Background: Anemia is increasingly recognized as a risk factor for DR. Nutritional anemia is a major cause of anemia in India. This study was undertaken to explore anemia as a risk factor for DR. ...Methodology: Patients with type 2 diabetes admitted to the medical wards of a tertiary care hospital were enrolled into the study, in the absence of renal failure, pregnancy and ocular disorders unrelated to diabetes. Retinopathy was classified as per ETDRS classification. Anemia was defined and graded based on WHO guidelines. In patients with anemia, serum B12, serum iron, total iron binding capacity (TIBC) and percent saturation were assayed. Results: A total of 170 patients were enrolled into the study (males 93, females 77). The mean age of the study group was 59 ± 12.30 (SD) years. Patients with DR (n=85) were classified as Group 1 and those without DR (n=85) as Group 2. The mean age of patients in Group 1 was 60.74 ± 13.00 (SD) years and that in Group 2 was 57.26 ± 11.39 (SD) years. The mean duration of diabetes was 12.40 ± 7.60 (SD) years for Group 1 and 6.64 ± 4.48 (SD) years for Group 2. The mean Hb of patients in Group 1 was 10.40 ± 0.25 (SD) gm% and in Group 2 was 12.70 ± 0.18 (SD) gm% (p=0.001). Within these groupings, 67 patients had anemia (56 in Group 1, 11 in Group 2). There was a significant association between anemia and DR (p=0.001) and a trend towards association between increasing grades of anemia and severity of DR (p=0.06). In Group 1, among patients with anemia, 28 (50%) patients had nutritional anemia (iron: 24, B12: 3 and dual: 1). On logistic regression analysis, anemia and duration of diabetes emerged as predictors of DR. Discussion: Anemia in patients with diabetes may be multifactorial in etiology. While metformin therapy, albuminuria and reduced renal function are implicated, vegetarian diet is a major contributor for nutritional anemia. Regular monitoring of Hb and treatment with supplements or dietary modifications may reduce occurrence and arrest progression of DR.
Breast cancer is the most common cancer in women across the world. Partner and localizer of BRCA2 (PALB2) were recently identified as a breast cancer predisposition gene. A mutation in this gene in ...familial breast cancer is about 1%-2% from different population reported. However, there are no extensive reports from the Indian population. The ultimate goal of this study is to understand the status of PALB2 mutations among the breast cancer subjects from the Indian population. We have evaluated the PALB2 gene mutation in 200 breast cancer patients and 200 controls that tested negative for BRCA1/2. Single Stranded Conformation Polymorphism (SSCP) assay was performed for screening the variants on amplified regions followed by direct sequencing for conforming mutations. Among the 200 breast cancer subjects analyzed, 128 patients were of inherited familial history and the rest 72 patients were of sporadic cases. Two novel deleterious mutations and one novel missense mutation were identified from this study, with the prevalence of about 3.5% (7/200). Among the deleterious mutations in familial breast cancer, PALB2 c.780delG was identified with the prevalence of 1.5% (3/200) and c.725delT was identified with the prevalence of 1% (2/200) in the fourth exonic region. One missense mutation of PALB2 c.404C>T was found in familial and one in sporadic breast cancer. In this study, the prevalence of PALB2 gene mutation in familial breast cancer is about 4.6% (6/128). Our study demonstrates that the PALB2 gene mutations prevail among familial breast cancer patients who had attended the tertiary care center at Madurai, India. Clinically, these data may be helpful in the genetic counseling for breast cancer patients with PALB2 germline mutation.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
IMPORTANCE: Patients with ischemic stroke attributed to large- or small-vessel disease are not considered at high risk for atrial fibrillation (AF), and the AF incidence rate in this population is ...unknown. OBJECTIVES: To determine whether long-term cardiac monitoring is more effective than usual care for AF detection in patients with stroke attributed to large- or small-vessel disease through 12 months of follow-up. DESIGN, SETTING, AND PARTICIPANTS: The STROKE-AF trial was a randomized (1:1), multicenter (33 sites in the US) clinical trial that enrolled 496 patients between April 2016 and July 2019, with primary end point follow-up through August 2020. Eligible patients were aged 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index stroke attributed to large- or small-vessel disease within 10 days prior to insertable cardiac monitor (ICM) insertion. INTERVENTIONS: Patients randomized to the intervention group (n = 242) received ICM insertion within 10 days of the index stroke; patients in the control group (n = 250) received site-specific usual care consisting of external cardiac monitoring, such as 12-lead electrocardiograms, Holter monitoring, telemetry, or event recorders. MAIN OUTCOMES AND MEASURES: Incident AF lasting more than 30 seconds through 12 months. RESULTS: Among 492 patients who were randomized (mean SD age, 67.1 9.4 years; 185 37.6% women), 417 (84.8%) completed 12 months of follow-up. The median (interquartile range) CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category) score was 5 (4-6). AF detection at 12 months was significantly higher in the ICM group vs the control group (27 patients 12.1% vs 4 patients 1.8%; hazard ratio, 7.4 95% CI, 2.6-21.3; P < .001). Among the 221 patients in the ICM group who received an ICM, 4 (1.8%) had ICM procedure–related adverse events (1 site infection, 2 incision site hemorrhages, and 1 implant site pain). CONCLUSIONS AND RELEVANCE: Among patients with stroke attributed to large- or small-vessel disease, monitoring with an ICM compared with usual care detected significantly more AF over 12 months. However, further research is needed to understand whether identifying AF in these patients is of clinical importance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02700945
Acute ischemic stroke (AIS) is a rare occurrence during pregnancy and the postpartum period. Existing literature evaluating endovascular mechanical thrombectomy (MT) for this patient population is ...limited.
The National Inpatient Sample was queried from 2012 to 2018 to identify and characterize pregnant and postpartum patients (up to 6 weeks following childbirth) with AIS treated with MT. Complications and outcomes were compared with nonpregnant female patients treated with MT and to other pregnant and postpartum patients managed medically. Complex samples regression models and propensity score matching were implemented to assess adjusted associations and to address confounding by indication, respectively.
Among 4590 pregnant and postpartum patients with AIS, 180 (3.9%) were treated with MT, and rates of utilization increased following the MT clinical trial era (2015-2018; 1.9% versus 5.3%,
=0.011). Compared with nonpregnant patients with AIS treated with MT, they experienced lower rates of intracranial hemorrhage (11% versus 24%,
=0.069) and poor functional outcome (50% versus 72%,
=0.003) at discharge. Pregnant/postpartum status was independently associated with a lower likelihood of development of intracranial hemorrhage (adjusted odds ratio, 0.26 95% CI, 0.09-0.70;
=0.008) following multivariable analysis adjusting for age, illness severity, and stroke severity. Following propensity score matching, pregnant and postpartum patients treated with MT and those medically managed differed in frequency of venous thromboembolism (17% versus 0%,
=0.001) and complications related to pregnancy (44% versus 64%,
=0.034), but not in functional outcome at discharge or hospital length of stay. Pregnant and postpartum women treated with MT did not experience mortality or miscarriage during hospitalization.
This large-scale analysis utilizing national claims data suggests that MT is a safe and efficacious therapy for AIS during pregnancy and the postpartum period. In the absence of prospective clinical trials, population-based cross-sectional analyses such as the present study provide valuable clinical insight.
The safety and efficacy of intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) for large vessel occlusion stroke remains a highly contested and unanswered clinical question. We aim ...to characterize the clinical profile, complications, and discharge disposition of EVT patients treated with and without preceding IVT using a large, nationally-representative sample.
The National Inpatient Sample was queried from 2015 to 2018 to identify adult patients with anterior circulation stroke treated with EVT with and without preceding IVT. Multivariable logistic regression analysis and propensity-score matching were employed to assess adjusted associations with clinical endpoints and to address confounding by indication for IVT, respectively.
Among 48,525 patients identified, 40.7% (n = 19,735) received IVT prior to EVT. On unadjusted analysis, patients treated with IVT bridging therapy experienced higher rates of intracranial hemorrhage (26% vs. 24%, p = 0.003) and routine discharge to home with or without services (33% vs. 27%, p < 0.001), a lower frequency of thromboembolic complications (3% vs. 5%, p < 0.001), and lower rates of extended hospital stays (eLOS) (20% vs. 24%, p < 0.001). Multivariable logistic regression analysis adjusting for demographic and baseline clinical characteristics demonstrated independent associations of IVT bridging therapy with intracranial hemorrhage (aOR 1.28, 95% CI 1.15, 1.43; p < 0.001), thromboembolic complications (aOR 0.66, 95% CI 0.53, 0.83; p < 0.001), routine discharge (aOR 1.27, 95% CI 1.15, 1.40; p < 0.001), and eLOS (aOR 0.76, 95% CI 0.68, 0.85; p < 0.001). Sensitivity testing confirmed these findings.
Preceding IVT was associated with favorable functional outcomes following endovascular therapy. Prospective randomized clinical trials are warranted for further evaluation.
•Thrombolysis prior to thrombectomy for ischemic stroke remains controversial.•Patients receiving thrombolysis experienced higher rates of favorable discharge.•Randomized trials are necessary to further evaluate thrombolysis before thrombectomy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
In the UK, dementia affects 5% of the population aged over 65 years and 25% of those over 85 years. Frontotemporal dementia (FTD) represents one subtype and is thought to account for up to ...16% of all degenerative dementias. Although the core of the diagnostic process in dementia rests firmly on clinical and cognitive assessments, a wide range of investigations are available to aid diagnosis.
Regional cerebral blood flow (rCBF) single‐photon emission computed tomography (SPECT) is an established clinical tool that uses an intravenously injected radiolabelled tracer to map blood flow in the brain. In FTD the characteristic pattern seen is hypoperfusion of the frontal and anterior temporal lobes. This pattern of blood flow is different to patterns seen in other subtypes of dementia and so can be used to differentiate FTD.
It has been proposed that a diagnosis of FTD, (particularly early stage), should be made not only on the basis of clinical criteria but using a combination of other diagnostic findings, including rCBF SPECT. However, more extensive testing comes at a financial cost, and with a potential risk to patient safety and comfort.
Objectives
To determine the diagnostic accuracy of rCBF SPECT for diagnosing FTD in populations with suspected dementia in secondary/tertiary healthcare settings and in the differential diagnosis of FTD from other dementia subtypes.
Search methods
Our search strategy used two concepts: (a) the index test and (b) the condition of interest. We searched citation databases, including MEDLINE (Ovid SP), EMBASE (Ovid SP), BIOSIS (Ovid SP), Web of Science Core Collection (ISI Web of Science), PsycINFO (Ovid SP), CINAHL (EBSCOhost) and LILACS (Bireme), using structured search strategies appropriate for each database. In addition we searched specialised sources of diagnostic test accuracy studies and reviews including: MEDION (Universities of Maastricht and Leuven), DARE (Database of s of Reviews of Effects) and HTA (Health Technology Assessment) database.
We requested a search of the Cochrane Register of Diagnostic Test Accuracy Studies and used the related articles feature in PubMed to search for additional studies. We tracked key studies in citation databases such as Science Citation Index and Scopus to ascertain any further relevant studies. We identified ‘grey’ literature, mainly in the form of conference s, through the Web of Science Core Collection, including Conference Proceedings Citation Index and Embase. The most recent search for this review was run on the 1 June 2013.
Following title and screening of the search results, full‐text papers were obtained for each potentially eligible study. These papers were then independently evaluated for inclusion or exclusion.
Selection criteria
We included both case‐control and cohort (delayed verification of diagnosis) studies. Where studies used a case‐control design we included all participants who had a clinical diagnosis of FTD or other dementia subtype using standard clinical diagnostic criteria. For cohort studies, we included studies where all participants with suspected dementia were administered rCBF SPECT at baseline. We excluded studies of participants from selected populations (e.g. post‐stroke) and studies of participants with a secondary cause of cognitive impairment.
Data collection and analysis
Two review authors extracted information on study characteristics and data for the assessment of methodological quality and the investigation of heterogeneity. We assessed the methodological quality of each study using the QUADAS‐2 (Quality Assessment of Diagnostic Accuracy Studies) tool. We produced a narrative summary describing numbers of studies that were found to have high/low/unclear risk of bias as well as concerns regarding applicability. To produce 2 x 2 tables, we dichotomised the rCBF SPECT results (scan positive or negative for FTD) and cross‐tabulated them against the results for the reference standard. These tables were then used to calculate the sensitivity and specificity of the index test. Meta‐analysis was not performed due to the considerable between‐study variation in clinical and methodological characteristics.
Main results
Eleven studies (1117 participants) met our inclusion criteria. These consisted of six case‐control studies, two retrospective cohort studies and three prospective cohort studies. Three studies used single‐headed camera SPECT while the remaining eight used multiple‐headed camera SPECT. Study design and methods varied widely. Overall, participant selection was not well described and the studies were judged as having either high or unclear risk of bias. Often the threshold used to define a positive SPECT result was not predefined and the results were reported with knowledge of the reference standard. Concerns regarding applicability of the studies to the review question were generally low across all three domains (participant selection, index test and reference standard).
Sensitivities and specificities for differentiating FTD from non‐FTD ranged from 0.73 to 1.00 and from 0.80 to 1.00, respectively, for the three multiple‐headed camera studies. Sensitivities were lower for the two single‐headed camera studies; one reported a sensitivity and specificity of 0.40 (95% confidence interval (CI) 0.05 to 0.85) and 0.95 (95% CI 0.90 to 0.98), respectively, and the other a sensitivity and specificity of 0.36 (95% CI 0.24 to 0.50) and 0.92 (95% CI 0.88 to 0.95), respectively.
Eight of the 11 studies which used SPECT to differentiate FTD from Alzheimer's disease used multiple‐headed camera SPECT. Of these studies, five used a case‐control design and reported sensitivities of between 0.52 and 1.00, and specificities of between 0.41 and 0.86. The remaining three studies used a cohort design and reported sensitivities of between 0.73 and 1.00, and specificities of between 0.94 and 1.00. The three studies that used single‐headed camera SPECT reported sensitivities of between 0.40 and 0.80, and specificities of between 0.61 and 0.97.
Authors' conclusions
At present, we would not recommend the routine use of rCBF SPECT in clinical practice because there is insufficient evidence from the available literature to support this.
Further research into the use of rCBF SPECT for differentiating FTD from other dementias is required. In particular, protocols should be standardised, study populations should be well described, the threshold for 'abnormal' scans predefined and clear details given on how scans are analysed. More prospective cohort studies that verify the presence or absence of FTD during a period of follow up should be undertaken.
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