Management Of At-risk Individuals Research Articles

Characterization of individuals with atherosclerotic cardiovascular disease, with and without chronic kidney disease: results from a UK electronic health record database

Abstract Introduction Elevated C-reactive protein (CRP) levels are often present in individuals with atherosclerotic cardiovascular disease (ASCVD), including in those who also have chronic kidney disease (CKD), and are associated with an increased risk of major adverse cardiovascular events (MACE). To understand unmet needs in the identification and management of at-risk individuals, we characterized patients with ASCVD in a UK database, according to CKD stage and CRP levels. Methods This study comprised separate retrospective cross-sectional and longitudinal cohort analyses of patients in the Clinical Practice Research Datalink (CPRD) Aurum database, a representative UK database of anonymized primary care records. In the cross-sectional analysis, CPRD Aurum was linked with Hospital Episode Statistics (HES) and Index of Multiple Deprivation data to assess patient characteristics on 1 Jan 2021 (defined as index date). In the cohort analysis, CPRD Aurum was linked with HES and Office for National Statistics mortality data to determine the incidence of 3-point MACE (3P-MACE) over approximately 5 years of follow-up (index date: 1 Jan 2016). Both analyses included individuals ≥ 18 years old with an ASCVD diagnosis in both primary and secondary care in the 5 years pre-index. Data were analysed using descriptive statistics. Patient characteristics were assessed by CKD stage; for individuals with CKD stage 3–4, characteristics were also assessed by CRP levels. Results In total, 225,767 and 230,055 individuals were included in the cross-sectional and cohort analyses, respectively. The prevalence of CKD stage 3–4 among individuals with ASCVD was 24.3% (Table 1). The proportion of individuals with elevated CRP (CRP ≥ 2 mg/L) and anaemia increased for successively higher CKD severity groups; in addition, glycated haemoglobin (HbA1c) ≥ 7% and elevated blood pressure were generally more frequently observed in individuals with CKD than in those without (Table 1). Individuals with ASCVD, CKD stage 3–4 and elevated CRP had higher HbA1c and total cholesterol levels and a greater proportion had obesity, anaemia and elevated blood pressure, compared with individuals with CRP < 2 mg/L (Table 2). Over 5 years’ follow-up, the incidence of 3P-MACE increased with CKD severity (Table 1) and with increasing CRP levels in individuals with ASCVD and CKD stage 3–4 (Table 2). However, only 28% of individuals with ASCVD and CKD stage 3–4 had CRP measurements. Conclusion Adults with ASCVD, CKD and elevated CRP identified from primary and secondary UK care records had a higher disease burden than individuals with CRP levels < 2 mg/L. In the UK, testing CRP levels is not routinely recommended, resulting in a high proportion of missing CRP measurements in this study. Routine testing of CRP may help in identifying patients with residual cardiovascular risk and has the potential to support risk assessment and management of patients with ASCVD and CKD.

Early life predictors of obstructive sleep apnoea in young adults: Insights from a longitudinal community cohort (Raine study)

ObjectiveEarly-life obstructive sleep apnoea (OSA) predictors are unavailable for young adults. This study identifies early-life factors predisposing young adults to OSA. MethodsThis retrospective study included 923 young adults and their mothers from the Western Australian Pregnancy Raine Study Cohort. OSA at 22 years was determined from in-laboratory polysomnography. Logistic regression was used to identify maternal and neonatal factors associated with OSA in young adulthood. ResultsOSA was observed in 20.8% (192) participants. Maternal predictors of OSA included gestational diabetes mellitus (odds ratio (OR) 9.54, 95% confidence interval (CI) 1.7, 58.5, P = 0.011), preterm delivery (OR 3.18, 95%CI 1.1,10.5, P = 0.043), preeclampsia (OR 2.95, 95%CI 1.1,8.0, P = 0.034), premature rupture of membranes (OR 2.46, 95%CI 1.2, 5.2, P = 0.015), age ≥35 years (OR 2.28, 95%CI 1.2,4.4, P = 0.011), overweight and obesity (pregnancy BMI≥25 kg/m2) (OR 2.00, 95%CI 1.2,3.2, P = 0.004), pregnancy-induced hypertension (OR 1.89, 95%CI 1.1,3.2, P = 0.019), and Chinese ethnicity (OR 2.36,95%CI 1.01,5.5, P = 0.047). Neonatal predictors included male child (OR 2.10, 95%CI 1.5,3.0, P < 0.0001), presence of meconium-stained liquor during delivery (OR 1.60, 95%CI 1.0,2.5, P = 0.044) and admission to special care nursery (OR 1.51 95%CI 1.0,2.2, P = 0.040). Higher birth lengths reduced OSA odds by 7% for each centimetre (OR 0.93, 95%CI 0.87, 0.99, P = 0.033). ConclusionsA range of maternal and neonatal factors predict OSA in young adults, including those related to poor maternal metabolic health, high-risk pregnancy and stressful perinatal events. This information could assist in the early identification and management of at-risk individuals and indicates that better maternal health may reduce the likelihood of young adults developing OSA.

Self-confidence and knowledge of suicide assessment and prevention amongst first-line health professionals in Nelson Mandela Bay, South Africa.

BackgroundFirst-line health professionals are uniquely positioned to recognise suicidal behaviours in patients. However, the opportunities are often missed or poorly managed. Self-confidence and knowledge of suicide prevention and assessment by health professionals can lead to prompt recognition and management of at-risk individuals. This study evaluates the first-line health professionals’ self-confidence and knowledge of suicide assessment in Nelson Mandela Bay Municipality (NMBM), South Africa.MethodsA cross-sectional study was conducted in six healthcare facilities across NMBM between January 2020 and March 2020. Five hundred first-line healthcare professionals were recruited to respond to a validated self-administered questionnaire to collect demographic characteristics, self-confidence levels and knowledge of suicide assessment and associated factors.ResultsA total of 344 first-line health professionals completed the questionnaire (68.8% response rate); 40% of the respondents work in emergency units and 77.3% reported frequent encounters with patients who attempted suicide. Most participants had not received suicide assessment training during their undergraduate or postgraduate years (59.6% and 81.1%, respectively). They also lacked adequate knowledge and self-confidence in suicide assessment. Younger age, minimal work experience and attendance of two or more hours of suicide prevention training were associated with higher knowledge of suicide assessment.ConclusionFindings revealed gaps in self-confidence and knowledge of suicide management, attributed to lack of training in suicide management. Health authorities should prioritise upskilling of front-line workers in suicide prevention and assessment, specifically targeting older nurses in the region.

Plasma 24-metabolite Panel Predicts Preclinical Transition to Clinical Stages of Alzheimer's Disease.

We recently documented plasma lipid dysregulation in preclinical late-onset Alzheimer’s disease (LOAD). A 10 plasma lipid panel, predicted phenoconversion and provided 90% sensitivity and 85% specificity in differentiating an at-risk group from those that would remain cognitively intact. Despite these encouraging results, low positive predictive values limit the clinical usefulness of this panel as a screening tool in subjects aged 70–80 years or younger. In this report, we re-examine our metabolomic data, analyzing baseline plasma specimens from our group of phenoconverters (n = 28) and a matched set of cognitively normal subjects (n = 73), and discover and internally validate a panel of 24 plasma metabolites. The new panel provides a classifier with receiver operating characteristic area under the curve for the discovery and internal validation cohort of 1.0 and 0.995 (95% confidence intervals of 1.0–1.0, and 0.981–1.0), respectively. Twenty-two of the 24 metabolites were significantly dysregulated lipids. While positive and negative predictive values were improved compared to our 10-lipid panel, low positive predictive values provide a reality check on the utility of such biomarkers in this age group (or younger). Through inclusion of additional significantly dysregulated analyte species, our new biomarker panel provides greater accuracy in our cohort but remains limited by predictive power. Unfortunately, the novel metabolite panel alone may not provide improvement in counseling and management of at-risk individuals but may further improve selection of subjects for LOAD secondary prevention trials. We expect that external validation will remain challenging due to our stringent study design, especially compared with more diverse subject cohorts. We do anticipate, however, external validation of reduced plasma lipid species as a predictor of phenoconversion to either prodromal or manifest LOAD.

A cross-sectional survey assessing the acceptability and feasibility of self-report electronic data collection about health risks from patients attending an Aboriginal Community Controlled Health Service.

BackgroundAboriginal Australians experience significantly worse health and a higher burden of chronic disease than non-Aboriginal Australians. Electronic self-report data collection is a systematic means of collecting data about health risk factors which could help to overcome screening barriers and assist in the provision of preventive health care. Yet this approach has not been tested in an Aboriginal health care setting. Therefore, the aim of this study was to examine the acceptability and feasibility of a health risk questionnaire administered on a touch screen laptop computer for patients attending an Aboriginal Community Controlled Health Service (ACCHS).MethodsIn 2012, consecutive adult patients attending an ACCHS in rural New South Wales, Australia, were asked to complete a health risk survey on a touch screen computer. Health risk factors assessed in the questionnaire included smoking status, body mass index, and level of physical activity. The questionnaire included visual cues to improve accuracy and minimise literacy barriers and was completed while participants were waiting for their appointment.ResultsA total of 188 participants completed the questionnaire, with a consent rate of 71%. The mean time taken to complete the questionnaire was less than 12 minutes. Over 90% of participants agreed that: the questionnaire instructions were easy to follow; the touch screen computer was easy to use; they had enough privacy; the questions were easy to understand; they felt comfortable answering all the questions.ConclusionsResults indicate that the use of a touch screen questionnaire to collect information from patients about health risk factors affecting Aboriginal Australians is feasible and acceptable in the ACCHS setting. This approach has potential to improve identification and management of at-risk individuals, therein providing significant opportunities to reduce the burden of disease among Aboriginal Australians.

Hereditary cancer risk assessment: essential tools for a better approach

Hereditary cancer risk assessment (HCRA) is a multidisciplinary process of estimating probabilities of germline mutations in cancer susceptibility genes and assessing empiric risks of cancer, based on personal and family history. It includes genetic counseling, testing and management of at-risk individuals so that they can make well-informed choices about cancer surveillance, surgical treatment and chemopreventive measures, including biomolecular cancer therapies. Providing patients and family members with an appropriate HCRA will contribute to a better process of making decisions about their personal and family risks of cancer. Following individuals at high risk through screening protocols, reassuring those at low risk, and referring those at increased risk of hereditary cancer to a cancer genetics center may be the best suitable approach of HCRA.

The shortened Örebro Musculoskeletal Screening Questionnaire: Evaluation in a work-injured population

The Örebro Musculoskeletal Screening Questionnaire (ÖMSQ) is a recently validated, 21-item instrument. It modified the original Örebro Musculoskeletal Pain Questionnaire (ÖMPainQ) providing broader focus and also improved development and practicality for identifying work-injured patients at-risk of persistent musculoskeletal problems. These instruments are critiqued for practicality and a shortened-version recommended. A 10-item ÖMPainQ was previously proposed for low-back-pain; however, general musculoskeletal populations require a broader validated instrument. To provide this, a two-stage retrospective study was performed. Stage 1 used three phases to: determined a minimum 12-item tool was required to ensure internal consistency (α > 0.70); subsequently developed two shortened ÖMSQ-12 versions from qualitative content-retention and quantitative factor analysis reductive methodologies; then calibrated both versions in a spine-cohort. Stage 2 validated and compared both versions' clinimetric properties in a general musculoskeletal-cohort to ascertain which was most appropriate. The ÖMPainQ-10 and a randomly-created ÖMPainQ-10 were compared post-hoc for criterion validity and factor structure. A physical therapy outpatients convenience sample (n = 279) was divided into developmental (spine = 136) and calibration (musculoskeletal = 143) cohorts. Primary outcomes were functional status, insurer-reported absenteeism and costs at six months. The qualitative-ÖMSQ-12 demonstrated preferred properties with higher 21-item-ÖMSQ correlation (r = 0.97; quantitative-ÖMSQ-12: r = 0.94; ÖMPainQ-10: r = 0.92; ÖMPainQ-10-random: r = 0.94) and improved predictive ability cut-offs for high-risk (72 ÖMSQ-12 points, 60%) and low-risk (57 ÖMSQ-12 points, 48%). The ÖMSQ-12 content-retention version is recommended. It demonstrated suitable internal consistency, a three-factor structure and high correlation with recovery time (r = 0.73). The ÖMSQ-12 will facilitate early identification and management of at-risk individuals and enable targeted intervention strategies through psychosocial informed management principles.

Hereditary Cancer Risk Assessment: How Best can we Achieve it?

Hereditary cancer risk assessment (HCRA) is a multidisciplinary process of estimating probabilities of germline mutations in cancer susceptibility genes and assessing empiric risks of cancer, based on personal and family histories. It includes genetic testing and management of at-risk individuals so that they can make informed choices about cancer screening, surgical and chemo preventive options, as well as genetically targeted cancer therapies. Providing patients with pre- and post-test genetic counseling may help them to get better informed decision making.Following individuals at increased risk with surveillance protocols, reassuring those at low risk, and referring those at high risk of a hereditary cancer to a cancer genetics center with outpatient clinics may be the best suitable approach to HCRA.

Familial Dilated Cardiomyopathy Associated with Congenital Defects in the Setting of a Novel VCL Mutation (Lys815Arg) in Conjunction with a Known MYPBC3 Variant

Idiopathic dilated cardiomyopathy (DCM) is a primary myocardial disorder characterized by ventricular chamber enlargement and systolic dysfunction. Twenty to fifty percent of idiopathic DCM cases are thought to have a genetic cause. Of more than 30 genes known to be associated with DCM, rare variants in the VCL and MYBPC3 genes have been reported in several cases of DCM. In this report, we describe a family with DCM and congenital abnormalities who carry a novel missense mutation in the VCL gene. More severely affected family members also possess a second missense variant in MYBPC3, raising the possibility that this variant may be a disease modifier. Interestingly, many of the affected individuals also have congenital defects, including two with bicuspid aortic valve with aortic regurgitation. We discuss the implications of the family history and genetic information on management of at-risk individuals with aortic regurgitation.

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The Örebro Musculoskeletal Screening Questionnaire (ÖMSQ) is a recently validated, 21-item instrument. It modified the original Örebro Musculoskeletal Pain Questionnaire (ÖMPainQ) providing broader focus and also improved development and practicality for identifying work-injured patients at-risk of persistent musculoskeletal problems. These instruments are critiqued for practicality and a shortened-version recommended. A 10-item ÖMPainQ was previously proposed for low-back-pain; however, general musculoskeletal populations require a broader validated instrument. To provide this, a two-stage retrospective study was performed. Stage 1 used three phases to: determined a minimum 12-item tool was required to ensure internal consistency (α > 0.70); subsequently developed two shortened ÖMSQ-12 versions from qualitative content-retention and quantitative factor analysis reductive methodologies; then calibrated both versions in a spine-cohort. Stage 2 validated and compared both versions' clinimetric properties in a general musculoskeletal-cohort to ascertain which was most appropriate. The ÖMPainQ-10 and a randomly-created ÖMPainQ-10 were compared post-hoc for criterion validity and factor structure. A physical therapy outpatients convenience sample (n = 279) was divided into developmental (spine = 136) and calibration (musculoskeletal = 143) cohorts. Primary outcomes were functional status, insurer-reported absenteeism and costs at six months. The qualitative-ÖMSQ-12 demonstrated preferred properties with higher 21-item-ÖMSQ correlation (r = 0.97; quantitative-ÖMSQ-12: r = 0.94; ÖMPainQ-10: r = 0.92; ÖMPainQ-10-random: r = 0.94) and improved predictive ability cut-offs for high-risk (72 ÖMSQ-12 points, 60%) and low-risk (57 ÖMSQ-12 points, 48%). The ÖMSQ-12 content-retention version is recommended. It demonstrated suitable internal consistency, a three-factor structure and high correlation with recovery time (r = 0.73). The ÖMSQ-12 will facilitate early identification and management of at-risk individuals and enable targeted intervention strategies through psychosocial informed management principles.