A longitudinal prospective study of active tuberculosis in a Western Europe setting: insights and findings

PURPOSE

This study investigates the potential of inflammatory parameters (IP), symptoms, and patient-related outcome measurements as biomarkers of severity and their ability to predict tuberculosis (TB) evolution.

METHODS

People with TB were included prospectively in the Stage-TB study conducted at five clinical sites in Barcelona (Spain) between April 2018 and December 2021. Data on demographics, epidemiology, clinical features, microbiology, and Sanit George Respiratory Questionnaire (SGRQ) and Kessler-10 as Health-Related Quality of Life (HRQoL) were collected at three time points during treatment. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil/lymphocyte, and monocyte/lymphocyte ratios (NLR and MLR), complement factors C3, C4, and cH50, clinical and microbiological data, and HRQoL questionnaires were assessed at baseline, 2 months, and 6 months. Their ability to predict sputum culture conversion (SCC) and symptom presence after 2 months of treatment was also analysed.

RESULTS

The study included 81 adults and 13 children with TB. The CRP, ESR, NLR, and MLR values, as well as the presence of symptoms, decreased significantly over time in both groups. Higher IP levels at baseline were associated with greater bacillary load and persistent symptoms. Clinical severity at baseline predicted a delayed SCC. Kessler-10 improved during follow-up, but self-reported lung impairment (SGRQ) persisted in all individuals after 6 months.

CONCLUSIONS

IP levels may indicate disease severity, and sustained high levels are linked to lower treatment efficacy. Baseline clinical severity is the best predictor of SCC. Implementing health strategies to evaluate lung function and mental health throughout the disease process may be crucial for individuals with TB.

Integrating vascular access surveillance with clinical monitoring for stenosis prediction

BACKGROUND

Arteriovenous fistula and arteriovenous graft are the most common types of vascular access for dialysis; stenosis and thrombosis are major complications leading to access failure and to an incresed risk of mortality. The aim of the present study was to assess the results of integrating  strict vascular access blood flow surveillance with routine clinical monitoring for predicting vascular access stenosis in chronic hemodialysis patients.

METHODS

In this retrospective study, chronic dialysis patients with arteriovenous fistula or arteriovenous graft were included from a setting in which all patients underwent quarterly blood flow surveillance in 2017. The results of blood flow surveillance were confirmed by thorough physical examination. Predictive performance of blood flow surveillance models in detecting stenosis in patients with arteriovenous fistula or arteriovenous graft was evaluated. The predictive performance of the quarterly blood flow surveillance model was described by confusion matrix. Differences in accuracy, positive predictive value (PPV), and negative predictive value (NPV) between blood flow surveillance models with distinct blood flow thresholds were evaluated.

RESULTS

Of 397 included patients, 336 had an arteriovenous fistula and 61 had an arteriovenous graft. In 2017, 106 percutaneous transluminal angioplasty procedures were performed in patients with an arteriovenous fistula, and 63 in patients with an arteriovenous graft. The results revealed similar predictive performance of surveillance models using an absolute blood flow threshold of < 500 or < 400 mL/min in predicting stenosis in patients with arteriovenous fistula. Blood flow surveillance models for patients with an arteriovenous fistula had significantly higher accuracy than those for patients with an arteriovenous graft. Furthermore, the use of a relative threshold, defined as blood flow < 1000 mL/min and a 25% decline in blood flow, did not affect the predictive performance of blood flow surveillance models.

CONCLUSION

Blood flow surveillance models using thresholds of < 400 and < 600 mL/min, followed by thorough physical examination, showed an accuracy of 91.54% and 72.15% in predicting stenosis in patients with arteriovenous fistula and arteriovenous graft, respectively. These two blood flow surveillance models may be integrated with routine clinical monitoring to improve early detection and treatment of stenosis in hemodialysis patients.

Expanded disability status scale by phone BR: Brazilian Portuguese validation

BACKGROUND

The Expanded Disability Status Scale (EDSS) is widely used and accepted by regulatory agencies for the assessment of neurological disability secondary to Multiple Sclerosis. The "Expanded Disability Status Scale (EDSS) by phone" was developed to be a patient-reported telephone-based alternative for the assessment of EDSS functional system scores when a physical examination is not possible. The scale has been validated in multiple languages; however, its reliability has not been assessed in Brazilian Portuguese.

METHODS

After cross-cultural translation and adaptation, 57 people with MS with a recent in-person visit (±6 months) were invited to answer the EDSS by phone scale on two occasions, 15 days apart. The agreement between scales (in-person and telephone-based) and between telephone-based assessments was evaluated using intraclass correlation coefficients (ICC) for absolute agreement and weighted Kappa coefficients.

RESULTS

An excellent reliability was obtained for the agreement between the in-person and telephone assessments (ICC: 0.95, 95 %CI 0.92-0.97, Kappa: 0.83, 95 %CI 0.78-0.89) and between telephone-based assessments (ICC: 0.99, 95 %CI 0.98-0.99, Kappa: 0.93, 95 %CI 0.88-0.97). After stratification by disability level, the agreement between scales was less pronounced for subjects with an EDSS ≤ 4.0.

CONCLUSION

this study offers evidence that supports the validity of the EDSS by phone questionnaire translated into Brazilian Portuguese, particularly for patients with higher EDSS scores.

The three-item patient-reported instrument for retrospective adherence in resource constrained settings: reliability, validity and potential utility

INTRODUCTION

Patient-report instruments remain the most feasible and sustainable approaches for monitoring medication adherence in clinical settings. However, questions of their reliability and validity persist. Studies suggest that the 3-item instrument for retrospective adherence (IRA) developed by Wilson et al. offers a viable option for clinically monitoring medication adherence. Here we report the reliability and validity of the IRA among patients recruited from community-based HIV clinics and antiretroviral therapy (ART) dispensaries in a resource constrained township in Cape Town, South Africa.

METHODS

Women (n = 794) and men (n = 228) receiving ART completed the IRA at three time points: (a) in a face-to-face administration at enrollment (b) in1-week phone interview and (c) 1-month phone interview. Participants also provided contemporaneous blood samples for HIV viral load testing as a clinical outcome and unannounced phone-based pill counts as an objective assessment of ART adherence.

RESULTS

The IRA was internally consistent and showed evidence of time stability. The IRA also demonstrated validity with respect to pill count adherence, correlates of adherence, and HIV viral load. Response operating curve analysis yielded an area under the curve of 0.646, using 75% adherence as the cut-off, with 0.637 sensitivity and 0.567 specificity.

CONCLUSIONS

The IRA demonstrated reliability, construct validity and criterion validity in a resource constrained setting, supporting use of the IRA in research and clinical care.

Laurel but Hardy: unintended poisoning, a case report of oleander misidentification as bay laurel

Introduction

Nerium oleander is a toxic plant containing cardiac glycosides throughout all its parts, thereby posing severe health risks upon ingestion. The clinical manifestations of oleander poisoning closely resemble those of digoxin toxicity, encompassing a spectrum of gastrointestinal symptoms, neuropsychiatric disorders, and cardiac disturbances. This scientific case report describes a case of accidental intoxication resulting from the consumption of an oleander leaves infusion misidentified as bay laurel leaves.

Case report

An 84-year-old patient consumed an oleander leaves infusion, and after four hours experienced gastrointestinal symptoms. He contacted the poison control center (PCC) and was advised to go to the emergency department (ED). Upon arrival, the patient presented stable vital signs without cardiac irregularities. The PCC recommended the administration of activated charcoal, vigilant monitoring, including electrocardiography (ECG). Subsequent ECGs assessments revealed the presence of third-degree atrioventricular block; in consultation with the PCC, digoxin-specific antibodies and external pacing were necessary. The patient was discharged on the eighth day in good hemodynamic condition, and outpatient follow-up visits showed clinical stability.

Discussion

This study offers insights for the management of similar cases. The limitations of conventional assays in measuring oleander cardiac glycosides were observed, emphasizing reliance on clinical evaluation. The patient's trajectory, remaining asymptomatic despite severe ECG changes post-ingestion, underscores the importance of prolonged clinical monitoring.

A duplex nested RT-PCR method for monitoring porcine epidemic diarrhea virus and porcine delta-coronavirus

BACKGROUND

Porcine epidemic diarrhea virus (PEDV) and porcine delta-coronavirus (PDCoV) are economically important pathogens that cause diarrhea in sows and acute death of newborn piglets. Moreover, the emerging PDCoV was reported to infect children. The current situation is that vaccine prevention has not met expectations, and emergency containment strategies following outbreaks cannot prevent the damages and losses already incurred. Therefore, a more sensitive detection method, that is both convenient and enables accurate and effective sequencing, that will provide early warning of PEDV and PDCoV is necessary. This will enable active, effective, and comprehensive prevention and control, which will possibly reduce disease occurrences.

RESULTS

Duplex nested RT-PCR (dnRT-PCR) is an ideal method to achieve early warning and monitoring of PEDV and PDCoV diseases, and to additionally investigate any molecular epidemiological characteristics. In this study, two pairs of primers were designed for each virus based upon the highly conserved N protein sequences of both PEDV and PDCoV strains retrieved from the NCBI Genbank. After optimization of the reaction conditions, the dnRT-PCR assay amplified a 749-bp fragment specific to PEDV and a 344-bp fragment specific to PDCoV. Meanwhile, the specificity and sensitivity of the primers and clinical samples were tested to verify and establish this dnRT-PCR method. The limit of detection (LoD)for both PEDV and PDCoV was 10 copies/µL. The results showed that among 251 samples, 1 sample contained PEDV infection, 19 samples contained a PDCoV infection, and 8 samples were infected with both viruses, following the use of dnRT-PCR. Subsequently, the positive samples were sent for sequencing, and the sequencing results confirmed that they were all positive for the viruses detected using dnRT-PCR, and conventional RT-PCR detection was conducted again after the onset of disease. As these results were consistent with previous results, a detection method for PEDV and PDCoV using dnRT-PCR was successfully established. In conclusion, the dnRT-PCR method established in this study was able to detect both PEDV and PDCoV, concomitantly.

CONCLUSIONS

The duplex nested RT-PCR method represents a convenient, reliable, specific, sensitive and anti-interference technique for detecting PEDV and PDCoV, and can additionally be used to simultaneously determine the molecular epidemiological background.

Clinician Monitoring

Since the first public demonstration of general anesthesia in 1846, anesthesiology has seen major advancements as a specialty. These include both important technological improvements and the development and implementation of internationally accepted patient safety standards. Together, these ultimately resulted in the recognition of anesthesiology as the leading medical specialty advocating for patient safety. Modern-day anesthesiology faces a new challenge of automated anesthesia delivery. Despite evidence for a more refined and precise delivery of anesthesia through this platform, there is currently no substitute for the presence of an appropriately trained anesthesia clinician to manage the complex interplay of human factors and patient safety in the perioperative setting.

Role of the community nurse in Parkinson's disease and lower urinary disorders

Parkinson's disease (PD) is an incurable and progressive neurodegenerative disorder. People with PD also have increased muscle weakness and the typical symptoms of tremor, stiffness, slowness, balance problems and/or gait disorders. Other symptoms may include an overactive bladder, urgency and nocturia which can often lead to incontinence. Treatment options vary are dependent on the cause of the incontinence and should focus on improving Quality of life with a multi-pronged diagnosis-specific approach that takes into consideration a patient's ability to comply with treatment. The article looks at the role of the community nurse in caring for patients with PD and lower urinary disorders. They have a key role in assessment of patients and supporting families with tailor made bladder training such as establish a regular toilet routine, education about pelvic floor exercises or supply of incontinence products.

Headache Gauge: a real-life calendar-based tool for headache monitoring

BACKGROUND

This study aimed to validate a semi-quantitative composite score tool, "Headache Gauge" (HG), to monitor the treatment effect in primary headaches in everyday clinic practice, adjustable to any chosen timeframe.

METHOD

A cohort validation study of HG was performed in primary headache patients, recovering their clinical data and patient-related outcome measures (PROMs) for headache (HIT-6, MIDAS, HURT), work impact (WPAIQ), quality-of-life (SF-12), and mood (STAI, ZUNG). HG score distribution, its relation to clinical variables, its internal consistency, and its convergent validity were determined.

RESULTS

HG was plotted in 233 patients: 90.1% females, age average 37 years, 86% with migraine, 27% with chronic headaches, and 28% with medication overuse. HG ranged from 0.21 to 58.3 in this sample, higher in chronic headaches (HG 16) and medication overuse (HG 15). HG presented good concurrent validity, significantly correlating with HIT-6 (p < 0.0001), SF-12 (p = 0.001), WPAIQ (p < 0.0001), MIDAS (p < 0.0001), and HURT (p < 0.0001). Good sensitivity to change (p < 0.001) and moderate test-retest reliability (p = 0.001) were calculated after reassessment of 147 patients (63.1% of the initial sample).

CONCLUSIONS

Headache Gauge is a clinical data-based outcome measure that conceptually translates the percentage of lost time to headache in any given timeframe. It relates to headache impact, therefore bearing the potential to be relevant in real-life clinical monitoring.

in vivo Monitoring with micro-implantable hypoxia sensor based on tissue acidosis

Hypoxia is a common medical problem, sometimes difficult to detect and caused by different situations. Control of hypoxia is of great medical importance and early detection is essential to prevent life threatening complications. However, the few current methods are invasive, expensive, and risky. Thus, the development of reliable and accurate sensors for the continuous monitoring of hypoxia is of vital importance for clinical monitoring. Herein, we report an implantable sensor to address these needs. The developed device is a low-cost, miniaturised implantable electrochemical sensor for monitoring hypoxia in tissue by means of pH detection. This technology is based on protonation/deprotonation of polypyrrole conductive polymer. The sensor was optimized in vitro and tested in vivo intramuscularly and ex vivo in blood in adult rabbits with respiration-induced hypoxia and correlated with the standard device ePOC^TM. The sensor demonstrated excellent sensitivity and reproducibility; 46.4 ± 0.4 mV/pH in the pH range of 4-9 and the selectivity coefficient exhibited low interference activity in vitro. The device was linear (R² = 0.925) with a low dispersion of the values (n = 11) with a cut-off of 7.1 for hypoxia in vivo and ex vivo. Statistics with one-way ANOVA (α = 0.05), shows statistical differences between hypoxia and normoxia states and the good performance of the pH sensor, which demonstrated good agreement with the standard device. The sensor was stable and functional after 18 months. The excellent results demonstrated the feasibility of the sensors in real-time monitoring of intramuscular tissue and blood for medical applications.

Clinical significance of miRNAs in autoimmunity

MicroRNAs (miRNAs) are evolutionally conserved, single-stranded RNAs that regulate gene expression at the posttranscriptional level by disrupting translation. MiRNAs are key players in variety of biological processes that regulate the differentiation, development and activation of immune cells in both innate and adaptive immunity. The disruption and dysfunction of miRNAs can perturb the immune response, stimulate the release of inflammatory cytokines and initiate the production of autoantibodies, and contribute to the pathogenesis of autoimmune diseases, including systemic lupus erythmatosus (SLE), rheumatoid arthritis (RA), primary biliary cholangitis (PBC), and multiple sclerosis (MS). Accumulating studies demonstrate that miRNAs, which can be collected by noninvasive methods, have the potential to be developed as diagnostic and therapeutic biomarkers, the discovery and validation of which is essential for the improvement of disease diagnosis and clinical monitoring. Recently, with the development of detection tools, such as microarrays and NGS (Next Generation Sequencing), large amounts of miRNAs have been identified and suggest a critical role in the pathogenesis of autoimmune diseases. Several miRNAs associated diagnostic biomarkers have been developed and applied clinically, though the pharmaceutical industry is still facing challenges in commercialization and drug delivery. The development of miRNAs is less advanced for autoimmune diseases compared with cancer. However, drugs that target miRNAs have been introduced as candidates and adopted in clinical trials. This review comprehensively summarizes the differentially expressed miRNAs in several types of autoimmune diseases and discusses the role and the significance of miRNAs in clinical management. The study of miRNAs in autoimmunity promises to provide novel and broad diagnostic and therapeutic strategies for a clinical market that is still in its infancy.

FREE-FLAP MONITORING: REVIEW AND CLINICAL APPROACH

Microvascular free flap reconstruction is a routine option for coverage of a variety of tissue defects. Accurate monitoring in the postoperative period is a crucial part of successful flap surgery allowing early detection of vascular compromise and prompt intervention in flap salvaging. Despite that many safety procedures to assess flap viability have been developed, flap failure is consistently seen in 2-5% of free tissue transfers. In addition, great progress is being made in relation to various state-of-the-art technologies for flap monitoring. However, the gold standard still remains clinical monitoring at most institutions even though there is no standardized management protocol. The review should present a prospective optimal monitoring protocol and introduce some of the latest monitoring devices based on the recent literature and personal experience.

The importance of cholesterol follow-up testing under current statin treatment guidelines

Under "treat to risk" goals, low-density (LDL)-cholesterol follow-up measurements monitor statin compliance rather than titration to target levels, however, there is little evidence showing that more-frequent monitoring reduces LDL-cholesterol. We therefore tested whether frequency of blood tests significantly predicted lipoprotein improvements in a large anonymized clinical laboratory database. Differences (∆ ± SE) in total cholesterol, triglycerides, and LDL-cholesterol between baseline and follow-up visits were calculated for 97,548 men and 110,424 women whose physicians sent blood to Boston Heart Diagnostics for analysis between 2010 and 2017. When adjusted for age and follow-up duration, plasma concentration changes per each follow-up measurement in men and women respectively were -2.84 ± 0.10 mg/dL and -3.03 ± 0.10 mg/dL for total cholesterol, -3.78 ± 0.30 mg/dL and -2.26 ± 0.19 mg/dL for triglycerides, and -2.54 ± 0.09 mg/dL and -3.06 ± 0.09 mg/dL for LDL-cholesterol (all P < 10^-16). Relative to baseline, significant decreases (P < 10^-16) were observed for the 1st, 2nd, and 3rd follow-up measurements for total cholesterol (mean ± SE, men: -9.4 ± 0.1, -11.9 ± 0.2, -13.7 ± 0.3; women: -8.0 ± 0.1, -10.5 ± 0.2, -12.6 ± 0.3 mg/dL, respectively), triglycerides (men: -10.3 ± 0.4, -12.8 ± 0.5, -13.4 ± 0.7; women: -6.4 ± 0.2, -8.8 ± 0.4, -10.1 ± 0.5 mg/dL, respectively) and LDL-cholesterol (men: -7.8 ± 0.1, -9.9 ± 0.2, -11.1 ± 0.2; women: -6.9 ± 0.1, -9.0 ± 0.2, -10.7 ± 0.2 mg/dL, respectively). When adjusted for regression to the mean, 6.9%, 9.9% and 11.8% of men, and 5.7%, 9.7% and 11.5% of women, went from having an LDL-cholesterol ≥160 to <160 mg/dL for their 1st, 2nd, and 3rd follow-up measurements, respectively. We conclude that under usual physician care, total cholesterol, triglyceride, and LDL-cholesterol concentrations decreased progressively with increased physician monitoring within a large patient population.

Postoperative Clinical Monitoring After Morphine Administration: A Retrospective Multicenter Practice Survey

BACKGROUND

The objective of this survey was to describe the clinical monitoring practically used after intravenous, subcutaneous or neuraxial (epidural or intrathecal) administration of morphine.

METHODS

It was a descriptive, retrospective, multicenter (10 hospitals) survey based on the medical charts' analysis, which evaluated the postoperative clinical monitoring after morphine administration.

RESULTS

Morphine was delivered intravenously (69%), intrathecally (19%), epidurally (10%) and/or subcutaneously (12%). Clinical monitoring protocols and protocols for the management of side effects were both present in 60% (n=6/10), only one of the two types of protocols in 10% (n=1/10) and both absent in 30% (n=3/10). Protocols for the management of respiratory depression and consciousness evaluation were present in 70% of cases (n=7/10). These events were reported on medical records without any prescription or protocol in 35% (n=14/40) and 37,5% (n=15/40) respectively. Prescriptions for respiratory rate evaluation and clinical monitoring of consciousness were in agreement with only 20% of the medical data and medical records. Different levels of respiratory rate were observed: 43% (n=3/7) below 8/min, 43% (n=3/7) below 10/min and 14% (n=1/7) below 12/min. Clinical monitoring was not performed in 31% (n=31/100) for consciousness and in 35% (n=35/100) for respiratory rate. Pulse oximeter was used in 48% (n=48/100) of patients. Capnography was never used. Respiratory depression occurred in 1% (n=1/100) of cases.

CONCLUSION

This survey emphasizes an important disparity in the prescription of medical monitoring and a lack of use of protocols when morphine is administered. It demonstrates the need for a standardization of protocols according to the existing guidelines.

Expansion and Determination of Antigen-Reactive T Cells by Flow Cytometry

The detection of antigen-reactive T cells has shown great utility for patient clinical monitoring. However, many of the methods commonly used to detect these cells face major limitations, like the predetermination of the given HLA type. The herein described protocol provides a means of overcoming many of the obstacles associated with the use of multimers and other common approaches in this field. In order to be able to detect rare cells which are below the detection limit of direct ex vivo measurement, in the present protocol, antigen-reactive T cells are first expanded in vitro using libraries of overlapping peptides which span the entire protein of interest and consist of 15 amino acid-long peptides that share a 12-amino-acid overlap. This theoretically allows the detection of T cells to any epitope within a protein of interest and consequently does not require the patient's HLA type to be characterized. Furthermore, this method simultaneously detects CD4+ and CD8+ T cells that produce cytokines upon encounter with antigen and thereby provides a functional insight into the behavior of the responding T cells. In our case, we have investigated the pro- or anti-inflammatory cytokines IL-2, IL-5, IL-10, IL-17, TNF-α, and IFN-γ.

Controlled Human Malaria Infection (CHMI) Studies: Over 100 Years of Experience with Parasite Injections

Human experimentation by deliberate infection with malarial parasites seems unethical yet has a long history in infectious disease research. After rigorous screening, volunteers are inoculated with Plasmodium sporozoites or blood stages and monitored under strict clinical supervision until they are treated with a licensed malaria drug and the infection is completely resolved. Historically, experimental Plasmodium challenge infections were applied to confirm that Anopheles mosquitoes were the malaria vector and to treat neurosyphilis in Treponema pallidum-infected patients. The lifesaving treatment with reliable parasite inoculation, monitoring, and drug cure was awarded with a Nobel Prize in 1927 and paved the way for human trials for clinical tests of candidate drugs and vaccines. Importantly, controlled human malaria infection (CHMI) studies are indispensable to bridge the major gap between phase I safety and phase II field trials. Here, we describe the biological basis, historical experiences, applications, and ethical considerations for CHMI studies. Acceleration of antimalarial drug and vaccine development remains a priority in medical research and critically depends on capacity building for CHMI studies.

Identify and monitor clinical variation using machine intelligence: a pilot in colorectal surgery

Standardized clinical pathways are useful tool to reduce variation in clinical management and may improve quality of care. However the evidence supporting a specific clinical pathway for a patient or patient population is often imperfect limiting adoption and efficacy of clinical pathway. Machine intelligence can potentially identify clinical variation and may provide useful insights to create and optimize clinical pathways. In this quality improvement project we analyzed the inpatient care of 1786 patients undergoing colorectal surgery from 2015 to 2016 across multiple Ohio hospitals in the Cleveland Clinic System. Data from four information subsystems was loaded in the Clinical Variation Management (CVM) application (Ayasdi, Inc., Menlo Park, CA). The CVM application uses machine intelligence and topological data analysis methods to identify groups of similar patients based on the treatment received. We defined "favorable performance" as groups with lower direct variable cost, lower length of stay, and lower 30-day readmissions. The software auto-generated 9 distinct groups of patients based on similarity analysis. Overall, favorable performance was seen with ketorolac use, lower intra-operative fluid use (< 2000 cc) and surgery for cancer. Multiple sub-groups were easily created and analyzed. Adherence reporting tools were easy to use enabling almost real time monitoring. Machine intelligence provided useful insights to create and monitor care pathways with several advantages over traditional analytic approaches including: (1) analysis across disparate data sets, (2) unsupervised discovery, (3) speed and auto-generation of clinical pathways, (4) ease of use by team members, and (5) adherence reporting.

Respiratory effort from the photoplethysmogram

The potential for a simple, non-invasive measure of respiratory effort based on the pulse oximeter signal - the photoplethysmogram or 'pleth' - was investigated in a pilot study. Several parameters were developed based on a variety of manifestations of respiratory effort in the signal, including modulation changes in amplitude, baseline, frequency and pulse transit times, as well as distinct baseline signal shifts. Thirteen candidate parameters were investigated using data from healthy volunteers. Each volunteer underwent a series of controlled respiratory effort maneuvers at various set flow resistances and respiratory rates. Six oximeter probes were tested at various body sites. In all, over three thousand pleth-based effort-airway pressure (EP) curves were generated across the various airway constrictions, respiratory efforts, respiratory rates, subjects, probe sites, and the candidate parameters considered. Regression analysis was performed to determine the existence of positive monotonic relationships between the respiratory effort parameters and resulting airway pressures. Six of the candidate parameters investigated exhibited a distinct positive relationship (p<0.001 across all probes tested) with increasing upper airway pressure repeatable across the range of respiratory rates and flow constrictions studied. These were: the three fundamental modulations in amplitude (AM-Effort), baseline (BM-Effort) and respiratory sinus arrhythmia (RSA-Effort); two pulse transit time modulations - one using a pulse oximeter probe and an ECG (P2E-Effort) and the other using two pulse oximeter probes placed at different peripheral body sites (P2-Effort); and baseline shifts in heart rate, (BL-HR-Effort). In conclusion, a clear monotonic relationship was found between several pleth-based parameters and imposed respiratory loadings at the mouth across a range of respiratory rates and flow constrictions. The results suggest that the pleth may provide a measure of changing upper airway dynamics indicative of the effort to breathe.

The effects of ventricular drainage on the intracranial pressure signal and the pressure reactivity index

In subarachnoid hemorrhage (SAH) patients intracranial pressure (ICP) is usually monitored via an extraventricular drain (EVD), which can produce false readings when the drain is open. It is established that both the ICP cardiac pulse frequency and long term trends over several hours are often seriously corrupted. The aim of this study was to establish whether or not the intermediate frequency bands [respiratory, Mayer wave and very low frequency (VLF)] were also corrupted. The VLF range is of special interest because it is important in cerebral autoregulation studies. Using a pattern recognition algorithm we retrospectively identified 718 cases of EVD opening in 80 SAH patients. An analysis of differences between closed and open-drain periods showed that ICP amplitude decreased significantly in all of the three lower frequency bands when the EVD was open. A similar analysis of systemic arterial pressure signal revealed similar changes in the same frequency bands that were positively correlated with the ICP changes. Therefore we concluded that the changes in the ICP signal represented real, physiological changes and not artifact. Pressure reactivity index (PRx) values were also computed during closed and open-drain periods. We found a small but statistically significant decrease during open-drain periods. Based on analysis of the change in the PRx distribution during open drainage we concluded that this decrease also represented physiological changes rather than artifact. In summary the ICP respiratory, Mayer wave, and VLF frequency bands are not corrupted when the EVD is open, and it safe to use these for autoregulation studies.

Clinical monitoring and high-risk conditions among patients with SUD newly prescribed opioids and benzodiazepines

BACKGROUND

Opioid therapy alone or in combination with benzodiazepines poses safety concerns among patients with substance use disorders (SUD). Guidelines for opioid therapy recommend SUD treatment and enhanced monitoring, especially in patients with additional risk factors, but information on monitoring practices is sparse. This study estimated high-risk conditions - psychiatric comorbidity, suicide risk, and age <35 and ≥65 - and described clinical monitoring among patients with SUD who were newly prescribed opioids alone and concurrent with benzodiazepines long-term.

METHODS

This study included VA Northwest Veterans Network patients with SUD who started opioids only (n=980) or benzodiazepines and opioids concurrently (n=353) long-term (≥90 days) in 2009-2010. Clinical characteristics, outpatient visits and urine drug screens (UDS) documented within 7-months after starting medications were extracted from VA data.

RESULTS

Approximately 67% (95% CI: 64-70) of opioids only and 94% (92-97) of concurrent medications groups had ≥1 psychiatric diagnoses. Prevalences of suicide risk and age <35 and ≥65 were 7% (5-8), 6% (5-8) and 18% (15-20) among the opioids only group, and 20% (16-24), 8% (5-11) and 13% (9-16) among the concurrent medications group. Among patients prescribed opioids only and medications concurrently, 87% and 91% attended primary care, whereas 28% and 26% attended SUD specialty-care. Overall, 30% and 48% of opioids only and concurrent medications groups engaged in mental health or SUD care, and 35% and 39% completed UDS.

CONCLUSIONS

Improvements in clinical monitoring are needed as many VA patients with SUD and comorbid risks who initiate opioid therapy do not receive sufficient mental health/SUD care or UDS monitoring.

Do prefrontal midline electrodes provide unique neurophysiologic information in Major Depressive Disorder?

Brain oscillatory activity from the midline prefrontal region has been shown to reflect brain dysfunction in subjects with Major Depressive Disorder (MDD). It is not known, however, whether electrodes from this area provide unique information about brain function in MDD. We examined a set of midline sites and two other prefrontal locations for detecting cerebral activity differences between subjects with MDD and healthy controls. Resting awake quantitative EEG (qEEG) data were recorded from 168 subjects: 47 never-depressed adults and 121 with a current major depressive episode. Individual midline electrodes (Fpz, Fz, Cz, Pz, and Oz) and prefrontal electrodes outside the hairline (Fp1, Fp2) were examined with absolute and relative power and cordance in the theta band. We found that MDD subjects exhibited higher values of cordance (p = 0.0066) at Fpz than controls; no significant differences were found at other locations, and power measures showed trend-level differences. Depressed adults showed higher midline cordance than did never-depressed subjects at the most-anterior midline channel. Salient abnormalities in MDD may be detectable by focusing on the prefrontal midline region, and EEG metrics from focused electrode arrays may offer clinical practicality for clinical monitoring.

Profile of adults with type 2 diabetes and uptake of clinical care best practices: results from the 2011 Survey on Living with Chronic Diseases in Canada - Diabetes component

AIMS

This study aimed to (1) describe the profile of adults with type 2 diabetes (T2D) in Canada and (2) assess the uptake of clinical care best practices, as defined by the Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPGs).

METHODS

We used data from the 2011 Survey on Living with Chronic Diseases in Canada - Diabetes component. Participants were aged 20 years and older, living in the 10 Canadian provinces, with self-reported T2D. Descriptive analyses present the prevalence of complications and comorbidities, as well as the level of clinical monitoring and self-monitoring/lifestyle management recommendations participants received.

RESULTS

We included 2335 participants with T2D, a mean age of 62.9 years, and high prevalence of complications/comorbidities and prescription medication use. Most participants reported being monitored as recommended for eye disease (73.9%), weight (81.0%), blood pressure (89.0%) and blood cholesterol levels (94.3%), but only 65.5% reported having at least two HbA1c tests during the last year and 46.5% reported an annual foot examination by a health professional. About two-thirds of the participants reported having received recommendations on weight management (59.9%) and physical activity (64.7%) from a health professional in the previous year; only 47.8% of the participants reported having received diet counseling to improve diabetes control.

CONCLUSION

Although the uptake of CDA CPGs for clinical and self-monitoring was high, with the majority of the participants reporting meeting most indicators, it was lower for HbA1c measurement and foot examination. Uptake of lifestyle management recommendations provided by health professionals was also significantly lower.

Strategies for ensuring quality data from Indian investigational sites

The topic of ensuring quality and compliance is and must be a top priority in the conduct of clinical trials, as warranted by regulatory guidelines as well as the inherent responsibility of the professionals conducting such research. Fast-growing emerging clinical geographies such as India demand special attention due to rapid growth and associated factors that may put study quality at risk. In this paper, we used the basic principle of PDCA (Plan, Do, Check, and Adjust) to structure the processes of a clinical trial from protocol to final analysis in order to highlight the interactive nature of involved people and processes required to ensure quality of data and site functioning.