Chronic Episodes Research Articles

Assessment of Cardiac Abnormalities in Sickle Cell Disease Patients Using Echocardiography

Background: Sickle Cell Disease (SCD) is characterized by chronic anemia and recurrent ischemia-reperfusion episodes that contribute to high output heart failure. The effects of SCD on the heart are significantly underrecognized. Methods: SCD patients who underwent echocardiography between March 2016 and March 2018 were retrospectively analyzed. Patients with reduced Left Ventricular Ejection Fraction (LVEF) and valvular heart disease were excluded. Cardiac chamber size, systolic and diastolic function parameters, and LV and RV strain were compared between hemoglobin SS (most severe form of SCD) and SC (less severe form) subtypes and against healthy controls. Wilcoxon signed rank test was used for statistical analysis. Results: SS patients (n = 48, mean age 31.9) had lower mean hemoglobin 8.9 g/dl vs 11.3 g/dl (p < 0.001) and hematocrit 25.8% vs 31.4% (p = 0.008) and higher LDH 437 IU/L vs 258 IU/L (p < 0.001) compared to SC patients (n = 11, mean age 34.4). Both SS and SC patients had worse diastolic function compared to healthy controls: higher E velocity 98.9 cm/s (SS), 86.4 cm/s (SC), 76.4 cm/s (control) (SS vs control, p < 0.01; SC vs control, p < 0.05) and higher E/A ratio 1.76 (SS), 1.59 (SC), 1.15 (control) (SS vs control, p < 0.001; SC vs control, p < 0.01). SS patients had larger indexed left atrial volume compared to SC patients (39.3 ml/m2 vs 28.4 ml/m2, p = 0.007). There was no significant difference in LVEF, left ventricular global longitudinal strain, or right ventricular strain between SS and SC subtypes compared to healthy controls. Furthermore, SS patients with a serum LDH > 500 IU/L had higher E/e' ratio (11.3 vs 7.2, p=0.001) and larger indexed Left Ventricular End Diastolic Volume (LVEDVi) (80.8 ml/m2 vs 53.4 ml/m2, p=0.002) compared to SS patients with LDH < 500 IU/L. Conclusion: SCD genotype adversely determines the degree of cardiac dysfunction in patients with SCD. LVEDVi, left atrial size, E velocity, E/A ratio, and E/e' ratio may serve as useful echocardiographic parameters to follow in this patient population. Serum LDH has been associated with poor clinical outcomes in patients with SCD, and as demonstrated by our study, it also portends worsening cardiac function in this population at high risk for heart failure. Figure Disclosures No relevant conflicts of interest to declare.

Sickle-Cell Disease in Greece: Patient Reported Outcomes Related to Clinical Complications, Treatment Choices and Attitudes, Beliefs and Trends Affecting Potential Participation in Clinical Trials - a Greek National Multicentric Study

Background: Sickle cell disease (SCD) is an autosomal recessive disorder caused by a point mutation in the β-globin chain of hemoglobin that forms hemoglobin S. It is clinically characterized by complicated episodes of veno-occlusive crises (VOC), emergency room (ER) visits and uncomplicated inpatient admissions. Aim: We investigated the clinical complications and treatment choices of a large cohort of Greek SCD patients, representative of the whole country. Most importantly, this study aimed to assess patients' attitudes and beliefs regarding their enrollment in clinical trials testing new drugs. We examined the factors influencing such a participation. Patients and Methods: A total of 254 patients from 10 Thalassemia and Sickle Cell Departments across Greece (110 men/144 women), aged 18 - over 65, 210 (82.7%) with β-thalassemia/sickle cell trait and 44 (17.3%) with homozygous SCD participated in the study. The participants had variable educational and socioeconomic background. They all answered an anonymous self-report questionnaire during their medical evaluations between November 2018 and May 2019, including their demographic and clinical characteristics, their current treatment and their opinion regarding a possible participation in a clinical trial for SCD. Descriptive statistical analysis using calculated scale variables and Chi-square test were performed. Results: All participants completed the survey. During the previous year, 64 patients (25.3%) had no admissions for VOC, 128 (50.6%) had 1-5, whereas 21 (8.3%) had 5-10 and 40 (15.8%) more than 10. Except for acute pain crises, the most frequent complications were chronic pain (59%), liver/spleen dysfunction (32.4%), infectious episodes (29.5%), iron overload (23.8%) and pulmonary hypertension (20.1%). In addition to hematological care, patients seeked medical attention from expert physicians for disease complications; 77.6% of the patients reported that they yearly visited a cardiologist, 42.4% an ophthalmologist, 31.9% an orthopedic, 28.4% a pneumonologist, 28.9% a hepatologist, 12.6% an urologist, 14% a nephrologist, 11.9% an infectious disease doctor, 10.1% a pain management specialist and 8.1% a neurologist. The therapeutic approaches included daily folic acid supplementation (86.1%), vaccines (68.3%), hydroxyurea (66.3%), antibiotics (57.1%), simple pain moderators (52.4%), opioids (48.8%) and iron chelators (30.2%). Previous experience in clinical trials was reported by only 17 patients (6.9%). Regarding the patients' attitudes towards a probable clinical trial, 41.3% were positive to try new therapies, 28.3% negative and 30.4% neutral. 67.2% were satisfied with their current treatment, without excluding a potential participation in clinical trials; such treatment satisfaction correlated significantly with older age, lower income and secondary hemochromatosis under chelation treatment (p<0.05). 40% reported that they had been waiting for years for a new treatment, but 43.2% strongly denied becoming an experimental mouse model, whereas 47.3% mentioned that they would trust their doctors' advice correlating positively with male gender and higher income (p<0.05). Lower educational status, prior intake of hydroxyurea and residence/origin in the capital in contrast to the countryside (chi-square, p<0.05) significantly correlated with a potential clinical trial participation. Internet and television information motivated patients to seek more details from their doctor. Concerning the factors rated as the most important for a potential participation in a clinical trial, 7 out of 10 patients of our cohort considered of utmost equal importance the effectiveness of a probable treatment and the relative toxicity. Conclusions: Most SCD patients have chronic complications and visit specialized physicians. Since the participation of larger number of patients in clinical trials is essential for the application of novel drugs, the most important factors of our cohort are the effectiveness of a probable treatment and the relative toxicity, along with the trust to the doctor. These factors are crucial, influencing patients' decision. Even though a proportion of our patients remain skeptical towards clinical trials, an increasing number is willing to participate, which correlates positively with residence in the capital, lower educational status and prior intake of hydroxyurea. Disclosures Kattamis: Apopharma: Honoraria; Vertex: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees; Ionis: Membership on an entity's Board of Directors or advisory committees; ViFOR: Membership on an entity's Board of Directors or advisory committees; Novartis Oncology: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Symeonidis:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; MSD: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Tekeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Non-invasive urinary biomarkers of renal function in sickle cell disease: an overview.

Sickle cell disease (SCD) is a hereditary condition characterized by homozygosis of the hemoglobin S (HbS) gene. Marked morbimortality is observed due to chronic hemolysis, endothelial injury, and episodes of vaso-occlusion, which leads to multi-organ damage. Renal impairment is common and may have different presentations, such as deficiency in urinary acidification or concentration, glomerulopathies, proteinuria, and hematuria, frequently resulting in end-stage renal disease (ESRD). Novel biomarkers of renal function, such as kidney injury molecule 1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL) and monocyte chemoattractant protein 1 (MCP-1) are being studied in order to enable early diagnosis of kidney damage in SCD.

Pollen Flowing over the Great Dividing Range, Australia

TPS 752: Respiratory effects and allergies, Exhibition Hall, Ground floor, August 27, 2019, 3:00 PM - 4:30 PM In 2018, asthma affected approximately 339 million people worldwide, of which 2.7 million people live in Australia (11.2% of Australia’s population). It is a chronic lower lung disease resulting from airway inflammation and narrowing resulting in periods of chronic or acute episodes of wheezing, breathing difficulties or cough. In the financial year 2015-16 it resulted in 39,448 hospitalisations in Australia at an estimated cost of $28 billion in 2015. It accounts for an average 2.1% of all GP encounters per year and both prevalence and incidence increase with remoteness and disadvantaged socioeconomically status. Asthma attacks have many possible triggers including atmospheric conditions, respiratory infections, dust mites, mould, dust and pollen. Thunderstorm asthma, results in an increased number of acute bronchospasm presentations following a thunderstorm. In Melbourne, Australia, on the 20-21 November 2016, approximately 10,000 people presented to emergency departments (ED) with acute asthma onset following a thunderstorm. This was a 992% increase compared to the expected number of exacerbated asthma cases for an average November. Ten people died. Of those that presented at ED, only 28% had been previously diagnosed with asthma but almost all were sensitized to ryegrass pollen (lolium grass pollen). It is suspected that grass pollen has caused several thunderstorm asthma incidents in Australia. Thus, modelling the flow of pollen across Australia during flowering season is critical in enhancing our understanding of the thunderstorm asthma risk. The project aims to develop a weather research forecasting (WRF), and using a hybrid single particle Lagrangian integrated trajectory (HYSPLIT) model, simulate grass pollen aerobiology and dispersion over the complex topography of the Great Dividing Range. Pollen traps will provide atmospheric concentrations of grass pollen which will be used to validate the model. Assessing the risk of thunderstorm asthma in Sydney will help develop a thunderstorm asthma response policy for NSW.

2009 Bleeding Intestinal Lymphangiectasia Diagnosed and Treated by Using Double Balloon Enteroscopy in a 41-Year-Old Female: Case Report and Review of Literature

INTRODUCTION: Intestinal lymphangiectasia (IL) is a rare disease characterized by dilated lymphatic vessels in the intestinal wall and small bowel mesentery, which induce loss of protein and lymphocytes into the bowel lumen. Gastrointestinal bleeding (GIB) rarely has been described as the only symptom of IL. We describe a case of obscure GIB in a young female caused by lymphangiectasia localized to the distal jejunum by antegrade double balloon enteroscopy. CASE DESCRIPTION/METHODS: A 41-year-old African American female who initially presented to her PCP with chronic fatigue and intermittent episodes of melena. The patient was subsequently placed on iron supplementation and referred to gastroenterology for further work up. Physical examination finding were largely unremarkable. On laboratory tests, her hemoglobin declined to 5.8 g/dL (from a baseline of 10 g/dL). Initial Esophagogastroduodenoscopy (EGD) showed 2 cm hiatal hernia but was otherwise unremarkable. A subsequent colonoscopy showed mild internal hemorrhoids and a 3 mm solitary ulcer in the distal rectum but no other obvious sources of GI bleeding. Magnetic resonance enterography (MRE) was unremarkable. Next, a video capsule endoscopy was done which showed a site of active bleeding from the mid-small bowel and was associated with nodular mucosa and prominent lacteals. A subsequent double balloon enteroscopy (DBE) showed an oozing fold in the distal jejunum with white speckled appearance consistent with a bleeding lymphangiectasia. A total of seven clips were placed on the lesion and during application of clips, a white milky substance was noted coming from the lesion suggesting the diagnosis of lymphangiectasia. DISCUSSION: IL is most commonly found in the small bowel, making its diagnosis difficult by EGD or colonoscopy. DBE and video capsule endoscopy (VCE) are the two most important diagnostic modalities available to evaluate the entire small intestine.The noninvasive nature of VCE and its capability to visualize the entire small bowel has made it a first-line tool in many centers. However, DBE is preferred over video capsule endoscopy because of higher sensitivity from better endoscopic visualization and ability to perform biopsies for pathologic diagnosis. In this report, we present an extremely rare case of primary intestinal lymphangiectasia in causing obscure GIB and successful intervention using DBE. We believe this is the second case to report small bowel bleeding from jejunal lymphangiectasia, which was successfully treated using DBE.

Improvement in Recurrent Dysphonia Associated with the Regular Use of a Robot Vacuum: A Case Study

ABSTRACT This case study describes the experience of a woman in her late 40s with chronic recurrent episodes of dysphonia. The patient reported that the purchase and use of a robot vacuum resulted in a significant decrease in the levels of dust in her home, particularly in locations she found difficult to clean thoroughly with a conventional vacuum (e.g., under the bed). She observed a concomitant decrease in a previously established pattern of work-related dysphonia, reporting fewer days of atypical voice quality and no episodes of aphonia across a one-year period. For patients whose dysphonia is exacerbated by environmental allergens, use of a robot vacuum is an automated, relatively inexpensive strategy to consider as a possible adjunct to more conventional approaches.

Chronic obstructive pulmonary disease exacerbation episodes derived from electronic health record data validated using clinical trial data

PurposeTo validate an algorithm for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) episodes derived in an electronic health record (EHR) database, against AECOPD episodes collected in a randomized clinical trial using an electronic case report form (eCRF).MethodsWe analyzed two data sources from the Salford Lung Study in COPD: trial eCRF and the Salford Integrated Record, a linked primary‐secondary routine care EHR database of all patients in Salford. For trial participants, AECOPD episodes reported in eCRF were compared with algorithmically derived moderate/severe AECOPD episodes identified in EHR. Episode characteristics (frequency, duration), sensitivity, and positive predictive value (PPV) were calculated. A match between eCRF and EHR episodes was defined as at least 1‐day overlap.ResultsIn the primary effectiveness analysis population (n = 2269), 3791 EHR episodes (mean [SD] length: 15.1 [3.59] days; range: 14‐54) and 4403 moderate/severe AECOPD eCRF episodes (mean length: 13.8 [16.20] days; range: 1‐372) were identified. eCRF episodes exceeding 28 days were usually broken up into shorter episodes in the EHR. Sensitivity was 63.6% and PPV 71.1%, where concordance was defined as at least 1‐day overlap.ConclusionsThe EHR algorithm performance was acceptable, indicating that EHR‐derived AECOPD episodes may provide an efficient, valid method of data collection. Comparing EHR‐derived AECOPD episodes with those collected by eCRF resulted in slightly fewer episodes, and eCRF episodes of extreme lengths were poorly captured in EHR. Analysis of routinely collected EHR data may be reasonable when relative, rather than absolute, rates of AECOPD are relevant for stakeholders' decision making.

Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016

The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines. To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines. This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018. Overlapping opioid and benzodiazepine prescriptions filled. The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription. Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines. This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.

Efecto del ejercicio y la actividad física sobre las funciones ejecutivas en niños y en jóvenes. Una revisión sistemática

En la presente revisión sistemática cualitativa se intenta avanzar en el conocimiento sobre la incidencia de la actividad física sobre las funciones ejecutivas, focalizada en poblaciones sanas infantiles, adolescentes y jóvenes. Se identificaron, categorizaron y analizaron artículos de bases de datos electrónicas como ISI Web of Knowledge, SCOPUS, PubMed, SPORTDiscus, PsyINFO, ERIC, Google Scholar y Dialnet. Atendiendo a los criterios de inclusión/exclusión, siguiendo la declaración PRISMA para registrar y categorizar los resultados, y mediante la herramienta de evaluación de calidad “The Effective Public Health Practice Project”, se seleccionaron finalmente 44 investigaciones experimentales, estructuradas en episodios agudos y crónicos de actividad física bajo dos enfoques: cuantitativos y cualitativos. Los resultados muestran una superior cantidad de experimentos con episodios agudos cuantitativos (45,45%), frente a los agudos cualitativos (18,18%), crónicos cuantitativos (20,45%) y crónicos cualitativos (15,92%). Los análisis de estas investigaciones han permitido identificar los beneficios de los diferentes tipos de actividad física estudiados sobre los componentes ejecutivos. This qualitative systematic review tries to advance knowledge about the effect of physical activity on executive functions, paying special attention to healthy children, teenagers and youngsters. Several articles have been identified, categorized and analyzed in electronic databases such as ISI Web of Knowledge, SCOPUS, PubMed, SPORTDiscus, PsyINFO, ERIC, Google Scholar and Dialnet. According to the inclusion/exclusion criteria, following the PRISMA statement to record and categorize the results and throughout the quality assessment tool "The Effective Public Health Practice Project”, 44 pieces of research, structured in acute and chronic episodes of physical activity under two approaches: qualitative and quantitative, were chosen. The results show a higher number of experiments with quantitative acute episodes (45,45%) against qualitative ones (18,18%), chronic quantitative (20,45%) and chronic qualitative episodes (15,92%). The analysis of these investigations has allowed identifying the benefits of different types of physical activity studied on executive components.

A prospective study of clinical characteristics and outcomes of acute kidney injury in a tertiary care Centre

BackgroundAcute kidney injury (AKI) is a major global health problem. We aim to evaluate the epidemiology, risk factors and outcomes of AKI episodes in our single centre.MethodologyWe prospectively identified 422 AKI and acute on chronic kidney disease episodes in 404 patients meeting KDIGO definitions using electronic medical records and clinical data from 15th July to 22nd October 2016, excluding patients with baseline estimated GFR (eGFR) of < 15 mL/min. Patients were followed up till 6 months after AKI diagnosis.ResultsThe mean age was 65.8 ± 14.1. Majority of patients were male (58.2%) of Chinese ethnicity (68.8%). One hundred and thirty-two patients (32.6%) were diagnosed in acute care units. Seventy-five percent of patients developed AKI during admission in a non-Renal specialty. Mean baseline eGFR was 50.2 ± 27.7 mL/min. Mean creatinine at AKI diagnosis was 297 ± 161 μmol/L. Renal consultations were initiated at KDIGO Stages 1, 2 and 3 in 58.9, 24.5 and 16.6% of patients, respectively. Three hundred and ten (76.7%) patients had a single etiology of AKI with the 3 most common etiologies of AKI being pre-renal (27.7%), sepsis-associated (25.5%) and ischemic acute tubular necrosis (15.3%). One hundred and nine (27%) patients received acute renal replacement therapy. In-hospital mortality was 20.3%. Six-month mortality post-AKI event was 9.4%. On survival analysis, patients with KDIGO Stage 3 AKI had significantly shorter survival than other stages.ConclusionAKI is associated with significant in-hospital to 6-month mortality. This signifies the pressing need for AKI prevention, early detection and intervention in mitigating reversible risk factors in order to optimize clinical outcomes.

Prostatic calcifications are associated with a more severe symptom burden in men with type II chronic bacterial prostatitis.

Although prostatic calculi/calcifications are encountered frequently in the urological practice, little is known about the incidence of such lesions, their mechanism of formation, their relationship to other prostate conditions and their clinical significance. The purpose of this study is to describe the characteristics and to investigate the clinical significance of prostatic calcifications (PCs) in patients with chronic bacterial prostatitis (CBP). This study was conducted between 01/02/2013 and 20/02/2018. The patient population for this study included subjects with or without PCs and a confirmed diagnosis of NIH category II Chronic Bacterial Prostatitis (CBP). Demographics and clinical history of each assessed patient were reviewed. Eligible patients underwent prostatic ultrasound with post-void residual measurement, and the Meares-Stamey "4-glass" test. Symptom severity was measured using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostatic Symptoms Score (IPSS). Antimicrobials were administered to confirmed cases of CBP according to the results of susceptibility tests. After four weeks off-therapy, the NIH-CPSI and IPSS tests were repeated. Variables were compared between patients with and without prostatic calcifications. Ninety-five CBP patients were included in the study. According to the presence of PCs detected by ultrasound examination, patients were divided into two groups: 41 had PCs (group 1) and 54 didn't (group 2). No significant between-group baseline differences were found regarding age, marital status, prostate volume, the proportion of common CBP pathogens. Concerning highrisk sexual behavior, a significantly higher number of men with PCs practiced anal penetration. Moreover, a significantly higher number of men with PCs had a history of chronic prostatitis relapsing episodes. Microbiological eradication and the complete resolution of clinical symptoms occurred in similar proportions between the two groups. However, intergroup analysis resulted in significantly higher scores of the NIH-CPSI test in group 1, both at the pre-therapy and at the post-therapy time points. Conversely, no IPSS score differences between groups 1 and 2 were found at both pre- and post-therapy time points. Prostatic calcifications do not seem to influence the microbiological outcome of antibacterial treatment. However, the CBP symptoms appear to be more severe in carriers of prostatic calcifications, either before or after antibacterial therapy.

Prescription Patterns of Sedative Hypnotic Medications in the Military Health System.

To evaluate prevalence of sedative hypnotic medications and their potential indication among active duty service members (ADSM) and non-ADSM receiving care in the Military Health System (MHS). Using a retrospective cohort study design, we extracted data on sedative hypnotic medications (benzodiazepine receptor agonists, benzodiazepines, sedating antidepressants, and melatonin receptor agonist) dispensed from January 2009 to December 2015. Prevalence was defined as ≥ 1 dispensing per patient per year whereas chronic episode was categorized as ≥ 90 days of continuous therapy. Chi square statistics, odds ratios, and 95% confidence intervals were calculated to assess meaningful differences between ADSM and non-ADSM. Mean age at dispensing was 33.5 years in ADSM compared to 59.1 years in non-ADSM. Of all drugs dispensed, 79.2% (n = 2.4 million) were to male ADSM compared to 34.5% (11.5 million) to male non-ADSM. Zolpidem and trazodone were the two most frequently used medications, comprising more than 75% of all prescriptions. Age- and sex-adjusted prevalence peaked at 8.1% in 2013 for ADSM and at 4.9% in 2012 for non-ADSM and remained stable thereafter for both groups. Most episodes for ADSM (81.0%) and non-ADSM (65.0%) were acute or intermittent. ADSM were significantly more likely to have a sleep-related diagnosis associated with their episode than non-ADSM (odds ratio 2.35, 95% confidence interval 2.33-2.36), most frequently insomnia. ADSM had a 2% to 3% higher adjusted prevalence of sedative hypnotic medications than non-ADSM. The use of sedative hypnotics in the young ADSM population highlights the need for military-appropriate sleep practices and novel interventions to mitigate sleep disturbances and chronic sleep disorders in this population.

Chronic use of tramadol after acute pain episode: cohort study

ObjectiveTo determine the risk of prolonged opioid use in patients receiving tramadol compared with other short acting opioids.DesignObservational study of administrative claims data.SettingUnited States commercial and Medicare Advantage insurance claims...

Abstract 270: Patients With Acute Ischemic Stroke and Associated Diagnosis of Obstructive Sleep Apnea Have Lower In-hospital Mortality

Background: Obstructive sleep apnea (OSA) is present in almost 60% of patients with cerebrovascular disease and it is an independent predictor of ischemic stroke. Yet, the impact of OSA on outcomes of ischemic stroke is unclear. Some, small cohort studies indicate increased short-term mortality, whereas larger studies, with more complex logistic regression models, show decreased in-hospital mortality. Lower mortality could be attributed to chronic intermittent episodes of hypoxia affecting the remodeling of cerebral collateral circulation. We thought to investigate outcomes in a large unselected population of patients presenting with acute ischemic stroke. Methods: In a retrospective cohort study, using the 2014 Nationwide Inpatient Sample (NIS), we analyzed adult patients with acute ischemic stroke and OSA. We performed univariate analysis of age, sex, race, hospital location, hospital teaching status, insurance type, hospital bed size, Charlson Comorbidity Index and other relevant comorbidities and we included variables with p&lt;0.2 in the multivariate logistic regression model. Results: A total of 95282 patients with acute ischemic stroke were identified. Patients with the associated diagnosis of OSA (5%) had a mean age of 66+/_0.2, vs 71+/_0.1, p&lt;0.001 and a higher percentage of them were male (63% vs 48%, p&lt;0.001). Patients with OSA were more likely to have hypertension (88% vs 83%, p&lt;0.001), heart failure (24% vs 14%, p&lt;0.001), chronic kidney disease (20% vs 14%, p&lt;0.001) ESRD (3% vs 2%, p&lt;0.001) and diabetes mellites (40% vs 30%, p&lt;0.001). Patients with associated diagnosis of OSA had higher incidence of ventricular fibrillation and ventricular tachycardia (OR=1.27, 95%CI=1.02-1.58, p=0.27) with no difference in incidence of cardiac arrest (OR=1.14, 95%CI=0.78-1.66, p=0.50) and lower in-hospital mortality (OR=0.68, 95%CI =0.57-0.82, p&lt;0.001). They were less likely to have hemiplegia (OR= 0.83, 95% CI=0.74-0.95, p=0.004) and less likely to receive a blood product transfusion (OR =0.71, 95%CI =0.54-0.93, p&lt;0.014). There was no difference in utilization of percutaneous endoscopic gastrostomy (OR=0.90, 95%CI=75-1.07, p=0.23), incidence of shock (OR=1.13, 95% CI =0.66-1.90, p=0.66) and utilization of mechanical ventilation (OR=0.96, 95%CI =0.82-1.11, p=0.55) as well as in length of stay (Coef. =-0.039, 95% CI=-0.23—0.16, p=0.70) and total costs of hospitalization (Coef. =180.73, 95% CI= -1925-2287, p=0.87). Conclusion: Patients with OSA and ischemic stroke have a higher number of cardiovascular comorbidities. After adjustment with a complex multivariate regression model in a large population of patients, they have lower in-hospital mortality and lower incidence of hemiplegia. We also uncovered underdiagnosing of obstructive sleep apnea in National Inpatient Sample registry, which is a limitation of the study.

Nearthrosis in true long-standing temporomandibular joint dislocation; a report on pathogenesis and clinical features with review of literature

The behavior and function of the condyle are not the same in every type of temporomandibular joint (TMJ) dislocation. Acute displacement or dislocation of the condyle is not a rare incident, and the treatment modalities have been well known by physicians for a long time. Chronic dislocation of the condyle is considered a relatively common entity for which treatment may indispensably be surgical intervention. Type of dislocation, duration and the number of episodes are taken into account while constructing the treatment plan.Chronic dislocation that has been left untreated for a long time is a relatively less often encountered type exhibiting difficult clinical conditions for treatment. This type of dislocation is usually seen in elderly patients with poor general health conditions and can be classified as “long-standing dislocation.” In this clinical condition, after having some chronic dislocation episodes, the condyle leaves the original fossa, sits in the anterior part of the eminence permanently, creates a new fossa and never gets back to the original place again. Duration is the most important criterion in classifying long-standing dislocations and has a great effect on decisions regarding the type of management. The relevant literature includes few reports, most of which speculate upon “duration,” which varies on a large scale ranging from 5 weeks to 33 years. There has been neither an agreement on time span within which long-standing dislocation develops, nor a universally accepted definition for what “long-standing” is indeed meant to be. On the other hand, in some cases, the condition has been named “true long-standing dislocation” due to some permanent pathological changes that the TMJ undergoes, such as pseudoarticulation/nearthrosis/false joint/neo-joint.In this paper, management of true long-standing/permanent dislocation in two patients, whose conditions lasted more than 1 year and resulted in permanent changes in TMJ anatomy, is presented. Due to the poor general health condition of the two elderly patients, they were treated in the most conservative way possible. In one of the patients, eminectomy and head-gear application were used to attain gradual relocation of the condyles. Rehabilitation of masticatory function of the other patient was improved prosthetically.

Hypoxic changes to the urothelium as a bystander of end-stage bladder disease

Urothelial cells harvested from benign diseased bladders have a compromised capacity to propagate or differentiate invitro, potentially limiting their application in autologous tissue engineering approaches. The causative pathways behind this altered phenotype are unknown. The hypothesis is that hypoxic damage to the urothelium occurs as a bystander to chronic or recurrent episodes of infection and inflammation. The aim of this study was to assess immunohistochemically detected nuclear hypoxia-inducible factor 1 alpha (HIF-1α) and vascular endothelial growth factor in the urothelium when exposed to hypoxia. Human bladder sections from a total of 29 adult and paediatric patients, representing a variety of different pathologies including neuropathy (n=15), were analysed. Tissues from adults with bladder outlet obstruction secondary to prostatic disease (n=1), urothelial carcinoma (n=1) and tonsil (n=1) were used as positive tissue controls for immunohistochemistry. Hypoxia-inducible factor 1 alpha-labelled sections were scanned using a Zeiss AxioScan Z1 slide scanner. Analysis of urothelial nuclear HIF-1α labelling was performed using HistoQuest image analysis software (TissueGnostics). Comparison of nuclear HIF-1α labelling between neuropathic and non-neuropathic sections was performed using one-way analysis of variance with the post hoc Tukey honestly significant difference (HSD) test. Patient urodynamic studies performed before tissue sample harvest were evaluated and correlated to the HIF-1α intensity using Spearman's rank correlation. Hypoxia-inducible factor 1 alpha appeared more intense in the urothelial compartment from neuropathic bladder samples (n=15) than in the control tissues, including non-obstructedsamples (n=9). Image analysis supported this; median nuclear HIF-1α labelling was 29.98±3.10 (standard deviation [SD]) (n=9) in controls and 74.29±7.55 (SD) in neuropathic samples (n=15). A statistically significant difference between the control and neuropathic tissue groups was shown (P<0.05). Of the 15 neuropathic samples, 11 had traceable urodynamic studies. Both initial and maximum detrusor pressures indicated a positive relationship when plotted against HIF-1α labelling. Spearman's rank correlation, with no missing events, confirmed significant correlations between both initial or maximum detrusor pressure and nuclear HIF-1α labelling intensity (median score); P≤0.046 and P≤0.05, respectively. The null hypothesis was accordingly rejected. This study indicates that urothelial nuclear HIF-1α may be a biomarker of hypoxia and a common feature in end-stage bladder disease associated with high-pressure systems.

Catastrophic health expenditure of Vietnamese patients with gallstone diseases - a case for health insurance policy revaluation.

PurposeDespite gallstone diseases (GSDs) being a major public health concern with both acute and chronic episodes, none of the studies in Vietnam has been conducted to investigate the household expenditure for the GSD treatment. The objective of this study was to estimate the costs of managing GSD and to explore the prevalence and determinants of catastrophic health expenditure (CHE) among Vietnamese patients.Materials and methodsA cross-sectional study was conducted from June 2016 to March 2017 in the Department of Hepatobiliary and Pancreatic Surgery, Viet Duc Hospital in Hanoi, Vietnam. A total of 206 patients were enrolled. Demographic and socioeconomic data, household income, and direct and indirect medical costs of patients seeking treatment for GSD were collected through face-to-face interview. Multivariate logistic regression was used to explore factors associated with CHE.ResultsThe prevalence of CHE in patients suffering from GSD was 35%. The percentage of patients who were covered by health insurance and at risk for CHE was 41.2%, significantly higher than that of those noninsured (15.8%). Proportions of patients with and without health insurance who sought outpatient treatment were 30.6% and 81.6%, respectively. Patients who were divorced or widowed and had intrahepatic gallstones were significantly more likely to experience CHE. Those who were outpatients, were women, had history of pharmacological treatment to parasitic infection, and belong to middle and highest monthly household income quantile were significantly less likely to experience CHE.ConclusionThe findings suggested that efforts to re-evaluate health insurance reimbursement capacity, especially for acute diseases and taking into account the varying preferences of people with different disease severity, should be conducted by health authority. Further studies concerning CHE of GSD in the context of ongoing health policy reform should consider utilizing WHO-recommended measures like the fairness in financial contribution index, as well as taking into consideration the behavioral aspects of health care spending.

Uveitis Presented as a Case of Ocular Syphilis – A Rare Presentation

Ocular syphilis is one of the clinical presentation or complication of syphilis. Uveitis is the most common ocular diagnosis of the condition but any component of the eyes can be affected. Serology test that include both treponemal and non-treponemal antibody detections play an important role for supporting the diagnosis. This condition is considered as part of neurosyphilis and the recommended treatment follows the treatment for neurosyphilis.&#x0D; We reported a 47-year-old man presented with chronic episode of blurring of vision associated with floaters involving both eyes. Both eyes showed abnormal visual acuity with involvement of optic disc on the left eye. Serology tests for non-treponemal antibody and treponemal antibody test were positive. He was diagnosed as a case of bilateral posterior uveitis with left eye neuroretinitis. He was successfully treated with intravenous aqueous crystalline penicillin 3 million unit every four hour daily for 14 days.&#x0D; J MEDICINE JUL 2019; 20 (1) : 52-54

A Rural Community based study on Morbidity, Health care Utilization and Health Expenditure in Tarakeswar Block, Hoogly District, West Bengal

Background: Rural community based recent study on morbidity, health care utilization and health expenditure is a rarity in India especially in West Bengal. Objectives: To find out the morbidity pattern, health care utilization and health expenditure in rural area of Tarakeswar block, Hoogly district, West Bengal. Methods: House to house survey of 720 families (total 2759 persons) from rural area of Tarakeswar block, Hoogly district, West Bengal, selected by 30 cluster sampling technique during 2013-14 with help of a predesigned pre-tested schedule by post-graduate students with one month recall. Results: Total 650 persons (23.6%) suffered from 728 monthly episodes (263.8/1000) of illnesses, more acute (147/1000) than chronic (117/1000), significantly more among males (279.9/1000) than females (246/1000). Major types of illnesses were Gastrointestinal (5.8%), cardiovascular (4.9%), respiratory (4.2%) and musculoskeletal (2.3%) including non-specific fevers (2.6%). These were primarily managed by government facilities (71.5%) and govt. doctors (66.1%) of allopathic system (93.4%). Total health expenditure (out of pocket) was 3.1% of their income, with INR 211.3 per acute illness episode and INR 84.6 per chronic illness episode. Treatment was major component both for acute (62%) and chronic (83%) illness expenditures; however, wage loss was considerable for acute illnesses (27%). These expenditures were significantly associated with social class and education (p=0.000...). Health insurance was practically nil (0.51%).Conclusions: There was considerable morbidity and out of pocket expenditure on health by study population. Proper implementation of any health insurance is absolutely essential.

Posttransplant Erythrocytosis Among Egyptian Living-Donor Kidney Transplant Recipients.

The goal when treating patients with end-stage renal disease is to increase patient survival and to provide a better quality of life, both of which can be achieved by kidney transplant. Identifying problems associated with kidney transplant is an essential step toward improved graft function. Here, we evaluated posttransplant erythrocytosis, a frequent complication among kidney transplant recipients. In this single-center retro-spective study, we identified 1850 kidney transplant recipients who were transplanted at the Mansoura Urology and Nephrology Center (Mansoura University, Mansoura, Egypt) from 1990 and 2013. From these patients, we identified 174 transplant recipients with posttransplant erythrocytosis and another 174 recipients without posttransplant erythrocytosis (control group). All recipients were evaluated retrospectively regarding incidence and risk factors for posttransplant erythrocytosis occurrence, graft function and survival, and patient survival. Both patient groups were comparable regarding age and sex (mean age of 32 years and higher percentage of male recipients in both groups). Degree of HLA class I and class II matching was not significantly different between groups. There were also no significant differences in immunosuppression protocols, although most patients were on steroid and cyclosporine therapy. Prevalence of acute and chronic rejection episodes was comparable between groups. Graft function was better in the posttransplant erythrocytosis group than in the control group, and higher patient survival was noted in patients with posttransplant erythrocytosis (P < .001). Posttransplant erythrocytosis was correlated with good graft function. In our study patients, those with posttransplant erythrocytosis had better graft and patient survival.