increase from 2004-2005 to 2014-2015, in addition to an increasing proportion of pregnancies to older mothers. Independent patient-level factors associated with SMM included increasing Maternal Comorbidity Index; maternal age 19 years or younger and 30 years or older, with the greatest risk experienced by women 45 years or older (odds ratio [OR], 2.69; 95% CI, 2.34-3.06 compared with maternal age 20-24 years); and lowest income quintile (OR, 1.19; 95% CI, 1.14-1.22 compared with highest income quintile). Hospital-level factors associated with SMM included specific provinces. Independent patient-level factors associated with maternal mortality included increasing Maternal Comorbidity Index, age 40 to 44 years (OR, 3.39; 95% CI, 1.68-6.82 compared with age 20-24 years), age 45 years or older (OR, 4.39; 95% CI, 1.01-19.10 compared with age 20-24 years), and lowest income quintile (OR, 4.14; 95% CI, 2.03-8.50 compared with highest income quintile). Hospital-level factors associated with maternal mortality included lowest hospital pregnancy volume.

CONCLUSIONS AND RELEVANCE

In Canada, maternal age and SMM have increased over the past decade. Results of this study suggest that province of residence, maternal comorbidity, residence income quintile, and extremes of maternal age, especially those 45 years or older, were associated with SMM and mortality. These findings are relevant to prospective parents, their health care team, and public health planning.

Association of Adding Aspirin to Warfarin Therapy Without an Apparent Indication With Bleeding and Other Adverse Events

IMPORTANCE

It is not clear how often patients receive aspirin (acetylsalicylic acid) while receiving oral anticoagulation with warfarin sodium without a clear therapeutic indication for aspirin, such as a mechanical heart valve replacement, recent percutaneous coronary intervention, or acute coronary syndrome. The clinical outcomes of such patients treated with warfarin and aspirin therapy compared with warfarin monotherapy are not well defined to date.

OBJECTIVE

To evaluate the frequency and outcomes of adding aspirin to warfarin for patients without a clear therapeutic indication for combination therapy.

DESIGN, SETTING, AND PARTICIPANTS

A registry-based cohort study of adults enrolled at 6 anticoagulation clinics in Michigan (January 1, 2010, to December 31, 2017) who were receiving warfarin therapy for atrial fibrillation or venous thromboembolism without documentation of a recent myocardial infarction or history of valve replacement.

EXPOSURE

Aspirin use without therapeutic indication.

MAIN OUTCOMES AND MEASURES

Rates of any bleeding, major bleeding events, emergency department visits, hospitalizations, and thrombotic events at 1, 2, and 3 years.

RESULTS

Of the study cohort of 6539 patients (3326 men [50.9%]; mean [SD] age, 66.1 [15.5] years), 2453 patients (37.5%) without a clear therapeutic indication for aspirin were receiving combination warfarin and aspirin therapy. Data from 2 propensity score-matched cohorts of 1844 patients were analyzed (warfarin and aspirin vs warfarin only). At 1 year, patients receiving combination warfarin and aspirin compared with those receiving warfarin only had higher rates of overall bleeding (cumulative incidence, 26.0%; 95% CI, 23.8%-28.3% vs 20.3%; 95% CI, 18.3%-22.3%; P < .001), major bleeding (5.7%; 95% CI, 4.6%-7.1% vs 3.3%; 95% CI, 2.4%-4.3%; P < .001), emergency department visits for bleeding (13.3%; 95% CI, 11.6%-15.1% vs 9.8%; 95% CI, 8.4%-11.4%; P = .001), and hospitalizations for bleeding (8.1%; 6.8%-9.6% vs 5.2%; 4.1%-6.4%; P = .001). Rates of thrombosis were similar, with a 1-year cumulative incidence of 2.3% (95% CI, 1.6%-3.1%) for those receiving combination warfarin and aspirin therapy compared with 2.7% (95% CI, 2.0%-3.6%) for those receiving warfarin alone (P = .40). Similar findings persisted during 3 years of follow-up as well as in sensitivity analyses.

CONCLUSIONS AND RELEVANCE

Compared with warfarin monotherapy, receipt of combination warfarin and aspirin therapy was associated with increased bleeding and similar observed rates of thrombosis. Further research is needed to better stratify which patients may benefit from aspirin while anticoagulated with warfarin for atrial fibrillation or venous thromboembolism; clinicians should be judicious in selecting patients for combination therapy.

Caffeine exposure and acute kidney injury in premature infants with necrotizing enterocolitis and spontaneous intestinal perforation

BACKGROUND

Acute kidney injury (AKI) is common in preterm infants, but specific therapies remain scarce. Recent studies have demonstrated an association between caffeine exposure and less frequent AKI in the first 7-10 days after birth. We hypothesized that patients with necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) would provide a better natural model of AKI to evaluate this association.

METHODS

We reviewed all premature patients diagnosed with NEC or SIP at our institution from 2008 to 2014. AKI was defined by change in serum creatinine using the neonatal Kidney Disease: Improving Global Outcomes definition. Caffeine was prescribed for apnea of prematurity and caffeine exposure was determined by chart review.

RESULTS

A total of 146 patients with NEC/SIP were reviewed. Of these, 119 (81.5%) received caffeine, and 91 (62.3%) developed AKI. AKI occurred less frequently in patients who received caffeine than in those who did not (55.5% vs. 92.6%; odds ratio (OR) 0.10; 95% confidence interval (CI) 0.02-0.44). This association persisted in multivariable models after adjustment for potential confounders (adjusted OR 0.08; 95% CI 0.01-0.42; number needed to be exposed to caffeine to prevent one case of AKI = 2.6). Although baseline serum creatinine did not differ by caffeine exposure, patients receiving caffeine had lower peak creatinine (median 1.0 mg/dl vs. 1.5 mg/dl; p = 0.008) and absolute creatinine change (median 0.42 mg/dl vs. 0.68 mg/dl; p = 0.003) than those who did not.

CONCLUSIONS

Caffeine exposure in preterm infants with NEC/SIP is associated with decreased incidence and severity of AKI.

Course and Contributors to Back Pain in Middle-aged Women Over 9 Years: Data From the Australian Longitudinal Study on Women's Health

STUDY DESIGN

Community-based, cohort study.

OBJECTIVE

Our aim was to determine the course of back pain in middle-aged women over a 9-year period, and assess whether obesity and physical inactivity are associated with more frequent back pain.

SUMMARY OF BACKGROUND DATA

Back pain is the leading cause of disability worldwide. With minimal effective therapies and rising financial burden, identifying modifiable risk factors remains a key priority.

METHODS

The Australian Longitudinal Study on Women's Health is a cohort study of community-based, middle-aged women who completed questionnaires every 3 years between 2004 and 2013. Approximately, 10,530 women completed the survey in 2004 (mean age 55.5 yrs), and 9020 completed follow-up 9 years later. Self-reported data on back pain in the last 12 months and other sociodemographic factors were collected at all four surveys. 'Frequent back pain' was defined as back pain reported at ≥ three surveys.

RESULTS

Back pain was common and persistent, with 48% having back pain in ≥ three out of four surveys. Baseline obesity (relative risk [RR] 1.18, 95% confidence interval [CI] 1.12-1.25), lack of vigorous physical activity (RR 1.17, 95% CI 1.10-1.25), depressive symptoms (RR 1.40, 95% CI 1.33-1.47), and low-education status (RR 1.17, 95% CI 1.12-1.24), were independently associated with an increased risk of frequent back pain (all P < 0.001). Overall, 28% of the risk of frequent back pain could be attributed to these factors, equating to one extra case of frequent back pain for every five women with depressive symptoms, for every 11 obese women, for every 12 women with low-education status, and for every 13 women who do not do vigorous physical activity, at baseline.

CONCLUSION

Obesity, depressive symptoms, low-education status, and lack of vigorous physical activity are associated with higher risk of frequent back pain over the following 9 years among women in their mid-50 s. Targeting these risk factors may lessen the burden of back pain.

LEVEL OF EVIDENCE

2.

Precancer diagnosis cardiorespiratory fitness, physical activity and cancer mortality in men

BACKGROUND

The preventive role of precancer diagnosis cardiorespiratory fitness (CRF) and physical activity (PA) in cancer mortality is poorly characterized. The aim of this study was to assess the association between CRF, PA at precancer-diagnosis and cancer mortality in men who diagnosed with cancer later in life.

METHODS

A total of 699 men (63±10 years) who were diagnosed with cancer during 7.5±4.9 years from a baseline treadmill exercise test and reported PA were analyzed. Multivariate Cox models for CRF and univariate model for PA were conducted. Population Attributable Risks (PARs%) and exposure impact number (EIN) of low CRF (<5 METs) and inactivity were determined.

RESULTS

During 6.5±5.2 years from cancer diagnosis, 56% died from cancer. CRF was inversely, graded and independently associated with cancer death. A 1-MET increase and categories of moderate and high CRF were associated with 7%, 28% and 51% reductions in risk of cancer death, respectively. Active compared to inactive individuals had a 23% reduced risk of cancer mortality (HR=0.77, 95% CI [0.63-0.94], P=0.01). PARs% of low CRF and inactivity were 4.8% and 9.4%, respectively, while the respective EIN were 3 and 9.

CONCLUSIONS

Higher CRF and being active at precancer-diagnosis were associated with lower cancer mortality and longer survival time in men who developed cancer later in life. Screening and intervening for low CRF and inactivity as risk factors during middle-age and maintaining at least moderate CRF and activity levels may be effective strategies for prevention of cancer mortality.

Association of Statin Use with Increased Risk of Musculoskeletal Conditions: A Retrospective Cohort Study

INTRODUCTION

Musculoskeletal conditions, including osteoarthritis (OA), result in tremendous disability and cost. Statins are among the most commonly prescribed medications and their use for primary prevention in many otherwise healthy individuals, including those who are physically active, is increasing. There is conflicting evidence regarding the relationship of statin use and musculoskeletal conditions. Given the rising disability associated with musculoskeletal conditions, understanding predisposing factors, including medication-related exposures, deserves further attention.

OBJECTIVES

We examined the association between statin use and the risk of being diagnosed with non-traumatic arthropathies, use-related injury, and undergoing rehabilitation in a cohort with longitudinal follow-up.

METHODS

Patients enrolled in a regional military healthcare system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match statin-users and nonusers using 115 baseline characteristics. Outcomes included ICD-9 diagnoses codes for Agency for Healthcare Research and Quality disease categories of: non-traumatic arthropathies, use-related injury and undergoing rehabilitation. Primary analysis examined the outcomes in statin-users and nonusers after propensity score matching using conditional logistic regression analysis.

RESULTS

Initially, 60,455 patients were identified. We propensity score-matched 6728 statin users with 6728 nonusers (52 years of age, ~ 47% women). In the propensity score-matched cohort, non-traumatic arthropathies occurred in 59.8% of statin users and 56.0% of nonusers [odds ratio (OR) 1.17, 95% confidence interval (95% CI) 1.09-1.25] and use related injury occurred in 31.9% of statin users and 29.8% of nonusers (OR 1.11, 95% CI 1.03-1.19). There was no difference between statin users and nonusers undergoing rehabilitation (22.6% among statin users, 21.9% among nonusers, OR 1.04, 95% CI 0.96-1.13).

CONCLUSION

Statin use was associated with a significant increased risk of non-traumatic arthropathies and use-related injury. Our results provide additional data that can inform patient and clinician conversations about the benefits and risks of statin use.

Risk of Severe Cardiovascular Events From Add-On Tiotropium in Chronic Obstructive Pulmonary Disease

OBJECTIVE

To examine the risk of cardiovascular disease (CVD) from tiotropium added to inhaled long-acting β₂ agonists (LABAs) and inhaled corticosteroids (ICSs) in a nationwide population with chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

This nested case-control study included 65,966 patients with COPD treated with LABAs and ICSs identified from the Taiwan nationwide health care claims database from January 1, 2007, through June 30, 2011. Cases were all patients with a first primary diagnosis of ischemic heart disease, heart failure, stroke, or arrhythmia from inpatient or emergency care settings during follow-up, and each was matched with 4 disease risk score-matched controls from risk sets. The use of tiotropium in the year before the index/event date was measured, stratified by duration since therapy initiation, concomitant COPD medications, and dosage form. Conditional logistic regression models were used to estimate odds ratios of the CVD risk from add-on tiotropium therapy.

RESULTS

From the study cohort, with a mean age of 70.3 years (interquartile range, 61.8-79.4 years), 3188 CVD cases (incidence rate, 6.2 [95% CI, 6.0-6.4] cases per 100 person-years) and 12,349 matched controls were identified. The new use of tiotropium was associated with a 1.88-fold (95% CI, 1.44-2.46) increased CVD risk within 30 days of therapy initiation, and the association was sustained up to 60 days after treatment initiation (adjusted odds ratio, 1.71; 95% CI, 1.08-2.70). The risk persisted across all tiotropium regimens, with a case-crossover analysis, and in comparison with new add-on theophylline therapy.

CONCLUSION

Tiotropium newly added to LABA/ICS combination therapy was associated with an increased cardiovascular risk in patients with COPD.

Association Between Early Caffeine Citrate Administration and Risk of Acute Kidney Injury in Preterm Neonates: Results From the AWAKEN Study

Importance

Acute kidney injury (AKI) occurs commonly in preterm neonates and is associated with increased morbidity and mortality.

Objectives

To examine the association between caffeine citrate administration and AKI in preterm neonates in the first 7 days after birth and to test the hypothesis that caffeine administration would be associated with reduced incidence and severity of AKI.

Design, Setting, and Participants

This study was a secondary analysis of the Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study, a retrospective observational cohort that enrolled neonates born from January 1 to March 31, 2014. The dates of analysis were October 2016 to December 2017. The setting was an international, multicenter cohort study of neonates admitted to 24 participating level III or IV neonatal intensive care units. Participants met the original inclusion and exclusion criteria of the AWAKEN study. Additional exclusion criteria for this study included participants greater than or equal to 33 weeks' gestation at birth, admission after age 7 days, use of theophylline in the neonatal intensive care unit, or lack of data to define AKI. There were 675 preterm neonates available for analysis.

Exposure

Administration of caffeine in the first 7 days after birth.

Main Outcomes and Measures

The primary outcome was the incidence of AKI (based on the modified neonatal Kidney Disease: Improving Global Outcomes [KDIGO] definition) in the first 7 days after birth. The hypothesis that caffeine administration would be associated with reduced AKI incidence was formulated before data analysis.

Results

The study cohort (n = 675) was 55.4% (n = 374) male, with a mean (SD) gestational age of 28.9 (2.8) weeks and a mean (SD) birth weight of 1285 (477) g. Acute kidney injury occurred in 122 neonates (18.1%) in the first 7 days after birth. Acute kidney injury occurred less frequently among neonates who received caffeine than among those who did not (50 of 447 [11.2%] vs 72 of 228 [31.6%], P < .01). After multivariable adjustment, administration of caffeine remained associated with reduced odds of developing AKI (adjusted odds ratio, 0.20; 95% CI, 0.11-0.34), indicating that for every 4.3 neonates exposed to caffeine one case of AKI was prevented. Among neonates with early AKI, those receiving caffeine were less likely to develop stage 2 or 3 AKI (adjusted odds ratio, 0.20; 95% CI, 0.12-0.34).

Conclusions and Relevance

Caffeine administration in preterm neonates is associated with reduced incidence and severity of AKI. Further studies should focus on the timing and dosage of caffeine to optimize the prevention of AKI.

Statins for primary prevention and rhabdomyolysis: A nationwide cohort study in France

AIMS

The purpose of this study was to investigate the risk of rhabdomyolysis in subjects initiating statin therapy for primary prevention of cardiovascular disease, focusing on the type of statin, dose and time since initiation.

METHODS AND RESULTS

A nationwide cohort study using French hospital discharge and claims databases was performed, studying subjects from the general population 40-75 years in 2009, with no history of cardiovascular disease and no lipid-lowering drugs during the preceding three-year period, followed for up to seven years. The primary outcome was hospitalization for rhabdomyolysis. Event-free survival analysis and case-time-control analysis were both performed, separately by gender. The cohort included 8,236,667 subjects, 969,460 of whom initiated a lipid-lowering drug for cardiovascular disease primary prevention. During 18,407,391 person-months exposed to statins, 168 events were observed, corresponding to an incidence of rhabdomyolysis of 1.10 per 10,000 person-years (1.54 in men vs 0.81 in women); 10/168 cases were fatal, and 18/168 and 57/168 cases occurred during the first month and first trimester of treatment, respectively. Survival analysis did not reveal any increased overall risk (hazard ratio = 1.02 (0.83-1.25) in men and 0.76 (0.60-0.96) in women). However, exposure to high-potency statins was associated with an increased risk in men (hazard ratio = 1.93 (1.27-2.94)). Rosuvastatin 20 mg (in men and women) and simvastatin 40 mg (in men) were associated with hazard ratios > 5. Case-time-control analyses showed similar patterns of risk. Drug interactions did not appear to significantly contribute to rhabdomyolysis events in this study.

CONCLUSION

Although the overall risk of statin-associated rhabdomyolysis in the context of primary prevention was not increased, the first months of treatment and the use of high-potency statins represent at-risk situations, which require appropriate monitoring, especially in men.

Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study

Purpose

Chlorhexidine oral care is widely used in critically and non-critically ill hospitalized patients to maintain oral health. We investigated the effect of chlorhexidine oral care on mortality in a general hospitalized population.

Methods

In this single-center, retrospective, hospital-wide, observational cohort study we included adult hospitalized patients (2012–2014). Mortality associated with chlorhexidine oral care was assessed by logistic regression analysis. A threshold cumulative dose of 300 mg served as a dichotomic proxy for chlorhexidine exposure. We adjusted for demographics, diagnostic category, and risk of mortality expressed in four categories (minor, moderate, major, and extreme).

Results

The study cohort included 82,274 patients of which 11,133 (14%) received chlorhexidine oral care. Low-level exposure to chlorhexidine oral care (≤ 300 mg) was associated with increased risk of death [odds ratio (OR) 2.61; 95% confidence interval (CI) 2.32–2.92]. This association was stronger among patients with a lower risk of death: OR 5.50 (95% CI 4.51–6.71) with minor/moderate risk, OR 2.33 (95% CI 1.96–2.78) with a major risk, and a not significant OR 1.13 (95% CI 0.90–1.41) with an extreme risk of mortality. Similar observations were made for high-level exposure (> 300 mg). No harmful effect was observed in ventilated and non-ventilated ICU patients. Increased risk of death was observed in patients who did not receive mechanical ventilation and were not admitted to ICUs. The adjusted number of patients needed to be exposed to result in one additional fatality case was 47.1 (95% CI 45.2–49.1).

Conclusions

These data argue against the indiscriminate widespread use of chlorhexidine oral care in hospitalized patients, in the absence of proven benefit in specific populations.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5171-3) contains supplementary material, which is available to authorized users.

Association of Childhood Irritability and Depressive/Anxious Mood Profiles With Adolescent Suicidal Ideation and Attempts

IMPORTANCE

Suicidal ideation and suicide attempt (suicidality) are common in adolescence and a public health concern. Childhood depression is a key risk factor for later suicidality and often co-occurs with irritability. No study to date has examined the joint association of depressive mood and irritability during childhood with later suicidality.

OBJECTIVE

To investigate the association of childhood irritability and depressive/anxious mood profiles with adolescent suicidality.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included 1430 participants in the Québec Longitudinal Study of Child Development. Participants underwent assessment yearly or bi-yearly (5 months to 17 years). Data were collected from March 16, 1998, through July 17, 2015.

EXPOSURES

Profiles defined by the joint developmental trajectories of irritability and depressive/anxious mood at 6 to 12 years of age.

MAIN OUTCOMES AND MEASURES

Self-reported past-year suicidality (ie, serious suicidal ideation or suicide attempt) at 13, 15, and 17 years of age. Irritability and depressive/anxious mood were assessed using teacher report 5 times from 6 to 12 years of age.

RESULTS

The study included 1430 participants (676 boys [47.3%] and 754 girls [52.7%]) followed up to 17 years of age. Group-based multitrajectory modeling identified the following profiles: combined no irritability and low depressive/anxious mood with low irritability and low depressive/anxious mood (831 [58.1%]; reference group), moderate irritability and low depressive/anxious mood (353 [24.7%]), high depressive/anxious mood only (94 [6.6%]), and high irritability and depressive/anxious mood (152 [10.6%]). Children with high irritability and high depressive/anxious mood reported higher rates of suicidality (25 of 152 [16.4%]) compared with the group with the lowest symptom levels (91 of 831 [11.0%]). In logistic regression analyses, the high irritability and depressive/anxious mood profile (odds ratio [OR], 2.22; 95% CI, 1.32-3.74; number needed to be exposed [NNE], 18) was associated with suicidality. To a lesser extent, the moderate irritability and low depressive/anxious mood profile was also associated with suicidality (OR, 1.51; 95% CI, 1.02-2.25; NNE = 48). The high depressive/anxious mood only profile was not associated with later suicidality (OR, 0.96; 95% CI, 0.47-1.95; NNE = -320). The high irritability and depressive/anxious mood profile was associated with a higher suicidal risk compared with the depressive/anxious mood only profile (OR, 2.28; 95% CI, 1.02-5.15). Girls with the high irritability and high depressive/anxious mood profile had higher risk for suicidality (OR, 3.07; 95% CI, 1.54-6.12; NNE = 5).

CONCLUSIONS AND RELEVANCE

Children with high irritability and depressive/anxious mood and, to a lesser extent, with moderate irritability only had a higher suicidal risk during adolescence compared with children with low symptom levels. Early manifestation of chronic irritability during childhood, especially when combined with depressive/anxious mood, may be associated with an elevated risk for adolescent suicidality. The putatively causal role of irritability should be investigated.

Association of Cardiovascular Risk With Inhaled Long-Acting Bronchodilators in Patients With Chronic Obstructive Pulmonary Disease: A Nested Case-Control Study

IMPORTANCE

The associations between cardiovascular disease (CVD) and inhaled long-acting β2-agonists (LABAs) or long-acting antimuscarinic antagonists (LAMAs) in chronic obstructive pulmonary disease (COPD) are greatly debated. Pivotal and relevant randomized clinical trials included prior LABA or LAMA users and excluded patients with baseline CVD; therefore, cardiovascular events arising from first-time LABA or LAMA use, if any, could not be observed. There is an urgent need to examine whether new use of and duration since initiating LABAs and LAMAs could act as important determinants of cardiovascular events.

OBJECTIVE

To investigate risk of CVD associated with LABAs and LAMAs, focusing on the initiation and duration of LABA and LAMA therapies.

DESIGN, SETTING, AND PARTICIPANTS

This nested case-control study included 284 220 LABA-LAMA-naïve patients with COPD at least 40 years old (mean age, 71.4 years; 68.9% men), retrieved from the Taiwan National Health Insurance Research Database for health care claims from 2007 to 2011.

EXPOSURE

LABA or LAMA use was measured in the year preceding the event or index date, stratified by duration since initiation of LABA or LAMA treatment, new and prevalent users, concomitant COPD medications, and individual agents.

MAIN OUTCOMES AND MEASURES

Cases with inpatient or emergency care visits for coronary artery disease, heart failure, ischemic stroke, or arrhythmia were identified and individually matched to 4 randomly selected controls. Conditional logistic regressions were performed to estimate odds ratios of CVD from LABA and LAMA treatment.

RESULTS

During a mean follow-up of 2.0 years, 37 719 patients with CVD (mean age, 75.6 years; 71.6% men) and 146 139 matched controls (mean age, 75.2 years; 70.1% men) were identified. New LABA and LAMA use in COPD was associated with a 1.50-fold (95% CI, 1.35-1.67; P < .001) and a 1.52-fold (95% CI, 1.28-1.80; P < .001) increased cardiovascular risk within 30 days of initiation, respectively, whereas the risk was absent, or even reduced with prevalent use. Individual LABA agents, LAMA dosage forms, and concomitant COPD regimens did not differ in the CVD risks. The risk persisted in an alternative case-crossover study and remained across subgroups without CVD history or prior exacerbations.

CONCLUSIONS AND RELEVANCE

New initiation of LABAs or LAMAs in patients with COPD is associated with an approximate 1.5-fold increased severe cardiovascular risk, irrespective of prior CVD status and history of exacerbations.

Temporal trends in renal function and birthweight in Japanese adolescent males (1998-2015)

Background

Low birthweight (LBW) is a worldwide public health problem, demonstrating an increasing incidence in developed countries, including Japan. LBW is also a risk factor for later development of chronic kidney disease (CKD). To date, studies have not evaluated the population impacts of increasing LBW rates on renal function.

Methods

Estimated glomerular filtration rate (eGFR) was evaluated in 3737 Japanese adolescent males (15–16 years old) using annual cross-sectional data over an 18-year period (1998–2015).

Results

Between the initial (1998–2003) and final (2010–15) periods of the study, the mean birthweight decreased from 3213.4 ± 383.8 to 3116.2 ± 382.3 g and the LBW rate increased from 2.5 to 5.5% (both P ≤ 0.01). Additionally, the mean eGFR decreased from 105.1 ± 15.9 to 97.4 ± 13.8 mL/min/1.73 m² and the prevalence of mildly reduced renal function (eGFR ≤ 60– <90 mL/min/1.73 m²) increased from 16.4 to 30.0% (both P ≤ 0.01), most evident in the LBW group (from 10.3 to 41.7%, P ≤0.01). The prevalence of proteinuria also increased significantly. Mildly reduced renal function was significantly associated with LBW [odds ratio (LBW 3000–3999 g) 1.51; 95% confidence interval 1.00–2.55; P = 0.047].

Conclusions

In this population of Japanese adolescents, the frequency of mildly reduced renal function increased as the LBW frequency increased. Our findings may have implications for the broader Japanese population as well as for other populations in which the prevalence of LBW is increasing.

Do Statins Increase the Risk of Esophageal Conditions? Findings from Four Propensity Score-Matched Analyses

BACKGROUND AND OBJECTIVE

Statins are commonly used medications. Whereas some observational studies suggested an association of statin use with Barrett's esophagus and some upper gastrointestinal symptoms, there is a dearth of data on the association of statins and common esophageal conditions such as gastroesophageal reflux disease and esophagitis. The aim of this study is to examine the association of statins with esophageal conditions.

METHODS

This is a retrospective cohort study using regional military healthcare data (1 October, 2003 to 1 March, 2012). The primary analyses evaluated the odds of: esophagitis; symptoms of esophagitis; gastroesophageal reflux disease/dyspepsia; and esophageal complications of gastroesophageal reflux disease in four propensity score-matched cohorts of statin users and non-users (propensity score-overall, propensity score-healthy, propensity score-women, and propensity score-men cohorts). Secondary and sensitivity analyses were performed.

RESULTS

In the propensity score-overall cohort (n = 12,684), statin users were more likely to be diagnosed with esophagitis (odds ratio 1.11, 95% confidence interval 1.01-1.22) and gastroesophageal reflux disease/dyspepsia (odds ratio 1.18, 95% confidence interval 1.10-1.27) compared with non-users. Similar findings were seen in the propensity score-healthy cohort and in the propensity score-men cohort. In the propensity score-women cohort, the odds of esophagitis was higher among statin users compared with non-users (odds ratio 1.16, 95% confidence interval 1.02-1.32) but other outcomes were not different. In sensitivity analyses, which excluded patients with obesity, statin use was not associated with an increased odds ratio of gastroesophageal reflux disease/dyspepsia.

CONCLUSION

Statin therapy was associated with higher odds of being diagnosed with esophagitis and gastroesophageal reflux disease/dyspepsia. Further study is warranted to elucidate the potential role of statins in these commonly diagnosed esophageal conditions.