Nevin Manimala

Rheumatology (Oxford). 2021 Jul 10:keab535. doi: 10.1093/rheumatology/keab535. Online ahead of print.

ABSTRACT

OBJECTIVE: To examine the association of long-term weight change with rheumatoid arthritis (RA) risk in a large prospective cohort study.

METHODS: The Nurses’ Health Study (NHS) II started in 1989 (baseline); after exclusions, we studied 108,505 women 25-42 years old without RA. Incident RA was reported by participant and confirmed by medical record review. Body weight was reported biennially through 2015. We investigated two time-varying exposures: weight changes from baseline and from age 18; change was divided into 5 categories. We used a marginal structural model (MSM) approach to account for time-varying weight change and covariates.

RESULTS: Over 2,583,266 person-years, with a median follow-up time of 25.3 years, 541 women developed RA. Compared to women with stable weight from baseline, weight change was significantly associated with increased RA risk [weight gain 2-<10 kg: RR = 1.98 (95% CI 1.38, 2.85); 10-<20 kg: RR = 3.28 (95% CI 2.20, 4.89); ≥20 kg: RR = 3.81 (95% CI 2.39, 6.07); and weight loss >2 kg: RR = 2.05 (95% CI 1.28, 3.28)]. Weight gain of 10 kg or more from age 18 compared with stable weight was also associated with increased RA risk [10-< 20 kg: RR = 2.12 (95% CI 1.37, 3.27), ≥20 kg: RR = 2.31 (95% CI 1.50, 3.56)]. Consistent findings were observed for seropositive and seronegative RA.

CONCLUSION: Long-term weight gain was strongly associated with increased RA risk in women, with weight gain of ≥ 20 kg associated with more than a three-fold increased RA risk. Maintenance of healthy weight may be a strategy to prevent or delay RA.

PMID:34247242 | DOI:10.1093/rheumatology/keab535

Rheumatology (Oxford). 2021 Jul 10:keab534. doi: 10.1093/rheumatology/keab534. Online ahead of print.

ABSTRACT

OBJECTIVES: Medication adherence is critical in the successful management of lupus. There is very limited existing literature on reasons why non-adherence is not reported. This study explores the impact of current and previous medical experiences on patient satisfaction, adherence and reporting of non-adherence.

METHODS: Mixed methodology involved thematic analysis of in-depth interviews (N = 23) to further explore the statistically analysed quantitative survey findings (N = 186).

RESULTS: This study identified five themes: 1) physician-patient discordance and a ‘hierarchy of evidence’ in medication decisions, 2) the association of adherence with satisfaction with care, 3) the persisting impact of past Adverse Medical Experiences (AMEs), 4) the dynamic balance of patient-physician control, and 5) holistic care – beyond a purely medication- based focus. Improving quality of life (43% of participants) and a supportive medical relationship (24%) were the main reasons for adherence. Patient-priorities and self-reported symptoms were perceived as less important to physicians than organ-protection and blood results. Non-reporters of non-adherence, non-adherers and those with past AMEs (e.g. psychosomatic misdiagnoses) had statistically significant lower satisfaction with care. The importance of listening to patients was a key component of every theme, and associated with patient satisfaction and adherence. The mean rating for rheumatologist’s listening skills was 2.88 for non-adherers compared to 3.53 for other participants (mean difference 0.65, P = 0.003).

CONCLUSION: Patients would like more weight and discussion given to self-reported symptoms and quality of life in medication decisions. Greater understanding and interventions are required to alleviate the persisting impact of past AMEs on some patients’ wellbeing, behaviour and current medical relationships.

PMID:34247235 | DOI:10.1093/rheumatology/keab534

Eur J Prev Cardiol. 2021 Jul 10;28(7):791-798. doi: 10.1177/2047487319867783.

ABSTRACT

AIMS: Previous prospective studies of the association between mortality and physical activity have generally not fully accounted for the interplay between movement behaviours. A compositional data modelling approach accounts for relative scale and co-dependency in time-use data across physical activity behaviours of the 24-hour day.

METHODS: A prospective analysis of the National Health and Nutrition Examination Survey 2005-2006 on N = 1468 adults (d = 135 deaths) in ages 50-79 years was undertaken using compositional Cox regression analysis. Daily time spent in sedentary behaviour, light intensity (LIPA) and moderate-to-vigorous physical activity (MVPA) was determined from waist-mounted accelerometer data (Actigraph 7164) and supplemented with self-reported sleep data to determine the daily time-use composition.

RESULTS: The composition of time spent in sedentary behaviour, LIPA, MVPA and sleep was associated with mortality rate after allowing for age and sex effects (p < 0.001), and remained significant when other lifestyle factors were added (p < 0.001). This was driven primarily by the preponderance of MVPA; however, significant changes are attributable to LIPA relative to sedentary behaviour and sleep, and sedentary behaviour relative to sleep. The final ratio ceased to be statistically significant after incorporating lifestyle factors. The preponderance of MVPA ceased to be statistically significant after incorporating health at outset and physical limitations on movement.

CONCLUSIONS: An association is inferred between survival rate and the physical activity composition of the day. The MVPA time share is important, but time spent in LIPA relative to sedentary behaviour and sleep is also a significant factor. Increased preponderance of MVPA may have detrimental associations at higher levels of MVPA.

PMID:34247228 | DOI:10.1177/2047487319867783

Clin Ter. 2021 Jul 5;172(4):347-357. doi: 10.7417/CT.2021.2339.

ABSTRACT

PURPOSE: To evaluate the diagnostic ability of pachymetric indexes obtained with Spectral Domain Optical Coherence Tomography (SD-OCT) for early detection of keratoconus (Kc).

METHODS: 64 patients with Kc in at least one eye (95 eyes, 46 men and 18 women, average age 27.84 ±13.50), 59 healthy control subjects (100 eyes, 28 men and 31 women, average age 27.15 ±16.14). All patients underwent detailed clinical examination, topography and anterior segment OCT. 37 subjects (37 eyes, 27 men and 10 women, average age 24.23 ± 14.24) having one eye with manifest Kc and the fellow eye without clinical signs of Kc were identified. We studied two groups of pachymetric indexes: C1-C2, M1-M2, pCLMI, Pmin-P2 (Group 1 indexes) and PPD, PSD, PSSD and PASD (Group 2 indexes). A ROC (Receiver Operating Characteristic) curve was developed to compare the diagnostic accuracy, relative sensitivity and specificity for each index.

RESULTS: In manifest keratoconus, C1-C2, M1-M2, and pCLMI are significantly higher compared to the control group (P<0.0001); for suspect keratoconus, all Group 1 indexes are significantly higher compared to healthy subjects (P<0.0001) excluding M1-M2 obtained using a constant area circle (P = 0.02). Furthermore, for manifest and suspect keratoconus, PPD, PSD, PSSD and PASD are significantly higher compared to the control group (P <0.0001).

CONCLUSION: The studied pachymetric indexes in patients with Kc have high diagnostic accuracy and are statistically significant when compared with healthy subjects (p<0.0001) and can provide a useful tool for keratoconus screening.

PMID:34247218 | DOI:10.7417/CT.2021.2339

Clin Ter. 2021 Jul 5;172(4):329-335. doi: 10.7417/CT.2021.2337.

ABSTRACT

INTRODUCTION: Haemorrhoids are a very common disease, with a great economic burden. Many treatments have been developed for trying to solve the problem, being the standard not yet found. In 1995, Doppler-guided haemorrhoidal artery ligation was introduced, aiming to reduce postoperative pain and complications. In this work, an evolu-tion of the aforementioned surgical technique was described.

MATERIALS AND METHODS: 183 patients treated with standard Doppler-Guided Haemorrhoidal Artery Ligation were statistically compared with 225 patients dealt with Colour Doppler-Guided Haemorrhoidal Artery Ligation. The procedures were performed under local anaes-thesia with patients in lithotomy position. A special proctoscope and a dedicated Colourdoppler US probe were employed in the second group. Superior haemorrhoidal artery terminal branches were con-secutively ligated according to provided technique in the first group and under vision in the second. In all cases, each ligation was followed by mucopexy.

RESULTS: No significant differences between the two groups, in terms of post-operative pain, early complications (bleeding, urinary retention, incontinence) or patient satisfaction, were demonstrated. Recurrence rate was significantly higher in patients treated with stan-dard DG-HAL. No late complications (after one-year follow-up) were registered in both groups.

CONCLUSIONS: Colour Doppler-Guided Haemorrhoidal Artery Li-gation represents an ideal management for 1-day surgery, and fulfils the requirements of minimally invasive surgery in patients with III-IV grade haemorrhoids. The absence of complications and the evidence of significant wellness of patients are the best advantages. Colour Doppler-Guided Haemorrhoidal Artery Ligation is a safe and easy procedure with good results and a very short-time training. It could be considered an easy and reliable method to treat symptomatic haemorrhoids.

PMID:34247216 | DOI:10.7417/CT.2021.2337

Eur Neurol. 2021 Jul 9:1-6. doi: 10.1159/000516320. Online ahead of print.

ABSTRACT

OBJECTIVE: During the SARS-CoV-2 pandemic, there has been a significant increase in the prevalence of anxiety and depression. This study sought to establish the probability of migraine progression by comparing data from week 0 with week 12 of quarantine.

METHODS: A retrospective cohort study. Three hundred ten patients were included, 238 with episodic migraine and 33 with chronic migraine; they all completed a self-administered questionnaire with demographic, clinical, and psychiatric symptom information. A multivariate statistical analysis was conducted to identify factors associated with the progression of migraine.

RESULTS: This study demonstrated a 22.5% progression probability from episodic migraine to chronic migraine with an RR 2.7 and CI (1.92-3.95, p < 0.001). The increase in depression scores (p < 0.005), anxiety (p < 0.001), and alteration in sleep quality (p < 0.003) were associated with the worsening of migraine.

CONCLUSION: During the SARS-CoV-2 pandemic, depression, anxiety, and the deterioration of sleep quality influenced the probability of progression from episodic migraine to chronic migraine.

PMID:34247177 | DOI:10.1159/000516320

Drug Metab Pers Ther. 2021 Jul 12. doi: 10.1515/dmdi-2021-0112. Online ahead of print.

ABSTRACT

OBJECTIVES: One of the key components of ERAS is adequate pain control in the postoperative period. There are no rational schemes for postoperative pain relief. At the same time, adequate postoperative pain relief promotes early activation and early rehabilitation of patients and shortens the duration of the postoperative stay, and does not cause postoperative complications associated with analgesia (weakness, intestinal paresis, nausea and vomiting). The aims of the present study are to assess the possible association of CYP2D6 and CYP2C9 polymorphisms with the efficacy and safety of tramadol and ketorolac in postoperative pain.

METHODS: A total of 107 patients were genotyped for CYP2D6 and CYP2C9 polymorphisms. All patients underwent laparoscopic cholecystectomy. Postoperative pain relief was carried out with ketorolac and tramadol. Postoperative pain syndrome was assessed using a visual analogue scale and McGill pain questionnaire. The profile of side effects was assessed by the dynamics of red blood counts as a possible trigger for the development of gastrointestinal bleeding according to the method of global assessment of triggers.

RESULTS: Pain was statistically significantly lower in CYP2C9*2 carriers, according to visual analogue scale (VAS): after 12 h – by 1.5 (p=0.002); after 24 h – by 1.1 (p=0.012); after 36 h – by 1.05 (p=0.004); after 48 h – by 0.7 (p=0.026). In CYP2C9*3 carriers the results were not statistically significant. In carriers of CYP2D6*4 pain syndromes were higher at all-time intervals, but statistically reliable results were obtained only after 2 h – by 1.01 (p=0.054) and after 24 h – by 0.8 (p=0.035). The profile of adverse reactions for NSAIDs was evaluated by the dynamics of hemoglobin and erythrocyte indices. A more pronounced decrease in the relative difference in hemoglobin levels was noted in CYP2C9*2 and CYP2C9*3 polymorphism carriers – by 1.7 (p=0.00268) and-by 2.2 (p=0.000143), respectively.

CONCLUSIONS: CYP2D6 and CYP2C9 can predict analgesic effectiveness of tramadol and ketorolac. CYP2C9 can predict the risk of gastrointestinal bleeding, including those hidden to ketorolac.

PMID:34246203 | DOI:10.1515/dmdi-2021-0112

Diagnosis (Berl). 2021 Jul 12. doi: 10.1515/dx-2020-0160. Online ahead of print.

ABSTRACT

OBJECTIVES: In 2015, the National Academy of Medicine IOM estimated that 12 million patients were misdiagnosed annually. This suggests that despite prolonged training in medical school and residency there remains a need to improve diagnostic reasoning education. This study evaluates a new approach.

METHODS: A total of 285 medical students were enrolled in this 8 center, IRB approved trial. Students were randomized to receive training in either abdominal pain (AP) or loss of consciousness (LOC). Baseline diagnostic accuracy of the two different symptoms was assessed by completing a multiple-choice question (MCQ) examination and virtual patient encounters. Following a structured educational intervention, including a lecture on the diagnostic approach to that symptom and three virtual patient practice cases, each student was re-assessed.

RESULTS: The change in diagnostic accuracy on virtual patient encounters was compared between (1) baseline and post intervention and (2) post intervention students trained in the prescribed symptom vs. the alternate symptom (controls). The completeness of the student’s differential diagnosis was also compared. Comparison of proportions were conducted using χ ²-tests. Mixed-effects regressions were used to examine differences accounting for case and repeated measures. Compared with baseline, both the AP and LOC groups had marked post-intervention improvements in obtaining a correct final diagnosis; a 27% absolute improvement in the AP group (p<0.001) and a 32% absolute improvement in the LOC group (p<0.001). Compared with controls (the groups trained in the alternate symptoms), the rate of correct diagnoses increased by 13% but was not statistically significant (p=0.132). The completeness and efficiency of the differential diagnoses increased by 16% (β=0.37, p<0.001) and 17% respectively (β=0.45, p<0.001).

CONCLUSIONS: The study showed that a virtual patient platform combined with a diagnostic reasoning framework could be used for education and diagnostic assessment and improved correct diagnosis compared with baseline performance in a simulated platform.

PMID:34246202 | DOI:10.1515/dx-2020-0160

BJOG. 2021 Jul 10. doi: 10.1111/1471-0528.16838. Online ahead of print.

ABSTRACT

OBJECTIVE: To compare adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) versus laparoscopy.

DESIGN: Parallel group, 1:1 single-centre single-blinded randomised trial, designed as non-inferiority study with a margin of 15%.

SETTING: Belgian teaching hospital POPULATION: Non-pregnant non-virgin women with an intact uterus and without obliteration of the pouch of Douglas scheduled to undergo removal of an adnexal mass assessed to be benign on ultrasound by IOTA criteria.

METHODS: Randomisation to laparoscopy (control group) or vNOTES (experimental group). Stratification according to adnexal size. Blinding of participants and outcome assessors by sham incisions.

MAIN OUTCOME MEASURES: The primary outcome measure was adnexectomy by the allocated technique. Secondary outcomes included duration of surgery, pain scores and analgesics used, quality of life and adverse events.

RESULTS: We randomly assigned 67 participants (34 to the vNOTES group and 33 to the laparoscopy group). The primary endpoint was always reached in both groups: there were no conversions. We performed a sensitivity analysis for the primary outcome, assuming one conversion in the vNOTES group and no conversions in the laparoscopy group: the one-sided 95% upper limit for the differences in proportions of conversion was estimated as 13%, which is below the predefined non-inferiority margin of 15%. The secondary outcomes demonstrated a shorter duration of surgery, lower pain scores, lower total dose of analgesics and a trend for more adverse events in the vNOTES group.

CONCLUSIONS: vNOTES is non-inferior to laparoscopy for a successful adnexectomy without conversion. vNOTES allowed shorter operating times and less postoperative pain but there was a trend for more adverse events.

PMID:34246198 | DOI:10.1111/1471-0528.16838

Nurse Educ Pract. 2021 Jun 28;54:103130. doi: 10.1016/j.nepr.2021.103130. Online ahead of print.

ABSTRACT

AIM: To investigate medical and nursing students’ education on hand hygiene, their attitude on hand hygiene education and how this education influences their hand hygiene knowledge and practices.

BACKGROUND: Hospital-acquired infections are associated with prolonged hospitalisation and mortality. The most effective measure for their control is healthcare workers’ hand hygiene compliance. Since medical and nursing students constitute the future healthcare workers, our study focuses on them.

DESIGN: Cross-sectional study METHODS: This study was conducted during the academic year 2016-2017, using a modified World Health Organisation questionnaire. Our sample consisted of 132 medical and 111 nursing students from National and Kapodistrian University of Athens, Greece. In data analysis, the Mann-Whitney and Fisher’s exact tests were applied to compare differences in continuous variables and proportions in categorical variables, respectively. Knowledge and practices overall scores were calculated per student group. Multiple linear regression analyses were performed to assess the influence of potential confounders on these scores.

RESULTS: We found that 73.1% of medical and 98.2% of nursing students had received relevant education, which was reported as “only theoretical” by 77.4% of the former and as “hands-on and theoretical” by 88.1% of the latter group. Besides the risk of infection, knowledge acquired in lectures and trainer’s behaviour were also considered very influential factors shaping hand hygiene attitude in both groups. Overall, medical students reported better hand hygiene practices than nursing ones (69.9% and 59.7%, respectively; p < 0.001). The opposite finding was observed regarding their overall knowledge on hand hygiene (57.2% of medical versus 60.4% of nursing students, p = 0.04). The majority of students (86.6% of all participants; p < 0.001) supported the inclusion of compulsory hand hygiene education in their curriculum. Compulsory education and seminars were assessed as the most effective measures to increase hand hygiene compliance (71.4% of all students).

CONCLUSION: In our study, medical students scored better in practices questions than nursing students; this did not apply for the knowledge score. The majority of students supported the inclusion of compulsory education on hand hygiene principles in their Departments’ curricula, highlighting compulsory education and seminars as the most effective measures to increase compliance with hand hygiene.

PMID:34246184 | DOI:10.1016/j.nepr.2021.103130