+Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.
+1. A multispecies probiotic did not change the incidence of antibiotic-associated diarrhea, compared to placebo, in pediatric patients receiving antibiotic treatment.
+2. The probiotic was associated with a lower rate of diarrhea from any cause compared to placebo.
+Evidence Rating Level: 1 (Excellent)
+Antibiotic-associated diarrhea (AAD) is defined as diarrhea occurring in the context of antibiotic use. This is because antibiotics eliminate bacteria that maintain the balance of organisms in the gut: Without this balance, bacteria such as C. difficile can proliferate, leading to diarrhea. A Cochrane review in 2019 found that probiotics can have a moderate protective effect for pediatric AAD: This review included limited studies on treatment with 3 or more probiotic strains. Therefore, the current randomized controlled trials aimed to determine whether a multispecies probiotic would be effective in preventing AAD in pediatric patients receiving antibiotics. This was a parallel-group, quadruple-blind, and placebo-controlled RCT, taking place at 5 centres in The Netherlands and Poland. The study population consisted of pediatric patients aged 3 months to 18 years, who were enrolled within 24 hours of antibiotic initiation, 155 randomized to placebo and 158 randomized to probiotic. The probiotic contained 8 strains of bacteria, and 10 billion colony forming units were administered daily, for a duration of 7-17 days after enrollment. The results showed that the incidence of AAD was similar in both groups (14.6% in probiotic vs 18.1% in placebo, relative risk 0.81, 95% CI 0.49-1.33). However, the incidence of diarrhea from any cause was lower in the probiotic group (20.9% vs 32.3%, RR 0.65, 95% CI 0.44-0.94). As well, there was a lower incidence of IV rehydration being required to replace fluid losses from diarrhea (0% vs 3.2%). Overall, this study demonstrated that a multispecies probiotic did not decrease the likelihood of AAD, but decreased rates of diarrhea from any cause, in pediatric patients receiving antibiotic therapy.
+1. At 10-year follow-up, patients with severe obesity randomized to laparoscopic Roux-en-Y gastric bypass (LRYGB) were found to have a higher mean percentage of excess weight lost (%EWL) compared to those randomized to laparoscopic sleeve gastrectomy (LSG).
+2. LRYGB patients had lower rates of esophagitis and lower burden of gastrointestinal reflux disease (GERD) symptoms than LSG patients, with no difference in rates of de novo Barrett esophagus (BE).
+3. LRYGB patients had a higher remission rate for hypertension than LSG patients, with no difference in remission for type 2 diabetes, dyslipidemia, or obstructive sleep apnea.
+Evidence Rating Level: 1 (Excellent)
+Laparoscopic sleeve gastrectomy (LSG) accounts for 60% of bariatric procedures globally, and is now more common than the previous standard of laparoscopic Roux-en-Y gastric bypass (LRYGB). However, results from long-term randomized controlled trials were not available prior to this transition. The Sleeve vs Bypass (SLEEVEPASS) trial found that at 5 and 7 years following surgery, LRYGB was associated with greater weight loss, but was not clinically significant. Other studies have found a high incidence of de novo gastroesophageal reflux (GERD), esophagitis, and Barrett esophagus (BE) in patients that underwent LSG. Therefore, the current study investigated the outcomes of SLEEVEPASS at 10-year follow-up, measuring the percentage of excess weight loss (%EWL), and the prevalence of GERD symptoms, esophagitis, and BE. The study population consisted of 240 patients aged 18-60 years recruited across 3 hospitals in Finland, with 121 randomized to LSG and 119 to LRYGB. They had a BMI of 40 and higher, or 35 and higher with a significant comorbidity related to obesity. The %EWL was calculated through a ratio, consisting of the difference between initial and final weight, divided by the difference between initial and ideal weight based on a BMI of 25. Symptoms of GERD were assessed through the GERD-HRQL questionnaire, out of a total score of 50, with higher scores indicating greater severity of symptoms. Esophagitis and BE were measured through endoscopy at study onset and at 10-year follow-up. The results showed a difference in %EWL between the two groups, with LSG having a mean of 43.5% (95% CI 39.8-47.2) and LRYGB having a mean of 51.9% (95% CI 48.1-55.6). The LRYGB group was 8.4 percentage points greater than the LSG group (95% CI 3.1-13.6), and the groups were deemed not equivalent based on predefined margins of equivalence for the confidence intervals (-9 to 9). Additionally, there was a higher prevalence of esophagitis in the LSG group (31% vs 7%, p < 0.001), and a greater remission rate for hypertension after LRYGB (24% vs 8%, p = 0.04). The LSG group also had greater intake of proton pump inhibitors (64% vs 36%, p < 0.001) and had higher median GERD-HRQL total scores (10.5 vs 0.0, p < 0.001). No differences were found in rates of de novo BE (4% for both, p = 0.29), nor for remission of type 2 diabetes, dyslipidemia, or obstructive sleep apnea. Overall, this study demonstrated that the %EWL was higher after LRYGB compared to LSG, and that LRYGB had lower rates of esophagitis and GERD symptoms, with no difference in rates of de novo BE.
+1. Extended anticoagulation therapy for 2.5 years post-pulmonary embolism (PE) was associated with lower rates of all-cause mortality, lower rates of venous thromboembolism (VTE) recurrence, and no difference in rates of bleeding events, compared to patients receiving anticoagulation for 3-6 months post-PE.
+Evidence Rating Level: 2 (Good)
+Patients who have had a pulmonary embolism (PE) are at greater risk of recurrent venous thromboembolism (VTE), chronic thromboembolic pulmonary hypertension, and post-thrombotic syndrome. As such, anticoagulation therapy, such as direct oral anticoagulants (DOACs), are used in-hospital and after discharge for a minimum of 3 months, to reduce VTE recurrence. However, recent guidelines suggest an extended or indefinite duration of anticoagulation therapy, although long-term data is needed to support extended therapy. Therefore, this multicentre prospective cohort study based in France examined the outcomes of all-cause death, VTE recurrence, and rates of bleeding, amongst PE patients who received anticoagulation therapy for 3-6 months versus those who received DOACs for the 3-6 months plus an extended duration of 2 years. The study population consisted of 858 (71.5%) on extended therapy and 341 (28.5%) not on extended therapy: Those who were prescribed extended therapy were more likely to be younger than 65 years old, female (52.8% in extended vs 46.0% in nonextended, p = 0.03), had a prior VTE (88.2% vs 11.8%, p < 0.001), and had more severe index PE (p < 0.001). In the study, there were 143 all-cause deaths and 74 recurrent VTEs. After adjustments, the composite outcome of all-cause death and recurrent VTE was achieved by 2.1% of the extended therapy group (95% CI 1.2-3.5) compared to 7.7% in the nonextended group (95% CI 4.8-12.1), with a hazard ratio of 0.23 (95% CI 0.17-0.31, p < 0.001). For all-cause mortality, the adjusted rates of all-cause mortality were 3.7% in the extended group (95% CI 2.1-6.5) and 8.0% in the nonextended group (95% CI 4.5-14.2, p < 0.001), whereas the adjusted rates of recurrent VTE were 0.07% in the extended group (95% CI 0.02-0.23) and 1.0% in the nonextended group (95% CI 0.4-2.3, p < 0.001). Furthermore, there were no differences between the extended and nonextended groups for major bleeding (5.1% versus 5.0% respectively) or for clinically relevant non-major bleeding (CRNMB) (4.6% versus 3.0% respectively). Overall, this study showed that extended anticoagulation therapy for 2.5 years post-PE was associated with reduced all-cause mortality, reduced VTE recurrence, and no difference in bleeding events, compared to anticoagulation therapy for 3-6 months post-PE.
+Nebivolol protects erectile functions compared to Metoprolol in hypertensive men with atherogenic, venogenic, psychogenic erectile dysfunction: A prospective, randomized, cross-over, clinical trial
+1. Married male patients with hypertension (HTN) experienced less of a negative impact on erectile function after 1 month of taking nebivolol, compared to 1 month of metoprolol.
+2. For patients with erectile dysfunction (ED) at baseline, metoprolol significantly worsened their symptoms whereas nebivolol did not.
+Evidence Rating Level: 1 (Excellent)
+Hypertension (HTN) can predispose patients to developing erectile dysfunction (ED) due to endothelial dysfunction. At the same time, taking anti-hypertensive medications may also be associated with ED, with 71% of patients on beta-blockers for at least 6 months reporting ED symptoms. However, some studies have reported that the beta-blocker nebivolol improves erectile function, due to its mechanism of releasing nitric oxide (NO), which is a central mediator for erections. Therefore, this current randomized controlled trial compared the erectile function of HTN patients taking the beta-blockers metoprolol or nebivolol. This was a cross-over trial, where all 73 patients used their first beta-blocker for 1 month (the order of which was randomized), followed by a 1-month period without using beta-blockers, and concluding with a 1-month period using the other beta-blocker. The doses were 5 mg PO daily for nebivolol and 50 mg PO daily for metoprolol. All patients were married males with a mean±SD age of 54.27±7.57 years, and having blood pressures (BPs) over 140/90 mmHg on two different measurements. To assess erectile function at baseline, the International Index of Erectile Function (IIEF-5) and the Sexual Encounter Profile (SEP) were used, with a score under 21 on the IIEF-5 or any negative answers on the SEP being classified as a patient having ED. The population consisted of 21.3% having no ED, 44.2% having psychogenic ED, 16.3% having arteriogenic ED, and 18% having ED related to venous insufficiency. The results of the study showed that there was a decrease in IIEF-5 score from baseline (15.52±5.54) after treatment with either medication, but that the metoprolol treatment had a greater decrease (11.31±4.67, p<0.001) compared to after the nebivolol treatment (14.93±5.04, p=0.026). Additionally, among patients who had ED at baseline, there was no difference in IIEF-5 score between baseline and after nebivolol, for psychogenic, arteriogenic, and venous insufficiency ED (p=0.201, 0.598, and 0.08 respectively), whereas IIEF-5 score was still significantly decreased for ED patients after metoprolol treatment. Furthermore, both beta-blockers decreased pulse rate, systolic BP, and diastolic BP significantly, after 1 month of use (p < 0.001 for all), with the decreases in these outcomes being similar for both medications (p = 0.82, 0.19, and 0.83 respectively). The plasma NO levels were also significantly increased after nebivolol, but not after metoprolol. Overall, this study demonstrated that nebivolol had a lower negative impact on erectile function compared to metoprolol, and in patients with ED at baseline, metoprolol significantly worsened their symptoms whereas nebivolol did not.
+1. Amongst women hospitalized and isolated for COVID-19, there were more patients with menstrual cycle lengths outside of the normal range, menstrual irregularity, and heavy menstrual bleeding (HMB) 3 months after discharge, compared to prior to infection.
+2. Patients who screened positive for mental health concerns after discharge were twice more likely to report abnormal menstrual cycle length, irregularity, and HMB.
+Evidence Rating Level: 2 (Good)
+Psychological distress is well known to being associated with changes in menstruation. For instance, depression and anxiety interfere with the hypothalamic-pituitary-adrenal axis, which can suppress luteinizing hormone and lead to ovulatory dysfunction. As well, cortisol released during times of stress can suppress gonadotropin-releasing hormone, which can lead to anovulation and amenorrhea. During COVID-19, a study found that the elevated level of stress and anxiety was correlated with menstrual cycle changes. However, most studies documenting mental health and menstrual changes during COVID-19 have focused on the general population, and not specifically those who were hospitalized. Therefore, this cross-sectional study based in Indonesia examined a cohort of female patients who were hospitalized with COVID-19, to assess their mental health status and menstrual changes. Surveys were distributed to enrolled patients, that asked about their menstrual pattern prior to COVID-19 infection and 3 months after discharge. This assessed the length of each cycle (normal was defined as 24-32 days), irregularity (defined as a cycle length difference of ≥7 days across months), and heavy menstrual bleeding (HMB, defined as lasting more than 7 days in a cycle). Also included was the Self Reporting Questionnaire-29, a tool used to screen for mental health disorders. In total, the study population consisted of 158 female patients with a mean±SD age of 33.8±6.1 years, all of whom were hospitalized in an isolation ward with COVID-19, for a mean duration of 13.2±6.9 days. The results showed that there were fewer patients with cycle lengths falling in the normal range, with 79.1% having 24-32 day cycles prior to infection, and 75.1% when surveyed 3 months after discharge (p = 0.001). Prior to infection, 10.8% had cycles < 24 days and 10.1% had cycles > 32 days, whereas after discharge, these were 15.2%, 75.1%, and 19.6% respectively (p = 0.001 for all). As well, there was a greater percentage of patients with menstrual irregularity after discharge (35.4% versus 17.7%, p < 0.001), and greater percentage of patients with HMB (33.5% versus 27.2%, p = 0.041). From the SQR-29, patients screening positive for mental health symptoms were more likely to have menstrual changes after discharge (odds ratio 2.17, 95% CI 1.12-4.22, p = 0.021), and bivariate analysis showed a weak association between isolation length and menstrual changes (r(156) = 0.21, p = 0.009). Overall, this study found that amongst women hospitalized with COVID-19, there were associated changes in menstrual cycle length, regularity, and menstrual bleeding, which were more likely in patients reporting mental health symptoms.
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