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On The Pulse - December 2019

On The Pulse

Tertius Lydgate

Friday, 27 December 2019

Opioid treatment during pregnancy
Risk for preterm birth and small for gestational age mainly linked to confounding factors

Many pregnant women experience pain during pregnancy, which can be treated with opioids. However, the consequences of using opioid medications to treat pain during pregnancy are unclear. A team of researchers writing in PLOS Medicine evaluated whether opioids used to treat pain during pregnancy increase the risk of two adverse birth outcomes, specifically preterm birth and foetal growth restriction. The results showed that the absolute risks of the outcomes were low following opioid analgesic treatment during pregnancy and suggested that observed associations between opioid analgesic treatment during pregnancy and the adverse birth outcomes were largely due to background factors rather than exposure to the medication itself. The authors stress the findings have important clinical implications as they could help doctors and patients better weigh the risks and benefits of opioid treatment during pregnancy.

Primary care-based opioid and pain review service
Health and wellbeing outcomes suggest a potential benefit

Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction. Researchers, writing in BJGP, invited 59 patients, out of which 34 enrolled in the service. A mixed-methods evaluation of the one-to-one service in two GP practices in England found that the median prescribed opioid dose reduced from 90 mg at baseline to 72 mg at follow-up; three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose. Following further service development, the authors conclude a randomised controlled trial to test this type of care pathway is warranted.

Prophylactic aspirin use
May reduce risk of mortality among older individuals

Aspirin use has been associated with reduced risk of cancer mortality, particularly of the colorectum. However, researchers writing in JAMA point out that aspirin efficacy may be influenced by biological characteristics, such as obesity and age. They therefore set out to investigate the association of aspirin use with risk of all-cause, any cancer, gastrointestinal (GI) cancer, and colorectal cancer (CRC) mortality among older adults and to perform an exploratory analysis of the association of aspirin use with mortality stratified by BMI. In this cohort study, which included a total of 146,152 individuals (mean age at baseline, 66.3 years; 74,742 women; 129,446 non-Hispanic white), aspirin use three or more times per week was associated with a reduction in all-cause, cancer, GI cancer and CRC mortality in older adults. This suggests prophylactic aspirin use may reduce risk of mortality among older individuals.

Diagnosis of pulmonary embolism
With d-dimer adjusted to clinical probability

Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP. Researchers, writing in The New England Journal of Medicine, performed a prospective study, including 2017 patients, in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for three months to detect venous thromboembolism. The results showed that a combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up.

The effects of canagliflozin on gout in type 2 diabetes
Reduced serum urate concentration and fewer events related to gout flare observed

Sodium glucose co-transporter 2 inhibitors have been shown to reduce serum urate concentration. The Canagliflozin Cardiovascular Assessment Study (CANVAS) Program integrated data from two similarly designed, randomised, double-blind, placebo-controlled trials (CANVAS and CANVAS-Renal) assessing the cardiovascular and renal safety of canagliflozin compared with placebo in patients with type 2 diabetes. In a post-hoc analysis, researchers, writing in The Lancet Rheumatology, aimed to investigate the effect of canagliflozin compared with placebo on gout in the CANVAS Program. Some 10,142 participants were included in analyses (mean age was 63 years, 36% female, mean serum urate concentration 348·9 μmol/L, and 5% had a history of gout). Mean follow-up was 3·6 years. The results show that compared with placebo, canagliflozin reduced serum urate concentration and also reduced events related to gout flare among patients with type 2 diabetes. The authors conclude a trial explicitly designed to test the effects of sodium glucose co-transporter 2 inhibition on gout is required to confirm these observations.

Up to two fifths of antibiotic prescriptions in US could be inappropriate
Findings have important implications for antibiotic stewardship, say researchers

Inappropriate antibiotic prescribing is a major public health problem. Studies examining the appropriateness of antibiotic prescribing rely on a documented indication in patients’ medical records. But these are not always required, leading to missing data and underestimates of antibiotic use. Researchers, writing in The BMJ set out to estimate how often antibiotics are prescribed without a documented indication in an ambulatory care settings in the United States, and what factors are associated with lack of documentation. Out of 28,332 visits analysed, 13% involved an antibiotic prescription and were included in the study. According to their criteria, 57% (around 74 million) antibiotic prescriptions were deemed appropriate, while 25% (around 32 million) were considered inappropriate, and 18% (around 24 million) lacked either an appropriate or inappropriate documented indication. As much as 43% of prescriptions in this analysis could therefore be potentially inappropriate. A linked editorial suggests a comprehensive coding system is central to effective antibiotic stewardship, and that, along with other strategies, it could help clinicians reflect on and refine their prescribing behaviour.

Iron therapy for preoperative anaemia
Insufficient evidence on whether iron therapy given before surgery prevents transfusions

Preoperative anaemia is common and occurs in 5% to 76% of patients preoperatively. A limited number of studies has investigated iron therapy for the treatment of preoperative anaemia. A Cochrane Review aimed to summarise the evidence for iron supplementation, both enteral and parenteral, for the management of preoperative anaemia. Six studies and a total of 372 participants were included. The review found that iron treatment did not reduce the risk of blood transfusion. However, there is currently insufficient evidence to say whether iron therapy given before surgery prevents transfusions. To date, too few studies involving too small a number of people have been undertaken, and it is not yet possible to obtain a reliable result for the effects of this treatment. The authors conclude higher quality studies are therefore required to determine the efficacy of iron therapy for the treatment of preoperative anaemia.

Breastfeeding and postpartum multiple sclerosis relapses
Breastfeeding appears to be protective but further studies needed

Multiple sclerosis (MS) relapses may be increased in the postpartum period, and whether breastfeeding is associated with reduction in the risk of postpartum relapses remains controversial. Researchers, writing in JAMA Neurology, therefore carried out a systematic review and meta-analysis of 24 studies, including 2,974 women. The results showed that there was a reduced rate of postpartum multiple sclerosis relapses in women who were breastfeeding compared with those who were not breastfeeding, with a stronger benefit of exclusive rather than non-exclusive breastfeeding. Compared with non-breastfeeding, breastfeeding was associated with a 43% lower rate of postpartum relapse, although the authors say it is not possible to exclude residual confounding. Breastfeeding therefore appears to be protective against postpartum multiple sclerosis relapses, however the authors point out that additional high-quality prospective studies appear to be needed.

Gait variability at multiple walking speeds
Has potential as an assessment tool for vestibular interventions

Understanding balance and gait deficits in vestibulopathy may help improve clinical care and our knowledge of the vestibular contributions to balance. Researchers writing in Scientific Reports, examined walking speed effects on gait variability in healthy adults and in adults with bilateral vestibulopathy (BVP). Forty-four people with BVP, 12 healthy young adults and 12 healthy older adults walked at 0.4 m/s to 1.6 m/s in 0.2 m/s increments on a dual belt, instrumented treadmill. Evaluations showed that walking speed significantly affected all gait parameters. Step length variability at slower speeds and step width variability at faster speeds were the most distinguishing parameters between the healthy participants and people with BVP, and among people with BVP with different locomotor capacities. Step width variability, specifically, indicated an apparent persistent importance of vestibular function at increasing speeds. Gait variability was not associated with the clinical vestibular tests. The researchers conclude the results indicate that gait variability at multiple walking speeds has potential as an assessment tool for vestibular interventions.

Author's Image

Tertius Lydgate

Originally from Northumberland, Tertius Lydgate studied medicine in Edinburgh, London and Paris. There he developed a special interest in communicable diseases and hoped to make great advances in treating and preventing them. But, after a promising start in a provincial centre of excellence in middle England, he was forced by circumstances (please, don't inquire) to abandon his high ideals. He now scrapes a living by pouring cold water on the over-enthusiastic at his private cryohydrotherapy clinic. Dreaming of the contributions he once hoped to make himself, he finds consolation in the latest medical journals and is happy to share his discoveries with his readers. He thinks that his creator, George Eliot, would have approved.
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