Intimate Partner Violence-Related Brain Injury: Unmasking and Addressing the Gaps

Intimate partner violence (IPV) is a significant, global public health concern. Women, individuals with historically underrepresented identities, and disabilities are at high risk for IPV and tend to experience severe injuries. There has been growing concern about the risk of exposure to IPV-related head trauma, resulting in IPV-related brain injury (IPV-BI), and its health consequences. Past work suggests that a significant proportion of women exposed to IPV experience IPV-BI, likely representing a distinct phenotype compared with BI of other etiologies. An IPV-BI often co-occurs with psychological trauma and mental health complaints, leading to unique issues related to identifying, prognosticating, and managing IPV-BI outcomes. The goal of this review is to identify important gaps in research and clinical practice in IPV-BI and suggest potential solutions to address them. We summarize IPV research in five key priority areas: (1) unique considerations for IPV-BI study design; (2) understanding non-fatal strangulation as a form of BI; (3) identifying objective biomarkers of IPV-BI; (4) consideration of the chronicity, cumulative and late effects of IPV-BI; and (5) BI as a risk factor for IPV engagement. Our review concludes with a call to action to help investigators develop ecologically valid research studies addressing the identified clinical-research knowledge gaps and strategies to improve care in individuals exposed to IPV-BI. By reducing the current gaps and answering these calls to action, we will approach IPV-BI in a trauma-informed manner, ultimately improving outcomes and quality of life for those impacted by IPV-BI.

Machine learning models developed and internally validated for predicting chronicity in pediatric immune thrombocytopenia

BACKGROUND

Primary immune thrombocytopenia (ITP) in children is typically self-limiting; however, 20% to 30% of patients may experience prolonged thrombocytopenia lasting over a year. The challenge is predicting chronicity to ensure personalized treatment approaches.

OBJECTIVES

To address this issue, we developed and internally validated 4 machine learning (ML) models using demographic and immunologic characteristics to predict the likelihood of chronicity.

METHODS

The present study was conducted at Beijing Children's Hospital from June 2018 to December 2021, aiming to develop predictive models for determining the chronicity of pediatric ITP. Four ML models, based on a logistic regression classifier, random forest classifier, eXtreme Gradient Boosting (XGBoost), and support vector machine, were employed. These models used a set of 16 variables, including 14 immunologic and 2 demographic predictors. The performance evaluation criteria included prediction accuracy, precision, recall, F1 score, and area under the receiver operating characteristic curve (AUROC).

RESULTS

Data were collected from 662 patients who were randomly assigned to either a training dataset or a testing dataset using a random number generator. Among them, 26.5% had chronic disease. All models performed well, with AUROC values ranging from 0.81 to 0.84, and XGBoost was selected for its highest AUROC score and interpretability in constructing the predictive model. Age, T helper 17, T helper 17-to-regulatory T cell ratio, T helper 1, and double-negative T cells were identified as significant predictors by the XGBoost algorithm.

CONCLUSION

We developed a precise predictive model for chronicity in pediatric ITP using ML during the initial phase. The XGBoost model achieved high predictive accuracy by using individual patient clinical parameters and demonstrated commendable interpretability.

Risk Factors for Rerupture After Proximal Hamstring Avulsion Injury Including the Optimal Timing for Surgery

BACKGROUND

Despite the prevalence of proximal hamstring avulsion injuries (PHAIs), the understanding of rerupture risk factors and the influence of injury chronicity on these rates remain limited.

PURPOSE

To investigate the rerupture rate after PHAI repair and identify its associated risk factors and the optimal time to primary surgery.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHOD

This is a retrospective analysis of prospectively collected data from the French Proximal Hamstring Avulsion Surgery Cohort Study targeting patients surgically treated for PHAI between 2002 and 2022. The primary outcome measure of this study was the rerupture rate of PHAI repair. The secondary outcome measures included the assessment of the potential risk factors for rerupture as well as the investigation of the incidence rate of rerupture for 100 person-years depending on various injury-surgery delay definitions.

RESULTS

This study analyzed 740 patients with a mean age of 45.9 years (SD, 13.6 years) and followed up for a mean of 4.9 years (SD, 3.9 years). The rerupture rate was 4.59% (34/740). Most reruptures (75%) occurred within the first 6 months after surgery (median, 88.5 days; interquartile range, 39.5-182 days), and 74% were atraumatic. Univariate analysis identified potential risk factors: longer initial surgery delay (hazard ratio [HR], 1.03; 95% CI, 1.01-1.04; P = .04) and initial complete ruptures (HR, 4.47; 95% CI, 1.07-18.7; P = .04). Receiver operating characteristic curve analysis found the optimal injury-surgery delay cutoff predicting rerupture to be 32 days (area under the curve, 0.62; 95% CI, 0.53-0.71). The relative Youden index was calculated at 0.24, corresponding to a sensitivity of 65% and a specificity of 59%. Surpassing this cutoff showed the highest HR (2.56), narrowest 95% CI (1.27-5.17), and highest incidence of rerupture (1.42 per 100 person-years) (P = .01). In the multivariate analysis, an injury-surgery delay of >32 days (HR, 2.5; 95% CI, 1.24-5.06; P = .01) and initial complete ruptures (HR, 4.33; 95% CI, 1.04-18.08; P = .04) emerged as significant risk factors for rerupture.

CONCLUSION

This study found a 4.59% rerupture risk after PHAI repair. Most reruptures (75%) occurred within the first 6 months after surgery. Risk factors for rerupture included chronicity and initial complete injury. The optimal threshold for chronicity of PHAI lesions, based on rerupture rate, was marked by an injury-surgery delay of >32 days.

Outcomes in people with eating disorders: a transdiagnostic and disorder-specific systematic review, meta-analysis and multivariable meta-regression analysis

Eating disorders (EDs) are known to be associated with high mortality and often chronic and severe course, but a recent comprehensive systematic review of their outcomes is currently missing. In the present systematic review and meta-analysis, we examined cohort studies and clinical trials published between 1980 and 2021 that reported, for DSM/ICD-defined EDs, overall ED outcomes (i.e., recovery, improvement and relapse, all-cause and ED-related hospitalization, and chronicity); the same outcomes related to purging, binge eating and body weight status; as well as mortality. We included 415 studies (N=88,372, mean age: 25.7±6.9 years, females: 72.4%, mean follow-up: 38.3±76.5 months), conducted in persons with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorders (OSFED), and/or mixed EDs, from all continents except Africa. In all EDs pooled together, overall recovery occurred in 46% of patients (95% CI: 44-49, n=283, mean follow-up: 44.9±62.8 months, no significant ED-group difference). The recovery rate was 42% at <2 years, 43% at 2 to <4 years, 54% at 4 to <6 years, 59% at 6 to <8 years, 64% at 8 to <10 years, and 67% at ≥10 years. Overall chronicity occurred in 25% of patients (95% CI: 23-29, n=170, mean follow-up: 59.3±71.2 months, no significant ED-group difference). The chronicity rate was 33% at <2 years, 40% at 2 to <4 years, 23% at 4 to <6 years, 25% at 6 to <8 years, 12% at 8 to <10 years, and 18% at ≥10 years. Mortality occurred in 0.4% of patients (95% CI: 0.2-0.7, n=214, mean follow-up: 72.2±117.7 months, no significant ED-group difference). Considering observational studies, the mortality rate was 5.2 deaths/1,000 person-years (95% CI: 4.4-6.1, n=167, mean follow-up: 88.7±120.5 months; significant difference among EDs: p<0.01, range: from 8.2 for mixed ED to 3.4 for BN). Hospitalization occurred in 26% of patients (95% CI: 18-36, n=18, mean follow-up: 43.2±41.6 months; significant difference among EDs: p<0.001, range: from 32% for AN to 4% for BN). Regarding diagnostic migration, 8% of patients with AN migrated to BN and 16% to OSFED; 2% of patients with BN migrated to AN, 5% to BED, and 19% to OSFED; 9% of patients with BED migrated to BN and 19% to OSFED; 7% of patients with OSFED migrated to AN and 10% to BN. Children/adolescents had more favorable outcomes across and within EDs than adults. Self-injurious behaviors were associated with lower recovery rates in pooled EDs. A higher socio-demographic index moderated lower recovery and higher chronicity in AN across countries. Specific treatments associated with higher recovery rates were family-based therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, and nutritional interventions for AN; self-help, CBT, dialectical behavioral therapy (DBT), psychodynamic therapy, nutritional and pharmacological treatments for BN; CBT, nutritional and pharmacological interventions, and DBT for BED; and CBT and psychodynamic therapy for OSFED. In AN, pharmacological treatment was associated with lower recovery, and waiting list with higher mortality. These results should inform future research, clinical practice and health service organization for persons with EDs.

Complexity of needs in amyotrophic lateral sclerosis (ALS) patients using the ENP-E scale in the north-eastern region of Spain

OBJECTIVES

This study aimed to explore the clinical characteristics of amyotrophic lateral sclerosis (ALS) patients in Spain's north-eastern region, their inclusion in chronic care programmes, and their psychosocial and spiritual needs (PSNs).

METHODS

A longitudinal descriptive study in adult patients with ALS. We analyzed clinical variables and participation in chronicity and PSNs assessment using the tool Psychosocial and Spiritual Needs Evaluation scale in end-of-life patients (ENP-E scale).

RESULTS

81 patients (average age 65.6 ± 11.7) were studied. At the study's outset, 29.7% employed non-invasive ventilation (NIV), increasing to 51.9% by its conclusion. Initial percutaneous endoscopic gastrostomy (PEG) utilization was 14.8%, rising to 35.85%. Chronic care programme participation was as follows: home care (24.7% initially, 50.6% end), palliative care (16% initially, 40.7% end), case management (13.6% initially, 50.6% end), and advance care planning registration (6.2% initially, 35.8% end). At study start, 47.8% of patients (n = 46) showed moderate-to-severe complexity in PSNs assessment using the ENP-E scale, without showing differences in age, sex, and time of evolution; whereas, on the evolutionary analysis, it was 75% (n = 24). A higher evolutionary complexity was observed in males <60 and >70 years, with no PEG and evolution of ALS of <2 and ≥5 years, and not included in chronicity programmes. When assessing concerns, physical pain and family aspects stand out in all measurements. Forty-eight percent of patients at study start and 71% at end of study showed external signs of emotional distress.

SIGNIFICANCE OF RESULTS

Most ALS patients showed a high degree of complexity and were not integrated in chronicity programmes. A "care path" is proposed to integrate ALS patients in these programmes and systematically assess their needs.

Topical corticosteroids inhibit allergic skin inflammation but are ineffective in impeding the formation and expansion of resident memory T cells

BACKGROUND

Tissue-resident memory T (TRM ) cells are detrimental in allergic contact dermatitis (ACD), in which they contribute to the chronicity and severity of the disease.

METHODS

We assessed the impact of a standard topical corticosteroid (TCS) treatment, triamcinolone acetonide (TA), on the formation, maintenance and reactivation of epidermal TRM cells in a preclinical model of ACD to 2,4-dinitrofluorobenzene. TA 0.01% was applied at different time points of ACD response and we monitored skin inflammation and tracked CD8+ CD69+ CD103+ TRM by flow cytometry and RNA sequencing.

RESULTS

The impact of TA on TRM formation depended on treatment regimen: (i) in a preventive mode, that is, in sensitized mice before challenge, TA transiently inhibited the infiltration of effector T cells and the accumulation of TRM upon hapten challenge. In contrast, (ii) in a curative mode, that is, at the peak of the ACD response, TA blocked skin inflammation but failed to prevent the formation of TRM . Finally, (iii) in a proactive mode, that is, on previous eczema lesions, TA had no effect on the survival of skin TRM , but transiently inhibited their reactivation program upon allergen reexposure. Indeed, specific TRM progressively regained proliferative functions upon TA discontinuation and expanded in the tissue, leading to exaggerated iterative responses. Interestingly, TRM re-expansion correlated with the decreased clearance of hapten moieties from the skin induced by repeated TA applications.

CONCLUSIONS

Our results demonstrate that TCS successfully treat ACD inflammation, but are mostly ineffective in impeding the formation and expansion of allergen-specific TRM , which certainly restricts the induction of lasting tolerance in patients with chronic dermatitis.

Machine Learning Model for Predicting Mortality Risk in Patients With Complex Chronic Conditions: Retrospective Analysis

Background

The health care system is undergoing a shift toward a more patient-centered approach for individuals with chronic and complex conditions, which presents a series of challenges, such as predicting hospital needs and optimizing resources. At the same time, the exponential increase in health data availability has made it possible to apply advanced statistics and artificial intelligence techniques to develop decision-support systems and improve resource planning, diagnosis, and patient screening. These methods are key to automating the analysis of large volumes of medical data and reducing professional workloads.

Objective

This article aims to present a machine learning model and a case study in a cohort of patients with highly complex conditions. The object was to predict mortality within the following 4 years and early mortality over 6 months following diagnosis. The method used easily accessible variables and health care resource utilization information.

Methods

A classification algorithm was selected among 6 models implemented and evaluated using a stratified cross-validation strategy with k=10 and a 70/30 train-test split. The evaluation metrics used included accuracy, recall, precision, F1-score, and area under the receiver operating characteristic (AUROC) curve.

Results

The model predicted patient death with an 87% accuracy, recall of 87%, precision of 82%, F1-score of 84%, and area under the curve (AUC) of 0.88 using the best model, the Extreme Gradient Boosting (XGBoost) classifier. The results were worse when predicting premature deaths (following 6 months) with an 83% accuracy (recall=55%, precision=64% F1-score=57%, and AUC=0.88) using the Gradient Boosting (GRBoost) classifier.

Conclusions

This study showcases encouraging outcomes in forecasting mortality among patients with intricate and persistent health conditions. The employed variables are conveniently accessible, and the incorporation of health care resource utilization information of the patient, which has not been employed by current state-of-the-art approaches, displays promising predictive power. The proposed prediction model is designed to efficiently identify cases that need customized care and proactively anticipate the demand for critical resources by health care providers.

How to Manage the Suffering of the Patient and the Family in the Final Stage of Life: A Qualitative Study

BACKGROUND

The end of life and death have changed from being issues managed within the family, assumed as part of life, to occur within health institutions for the majority of patients. The amount of patients dying at home has decreased, and the roles of families and communities in death and dying have become involuted, threatening related traditions and knowledge. As a result, a need to promote the end of life at home in this new self-serving society has arisen. In that context, the main objective of this study was to find out what patients and their families need during the end-of-life process in order to feel effectively accompanied at this time.

METHODS

With that objective, a descriptive qualitative study was conducted via the content analysis of data from semi-structured interviews and focus groups. This research adhered to the COREQ guidelines. The sample consisted of 36 informants selected via intentional sampling of family members and patients integrated into the Comprehensive Palliative Care Process (PAI Paliativos).

RESULTS

The results suggest the existence of several common needs such as communication and presence, including the conspiracy of silence as an important factor generating suffering for both. However, there are specific needs such as autonomy, dignity, and respect for patients, which must be taken into account.

CONCLUSIONS

The results of this study will allow us to establish intervention strategies for effective accompaniment of patients' family members at the end of life and the avoidance of ethnocentrism in this process. This study was retrospectively registered with the (nursrep-1194226) on the (21 April 2023).

Circadian Rhythms and Depression in Adolescents: A Comparative Analysis of First Episode and Recurrent-Episode Groups

Circadian rhythm disruptions are a hallmark feature of mood disorders. Patients experiencing acute depressive episodes report noticeable changes in their sleep-wake cycles. This research explains the association between depression and various circadian rhythm metrics, explicitly focusing on adolescents diagnosed with depressive disorders. Adolescence is a critical period marked by significant physiological and psychological changes, making it imperative to understand how mood disorders manifest during this phase. However, there have been minimal specific studies in pediatric populations to determine whether circadian rhythm changes differ between adolescents with first and multiple-recurrent depressive episodes. Our study involved a group of 61 adolescents aged between 13 and 18. We performed a cross-sectional study of a clinical population of patients presenting to a child and adolescent psychiatry clinic diagnosed with depression. Participants were asked to complete self-report evaluations using several tools: the Korean version of the Biological Rhythms Interview of Assessment in Neuropsychiatry (K-BRIAN), the Korean Translation of Composite Scale to Measure Morningness-Eveningness (KtCS), and the Seasonal Pattern Assessment Questionnaire (SPAQ). Tools such as the Children's Depression Inventory (CDI), State-Trait Anxiety Inventory (STAI), and K-Mood Disorder Questionnaire (K-MDQ) were employed for the assessment of clinical characteristics of depression. Based on the frequency of their depressive episodes, participants were bifurcated into two distinct groups: those experiencing their first episode (n = 22, mean age: 15.09 ± 1.44 years) and those with recurrent episodes (n = 39, mean age: 15.95 ± 1.26 years). At first, the two groups' data revealed no significant differences regarding mood or circadian rhythm metrics (CDI: first episode 26.18 ± 10.54 and recurrent episode 25.90 ± 10.59, STAI-S: first episode 56.91 ± 12.12 and recurrent episode 57.49 ± 11.93, STAI-T: first episode 60.36 ± 11.63 and recurrent episode 59.09 ± 12.10, SPAQ-total: first episode 6.59 ± 4.86 and recurrent episode 6.77 ± 5.23, KtCS: first episode 30.32 ± 5.83 and recurrent episode 28.13 ± 7.36). However, we observed significant correlations between circadian rhythm disruptions and depression scales (CDI with SPAQ-weight (r = 0.26), KtCS (r = -0.48), K-BRIAN-sleep (r = 0.58), K-BRIAN-activity (r = 0.64), K-BRIAN-social (r = 0.71), and K-BRIAN-eating (r = 0.40)). These correlations were especially pronounced in the recurrent episode group, suggesting that with the progression and chronicity of depression, the relationship between circadian rhythms and depression becomes more intertwined and evident. In conclusion, especially in adolescents, as the severity and chronicity of depression increase, the interplay between circadian rhythms and mood disorders becomes more pronounced, warranting further research and clinical attention.

An exotic pathogenetic mechanism of angiogenesis in oral lichen planus-A systematic review

OBJECTIVE

Angiogenesis plays a vital role at the molecular level in various inflammatory lesions, that lead to their chronicity. Oral lichen planus is an immune-mediated chronic inflammatory disorder. The angiogenetic role and exact mechanisms in oral lichen planus are still unclear due to a dearth of studies. Its clinical significance with angiogenesis also requires further elucidation necessitating a thorough review of the studies that have been conducted so far. The present review was designed to identify the dependence of oral lichen planus progression on angiogenesis which could aid in devising metronomic treatments required to halt the progression of this disease.

MATERIALS AND METHODS

A thorough search was made using MEDLINE by PubMed, Scopus, Google scholar, Cochrane library, and EMBASE databases. Original research articles, that immunohistochemically evaluated angiogenesis in oral lichen planus were included for review. Risk of bias was analysed for each study using Modified Newcastle-Ottawa scale and Review Manager 5.4 was used to output its result.

RESULTS

Twenty-nine published articles were included for data synthesis. The most commonly employed antibody was CD34, however, upregulated VEGF expression was the principal while ICAM-1, VCAM-1, and PECAM-1 were critical angiogenic factors to mediate angiogenesis in oral lichen planus.

CONCLUSION

The current evidence supports that angiogenesis, a fundamental pathogenetic mechanism of oral lichen planus, leads to its persistence and chronicity. However, studies with a larger sample size, standard evaluation criteria, different subtypes, and adequate follow-up are warranted.

Occupational mechanical exposures as risk factor for chronic low-back pain: a systematic review and meta-analysis

OBJECTIVES

The association between occupational mechanical exposures and low-back pain (LBP) has been studied in several systematic reviews. However, no systematic review addressing chronic LBP exists. The aim of this systematic review and meta-analysis was to examine the association between occupational mechanical exposures and chronic LBP.

METHODS

The study was registered in PROSPERO. We used an existing systematic review to identify articles published before January 2014. For studies published between January 2014 and September 2022, a systematic literature search was conducted in six databases. Two authors independently excluded articles, extracted data, and assessed risk of bias and level of evidence (GRADE). Meta-analyses were conducted using random-effects models comparing highest versus lowest exposure group with sensitivity analyses based on study quality (low/moderate versus high risk of bias), study design (cohort versus case-control), and outcome definition (non-specific LBP versus specific chronic LBP).

RESULTS

Twenty-six articles were included. Highest pooled odd ratios (OR) were found for combined mechanical exposures [OR 2.2, 95% confidence interval (CI) 1.4-3.6], lifting/carrying loads (OR 1.7, 95% CI 1.4-2.2), and non-neutral postures (OR 1.5, 95% CI 1.2-1.9). For the remaining mechanical exposures (ie, whole-body vibrations, standing/walking, and sitting), OR ranged between 1.0 and 1.4. In the sensitivity analyses, generally, higher pooled OR were found in low/moderate risk of bias studies, case-control studies, and studies of specific chronic LBP.

CONCLUSIONS

Moderate evidence of an association was found for lifting/carrying loads, non-neutral postures, and combined mechanical exposures. Low or very low evidence was found for whole-body vibrations, standing/walking, and sitting. Studies using standardized exposure definition, metric, and technical measurements are highly warranted.

The pathology of oxidative stress-induced autophagy in a chronic rotator cuff enthesis tear

Partial-thickness rotator cuff tears (PTRCTs) are often found in daily orthopedic practice, with most of the tears occurring in middle-aged patients. An anaerobic process and imbalanced oxygenation have been observed in PTRCTs, resulting in oxidative stress. Studies have shown the roles of oxidative stress in autophagy and the potential of unregulated mechanisms causing disturbance in soft tissue healing. This article aims to review literature works and summarize the potential pathology of oxidative stress and unregulated autophagy in the rotator cuff enthesis correlated with chronicity. We collected and reviewed the literature using appropriate keywords, in addition to the manually retrieved literature. Autophagy is a normal mechanism of tissue repair or conversion to energy needed for the repair of rotator cuff tears. However, excessive mechanisms will degenerate the tendon, resulting in an abnormal state. Chronic overloading of the enthesis in PTRCTs and the hypovascular nature of the proximal tendon insertion will lead to hypoxia. The hypoxia state results in oxidative stress. An autophagy mechanism is induced in hypoxia via hypoxia-inducible factors (HIFs) 1/Bcl-2 adenovirus E1B 19-kDa interacting protein (BNIP) 3, releasing beclin-1, which results in autophagy induction. Reactive oxygen species (ROS) accumulation would induce autophagy as the regulator of cell oxidation. Oxidative stress will also remove the mammalian target of rapamycin (mTOR) from the induction complex, causing phosphorylation and initiating autophagy. Hypoxia and endoplasmic reticulum (ER) stress would initiate unfolded protein response (UPR) through protein kinase RNA-like ER kinase (PERK) and activate transcription factor 4, which induces autophagy. Oxidative stress occurring in the hypovascularized chronic rotator cuff tear due to hypoxia and ROS accumulation would result in unregulated autophagy directly or autophagy mediated by HIF-1, mTOR, and UPR. These mechanisms would disrupt enthesis healing.

When the clinic becomes home: on the limits of kinship care in an eating disorder treatment centre in Italy

Drawing on fieldwork in a public residential facility for eating disorders in central Italy, the paper examines the relational temporalities of therapeutics by looking at how time affects treatment at the intersection of professional and family care practices. In arguing that 'chronic cases' put into question the specific kind of kinship care that is at the basis of treatment, the paper contributes to the anthropological literature on eating disorders by bringing time under the analytical lens, and to the literature on 'chronicity' by complicating simplified assumptions about structural care problems. In addition, the paper draws on and goes beyond anthropological works that have highlighted the potentially harmful side of kinship - including those that have explored how kinship can be framed as a source of mental distress and at the same time as a therapeutic tool. Kinship as a therapeutic tool here becomes risky because professionals need to borrow from kinship practices in their own work with patients, balancing those with the necessary clinical detachment. The paper shows that the time chronic patients need in residential treatment generates a particularly complex mix between what is seen as 'functional' and what is seen as 'dysfunctional' in kinship care, because the 'efficacy' of the kinship work that is at the basis of treatment rests on that being partial and temporary. Long term care in the facility complicates what otherwise allows clinical detachment: the treatment team ends up literally substituting the patient's family, with professional and family care mixing 'too much' with one another.

New insights into phenotype and genotype relationships in Neospora caninum

The successful isolation of four new Neospora caninum strains from different regions and with different backgrounds (obtained from an abortion storm or congenitally infected and asymptomatic calves) allowed us previously to characterize natural isolates, finding differences in phenotype and microsatellites. Given the variability observed, we wondered in this work whether these differences had consequences in virulence, invasion and vertical transmission using cell cultures and murine neosporosis models. In addition, we performed the genomic analysis and SNP comparative studies of the NcURU isolates. The results obtained in this work allowed us to establish that NcURU isolates are of low virulence and have unique phenotypic characteristics. Likewise, sequencing their genomes has allowed us to delve into the genetic singularities underlying these phenotypes, as well as the common mutated genes. This work opens a new perspective for diagnostic purposes and formulating possible vaccines based on attenuated strains.

Similarities in cognitive impairment between recent- onset and chronic schizophrenia patients: a consideration for the neurodevelopmental hypothesis

Impairment in attention, memory, processing speed and executive functions have been described in patients with schizophrenia. Such impairments can be observed in early stages of the disease and in chronic patients; discrepancy in findings regarding the cognitive deficits at different stages of the illness keeps the debate about schizophrenia as a neurodegenerative condition which courses with continuous deterioration, or if deficits remain stable, as the neurodevelopmental hypothesis suggests.

Multidimensional risk factor analysis of acute low back pain progressing to chronicity: a longitudinal cohort study protocol

Introduction

Approximately 40% of patients with acute low back pain (LBP) develop chronic low back pain, which significantly increases the risk of poor prognosis. To reduce the risk of acute LBP becoming chronic, effective preventive strategies are needed. Early identification of risk factors for the development of chronic LBP can help clinicians choose appropriate treatment options and improve patient outcomes. However, previous screening tools have not considered medical imaging findings. The aim of this study is to identify factors that can predict the risk of acute LBP becoming chronic based on clinical information, pain and disability assessment, and MRI imaging findings. This protocol describes the methodology and plan for investigating multidimensional risk factors for acute LBP becoming chronic, in order to better understand the development of acute LBP and prevent chronic LBP.

Methods

This is a prospective multicenter study. We plan to recruit 1,000 adult patients with acute low back pain from four centers. In order to select four representative centers, we find the larger hospitals from different regions in Yunnan Province. The study will use a longitudinal cohort design. Patients will undergo baseline assessments upon admission and will be followed up for 5 years to collect the time of chronicity and associated risk factors. Upon admission, patients will be collected detailed demographic information, subjective and objective pain scores, disability scale, and lumbar spine MRI scanning. In addition, patient's medical history, lifestyle, psychological factors will be collected. Patients will be followed up at 3 months, 6 months, 1 year, 2 years and up for 5 years after admission to collect the time of chronicity and associated factors. Multivariate analysis will be used to explore the multidimensional risk factors affecting the chronicity of acute LBP patients (such as age, gender, BMI, degree of intervertebral disc degeneration, etc.), and survival analysis will be performed to explore the impact of each factor on the time of chronicity.

Ethics and dissemination

The study has been approved by the institutional research ethics committee of each study center (main center number: 2022-L-305). Results will be disseminated through scientific conferences and peer-reviewed publications, as well as meetings with stakeholders.

Role of personal aptitudes as determinants of incident morbidity, lifestyles, quality of life, use of health services, and mortality (DESVELA cohort): quantitative study protocol for a prospective cohort study in a hybrid analysis

Introduction

The healthcare and well-being of the population depend on multiple factors and should adapt to societal changes. The opposite is also occurring; society has evolved concerning the individuals' approach to their care, which includes participation in decision-making processes. In this scenario, health promotion and prevention become crucial to provide an integrated perspective in the organization and management of the health systems.Health status and well-being depend on many aspects, determinants of health, which in turn may be modulated by individual behavior. Certain models and frameworks try to study the determinants of health and individual human behaviors, separately. However, the interrelation between these two aspects has not been examined in our population.Our main objective is to analyze whether personal aptitudes related to behaviors are independently associated with the incidence of morbidity. A secondary objective will enquire whether these personal aptitudes are independently associated with lower all-cause mortality, enhanced adoption of healthy lifestyles, higher quality of life, and lower utilization of health services during follow-up.

Methods

This protocol addresses the quantitative branch of a multicenter project (10 teams) for the creation of a cohort of at least 3,083 persons aged 35 to 74 years from 9 Autonomous Communities (AACC). The personal variables to evaluate are self-efficacy, activation, health literacy, resilience, locus of control, and personality traits. Socio-demographic covariates and social capital will be recorded. A physical examination, blood analysis, and cognitive evaluation will be carried out.Several sets of six Cox models (one for each independent variable) will analyze the incidence of morbidity (objective 1); all-cause mortality and the rest of the dependent variables (objective 2). The models will be adjusted for the indicated covariates, and random effects will estimate Potential heterogeneity between AACC.

Discussion

The analysis of the association of certain behavioral patterns and determinants of health is essential and will contribute to improving health promotion and prevention strategies. The description of the individual elements and interrelated aspects that modulate the onset and persistence of diseases will allow the evaluation of their role as prognostic factors and contribute to the development of patient-tailored preventive measures and healthcare.Clinical Trial Registration: ClinicalTrials.gov, NCT04386135. Registered on April 30, 2020.

Care as a creative practice: comics, dementia and graphic medicine

Care paves efficient ways to sustain life during illness, nonetheless, caring for a chronically ill person is a hard, demanding, tedious and unglamorous work, often fraught with challenges. In contrast, creativity refers to a generative process that brings something new into existence. For instance, creativity implies a moment of discovery, the birth of new ideas, crossing existing boundaries among others. Perfusing creativity with care practices mitigates the difficult experiences, and aid in the healthy management of challenges put forth by the illness. The present article after elaborating on how creativity transforms care as a meaningful and constructive life-changing practice in the context of one of the chronic illnesses, dementia/AD, and briefing on graphic medicine-an interdisciplinary field of healthcare and comics, seeks to close-read Dana Walrath's Aliceheimer's: Alzheimer's Through the Looking Glass to demonstrate how care as creative practice provides a therapeutic direction when biomedical cure becomes impossible. The article investigates how such distinctive caring practices challenges the predominant perspective of dementia as a social death and aid in finding meaning in the alternative experiential realities of the person living with dementia. Further, the article also examines how these practices help in retaining the personhood and humanity of the care-receiver.

"Initially, medicines will be given, and then we need to study the case": Medicalized perspectives about chronicity and mental health care in Kerala

In response to the global call to upscale mental health services in low--income countries, mental health non-governmental organisations (MHNGOs) have sprung up in Kerala to address mental health needs by partnering with pre-existing locally grown, bottom-up, community-led pain and palliative clinics (PPCs) to increase access to mental health care through task-shifting. The MHNGOs mandate filtering only patients with 'severe mental disorders' from low socioeconomic backgrounds for their free services. This eligibility criterion mandated by the MHNGO is ruffling feathers within the palliative clinics that oppose such -classifications. They believe that suffering cuts across all divisions and should not be discriminated against based on economic background and severity of illnesses. When chronicity and suffering are held universal by the MHNGO and palliative care, respectively, it brings to the fore the enactment of two perspectives of care. Drawing on observations of clinical interactions between patients, MHNGO staff and mental health professionals and interviews with community volunteers of palliative care clinics in Kerala, this paper demonstrates how chronicity narrative promoted by MHNGOs based on biopsychiatric model gains hegemony, whereas the community care model loses traction progressively. The state, caught between these two narratives, frontstages development by submitting its health machinery to the MHNGOs flouting basic medical safety laws in its services to marginalised people like the tribal population. This paper argues that the rising dominance of chronicity narrative in community mental health clinics as well as in popular media discourses evolves out of power relations between the MHNGOs and the palliative clinics.

Neuropathic pain component and its association with time elapsed since pain onset in patients with low back pain

BACKGROUND

Time elapsed since pain onset might affect the likelihood of neuropathic component in low back pain. The aim of this study was to investigate the relationship between neuropathic pain component and pain duration in patients with low back pain and to identify factors associated with neuropathic pain component.

METHODS

Patients with low back pain who received treatment at our clinic were enrolled. Neuropathic component was assessed using the painDETECT questionnaire at the initial visit. PainDETECT scores and the results for each item were compared according to pain duration category (< 3 months, 3 months to 1 year, 1 year to 3 years, 3 years to 10 years, and ≥ 10 years). A multivariate analysis was used to identify factors associated with neuropathic pain component (painDETECT score ≥ 13) in low back pain.

RESULTS

A total of 1957 patients, including 255 patients who reported neuropathic-like pain symptoms (13.0%), fully satisfied the study criteria for analysis. No significant correlation between painDETECT score and pain duration was observed (ρ = -0.025, p = 0.272), and there were no significant differences between median painDETECT score or trend of change in the proportion of patients with neuropathic component and the pain duration category (p = 0.307, p = 0.427, respectively). The electric shock-like pain symptom was frequently reported in patients with acute low back pain, and the persistent pain pattern with slight fluctuations was predominant in chronic low back pain. The pattern of attacks with pain between them was much less common in patients with pain for 10 years or longer. Multivariate analysis revealed that a history of lumbar surgery, severe maximum pain, opioid use, lumbosacral radiculopathy, and sleep disturbance were significantly associated with a neuropathic component in low back pain.

CONCLUSION

Time elapsed since current pain onset did not correlate with neuropathic pain component in patients with low back pain. Therefore, diagnostic and therapeutic approaches for this condition should be based on a multidimensional evaluation at assessment and not on pain duration alone.

[Anchor your resources with the bullet journal]

The ordeal of chronicity is marked, from the outside, by an impression of dependence on the institution. Considering the discharge of a patient who has been hospitalized for a long period of time requires reflection at different levels and is based on a major challenge, that of integrating a new model of care. The clinical situation presented allows us to highlight both the caregiving skills and the impact on the group that this implies in a clearly defined dynamic: mobilizing the patient's resources.

Clinicopathological characteristics and disease chronicity in native kidney biopsies in Flanders

Background

The Flemish Collaborative Glomerulonephritis Group (FCGG) registry provides complete population data on kidney disease epidemiology in the region of Flanders (Belgium), as it captures all native kidney biopsies performed in its population of 6.5 million inhabitants.

Methods

From 2017 until 2019, 2054 adult kidney biopsies were included from 26 nephrology centers (one biopsy per patient). Data on nephrotic and nephritic syndrome were available in 1992 and 2026 biopsies, respectively. In a subgroup of 898 biopsies containing ≥10 glomeruli from 2018 to 2019, disease chronicity was graded using the Mayo Clinic Chronicity Score (MCCS). The association between clinical variables and MCCS was determined using simple and multiple linear regression models.

Results

Nephrotic syndrome (present in 378 patients, 19.0%) was most frequently caused by minimal change disease in younger patients (18-44 years), membranous nephropathy in older patients (45-74 years) and amyloidosis in the elderly (>75 years). Nephritic syndrome (present in 421 patients, 20.8%) was most frequently caused by immunoglobulin A nephropathy (IgAN) in younger patients (18-64 years) and ANCA-associated vasculitis (AAV) in older patients (>64 years). AAV and IgAN were the most frequent underlying diagnoses in biopsies in which crescents were identified. In multivariable analysis, acute and chronic kidney disease and diagnoses of diabetic kidney disease, nephrosclerosis and hyperoxaluria/hypercalcemic nephropathy were associated with the highest MCCS increases.

Conclusions

The FCGG registry validates data from previous Western European registries and provides a snapshot of disease chronicity in the whole biopsied Flemish population.

Sociodemographic Differences in Intimate Partner Violence Prevalence, Chronicity, and Severity Among Young Sexual and Gender Minorities Assigned Male at Birth: The P18 Cohort Study

Intimate partner violence (IPV) is prevalent among young sexual and gender minorities assigned male at birth (YSGM-AMAB). However, few studies have examined the chronicity or distinguished between minor and severe forms of IPV among YSGM-AMAB. Furthermore, while past research has documented differences in IPV by race/ethnicity, sexual identity, gender identity, income, and education in other populations, few studies have examined these sociodemographic characteristics in relation to IPV in YSGM-AMAB. Thus, the present study aims to: (1) estimate past year prevalence and chronicity of minor and severe forms of IPV victimization and perpetration in a diverse sample of (N = 665) YSGM-AMAB in New York City, and (2) examine differences in IPV prevalence and chronicity by the aforementioned sociodemographic characteristics. Cross-sectional data from [BLINDED] informed these descriptive and inferential analyses. Nearly half of all participants reported past year IPV victimization and approximately 40% reported perpetration. Psychological violence was the most common form of victimization, followed by sexual, physical, and injury victimization. Psychological violence was the most common form of perpetration, followed by physical, sexual, and injury perpetration. Regarding sociodemographic differences in last year IPV prevalence, bisexual, transgender, and lower income YSGM-AMAB were more likely to report several subtypes of IPV victimization. Whereas Asian/API, bisexual, transgender, and lower income participants were more likely to report several subtypes of IPV perpetration. Regarding last year IPV chronicity, non-graduate YSGM-AMAB reported more instances of two subtypes of IPV victimization, while Black, White, cisgender, upper income, non-graduate participants reported more instances of several subtypes of IPV perpetration. These findings may be used to develop IPV prevention and intervention programs, inform future research endeavors, and develop and strengthen policies that reduce sociodemographic inequalities and promote more favorable sociopolitical conditions for YSGM-AMAB.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Characteristics of maternal depression and children's functioning: A meta-analytic review

Maternal depression is associated with cognitive, emotional, and behavioral problems in offspring, but the substantial heterogeneity of depression precludes a full understanding of these associations. Variation in course of depression, characterized by severity or chronicity, may be related differentially to children's development. The current meta-analytic review examined the relations of these characteristics of maternal depression to children's developmental outcomes. Twenty-nine studies were identified and reviewed; the majority (93%) of studies reported a negative association between some aspect of maternal depression and children's adjustment. Separate meta-analyses revealed significant effect sizes for severity (Fisher's z = -.243) and chronicity (adjusted Fisher's z = -.337) of maternal depression and children's cognitive or behavioral functioning. Findings are synthesized across features of maternal depression; methodological limitations within the empirical literature are discussed; and recommendations for future research are suggested. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Increased plasma level of kynurenic acid in drug-free patients with first-episode schizophrenia compared to patients with chronic schizophrenia and healthy controls: preliminary data

BACKGROUND

Kynurenic acid (KYNA) is a metabolite of tryptophan (TRP). KYNA levels have been reported with controversial findings in patients with schizophrenia.

AIM

This study aimed to investigate the probable effects of medication and illness chronicity on peripheral KYNA levels in schizophrenia.

METHODS

We assessed peripheral (plasma) TRP metabolite levels in 38 drug-free patients with first-episode schizophrenia (FES), 65 patients with chronic schizophrenia (CHS), and 70 healthy controls by using high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). The symptom severity of patients was evaluated by using the Positive and Negative Syndrome Scale (PANSS). Finally, we analyzed the association of TRP metabolites with symptom severity.

RESULTS

We found significantly higher KYNA levels in FES patients than in both healthy controls (p < 0.01) and CHS patients (p < 0.05). No significant association was observed between plasma TRP metabolite levels and PANSS scores in either FES or CHS patients.

CONCLUSIONS

In conclusion, elevated plasma KYNA levels may be a promising biomarker in FES patients. Medication and illness chronicity may affect peripheral KYNA levels with a currently unknown mechanism.

"I Do Not Have to Hurt My Body Anymore": Reproductive Chronicity and Sterilization as Ambivalent Care in Rural North India

Drawing on 18 months of ethnographic fieldwork in rural Rajasthan, India, I examine women's narratives of chronic reproductive suffering and the practices they employed to relieve it. Cumulative effects of adverse and ordinary reproductive events and exhaustion from caregiving were often seen as reproductive suffering, while sterilization emerged as an act of care toward women's ever-weakening bodies. Sterilization has been an integral part of the often coercive, incentive- and target-driven population control program in India. Rural women, however, described sterilization not as a form of violence but as an act of care, despite its ambivalence. In the context of reproductive chronicity-a persistent reproductive suffering recurring alongside reproductive events, available care options, relations within which these options are located, and structural conditions that shape women's lives-care and suffering are intimately and ambiguously intertwined.

Alteration of Bile Acids and Omega-6 PUFAs Are Correlated With the Progression and Prognosis of Drug-Induced Liver Injury

Background & Aims

Drug-induced liver injury (DILI) is one of the leading causes of liver failure with some of the patients progressed to chronic DILI. The mechanisms underlying the severity and chronicity of DILI are poorly elucidated and the biomarkers are limited. Metabolites and gut microbiota played a crucial role in the development of various liver diseases. Herein, a systematic analysis of serum metabolites and gut microbiota was performed in DILI patients, aiming to identify metabolites correlated with the progression and clinical prognosis of DILI.

Methods

Various serum metabolites were quantitated using a metabolite array technology in this prospective study. Gut microbiome compositions and the expression profiles of liver genes were determined in patients with DILI and healthy controls.

Results

Metabolomic analysis revealed that bile acids (BAs) and polyunsaturated fatty acids (PUFAs) were closely related to DILI severity and chronicity respectively. The ratios of serum primary/secondary BAs and omega-6/omega-3 PUFAs were elevated in DILI patients. A model established by adrenic acid (AdA) and aspartic acid (Asp) exerts good performance for predicting the chronicity of DLIL. Hepatic transcriptome revealed enhanced expression of PUFA peroxidation and supressed expression of BA synthesis related genes in DILI patients. In addition, Lactic acid bacteria and BA converting bacteria were increased in gut of DILI patients. Besides, elevated serum malondialdehyde (MDA) and fibroblast growth factor 19 (FGF19) was observed in DILI patients.

Conclusion

BAs and PUFAs could be potent markers for the severity and chronicity of DILI respectively. The panel of AdA and Asp could be ideal predictive model for the risk of chronicity at the acute stage of DILI. Gut microbiota might act as a negative feedback mechanism to maintain the homeostasis of BAs and PUFAs via FGF19 signalling and PUFA saturation, respectively. Our study revealed novel biomarkers for severe and chronic DILI and provided new therapeutic targets for DILI.

Psychological interventions in preventing chronicity of sub-acute back pain: a systematic review

OBJECTIVES

There is scarce information on preventive psychological and behavioural methods applicable to sub-acute (4-12 weeks) back pain, a precursor to chronic back pain. We conducted a systematic literature review of the efficacy of psychological interventions in preventing chronicity of sub-acute back pain.

METHODS

A systematic literature search in CINAHL, CENTRAL, MEDLINE, PubMed®, PsychINFO, Scopus and Web of Science databases.

RESULTS

From a total of 271 records, only three studies met the eligibility criteria. In two of the reviewed studies, the interventions had an insignificant preventive impact on the chronification of back pain. In one study the CBT intervention proved promising in preventing back pain related disability. None of the studies reported a significant impact on pain intensity at follow-up.

CONCLUSIONS

The psychological interventions did not impact pain outcomes. There is a disproportion between novel knowledge on psychological factors involved in the transition to chronic pain and corresponding preventive treatments. Additional studies on psychological interventions on sub-acute back pain prevention are highly warranted due to the enormous burden that back pain creates when it becomes chronic. The research project has the ethical approval of the Research Ethical Committee at Helsinki University Hospital, HUS/2435/2017.

Text Message Intervention for Latino Adults to Improve Diabetes Outcomes

Introduction: Determine the effectiveness of a diabetes text message intervention to improve diabetes outcomes in Latino adults at a free clinic in the southeastern United States. Methods: A pre-post, one-group design was used with a convenience sample (n = 24) of Latino adults with type 2 diabetes and A1C ≥ 7 who consented to participate. Over 8 weeks, participants were sent 23 educational and motivational text messages that were based on the American Association of Diabetes Educators (AADE) 7 self-care tasks and the American Diabetes Association (ADA) Standards of Medical Care in Diabetes Mellitus (DM). Diabetes knowledge, self-efficacy, self-care, and A1C were measured. Results: Diabetes knowledge, self-efficacy, self-care, and A1C improved after 8 weeks. Statistically significant results (p < .05) were seen in two of the four evaluation instruments administered (Spoken Knowledge in Low Literacy in Diabetes Scale [SKILLD], p = .001, Diabetes Self-Efficacy Scale [DSES], p = .000). A1C improvements were significant (0.86 or 10 mmol/mol) from the pre-intervention (M = 9.06 [76 mmol/mol], SD = 1.49) to the post-intervention (M = 8.20 [66 mmol/mol], SD = 1.27, t [23] = 3.02, p = .006). Conclusion: Personalized communication, education, and follow-up via text messages improved diabetes knowledge, self-efficacy, self-care, and A1C among pilot project participants. Text messages are a useful tool for diabetes management.

HIV Support Groups and the Chronicities of Everyday Life in eSwatini

Drawing on ethnographic research, I examine the evolution of HIV support groups and biosociality during the "treat-all era" in eSwatini. I show how support groups are shaped by local actors to cater to a need for social solidarity that transcends diagnostic status, and thereby move beyond donors' HIV-centric rationales to use the groups for HIV treatment scale-up. In this particular phase of the HIV epidemic, I suggest, support groups make up a particular kind of biosociality, which is shaped by shared experiences of structural vulnerability to chronic illness, and a desire to be prepared for future diseases and other misfortune.

Vaccinal chronicity: immunotherapy, primary care, and the temporal remaking of lung cancer's patienthood in Cuba

The Cuban biotechnology industry is producing cancer immunotherapy, in particular, therapeutic vaccines that actively stimulate the immune system to stabilise the tumour. These products aim to transform metastatic malignancies into a chronic disease. Since 2010, this therapeutic concept has been integrated within a public health experiment, consisting of the large distribution of immunotherapies, including in primary healthcare centres, to enhance access and assess its effectiveness on a wider population of patients. Such experimental intervention, consisting of post-marketing clinical trials, has focused only on lung cancer, one of the most widespread and lethal cancers on the island. Combining interviews with ethnographic observations focusing on care performed by professionals, patients, and their relatives, this paper analyses the experience of lung cancer chronicity under this type of immunotherapy in Cuba. It shows how a certain form of continuity is made between prophylactic and therapeutic vaccination to shape a new temporality of cancer care, through the integration within primary care, constant access to biotechnology, and multiple care practices directed to strengthen the immunotherapy's efficacy. If vaccinal chronicity remains fragile due to its experimental dimension and the fact that long-term survivorship is still an exceptional phenomenon, lung cancer patienthood is deeply transformed through a shared effort of the people and the state to provide more stable, meaningful, and inclusive care.

Failing livers, anticipated futures and un/desired transplants

This article looks at liver transplants as life-prolonging treatment for chronic liver failure and examines the role anticipation plays in the context of chronic liver conditions. Based on anthropological fieldwork in Germany, this article draws on three exemplary patient accounts to show how the anticipatory experience of waiting for a liver transplant serves as an important period in transplant trajectories, and how the lack of a wait may have long-term consequences for patients' wellbeing. A focus on waiting and anticipation in the context of chronic livers enables new understandings of the complex temporal qualities that living with chronic conditions entails. As the sole long-term treatment available for failing livers, the possibilities of transplant medicine shape patients' anticipation of their future. Conversely, the particular futures that patients anticipate mould how they make sense of their transplant and their chronic pre- and post-transplant lives. This article shows that rather than offering a unilinear treatment with a clear-cut end, liver transplants, as treatment for a wide range of chronic conditions, reproduce chronic lives.

Risk factors for developing chronic whiplash disorders

BACKGROUND

Whiplash injury is one of the most common injuries in traffic accidents. Most of the injured recover within three months, however, a significant number have symptoms much longer.

OBJECTIVE

The aim of this study was to determine the basic epidemiological characteristics of whiplash (gender, age, collision type, the type of participants in an accident, clinical signs) on Bosnia and Herzegovina roads and identify risk factors for chronic symptoms.

METHODS

The subjects of this retrospective study were traffic accident whiplash patients who were diagnosed, treated and monitored in a single hospital center. The initial examination was performed on the day or the day after the accident and follow-up examinations after four weeks, three months, and six months.

RESULTS

Out of the 241 patients in this study, 14.1% had symptoms over six months after the trauma. 54.7% of the injured belong to the third and fourth decade and close to 80% were younger than 50 years. In addition to neck pain, the most common symptoms were limited neck mobility (69.7%), muscle spasms (63.5%), palpable pain of neck muscles (56%), headache (43.6%), nausea (23.7%). Statistical analysis showed a positive impact of age, Quebec Task Force (QTF) grade II, and more injury severity and cervical spine degenerative changes on prolonged recovery.

CONCLUSIONS

The overwhelming majority of the injured belong to the working population. QTF2+ score is a useful indicator for prolonged recovery and chronic symptoms. Age, QTF score and degenerative changes of the cervical spine indicate an increased risk for poor recovery and chronic symptoms.

The (failed) promise of multimorbidity: chronicity, biomedical categories, and public health

Multimorbidity has become an increasingly prominent lens through which public health focuses on the 'burden' of ill health in ageing populations, with the promise of a more upstream and holistic approach. We use a situational analysis (drawing on documentary analysis and interviews with service providers, policy actors and people living with multiple conditions) in south London, UK, to explore what this lens brings into focus, and what it obscures. Local initiatives mobilised the concept of multimorbidity in initiatives for integrating health care systems and for commissioning for prevention as well as care. However, as the latest of a series of historical attempts to address system fragmentation, these initiatives generated more complexity, and a system orientated to constant transformation, rather than repair or restoration. Service providers and patients continued to struggle to navigate the system. Dominant policy and practice narratives framed patient self-management as the primary route for addressing individualised risk factors on a trajectory to multimorbidity, whereas the narratives of those living with multiple conditions were more oriented to a relational model of health. The findings suggest possibilities and limitations for leveraging the concept of multimorbidity for public health. In this field, the promise arose from its potential to make spaces for a focus on populations, not patients with discrete diseases. Realising this promise, however, was limited by the inherent tensions of biomedical nosologies, which separate discrete diseases within individual bodies, and from epidemiological approaches that reify the socio-material contexts of failing health as risks for individuals.

Failure to resolve loss and compromised mentalizing in female inpatients with major depressive disorder

Attachment and mentalizing are central concepts in research on the etiology, course, and treatment of depression. The goal of this cross-sectional study was to clarify the unique value of these constructs in characterizing the presence, severity, and chronicity of depression. We examined 50 female inpatients suffering from Major Depressive Disorder (MDD) in comparison to 47 matched healthy controls regarding their attachment states of mind, mentalizing capacities, and clinical variables indicating depression severity and chronicity (e.g. illness duration, number of hospitalizations). In the group of depressed patients, unresolved attachment with regard to loss was significantly overrepresented. Dimensionally, patients were more disorganized and more insecure, whereas there was no difference on the dismissing-preoccupied dimension between the two groups. Mentalizing was significantly lower in patients than in healthy controls. Logistic regression analysis revealed attachment insecurity, mentalizing deficits, and unresolved loss to be incrementally relevant to predict MDD. Correlations with clinical parameters in the group of depressed patients showed positive associations between mentalizing deficits, attachment insecurity, and variables indicating illness chronicity. Our findings highlight the relevance of the inability to resolve or reappraise loss experiences in depressive states.

Adjusted Morbidity Groups and Intracerebral Haemorrhage: A Retrospective Primary Care Cohort Study

Background: Intracerebral haemorrhage rates are increasing among highly complex, elderly patients. The main objective of this study was to identify modifiable risk factors of intracerebral haemorrhage. Methods: Multicentre, retrospective, community-based cohort study was conducted, including patients in the Adjusted Morbidity Group 4 with no history of intracerebral haemorrhage. Cases were obtained from electronic clinical records of the Catalan Institute of Health and were followed up for five years. The primary outcome was the occurrence of intracerebral haemorrhage during the study period. Demographic, clinical and pharmacological variables were included. Logistic regression analyses were carried out to detect prognostic variables for intracerebral haemorrhage. Results: 4686 subjects were included; 170 (3.6%) suffered an intracerebral haemorrhage (85.8/10,000 person–year [95% CI 85.4 to 86.2]). The HAS-BLED score for intracerebral haemorrhage risk detection obtained the best AUC (0.7) when used in the highest complexity level (cut-off point ≥3). Associated independent risk factors were age ≥80 years, high complexity and use of antiplatelet agents. Conclusions: The Adjusted Morbidity Group 4 is associated with a high risk of intracerebral haemorrhage, particularly for highly complex patients and the use of antiplatelet agents. The risk of bleeding in these patients must be closely monitored.

Patients recovering from exacerbations of COPD with and without hospitalization need: could ICF score be an additional pulmonary rehabilitation outcome?

OBJECTIVE

To compare disability changes measured with the Respiratory ICF Maugeri core set on COPD patients, recovering from acute exacerbation with and without hospitalization, submitted to pulmonary rehabilitation (PR).

MATERIALS AND METHODS

All COPD inpatients admitted for rehabilitation in 9 Respiratory Units (January-August 2019) were considered eligible. 2066 patients were included (540 discharged from an acute Hospital = Hospital group and 1526 coming from their home = Home group). Healthcare professionals filled, in a digitalized chart, the Respiratory ICF Maugeri core set (26 items), assessing ICF categories at admission and discharge.

RESULTS

The baseline distribution of the more severe ICF qualifiers was higher in the Hospital group (p < .001) when compared to the Home group. After rehabilitation, all patients -irrespective of hospitalization need- statistically decreased the rate of the higher ICF qualifiers (p < .0001). Hospital group improved more both the rate of qualifiers ≥2 [Δ: -21.32 (22.41) vs -15.48 (17.32), p < .001] and the rate of qualifiers 0-1 [Δ: + 18.38 (24.67) vs 13.25 (19.13), p < .001] than Home group.

CONCLUSIONS

Disability measured with the "Respiratory ICF Maugeri core set" after PR improves in COPD patients recovering from acute exacerbation irrespective of hospitalization need. Its use an additional outcome remains to be further elucidated.KEY MESSAGESRoutine implementation of an ICF set for chronic respiratory diseases can enhance a patient-centered approach in rehabilitation for different severity conditions.Pulmonary rehabilitation (PR) seems to improve global disability measured with the Respiratory ICF Maugeri core set in COPD patients recovering from acute exacerbation irrespective of hospitalization need, suggesting the use of ICF set as additional PR outcome.The description, through the ICF language, of rehabilitative needs of patients, coming "from-Home" and "from-Hospital" settings, could help staff and instrument organization.

Irrigation and Debridement With Implant Retention: Does Chronicity of Symptoms Matter?

BACKGROUND

Periprosthetic joint infection (PJI) remains a rare, yet devastating complication of total joint arthroplasty (TJA). Chronic infection is generally considered a contraindication to debridement, antibiotics, and implant retention (DAIR); however, outcomes stratified by chronicity have not been well documented.

METHODS

A retrospective review of all DAIR cases performed at a single institution from 2008 to 2015 was performed. Chronicity of PJI was categorized as acute postoperative, chronic, or acute hematogenous. Failure after DAIR, defined as re-revision for infection recurrence with the same organism, was evaluated between the 3 chronicity groups at 90 days as well as at a minimum 2-year follow-up.

RESULTS

Overall, 248 patients undergoing DAIR for total hip arthroplasty or total knee arthroplasty PJI were included. Categorization of PJI was acute (acute postoperative) in 59 cases (24%), chronic in 54 (22%), and acute hematogenous in 135 (54%). DAIR survivorship was 47% (range 0.3-10 years). Overall, there were 118 (47.6%) treatment failures after DAIR with a minimum of 2-year follow-up. There was no difference in failure rate between total hip or total knee arthroplasty patients (P = .07). Patients infected with Staphylococcus conferred a higher risk of failure for all DAIR procedures regardless of chronicity category.

CONCLUSION

Identification of microbial species prior to undertaking DAIR may be more clinically relevant than stratification according to chronicity category when considering treatment options.

Genetic Mutations in TNFSF11 Were Associated With the Chronicity of Hepatitis C Among Chinese Han Population

Background: Recently, several studies have reported that the host immune response can be related to the RANKL/RANK/OPG signaling pathway. However, the associations of TNFSF11, TNFRSF11A, and TNFRSF11B gene polymorphisms in the RANKL/RANK/OPG pathway with hepatitis C virus (HCV) infection outcomes remain unclear.

Methods: In this case-control study, 768 persistent HCV infection and 503 spontaneous HCV clearance cases, and 1,259 control subjects were included. The Taman-MGB probe method was utilized to detect TNFSF11 rs9525641, TNFRSF11A rs8686340, and TNFRSF11B rs2073618 genotypes. The distribution of three single nucleotide polymorphisms (SNPs) genotypes was analyzed using stata14.0.

Results: SNPs rs9525641, rs8086340, and rs2073618 genotype frequencies followed the Hardy-Weinberg natural population equilibrium (p = 0.637, 0.250, and 0.113, respectively). Also, rs9525641 was significantly associated with HCV chronicity risk in recessive (OR = 1.203, 95% CI: 1.018–1.420, p = 0.030) and additive models (OR = 1.545, 95% CI: 1.150–2.075, p = 0.004). The stratified analysis showed that rs9525641 variant genotypes were associated with HCV chronicity among people older than 50 years (OR =1.562, 95% CI: 1.079–2.262, p = 0.018), females (OR = 1.667, 95% CI: 1.145–2.429, p = 0.008), ALT <40 U/L (OR = 1.532, 95% CI: 1.074–2.286, p = 0.018), and AST < 40 U/L (OR = 1.552, 95% CI: 1.095–2.201, p = 0.014).

Conclusion:TNFRSF11 rs9525641 was significantly associated with HCV chronicity in the Chinese population.

Machine Learning to Identify Interaction of Single-Nucleotide Polymorphisms as a Risk Factor for Chronic Drug-Induced Liver Injury

Drug-induced liver injury (DILI) is a major cause of drug development failure and drug withdrawal from the market after approval. The identification of human risk factors associated with susceptibility to DILI is of paramount importance. Increasing evidence suggests that genetic variants may lead to inter-individual differences in drug response; however, individual single-nucleotide polymorphisms (SNPs) usually have limited power to predict human phenotypes such as DILI. In this study, we aim to identify appropriate statistical methods to investigate gene-gene and/or gene-environment interactions that impact DILI susceptibility. Three machine learning approaches, including Multivariate Adaptive Regression Splines (MARS), Multifactor Dimensionality Reduction (MDR), and logistic regression, were used. The simulation study suggested that all three methods were robust and could identify the known SNP-SNP interaction when up to 4% of genotypes were randomly permutated. When applied to a real-life DILI chronicity dataset, both MARS and MDR, but not logistic regression, identified combined genetic variants having better associations with DILI chronicity in comparison to the use of individual SNPs. Furthermore, a simple decision tree model using the SNPs identified by MARS and MDR was developed to predict DILI chronicity, with fair performance. Our study suggests that machine learning approaches may help identify gene-gene interactions as potential risk factors for better assessing complicated diseases such as DILI chronicity.

Surveillance life and the shaping of 'genetically at risk' chronicities in Denmark

Today, in the field of hereditary colorectal cancer in Denmark, more than 40,000 identified healthy individuals with an increased risk of cancer are enrolled in a surveillance program aimed at preventing cancer from developing, with numbers still growing. What this group of healthy individuals has in common is lifelong regular interaction with a healthcare system that has traditionally been geared towards treating the acutely and chronically ill. In this article, we explore how people living with an inherited elevated risk of colorectal cancer orient themselves towards their families' and their own predispositions as well as the lifelong surveillance trajectories that they have embarked upon - what we call surveillance life. Unlike prior critiques of predictive genetic testing as generative of 'pre-patients' or 'pre-symptomatically ill', we suggest that for those enrolled in lifelong surveillance programmes in welfare state Denmark, the relevance of risk fluctuates according to certain moments in life, e.g. at family reunions, when a close relative falls ill, in the time leading up to a surveillance colonoscopy or when enduring the procedures themselves. As such, rather than characterising surveillance life in terms of 'living with chronic risk' we show how 'genetically at risk' chronicities take shape as persons come to terms with a disease that possibly awaits them leading them to recalibrate familial bonds and responsibilities while leading lives punctuated by regular medical check-ups.

Pediatric lupus nephritis - An evil cousin of its adult counterpart: A single-center based experience from a tertiary care hospital of Eastern India

Context

Systemic lupus erythematosus is an autoimmune multisystem disease with a high predilection for renal involvement. Lupus nephritis develops in 20% to 75% within the first two years. Presentation varies from subnephrotic proteinuria to end-stage renal disease.

Aims

To study clinical features, biochemical, and serological parameters and correlate with histological activity and chronicity score [modified National Institute of Health (NIH) score].

Settings and Design

Retrospective, cross-sectional, single-center based study in a tertiary care hospital of Eastern India.

Subjects and Methods

We incuded 36 children with lupus nephritis diagnosed from February 2018 to March 2019. Laboratory data included were complete blood count (CBC), blood glucose, urine analysis, serum urea, creatinine, blood urea nitrogen (BUN), albumin, cholesterol, HBsAg, antihepatitis C virus (HCV) antibody, antistreptolysin O (ASO) titer, antinuclear antibody (ANA), myeloperoxidase antineutrophil cytoplasmic antibody (MPO ANCA), proteinase 3 antineutrophil cytoplasmic antibody (PR3 ANCA), double-stranded DNA (dsDNA), C3, and C4. Clinical parameters were age, sex, blood pressure (BP), skin lesions, arthralgia, edema, obesity. Renal biopsies examined with light microscopy, hematoxylin and eosin (H and E), periodic acid-Schiff (PAS), silver methanamine, Masson's trichrome (MT) stains. Immunofluorescence microscopy done with IgG, IgM, IgA, C3c, C1q, kappa, lambda antibodies.

Statistical Analysis Used

Kruskal-Wallis and χ² tests.

Results

Mean age was 15.12 ± 3.49 and 12.5 ± 1.73 years for lupus nephritis (LN) with activity and LN without activity, respectively. Mean dsDNA was higher and mean C3 was lower (52.35 ± 22.21 mg/dl) in active LN. Mean 24-hour urinary protein was higher in LN without activity. Serum creatinine was raised in active LN. LN class III and IV showed higher activity than chronicity.

Conclusions

Pediatric LN is proliferative and more active as compared with adult counterparts. Activity scores are much higher than chronicity scores.

[Vertigo and dizziness]

Pathophysiology of vertigo/dizziness can be understood by eye deviation (nystagmus). In benign paroxysmal positional vertigo, eye deviation of causative semicircular canal stimulation is directly observed. In other peripheral vestibular disorders, eye deviation results from the sum of unilateral all semicircular canal disorders. The central vestibular pathway is controlled by the cerebellum. Thus, in vertigo/dizziness of central origin, not only eye deviation due to impairment of the central vestibular pathway but also deviation due to disinhibition of the pathway from the cerebellum is observed. The cerebellar control on the central vestibular pathway also plays an important role in vestibular compensation. When treating vertigo/dizziness, it is necessary to understand the pathophysiology of the vertigo/dizziness, to set the treatment target based on the pathophysiology, and to intervene for the target.

Couples Coping With the Serious Illness of One of the Partners

Chronic kidney failure is a serious somatic disease. Addressing the issue of living with a chronic disease means fully considering the patients’ entourage, their families, and those close to them, especially their children and spouses.

Objectives: The present paper focuses on the couple’s psychological experience when one of them suffers from a chronic disease, in this instance kidney disease. In particular, how is the spouse affected by the treatment provided? The aim is not only to see how care for sick people can be improved, but also, more specifically, how relatives and especially partners can receive attention.

Methodology: A qualitative approach is not only adopted, being based on the psychotherapeutic follow-up of the partners of patients with chronic kidney disease, but also of the patients themselves, addressing the matter of their life as a couple. Three couples were considered, and two case studies are presented here. The issues that cut across these different situations are examined.

Results and Discussion: Some couples show considerable resourcefulness. However, over the years, that capacity for adaptation and inventiveness can also be interrupted by the periods of greater suffering and even despair, especially when the somatic pathology becomes chronic. Many spouses talk about how living with a sick partner weighs down on them, causing severe fatigue. Some aspects of the illness can also become traumatic. The disease regularly disrupts the daily life of the couple and the family. This leads to a reworking of family relations. Each couple has its own history with the condition. As it emerges, it can disrupt the bonds of filiation, especially when the illness is hereditary. Making psychological care more accessible to the partners involved constitutes a major challenge for our hospital care systems.

Mycobacterial biofilms as players in human infections: a review

The role of biofilms in pathogenicity and treatment strategies is often neglected in mycobacterial infections. In recent years, the emergence of nontuberculous mycobacterial infections has necessitated the development of novel prophylactic strategies and elucidation of the mechanisms underlying the establishment of chronic infections. More importantly, the question arises whether members of the Mycobacterium tuberculosis complex can form biofilms and contribute to latent tuberculosis and drug resistance because of the long-lasting and recalcitrant nature of its infections. This review discusses some of the molecular mechanisms by which biofilms could play a role in infection or pathological events in humans.

Lupus nephritis: correlation of immunohistochemical expression of C4d, CD163-positive M2c-like macrophages and Foxp3-expressing regulatory T cells with disease activity and chronicity

BACKGROUND

C4d, which is a serum complement cleavage product of the activated complement component C4, was found to be an accurate indicator of lupus activity compared to complement levels. Recently, macrophages have been considered to be pivotal members in the pathogenesis of lupus nephritis (LN). M2c-like macrophages have anti-inflammatory functions and promote fibrosis. Multiple studies have detected that LN is associated with an imbalance between the regulatory T cell (Treg) population and the inflammatory T helper subtypes.

METHODS

We evaluated and scored the immunohistochemical expression of C4d, CD163-positive M2C-macrophages and Foxp3-expressing Tregs in 53 renal biopsies of LN. Their expression was scored and correlated with clinical and histological disease activity and chronicity.

RESULTS

Class IV was the most prevalent class (50.9%), followed by class III (17%). PTC-C4d intensity score, CD163% of positive M2c macrophages and FOXP3% of positive Tregs were significantly correlated with chronicity index (r_s = 0.292, p = 0.034; r_s = 0.407, p = 0.003; and r_s = 0.296, p = 0.031, respectively). Also, FOXP3% of positive Tregs was significantly correlated with LN class (r_s = 0.31, p = 0.024).

CONCLUSION

C4d-PTC, CD163-positive M2c macrophages and FOXP3-positive Tregs are markers that significantly correlated with chronicity in LN. Further studies are needed to evaluate their prognostic value.

[The organisation of time and caregivers]

Caregivers put in place various mechanisms to manage their relationship with time. The time of silence and that of chronicity try to mask the confrontation with the finite nature of the human condition. Time in end-of-life care reminds them however that this life is finite.

Serum Vitamin D Levels in Children with Immune Thrombocytopenia

OBJECTIVE

Immune thrombocytopenia (ITP) is an acquired immuno-mediated disorder characterized by thrombocytopenia with an increased risk of bleeding. In recent years 1,25[OH]2D3 has been rediscovered as an immune modulator. We decided to evaluate serum Vitamin D levels in a cohort of children with immune thrombocytopenia in order to discover if Vitamin D concentrations may predict ITP duration.

METHODS

Thirty children were enrolled in this study (sixteen with chronic ITP and fourteen with newly diagnosed ITP) to assess serum Vitamin D levels.

RESULTS

The results showed that 80% of the enrolled children presented a D hypovitaminosis status. Children with newly diagnosis ITP showed no statistically significantly higher median values of Vitamin D compared to chronic ITP.

CONCLUSION

This study may suggest that Vitamin D deficiency does not represent a chronicity factor for ITP. However, further studies are needed to understand the role of Vitamin D in ITP pathogenesis.