Category: Nevin Manimala

Open Heart. 2023 May;10(1):e002275. doi: 10.1136/openhrt-2023-002275.

ABSTRACT

OBJECTIVE: There is a substantial incidence of stroke in patients with atrial fibrillation (AF) not receiving anticoagulation. The reasons for not receiving anticoagulation are generally attributed to clinician’s choice, however, a proportion of AF patients refuse anticoagulation. The aim of our study was to investigate factors associated with patient refusal of anticoagulation and the clinical outcomes in these patients.

METHODS: Our study population comprised patients in the Global Anticoagulant Registry in the FIELD (GARFIELD-AF) registry with CHA₂DS₂-VASc≥2. A logistic regression was developed with predictors of patient anticoagulation refusal identified by least absolute shrinkage and selection operator methodology. Patient demographics, medical and cardiovascular history, lifestyle factors, vital signs (body mass index, pulse, systolic and diastolic blood pressure), type of AF and care setting at diagnosis were considered as potential predictors. We also investigated 2-year outcomes of non-haemorrhagic stroke/systemic embolism (SE), major bleeding and all-cause mortality in patients who refused versus patients who received and patients who did not receive anticoagulation for other reasons.

RESULTS: Out of 43 154 AF patients, who were at high risk of stroke, 13 283 (30.8%) did not receive anticoagulation at baseline. The reason for not receiving anticoagulation was unavailable for 38.7% (5146/13 283); of the patients with a known reason for not receiving anticoagulation, 12.5% (1014/8137) refused anticoagulation. Diagnosis in primary care/general practitioner, Asian ethnicity and presence of vascular disease were strongly associated with a higher risk of patient refusal of anticoagulation. Patient refusal of anticoagulation was associated with a higher risk of non-haemorrhagic stroke/SE (adjusted HR (aHR) 1.16 (95% CI 0.77 to 1.76)) but lower all-cause mortality (aHR 0.59 (95% CI 0.43 to 0.80)) compared with patients who received anticoagulation. The GARFIELD-AF mortality score corroborated this result.

CONCLUSION: The data suggest patient refusal of anticoagulation is a missed opportunity to prevent AF-related stroke. Further research is required to understand the patient profile and mortality outcome of patients who refuse anticoagulation.

PMID:37169491 | DOI:10.1136/openhrt-2023-002275

Open Heart. 2023 May;10(1):e002197. doi: 10.1136/openhrt-2022-002197.

ABSTRACT

OBJECTIVE: Postmarketing observational studies report that a substantial percentage of patients with atrial fibrillation (AF) receive a reduced non-vitamin K antagonist oral anticoagulant (NOAC) dose without a clear indication. Recently, increasing evidence has become available to explore the clinical consequences of such off-label reduced dosing (OLRD). This study aims to systematically review and meta-analyse observational studies that report clinical outcomes associated with OLRD of NOACs compared with on-label non-reduced dosing (OLNRD) of NOACs in patients with AF.

METHODS AND ANALYSIS: We performed a systematic literature review and meta-analysis of observational studies reporting clinical outcomes in AF patients with OLRD of an NOAC compared with AF patients with OLNRD of an NOAC. Using random effects meta-analyses, we estimated the risk of stroke/thromboembolism, bleeding and all-cause mortality.

RESULTS: We included 19 studies with a total of 170 394 NOAC users. In these studies, the percentage of OLRD among patients with an indication for an on-label non-reduced NOAC dose ranged between 9% and 53%. 7 of these 19 studies met the predefined criteria for meta-analysis (n=80 725 patients). The pooled HR associated with OLRD of NOACs was 1.04 (95% CI 0.83 to 1.29; 95% prediction interval (PI) 0.60 to 1.79) for stroke/thromboembolism, 1.10 (95% CI 0.95 to 1.29; 95% PI 0.81 to 1.50) for bleeding and 1.22 (95% CI 0.81 to 1.84; 95% PI 0.55 to 2.70) for all-cause mortality.

CONCLUSION: This meta-analysis shows no statistically significant increased risk of stroke/thromboembolism, nor a decreased bleeding risk, nor a difference in risk of all-cause mortality in patients with OLRD of NOACs. Future research may focus on differences between NOACs.

PMID:37169490 | DOI:10.1136/openhrt-2022-002197

Neurologia (Engl Ed). 2023 May;38(4):278-283. doi: 10.1016/j.nrleng.2021.10.006.

ABSTRACT

INTRODUCTION: Stroke is highly prevalent in Latin America and one of the leading causes of morbidity and mortality in the world. Educating children about stroke has been established as an effective method to detect symptoms early, reduce hospital visits, and raise awareness among adults.

OBJECTIVE: To analyze the effectiveness of a mobile application to improve knowledge and understanding of stroke among children.

METHOD: We conducted a focus group session including 12 children in order to analyze the behavior of 6 questions previously validated by expert neurologists. Subsequently, 105 primary school students between the ages of 7 and 12 completed a questionnaire on stroke symptoms and how to contact the emergency services before and after using an application on stroke symptoms. Qualitative analyses and the Student t test were used to verify the existence of differences between pre- and post-intervention test results.

RESULTS: After a single 40-min working session with the application, between 50% and 67% of the children were able to identify the signs of stroke, and 96.2% knew the national emergency services telephone number. Statistical analysis revealed statistically significant differences before and after the intervention with the digital application (t=19.54; p<0.001) and intragroup differences in the post-intervention test results (t=40.71; p<0.001).

CONCLUSION: Primary school children who used our digital application increased their knowledge, understanding, and learning of stroke symptoms.

PMID:37169470 | DOI:10.1016/j.nrleng.2021.10.006

Can J Surg. 2023 May 11;66(3):E269-E273. doi: 10.1503/cjs.012322. Print 2023 May-Jun.

ABSTRACT

BACKGROUND: Patients with knee osteoarthritis (OA) in northwestern Ontario are referred by their primary care provider (PCP) to a centralized assessment clinic for evaluation by an advanced practice physiotherapist (APP) to determine if they will require surgical management. However, many patients are found to not require surgical management, resulting in delays for patients who do. A decision-support tool was developed to address this issue and to guide treatment options by determining the need for surgical or nonsurgical approaches.

METHODS: We used a proof-of-concept method to assess the use of the decision-support tool in northwestern Ontario. Data from 100 consecutive patients assessed for knee OA management were collected from the Thunder Bay centralized assessment clinic. Two levels of agreement analyses (calculated using Cohen κ statistic) were performed, between the APP assessment decision (surgical or non-surgical) and the decision-support tool recommendation, and between the surgeon’s decision (surgical or non-surgical) and the decision-support tool recommendation.

RESULTS: We found a near-perfect agreement (κ = 0.870, n = 65) between the APP decision and the decision-support tool recommendation, when controlled for patient preference. There was a substantial level of agreement (κ = 0.618, n = 72) between the decision-support tool recommendation and the surgeon’s decision.

CONCLUSION: The decision-support tool recommendation showed considerable agreement with the decisions of the APP and surgeon indicating that it could be a valuable tool to guide PCPs caring for patients with knee OA. The applicability of a decision-support tool in northwestern Ontario displayed promising results, but further research is needed to examine the feasibility in a primary care setting.

PMID:37169385 | DOI:10.1503/cjs.012322

Braz J Psychiatry. 2023 May 11;45(2):127-131. doi: 10.47626/1516-4446-2022-2811.

ABSTRACT

OBJECTIVE: Childhood maltreatment (CM) is a significant risk factor for the development and severity of bipolar disorder (BD) with increased risk of suicide attempts (SA). This study evaluated whether a machine learning algorithm could be trained to predict if a patient with BD has a history of CM or previous SA based on brain metabolism measured by positron emission tomography.

METHODS: Thirty-six euthymic patients diagnosed with BD type I, with and without a history of CM were assessed using the Childhood Trauma Questionnaire. Suicide attempts were assessed through the Mini International Neuropsychiatric Interview (MINI-Plus) and a semi-structured interview. Resting-state positron emission tomography with 18F-fluorodeoxyglucose was conducted, electing only grey matter voxels through the Statistical Parametric Mapping toolbox. Imaging analysis was performed using a supervised machine learning approach following Gaussian Process Classification.

RESULTS: Patients were divided into 18 participants with a history of CM and 18 participants without it, along with 18 individuals with previous SA and 18 individuals without such history. The predictions for CM and SA were not significant (accuracy = 41.67%; p = 0.879).

CONCLUSION: Further investigation is needed to improve the accuracy of machine learning, as its predictive qualities could potentially be highly useful in determining histories and possible outcomes of high-risk psychiatric patients.

PMID:37169366 | DOI:10.47626/1516-4446-2022-2811

J Am Med Dir Assoc. 2023 May 8:S1525-8610(23)00379-1. doi: 10.1016/j.jamda.2023.04.002. Online ahead of print.

ABSTRACT

OBJECTIVE: To investigate mental health needs and barriers to seeking mental health support in Medicaid-funded Assisted Living Facility (M-ALF).

DESIGN: A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews.

SETTING AND PARTICIPANTS: The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or African American, 2 Asian) using purposive sampling.

METHODS: Demographic data and mental health indicators (depression, anxiety, stress, hopelessness) were measured with questionnaires (Center for Epidemiological Studies Depression Scale, Edmonton Symptom Assessment System, Perceived Stress Scale, Beck Hopelessness Survey) and analyzed with descriptive statistics. Interviews were conducted between June and November 2021, transcribed, and analyzed using conventional content analysis.

RESULTS: Thirteen residents (mean age: 73.4 years, mean length of stay: 3.5 years; range: 1.0-7.5) completed data collection. Quantitatively indicators of unmet mental health were common. Qualitatively, residents reported barriers to mental health access to address depression, anxiety, and substance use. This was accompanied by concerns surrounding loss of autonomy, mistrust for M-ALF organizational support, isolation and uncertainty about how to receive mental health support. Perspectives were shaped by past experiences with institutional living, serious illness, and being unhoused. Themes and subthemes were (1) mental health need (unmet mental health need, depression, and anxiety and seeking support through non-mental health resources) and (2) barriers to mental health support (dissatisfaction with M-ALF care, perceived threats to autonomy, desire for autonomy that leads to diminished care seeking).

CONCLUSION AND IMPLICATIONS: Residents of M-ALF have mental health needs for which care is stymied by loss of autonomy, lack of resources, and the M-ALF environment. Residents use unconventional resources to address needs that may be neither efficient nor effective. Novel mental health interventions and processes are needed to improve mental health access and should prioritize residents’ desire for autonomy and the unique circumstances of living in M-ALF.

PMID:37169346 | DOI:10.1016/j.jamda.2023.04.002

J Pediatr (Rio J). 2023 May 8:S0021-7557(23)00051-7. doi: 10.1016/j.jped.2023.03.007. Online ahead of print.

ABSTRACT

OBJECTIVE: To determine reference intervals (RI) for serum immunoglobulin A (IgA) levels in healthy children aged 1 to 11 years residing in the central region of Brazil.

METHODS: This cross-sectional study was conducted on 1,743 healthy children randomly selected from kindergartens and public schools in Cuiabá, MT, Brazil. The IgA RIs were defined using the statistical methods postulated by the guidelines of the United States Clinical and Laboratory Standards Institute, the nonparametric bootstrap method, and Horn’s robust method after the correction of discrepancies by Tukey’s, Dixon’s, and Horn’s methods, respectively. The results were defined based on the values contained between the 2.5th and 97.5th percentiles and their respective 95% confidence intervals.

RESULTS: Partition by sex was not necessary to determine the IgA RI of the studied children. Homogeneous subgroups were identified among children aged 1-<2, 2-<5, and 5-<11 years, whose IgA-specific RIs were determined.

CONCLUSION: The serum IgA RIs were established for three groups of Brazilian children aged 1-11 years, which differed from those currently applied in Brazilian pediatric practice and from those defined by international studies. This definition will help Brazilian pediatricians formulate an accurate diagnosis and facilitate decision-making.

PMID:37169344 | DOI:10.1016/j.jped.2023.03.007

Microb Pathog. 2023 May 9:106149. doi: 10.1016/j.micpath.2023.106149. Online ahead of print.

ABSTRACT

The abundance of specific gut microorganisms is strongly associated with the concentrations of microbially modified bile acids. This study aimed to investigate the composition of intestinal microbiota in rats subjected to bile duct ligation or biliary drainage. Extrahepatic bile duct ligation was conducted to induce bile duct obstruction in rats. The bile was drained via a percutaneous biliary drainage catheter to cause bile deficiency. The total DNA extracted from fecal samples was sequenced with 16S DNA sequencing. Taxonomic classifications were conducted using the Mothur algorithm and SILVA138 database and were presented along with the abundance presented using a heatmap. The inter- and intra-group differences in the intestinal microbiome composition were analyzed by ANOSIM test. The biomarker microorganisms were screened using the Linear discriminant analysis Effect size method. The possible functional pathways were predicted using the Tax4Fun package. A total of 3277 operational taxonomic units (OTUs) were examined, with 2410 in the Kongbai group, 2236 in the Gengzu group, and 1763 in the Yinliu group. The composition of microorganisms at the levels of phylum, class, order, family, and genus was altered in rats with bile duct obstruction. This composition was then restored by biliary drainage. The top 10 predominant microorganisms were identified that led to the inter-group differences. Functional annotation revealed that the potential functions of the microorganisms with significant differences were enriched in metabolism, cellular processes, and genetic and environmental information processing. The intestinal microbial community was significantly changed in rats with bile duct obstruction. The changes in the abundance of intestinal microbiota Prevotellaceae and Enterobacteriaceae were statistically significant after biliary drainage treatment.

PMID:37169314 | DOI:10.1016/j.micpath.2023.106149

Prev Med. 2023 May 9:107536. doi: 10.1016/j.ypmed.2023.107536. Online ahead of print.

ABSTRACT

Few studies have examined associations between the retail food environment and weight maintenance. This study examined the residential Retail Food Environment Index (RFEI) of weight loss maintainers and associations with weight maintenance duration, perceived effort and difficulty managing weight, and coping and monitoring strategies. Participants were 6947 members of the WW Success Registry (enrolled January 2018-February 2020), a nationwide (United States) convenience sample of individuals who lost weight using Weight Watchers (WW) and maintained a ≥ 9.1 kg weight loss for ≥1 year (Mean 24.7 kg loss for 3.4 years). Home addresses were geo-coded and the RFEI (ratio of unhealthy [fast-food and convenience stores] to healthy [supermarkets, grocery stores, and fruit/vegetable vendors] outlets) was used to classify the healthfulness of the food environments. Validated questionnaires measured psychological coping and self-monitoring. Compared to individuals living in the healthiest food environments (RFEI<1.6), those in the least healthy food environments (RFEI ≥4.0) maintained weight loss for 0.5 years less (3.2 vs 3.7 years; 95% CI between-group difference = 0.20, 0.80), reported statistically higher scores but not clinically relevant differences on perceived effort (4.6 vs. 4.5; 95% between-group difference = 0.01, 0.21) and difficulty managing their weight (3.1 vs. 3.0; 95% CI between-group difference = 0.01, 0.17) and practice of self-monitoring (2.7 vs. 2.6; 95% CI between-group difference = 0.01, 0.14). No differences in psychological coping were observed. Weight loss maintainers living in the least healthy retail food environments maintained weight loss for a shorter duration compared to those in the healthiest food environments.

PMID:37169304 | DOI:10.1016/j.ypmed.2023.107536

Radiother Oncol. 2023 May 9:109700. doi: 10.1016/j.radonc.2023.109700. Online ahead of print.

ABSTRACT

PURPOSE: The aim of this study was to evaluate the effectiveness and safety of high-dose (HD-RT) versus standard-dose radiotherapy (SD-RT) in concurrent chemoradiotherapy (CCRT) for inoperable esophageal cancer (EC) patients.

METHODS: A systematic search of the literature was conducted by screening PubMed, Web of Science, EMBASE and Cochrane Library databases before October 7, 2022 to collect controlled clinical studies of high-dose (≥ 60Gy) and standard-dose (50-50.4Gy) radiation in CCRT for EC. For statistical analysis, a fixed-effects model was used to synthesize HR and OR if there was no significant heterogeneity among studies; otherwise, a random-effects model was employed.

RESULTS: There were ten studies with 4625 patients included in the study, 3667 of whom (79.3%) were esophageal squamous cell carcinoma (ESCC). The HD-RT group had no significant benefits in overall survival (OS) (HR = 0.88, 95% confidence interval [CI] = 0.74-1.05, P = 0.16) and progression-free survival (HR = 0.84, 95%CI = 0.67-1.04, P = 0.12) in total EC patients, compared with SD-RT group. However, in ESCC subgroup analysis, compared with SD-RT group, a better OS was observed in the HD-RT group (HR = 0.78, 95%CI = 0.70-0.88, P < 0.0001).

CONCLUSION: Compared with the radiation dose of 50-50.4Gy, the increase of radiation dose (≥ 60Gy) did not achieve benefits in survival for inoperable EC patients receiving CCRT. However, in patients with ESCC, high dose (≥ 60Gy) of radiation probably improved OS.

PMID:37169302 | DOI:10.1016/j.radonc.2023.109700