bluuebunny/crossref_metadata_2025 huggingface dataset:
Differences in outcomes following an intensive upper-limb rehabilitation program for patients with common central nervous system-acting drug prescriptions
Authors: Johnstone Ainslie , Brander Fran , Kelly Kate , Bestmann Sven , Ward Nick
Published: March 2021

Background: Difficulty using the upper-limb is a major barrier to independence for many patients post-stroke or brain injury. High dose rehabilitation can result in clinically significant improvements in function even years after the incident; however, there is still high variability in patient responsiveness to such interventions that cannot be explained by age, sex, or time since stroke. Methods: This retrospective study investigated whether patients prescribed certain classes of central nervous system-acting drugs—γ-aminobutyric acid (GABA) agonists, antiepileptics, and antidepressants—differed in their outcomes on the three-week intensive Queen Square Upper-Limb program. For 277 stroke or brain injury patients (167 male, median age 52 years (IQR: 21), median time since incident 20 months (IQR: 26)) upper-limb impairment and activity was assessed at admission to the program and at six months post-discharge, using the upper limb component of the Fugl-Meyer, Action Research Arm Test, and Chedoke Arm and Hand Activity Inventory. Drug prescriptions were obtained from primary care physicians at referral. Specification curve analysis was used to protect against selective reporting results and add robustness to the conclusions of this retrospective study. Results: Patients with GABA agonist prescriptions had significantly worse upper-limb scores at admission but no evidence for a significant difference in program-induced improvements was found. Additionally, no evidence of significant differences in patients with or without antiepileptic drug prescriptions on either admission to, or improvement on, the program was found in this study. Although no evidence was found for differences in admission scores, patients with antidepressant prescriptions experienced reduced improvement in upper-limb function, even when accounting for anxiety and depression scores. Conclusions: These results demonstrate that, when prescribed typically, there was no evidence that patients prescribed GABA agonists performed worse on this high-intensity rehabilitation program. Patients prescribed antidepressants, however, performed poorer than expected on the Queen Square Upper-Limb rehabilitation program. While the reasons for these differences are unclear, identifying these patients prior to admission may allow for better accommodation of differences in their rehabilitation needs.
Methodology of the fatigue after stroke educational recovery group randomized controlled trial
Authors: Barker-Collo Suzanne , Krishnamurthi Rita , Ikeda Takayoshi , TeAo Braden , Green Geoff , Ratnasabapathy Yogini , DeSilva Sulekha , Feigin Valery , Jones Kelly
Published: March 2021

Rationale

Post-stroke fatigue affects up to 92% of stroke survivors, causing significant burden. Educational cognitive behavioral therapy fatigue groups show positive results in other health conditions.

Aims

FASTER will determine if educational cognitive behavioral therapy fatigue management group reduces subjective fatigue in adults post-stroke.

Design

Prospective, multi-centre, two-arm, single-blind, phase III RCT (parallel, superiority design), with blinded assessments at baseline, six weeks, and three months post-program commencement. With n = 200 (100 per group, 20% drop-out), the trial will have 85% power (2-sided, p = 0.05) to detect minimally clinically important differences of 0.60 (SD = 1.27) in fatigue severity scale and 1.70 points (SD = 3.6) in multidimensional fatigue inventory-20 at three months.

Outcomes

Primary outcomes are self-reported fatigue severity and dimensionality (i.e. types of fatigue experienced – physical, psychological and/or cognitive) post-intervention (six weeks). Secondary outcomes include subjective fatigue at three months, and health-related quality of life, disability, sleep, pain, mood, service use/costs, and caregiver burden at each follow-up.

Discussion

FASTER will determine whether fatigue management group reduces fatigue post-stroke. Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000626167).
Dependence of seasonal dynamics of hemorrhagic and ischemic strokes on the climate of a region: A meta-analysis
Authors: Kuzmenko NV , Galagudza MM
Published: March 2021

Background

Cardiovascular events occur more often in winter than in summer; however, the dependence of strokes on various meteorological factors remains unclear.

Aims

The purpose of this meta-analysis was to determine the dependence of the circannual dynamics of hospitalizations for hemorrhagic stroke and ischemic stroke on seasonal fluctuations in meteorological factors.

Summary of review and conclusions

For our meta-analysis, we selected 20 and 26 publications examining the seasonal dynamics of hemorrhagic stroke and ischemic stroke, respectively . The meta-analysis showed that hemorrhagic stroke is less likely to occur in summer than in other seasons and does not depend on a region’s climate. The seasonal dynamics of ischemic stroke are not clearly expressed and are determined by the characteristics of a region’s climate. In a climate without pronounced seasonal dynamics of atmospheric pressure and in wet winters, the vector of ischemic stroke incidents will not be expressed or slightly shifted toward winter. Low atmospheric pressure in summer is associated with an increased likelihood of ischemic stroke during this season compared to winter. There was also a relation between ischemic stroke risk with high relative humidity and a significant decrease in ρO2 in summer, but there is not enough evidence regarding this association. We did not reveal dependence of the seasonal dynamics of strokes on the amplitude of annual fluctuations in air temperature.
Variation of stroke-associated pneumonia in stroke units across England and Wales: A registry-based cohort study
Authors: Chaves MA Lobo , Gittins Matthew , Bray Benjamin , Vail Andy , Smith Craig J
Published: March 2021

Background

Pneumonia is common in stroke patients and is associated with worse clinical outcomes. Prevalence of stroke-associated pneumonia varies between studies, and reasons for this variation remain unclear. We aimed to describe the variation of observed stroke-associated pneumonia in England and Wales and explore the influence of patient baseline characteristics on this variation.

Methods

Patient data were obtained from the Sentinel Stroke National Audit Programme for all confirmed strokes between 1 April 2013 and 31 December 2018. Stroke-associated pneumonia was defined by new antibiotic initiation for pneumonia within the first seven days of admission. The probability of stroke-associated pneumonia occurrence within stroke units was estimated and compared using a multilevel mixed model with and without adjustment for patient-level characteristics at admission.

Results

Of the 413,133 patients included, median National Institutes of Health Stroke Scale was 4 (IQR: 2–10) and 42.3% were aged over 80 years. Stroke-associated pneumonia was identified in 8.5% of patients. The median within stroke unit stroke-associated pneumonia prevalence was 8.5% (IQR: 6.1–11.5%) with a maximum of 21.4%. The mean and variance of the predicted stroke-associated pneumonia probability across stroke units decreased from 0.08 (0.68) to 0.05 (0.63) when adjusting for patient admission characteristics. This difference in the variance suggests that clinical characteristics account for 5% of the observed variation in stroke-associated pneumonia between units.

Conclusions

Patient-level clinical characteristics contributed minimally to the observed variation of stroke-associated pneumonia between stroke units. Additional explanations for the observed variation in stroke-associated pneumonia need to be explored which could reduce variation in antibiotic use for stroke patients.
Does non-implanted electrical stimulation reduce post-stroke urinary or fecal incontinence? A systematic review with meta-analysis
Authors: Cruz Enrique , Miller Charne , Zhang WenWen , Rogers Kathryn , Lee Hsiu-Ju , Wells Yvonne , Cloud Geoffrey C , Lannin Natasha A
Published: March 2021

Background

Urinary and fecal incontinence are disabling impairments after stroke that can be clinically managed with electrical stimulation.

Aim

The purpose of this systematic review was to determine the effectiveness of non-implanted electrical stimulation to reduce the severity of post-stroke incontinence.

Summary of review

Clinical trials of non-implanted electrical stimulation applied for the purposes of treating post-stroke incontinence were searched in MEDLINE, EMBASE, CINAHL, PEDro, and CENTRAL. From a total of 5043 manuscripts, 10 trials met the eligibility criteria ( n = 894 subjects). Nine trials reported urinary incontinence severity outcomes enabling meta-analysis of transcutaneous electrical nerve stimulation (TENS; five trials) and electroacupuncture (four trials). Studies provide good-to-fair quality evidence that TENS commenced <3 months post-stroke has a large effect on urinary continence ( SMD = −3.40, 95% CI −4.46 to −2.34) and a medium effect when commenced >3 months after stroke ( SMD = −0.67, 95% CI −1.09 to −0.26). Electroacupuncture has a large effect when administered >5 times a week ( SMD = −2.32, 95% CI −2.96 to −1.68) and a small effect when administered five times a week ( SMD = −0.44, 95% CI −0.69 to −0.18). Only one trial reported the effect of non-implanted electrical stimulation on post-stroke fecal incontinence.

Conclusions

Published trials evaluating the effect of non-implanted electrical stimulation on post-stroke incontinence are few and heterogenous. Synthesized trials suggest that early and frequent treatment using electrical stimulation is probably more effective than sham or no treatment. Further trials measuring incontinence in an objective manner are required.
Does context matter? Unpacking differences in program quality and developmental experiences across competitive and recreational youth sport
Authors: Bean Corliss , Shaikh Majidullah , Kramers Sara , Forneris Tanya
Published: March 2021

To date, little research has explored differences between competitive and recreational youth sport contexts beyond descriptions of inherent features. The purpose of this exploratory study was to examine if differences existed between competitive and recreational youth sport on (a) observed quality delivery and (b) youth’s perceptions of basic psychological needs satisfaction and developmental experiences. Forty-six youth sport teams participated in the study from competitive ( n = 23) and recreational contexts. This study adopted a multi-method approach of self-report questionnaires and researcher observations. Teams agreed to be involved in observations ( n = 3), questionnaires ( n = 12) or both methods of data collection ( n = 31). Quality was assessed through 216 observations ( n = 134 competitive; Mper team = 6.55), while basic psychological needs satisfaction and developmental experiences were examined through two questionnaires ( N = 413) completed at season end. Descriptive statistics and MANOVAs were calculated for all measures and associated subscales. Results revealed non-significant differences between competitive and recreational programs, despite high scores across the three measures. Significant effects are discussed related to of coaches’ years of coaching experience on program quality and ethnicity ratios on positive developmental experiences. Also discussed are notable effect sizes on opportunities for belonging and choice, where recreational contexts scored higher than competitive on each factor. Results offer understandings of how coach delivery can be enhanced, regardless of context, to optimize developmental benefits for youth. Implications are discussed for how future research can explore the complexities of different sport contexts, including associated coaching practices.
Communication architecture for autonomous passenger ship
Authors: Amro Ahmed , Gkioulos Vasileios , Katsikas Sokratis
Published: March 2021

Novel innovations have been witnessed in the past few years in the field of technology for autonomous vehicles. These have been exploited in various applications in the maritime domain; one such application is the proposal to develop autonomous passenger ships (APS) or ferries for carrying passengers in urban waterways. Such technology requires the integration of several components to support the safe and secure operation of the ferries. In this paper, a communication architecture is proposed, that satisfies pre-established communication requirements and supports autonomous and remotely controlled functions of an APS. The architecture was designed using the Architecture Analysis and Design Language (AADL); this enabled an iterative design process to be followed and allows for future improvements. The proposed architecture is verified by showcasing the role of the different architectural components in addressing the requirements and in supporting the expected functions in a number of operational scenarios based on the expected operations of an APS use case called “Autoferry.” Furthermore, the proposed architecture has been evaluated by demonstrating its ability to achieve the expected performance according to the requirements, in simulated experiments using the network simulator GNS3.
A comparison of hazard analysis methods capability for safety requirements generation
Authors: Zikrullah Nanda Anugrah , Kim Hyungju , van der Meulen Meine JP , Skofteland Gunleiv , Lundteigen Mary Ann
Published: March 2021

A safety-critical system comprising several interacting and software-intensive systems must be carefully analyzed to detect whether new functional requirements are needed to ensure safety. This involves an analysis of the systemic properties of the system, which addresses the effect of the interaction between systems and system parts. The paper compares two hazard analysis methods, which are often considered well-suited for such software-intensive systems: the Functional Hazard Analysis (FHA) and Systems-Theoretic Process Analysis (STPA). The focus is on the selection and improvement of the best methods, based on the lesson learned from the comparison of FHA and STPA. The analyses cover the hazard analysis processes, systemic properties, and the criteria of requirements. The paper concludes that STPA is the better choice over FHA. Insights are obtained to align both STPA and FHA methods with the broader topic on risk management, that is, hazard analysis method improvement, cautionary thinking, uncertainty management, and resilience management.
Reviewing the evidence for shockwave- and cell-based regenerative therapies in the treatment of erectile dysfunction
Authors: Drury Robert , Natale Caleb , Hellstrom Wayne J. G.
Published: March 2021

Erectile dysfunction (ED) is both a common and complex disease process. Existing ED treatments do not always achieve adequate results. There is clinical interest in employing regenerative therapies, including low-intensity extracorporeal shockwave therapy (Li-ESWT), platelet rich plasma (PRP), and stem cell therapy (SCT), in the treatment of ED as adjunct or alternative treatments. Here, we present evidence for emerging shockwave- and cell-based regenerative therapies for the treatment of ED following a thorough review of the existing PubMed literature pertaining to Li-ESWT, PRP, and SCT in relation to the treatment of ED. Li-ESWT causes microtrauma in tissue that hypothetically upregulates angiogenesis and recruits stem cells. Several large-scale systematic reviews and meta-analyses have reported that Li-ESWT improved ED in humans. Additionally, evidence has commenced to show that Li-ESWT may be effective against two recognized and complex etiologies of ED: diabetic and neurogenic. PRP delivers an autologous sample rich in growth factors to damaged tissue. Animal model studies have demonstrated improved erectile function recovery as well as preservation of cavernous nerve axons. Studies with PRP in humans are limited. SCT utilizes the regenerative potential of stem cells for healing of damaged tissue. In the treatment of ED, SCT has been used in the setting of diabetic and post-prostatectomy ED. Results of human studies are varied, although SCT treatments did result in increased erectile rigidity with some patients recovering the ability to achieve penetration. While these regenerative therapies show potential to augment the current treatment regimen for ED, there is a paucity of evidence to support the safety and efficacy of these treatments. Further research is necessary to define the role of these alternative therapies in the treatment of ED.
Creating Loyal Prosocial Transformative Service Consumers: A Proposed Model With Direct and Indirect Effects
Authors: Mulcahy Rory , Russell-Bennett Rebekah , Previte Jo
Published: March 2021

Understanding transformative services, where the consumer is not the primary well-being beneficiary, is fundamental to furthering the transformative service research (TSR) paradigm. Furthermore, it is imperative to understand the co-creation behaviors consumers can partake in during prosocial transformative services to improve their service experience and, ultimately, their repeat usage of the service. This study is one of the first to develop a model drawing together three key service frameworks (co-creation behavior, service quality, and consumer value), which is empirically validated using real consumers of a prosocial transformative service, namely blood donation. In addition, a key strength of the study is the objective measurement of behavioral loyalty using organizational records, which is an important extension to prior TSR studies that often measure attitudinal loyalty (behavioral intentions) as a proxy. The findings have important implications for furthering transformative scholars’ and practitioners’ understanding of how services can improve individual and societal well-being.
The Rise of Deepfakes: A Conceptual Framework and Research Agenda for Marketing
Authors: Whittaker Lucas , Letheren Kate , Mulcahy Rory
Published: March 2021

Deepfakes, digital content created via machine learning, a form of artificial intelligence technology, are generating interest among marketers and the general population alike and are often portrayed as a “phantom menace” in the media. Despite relevance to marketing theory and practice, deepfakes—and the opportunities for benefit or deviance they provide—are little understood or discussed. This article introduces deepfakes to the marketing literature and proposes a typology, conceptual framework, and associated research agenda, underpinned by theorizing based on balanced centricity, to guide the future investigation of deepfakes in marketing scholarship. The article makes an argument for balance (i.e., situations where all stakeholders benefit), and it is hoped that this article may provide a foundation for future research and application of deepfakes as “a new hope” for marketing.
Injuries of the Peripheral Mandibular Nerve, Evaluation of Interventions and Outcomes: A Systematic Review
Authors: Weyh Ashleigh , Pucci Resi , Valentini Valentino , Fernandes Rui , Salman Salam
Published: March 2021

Trigeminal nerve injuries are common and there is currently no consensus on both timing and type of intervention to achieve the best outcomes. A systematic review was performed to compare the outcomes of the many different types of therapeutic interventions for nerve injury. PubMed, EBSCO, and Cochrane Review databases were used to search for studies published from January 1, 2000 to December 31, 2019. Included studies detailed treatment of an injury to peripheral branches of the trigeminal nerve, either known transection or injury causing persistent alteration in sensation. The primary outcome was functional sensory recovery via the Medical Research Council scale. Twenty studies were included, detailing outcomes of 608 subjects undergoing intervention for 622 nerve injuries. Surgical interventions were able to achieve functional sensory recovery in approximately >80% or more of the subjects. There was heterogeneity among how procedures were performed, timing to intervention, and methods of measuring recovery. The data of this study supports the ability of surgical intervention to achieve functional sensory recovery in a significant number of subjects, and found evidence for better outcomes with intervention closer to the time of injury.
The Journey of the Lingual Artery from the Neck to the Oral Cavity: A Cadaveric Study
Authors: Sarna Krishan , Sonigra Khushboo Jayant , Amuti Thomas , Kamau Martin , Ngeow Wei Cheong , Mandela Idenya Pamela
Published: March 2021

Study Design:

Descriptive cross-sectional.

Objective:

The origin of the lingual artery (LA) has been well studied due to its implication in neck dissection, but the course thereafter to the oral cavity is less described. This cadaveric study traced the journey of the LA from the external carotid artery to its terminal branches in the tongue.

Methods:

Following bilateral neck dissections in 35 black Kenyan cadavers, the incidence of Beclard’s, Lesser’s and Pirogoff’s triangles, the types of LA origin with its length, relationship to the hyoglossus muscle and anastomosis with other vessels were documented.

Results:

Beclard’s triangle was found in 64 dissections (91.42%), Lesser’s in 46 dissections (65.71%) and Pirogoff’s in 39 dissections (55.71%). The LA presented either as a solitary branch (67.15%) or as a branch of either the linguofacial (LFT–24.29%), thyrolingual (TLT–2.72%) or thyrolinguofacial (TLFT–2.86%) trunk. The solitary LA was the longest at 6.93 mm, followed by the TLT branch (6.58 mm), LFT branch (6.12 mm) and TLFT branch (5.65 mm). The majority of solitary LA and LA branches of LFT and TLFT passed through the hyoglossus, while all LA branches of the TLT coursed medial to the muscle. All variants of LA have been found to anastomose with the submental artery (SMA) at frequencies that ranged from 11.10% to 100%.

Conclusions:

The LA was found in all cadavers and all Beclards’ triangles. There is a significant incidence of LFT and TLFT variants in the Kenyan population. The LA passed either through or medial to the hyoglossus with no lateral relationship being observed.
Medical Malpractice Allegations in Nasal Turbinate Surgery
Authors: Coppess Steven M. , Weymuller Sims G. , Davis Greg E.
Published: March 2021

Background

Despite studies showing most patients significantly improve their nasal congestion with surgical management of nasal turbinates, not all achieve acceptable results. Rarely, patients report substantial worsening of symptoms leading to litigation risk.

Objective

Document the United States medicolegal environment for nasal turbinate surgery.

Methods

We searched the Westlaw database for turbinate related terms for 1987- July 2019, recording demographics, claims, legal arguments, and outcomes in legal cases related to nasal turbinate surgery. We assessed prevalence and correlations with case outcomes.

Results

Of the 39 cases identified, the most common complaint was nose/facial pain (53.8% of cases). Surgeons prevailed in 87.2% of cases, with total liabilities of $3,224,606 [mean $97,715.3, ±$283,900.8]. Surgeons had statistically significant favorable outcomes when patients claimed dryness, headache, congestion, crusting, breathing problems, and disfigurement (all p < 0.05). Revision surgery was indicated in 23.1% of cases and was claimed in 40.0% of patient awards. Surgical negligence was claimed in 40.0% of patient awards versus 67.9% of surgeon awards (p = 0.333). Lack of informed consent was claimed in 20.0% of patient awards versus 32.1% of surgeon awards (p = 0.601).

Conclusions

There are inherent litigation risks for surgeons when performing nasal turbinate surgery. Most claims against surgeons, are resolved in favor of the surgeon. Understanding the types of claims and legal arguments that are made by patients could help assessing the risks of a proposed litigation. Documenting clear indications for surgery and written informed consent may reduce litigations against surgeons.
Clinical approaches to treat impaired awareness of hypoglycaemia
Authors: Farrell Catriona M. , McCrimmon Rory J.
Published: March 2021

Impaired awareness of hypoglycaemia (IAH) affects between 25% and 30% of all people with type 1 diabetes (T1D) and markedly increases risk of severe hypoglycaemia. This greatly feared complication of T1D impairs quality of life and has a recognised morbidity. People with T1D have an increased propensity to hypoglycaemia as a result of fundamental physiological defects in their ability to respond appropriately to a fall in blood glucose levels. With repeated exposure to low glucose, many then develop a condition referred to as IAH, where there is a reduced ability to perceive the onset of hypoglycaemia and take appropriate corrective action. The management of individuals with IAH relies initially on its identification in the clinic through a detailed exploration of the frequency of hypoglycaemia and an assessment of the individual’s ability to recognise these episodes. In this review article, we will address the clinical strategies that may help in the management of the patient with IAH once identified, who may or may not also suffer from problematic hypoglycaemia. The initial focus is on how to identify such patients and then on the variety of approaches involving educational programmes and technological approaches that may be taken to minimise hypoglycaemia risk. No single approach can be advocated for all patients, and it is the role of the health care professional to identify the clinical strategy that best enables their patient to achieve this goal.
Dapagliflozin improves cardiovascular risk factors in Emirati patients with T2DM
Authors: Nada Aml Mohamed , Younan Mariam Adel
Published: March 2021

Background:

Dapagliflozin is a sodium–glucose co transporter-2 inhibitor that proved efficacy in reduction of blood glucose level through extrusion of glucose in urine. It is used in treatment of type 2 diabetes mellitus (T2DM). It also has reported cardiovascular and renal benefits in patients with T2DM. Data are very limited about its effects in Emirati patients with diabetes. Our aim was to evaluate dapagliflozin treatment in Emirati patients with T2DM.

Patients and methods:

This is a retrospective study involving 89 diabetes patients who were using dapagliflozin 10 mg once daily as add-on therapy for 12 months. All patients had T2DM, aged over 18 years and had an estimated glomerular filtration rate (eGFR) over 60 ml/min/1.73 m². Body weight, height, body mass index, sitting blood pressure and heart rate were collected. Fasting plasma glucose, glycosylated hemoglobin (HbA1c), lipid profile and other available biochemical parameters, for example, creatinine, blood urea nitrogen, and urine albumin/creatinine ratio were traced from medical records and eGFR was calculated.

Results:

Patients were aged 62.3 ± 9.4 years with a median duration of diabetes of 15 (10–20) years. Data were analyzed before, at 6 months and 12 months of treatment. Fasting plasma glucose, HbA1c, body mass index, systolic and diastolic blood pressure significantly decreased ( p = 0.002, p < 0.0005, p < 0.002, p < 0.0005, p < 0.0005, respectively). The median reduction of HbA1c was 0.7% (0.2–1.2) and 0.9% (0.5–1.8) at 6 and 12 months, respectively. Systolic blood pressure decreased by a median of 7 mmHg (4–20 mmHg) and 9 mmHg (1–10 mmHg) on the 6th and 12th month of treatment, respectively, while the diastolic decreased by a median of 3 mmHg (4 to 10 mmHg) and 6 mmHg (1–10 mmHg); without increase in heart rate ( p = 0.188). A significant reduction of body mass index, C-reactive protein and rate pressure product was noticed ( p = 0.002, p = 0.001, p < 0.0005, respectively). No decline in eGFR or microalbuminuria was noticed. Stage I chronic kidney disease with eGFR < 90 ml/min/1.73 m² showed continuous progressive reduction of HbA1c without a significant change in other variables.

Conclusion:

Our data indicate improved cardiovascular risk profile in dapagliflozin-treated Emirati patients with T2DM.
Metformin reduces 12-month change in body weight among people newly commenced on clozapine: a retrospective naturalistic cohort study
Authors: Spokes Jessica , Hollingworth Samantha , Winckel Karl , Kisely Steve , Baker Andrea , Cosgrove Peter , Siskind Dan
Published: March 2021

Background:

People with schizophrenia have a 15–20-year reduction in life expectancy, driven in part by the metabolic effects of antipsychotics. Clozapine is associated with the highest rates of weight gain. As clozapine remains the most effective antipsychotic for treatment-resistant schizophrenia (TRS), identifying treatments to ameliorate clozapine-induced weight gain (CIWG) is urgently needed to reduce this morality gap.

Methods:

We retrospectively analysed digital health records of patients with TRS aged 18–65 newly initiated on clozapine at four tertiary hospitals in south-east Queensland from 1 March 2017 to 30 June 2019. Our primary outcome was the effect of metformin on change in percentage bodyweight at 12 months after clozapine initiation, with secondary outcome being proportion with >5% or >7% bodyweight change. We also explored impact on bodyweight change of other variables including sex, tobacco smoking, type 2 diabetes (T2DM), age, clozapine level and dose and clozapine/norclozapine ratio.

Results:

Among 90 patients initiated on clozapine, metformin use ( n = 48) was associated with a smaller increase in percentage bodyweight (1.32% versus 5.95%, p = 0.031), lower rates of >7% gain in bodyweight (37.8% versus 63.0%, p = 0.025) but not >5% gain in bodyweight. Age below the median (32.0 years) was associated with greater bodyweight gain (5.55% versus 1.22%, p = 0.046). Sex, tobacco smoking, T2DM, clozapine dose and level and clozapine/norclozapine ratio were not associated with differences in change in bodyweight.

Conclusion:

In this small retrospective cohort study, use of metformin within 12-months of clozapine initiation was associated with a statistically and clinically significant reduction in CIWG. Although there is increasing evidence for the role of metformin to ameliorate bodyweight gain at time of clozapine initiation, our findings need replication and testing in a randomised controlled trial before recommending metformin co-commencement with clozapine as standard clinical practice.
Hamlet’s augury: how to manage discontinuation of mood stabilizers in bipolar disorder
Authors: Qureshi Mutahira M. , Young Allan H.
Published: March 2021

Research has generated good quality evidence about the treatment and management of bipolar disorder in acute and, to some degree, sub-acute/continuation phases. This has informed various guidelines about the treatment and management of bipolar disorder (BD). However, for the long-term or maintenance phase of illness, most guidelines peter out and, in the absence of sufficiently high-quality research evidence, remain vague. This is particularly evident for the important clinical question of discontinuing mood stabilizing pharmacological agents after a period of remission has been achieved. The aim of this review is to put together current existing evidence about discontinuing mood stabilizers after a period of remission in order to come up with a structured and coherent strategy for managing such discontinuation and to make recommendations for future research. To this end, we reviewed the main relevant treatment guidelines and subsequent evidence following the publication of these guidelines. The current recommended long-term treatment of BD is usually considered within the same principles applicable to any chronic health condition (e.g. hypertension or diabetes) where the focus is on continuing treatment at minimum effective medication dose often life-long, switching to alternative choice of medication due to side-effects and very few, if any, indications for complete cessation. However, in the absence of strong evidence on long-term treatment and the high rate of non-concordance in BD, medication discontinuation is a very important aspect of the treatment that should be given due consideration at every aspect of the treatment.
What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications
Authors: Framer Adele
Published: March 2021

Although psychiatric drug withdrawal syndromes have been recognized since the 1950s – recent studies confirm antidepressant withdrawal syndrome incidence upwards of 40% – medical information about how to safely go off the drugs has been lacking. To fill this gap, over the last 25 years, patients have developed a robust Internet-based subculture of peer support for tapering off psychiatric drugs and recovering from withdrawal syndrome. This account from the founder of such an online community covers lessons learned from thousands of patients regarding common experiences with medical providers, identification of adverse drug reactions, risk factors for withdrawal, tapering techniques, withdrawal symptoms, protracted withdrawal syndrome, and strategies to cope with symptoms, in the context of the existing scientific literature.
Instagram Dentistry
Authors: Ooi Hui Lynn , Kelleher Martin G.D.
Published: March 2021

Instagram, a photo and video social networking site, is gaining popularity in the dental world and it is easy to see why this is so. Instagram’s potential to share information in an engaging way allows dental professionals to share clinical work and provides a unique way of learning.

Advertising on Instagram has blossomed. Some of this is for self-promotional reasons, for practice building, or for marketing of new techniques and products by manufacturers. One ought to be cautious about the implications of some patients’ quest for ‘dental perfection’. That is especially the case when destructive dentistry is being undertaken by dentists trying to replicate what they have seen on Instagram in potentially much more challenging patients. Some of those demanding patients request very ambitious treatments with sometimes hugely unrealistic expectations. Arguably, Instagram could be the new major trend in dentistry.
Effect of Vital Bleaching on Micromorphology of Enamel Surface: an in Vitro Study
Authors: Karimi Zakaria , Saoui Houda , Sakout Majid , Abdallaoui Faiza
Published: March 2021

Objectives:

The aims of this in vitro study was to investigate the effects of bleaching agents commonly used in micromorphology of the enamel surface and to assess the effect of concentration and of adding fluoride in the bleaching agents.

Methods:

Sixty freshly extracted intact teeth were stored in distilled water. One half of each tooth was served as control, the other part was treated with bleaching agent. Samples were randomly divided into six groups of ten, according to the bleaching agents: G1- at-home-CP10; G2- at-home-CP16; G3- at-home-CP22; G4- in-office-CP35; G5- in-office-HP40 with fluoride; G6- in-office-HP40 without fluoride. Enamel specimens for each group were then submitted to a quantitative scanning electron microscopy. Number of pores and their diameter were measured to assess porosity of enamel surface.

Results:

SEM analysis revealed enamel surface porosity after bleaching. Significant increase in number and major diameter of pores in bleached samples (p<0.001) were observed. The comparison between samples treated with 10% PC and samples treated with 22% PC showed significant increase in number of pores (p=0.006) and major diameter (p=0.001) from samples treated with 22% PC. Statistical analyses showed significant increase in the number of pores (p=0.006) from samples treated with 40% HP without fluoride compared to samples treated with 40% HP containing fluoride.

Conclusions:

Bleaching products with low concentration cause less porosity at surface of the enamel compared to concentrated products. Adding fluoride in the bleaching agent appears to reduce porosity of enamel surface.
Treatment of Tooth Wear Associated with Reduced Occlusal Vertical Dimension Using Direct Composite Restorations and a Removable Prosthesis
Authors: Caga Daniel , Lewis Nicholas
Published: March 2021

Tooth wear is increasing in prevalence within the United Kingdom. Treatment of tooth surface loss can be daunting for both the clinician and patient. However, use of additive resin composite restorations is a minimally invasive treatment modality. This case illustrates the treatment of tooth surface loss in both the maxillary and mandibular arches with direct composites restorations using putty indices generated from a diagnostic wax-up recorded in centric relation. The tooth surface loss had resulted in reduced restorative space on the right hand side. The restorative treatment involved increasing the anterior vertical dimension, enabling the provision of a cobalt-chrome partial denture. This case shows the restoration of form, function and aesthetics using a reorganised occlusal approach.
Safeguarding: Doing the Difficult Thing
Authors: Offen Elizabeth
Published: March 2021

As dentists, we are well positioned to detect signs of abuse. Though many practitioners are aware of their duty to report concerns, multiple barriers to referral still exist. This article defines abuse, safeguarding and our role as dental healthcare professionals. It provides an overview of the types of abuse and signs that raise concern.

Uncertainty over the findings was highlighted as the most common barrier to referral. This article provides an overview of the referral process. Regular training is recommended to improve familiarisation with the safeguarding procedure. Furthermore, discussing concerns with colleagues when uncertain can provide reassurance to the referring practitioner. Additional barriers include fear of the consequences to the patient, fear of implications for the practice, and time pressures. By focusing on preparation and a supportive environment, we can reduce the influence of these barriers.

Although raising concerns can be stressful, there are many resources available to support dental healthcare professionals. The key focus must be the wellbeing and safety of the vulnerable patient. Your referral may help the patient and family access the support they need.
Developing a Patient Safety Culture in Primary Dental Care
Authors: Bailey Edmund , Dungarwalla Mohammed
Published: March 2021

Patient safety should be at the heart of any healthcare service. Systems, teams, individuals and environments must work in tandem to strive for safety and quality. Research into patient safety in dentistry is still in the early stages. The vast majority of the research in this area has originated from the secondary care and academic fields. Approximately 95% of dental care is provided in the primary care sector. In this paper, we provide an overview of the evidence base for patient safety in dentistry and discuss the following aspects of patient safety: human factors; best practice; the second victim concept; potential for over-regulation and creating a patient safety culture. Through discussion of these concepts, we hope to provide the reader with the necessary tools to develop a patient safety culture in their practice.
Facts and Fallacies About Occlusal Philosophies for Full Mouth Rehabilitation
Authors: Kelleher Martin G.D. , Ooi Hui Lynn , Blum Igor R.
Published: March 2021

This article reviews various full mouth rehabilitation occlusal concepts along with their main beliefs and controversies. Many of those occlusal teachings were well-meant at the time they were introduced. However, closer examination reveals that many of them involved serious destruction of sound tooth tissue – without delivering many of their purported benefits.

The biologic and structural disadvantages of ‘subtractive’ dental procedures, which were, and still are, undertaken to provide traditional full mouth rehabilitation are discussed. Those approaches are contrasted with the proven advantages of minimally destructive additive techniques, which can solve frequently encountered clinical problems previously deemed to require traditional ‘full mouth rehabilitations’. Pragmatic clinical cases are used to illustrate how to solve common clinical problems by using minimally destructive means, without causing structural damage to residual sound tooth tissue.
Metformin: The next angiogenesis panacea?
Authors: Ren Yu , Luo Hua
Published: March 2021

Angiogenesis, the development of new blood vessels from existing ones, is a critical process in wound healing and skeletal muscle hypertrophy. It also leads to pathological conditions such as retinopathy and tumor genesis. Metformin, the first-line treatment for type 2 diabetic mellitus, has a specific regulatory effect on the process of angiogenesis. Anti-angiogenesis can inhibit the occurrence and metastasis of tumors and alleviate patients’ symptoms with polycystic ovary syndrome. Moreover, promoting angiogenesis effect can accelerate wound healing and promote stroke recovery and limb ischemia reconstruction. This review reorganizes metformin in angiogenesis, and the underlying mechanism in alleviating disease to bring some inspiration to relevant researchers.
Effectiveness of a health and social care integration programme for home-dwelling frail older persons in Argentina
Authors: Perman Gastón , Prevettoni Mariana , Guenzelovich Tami , Schapira Marcelo , Infantino Verónica Martínez , Ramos Roxana , Saimovici Javier , Gallo Cristian , Ferré María Florencia Cunha , Scozzafava Silvana , Hornstein Lucila , Garfi Leonardo
Published: March 2021

Introduction

The evidence of effectiveness of integrated care initiatives for home-dwelling frail older persons is still inconclusive. There is a need for more studies, especially in developing countries. Our objective was to assess the effectiveness of a health and social care integration programme versus the best standard of care to date in this population.

Methods

Quasi-experimental study performed in patients' homes in Buenos Aires, Argentina. The intervention arm had a health and social care counsellor that systematically reviewed the social and biological situation following a structured process, evaluating: functionality, nutrition, mobility, pain, cognition, medication reconciliation and adherence, need for care, quality of care, and environmental safety. The control group received the best standard of care to date, with access to the same health or social care services, but without the counsellor and related processes. The main outcome was the adjusted hazard ratio for hospitalizations after one year using a Cox-proportional hazards model.

Results

We recruited 121 persons in each group. The crude hazard ratio for hospital admissions, comparing the intervention to the control group was 0.622 (95% CI: 0.427–0.904; p = 0.013). The adjusted hazard ratio (aHR) was 0.503 (95% CI: 0.340–0.746; p = 0.001). The aHR for death was 0.993 (95% CI: 0.492–2.002; p = 0.984). The absolute difference in the quality of life was 16.59 points (95% CI: 12.03–21.14; p < 0.001).

Discussion

The integration programme had lower hospital admissions and better quality of life than the usual care. There was no significant difference in death rates.
The Association Between Estimated Glomerular Filtration Rate and Hospitalization for Fatigue: A Population-Based Cohort Study
Authors: Farragher Janine F. , Zhang Jianguo , Harrison Tyrone G. , Ravani Pietro , Elliott Meghan J. , Hemmelgarn Brenda
Published: March 2021

Background:

Fatigue is a pervasive symptom among patients with chronic kidney disease (CKD) that is associated with several adverse outcomes, but the incidence of hospitalization for fatigue is unknown.

Objective:

To explore the association between estimated glomerular filtration rate (eGFR) and incidence of hospitalization for fatigue.

Design:

Population-based retrospective cohort study using a provincial administrative dataset.

Setting:

Alberta, Canada.

Patients:

People above age 18 who had at least 1 outpatient serum creatinine measurement taken in Alberta between January 1, 2009, and December 31, 2016.

Measurements:

The first outpatient serum creatinine was used to estimate GFR. Hospitalization for fatigue was identified using International Classification of Diseases, Tenth Revision (ICD-10) code R53.x.

Methods:

Patients were stratified by CKD category based on their index eGFR. We used negative binomial regression to determine if there was an increased incidence of hospitalization for fatigue by declining kidney function (reference eGFR ≥ 60 mL/min/1.73m2). Estimates were stratified by age, and adjusted for age, sex, socioeconomic status, and comorbidity.

Results:

The study cohort consisted of 2 823 270 adults, with a mean age of 46.1 years and median follow-up duration of 6.0 years; 5 422 hospitalizations for fatigue occurred over 14 703 914 person-years of follow-up. Adjusted rates of hospitalization for fatigue increased with decreasing kidney function, across all age strata. The highest rates were seen in adults on dialysis (adjusted incident rate ratios 24.47, 6.66, and 3.13 for those aged 18 to 64, 65 to 74, and 75+, respectively, compared with eGFR ≥ 60 mL/min/1.73m2).

Limitations:

Fatigue hospitalization codes have not been validated; reference group limited to adults with at least 1 outpatient serum creatinine measurement; remaining potential for residual confounding.

Conclusions:

Declining kidney function was associated with increased incidence of hospitalization for fatigue. Further research into ways to address fatigue in the CKD population is warranted.

Trial Registration:

Not applicable (not a clinical trial).
Haematomyelia and myelomalacia following an inadvertent thoracic intraspinal injection in a cat
Authors: Dutil Guillaume F , Schweizer Daniela , Oevermann Anna , Stein Veronika M , Maiolini Arianna
Published: March 2021

Case summary

A 4-month-old cat was presented with acute paraplegia after the referring veterinarian performed a subcutaneous injection (cefovecin and dexamethasone) in the caudodorsal thoracic area, during which the cat suddenly became uncooperative. A complete neurological examination performed 1 day after the injection revealed paraplegia without deep pain perception and reduced segmental spinal reflexes in the pelvic limbs. Findings were consistent with either an L4–S3 myelopathy or a T3–L3 myelopathy with subsequent spinal shock. MRI showed swelling of the spinal cord from T1 to L1 with heterogeneous T2-weighted intramedullary hyperintensity and no contrast enhancement. A centrally located intraspinal signal void was visible in T2*-weighted images. These changes were compatible with a suspected traumatic intraspinal injection. Despite intensive supportive care over 4 days, neurological status did not improve and the cat was euthanased. Gross pathology findings revealed severe intramedullary haemorrhage and myelomalacia in the T10–L1 spinal cord segments. Histopathology of the spinal cord after haematoxylin and eosin staining revealed a severe intramedullary space-occupying haemorrhage with focal malacia. A trajectory-like, optically empty cavity containing some eosinophilic droplets at the edges was detected. Although no further evidence of trauma was noted in the surrounding structures, the spinal cord changes were compatible with a perforating trauma.

Relevance and novel information

To our knowledge, this is the first report of thoracic intraspinal injection causing myelomalacia defined by an ante-mortem MRI and confirmed post mortem by histopathology. The traumatic myelopathy appeared to be most compatible with an intraspinal injection causing vascular rupture.