Nevin Manimala

Am J Clin Nutr. 2023 Oct 7:S0002-9165(23)66176-3. doi: 10.1016/j.ajcnut.2023.10.002. Online ahead of print.

ABSTRACT

BACKGROUND: Evidence on associations between dairy consumption and incident prediabetes is inconsistent. One potential explanation for heterogeneity is that health behavior and food intake co-vary with the consumption of various high-fat and low-fat dairy types.

OBJECTIVE: The objective was to investigate the associations of total dairy and dairy types with incident prediabetes, and to assess how dairy intake is linked with metabolic risk factors, lifestyle behaviors and foods, as potential explanations for these associations.

METHODS: 74,132 participants from the prospective population-based Lifelines study were included (mean age 45.5±12.3 years, 59.7% female). Baseline dairy intake was measured using a validated food frequency questionnaire. Prediabetes at follow-up was defined based on the WHO/International Expert Committee (IEC) criteria as fasting plasma glucose (FPG) of 110-125 mg/dl or glycated hemoglobin (A1C) levels of 6.0-6.5%. Associations were analyzed using Poisson regression models adjusted for social demographics, lifestyle behaviors, family history of diabetes and food group intake. Interconnections were assessed with mixed graphical model (MGM) networks.

RESULTS: At a mean follow-up of 4.1±1.1 years, 2,746 participants developed prediabetes (3.7%). In regression analyses, neutral associations were found for most dairy types. Intake of plain milk and low-fat milk were associated with a higher risk of prediabetes in the top vs. bottom quartiles (RR 1.17, 95%CI 1.05-1.30, p_trend=0.04 and 1.18, 95%CI 1.06-1.31, p_trend=0.01). Strong but non-significant effect estimates for high-fat yogurt in relation to prediabetes were found (RR_servings/day 0.80, 95%CI 0.64-1.01). The network analysis showed that low-fat milk clustered with energy-dense foods including bread, meat, and high-fat cheese, while high-fat yogurt had no clear link with lifestyle risk factors and food intake.

CONCLUSIONS: In this large cohort of Dutch adults, low-fat milk intake was associated with higher prediabetes risk. Heterogeneous associations by dairy type and fat content might partly be attributed to confounding caused by behaviors and food intake related to dairy intake.

PMID:37813340 | DOI:10.1016/j.ajcnut.2023.10.002

World Neurosurg. 2023 Oct 7:S1878-8750(23)01400-6. doi: 10.1016/j.wneu.2023.10.006. Online ahead of print.

ABSTRACT

OBJECTIVE: Traumatic middle meningeal artery (MMA)-middle meningeal vein (MMV) fistula (MMA-MMV fistula) and MMA pseudoaneurysm are the two main MMA-related vascular diseases occurring after blunt head trauma. These are rare but known causes of delayed intracranial hemorrhage. This study investigated predictors that may aid in the diagnosis of these diseases.

METHODS: In our department, screening digital subtraction angiography (DSA) is performed for patients with blunt head trauma accompanied by intracranial hemorrhage and skull or facial bone fracture. This study included 87 patients who underwent screening DSA without craniotomy from January 2019 to June 2023. The patients’ clinical characteristics were retrospectively collected from the database. Statistical analysis was performed to examine the associations of various evaluation items with MMA-related vascular diseases.

RESULTS: The first DSA examination revealed 34 MMA-MMV fistulas and one MMA pseudoaneurysms. The second follow-up DSA examination revealed 13 MMA-MMV fistulas and four MMA pseudoaneurysms. Temporal/parietal bone fracture (odds ratio, 5.33; p = 0.0005; 95% confidence interval, 1.95-14.60) was significantly associated with MMA-related vascular diseases. Endovascular treatments were performed in 9 patients. All procedures were successfully completed without complications; no delayed bleeding was observed.

CONCLUSIONS: Temporal/parietal bone fracture in patients with blunt head trauma is a likely predictor of MMA-related vascular diseases. When initial head computed tomography reveals this pathology, we recommend careful imaging follow-up (e.g., DSA) and treatment as needed, while considering the possibility of MMA-related vascular diseases.

PMID:37813338 | DOI:10.1016/j.wneu.2023.10.006

World Neurosurg. 2023 Oct 7:S1878-8750(23)01411-0. doi: 10.1016/j.wneu.2023.10.017. Online ahead of print.

ABSTRACT

BACKGROUND: There are several approaches used for surgical treatment of neurogenic thoracic outlet syndrome (n-TOS). The posterior upper rib excision and decompression (PURED) technique is a novel technique which was developed and used by the author for the last eight years. The purpose of this paper is to report clinical outcomes of patients treated with this approach.

METHODS: All patients with n-TOS operated by single surgeon from 2015 to 2023 were retrospectively analyzed. Demographic, clinical, radiological, surgical and postoperative data were collected and reported with emphasis on efficacy and complications. The surgical success was evaluated subjectively as excellent, good, fair, poor and bad. Radiological data were analyzed to assess the extent of accessory/first rib removal.

RESULTS: 80 procedures were performed in 61 patients with mean follow up 1153 (87-3048) days. 60.7% of patients were females and 39.3% were males. In 11 cases (18%) causative factor was bone abnormality. Two patients were previously operated at another centers (3.3%). Total mean subjective improvement rate was 91.5%. 55 patients reported “excellent” (>75%) and 6 “good” improvements (50-75%); no fair, poor and worse outcomes were reported. Patients reporting “good” outcome had statistically significant shorter follow ups than “excellent” group (p<0.001). Complications included pleural opening, Horner syndrome and apical hematoma and none of them were permanent.

CONCLUSION: PURED approach provides excellent clinical outcomes in patients with n-TOS. It allows better intraoperative visualization and removal of the first rib and full decompression of the neuro-vascular bundle.

PMID:37813334 | DOI:10.1016/j.wneu.2023.10.017

Am J Respir Crit Care Med. 2023 Oct 9. doi: 10.1164/rccm.202207-1349OC. Online ahead of print.

ABSTRACT

RATIONALE: The global burden of sepsis is greatest in low-resource settings. Melioidosis, infection with the Gram-negative bacterium Burkholderia pseudomallei, is a frequent cause of fatal sepsis in endemic tropical regions such as Southeast Asia.

OBJECTIVES: To investigate whether plasma metabolomics would identify biological pathways specific to melioidosis and yield clinically meaningful biomarkers.

METHODS: Using a comprehensive approach, differential enrichment of plasma metabolites and pathways were systematically evaluated in patients from a prospective cohort of individuals hospitalized in rural Thailand with infection. Statistical and bioinformatics methods were used to distinguish metabolomic features and processes specific to melioidosis patients, and between fatal and non-fatal cases.

MEASUREMENTS AND MAIN RESULTS: Metabolomic profiling and pathway enrichment analysis of plasma samples of melioidosis (n=175) and non-melioidosis infections (n=75) revealed a distinct immuno-metabolic state among patients with melioidosis, as suggested by excessive tryptophan catabolism in the kynurenine pathway and significantly increased lipid metabolism such as sphingomyelins and ceramide species. We derived a 12-metabolite classifier to distinguish melioidosis from other infections, with an area under the receiver operating characteristic curve of 0.87 in a second validation set of patients. Melioidosis non-survivors (n=94) had a significantly disturbed metabolome compared to survivors (n=81) with increased leucine, isoleucine and valine metabolism, and elevated circulating free fatty acids and acylcarnitines. A limited 8-metabolite panel shows promise as an early prognosticator of mortality in melioidosis.

CONCLUSIONS: Melioidosis induces a distinct metabolomic state that can be leveraged to distinguish underlying pathophysiological mechanisms leading to increased risk of death. A twelve-metabolite signature accurately differentiates melioidosis from other infections and may have diagnostic applications.

PMID:37812796 | DOI:10.1164/rccm.202207-1349OC

Can Urol Assoc J. 2023 Sep 29. doi: 10.5489/cuaj.8451. Online ahead of print.

ABSTRACT

INTRODUCTION: Penile cancers are a rare subset of carcinomas accounting for <1% of all diagnosed malignancies. There have been recent reports of increasing incidence globally; however, there is limited Canadian literature pertaining to these neoplasms. The province of Newfoundland and Labrador (NL) represents an important entity to study, possessing the highest national incidence of cancer, along with a plethora of relevant risk factors for penile cancer.

METHODS: A retrospective chart analysis of all patients with a diagnosis of penile cancer in NL between the years of 2006 and 2018 was conducted. The main outcomes included overall incidence, proportion with metastatic disease, tumor demographics, and overall survival (OS). Incidence among the male population was calculated using Statistics Canada annual reports.

RESULTS: An identified 81 cases satisfied the inclusion criteria, with a median age at diagnosis of 65 (interquartile range 20) years. Crude incidence of penile cancer ranged from 1.20 to 4.27/100 000 males in 2007 and 2010, respectively, while the average age-standardized incidence was 2.34/100 000 males across the study timeframe. Metastatic disease was noted in 17 (21.0%) patients, with a five-year OS of 74% for all penile malignancies, decreasing to 66% in those with invasive squamous cell carcinoma.

CONCLUSIONS: The incidence of penile cancer in our population was higher than reported Western jurisdictions and showed frequent rates of metastatic spread. These observations are likely multifactorial, resultant of chronic inflammation paired with high rates of modifiable risk factors and diagnostic delays. An evident need for greater examination and improved reporting of these malignancies in the province was identified.

PMID:37812793 | DOI:10.5489/cuaj.8451

Can Urol Assoc J. 2023 Sep 29. doi: 10.5489/cuaj.8450. Online ahead of print.

ABSTRACT

INTRODUCTION: During the early stages of the COVID-19 pandemic, hospitals shifted their resources and focus toward COVID-19 care and non-deferrable conditions. Renal colic is one of the most common urologic presentations to the emergency department (ED). In our study, we examined whether there was an increase in septic/febrile stone presentations to the ED requiring ureteral stent insertion after the public health restrictions during the COVID-19 pandemic.

METHODS: We carried out a retrospective cohort study and reviewed charts of septic/febrile stone patients requiring ureteral stent insertion from January 1, 2019, to March 16, 2020 (pre-COVID) and July 1, 2020, to December 31, 2021 (intra-COVID) at the QEII, Halifax, NS. The incidence of septic/febrile stone presentation, baseline characteristics, and perioperative outcomes were captured.

RESULTS: There were 54 patients in the pre-COVID group and 74 patients in the intra-COVID group. There were no statistically significant differences found in baseline or stone characteristics between the two groups (p>0.05). Patients in the intra-COVID group were found to have a longer presentation to operating room time when compared to the pre-COVID cohort (U=961.00, p=0.04). The intra-COVID group had 20 more cases of septic stone presentations compared to the pre-COVID group at the 15-month mark (pre-COVID, n=54; intra-COVID, n=74).

CONCLUSIONS: We found increased time to operative intervention in the intra-COVID cohort compared to the pre-COVID cohort. The overall number of urgent and/or critically ill ureteric stone patients increased between cohorts but was not statistically significant.

PMID:37812788 | DOI:10.5489/cuaj.8450

Ann Intern Med. 2023 Oct 10. doi: 10.7326/M23-0949. Online ahead of print.

ABSTRACT

BACKGROUND: Substantial effort has been directed toward demonstrating uses of predictive models in health care. However, implementation of these models into clinical practice may influence patient outcomes, which in turn are captured in electronic health record data. As a result, deployed models may affect the predictive ability of current and future models.

OBJECTIVE: To estimate changes in predictive model performance with use through 3 common scenarios: model retraining, sequentially implementing 1 model after another, and intervening in response to a model when 2 are simultaneously implemented.

DESIGN: Simulation of model implementation and use in critical care settings at various levels of intervention effectiveness and clinician adherence. Models were either trained or retrained after simulated implementation.

SETTING: Admissions to the intensive care unit (ICU) at Mount Sinai Health System (New York, New York) and Beth Israel Deaconess Medical Center (Boston, Massachusetts).

PATIENTS: 130 000 critical care admissions across both health systems.

INTERVENTION: Across 3 scenarios, interventions were simulated at varying levels of clinician adherence and effectiveness.

MEASUREMENTS: Statistical measures of performance, including threshold-independent (area under the curve) and threshold-dependent measures.

RESULTS: At fixed 90% sensitivity, in scenario 1 a mortality prediction model lost 9% to 39% specificity after retraining once and in scenario 2 a mortality prediction model lost 8% to 15% specificity when created after the implementation of an acute kidney injury (AKI) prediction model; in scenario 3, models for AKI and mortality prediction implemented simultaneously, each led to reduced effective accuracy of the other by 1% to 28%.

LIMITATIONS: In real-world practice, the effectiveness of and adherence to model-based recommendations are rarely known in advance. Only binary classifiers for tabular ICU admissions data were simulated.

CONCLUSION: In simulated ICU settings, a universally effective model-updating approach for maintaining model performance does not seem to exist. Model use may have to be recorded to maintain viability of predictive modeling.

PRIMARY FUNDING SOURCE: National Center for Advancing Translational Sciences.

PMID:37812781 | DOI:10.7326/M23-0949

Ann Intern Med. 2023 Oct 10. doi: 10.7326/M23-1808. Online ahead of print.

ABSTRACT

Dementia, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is defined by a significant decline in 1 or more cognitive domains that interferes with a person’s independence in daily activities. Mild cognitive impairment (MCI) differs from dementia in that the impairment is not sufficient to interfere with independence. For the purposes of this discussion, cognitive impairment (CI) includes both dementia and MCI. Various screening tests are available for CI. These tests ask patients to perform a series of tasks that assess 1 or more domains of cognitive function or ask a caregiver to report on the patient’s abilities. A positive result on a screening test does not equate to a diagnosis of CI; rather, it should lead to additional testing to confirm the diagnosis. On review of the evidence, the U.S. Preventive Services Task Force (USPSTF) concluded in 2020 that the evidence was insufficient to assess the balance of benefits and harms of screening for CI in older adults (“I statement”). The USPSTF did clarify that although there is insufficient evidence, there may be important reasons to identify CI. In this article, 2 experts review the available evidence to answer the following questions: What screening tools are available, and how effective are they in identifying patients with CI? What interventions are available for patients found to have CI, to what extent do they improve patient outcomes, and what, if any, negative effects occur? And, would they recommend screening for CI, and why or why not?

PMID:37812780 | DOI:10.7326/M23-1808

Ann Intern Med. 2023 Oct 10. doi: 10.7326/M23-0872. Online ahead of print.

ABSTRACT

BACKGROUND: More than 2 million children are conceived annually using assisted reproductive technologies (ARTs), with a similar number conceived using ovulation induction and intrauterine insemination (OI/IUI). Previous studies suggest that ART-conceived children are at increased risk for congenital anomalies (CAs). However, the role of underlying infertility in this risk remains unclear, and ART clinical and laboratory practices have changed drastically over time, particularly there has been an increase in intracytoplasmic sperm injection (ICSI) and cryopreservation.

OBJECTIVE: To investigate the role of underlying infertility and fertility treatment on CA risks in the first 2 years of life.

DESIGN: Propensity score-weighted population-based cohort study.

SETTING: New South Wales, Australia.

PARTICIPANTS: 851 984 infants (828 099 singletons and 23 885 plural children) delivered between 2009 and 2017.

MEASUREMENTS: Adjusted risk difference (aRD) in CAs of infants conceived through fertility treatment compared with 2 naturally conceived (NC) control groups-those with and without a parental history of infertility (NC-infertile and NC-fertile).

RESULTS: The overall incidence of CAs was 459 per 10 000 singleton births and 757 per 10 000 plural births. Compared with NC-fertile singleton control infants (n = 747 018), ART-conceived singleton infants (n = 31 256) had an elevated risk for major genitourinary abnormalities (aRD, 19.0 cases per 10 000 births [95% CI, 2.3 to 35.6]); the risk remained unchanged (aRD, 22 cases per 10 000 births [CI, 4.6 to 39.4]) when compared with NC-infertile singleton control infants (n = 36 251) (that is, after accounting for parental infertility), indicating that ART remained an independent risk. After accounting for parental infertility, ICSI in couples without male infertility was associated with an increased risk for major genitourinary abnormalities (aRD, 47.8 cases per 10 000 singleton births [CI, 12.6 to 83.1]). There was some suggestion of increased risk for CAs after fresh embryo transfer, although estimates were imprecise and inconsistent. There were no increased risks for CAs among OI/IUI-conceived infants (n = 13 574).

LIMITATIONS: This study measured the risk for CAs only in those children who were born at or after 20 weeks’ gestation. Observational study design precludes causal inference. Many estimates were imprecise.

CONCLUSION: Patients should be counseled on the small increased risk for genitourinary abnormalities after ART, particularly after ICSI, which should be avoided in couples without problems of male infertility.

PRIMARY FUNDING SOURCE: Australian National Health and Medical Research Council.

PMID:37812776 | DOI:10.7326/M23-0872

J Intensive Care Med. 2023 Oct 9:8850666231201528. doi: 10.1177/08850666231201528. Online ahead of print.

ABSTRACT

INTRODUCTION: The Fundamental Critical Care Support Course (FCCS) is a standardized multidisciplinary program designed to educate participants on the basics of identification and management of patients with critical illness. Our objective was to evaluate the effect of FCCS participation on confidence in the assessment and management of critically ill patients and attitudes towards multidisciplinary education and interprofessional care in a multidisciplinary group of participants.

METHODS: Participants enrolled in the FCCS course from May 2018 to November 2019 were solicited to participate in a series of surveys evaluating their course experience and confidence in critical care. Attitudes towards multidisciplinary education and interprofessional care were evaluated using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument version 2 (SPICE-R2) tool. A prospective pre- and post-design with a self-report survey including retrospective pre-training assessment and a 3-month follow-up was conducted. Statistical analysis was performed using descriptive statics and non-parametric methods.

RESULTS: 321 (97.9%) of the course participants enrolled in the study and completed the confidence survey and SPICE-R2 tool pre-course. Nurses (113, 35.4%) and physicians (110, 34.4%) made up the largest groups of participants, although physician assistants and paramedics were also well represented. Confidence in recognition and management of critical illness significantly improved across all studied domains after course completion, with the mean total confidence score improving from 32.96 pre-course to 41.10 post-course, P < 0.001. Attitudes towards multidisciplinary education and interprofessional care also improved (mean score 41.37 pre-course vs 42.71 post-course, P < 0.001), although pre-course numbers were higher than expected which limited the significance to only certain domains.

DISCUSSION: In a multidisciplinary group, completion of FCCS training led to increased confidence in all aspects of critical illness measured. A modest increase in attitudes regarding multidisciplinary education and interprofessional care was also demonstrated. Further study is needed to assess whether this increased confidence translates to improvements in patient care and outcomes.

PMID:37812739 | DOI:10.1177/08850666231201528