Specific Clinical Risk Factors Research Articles

Posterior Reversible Encephalopathy Syndrome: A Clinico-Radiological Approach.

Introduction Posterior reversible encephalopathy syndrome (PRES) is a self-limiting neurological condition usually seen in young to middle-aged adults. Although most cases occur in the context of hypertension, PRES is not uncommon in normotensives. PRES is a clinico-radiological diagnosisthat embodies specific clinical features, risk factors, and imaging findings. This study analyzes the clinico-radiological profile, typical and atypical features, and outcomes of patients presenting with PRES. Methodology This prospective observational study spanned 18 months and included 38 patients with suspected PRES who were referred from the neurologydepartment. The patients' brain MRIs were evaluated, andthe affected regions and their signal intensity depicted inthe T1-weighted, T2-weighted, fluid attenuation inversion recovery (FLAIR), and diffusion-weighted images were recorded. The pattern of involvement, atypical findings, and predisposing factors were examined. Results The subcortical white matter of the parieto-occipital lobes was the most typical area affected. The atypical regions affected were the cerebellum, thalamus, brainstem, and basal ganglia. Three cases exhibited isolated involvement of infratentorial structures. Spinal cord involvement was observed in two cases, of which one demonstrated dorsal cord involvement. Conclusion Most lesions are reversible. Long-term follow-up is recommended in hemorrhagic PRES and PRES with spinal cord involvement. Radiologists should be aware of the risk factors, and atypical clinical and imaging features to enable an early diagnosis and prevent further complications.

Cerebral venous thrombosis in elderly patients.

We aimed to report the characteristics of cerebral venous thrombosis (CVT) in elderly people (aged ≥65 years). This multicenter retrospective cohort included elderly patients hospitalized for a first CVT in nine Paris-Ile-de-France hospitals between 2011 and 2021. The estimated incidence was compared to CVT recorded by the French health insurance data system. Lariboisière Hospital's CVT registry allowed comparisons of our elderly cohort with individuals younger than 65 years. One hundred fourteen patients were included in this study (mean age = 74.2 years, range = 65-93, 61% female). The CVT annual incidence in Ile-de-France was 5.9-7.1 per million elderly individuals versus 8.5 per million nationwide. Headaches and focal deficits were the most common initial clinical features (50% and 51%, respectively), followed by seizures and confusion (40% and 27%). Treatment included anticoagulation (93%) and, rarely, endovascular procedure (2%) or craniectomy (1%). Compared with adult patients aged <65 years (younger adults), elderly patients presented fewer headaches (50% vs. 96%, p < 0.01) and intracranial hypertension (7% vs. 22%, p < 0.01) but more seizures and focal deficits (40% vs. 27% and 51% vs. 38%, respectively, p < 0.01). Underlying cancer, hemopathy, and locoregional infections were more frequent in elderly patients than among younger adults (p < 0.01). The prognosis of patients from our elderly cohort was poorer than that of younger adults; 8% died in the acute phase, and 73% had a favorable outcome at 1 year (vs. 1.7% and 87%, respectively, p < 0.01). CVT in elderly patients has a specific clinical presentation, epidemiology, and risk factors such as cancer or hemopathy, justifying specialized management.

Interpretation of Ferritin Concentrations in the Dermatology Clinic.

Ferritin is a commonly measured laboratory test in dermatology. It is a marker of iron storage in the human body but also elevated in inflammatory states. Changes in ferritin are therefore non-specific and correlation of specific clinical findings and risk factors with ferritin concentration and other biomarkers e.g. iron studies or CRP are recommended. The article discusses iron metabolism and the indications for ferritin measurement in dermatology and how to interpret the results.

Precision symptom phenotyping identifies early clinical and proteomic predictors of distinct COVID-19 sequelae.

Post-COVID conditions (PCC) are difficult to characterize, diagnose, predict, and treat due to overlapping symptoms and poorly understood pathology. Identifying inflammatory profiles may improve clinical prognostication and trial endpoints. 1,988 SARS-CoV-2 positive U.S. Military Health System beneficiaries with quantitative post-COVID symptom scores were included in this analysis. Among participants who reported moderate-to-severe symptoms on surveys collected 6-months post-SARS-CoV-2 infection, principal component analysis (PCA) followed by K-means clustering identified distinct clusters of symptoms. Three symptom-based clusters were identified: a sensory cluster (loss of smell and/or taste), a fatigue/difficulty thinking cluster, and a difficulty breathing/exercise intolerance cluster. Individuals within the sensory cluster were all outpatients during their initial COVID-19 presentation. The difficulty breathing cluster had a higher likelihood of obesity and COVID-19 hospitalization compared to those with no/mild symptoms at 6-months post-infection. Multinomial regression linked early post-infection D-dimer and IL-1RA elevation to fatigue/difficulty thinking, and elevated ICAM-1 concentrations to sensory symptoms. We identified three distinct symptom-based PCC phenotypes with specific clinical risk factors and early post-infection inflammatory predictors. With further validation and characterization, this framework may allow more precise classification of PCC cases and potentially improve the diagnosis, prognostication, and treatment of PCC.

A Comprehensive Risk Factor Exploration: Korean Nationwide Cross-Sectional Study of Sarcopenia Obesity in Young-Old Males-Investigating the Prevalence, Somatometric, Biochemical, and Behavioral Traits.

Sarcopenic obesity refers to the coexistence of sarcopenia and obesity. This study assessed the prevalence of and risk factors for sarcopenic obesity in community-dwelling older males in Korea. This cross-sectional study analyzed data from 1060 community-dwelling participants. The participants were screened for sarcopenia and obesity. This study examined various risk factors, composed of somatometric, biochemical, and behavioral traits, including age; height; weight; body mass index; waist circumference; skeletal muscle mass index; fasting glucose, triglycerides, and cholesterol levels; systolic and diastolic blood pressure; and smoking and drinking traits. The prevalence of sarcopenic obesity in men had a weighted value of 9.09% (95% CI: 7.20-11.41). The clinical risk factors included short height, as well as high weight, body mass index, waist circumference, skeletal muscle mass index, triglyceride levels, systolic blood pressure, and diastolic blood pressure. Specific prevalence and clinical risk factors for sarcopenic obesity were found among community-dwelling older men. These findings may be beneficial for primary care clinicians and healthcare professionals for identifying individuals with sarcopenic obesity and referring them for early detection and treatment.

Rational clinical approach to transient ischaemic attack, stroke and associated mimics: A retrospective cohort study.

The present study was performed to identify the individual clinical features and risk factors most strongly associated with the diagnosis of transient neurological symptoms with a cerebrovascular cause (transient ischaemic attack (TIA) or stroke), as compared to common TIA mimics (including retinal ischaemia, migraine and seizure). In a retrospective cohort study, consecutive patients presenting with transient neurological symptoms to TIA clinic in Royal Adelaide Hospital were included. Clinical features and risk factors were recorded in a standardised form, categorised into subgroups, and analysed using descriptive statistics and diagnostic performance indicators, such as sensitivity, specificity and likelihood ratios. For 218/1273 individuals diagnosed with stroke, the three features with the highest positive likelihood ratio were the presence of diffusion weighted imaging positive lesion on magnetic resonance imaging (23.66, 95% confidence interval (CI) 14.35-51.08), extracranial carotid atherosclerosis (3.98, 95% CI 1.19-6.87) and a history of peripheral vascular disease (3.33, 95% CI 1.64-6.27). For TIA, the three features with the highest positive likelihood ratio were extracranial carotid atherosclerosis (3.98, 95% CI 1.19-8.27), presence of atrial fibrillation (2.43, 95% CI 1.54-3.46) and pre-existing anticoagulant therapy (2.39, 95% CI 1.61-3.29). For stroke and TIA, the respective features with the lowest negative likelihood ratios were limb weakness (0.71, 95% CI 0.65-0.77) and hypertension (0.66, 95% CI 0.49-0.84). The present study demonstrated that specific clinical features and risk factors were associated with the final diagnosis at TIA clinic. These clinical features may assist with diagnosis of TIA in centres without access to a vascular neurologist.

Are there specific clinical risk factors for the occurrence of multiple fractures? The FRISBEE study.

To identify clinical risk factors (CRFs) which would specifically increase the risk of multiple fractures. Data of the 3560 postmenopausal women of the FRISBEE study were analysed. The CRFs and the fractures are collected annually. The cohort was divided into three groups: those who had no incident fracture, those who had a single incident fracture and those who had 2 two or more incident fractures (i.e. multiple fractures). Statistical analyses were performed using Cox proportional hazards models. Among the 3560 subjects (followed for 9.1 (7.2-10.6) years), 261 subjects had two or more validated fractures during follow-up (146 were major osteoporotic fractures (MOFs)), 628 had one fracture (435 MOFs), 2671 had no fracture (2979 had no MOF); 157 subjects had two or more central fractures, 389 had only one and 3014 had none. The risk factors for those with multiple fractures at any site were age, history of fracture, history of fall, total hip bone mineral density (BMD), spine BMD and rheumatoid arthritis. For those with multiple MOFs, significant CRFs were age, history of fracture, parental hip fracture, total hip BMD and rheumatoid arthritis. We found in a prospective cohort study that there were more CRFs and higher hazard ratios for the occurrence of multiple fractures than for a single fracture.

Clinical features of glioma patients who develop pneumocystis pneumonia with temozolomide chemoradiotherapy.

The treatment of glioma with temozolomide chemoradiotherapy predisposes patients to pneumocystis pneumonia (PCP). Because PCP is a rare outcome, very little is known about specific clinical risk factors for its development in patients with glioma. We performed a population-based retrospective cohort study of glioma patients undergoing temozolomide chemoradiotherapy 2005 to 2019 in Ontario, Canada. We compared clinical features of patients who did not versus did develop PCP within one year of chemoradiotherapy. We examined the overall survival of patients by PCP status. There were 5130 patients with glioma treated with temozolomide chemoradiotherapy. Ultimately, 38 patients (0.74%) were diagnosed with PCP within 1year of chemoradiotherapy. Most (71%) infections occurred between 0-90days and 29% occurred between 91-365days. Median survival was 12.3months in patients who did not develop PCP and 8.6months in those who did develop PCP (P < 0.001). Trough 90-day lymphocyte counts were lower in the PCP group. When the lymphocytes fell below 0.19 × 109/L (or 0.25 × 109/L among patients without PCP prophylaxis), the risk of PCP was > 3.5%. Pneumocystis pneumonia is rare in glioma patients who receive temozolomide chemoradiotherapy. Infection is associated with shorter survival and the development of lymphopenia. Reserving PCP prophylaxis for patients whose lymphocyte counts drop below 0.25 × 109/L may be a reasonable strategy.

AI models predicting Risk of Cardio Vascular Diseases - The Limitations, Challenges and Necessity for Regulatory Framework

Artificial intelligence (AI) algorithms have changed the landscape of Cardio Vascular Disease (CVD) risk assessment and demonstrated a better performance mainly due to its ability to handle the input nonlinear variations. Further, it has the flexibility to add risk factors derived from medical imaging modalities using Computer Vision (CV). Most commonly used algorithms in CVD risk predications were classification and regression tress (CART).&#x0D; Though most of the developed models have shown good accuracy but have not considered risks factors or dependent variables related to specific population which plays an integral role in predicting the risk of CVDs. This Include gender specific clinical risk factors (hormonal changes, bone density etc.), metrological, chronological data, exposure to environmental pollutants, race, genotype, hereditary, dietary intake, physical inactivity, psychological stress etc. Secondly the existing models have not included the weighing and grading of the risks, as all factors won’t contribute equally to the Cardiac Risk. Importantly predictive models can be readily used within the populations in which they were developed but practically they often give a less than satisfactory performance, when applied to another population because of the Inter genetic variations especially in CVDs.&#x0D; India accounts for one-fifth of these deaths worldwide especially in younger population. The results of Global Burden of Disease study state age-standardized CVD death rate of 272 per 100000 populations in India, which is much higher than that of global average of 225. CVDs strike Indians a decade earlier than the western population. For Indians, particular causes of concern in CVD are early age of onset, rapid progression and high mortality rate. Indians are known to have the highest coronary artery disease (CAD) rates, and the conventional risk factors fail to explain this increased risk.&#x0D; In Indian context, aggressive screening tests should begin at an early age and will be beneficial for early detection and treatment to reduce the mortality. Hence there is necessity to develop upgraded AI models specific to a subset of population (Indian, Caucasoid, Dravidian etc.) inclusive of the risk factors in that specific population. Secondly allotting weighing, grading of risk factors in the model will provide accurate cardiac risk prediction compared to other approaches.&#x0D; The regulatory and policy landscape for AI is an emerging issue in jurisdictions globally, including in the European Union and in supra-national bodies like the IEEE, OECD and others. Since 2016, a wave of AI ethics guidelines has been published in order to maintain social control over the technology.

Role of Cardiosphere‐Derived Cell Extracellular Vesicles (CDC‐EVs) in Modulating CCR2 Mediated Pro‐inflammatory Signaling following Cardiac Injury

BackgroundFollowing myocardial injury, CCL2 (a cytokine released by the injured cardiac tissue) recruits CCR2+ monocytes to the site of injury to begin the repair process. Heightened CCL2 levels, however, over‐activate the CCR2+ mediated pro‐inflammatory response which in turn leads to poor cardiac healing and gives rise to downstream complications like congestive heart failure (CHF) and arrhythmias. Cardiosphere‐derived cell extracellular vesicles (CDC‐EVs) have been shown to down regulate this CCL2‐mediated inflammatory response by decreasing CCR2 expression on monocytes in healthy patients. We hypothesized that patients with acute myocardial infarction (MI) and decompensated heart failure would have higher levels of peripheral monocyte CCR2 expression compared with healthy controls and treatment with CDC‐EVs would suppress CCR2 expression regardless of patient presentation.MethodsA prospective single arm observational study was performed to investigate the immune response in patients presenting with cardiac injury. We recruited inpatients at Buffalo General Medical Center who met the following inclusion criteria: 1) &gt; 18 years of age AND 2) a type I MI or 3) acute on chronic CHF exacerbation or 4) chronic compensated CHF. Subjects were excluded from the study for the following: 1) fever in last 2 days/infection, 2) is or may be pregnant, and 3) currently undergoing cancer treatment. For part 1 of the study, blood samples from 32 patients with recent MI, acute CHF, or compensated CHF (between day 1 to 3 of admission) were drawn. Human monocytes were isolated from peripheral blood using Ficoll/centrifugation followed by magnetically activated cell sorting. Isolated monocytes were incubated with either PBS, normal human dermal fibroblast‐EVs (NHDF‐EVs) or CDC‐EVs and analyzed for CCR2 expression by flow cytometry. Multi‐variate analysis was performed to investigate the relationship of CCR2 expression and specific clinical risk factors for heart disease.ResultsCDC‐EVs significantly reduced classical monocyte (CD14hiCD16‐) surface expression of CCR2 expression by 35% as quantified by flow cytometry when compared with PBS and NHDF‐EVs (p&lt;0.005, Kruskal‐Wallis, n=31) in patients with recent MI, acute CHF exacerbation and chronic compensated CHF. This reduction was seen regardless of patients’ pre‐existing co‐morbidities like hypertension, diabetes, hyperlipidemia, chronic kidney disease, ongoing treatment with chronic medications (Aspirin, statins or ACE inhibitors), cardiac ejection fraction, prior history of coronary stents, CCR2 genotype, sex, or age. Smoking was associated with decreased response to CDC‐EV mediated CCR2 suppression when compared to PBS (linear regression model R ‐0.93, p&lt;0.05, n=26).ConclusionsCDC‐EVs down regulated CCR2 expression in non‐smoking patients with recent MI, acute CHF, or chronic compensated CHF. This immune‐modulatory effect of CDC‐EVs may be used in the future as an adjunct to current clinical therapy to improve cardiac healing.

Fragility Fractures in Postmenopausal Women: Development of 5-Year Prediction Models Using the FRISBEE Study.

ContextIndividualized fracture risk may help to select patients requiring a pharmacological treatment for osteoporosis. FRAX and the Garvan fracture risk calculators are the most used tools, although their external validation has shown significant differences in their risk prediction ability.Objective and MethodsUsing data from the Fracture Risk Brussels Epidemiological Enquiry study, a cohort of 3560 postmenopausal women aged 60 to 85 years, we aimed to construct original 5-year fracture risk prediction models using validated clinical risk factors (CRFs). Three models of competing risk analysis were developed to predict major osteoporotic fractures (MOFs), all fractures, and central fractures (femoral neck, shoulder, clinical spine, pelvis, ribs, scapula, clavicle, sternum).ResultsAge, a history of fracture, and hip or spine BMD were predictors common to the 3 models. Excessive alcohol intake and the presence of comorbidities were specific additional CRFs for MOFs, a history of fall for all fractures, and rheumatoid arthritis for central fractures. Our models predicted the fracture probability at 5 years with an acceptable accuracy (Brier scores ≤ 0.1) and had a good discrimination power (area under the receiver operating curve of 0.73 for MOFs and 0.72 for central fractures) when internally validated by bootstrap. Three simple nomograms, integrating significant CRFs and the mortality risk, were constructed for different fracture sites. In conclusion, we derived 3 models predicting fractures with an acceptable accuracy, particularly for MOFs and central fractures. The models are based on a limited number of CRFs, and we constructed nomograms for use in clinical practice.

Prevalence and predictors of elevated liver enzyme levels in Mexico: The Mexican National Health and Nutrition Survey, 2016

Introduction and objectiveTo determine the prevalence of elevated liver enzyme levels and the fatty liver index according to specific sociodemographic, clinical, anthropometric, and metabolic risk factors in Mexican adult population. Material and methodsThe present analysis was conducted using data from the Mexican National Health and Nutrition Survey 2016. For the present study, 3,490 adults with complete information on liver enzymes, sociodemographic, lifestyle, and metabolic factors were analyzed. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) levels were determined from blood samples. We computed the fatty liver Index (FLI), as a surrogate marker of non-alcoholic fatty liver disease. The associations are reported as adjusted odds ratios (OR) and 95% confidence intervals (95%CI). ResultsAt the national level, the prevalence of high serum levels of ALT, AST, and GGT were 7.9%, 13.5, and 12.9 respectively. We observed that men had higher prevalences of altered ALT, GGT and FLI compared to women. Additionally, we observe that individuals with obesity, metabolic syndrome and insulin resistance are significantly more likely to present elevated concentrations of AST, ALT, GGT and FLI. Finally, we found that the subjects of the lowest socioeconomic level and indigenous population were more likely to present elevated levels of AST, ALT, GGT, and FLI. ConclusionIn Mexico, non-alcoholic fatty liver disease affect people with obesity, diabetes, and metabolic syndrome as well as men, subjects of low socioeconomic status, subjects who live in rural areas and indigenous population. Interventions to reduce this condition should be a public health priority.

Pre-stroke factors (morbitities, diet, medication, demograhics) that affect the severity of a stroke

BackgroundThe goal of this study is to elucidate clinical characteristics in patients with acute ischemic stroke (AIS) that are associated with a potential improvement or worsening neurologic function who previously were taking an anti-hypertensive medication and then received recombinant tissue plasminogen activator (rtPA). MethodsThe binary logistical regression model was developed to identify clinical determinants that are associated with an improving or worsening neurologic function in AIS patients taking an anti-HTN medication who received thrombolytic therapy. The area under the receiver operating curve was used to determine the sensitivity of the model. ResultsIn the adjusted analysis for AIS population on combined rtPA and an anti-HTN medication therapy, increasing age (Odd ratio; OR = 1.035, 95% CI, 1.022–1.049, P < 0.001), female (OR = 1.630, 95% CI, 1.182–2.248, P = 0.002), and history of substance abuse (OR = 2.315, 95% CI, 1.107–4.842, P = 0.026) were associated with a worsening neurologic function. Caucasian patients (OR = 0.535, 95% CI, 0.361–0.793, P = 0.002), with the clinical presentations of dyslipidemia (OR = 0.655, 95% CI, 0.479–0.897, P = 0.008), obesity (OR = 0.642, 95% CI, 0.472–0.873, P = 0.005), HDL (OR = 0.988, 95% CI, 0.976–1.000, P = 0.045), and directedly admitted for treatment (OR = 0.509, 95% CI, 0.341–0.761, P = 0.001) were associated with improving neurologic function. In AIS who received rtPA and were not taking an anti-HTN medications, increasing age (OR = 1.021, 95% CI, 1.004–1.038, P = 0.015) and improvement in ambulation (OR = 1.762, 95% CI, 1.077–2.882, P = 0.024) were associated with a worsening neurologic function, while a direct admission (OR = 0.317, 95% CI, 0.158–0.635, P = 0.001) was correlated with progressing neurologic function. ConclusionOur findings reveal specific demographic and clinical risk factors that are associated with worsening or improving neurological functions in AIS pretreated with an anti-HTN medication with a subsequent thrombolytic therapy. This finding suggests the development of management strategies to manage identified clinical risk factors in AIS pretreated with an anti-HTN medication prior to thrombolytic therapy.

Clinical Features and Risk Factors for Nasal Rosacea: A Hospital-Based Retrospective Study.

IntroductionAt present, some studies have reported that nasal rosacea may be an independent disease, but phenotypic characteristics and risk factors for nasal rosacea remain unknown. This study aimed to clarify the clinical features and explore the risk factors for nasal rosacea.MethodsA hospital-based retrospective study was conducted, including 1615 rosacea patients and 1501 healthy individuals. The patients were divided into three groups based on the involved areas of the lesions (non-nasal, intermediate and nasal rosacea group). Their demographic data and clinical features were obtained from patients’ medical records, and risk factors of nasal rosacea were analyzed.ResultsThere were 927 (57.4%), 647 (40.1%) and 41 (2.5%) cases in the non-nasal, intermediate and nasal rosacea groups, respectively. Of 41 patients with nasal rosacea, all (100.0%) had fixed erythema and 17 cases (41.5%) had phymatous changes. Compared with control group, male gender (adjusted odds ratio [aOR] = 2.39, 95% confidence interval [CI] = 1.14, 4.99), obesity (aOR = 3.19, 95% CI 1.86, 11.79) and alcohol use (aOR = 1.58, 95% CI 1.22, 5.40) were risk factors for nasal rosacea, but these three factors were not risk factors for non-nasal rosacea and intermediate rosacea groups. Among patients with nasal lesions (compared with patients without nasal phymatous changes), family history of rosacea was a risk factor (aOR = 2.12, 95% CI 1.01, 4.46) for nasal phymatous changes and Fitzpatrick IV skin type was a protective factor (aOR = 0.49, 95% CI 0.28, 0.86).ConclusionNasal rosacea has relatively specific clinical features and independent risk factors, suggesting that it may be a special type of rosacea.

Identification of specific clinical risk factors associated with the malignant transformation of oral epithelial dysplasia

Factors that increase the risk of malignant transformation of oral epithelial dysplasia (OED) are not completely elucidated. A retrospective chart review was performed assessing risk factors for transformation of OED, and cancer staging for transformed cases at Sunnybrook Health Sciences Centre. Two-hundred four patients were diagnosed with OED, and 16.7% (34) underwent malignant transformation. Risk factors associated with transformation included: heavy tobacco smoking, excessive EtOH consumption, non-homogenous leukoplakia, size >200 mm2 , moderate dysplasia or greater than moderate, progression of dysplasia grades, and immunosuppression. Transformed cases followed for a dysplastic lesion were associated with a stage-I cancer diagnosis, and cancer cases with no prior biopsy were associated with a stage-IV diagnosis. In addition to commonly cited risk factors, immunosuppression was associated with malignant transformation, including the use of topical steroids. Analyzing risk factors can help clinicians define risk of progression in patients with OED.

Factors Associated With Pediatric Emergency Airway Management by the Difficult Airway Response Team.

BackgroundThe goal of this study was to determine if difficult airway risk factors were similar in children cared for by the difficult airway response team (DART) and those cared for by the rapid response team (RRT).MethodsIn this retrospective database analysis of prospectively collected data, we analyzed patient demographics, comorbidities, history of difficult intubation, and intubation event details, including time and place of the emergency and devices used to successfully secure the airway.ResultsWithin the 110-patient cohort, median age (IQR) was higher among DART patients than among RRT patients [8.5 years (0.9-14.6) versus 0.3 years (0.04-3.6); P < 0.001]. The odds of DART management were higher for children ages 1-2 years (aOR, 43.3; 95% CI: 2.73-684.3) and >5 years (aOR, 13.1; 95% CI: 1.85-93.4) than for those less than one-year-old. DART patients were more likely to have craniofacial abnormalities (aOR, 51.6; 95% CI: 2.50-1065.1), airway swelling (aOR, 240.1; 95% CI: 13.6-4237.2), or trauma (all DART managed). Among patients intubated by the DART, children with a history of difficult airway were more likely to have musculoskeletal (P = 0.04) and craniofacial abnormalities (P < 0.001), whereas children without a known history of difficult airway were more likely to have airway swelling (P = 0.04).ConclusionSpecific clinical risk factors predict the need for emergency airway management by the DART in the pediatric hospital setting. The coordinated use of a DART to respond to difficult airway emergencies may limit attempts at endotracheal tube placement and mitigate morbidity.

Incidence and Risk Factors for Postoperative Urinary Retention Following Lumbar Spine Fusion.

This was a prospective cohort study (observational-retrospective chart review). The objective of this study was to determine clinical rates and correlations of postoperative urinary retention (POUR) in elective spine decompression and fusion procedures. POUR is a common postoperative complication that often has a major adverse impact on a patient's recovery from elective lumbar spine surgery. The etiology of POUR in most cases is unknown. Patients undergoing lumbar spine surgery are considered to be at increased risk for POUR due to prone positioning during surgery and intraoperative cauda equina nerve root manipulation. Current studies reporting on POUR after elective spine surgery provide limited insight regarding risk factors and effective prevention strategies for this at-risk population. The purpose of this study is to identify risk factors for POUR after elective lumbar spine surgery and strategies for reducing its incidence. Two hundred consecutive patients aged 50 years or older undergoing combined lumbar decompression and fusion procedures over a 5-month period at a single institution were prospectively observed. Demographic and clinical data were prospectively recorded, including: medical history, surgical data, medications administered, complications, and postoperative hospital course. Factors correlating with POUR through a univariate analysis with P≤0.20 were considered for multivariate analysis. POUR occurred in 19 of 200 patients. Those with POUR were more likely to be male (20% vs. 4%, odds ratio=6.2). Administration of scopolamine (P=0.02), neostigmine (P=0.01), and the total number of levels operated on (P=0.02) were found to be independent risk factors for the development of POUR. Length of surgery, surgical level, the performance of an interbody fusion did not have a bearing on the development of POUR (P>0.05). We describe a single institution's experience of POUR incidence in 200 consecutive patients aged 50 years or older undergoing single or multilevel lumbar spine fusion procedures by 1 of 4 surgeons. Specific demographic and clinical risk factors were identified and a codified classification for POUR in a surgical population is presented.The results of this study will help clinicians appropriately counsel patients undergoing elective lumbar fusion about the potential development of POUR. The perioperative administration of scopolamine and neostigmine should be cautiously considered in men over 50 years of age due to the increased POUR risk. Perioperative scopolamine and neostigmine administration in men over 50 should be avoided when possible to minimize the risk of POUR. Level III.

Obstructive sleep apnea and stroke severity: Impact of clinical risk factors.

BACKGROUND:Specific clinical and demographic risk factors may be associated with improving or worsening neurologic outcomes within a population of acute ischemic stroke (AIS) patients with a history of obstructive sleep apnea (OSA). The objective of this study was to determine the changes in neurologic outcome during a 14-day recovery as it relates to initial stroke severity in AIS patients with OSA.METHODS:This retrospective study analyzed baseline clinical risk factors and demographic data collected in a regional stroke center from January 2010 to June 2016. Our primary endpoint measure was the National Institutes of Health Stroke Scale (NIHSS) score and our secondary endpoint measures included the clinical factors associated with improving (NIHSS score ≤7) or worsening (NIHSS score >7) neurological outcome. The relative contribution of each variable to stroke severity and related outcome was determined using a logistic regression. The regression models were checked for the overall correct classification percentage using a Hosmer–Lemeshow test, and the sensitivity of our models was determined by the area under the receiver operating characteristic curve.RESULTS:A total of 5469 AIS patients were identified. Of this, 96.89% did not present with OSA while 3.11% of AIS patients presented with OSA. Adjusted multivariate analysis demonstrated that in the AIS population with OSA, atrial fibrillation (AF) (odds ratio [OR] = 3.36, 95% confidence interval [CI], 1.289–8.762, P = 0.013) and changes in ambulatory status (OR = 2.813, 95% CI, 1.123–7.041, P = 0.027) showed an association with NIHSS score >7 while being Caucasian (OR = 0.214, 95% CI, 0.06–0.767, P = 0.018) was associated with NIHSS score ≤7.CONCLUSION:In AIS patients with OSA, AF and changes in ambulatory status were associated with worsening neurological outcome while Caucasian patients were associated with improving neurological outcome. Our findings may have significant implications for patient stratification when determining treatment protocols with respect to neurologic outcomes in AIS patients with OSA.

Comorbidities associated with different levels of total cholesterol in male and female acute ischemic stroke patients.

Men and women differ in their clinical risk factors with respect to various predictors of severity in acute ischemic stroke (AIS). High cholesterol is a risk factor for AIS and the mechanism by which high cholesterol levels lead to an AIS is well established. However, the specific relationship between demographic, clinical risk factors, total cholesterol, and the resulting gender difference in AIS patients is yet to be investigated. This study recruited AIS patients between January 2000 and June 2016 classified into normal, borderline or high total cholesterol (TC). Normal was defined as ≤200 mg/dl, borderline 200 to 239 mg/dl and high ≥240 mg/dl based on Adult Treatment Panel III (ATP III) Guidelines for the classification of TC levels. The logistic regression model was used to predict clinical risk factors associated within men and women AIS patients with different levels of TC. A total of 3532 AIS patients presented with normal TC, 760 patients with borderline TC and 427 patients with high TC. The high total cholesterol group was more likely to be women with increasing age (OR = 1.028, 95% CI, 1.006–1.052, P = .014), body mass index (BMI) (OR = 1.052, 95% CI, 1.004–1.102, P = .033), and high-density lipoprotein cholesterol (HDL-C) (OR = 1.039, 95% CI, 1.019–1.060, P < .001), while those with coronary artery disease (OR = 0.435, 95% CI, 0.234–0.809, P = .003), history of drug or alcohol abuse (OR = 0.261, 95% CI, 0.079–0.867, P = .028), increasing INR (OR = 0.187, 95% CI, 0.047–0.748, P = .018), and elevated diastolic blood pressure (OR = 0.982, 95% CI, 0.970–0.995, P = .006) were associated with being a male AIS patient. There were disparities in demographic and clinical risk factors associated with high TC levels in men when compared to women and more clinical risk factors were associated with high TC levels in men when compared to women with AIS. It is important to take into account specific clinical risk factors associated with gender-related differences in total cholesterol in AIS population to facilitate personalizing their therapeutic actions.

Use of resources for pediatric cellulitis in hospitalized patients: Evaluating the benefit of imaging and blood cultures

Use of resources for pediatric cellulitis in hospitalized patients: Evaluating the benefit of imaging and blood cultures