Multispecies Probiotic for the Prevention of Antibiotic-Associated Diarrhea in Children: A Randomized Clinical Trial

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.


Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity: The SLEEVEPASS Randomized Clinical Trial

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.


Extended Anticoagulation After Pulmonary Embolism: A Multicenter Observational Cohort Analysis

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.


Menstrual cycle changes and mental health states of women hospitalized due to COVID-19

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.

Image: PD

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