Patients with chronic gastrointestinal ischemia have a higher cardiovascular disease risk and mortality

ObjectivesWe determined the prevalence of classical risk factors for atherosclerosis and mortality risk in patients with CGI.MethodsA case–control study was conducted. Patients referred with suspected CGI underwent a standard work-up including risk factors for atherosclerosis, radiological imaging of abdominal vessels and tonometry. Cases were patients with confirmed atherosclerotic CGI. Controls were healthy subjects previously not known with CGI. The mortality risk was calculated as standardized mortality ratio derived from observed mortality, and was estimated with ten-year risk of death using SCORE and PREDICT.ResultsBetween 2006 and 2009, 195 patients were evaluated for suspected CGI. After a median follow-up of 19 months, atherosclerotic CGI was diagnosed in 68 patients. Controls consisted of 132 subjects. Female gender, diabetes, hypercholesterolemia, a personal and family history of cardiovascular disease (CVD), and current smoking are highly associated with CGI. After adjustment, female gender (OR 2.14 95% CI 1.05–4.36), diabetes (OR 5.59, 95% CI 1.95–16.01), current smoking (OR 5.78, 95% CI 2.27–14.72), and history of CVD (OR 21.61, 95% CI 8.40–55.55) remained significant. CGI patients >55 years had a higher median ten-year risk of death (15% vs. 5%, P = 0.001) compared to controls. During follow-up of 116 person-years, standardized mortality rate was higher in CGI patients (3.55; 95% CI 1.70–6.52).ConclusionsPatients with atherosclerotic CGI have an increased estimated CVD risk, and severe excess mortality. Secondary cardiovascular prevention therapy should be advocated in patients with CGI.     

Sequence-analysis of video-recorded practitioner–patient communication about smoking in general practice: Do smokers express negative statements about quitting?

Objective

To examine the extent to which smokers express negative statements about quitting and the extent to which these statements influence general practitioners’ (GPs’) and practice nurses’ (PNs’) (dis)continuation of guideline-recommended smoking cessation care.

Methods

Fifty-two video-consultations were observed (GP-consultations: 2007–2008; PN-consultations: 2010–2011). Dialogues were transcribed verbatim and professionals’ and patients’ speech units were coded and analysed using sequential analyses (n = 1424 speech units).

Results

GPs focused on asking about smoking (GPs: 42.4% versus PNs: 26.2%, p = 0.011) and advising them to quit (GPs: 15.3% versus PNs: 3.5%, p < 0.001), whereas PNs focused on assisting them with quitting (GPs: 25.4% versus PNs: 55.2%, p < 0.001). Overall, patients expressed more negative statements about quitting than positive statements (negative: 25.3% versus positive: 11.9%, p < 0.001), especially when PNs assessed their willingness to quit (OR 3.61, 95% CI 1.44–9.01) or assisted them with quitting (OR 2.23, 95% CI 1.43–3.48).

Practice implications

An alternative approach to smoking cessation care is proposed in which GPs’ tasks are limited to asking, advising, and arranging follow-up. This approach seems the least likely to evoke negative statements of patients about quitting during dialogues with GPs and is compatible with the tasks and skills of PNs who could, subsequently, assist smokers with quitting.     

Discrepancies between adolescents’ attributed relevance and experiences regarding communication are associated with poorer client participation and learning processes in psychosocial care

Objective

To examine adolescents’ attributed relevance and experiences regarding communication, and whether discrepancies in these are associated with clients’ participation and learning processes in psychosocial care.

Methods

Adolescents receiving psychosocial care (n = 211) completed measures of communication in three domains: affective communication, information provision, and shared decision-making. Participation involved clients’ attendance and adherence (professional-reported). Learning processes involved clients’ improved understanding and improved confidence (client and professional-reported).

Results

Important but less often experienced affective communication was associated with low adherence (odds ratio, 95% confidence interval: 2.8, 1.1–6.8), less improvement in understanding (3.7, 1.5–9.0), and less improvement in confidence (4.5, 1.8–11.6). If information provision or shared decision-making was important but less often experienced, adolescents were more likely to demonstrate less improvement in understanding (3.1, 1.1–8.5; 4.2, 1.7–10.8). The combination “less important but experienced” only had an effect regarding affective communication; these adolescents were more likely to demonstrate less improvement in confidence (6.0, 2.3–15.4).

Conclusion

Discrepancies between attributed relevance and experiences frequently occur. These discrepancies negatively affect adolescents’ participation and their learning processes, although the pattern differs across communication domains.

Practice implications

Care professionals should pay considerable attention to their clients’ communication preferences and adapt their communication style when necessary.     

Vitamin D intake of Dutch infants from the combination of (fortified) foods,infant formula,and dietary supplements

Purpose

Due to changes in the Dutch fortification policy for vitamin D and the vitamin D supplementation advice for infants (10-μg/d for 0–4 year olds), a partially virtual scenario study was conducted to evaluate the risk of excessive vitamin D intake assigning all infants to a 100 % adherence to the supplementation advice and considering the current fortification practice.

Methods

Food consumption data from the Nutrition Intake Study (2002; N = 941, 7–19 months) were combined with Dutch food composition data from 2011 to estimate vitamin D intake from (fortified) foods. For infants 0–6 months of age, the consumption volume infant formula was estimated from energy requirement and body weight. All subjects were assigned to take a daily 10 µg vitamin D supplement, according the Dutch supplementation advice for infants. Habitual vitamin D intake was estimated using the Statistical Program to Assess Dietary Exposure and compared with the tolerable upper intake levels (ULs) set by the European Food Safety Authority.

Results

The median habitual total vitamin D intake was 16–22 µg/day for infants aged 0–6 months (increasing with age) and 13–21 µg/day for infants aged 7–19 months (decreasing with age). About 4–12 % of infants aged 7–11 months exceeded the UL. At the 99th percentile, the intake was 2–4 µg above the UL, depending on age. Infants aged 0–6 and 12–19 months did not exceed the UL.

Conclusions

In case of combined intake from infant formula, (fortified) foods, and supplements, vitamin D intakes above the UL are possible among some infants during a limited time period.

     

CYP2C9 Genotypes Modify Benzodiazepine-Related Fall Risk: Original Results From Three Studies With Meta-Analysis

Objective

To investigate whether the CYP2C9*2 and *3 variants modify benzodiazepine-related fall risk.

Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study

Background

The optimal diagnostic strategy and timing of intervention in infected necrotizing pancreatitis is subject to debate. We performed a survey on these topics amongst a group of international expert pancreatologists.

Methods

An online survey including case vignettes was sent to 118 international pancreatologists. We evaluated the use and timing of fine needle aspiration (FNA), antibiotics, catheter drainage and (minimally invasive) necrosectomy.

Results

The response rate was 74% (N = 87). None of the respondents use FNA routinely, 85% selectively and 15% never. Most respondents (87%) use a step-up approach in patients with infected necrosis. Walled-off necrosis (WON) is considered a prerequisite for endoscopic drainage and percutaneous drainage by 66% and 12%, respectively. After diagnosing infected necrosis, 55% routinely postpone invasive interventions, whereas 45% proceed immediately to intervention. Lack of consensus about timing of intervention was apparent on day 14 with proven infected necrosis (58% intervention vs. 42% non-invasive) as well as on day 20 with only clinically suspected infected necrosis (59% intervention vs. 41% non-invasive).

Discussion

The step-up approach is the preferred treatment strategy in infected necrotizing pancreatitis amongst expert pancreatologists. There is no uniformity regarding the use of FNA and timing of intervention in the first 2–3 weeks of infected necrotizing pancreatitis.     

Impurity profiling of methamphetamine synthesized from methyl α-acetylphenylacetate

The group of P2P precursors including α-phenylacetoacetonitrile (APAAN), α-phenylacetoamide (APAA) and methyl α-acetylphenylacetate (MAPA) has become increasingly popular in Europe and other parts of the world in the last decade. Previous investigations have reported the use of APAAN in the synthesis of amphetamine and methamphetamine and identified a range of characteristic impurities. This research has expanded upon the current literature by investigating the use of MAPA in the synthesis of methamphetamine. In this study methamphetamine was synthesized via three common clandestine methods: the Leuckart synthesis and two reductive amination methods. We report the identification of seven impurities, four of which are methyl ester equivalents of impurities previously reported for the detection of APAAN. These are methyl 2-phenylbut-2-enoate, methyl 2-phenyl-3-hydroxybutanoate, methyl 3-(methylamino)-2-phenylbut-2-enoate and methyl 3-(methylamino)-2-phenylbutanoate. The other impurities identified are ethyl ester compounds formed via transesterification of the methyl ester due to the reaction solvent. This susceptibility for transesterification suggests that identification of the pre-precursor used may not always be straightforward and may be dependent on the reaction conditions employed. Of the impurities reported, methyl 3-(methylamino)-2-phenylbutanoate was deemed to be a potentially reliable impurity for detection of the use of MAPA; however, it is expected that lower levels of characteristic impurities may be detected in methamphetamine synthesized from MAPA than that from APAAN.