Nevin Manimala

BMJ Open Gastroenterol. 2024 Jul 17;11(1):e001404. doi: 10.1136/bmjgast-2024-001404.

ABSTRACT

OBJECTIVE: We aimed to determine the association of statins with progression to a high risk for advanced fibrosis in primary care patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

DESIGN: This retrospective cohort study of electronic health record data included patients with MASLD and an initial low or indeterminate risk for advanced fibrosis, determined by Fibrosis-4 Index (FIB-4) score (<2.67). Patients were followed from the index FIB-4 until the primary outcome of a high-risk FIB-4 (≥2.67) or the end of the study period. Prescription for a statin during follow-up was the primary exposure. We developed Cox regression models for the time to a high-risk FIB-4 score with statin therapy as the primary covariate and adjusting for baseline fibrosis risk, demographic and comorbidity variables.

RESULTS: The cohort of 1238 patients with MASLD was followed for a mean of 3.3 years, with 47% of patients receiving a prescription for a statin, and 18% of patients progressing to a high-risk FIB-4. In the adjusted Cox model with statin prescription as the primary exposure, statins were associated with a lower risk (HR 0.60; 95% CI 0.45 to 0.80) of progressing to a FIB-4≥2.67. In the adjusted Cox models with statin prescription intensity as the exposure, moderate (HR 0.60; 95% CI 0.42 to 0.84) and high intensity (HR 0.61; 95% CI 0.42 to 0.88) statins were associated with a lower risk of progressing to a high-risk FIB-4.

CONCLUSION: Statin prescriptions, and specifically moderate and high intensity statin prescriptions, demonstrate a protective association with fibrosis risk progression in primary care patients with MASLD.

PMID:39019623 | DOI:10.1136/bmjgast-2024-001404

BMJ Open Gastroenterol. 2024 Jul 17;11(1):e001376. doi: 10.1136/bmjgast-2024-001376.

ABSTRACT

OBJECTIVE: To identify the optimal incentive protocol for maximising participation while managing study costs during the Voyage trial.

DESIGN: Prospective cohort (Voyage trial) of colorectal cancer (CRC) incidence and mortality outcomes in individuals screened with multitarget stool DNA (mt-sDNA) served as the population. A subset was randomised to receive postage stamps as a pre-consent incentive, or as a post-consent incentive after completion of the consent and questionnaire. Descriptive statistics from year 1 are reported.

RESULTS: During year 1 of the Voyage trial, a total of 600 258 individuals with mt-sDNA orders received at Exact Sciences Laboratories were randomly selected and invited to participate. Of those, 26 429 (4.4%) opted in, 14 365 of whom (54.3%) consented. The opt-in and consent samples were similar to the target population with respect to sex but differed by geographic residence and age (p<0.001). For the embedded incentive experiment, 2333 were randomised to the pre-incentive arm, while 2342 were randomised to the post-incentive arm. Overall consent rate in the incentive trial was 56.4% (60.9% for the pre-consent incentive arm (1421/2333) vs 52.0% for the post-consent incentive arm (1217/2342), p<0.001). Cost reduction was observed for the pre-consent incentive group, and higher response rates were seen among older versus younger individuals.

CONCLUSIONS: Pre-consent incentive option was associated with a higher participation rate and lower costs and was used for the remainder of study recruitment. CRC incidence and mortality vary with age; thus, adjusting for differential participation by age and region will be important in analyses of Voyage data.

TRIAL REGISTRATION NUMBER: NCT04124406.

PMID:39019622 | DOI:10.1136/bmjgast-2024-001376

Environ Health Prev Med. 2024;29:34. doi: 10.1265/ehpm.24-00105.

ABSTRACT

BACKGROUND: Exposure to fine particulate matter (PM_2.5) has been associated with allergic diseases, including asthma. However, information about the effects of specific PM_2.5 components is limited. This study aimed to investigate the relationship of exposure to chemical components of PM_2.5 during pregnancy and early childhood with the development of asthma, allergies, and sensitization in school-age children.

METHODS: This study included 2,408 children in the second grade of elementary school. Questionnaire surveys of respiratory/allergic symptoms and measurements of serum total IgE and specific IgE levels to house dust mite (HDM) and animal proteins were conducted. Exposures to ambient PM_2.5 mass, sulfate (SO₄^2-), nitrate (NO₃^–), ammonium (NH₄⁺), elemental carbon (EC), and organic carbon (OC) of PM_2.5 in participants’ residences from conception to age six were estimated using predictive models. Multiple logistic regression analysis was used to analyze the association of respiratory/allergic symptoms and allergen sensitization with estimated exposure concentrations, after adjustment for survey year, sex, season of birth, feeding method during infancy, presence of siblings, history of lower respiratory tract infection, use of childcare facilities, passive smoking, presence of pets, mother’s age, history of allergic diseases, smoking during pregnancy, and annual household income.

RESULTS: No significant association was found between PM_2.5 and its component concentrations and asthma. However, wheezing significantly increased with mean NO₃^– concentrations during pregnancy (odds ratio of 1.64 [95% confidence interval: 1.10, 2.47] for an interquartile range increase). Significant associations were also found between EC in the second trimester of pregnancy and PM_2.5, NO₃^–, EC, and OC concentrations in early childhood. Higher PM_2.5, SO₄^–, and NH₄⁺ concentrations during the second trimester increased the risk of rhinitis. Sensitizations to HDM and animal proteins were significantly associated with exposure to components such as SO₄^2- and NH₄⁺ during pregnancy but not with postnatal exposure.

CONCLUSIONS: Exposures to NO₃^–, EC, and OC during pregnancy and early childhood were associated with wheezing. SO₄^2- and NH₄⁺ exposures during pregnancy were associated with sensitization to HDM and animal proteins. Asthma was not associated with exposure to PM_2.5 and its main components at any period.

PMID:39019615 | DOI:10.1265/ehpm.24-00105

J Matern Fetal Neonatal Med. 2024 Dec;37(1):2375021. doi: 10.1080/14767058.2024.2375021. Epub 2024 Jul 17.

ABSTRACT

OBJECTIVE: This study aimed to evaluate if placement of transverse cesarean skin incision above or below the overhanging pannus is associated with wound morbidity in morbidly obese patients.

STUDY DESIGN: We identified a cohort of patients with body mass index (BMI) ≥40 kg/m² undergoing cesarean delivery at a single center from 2017-2020 with complete postpartum records. Data was abstracted after institutional review board exemption, and patients were grouped by low transverse or high transverse skin incision. The primary outcome was a composite of wound infection, fascial dehiscence, incisional hernia, therapeutic wound vacuum, and reoperation. Secondary outcomes included the individual components of the composite, blood transfusion, operative time, and immediate neonatal outcome. T test and χ² were used for continuous and categorical comparisons. Logistic regression was used to compute adjusted odds ratios for categorical outcomes and linear regression to compare operative times adjusting for factors associated with wound complications and surgical duration respectively.

RESULTS: 328 patients met inclusion criteria: 65 with high transverse (infraumbilical and supraumbilical) and 263 with low transverse (Pfannenstiel) incision. 11% of patients had wound morbidity; high transverse incision was associated with 3.64-fold increased odds of composite wound morbidity (23.1% vs 8%, aOR 3.64, 95% CI 1.52-8.70) and 5.73-fold increased odds of wound infection (13.8% vs. 4.9%, aOR 5.73, 95% CI 1.83-17.96). Time from skin incision to delivery was 1.87 min longer (11.09 vs 14.98 min, β = 1.87, 95% CI 0.17-4.61). There was no significant difference in neonatal outcomes, non-low transverse hysterotomy, or total operative time.

CONCLUSION: High transverse skin incision for cesarean delivery was strongly associated with increased wound morbidity in morbidly obese patients.

PMID:39019608 | DOI:10.1080/14767058.2024.2375021

J Prosthodont Res. 2024 Jul 17. doi: 10.2186/jpr.JPR_D_23_00158. Online ahead of print.

ABSTRACT

PURPOSE: Acute stroke often leads to dysphagia. In the oral stage of dysphagia, there is a potential for immediate benefit from using a palatal augmentation prosthesis (PAP). We investigated whether our quickly fabricated, simple, and expedited version of PAP would result in an immediate improvement in swallowing function after an acute stroke.

METHODS: We analyzed the records of stroke patients that were hospitalized between October 2019 and March 2022 and met the following criteria: they had a rehabilitation prescription and had paralysis of facial or hypoglossal nerves and either repeated salivary swallowing test ≤2 times or modified water swallow test ≤3, they were fasting, were within 3 weeks of onset, and had a simple PAP made for them. Outcomes included with/without PAP, maximum tongue pressure, repeated salivary swallowing test, and modified water swallow test on the day after starting to wear PAP was started. In addition, within one week, a videofluoroscopic examination was performed to measure the oral transit time, pharyngeal transit time, and penetration aspiration scale. Statistical analyses were performed using Wilcoxon signed-rank tests. Statistical significance was set at P < 0.05.

RESULTS: Fifteen patients met the inclusion criteria and were included in this study. The mean age of the subjects was 76.9 ± 9.0 years. The use of PAP significantly increased maximum tongue pressure (P < 0.0001*) and shortened oral transit time (P < 0.0091*). There were no significant differences among the other items.

CONCLUSIONS: Simple PAP immediately increased the maximum tongue pressure and improved swallowing function during the oral stage.

PMID:39019592 | DOI:10.2186/jpr.JPR_D_23_00158

BMJ Open Qual. 2024 Jul 17;13(3):e002619. doi: 10.1136/bmjoq-2023-002619.

NO ABSTRACT

PMID:39019588 | DOI:10.1136/bmjoq-2023-002619

BMJ Open Qual. 2024 Jul 17;13(3):e002540. doi: 10.1136/bmjoq-2023-002540.

ABSTRACT

BACKGROUND: Rapid response teams (RRTs) help in the early recognition of deteriorating patients in hospital wards and provide the needed management at the bedside by a qualified team. RRT implementation is still questionable because there is insufficient evidence regarding its effects. To date, according to our knowledge, no published studies have addressed the effectiveness of RRT implementation on inpatient care outcomes in Egypt.

OBJECTIVE: We aimed to assess the impact of an RRT on the rates of inpatient mortality, cardiopulmonary arrest calls and unplanned intensive care unit (ICU) admission in an Egyptian tertiary hospital.

METHODS: An interventional study was conducted at a university hospital. Data was evaluated for 24 months before the intervention (January 2018 till December 2019, which included 4242 admissions). The intervention was implemented for 12 months (January 2021 till December 2021), ending with postintervention evaluation of 2338 admissions.

RESULTS: RRT implementation was associated with a significant reduction in inpatient mortality rate from 88.93 to 46.44 deaths per 1000 discharges (relative risk reduction (RRR)=0.48; 95% CI, 0.36 to 0.58). Inpatient cardiopulmonary arrest rate decreased from 7.41 to 1.77 calls per 1000 discharges (RRR, 0.76; 95% CI, 0.32 to 0.92), while unplanned ICU admissions decreased from 5.98 to 4.87 per 1000 discharges (RRR, 0.19; 95% CI, -0.65 to 0.60).

CONCLUSIONS: RRT implementation was associated with a significantly reduced hospital inpatient mortality rate, cardiopulmonary arrest call rate as well as reduced unplanned ICU admission rate. Our results reveal that RRT can contribute to improving the quality of care in similar settings in developing countries.

PMID:39019587 | DOI:10.1136/bmjoq-2023-002540

Emerg Med J. 2024 Jul 17:emermed-2023-213591. doi: 10.1136/emermed-2023-213591. Online ahead of print.

ABSTRACT

BACKGROUND: Forearm fractures are a common ED presentation. This study aimed to compare the resource utilisation of three anaesthetic techniques used for closed forearm fracture reduction in the ED: haematoma block (HB), Bier’s block (BB) and procedural sedation (PS).

METHODS: A retrospective multicentre cohort study was conducted of adult patients presenting to either Port Macquarie Base Hospital ED or Kempsey District Hospital ED in New South Wales, Australia, from January 2018 to June 2021. Patients requiring a closed reduction in the ED were included. ED length of stay (LOS) was compared using a likelihood ratio test. Successful reduction on the first attempt and the number of ED specialists present for each method were both modelled with a linear regression. Staff utilisation by the level of training, cost of consumables and complications for each group were presented as descriptive statistics.

RESULTS: A total of 226 forearm fractures were included. 84 used HB, 35 BB and 107 PS. The mean ED LOS was lowest for HB (187.7 min) compared with BB (227.2 min) and PS (239.3 min) (p=0.023). The number of ED specialists required for PS was higher when compared with HB and BB (p=0.001). The cost of consumables and a total number of staff were considerably lower for HB compared with PS and BB methods. PS had the highest proportion of successful reductions on the first attempt (94.4%) compared with BB (88.6%) and HB (76.2%) (p=0.006). More patients experienced complications from PS (17.8%) compared with BB (14.3%) and HB (13.1%).

CONCLUSIONS: In this study, the HB method was the most efficient as it was associated with a shorter ED LOS, lower cost and staff resource utilisation. Although PS had a significantly greater proportion of successful reductions on the first attempt, HB had fewer complications than BB and PS. EDs with limited resources should consider using HB or BB as the initial technique for fracture reduction with PS used for failed HB or when regional blocks are contraindicated.

PMID:39019579 | DOI:10.1136/emermed-2023-213591

Eur J Hosp Pharm. 2024 Jul 17:ejhpharm-2024-004205. doi: 10.1136/ejhpharm-2024-004205. Online ahead of print.

ABSTRACT

OBJECTIVES: Patients on oral anticancer therapy regularly experience medication-related problems (MRPs), potentially leading to non-adherence and medication waste. Most studies reporting these experiences have cross-sectional designs. The aim of our study was to explore patient reported MRPs, adherence and waste of oral anticancer medication over time.

METHODS: A prospective longitudinal quantitative interview study with 4 months follow-up was performed among patients on oral anticancer medication (mainly tyrosine kinase inhibitors, (anti)hormonal therapy, pyrimidine antagonists) using a semi-structured questionnaire. Patients from two Dutch university medical centres were included from March to December 2022 after informed consent was given. Four interviews were performed with 1 month in between. All interviews were audiotaped, after which the data were entered into an electronic case report form. The primary outcome was the mean number of MRPs per patient per interview round. Secondary outcomes were the proportion of patients with at least one MRP, types of MRPs, perceived non-adherence, medication waste (both in general and specifically for anticancer medication), costs of anticancer medication waste, and factors associated with medication waste as mentioned by the patient. Descriptive statistics were used to analyse the data.

RESULTS: Forty patients were included with a mean (SD) age of 64 (9) years; 43% were male. The mean number of MRPs per patient was 2.1 in the first interview and 1.2, 1.0 and 0.9 in the second, third and fourth interviews, respectively. Adverse drug reactions were the most frequently reported type of MRPs (30 (75%) patients in the first interview and 19 (65%) in the last interview). Unintentional non-adherence was regularly reported, especially in the first interview. Medication changes were frequent and associated medication waste was mentioned in all interviews.

CONCLUSIONS: Many patients using oral anticancer treatment report MRPs and this number remains substantial over time.

PMID:39019578 | DOI:10.1136/ejhpharm-2024-004205

Br J Ophthalmol. 2024 Jul 17:bjo-2023-324526. doi: 10.1136/bjo-2023-324526. Online ahead of print.

ABSTRACT

BACKGROUND: Large language models (LLMs), such as ChatGPT, have considerable implications for various medical applications. However, ChatGPT’s training primarily draws from English-centric internet data and is not tailored explicitly to the medical domain. Thus, an ophthalmic LLM in Chinese is clinically essential for both healthcare providers and patients in mainland China.

METHODS: We developed an LLM of ophthalmology (MOPH) using Chinese corpora and evaluated its performance in three clinical scenarios: ophthalmic board exams in Chinese, answering evidence-based medicine-oriented ophthalmic questions and diagnostic accuracy for clinical vignettes. Additionally, we compared MOPH’s performance to that of human doctors.

RESULTS: In the ophthalmic exam, MOPH’s average score closely aligned with the mean score of trainees (64.7 (range 62-68) vs 66.2 (range 50-92), p=0.817), but achieving a score above 60 in all seven mock exams. In answering ophthalmic questions, MOPH demonstrated an adherence of 83.3% (25/30) of responses following Chinese guidelines (Likert scale 4-5). Only 6.7% (2/30, Likert scale 1-2) and 10% (3/30, Likert scale 3) of responses were rated as ‘poor or very poor’ or ‘potentially misinterpretable inaccuracies’ by reviewers. In diagnostic accuracy, although the rate of correct diagnosis by ophthalmologists was superior to that by MOPH (96.1% vs 81.1%, p>0.05), the difference was not statistically significant.

CONCLUSION: This study demonstrated the promising performance of MOPH, a Chinese-specific ophthalmic LLM, in diverse clinical scenarios. MOPH has potential real-world applications in Chinese-language ophthalmology settings.

PMID:39019566 | DOI:10.1136/bjo-2023-324526