bluuebunny/crossref_metadata_2025 huggingface dataset:
17β-estradiol vaginal tablet versus conjugated equine estrogen vaginal cream to relieve menopausal atrophic vaginitis
Authors: Rioux Jacques Emile , Devlin M. Corinne , Gelfand Morrie M. , Steinberg Wilfred M. , Hepburn Douglas S.
Published: October 2018

Objectives:

The efficacy and safety of 25-μg 17β-estradiol vaginal tablets (Vagifem) were assessed and compared with 1.25-mg conjugated equine estrogen vaginal cream (Premarin Vaginal Cream) for the relief of menopausal-derived atrophic vaginitis, resulting from estrogen deficiency.

Design:

In a multicenter, open-label, randomized, parallel-group study, 159 menopausal women were treated for 24 weeks with either vaginal tablets or vaginal cream. Efficacy was evaluated by relief of vaginal symptoms and concentrations of serum estradiol and follicle-stimulating hormone. Safety was monitored by the incidence of adverse events, evaluation of endometrial biopsies, and clinical laboratory results. Patients also assessed the acceptability of the study medications.

Results:

Composite scores of vaginal symptoms (dryness, soreness, and irritation) demonstrated that both treatments provided equivalent relief of the symptoms of atrophic vaginitis. At weeks 2, 12, and 24, increases in serum estradiol concentrations and suppression of follicle-stimulating hormone were observed in significantly more patients who were using the vaginal cream than in those who were using the vaginal tablets (p < 0.001). Fewer patients who were using the vaginal tablets experienced endometrial proliferation or hyperplasia compared with patients who were using the vaginal cream. Significantly more patients who were using the vaginal tablets rated their medication favorably than did patients who were using the vaginal cream (p ≤ 0.001). Patients who were receiving the vaginal tablets also had a lower incidence of patient withdrawal (10% versus 32%).

Conclusions:

Treatment regimens with 25-μg 17β-estradiol vaginal tablets and with 1.25-mg conjugated equine estrogen vaginal cream were equivalent in relieving symptoms of atrophic vaginitis. The vaginal tablets demonstrated a localized effect without appreciable systemic estradiol increases or estrogenic side effects. Vaginal tablet therapy resulted in greater patient acceptance and lower withdrawal rates compared with vaginal cream therapy.
Estrogen effects on arteries vary with stage of reproductive life and extent of subclinical atherosclerosis progression
Authors: Clarkson Thomas B.
Published: October 2018

The past several years have been marked by confusion and controversy concerning whether estrogens are cardioprotective. The issue is of utmost public health importance because coronary heart disease (CHD) remains the leading cause of death among postmenopausal women. Fortunately, a unifying hypothesis has emerged that reproductive stage is a major determinant of the effect of estrogens on atherosclerosis progression, complications, and plaque vulnerability.

Premenopausal Years:

Premenopausal atherosclerosis progression seems to be an important determinant of postmenopausal atherosclerosis and thus the risk for CHD. Clearly, plasma lipids/lipoproteins influence this progression; however, estradiol deficiency seems to be the major modulator. Both monkeys and women with premenopausal estrogen deficiency develop premature atherosclerosis, an effect that can be prevented in both species by estrogen-containing oral contraceptives.

Perimenopausal/Early Postmenopausal Years:

During this stage, there are robust estrogen benefits. Monkeys given estrogens immediately after surgical menopause have a 70% inhibition in coronary atherosclerosis progression. Estrogen treatment prevented progression of atherosclerosis of women in the Estrogen in the Prevention of Atherosclerosis Trial. A meta-analysis of women younger than 60 years given hormone therapy had reduced total mortality (relative risk = 0.61, 95% CI: 0.39-0.95).

Late Postmenopausal Years:

This stage is one in which there are no or possible deleterious estrogen effects. Monkeys lose CHD benefits of estrogens when treatment is delayed. The increase in CHD events associated with initiating hormone therapy 10 or more years after menopause seems to be related to up-regulation of the plaque inflammatory processes and plaque instability and may be down-regulated by statin pretreatment.
Diagnostic Stability in Bipolar Disorder: A Narrative Review
Authors: Cegla-Schvartzman Fanny B. , Ovejero Santiago , López-Castroman Jorge , Baca-García Enrique
Published: October 2018

Learning objectives

After participating in this activity, learners should be better able to:

• Evaluate diagnostic stability in bipolar disorder

• Analyze the factors contributing to diagnostic stability

Objective

Diagnostic stability is the degree to which a diagnosis remains unchanged during follow-up. It is an important measure of predictive validity in bipolar disorder (BD). In this study, we review the literature concerning diagnostic stability in BD, analyze the factors contributing to diagnostic stability, and describe the implications of diagnostic boundaries and diagnostic delay.

Methods

A comprehensive literature search of MEDLINE and EMBASE databases was conducted, including all studies published from 1980 to 2016, to evaluate the diagnostic stability of BD. Thirty-seven articles were included: 6 focusing mainly on BD, 18 on psychotic disorders, 10 on depression, and 3 on diagnostic stability in psychiatric disorders in general. Data analysis was performed in standardized fashion using a predefined form.

Results

Despite a high variability of the methodological approaches taken, an acceptable degree of diagnostic stability was found. The most common criteria for evaluating diagnostic stability were prospective consistency and retrospective consistency. The mean prospective and retrospective consistencies were 77.4% and 67.6%, respectively. A large majority of studies were performed in Europe or in North America (67.5%), compared to 21.6% in Asia and only 10.8% in Africa, Oceania, and South America. Extreme ages, female gender, psychotic symptoms, changes to treatment, substance abuse, and family history of affective disorder have been related to diagnostic instability.

Conclusions

Several factors appear to have a negative impact on the diagnostic stability, but the evidence is insufficient to draw any robust conclusions. Nevertheless, despite variable prospective and retrospective consistencies, the overall diagnostic stability is good. Standardized methods need to be used to obtain more accurate assessments of stability.
Preventing Central Line-Associated Bloodstream Infections in the Intensive Care Unit: Application of High-Reliability Principles
Authors: McCraw Beth , Crutcher Terri , Polancich Shea , Jones Pam
Published: October 2018

This department column highlights translation of research into healthcare quality practice. Achieving the highest quality in healthcare requires organizations to understand care delivery and to proactively mitigate risks in care delivery processes. The purpose of this article is to describe a quality initiative that used principles of high reliability to develop a zero tolerance culture for central line–associated bloodstream infections in an intensive care unit at an independent, nonprofit acute care community hospital.
Assessment of Maternal Knowledge and Confidence About Abusive Head Trauma and Coping With Infant Crying Before and After Infant Safety Education in the Neonatal Intensive Care Unit
Authors: Rabbitt Angela L. , Bretl Deborah , Parker Matthew , Yan Ke , Zhang Liyun
Published: October 2018

Infants with a history of perinatal illness are at higher risk for abusive head trauma (AHT). Crying is a common trigger for physical abuse, and education on coping with infant crying is an important component of AHT prevention. This study assesses the effects of education in the neonatal intensive care unit (NICU) on mothers' knowledge about AHT and infant crying, self-efficacy in applying the education to infant cares and providing the education to others, and the quality of AHT and infant crying education after discharge. Mothers received a standardized education program about AHT and infant crying and completed a preeducation survey, posteducation survey, and 4- to 5-month follow-up survey. Overall, there was a sustained increase in knowledge (P < .001) and confidence (P < .001). Mothers who received verbal education reported a higher increase in confidence (P = .03). Few received information from healthcare providers about crying (35%) and AHT (20%) after discharge. At follow-up survey, most felt highly confident in their ability to share information about AHT (97%) and calm their infant (95%). Most had shared the education with others (77%). Education on AHT and crying in the NICU can produce sustained increases in mothers' knowledge and confidence, but the effectiveness may be improved by addressing unique barriers to education in this population.
A case report of granulomatous polyangiitis complicated by tuberculous lymphadenitis
Authors: Iijima Yuki , Kobayashi Yoichi , Uchida Yoshinori , Tsutsui Toshiharu , Kakizaki Yumiko , Naganuma Tsukasa , Tsukamoto Katsuhiko , Oyama Toshio , Miyashita Yoshihiro
Published: October 2018

Rational:

Granulomatous polyangiitis (GPA) is a type of vasculitis involving medium and small arteries, typically affecting the upper and lower respiratory tract with coexisting glomerulonephritis. GPA is also characterized by necrotizing granulomatous inflammation and the presence of antineutrophil cytoplasm antibodies (ANCA). So far, various infections have lead to elevation of titers of serum ANCA, making it difficult to diagnose.

Patient Concerns:

We report a 50-year-old woman who was diagnosed as tuberculous lymphadenitis. During the treatment by anti-tuberculosis (TB) drugs, rapidly progressive renal failure and pleurisy had appeared with elevated titer of PR3-ANCA. Renal biopsy revealed crescentic glomerulonephritis.

Diagnosis:

Renal biopsy revealed crescentic glomerulonephritis and diagnosis of GPA was made.

Interventions:

Steroid therapy had been started with continuation of anti-TB drugs.

Outcomes:

Renal dysfunction had gradually recovered and pleurisy had disappeared with decreasing titer of PR3-ANCA.

Lessons:

This is the first report of GPA complicated by TB infection. When we encounter a case with rapidly progressive renal failure during the TB infection, complication of GPA should be suspected as 1 of the different diagnosis.
The association of high D-dimer level with high risk of ischemic stroke in nonvalvular atrial fibrillation patients
Authors: You Li-Rui , Tang Mei
Published: October 2018

This study aimed to explore the relationship of D-dimer level with the risk stratification of ischemic stroke, and determine whether high D-dimer levels could be used as a risk factor of ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF).

This single-center, retrospective study recruited NVAF patients who did not undergo anticoagulant therapy. These patients were divided into 2 groups: ischemic stroke group and no-stroke group. The medical records of each patient were reviewed, demographic and clinical analyses were performed, and the laboratory results were summarized.

A total of 323 eligible in-patients with NVAF, who did not receive anticoagulant therapy, were recruited (206 male and 117 female patients, median age was 75.18 ± 10.46 years old). Among these patients, 78 patients suffered from acute ischemic stroke. D-dimer level increased with age, and was positively correlated with the risk stratification of stroke, CHADS2 score (rs = 0.441, P < .001), and CHA2DS2-VASC score (rs = 0.412, P < .001), even after adjustment for age and gender (rs = 0.422, P < .001). The difference in baseline D-dimer level between these 2 groups was not statistically significant (0.70 vs 0.66 mg/L, P = .330), but this significantly increased when patients suffered from stroke (1.34 vs 0.70 mg/L, P < .001). The D-dimer level after stroke (≥6 months) was also higher than the baseline (1.16 vs 0.68 mg/L, P = .514) in 6 months, and this level nearly returned to baseline level after one year (0.69 vs 0.68 mg/L, P = .158). However, logistic regression revealed that only the D-dimer level at stroke onset and OMI were independent risk factors for ischemic stroke (P < .001), while the increase from baseline D-dimer levels was not an independent risk factor (P = .125).

D-dimer level is positively correlated with the risk stratification of ischemic stroke, but has no predictive value on the occurrence of ischemic stroke in patients with NVAF.
Association of lymphocyte to monocyte ratio with severity of coronary artery disease
Authors: Gong Shu , Gao Ximei , Xu Fubiao , Shang Zhi , Li Shuai , Chen Wenqiang , Yang Jianmin , Li Jifu
Published: October 2018

The aim of this study was to investigate the relationship between lymphocyte to monocyte ratio (LMR) and the severity of coronary artery disease (CAD) by using Gensini score.

A total of 199 patients, who had undergone coronary angiography, were included in the study and retrospectively analyzed. Among them, 49 patients who had normal coronary arteries were selected as the control group. Patients with CAD were divided into 2 groups, those with low Gensini score (≤40) and those with high Gensini score (≥40).

Our results showed that LMR in the severe atherosclerosis group was significantly lower than those of the mild atherosclerosis group and the control group. There was a closely significant correlation between the Gensini score and LMR (r = −0.362, P < .001). Furthermore, multivariate logistic regression analysis demonstrated that LMR (odds ratio, 0.715; 95% confidence interval [CI], 0.551–0.927; P = .012) was independent predictors of severe atherosclerosis. Using an optimal LMR cut-off value of 5.06, LMR predicted severe atherosclerosis with a sensitivity of 57.1% and specificity of 69.7% (area under curve = 0.634; 95% CI, 0.545–0.724; P = .005). Then patients with CAD group was divided into 2 groups according to the LMR value of 5.06. Patients with LMR ≤ 5.06 had worse prognosis, with a higher rate of cardiovascular events during up to 1 year follow-up.

Our study demonstrated that LMR was independently and positively associated with the severity of coronary atherosclerosis, providing a new insight in the application of inflammation index evaluating the severity of CAD. And LMR may be a useful predictor of future cardiovascular events in patients with CAD.
Prognostic significance of programmed cell death ligand 1 expression in patients with ovarian carcinoma
Authors: Huang Li-Jun , Deng Xiao-Feng , Chang Fan , Wu Xian-Lan , Wu Yang , Diao Qi-Zhi
Published: October 2018

Background:

Programmed cell death ligand 1 (PD-L1) overexpression has been reported to be associated with poor prognosis in several human cancers. However, studies on the prognostic value of PD-L1 expression in ovarian carcinoma (OC) remain controversial. This meta-analysis aimed to evaluate comprehensively the prognostic value of PD-L1 in OC.

Methods:

Electronic databases, including PubMed, EMBASE, and the Cochrane Library, were searched up until March 28, 2018. Hazard ratio (HR), along with 95% confidence interval (CI), was used to analyze the included outcomes.

Results:

A total of 10 studies with 1179 OC patients were included in this meta-analysis. There was no significant correlation between PD-L1 expression and overall survival (OS) (HR 1.23, 95% CI 0.85–1.79) and progression-free survival (PFS) (HR 0.88, 95% CI 0.52–1.47) of OC patients. However, the subgroup analysis suggested that positive PD-L1 expression was significantly associated with poor OS (HR 1.66, 95% CI 1.08–2.55) and PFS (HR 2.17, 95% CI 1.31–3.61) among OC patients from Asian countries. Increased PD-L1 expression was also a favorable factor for OS (HR 0.73, 95% CI 0.53–0.99) and PFS (HR 0.58, 95% CI 0.45–0.75) in OC patients from non-Asian regions. No evidence of publication bias was detected by the Egger linear regression test and Begg funnel plot. Sensitivity analyses suggested that the results of this meta-analysis were robust.

Conclusions:

The results indicated that PD-L1 expression may be a negative predictor for prognosis of OC patients from Asian countries, and a good predictor for favorable prognosis of OC patients from non-Asian countries. PD-L1 expression has potential to be a prognostic biomarker to guide clinicians for the selection of individuals who may get clinical benefit from anti-PD-1/PD-L1 immunotherapy. Prospective clinical studies are needed to support these findings.
A special superior cortex compressive fracture of femoral neck
Authors: Xian Hang , Zhang Hang , Lian Kejian , Lin Dasheng
Published: October 2018

Rationale:

Garden type I femoral neck fractures are incomplete stable fractures with impaction in valgus fractures that the question of whether there exists Garden type I femoral neck fracture is currently uncertain. There is still disagreement on the existence of the Garden type I fractures.

Patient concerns:

Herein we report 2 cases with the Garden type I femoral neck fractures. Both of them had a history of simple fall.

Diagnoses:

The X-ray showed incomplete fractures of the femoral neck and the Garden classification is type I. Further computed tomography and magnetic resonance imaging were used to confirm the diagnosis of this type fracture, which showed that the superior cortex of femoral neck was discontinuous and the inferior cortex remains intact.

Interventions:

The conservative treatment schedule including immobilization of the affected lower limb, strict bed rest, bed-to-wheelchair transfer training, and half-to-full weight bearing mobilization were chosen to treat the patients.

Outcomes:

Both of them achieved fracture union with conservative treatment at 3-month follow-up. No secondary displacement, signal of osteonecrosis of the femoral head or other complications occurred during 24-month follow-up in 2 cases.

Lessons:

Although the Garden type I femoral neck fractures are rare, our report is in line with the real existence of it.
The pretreatment platelet-to-lymphocyte ratio predicts clinical outcomes in patients with cervical cancer
Authors: Ma Jian-ying , Ke Li-chi , Liu Qin
Published: October 2018

Introduction:

The platelet-to-lymphocyte ratio (PLR) has been reported to possess significant prognostic value in multiple types of cancer. However, its prognostic value in patients with cervical remains controversial. We conducted a meta-analysis to evaluate the prognostic value of pretreatment PLR in cervical cancer.

Methods:

We searched the MEDLINE, EMBASE, and Cochrane databases to identify studies evaluating the prognostic significance of the pretreatment PLR in patients with cervical cancer. The end points were overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), and clinicopathological parameters. All statistical analyses were conducted with Stata 13.0.

Results:

A total of 12 studies comprising 3668 patients with cervical cancer were included. Elevated PLR was significantly correlated with poor OS [hazard ratio (HR): 1.56, 95% confidence interval (CI): 1.32–1.85, P < .001] and DFS/PFS (HR = 1.56; 95% CI = 1.26–1.94; P < .001). In addition, elevated PLR was highly correlated with lymphovascular space invasion (+), lymph node metastasis (+), tumor size (>4 cm), grade (G3).

Conclusion:

The pretreatment PLR could serve as a predicative biomarker of poor prognosis for patients with cervical cancer.
Diagnostic accuracy of endoscopic ultrasound, computed tomography, magnetic resonance imaging, and endorectal ultrasonography for detecting lymph node involvement in patients with rectal cancer
Authors: Wang Xin , Gao Ya , Li Jipin , Wu Jiarui , Wang Bo , Ma Xueni , Tian Jinhui , Shen Minghui , Wang Jiancheng
Published: October 2018

Background:

Rectal cancer is one of the most common tumors and is the leading cause of cancer-related deaths in developed countries. Lymph node involvement remains the strongest prognostic factor associated with a worse prognosis in patients with rectal cancer. Several systematic reviews have investigated the accuracy of endoscopic ultrasound, computed tomography, magnetic resonance imaging, and endorectal ultrasonography for lymph node involvement of rectal cancer and compared the diagnostic accuracy of different imaging techniques, but there are considerable differences in conclusions. This study aims to assess the methodological quality and reporting quality of systematic reviews and to determine which diagnostic imaging techniques is the optimal modality for the diagnosis of lymph node involvement in patients with rectal cancer.

Methods:

We will search PubMed, EMBASE, Cochrane Library, and Chinese Biomedicine Literature to identify relevant studies from inception to June 2018. We will include systematic reviews that evaluated the accuracy of diagnostic imaging techniques for lymph node involvement. The methodological quality will be assessed using AMASAR checklist, and the reporting quality will be assessed using PRISMA-DTA checklist. The pairwise meta-analysis and indirect comparisons will be performed using STATA V.12.0.

Results:

The results of this overview will be submitted to a peer-reviewed journal for publication.

Conclusion:

This overview will provide comprehensive evidence of different diagnostic imaging techniques for detecting lymph node involvement in patients with rectal cancer.

Ethics and dissemination:

Ethics approval and patient consent are not required as this study is an overview based on published systematic reviews.

PROSPERO registration number:

CRD42018104906.
The prognostic impact of tumor length in esophageal cancer
Authors: Zhang Xiangwei , Wang Yang , Jiang Yuanzhu , Wang Zhaoyang , Zhao Linping , Xue Xianbiao , Sang Shaowei , Zhang Lin
Published: October 2018

Background:

More and more studies were performed to explore the prognostic role of tumor length in esophageal cancer (EC). However, the results remain controversial. Hence, the aim of the review was to evaluate the association between tumor length and oncologic outcome in EC patients through meta-analysis.

Methods:

A systematic literature search for relevant articles published in English language will be conducted in the PubMed, Web of Science, and Embase. Hazard ratio and 95% confidence intervals (CIs) will be employed as effect measures to estimate the correlation between tumor length and the oncologic outcomes including overall survival, disease-free survival, progression-free survival, relapse-free survival, and cancer-specific survival. We will use the software STATA 14.0 to perform the meta-analysis to calculate the data synthesis.

Results:

The review will provide a high-quality synthesis of current evidence of the prognostic role of tumor length in ECs. The results will be published in a peer-reviewed journal.

Conclusion:

This will be the first systematic review and meta-analysis to evaluate the prognostic role of tumor length in EC patients. The results will better predict EC survival and identify higher-risk patients for postoperative therapy.

PROSPERO registration number:

This systematic review protocol has been registered in the PROSPERO network (No. CRD42018106851).
Association of 18F-FDG PET or PET/CT results with spontaneous remission in classic fever of unknown origin
Authors: Takeuchi Motoki , Nihashi Takashi , Gafter-Gvili Anat , García-Gómez Francisco Javier , Andres Emmanuel , Blockmans Daniel , Iwata Mitsunaga , Terasawa Teruhiko
Published: October 2018

Background:

Spontaneous remission is common in patients with undiagnosed classic fever of unknown origin (FUO). Although identifying reliable predictors of spontaneous remission in such diagnostically challenging cases could improve their management strategies, few studies have assessed such clinical factors. Recently, studies have reported that 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) alone and integrated with computed tomography (PET/CT) were useful in localizing the source of FUO. In this systematic review and meta-analysis, we assessed the association of results of these imaging modalities with spontaneous remission in patients with classic FUO.

Methods:

We searched PubMed and Scopus from inception until June 30, 2018, and studies that evaluated the PET or PET/CT results of ≥10 adult or adolescent patients with classic FUO who were followed up for at least 3 months were included. At least 2 investigators extracted data and rated quality using the QUIPS-2 tool. We used a random-effects meta-analysis to calculate summary risk ratios (RRs) with 95% confidence intervals (CIs).

Results:

Nine studies of PET/CT results (418 patients) and 4 studies of standalone PET results (128 patients) were eligible. None explicitly specified the incidence of spontaneous remission as the primary or secondary outcomes of interest. The risk of bias was considered high in all studies because patients received subsequent diagnostic workup based on imaging results. Patients with negative PET/CT results were significantly more likely to present with spontaneous regression than those with positive results (summary RR = 5.6; 95% CI: 3.4–9.2; P < .001; I

2
 = 0%). In contrast, no significant association was found between standalone PET results and spontaneous remission. The random-effects study-level meta-regression found that PET/CT results [relative RR (rRR) = 7.4; 95% CI: 2.5–21.3; P = .002], compared with standalone PET results, and publication year (rRR = 1.2 per 1 year; 95% CI: 1.0–1.3; P = .013) were significantly associated with spontaneous remission.

Conclusion:

Limited data suggest that undiagnosed classic FUO patients with negative PET/CT results had a high likelihood of spontaneous remission after a series of unsuccessful investigations for fever workup. Prospective studies should validate these results.
An aortic intra mural hematoma in ventilation/perfusion SPECT/CT
Authors: Robin Philippe , Delcroix Olivier , Abgral Ronan , Le Roux Pierre-Yves , Salaun Pierre-Yves
Published: October 2018

Rationale:

Ventilation/perfusion (V/Q) single-photon-emission computed tomography (SPECT) has arisen as an alternative to computed tomography pulmonary angiography (CTPA) in patients with pulmonary embolism (PE) suspicion. The addition of low dose CT (ldCT) to V/Q SPECT improves the specificity of the test, allowing for potential alternative diagnosis.

Patient concerns and diagnosis:

Here we presented a case of an aortic intramural hematoma (IMH) diagnosed on the ldCT portion of V/Q SPECT combined with CT. A 74-year-old man suffering from sudden-onset chest pain was referred to our nuclear medicine department for PE suspicion.

Intervention and outcome:

A V/Q SPECT combined with nonenhanced ldCT ruled out PE diagnosis. Nevertheless, ldCT revealed high attenuation aortic wall thickening suggestive of aortic IMH. Chest CT angiography showed mild dilatation and circumferential thickening of aortic wall confirming Stanford type A IMH involving the entire ascending aorta.

Lesson:

This case illustrates the potential usefulness of combining ldCT to V/Q SPECT in providing alternative diagnosis in suspected PE patients.
Diabetes management in a Primary Care Network (PCN) of private general practitioners in Singapore
Authors: Luo Miyang , Poh Zhongxian , Koh Gerald , Tham Tat Yean , Lau Winifred , Toh Sue Anne , Chong Chin Kwang , Low Lian Leng , Venkataraman Kavita
Published: October 2018

A Primary Care Network (PCN) is a virtual network of general practitioners (GPs), sharing common resources and common clinical governance framework for effective chronic disease management. In this study, we analyzed the frequency of assessment as well as control of HbA1c, blood pressure (BP), and low-density lipoprotein (LDL) over time among adult patients with diabetes managed by a group of private GPs under PCN.

Data, including clinical measurements of HbA1c, BP, and LDL from 2012 to 2015, of 943 subjects at 9 GP clinics that piloted PCN in Singapore in 2012 was obtained from the chronic disease register for this analysis.

The total number of PCN patients increased from 371 in 2012 to 911 in 2015. The average HbA1c decreased from 7.5% in 2012 to 7.3% in 2015, with a significant yearly improving trend of −0.11% (P < .001). The trends in change for systolic BP and LDL were not statistically significant during the same follow-up period. Regular assessment of HbA1c decreased from 80% in 2012 to 55% in 2015. Such decreases were also found in BP and LDL assessments. We also found that receiving government subsidies under a national scheme was a major determinant for maintaining regular assessment, with patients so covered 3 to 20 times more likely to have regular assessments.

The PCN model can help improve care and clinical outcomes in adult patients with diabetes in the private primary care sector. Investing greater financial and human resources to augment service capacity and expanding subsidy coverage may be important to ensure the effectiveness, scalability, and sustainability of such a model of care.
Vitamin D and bisphosphonates therapies for osteoporosis are associated with different risks of atrial fibrillation in women
Authors: Yang Hung-Yu , Huang Jen-Hung , Chiu Hung-Wen , Lin Yung-Kuo , Hsu Chien-Yeh , Chen Yi-Jen
Published: October 2018

Osteoporosis and atrial fibrillation (AF) are common in post-menopausal women. Vitamin D and bisphosphonates are widely used to treat osteoporosis, and these may have different effects on the risk of AF.

The goal of this study was to evaluate whether different agents for treating osteoporosis modulate the risk of AF in a population-based database.

We identified 20,788 female patients suffering from osteoporosis who were or were not treated with vitamin D or bisphosphonates using the Taiwan National Health Insurance nationwide database from 2000 to 2008 and followed them up for 5 consecutive years to determine if they had a new diagnosis of AF after the diagnosis of osteoporosis.

There were 14 (2.67%) new AF diagnoses in osteoporosis patients treated with bisphosphonates, one (0.28%) new AF diagnosis in patients treated with vitamin D, and 279 (1.40%) new AF diagnoses in patients who were not treated with vitamin D or bisphosphonates (neither group). Osteoporosis patients who received bisphosphonates showed a higher incidence of AF occurrence than those that were not treated with bisphosphonates (P = .015). In contrast, 1 patient who received vitamin D had a new diagnosis of AF during the study period; thus, the incidence was significantly lower than that in the patients treated with bisphosphonates (P = .007). In addition, the patients who were treated with vitamin D had a lower incidence of AF than did those who were not treated with either vitamin D or bisphosphonates (P = .074). Kaplan–Meier analysis also showed a significant difference in AF occurrence in different groups during the 5-year follow-up (P = .010).

Different treatment for osteoporosis may carry diverse risks of AF occurrence. Vitamin D may have potential beneficial effects of reducing AF occurrence in osteoporosis patients.
Evaluation of the clinical outcomes of telehealth for managing diabetes
Authors: Wu Cong , Wu Zixiang , Yang Lingfei , Zhu Wenjun , Zhang Meng , Zhu Qian , Chen Xiaoying , Pan Yongmiao
Published: October 2018

Introduction:

The objective of this study was to systematically review the literature and perform a meta-analysis comparing the clinical outcomes of telehealth and usual care in the management of diabetes.

Methods:

Multiple strategies, including database searches (MEDLINE, PsycINFO, PubMed, EMBASE, and CINAHL), searches of related journals and reference tracking, were employed to widely search publications from January 2005 to December 2017. The change in hemoglobin A1c (HbA1c) levels was assessed as the primary outcome, and changes in blood pressure, blood lipids, body mass index (BMI), and quality of life were examined as secondary outcomes.

Results:

Nineteen randomized controlled trials (n = 6294 participants) were selected. Telehealth was more effective than usual care in controlling the glycemic index in diabetes patients (weighted mean difference = −0.22%; 95% confidence intervals, −0.28 to −0.15; P < .001). This intervention showed promise in reducing systolic blood pressure levels (P < .001) and diastolic blood pressure levels (P < .001), while no benefits were observed in the control of BMI (P = .79). For total cholesterol and quality of life, telehealth was similar or superior to usual care.

Conclusion:

Telehealth holds promise for improving the clinical effectiveness of diabetes management. Targeting patients with higher HbA1c (≥9%) levels and delivering more frequent intervention (at least 6 times 1 year) may achieve greater improvement.
Role of Xingnaojing combined with naloxone in treating intracerebral haemorrhage
Authors: Xu Yu-Min , Wang Xin-Chen , Zhang Shi-Jie , Xu Ting-Ting , Li Hong-Ying , Hei Shang-Yan , Wen Ze-Huai , Ma Yun-Zhi , Wang Qi , Liang Wei-Xiong
Published: October 2018

Background:

Xingnaojing injection (XNJ) sharpen the mind and induce consciousness and are widely used in acute phases of intracerebral hemorrhage (ICH). Naloxone hydrochloride injection (NX) performs equally well and replace the effects of morphine-like substances to promote conscious awareness. The applications of XNJ combined with NX for ICH show some advantages compared with NX applied individually. The aim of this systematic review is to evaluate the effectiveness and safety of XNJ combined with NX for ICH.

Methods:

Comprehensive searches were conducted in 8 medical databases (PubMed, Cochrane Library, Web of Science, Embase, CNKI, VIP, CBM and Wanfang database) from inceptions to October 2017 for randomized controlled trials (RCTs) that compared the applications of XNJ and NX with NX applied individually in ICH. Literature screening, assessing risk of bias and data extraction were conducted by 2 reviewers independently. According to the Cochrane Collaboration's RevMan5.3 software to perform the data analysis.

Results:

32 RCTs (3068 cases) were selected and the quality of studies were low. All trials compared XNJ and NX with NX applied individually. The overall meta-analysis results showed that XNJ combined with NX have significant effect on clinical efficacy (OR 3.78, 95% CI: 3.03–4.73; P < .00001), GCS score (MD 3.86, 95% CI: 3.46–4.25; P < .00001), coma duration (MD −5.59, 95% CI: −6.96 to −4.22; P < .00001), NIHSS score (MD −6.24, 95% CI: -8.05 to −4.42; P < .00001), Barthel Index score (MD 14.12, 95% CI: 6.7–21.54; P < .0002), cerebral hematoma volume (MD -6.05, 95% CI: −6.85 to −5.24; P < .00001) than NX applied individually. Adverse events reported in 4 studies and included mild discomfort symptoms.

Conclusion:

The effectiveness and safety of XNJ combined with NX for ICH cannot be determined due to the low quality of literature, publication bias and heterogeneity. More rigorous RCTs are necessary to verify the role of XNJ combined with NX in the treatment of ICH.
Clinicopathologic features of endometrial cancer in Chinese patients younger than 50 years with a family history of cancer
Authors: He Yuan , Tao Xiang , Huang Feifei , Jia Nan , Du Yan , Yu Jinming , Feng Weiwei
Published: October 2018

Genetic factors play an important role in shaping the biologic characteristics of malignant tumors, especially in young patients. We aimed to determine the clinicopathologic features of endometrial cancer (EC) in patients younger than 50 years with a family history of cancer.

Overall, 229 patients with EC, including 40 with a positive family history of cancer (PFH) and 189 with a negative family history of cancer (NFH), were enrolled in this case–control study. The family history of cancer in a 2-generation pedigree was recorded for the PFH group. Clinicopathologic features such as menarche age, body mass index, personal cancer history, grade, and histologic type were compared between the 2 groups. Mismatch repair (MMR) proteins including MLH1, PMS2, MSH2, and MSH6 were assessed by immunohistochemistry (IHC) in surgical samples. Univariate (Pearson Chi-squared test, Fisher exact test, T test, Wilcoxon rank sum test, logistic regression) statistics and stepwise multivariate logistic regression were used to identify factors associated with PFH in the analysis.

Among young patients with EC, the PFH group had younger age-of-onset age of endometrial cancer (≤40 years) (odds ratio [OR] = 2.21, 95% confidence interval [95% CI]: 1.01–4.82) than the NFH group. The proportion of overweight/obese patients was high in both the NFH (58.7%) and PFH (80%) groups. Colorectal, lung, endometrial, breast, and hepatocellular carcinoma accounted for 58.6% of all cancer types among 1st- and 2nd-degree relatives. Additionally, 19.2% of patients displayed deficiency in at least 1 MMR protein, with a significantly higher proportion of MMR protein deficiency in the PFH group than in the NFH group (adjusted OR = 4.81, 95% CI: 2.14–8.83).

Clinicopathologic features differ for young patients with EC with and without a family history of cancer. Surveillance of age-of-onset and family history of endometrial cancer, reduction of barriers to healthy lifestyles, and development of risk-appropriate Lynch syndrome screening tools, such as IHC, are needed for these women in Shanghai and other developing cities in China.
Branch ostial optimization treatment and optimized provisional t-stenting with polymeric bioresorbable scaffolds
Authors: Cai Wei , Chen Lianglong , Zhang Linlin , Tu Sheng , Fan Lin , Chen Zhaoyang , Luo Yukun , Zheng Xingchun
Published: October 2018

The optimal side-branch (SB) ostium treatment after provisional side-branch scaffolding remains a subject of debate in bioresorbable vascular scaffold (BVS) era. In this study, we evaluated a novel optimized provisional T-stenting technique (OPT) and assessed its feasibility by comparison with T and small protrusion technique (TAP).

Two provisional SB scaffolding techniques (OPT, n = 5; TAP, n = 5) were performed using polymeric BVS in a bifurcated phantom. The sequential intermediate snuggling balloon dilation, also called ostial optimal technique, was added to OPT but not TAP to dilate the side-branch ostium while the final snuggling balloon dilation applied for both procedures. Microcomputed tomography (microCT) and optical coherence tomography (OCT) were performed to assess morphology, and computational fluid dynamics (CFD) was performed to assess hemodynamics in the scaffolded bifurcations. Compared with TAP in microCT analysis, OPT created shorter neo-carina length than TAP (0.34 ± 0.10 mm vs 1.02 ± 0.26 mm, P < .01), longer valgus struts length (2.49 ± 0.27 mm vs 1.78 ± 0.33 mm, P < .01) with larger MB ostial area (9.46 ± 0.04 mm2 vs 8.34 ± 0.09 mm2, P < .01). OCT found that OPT significantly decreased the struts mal-apposition (13.20 ± 0.16% vs 1.94 ± 0.54%, P < .01). CFD revealed that OPT generated more favorable flow pattern than TAP, as indicated by less percent (4.68 ± 1.40% vs 8.88 ± 1.21%, P < .01) of low wall shear stress (<0.4 Pa) along the lateral walls.

By using BVSs for bifurcation intervention, the sequential intermediate snuggling balloon dilation is feasible for optimizing ostial SB and facilitating subsequent SB scaffolding. Results show OPT is better than TAP for bifurcated morphology and hemodynamics in this ex-vivo study.
Relapsed/refractory acquired thrombotic thrombocytopenic purpura in a patient with Sjögren syndrome
Authors: Sun Rurong , Gu Weiying , Ma Yingchun , Wang Jing , Wu Min
Published: October 2018

Rationale:

Thrombotic thrombocytopenic purpura (TTP) is a rare, fatal disorder which could be caused by autoimmune diseases. However, TTP secondary to Sjögren syndrome (SS) is extremely rare.

Patient concerns:

A 47-year- old woman with an 8-year history of SS was admitted due to skin ecchymosis and bleeding gums. Then she gradually developed fever and headache.

Diagnoses:

Laboratory investigations suggested anemia, thrombocytopenia, increased lactic dehydrogenase, and a disintegrin-like metalloproteinase with thrombospondin motif type 1 member 13 (ADAMTS13) activity deficiency with high inhibitor titers. Acquired TTP was thus diagnosed.

Interventions:

Plasma exchange (PE) was the first choice for treatment, while glucocorticoid, cyclosporine A (CSA), rituximab, and intravenous immunoglobulin (IVIG) were used simultaneously. Bortezomib, a selective proteasome inhibitor and thereby inducing apoptosis in both B-cells and plasma cells, was added.

Outcomes:

She was discharged from the hospital and then treated with prednisone of 40 mg/d and hydroxychloroquine. The patient remained in full remission.

Lessons:

We conclude that bortezomib should be considered for patients with TTP refractory to PE, steroids, and rituximab due to its efficacy and relatively favorable side effect profile.
Whole grain diet reduces systemic inflammation
Authors: Xu Yujie , Wan Qianyi , Feng Jinhua , Du Liang , Li Ka , Zhou Yong
Published: October 2018

Backgrounds:

Observational studies had suggested an inverse association between whole grain consumption and concentration of inflammatory markers, but evidence from interventional studies was inconsistent. Therefore, we conducted a meta-analysis of randomized trials to have a better understanding of this issue.

Methods:

This study has been registered in PROSPERO (ID: CRD42018096533). We searched PubMed, Web of Science, Embase, Medline, and Cochrane Library for articles focusing on the topic from inception to 1 January, 2018. Summary standardized mean difference (SMD) and 95% confidence interval (CI) were calculated by using either random effect model or fixed effect model according to the heterogeneity of included studies. Subgroup analysis was also performed.

Results:

Totally 9 randomized trials included 838 participants were identified. In a pooled analysis of all studies, consumption of whole grains had an inverse association with inflammatory markers (SMD 0.16, 95% CI, 0.02–0.30), including C-reactive protein (CRP), Interleukin-6 (IL-6), Tumor necrosis factor-α (TNF-α), Interleukin-1β (IL-1β). Specific analyses for CRP and IL-6 yielded that whole grain diet was related with a significant decrease in the concentration of CRP (SMD 0.29, 95% CI, 0.08–0.50) and IL-6 (SMD 0.19, 95% CI, 0.03–0.36).

Conclusions:

The evidence suggested that citizens could benefit from increased whole grain intake for reducing systemic inflammation. Further well-designed studies are required to investigate the mechanism under the appearance.
Spontaneous perforation and intraabdominal abscess due to Meckel's diverticulum revealed on SPECT/CT with 99m-technetium pertechnetate
Authors: Zhu Yangjun , Dong Mengjie , Weng Wanwen , Yang Jun
Published: October 2018

Rationale:

Meckel's diverticulum (MD) is common congenital abnormality of gastrointestinal tract, only about 6.4% of patients become symptomatic. A smaller minority develop potential fatal complications such as hemorrhage, perforation, abscess, and bowel obstruction.

Patient concerns:

A 15-year-old boy with history of appendicitis was admitted due to worsening abdominal pain and nausea for 1 day. The physical examination showed the abdomen was soft, with the diffuse tenderness to palpation and voluntary guarding.

Diagnosis:

Abdominal computed tomography showed a probable MD in the distal ileum. Single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging revealed the focal concentration at the right lower quadrant of abdomen region.

Intervention:

After the initial management including antibiotic administration and intravenous fluid resuscitation, MD with perforation and localized suppurative peritonitis was confirmed in surgery. The patient underwent a diverticulectomy. Histological examination was confirmed as MD with focal heterotopic gastric tissue.

Outcomes:

After surgery, the patient had uneventful recovery during 3 months follow-up.

Lessons:

Spontaneous perforation and intraabdominal abscess due to MD is very rare. Accurate diagnosis of MD remains challenging as clinical symptoms from these complications occur nonspecifically. SPECT/CT fusion imaging is critical for prompt recognition and accurate diagnosis in the successful management of this rarely life-threating complication.
Integrase inhibitor-based regimens result in more rapid virologic suppression rates among treatment-naïve human immunodeficiency virus–infected patients compared to non-nucleoside and protease inhibitor–based regimens in a real-world clinical setting
Authors: Jacobson Karen , Ogbuagu Onyema
Published: October 2018

The integrase strand transfer inhibitor (INSTI) class of antiretroviral therapy (ART) may result in faster time to virologic suppression compared with regimens that contain protease inhibitors (PIs) or non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, differences in time to achieve virologic suppression are not well-defined in routine clinical settings with contemporary antiretroviral agents.

Study was a retrospective single-center study of treatment-naïve human immunodeficiency virus (HIV) patients initiating ART between 2013 and 2016. Among patients on different ART regimen types, we compared rates of and median time to virologic suppression [viral load (VL) <50 copies/mL].

A total of 155 patients—45 (29%) female and 110 (71%) male—met study inclusion criteria. Median age was 42 years (interquartile range 31–52), and median baseline CD4 count was 288 cells/μL and VL was 60,000 copies/mL. Seventy-one (46%) initiated an INSTI-based regimen, 58 (37%) were on NNRTI-based regimens, and 26 (17%) on PI-based regimens. In total, 112 (72%) patients achieved virologic suppression at 12 months. Patients on INSTI-based regimens were more likely to achieve virologic suppression by 3, 6, and 12 months (P < .01), and had lower median time to suppression (60 vs 137 days on NNRTI-based regimens and 147 days on PI-based regimens, P < .01).

Patients on INSTI-based ART regimens in a real-world setting experienced higher rates of virologic suppression and shorter time from ART initiation to virologic suppression. For HIV patients on INSTI-based ART regimens, virologic failure should be suspected in those with VLs >50 copies/mL before the current recommendation of 48 weeks.
What recovery position should patients adopt after percutaneous liver biopsy?
Authors: Costa Rita S. , Cardoso Ana F. , Ferreira Anibal , Costa Juliana , Costa Dalila , Fernandes Dália , Caetano Ana C.
Published: October 2018

Introduction

Percutaneous liver biopsy (PLB) is an invasive procedure used for the assessment of liver diseases. The patient’s recovery position after the PLB differs among hospitals and departments. This study aims to evaluate adverse events and patient acceptability according to the recovery position adopted after the PLB.

Patients and methods

From September 2014 to March 2017, patients submitted to PLB were randomly assigned to a recovery position arm: right-side position (RRP), dorsal position (DRP), or combined position. A validated numerical rating scale was used to evaluate the level of pain and the overall acceptability of the PLB experience.

Results

Ninety (27 patients in RRP, 33 in DRP and 30 in combined position arm) patients were included in the study. There were no differences between the three groups regarding demographic and clinical parameters, except for the number of previous biopsies – higher in the combined group (P=0.03). No major adverse events occurred. Minor complications described were pain (36.7% of patients), vasovagal reaction (2.2%) and nauseas/vomit (3.3%). Pain level and pain duration did not differ significantly between groups. Pain occurred more often in women (P=0.04) and younger patients (P=0.02). The number of passages, operator and previous biopsy did not influence the occurrence of pain. The RRP group considered the procedure less acceptable than the DRP group (P=0.001) or the combined group (P=0.002). There were no differences between the last two arms.

Conclusion

Although RRP is the most frequently used position, it appears to be less acceptable without any protective role in terms of adverse events.