The prognostic value of serum pregnancy-associated plasma protein A,S100 and high sensitivity C-reactive protein in acute ischemic stroke patients without heparin administration

ObjectivesThe concerns regarding the pre-analytical bias caused by medicine treatments have been raised in the diagnosis and prognosis of ischemic stroke recently. The aim of this study was to examine the prognostic value of serum pregnancy-associated plasma protein A (PAPP-A), S100 and high sensitivity C-reactive protein (hs-CRP) in heparin-naïve patients of acute ischemic stroke.Design and methodsSerum levels of PAPP-A, S100 and hs-CRP were determined in 205 heparin-naïve patients of acute ischemic stroke and 50 healthy controls. Clinical information and radiological information were collected. Unfavorable outcomes (stroke recurrence, myocardial infarction or death) were also recorded after six months. The associations between serum biomarker levels and stroke severity/outcome were assessed.ResultsSerum PAPP-A, S100 and hs-CRP levels increased in patients compared with controls (P < 0.05). S100 and hs-CRP levels were significantly higher in patients with larger cerebral infarction sizes (P < 0.05) and more severe neurological impairment (P < 0.05). Serum PAPP-A level showed a progressive increase with the increase of stroke severity (P < 0.05). Serum hs-CRP and National Institutes of Health Stroke Scale (NIHSS) scores were identified as independent predictors for unfavorable outcomes with odds ratios of 2.884 (1.154 to 7.210, P = 0.023) and 2.887 (1.146 to 7.273, P = 0.024), respectively.ConclusionSerum PAPP-A, S100 and hs-CRP were associated with stroke severity or outcome after ischemic stroke and may offer complementary information, essential for clinical decision making. Serum PAPP-A showed a potential value for the evaluation of stroke clinically.     

The validity and reliability of the Incremental Shuttle Walk Test and Six-minute Walk Test compared to an Incremental Cycle Test for people who have had a mild-to-moderate stroke

ObjectiveTo determine the construct validity and test re-test reliability of the Six-minute Walk Test (6MWT) and Incremental Shuttle Walk Test (ISWT) in the sub-acute recovery phase following mild-to-moderate severity stroke.Participants40 stroke patients (mean age: 68.27 years, SD: 13.48) of median National Institutes of Health Stroke Scale (NIHSS) score 1.2 (range: 0 to 8) within six months of stroke.MethodEach participant completed one Incremental Cycle Test (ICT) followed by two ISWT and two 6MWT in a randomised order. Pearson’s Correlation Coefficients were used to determine the validity and Bland Altman plots were used to determine the test re-test reliability.ResultsThe Incremental Cycle Test (ICT) was positively correlated with the ISWT (r = 0.59, 95% confidence intervals 0.35 to 0.76, P = 0.001) and the 6MWT (0.55, 0.35 to 0.71, P < 0.001). The correlation of the ICT with the ISWT and 6MWT was higher for the 17 patients with no residual (ISWT: r = 0.79, P < 0.001; 6MWT: 0.826, P < 0.001) compared to mild-to-moderate neurological impairment (ISWT: r = 0.45, P = 0.03; 6MWT: r = 0.38, P = 0.08). Test–retest reliability for both the ISWT and the 6MWT showed that there was some variability between the first and second tests with a better performance on the second test.ConclusionThe ISWT and 6MWT have a significant, modest correlation with the ICT for stroke patients in the sub-acute recovery phase. The ISWT and 6MWT are not strongly correlated with ICT (VO₂ peak) in a stroke population that is disabled. The test–retest reliability of the ISWT and 6MWT indicated that two tests may be needed to accurately assess an individual’s capabilities.     

Serum caspase 3 levels are associated with early mortality in severe septic patients

ObjectiveHigher caspase 3 activity has been found in lymphocytes of septic patients than of healthy controls. However, an association between serum caspase 3 levels at moment of severe sepsis diagnosis and mortality in septic patients has not been previously demonstrated, and this was the main objective of the present study.MethodsThis is an observational study of 216 patients with severe sepsis in 6 Spanish intensive care units. We collected serum samples at moment of severe sepsis diagnosis to determine levels of caspase 3 and caspase-cleaved cytokeratin (CCCK) 18. End point was 30-day mortality.ResultsWe found higher serum caspase 3 levels (P < .001) and caspase-cleaved cytokeratin 18 (P = .001) in nonsurvivors (n = 76) than in survivors (n = 140). Multiple binary logistic regression analysis showed that serum caspase 3 levels greater than 0.25 ng/mL were associated with 30-day mortality (odds ratio, 6.51; 95% confidence interval, 3.32-12.77; P < .001). Receiver operating characteristic analysis showed that the area under the curve to predict 30-day mortality for serum caspase 3 levels was 0.73 (95% confidence interval, 0.67-0.79; P < .001).ConclusionsThe major novel findings of our study were that there is an association between serum caspase 3 levels at moment of severe sepsis diagnosis and mortality in septic patients and that serum caspase 3 levels could be used as prognostic biomarker, and further studies are needed to corroborate these findings.     

Predictors of health-related quality of life after non-catastrophic injury sustained in a road traffic crash

BackgroundHealth-related quality of life (HRQoL) is an important patient-reported outcome that warrants greater attention in individuals who sustained a non-catastrophic injury in a road traffic crash. Additional robust data on HRQoL outcomes after a non-catastrophic injury are needed to effectively identify potential targets for studies of tertiary prevention of poor recovery after a crash.ObjectiveWe assessed the association between non-catastrophic road traffic crash injuries and HRQoL and factors that independently affect long-term HRQoL.MethodsIn this inception cohort study, injured participants (≥ 17 years old) were identified from various sources including hospital emergency departments by a medical examination by a registered healthcare professional in New South Wales (Australia) and followed up after 12 months. HRQoL was measured by the European Quality of Life–5 Dimensions (EQ-5D-3L) and Medical Outcomes Survey Short Form 12 items (SF-12). A range of socio-demographic, pre-injury health, psychological, and injury-related factors were considered potential predictors of HRQoL in regression analyses.ResultsAmong 2019 individuals identified, 1201 (59.5%) were followed up after 12 months. HRQoL significantly improved between baseline and 12-month follow-up: EQ-5D-3L summary score (0.41-unit difference); SF-12 physical component summary score (PCS; 13.6-unit difference) and mental component summary score (MCS; 3.5-unit difference). Over 12 months, HRQoL score was lower for people claiming compensation than others (P < 0.0001). Key predictors of better 12-month EQ-5D-3L summary score and visual analogue scale score for pain were age, not claiming compensation, reduced body mass index, less pain severity, less pain-related disability, and less general psychological distress. Significant predictors of SF-12 PCS score were injury to the neck (P = 0.02) or head or face (P = 0.01), being a driver or passenger at the time of the crash (P < 0.0001), hospital admission (P < 0.0001) and pain severity (P < 0.0001). Baseline variables associated with 12-month SF-12 MCS scores were head or face injury (P = 0.02), pre-injury health (P = 0.04), pre-injury psychological conditions (P = 0.04), trauma-related distress (P = 0.0002) and general psychological distress (P < 0.0001).ConclusionsA wide spectrum of biopsychosocial factors contribute to HRQoL after a road traffic crash injury. These epidemiological data are potentially important because they could identify potential targets for studies of tertiary prevention of persistently poor HRQoL after such an injury.     

Diagnostic and prognostic potentials of microRNA-27a in osteosarcoma

AimGrowing evidence suggest that the microRNA (miR)-23a/24-2/27a cluster may play a crucial role in mammary tumorigenesis and act as a novel class of oncogenes. Among these members, miR-27a has been reported to promote proliferation, migration and invasion in human osteosarcoma cells. The aim of this study was to detect the serum levels of miR-27a in osteosarcoma patients and to investigate its associations with clinicopathological features and prognosis.MethodsmiR-27a levels in sera from 166 osteosarcoma patients and 60 healthy controls were detected by real-time quantitative RT-PCR. Then, the associations of serum miR-27a level with clinicopathological factors or survival of osteosarcoma patients were further evaluated.ResultsCompared to healthy controls, the serum levels of miR-27a were significantly increased in osteosarcoma patients (P < 0.001). Importantly, miR-27a could efficiently screen osteosarcoma patients from healthy controls (Area under receiver operating characteristic curve, AUC = 0.867). Then, high miR-27a expression was more frequently occurred in osteosarcoma patients with advanced clinical stage (P = 0.001), positive distant metastasis (P = 0.01) and poor response to chemotherapy (P = 0.008). In Kaplan–Meier survival analysis, high miR-27a expression was a significant indicator for poor overall survival (P = 0.006) as well as poor disease-free survival (P = 0.01). Furthermore, multivariate analysis demonstrated that miR-27a expression was an independent and significant prognostic factor to predict overall survival (P = 0.01) and disease-free survival (P = 0.03).ConclusionmiR-27a expression may be elevated in sera of osteosarcoma patients and in turn contributes to aggressive progression of this malignancy. Detection of serum miR-27a levels may have clinical potentials as a non-invasive diagnostic/prognostic biomarker for osteosarcoma patients.     

Reduced inspiratory muscle strength increases pneumonia in patients with acute myocardial infarction

BackgroundInspiratory muscle strength is associated with pneumonia in patients after surgery or those with subacute stroke. However, inspiratory muscle strength in patients with acute myocardial infarction (AMI) has not been studied.ObjectiveTo evaluate the predictive value of inspiratory muscle strength for pneumonia in patients with AMI.MethodsPatients with AMI were consecutively enrolled from March 2019 to September 2019. Measurements of maximal inspiratory pressure (MIP) were used to estimate inspiratory muscle strength and mostly were taken within 24 hr after culprit-vessel revascularization. Patients were divided into 3 groups by MIP tertile (T1: < 56.1 cm H₂O, n = 88; T2: 56.1–84.9 cm H₂O, n = 88; T3: > 84.9 cm H₂O, n = 89). The primary endpoint was in-hospital pneumonia.ResultsAmong 265 enrolled patients, pneumonia developed in 26 (10%). The rates of pneumonia were decreased from MIP T1 to T3 (T1: 17%, T2: 10%, T3: 2%, P = 0.004). In-hospital all-cause mortality and major adverse cardiovascular events (MACEs) did not differ between groups. Multivariate logistic regression confirmed increased MIP associated with reduced risk of pneumonia (odds ratio 0.78, 95% confidence interval 0.65–0.94, P = 0.008). Receiver operating characteristic curve analysis indicated that MIP had good performance for predicting in-hospital pneumonia, with an area under the curve of 0.72 (95% confidence interval 0.64–0.81, P < 0.001).ConclusionsThe risk of pneumonia but not in-hospital mortality and MACEs was increased in AMI patients with inspiratory muscle weakness. Future study focused on training inspiratory muscle may be helpful.     

Effects of a nurse-led transitional care program on clinical outcomes,health-related knowledge,physical and mental health status among Chinese patients with coronary artery disease: A randomized controlled trial

BackgroundCoronary artery disease is a major cause of morbidity and mortality among adults worldwide, including China. After a hospital stay, transitional care could help to ensure improved patient care and outcomes, and reduce Medicare costs. Nevertheless, the results of the existing transitional care are not always satisfactory and our knowledge of how to perform effective transitional care for patients with coronary artery disease is limited in mainland China.ObjectivesTo examine the effectiveness of a nurse-led transitional care program on clinical outcomes, health-related knowledge, and physical and mental health status among Chinese patients with coronary artery disease.DesignRandomized controlled trial.MethodsThe Omaha system and Pender’s health promoting model were employed in planning and implementing this nurse-led transitional care program. The sample was comprised of 199 Chinese patients with coronary artery disease. The experimental group (n = 100) received nurse-led transitional care intervention in addition to routine care. The nurse-led transitional care intervention included a structured assessment and health education, followed by 7 months of individual teaching and coaching (home visits, telephone follow-up and group activity). The control group (n = 99) received a comparable length routine care and follow-up contacts. Evaluations were conducted at baseline and completion of the interventions using the perceived knowledge scale for coronary heart disease, the medical outcomes study 36-item short-form health survey and clinical measures (blood pressure, blood glucose, lipids, body mass index). Data were collected between March and October 2014.ResultsCompared with the control group, participants in the experimental group showed significant better clinical outcomes (systolic blood pressure, t = 5.762, P = 0.000; diastolic blood pressure, t = 4.250, P = 0.000; fasting blood glucose, t = 2.249, P = 0.027; total cholesterol, t = 4.362, P = 0.000; triglyceride, t = 3.147, P = 0.002; low density lipoprotein cholesterol, t = 2.399, P = 0.018; and body mass index, t = 3.166, P = 0.002), higher knowledge scores for coronary artery disease (total knowledge score, t = −7.099, P = 0.000), better physical health status (t = −2.503, P = 0.014) and mental health status (t = −2.950, P = 0.004).ConclusionsThis study provides evidence for the value of a nurse-led transitional care program using both the Omaha system and Pender’s health promoting model as its theoretical framework. The structured interventions in this nurse-led transitional care program facilitate the use of this program in other settings.     

Neuropeptide Y polymorphisms and ischemic stroke in Chinese population

BackgroundStroke is the second most common cause of death in developed countries and a major cause of adult disability and mortality worldwide. New data strongly suggest that neuropeptide Y (NPY) may be a candidate gene for ischemic stroke.MethodsWe investigated 450 ischemic stroke patients and 423 healthy controls matched for sex and age in a Han Chinese population. Three functional polymorphisms (? 883TGins/del, ? 602G/T and ? 399 T/C) located in NPY gene promoter were genotyped using DNA sequencing methods.ResultsOf 3 NPY polymorphisms investigated in our study, the ? 399CC genotype (OR: 1.699, 95% CI: 1.124–2.567, P = 0.011) and the ? 399C allele (OR: 1.254, 95% CI: 1.031–1.524, P = 0.023) were more frequent among ischemic stroke patients than in controls, especially in the small vessel disease (SVD) subtype patients. The similar results were observed in multivariable logistic regression analysis. Haplotype analysis revealed that the ? 883ins/?399C haplotype was a risk marker for ischemic stroke (P = 0.008).ConclusionsThe C allele of ? 399 T/C polymorphism in the promoter regions of NPY is an independent risk factor for ischemic stroke, suggesting that NYP system may involve in the mechanisms of stroke pathology.     

Ambulatory activity in stroke survivors associated with functional outcome and quality of life: An observational cohort study

BackgroundPhysical activity is beneficial in stroke prevention and recovery. Understanding activity dynamics and its effect on outcome after stroke is important to improve recommendations and develop interventions.ObjectivesWe examined serial changes in daily ambulatory activity (AA) averaged over 1 week in people with subacute to chronic stroke and its association with functional outcome (modified Rankin scale [mRS]) and quality of life (EQ-5D-3L).MethodsThis observational study examined AA in stroke survivors with no to moderate disability (US National Institute of Stroke Scale [NIHSS] score) who were mostly community dwelling and had cryptogenic stroke based on data from the Continuous Cardiac Monitoring to Assess Atrial Fibrillation After Cryptogenic Stroke study. The participants underwent long-term AA monitoring by accelerometric activity data obtained from an insertable cardiac monitor without receiving any specific encouragement regarding physical activity. We analysed AA changes and assessed the association between baseline AA and mRS/EQ-5D-3L scores. A small group of participants had follow-up data for 2 years, which allowed for analysing long-term serial changes.ResultsWe included 186 participants (mean [SD] age 61.3 [11.2] years, 67% male, mean 39 [28] days after stroke). AA increased during the subacute phase in individuals with mild (NIHSS score 1–4, P < 0.001) and moderate (NIHSS score 5–10, P = 0.013) disability but not in the non-impaired group. Baseline AA was inversely associated with NIHSS score (P < 0.001) and was associated with mRS score (P = 0.001) and weakly correlated with EQ-5D-3L score at 6 months (P = 0.032, r = 0.22). For the 45 participants with follow-up data (mean age 64.5 [9.7] years, 80% male, mean 34 [21] days after stroke), AA remained stable.ConclusionAA increased in stroke survivors with impairments but remained stable in those whose symptoms had resolved. AA during the early subacute period was associated with mRS and EQ-5D-3L scores at 6 months. Insertable cardiac monitoring offers a feasible method for monitoring activity over prolonged periods in people after stroke. Its increased use may offer an opportunity to overcome the limited reliability and validity of many existing measures.Trial registrationClinicalTrials.gov (NCT00924638).     

Evaluating the effect of Matricaria recutita and Mentha piperita herbal mouthwash on management of oral mucositis in patients undergoing hematopoietic stem cell transplantation: A randomized,double blind,placebo controlled clinical trial

ObjectivesTo investigate the effects of Matricaria recutita and Mentha piperita on oral mucositis (OM) in patients undergoing hematopoietic stem cell transplantation (HSCT).DesignRandomized double blind placebo controlled clinical trial.SettingFaculty of Pharmacy, Shahid Beheshti University of Medical Sciences, and Bone Marrow Transplantation Center at Taleghani Teaching Hospital, Tehran, Iran.ParticipantsSixty patients undergoing HSCT were randomly assigned to two groups: placebo (n = 33), and herbal mouthwash group (n = 27).InterventionsAll patients received the mouthwash one week before HSCT and were instructed to use it three times daily for at least 30 s.Main outcome measuresOM was graded using National Cancer Institute Common Toxicity Criteria (NCI-CTC) scale (grade 0–5). The Numerical Rating Scale (NRS: 0–10 scale) measured the severity of OM symptoms.ResultsThe duration, maximum and average daily grade of OM were significantly reduced in the treatment group (P < 0.05). The use of herbal mouthwash led to significant improvements in pain intensity (P = 0.009), dryness (P = 0.04) and dysphagia (P = 0.009). Other significant results included: reduced need for complementary medications (P = 0.03), narcotic analgesics (P = 0.047), total parenteral nutrition (TPN) (P = 0.02) and the duration of TPN (P = 0.03).ConclusionThis study shows that patients receiving the herbal mouthwash experienced less complications and symptoms associated with OM. In summary, it seems that the use of our prepared herbal mouthwash is beneficial for patients undergoing HSCT.     

Correlations between ankle–foot impairments and dropped foot gait deviations among stroke survivors

BackgroundThe purpose of this paper is to 1) evaluate the relationship between ankle kinematics during gait and standardized measures of ankle impairments among sub-acute stroke survivors, and 2) compare the degree of stroke-related ankle impairment between individuals with and without dropped foot gait deviations.MethodsFifty-five independently ambulating stroke survivors participated in this study. Dropped foot was defined as decreased peak dorsiflexion during the swing phase and reduced ankle joint motion in stance. Standardized outcome measures included the Chedoke–McMaster Stroke Assessment (motor impairment), Modified Ashworth Scale (spasticity), Medical Research Council (muscle strength), passive and active range of motion, and isometric muscle force.FindingsFoot impairment was not related to peak dorsiflexion during swing (r = ? 0.17, P = 0.247) and joint motion during stance (r = 0.05, P = 0.735). Active (r = 0.45, P < 0.001) and passive (r = 0.48, P < 0.001) range of motion was associated with stance phase joint motion. Peak dorsiflexion during swing was related to isometric dorsiflexor muscle force (r = ? 0.32, P = 0.039). Individuals with dropped foot demonstrated greater motor impairment, plantarflexor spasticity and ankle muscle weakness compared to those without dropped foot.InterpretationOur investigation suggests that ankle–foot impairments are related to ankle deviations during gait, as indicated by greater impairment among individuals with dropped foot. These findings contribute to a better understanding of gait-specific ankle deviations, and may lead to the development of a more effective clinical assessment of dropped foot impairment.     

Bi-cephalic transcranial direct current stimulation combined with functional electrical stimulation for upper-limb stroke rehabilitation: A double-blind randomized controlled trial

BackgroundStroke survivors often present poor upper-limb (UL) motor performance and reduced movement quality during reaching tasks. Transcranial direct current stimulation (tDCS) and functional electrical stimulation (FES) are widely used strategies for stroke rehabilitation. However, the effects of combining these two therapies to rehabilitate individuals with moderate and severe impairment after stroke are still unknown.ObjectiveOur primary aim was to evaluate the effects of concurrent bi-cephalic tDCS and FES on UL kinematic motor performance and movement quality of chronic post-stroke subjects with moderate and severe compromise. Our secondary aim was to verify the effects of combining these therapies on handgrip force and UL motor impairment.MethodsWe randomized 30 individuals with moderate and severe chronic hemiparesis after stroke into tDCS plus FES (n = 15) and sham tDCS plus FES (n = 15) groups. Participants were treated 5 times a week for 2 weeks. Kinematic motor performance (movement cycle time, velocity profile) and movement quality (smoothness, trunk contribution, joint angles) were assessed during an UL reach-to-target task.Handgrip force and motor impairment were also recorded before and after the intervention.ResultsParticipants allocated to the tDCS plus FES group improved movement cycle time (P = 0.039), mean reaching velocity (P = 0.022) and handgrip force (P = 0.034). Both groups improved the mean returning phase velocity (P = 0.018), trunk contribution (P = 0.022), movement smoothness (P = 0.001) and UL motor impairment (P = 0.002).ConclusionsConcurrent bi-cephalic tDCS and FES slightly improved reaching motor performance and handgrip force of chronic post-stroke individuals with moderate and severe UL impairment.Trial registrationClinicalTrials.gov (NCT02818608).     

Intravenous magnesium therapy in adult patients with an aneurysmal subarachnoid haemorrhage: A systematic review and meta-analysis

BackgroundThe value of magnesium for the prevention of cerebral arterial vasospasm in patients with aneurysmal subarachnoid haemorrhage (SAH) is debatable. We performed a systematic review to collate the available evidence to evaluate the effects of intravenous magnesium for the prevention of cerebral arterial vasospasm.Materials and methodsAn electronic search of MEDLINE (Ovid), ProQuest, CINAHL and the Cochrane Database of Systematic Reviews was undertaken up to 1st October 2012 for randomised controlled trials (RCTs) of intravenous magnesium for the prevention of vasospasm in adult patients with aneurysmal SAH. Primary outcome measures were risk of vasospasm, functional outcomes and mortality. Results are presented as risk ratios (RR) and 95% confidence intervals (CI).ResultsNine of 38 trials were included in this review. Not all trials could be combined for analyses due to differences in reported outcomes and outcome definitions. Of the trials that could be combined we found a statistically significant reduction on the incidence of vasospasm with magnesium (RR 0.83; 95% CI 0.71, 0.98; P = 0.03). No statistical difference for the last reported favourable functional outcome (RR 1.00; 95% CI 0.96, 1.05; P = 0.84); or mortality (RR 0.95; 95% CI 0.77, 1.18; P = 0.67) between magnesium treated and standard care/control groups was found.ConclusionWe identified a benefit in the role of magnesium to reduce the incidence of cerebral vasospasm in patients with an aneurysmal SAH. However no benefit was found regarding improved favourable functional outcome or a reduction of mortality.     

Recovery of balance and gait after stroke is deteriorated by confluent white matter hyperintensities: Cohort study

BackgroundWhite matter hyperintensities (WMHs) are well known to affect post-stroke disability, mainly by cognitive impairment. Their impact on post-stroke balance and gait disorders is unclear.ObjectivesWe aimed to test the hypothesis that WMHs would independently deteriorate post-stroke balance and gait recovery.MethodsThis study was performed in 210 individuals of the cohort Determinants of Balance Recovery After Stroke (DOBRAS), consecutively enrolled after a first-ever hemisphere stroke. Clinical data were systematically collected on day 30 ± 3 (D30) post-stroke and at discharge from the rehabilitation ward. WMHs were searched on MRI, graded with the Fazekas scale, and dichotomized as no/mild (absence/sparse) or moderate/severe (confluent). The primary endpoint was the recovery of the single limb stance, assessed with the Postural Assessment Scale for Stroke (PASS). The secondary endpoint was the recovery of independent gait, assessed with the modified Fugl–Meyer Gait Assessment (mFMA). The adjusted hazard ratios (aHRs) of achievements of these endpoints by level of WMHs were estimated by using Cox models, accounting for other relevant clinical and imaging factors.ResultsIndividuals with moderate/severe WMHs (n = 86, 41%) had greater balance and gait disorders and were more often fallers than others (n = 124, 59%). Overall, they had worse and slower recovery of single limb stance and independent gait (P < 0.001). Moderate/severe WMHs was the most detrimental factor for recovery of balance (aHR 0.46, 95% confidence interval [CI] 0.32–0.68, P < 0.001) and gait (0.51, 0.35–0.74, P < 0.001), along with age, stroke severity, lesion volume and disrupted corticospinal tract. With cerebral infarct, endovascular treatments had an independent positive effect, both on the recovery of balance (aHR 1.65, 95% CI 1.13–2.4, P = 0.009) and gait (1.78, 1.24–2.55, P = 0.002).ConclusionsWMHs magnify balance and gait disorders after stroke and worsen their recovery. They should be better accounted for in post-stroke rehabilitation, especially to help establish a prognosis of mobility.ClinicalTrials.gov registrationNCT03203109.     

Oxygen therapy for acute myocardial infarction: A systematic review and meta-analysis

BackgroundPotential benefits or risks of oxygen inhalation for patients with acute myocardial infarction are not fully understood.ObjectiveWe performed this study to systematically assess the effectiveness and safety of oxygen therapy for patients with acute myocardial infarction.DesignA systematic review and meta-analysis.Data sourcesWe searched randomized controlled trials systematically in PubMed, EMBASE, Web of Science and Cochrane Library up to June 2016.Review methodsRandomized controlled trials that estimated the effectiveness and safety of oxygen therapy for patients with acute myocardial infarction were identified by two independent reviewers. The primary outcomes were short-term mortality and recurrent rate of myocardial infarction, and the secondary outcomes were arrhythmia incidence and pain incidence. Relative risks (RRs) and 95% confidence intervals (CIs) were used to measure the pooled data.ResultsA total of five randomized controlled trials were in accordance with inclusion criteria and were included in this meta-analysis. Compared with no oxygen group, the oxygen group did not significantly reduce short-term death (RR: 1.08, 95%CI: 0.31–3.74), and there was moderate heterogeneity (I² = 50.8%, P < 0.107) among studies. We found a significant increase in the rate of recurrent myocardial infarction (RR: 6.73, 95%CI: 1.80–25.17, I² = 0.0%, P = 0.598) in the oxygen group. The oxygen group did not have a significant reduction in arrhythmia (RR: 1.12, 95%CI: 0.91–1.36; I² = 46.2%, P < 0.156) or pain (RR: 0.97, 95%CI: 0.91–1.04; I² = 7.2%, P = 0.340).ConclusionsOxygen inhalation did not benefit patients with acute myocardial infarction with normal oxygen saturation. It may increase the rate of recurrent myocardial infarction. High quality trials with larger sample sizes are required.     

Mortality and neurological outcome in the elderly after target temperature management for out-of-hospital cardiac arrest

AimTo assess older age as a prognostic factor in patients resuscitated from out-of-hospital-cardiac arrest (OHCA) and the interaction between age and level of target temperature management.Methods and results950 patients included in the target temperature management (TTM) trial were randomly allocated to TTM at 33 or 36 °C for 24 h. We assessed survival and cerebral outcome (cerebral performance category, CPC and modified Rankin scale, mRS) using age as predictor, dividing patients into 5 age groups: ≤65 (median), 66–70, 71–75, 76–80 and >80 years of age. Shockable rhythm decreased with higher age groups, p = 0.001, the same was true for ST segment elevation on ECG at admission, p < 0.01. Increasing age was associated with a higher mortality rate (HR = 1.04 per year, 95% CI = 1.03–1.06, p < 0.001) after adjusting for confounders. Octogenarians had an increased mortality (HR = 3.5, CI: 2.5–5.0, p < 0.001) compared to patients ≤65 years of age. Favorable vs. unfavorable outcome measured by CPC and mRS in survivors was different between age groups with adverse outcomes more prevalent in higher age groups (CPC: p = 0.04, mRS: p = 0.001). The interaction between age and target temperature allocation was not statistically significant for either mortality or neurological outcome.ConclusionIncreasing age is associated with significantly increased mortality after OHCA, but mortality rate is not influenced by level of target temperature. Risk of poor neurological outcome also increases with age, but is not modified by level of target temperature.     

Effectiveness of a community based nurse-pharmacist managed pain clinic: A mixed-methods study

BackgroundChronic pain is predominantly managed in primary care, although often ineffectively. There is growing evidence to support the potential role of nurses and pharmacists in the effective management of chronic pain.ObjectivesTo evaluate the effectiveness of a pain clinic jointly managed by a nurse and pharmacist.DesignA mixed-methods design consisting of qualitative interviews embedded within a quasi-experimental study.SettingsA community-based nurse-pharmacist led pain clinic in the north of England.ParticipantsAdult chronic pain (non-malignant) patients referred to the pain clinic.MethodsPain intensity was the primary outcome. Questionnaires (the Brief Pain Inventory, the Hospital Anxiety and Depression Scale, the SF-36 and the Chronic Pain Grade questionnaire) were administered at the baseline, on discharge and at 3-month post-discharge (Brief Pain Inventory and Hospital Anxiety and Depression Scale only). Patient satisfaction was explored using face-to-face, semi-structured qualitative interviews.ResultsSeventy-nine patients with a mean age of 46.5 years (SD ± 14.4) took part in the quasi-experimental study. Thirty-six and nine patients completed the discharge and 3-month follow-up questionnaires respectively. Compared to baseline, statistically significant reductions were noted for two of the outcome measures: pain intensity (P = 0.02), and interference of pain with physical functioning (P = 0.02) on discharge from the service. Nineteen patients participated in qualitative interviews. The patients were, in general, satisfied with the quality of service. Four contributing factors to patient satisfaction were identified: ample consultation time, in-depth specialised knowledge, listening and understanding to patients’ needs, and a holistic approach.ConclusionsNurse and pharmacist managed community-based pain clinics can effectively deliver quality pain management services as they offer an interdisciplinary holistic approach to pain management. Such services have the potential not only to reduce the burden on secondary care but also decrease long waiting times for referral to secondary care. Further research is required to support the development of evidence based referral guidelines to such services.     

The effectiveness of manual-guided,problem-solving-based self-learning programme for family caregivers of people with recent-onset psychosis: A randomised controlled trial with 6-month follow-up

BackgroundFamily intervention for psychotic disorders is an integral part of psychiatric treatment with positive effects on patients’ mental state and relapse rate. However, the effect of such family-based intervention on caregivers’ psychological distress and well-being, especially in non-Western countries, has received comparatively much less attention.ObjectivesTo test the effects of guided problem-solving-based manual-guided self-learning programme for family caregivers of adults with recent-onset psychosis over a 6-month period of follow-up, when compared with those in usual family support service.DesignA single-centre randomised controlled trial, which was registered at ClinicalTrials.gov (NCT02391649), with a repeated-measures, two-arm (parallel-group) design.SettingsOne main psychiatric outpatient clinic in the New Territories of Hong Kong.ParticipantsA random sample of 116 family caregiverss of adult outpatients with recent-onset psychosis.MethodsFollowing pre-test measurement, caregivers were assigned randomly to one of two study groups: a 5-month self-help, problem-solving-based manual-guided self-learning (or bibliotherapy) programme (in addition to usual care), or usual family support service only. Varieties of patient and caregiver health outcomes were assessed and compared at baseline and at 1-week and 6-month post-intervention.ResultsOne hundred and eleven (96%) caregivers completed the 6-month follow-up (two post-tests); 55 of them (95%) completed ≥4 modules and attended ≥2 review sessions (i.e., 75% of the intervention). The family participants’ mean age was about 38 years and over 64% of them were female and patient's parent or spouse. Multivariate analyses of variance indicated that the manual-guided self-learning group reported significantly greater improvements than the usual care group in family burden [F(1,110) = 6.21, p = 0.006] and caregiving experience [F(1,110) = 6.88, p = 0.0004], and patients’ psychotic symptoms [F(1,110) = 6.25, p = 0.0003], functioning [F(1,110) = 7.01, p = 0.0005] and number of hospitalisations [F(1,110) = 5.71, p = 0.005] over 6-month follow-up.ConclusionsProblem-solving-based, manual-guided self-learning programme for family caregivers of adults with recent-onset psychosis can be an effective self-help programme and provide medium-term benefits to patients’ and caregivers’ mental health and duration of patients’ re-hospitalisations.     

Repeated diffusion weighted imaging in comatose cardiac arrest patients with therapeutic hypothermia

BackgroundThe aim of this study was to evaluate the changing pattern and prognostic values of diffusion-weighted imaging (DWI) at two time points in cardiac arrest patients treated with therapeutic hypothermia.MethodsTwenty two patients with cardiac arrest who underwent two DWI studies were enrolled in the retrospective study. The first DWI was performed after the induction of therapeutic hypothermia (median 6.0 h) and was repeated between 48 h and 168 h (second DWI, median 74 h). Apparent diffusion coefficient (ADC) values were measured in the predefined brain regions, and qualitative analysis was also performed. Good neurologic outcomes were defined as Cerebral Performance Category (CPC) scores of 1 and 2.ResultsThe ADC value tended to increase over time except the cortical regions of the poor outcome group (N = 10). In the comparisons of receiver operating characteristic (ROC) curve to predict poor outcome using ADC value, postcentral cortex in the second DWI has a better association with neurological outcome (p = 0.001, area under the curve (AUC) = 0.996 for second DWI, AUC = 0.571 for first DWI). In the same analysis using qualitative score, precentral cortex, postcentral cortex, parietal lobe, occipital lobe, caudate and putamen in the second DWI have a better association with neurological outcome.ConclusionsThe changing pattern of ADC values after cardiac arrest is different according to anatomic region and neurologic status. The DWI after 48 h has a better association with neurological outcome of cardiac arrest patients in both quantitative and qualitative analysis.