Special Clinical Settings Research Articles

2024 Chinese Expert Consensus Guidelines on the Diagnosis and Treatment of Atrial Fibrillation in the Elderly, Endorsed by Geriatric Society of Chinese Medical Association (Cardiovascular Group) and Chinese Society of Geriatric Health Medicine (Cardiovascular Branch): Executive Summary.

The consensus guidelines of the Geriatric Society of Chinese Medical Association on the management of atrial fibrillation (AF) in the elderly was first published in 2011 and updated in 2016, with endorsement by Chinese Society of Geriatric Health Medicine. Since then, many important studies regarding the screening and treatment in the elderly population have been reported, necessitating this updated expert consensus guideline. The writing committee members comprehensively reviewed updated evidence pertaining to elderly patients with AF, and formulated this 2024 update. The highlighted issues focused on the following: screening for AF, geriatric comprehensive assessment, use of the Atrial fibrillation Better Care (ABC) pathway for the elderly patients, and special clinical settings related to elderly patients with AF. New recommendations addressing smart technology facilitated AF screening, ABC pathway based management, and optimal anticoagulation were developed, with a focus on the elderly.

Understanding adaptive responses in PrEP service delivery in Belgian HIV clinics: a multiple case study using an implementation science framework.

In Belgium, oral HIV pre-exposure prophylaxis (PrEP) is primarily provided in specialized clinical settings. Optimal implementation of PrEP services can help to substantially reduce HIV transmission. However, insights into implementation processes, and their complex interactions with local context, are limited. This study examined factors that influence providers' adaptive responses in the implementation of PrEP services in Belgian HIV clinics. We conducted a qualitative multiple case study on PrEP care implementation in eight HIV clinics. Thirty-six semi-structured interviews were conducted between January 2021 and May 2022 with a purposive sample of PrEP care providers (e.g. physicians, nurses, psychologists), supplemented by 50 hours of observations of healthcare settings and clinical interactions. Field notes from observations and verbatim interview transcripts were thematically analysed guided by a refined iteration of extended Normalisation Process Theory. Implementing PrEP care in a centralized service delivery system required considerable adaptive capacity of providers to balance the increasing workload with an adequate response to PrEP users' individual care needs. As a result, clinic structures were re-organized to allow for more efficient PrEP care processes, compatible with other clinic-level priorities. Providers adapted clinical and policy norms on PrEP care (e.g. related to PrEP prescribing practices and which providers can deliver PrEP services), to flexibly tailor care to individual clients' situations. Interprofessional relationships were reconfigured in line with organizational and clinical adaptations; these included task-shifting from physicians to nurses, leading them to become increasingly trained and specialized in PrEP care. As nurse involvement grew, they adopted a crucial role in responding to PrEP users' non-medical needs (e.g. providing psychosocial support). Moreover, clinicians' growing collaboration with sexologists and psychologists, and interactions with PrEP users' family physician, became crucial in addressing complex psychosocial needs of PrEP clients, while also alleviating the burden of care on busy HIV clinics. Our study in Belgian HIV clinics reveals that the implementation of PrEP care presents a complex-multifaceted-undertaking that requires substantial adaptive work to ensure seamless integration within existing health services. To optimize integration in different settings, policies and guidelines governing PrEP care implementation should allow for sufficient flexibility and tailoring according to respective local health systems.

Proposal of a diagnostic algorithm for radiation-induced dropped head syndrome in long-term childhood cancer survivors based on a prospective study in a specialized clinical setting and a review of the literature

PurposeTo prospectively assess the incidence of Dropped Head Syndrome (DHS) in childhood cancer survivors (CCS) and to develop and evaluate a diagnostic algorithm for DHS.MethodsA systematic literature search for DHS in combination with neck radiotherapy (RT) exposure was performed. Analyses and a combination of the most common examination methods were integrated into a diagnostic algorithm. Almost all CCSs visiting the local late effects clinic between May 2020 and April 2022 were included in the study. CCS exposed to neck RT with doses ≥ 19 Gy received standardized clinical and neurological assessment and, in case of abnormal results, an MRI scan to confirm muscle atrophy.ResultsTwo hundred and five CCS were included of whom 41 received RT to the neck with ≥ 19 Gy. In the entire cohort and in the subgroup receiving RT, 2.4% and 12% of CCS were affected by DHS, respectively. Results of clinical and neurological assessment correlated well with MRI results. Neck circumference and neck/thigh ratio were lower after neck RT. Over 50% of CCS experienced neck disability and pain.ConclusionsA relevant proportion of CCS exposed to neck RT is affected by DHS. High concordance of MRI results with the neurological examination supports the clinical value of the diagnostic algorithm. Measurement of neck circumference might be an easy tool for assessment of neck muscle atrophy in survivors at risk.Implications for cancer survivorsIntegration of a diagnostic algorithm for DHS in standard long-term follow-up care facilitates diagnosis as well as initiation of early treatment and obviates the need for invasive examinations.

EEGAlzheimer’sNet: Development of transformer-based attention long short term memory network for detecting Alzheimer disease using EEG signal

A previous diagnosis of Alzheimer's disease (AD) in its initial stages is needed for patient care because it helps patients adopt preventative measures before irreversible brain damage occurs. Several studies have used computers to detect AD, although hereditary results limit most computer detection methods. There is no straightforward method to screen for AD, partly because the condition is difficult to diagnose and sometimes requires costly and occasionally intrusive testing that is uncommon outside of highly specialized clinical settings. Therefore, this study implements a deep learning strategy for detecting AD with the help of the “Electroencephalogram (EEG)” signal. Initially, the required EEG signal is obtained from traditional online databases and then applied to the 3-level “Lifting Wavelet Transform (LWT)” decomposition to decompose the signal into many wavelets. From the decomposed signal, the temporal features are retrieved by a “Recurrent Neural Network (RNN)”, and the spatial features are extracted from a “Multi-scale dilated Convolutional Neural Network (CNN)”. Further, the Enhanced Wild Geese Lemurs Optimizer (EWGLO) algorithm is implemented to find the optimal weight value for acquiring the weighted stacked features. These resultant weighted stacked features are applied to the semi-detection stage, where the “Optimized Transformer-based Attention Long Short Term Memory (OTA-LSTM)” model is utilized to detect AD. In the detection stage, parameter optimization takes place to increase the performance of the detection process using the same EWGLO. The designed model is validated with various performance metrics to show the effective outcome. Moreover, the developed model attains 96% and 98% in terms of accuracy and MCC. Throughout the validation, the offered model shows enriched performance when compared with other-state-of-art methods.

The clinical utility of rapid exome sequencing in a consanguineous population

BackgroundThe clinical utility of exome sequencing is now well documented. Rapid exome sequencing (RES) is more resource-intensive than regular exome sequencing and is typically employed in specialized clinical settings wherein urgent molecular diagnosis is thought to influence acute management. Studies on the clinical utility of RES have been largely limited to outbred populations.MethodsHere, we describe our experience with rapid exome sequencing (RES) in a highly consanguineous population. Clinical settings included intensive care units, prenatal cases approaching the legal cutoff for termination, and urgent transplant decisions.ResultsA positive molecular finding (a pathogenic or likely pathogenic variant that explains the phenotype) was observed in 80 of 189 cases (42%), while 15 (8%) and 94 (50%) received ambiguous (variant of uncertain significance (VUS)) and negative results, respectively. The consanguineous nature of the study population gave us an opportunity to observe highly unusual and severe phenotypic expressions of previously reported genes. Clinical utility was observed in nearly all (79/80) cases with positive molecular findings and included management decisions, prognostication, and reproductive counseling. Reproductive counseling is a particularly important utility in this population where the overwhelming majority (86%) of identified variants are autosomal recessive, which are more actionable in this regard than the de novo variants typically reported by RES elsewhere. Indeed, our cost-effectiveness analysis shows compelling cost savings in the study population. ConclusionsThis work expands the diversity of environments in which RES has a demonstrable clinical utility.

Translating measurement into practice: Brazilian norms for the Patient Health Questionnaire (PHQ-9) for assessing depressive symptoms.

To provide practical norms for measuring depressive symptoms using the Patient Health Questionnaire 9 (PHQ-9) in Brazil using a state-of-art psychometrics analysis. We used a large and representative Brazilian dataset from the 'Pesquisa Nacional de Saúde - 2019'(PNS-2019), which includes 90,846 Brazilian citizens. First, to assess the scale structure, we assessed the unidimensional model using Confirmatory Factor Analysis (CFA). Second, we used Item Response Theory (IRT) to characterize depressive symptoms´ distribution. Then, we linked summed- and meanbased PHQ-9 scores with the IRT-based score by using generalized additive models. Finally, we generated percentiles, T scores, and a newly developed score, called D scores (decimal scores), to describe the PHQ-9 norms for Brazilian population. CFA revealed a good fit to the unidimensional model, showing to be invariant to age and sex. IRT captured item-level information of the latent trait (reliable from 1 to 3 standard deviations above the mean). Brazilian norms were presented using summed-, T-scores, and D-scores. This is the first study to define Brazilian´s norms for the PHQ-9 among a large representative sample, using robust psychometric tools. More precise PHQ-9 scores are now available and may be widely used in primary and specialized clinical care settings.

Artificial Intelligence-Enabled End-To-End Detection and Assessment of Alzheimer's Disease Using Voice.

There is currently no simple, widely available screening method for Alzheimer's disease (AD), partly because the diagnosis of AD is complex and typically involves expensive and sometimes invasive tests not commonly available outside highly specialized clinical settings. Here, we developed an artificial intelligence (AI)-powered end-to-end system to detect AD and predict its severity directly from voice recordings. At the core of our system is the pre-trained data2vec model, the first high-performance self-supervised algorithm that works for speech, vision, and text. Our model was internally evaluated on the ADReSSo (Alzheimer's Dementia Recognition through Spontaneous Speech only) dataset containing voice recordings of subjects describing the Cookie Theft picture, and externally validated on a test dataset from DementiaBank. The AI model can detect AD with average area under the curve (AUC) of 0.846 and 0.835 on held-out and external test set, respectively. The model was well-calibrated (Hosmer-Lemeshow goodness-of-fit p-value = 0.9616). Moreover, the model can reliably predict the subject's cognitive testing score solely based on raw voice recordings. Our study demonstrates the feasibility of using the AI-powered end-to-end model for early AD diagnosis and severity prediction directly based on voice, showing its potential for screening Alzheimer's disease in a community setting.

Which biomarkers for diagnosis and guidance of anti-infection treatment in sepsis?

Die Identifikation eines Biomarkers, der idealerweise eine perfekte Sensitivität und Spezifität mitbringt, um eine Inflammation von einer Infektion zu unterscheiden, ist bis heute nicht gelungen. Seit mehr als 80 Jahren werden immer neue Marker der Gewebs- und Endothelschädigung identifiziert, die jedoch nicht in jeder klinischen Situation eine Infektion sicher identifizieren können und damit eine frühe Initiierung einer Antibiotikatherapie ermöglichen. In dieser Übersicht werden die wichtigsten, etablierten „klassischen“ Biomarker ebenso wie neue, molekularbiologische Ansätze angesprochen und im Hinblick auf spezielle klinische Situationen und die Steuerung einer Antibiotikatherapie beleuchtet. Das Problem der Differenzierung zwischen Infektion und Inflammation ist bis heute nicht gelöst. Anhand eines singulären Biomarkers ist die Entscheidung unsicher zu treffen, ob eine Infektion ursächlich für eine sich aggravierende Situation ist, aber unter bestimmten klinischen Bedingungen kann die Kombination von Biomarkern oder die Einbindung neuer Biomarker eine sinnvolle Ergänzung darstellen. Die Bestimmung verschiedener Biomarker einer Infektion oder Inflammation ist Teil der intensivmedizinischen Routine und wird auch in Zukunft unverzichtbar sein.

Learning to mentalize: Exploring vulnerable parents\u2019 experiences of change during video guidance in an infant mental health clinic

BackgroundInterventions that promote infant mental health face challenges when applied for parents who struggle with psychosocial and psychological burdens. Video-based guidance using the Marte Meo method is used in specialized clinical settings with high-risk families to improve parent-child interaction, parental sensitivity and mentalizing. However, knowledge about the lifeworlds of these parents and their experiences of the therapeutic process during video guidance is limited.AimThis qualitative study explores how parents in an infant mental health outpatient clinic who had difficulties mentalizing and maintaining an emotional connection with their infants experienced the change process during Marte Meo video guidance.MethodsWe identified a strategic sample of parents with difficulties mentalizing and maintaining an emotional connection with their infants through the Parent Development Interview. Twelve parents received video guidance and were afterwards interviewed in-depth. The research interviews were qualitatively analysed via a team-based reflexive thematic analysis.ResultWe identified four themes: a) feeling inadequate or disconnected as a parent; b) discovering the infant as a relating and intentional person; c) becoming more agentic and interconnected; and d) still feeling challenged by personal mental health issues.ConclusionParents described positive changes in their interactions, in mentalizing their infants, the relationship and themselves as parents, in their experiences of self-efficacy and on a representational level. They also described increased confidence and improved coping despite ongoing personal mental health challenges. The findings suggest that video guidance using the Marte Meo method can be a critical intervention for vulnerable parents but should be coordinated with parents’ primary treatments when complex parental mental health issues are involved.

From One Pain to Many: The Emergence of Overlapping Pains in Children and Adolescents.

The objective of this study was to compare children and adolescents with overlapping chronic pains (OCP) to those with single chronic pains (SCP) among youth presenting in specialized clinical settings, in an effort to identify potential risk factors for developing overlapping pains. A total of 1235 youth ages 8 to 18 seen in a tertiary care multidisciplinary pain clinic or a multidisciplinary headache clinic completed self-report measures of pain, disability, psychological functioning and clinical history and characteristics at the time of initial clinic visit. Information was captured in a chronic pain data repository and accessed for the current study. Subsequent pain symptoms developed on average 11.9 months (SD=24.5 mo) after onset of the first pain symptom. Compared with patients with SCP, patients with OCP report more medical comorbidity, more developmental issues, and poorer current sleep and school functioning. They also scored significantly higher than patients with SCP on self-reported functional disability, pain catastrophizing, fear of pain, depression, anxiety, and psychological stress and lower quality of life (all Ps<0.001). In multivariate analysis, variables most strongly associated with presenting with OCP were age (odds ratio [OR]: 1.1, P<0.001), having a clinically significant high functional disability (OR: 1.4, P=0.3), and low quality of life (OR: 2.5, P<0.001). Given their tendency toward more psychological and medical comorbidities, patients with OCP may require more intense and diverse treatment approaches. Some early life experiences may be a risk factor for development of OCP. Longitudinal studies are needed to fully evaluate the heightened risk for OCP associated with some of these factors.

Management of acute disturbance: The intravenous route

IntroductionThe intravenous (IV) is one of the main parenteral routes for drug administration. Rapid onset of action, precise titration, patient-specific dosing and bypass of liver metabolism are a few of its advantages, while hypersensitivity reactions, adverse effects, infection risk and a higher overall cost some of its most debated downsides. Unlike other areas of Medicine, IV has been significantly under-utilized in Psychiatry.ObjectivesThis systematic review analyzed the evidence for effectiveness and safety behind the use of IV medication used for the management of acute disturbance.MethodsAPA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible studies. Studies were included if they used IV medication to treat acute disturbance, in English language, had participants aged &gt;18. The quality of the included studies was assessed using the National Institutes of Health quality checklist.Results17 studies were deemed eligible. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly between each study. Findings showed strong evidence for efficacy and safety of dexmedetomidine, droperidol, midazolam, and olanzapine. These medications displayed a short time to sedation, reduction in agitation levels, or large percentage of patients adequately sedated with a low number of adverse events. Results did not provide enough evidence for the use of IV ketamine, haloperidol, diazepam, lorazepam, and promethazine.ConclusionsThis review supports dexmedetomidine, droperidol, midazolam, and olanzapine as safe and efficacious options for managing acute disturbance via the intravenous route, particularly in special clinical settings where trained staff, optimal monitoring, resuscitation equipment and ventilators are all at hand.

Clinical Utility of Genetic Testing in the Precision Diagnosis and Management of Pediatric Patients with Kidney and Urinary Tract Diseases.

As genetic testing increasingly integrates into the practice of nephrology, our understanding of the basis of many kidney disorders has exponentially increased. Given this, we recently initiated a Renal Genetics Clinic (RGC) at our large, urban children's hospital for patients with kidney disorders. Genetic testing was performed in Clinical Laboratory Improvement Amendments-certified laboratories using single gene testing, multigene panels, chromosomal microarray, or exome sequencing. A total of 192 patients were evaluated in this clinic, with cystic kidney disease (49/192) being the most common reason for referral, followed by congenital anomalies of the kidney and urinary tract (41/192) and hematuria (38/192). Genetic testing was performed for 158 patients, with an overall diagnostic yield of 81 out of 158 (51%). In the 16 out of 81 (20%) of patients who reached a genetic diagnosis, medical or surgical treatment of the patients were affected, and previous clinical diagnoses were changed to more accurate genetic diagnoses in 12 of 81 (15%) patients. Our genetic testing provided an accurate diagnosis for children and, in some cases, led to further diagnoses in seemingly asymptomatic family members and changes to overall medical management. Genetic testing, as facilitated by such a specialized clinical setting, thus appears to have clear utility in the diagnosis and counseling of patients with a wide range of kidney manifestations.

Ten years of non-vitamin K antagonists oral anticoagulants for stroke prevention in atrial fibrillation: is warfarin obsolete?

Currently, four non-vitamin K antagonists oral anticoagulants (NOACs) are available for stroke prevention in atrial fibrillation (AF). These have been in clinical use for up to 10 years now. Besides data of the initial phase III clinical trials, now clinical data, several sub-studies, meta-analyses, and studies in special clinical settings and specific patient populations are available. This review shall give an overview on the history of NOAC development, sum up study data and ‘real-world’ clinical data as well as discuss several special clinical settings like NOAC treatment in patients that require coronary artery stenting or cardioversion (CV). Furthermore, treatment considerations in special patient populations like patients with renal impairment, obesity, or patients requiring NOACs for secondary prevention are discussed. The significance of NOAC treatment will be discussed under consideration of the recently published 2020 ESC/EACTS Guidelines for the diagnosis and management of AF.

Factors predicting outcomes of hepatitis B-related cirrhosis patients with long-term antiviral therapy

Long-term nucleos(t)ide analog (NA) therapy has been shown to improve the survival in patients with HBV-related cirrhosis. The aim of this study was to evaluate the clinical outcomes and factors associated with survival in HBV-related cirrhotic patients receiving long-term NA treatment. A total of 126 HBV-related cirrhosis patients with long-term NA treatment, including 67 compensated cirrhosis and 59 decompensated cirrhosis, were retrospectively enrolled. The effectiveness of treatment, survival and risk factors of mortality were determined. Patients with decompensated cirrhosis had significantly lower baseline serum HBV DNA levels than compensated cirrhotic patients (4.98±1.91 vs. 5.67±1.26 log10 IU/ml, P=0.031). The mean follow-up duration was 84 and 42 months in compensated cirrhotic and decompensated cirrhotic patients (P<0.0001), respectively. The 1, 2 and 3-year cumulative survival rates were significantly higher in compensated cirrhotic patients than those with decompensated cirrhosis (100%, 98.5%, 98.5% vs. 81.2%, 75.6%, 69.5%; P<0.0001). Multivariate analysis for risk factors of mortality in cirrhotic patients showed that older age (hazard ratio: 3.28, 95% CI: 1.25-8.62, P=0.016) and decompensated cirrhosis (hazard ratio: 8.30, 95% CI: 2.45-28.06, P=0.0007) were independently associated with liver-related mortality. A total of 31 patients developed HCC during the follow-up. Among them, 70.9% were at the earlier stages of BCLC system, and 83.8% received potentially curative treatment. Antiviral therapy improves liver function of HBV-related cirrhotic patients and provides a better chance of curative treatment in those with HCC development. Decompensated cirrhosis is a risk factor for liver-related mortality in this special clinical setting.

Beyond therapists: Technology-aided physical MS rehabilitation delivery

In the last decade, rehabilitation technology has been developed, investigated, and entered specialized clinical settings. In this chapter, we first discuss the potential of rehabilitation technology to support the achievement of key factors in motor recovery, such as delivering massed practice with good movement quality but also question task-specificity and cognitive motor control mechanisms. Second, we discuss available technology-supported rehabilitation methods for improving gait, balance and fitness, and upper limb function. Finally, we discuss considerations in relation to the professional workforce in order to deliver optimal rehabilitation.

“Convince Your Patients and You Will Convince Society”: Career Decisions and Professional Identity Among Nurses in India

This article reports on the results of qualitative research to investigate the career plans of Indian nurses working in the southern Indian city of Bangalore. The globalized health care market in Bangalore has generated opportunities for an increasingly diversifying profession, many of whose members are keen to pursue global careers, work in specialized clinical settings, and pursue further education, and whose sense of professional identity is strongly influenced by these career choices. The research drew upon interviews with 56 nurses employed across six sites, including public and private health facilities. Decision-making related to the setting of nursing work and the negotiation of boundaries between medical “treatment” were of analytical interest in understanding career drivers and the professional identity of nurses working predominantly in the context of hospital care. Lateral trajectories were found to be important to the construction of a career in nursing—where the extent to which nurses could demonstrate competencies in clinical skill and knowledge and maintain professional control over the practice of nursing are key aspects in constructing a career. The renegotiation of nursing’s public image is at the heart of professionalizing strategies being adopted by nursing’s leaders and is also evident in the accounts presented by hospital nurses in their depictions of nursing practice and career plans. The findings suggest that greater attention to the professional project of nursing in India and the construction of nursing careers would benefit the development of more responsive human resource policies around the retention of nurses.

Vedolizumab in IBD-Lessons From Real-world Experience; A Systematic Review and Pooled Analysis.

Vedolizumab [VDZ] is an anti-integrin monoclonal antibody effective in ulcerative colitis [UC] and Crohn's disease [CD]. Several real-world experience [RWE] studies with VDZ have been published to date. The aim of this systematic review was to summarise the available real-life experience with VDZ. We performed a systematic review of the available RWE studies of VDZ in CD and UC. We performed a pooled analysis of the available efficacy and safety data for induction and maintenance treatment in adult cohorts. A narrative review of VDZ use in special clinical settings was also performed. Nine studies including 1565 [571 UC, 994 CD] adult patients were identified. In CD, clinical response and remission were achieved in 54% (95% confidence interval [CI] 41-66%) and 22% [95% CI 13-35%] by Week 6 and in 49% [95% CI 37-51%] and 32% [95% CI 23-42%] by Week 14; at Week 52, 45% [95% CI 28-64%] and 32% [95% CI 12-62] of the patients responded, and were in clinical remission, respectively. In UC, clinical response and remission were achieved in 43% [95% CI 37-49] and 25% [95% CI 12-45] by Week 6, respectively, and in 51% [95% CI 43-61%]and 30% [95% CI 24-36%] by Week 14/22, respectively; at week 52, clinical response and remission were achieved in 48% and 39% of the patients, respectively. Adverse effects were mostly minor and occurred in 30.6% of the patients; infections were reported in 3.4% of the patients. VDZ is efficacious in CD and UC and has a favourable safety profile in RWE studies.

Dabigatran - Metabolism, Pharmacologic Properties and Drug Interactions.

The superiority of dabigatran has been well proven in the standard dosing regimen in prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) and extended venous thromboembolism (VTE) treatment. Dabigatran, an anticoagulant with a good safety profile, reduces intracranial bleeding in patients with atrial fibrillation and decreases major and clinically relevant non-major bleeding in acute VTE treatment. However, several important clinical issues are not fully covered by currently available directions with regard to dabigatran administration. The prominent one is reflected in the fact that dynamic impairment in renal function due to dehydratation may lead to haemorragic complications on the one hand, while on the other hand glomerular hyperfiltration may be a possible cause of dabigatran subdosing, hence reducing the drug's efficacy. Furthermore, limitations of the Cockcroft-Gault formula, considered a standard equation for assessing the renal function, may imply that other calculations are likely to obtain more accurate estimates of the kidney function in specific patient populations. Method and Conclusions: Although not routinely recommended, a possibility of monitoring dabigatran in special clinical settings adds to optimization of its dosage regimens, timely perioperative care and administration of urgently demanded thrombolytic therapy, therefore significantly improving this drug's safety profile. Despite the fact that dabigatran has fewer reported interactions with drugs, food constituents, and dietary supplements, certain interactions still remain, requiring considerable caution, notably in elderly, high bleeding risk patients, patients with decreased renal function and those on complex drug regimens. Additionally, upon approval of idarucizumab, an antidote to dabigatran solution, hitherto being a major safety concern, has been finally reached, which plays a vital role in life-threatening bleeding and emergency interventions and surgery.

Cardiorespiratory fitness, muscle strength and risk of cardiovascular outcomes

Physical fitness is associated with lower cardiovascular disease (CVD) mortality, with multiple studies demonstrating a consistent, inverse association between cardiorespiratory fitness (CRF) and mortality even after adjustment for the traditional risk factor burden (1,2). This association has persisted across the lifespan, as a single measurement of CRF in midlife is strongly associated with the lifetime risk for cardiovascular mortality decades later. Cardiorespiratory fitness is associated with a reduced risk of several adverse health outcomes (3-9). Although CRF is recognized as an important marker of both functional ability and cardiovascular health, it is currently one of the most important risk factors that is not routinely and regularly assessed in either the general or specialized clinical setting. The relationship between CRF and other nonfatal cardiovascular outcomes is not well understood, which reflects the limited data on nonfatal cardiovascular events including atrial fibrillation, heart failure (HF) and stroke with objectively measured physical fitness and muscle strength. Much of the focus on the mechanisms of benefit of physical exercise and CRF have focused on prevention of atherosclerosis and its complications, although the specific effects of physical exercise on cardiac and vascular function suggest that low CRF might be an important risk factor for HF and other nonfatal cardiovascular events (10).

Potential Impact of Rapid Blood Culture Testing for Gram-Positive Bacteremia in Japan with the Verigene Gram-Positive Blood Culture Test.

Background. Early detection of Gram-positive bacteremia and timely appropriate antimicrobial therapy are required for decreasing patient mortality. The purpose of our study was to evaluate the performance of the Verigene Gram-positive blood culture assay (BC-GP) in two special healthcare settings and determine the potential impact of rapid blood culture testing for Gram-positive bacteremia within the Japanese healthcare delivery system. Furthermore, the study included simulated blood cultures, which included a library of well-characterized methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) isolates reflecting different geographical regions in Japan. Methods. A total 347 BC-GP assays were performed on clinical and simulated blood cultures. BC-GP results were compared to results obtained by reference methods for genus/species identification and detection of resistance genes using molecular and MALDI-TOF MS methodologies. Results. For identification and detection of resistance genes at two clinical sites and simulated blood cultures, overall concordance of BC-GP with reference methods was 327/347 (94%). The time for identification and antimicrobial resistance detection by BC-GP was significantly shorter compared to routine testing especially at the cardiology hospital, which does not offer clinical microbiology services on weekends and holidays. Conclusion. BC-GP generated accurate identification and detection of resistance markers compared with routine laboratory methods for Gram-positive organisms in specialized clinical settings providing more rapid results than current routine testing.