Association between heavy alcohol consumption and cryptogenic ischaemic stroke in young adults: a case-control study.

BACKGROUND: The underlying risk factors for young-onset cryptogenic ischaemic stroke (CIS) remain unclear. This multicentre study aimed to explore the association between heavy alcohol consumption and CIS with subgroup analyses stratified by sex and age. METHODS: Altogether, 540 patients aged 18-49 years (median age 41; 47.2% women) with a recent CIS and 540 sex-matched and age-matched stroke-free controls were included. Heavy alcohol consumption was defined as >7 (women) and >14 (men) units per week or at least an average of two times per month ≥5 (women) and ≥7 (men) units per instance (binge drinking). A conditional logistic regression adjusting for age, sex, education, hypertension, cardiovascular diseases, diabetes, hypercholesterolaemia, current smoking, obesity, diet and physical inactivity was used to assess the independent association between alcohol consumption and CIS. RESULTS: Patients were twice as more often heavy alcohol users compared with controls (13.7% vs 6.7%, p<0.001), were more likely to have hypertension and they were more often current smokers, overweight and physically inactive. In the entire study population, heavy alcohol consumption was independently associated with CIS (adjusted OR 2.11; 95% CI 1.22 to 3.63). In sex-specific analysis, heavy alcohol consumption was associated with CIS in men (2.72; 95% CI 1.25 to 5.92), but not in women (1.56; 95% CI 0.71 to 3.41). When exploring the association with binge drinking alone, a significant association was shown in the entire cohort (2.43; 95% CI 1.31 to 4.53) and in men (3.36; 95% CI 1.44 to 7.84), but not in women. CONCLUSIONS: Heavy alcohol consumption, particularly binge drinking, appears to be an independent risk factor in young men with CIS.

Obesity and the Risk of Cryptogenic Ischemic Stroke in Young Adults.

OBJECTIVES: We examined the association between obesity and early-onset cryptogenic ischemic stroke (CIS) and whether fat distribution or sex altered this association. MATERIALS AND METHODS: This prospective, multi-center, case-control study included 345 patients, aged 18-49 years, with first-ever, acute CIS. The control group included 345 age- and sex-matched stroke-free individuals. We measured height, weight, waist circumference, and hip circumference. Obesity metrics analyzed included body mass index (BMI), waist-to-hip ratio (WHR), waist-to-stature ratio (WSR), and a body shape index (ABSI). Models were adjusted for age, level of education, vascular risk factors, and migraine with aura. RESULTS: After adjusting for demographics, vascular risk factors, and migraine with aura, the highest tertile of WHR was associated with CIS (OR for highest versus lowest WHR tertile 2.81, 95%CI 1.43-5.51; P=0.003). In sex-specific analyses, WHR tertiles were not associated with CIS. However, using WHO WHR cutoff values (>0.85 for women, >0.90 for men), abdominally obese women were at increased risk of CIS (OR 2.09, 95%CI 1.02-4.27; P=0.045). After adjusting for confounders, WC, BMI, WSR, or ABSI were not associated with CIS. CONCLUSIONS: Abdominal obesity measured with WHR was an independent risk factor for CIS in young adults after rigorous adjustment for concomitant risk factors.

An Unusual First Presentation of Stroke and Seizure in a 32-Year-Old Patient With Brugada Syndrome Type 2 Electrocardiogram Pattern.

We report a case of a 32-year-old lady who was admitted to the hospital with right-sided weakness that preceded an episode of seizure. On the day of admission, she woke up early in the morning with mild right-sided weakness and numbness. She had difficulty walking and later had a seizure, which was witnessed by her son. She had no signs of infection prior to this. She had no fever, chest or abdominal pain, or urinary symptoms. In the emergency department, she complained of left-sided chest tightness and heaviness, which lasted for a few minutes with associated tachycardia, electrocardiogram (ECG) was consistent with Brugada syndrome type 2. A magnetic resonant imaging (MRI) scan of her head shows a left hemispheric infarct involving the frontoparietal cortex. She was treated for an ischaemic stroke and seizure. She made a good recovery and was discharged home on secondary stroke prevention medication with community physiotherapy. She was followed up in the cardiology, genetics, and stroke outpatient clinics. The occurrence of ECG changes consistent with Brugada syndrome, stroke, and seizure in a young patient with no other risk factors for stroke is rare.

Enhancing the evidence-based healthcare principles in clinical practice guidelines development in the Czech Republic: a best practice implementation project.

OBJECTIVES: The main aim of this project was to enhance compliance with the best available evidence in clinical practice guidelines (CPGs) development based on evidence-based healthcare (EBHC) and GRADE (grading of recommendations, assessment, development and evaluation) principles in healthcare professionals and healthcare providers. INTRODUCTION: In various healthcare fields, the quality of care provided in different healthcare settings may vary. Guidelines following the EBHC principles should help make the right decisions in healthcare by providing the best healthcare option and be available for all patients. The perspectives of all engaged stakeholders should be respected, however. Within the Czech Republic, there had been no standardized process of CPG development. METHODS: A baseline audit was conducted to demonstrate the status quo of the EBHC in the Czech Republic, which identified several barriers. Consequently, strategies (educational activities, methodological guidelines) to overcome the barriers were suggested and implemented. Two more audits followed (November 2017, November 2020). RESULTS: The baseline audit results showed no or very low compliance to the best available evidence in CPG development. After the implementation, an increased compliance in all audit criteria (national methodology guidelines, trustworthy CPGs, experienced methodologists, clinical summaries) has been reported. The project has helped to establish procedures of CPGs development, enhanced knowledge and skills on EBHC in healthcare professionals, and ignited patients' involvement in CPG development. CONCLUSIONS: The implementation project showed an increasing number of national methodology guidelines, CPGs being developed using EBHC and GRADE principles and HC professionals educated in EBHC. A national center for CPGs development within the Ministry of Health is being planned to sustain the project achievements.

Visual transformation for guidelines presentation of the strength of recommendations and the certainty of evidence.

OBJECTIVE: The objective of this paper is to propose an approach to visual unification of adapted guidelines and transformation of classifications of certainty of evidence (CoE) and strength of recommendations (SoR) into the approach suggested by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. STUDY DESIGN AND SETTING: We carried out a literature search in MEDLINE and Epistemonikos, an analysis of selected guidelines, and an iterative discussion to decide on a consistent visual presentation and CoE and SoR depictions. RESULTS: The results of the literature search suggested this issue had not been addressed yet. The analysis of the chosen eight guidelines showed significant heterogeneity in the visual presentation of recommendations. Recommendations were often worded similarly to whether or not they were strong or conditional. Many guidelines contained "statements," almost all of which did not fulfill the good practice statement (GPS) criteria. We proposed an approach for transforming recommendations that are being adapted and which use various classification systems for CoE and SoR into GRADE and a consistent visual style. CONCLUSION: Guideline developers should aim for unification in the formulation of recommendations to improve transferability.

COVID-19-Associated Mucormycosis (CAM): An Updated Evidence Mapping.

Mucormycosis, a serious and rare fungal infection, has recently been reported in COVID-19 patients worldwide. This study aims to map all the emerging evidence on the COVID-19-associated mucormycosis (CAM) with a special focus on clinical presentation, treatment modalities, and patient outcomes. An extensive literature search was performed in MEDLINE (Ovid), Embase (Ovid), Cochrane COVID-19 Study Register, and WHO COVID-19 database till 9 June 2021. The primary outcome was to summarize the clinical presentation, treatment modalities, and patient outcomes of CAM. Data were summarized using descriptive statistics and presented in tabular form. This evidence mapping was based on a total of 167 CAM patients with a mean age of 51 ± 14.62 years, and 56.28% of them were male. Diabetes mellitus (73.65% (n = 123)), hypertension (22.75% (n = 38)), and renal failure (10.77% (n = 18)) were the most common co-morbidities among CAM patients. The most common symptoms observed in CAM patients were facial pain, ptosis, proptosis, visual acuity, and vision loss. Survival was higher in patients who underwent both medical and surgical management (64.96%). Overall mortality among CAM patients was found to be 38.32%. In conclusion, this study found a high incidence of CAM with a high mortality rate. Optimal glycemic control and early identification of mucormycosis should be the priority to reduce the morbidity and mortality related to CAM.

Association of Acute Kidney Injury with the Risk of Dementia: A Meta-Analysis.

Acute kidney injury (AKI) is associated with several adverse outcomes, including new or progressive chronic kidney disease, end-stage kidney disease, and mortality. Epidemiological studies have reported an association between AKI and dementia as a long-term adverse outcome. This meta-analysis was aimed to understand the association between AKI and dementia risk. A literature search was performed in MEDLINE and Embase databases, from inception to July 2021, to identify epidemiological studies reporting the association between AKI and dementia risk. Title and abstract followed by the full-text of retrieved articles were screened, data were extracted, and quality was assessed, using the Newcastle-Ottawa scale by two investigators independently. The primary outcome was to compute the pooled risk of dementia in AKI patients. Subgroup analysis was also performed based on age and co-morbidities. Certainty of evidence was assessed using the GRADE approach. Statistical analysis was performed using Review Manager 5.4 software. Four studies (cohort (n = 3) and case-control (n = 1)) with a total of 429,211 patients, of which 211,749 had AKI, were identified. The mean age of the patients and the follow-up period were 64.15 ± 16.09 years and 8.9 years, respectively. Included studies were of moderate to high quality. The pooled estimate revealed a significantly higher risk of dementia in AKI patients with an overall relative risk/risk ratio (RR) of 1.92 (95% CI: 1.52-2.43), p ≤ 0.00001. Dementia risk increases by 10% with one year increase in age with an RR of 1.10 (95% CI: 1.09-1.11), p < 0.00001. Subgroup analysis based on stroke as a co-morbid condition also revealed significantly higher dementia risk in AKI patients (RR 2.30 (95% CI: 1.62-3.28), p = 0.009). All-cause mortality risk was also significantly higher in AKI patients with dementia with a pooled RR of 2.11 (95% CI: 1.20-3.70), p = 0.009. The strength of the evidence was of very low certainty as per the GRADE assessment. Patients with AKI have a higher risk of dementia. Further large epidemiological studies are needed to confirm the mechanistic association.

Czech national project 'Clinical Practice Guidelines' methodology and current results.

Currently in the Czech Republic, there does not exist such an institution as a 'National Centre for Clinical Practice Guidelines'. In 2017, there were about 123 professional medical organizations which developed about 1909 'guidelines' until 2017. However, the majority of these guidelines are 'expert opinion' or 'consensual' based 'guidance' or rather recommendations in the most cases missing a systematic approach that reflects evidence-based medicine principles and methods. The project is led by the Czech Health Research Council, the first partner is the Ministry of Health of the Czech Republic and the second partner is the Institute of Health Information and Statistics of the Czech Republic with support from policy makers, academics, clinicians and members of the Czech National Centre for Evidence-Based Healthcare and Knowledge Translations. This centre is an umbrella for three very important international collaborations which play a key role in Evidence-Based Healthcare, Evidence Synthesis, Evidence Implementation and trustworthy guidelines development. These are Cochrane Czech Republic, Masaryk University Grade Centre and the Czech Republic Centre for Evidence-Based Healthcare: The Joanna Briggs Institute Centre of Excellence.The main aim of this article is to present the Czech National Methodology of the Trustworthy Clinical Practice Guideline (CPG) development and the first results of the project 'Clinical Practice Guidelines'.A pilot phase of the project was realized during the first year of the project from January to December 2018. As the first step, there were established managing authorities including a Guarantee Committee and an Appraisal (Methodological) Committee. The Members of the Appraisal Committee developed a pilot version of the National Methodology of CPG development based on the best available approaches to Trustworthy CPGs development followed by testing on the first five pilot CPGs.

Development of Czech National Stroke Guidelines.

Despite a significant transformation of ischaemic stroke management, it remains one of the leading causes of death, disability, functional impairment and cognitive deficits. With the advent of intravenous thrombolysis and mechanical thrombectomy, stroke is not an untreatable disease, mostly occurring in older people, any more. The most common cause of cardioembolic strokes is atrial fibrillation or flutter and atrial fibrillation is the most prevalent arrhythmia.The aim of this short communication is to describe the methodology of the Czech stroke guidelines development.High-quality 2017 Australian Stroke Foundation stroke guideline was considered for adaptation and a new guideline was developed and disseminated.

Epidemiological analyses for preparation of Clinical Practice Guidelines related to acute coronary syndromes in the Czech Republic.

Coronary heart disease, sometimes also referred to as ischemic heart disease, remains the leading condition causing most deaths and disability-adjusted life years worldwide. Acute coronary syndrome (ACS) represents a subset that is defined by sudden reduction of blood supply in the coronary arteries. ACS consists of unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).The current short communication aims to provide current ACS prevalence and incidence data analysis to inform development of clinical practice guidelines in the Czech Republic.The Institute of Health Information and Statistics of the Czech Republic has provided the data that are collected by the National Health Information System with the National Register of Reimbursed Health Services as a primary source providing data for the period from 2015 to 2017.There has been a slight decrease in the number of hospitalized patients for ACS in the Czech Republic from 2015 to 2017. Sex difference remains large, with majority (two thirds) of those hospitalized for unstable angina, NSTEMI, or STEMI being men. Hospitalization with STEMI is reported in younger age with no sex difference compared with NSTEMI and unstable angina.

Use of epidemiological analyses in Clinical Practice Guideline development focused on the diabetic patients treated with insulin.

The prevalence of diabetes is on the rise worldwide especially in developed countries. The aim of glucose management in all types of diabetes is to minimize chronic and acute complications associated with diabetes. All patients with type 1 diabetes mellitus (T1DM) require insulin. Main areas of technology advances in diabetes are continuous subcutaneous insulin infusion (CSII) and also continuous glucose monitoring systems for the management of patients with both types of diabetes. It is very important to analyse the epidemiological situation within each country before and during the clinical practice guidelines (CPGs) development and implementation. The analyses will allow us to monitor the effect of the CPG after its implementation.The aim of this short communication is to analyse the epidemiology of prevalence and incidence of diabetes mellitus and use of CSII to inform development of CPGs in the Czech Republic.The analysis is developed based on the data managed by Institute of Health Information and Statistics of the Czech Republic. We used the National Register of Reimbursed Health Services 2015-2017 as primary source, and the annual report type A (Ministry of Health) 1-01: for Diabetology (A MH 004) 2007-2017 was used as validation source. The presented data are related to the year 2016 because we were able to validate them based on the data from 2015 to 2017 for this cohort of patients.The number of patients with T1DM is increasing in the Czech Republic with no significant sex difference. Life expectancy is about 11 years lower in the T1DM population. The majority of the patients are in older age; however, these are not treated with CSII compared with the younger population. From 61 533 patients with T1DM, 81% were reported with acute and chronic complications in 2016. Only 5011 of these patients were reported as using CSII.

Use of epidemiological analyses in development of colorectal cancer clinical practice guidelines in the Czech Republic.

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the fourth most common cause of cancer death worldwide. Crucial in CRC as well as for other effective diagnostics and treatment is the knowledge translation and implementation of the current best available evidence into clinical practice and public health. Clinical practice guidelines are one of the useful tools to be able to improve diagnostics and increase survival rate.The epidemiological analysis was performed based on the data of the Czech National Cancer Registry from 1977 to 2017. We have analysed incidence, prevalence, mortality and primary treatment of CRC in the Czech Republic.The incidence of CRC increased significantly from 1982 to 2002 and is higher in men compared with women based on the data from the National Health Information System in the Czech Republic. The majority of the patients with CRC were diagnosed in early stages. Women were diagnosed at slightly higher age than men. An increase in surgical therapy performed in primary treatment of early CRC was reported from 2006 to 2016. Relative time of survival increased in reported patients with CRC.This analysis reported significant changes in incidence of CRC in the last 40 years as well as in diagnostics and primary therapy in early stages of CRC in the last 12 years. The first ever evidence-based clinical practice guideline on diagnostics and therapy of early CRC in the Czech Republic was developed and disseminated.

Epidemiological analyses to inform stroke clinical practice guidelines development.

Stroke is one of the leading causes of mortality and the leading cause of functional impairment and cognitive deficits worldwide. It is important that clinical practice guidelines development is based on robust statistical and epidemiological data and their analysis throughout the whole process of guidelines development and implementation. The aim of this short communication is to analyse epidemiology of prevalence and incidence of ischaemic stroke, its main causes, brain imaging using MRI, recanalization therapies, secondary prevention with antiplatelet and anticoagulants, mortality data and to inform development of stroke clinical practice guidelines in the Czech Republic. The main analysed diagnosis was I63 (cerebral infarction) and secondary diagnoses were: I48 (atrial fibrillation and flutter), I35.9 (nonspecified aortic valve disease), Q21.1 (atrial septal defect) or I33.0 (acute and subacute endocarditis). We have also analysed use of brain imaging with MRI, recanalization treatment using intravenous thrombolysis and mechanical thrombectomy, stroke secondary prevention with antiplatelet drugs and anticoagulation as well as hospital admissions and mortality. In total, 159 344 patients were diagnosed with an ischaemic stroke from 2015 to 2017. Average prevalence of ischaemic stroke in the Czech Republic is 54.9 patients per 100 000. 22.2% of patients with stroke received intravenous thrombolysis or mechanical thrombectomy in 2017.