Nevin Manimala

Heart. 2021 Sep 20:heartjnl-2021-319225. doi: 10.1136/heartjnl-2021-319225. Online ahead of print.

ABSTRACT

BACKGROUND AND AIM: Although the diagnostic usefulness of high-sensitivity cardiac troponin T (hs-cTnT) is well established in ST-segment elevation myocardial infarction (STEMI), its prognostic relevance in risk stratification of patients with STEMI remains obscure. This study sought to determine the prognostic value of pre-reperfusion (admission) and post-reperfusion (12-hour) hs-cTnT in patients with STEMI treated with primary percutaneous coronary intervention (PPCI).

METHODS: Retrospective observational longitudinal study including consecutive patients with STEMI treated with PPCI at a university hospital in the northeast of England. hs-cTnT was measured at admission to the catheterisation laboratory and 12 hours after PPCI. Clinical, procedural and laboratory data were prospectively collected during patient hospitalisation (June 2010-December 2014). Mortality data were obtained from the UK Office of National Statistics. The study endpoints were in-hospital and overall mortality.

RESULTS: A total of 3113 patients were included. Median follow-up was 53 months. Admission hs-cTnT >515 ng/L (fourth quartile) was independently associated with in-hospital mortality (HR=2.53 per highest to lower quartiles; 95% CI: 1.32 to 4.85; p=0.005) after multivariable adjustment for a clinical model of mortality prediction. Likewise, admission hs-cTnT >515 ng/L independently predicted overall mortality (HR=1.27 per highest to lower quartiles; 95% CI: 1.02 to 1.59; p=0.029). Admission hs-cTnT correctly reclassified risk for in-hospital death (net reclassification index (NRI)=0.588, p<0.001) and overall mortality (NRI=0.178, p=0.001). Conversely, 12-hour hs-cTnT was not independently associated with mortality.

CONCLUSION: Admission, but not 12-hour post-reperfusion, hs-cTnT predicts mortality and improves risk stratification in the PPCI era. These results support a prognostic role for admission hs-cTnT while challenge the cost-effectiveness of routine 12-hour hs-cTnT measurements in patients with STEMI.

PMID:34544804 | DOI:10.1136/heartjnl-2021-319225

Emerg Med J. 2021 Sep 20:emermed-2020-210947. doi: 10.1136/emermed-2020-210947. Online ahead of print.

ABSTRACT

BACKGROUND: Following blunt trauma, diagnosis of shoulder dislocation based on physical examination alone is difficult due to possible concurrent proximal humeral fractures. X-rays are therefore used to confirm diagnosis. Results from recent observational studies comparing diagnostic accuracy of point-of-care ultrasound (PoCUS) with X-rays for shoulder dislocation have been encouraging. The aim of this study was to determine whether PoCUS improves diagnostic accuracy when used with physical examination for the diagnosis of shoulder dislocation, proximal humeral fracture and ascertaining successful reduction in the ED.

METHODS: A prospective, single-centre, open, parallel randomised control study over a 6-month period was used to answer the research question and test the null hypothesis. Consecutive eligible adult patients attending the ED of Mater Dei Hospital in Malta were randomised to either the control (C) (physical examination only) or experimental group (E) (physical examination and a two-point PoCUS scan). The study objectives were to measure diagnostic accuracy for both examinations for detecting shoulder dislocation, any associated proximal humeral fractures and confirming reduction. X-rays were used as reference standard for both groups.

RESULTS: 1206 patients were enrolled in this study (C n=600, E n=606). 290 dislocations (C n=132 and E n=158), 332 proximal humeral fractures (C n=154 and E n=178) and 278 reductions (C n=130 and E n=148) were analysed. A statistically significant difference (p<0.001) was found between the two groups for diagnostic accuracy in shoulder dislocation (C=65%, likelihood ratio (LR)+=2.03 and LR-=0.35 and E=100%, LR+=∞ and LR-=0), proximal humeral fractures (C=45.7%, LR+=1.23 and LR-=0.52 and E=98.3%, LR+=103.9 and LR-=0.03) and reduction (C=68.7%, E=100%). The null hypothesis for this study was thus rejected.

CONCLUSIONS: The addition of PoCUS to a physical examination significantly improves diagnostic accuracy for dislocations, proximal humeral fractures and reduction confirmation.

TRIAL REGISTRATION NUMBER: International Standard Randomised Controlled Trials Number Registry (ISRCTN17048126).

PMID:34544780 | DOI:10.1136/emermed-2020-210947

Br J Gen Pract. 2021 Jun 25:BJGP.2020.1030. doi: 10.3399/BJGP.2020.1030. Online ahead of print.

ABSTRACT

BACKGROUND: There is substantial variation in the use of urgent suspected cancer referral (2-week wait [2WW]) between practices.

AIM: To examine the change in use of 2WW referrals in England over 10 years (2009/2010 to 2018/2019) and the practice and population factors associated with cancer detection.

DESIGN AND SETTING: Retrospective cross-sectional study of English general practices and their 2WW referral and Cancer Waiting Times database detection data (all cancers other than non-melanoma skin cancers) from 2009/2010 to 2018/2019.

METHOD: A retrospective study conducted using descriptive statistics of changes over 10 years in 2WW referral data. Yearly linear regression models were used to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated, as well as the difference between lowest to highest quintiles.

RESULTS: Over the 10 years studied there were 14.89 million 2WW referrals (2.24 million in 2018/2019), and 2.68 million new cancer diagnoses, of which 1.26 million were detected following 2WW. The detection rate increased from 41% to 52% over the time period. In 2018/2019 an additional 66 172 cancers were detected via 2WW compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/2017 onwards more deprived practice populations were associated with decreased cancer detection.

CONCLUSION: From 2009/2010 to 2018/2019 2WW referrals increased on average by 10% year on year. The most consistent association with higher cancer detection was found for larger practices and those with younger GPs, though these differences became attenuated over time. The more recent association between increased practice deprivation and lower cancer detection is a cause for concern. The COVID-19 pandemic has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.

PMID:34544690 | DOI:10.3399/BJGP.2020.1030

Dig Liver Dis. 2021 Sep 17:S1590-8658(21)00762-3. doi: 10.1016/j.dld.2021.08.022. Online ahead of print.

ABSTRACT

BACKGROUND: Prognostic stratification in ChronicPancreatitis(CP) remains suboptimal and cumbersome. Chronic Pancreatitis Prognostic Score(COPPS) was recently developed to predict one-year hospitalisations in CP.

AIM: External validation of COPPS in a geographically divergent patient population.

METHODS: A single-center prospective cohort study, conducted on out-patients of a tertiary-care hospital. Consecutive adults with CP were assessed for COPPS risk predictors at baseline, similar to the original development cohort, and followed for one-year for: 1)hospitalisations; 2)development of pancreatitis-related complications; and 3)need for endoscopic and/or surgical interventions. Outcomes were compared by Kendall’s tau-b(τ_b) and other statistical tests. Only those who had complete one-year follow-up were included in analysis.

RESULTS: There were 177 patients(mean±SD age: 35.9 ± 11.2 years), 116(65%) males and 117(66%) with Idiopathic CP. Despite being younger, with significantly more females and Idiopathic CP, than the original development cohort, our cohort was similar to the latter regarding COPPS severity at baseline. Eight patients died over one-year; 169 were evaluated for outcomes. Increasingly severe COPPS categories correlated with increasing number of hospitalisations(both overall and pancreatitis-related) and increasing number of days spent in hospital(both overall and pancreatitis-related) irrespective of age at symptoms-onset(≤35 vs >35years), etiology(idiopathic vs alcohol) and smoking-status.

CONCLUSIONS: COPPS is effective in a geographically distinct cohort having a different case-mix of CP patients(ClincialTrials.gov ID:NCT04907266).

PMID:34544675 | DOI:10.1016/j.dld.2021.08.022

Pulmonology. 2021 Sep 17:S2531-0437(21)00158-6. doi: 10.1016/j.pulmoe.2021.08.002. Online ahead of print.

ABSTRACT

BACKGROUND: Tuberculosis (TB) incidence declined in Portugal in recent decades, but trends differ between regions and population subgroups. We investigated these differences to inform prevention and control programmes.

METHODS: We extracted TB notifications from the Portuguese National TB Surveillance System (SVIG-TB) in 2010-2017, disaggregated by region, age group, country of birth and HIV status. We calculated notification rates using denominators from the Portuguese National Institute of Statistics and the Joint United Nations Programme on HIV/AIDS and performed stratified time series analysis. We estimated interannual decline percentages and 95% confidence intervals (CI) using Poisson and binomial negative regression models.

RESULTS: The overall TB notification rate decreased from 25.7 to 17.5/100,000 population from 2010 to 2017 (5.2%/year) in Portugal. Interannual decline did not differ significantly between regions, but it was smaller amongst non-Portuguese nationals (-1.57% [CI: -4.79%, 1.75%] vs -5.85% [CI: -6.98%, -4.70%] in Portuguese nationals); children under five years of age (+1.77% [CI: -4.61%, 8.58%] vs -5.38% [CI: -6.33%, -4.42%] in other age groups); and HIV-negative people (-6.47% [CI: -9.10%, -3.77%] vs -11.29% [CI; -17.51%, -4.60%] in HIV-positive).

CONCLUSIONS: The decline in TB notification rates in Portugal during the study period has been steady. However, the decline amongst non-Portuguese nationals, children under five years of age and non-infected-HIV patients was lower. No significant differences were observed between regions. Changes in TB epidemiology in specific risk groups and geographical areas should be closely monitored to achieve the objectives of the End TB Strategy. We recommend intensifying screening of TB in the subpopulations identified.

PMID:34544672 | DOI:10.1016/j.pulmoe.2021.08.002

Neurologia (Engl Ed). 2021 Sep 17:S2173-5808(21)00133-4. doi: 10.1016/j.nrleng.2019.08.004. Online ahead of print.

ABSTRACT

BACKGROUND: Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site.

METHODS: We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present.

RESULTS: Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site-resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72 minutes, respectively (P = .003). DNTs were 59, 74, and 68 minutes (P = .001), respectively, for the on-site, off-site, and off-site-resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends.

CONCLUSION: DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.

PMID:34544671 | DOI:10.1016/j.nrleng.2019.08.004

Int Orthod. 2021 Sep 17:S1761-7227(21)00114-5. doi: 10.1016/j.ortho.2021.08.007. Online ahead of print.

ABSTRACT

OBJECTIVE: The purpose of this study is to compare and analyze the similarities between three-dimensional images captured by a smartphone camera with depth sensors and a conventional 3dMD Face system.

MATERIALS AND METHODS: Twenty six individuals (16 female, 10 male) were involved in this study, agreed to take part and as such had no paralysis, tics, etc., which may prevent taking the image. Anthropometric points were marked, and plasters were placed on the forehead, upper nasal dorsum and zygoma to determine matching areas. 3D images were captured with a DOF (Depth of Field) camera of a smartphone (iPhone X, Apple Inc. CA, USA) and a 3D imaging system (3dMD, Atlanta, GA, USA). Linear and angular measurements were carried. Overlapping area amounts of matched images and X, Y and Z coordinates of landmarks were compared. For comparison of the data, student t-test and Mann-Whitney U test were used at P<0.05.

RESULTS: Statistically significant changes were found in distance between inner commissures of right and left eye fissure and nasolabial angle. RMS (Root Mean Square) values were found between 0.58 and 1.

CONCLUSION: Images captured with a DOF camera of a smartphone, can be used to record and evaluate 3D soft tissue changes. However, due to the anatomical features of some regions, the deficiency of clear visualization needs improvements.

PMID:34544662 | DOI:10.1016/j.ortho.2021.08.007

P R Health Sci J. 2021 Jun;40(2):75-80.

ABSTRACT

OBJECTIVE: The objective of this study was to determine the age-related anatomical changes that take place at the cementodentinal junction (CDJ).

METHODS: Eighty-four teeth were extracted; 42 samples came from patients ranging in age from 18 to 30 years, and 42 came from patients aged from 40 to 60 years. Upper and lower and anterior and posterior teeth were included. Longitudinal slices were made, and 1% toluidine blue was used to stain all the samples prior to microscopic examination. Anatomical landmarks (apical foramen [AF], apical vertex, and cementoenamel junction) in the apical third were identified, and a pre-calibrated software package was employed to take digital measurements. Statistical analysis was performed by means of the Wilcoxon rank-sum test.

RESULTS: The data obtained showed that there were anatomical variations in the apical third in the older patients and that these changes were related to the age of the patient. Narrower root canals and smaller CDJ diameters were found in older patients’ samples.

CONCLUSION: The results of this study suggest that instrumentation and obturation should take place 1 mm from the AF in older patients, and not 0.5 mm, as is usually recommended.

PMID:34543565

P R Health Sci J. 2021 Jun;40(2):63-67.

ABSTRACT

OBJECTIVE: This study aims to describe the frequency of biologic therapy failure in psoriasis patients along with associated patient demographics and characteristics.

METHODS: This was a retrospective medical-record review of psoriasis patients evaluated from January 1st, 2013, through May 1st, 2018, and who failed at least once to adhere to their biologic therapy.

RESULTS: Seventy-seven patients with psoriasis who had discontinued biologic therapy at least once were included in this study. Hypertension (58.4%), diabetes (37.7%), dyslipidemia (27.3%), and psoriatic arthritis (23.4%) were the main comorbidities observed. Adalimumab (ADA, 80.5%), ustekinumab (UST, 70.1%), and etanercept (ETA, 14.2%) were the most frequently used biologics in our cohort. The biologic with the longest mean duration of use prior to its discontinuation was UST (17.0 months), followed by ADA (15.9 months) and ETA (13.6 months).

CONCLUSION: The most common reason for discontinuing biologic therapy was that said therapy was not effective, though for ETA and UST, the fact that biologic therapies are not universally covered by insurance company was found to be associated with their discontinuation, as well. There were no statistically significant associations found between biologic therapy discontinuation and age, gender, or comorbidities, which last included obesity, class I. Larger studies are warranted to identify risk factors associated with biologic therapy failure to help guide drug selection, decrease morbidity associated with such nonadherence and improve patient outcomes.

PMID:34543563

Klin Lab Diagn. 2021 Sep 10;66(9):565-570. doi: 10.51620/0869-2084-2021-66-9-565-570.

ABSTRACT

The concentration of bacterial plasmalogen 18a and endotoxin in the blood of elderly people 45-90 years old with the pathology of type 2 diabetes mellitus (DM 2) – the main group and without diabetes mellitus – the comparison group was investigated. The concentration of both plasmalogen 18a and endotoxin in the blood of individuals with DM 2 pathology is statistically significantly higher than in the blood of individuals without DM 2 pathology. To assess the state of microbiocenosis and predict type 2 diabetes mellitus, decisive rules have been determined in the form of threshold values of plasma concentrations 18a and endotoxin in the blood of elderly people with a suspected or established diagnosis of type 2 diabetes. Using ROC analysis, it was found that values above 20.66 μg / ml for plasmalogen 18a, and 0.48 nmol / ml for endotoxin, determine the presence of type 2 diabetes mellitus pathology in the 45-90 age group.

PMID:34543536 | DOI:10.51620/0869-2084-2021-66-9-565-570