Management Strategies For Patients Research Articles

Practical approach to diagnose and manage benign liver masses.

Benign liver lesions are among the most commonly diagnosed abnormalities in liver imaging. They are often discovered incidentally during routine examinations or imaging conducted for unrelated reasons. These can be solid lesions, such as hemangiomas, focal nodular hyperplasia, hepatic adenomas, or cystic lesions. Recent advancements in MRI technology, particularly with hepatocyte-specific contrast agents, have enhanced the characterization of these lesions, reducing the reliance on invasive tissue sampling. Nevertheless, tissue sampling retains a crucial role in the evaluation of indeterminate lesions or those with malignant potential. While most benign liver lesions are asymptomatic, some can become symptomatic, causing discomfort, pain, or bleeding, particularly if the lesion is large. A deep understanding of the molecular underpinnings of the lesions is crucial for tailoring patient management strategies, particularly in distinguishing lesions that require surgical intervention from those that can be monitored. For instance, the molecular subclassification of hepatic adenomas has provided mechanistic insights and identified certain subtypes that are at higher risk of malignancy. Most benign liver lesions can be safely monitored; however, in patients with cirrhosis or a known primary malignancy, a high index of suspicion for cancer is required. It is crucial to carefully evaluate any liver lesion identified in these patients to ensure that indeterminate lesions are not overlooked. Effective management of benign liver lesions involves a multidisciplinary team, including hepatologists, surgeons, and radiologists, ensuring a comprehensive and individualized approach to patient care. This review outlines the clinical presentation of common benign liver lesions, providing a diagnostic and management framework. Emphasis is placed on a personalized approach to minimize patient distress and optimize outcomes by leveraging imaging advancements and multidisciplinary collaboration.

Sex differences in cardiovascular outcomes in patients with acute pancreatitis.

The risk of cardiovascular disease increases in patients with acute pancreatitis. However, it remains unknown whether this increase varies between males and females. To assess sex differences in cardiovascular outcomes among acute pancreatitis patients during long-term follow-up. Participants were recruited from the UK-biobank, which is a population-based cohort study consisting of 502 368 individuals aged 40-69 years old. Cardiovascular outcomes were defined as major cardiovascular and cerebrovascular adverse events (MACCE), encompassing all-cause death, myocardial infarction, and stroke. We compared sex difference in MACCE incidence using incidence rate per 1,000 person-years. The association between sex and MACCE risk was assessed using Cox proportional hazards models and win-ratio method, adjusted for demographic, lifestyle, metabolic factors and medication use. A total of 1371 participants with acute pancreatitis were included, 42.5% were male. Over a median follow-up of 13.9 years, 226 MACCE cases occurred. The incidence rate of MACCE for male was 16.44, compared to 9.80 in female. Multivariate Cox regression analysis indicated a higher risk of MACCE in male compared to female (HR 1.80 [95% CI 1.36-2.38]). Adjusted HR for all-cause mortality, myocardial infarction, and stroke were 1.49, 2.75, and 1.67, respectively. The adjusted win ratio by inverse probability of treatment weighting was 0.55 (P <0.001), suggesting a worse outcome in male acute pancreatitis patients. Male experienced more adverse cardiovascular outcomes than female in the long follow-up after acute pancreatitis, suggesting a need for sex-specific management strategies in acute pancreatitis patients.

Fibrinogen to pre-albumin ratio is an independent prognostic index for patients with pancreatic ductal adenocarcinoma after radical resection

BackgroundThis study aims to elucidate the significance of the preoperative fibrinogen to pre-albumin ratio (FPR) in predicting the prognosis of pancreatic ductal adenocarcinoma (PDAC), a correlation not extensively explored previously.MethodsA cohort of 563 patients diagnosed with PDAC and subjected to radical surgical resection was examined. We meticulously documented a range of inflammatory markers, clinical-pathological features, and oncological outcomes. The prognostic value of preoperative FPR was assessed using Kaplan–Meier survival analysis and Cox proportional hazards regression modeling. Furthermore, the predictive accuracy of FPR was evaluated through time-dependent receiver operating characteristic (ROC) curves and decision curve analyses (DCA).ResultsThe determined optimal threshold for FPR was 14.77, which facilitated the stratification of patients into groups with low and high FPR levels. Notably, patients in the high FPR cohort exhibited significantly reduced recurrence-free survival (RFS) and overall survival (OS) rates compared to their low FPR counterparts. Multivariate Cox regression analysis underscored FPR as an independent prognostic indicator for both RFS and OS. In comparison to the neutrophil-to-lymphocyte ratio (NLR), FPR demonstrated superior prognostic accuracy and clinical utility.ConclusionThe preoperative fibrinogen to pre-albumin ratio serves as an independent prognostic marker for RFS and OS among PDAC patients undergoing radical resection. Our findings suggest that FPR could be a valuable addition to the current prognostic models, potentially guiding therapeutic decision-making and patient management strategies in PDAC.

Social Media and Role of Health Care Professionals: Past, Present and Future Direction

Health care professionals can use social media for variety of purposes. Social media has huge impact in terms of patient education, awareness buildup and patient management strategies. Global impact of social media has been undoubtedly appreciable in terms of different awareness programs. At the same time, for personal branding, social media is contributing more and more than ever. However, potential risks related to unreliable information, violation of medical ethics including patient’s privacy rights should always be considered for safe use of social media and for personal safety against nations copyright act. EWMCJ Vol. 12, No. 1&amp;2, January-July 2024: 1-3

Independent risk factors of ejection fraction deterioration post discharge in hospitalized heart failure patients with mildly reduced ejection fraction

Abstract Background The identification of independent risk factors for left ventricular ejection fraction (LVEF) deterioration is of clinical importance in patients diagnosed heart failure with mildly reduced ejection fraction (HFmrEF). This study aimed to determine the independent risk factors of LVEF deterioration post discharge among hospitalized HFmrEF patients. Methods This retrospective study analyzed data from 807 HFmrEF patients admitted to our hospital between January 2015 and August 2020. LVEF values were assessed by echocardiography between 6 months and 1 year after discharge. Patients were followed up to a mean of 33 months. The primary endpoint was disease progression expressed as heart failure with reduced ejection fraction (HFrEF) between 6 months and 1 year post discharge. The secondary endpoint was all-cause death. Multivariate logistic regression analysis was conducted to identify independent risk factors associated with LVEF deterioration. Results There were 225 patients progressed to HFrEF between 6 months and 1 year post discharge. All-cause death was significantly higher in HFrEF patients (43%) compared to patients with stable LVEF (unchanged or improved, 24%, P&amp;lt;0.001). Multivariate logistic regression analysis showed that the independent risk factors associated with worsening LVEF in patients with HFmrEF were: female (OR=1.71, 95% CI 1.14 to 2.57, P=0.009), higher NT-proBNP (≥2312 pg/ml, OR=1.71, 95% CI 1.14 to 2.57, P=0.010), higher uric acid (≥318 µmol/L, OR=11.63, 95% CI 7.89 to 17.15, P&amp;lt;0.001), and larger end-diastolic left ventricular dimension (OR=1.05, 95% CI 1.02 to 1.08, P&amp;lt;0.001). Conclusion Results of this study might help risk stratification to identify hospitalized HFmrEF patients with increased risk of progression to HFrEF post discharge. Patients with above clinical features should undergo more intensively monitoring and enhance care adherence to HF guideline medications. Future studies are needed to validate if tailored guideline adherence management strategies for post-discharged HFmrEF patients based on personalized risk stratification could mitigate LVEF progression and improve survival of these patients.

The influence of genetic mutations on multilayer global longitudinal strain values in patients with hypertrophic cardiomyopaty

Abstract Background Hypertrophic cardiomyopathy (HCM) is a hereditary heart muscle disorder characterized by diverse genetic mutations. Multilayer global longitudinal strain (GLS) analysis has emerged as a valuable tool for assessing myocardial function. This study aimed to investigate the influence of genetic mutations on myocardial deformation patterns in HCM patients using multilayer GLS analysis. Methods A total of 83 adult patients diagnosed with HCM were included in the study. Genetic testing was performed to identify specific genetic mutations associated with HCM. Echocardiographic assessments were conducted to measure multilayer GLS values for endocardial, mid-myocardial, and epicardial layers. Patients were divided into gene-positive and gene-negative groups for comparative analysis. Results In the gene-negative group (n=41), the mean age was 57.1 ± 11.0 years, whereas in the gene-positive group (n=42), it was 55.5 ± 11.6 years (p=0.516). Significant differences were observed in endocardial (-16.1 ± 2.3 vs. -13.4 ± 3.2, p &amp;lt; 0.001) and mid-myocardial (-14.2 ± 2.1 vs. -12.3 ± 3.1, p = 0.002) GLS involvement between gene-negative and gene-positive HCM patients. However, no significant disparity in epicardial strain was detected. Conclusion The findings demonstrated a greater involvement of the endocardial and mid-myocardial layers in the group of HCM patients with positive genetic mutations. Multilayer GLS analysis has the potential to aid in the identification of subtle alterations in myocardial function associated with specific genetic mutations, contributing to refined risk assessment and personalized management strategies for HCM patients.

Patient characteristics and mortality trends among octogenarians with heart failure over two decades - a Danish nationwide study

Abstract Background Mortality rates among octogenarians with heart failure (HF) have changed little despite significant advancements in care over recent decades. Investigating the factors contributing to this trend may offer valuable insights for devising targeted management strategies for the oldest HF patients. Purpose We aimed to examine different patient characteristics associated with mortality among octogenarians with HF over the past 20 years. Methods From nationwide Danish healthcare registries, we included all patients with new-onset HF between 2001-2020 who were ≥ 80 years old at the time of diagnosis. The patients were categorized into 5-year calendar periods depending on the time of their diagnosis, the first period being between 2001-2005 and the last 2016-2020. The Kaplan-Meier estimator was used to assess the mortality risk. Mortality rates were examined with multivariable Cox regression models, comparing the first (reference) and the last calendar period and adjusting for predefined covariables. Results We included 47,754 octogenarian patients with new-onset HF, of whom 13,293 (51%) were diagnosed between 2001-2005 and 12,813 (49%) between 2016-2020. The distribution of males and females changed between the two calendar periods, with 5696 (43%) males in the first period and 6631 (52%) in the last period. The 3-year absolute mortality risk decreased by 8% [95% CI, 7.9-8.0] from 2001-2005 (64% [95% CI, 63.9-64.7]) to 2016-2020 (56% [95% CI, 55.3-56.7]) (p-value &amp;lt;0.001) (Figure 1). After adjustment for covariables, patients diagnosed in the last period exhibited a mortality hazard ratio (HR) of 0.94 [CI 95% 0.90-0.99] (p-value 0.02) compared to those diagnosed in the first period. An interaction was observed between the first and the last calendar periods among patients with a history of myocardial infarction and those aged &amp;lt;85 years. The survival rates improved over time for patients with a history of myocardial infarction (HR 0.80 [95% CI, 0.72-0.90], p-value for interaction&amp;lt;0.001), as well as for those aged between 80 and 85 years (HR 0.86 [95% CI, 0.80-0.91], p-value for interaction&amp;lt;0.001) (Figure 2). Conclusion Over two decades the mortality risk among octogenarians with HF has improved slightly, however it remains high. Patients with a history of myocardial infarction and those aged 80 to 85 years emerge as subgroups experiencing the most improved survival rates over time.3-year mortality riskMortality rates in selected subgroups

Risk factors of all-cause mortality in heart failure with mildly reduced ejection fraction patients with different post-discharge left ventricular ejection fraction variation patterns

Abstract Background The identification of risk factors for all-cause mortality in patients diagnosed with heart failure with mildly reduced ejection fraction (HFmrEF) and exhibiting varying post-discharge left ventricular ejection fraction (LVEF) patterns remains incomplete. This study aimed to determine the independent risk factors of all-cause mortality among HFmrEF patients with different LVEF variation patterns post-discharge. Methods This retrospective study analyzed data from 807 HFmrEF patients admitted to our hospital between January 2015 and August 2020. Patients were categorized into three groups based on LVEF variation patterns within 6 months to one year post-discharge: Group A (transitioning to heart failure with reduced ejection fraction [HFrEF], n=225), Group B (remaining as HFmrEF, n=335), and Group C (reverting to heart failure with preserved ejection fraction [HFpEF], n=227). Patients were followed up for a mean of 33 months, with all-cause mortality as the primary endpoint. Multivariate Cox regression analysis was conducted to identify independent risk factors for all-cause mortality in each group. Results The mortality rates for Groups A, B, and C were 43.11%, 23.94%, and 24.67%, respectively (P&amp;lt;0.001). Independent risk factors for all-cause mortality in Group A included age (HR=1.04, P=0.007), obesity (HR=1.76, P=0.040), higher creatinine (&amp;gt;100 µmol/L, HR=1.83, P=0.029), higher E/e’ (HR=1.06, P=0.001), absence of PCI (HR=0.51, P=0.019), and non-use of ACEI/ARB (HR=0.039, P=0.006). In Group B, independent risk factors for all-cause mortality were age (HR=1.06, P&amp;lt;0.001), higher NT-proBNP (&amp;gt;2505 pg/ml, HR=2.50, P=0.002), and absence of PCI (HR=0.040, P=0.005). Group C exhibited age (HR=1.04, P=0.002), pleural effusion (HR=2.38, P=0.007), higher creatinine (&amp;gt;100 µmol/L, HR=2.84, P&amp;lt;0.001), and non-use of ACEI/ARB (HR=0.42, P=0.021) as significant independent risk factors associated with increased all-cause mortality risk. Conclusion This study highlights distinct risk factors associated with all-cause mortality in HFmrEF patients exhibiting different post-discharge LVEF variation patterns. Age emerged as a consistent risk factor across all groups, underscoring the importance of age-related considerations in managing HFmrEF patients. Additionally, factors such as obesity, renal function, echocardiographic parameters, and medication adherence played varying roles in influencing mortality risk depending on the evolution of LVEF following discharge. These findings emphasize the need for personalized risk stratification and tailored management strategies for HFmrEF patients to improve outcomes and reduce mortality rates.

Impact of agitation status during intensive care on functional outcomes and mortality in patients with cardiovascular disease

Abstract Background Agitation in patients during intensive care is a frequent complication. Several studies have reported that restlessness and agitation are risk factors for prolonged intensive care unit (ICU) stay and poor prognosis. Since patients with cardiovascular disease (CVD) requiring intensive care are ageing and thereby easily affected by responses, including changes in mental status, optimal management of sedation and agitation statuses during ICU stay is considered crucial. However, the influence of different agitation levels during CVD treatment in the ICU on clinical outcomes after ICU discharge is still unclear. Purpose To investigate the associations of the agitation level during ICU stay with mortality after ICU admission and functional outcomes at hospital discharge. Methods We studied 2236 patients (mean age 67.8±0.3 years) who were admitted to the ICU of a university hospital for CVD treatment and whose highest Richmond Agitation-Sedation Scale (RASS) ≥0, measured daily during ICU stay. In addition to clinical characteristics, we investigated the incidence of all-cause mortality during hospitalization and after hospital discharge. We also measured functional outcomes at discharge among 1625 patients, including 6 minutes walk distance (6MWD), Mini-Cog test, and Patient Health Questionnaire-2 (PHQ-2) as physical, cognitive, and mental functions, respectively. In statistical analysis, patients were divided into three groups based on the highest RASS levels during ICU stay in each patient (Calm: RASS=0, Restless: RASS=1, Agitation: RASS≥2). Kaplan-Meier analysis with a log-rank test and the multivariate Cox proportional hazard model were used to clarify whether higher agitation levels were associated with all-cause mortality. Moreover, the differences between the agitation levels and functional outcomes at hospital discharge were compared using the analysis of covariance. Results During the median follow-up of 1.9 years, all-cause death occurred in 280 patients (12.5%), with an incidence rate of 5.57/100 person-years. The Restless and Agitation groups showed higher mortality than the Calm group (P&amp;lt;0.001), and higher agitation levels in the ICU were significantly associated with a higher rate of all-cause mortality (adjusted hazard ratio: 1.37, 95% confidence interval: 1.19–1.57, P&amp;lt;0.001). Furthermore, as compared with the Calm group, the Restless and Agitation groups showed significantly lower levels of 6MWD (all P&amp;lt;0.001) and Mini-cog (P=0.004 and P&amp;lt;0.001, respectively) and a higher PHQ-2 (all P&amp;lt;0.001), even after adjusting for clinical confounders. Conclusions Agitation during ICU stay in CVD patients was associated with low functional outcomes at hospital discharge and high mortality rate after discharge, irrespective of agitation level. Detailed information on the agitation status during intensive care may be an important indicator in developing management and treatment strategies for patients with CVD admitted to ICU.

A comparative analysis of conduction system pacing and biventricular pacing in patients undergoing atrioventricular node ablation: a systematic review and meta-analysis

Abstract Background Atrioventricular node ablation (AVNA) with concomitant permanent pacemaker implantation is a well-established management strategy for patients with atrial fibrillation demonstrating refractory and uncontrolled ventricular rates. Conduction system pacing (CSP) utilising His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), has emerged as an alternative to conventional pacing (CP) (including right ventricular pacing (RVP) and biventricular pacing (BVP). The aims and objectives of this systematic review and meta-analysis is to provide a comprehensive summary and synthesis of clinical outcomes in the literature for CSP in comparison to BVP when facilitated with AVNA. Methods This study protocol was registered in the PROSPERO registry and the review was conducted as per the PRISMA guidelines. MEDLINE, EMBASE and Cochrane Library were searched for relevant studies from inception till January 11th, 2024. Results were synthesised using a random effects meta-analysis. Risk of bias (ROB) assessment was carried out with the RoB 2 and ROBINS-I tool. Results From a total of 259 references identified, 122 full texts were assessed and 5 studies (1 randomised control trial, 2 prospective observational studies, and 2 retrospective observational studies) were included in the review. A total of 738 patients (HBP-294 and LBBAP-444) received CSP and BVP implantation with AVNA, respectively. All devices were implanted successfully with a cumulative total of 4 patients in the HBP population demonstrating acute threshold hold increase following AVN. There was no loss of capture on follow-up in either treatment groups. HBP resulted in a narrower QRSd with a reduction of -35.3 ms (95% confidence interval [CI] -63.8 to -6.78; P&amp;lt;0.05; I2=96.6%) vs BVP. For left ventricular ejection fraction (LVEF), a weighted mean increase of 3.50% (95% CI -0.55%-7.54%; P=0.02, I2=65.8%) was observed following HBP implantation in comparison to BVP (Figure 1). Furthermore, LBBAP also demonstrated a weighted mean increase in LVEF of 6.02% (95%CI -4.05%-16.1%; P&amp;lt;0.05; I2=90.7%) in comparison to BVP. The mean NYHA score was reduced by -0.54 (95% CI -1.07 to -0.02; P=0.05, I2=65.5%) after HBP implantation when compared to BVP. There was a cumulative total of 45 and 65 events of heart failure associated hospitalisation in the HBP and BVP, respectively (OR 0.69; 95% CI 0.19-1.18; P=0.99, I2 =0.00). Conclusion To our knowledge, this is the first methodologically robust systematic review and meta-analysis evaluating the outcomes of CSP with AVNA. Overall, both CSP modalities demonstrated feasibility and application as an effective CRT alternative to facilitate AVNA along with a narrower QRSd ,improved LVEF and trend of better clinical outcomes. While these preliminary findings are promising, further RCTs will be necessary to establish the long-term efficacy and safety of this approach.

Construction of an inflammatory, nutritional, and metabolic prognostic risk score in patients with heart failure with preserved ejection fraction: a machine learning-based approach

Abstract Background Chronic inflammation, malnutrition, and metabolic syndrome contribute to the underlying mechanisms of heart failure with preserved ejection fraction (HFpEF). Inflammatory, nutritional, and metabolic biomarkers often interact with each other and affect the prognosis of patients. Purpose We aimed to identify the most predictive indicators from a pool of 21 biomarkers encompassing inflammation, nutritional status, as well as lipid, glucose, thyroid, and uric acid metabolism. Subsequently, predictive biomarkers were used to develop a risk score to enhance risk prediction for patients with HFpEF. Methods We included patients diagnosed with HFpEF and without infective or systemic disease. The primary outcome was all-cause mortality. We employed the Least Absolute Shrinkage and Selection Operator (LASSO) regression to screen the biomarkers. A machine learning-based approach was utilized to fine-tune the optimal model parameters. Additionally, we generated 1000 bootstrapping datasets to identify biomarkers recurring above a 95% frequency in repetitions, which were then employed to formulate the biomarker risk score. The discrimination of incorporating the risk score into the basic model was evaluated using 100 iterations of 5-fold cross-validation to assess the predictive efficacy. Results Among the 1311 included patients (with a median age of 64 years and 42.6% female), 363 patients (27.7%) experienced mortality over a median follow-up period of 2.7 years. The final risk score model was derived from 5 biomarkers—albumin (ALB), red blood cell distribution width-standard deviation (RDW-SD), lymphocytes, triiodothyronine (T3), and uric acid—each selected in over 95% of 1000 bootstrapping iterations. Integration of this risk score into the basic model notably enhanced discrimination (∆C-index=0.015, 95% CI 0.005-0.023) and reclassification (IDI: 3.3%, 95% CI 1.7%-5.8%; NRI: 15.2%, 95% CI 6.5%-22.5%) for risk stratification. In time-dependent receiver operating characteristic (ROC) analysis, the mean area under the curve (AUC) of the risk score was 0.688, 0.710, and 0.738 at 1, 3, and 5 years post-discharge, respectively, in the cross-validation sets. Incorporating the risk score into the basic model significantly improved the AUC at 1, 3, and 5 years (DeLong test P-value&amp;lt;0.05). Furthermore, in multivariable Cox regression, the risk score demonstrated an independent association with all-cause mortality (HR: 1.81, 95% CI 1.51-2.16, P&amp;lt;0.001 per 1 score increase). Conclusions A risk score derived from 5 commonly used inflammatory, nutritional, thyroid and uric acid metabolic biomarkers can effectively identify high-risk patients with HFpEF. This approach supports the development of potential individualized management strategies for patients with HFpEF.Study population and model constructionPredictive performance of the risk score

Screening for subclinical atherosclerosis in patients clinically diagnosed with familial hypercholesterolemia and determination of imaging-guided patient management strategy

Abstract Introduction Familial hypercholesterolemia (FH) is a monogenic dyslipidemia characterized by elevated plasma LDL-C levels, leading to early cardiovascular disease. The Dutch Lipid Clinic Network (DLCN) score is the most widely used clinical scoring system in current practice. Subclinical atherosclerosis is defined as the detection of atheromatous plaques in arterial territories, such as coronary, carotid or iliofemoral, before a symptom or event occurs. It is an early indicator of atherosclerotic burden. In this study, we investigated the presence of subclinical atherosclerosis in FH patients with a definite or probable clinical diagnosis according to DLCN score. We also tried to identify independent predictors of subclinical atherosclerosis. Methods This study is a single-center, prospective, and cross-sectional investigation involving a cohort of 215 FH patients. These patients are primary prevention patients and among them, 120 patients received a definite clinical diagnosis, while 95 patients received a probable clinical diagnosis based on the DLCN score. Carotid USG and Femoral USG were performed to screen for subclinical atherosclerosis and CAC score was calculated by non-contrast CT. Apo A-I, Apo B and Lp (a) measurements were analyzed by immunonephelometric method. Results The study population consisted of 136 (63%) women and 79 (37%) men. The mean age was 54 years (43-62) and the stigmata rate was 18%. Initially, 17% of patients were on aspirin, and 32% were receiving statin treatment; however, following subclinical atherosclerosis screening, these proportions significantly increased (aspirin usage to %32 and statin usage to %96) within the population. 148 patients (69%) had subclinical atherosclerosis in at least one site. Upon regional analysis, subclinical atherosclerosis rates were 48% in the coronary arteries, 47.5% in the carotid bifurcation region, and 40.5% in the femoral bifurcation region. Additionally, 25% of patients had atherosclerosis at one site, 27% at two sites, and 17% at all three sites. Age, male gender, pretreatment LDL-C level, Apo A-I/Apo B ratio and DM were identified as independent predictors of the presence of subclinical atherosclerosis in the FH patients. Furthermore age, male gender, pretreatment nonHDL-C level, Lp (a) ≥ 30 mg/dl and presence of femoral plaque were identified as independent predictors of coronary atherosclerosis. Conclusion Subclinical atherosclerosis is prevalent among FH patients, and this study has identified independent predictors associated with presence of subclinical atherosclerosis. However, despite this heightened risk, medication utilization among these patients remains below optimal levels and only a small proportion of the population has achieved their treatment goals. Our study highlights the influence of subclinical atherosclerosis on treatment approaches, as demonstrated by the notable rise in statin and aspirin utilization observed after screening.Clinical and biochemical characteristicsSubclinical Atherosclerosis Rates

Automatic telephonic follow up in heart failure by a natural language processing artificial intelligence: pilot program

Abstract Introduction Heart failure (HF) burden on public health is substantial and efficient patient management strategies are needed. Traditional methods of HF monitoring face limitations in scalability and effectiveness. Artificial Intelligence (AI) might offer novel solutions for enhanced resource management and alleviation of healthcare burdens. Purpose To study the feasibility of implementing automatic remote monitoring via phone calls operated by AI in a HF unit. Methods We conducted a non-randomized, open, pilot trial employing an AI technology based on natural language processing for autonomous telephone outreach for the follow up of HF patients. 86 patients from a tertiary hospital HF unit undergoing pharmacological titration and education were enrolled. The AI conducted weekly calls to gather symptomatology, vital signs, and health status changes, which were then displayed on a virtual platform featuring alerts preconfigured by the research team. These alerts guided patient communication and intervention as deemed necessary by a specialized nurse. Results Characteristics of patients are shown in Table 1. The AI followed these patients for a median of 251.5 days. 2773 telephonic calls were performed. We estimate an equivalent to 1445h of work (17.2 days/month). Adherence was high during the study, with 98% of the calls completed. 1427 alerts were generated, being the most frequent weight change (251; 17.6%), orthopnea (220; 15.4%) and fatigue (187; 13.1%). It led to 487 remote interventions, most of them consisting in calling the patient for assessment (409; 84.0%), but also in adjusting medication remotely (34; 7.0%). See Figure 2. A HF telemedicine specialized nurse required 205min per week for alert review, 2.38min/patient-week. 2 patients died, one from cardiovascular causes, and 7 patients had a HF hospitalization, 42.9% with previous alarms. 20 events of worsening HF were recorded, comprising hospitalization, emergency visit or IV diuretic administration. Oral diuretic dose was increased in 22 occasions, 15 of them remotely in response to an alert raised by the AI operator. At 6 months functional class globally improved (p = 0.028), but NTproBNP increased (p=0.0472). Quality of life was evaluated at baseline and at 6 months, with no change in EQ5D5L (median 0.717, change -0.005, p 0.71) or PHQ4 (median 2.88, change -0.29, p 0.7792), but KCCQ12 total score worsened (median 74.49, change -2.32, p 0.048). Experience was rated with 8.97/10 in a satisfaction questionnaire. All patients recommended the program, remarking a closer follow up, better communication and a safety feeling. Conclusions AI enables closer monitoring of patients with HF, maintaining contact with stable patients while also allowing for resource allocation and tracking of higher-risk patients or those experiencing changes in symptoms. A randomized clinical trial comparing to standard follow-up is needed to evaluate this promising technology.Table 1Figure 2

Uncovering Prognostic Clinical Phenotypes in Children and Adolescents with SARS-CoV-2 Infection

Abstract Background Characterizing clinical phenotypes is important for classifying patients, predicting disease outcomes, and adapting treatment. We aimed to identify distinct clinical phenotypes among hospitalized children and adolescents with SARS-CoV-2 infection and to evaluate variations in prognosis across these phenotypes. Methods The DGPI (German Society of Pediatric Infectious Diseases) registry serves as a nationwide, prospective registry for children and adolescents hospitalized with a SARS-CoV-2 infection in Germany. We applied hierarchical clustering and integrated variables such as sex, SARS-CoV-2-related symptoms, pre-existing comorbidities, clinically relevant coinfection, and SARS-CoV-2 risk factors to describe distinct clinical phenotypes. Subsequently, we applied a multinomial logistic regression model to examine the association between these phenotypes and discharge status. Results The DGPI registry encompassed 6983 patients and facilitated the identification of six distinct phenotypes for children and adolescents with SARS-CoV-2. Phenotype A had a similar symptom pattern as the total sample. Predominant symptoms of patients with other phenotypes were gastrointestinal (95.9%, B), asymptomatic (95.9%, C), lower respiratory tract (49.8%, D), lower respiratory tract and ear, nose and throat (86.2% and 41.7%, E), and neurological (99.2%, F). Patients with phenotype C had lower odds of residual symptoms (OR: 0.10 [0.06, 0.15]) than those with phenotype A, whereas patients with phenotype D and E had higher odds of residual symptoms (OR: 1.33 [1.11, 1.59] and 1.91 [1.65, 2.21], respectively) than those with phenotype A. Patients with phenotype D were significantly more likely (OR: 4.00 [1.95, 8.19]) to have an unfavorable outcome, compared to patients with phenotype A. Conclusions We could show that the identified phenotypes could facilitate early risk assessment and aid in tailoring individualized patient management strategies. Key messages • Six distinct clinical phenotypes existed in children and adolescents with SARS-CoV-2 infection. • Phenotypes could assist in risk evaluation and help personalize patient care.

Eagle Syndrome: The Huge Socioprofessional Impact of a Minor Lengthening of the Styloid Process

agle Syndrome (ES) is a rare clinical condition presenting with anterolateral neck pain and potential serious complications. This case report details a head nurse in the emergency room (ER) with a severe throbbing headache, trismus, left-sided dysphagia, left otalgia, gum pain, and a very intense left-sided headache, associated with ipsilateral facial hypoesthesia. The patient met the International Classification of Headache Disorders (ICHD-3) criteria for headaches attributed to inflammation of the stylohyoid ligament, establishing the diagnosis of Eagle syndrome. Chronic headaches associated with ES, as observed in this case, can impact concentration, comprehension, communication, and work performance, leading to economic loss. This prompts the question: Are individuals with ES capable of working under intense physical and psychological conditions? The paper proposes a management strategy for ES patients, emphasizing the need for further research on the impact of ES on occupational fitness, as no published studies currently address this concern.

Obesity, kidney and metabolic bariatric surgery: a surgeon’s narrative review

Excess body weight impacts kidney function in individuals with severe obesity, primarily through metabolic alterations in adipocytes, especially in visceral adipose tissue. The relationship between persistent sterile inflammation associated with obesity and the progression of obesity-related kidney disease to chronic kidney disease (CKD) is an area of growing interest. The beneficial effects of weight loss on the prevention of kidney disease and the improvement of kidney function in individuals with obesity have been well documented. Currently, the most effective weight loss strategy is metabolic bariatric surgery (MBS), which has been proven to not only prevent the progression of CKD but also reverse it. However, awareness and understanding of the impact of obesity on the kidney should also extend to the severely obese population with clinically normal renal function. The purpose of this review is to outline the current knowledge on the pathophysiology of obesity-induced kidney damage, the effects of MBS on renal function in severely obese individuals with or without CKD, and provide the current evidence on perioperative management strategies for CKD patients, including diet and nutrition.

Clinical implications of persistently increased blood urea nitrogen/serum creatinine ratio (PI-BUN/Cr) in severe COVID-19 patients

BackgroundPatients with COVID-19 may experience a persistent increase in the blood urea nitrogen over creatinine ratio (PI-BUN/Cr). Its elevation could reflect multiple underlying pathophysiological processes beyond prerenal injury but also warrants nuanced interpretation due to its complex interplay with various factors, underscoring the importance of investigating its effects on mortality and acute kidney injury in this population.MethodsWe analized a retrospective and longitudinal cohort of patients admitted to a single center in Mexico City for patients with severe COVID-19. Between March 5, 2020 and August 25, 2021, we included patients with confirmed positive diagnosis for SARS-CoV-2, age > 18 years, disease severity was defined by clinical data of respiratory distress syndrome and a ratio of partial oxygen pressure to inspired oxygen fraction < 300 mmHg on admission. We excluded patients with End Stage Kidney Disease. Data was obtained from electronic medical records. PI-BUN/Cr was defined as an increase in the BUN/Cr ratio > 30 in more than 60% of measurements in the hospital. The outcomes included: risk factors to mortality and AKI in-hospital.ResultsThe cohort included 3,007 patients with a median age of 54.6 ± 14.5 years. 35% of patients died; 44.6% developed PI-BUN/Cr ratio and 71.4% AKI. Mortality was associated with older age > 60 years [Hazard ratio (HR)] = 1.45, 95% CI: 1.28–1.65; p < 0.001); male (HR 1.25, 95% CI 1.09–1.44; p = 0.002) and AKI (HR 3.29, 95% CI 2.42–4.46; p < 0.001); PI-BUN/CR & Non-AKI (HR = 2.82, 95% CI: 1.61–4.93; p < 0.001); Non PI-BUN/CR & AKI (HR = 5.47, 95% CI: 3.54–8.44; p < 0.001); and PI-BUN/CR & AKI (HR = 4.26, 95% CI: 2.75–6.62, p < 0.001). Only hiperuricemia was a risk factor for AKI (HR = 1.71, 95% CI: 1.30–2.25, p < 0.001).ConclusionsWhile PI-BUN/Cr alone may not directly associate with mortality, its capacity to sub-phenotype patients according to their AKI status holds significant promise in offering valuable insights into patient prognosis and outcomes. Understanding the nuanced relationship between PI-BUN/Cr and AKI enhances our comprehension of renal function dynamics. It equips healthcare providers with a refined tool for risk stratification and personalized patient management strategies.

Mechanical properties of pediatric low-grade gliomas in children with and without neurofibromatosis type 1.

Prognoses for pediatric brain tumors are suboptimal, as even in low-grade tumors, management techniques can lead to damage in the developing brain. Therefore, advanced neuroimaging methods are critical for developing optimal management plans and improving patient care. Magnetic resonance elastography (MRE) has allowed for the characterization of adult gliomas by their mechanical properties, which are uniquely sensitive to the complex interplay of cellularity, vasculature, and interstitium. However, pediatric tumors differ in behavior and cytoarchitecture, and their mechanical properties have never been assessed. Here, we conduct the first study of pediatric brain tumor mechanical properties by using MRE to measure tissue stiffness and damping ratio in low grade gliomas (LGGs). We additionally measure the mechanical properties of non-neoplastic focal abnormal signal intensities (FASIs) in children with neurofibromatosis type 1 (NF1). 23 patients age 4-17 years who had MR imaging results consistent with a primary LGG or with NF1 were included in this study. We found that pediatric gliomas are on an average 10.9% softer (p = 0.010) with a 17.3% lower (p = 0.009) viscosity than reference tissue. Softness of tumors appeared consistent across tumor subtypes and unrelated to tumor size or contrast-enhancement. In NF1 we found that, unlike gliomas, FASIs are stiffer, though not significantly, than reference tissue by an average of 10.4% and have a 16.7% lower damping ratio. Measuring tumor mechanical properties patterning and heterogeneity has potential to aid in prediction of biological behavior and inform management strategies for pediatric patients.

Successful Management of Inferior Wall STEMI in a Patient with Obstructive Three-Vessel Disease, Diabetes Mellitus, and Hypertension: A Case Report

We report the case of a 67-year-old female with a complex medical history, including poorly controlled Type 2 diabetes mellitus, hypertension and recent inferior wall ST-segment elevation myocardial infarction (STEMI). She presented with generalized body aches, arm numbness and vomiting. Coronary angiography revealed severe three-vessel coronary artery disease including a 100% thrombotic occlusion of the right coronary artery (RCA). The patient underwent successful percutaneous coronary intervention (PCI) to both the distal and most-proximal RCA, followed by recommendations for further intervention on the left circumflex (LCx) and left anterior descending (LAD) arteries. This case highlights the challenges and successful management strategies in patients with multivessel coronary artery disease, comorbid diabetes and hypertension.

The impact of immune dysregulation on the risk of malignancy in common variable immunodeficiency: insights from a multicenter study.

Common Variable Immunodeficiency (CVID) represents a heterogenic group of primary immunodeficiencies (PID) characterized by impaired antibody production and susceptibility to infections. Non-infectious complications, such as autoimmune diseases, lymphoproliferative disorders, and malignancies, now significantly impact prognosis. Moreover, both hematologic and solid organ malignancies are more frequently observed in CVID patients compared to other PIDs. The risk factors for carcinogenesis in CVID remain largely unknown. This multicenter study aims to characterize the clinical profile of cancer in CVID patients in Spain and to identify independent risk factors associated with malignancy development, focusing on the role of immune dysregulation. A nationwide, cross-sectional study was conducted from November 2019 to May 2022, involving 17 hospitals treating PID patients in Spain. Data were collected systematically on demographics, infectious and non-infectious comorbidities, immunological parameters, and treatment. Statistical analysis, including multivariate logistic regression, was performed to identify risk factors associated to malignancy. Of 250 CVID patients, 38 (15.26%) were diagnosed with cancer, predominantly non-Hodgkin lymphoma, gastric cancer, and lung adenocarcinoma. Cancer patients were significantly older (mean age 60.70 vs. 49.36 years, p<0.001) and had higher rates of immune dysregulation (81.58% vs. 59.7%, p=0.01). Immune dysregulation was an independent risk factor for cancer (OR 2.19, p=0.04), alongside previous immunosuppressant therapy (OR 2, p=0.031), higher IgM levels (OR 1.008 per SD, p=0.012), older age (OR 1.04, p<0.001), and lower CD4 cell counts at diagnosis (OR 0.997, p<0.001). This study highlights the increased cancer risk in CVID patients, with immune dysregulation, prior immunosuppressant use, elevated IgM levels, and lower CD4 cell counts as conjointly associated. These findings underscore the need for vigilant cancer screening and tailored management strategies in CVID patients to improve outcomes. Future research should focus on elucidating the molecular mechanisms linking immune dysregulation and malignancy in CVID.