2 Minute Medicine Rewind December 26, 2022

Effects of a Smartphone-Based Self-Management Intervention for Individuals with Bipolar Disorder on Relapse, Symptom Burden, and Quality of Life: A Randomized Clinical Trial 

1. In patients with Bipolar Disorder Type 1, a smartphone-based self-management intervention decreased relapse risk in individuals in asymptomatic recovery but not in those with a higher relapse risk.

Evidence Rating Level: 1 (Excellent) 

Bipolar disorder, characterized by episodes of mania and depression, is a severe mental illness that causes significant disability even with appropriate pharmacological therapy. While evidence suggests that dual treatment with psychotherapy and pharmacotherapy is ideal in improving relapse risk and symptom burden, access to this is limited. Smart phone-based interventions provide a means for individuals to access self-management strategies derived from present bipolar disorder psychotherapy; however, the exact effect of this is unknown. In this randomized controlled trial, 205 adults with an established diagnosis of bipolar disorder type 1 who were receiving mental health care from a psychiatrist, were randomized to either the intervention group or control group and stratified based on their risk of relapse. Individuals assigned to the smart phone intervention group used an app over a period of 16 weeks which provided adaptive feedback and information for developing a personalized wellness plan and additionally visited a coach for support. The primary outcomes of this study were time to relapse, and quality of life measured by the World Health Organization (WHO) Quality of Life (QOL) questionnaire. The results of this study showed that time to relapse was longer in the intervention group compared to the control group in the low-risk group (HR 0.32, 95%CI 0.47-1.57) than the high-risk group (HR 0.86, 95%CI 0.47-1.57). Additionally, there was no difference in quality-of-life scores between the two groups. In conclusion, this paper did not observe a difference in relapse of a mood episode amongst the smart phone-based self-management group. However, in individuals with a lower risk of relapse to begin with, the relapse risk was lower with the smartphone intervention. This study had several limitations that must be taken into consideration. A significant portion of the sample was Caucasian participants so the generalizability of these findings may be limited. Nevertheless, as this study does demonstrate some benefit of smartphone interventions in those at a lower risk for relapse, further research into this area may be beneficial. 

 

Comparison of Postoperative Outcomes of Laparoscopic vs Open Inguinal Hernia Repair

1. In patients undergoing inguinal hernia repair, there was not a significant difference in postoperative complications between laparoscopic surgery, and open repair with local and general anesthesia. 

Evidence Rating Level: 2 (Good) 

Inguinal hernia repair continues to be one of the most common general surgery procedures in the United States. Unilateral inguinal hernias are usually repaired using an open surgery technique while laparoscopic methods are traditionally reserved for more complicated recurrent or bilateral hernias. However, recent evidence has suggested that laparoscopic surgery may improve postoperative outcomes, although this has not taken anesthesia modalities into consideration. This study aimed to compare short-term outcomes of open inguinal hernia repair performed with local anesthetic or general anesthetic and laparoscopic surgery performed with general anesthetic. In this retrospective cohort study, 107 073 participants who underwent inguinal hernia repair were divided into three groups for comparison: laparoscopic repair under general anesthesia, open repair under local anesthesia, and open repair under general anesthesia. The primary outcome of interest was any postoperative complication including infection, thromboembolism, bleeding, or wound complications within 30 days of surgery. The results of this study showed that laparoscopic hernia repair did not significantly reduce postoperative complications compared to open inguinal hernia repair under general anesthesia (difference 0.15%, 95%CI -0.39-0.09). Additionally, there was no difference identified in the incidence of postoperative complications between laparoscopic surgery and open hernia repair with local anesthesia (difference 0.05%, 95%CI -0.34-0.28). However, laparoscopic inguinal hernia repair was associated with a longer operative time compared with open repair surgery in general. In conclusion, this study depicts that laparoscopic surgery was not associated with a clear advantage compared with open repair and resulted in a significantly longer operative time. However, this study has several limitations which are important to note. Firstly, while general postoperative complications were discussed, this paper did not examine hernia-specific outcomes such as recurrence or pain. Additionally, some postoperative complications such as postoperative delirium or urinary retention which may be common following general anesthesia were not assessed. Nevertheless, this study presents evidence that laparoscopic and open surgeries in the context of hernia repair may have similar outcomes and supports taking patient factors as well as surgeon preference into consideration when making a decision regarding surgical technique. 

 

Dexmedetomidine Premedication Increases Preoperative Sedation and Inhibits Stress Induced by Tracheal Intubation in Adult: A Prospective Randomized Double-Blind Clinical Study 

1. The use of oral dexmedetomidine as premedication prior to neurosurgery increased preoperative sedation and reduced the stress reaction induced by tracheal intubation under general anesthesia. 

Evidence Rating Level: 1 (Excellent) 

Preoperative anxiety can significantly impact an individual’s experience prior to surgery and cause many physical manifestations such as increased incidence of nausea, vomiting, and postoperative pain. There is evidence that suggests that premedication for peri-operative anxiety improves quality of anesthesia and surgical recovery. There are medications such as opioids or benzodiazepines that are routinely used; however, there is minimal clinical evidence supporting the use of routine sedative premedication in general anesthesia. Dexmedetomidine (DEX) is a highly selective alpha-2 agonist receptor with sedative, anxiolytic, and analgesic features but not much about this medication is known in the context of surgery pre-medication. In this prospective randomized clinical study, 115 patients scheduled for elective neurosurgery were randomized to either the control group or the oral DEX premedication group. In the intervention group, DEX was administered orally two hours prior to general anesthesia induction. After induction and confirming muscle relaxation, tracheal intubation was performed with video laryngoscope. The primary outcome of this study was differences in patient sedation which was assessed using the Richmond Agitation-Sedation Scale (RASS) score, measured prior to DEX administration and one hour after. Secondary outcomes included stress response induced by tracheal intubation and family member satisfaction. The results of this study showed that DEX administration significantly increased the level of patient sedation compared to the placebo group (RASS score -0.90 in DEX and 1.12 in control, P < 0.05). Additionally, the DEX premedication group had reductions in blood cortisol levels compared to the control group during tracheal intubation, suggesting lower stress levels in this group. However, the quantity of anesthetics used between both groups was similar. In conclusion, this study confirms that the use of oral DEX as premedication prior to surgery is an efficient intervention in increasing preoperative sedation and reducing stress during tracheal intubation. It is important to note several limitations in this study. Firstly, anxiety levels of the participants were not adequately assessed pre- and post-surgery, which may bias these results. As well, this methodology was conducted only in the context of neurosurgery and these findings cannot be generalized to other types of surgeries. Nevertheless, future multicenter trials investigating the use of DEX perioperatively can be very beneficial in improving post-surgery outcomes.  

 

Emergency Department Crowding Negatively Influences Outcomes for Adults Presenting With Asthma: A Population-Based Retrospective Cohort Study 

1. Amongst patients presenting to the emergency department with acute asthma exacerbations, crowding negatively impacted the care provided in all triage groups. 

Evidence Rating Level: 2 (Good)  

Crowding in the emergency department, a state where demand for care services exceeds the capacity of providers, has been a longstanding healthcare concern. Studies have demonstrated that crowding can lead to poor patient outcomes, incomplete patient care, increased health care costs, as well as higher mortality. These delays on time-sensitive interventions can impact patients presenting with acute asthma exacerbations; although, literature investigating this association is scarce. In this retrospective cohort study, 1 264 025 adults presenting with acute asthma exacerbations to a hospital in Alberta, Canada were examined. Emergency department (ED) triage was determined based on the Canadian Triage and Acuity Scale (CTAS) which is employed in most Canadian EDs. The primary outcomes assessed in this paper include length of stay and physician initial assessment (PIA) time. The results showed that emergency department crowding affected all triage groups. However, higher acuity patients with acute asthma were less impacted by ED crowding compared to mild or moderate asthma presentations. Crowding was associated with a 26-minute increase in wait time for the high acuity group, 54 minutes in the moderate acuity group, and 61 minutes in the low acuity group (95%CI 24-28; 95%CI 53-55; 95%CI 59-63, respectively). Additionally, crowding and delays in physician initial assessment time increased risk of admission for the higher acuity group. In conclusion, while emergent care provided in all three triage groups was impacted by ED crowding, moderate and low acuity groups were affected more significantly. While this study does have a large sample size and robust data, it still has some limitations. Firstly, information regarding the asthma management and control of each individual patient is not known, and variations in pre-existing asthma severity may impact these results. As well, as this study was only conducted in Alberta, these results cannot be generalized to a wider population. Nevertheless, this paper provides strong insight into the negative impacts of emergency room crowding on patient outcomes. Further research and strategies mitigating crowding in the ED are essential to improve patient care.

 

On-Treatment Platelet Reactivity and Ischemic Outcomes in Patients with Diabetes Mellitus: Two-Year Results from ADAPT-DES 

1. In patients with diabetes mellitus who are on therapy with clopidogrel following percutaneous coronary intervention, high platelet reactivity was more frequent compared to those without diabetes mellitus

2. Patients with diabetes mellitus had an increased risk of major adverse cardiac events compared to those without diabetes mellitus

3. Patients with insulin-dependent diabetes mellitus had an increased incidence of major adverse cardiac events compared to patients with non-insulin-dependent diabetes mellitus 

Evidence Rating Level: 2 (Good) 

Diabetes mellitus and high platelet reactivity (HPR) on clopidogrel are known to be associated with an increased risk of ischemic events following percutaneous coronary intervention (PCI). Studies have demonstrated that in patients with diabetes mellitus, there is a higher prevalence of HPR; however, the association between HPR and thromboembolic events in unknown. In this prospective cohort study, 8582 patients undergoing PCI with drug-eluting stents, loaded with aspirin and clopidogrel were included. Platelet reactivity was assessed after successful PCI using the VerifyNow Aspirin, P2Y12, and IIb/IIa assays. The primary endpoint in this study was definite or probable stent thrombosis. Out of all the patients included in the ADAPT-DES study, 2429 (28.3%) had diabetes mellitus. The results of this study showed that patients with diabetes mellitus had significantly higher mean P2Y12 reaction units than patients without diabetes mellitus, and the frequency of HPR was higher in patients with diabetes mellitus (56.8% vs 37.2%). The increase in HPR in patients with diabetes mellitus was associated with a higher incidence of major adverse cardiac events (aHR 1.44, 95%CI 1.07-1.93). Interestingly, patients with insulin-dependent diabetes mellitus (IDDM) had higher rates of MACE compared with those with non-insulin dependent diabetes mellitus (NIDDM) (aHR 1.02, 95%CI 0.70-1.50; and aHR 2.28, 95%CI 1.39-3.73, respectively). In conclusion, high platelet reactivity was more common amongst patients with diabetes mellitus and was associated with an increased incidence of adverse events. There are several limitations of this study that should be noted. Firstly, individuals with IDDM versus NIDDM may have different therapies such as the use of SGLT2-inhibitors (sodium-glucose cotransporter 2) which can affect cardiovascular health and impact the interpretation of these findings. Additionally, testing for platelet reactivity in this study was only conducted at one time point but this may vary throughout the disease process. Nevertheless, these findings warrant further investigation into variations in ischemic outcomes between NIDDM and IDDM patients, as well as whether diabetics could benefit from increased platelet reactivity testing and different anti-platelet therapy overall. 

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