Nevin Manimala

Am J Emerg Med. 2021 Oct 30;51:290-295. doi: 10.1016/j.ajem.2021.10.034. Online ahead of print.

ABSTRACT

OBJECTIVES: To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints.

METHODS: Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7 and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities.

RESULTS: A total of 9850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p < .001). Similarly, we found that patients presenting with AMS had a significantly higher risk of dying within 30 days compared to patients with chest pain (HR 3.65, 95% CI 2.49 to 5.37, p < .001), and headache (HR 2.09, 95% CI 1.09 to 4.01, p = .026). Differences were not statistically significant for comparisons with abdominal pain and generalized weakness, but confidence intervals were wide.

CONCLUSION: Patients presenting with AMS have worse short-term prognosis than patients presenting to the ED with chest pain or headache. AMS may indicate an underlying brain dysfunction (delirium), which is associated with adverse outcomes and increased mortality.

PMID:34785485 | DOI:10.1016/j.ajem.2021.10.034

Am J Emerg Med. 2021 Oct 30;51:285-289. doi: 10.1016/j.ajem.2021.10.050. Online ahead of print.

ABSTRACT

OBJECTIVES: Ultrasound (US) is an essential component of emergency department patient care. US machines have become smaller and more affordable. Handheld ultrasound (HUS) machines are even more portable and easy to use at the patient’s bedside. However, miniaturization may come with consequences. The ability to accurately interpret ultrasound on a smaller screen is unknown. This pilot study aims to assess how screen size affects the ability of emergency medicine clinicians to accurately interpret US videos.

METHODS: This pilot study enrolled a prospective convenience sample of emergency medicine physicians. Participants completed a survey and were randomized to interpret US videos starting with either a phone-sized screen or a laptop-sized screen, switching to the other device at the halfway point. 50 unique US videos depicting right upper quadrant (RUQ) views of the Focused Assessment with Sonography in Trauma (FAST) examination were chosen for inclusion in the study. There were 25 US videos per device. All of the images were previously obtained on a cart-based machine (Mindray M9) and preselected by the study authors. Participants answered “Yes” or “No” in response to whether they identified free fluid. The time that each participant took to interpret each video was also recorded. Following the assessment, participants completed a post-interpretation survey. The goal of the pilot was to determine the accuracy of image interpretation on a small screen as compared to a laptop-sized screen. Statistical analyses were performed using MATLAB (The MathWorks, Inc., Natick, MA). Nonparametric statistical tests were utilized to compare subgroups, with a Wilcoxon signed rank test used for paired data and a Wilcoxon rank sum test for unpaired data.

RESULTS: 52 emergency medicine physicians were enrolled in the study. The median accuracy of US interpretation for phone versus laptop image screen was 88.0% and 87.6% (p = 0.67). The mean time to interpret with phone versus laptop screen was 293 and 290 s (p = 0.66).

CONCLUSIONS: The study found no statistically significant difference in the accuracy of US interpretation nor time spent interpreting when the pre-selected RUQ videos generated on a cart-based ultrasound machine were reviewed on a phone-sized versus a laptop-sized screen. This pilot study suggests that the accuracy of US interpretation may not be dependent upon the size of the screen utilized.

PMID:34785484 | DOI:10.1016/j.ajem.2021.10.050

J Stroke Cerebrovasc Dis. 2021 Nov 13;31(1):106167. doi: 10.1016/j.jstrokecerebrovasdis.2021.106167. Online ahead of print.

ABSTRACT

PURPOSE: Patients with polycythemia, either primary or secondary, are at elevated risk for thrombotic complications, including stroke. We aimed to investigate the clinical and radiological characteristics of cerebrovascular disease (CVD) in polycythemia, and describe other neurologic manifestations.

METHODOLOGY: We conducted a cross-sectional study of patients diagnosed with polycythemia between 2014 and 2019 at a tertiary care center and collected relevant medical data with a special focus on cerebrovascular disease and neurologic manifestations. We performed descriptive and inferential analyses. We have also described and analyzed the available neuroimaging features.

RESULTS: We analyzed data from 56 patients. 20 patients (35.7%) had ischemic stroke. The incidence of CVD was higher in those with primary polycythemia (43%) than in those with secondary polycythemia (8%). The most common subtype of stroke was large vessel disease, and the most common arterial territory was the anterior circulation. There was no statistically significant difference in the hematocrit level between those with or without CVD. Neuroimaging revealed multiple large vessel intracranial stenoses on MR Angiography, and hyperdense vessels on plain CT. Other neurologic manifestations included headache, seizures, dizziness, visual symptoms and papilledema, and these were significantly more common in primary polycythemia.

CONCLUSIONS: CVD is common in patients with polycythemia. The most common type observed was large vessel occlusion, predominantly in the anterior circulation. In stroke patients, multiple vessel stenosis and hyperdense vessels may be clues to polycythemia.

PMID:34785446 | DOI:10.1016/j.jstrokecerebrovasdis.2021.106167

Neural Netw. 2021 Nov 8;145:300-307. doi: 10.1016/j.neunet.2021.10.026. Online ahead of print.

ABSTRACT

Clipping on learning rates in Adam leads to an effective stochastic algorithm-AdaBound. In spite of its effectiveness in practice, convergence analysis of AdaBound has not been fully explored, especially for non-convex optimization. To this end, we address the convergence of the last individual output of AdaBound for non-convex stochastic optimization problems, which is called individual convergence. We prove that, with the iteration of the AdaBound, the cost function converges to a finite value and the corresponding gradient converges to zero. The novelty of this proof is that the convergence conditions on the bound functions and momentum factors are much more relaxed than the existing results, especially when we remove the monotonicity and convergence of the bound functions, and only keep their boundedness. The momentum factors can be fixed to be constant, without the restriction of monotonically decreasing. This provides a new perspective on understanding the bound functions and momentum factors of AdaBound. At last, numerical experiments are provided to corroborate our theory and show that the convergence of AdaBound extends to more general bound functions.

PMID:34785445 | DOI:10.1016/j.neunet.2021.10.026

Epilepsy Behav. 2021 Nov 13;125:108399. doi: 10.1016/j.yebeh.2021.108399. Online ahead of print.

ABSTRACT

PURPOSE: To evaluate Sexual Function Scores in women of childbearing age with epilepsy.

METHOD: Cross-sectional study and comparison of two groups, one with and the other without epilepsy. The instruments used were: semi-structured socioeconomic, demographic and clinical questionnaire; Beck Anxiety and Depression Inventories; Word Health Organization Quality of Life (WHOQOL-brief); Female Sexual Function Index (FSFI); and Female Genital Self Image Scale (FGSIS). Statistical analysis was performed using Fisher’s Exact Test, Chi-Square, Mann-Whitney, and Spearman’s Correlation, considering p < 0.05 as a measure of significance.

RESULTS: 110 women were included (55 with epilepsy and 55 without epilepsy) with a mean age of 32 years. Both groups had sexual dysfunction (with epilepsy: 19.28 vs. without epilepsy: 21.05; p = 0.416). There was no significant difference between groups in the analysis of self-image of the genitalia, Quality of Life, or Anxiety. However, there was a statistical difference in Depression Symptoms (with epilepsy: 11.44 vs. without epilepsy:13.82, p = 0.038). When evaluating the influence of epilepsy on sexual function score, women who used enzyme-inducing drugs had worse scores in desire domain (5.21 vs. 6.65; p = 0.020) and lubrication domain (9.48 vs. 12.95; p = 0.047) when compared to women who used non-enzyme-inducing drugs, respectively. In the correlation of Sexual Function with Anxiety, Depression, Quality of Life, and Self-Image of the genitalia, it was observed that when Depression levels increase, desire is impaired [-0.273(p = 0.043)]. In Quality of Life, the psychological [0.311(p = 0.021)] and environmental [0.268(p = 0.048)] domains positively influenced desire. The social relationships domain improved desire [0.504(p = 0.000)], excitement [0.461(p = 0.000)], lubrication [0.342(p = 0.011)], orgasm [0.425(p = 0.001)], satisfaction [0.449(p = 0.001)], and decreased pain [0.402(p = 0.002)]. Consequently, these influence appeared to improve sexual function [0.521(p = 0.000)].

CONCLUSION: Women of childbearing age with epilepsy have sexual dysfunction. The presence of signs of depression and the use of enzyme-inducing drugs must be carefully analyzed, as they can worsen the sexual function score. Health professionals need to be aware that sexual dysfunction must be investigated because this issue influences the quality of life of these women.

PMID:34785412 | DOI:10.1016/j.yebeh.2021.108399

Photodiagnosis Photodyn Ther. 2021 Nov 13:102626. doi: 10.1016/j.pdpdt.2021.102626. Online ahead of print.

ABSTRACT

AIM: To evaluate the effect of prematurity on choroidal structure in children born preterm with no history of retinopathy of prematurity (ROP) by comparing them with age-matched healthy children born at full term.

METHODS: Enhanced depth imaging optical coherence tomography (EDI-OCT) scans of children aged 5 to 9 years with a history of prematurity but no history of ROP, and age-matched full-term healthy children were evaluated, retrospectively. Choroidal thicknesses (CTs) were measured at subfoveal (SFCT), 1000 µm temporal and nasal from the fovea (T1, N1), and 2000 µm temporal and nasal (T2, N2) from the fovea. The EDI-OCT images were binarized to stromal (SA) and luminal areas (LA) using the ImageJ software. The choroidal vascularity index (CVI) was calculated by dividing LA by the total choroidal area (TCA).

RESULTS: Twenty-nine eyes of 15 preterm children and 41 eyes of 26 full-term children were included. Demographic characteristics including axial length (AL), eye side, age, and the sex of the children in the groups were similar (p>0.05). There was no statistically significant difference in the mean CVI, SFCT, N1, and T1 values between the groups (p>0.05); however, the mean T2 and N2 values were significantly higher in the full-term group than in the preterm group (p<0.05). There was a significant positive correlation between the birth week and the T1 (p<0.05) CONCLUSION: : Prematurity can affect CT even with no history of ROP. The decreases in CTs were significant at 2000 µm nasal and temporal from the fovea. The impairment of temporal choroidal region was more evident than nasal choroidal region. The mean CVI values were similar between the groups.

PMID:34785405 | DOI:10.1016/j.pdpdt.2021.102626

J Gynecol Obstet Hum Reprod. 2021 Nov 13:102271. doi: 10.1016/j.jogoh.2021.102271. Online ahead of print.

ABSTRACT

INTRODUCTION: Up to 30% of couples may face secondary infertility. The impact of ectopic pregnancy, spontaneous abortion, pregnancy termination or live birth with caesarean section may impair further fertility in different ways. However, secondary infertility after physiological vaginal life childbirth has been little studied. The aim of this study was to describe the population and the fertility issues and analyze the predictive factors of success in in vitro fertilization in women presenting secondary infertility after a physiological vaginal childbirth.

MATERIAL AND METHODS: This single-centre retrospective study included women aged 18-43 years consulting between 2013 and 2020 for secondary infertility in a couple having already had previous vaginal life childbirth. Couples’ characteristics, management decision after the first consultation and IVF outcomes were analyzed.

RESULTS: Secondary infertility was found in 286 couples, out of whom 138 had a history of vaginal life childbirth. Population was characterized by an advanced female age and overweight. After the first consultation, IVF was performed in only 40% of couples. No predictive factor of live birth was found.

CONCLUSION: Our study shows that in couples with secondary infertility after prior physiological delivery cigarette smoking is frequent in male partners, and ovarian reserve markers are altered. However, no statistically significant predictive factor of live birth after IVF treatment has been identified. Further large prospective studies are necessary.

PMID:34785399 | DOI:10.1016/j.jogoh.2021.102271

Ann Epidemiol. 2021 Nov 13:S1047-2797(21)00324-0. doi: 10.1016/j.annepidem.2021.11.006. Online ahead of print.

ABSTRACT

PURPOSE: The Veterans Health Administration (VA) is the largest single integrated healthcare system in the US and is likely the largest healthcare provider for people with minoritized sexual orientations (e.g., gay, lesbian, bisexual). The purpose of this study was to use electronic health record (EHR) data to replicate self-reported survey findings from the general US population and assess whether sexual orientation is associated with diagnosed physical health conditions that may elevate risk of COVID-19 severity among veterans who utilize the VA.

METHODS: A retrospective analysis of VA EHR data from 10/01/1999-07-01-2019 analyzed in 2021. Veterans with minoritized sexual orientations were included if they had documentation of a minoritized sexual orientation within clinical notes identified via natural language processing. Veterans without minoritized sexual orientation documentation comprised the comparison group. Adjusted prevalence and prevalence ratios (aPR) were calculated overall and by race/ethnicity while accounting for differences in distributions of sex assigned at birth, age, calendar year of first VA visit, volumes of healthcare utilization, and VA priority group.

RESULTS: Data from 108,401 veterans with minoritized sexual orientation and 6,511,698 controls were analyzed. After adjustment, veterans with minoritized sexual orientations had a statistically significant elevated prevalence of 10 of the 11 conditions. Amongst the highest disparities observed were COPD (aPR:1.24 [95% confidence interval:1.23-1.26]), asthma (1.22 [1.20-1.24]), and stroke (1.26 [1.24-1.28]).

CONCLUSIONS: Findings largely corroborated patterns among the general US population. Further research is needed to determine if these disparities translate to poorer COVID-19 outcomes for individuals with minoritized sexual orientation.

PMID:34785397 | DOI:10.1016/j.annepidem.2021.11.006

J Allergy Clin Immunol Pract. 2021 Nov 13:S2213-2198(21)01259-9. doi: 10.1016/j.jaip.2021.10.068. Online ahead of print.

ABSTRACT

BACKGROUND: Autonomy is the ability of patients to make informed medical decisions. Autonomy is rooted in disease state understanding. Medical ethics, especially the principle of autonomy, plays an important role in healthcare delivery when caring for diverse populations.

OBJECTIVE: We sought to identify patient characteristics that influence autonomy.

METHODS: 295 adults with moderate to severe asthma completed two surveys at the beginning of a one year randomized clinical trial. The Navigating Ability and Inhaled Corticosteroids Knowledge questionnaires were combined to create a 21-question assessment of autonomy with possible scores ranging from 10-105. Linear regression was performed on the derived autonomy score predicted by patient baseline characteristics.

RESULTS: Comparison revealed statistically significant differences in baseline autonomy scores in patients who reported Spanish as their primary language (p=0.01), patients with diabetes (p=0.01), and those with depressive symptoms (p=0.03) at -11.4 (95% CI, -20.5, -2.3), -4.8 (95% CI, -8.3, -1.3), and -3.1 (95% CI, -5.9, -0.3) points respectively. Non-Hispanic White participants on average were found to have 8.2 (95% CI, 4.5, 12.0) points higher autonomy scores compared to non-Hispanic Black participants (Bonferroni adjusted p<0.01). Patients with higher functional health literacy had higher autonomy scores (coefficient=0.24, 95% CI, 0.1, 0.4, p<0.01) CONCLUSIONS: Autonomy is associated with comorbidities, demographics, and literacy. These results may reflect differences in social, educational, and economic opportunities encountered by patients. Further investigation is needed to assess and understand how socioeconomic and educational factors influence autonomy. By identifying differences in autonomy based on baseline patient characteristics, this project serves as an initial step in adjusting current and developing new treatment guidelines and interventions to improve patient autonomy.

PMID:34785390 | DOI:10.1016/j.jaip.2021.10.068

Ann Vasc Surg. 2021 Nov 13:S0890-5096(21)00883-9. doi: 10.1016/j.avsg.2021.10.047. Online ahead of print.

ABSTRACT

OBJECTIVE: to identify predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU).

METHODS: We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN-USA, residents diagnosed with AD, IMH, and PAU (1995-2015). The endpoints were aortic diameter change, freedom from clinical disease progression (any related intervention, aortic aneurysm, new aortic syndrome, rupture or death) and disease resolution (complete spontaneous radiological disappear). Linear regression was used to assess aortic growth rate; predictors of disease progression were identified with Cox proportional hazards.

RESULTS: Of 133 incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included. Overall median follow-up was 8.1 years. Aortic diameter increase occurred in 40 ADs (87%, median 1.0 mm/year), 5 IMHs (42%, median 0.2 mm/year) and 14 PAUs (50%, median 0.4 mm/year). Symptomatic presentation (P=.045), connective tissue disorders (P=.005), and initial aortic diameter >42 mm (P=.013) were associated with AD growth rate. PAU depth >9 mm (P=.047) and female sex (P=.013) were associated with aortic growth rate in PAUs and IMHs. At 10 years, freedom from disease progression was 22% (95%CI 12-41) for ADs, 44% (95%CI 22-92) for IMHs, and 46% (95%CI 27-78) for PAUs. DeBakey I/IIIB AD (HR 3.09; P=.038), initial IMH aortic diameter (HR 1.4; P=.037) and PAU depth >10 mm (HR 3.92; P=.018) were associated with disease progression. No AD spontaneously resolved; resolution rate at 10 years was 22% (95%CI 0-45) for IMHs and 11% (95%CI 0-23) for PAUs.

CONCLUSIONS: Aortic growth and clinical disease progression are observed in most patients with aortic syndromes, while spontaneous resolution is uncommon. Predictors of aortic growth and disease progression may be used to tailor appropriate follow-up and eventual early intervention.

PMID:34785342 | DOI:10.1016/j.avsg.2021.10.047