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It is well known that higher fasting plasma glucose (FPG) is associated with metabolic syndrome (MetS). This relationship still exists even the FPG is within the normal range. However, most of these studies did not exclude subjects who were on medications which would affect the results of the studies. At the same time, there is no longitudinal study done to validate this correlation, especially in elderly. In this study, the relationships between normal FPG and MetS were evaluated.
We randomly selected 57,517 subjects who were ≥ 60-years old from health screening centre. In the first part of study, subjects were enrolled in the cross-sectional study to find out the optimal cut-off value of FPG with higher chances to have MetS. In the second part of current study, subjects with MetS at baseline were excluded from the same study group, and performed a median 5.3-year longitudinal study.
There were 18,287 subjects enrolled in this study. In the first part of study, the cross-sectional study, optimal cut-off values of FPG were determined by the ROC curve and the sensitivity for these cut-off values were 56.6% in men and 60.9% in women, respectively. The result showed that lower FPG is healthier than the higher (log-rank test, p < 0.001). During the follow-up period, 5039 subjects showed hazard ratios of 2.09 for men and 1.884 for women developing future MetS.
Our study is the first longitudinal design in elderly and showed that older subjects with higher FPG proved to have higher risk of Mets even the FPG is still within its normal range.
Women represent a large proportion of patients with atrial fibrillation (AF) and tend to have higher risk of stroke.
This study examines gender differences in the utilisation of oral anticoagulation (OAC) and prognosis (i.e. stroke and death) in AF patients in UK general practice.
Retrospective observational study.
The Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation (GRASP-AF) tool was employed to identify AF patients from 11 general practices in Darlington, England.
Two thousand two hundred and fifty-nine AF patients (mean±SD age 76 ± 12 years; 46% female) were identified. Based on CHA2DS2-VASc score 95% of women and 90% of men were at moderate-high risk of stroke. Women with moderate-high risk of stroke were treated with OAC less frequently than men (47% vs. 52%, p = 0.006). Overall rates of stroke and all-cause mortality were higher among women than men (p = 0.02 and p < 0.001). However, there was no significant gender difference in these outcomes in patients receiving OAC (p = 0.52 for stroke, p = 0.18 for death). Among people not receiving OAC where indicated, female gender was associated with an increased risk of stroke before (p = 0.01), and after (p = 0.04), adjustment for stroke risk factors. Women not receiving OAC had a higher risk of death on univariate regression analysis (p = 0.002), but not after adjustment for stroke risk factors (p = 0.53).
Women with AF are at higher risk of stroke than men without OAC. The gender-related differences in risk of stroke disappear if OAC is used. Despite this, women are more likely not to receive OAC.
This systematic review applied meta-analytic procedures to synthesise medication adherence (also termed compliance) interventions that focus on healthcare providers.
Comprehensive searching located studies testing interventions that targeted healthcare providers and reported patient medication adherence behaviour outcomes. Search strategies included 13 computerised databases, hand searches of 57 journals, and both author and ancestry searches. Study sample, intervention characteristics, design and outcomes were reliably coded. Standardised mean difference effect sizes were calculated using random-effects models. Heterogeneity was examined with Q and I2 statistics. Exploratory moderator analyses used meta-analytic analogue of ANOVA and regression.
Codable data were extracted from 218 reports of 151,182 subjects. The mean difference effect size was 0.233. Effect sizes for individual interventions varied from 0.088 to 0.301. Interventions were more effective when they included multiple strategies. Risk of bias assessment documented larger effect sizes in studies with larger samples, studies that used true control groups (as compared with attention control), and studies without intention-to-treat analyses.
Overall, this meta-analysis documented that interventions targeted to healthcare providers significantly improved patient medication adherence. The modest overall effect size suggests that interventions addressing multiple levels of influence on medication adherence may be necessary to achieve therapeutic outcomes.
Haemoglobinopathies are a major public health problem in Sicily: it was estimated a frequency of 1/245 couples are at risk of haemoglobinopathies. This paper reviews legislative actions, prevention activities, carrier screening, genetic counselling, foetal sampling and laboratory methodology analysis evolution reporting the results of 30 years of prevention actions to assess the efficiency of our preventative programme in the control of haemoglobinopathies in Sicily.
This programme consisted principally of five phases: legislative actions, public awareness campaign, carrier screening, genetic counselling and prenatal diagnosis.
These programmes have been very effective, which we can see from a greater public awareness of thalassaemia and its prevention in the target population furthermore by a marked decline in the incidence of thalassaemia major and sickle cell anaemia from 1 in 245 live births in the absence of prevention to 1 in 2000, with a reduction in about 85%. The residual cases were because of a conscious choice by expecting parents in relation to improved life expectancy as well as improved quality of life of the affected patients.
The study suggests that public health authorities should act and invest in a similar programme for prevention of thalassaemia, as well as in relation to the increased survival of patients and the consequent organ complications.
Endothelial dysfunction is a marker of future cardiovascular disease (CVD) risk, yet epidemiological studies have yielded inconsistent results. We therefore studied the association between endothelial dysfunction and CVD under diverse circumstances.
Literature-based meta-analysis of prospective observational studies with ≥ 12 months of follow-up published in Medline and having information on endothelial function and CVD outcomes. Tabular data on participant characteristics, endothelial function assessments and incident CVD outcomes were abstracted from individual studies. Random-effects meta-analysis was used to quantify pooled associations, and I2 statistic to evaluate between-study heterogeneity. Potential sources of heterogeneity were explored by subgroup analyses and meta-regression. Thirty five studies involving 17,206 participants met the inclusion criteria. During more than 80,000 person-years of observation, up to 2755 CVD events were accrued, yielding a pooled relative risk (RR) of 1.25 (95% confidence interval 1.15–1.35) for CVD comparing top (i.e. more severe) vs. bottom (less severe) third of endothelial dysfunction. There was significant between-study heterogeneity and evidence of publication bias. RRs varied importantly according to the method used to ascertain endothelial function, and were higher among older individuals and among participants with risk factors for CVD or established CVD at baseline.
Although endothelial dysfunction is an important determinant of cardiovascular outcomes in people with pre-existing CVD, current evidence base does not support its use as a potentially useful measurement for risk stratification in people at lower risk of CVD.
The impacts of renin–angiotensin system (RAS)-targeting antihypertensive drugs on Alzheimer's disease (AD) remain controversial. We performed this meta-analysis to evaluate the precise value of RAS-targeting antihypertensive drugs in terms of attenuating incidence of AD and slowing down cognitive decline in patients with AD.
A systematic literature search was conducted using PubMed, Embase, ScienceDirect and CBM (China Biology Medicine Disc) before September 2014. Studies analysing incidence of AD and cognitive changes in AD patients with RAS-targeting antihypertensive drugs were identified. The principal outcome measures were hazard ratios (HRs) for incidence of AD and standardised mean difference (SMD) for cognitive changes in AD patients. Pooled data were calculated using fixed or random effects models according to the heterogeneity.
In total, 12 studies involving 896,410 participants met our inclusion criteria. RAS-targeting antihypertensive drugs were significantly associated with a reduced incidence rate of AD (HR 0.81, 95% CI 0.72–0.92, p = 0.001). In subgroup analysis, both angiotensin renin blockers and angiotensin converting enzyme inhibitors were shown to effectively decrease the incidence rate of AD. In the analysis of cognitive changes, a slower rate of cognitive decline was observed in AD patients with RAS-targeting antihypertensive drug (SMD 0.30, 95% CI 0.09–0.50, p = 0.004), when randomised trials and observational trials were combined. However, analysis of randomised trials alone did not show the same result (SMD 0.20, 95% CI −0.10 to 0.50, p = 0.182).
Renin–angiotensin system-targeting antihypertensive drugs may be a potential treatment for reducing the incidence and progression of AD. Further studies on RAS-targeting antihypertensive drugs, especially large randomised clinical trials, should be conducted in the future.
Proton pump inhibitors (PPIs) are the treatment of choice for reflux esophagitis (RE). The effectiveness of PPIs throughout RE management, from healing to maintenance, has not been fully studied.
To compare esomeprazole with lansoprazole or pantoprazole for RE management using a management model.
Data from six studies comparing esomeprazole with lansoprazole or pantoprazole for healing (4–8 weeks) or maintenance of healing (6 months) of RE were incorporated into hypothetical management models to determine the proportion of patients in endoscopic remission after sequential healing and maintenance therapy, assuming that patients received the same PPI throughout. The number needed to treat (NNT) to achieve one more patient in remission with esomeprazole vs. other PPIs was estimated. The hypothetical model was validated using results from the EXPO study, which compared esomeprazole with pantoprazole for RE healing and maintenance.
Overall, esomeprazole 40 mg produced higher rates of healing (life-table estimates) than lansoprazole 30 mg (82.4–92.6% vs. 77.5–88.8%; p < 0.01) or pantoprazole 40 mg (95.5% vs. 92.0%; p < 0.001) and higher rates of endoscopic and symptomatic remission at 6 months than lansoprazole (83.0–84.8% vs. 74.0–75.9%; p < 0.001; life-table estimates) or pantoprazole (70.9% vs. 59.6%; p < 0.0001; observed rates). In the hypothetical management model, the NNT for esomeprazole was 9 vs. lansoprazole and 8 vs. pantoprazole. The actual NNT for esomeprazole vs. pantoprazole in the EXPO study was 9 (95% confidence interval: 6; 16).
In this management model, esomeprazole was more effective than either lansoprazole or pantoprazole for maintaining remission after sequential healing and 6 months' maintenance therapy for RE.
Ischaemic stroke (IS), brain haemorrhage and cerebral venous thrombosis can occur as an early and late complication of cancer in the clinical course. Cancer patients are at increased risk for stroke from direct and indirect effects of their malignancy.
The aim of our study was to evaluate the relationship between neoplastic disease and the long-term outcome, mortality and the presence of haemorrhagic complications in patients with acute IS treated with i.v. thrombolysis.
We retrospectively evaluated the demographic and clinical data of 495 Caucasian patients with acute IS and 40 patients with IS and concomitant neoplastic disease who were consecutively treated from 2006 to 2013 in two experienced stroke centres.
In analysed group, there were 7.8% of patients with cancer [50.0% male, mean age 72.3 ± 9.3; National Institutes of Health Stroke Scale – 13 (range 9.5–17)]. Cancer was diagnosed before i.v.-thrombolysis in 28 (70.0%) patients. After 3 months of follow up, 60% of patients were independent (mRS 0–2) compared with the group of patients without cancer – 55% (p = 0.54), 17.5% died (18.4%; p = 0.89), 12.4% suffered haemorrhagic transformation (HT) (17.6%; p = 0.41) and 2.5% experienced SICH (4.4%; p = 0.56, respectively). Other clinical complications were not found. A multivariate analysis showed no impact of neoplastic disease on unfavourable outcomes [modified Rankin scale 3–6)] after 3 months (p = 0.15).
Intravenous thrombolysis performed in Caucasian stroke patients with past or current neoplastic diseases, but not in the course of chemo- and radiotherapy, can be a safe and effective method of treatment. In making decision on the thrombolytic treatment, the risk of bleeding complications and the life expectancy should be assessed.
Few studies have investigated the relationship between sleep disorders (SD) and erectile dysfunction (ED). Therefore, this study explored whether patients with SD in an Asian population are at an increased risk of developing ED.
This longitudinal nationwide population-based cohort study investigated the incidence and risk of developing ED in 34,548 men newly diagnosed with SD between 2002 and 2008 from the National Health Insurance Research Database. A total of 138,192 controls without SD were randomly recruited from the general population and frequency matched according to age and sex. The follow-up period began from the date of entering the study cohort until the date of an ED event, censoring, or 31 December 2010. We conducted Cox proportional hazard regression analyses to estimate the effects of SD on the risk of ED.
The SD cohort had a 2.11-fold adjusted hazard ratio (HR) of subsequent ED development compared with the non-SD cohort [95% confidence interval (CI) = 1.89–2.37]. The incidence of ED increased with age for both cohorts and was higher for the patients in the SD cohort. Compared with the participants without SD or comorbidities, the patients without SD with any comorbidity exhibited a 1.79-fold risk of developing ED (95% CI = 1.54–2.09); the highest risk was for those with both SD and any comorbidity (HR = 3.34, 95% CI = 2.82–3.95). Furthermore, SD patients who had a particular number of comorbidities showed the dose–response effect of developing ED.
This nationwide cohort study determined that ED risk evidently increased in SD patients compared with the general population.
Accidental falls during hospitalisation have a range of complications and more information is needed to improve prevention. We investigated patterns of in-hospital fall-related major injuries in the period 2000–2012 and the association between chronic conditions and in-hospital fall-related major injuries.
Using administrative databases, patients aged 65+ years with in-hospital falls causing fractures or head injuries with need for surgery or intensive observation were identified as cases and were individually matched with five controls. Joinpoint regression was used to examine time trends and conditional logistic regression was used to analyse odds ratio (OR) for in-hospital falls-related major injuries according to a range of comorbidities.
Four thousand seven hundred and fifty-four cases were identified from 2000 to 2012 and the most common injury was femur fracture (61.55%). For individuals aged 65–74 and 75+ years, the incidence of in-hospital falls-related major injuries per 100,000 hospital days increased significantly in 2000–2012 (average annual change: 3.2%, CI: 0.6–5.8) and 2007–2012 (average annual change: 11.4%, CI: 5.7–17.5), respectively. Significantly increased OR for in-hospital fall-related major injuries were found for individuals with dementia (OR = 2.34, CI: 1.87–2.92), osteoporosis (OR = 1.68, CI: 1.43–1.99), stroke (OR = 1.63, CI: 1.41–1.88), depression (OR = 1.24, CI: 1.09–1.41), chronic obstructive pulmonary disease (OR = 1.18, CI: 1.01–1.39) and Parkinson disease (OR = 1.17, CI: 1.01–1.34).
In-hospital falls-related major injuries increased significantly during the study period. Elderly with dementia, osteoporosis, stroke, depression, chronic obstructive pulmonary disease and Parkinson disease were associated with increased OR for in-hospital fall-related major injuries. Increased focus on patients with these comorbidities is warranted to decrease the increasing incidence in in-hospital major injuries.
To determine the relationship between proprotein convertase subtilisin kexin 9 (PCSK9) levels and atheroma burden in Pakistanis presenting to an ambulatory centre with chest pain.
A prospective matched case–control study of 400 patients selected for presence/absence of angiographic disease referred between 2001 and 2003. A comprehensive cardiovascular disease risk factor profile was assessed including demographics, environmental and biochemical risk factors including insulin resistance and PCSK-9 levels. Coronary atheroma burden was quantified by Gensini score.
In this population, PCSK-9 levels were weakly correlated (r = 0.23) with male gender (p = 0.06) and number of diabetes years (p = 0.09), and inversely with log10 of lipoprotein (a) concentration (p = 0.07) but not LDL-C. In multiple regression analysis, Gensini score was associated with age (p = 0.002), established angina (p = 0.001), duration of diabetes (p = 0.05), low HDL-C (p < 0.001), lipoprotein (a) (p = 0.01), creatinine (p < 0.001), C-Reactive Protein (p = 0.02) and PSCK-9 (p = 0.05) concentrations. PCSK9 added to the regression model. Neither total cholesterol nor LDL-C were significant risk factors in this study.
Proprotein convertase subtilisin kexin 9 concentrations are correlated with atheroma burden in Indian Asian populations from the sub-continent, not taking statin therapy, independent of LDL-C or other CVD risk factors.
The influence of beta-blocker therapy (bisoprolol or carvedilol) (bB) on the prognosis of heart failure (HF) patients with diabetes mellitus (DM) is uncertain.
To assess the effect of bB on the prognosis of HF patients with new-onset DM treated with a contemporary medical regime.
Prospective study of 5314 HF patients with previously unknown DM. Mean age was 71.8 ± 7.9 years, 53.0% were women, and 50.2% had HF with preserved ejection fraction (HFpEF). During a median follow-up of 56.9 ± 18.2 months, 68.9% of the patients died, 88.6% were hospitalised for HF, and 1519 (27.3%) developed DM (62.3% of them received bB, 947 patients). We propensity-matched 572 HF patients with DM on bB, with 572 HF patients with DM non-treated with bB.
Beta-blocker therapy was associated with a decreased hazard risk (HR) of all-cause death [HR: 0.68, CI 95% (0.61–0.75)], mainly because of a reduced risk of death from cardiovascular causes [HR: 0.70 (0.64–0.77)] (p < 0.001). Similarly, bB was associated with a decreased HR of hospitalisation [HR: 0.82 (0.72–0.92)] (p < 0.001). Nevertheless, the 30-day re-admission rate and the number of visits were not significantly associated with bB. These relationships of bB with prognosis were maintained, independently of the gender, the type of HF (HFpEF ot HFdEF), the comorbidities and the medication used (p < 0.01).
Therapy with bB, bisoprolol or carvedilol, is associated with a reduced mortality and morbidity of HF patients with new-onset DM, not only in men but also in women, as well as in patients with HFpEF or HFdEF.
To evaluate how the rating of the severity of sickness – as performed by the physician, nurse and patient – is associated with hospitalisation and acute morbidity.
Prospective observational study, performed in the emergency department of a tertiary hospital. Patients, physicians and nurses were interviewed separately after the first contact from 21 October through to 11 November 2013.
Of 2426 presenting patients, 1861 were screened, and 1196 were included. A total of 299 (25%) were hospitalised, 504 (42%) suffered acute morbidity. In the univariate analysis, the physician's, nurse's and patient's rating of severity of sickness, expressed on a scale from 0 to 10, was significantly associated with hospitalisation (physicians: OR 1.61, 95% CI 1.50–1.73; nurses: OR 1.52, 1.41–1.64; patients: OR 1.16, 1.10–1.22), and with acute morbidity (OR 1.49, 1.40–1.59; OR 1.39, 1.30–1.48 and OR 1.05, 1.003–1.09 respectively). The area under the curve of the receiver operating characteristic curves was 0.77, 0.72 and 0.61 for hospitalisation, and 0.72, 0.68 and 0.54 for acute morbidity. The interrater reliability was estimated by the intraclass correlation, which was 0.49 for physician/nurse, 0.17 for nurse/patient and 0.07 for physician/patient. In a multivariable analysis model consisting of age, male sex, ethnic origin, ratings of severity of sickness, symptoms, ability to go home and hospitalisation during the preceding 12 months, only age, and the physician's and nurses' rating of severity of sickness remained significantly associated with both outcomes.
The first impression of severity of sickness was associated with hospitalisation and morbidity.
Rivastigmine patch is approved for the treatment of all stages of Alzheimer's disease (AD). Application site reactions may be a concern to clinicians and we used two large clinical trial databases to investigate the incidence of skin reactions in patients receiving rivastigmine patch.
Data from a 24-week, randomised, double-blind (DB) evaluation of 13.3 vs. 4.6 mg/24 h rivastigmine patch in severe AD (ACTION) and a 72- to 96-week study comprising an initial open-label (IOL) phase followed by a 48-week randomised, DB phase (13.3 vs. 9.5 mg/24 h rivastigmine patch) in declining patients with mild-to-moderate AD (OPTIMA) were analyzed. The incidence, frequency, severity, management and predictors of application site reactions were assessed.
Application site reactions were mostly mild or moderate in severity and reported by similar proportions in each treatment group (ACTION: 13.3 mg/24 h, 24.5% and 4.6 mg/24 h, 24.2%; OPTIMA: IOL 9.5 mg/24 h, 22.9%; DB 13.3 mg/24 h, 11.4% and 9.5 mg/24 h, 12.0%); none were rated serious. In both studies, < 9% of patients required treatment for application site reactions. Application site reactions led to discontinuation of 1.7% and 2.5% of the 13.3 mg/24 h and 4.6 mg/24 h groups, respectively, in ACTION, 8.7% in OPTIMA IOL and 1.8% and 3.5% of the 13.3 mg/24 h and 9.5 mg/24 h groups, respectively, in OPTIMA DB.
Application site reactions were experienced by < 25% of patients in both studies, with no notable effect of dose. No reactions qualified as serious and skin reactions were uncommon as a reason for study discontinuation.
We aimed to compare community-onset healthcare-associated (CO-HCA) and hospital-acquired (HA) urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli in terms of epidemiology, clinical outcomes and antimicrobial activities.
Patients from both groups with ESBL-producing E. coli detected by urine culture between January 2009 and January 2011 were included in this retrospective study. Relevant demographical, microbiologic and clinical data were obtained from case records.
A total of 173 patients (mean age of 58 years, 74% female) were included, of whom 75 (43.4%) had a CO-HCA UTI and 98 (56.6%) had an HA UTI. Eighty (46.2%) patients had more than one comorbid disease, of whom 57 (32.5%) had urological problems. The most common clinical manifestations were pyelonephritis (43.9%) and urosepsis (16.2%). An age of > 65 years (p = 0.005) in addition to urinary catheterisation (p = 0.001), urosepsis (p = 0.001) and mortality (p = 0.001) were significantly more common in the HA UTI group. Acute cystitis (p = 0.027), complicated cystitis (p = 0.001) and non-urologic neoplasm (p = 0.032) were significantly more common in the CO-HCA UTI group. No isolate was resistant to carbapenems or fosfomycin. Sensitivities to nitrofurantoin, amikacin, trimethoprim sulfamethoxazole-trimoxazole and quinolones were 97.6%, 89%, 29.4% and 17.9% respectively. Both groups showed similar rates of antibiotic resistance.
ESBL-producing E. coli should be taken into consideration in patients with a CO HCA UTI, not only in hospital settings but also in outpatient settings. We suggest ertapenem as a first-line empirical treatment for patients with an upper UTI and fosfomycin and nitrofurantoin for those with a lower UTI when ESBL-producing E. coli is suspected.
Allopurinol is used as long-term therapy to reduce the occurrence of gout flares. This study estimated the impact of patient adherence to allopurinol on hyperuricaemia (serum uric acid levels, sUA > 6 mg/dl) and the identification of non-adherence predictors.
The Italian Health Search-CSD Longitudinal Patient Database was accessed to identify outpatients aged ≥ 18 years with gout and prescribed with allopurinol during the years 2002–2011. Patients with a proportion of days covered ≥ 80% were considered adherent to allopurinol. Data on sUA levels over the first year of therapy were categorised in three time-windows (30–89; 90–149; 150–365 days). Logistic regressions were used to estimate the association between adherence and hyperuricaemia, as well as non-adherence predictors.
A total of 3727 patients were included. In the interval 0–29 days, the proportion of patients adherent to allopurinol was 45.9%, while up to 89, 149 and 365 days the percentages were 16.7%, 10.0% and 3.2%, respectively. The proportions of hyperuricaemic patients for each time-window were 43.1%, 42.4%, 32.6% and 59.0%, 64.0%, 66.4% among adherent and non-adherent patients, respectively. In the multivariable analysis, adherence was associated with a significant lower risk of hyperuricaemia. The adjusted ORs were 0.49 (95% CI: 0.33–0.73), 0.40 (95% CI: 0.24–0.67) and 0.23 (95% CI: 0.15–0.34) for the first, second and third time-window, respectively. Patients with hypertension (adjusted OR = 0.64, 95% CI: 0.42–0.99) and history of gout flares (adjusted OR = 0.55, 95% CI: 0.32–0.95) were significantly adherent to allopurinol.
Adherence monitoring in patients with gout is pivotal to ensure the effectiveness of therapy. To gain a better patient adherence, the communication between physicians and patients should be improved.
Arterial hypertension is a well-established factor for increased risk of cardiovascular diseases, but low admission blood pressure has also been suggested as predictor for increased mortality. We hypothesised that in patients with acute myocardial infarction admission blood pressure at the Emergency Department predicts long-term mortality.
We included consecutive patients treated for acute myocardial infarction (AMI) at our 2,200-bed tertiary care hospital from 1991 to 2009 into our cohort. Systolic, diastolic and pulse pressure on admission were analysed as main predictors for 1-year mortality. We adjusted for several baseline factors and tested for interactions using multivariable regression models.
We included 3943 patients among whom 3604 were alive after 1 year. With increasing admission blood pressure 1-year mortality risk decreased incrementally to a 70% reduced relative risk in the highest blood pressure categories vs. the lowest categories. This effect was independent of blood pressure modifying interventions.
In acute myocardial infarction, admission blood pressure predicts long-term mortality in an inverse relation. With increasing admission blood pressure long-term mortality decreases. Low admission blood pressure should serve as a warning sign in patients with AMI. Admission blood pressure should therefore be interpreted in opposite to the regular, preventive, point of view.
Renal function is an important prognostic factor in heart failure. The aim of this study was to compare the predictive value of estimated renal function calculated by the Chronic Kidney Disease-Epidemiology Collaboration equation (CKD-EPI) and the abbreviated Modification of Diet in Renal Disease (MDRD-4) equation for long-term all-cause mortality in patients admitted for acute decompensated heart failure (ADHF) with both preserved ejection fraction (HF-PEF) and reduced ejection fraction (HF-REF).
We evaluated patients included in the Spanish National Registry of Heart Failure (RICA). RICA is a multicentre, prospective, cohort study that included patients admitted to the Internal Medicine units with ADHF. Estimated glomerular filtration rate (eGFR) was calculated with CKD-EPI and MDRD-4 equations. A total of 1805 patients admitted for ADHF were studied (52% women; median age 80 years, interquartile range 73.9–84.6 years); of these, 1044 (58%) had HF-PEF. eGFR values were lower with the CKD-EPI formula than with the MDRD-4 formula (51 ml/min/1.73 m2 vs. 55.7 ml/min/1.73 m2; p < 0.001). The two formulas provided independent prognostic information over long-term follow-up, in both HF-PEF and HF-REF patients. However, in HF-PEF patients, CKD-EPI equation was associated with a significant improvement in reclassification analyses (net reclassification improvement 6.78%; p = 0.009).
In this clinical cohort of ADHF patients, eGFR as calculated by both the CKD-EPI and the MDRD-4 formulas offered similar prognostic information, irrespective of ejection fraction status, but in HF-PEF patients specifically, the CKD-EPI formula seems to improve clinical risk stratification as compared with MDRD-4.
Phaeochromocytomas (PC) and paragangliomas (PGL) are rare neuroendocrine tumours of chromaffin cells. Diagnosis depends on biochemical evidence of excessive production of catecholamines. This is straightforward when test results are orders of magnitude above the concentrations expected in healthy individuals and those with essential hypertension. Equivocal results pose a management dilemma.
We reviewed biochemical screens that were positive and the ensuing management for PC/PGL at our institution. The objective was to inform the development of a standardised approach to investigation and clinical follow-up.
All records of positive biochemical screening for PC/PGL were extracted from the laboratory information system between January 2004 and June 2012. Clinical notes of patients with positive results were reviewed.
A total of 2749 biochemical screens were performed during the evaluation period. Of these, 106 (3.9%) performed on 82 patients were positive. Chart review determined that 12/82 patients had histologically confirmed PC/PG. Of the 70 patients remaining, the most common indication for biochemical screening was hypertension and the medical subspecialty most frequently requesting the test was Endocrinology. The primary team carried out repeat testing on 35/70 (50%) patients and in 29 results normalised. Notably, 35/70 (50%) patients did not have any follow-up of positive test results.
This study highlights the necessity for a standardised diagnostic protocol for PC/PGL. We suggest that appropriate follow-up of borderline-elevated results should first include repeat biochemical testing. This should be performed under standardised pre-analytical conditions and where possible off all potentially interfering medications, measuring plasma free metadrenalines.
Proton pump inhibitors (PPIs) are recommended for the prevention of traditional non-steroidal anti-inflammatory drugs (tNSAIDs)-related ulcer complications in high-risk patients. We aimed to study to which extent older persons initiating tNSAIDs with and without oral corticosteroids receive PPIs and whether sex and age influence treatment.
We analysed claims data of the German health insurance company BARMER GEK, covering about 9 million persons. A cohort of new users of tNSAIDs aged 65 years and older starting treatment from 1 January 2011, through 1 December 2012 was included. Concurrent use of oral corticosteroids was assessed within the 28 days before the index date. Persons were categorised as users of PPIs if they filled a prescription within 28 days before or after the index prescription.
A total of 83,326 persons met the inclusion criteria (64.1% females; mean age: 74.7 years). Of these new users of tNSAID, 27.8% received PPIs within 28 days before or after the index date (females: 29.4% and males: 25.0%). Of the 2857 persons with concurrent prescriptions of oral corticosteroids, 42.8% also received PPIs (females: 43.4% and males: 41.8%). An increase in prescribing of PPIs with age was found in all new users as well as in those concurrently receiving oral corticosteroids.
We found that gastroprotective agents are not prescribed to older new users of tNSAIDs as recommended. When compared with earlier studies, adherence to guidelines still remains low.
In the USA, 45% of patients with type 2 diabetes mellitus (T2DM) are elderly (≥ 65 years old). In general, use of sulfonylurea increases with patient age as does the associated risk for hypoglycaemia, and the consequences of hypoglycaemia can be more pronounced in elderly patients. Sitagliptin, a DPP-4 inhibitor, improves glycaemic control in adult patients of all ages with T2DM, with a low risk of hypoglycaemia when used alone or in combination with other antidiabetic agents that are not generally associated with hypoglycaemia when used independently.
In a post hoc analysis, pooled data from elderly patients who participated in one of three double-blind studies comparing the effects of therapy with sitagliptin (100 mg/day) vs. sulfonylurea (in titrated doses) were analysed for changes from baseline in HbA1c, fasting plasma glucose (FPG), and body weight and for the incidence of reported symptomatic hypoglycaemia. In these studies, patients on diet alone or metformin were randomised to sitagliptin or glipizide for 104 weeks (studies 1 and 2) or glimepiride for 30 weeks (study 3). The analysis included 372 elderly patients who completed a trial through 25 or 30 weeks.
Both HbA1c and FPG decreased from baseline with each treatment, with no statistically significant differences between treatments. A significantly lower incidence of reported hypoglycaemia was observed with sitagliptin compared with sulfonylurea (6.2% vs. 27.8%; p < 0.001). Body weight decreased significantly with sitagliptin but not with sulfonylurea. Significantly more patients on sitagliptin than on sulfonylureas achieved a composite end-point of >0.5% HbA1c reduction with no reported hypoglycaemia or increase in body weight (44.1% vs. 16.0%; p < 0.001).
In this analysis of elderly patients with T2DM, compared with sulfonylurea, sitagliptin provided similar glycaemic efficacy with less hypoglycaemia and with body weight loss.
Previous studies have demonstrated significant variability in the processes of care and outcomes of chronic obstructive pulmonary disease (COPD) exacerbations. The AUDIPOC is a Spanish nationwide clinical audit that identified large between-hospital variations in care and clinical outcomes. Here, we test the hypothesis that these variations can be attributed to either patient characteristics, hospital characteristics and/or the so-called hospital-clustering effect, which indicates that patients with similar characteristics may experience different processes of care and outcomes depending on the hospital to which they are admitted.
A clinical audit of 5178 COPD patients consecutively admitted to 129 Spanish public hospitals was performed, with a 90-day follow-up. Multilevel regression analysis was conducted to model the probability of patients experiencing adverse outcomes. For each outcome, an empty model (with no independent variables) was fitted to assess the clustering effect, followed by a model adjusted for the patient- and hospital-level covariables. The hospital-clustering effect was estimated using the intracluster correlation coefficient (ICC); the cluster heterogeneity was estimated with the median odds ratio (MOR), and the coefficients of predictors were estimated with the odds ratio (OR).
In the empty models, the ICC (MOR) for inpatient mortality and the follow-up mortality and readmission were 0.10 (1.80), 0.08 (1.65) and 0.01 (1.24), respectively. In the adjusted models, the variables that most represented the patients' clinical conditions and interventions were identified as outcome predictors and further reduced the hospital variations. By contrast, the resource factors were primarily unrelated with outcomes.
This study demonstrates a noteworthy reduction in the observed crude between-hospital variation in outcomes after accounting for the hospital-cluster effect and the variables representing patient's clinical conditions. This emphasises the predictor importance of the patients' clinical conditions and interventions, and understates the impacts of hospital resources and organisational factors.
To explore the validity and reliability of eye healthcare professionals with different levels of training in diagnosing and/or identifying glaucomatous progression.
Substantial pressure is being placed on our current eye healthcare workforce by chronic diseases such as glaucoma. Shared care schemes and role expansion of professionals other than ophthalmologists are being proposed to alleviate this pressure. A sound evidence base is imperative to determine whether other allied health professionals are skilled and clinically competent, when it comes to taking on these new roles in glaucoma management.
A systematic review of research articles identified in MEDLINE, CINAHL, Embase, Scopus and Cochrane Library was performed. Studies which investigated rater reliability of various health professionals in diagnosing and/or identifying glaucoma progression against a reference standard were included.
Of the 4088 publications identified by the initial database search, 32 met the inclusion criteria. The majority of studies demonstrated positive results, with most finding moderate to substantial agreement for inter- and intra-rater reliability across all testing modalities. The eye health professionals with ophthalmology training consistently attained the greatest agreement. When allied health professionals with different levels of training were compared, those who had completed residency training were significantly better than those who had not.
The studies included in this review show promising results, including those raters without ophthalmology training. A lack of power calculations, unequal sample sizes in some studies and the diversity of the testing procedures used make it difficult to make sound inferences.
The purpose of this study was to evaluate the risk of acute pancreatitis following pneumococcal pneumonia in Taiwan.
We undertook a retrospective cohort study using the hospitalisation claims data of the Taiwan National Health Insurance Program. We identified 16709 subjects aged 20–84 with the first-attack of pneumococcal pneumonia between 1998 and 2010 as the pneumonia group and we randomly selected 66836 subjects without a history of pneumonia as the non-pneumonia group. Both groups were matched for gender, age and index year. We examined the incidence of acute pancreatitis by the end of 2010 and we used a multivariable Cox proportional hazards regression model to calculate the hazard ratio (HR) and 95% confidence interval (95% CI) of acute pancreatitis associated with pneumococcal pneumonia and other comorbidities.
Subjects with pneumococcal pneumonia had higher incidence of acute pancreatitis, when compared with non-pneumonia subjects (2.41 vs. 1.47 per 1000 person-years, crude HR 1.65, 95% CI = 1.38, 1.97). The highest risk of developing acute pancreatitis occurred during the first 3 months after diagnosing pneumococcal pneumonia (crude HR 4.11, 95% CI 1.98, 8.52). After adjusted for potential confounders, the adjusted HR of acute pancreatitis was 1.51 (95% CI 1.25, 1.82) for the pneumonia group, as compared with the non-pneumonia group.
Overall, this study reveals a 51% increased hazard of acute pancreatitis following infection with pneumococcal pneumonia. Patients with pneumococcal pneumonia should receive close surveillance for risk of developing acute pancreatitis during the first 3 months after diagnosing pneumococcal pneumonia.
Investigate if angiotensin II receptor blocker (ARB) decreases risk of upper gastrointestinal bleeding (UGIB) in hypertensive patients with chronic kidney disease (CKD) not on dialysis.
All hypertensive patients with CKD not on dialysis in outpatient department of China Medical University Hospital from 2003 to May 2013 were enrolled. The risk of UGIB was analysed using Cox proportional hazard regression.
A total of 2744 hypertensive CKD patients including 1515 male and 1229 female, aged 64.9 ± 13.8 years old in a median of 1.9 (0.9–3.9) years were analysed. The incidence of UGIB was 4.5 per 100 patient-years. ARB was associated with a decreased risk of UGIB (p < 0.001) with an adjusted hazard ratio (HR) of 0.533 [95% confidence interval (CI) 0.404–0.703]. A history of UGIB, Helicobacter pylori infection, diabetes, lower estimated glomerular filtration rate, elevated blood urea nitrogen and decreased serum albumin were independently associated with an increased risk of UGIB.
Angiotensin II receptor blocker is associated with a decreased risk of UGIB in hypertensive CKD patients not on dialysis, independent of their renal function, history of gastrointestinal bleeding and nutrition status.
Synovial fluid analysis is an indispensable investigation to attain a diagnosis in a patient with acute hot swollen joint(s), septic arthritis in particular. A delay in appropriate early management results in serious undesired consequences.
We evaluated clinical practice at two teaching hospitals including 81 patients. We analysed medical records, laboratory pathology results and discharge summaries with regard to documentation of joint aspiration, blood cultures, antibiotic treatment and specialist referral. We then conducted a survey of 140 medical trainees to evaluate their self-reported competence at managing the acute hot swollen joint.
We found that synovial aspiration and blood cultures were performed in only 42(52%) and 30(37%) patients, respectively, not in accord with current guidelines. Given trainee doctors are responsible for the early management of acute hot swollen joint(s), our survey reveal low self-reported levels of competence and confidence at managing acute hot swollen joint(s) in 72(52%) and 37(27%) respondents, respectively. Furthermore, 101(75%) trainees indicated a need for more training in joint aspiration. We also report that 13 of 15 hospitals surveyed in London and South East UK do not provide specific training on the management of the hot swollen joint and joint aspiration as part of their induction programme.
Early management of patients with hot swollen joint(s) to perform synovial fluid aspiration and blood cultures are not being done in accordance with guidelines. We suggest that the medical trainee curricula should incorporate joint aspiration skills as an 'essential procedure', to improve the trainee doctor's confidence and competence at managing acute hot swollen joint(s) to improve adherence to guidelines, and consequently, patient outcomes.
The objective of this study is to externally validate the SOAR stroke score (Stroke subtype, Oxfordshire Community Stroke Project Classification, Age and prestroke modified Rankin score) in predicting hospital length of stay (LOS) following an admission for acute stroke.
We conducted a multi-centre observational study in eight National Health Service hospital trusts in the Anglia Stroke & Heart Clinical Network between September 2008 and April 2011. The usefulness of the SOAR stroke score in predicting hospital LOS in the acute settings was examined for all stroke and then stratified by discharge status (discharged alive or died during the admission).
A total of 3596 patients (mean age 77 years) with first-ever or recurrent stroke (92% ischaemic) were included. Increasing LOS was observed with increasing SOAR stroke score (p < 0.001 for both mean and median) and the SOAR stroke score of 0 had the shortest mean LOS (12 ± 20 days) while the SOAR stroke score of 6 had the longest mean LOS (26 ± 28 days). Among patients who were discharged alive, increasing SOAR stroke score had a significantly higher mean and median LOS (p < 0.001 for both mean and median) and the LOS peaked among patients with score value of 6 [mean (SD) 35 ± 31 days, median (IQR) 23 (14–48) days]. For patients who died as in-patient, there was no significant difference in mean or median LOS with increasing SOAR stroke score (p = 0.68 and p = 0.79, respectively).
This external validation study confirms the usefulness of the SOAR stroke score in predicting LOS in patients with acute stroke especially in those who are likely to survive to discharge. This provides a simple prognostic score useful for clinicians, patients and service providers.
Primary non-adherence occurs when a drug has been prescribed but the patient fails to have it dispensed at the pharmacy.
To assess primary non-adherence to statins and antidepressants in Iceland, the association of demographic factors with primary non-adherence, and the time from when a prescription is issued until it is dispensed.
Data on patients receiving a new prescription for a statin or an antidepressant from the Primary Health Care database were linked with dispensing histories from The Icelandic Prescription Database. The proportion of patients who did not have their prescription dispensed within a year from issuing (primary non-adherent) was assessed, as well as the time from issue until dispensing. Associations between demographic factors and primary non-adherence were estimated using logistic regression.
The overall primary non-adherence was 6.3% and 8.0% for statins and antidepressants, respectively. The majority of patients had their prescription dispensed within 7 days (85% for statins, 87% for antidepressants). Being disabled and receiving a prescription for an expensive drug was associated with higher rates of primary non-adherence.
The rate of primary non-adherence to statins and antidepressants in Iceland is low. Vulnerable groups such as the disabled should be given special attention when new drugs are prescribed.
The association between Helicobacter pylori infection and end-stage renal disease (ESRD) events remains unknown. We assessed the relationship between H. pylori infection requiring hospital admission and the subsequent risks of ESRD.
This was a retrospective cohort study in which data from the National Health Insurance system of Taiwan was used. The H. pylori-infected cohort comprised 20,068 patients. Each participant was frequency-matched by age and sex with 4 individuals from the general population without H. pylori-infected. Cox proportional hazards regression analysis was used to estimate the influence of H. pylori infection on the risk of ESRD.
The overall incidence of ESRD was 3.72 times greater in the H. pylori-infected cohort than in the non-infected cohort (11.1 vs. 2.96 per 1000 person-years), with an adjusted HR of 2.58 [95% confidence interval (CI) = 2.33–2.86]. The risk of ESRD markedly increased in patients with H. pylori infection combined with at least one of the following concomitant comorbidities: hypertension, diabetes, hyperlipidaemia and coronary artery disease.
This is currently the largest nation-based study in which the risk of ESRD in H. pylori-infected patients was examined. H. pylori infection was associated with a subsequent risk of ESRD. H. pylori-infected patients with concomitant chronic kidney disease (CKD) or cardiovascular disease (CVD) risk factors were at higher risk of ESRD than were those who had a single CKD or CVD risk factor.
Results of studies examining the influence of age on thyroid function and TSH levels, in the absence of thyroid disease, remain controversial. The aim of this study was to determine the course of thyroid function over 11 years in a population with normal thyroid function.
This is a population-based prospective study started in 1995–1997 (first phase), and reassessed 6 (second phase) and 11 years later (third phase).
The TSH and FT4 in the third phase were significantly increased (p = 0.001 and p = 0.001, respectively), with the values being higher particularly from the age of 50 years. In those persons with a baseline TSH ≥ 1.2 and < 3 μIU/mL, the OR of having a TSH of 3–5 μIU/mL in the third phase was 6.10 (p = 0.004). In those with a baseline TSH ≥ 3 and ≤ 5 μIU/mL, the OR of having a TSH of 3–5 μIU/mL in the third phase was 20.8 (p < 0.0001). Similar results were found for FT4.
In a population free of clinical thyroid disease, TSH and FT4 values rise over the years. This increase occurs in all age groups, but depends mainly on the basal concentrations of TSH and FT4.
Several previous studies have suggested that detection of a third heart sound (S3) in patients with chronic congestive heart failure is associated with adverse long-term outcomes. However, the short-term prognostic value of identifying an S3 on admission in patients with acute heart failure (AHF) is not well established. We therefore analysed the in-hospital prognostic value of detecting an S3 on admission in hospitalised patients with AHF.
The Acute Decompensated Heart Failure Syndromes (ATTEND) study investigators enrolled 4107 patients hospitalised with AHF. Investigators evaluated the presence or absence of an S3 during routine physical examination.
On admission to hospital, 1673 patients (41%) had an S3. Patients with an S3 had a higher heart rate, higher serum level of B-type natriuretic peptide and higher creatinine levels than patients without an S3. However, there were no significant differences of systolic blood pressure, serum sodium, haemoglobin, C-reactive protein and total bilirubin between the two groups. Multivariate analysis adjusted for various markers of disease severity revealed that only the presence of an S3 was independently associated with an increase of in-hospital all cause death [adjusted odds ratio (OR), 1.69; 95% confidence interval (CI), 1.19–2.41; p = 0.003] and cardiac death (adjusted OR, 1.66; 95% CI, 1.08–2.54; p = 0.020) among the congestive physical findings related to heart failure (S3, rales, jugular venous distension and peripheral oedema).
Detecting an S3 on admission was independently associated with adverse in-hospital outcomes in patients with AHF. Our findings suggest that careful bedside assessment is clinically meaningful.
A certain degree of impaired kidney function is related to an increased cardiovascular risk. The cardiovascular protection exerted in the postmenopausal state by the hormone replacement therapy (HRT) is debated. No studies have so far explored the relationship between menopause, renal function and cardiovascular risk profile in healthy menopausal women in relation with HRT.
A total of 362 postmenopausal healthy women with normal albumin excretion rate were recruited and divided into two groups (HRT+ and HRT−) according to the presence or absence of HRT. All participants underwent a complete routine biochemical analyses and an echocardiogram.
Clinical characteristics of the two groups were similar, but HRT+ showed a significantly higher estimated glomerular filtration rate (GFR; by CKD-EPI formula). Regarding the heart ultrasonography, HRT+ had a significantly lower size of the aortic root and left atrium diameter (p = 0.038 and p = 0.012, respectively); no differences were found in the ejection fraction and Left Ventricular Mass Index (LVMI). In the whole study group, eGFR correlated inversely with LVMI and with the size of the aortic root (both p < 0.0001), being GFR the only determinant of the former by a stepwise regression. Dividing the study population according to an eGFR cut-off (> 80 and < 80 ml/min/1.73 m2); > 80 women, in comparison with < 80, showed a significantly lower LVMI and lower size of aortic bulb, further reduced in the HRT+.
In a cohort of healthy, drug-naïve, postmenopausal women, HRT seems to positively affect glomerular filtration and is associated with lower values of left ventricular mass and aortic root size, thus offering a further mechanism through female hormones exert cardioprotection.
Micronutrient deficiencies occur in morbidly obese patients. The aim of this study was to assess vitamin deficiencies prior to bariatric surgery including vitamin K about which there is little data in this population.
A prospective assessment of 118 consecutive patients was performed. Clinical allied with haematological and biochemical variables were measured. Micronutrients measured included vitamins K1, PIVKA-II (protein-induced in vitamin K absence factor II), vitamin D, vitamin B12 (holotranscobalamin), iron, transferrin and folate.
Patients were aged 49 ± 11 [mean (SD, standard deviation)] years, body mass index (BMI) 50 ± 8 kg/m2, 66% female and 78% Caucasian. Hypertension was present in 47% and type 2 diabetes in 32%. Vitamin D supplements had been prescribed in 8%. Micronutrient insufficiencies were found for vitamin K (40%), vitamin D (92%) and vitamin B12 (25%), and also iron (44%) and folate (18%). Normocalcaemic vitamin D insufficiency with secondary hyperparathyroidism was present in 18%. Iron and transferrin levels were associated with age, sex and estimated glomerular filtration rate. Vitamin K levels were associated with age, and inversely with BMI and diabetes mellitus; and PIVKA-II with smoking, triglycerides and liver function markers. Vitamin D levels were associated with statin use and prescription of supplements and inversely with BMI. Vitamin B12 levels were associated with ethnicity and HbA1c.
Micronutrient status shows differing relationships with age, gender and BMI. Vitamin K insufficiency was present in 40% and not related to deficiencies in other vitamins or micronutrients. Vitamin D and vitamin K supplementation should be considered prebariatric surgery in patients with diabetes or severe insulin resistance.
This study evaluated levels of metabolic control, resource use and quality of life in Turkish patients with type 2 diabetes initiated on insulin in routine care.
The prospective, observational TREAT study evaluated patients from five different countries who were initiated on insulin and followed for 24 months. In this paper, we present the results of a cohort analysis specific to Turkish patients from the study.
A total of 211 patients in the Turkish multicenter cohort [male patients 50.2%, age 56.5 year ± 8.9 SD, body mass index (BMI) 30.6 kg/m2 ± 5.4 SD, diabetes duration 9.7 year ± 5.9 SD] initiated insulin at baseline. Oral antidiabetic drugs had been used by 93.4% of patients prior to insulin initiation, and 65.9% had used more than one regimen. Pre-existing metformin therapy was continued by 68.7% of patients after insulin initiation. In the three most common insulin regimens, glycosylated haemoglobin (HbA1C) declined over 24 months from 10.27% to 7.82% (long/intermediate acting), from 10.82% to 7.52% (premixed) and from 10.42% to 7.67% (basal-bolus). Less than 25% achieved a glycaemic goal of HbA1C ≤ 7.0% and changes in insulin dose or regimen rarely occurred. Premixed insulin regimens were associated with greatest weight gain. Hypoglycaemic episodes were reported by more patients at 3, 6 and 12 months than at baseline or at 18 or 24 months. Healthcare use increased over baseline levels in the first 6 months, but was closer to baseline levels at subsequent assessments.
Patient recorded health profiles improved after initiating insulin, particularly quality of life scores related to psychological distress and pain/discomfort. Morisky scores predictive of medication adherence and treatment persistence also improved.
In Turkish patients with type 2 diabetes, metabolic control remained suboptimal after initiating insulin as part of routine care even after 24 months of insulin treatment. Apparent shortcomings in routine care in most patients included a high baseline HbA1C because of delayed insulin initiation and an unwillingness to individualise insulin regimens.
Studies that have investigated the epidemiological relationship between bronchiectasis and cancers are scarce.
In this study, we investigated the incidence and risk of cancer in 53,755 patients newly hospitalized with bronchiectasis between 1998 and 2010 using data from the Taiwan National Health Insurance Research Database. The comparison cohort comprised 215,020 people from the general population without bronchiectasis. The follow-up period extended from the initial hospitalization date for bronchiectasis to the date of a cancer diagnosis, censoring, or 31 December 2011. We used Cox proportional hazard regression models to analyze the risks of cancer by including the variables of sex, age, and comorbidities.
The overall cancer incidence was higher in patients with bronchiectasis than in the comparison cohort (17.0 vs. 12.2 per 1000 person-years). The bronchiectasis patients exhibited a 1.46-fold greater risk of cancer than did the comparison cohort after we adjusted for age, sex and comorbidities [adjusted hazard ratio (aHR) = 1.46, 95% CI = 1.41–1.52]. Although the cancer incidence increased with age in both cohorts, the younger patients with bronchiectasis exhibited the greatest risk of cancer compared with the comparison cohort. Patients with bronchiectasis had a considerably higher risk of lung cancer (aHR = 2.40, 95% CI = 2.22–2.60), oesophageal cancer (aHR = 2.06, 95% CI = 1.61–2.64), and hematologic malignancy (aHR = 2.02, 95% CI = 1.72–2.37) than did the comparison cohort.
This nationwide cohort study suggested the patients with bronchiectasis exhibited increased substantial risks of certain cancer compared with the general population.
The objective of this study was to determine the association between statin use and female lung cancer in Taiwan.
In this case–control study, we used information from the Taiwan National Health Institute Research Database on 17,329 patients (cases) aged 20 years or older recently diagnosed with lung cancer between 2005 and 2010 and 17,329 patients without lung cancer to assess the association between female lung cancer and statin use, even adjustment for its comorbidities.
After adjusting for age and associated risk factors, we determined that women who engaged in long-term use of simvastatin at a defined daily dose (DDD) of over 150 have a reduced risk of lung cancer compared with those who did not use statins (odds ratio: 0.77, 95% confidence interval: 0.62–0.97) in women. However, lovastatin was not significantly associated with lung cancer in women. Among female patients with pre-existing comorbidities of respiratory diseases such as chronic obstructive pulmonary disease, hypertension, stroke and pulmonary tuberculosis, statins reduced the risk of lung cancer.
Simvastatin use at a DDD of more than 150 is correlated with an approximately 20% reduction in the risk of lung cancer in women.
The study aimed to compare the adherence and persistence among newly diagnosed hypertensive patients using fixed-dose (FDC) and free combinations (FC) of angiotensin receptor blocker (ARB)/thiazide diuretic using Taiwan's National Health Insurance Research Database.
General linear regression and Kaplan–Meier analyses were used to estimate the impact of FDC on adherence [measured by medication possession ratio (MPR)] and persistence (time from day of initiation to treatment discontinuation) of ARB/thiazide diuretic.
The adjusted MPRs were all significantly higher among FDC group compared with FC group (6 months: 66.55% vs. 63.86%; 1 year: 52.58% vs. 46.73%, 1.5 year: 46.30% vs. 38.07%; 2 year: 42.06% vs. 32.45%, all p < 0.001). Patients received FDC therapy were less likely to discontinue their therapy [adjusted hazard ratio (HR) 0.79, 95% CI = 0.74–0.85].
Our findings suggest that use of FDC is associated with higher adherence and persistence rates than use of FC in newly diagnosed hypertensive patients.
Incretin-based therapies offer another treatment option for patients with type 2 diabetes. Agents that provide glycaemic control in addition to attenuating cardiovascular disease (CVD) risk factors are important for diabetes management. This review will focus on the off-target effects of incretin-based therapies on CVD risk factors [body weight, blood pressure (BP), lipid profile and albuminuria], major adverse cardiovascular events (MACE), heart failure (HF) and beta-cell preservation.
A literature search was conducted to identify English-language publications for incretin-based therapies evaluating the following off-target end-points: body weight, BP, lipid profile, albuminuria, MACE, HF and beta-cell function. Randomised controlled trials (RCTs) were prioritised as the primary source of information.
Overall, incretin-based therapies have shown beneficial effects on CVD risk factors, and glucagon-like peptide 1 (GLP-1) receptor agonists appear to have a more pronounced effect compared with dipeptidyl peptidase-4 inhibitors. RCTs are being conducted to determine if these positive effects on CVD risk factors translate to a reduction in MACE. To date, these studies have not shown an increase in MACE. A signal of increased hospitalisations for HF was observed with saxagliptin, warranting continued evaluation and vigilance in high-risk patients. In addition, incretin-based therapies have shown positive effects on measures of beta-cell function supporting their durability in the management of diabetes.
Incretin-based therapies are an important treatment option for patients with type 2 diabetes, offering beneficial effects on CVD risk factors without increasing MACE.
Non-cardiac chest pain (NCCP) affects up to 80% of patients attending chest pain clinics, but its treatment is suboptimal.
To describe the outcomes of a pilot, stepped care, biopsychosocial management programme in terms of improvements in chest pain, psychosocial scores and use of healthcare resources.
Of 198 referrals, 77 patients were suitable for the clinic and received a one hour biopsychosocial assessment. Stepped care consisted of assessment only, low intensity Cognitive Behaviour Therapy (CBT), or high intensity CBT.
The proportion with pain occurring more than once monthly fell from 100% at baseline to 61% at 3 months (p < 0.001). Pain interference reduced significantly (p < 0.001) from 5.9 [SD 2.2] at baseline to 3.2 [SD 2.6] at 3 months. Depression scores improved from a mean 8.8 to 5.4 (p < 0.05) and anxiety from 6.9 to 4.6 (p < 0.05). Use of healthcare resources improved with a fall in consultations for chest pain over 6 months from a mean 2.6 to 0.1 (p < 0.05). The impact on work and social functioning reduced from 10.4 [SD 10.4] to 3.9 [SD 7.5]: [t (70) = 6.3, p < 0.001). Further improvements occurred at 6 months for chest pain frequency (which fell to 51%, p = 0.003), interference (2.6 [SD 2.1], p < 0.05) and avoidance of exercise (p = 0.03). Otherwise improvements were maintained between 3 and 6 months.
A stepped-care biopsychosocial approach to NCCP is effective in reducing chest pain frequency and improving behaviour and wellbeing. It can be delivered in part by a nurse allowing integration into any chest pain clinic.
We previously showed that hyperglycaemia in newly hospitalised medical inpatients is associated with longer length of hospital stay, higher 28-day readmission rates and increased 28-day mortality. We aimed to assess whether a single blood glucose measurement taken at the time of admission could help to predict 1 and 2 years mortality.
We retrospectively reviewed data from all 1502 patients admitted to our Acute Medical Unit during February 2010.
By using a blood glucose range of 6.5–7.0 mmol/l as the comparator, an admission blood glucose between 9.1 and 20 mmol/l was associated with an increased risk of death at 1 year (p < 0.05). In addition, those people with admission glucose readings of < 6.5 mmol/l showed a strong trend towards a higher mortality (p = 0.053) at 1 year.
Thus admission blood glucose can be used to help predict the risk of 1 year mortality in an unselected cohort of general medical admissions.
Obesity is related to inflammation and cardiovascular disease. The increase in saturated fatty acid intake (SFA) can potentiate cardiovascular risks. The aim of this study was to assess the influence of change in SFA on carotid intima-media thickness (cIMT), metabolic profile and anti/pro-inflammatory adipokines in obese adolescents.
Sixty obese adolescents were subjected to 1 year of interdisciplinary intervention (nutrition, psychology, physical exercise and clinical therapy). Blood glucose, insulin, lipid profile, leptin and adiponectin were analysed. Insulin resistance was estimated by HOMA-IR and HOMA-AD. cIMT was measured by ultrasonography. Dietetic intake was calculated by 3-day dietary record. Volunteers were analysed according to tertiles of change (Δ) in SFA intake: Low-SFA reduction < 3.68 g; Moderate-SFA reduction 3.68–13.67 g; and High-SFA reduction > 13.67 g.
Moderate and High-SFA tertiles presented reduction in insulin, leptin/adiponectin ratio, cIMT and increase in adiponectin and adiponectin/leptin ratio. Adiponectin/leptin ratio was predictor of cIMT. HOMA-IR, total cholesterol and LDL-cholesterol reduced only in High-SFA tertile, and was associated with SFA independent of visceral fat. Negative correlations between Δ of SFA and adiponectin and adiponectin/leptin ratio were observed.
Obese adolescents with moderate and high reduction in SFA presented improvements on pro/anti-inflammatory biomarkers and cIMT, leading to reduction in cardiovascular risks.
Linked Comment: Lim et al. Int J Clin Pract 2015; 69: 422–8.]]>
Linked Comment: Palmer and Newman. Int J Clin Pract 2015; 69: 429–35.]]>
The beauty of science is that well-conducted experiments provide answers to questions which were posed in times of greater ignorance. Cardiovascular disease (CVD) is the leading cause of death worldwide and will be for some time. Cholesterol is a critical player which drives the underlying pathophysiological process of atherosclerosis. Statins are the first line treatment for lipids in CVD given their ability to low-density lipoprotein cholesterol (LDL-C) by up to 50%, and their proven benefits in both primary and secondary intervention . Despite the unprecedented efficacy of statins, additional treatments are sought to potentially reduce the residual risk that remains despite statin treatment such as that associated with reduced high-density lipoprotein cholesterol levels (HDL-C) or triglycerides . In the last 5 years, several trials have reported on their potential additional benefit beyond statin therapy. These include omega-3 fatty acids in patients with prediabetes or diabetes , fibrates in diabetes , nicotinic acid/niacin in cardiovascular disease and cholesterol ester transfer protein inhibitors in cardiovascular disease . Despite their promise, none of these treatments were able to demonstrate benefit beyond baseline statin therapy when compared with placebo . The idea that benefit beyond statin treatment may be an unachievable goal has dogged the medical community working on CVD prevention. The phrase, 'Statins for atherosclerosis – as good as it gets?' was coined in 2005 and has rung true up until now .]]>
Diagnostic error has implications for both clinical outcome and resource utilisation, and may often be traced to impaired data gathering, processing or synthesis because of the influence of cognitive bias. Factors inherent to the intensive/acute care environment afford multiple additional opportunities for such errors to occur. This article illustrates many of these with reference to a case encountered on our intensive care unit. Strategies to improve completeness of data gathering, processing and synthesis in the acute care environment are critically appraised in the context of early detection and amelioration of cognitive bias. These include reflection, targeted simulation training and the integration of social media and IT based aids in complex diagnostic processes. A framework which can be quickly and easily employed in a variety of clinical environments is then presented.]]>
Medical photographic image capture and data management has undergone a rapid and compelling change in complexity over the last 20 years. This is because of multiple factors, including significant advances in ease of photograph capture, alongside an evolution of mechanisms of data portability/dissemination, combined with governmental focus on health information privacy. Literature to guide medical, legal, governmental and business professionals when dealing with issues related to medical photography is virtually nonexistent. Herein, we will address the breadth of uses of medical photography, device properties/specific devices utilised for image capture, methods of data transfer and dissemination and patient perceptions and attitudes regarding photography in a medical setting. In addition, we will address the legal implications, including legal precedent, copyright and privacy law, informed consent, protected health information and the Health Insurance Portability and Accountability Act (HIPAA), as they pertain to medical photography.
To describe the efficacy and safety of lisdexamfetamine dimesylate (LDX) for the treatment of binge eating disorder (BED).
The pivotal registration trials were accessed by querying http://www.ncbi.nlm.nih.gov/pubmed/, http://www.clinicaltrials.gov and http://www.clinicaltrialsregister.eu for the search terms 'lisdexamfetamine' and 'binge', and by also querying the Web of Science (Thomson Reuters) and Embase (Elsevier) commercial databases, and by asking the manufacturer for copies of posters presented at congresses. Product labelling provided additional information.
All available clinical reports of studies were identified.
Descriptions of the principal results and calculation of number needed to treat (NNT) and number needed to harm (NNH) for relevant dichotomous outcomes were extracted from the available study reports and other sources of information.
LDX is a central nervous system stimulant indicated for the treatment of moderate to severe BED. The recommended dose range is 50–70 mg/day. Approval for the treatment of BED was based on a clinical development programme that included an 11-week Phase II proof-of-concept, placebo-controlled study, testing fixed doses of LDX 30, 50 and 70 mg/day, and two 12-week Phase III placebo-controlled studies examining LDX 50–70 mg/day. Statistically significant reductions in binge eating days/week, the primary outcome measure, were observed for LDX doses of 50 and 70 mg/day, with effect sizes in the Phase III trials ranging from 0.83 to 0.97. The pooled NNT for response across all trials (as defined by a Clinical Global Impressions-Improvement score of 'very much improved' or 'much improved') for LDX vs. placebo was 3 (95% CI 3–4), and NNT for remission (as defined by 4-week cessation of binge eating) for LDX vs. placebo was 4 (95% CI 4–6). Reductions in weight ranged between 5.2% and 6.25% for LDX 50 or 70 mg/day. Discontinuation rates because of adverse events (AEs) were low; NNH for discontinuation because of an AE for LDX vs. placebo was 44 (95% CI 23–1971). The most commonly encountered AEs (incidence ≥ 10% and greater than the rate for placebo) were dry mouth, decreased appetite, insomnia and headache, with NNH values vs. placebo of 4 (95% CI 3–5), 11 (95% CI 8–17), 11 (95% CI 8–18) and 19 (95% CI 11–75), respectively.
LDX is the first pharmacological agent that has received regulatory approval for the treatment of BED. LDX 50 or 70 mg/day significantly reduced BED symptoms as measured by the number of binge eating days per week. Effect sizes were highly robust. Pending clinical trials include a long-term study examining maintenance of efficacy.
We investigated new-onset constipation in patients with stroke compared with orthopaedic conditions and explored the predictors associated with constipation during acute hospitalisation.
This was a prospective matched cohort study of 110 patients comparing stroke patients (n = 55) with orthopaedic patients (n = 55) admitted to a large tertiary acute hospital. Both cohorts were matched by age and sex. The incidence of new-onset constipation which occurred during a patient's acute hospitalisation was determined. Demographics, comorbidity, clinical factors, laboratory parameters and medications were evaluated as possible predictors of constipation.
The incidence of new-onset constipation was high for both stroke (33%) and orthopaedic patients (27%; p = 0.66). Seven stroke patients (39%) and four orthopaedic patients (27%) developed their first onset of constipation on day 2 of admission. Mobility gains (RR 0.741, p < 0.001) and the use of prophylactic laxatives (RR 0.331, p < 0.01) had a protective effect against constipation. Bedpan use (RR 2.058, p < 0.05) and longer length of stay (RR 1.032, p < 0.05) increased the risk of developing new-onset constipation.
New-onset constipation is common among patients admitted for stroke and orthopaedic conditions during acute hospitalisation. The early occurrence, on day 2 of admission, calls for prompt preventive intervention for constipation.
An online survey of female advanced practice providers (APPs) in a large urban healthcare system was conducted to describe behaviours they use to manage their personal bladder emptying.
The questionnaire contained items on demographics, presence of urinary incontinence (UI), and behaviours used to void in work, public and home settings.
One hundred thirteen female APPs responded to the survey and 109 responded to items on UI. Over half (53%) reported experiencing UI at least once a week. In general, the APPs reported being worried about the cleanliness of public toilets and delaying voiding when busy. Incontinent APPs were older and had histories of more pregnancies than continent women. Incontinent APPs also used public toilets more frequently and when there was no or little need to void, and delayed or put off voiding while at work and when busy.
Although APPs have specialised knowledge about lower urinary tract anatomy and physiology, many engage in behaviours that may be detrimental to bladder health. More research is needed to explore behaviours women use to manage voiding and the effect of these behaviours on bladder health.
Erectile dysfunction (ED) is a common male sexual disorder worldwide. Three oral phosphodiesterase type 5 inhibitors (PDE5Is) – sildenafil, tadalafil and vardenafil – are available for treatment of ED. This study quantitatively evaluated the therapeutic efficacy and safety of these medications to assist treatment decision making.
We used multiple criteria decision analysis (MCDA) to assess the totality of risk–benefit of PDE5Is. We created two models: (i) the overall model included 'overall improvement in erections' and 'any adverse events' and (ii) the detailed model included 'erectile function domain', 'ability for sexual intercourse', 'duration of erection last', 'serious adverse events', 'headache', 'flushing' and 'dyspepsia'. We calculated a synthetic utility for each drug accounting for all of its benefits and risks.
Considering the overall risk–benefit, vardenafil had the highest synthetic utility among three medications; in the order of synthetic utilities: vardenafil (0.568), tadalafil (0.478) and sildenafil (0.437). However, when specific risk and benefit criteria were assessed, tadalafil had the highest synthetic utility (0.602) according to the conjoint evaluation (synthetic utility for vardenafil is 0.491 and sildenafil is 0.442, respectively). The sensitivity analysis based on the uncertainties of weight on risks of any adverse events (including serious adverse events and headache) suggested our results were robust.
This study provides a useful approach that comprehensively and systematically assesses and compares the risk–benefit of several treatment alternatives. Our study not only rank treatment alternatives by synthetic utilities based on the risk–benefit balance but also compare specific risk and benefit criteria between these medicines. Our results provide valuable evidence that can guide clinicians and patients in making treatment decisions.
To explore the rate of add-on therapy with solifenacin in men with voiding and storage lower urinary tract symptoms (LUTS) after tamsulosin monotherapy and to explore predictive factors for starting solifenacin add-on therapy.
Men aged ≥ 45 years with IPSS ≥ 12 and symptoms of OAB (OAB-V8 ≥ 8, micturition ≥ 8/24 h, urgency ≥ 2/24 h) were enrolled to receive tamsulosin 0.2 mg once daily. After 4 weeks, men with residual symptoms of OAB and reported 'dissatisfied' or 'a little satisfied' were received solifenacin 5 mg in combination with tamsulosin monotherapy. Subjects completed an IPSS, a Quality of life (QoL) index, OAB V8, and an International Consultation of Incontinence Questionnaire (ICIQ)-Male LUTS, and patient perception of bladder condition (PPBC) at baseline and week 4.
Of a total of 305 patients, 254 patients completed 4 weeks of tamsulosin treatment. For 176 patients, solifenacin was added (69.3%). Significant predictive factors of solifenacin add-on therapy included long LUTS duration, high IPSS, number of micturitions per 24 h, more urgency episodes, high urgency severity score in a voiding diary and high OAB V8 score. Based on multivariable analysis, potential predictive factors of solifenacin add-on therapy included long LUTS duration (OR = 1.008, 95% CI: 1.001–1.014), high serum PSA (OR = 1.543, 95% CI: 1.136–2.095) and small prostate size (OR = 0.970, 95% CI: 0.947–0.994) (p < 0.05). IPSS, daytime micturitions and urgency episodes, OAB V8 scores, ICIQ and PPBC were improved after tamsulosin monotherapy.
Two thirds of men with voiding and storage LUTS needed to add anticholinergics after 4 weeks of tamsulosin monotherapy. Patients with longer lasting symptoms and storage symptoms with small prostate volume may require the anticholinergic add-on.
The aim of this qualitative analysis was to establish the content validity of two new patient-reported outcome (PRO) measures: Sexual Arousal, Interest, and Drive Scale (SAID) and Hypogonadism Energy Diary (HED).
Four separate qualitative studies were conducted with 125 men with hypogonadism (mean age: 53 years, 85% adult onset). Study 1 used focus groups/interviews to identify important and relevant concepts related to the experience of hypogonadism and its treatment in men primarily with adult-onset hypogonadism. Study 2 tested items generated for assessments of low sex drive and low energy. Study 3 used interviews to confirm in men with early-onset hypogonadism that low sex drive and low energy were also important and relevant symptoms. Study 4 tested final versions of the two PROs and determined equivalency of paper-based and electronic versions of the two PROs.
Of the concepts emerging in Studies 1 and 3, low sex drive and low energy were the symptoms most often spontaneously mentioned. Coding of transcripts from Studies 1 and 3 led to the generation of items for the SAID and HED. After item testing (Studies 2 and 4), the final SAID included five items pertaining to arousal, interest in sex and sex drive with a 7-day recall period and the final HED included two items (energy, tired/exhausted) to be administered three times per day.
The SAID and HED have content validity established according to regulatory guidance and, therefore, the potential to provide the patient perspective of treatments for hypogonadism.
To describe perceptions of chronic care among diabetes patients 6 years after diagnosis by screening and to examine the impact of intensive treatment on patients' perceptions of chronic care.
The ADDITION-Denmark (2001–2006) trial compared the effects of intensive multifactorial therapy (IT) with routine care (RC) among individuals with screen-detected diabetes. Perceptions of chronic care were assessed using the Patient Assessment of Chronic Illness Care (PACIC) measure after 6-year follow-up (n = 937). Analysis was by intention-to-treat, accounting for clustering by general practice.
The mean (SD) summary PACIC score was 2.4 (0.79) in the RC and 2.4 (0.82) in the IT group. The highest mean (SD) PACIC subscale score was for Delivery System Design/Decision Support [RC: 3.2 (0.95), IT: 3.3 (0.91)] and the lowest was for Follow-up/Coordination [RC: 2.1 (0.84), IT: 2.1 (0.87)]. Perceptions of chronic care did not differ between trial groups.
Compared to RC, an intensive multifactorial intervention was not associated with differences in perceptions of chronic care among patients with screen-detected diabetes after 6 years. Intensive treatment does not adversely affect perceptions of chronic care early in the course of the disease. However, there is potentially room for improvement in some aspects of chronic care.
Many authors have analysed premature mortality in cohorts of type 2 diabetic patients, but no analyses have assessed mortality in hospitalised diabetic patients.
To construct predictive models to estimate the likelihood of all-cause mortality and cardiovascular mortality in type 2 diabetic inpatients.
Cohort study with follow-up from 2010 to 2014.
We evaluated mortality in a randomly selected cohort of 112 type 2 diabetic inpatients at the Hospital of Elda (Spain) in 2010–2012. Outcomes: all-cause mortality and cardiovascular mortality during the follow-up. Other variables: gender, age, depression, asthma/chronic obstructive pulmonary disease, hypertension, dyslipidemia, insulin, pills, smoking, walking, baseline blood glucose and creatinine. Predictive tables with risk groups were constructed to estimate the likelihood of all-cause mortality and cardiovascular mortality. Calculations were made of the area under the ROC curve (AUC).
During the follow-up, 52 inpatients died (46.4%, 95% CI, confidence interval: 37.2–55.7%), 22 because of cardiovascular causes (19.6%, 95% CI: 12.3–27.0%). The mean follow-up time was 2.7 ± 1.5 years. The AUC for the all-cause mortality model was 0.84 (95% CI: 0.77–0.92, p < 0.001). Associated parameters: pills, smoking, walking, gender, insulin and age. The AUC for the cardiovascular mortality model was 0.79 (95% CI: 0.67–0.91, p < 0.001). Associated parameters: age, pills, walking, smoking, depression and insulin.
This study provides tools to predict premature mortality in type 2 diabetic inpatients. However, before their general application they require joint validation by the internal medicine unit, emergency department, primary healthcare unit and endocrinology service to enable better prediction of the prognosis and more adequate decision-taking.
Systolic aortic regurgitation (SAR) is a curious phenomenon that has been found to be associated with heart failure (HF). We aimed to determine de diagnostic value of SAR as a black box predictive tool in patients with suspected HF admitted to hospital with dyspnea as leading symptom.
Cross-sectional study including 269 consecutive patients admitted to hospital with dyspnea as leading symptom without definite clinical diagnosis. SAR was defined by echocardiography as the presence of blood flow from the aorta to the left ventricular outflow tract during a complete systole. The reference standard was the presence of HF diagnosis at discharge. SAR was present in 9 (3.3%) patients. Prevalence of HF was 40.3%. Specificity of SAR in the diagnosis of HF was high at 99.4% (95% CI 96.5–99.9%). Sensitivity was 7.5% (95% CI 3.9–14.2%). Positive predictive value (PPV) was 88.9% (95% CI 56.5–98.0%). Positive likelihood ratio was 11.85. Estimated PPV of SAR was significantly higher than 50% for any hypothetical prevalence of HF.
In patients admitted to hospital with dyspnea, the finding of systolic aortic regurgitation in echocardiography has a high PPV for HF diagnosis at discharge.
The impact of hip fracture because of a fall on health-related quality of life (HRQoL) and activities of daily living (ADL) have not been well established.
To evaluate changes in HRQoL and the ability to conduct ADL among patients with hip fracture because of a fall and to compare these changes with patients who did not fall and break a hip, adjusting by gender and age.
Adults aged 65 or more who attended the emergency departments of seven public hospitals were recruited in a prospective double-cohort study (fracture cohort, n = 776; non-fracture cohort, n = 115). ADL and HRQoL were assessed at baseline (during the postfall hospitalisation or by telephone afterwards) and 6 months later using the Barthel Index and the Lawton Brody Index for ADL, and the Short Form Health Survey (SF-12) and Western Ontario and McMaster Universities Osteoarthritis Index short form (WOMAC-SF) for HRQoL.
Adjusting by gender, age and baseline status, a hip fracture was a strong predictor of decline in all outcomes measured except for mental quality of life among men (measured by SF-12). Hip fracture patients younger than 74 years reported significantly more pain (measured by WOMAC-SF) than the comparison group (p = 0.02), but this difference was not observed among older patients (p = 0.19 for 75–84 years; p = 0.39 for ≥ 85 years).
Hip fractures have profound effects on HRQoL and ADL in both men and women, regardless of age. This indicates the need for special follow-up care of elderly hip fracture patients in the immediate and late postfracture periods.
This study addresses the common practice of providing aggressive treatments of limited clinical benefit and cost-effectiveness to seriously ill and frail elderly. We have created a statistical model of 6-month mortality risk prediction following acute hospitalisation admission, and identified a subset of patients with poorest prognosis that requires comfort-focused care.
We have studied electronic medical records of 26,937 patients age 65 years or older, hospitalised in the internal medicine departments of one tertiary-care teaching medical center in Northern Israel from January 1, 2008 through December 31, 2011 and mortality data from the Israeli Internal Ministry Registry. Norton score records were employed for the performance status evaluation. Multivariate logistic regression analysis was used to predict the risk of 6-month mortality.
Variables associated with an increased risk of 6-month mortality included: metastatic cancer, age above 85 years, decreased values of blood albumin and haemoglobin, increased blood urea nitrogen and decreased physical/mental status and activity. The receiver operating characteristic area for the predicted probability of death was 0.845 and 0.847 in external validation cohort. Using predictive values of the logistic regression analysis, the study cohort was stratified into six groups with various predictive mortality risks.
The majority of deaths that have occurred within 6 months following the acute hospitalisation could be predicted on patient admission based on a few simple and easily obtained parameters. Earlier recognition of patients nearing the end of their lives may lead to better care and more efficient use of available resource.


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Angie Trzepacz, Ph.D.
Psychologist, Director and Counselor
Angie has been at MSU since 2008. She was previously the Director of the Psychological Center but became the Director of University Counseling Services in 2012. She enjoys working with students and helping them identify their goals and strive to reach them. She has three children and spends most of her free time attending their extra-curricular activities and sporting events.
Abigail French, M.S.
LPA, Counselor and Women's Center Director
Abigail is currently the Director of the Women's Center at Murray State University. She provides programming on campus concerning issues such as: sexual assault, domestic violence, stalking, eating disorders, and social justice issues. In addition to programming, Mrs. French provides individual counseling to Murray State students, faculty, and staff. She received her Bachelor of Science degree in organizational communication and psychology and Master's of Science degree in clinical psychology from Murray State University.
Allyson Taylor, M.A.
LPA, Counselor
Allyson graduated from the MSU Clinical Psychology Master's program. She has received specialized training and experience with working with sexual trauma survivors and veterans. Allyson also enjoys integrating mindfulness into her work and personal life and is a yoga teacher in her spare time. She is an animal lover and has a certified therapy dog, Digby. Allyson's personal interests include being in nature, traveling and being adventurous, reading, and spending time with friends and family.
Sarah Kerrick, Psy. D.
LPCC, Counselor
Sarah has been at MSU since Spring 2010, but she has been a counselor since 2000. Her professional interests include helping students experience success in college and in life, working with issues in women's psychology, relationships with food, spirituality and positive coping, and strength-based personal development. Her personal interests include being outside in all types of weather, creek exploring, table games, mystery shows, food, family, and friends.
Jennifer Taylor, M.S.
LPCC, Counselor
Jennifer Taylor is a Licensed Professional Clinical Counselor. She graduated with a Bachelor of Professional Studies - Psychodramatic Counseling, and a Rehabilitation Counseling Master's Degree both from the University of Memphis. Her specialty is helping students manage anxiety. Her desire is to help people discover what they really want in life and help them find ways to achieve it. She has been a counselor at Murray State University since 2006. Jennifer enjoys playing and listening to music, cooking, gardening, and spending time with her family.
Jeff Watson, M.S.
LPA, Counselor
Jeff graduated from the MSU Clinical Psychology Master's program. His professional interest include depression, self-injury, and the existential dilemmas we all face. In his personal time he enjoys exploring wooded areas, reading, and cooking.
Zebreina Patterson
Testing Center Supervisor
Zebreina has a BS from MSU in Radio/TV. She has been an administrative assistant for over 30 years and has worked at MSU for over 5 years. She is a single mom to a busy 13-year-old boy and loves classic movies, music, reading, and gardening.

subset: commoncrawl


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How Does The Aids Virus Work
Here's a taste of what TheBody.com has to offer on this topic:
Get the Facts
Blood Work: Two Common Tests to Use for Monitoring HIV Disease...and your doctor will use to monitor your health are CD4+ cell counts and viral load tests. CD4+ cell counts indicate the state of your immune system -- your body's defense against disease. Viral load tests indicate how active HIV is. Coupled with information about how you're feeling, these two values give a clearer picture of your state of health. They also help to assess your risk of disease progression and response to anti-HIV therapy that...
Ask the Experts
When working as a volunteer health care worker, is it possible I contracted the HIV virus?Two summers ago I volunteered in a developing country. I work mostly in a clinic for men and women living with HIV and AIDS. I often had to change incontinent residents and their soiled bedsheets. I would also have to lift them up while another...
Response from Robert J. Frascino, M.D.
The Robert James Frascino AIDS Foundation...elsewhere).Be well. Stay well.Dr. BobWhat You Need to Know About HIV and AIDS If you are going to be caring for someone with HIV infection, you need to understand the basic facts about HIV and AIDS. AIDS (acquired immunodeficiency syndrome) is... Read more »
Work & HIVI would like to know how an office enviroment and possibly work related stress would influence a person living with HIV.I work in an open plan office enviroment and I am sure like most there are a lot of negativity in and around the work place....
Response from Ewald Horwath, M.D.
University of Miami School of Medicine...I imagine all work environments have their share of both positive and negative elements. I cannot comment on the merits of your particular workplace. Read more »
Working with HIVi wonder how does HIV effect on our work? I read many peoples need to stop working because of HIV. I haven't had the problem yet but i need to be prepare of it. Is there any specific job that you do not encourage me to take?
Response from Keith Henry, M.D.
University of Minnesota, School of Medicine...patients who have access to good HIV and health care (including antiretrovirals) are able to maintain their health and continue working without restrictions. I would discuss any concerns you have about any particular type of work with your HIV... Read more »
Should those with AIDS/HIV be allowed to work in the medical field???I am wondering if are those infected with the AIDS/HIV virus are allowed with to work in the medical field. If yes why?? Doesn't this pose a threat to people who are not infected with this virus??? I know that the disease is not spread through...
Response from Lynne Gabriel
WorkPositive, Inc....This is an answer to a similar question, previously answered:Depending on the state, Health care workers have the same right of confidentiality about their HIV status as anyone living with HIV. Moreover, because all health workers Read more »
HIV Health Care Access Working Group Action Alert: Tell Congress to Make Health Care Reform Work for People With HIV/AIDS...information and analyses of various health care reform proposals and the impact on people with HIV/AIDS. The HIV Health Care Access Working Group is hosting regular conference calls to update the community about health care reform efforts and... Read more »
Former Botswana President Mogae Wins Award for Leadership, Work on HIV/AIDS...one of the world's highest prevalence rates, the AP/Long Island Newsday reports. During his two terms as president, Mogae worked to curb the spread of the disease by receiving a public HIV test, pressing to cut the prevalence of... Read more »
Girls, Women Trafficked in Asia for Commercial Sex Work Emerging as HIV/AIDS Risk Factor, Report Says... Young women and girls in Asia who are trafficked for commercial sex work are emerging as an HIV/AIDS risk factor, according to a report released by the United Nations Wednesday at the 8th International Read more »
Decision to Allow HIV-Positive Inmates in Alabama to Participate in Work-Release Program Makes "Significant Statement," Editorial Says... Alabama Department of Corrections' " decision to stop barring inmates with HIV from work-release programs is an indication of how far society, not just the department, has come in understanding the virus and understanding Read more »
Connect With Others
HIV+ and working in academia
Posted by kuanRC, 6 Replies...I'm looking to connect with anyone who has experience as an HIV+ person working on faculty, as a researcher or graduate student in academia. I'm a PhD student in an extremely competitive program at a major Read more »
Posted by help290, 1 ReplyI have been dealing with this for over three years 7 doctors 8 negative antibody test 1 negative pcr and lately 1 indeterminate western blot 1 band not sure which one and now the ID doctor wants me to wait a month for another western blot. I... Read more »
hiv & working out/bodybuilding
Posted by windycitypozdude, 2 Replies...hey everyone! i have always been a "working out," active kind of guy, and always been interested in getting bigger/more muscular, etc. i shy away from the term "bodybuilding" Read more »
working with hiv positive person
Posted by work35, 1 Reply...Hello.. I hope this is not an ignorant question but here goes.. two part question.. Part one.. I just found out my co-worker is hiv positive.. he is healthy thank god.. and i really like him but I admit I am VERY uncomfortable at work.. we both... Read more »
Resource Centers
Guides for People With HIV


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Capital Markets
Company Overview of Gotham Short Strategies
Company Overview
Gotham Short Strategies is a hedge fund launched and managed by Gotham Asset Management, LLC. It invests in the public equity markets. Gotham Short Strategies was formed in October 2012 and is domiciled in Cayman Islands.
535 Madison Avenue
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New York, NY 10022
United States
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