Showing papers in "International Journal of Clinical Practice in 2018"

Epidemiology of atrial fibrillation.

Abstract: Background The most common type of arrhythmia in the USA and in European countries is atrial fibrillation (AF). The prevalence of AF is increasing worldwide with advances in technology, better prediction methods and increased awareness among healthcare professionals and patients. Methods This article summarises the literature on the epidemiology of AF worldwide according to continents, age and ethnicity/race, and also includes the prevalence of AF in stroke patients. Results In Australia, Europe and the USA, the current estimated prevalence of AF is about between 1% and 4%, with lower prevalence evident in Asia (0.49%-1.9%). AF prevalence is highest among Whites. In Western Europe, Australia and North America 70% of people with AF are aged >65 years, whereas the average age of AF patients in other geographical regions is often lower. Conclusions Although the prevalence of AF worldwide is increasing steadily, large variation can be seen between studies and countries. Further epidemiological studies should be undertaken globally, especially in Asian and African countries so that a better and more accurate picture of the incidence and prevalence of AF can be captured, to enable stroke prevention strategies to be appropriately implemented to prevent or reduce the risk of stroke, the most severe consequence of AF.

Computer vision syndrome and ergonomic practices among undergraduate university students.

Abstract: SummaryAim To determine the prevalence of computer vision syndrome (CVS) and ergonomic practices among students in the Faculty of Medical Sciences at The University of the West Indies (UWI), Jamaica. Method A cross-sectional study was done with a self-administered questionnaire. Results Four hundred and nine students participated; 78% were females. The mean age was 21.6 years. Neck pain (75.1%), eye strain (67%), shoulder pain (65.5%) and eye burn (61.9%) were the most common CVS symptoms. Dry eyes (26.2%), double vision (28.9%) and blurred vision (51.6%) were the least commonly experienced symptoms. Eye burning (P = .001), eye strain (P = .041) and neck pain (P = .023) were significantly related to level of viewing. Moderate eye burning (55.1%) and double vision (56%) occurred in those who used handheld devices (P = .001 and .007, respectively). Moderate blurred vision was reported in 52% who looked down at the device compared with 14.8% who held it at an angle. Severe eye strain occurred in 63% of those who looked down at a device compared with 21% who kept the device at eye level. Shoulder pain was not related to pattern of use. Conclusion Ocular symptoms and neck pain were less likely if the device was held just below eye level. There is a high prevalence of Symptoms of CVS amongst university students which could be reduced, in particular neck pain and eye strain and burning, with improved ergonomic practices.

Are obesity and rheumatoid arthritis interrelated

Abstract: OBJECTIVES In recent years, both the prevalence of obesity and the incidence of RA have been rising. Our aim was to assess the association between overweight or obesity and rheumatoid arthritis (RA). DESIGN Patients who were diagnosed with RA were compared with population-based controls, matched for age and sex (by a ratio of 1:5). Body measurements and smoking status were collected from medical records. Body mass index was classified in WHO categories of underweight, normal, overweight and obese (<18.5, 18.5-<25, 25-<30, ≥30 kg/m2 ). χ2 and t-tests and logistic regression models were used to compare the study groups and to assess the association between obesity and RA. SETTING A cross-sectional analysis performed utilizing the database of Clalit Health Services, the largest healthcare provider organisation in Israel. Data were collected from the beginning of computerised database usage (around year 2000) until 2015. PARTICIPANTS CHS covers over 4.4 million enrollees, of which all RA patients and matched controls were selected. MAIN OUTCOME MEASURES Proportion of obesity (BMI≥30.0 kg/m2 ) among RA patients and controls. RESULTS The study included 11 406 patients with RA and 54 701 controls. The proportion of obese subjects among RA patients was higher in comparison with controls, (33.4% vs 31.6%, respectively). In multivariate regression model, smoking and obesity were found to be associated with RA, whereas male gender was found as inversely related to RA. CONCLUSIONS Our findings demonstrate that obesity is significantly associated with RA. This finding underlines the role that obesity plays in inflammation and autoimmune conditions.

Psychometric properties of Hope Scales: A systematic review.

Abstract: Introduction Hope is recognised as an important factor in health, illness, and well-being. Many scales to measure hope have been developed and used in various disciplines, yet, their psychometric properties have not been systematically reviewed. Aim To systematically review the psychometric properties of hope scales. Design Systematic review. Methods Four electronic databases were searched followed by a hand search. The data were extracted and qualitatively evaluated by the COSMIN checklist, an instrument designed as a quality rating tool for systematic reviews of psychometric properties. Results From 1271 retrieved abstracts, 68 papers met the inclusion criteria. The most used scale was the Snyder Hope Scale (46%) followed by the Herth Hope Index (16%). All other scales (n = 16) were evaluated in less than 10% of the papers. Structural validity (91%), internal consistency (88%), and hypothesis testing (74%) were the most reported properties. Reliability (34%), cross-cultural validity (34%), content validity (25%), and criterion validity (15%) were reported in less than 50% of the papers. Only two (3%) studies reported responsiveness, and none reported measurement error. Less than 35% of the validation studies achieved excellent or good quality for any of the measurement properties. Conclusion The results show that no robust and valid scale exists for measuring hope. It highlights important gaps in psychometric properties of hope scales. Despite more than 40 years of research and development of hope scales, the currently available scales do not meet the standards of psychometric evaluation. This calls for efforts to improve the quality of hope scales.

Current evidence for the treatment of hypothyroidism with levothyroxine/levotriiodothyronine combination therapy versus levothyroxine monotherapy

Abstract: Objective Hypothyroidism is relatively common, occurring in approximately 5% of the general US population aged ≥12 years. Levothyroxine (LT4) monotherapy is the standard of care. Approximately, 5%-10% of patients who normalise thyroid-stimulating hormone levels with LT4 monotherapy may have persistent symptoms that patients and clinicians may attribute to hypothyroidism. A long-standing debate in the literature is whether addition of levotriiodothyronine (LT3) to LT4 will ameliorate lingering symptoms. Here, we explore the evidence for and against LT4/LT3 combination therapy as the optimal approach to treat euthyroid patients with persistent complaints. Methods Recent literature indexed on PubMed was searched in March 2017 using the terms "hypothyroid" or "hypothyroidism" and "triiodothyronine combination" or "T3 combination." Relevant non-review articles published in English during the past 10 years were included and supplemented with articles already known to the authors. Findings Current clinical evidence is not sufficiently strong to support LT4/LT3 combination therapy in patients with hypothyroidism. Polymorphisms in deiodinase genes that encode the enzymes that convert T4 to T3 in the periphery may provide potential mechanisms underlying unsatisfactory treatment results with LT4 monotherapy. However, results of studies on the effect of LT4/LT3 therapy on clinical symptoms and thyroid-responsive genes have thus far not been conclusive. Conclusions Persistent symptoms in patients who are biochemically euthyroid with LT4 monotherapy may be caused by several other conditions unrelated to thyroid function, and their cause should be aggressively investigated by the clinician.

Seasonal influenza immunisation: Strategies for older adults.

Abstract: Adults over the age of 60-65 years suffer disproportionally from seasonal influenza, experiencing high rates of complications, exacerbation of underlying medical comorbidities, and excess mortality. Thus, older adults are an important priority for influenza immunisation campaigns. Unfortunately, older adults generally display lower immune responses to standard influenza vaccines because of immunosenescence, with resulting suboptimal vaccine effectiveness. Thus, the development of improved vaccines that heighten immune responses and improve effectiveness is an important medical need. To this end, enhanced influenza vaccines specifically targeting this age group have been developed, which seek to overcome the inherent limitations in the immune responses of older adults. Both the licensed high-dose trivalent influenza vaccine (hdTIV) containing fourfold higher antigen contents than standard vaccine, and the MF59® -adjuvanted trivalent influenza vaccine (aTIV) have been proven to be safe and well-tolerated while enhancing the immune response. Healthcare providers for populations of older adults should be advised to routinely use these enhanced influenza vaccines in seasonal immunisation campaigns to provide improved immunity against influenza and its consequences in this particularly susceptible age group.

Nocturia is more bothersome than daytime LUTS: Results from an Observational, Real-life Practice Database including 8659 European and American LUTS patients.

Abstract: PURPOSE Lower urinary tract symptoms (LUTS) encompass several diagnoses, including overactive bladder (OAB) and benign prostatic hyperplasia (BPH). Nocturia is a standalone symptom, but also included in OAB and BPH. Current discussion addresses whether the overlap of the diagnoses is too broad, leading to misdiagnosis. This study explored the differences in level, causes and consequences for patients with a diagnosis of daytime LUTS compared with a diagnosis of nocturia, and discussed whether people are being treated for the symptoms that truly bother them the most. PATIENTS AND METHODS Data were drawn from a survey of physicians and patients in France, Germany, Spain, UK and USA. Physicians filled out patient record forms (PRFs) for patients with LUTS diagnosis. The patients completed the patient self-completion form (PSC). Three PRO questionnaires were included; the OAB-q SF, NI-Diary and WPAI. Patients were grouped based on the diagnoses assigned to them by their physicians in a real-life setting. RESULTS Eight thousand seven hundred and thirty eight patients had a LUTS diagnosis and 5335 completed a PSC. Patients diagnosed with night-time symptoms were significantly more bothered by their LUTS than only daytime LUTS patients (all questionnaires P < .0001). Patients with nocturia reported being tired "always" or "usually" more often than patients with daytime problems only (P < .0001). Only 13% of patients with nocturia had an initial sleep period of more than 2-3 hours. CONCLUSION In this population of real-life patients, those with a diagnosis of nocturia reported significantly higher impact on their quality of life than patients with a diagnosis of daytime LUTS only. The underlying causes of bother were related to sleep problems. It is essential that nocturia is understood, treated and monitored as a distinct problem from OAB and BPH, to ensure that patients are treated for their main symptom.

Association between biofilm and multi/extensive drug resistance in diabetic foot infection.

Abstract: PURPOSE We aimed to determine significant risk factors for biofilm production and to investigate the association between antimicrobial resistance profile and biofilm formation in the bacterial isolates obtained from patients with diabetic foot infection (DFI). METHODS Demographic, clinical, laboratory and outcome data of 165 patients, prospectively recorded and followed between January 2008 and December 2015 by a multidisciplinary committee, were analysed. Standard microbiological methods were adopted. Risk factors associated with biofilm were determined by univariate and multivariate analyses. RESULTS The overall rate of biofilm production among 339 wound isolates was 34%. The biofilm production rate was significantly higher in Gram-negative micro-organisms (39%) in comparison with Gram positives (21%) (P = .01). A. baumannii presented the highest biofilm production (62%), followed by P. aeruginosa (52%) and Klebsiella spp. (40%). On univariate analysis, significant factors associated with biofilm were antibiotic use within last 3 months (OR:2.94, CI: 1.5-5.75, P = .002), recurrent DFI within last 6 months (OR:2.35, CI: 1.23-4.53, P = .01), hospitalisation within last 3 months due to ipsilateral recurrent DFI (OR:2.44, CI: 1.06-5.58, P = .03), presence of amputation history (OR: 2.20, CI: 1.14-4.24, P = .01), multidrug-resistant (MDR) micro-organism (OR: 7.76, CI: 4.53-13.35, P<.001) and extensively drug-resistant (XDR) micro-organism (OR:11.33, CI:4.97-26.55, P<.001). Multivariate regression analysis revealed two variables to be significant factors associated with biofilm: MDR micro-organism (OR: 3.63, CI: 1.58-8.33, P = .002) and XDR micro-organism (OR:4.06, CI: 1.25-13.1, P = .01). CONCLUSIONS Multi/extensive drug resistance and previous recurrent DFIs were significantly associated with biofilm formation in patients with diabetic foot.

Real-world observational results from a database of 48 million men in the United States: Relationship of cardiovascular disease, diabetes mellitus and depression with age and erectile dysfunction.

Abstract: AIMS To evaluate the relationship of comorbidities (cardiovascular disease [CVD], diabetes mellitus [DM] and depression) with erectile dysfunction (ED) and age using real-world claims data from 48 million men in the United States. METHODS This was a cross-sectional, non-interventional study in men aged ≥18 years using data from the Truven Health MarketScan® and Medicare Supplemental Research Databases from January 2010 to December 2015, with an observational period of January 2011 to December 2014 to allow for 12 months pre- and post-index. Comorbidity rate was compared between ED and non-ED groups by age using the χ2 (bivariate) test. Comorbidity relationship to ED after controlling for categorical variables was assessed using logistic regression analysis. RESULTS In all, 48 004 379 men were in the database. Of the 9 839 578 who met the inclusion criteria, 573 313 (6%) were ED patients and 9 266 265 (94%) were non-ED patients. ED diagnosis increased decade to decade from 18-29 years to 50-59 years but decreased from 60-69 years to ≥90 years. ED patients had a higher prevalence of CVD, DM and depression than non-ED patients in all periods (P < .0001). After controlling for potential demographic and baseline confounders, the association between ED and CVD, DM and depression remained significant for each age group beginning at 30-39 years (P < .0001). DISCUSSION Conversations with patients concerning ED should be comprehensive regardless of patient age, in particular in those who have CVD, DM and/or depression. CONCLUSIONS In the real-world setting, ED diagnosis was associated with CVD, DM and depression across age groups, suggesting a need for inquiry about the potential for comorbidities among these men as a preventative measure against potentially serious future events.

Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician

Abstract: Aims In exocrine pancreatic insufficiency (EPI), the quantity and/or activity of pancreatic digestive enzymes are below the levels required for normal digestion, leading to maldigestion and malabsorption. Diagnosis of EPI is often challenging because the characteristic signs and symptoms overlap with those of other gastrointestinal conditions. Additionally, there is no single convenient, or specific diagnostic test for EPI. The aim of this review is to provide a framework for differential diagnosis of EPI vs other malabsorptive conditions. Methods This is a non-systematic narrative review summarising information pertaining to the aetiology, diagnosis and management of EPI. Results Exocrine pancreatic insufficiency may be caused by pancreatic disorders, including chronic pancreatitis, cystic fibrosis, pancreatic resection and pancreatic cancer. EPI may also result from extra-pancreatic conditions, including coeliac disease, Zollinger-Ellison syndrome and gastric surgery. Timely and accurate diagnosis of EPI is important, as delays in treatment prolong maldigestion and malabsorption, with potentially serious consequences for malnutrition, overall health and quality of life. Symptoms of EPI are non-specific; therefore, a high index of clinical suspicion is required to make a correct diagnosis.

Anticoagulation knowledge in patients with atrial fibrillation: An Australian survey.

Abstract: Background: Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia in clinical practice, and is associated with a significant medical and economic burden. Anticoagulants reduce the risk of stroke and systemic embolism by approximately two-thirds compared with no therapy. Knowledge regarding anticoagulant therapy can influence treatment outcomes in patients with AF. Objective: To measure the level of anticoagulation knowledge in patients with AF taking oral anticoagulants (OACs), investigate the association between patient-related factors and anticoagulation knowledge, and compare these results in patients taking warfarin and direct-acting oral anticoagulant (DOACs). Methods: Participants were recruited for an online survey via Facebook. Survey components included the Anticoagulation Knowledge Tool, the Perception of Anticoagulant Treatment Questionnaires (assessing treatment expectations, convenience and satisfaction), a modified Cancer Information Overload scale and the Morisky Medication Adherence Scale. Treatment groups were compared and predictors of OAC knowledge were identified. Results: Participants taking warfarin had a higher knowledge score compared with those taking DOACs (n = 386, 73% ± 13% vs 66% ± 14%, P Conclusion: The study identified knowledge gaps in patients taking OACs, and these deficiencies appeared to be greater in participants taking DOACs. Knowledge assessment should be integrated into patient counselling sessions to help identify and resolve knowledge deficits.

Very long-term outcome of schizophrenia.

Abstract: Purpose The principal aim is to review recent data concerning the very long-term outcome of schizophrenia and schizophrenia spectrum disorders. We examine factors that influence outcome, including therapeutic interventions. Method PubMed and Scopus databases were searched for papers published between 2008 and 2017 reporting on prospective studies of schizophrenia or schizophrenia spectrum with a follow-up period ≥5 years with adequate outcome information. Additional publications were found in reference lists and authors' reference libraries. Results The average proportion of patients with symptomatic remission at follow-up ranged between 16.4% in never-treated patients to 37.5% in patients who were systematically treated with antipsychotics. Good outcomes at follow-up were observed in schizophrenia and schizophrenia spectrum patients on low doses of antipsychotics and in patients with no pharmacological treatment at that time. Early detection and intensive treatment of the first episode as well as the availability of continued psychosocial treatment and support over subsequent years appeared associated with better outcomes. Conclusion The long-term outcome of schizophrenia is highly variable, depending on access to mental healthcare, early detection of psychosis and pharmacological treatment. Recent data support the effectiveness of low-dose antipsychotic treatment for long-term maintenance in some patients. A proportion of first-episode schizophrenia patients, perhaps 20%, do not need long-term maintenance antipsychotic treatment. That proportion may be higher in schizophrenia spectrum patients. The reasons why these patients do not need the long-term treatment are not well understood. Methods to predict the membership in this subgroup are not yet good enough for clinical use in individual patients.

Metabolic syndrome and its components are associated with increased chronic kidney disease risk: Evidence from a meta-analysis on 11 109 003 participants from 66 studies.

Abstract: BACKGROUND & AIMS Observational studies examining the relationship between metabolic syndrome and the risk of chronic kidney disease (CKD) have reported inconclusive results. This meta-analysis was performed to resolve these controversies. METHODS The MEDLINE, EMBASE, and PubMed databases were systematically searched from their inception until March 2016 to identify all relevant studies. Risk estimates and their corresponding 95% confidence intervals (CIs) for the associations of MetS and its components with CKD risk were extracted and pooled using a random-effects model. RESULTS A total of 66 studies, including 18 prospective cohorts and 48 cross-sectional studies, with 699 065 CKD patients and 11 109 003 participants were included in the meta-analysis. When all definitions were pooled, the presence of MetS was associated with a significant 50% increase of CKD risk (OR = 1.50, 95% CI = 1.43-1.56), with evidence of moderate heterogeneity (I2 = 72.3%, P < .001). The risk of CKD associated with MetS was higher in studies using the American Heart Association/National Heart, Lung, and Blood Institute criteria (OR = 1.68, 95% CI = 1.25-2.10) compared with those using the Adult Treatment Panel III (OR = 1.49, 95% CI = 1.42-1.56) and the International Diabetes Federation (OR = 1.32, 95% CI = 1.22-1.41) definitions. This relationship was independent of diabetes status. Moreover, all individual components of the MetS were significantly associated with CKD, and their coexistence resulted in an escalating dose-response relationship. The sensitivity and subgroup analyses established the stability of the findings. CONCLUSIONS This meta-analysis strongly suggests that the metabolic syndrome and its components are independently associated with the increased risk of CKD.

Safety and effectiveness of 'hospital in the home' and 'outpatient parenteral antimicrobial therapy' in different age groups: A systematic review of observational studies.

Abstract: Objective The aim of this study was .to systematically review the published literature of observational studies evaluating the safety and effectiveness of hospital in the home (HITH) and outpatient parenteral antimicrobial therapy (OPAT) in the general population, older people and children. Study design The review included retrospective studies and prospective studies performed on HITH and OPAT within different age groups. Only the studies that analysed the safety and effectiveness of HITH and OPAT were included for review. Data sources A literature search of electronic databases CINAHL, Web of Science, PubMed and SCOPUS from 1997 to 2016 was performed. Data synthesis Forty-four studies met the inclusion criteria. Five studies were undertaken on HITH within the general population, 26 studies were undertaken on OPAT within the general population, 8 studies were on HITH and OPAT for older people and 5 studies were on OPAT with children. More than 88% of the studies reported a cure or treatment success rate of greater than 80%. Adverse events with drugs ranged from 0% to 30.2%; adverse events with vascular access devices ranged from 0% to 29%; readmission rate varied from 1% to 26%; mortality varied from 0% to 27.5%. Conclusions This review quantifies the rates of success and harm in real world practice, and demonstrates that while most patients experience treatment success, adverse events may be high in some groups. However, the methodologies used to measure these parameters were inconsistent and some demographic groups had only a small number of studies.

Risk of psychiatric disorders in irritable bowel syndrome-A nationwide, population-based, cohort study.

Abstract: AIMS This cohort study aimed to investigate the association between irritable bowel syndrome (IBS) and the risk of developing psychiatric disorders. METHODS Utilizing the National Health Insurance Research Database (NHIRD) of Taiwan, IBS patients were identified and compared with age, sex, and index year-matched controls (1:3). RESULTS Of the IBS subjects, 3934 in 22 356 (17.60%, or 1533.68 per 100 000 person-years) developed psychiatric disorders when compared with 6127 in 67 068 (9.14%, or 802 per 100 000 person-years) in the non-IBS control group. Fine and Gray's survival analysis revealed that the study subjects were more likely to develop psychiatric disorders. The crude hazard ratio (HR) is 3.767 (95% CI: 3.614-3.925, P < .001), and the adjusted HR is 3.598 (95% CI: 3.452-3.752, P < .001) in the risk of developing psychiatric disorders after being adjusted for age, sex, comorbidities, geographical area of residence, urbanisation level of residence, and monthly insurance premiums. The cohort study revealed that IBS subjects were associated with an increased risk of anxiety, depression, bipolar, and sleep disorders. CONCLUSIONS This cohort study, using NHIRD, shows evidence support that patients with IBS have a 3.6-fold risk of developing psychiatric disorders. Other large or national datasets should be done to explore to underlying mechanisms.

EBUS: Faster, cheaper and most effective in lung cancer staging.

Abstract: The use of endobronchial ultrasound trans-bronchial needle aspiration (EBUS-TBNA) as the initial diagnostic and staging procedure in patients with suspected, non-metastatic lung cancer has gained substantial support, and is now recommended by numerous guidelines. Whereas considerable attention has been pointed to the reductions in costs achieved by EBUS-TBNA, that has not been the case for some of its more significant benefits, namely the reduction of the diagnostic work-up time and its ability to accurately assess and restage lymph nodes, which were previously stated incorrectly by CT or PET scan. Both these benefits translate into improved outcomes for patients, as delays are reduced, futile surgeries are prevented and curable operations can be performed on patients previously excluded by CT or PET scan. Indeed, the use of EBUS as the initial diagnostic and staging procedure has been proven to significantly increase survival, compared with conventional diagnostic and staging procedures, in a pragmatic, randomised controlled trial (Navani N. et al, 2015). The instalment of EBUS will have the greatest effect on overwhelmed, suboptimally functioning national healthcare systems, by decreasing the number of required diagnostic and staging procedures, therefore reducing both treatment delays and costs. The improved selection of surgical candidates by EBUS will result in improved patient outcomes. The latest findings regarding the benefits of EBUS are outlined in this review, which, to the best of our knowledge, is the first to emphasise the impact of the procedure, both on timing and costs of lung cancer staging, as well as on survival.

Uric acid and cardiovascular risk: What genes can say.

Abstract: Background Although the relationship of elevated serum uric acid levels and cardiovascular disease has been established in a great number of studies, the causal relevance of this finding remains ambiguous. An approach to evaluate the causal relevance of biomarkers is to exploit the natural randomised allocation of allelic variation in genes affecting their level, also known as Mendelian randomisation. Aim The aim of this paper is to review the current literature regarding serum uric acid levels and cardiovascular and renal disease risk in Mendelian randomisation studies. Methods PubMed and Scopus databases were searched to retrieve Mendelian studies regarding uric acid, hyperuricaemia and cardiovascular risk. Conclusions Genetic evidence based on conventional and novel Mendelian randomisation approaches suggest a modest, if any, causal effect of serum uric acid concentration on the development of cardiovascular disease, suggesting that further study of uric acid genes is needed in order to elucidate the relationship of serum uric acid levels and cardiovascular disease.

The analysis of microbial spectrum and antibiotic resistance of uropathogens isolated from patients with urinary stones.

Abstract: Purpose The characteristics and resistance patterns of urine bacteriology in patients with urinary tract stones have not been extensively studied. This study aims to investigate the microbial spectrum and antibiotic resistance of uropathogens isolated from urinary tract infections in patients with urinary stones and provide a basis for appropriate antimicrobial treatments. Methods The results of positive bladder midstream urine cultures and their antimicrobial susceptibility were retrospectively analysed from hospitalised patients with diagnosis of urinary calculi and urinary tract infections between January 2010 and December 2015. Results A total of 3892 samples were analysed during the study period: 2201 were female patients (56.6%) and 1691 were male patients (43.4%). The 4 most common uropathogens were Escherichia coli (48.7%), Klebsiella pneumoniae (10.4%), Enterococcus faecalis (8.7%) and Proteus mirabilis (5.2%). Both E. coli (60.8%) and Proteus mirabilis (7.5%) were higher in female patients than in male patients (32.8%; 2.3%; P 20%). Conclusions The microbial spectrum in patients with urinary stones had a complex pattern. The uropathogens showed marked multidrug resistance and a large proportion of the uropathogens were able to produce β-lactamase.

Evaluation of treatment outcomes of patients with MRSA bacteremia following antimicrobial stewardship programs with pharmacist intervention

Abstract: SummaryBackground Methicillin-resistant Staphylococcus aureus bacteremia (MRSA-B) is associated with high mortality and implementing an appropriate antimicrobial stewardship (AS) program with treatment intervention is essential. The aim of this study was to evaluate the impact of AS with pharmacist intervention on patients with MRSA-B. Methods Patients who were diagnosed with MRSA-B between January 2012 and April 2013 were defined as the pre-intervention group, while those diagnosed between May 2013 and December 2015 were defined as the intervention group (ie, AS with pharmacist intervention). The factors affecting bundle compliance rates and mortality were analysed. Result The pre-intervention group comprised 43 patients and the intervention group comprised 51 patients. Bundle compliance rates were estimated as follows in the intervention group: an increase was observed in the appropriate duration of therapy (from 44.8% to 72.1%, P = .027), incidences of the early use of anti-MRSA drugs (from 62.3% to 82.4%, P = .038), and the number of negative follow-up blood cultures (from 40.0% to 80.0%, P < .001), and a decrease was observed for 30-day mortality (from 41.8% to 21.6%, P = .044) and hospital mortality (from 58.1% to 27.5%, P = .003). In multivariate analysis, the intervention group was independent of 30-day mortality and hospital mortality risk reduction factors (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.12-0.86, and OR, 0.20; 95% CI, 0.07-0.53). Conclusions AS programs with pharmacist intervention improve mortality in patients with MRSA-B.

The importance of integrated left atrial evaluation: From hypertension to heart failure with preserved ejection fraction

Abstract: AIM Functional analysis and measurement of left atrium are an integral part of cardiac evaluation, and they represent a key element during non-invasive analysis of diastolic function in patients with hypertension (HT) and/or heart failure with preserved ejection fraction (HFpEF). However, diastolic dysfunction remains quite elusive regarding classification, and atrial size and function are two key factors for left ventricular (LV) filling evaluation. Chronic left atrial (LA) remodelling is the final step of chronic intra-cavitary pressure overload, and it accompanies increased neurohormonal, proarrhythmic and prothrombotic activities. In this systematic review, we aim to purpose a multi-modality approach for LA geometry and function analysis, which integrates diastolic flow with LA characteristics and remodelling through application of both traditional and new diagnostic tools. METHODS The most important studies published in the literature on LA size, function and diastolic dysfunction in patients with HFpEF, HT and/or atrial fibrillation (AF) are considered and discussed. RESULTS In HFpEF and HT, pulsed and tissue Doppler assessments are useful tools to estimate LV filling pressure, atrio-ventricular coupling and LV relaxation but they need to be enriched with LA evaluation in terms of morphology and function. An integrated evaluation should be also applied to patients with a high arrhythmic risk, in whom eccentric LA remodelling and higher LA stiffness are associated with a greater AF risk. CONCLUSION Evaluation of LA size, volume, function and structure are mandatory in the management of patients with HT, HFpEF and AF. A multi-modality approach could provide additional information, identifying subjects with more severe LA remodelling. Left atrium assessment deserves an accurate study inside the cardiac imaging approach and optimised measurement with established cut-offs need to be better recognised through multicenter studies.

Effect of characteristics of pharmacotherapy on non-adherence in chronic cardiovascular disease: A systematic review and meta-analysis of observational studies.

Abstract: INTRODUCTION Cardiovascular medications are effective in prevention of cardiovascular diseases (CVD); however, medication non-adherence contributes to morbidity and mortality. OBJECTIVE This systematic review and meta-analysis aims to summarise the evidence regarding the relationship between characteristics of drug therapy (pharmacotherapy) and medication non-adherence in the CVD population. METHODS Systematic searches in PubMed, LILACS, Academic Search and CINAHL databases for observational studies that enrolled adults with CVD were performed, from January 1960 to December 2015. The meta-analysis tested the association between characteristics of pharmacotherapy and self-reported medication non-adherence outcome, using a random effects model. To investigate heterogeneity, we performed subgroup analysis and sensitivity analysis. RESULTS Twenty-four cross-sectional studies and 7 cohort studies were included in this review. Based on 31 studies including 27 441 participants, we performed meta-analyses for all the characteristics of drug therapy that at least 2 studies evaluated, with a total of fourteen meta-analyses. The pooled results showed that studies which evaluate whether participants have insurance or another program that assists with medication costs, but not full coverage (OR = 0.63; 95% CI: 0.53-0.74; P < .001; I2 = 0%, P = .938), and a dosing frequency of twice or more daily (OR = 1.38; 95% CI: 1.13-1.69; P < .001) were associated with non-adherence. CONCLUSIONS AND RELEVANCE The results of this review suggest that access to insurance or another program that assists with medication costs was a protection factor for non-adherence. On the other hand, a high frequency of dosing was a risk factor for non-adherence. Therefore, these characteristics of pharmacotherapy must be considered to improve medication adherence among CVD patients.

Health consumer and health provider preferences for an integrative healthcare service delivery model: A national cross-sectional study.

Abstract: Background Although global interest in integrative healthcare (IHC) has escalated over the past few decades, stakeholder perspectives and preferences in relation to IHC remain poorly understood. Our study aimed to address this knowledge gap by exploring Australian health consumer (HC) and healthcare provider (HCP) understanding, attitudes and preferences for an IHC service delivery model, and to translate these views into an operational framework for IHC. Method The research used a cross-sectional study design. Eligible persons were informed of the study using a multi-modal recruitment approach. Adult HCs and HCPs from any medical, nursing, allied and traditional and complementary medicine discipline, who had internet access and resided in Australia, were eligible to complete the 55-item online questionnaire. Results Four hundred and nine participants completed the survey. HCs and HCPs shared a common understanding of, and positive attitude towards, IHC. When asked about the IHC service delivery model, participants advocated the provision of diverse healthcare and support services across multiple centres, to individuals mainly presenting with chronic/terminal conditions. The preference was for these services to be charged as fee-for-service, paid using a split payment system, and managed by a customised team of clinicians following triage by a non-medical staff member. These findings were subsequently translated into an operational framework for IHC. Conclusions This is first known study to translate HC and HCP attitudes and preferences into an operational framework for IHC. A logical next step of this work will be to ascertain the feasibility of this model in primary care.

Admission calcium levels and risk of acute kidney injury in hospitalised patients.

Abstract: Background The risk of acute kidney injury (AKI) development among hospitalised patients with elevated calcium levels on admission remains unclear. The aim of this study was to assess the risk of AKI in hospitalised patients stratified by various admission serum calcium levels. Methods This is a single-centre retrospective study conducted at a tertiary referral hospital. All hospitalised adult patients who had admission calcium levels available between 2009 and 2013 were enrolled. Admission calcium was categorised based on its distribution into six groups (≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9, and ≥10.0 mg/dL). The primary outcome was hospital-acquired AKI. Logistic regression analysis was performed to obtain the odds ratio of AKI for various admission calcium strata using calcium levels of 8.0-8.4 mg/dL (lowest incidence of AKI) as the reference group. Results A total of 12 784 patients were studied. Hospital-acquired AKI occurred in 1779 (13.9%) patients. The incidence of AKI among patients with admission calcium ≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9 and ≥10 mg/dL was 14.7%, 11.7%, 11.8%, 14.6%, 15.8% and 17.3%, respectively. After adjusting for potential confounders, admission calcium levels ≤7.9, 9.0-9.4, 9.5-9.9 and ≥10 mg/dL were associated with increased risk of AKI with odds ratios of 1.36 (95%CI 1.08-1.72), 1.29 (95%CI 1.08-1.56), 1.38 (95%CI 1.14-1.68) and 1.51 (95%CI 1.19-1.91), respectively. Conclusion Admission hypocalcaemia and hypercalcaemia are associated with an increased risk for hospital acquired AKI. Patients with admission hypercalcaemia (≥10 mg/dL) carry a 1.51-fold risk for AKI development during hospitalisation.

Factors that lead to hospitalisation in patients with Parkinson disease-A systematic review.

Abstract: OBJECTIVES Parkinson disease (PD) frequently leads to acute hospitalisation resulting in increased cost to health care systems and reduced quality of life for patients. The objective of this review was to identify causes that lead to acute hospitalisation of patients with PD. METHODS A systematic review of English language literature from 1997 to present. FINDINGS The incidences of acute general medical or surgical problems that trigger acute hospitalisation in patients with PD are similar to those in the general population. However, falls, acute decompensation of PD symptoms and infections are far more common in PD patients and are responsible for more than 50% of the causes of hospitalisation in this patients' group. IMPLICATIONS Preventive strategies to avoid decompensation of PD symptoms and early detection and treatment of infections are needed to reduce hospitalisation in patients with PD.

Hydroxychloroquine may be associated with reduced risk of coronary artery diseases in patients with rheumatoid arthritis: A nationwide population-based cohort study.

Abstract: OBJECTIVES The aim of this study was to determine whether hydroxychloroquine (HCQ) usage is associated with incidental risk of coronary artery diseases (CAD) in patients with rheumatoid arthritis (RA). METHODS The Longitudinal Health Insurance Database in Taiwan was used. The study cohort comprised of 1104 newly diagnosed RA patients between 2001-2010, and patients were followed until 31 December 2011. Patients with history of CAD before RA diagnosis were excluded. We define as HCQ users if the usage duration of HCQ>180 days and non-users if less than 90 days. After propensity score matching of age, sex, index date and comorbidities, the study cohort was comprised of 346 patients: 173 HCQ users and 173 non-users. The study outcome was incidence of CAD. Cox regression model was used to estimate the hazard ratio (HR) of disease after controlling for demographic, other comorbidities and drugs. We also evaluate the effects of HCQ use and CAD events on different characteristics of RA patients. RESULTS Kaplan-Meier curves comparing the HCQ users and non-users revealed a statistical significant difference (P value of log-rank test <.001). The adjusted HR for HCQ users versus non-users for CAD events was 0.32 (95% CI, 0.18-0.56, P value <.01) over up to 10 years of follow-up. The adjusted HR (95% CI) of CAD for different age group, gender and other subgroups showed no effect of interaction among each subgroup analysis parameter. CONCLUSIONS This study revealed association of decreased CAD risk in RA patients taking HCQ. The protective effect of HCQ on CAD is consistent regarding subgroup analysis on age, gender and different comorbidities groups.

Efficacy and safety of a triple active sore throat lozenge in the treatment of patients with acute pharyngitis: Results of a multi-centre, randomised, placebo-controlled, double-blind, parallel-group trial (DoriPha).

Abstract: OBJECTIVE The aim of this multi-centre, randomised, double-blind, placebo-controlled trial was to compare the efficacy and safety of the fixed combination of 0.5 mg tyrothricin, 1.0 mg benzalkonium chloride, and 1.5 mg benzocaine (study drug marketed as Dorithricin® ) in repeat dosing for 3 days to match placebo lozenges in the treatment of acute pharyngitis in adults. METHODS Patients (pts, aged ≥18 years) with acute pharyngitis, ie, non-streptococcal sore throat and moderate-to-severe pain (intensity NRS ≥ 7; VAS ≥ 50) were assigned to study drug (n = 160) or matching placebo (n = 161). Efficacy was assessed by investigator for 2 hours post initial dose (p.i.d.), and 3 days later (Visit 2). Primary efficacy endpoint was the complete resolution of throat pain and difficulty in swallowing at Visit 2 (3 days p.i.d.). Safety and local tolerability were also assessed. RESULTS Seventy-two hours (p.i.d.), complete resolution of throat pain and difficulty in swallowing were achieved by 44.6% patients on study drug compared with 27.2% patients on placebo (difference 17.4% (CI [5.8%; 29.7%]; 64% improvement [GEE, P = 0.0022]). Until 2 hours p.i.d., reduction in symptoms was better with study drug (P < 0.005). Treatment satisfaction was higher with study drug (patients'/investigators' assessment (78.9%/78.9% vs 55.0%/55.6% for placebo) and was well tolerated, overall safety profile was comparable to placebo. CONCLUSION The strength of this randomised controlled trial lies in the endpoint of complete remission after 3 days p.i.d., especially in the light of other trials addressing acute pharyngitis. The results of this study show a significant benefit of the study drug over placebo in the treatment of acute pharyngitis. Local treatment with the fixed combination (0.5 mg tyrothricin, 1.0 mg benzalkonium chloride, and 1.5 mg benzocaine) provides a rapid analgesic effect and is effective in relieving both severe throat pain as well as difficulty in swallowing associated with acute pharyngitis leading to a 64% improved complete remission within 72 hours. The triple active combination is a suitable treatment option for patients in the self-management of acute pharyngitis and sore throat. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03323528.

Risk factors for infection in patients with chronic leg ulcers: A survival analysis.

Abstract: Aim: This study aimed to validate the relationships between possible predictive factors and clinically diagnosed infection in adult patients with chronic leg ulcers. Methods: This study used a sample of 636 adult participants whose ulcers were diagnosed as either venous, arterial or mixed aetiology leg ulcers and had no clinical signs of infection at recruitment. Data were extracted from recruitment to 12 weeks from six longitudinal prospective studies from 2004 to 2015. Survival analysis was used to investigate mean time-to-infection, including the Kaplan-Meier method and the Cox proportional-hazards regression model. Results: The sample included 74.7% venous, 19.6% mixed and 5.7% arterial leg ulcers. There were 101 (15.9%) participants diagnosed with infection at least once within 12 weeks of follow-up. Mean time-to-infection was 10.89 weeks (95% CI = 10.66-11.12). After adjustment for potential confounders, a Cox proportional hazards regression model found that depression, using walking aids, calf ankle ratio <1.3, wound area ≥10 cm2 and ulcers with slough tissue at recruitment were significant risk factors for wound infection. Conclusion: This study has validated the predictive ability of factors which have been found in a cross-sectional study to be significantly associated with infection in patients with leg ulcers, including venous leg ulcers, arterial leg ulcers and mixed aetiology leg ulcers. Results showed that patients with chronic leg ulcers, who either presented with depression, used walking aids, had a calf ankle ratio <1.3, a wound area ≥10 cm2 or an ulcer with slough tissue, had greater likelihood of developing infection compared to those without these factors.

Low serum zinc level: The relationship with severe pneumonia and survival in critically ill children.

Abstract: BACKGROUND Zinc deficiency is common among children in developing countries; but, there is still conflicting evidence on whether the alteration in zinc metabolism is the predictive of disease severity in the setting of critical illness. OBJECTIVES To assess serum zinc levels in children admitted with pneumonia, and also to study the relationship between zinc levels and severity and mortality from pneumonia. METHODS In a prospective cohort study, we enrolled 320 critically ill children admitted to the paediatric intensive care unit (PICU) with severe pneumonia (group 1) in addition to 160 children admitted into wards with pneumonia (group 2). Serum zinc measured in all patients on admission. RESULTS Serum zinc level was significantly lower among patients admitted to PICU (group 1) compared with patients admitted to wards (group 2) (P < .001). There was a highly statistically significant decrease in zinc level in critically ill children complicated by sepsis, mechanically ventilated cases and those who died. Regarding the diagnosis of sepsis, zinc had an area under the curve (AUC) of 0.81 while C-reactive protein (CRP) had an AUC of 0.83. Regarding the prognosis, zinc had an AUC of 0.649 for prediction of mortality, whereas the AUC for Pediatric risk of mortality (PRISM), Pediatric index of mortality2 (PIM2) and CRP were 0.83, 0.82 and 0.78, respectively. The combined zinc with PRISM and PIM2 has increased the sensitivity of zinc for mortality from 86.5% to 94.9%. CONCLUSION Zinc has both a diagnostic and a prognostic value for children with pneumonia.

Melatonin for preventing primary headache: A systematic review.

Abstract: Background The aim of this study was to assess the effectiveness and safety of melatonin for primary headache. Methods This systematic review following the Cochrane Handbook for Systematic Reviews of Interventions recommendations and PRISMA Statement. Results Four randomized controlled trials were included (351 participants). According to the GRADE approach the quality of evidence was very low. The use of melatonin for migraine showed that (i) reduced the number of days with pain and the analgesic consumption when compared with placebo, (ii) no benefits on headache intensity, number of headache days and analgesics consumption when compared with amitriptyline, (iii) reduced the number of analgesic consumption, the attack frequency and the headache intensity when associated with propranolol plus nortriptyline vs placebo plus propranolol plus nortriptyline, and (iv) no difference for any of the interest outcomes when associated with propranolol plus nortriptyline vs sodium valproate plus propranolol plus nortriptyline. The use of melatonin for cluster headache when compared with placebo showed a reduction in the daily number of analgesic consumption and no difference in the number of daily attacks. Adverse events were poorly reported by all of the studies. Conclusion This review found that so far there are few clinical trials, with poor methodological quality about melatonin for primary headaches. The available evidence is not sufficient to support the use of melatonin in clinical practice for this population. Further research is still necessary for assess its effects (benefits and harms) for primary headaches patients. Number of Protocol registration in PROSPERO database: CRD42017067105 (available at https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017067105) .

The effect of 12-week garlic supplementation on symptom relief in overweight or obese women with knee osteoarthritis.

Abstract: AIMS Chronic joint pain and stiffness, and functional disability, are the major debilitating features of osteoarthritis (OA). The aim of this study was to assess the effect of 12-week supplementation with a garlic supplement on knee osteoarthritis outcomes in overweight or obese women. METHODS Seventy-six postmenopausal overweight or obese women (25≤BMI≤40 kg/m2 ) with medically diagnosed knee OA participated in this randomised double-blind, placebo-controlled, parallel-design trial. After randomisation into 2 groups, patients received a daily dose of either 1000 mg odourless garlic tablet, or placebo, for 12 weeks. The total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), as well as pain, stiffness and physical function subscales, were evaluated pre- and poststudy. Anthropometric parameters and body composition (using bioelectrical impedance analysis) were also assessed. RESULTS Following 12-week supplementation in overweight or obese women with OA, stiffness (but not pain, function or WOMAC total score) was significantly lower in the garlic group compared with the placebo group (1.4 ± 1.6 vs 2.5 ± 1.9, P = .023). The changes in WOMAC parameters showed no statistically significant differences between the 2 groups. WOMAC total score (38.4 ± 15.9-30.6 ± 15.7, P = .004) and all the subscales, including pain (8.3 ± 3.7-7 ± 4.4, P = .026), stiffness (2.3 ± 1.6-1.4 ± 1.6, P = .013) and physical function (27.7 ± 11.9-22.2 ± 12.4, P = .001) improved significantly in the garlic group postintervention compared with pre-intervention; although pain subscale also decreased in the placebo group (9.6 ± 3.1-6.9 ± 3.7, P < .001). CONCLUSIONS Although pre- to postintervention knee OA symptoms were improved in overweight or obese women receiving 12 weeks garlic supplement, there was no significant difference in WOMAC changes compared with the placebo group. Further clinical trials are required to investigate the therapeutic value of garlic ingredients, and the potential role of placebo effect, in the management of OA symptoms.