Contemporary Clinical Guidelines Research Articles

Comparative Analysis of Barium Enema and Computed Tomography Colonography

Background: Large bowel lesions present a diagnostic challenge, with both benign polyps and colorectal cancer requiring accurate identification for effective treatment. Traditional diagnostic methods, notably barium enema (BE), have been hampered by limitations in sensitivity and patient comfort. This necessitates a critical evaluation of more advanced methods, such as computed tomography colonography (CTC), to improve diagnostic outcomes. Objective: This review narrative aimed to (i) conduct a thorough comparative analysis of BE and CTC, specifically concentrating on their diagnostic efficacy, patient experiences, and versatility in diverse clinical settings and (ii) provide clinicians with in-depth insights and actionable recommendations, aimed at enhancing the strategies for imaging and diagnosing large bowel lesions, as well as aiding in the effective setup and planning of diagnostic services. Methods: We conducted an exhaustive literature review across multiple databases including PubMed, MEDLINE, EMBASE, and the Cochrane Library. The selection criteria focused on studies that directly compared BE and CTC. We examined aspects such as diagnostic accuracy, patient experiences during the procedures, and their economic impact on healthcare systems. Results: The findings indicate a marked superiority of CTC over BE in terms of diagnostic sensitivity and specificity, particularly in polyp detection. CTC is shown to be more patient-centric, offering enhanced comfort and suitability, especially for vulnerable groups like the elderly and patients with conditions like renal insufficiency. Furthermore, the integration of CTC with ongoing technological advancements and adherence to contemporary clinical guidelines highlights its pivotal role in current preventive healthcare strategies. The application of CTC presents substantial benefits for long-term patient safety and demonstrates cost-effectiveness, making it a preferential choice for adoption in the radiology departments of new healthcare institutions. Conclusion: CTC stands out as a superior diagnostic tool for large bowel lesions, surpassing BE in effectiveness, patient comfort, and economic viability. It is in harmony with modern healthcare practices and is particularly advantageous in settings with ample resources. This review strongly supports a shift towards CTC in clinical settings, to enhance the quality of patient care and outcomes in the detection and management of colorectal lesions.

Comparison of attitudes and beliefs of physical therapists and primary care physicians regarding low back pain management: A cross-sectional study.

BACKGROUND: The first-line contact for patients seeking care for low back pain (LBP) can potentially change the disease course. The beliefs and attitudes of healthcare providers (HCPs) can influence LBP management. Although referring patients with LBP to physical therapy is common, the first-line contact for patients with LBP in Saudi Arabia is the primary care physician (PCP). Physical therapy will soon be integrated into primary care; therefore, it is rational to compare physical therapists’ (PTs) beliefs and attitudes regarding LBP with those of PCPs.OBJECTIVE: We compared PCPs’ and PTs’ attitudes and beliefs regarding LBP management.METHODS: We employed a cross-sectional, voluntary response sample research design using the Pain Attitudes and Beliefs Scale (PABS). Participants were PTs and PCPs practicing in Saudi Arabia.RESULTS:In total, 153 participants completed the PABS (111 PTs and 52 PCPs). PCPs demonstrated significantly higher PABS biomedical subscale scores than did the PTs.CONCLUSIONS: HCPs in Saudi Arabia should receive additional training to adopt a biopsychosocial approach to managing LBP. In this study, the HCPs’ treatment recommendations may not correspond with contemporary clinical guidelines. Research to facilitate the implementation of optimal professional education and training to adopt a biopsychosocial approach is an urgent priority.

Costs of Diabetes Mellitus and Its Complications in Bosnia and Herzegovina.

Background:The economic burden induced by all types of Diabetes mellitus (DM) and their complications has reached 1.8% of gross domestic product (GDP) globally. The economic burden of diabetes mellitus in Bosnia & Herzegovina (B&H) is still unknown.Objective:To investigate the economic burden of diabetes in Bosnia and Herzegovina, including the costs of diagnosing and treating diabetes and its complications.Methods:The study was designed as a top-down cost of illness study, based on prevalence, analyzing both direct and indirect costs of DM and complications caused by DM. All types of DM were taken into account, and estimates were based on total B&H population. Costs of services per patient were calculated by multiplication of share of treated population, service utilization data and unit costs. Results:Annual economic burden associated with DM in B&H is around 189 million euro (739 euro per patient), which makes 1.11% of gross domestic product (GDP) of B&H in 2020 (16,993,101,523 euro, according to the World Bank data). The largest part of this burden was created by DM medication and costs of managing complications (heart failure and stable angina being major cost drivers among the complications), followed by laboratory tests and physician visits.Conclusion:Total costs of DM per patient in B&H are within the range of costs in other Central-Eastern European (CEE) countries, reflecting significant economic burden, but also determination of healthcare payers in B&H to provide optimal management of DM in congruence with contemporary clinical guidelines

Прогностическая роль циркулирующего N-терминального фрагмента промозгового натрийуретического пептида у пациентов после лечения множественной миеломы

Целью настоящего исследования было выявление прогностической значимости циркулирующего N-терминального фрагмента промозгового натрийуретического пептида (NT-pro-МНУП) в возникновении кардиоваскулярных событий у пациентов после лечения множественной миеломы. Материалы и методы. В исследование были включены 89 пациентов после лечения множественной миеломы, период наблюдения составил 12 месяцев. Забор плазмы крови производился для определения уровня циркулирующего NT-pro-МНУП с помощью иммуносорбентного метода. Результаты. Было зафиксировано 92 кардиоваскулярных события у 36 пациентов (40,5 %): 8 смертей вследствие кардиоваскулярной причины, 46 кардиальных аритмий, 6 кардиальных ишемических событий, 2 инсульта, 8 случаев возникновения хронической сердечной недостаточности, 22 госпитализации, связанные с кардиоваскулярными причинами. Медиана циркулирующего NT-pro-МНУП у пациентов без кардиоваскулярных событий составила 5,68 пг/мл (95% ДИ — 2,74–11,51 пг/мл), у пациентов с кардиоваскулярными событиями — 23,87 пг/мл (95% ДИ 8,22–31,84 пг/мл) (р = 0,06). Мультивариантный регрессионный анализ показал, что циркулирующий NT-pro-МНУП является независимым прогностическим фактором возникновения кардиоваскулярных событий (отношение шансов OШ = 1,06; 95% ДИ 1,03–1,17; р < 0,01) на протяжении 1 года. В то же время наличие сахарного диабета, артериальной гипертензии, ожирения не показало прогностической значимости. Выводы. Установлено, что среди пациентов после лечения множественной миеломы с достижением ремиссии повышение содержания циркулирующего NT-pro-МНУП может ассоциироваться с увеличением числа кумулятивных кардиоваскулярных событий в течение 1 года.

Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn.

Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..

Costs of Diabetes Mellitus and Its Complications in Bosnia and Herzegovina

Background: The economic burden induced by all types of Diabetes mellitus (DM) and their complications has reached 1.8% of gross domestic product (GDP) globally. The economic burden of diabetes mellitus in Bosnia & Herzegovina (B and H) is still unknown. Objective: To investigate the economic burden of diabetes in Bosnia and Herzegovina, including the costs of diagnosing and treating diabetes and its complications. Methods: The study was designed as a top-down cost of illness study, based on prevalence, analyzing both direct and indirect costs of DM and complications caused by DM. All types of DM were taken into account, and estimates were based on total B and H population. Costs of services per patient were calculated by multiplication of share of treated population, service utilization data and unit costs. Results: Annual economic burden associated with DM in B and H is around 189 million euro (739 euro per patient), which makes 1.11% of gross domestic product (GDP) of B and H in 2020 (16,993,101,523 euro, according to the World Bank data). The largest part of this burden was created by DM medication and costs of managing complications (heart failure and stable angina being major cost drivers among the complications), followed by laboratory tests and physician visits. Conclusion: Total costs of DM per patient in B and H are within the range of costs in other Central-Eastern European (CEE) countries, reflecting significant economic burden, but also determination of healthcare payers in B and H to provide optimal management of DM in congruence with contemporary clinical guidelines.

Current Status of Immune Checkpoint Inhibitor Immunotherapy for Lung Cancer.

Immunotherapy is a major breakthrough in the treatment of cancer in recent years. Immune checkpoint inhibitors (ICIs) including programmed death-ligand 1 (PD-L1)/programmed death-1 (PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4) have been used for different histologic types of cancer including primary lung cancer that represents the most common and fatal cancer globally. Among ICI immunotherapy agents, atezolizumab, durvalumab, ipilimumab, nivolumab, and pembrolizumab are currently used as standard-of-care (SOC) treatment for metastatic or earlier stages of lung cancer. Major issues of ICI immunotherapy in lung cancer comprise the use of immune biomarkers prior to ICI therapy, selection of ICI agents, combination of ICIs/chemotherapy, combination of ICIs/radiotherapy, sequence of tyrosine kinase inhibitor (TKI) targeted therapy and ICI immunotherapy, sequence of chemotherapy and ICI immunotherapy, treatment duration of ICI regimen and ICI therapy for different histopathology, stage, PD-L1, and performance status. Based on the contemporary major clinical trials and authoritative guidelines, the objective of this review is to present an overview of the current status of ICI immunotherapy in lung cancer.

Cardiovascular Benefits of Angiotensin-Converting Enzyme Inhibition Plus Calcium Channel Blockade in Patients Achieving Tight Blood Pressure Control and With Resistant Hypertension.

The 2017 hypertension guidelines lowered systolic blood pressure (BP) goals to <130 mm Hg and redefined resistant hypertension. We investigated if these changes alter the cardiovascular benefits demonstrated by combining a calcium channel blocker (CCB), rather than hydrochlorothiazide (HCTZ), with an angiotensin-converting enzyme inhibitor (ACEI). In this post hoc analysis of the Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension trial (n = 11,506), we compared the primary composite outcome (cardiovascular death, myocardial infarction, stroke, hospitalization for angina, resuscitation after sudden cardiac death, and coronary revascularization) between the 2 combination-treatment limbs in patients achieving a systolic BP ≤130 mm Hg and those with "apparent resistant hypertension" (prescribed ≥4 antihypertensive medications). Among study patients, 5,221 (45.4%) achieved a systolic BP ≤130 mm Hg. There were fewer primary endpoints in the amlodipine/benazepril (9.2%) vs. the HCTZ/benazepril (10.9%) limb (adjusted hazard ratio [HR] 0.83, 95% confidence interval [CI], 0.70-0.99). There were also fewer primary endpoints in the amlodipine/benazepril (12.8%) vs. the HCTZ/benazepril (15.2%) limb (n = 4,451, 38.7%) among patients with apparent resistant hypertension (HR 0.81, 95% CI, 0.70-0.95). Combination therapy adding a CCB, rather than HCTZ, to an ACEI was more effective in preventing composite cardiovascular events even in hypertensive patients achieving aggressive systolic BP targets as well as in those with apparent resistant hypertension. Our findings add support that most patients, including those following contemporary clinical guidelines, will benefit from this combination. Trial Number NCT00170950.

Reductions in Cardiac Structure and Function 24 Months After Spinal Cord Injury

Smaller heart structures and reduced cardiac function are documented in cross‐sectional comparisons of individuals with spinal cord injury (SCI) and age/weight matched able bodied controls. The smaller heart structures and reduced function may result from progressive cardiac atrophy similar to that observed with diminished physical activity, extended periods of bed rest, and space flight. It is unknown if there is progressive cardiac atrophy in the months following SCI. Additionally, slightly larger hearts and greater retention of function are found in individuals with thoracic compared to cervical injuries, suggesting that the level of spinal injury may differentially affect reductions in heart structure and function after SCI. Therefore, the purpose of this research was to 1) quantify cardiac structure and function of individuals within the first 24 months after injury, 2) identify the relationship between cardiac structure and function and time since injury, and 3) examine injury level’s effect on heart structure/function and time since injury. A cross‐sectional assessment of cardiac structure and function was made using transthoracic echocardiography (Vivid‐Q; GE Healthcare) on twenty‐nine (4F) volunteers who were 3‐ to 24‐months post‐injury. Myocardial structure and function were assessed using 2D, speckle‐tracking, and tissue Doppler in accordance with contemporary clinical echocardiographic guidelines. Heart rate and blood pressures were assessed simultaneously using a combination of a standard lead II electrocardiogram (ECG) and brachial oscillometric blood pressure monitor (Dash 5000 patient monitor, GE). The relationship between cardiac structure/function and time since injury were analyzed using linear regression. Neurological and sensory level of injury were entered into the model as covariates to determine whether or not the relationships differed with time since injury. Time since injury was most strongly associated with a reduction in left ventricular end‐diastolic volume (Δ= −2.07±0.70 ml·mo−1, r2=0.266, p=0.007), end‐systolic volume (Δ= −1.05±0.38 ml·mo−1, r2=0.237, p=0.012), and left ventricular mass (Δ= −3.0 ± 1.2 g·mo−1, r2=0.192, p=0.018). These changes in left ventricular structure were paralleled by a reduced stroke volume (Δ= −1.03±0.50 ml·mo−1, r2=0.154 p=0.048) and cardiac output (Δ= −0.12±0.04 L·min−1·mo−1, r2=0.322, p=0.002). There were no significant associations of blood pressures, wall thickness, or measures of diastolic function with time since injury (p&gt;0.050). The reductions in left ventricular structure and systolic function were not differentially affected by neurological or sensory level of injury (p= 0.412–0.973). These results suggest there are gradual reductions in left ventricular structure and systolic function over the 24 months following spinal cord injury which are not affected by the neurological or sensory level of injury. Although there is loss of left ventricular structure and function, blood pressure appears maintained suggesting peripheral compensatory adjustments. This information indicates that cardiac rehabilitation interventions should occur relatively soon after spinal cord injury to mitigate cardiac atrophy.Support or Funding InformationFunded by NIH Grant (R01‐HL‐117037) and The Spaulding Research Institute Leadership Catalyst

Going Beyond the Guidelines in Individualising the Use of Antihypertensive Drugs in Older Patients.

Hypertension is commonly diagnosed in older patients, with increasing cardiovascular (CV) risk as systolic blood pressure (BP) increases. Maximising CV risk reduction must be reconciled with minimising the risk of treatment-related harms and burden, especially among frail, multi-morbid and older old patients who have been excluded from most randomised trials. Contemporary clinical guidelines, based on such trials, differ in their recommendations as to threshold levels warranting treatment with antihypertensive drugs (AHDs) and target levels that should be achieved. In optimising AHD prescribing in older patients, we propose the following decision framework: decide therapeutic goals in accordance with patient characteristics and preferences; estimate absolute CV risk; measure and profile BP accurately in ways that account for lability in BP levels and minimise error in BP measurement; determine threshold and target BP levels likely to confer net benefit, taking into account age, co-morbidities, frailty and cognitive function; and consider situations that warrant AHD deprescribing on the basis of potential current or future harm. In applying this framework to older persons, and based on a review of relevant randomised trials and observational studies, individuals most likely to benefit from treating systolic BP to no less than 130mmHg are those of any age who are fit and have high baseline systolic BP (≥160mmHg); high CV risk, i.e. established CV disease or risk of CV events exceeding 20% at 10years; previous stroke or transient ischaemic attack; heart failure; and stage 3-4 chronic kidney disease with proteinuria. Individuals most likely to be harmed from treating BP to target systolic <140mmHg are those who have no CV disease and aged over 80years; moderate to severe frailty, cognitive impairment or functional limitations; labile BP and/or history of orthostatic hypotension, syncope and falls; or life expectancy < 12months. Treatment should never be so intense as to reduce diastolic BP to < 60mmHg in any older person. At a time when guidelines are calling for less conservative management of hypertension in all age groups, we contend that a more temperate approach, such as that offered here and based on the totality of available evidence, may assist in maximising net benefit in older patients.

PHARMACOLOGICAL CARDIAC PROTECTION: WHAT IS NEW?

The lecture is devoted to the current state of pharmacological cardiac protection in patients with a high cardiac risk undergoing non-cardiac and cardiac surgery with cardiopulmonary bypass. It describes the main etiopathogenetic mechanisms of ischemic reperfusion myocardial damage. The possible cardioprotection mechanisms when using inhalation anesthetics, β-adrenoreceptor blocking agents, calcium channel blockers, statins, nitrates, α2 -agonists, ACE inhibitors and sartans, levosimendan, phosphocreatine, and glucose-insulin-potassium mixture are analyzed. New research data are reviewed, including recent meta-analyses and extensive randomized studies aimed to assess the efficacy of the above medicines. It presents contemporary clinical guidelines on the use of pharmacological cardioprotection in various clinical situations. It has been concluded that the range of drugs recommended for cardioprotection is constantly changing in accordance with latest data, and updating the scientific information on this issue is an important to improve the professional competence of anesthesiologists and emergency physicians.

Providing quality care for women with vasa praevia: Challenges and barriers faced by Australian midwives

ObjectiveTo explore the barriers to providing quality maternity care for women with vasa praevia as identified by Australian midwives. DesignA qualitative descriptive study using semi-structured in-depth telephone interviews. SettingAustralian maternity system. MethodsMidwives were recruited from across Australia. Interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. ParticipantsTwenty midwives from five Australian states practising in 15 different public or private hospitals who had cared for at least one woman with vasa praevia during 2010–2016 were interviewed. More than half of the participants held senior positions. Twelve were involved in a neonatal death or ‘near-miss’ due to vasa praevia. FindingsTwo categories and five themes were identified in relation to barriers to the provision of quality care. Practitioner-level barriers included two themes: identifying lack of midwifery education and lack of knowledge. System-level barriers included lack of a local policy to guide practice, limited information for women, and paucity of research about vasa praevia. ConclusionMidwives experienced a number of barriers in caring for women with vasa praevia. Offering more comprehensive pre-registration and continuing professional education to midwives, developing local protocols, and providing clear written information for women may improve the provision of quality care. Implications for practiceMidwives have a critical role in caring for and supporting women with vasa praevia. Improving midwives’ knowledge with contemporary evidence and clinical guidelines could enable them to deliver safer maternity care and improve a women's journey through this potentially catastrophic condition.

Timing of intervention in aortic stenosis: a review of current and future strategies

### Learning objectives Aortic stenosis (AS) is the most common valve disease requiring surgical intervention in high-income countries.1 It is characterised by progressive thickening, fibrosis and calcification of the leaflets...

Rates and Risk Factors for Arterial Ischemic Stroke Recurrence in Children.

Recurrent ischemic events are common in children with arterial ischemic stroke (AIS) and put patients at risk for further neurological impairment. This study sought to identify rates and risk factors for recurrent AIS or transient ischemic attack in a cohort of children seen after index AIS and uniformly investigated and managed using contemporary clinical guidelines. Case note and radiology review of children >28 days and <18 years of age who presented to Great Ormond Street Hospital from 2005 to 2015 with index AIS. Demographic characteristics, medical history, index AIS features, radiological findings, and neurological outcome were examined. Recurrence was identified from clinical records and coded as AIS (if there was associated new cerebral infarction) or transient ischemic attack. Eighty-four children (43 girls; median age at index AIS, 4.1 years) were identified. Cumulative AIS recurrence was 5% at 1 month, 10% at 3 months, 12% at 6 months, 12% at 12 months, and 15% at 60 months after index event. Factors that independently predicted AIS recurrence were referral to Great Ormond Street Hospital from outside the catchment area, a prior relevant diagnosis, bilateral arteriopathy, and AIS CASCADE category 3A or 3B (Childhood AIS Standardized Classification and Diagnostic Evaluation). Multiple infarcts and evidence of mature, as well as acute, infarcts on first brain imaging, although independently associated with AIS recurrence, were also associated with bilateral arteriopathy. Only CASCADE categories 3A and 3B (bilateral cerebral arteriopathy with or without collaterals) remained significant in multivariate analysis. AIS recurrence was not associated with poor neurological outcome. AIS recurrence remains a significant problem, despite the wide use of antithrombotic medications. AIS subtypes should direct clinicians and future trials to use stratified management strategies and durations of treatment. Bilateral cerebral arteriopathies are especially sinister, and consensus criteria should be developed to improve consistency of management.

Tumor Volume on Biopsy of Low Risk Prostate Cancer Managed with Active Surveillance

Contemporary clinical guidelines recommend active surveillance of men with low risk prostate cancer. Low risk disease spans any potential volume of Gleason score 6 cancer without sufficient attention to tumor volume in the past. Therefore, we compared tumor characteristics in men at low risk on active surveillance to men treated with radical prostatectomy. We evaluated an institutional cohort of 1,633 men with very low risk disease (clinical stage T1c, prostate specific antigen density less than 0.15 ng/ml/cm3, 2 or more positive cores and 50% or greater core involvement) and low risk disease (clinical stage T2a or less, prostate specific antigen less than 10 ng/ml and Gleason score 6 or less). Among patients at low risk we calculated the proportion who failed to meet very low risk volume criteria (greater than 2 positive cores or greater than 50% core involvement). Clinical and pathological metrics in the active surveillance cohort were compared to those in a cohort of men at low risk who underwent radical prostatectomy in the current era of 2011 to 2016. In the active surveillance cohort 1,119 men (69%) met very low risk criteria and 514 (31%) had low risk disease. In the low risk population only 138 men (27%) harbored higher volume cancer exceeding very low risk criteria compared to 815 (82%) at low risk who underwent radical prostatectomy (p<0.001). Overall the low risk active surveillance population had fewer positive biopsy cores (median 1 vs 3, p <0.001) and a lower maximum percent of core involvement (median 10% vs 40%, p <0.001) compared to patients at low risk who underwent radical prostatectomy. Data supporting the safety of active surveillance in men at low risk at our institution were derived from a distinct subgroup harboring a limited cancer volume. Until acceptable outcomes are confirmed for higher volume tumors it is important to remain mindful of these limitations before broadly recommending active surveillance to all low risk men.

Physiotherapy management of knee osteoarthritis in Nigeria-A survey of self-reported treatment preferences.

Background:knee osteoarthritis (OA) is a prevalent condition. Little is known about whether treatments provided by physiotherapists to patients with knee OA in Nigeria follow recommended clinical practice guidelines.Objective:The aims of this study were to investigate Nigerian physiotherapists' treatment preferences for knee osteoarthritis (OA) and to evaluate if their preferences were in line with contemporary clinical practice guidelines and recommendations.Methods:A cross-sectional survey of 267 physiotherapists from various health institutions in Nigeria were surveyed, using a structured questionnaire incorporating a clinical vignette on knee OA.Results:Based on the clinical vignette, the majority of the respondents (68.2%) recommended review of x-rays as part of the diagnostic process for knee OA. Thermotherapy was the most utilized modality (86.1%), followed by therapeutic exercise (81.3%). Only 11.1% of the physiotherapists used therapeutic exercise alone. Manual therapy in conjunction with other modalities was the choice for 18% of the physiotherapists. Only 49.1% of the physiotherapists reported including advice on weight control and up to 39% reported bed rest as part of the treatment approach.Conclusion:There was a poor consensus among the physiotherapists in Nigeria on how knee OA is managed compared with contemporary clinical guidelines and recommendations which emphasized application of core modalities, such as therapeutic exercises, patients' education, and weight control over passive modalities. Some areas of practice are in line with contemporary guidelines, while some were in conflict with evidence-based practice.

The Association of Subclinical Hypothyroidism and Pattern of Circulating Endothelial-Derived Microparticles Among Chronic Heart Failure Patients.

Background:Subclinical hypothyroidism (SH) is diagnosed biochemically by the presence of normal serum free thyroxine concentration, in conjunction with an elevated serum thyroid-stimulating hormone level. Recent studies have demonstrated the frequent association between SH and cardiovascular diseases and risk factors.Objectives:To evaluate the impact of SH on patterns of circulating endothelial-derived microparticles, (EMPs) among chronic heart failure (CHF) patientsPatients and Methods:This is a retrospective study involving a cohort of 388 patients with CHF. Fifty-three CHF subjects had SH and 335 patients were free from thyroid dysfunction. Circulating levels of N-terminal-pro brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), thyroid-stimulating hormone (TSH), total and free thyroxine (T4), and triiodothyronine (T3), and endothelial apoptotic microparticles (EMPs), were measured at baseline. SH was defined, according to contemporary clinical guidelines, as a biochemical state associated with an elevated serum TSH level of greater 10 μU/L and normal basal free T3 and T4 concentrations.Results:Circulating CD31+/annexin V+ EMPs were higher in patients with SH compared to those without SH. In contrast, activated CD62E+ EMP numbers were not significantly different between both patient cohorts. Using uni (bi) variate and multivariate age- and gender-adjusted regression analysis, we found several predictors that affected the increase of the CD31+/annexin V+ to CD62E+ ratio in the patient study population. The independent impact of TSH per 6.5 μU/L (odds ratio [OR] = 1.23, P = 0.001), SH (OR = 1.22, P = 0.001), NT-proBNP (OR = 1.19, P = 0.001), NYHA class (OR = 1.09, P = 0.001), hs-CRP per 4.50 mg/L (OR = 1.05, P = 0.001), dyslipidemia (OR = 1.06, P = 0.001), serum uric acid per 9.5 mmol/L (OR = 1.04, P = 0.022) on the increase in the CD31+/annexin V+ to CD62E+ ratio, was determined.Conclusions:We believe that the SH state in CHF patients may be associated with the impaired pattern of circulating EMPs, with the predominantly increased number of apoptotic-derived microparticles.

Sleeping through the night: A community survey of parents' opinions about and expectations of infant sleep consolidation

This study examined parents' expectations of and opinions about infant sleep consolidation, the temporal timing and definitions of sleeping through the night and sources of advice about their infant's sleep. Participants were 412 parents (mean age 31 years ±6.8) with a child 2 years or younger recruited at shopping malls and other public places. Parents completed a brief survey on (i) the nocturnal duration they considered an infant should sustain uninterrupted sleep; (ii) a temporal location within the night for a criterion for sleeping through the night; (iii) their agreement or disagreement with Moore and Ucko's (1957) 24:00-05:00 h criterion defining sleeping through the night; and (iv) the sources of advice they had sought about infant's sleep. Parents expected infants to sustain sleep on average for 9.6 ± 3.4 h, with trends indicating the more children in the family (P = 0.02; d = 0.26) and lower family socio-economic status (P = 0.01; d = 0.34) the shorter the durations expected. Sleeping through the night was defined within a temporal location from 20:00 to 06:30 h. Over 80% of parents disagreed that 24:00-05:00 h criterion defined sleeping through the night. Forty-seven per cent of parents had sought advice regarding their infants' sleep, with Child Health Care Nurses the most popular source. New Zealand parents have realistic expectations of infant capabilities for sleep consolidation that were within contemporary clinical guidelines. A new parent-based definition of sleeping through the night is presented that has social and developmental validity.

Disease‐specific knowledge and clinical skills required by community‐based physiotherapists to co‐manage patients with rheumatoid arthritis

While strong evidence supports the role of physiotherapy in the co-management of patients with rheumatoid arthritis (RA), it remains unclear what constitutes the essential disease-specific knowledge and clinical skills required by community-based physiotherapists to effectively and safely deliver recommended care. This study aimed to identify essential disease-specific knowledge and skills, link these with evidence from clinical guidelines, and broadly determine the professional development (PD) needs and confidence related to the management of RA among physiotherapists. An international Delphi panel of rheumatologists, physiotherapists, and consumers (n = 27) identified essential disease-specific knowledge and clinical skills over 3 rounds. Physiotherapy-relevant recommendations from high-quality, contemporary clinical guidelines were linked to Delphi responses. Finally, an e-survey of PD needs among registered physiotherapists (n = 285) was undertaken. Overarching themes identified by the Delphi panel across the RA disease stages included the need for excellent communication, the importance of a multidisciplinary team and early referral, adoption of chronic disease management principles, and disease monitoring. Of the essential Delphi themes, 86.7% aligned with clinical guideline recommendations. Up to 77.5% of physiotherapists reported not being confident in managing patients with RA. Across the range of essential knowledge and skills themes, 45.1-93.5% and 71.1-95.2% of respondents, respectively, indicated they would benefit from or definitely need PD. To effectively manage RA, community-based physiotherapists require excellent communication skills and disease-specific knowledge, including understanding the role of the multidisciplinary team and the principles of early referral, chronic disease management, and monitoring. Physiotherapists identified a need for PD to develop these skills.

Evaluating percutaneous support for cardiogenic shock: data shock and sticker shock

Cardiogenic shock, a state of systemic hypoperfusion resulting from cardiovascular dysfunction, is the leading cause of death in patients with ST-elevation myocardial infarction (STEMI).1 In spite of tremendous advances in cardiovascular care over the past two decades, mortality rates for patients with cardiogenic shock remain quite high, with some estimates as high as 50%.2 Given the underlying pathophysiology of cardiogenic shock, most commonly attributed to left ventricular failure resulting from STEMI, prompt institution of mechanical circulatory support seems intuitively important. The intra-aortic balloon pump (IABP) counterpulsation device was first introduced in the 1960s and has gained widespread acceptance as the device of choice for most patients with cardiogenic shock. Registry data suggest that cardiogenic shock is one of the most common conditions for which IABPs are used, accounting for 20% of all insertions.3 In fact, the ESC and ACC/AHA guidelines on STEMI strongly endorse the placement of an IABP in patients with cardiogenic shock refractory to pharmacological therapy.4,5 However, the evidence base from which these recommendations emanate is limited. There are no large randomized controlled trials which have rigorously evaluated the impact of IABPs in cardiogenic shock. Observational data from the Should We Emergently Revascularize Occluded Coronary Arteries in Shock (SHOCK) trial registry as well as the National Registry of Myocardial Infarction (NRMI)-2 suggest that patients treated with an IABP in addition to thrombolytics had lower in-hospital mortality than those receiving thrombolytics alone.6,7 Notably, patients undergoing primary percutaneous coronary intervention (PCI) in NRMI-2 did not benefit from IABP placement. A recent systematic review of >10 000 patients with cardiogenic shock in the setting of acute myocardial infarction (AMI) published in the European Heart Journal presented similar findings and concluded by challenging contemporary clinical guidelines.8 One of the theoretical shortcomings of … *Corresponding author. Tel: +1 857 203 6840/6841, Fax: +1 857 203 5550, Email: dlbhattmd{at}alum.mit.edu