Nevin Manimala

J Integr Med. 2022 Aug 13:S2095-4964(22)00090-5. doi: 10.1016/j.joim.2022.08.002. Online ahead of print.

ABSTRACT

OBJECTIVE: Appraisal of treatment outcomes in integrative medicine is a challenge due to a gap between the concepts of Western medicine (WM) disease and traditional Chinese medicine (TCM) syndrome. This study presents an approach for the appraisal of integrative medicine that is based on targeted metabolomics. We use non-alcoholic fatty liver disease with spleen deficiency syndrome as a test case.

METHODS: A patient-reported outcome (PRO) scale was developed based on literature review, Delphi consensus survey, and reliability and validity test, to quantitatively evaluate spleen deficiency syndrome. Then, a metabonomic foundation for the treatment of non-alcoholic fatty liver disease with spleen deficiency syndrome was identified via a longitudinal interventional trial and targeted metabolomics. Finally, an integrated appraisal model was established by identifying metabolites that responded in the treatment of WM disease and TCM syndrome as positive outcomes and using other aspects of the metabonomic foundation as independent variables.

RESULTS: Ten symptoms and signs were included in the spleen deficiency PRO scale. The internal reliability, content validity, discriminative validity and structural validity of the scale were all qualified. Based on treatment responses to treatments for WM disease (homeostasis model assessment of insulin resistance) or TCM syndrome (spleen deficiency PRO scale score) from a previous randomized controlled trial, two cohorts comprised of 30 participants each were established for targeted metabolomics detection. Twenty-five metabolites were found to be involved in successful treatment outcomes to both WM and TCM, following quantitative comparison and multivariate analysis. Finally, the model of the integrated appraisal system was exploratively established using binary logistic regression; it included 9 core metabolites and had the prediction probability of 83.3%.

CONCLUSION: This study presented a new and comprehensive research route for integrative appraisal of treatment outcomes for WM disease and TCM syndrome. Critical research techniques used in this research included the development of a TCM syndrome assessment tool, a longitudinal interventional trial with verified TCM treatment, identification of homogeneous metabolites, and statistical modeling.

PMID:36031542 | DOI:10.1016/j.joim.2022.08.002

Cardiovasc Res. 2022 Aug 29:cvac135. doi: 10.1093/cvr/cvac135. Online ahead of print.

ABSTRACT

AIM: Evidence for the effect of elevated blood pressure on the risk of venous thromboembolism (VTE) has been conflicting. We sought to assess the association between systolic blood pressure and the risk of VTE.

METHODS AND RESULTS: Three complementary studies comprising an observational cohort analysis, a one-sample and two-sample Mendelian randomization were conducted using data from 5,588,280 patients registered in the Clinical Practice Research Datalink (CPRD) dataset and 432,173 UK Biobank participants with valid genetic data. Summary statistics of International Network on Venous Thrombosis (INVENT) genome-wide association meta-analysis was used for two-sample Mendelian randomization. The primary outcome was the first occurrence of VTE event, identified from hospital discharge reports, death registers, and/or primary care records. In the CPRD cohort, 104,017 (1.9%) patients had a first diagnosis of VTE during the 9.6-year follow-up. Each 20 mmHg increase in systolic blood pressure was associated with a 7% lower risk of VTE (hazard ratio 0.93, 95% CI [0.92 to 0.94]). Statistically significant interactions were found for sex and body mass index, but not for age and subtype of VTE (pulmonary embolism and deep venous thrombosis). Mendelian randomization studies provided strong evidence for the association between systolic blood pressure and VTE, both in the one-sample (odds ratio [OR]: 0.69 [95% CI 0.57 to 0.83] and two-sample analyses (OR 0.80, 95% CI [0.70 to 0.92]).

CONCLUSIONS: We found an increased risk of VTE with lower blood pressure and this association was independently confirmed in two Mendelian randomization analyses. The benefits of blood pressure reduction are likely to outweigh the harms in most patient groups, but in people with predisposing factors for VTE, further blood pressure reduction should be made cautiously.

TRANSLATIONAL PERSPECTIVE: In a large-scale population cohort, with over 100,000 first episodes of VTE and a median follow-up of about 10 years, we found a 7% higher risk of VTE for each 20 mmHg lower systolic blood pressure. The association was comparable when we examined pulmonary embolism and deep venous thrombosis separately, and persisted after taking into account age and other factors, including anticoagulant treatment during follow-up. These results were confirmed using two independent Mendelian randomization studies. Although the beneficial effects of blood pressure-lowering are likely to outweigh any harms in most patient groups, clinicians should be aware of the potential risk of VTE from antihypertensive therapy, in particular in people who have predisposing factors for VTE.

PMID:36031541 | DOI:10.1093/cvr/cvac135

J Orthop Sci. 2022 Aug 25:S0949-2658(22)00191-9. doi: 10.1016/j.jos.2022.07.010. Online ahead of print.

ABSTRACT

BACKGROUND: This study aimed to assess the impact of delay between admission and surgery on the postoperative outcomes such as mortality and related complications in elderly patients with acute hip fractures.

METHODS: 840 patients aged ≥65 years from January 2009 to September 2015 were included in this retrospective study. According to the interval from admission to surgery, the patients were divided into four groups: group A (surgery within 24 h), group B (surgery within 24 h-48 h), group C (surgery within 48 h-72 h), and group D (surgery later than 72 h). Postoperative complications during hospitalization and mortality at different follow-up time points were compared.

RESULTS: A total of 763 cases were successfully followed up, with an average follow-up time of 30.4 ± 13.1 months. The mean age of the patients was 79.4 ± 6.8 years. The difference in gross postoperative complications among groups was statistically significant in terms of pressure sore (P = 0.02), respiratory complications (P = 0.001), and urological complications (P < 0.001). The multivariate logistic regression analysis identified 3 factors independently associated with the postoperative morbidity, including age (odds ratio [OR] = 1.040), postoperative drainage volume (OR = 1.002) and time from admission to surgery (OR = 1.108). The difference in postoperative mortality among groups was statistically significant at 1 year (P = 0.046) after operation. The multivariate logistic regression analysis identified that age, postoperative drainage volume and time from admission to surgery were independently associated with mortality at 1 year postsurgery.

CONCLUSION: The incidence of postoperative morbidity and mortality in elderly patients with hip fracture is usually the result of multiple factors, surgeons should pay attention to the patient’s age, postoperative wound status and surgical delay time, which may significantly affect the outcome of the treatment.

PMID:36031534 | DOI:10.1016/j.jos.2022.07.010

J Microbiol Immunol Infect. 2022 Aug 17:S1684-1182(22)00135-9. doi: 10.1016/j.jmii.2022.08.006. Online ahead of print.

ABSTRACT

BACKGROUND AND PURPOSE: Urinary tract infections (UTIs) are the most common bacterial infection in young children. This study aimed to formulate nomogram plots for clinicians to predict UTIs in children aged <3 years by evaluating the risk factors for UTIs in these children.

METHODS: This retrospective study was conducted at a tertiary medical center from December 2017 to November 2020. Children less than three years of age were eligible for the study if they had undergone both urine culture and urinalysis during the study period. Mixed-effects logistic regression models with a stepwise procedure were used to determine the relationship between outcome (positive/negative UTI) and covariates of interest (e.g., weight percentile, laboratory) for each patient. Nomogram plots were constructed on the basis of significant factors. We repeated the analysis thrice to adapt it to three different medical settings: medical centers, regional hospitals, and local clinics.

RESULTS: In the medical center setting, the two most significant factors were urine leukocyte count ≥100 (OR =8.87; 95% CI (Confidence Interval), 4.135-19.027) and urine nitrite level (OR =8.809; 95% CI, 5.009-15.489). The two factors showed similar significance at the regional hospital and local clinic settings. Abnormal renal echo findings were positively correlated with UTI in the medical center setting (OR =2.534; 95% CI 1.757-3.655). Three nomogram plots for the prediction of UTIs were drawn for medical centers, regional hospitals, and local clinics.

CONCLUSION: Using the three nomogram plots, frontline doctors can formulate the probabilities of pediatric UTIs for better decision-making.

PMID:36031532 | DOI:10.1016/j.jmii.2022.08.006

Med Eng Phys. 2022 Jun 24:103841. doi: 10.1016/j.medengphy.2022.103841. Online ahead of print.

ABSTRACT

This study investigates the novel combination of an active shape and mean appearance model to estimate missing bone geometry and density distribution from sparse inputs simulating segmental bone loss of the femoral diaphysis. An active shape Gaussian Process Morphable model was trained on healthy right femurs of South African males to model shape. The density distribution was approximated based on the mean appearance of computed tomography images from the training set. Estimations of diaphyseal resections were obtained by probabilistic fitting of the active shape model to sparse inputs consisting of proximal and distal femoral data on computed tomography images. The resulting shape estimates of the diaphyseal resections were then used to map the mean appearance model to the patients’ missing bone geometry, constructing density estimations. In this way, resected bone surfaces were estimated with an average error of 2.24 (0.5) mm. Density distributions were approximated within 87 (0.7) % of the intensity of the original target images before the simulated segmental bone loss. These results fall within the acceptable tolerances required for surgical planning and reconstruction of long bone defects.

PMID:36031526 | DOI:10.1016/j.medengphy.2022.103841

Radiography (Lond). 2022 Aug 25:S1078-8174(22)00113-4. doi: 10.1016/j.radi.2022.08.003. Online ahead of print.

ABSTRACT

INTRODUCTION: A clinical visit (work experience) provides an opportunity for prospective students, prior to registration, to visit a clinical department to observe health professionals in practice. The Covid-19 pandemic interrupted access to clinical visits; this article explores the value of clinical visits and the alternatives implemented as a response to Covid-19 restrictions from an academic perspective.

METHODS: This article reports the quantitative phase of a three-phase mixed methods study. A survey was distributed to Higher Education Institution (HEI) education leaders for onward distribution to academics supporting recruitment for diagnostic radiography, therapeutic radiography and operating department practice programmes. Qualtrics online survey software was used to administer the survey which was launched in October 2020. Descriptive statistics summarised the data.

RESULTS: Representing 37.7% (n = 18/49) of eligible universities, 34 responses from 18 HEIs across England and Wales were received Seventy-eight percent of respondents strongly agreed that they are vital in confirming career choices. Prior to the Covid-19 pandemic, 64% of respondents’ programmes had a clinical visit requirement, yet with improvements in simulation and online learning alternatives, 48% agreed that in the longer-term clinical visits will become obsolete.

CONCLUSION: Requirements for clinical visits vary between professions and HEIs; academics welcome an opportunity to standardise work experience. Regardless of prospective student background and selected profession/university, all should have equitable and easily available access to high quality resources to support career decision-making.

IMPLICATIONS FOR PRACTICE: The enforced withdrawal of clinical visits may impact upon subsequent attrition associated with ‘misinformed career choice’. Alternatives to clinical visits, while less onerous for students, admissions staff and clinical colleagues alike, need to be carefully evaluated to ensure they offer prospective students a realistic understanding of the profession.

PMID:36031518 | DOI:10.1016/j.radi.2022.08.003

Intensive Crit Care Nurs. 2022 Aug 25:103294. doi: 10.1016/j.iccn.2022.103294. Online ahead of print.

ABSTRACT

BACKGROUND: Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration.

OBJECTIVE: To explore the characteristics of a collaborative rapid response team model.

DESIGN: Dual methodology was used for this descriptive study.

SETTING: The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia).

PARTICIPANTS: Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards.

METHODS: A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically.

RESULTS: The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) ‘staff concern’ rapid response activation.

CONCLUSIONS: Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

PMID:36031517 | DOI:10.1016/j.iccn.2022.103294

Am J Orthod Dentofacial Orthop. 2022 Aug 26:S0889-5406(22)00432-2. doi: 10.1016/j.ajodo.2022.07.003. Online ahead of print.

ABSTRACT

INTRODUCTION: Orthodontic fixed retainers are preferred as they depend less on patient compliance. Recently, researchers tried to use fiber-reinforced composite (FRC) to replace the multistranded stainless-steel wire (MSW) of the fixed retainers to enhance the mechanical properties and esthetics. This systematic review aimed to analyze the effectiveness of the FRC retainers.

METHODS: We searched the electronic databases (May 1, 2021), including Medline, the Cochrane Library, EMBASE, PubMed, Web of Science, and CINAHL. We applied no language or date restrictions in the searches of the databases. Only randomized controlled trials (RCTs) and prospective clinical controlled trials were included. The revised Cochrane risk of bias tool for randomized trials and risk of bias in nonrandomized studies of interventions were used to evaluate the risk of bias in RCTs and non-RCTs, respectively. The outcomes were pooled using Review Manager 5.4. The primary outcome of this review was teeth relapse, and the secondary outcomes were bonded retainer failure rate, adverse effect on oral health, and patient’s satisfaction.

RESULTS: Eleven out of 99 studies, which included 873 participants, were used in this review, with the follow-up ranging from 6 months to 6 years. Ten studies compared the FRC retainers with MSW retainers, and 1 study compared FRC retainers with a different fiber material. Ten studies were RCT, and 1 was non-RCT. There was 0.39 less relapse with the FRC retainers than with MSW retainers (mean difference, -0.39; 95% confidence interval [CI], -0.41 to -0.37; P <0.00001). There was no statistically significant difference in the failure rate between the FRC and MSW with the whole retainer as an outcome unit risk ratio of 1.72 (95% CI, 0.57-5.14; P = 0.33) or with the teeth an as outcome unit risk ratio of 0.85 (95% CI, 0.47-1.52; P = 0.58). There was insufficient evidence to conduct the meta-analysis of the adverse effect on oral health and patient satisfaction.

CONCLUSIONS: Low-quality evidence is available to suggest that the effectiveness of the FRC is comparable to the MSW with no significant difference in the failure rate. However, we have very low certainty on these results. It is worth conducting future robust clinical studies to assess the effectiveness of FRC retainers with long follow-up.

PMID:36031511 | DOI:10.1016/j.ajodo.2022.07.003

Clin Cardiol. 2022 Aug 28. doi: 10.1002/clc.23909. Online ahead of print.

ABSTRACT

In the past decade, direct oral anticoagulants (DOACs) have proven to be the best option for patients with nonvalvular atrial fibrillation. Nevertheless, evidence for the use of DOACs for anticoagulation in valvular atrial fibrillation, particularly after aortic valve replacement, remains inadequate. Thus, we conducted a meta-analysis to compare the efficacy and safety of vitamin K antagonists (VKAs) and DOACs in patients with atrial fibrillation after transcatheter aortic valve replacement (TAVR). We conducted a comprehensive search of online databases, and 11 studies were included in the final analysis. The primary endpoint was all-cause mortality. Secondary endpoints included stroke and cardiovascular death. The safe endpoint is major and/or life-threatening bleeding. Subgroup analysis was conducted according to the different follow-up time of each study. Random-effects models were used for all outcomes. Statistical heterogeneity was assessed using χ² tests and quantified using I² statistics. Patients in the DOACs group had a significantly lower risk of all-cause mortality compared with patients in the VKAs group (relative risk [RR]: 1.20, 95% confidence interval [CI]: 1.01-1.43, p = .04). This benefit may be greater with longer follow-up. In a subgroup analysis based on the length of follow-up, a significantly lower risk of all-cause mortality was found in the DOACs group in the subgroup with a follow-up time of >12 months (RR: 1.50, 95% CI: 1.07-2.09, p = .001). There were no significant differences between the two groups in cardiovascular death, stroke, and major and/or life-threatening bleeding. For patients with atrial fibrillation after TAVR, the use of DOACs may be superior to VKAs, and the benefit may be greater with longer follow-up. The anticoagulant strategy for atrial fibrillation after TAVR is a valuable direction for future research.

PMID:36030549 | DOI:10.1002/clc.23909

Br J Sociol. 2022 Aug 28. doi: 10.1111/1468-4446.12972. Online ahead of print.

ABSTRACT

The link between university graduation and liberal values is well-established and often taken as evidence that higher education participation causes attitudinal change. Identification of education’s causal influence in shaping individual preferences is notoriously difficult as it necessitates isolating education’s effect from self-selection mechanisms. This study exploits the household structure of the Harmonized British Household Panel Study and Understanding Society data to tighten the bounds of causal inference in this area and ultimately, to provide a more robust estimate of the independent effect of university graduation on political attitudes. Results demonstrate that leveraging sibling fixed-effects to control for family-invariant pre-adult experiences reduces the size of higher education’s effect on cultural attitudes by at least 70%, compared to conventional methods. Significantly, within-sibship models show that obtaining higher education qualifications only has a small direct causal effect on British individuals’ adult attitudes, and that this effect is not always liberalizing. This has important implications for our understanding of the relationship between higher education and political values. Contrary to popular assumptions about education’s liberalizing role, this study demonstrates that the education-political values linkage is largely spurious. It materializes predominately because those experiencing pre-adult environments conducive to the formation of particular values disproportionately enroll at universities.

PMID:36030542 | DOI:10.1111/1468-4446.12972