Pubertal gynecomastia incidence among 530,000 boys: a cross sectional population based study.

Background: Adolescent gynecomastia, a benign proliferation of male breast tissue, can lead to psychological issues during adolescence. The prevalence varies widely (4%-69%). The incidence peaks are during neonatal, pubertal, and senescent periods. Its affect on emotional well-being necessitates understanding and occasional intervention. This study aimed to determine the incidence of gynecomastia among male adolescents aged 12-15 years. Methods: A retrospective cross-sectional study utilized the Clalit Health Care Services database (2008-2021) with a population of approximately 4.5 million. Participants aged 12-15 years were included if diagnosed with gynecomastia (International classification of diseases-9 code 611.1) and having a body mass index (BMI) measurement and no obesity diagnosis (ICD9 code 278.0). Data analysis included incidence rates and associations with ethnicity, age, BMI, and socioeconomic status. Results: 531,686 participants included with an incidence of 1.08%. Of all participants, 478,140 had a BMI ≤ 25 with an incidence of 0.7%, and 0.25%-0.35% yearly, and 70% of gynecomastia patients were aged 13-14 years. The prevalence of gynecomastia differed between Jews (1.28%) and Arabs (0.67%), but the disparity diminished when socioeconomic status was considered. Conclusions: This unprecedented Population study establishes a definitive rate of true pubertal gynecomastia, revealing a lower yearly incidence as compared to previous reports. The higher observed prevalence among Jewish adolescents, may be caused due to complex interactions between different influencing factors. Understanding these dynamics can aid in formulating more targeted interventions and policy strategies to address gynecomastia's affect on adolescent well-being.

Gaps in pediatric oncologic end of life care as recounted by the bereaved parents in Isarel.

PURPOSE: This study investigated parents' perception of their needs and those of their children with cancer at the end-of-life period, including unmet needs and their expectations regarding providers. DESIGN AND METHODS: This cross-sectional study involved 26 parents recruited from three pediatric hematology-oncology wards in Israel who completed demographic and medical questionnaires of the child, and a parental needs questionnaire based on The Needs Assessment of Family Caregivers-Cancer questionnaire, following the death of their child. FINDINGS: Parents expressed needs related to medical care, including pain management, decision-making, and finding optimal treatment options for their children. The most prominent unmet needs were financial and psychological factors, of which, paying for medical expenses and helping their child adjust to the end of their life received the highest mean scores. There were notable gaps between desired and actual support from service providers, particularly in relation to emotional aspects. While over half of the parents believed the psychosocial team should assist with their child's emotional distress, this need was not adequately fulfilled. Some parents also expressed a desire for better emotional support during the end-of-life period. CONCLUSIONS: The study emphasizes the importance of understanding parents' needs and perspectives during this challenging time. The identified gaps in support can be attributed to parental roles, the struggle with losing hope, communication barriers between care teams and parents, among others. PRACTICE IMPLICATIONS: By gaining insight into these needs and perceptions, care teams can enhance the provision of palliative care and optimize the distribution of responsibilities within the team.

Association Between Thyroid-Stimulating Hormone Level and Bell's Palsy.

OBJECTIVE: To investigate whether dysregulated thyroid hormone function is associated with Bell's palsy. STUDY DESIGN: Cross-sectional. SETTING: Electronic medical record database of Clalit Health Services (CHS). CHS is an Israeli payer-provider, integrated health care system, serving >4.5 million members (54% of the Israeli population). PATIENTS: Older than 18 years with Bell's palsy, during 2002 to 2019. INTERVENTIONS: None. METHODS: A total of 1,374 patients with Bell's palsy who had thyroid-stimulating hormone (TSH) blood levels measured up to 60 days before the palsy were matched (1:2) for age and sex with 2,748 controls who had TSH blood levels and no history of Bell's palsy. RESULTS: Retrospective review of the CHS database, from 2002 to 2019 yielded 11,268 patients with Bell's palsy, of which, 1,374 met the inclusion criteria. Mean age was 57.9 years, and 61.4% were female. A higher percentage of patients in the Bell's palsy group had low TSH (≤0.55 mIU/L) compared with controls (5.7% vs. 3.6%, p < 0.001). Low TSH compared with TSH > 0.55 mIU/L, was independently associated with 1.45-fold increased odds for having Bell's palsy (95% CI 1.11-2.02, p < 0.001), when controlled for age, sex, body mass index, diabetes, hypertension, prior cerebrovascular accident, hemoglobin level, and purchasing thyroid hormone drugs. Among the patients with TSH ≤ 0.55 mIU/L, 95.5% had normal free thyroxin and 97.7% had normal free triiodothyronine levels (subclinical hyperthyroidism). For 47.1% of patients, TSH remained ≤0.55 mIU/L, 3 to 12 months after the Bell's palsy occurred and most patients had normal free thyroxin (95.4%) and normal free triiodothyronine (91.8%). CONCLUSIONS: Subclinical hyperthyroidism is independently associated with Bell's palsy after controlling for multiple confounding factors.

Clinical efficacy of the fourth dose of the BNT162b2 vaccine in maintenance dialysis patients.

BACKGROUND AND OBJECTIVES: Highly effective vaccines against severe acute respiratory syndrome virus 2 have been developed and administered worldwide. However, protection from coronavirus disease 2019 is not absolute and an optimal vaccination regimen needs to be established. This study assessed the clinical efficacy of the coronavirus disease 2019 vaccine among dialysis patients receiving 3 or 4 doses of vaccine. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: This retrospective study was conducted using the electronic database of Clalit Health Maintenance Organization in Israel. Chronic dialysis patients treated with either hemodialysis or peritoneal dialysis during the coronavirus disease 2019 pandemic were included. We compared clinical outcomes of patients who had received three or four doses of the severe acute respiratory syndrome virus 2 vaccine. RESULTS: This study included 1,030 patients on chronic dialysis, with a mean age of 68 ± 13 years. Among them, 502 patients had received 3 doses of the vaccine and 528 received 4 doses. Severe acute respiratory syndrome virus 2 infection rates, severe COVID-19 that resulted in hospitalizations, COVID-19-related mortality and all-cause mortality rates were lower among chronic dialysis patients who received a fourth dose of vaccine as compared to those who received only 3 doses (after controlling for age, sex and comorbidities). Despite lower mortality rates observed with the Omicron variant, the fourth dose was significantly associated with reduced COVID-19-related mortality (1.7% vs. 3.8%, p = 0.04). Odds ratio for COVID-19-related mortality was 0.44 with 95% CI 0.2-0.98. CONCLUSIONS: As seen in the general population and with previous vaccine boosters, the fourth dose of the BNT162b2 vaccine reduced rates of severe COVID-19-related hospitalization and mortality among chronic dialysis patients. Further studies are needed to establish the optimal regimens of vaccination for patients on chronic dialysis.

αvß3 Integrin as a Link between the Development of Fibrosis and Thyroid Hormones in Systemic Sclerosis.

Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs. Key players mediating fibrosis are myofibroblasts (MF) that, following transforming growth factor ß (TGFß) exposure, produce a collagen-rich extracellular matrix (ECM) that induces myofibroblast differentiation. Myofibroblasts express αvß3 integrin (a membrane receptor for thyroid hormones) and miRNA-21 that promotes deiodinase-type-3 expression (D3), causing the degradation of triiodothyronine (T3) that attenuates fibrosis. We hypothesized that αvß3 affects the fibrotic processes through its thyroid hormones (THs) binding site. To test this, dermal fibroblasts (DF) were cultured with/without TGFß and removed with a base, leaving only normal/fibrotic ECMs in wells. Then, DF were cultured on the ECMs with/without tetrac (αvß3 ligand, T4 antagonist), and evaluated for pro-fibrotic characteristics, αvß3, miRNA-21, and D3 levels. Blood free-T3 (fT3), miRNA-21 levels, and the modified Rodnan skin score (MRSS) were evaluated in SSc patients. We found that the "fibrotic-ECM" significantly increased the pro-fibrotic characteristics of DF and the levels of miRNA-21, D3, and αvß3, compared to the "normal-ECM." Tetrac significantly inhibited the effects of the "fibrotic-ECM" on the cells. In accordance with tetrac's effect on D3/miRNA-21, a negative correlation was found between the patients' fT3 to miRNA-21 levels, and to the development of pulmonary arterial hypertension (PAH). We conclude that occupying the THs binding site of αvß3 may delay the development of fibrosis.

Cow's milk allergy skin tests: fresh milk, commercial extracts, or both?

BACKGROUND: The diagnosis of food allergy is based on a history of immediate allergic reaction following food ingestion, and skin prick test (SPT) demonstrating sensitization with commercial extracts (CE) or fresh food (FF). For most food allergens, the SPT with FF is considered more accurate and predictive. Regarding cow's milk, the results are inconclusive. This retrospective study aimed to evaluate the accuracy of SPT with fresh milk compared to CE (cow's milk and casein) for evaluation of cow's milk allergy (CMA). METHODS: This study summarized the medical records of children, diagnosed with CMA. The data include demographics, skin tests and oral food challenge results, as well as atopic comorbidities. RESULTS: Records of 698 patients with the diagnosis of CMA were reviewed, 388 fulfilled the inclusion criteria. Overall, 134 patients (34.54%) had an additional atopic disease. The SPT wheal size with fresh milk was significantly larger than with CE (cow's milk and casein) at first evaluation or before oral food challenge (OFC). Combination of SPT results (CE and FF) gave the maximal odds ratio for reaction during OFC and SPT with fresh milk alone gave the minimal OR (34.18 and 4.74, respectively). CONCLUSIONS: SPT with CE for CMA evaluation is more reliable than SPT performed with fresh milk. In patients suspected of having IgE-mediated CMA, before deciding on performing OFC, it is advised to perform SPT with at least two different extracts, and always include casein. Fresh milk can serve as a backup if commercial extracts are not available. In cases that the SPT with fresh milk is 3 mm or less, there is 93.3% chance that the OFC will pass without reaction. Trial registration This study protocol was reviewed and approved by the Ethics Committee of Meir Medical Center, IRB Number 0083-18 MMC.

Transcatheter Left Atrial Appendage Occlusion: A Multi-Center Real Life Experience.

(1) Background: left atrial appendage occlusion (LAAO) is considered an effective and relatively safe treatment for the prevention of thromboembolic events in patients with atrial fibrillation and a contra-indication for anticoagulation. We present a large multicenter real-world experience of transcatheter LAAO implementation in patients with atrial fibrillation who cannot be treated with chronic anti-coagulation; (2) Methods: included were atrial fibrillation patients who underwent transcatheter LAAO between 1 January 2016 and 30 June 2021. The study was conducted using the electronic health record database of Clalit Health Services (CHS). The primary outcomes included hemorrhagic and ischemic stroke following LAAO; (3) Results: included were 389 atrial fibrillation patients. During a median follow-up of 2.1 years, 13% patients had ischemic cerebrovascular accident (CVA), and 4.4% patients had hemorrhagic CVA. While the risk of ischemic stroke increased gradually over time, the risk of hemorrhagic CVA was highest during the first 3 months following the procedure. Moreover, previous ischemic stroke was the only significant predictor for both hemorrhagic and ischemic stroke following LAAO; (4) Conclusions: while the annual performance rate of transcatheter LAAO has increased significantly over the past years, post procedural long-term prognosis remains poor with a substantial risk of both thrombotic and bleeding events.

The effect of asthma specialist intervention on asthma control among adults.

Background: Various ways to improve asthma control have been studied, with only a modest effect. Purpose: To evaluate the effect of asthma specialist visit on asthma control among adult asthma patients. Patients and methods: This matched cohort study included patients ages 21-50 with asthma and at least 1 visit to an asthma specialist. Patients were compared to adult asthma patients treated only by primary care physicians. The study outcomes, included use of asthma medication, healthcare visits, and mortality. All outcomes were compared one year before and after specialist visit. Results: 4166 pairs were included in the study. In the study group, a statistically significant decrease in the average number of relievers (1.5 ± 3.2 vs. 1.17 ± 2.9, p < 0.001) and systemic steroids purchased (0.53 ± 1.2 vs. 0.4 ± 1.2, p < 0.001), with an increase in average number of inhaled steroid purchased (1.6 ± 2.5 vs. 2.3 ± 33, p < 0.001) was seen over time. A significant decrease in the average number of PCP visits (9.5 ± 7.2 vs. 8.9 ± 7.3, p < 0.001), emergency department (ED) visits (0.46 ± 1 vs. 0.4 ± 0.9, p = 0.05) and all-cause hospitalization (0.03 ± 0.22 vs. 0.01 ± 1.9, p < 0.001) was seen in the study group but not in controls. Generalized linear modeling demonstrated an overall significant effect of specialist intervention for all parameters (p < 0.01), except ED visits (p = 0.06). During follow-up, eight (0.2%) study group patients vs. 19 (0.5%) controls died (p = 0.03). Conclusion: We found that asthma specialist intervention significantly improved asthma outcomes in adults. Referring adult asthma patients to an asthma specialist should be a goal of asthma management plans. Trial registration: Not relevant.

Changes in peripheral blood eosinophils may predict colorectal cancer - A retrospective study.

Background: Colorectal cancer (CRC) is a leading cause of morbidity and mortality worldwide. Eosinophils are traditionally associated and studied in context of allergic diseases. However, recent data implicate their involvement in mucosal tumors, especially in CRC where they may have an anti-tumorigenic function.Our objective was to evaluate whether trends in peripheral blood eosinophil numbers are associated with future diagnosis of CRC. Methods: This retrospective cohort study included adult patients diagnosed with CRC compared to matched controls. We evaluated the linear change in the absolute number of eosinophils (ANE) in peripheral blood over time, described as a correlation coefficient (r). The timeline started 7 years and ended 3 months before diagnosis of CRC. Results: We included 8334 CRC patient/control pairs. Over the study period, no linear correlation was found between levels of eosinophils and time in either group. In a subset of patients (1350, 8.1%), a positive linear correlation was found between levels of eosinophils and time. CRC was significantly more common in these patients (59% vs. 41%, p < 0.01). In a logistic regression, positive r was found to be an independent predictor for CRC (OR 1.31, 95%CI: 1.22-1.41, p < 0.001) with high specificity (0.93) but low sensitivity (0.1). Conclusion: We found higher risk for CRC in patients with a positive linear increase in peripheral eosinophils over time. This may be an indirect clue that eosinophils play a role in the pathogenesis of CRC. Linear changes in ANE may be used in the future to improve screening measures for CRC. Trial registration: Not relevant.

CHA2DS2-VASc Score, Mortality and Acute Myocardial Infarction in Patients With Nonvalvular Atrial Fibrillation.

Patients with atrial fibrillation (AF) are at increased cardiovascular risk. The CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, previous stroke, vascular disease, age 65 to 74 years, female gender) has been used to predict thromboembolic risk in patients with nonvalvular AF. We aimed to evaluate the association between the CHA2DS2-VASc score and the risk of acute myocardial infarction (AMI) and all-cause mortality in patients with AF treated with direct oral anticoagulants (DOACs). The study was based on the Clalit Health Services database. Included were 21,129 patients with nonvalvular AF treated with DOACs. Patients were stratified into four groups according to the CHA2DS2-VASc score.1-9 The primary end point was the occurrence of AMI and all-cause mortality. During 21,129 patient-years, there were 1,253 incidents (5.9%) of AMI. A higher CHA2DS2-VASc score was associated with a significantly increased risk of AMI (7.8, 14.9, 23.9, and 35.3 cases per 1,000 person-years, for patients with CHA2DS2-VASc score of 1 to 2, 3 to 4, 5 to 6, and 7 to 9, respectively, p <0.001). Each 1-point increase in the CHA2DS2-VASc score was associated with a 27% increased risk of AMI. A higher CHA2DS2-VASc score was also associated with a significantly increased ll-cause mortality rate (21.7, 60.2, 103.9, 162.6 cases per 1,000 person-years, for patients with CHA2DS2-VASc score of 1 to 2, 3 to 4, 5 to 6, 7 to 9, respectively, p <0.001). All associations remained statistically significant after a multivariate analysis. In conclusion, among patients with nonvalvular AF treated with DOACs, the CHA2DS2-VASc score was associated with increased risk of AMI and all-cause mortality.

Does anatomical type of proximal hip fracture affect rehabilitation outcomes among older adults?

BACKGROUND AND PURPOSE: Numerous studies have detailed the potential benefits of inpatient geriatric rehabilitation for older adults with hip fractures. However, data regarding effect of fracture type (femoral neck, intertrochanteric, or subtrochanteric) on rehabilitation outcomes are limited. This study assessed whether the anatomical type of proximal hip fracture affects rehabilitation outcomes among disabled older adults. METHODS: A population-based study was conducted comparing all patients with a recent hip fracture who were admitted to a geriatric rehabilitation facility in Israel. Data were collected retrospectively from an electronic database during a 5-year period (2014-2019). The Functional Independence Measure (FIM) was used to assess physical and cognitive function at admission and discharge. RESULTS: The analyses included 624 older adults with hip fractures. We found significant differences in motor FIM score at admission, as patients with femoral neck fracture performed better than patients with intertrochanteric and subtrochanteric fracture did. The disparity in motor FIM score remained consistent through discharge, with all groups achieving a median gain of 14 points. Within one month of rehabilitation, about a third of all patients achieved a higher functional level. CONCLUSIONS: Patients with femoral neck fracture have better motor ability than do those with intertrochanteric and subtrochanteric fractures, which were retained throughout the course of rehabilitation; yet, the level of improvement remained similar. Clinicians should be aware of such differences in functional ability when discussing goals of care with older adults with hip fractures and consider them when implementing individual rehabilitation programs .

Mesenteric panniculitis is associated with cardiovascular risk-factors: A case-control study.

BACKGROUND: This study evaluated the prevalence of cardiovascular risk-factors in patients with mesenteric panniculitis. AIMS: To determine whether cardiovascular risk-factors and mesenteric panniculitis are associated. METHODS: Retrospective, matched case-control study of patients referred to Meir Medical Center, Israel, 2014-2019, who underwent computerized tomography scan, were diagnosed mesenteric panniculitis by radiologic criteria. They were compared to two, matched case-control groups: hospitalized patients without mesenteric panniculitis and the general population based on Israeli Ministry of Health surveys. Patients with active malignancy, IBD or significant intra-abdominal morbidity were excluded. RESULTS: Of 376 patients with mesenteric panniculitis diagnosed by computerized tomography, 187 were included. Compared to hospital patients, they had higher incidence of dyslipidemia (77.5%/56.7%), hypertension (52.4%/40.6%), obesity (body mass index>30) (60.4%/30.5%) and nonalcoholic fatty liver disease (42.2%/16.6%). Similar differences were observed compared to the general population. In multivariable logistic regression, dyslipidemia, obesity, and nonalcoholic fatty liver disease were independent predictors for mesenteric panniculitis. CONCLUSIONS: Patients with mesenteric panniculitis have more cardiovascular risk-factors compared to a case-control group and to the general population. This suggests that mesenteric panniculitis is clinically significant and may be part of the metabolic morbidity burden. This association should be further explored.

MiRNAs in Systemic Sclerosis Patients with Pulmonary Arterial Hypertension: Markers and Effectors.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a major cause of death in systemic sclerosis (SSc). Early detection may improve patient outcomes. METHODS: We searched for circulating miRNAs that would constitute biomarkers in SSc patients with PAH (SSc-PAH). We compared miRNA levels and laboratory parameters while evaluating miRNA levels in white blood cells (WBCs) and myofibroblasts. RESULTS: Our study found: 1) miR-26 and miR-let-7d levels were significantly lower in SSc-PAH (n = 12) versus SSc without PAH (SSc-noPAH) patients (n = 25); 2) a positive correlation between miR-26 and miR-let-7d and complement-C3; 3) GO-annotations of genes that are miR-26/miR-let-7d targets and that are expressed in myofibroblast cells, suggesting that these miRNAs regulate the TGF-ß-pathway; 4) reduced levels of both miRNAs accompanied fibroblast differentiation to myofibroblasts, while macitentan (endothelin receptor-antagonist) increased the levels. WBCs of SSc-noPAH and SSc-PAH patients contained equal amounts of miR-26/miR-let-7d. During the study, an echocardiograph that predicted PAH development, showed increased pulmonary artery pressure in three SSc-noPAH patients. At study initiation, those patients and an additional SSc-noPAH patient, who eventually developed PAH, had miR-let-7d/miR-26 levels similar to those of SSc-PAH patients. This implies that reduced miR-let-7d/miR-26 levels might be an early indication of PAH. CONCLUSIONS: miR-26 and miR-let-7d may be serological markers for SSc-PAH. The results of our study suggest their involvement in myofibroblast differentiation and complement pathway activation, both of which are active in PAH development.

Renal function and outcome of patients with non-valvular atrial fibrillation.

AIMS: Atrial fibrillation and renal dysfunction are associated with increased cardiovascular risk. We examined the association between renal function and incident ischaemic stroke or myocardial infarction in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs). METHODS AND RESULTS: This study was conducted using a large health record database. Included were 19 713 patients with first time diagnosis of non-valvular atrial fibrillation treated with DOACs between 2010 and 2018. Patients were categorized into four groups according to the estimated glomerular filtration rate (eGFR) (<30, 30-59, 60-89, and ≥90 mL/min/1.73 m2). Ischaemic stroke and acute myocardial infarction rates were compared between the groups. During 55 086 person-years of follow-up, there were 2295 (11.6%) cases of ischaemic stroke and 1158 (5.9%) cases of acute myocardial infarction. There was a significant inverse association between eGFR and the risk of myocardial infarction. A multivariate analysis using the group with eGFR ≥90 mL/min/1.73 m2 as a reference demonstrated an increased risk of myocardial infarction with lower eGFR [hazard ratio (HR) = 1.2 95% confidence interval (CI) 0.9-1.4, HR = 1.4, 95% CI 1.2-1.7, and HR = 2.5, 95% CI 1.8-3.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P < 0.001]. Each 10 mL decrease in eGFR was associated with an 8% increase in the risk of myocardial infarction. There was no association between eGFR and the risk of ischaemic stroke (HR = 0.9 95% CI 0.8-1.1, HR = 0.93, 95% CI 0.8-1.1, and HR = 1.1, 95% CI 0.8-1.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P = 0.325). CONCLUSIONS: Renal dysfunction is associated with an increased risk of myocardial infarction but not of ischaemic stroke among patients with atrial fibrillation treated with DOACs.

Can we improve our ability to interpret category II fetal heart rate tracings using additional clinical parameters?

OBJECTIVES: This study examined predictive factors, in addition to Category II Fetal Herat Rate (FHR) monitoring that might imply fetal acidosis and risk of asphyxia. METHODS: This retrospective cohort study compared three groups of patients with Category II FHR monitoring indicating need for imminent delivery. Groups were divided based on fetal cord blood pH: pH≤7.0, 7.0

LDL Cholesterol and Ischemic Stroke in Patients with Nonvalvular Atrial Fibrillation.

BACKGROUND: Atrial fibrillation confers higher risk of ischemic stroke, but the contribution of low-density lipoprotein cholesterol (LDL-C) levels to this risk remains unclear. We examined the association between LDL-C levels and incident stroke in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs). METHODS: This study was conducted using the electronic database of Clalit Health Services in Israel. Included were 21,229 patients with first-time diagnosis of nonvalvular atrial fibrillation treated with DOACs between 2010 and 2017. Patients were categorized into 4 groups according to the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], type 2 diabetes, previous stroke or transient ischemic attack [doubled], vascular disease, age 65-74 years, and sex category) score (1-2, 3-4, 5-6, 7-9). Each group was further stratified to 4 sub-groups according to LDL-C levels (<70, 70-99, 100-130, >130 mg/dL). Ischemic stroke rates were compared among the 4 LDL-C subgroups of each CHA2DS2-VASc category. RESULTS: During 56,467 person-years of follow-up, there were 2481 incidents of ischemic stroke. Higher CHA2DS2-VASc score was associated with significantly increased risk of ischemic stroke (17.5, 26.9, 46.3, 94.9 cases per 1000 person-years, for patients with CHA2DS2-VASc score of 1-2, 3-4, 5-6, and 7-9, respectively; P < .001). However, there was no association between LDL-C levels and incident ischemic stroke within each CHA2DS2-VASc score group, even following a multivariate adjustment. Subanalyses of patients with previous stroke and those treated with statins also failed to show any association between LDL-C levels and incident ischemic stroke. CONCLUSIONS: Unlike the general population, LDL-C levels were not associated with ischemic stroke risk among patients with atrial fibrillation treated with DOACs. The findings support the noninclusion of dyslipidemia in ischemic stroke risk stratification of patients with atrial fibrillation.

Implementing recovery-oriented interventions with staff in a psychiatric hospital: A mixed-methods study.

WHAT IS KNOWN ON THE SUBJECT?: Recovery-oriented care is a means of providing mental health treatment, focused on the patient's individual needs and active involvement in one's own care. However, this approach presents with challenges, particularly in psychiatric hospitals, which tend to be focused on symptom reduction. WHAT DOES THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study examines the influence of three different recovery-oriented training programmes/interventions (namely, illness management and recovery, peer support, and psychiatric advance directives) on the attitudes and practice of mental health staff (including nurses) in an inpatient setting, using a mixed-methods methodology. We quantitatively assess the knowledge, attitudes and practices developed following recovery-oriented training, compared to staff not trained in these interventions. We interviewed staff exposed to the different interventions to learn about their personal views and characterized the benefits and challenges they experienced. Mainly, the illness management and recovery training created a positive change in the work attitude and some work-related practices of mental health staff and the increased presence of a person-centred approach supporting patient autonomy. However, and contrary to expectations, there was no increase in practices that support personal goals or provide individually tailored services. Peer support had an experiential impact among mental health staff, initiating a more humane, positive approach to patients. Psychiatric advance directives were reported as more challenging to implement and with limited impact. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Recovery-oriented trainings can be internalized and implemented by staff in medical model psychiatric settings. Despite recovery-oriented training, challenges do occur-notably, they are hardest to implement in acute wards/patient states and by psychiatric nurses. Using multiple recovery-oriented programmes/interventions can accelerate the momentum for change in traditional settings and promote positive practice. Ongoing comprehensive mental health staff training on recovery-oriented care programmes is essential in order to sustain change over time. Training is not enough in itself-hospital administrations need to be actively involved in promoting recovery-oriented policies. ABSTRACT: Introduction Developing person-centred recovery-oriented care is a challenge in mental health systems, particularly psychiatric hospitals. Aim To assess the knowledge, attitudes and practices developed following recovery-oriented training of nurses and other staff; to identify the benefits and challenges involved in the implementation of recovery-oriented intervention in psychiatric wards. Method A mixed-methods study compared recovery knowledge, attitudes and practices of 37 mental health ward staff trained in recovery-oriented intervention, against 35 staff not trained. Fifteen staff were interviewed about their experiences, and protocols were qualitatively analysed. Results The quantitative outcomes partially confirmed positive changes in attitudes and some practices. Qualitative interviews complemented these findings, revealing greater use of a person-centred approach and support for patient autonomy. However, we did not find differences between groups in quantitative outcomes pertaining to personal goals or providing individually tailored services. Discussion This study validates the implementation of recovery training and practices in psychiatric settings, and identifies the challenges involved. We discuss psychiatric nurse conflicts in implementation in acute wards. Implications for practice Our findings support the need for broader staff training in recovery-oriented interventions. Recruiting the support of the hospital administration for recovery-oriented intervention programmes is key, both ethically and structurally.

A population-based study of premorbid scholastic achievement among patients with psychiatric disorders.

Population-based studies of premorbid cognitive functioning in schizophrenia have found verbal deficits and low IQ scores. It remains unclear, however, whether premorbid deficits are specific to schizophrenia, compared with other psychiatric disorders. Moreover, studies using school-based measures are few and their results inconsistent. This study assesses the eighth-grade (ages 13-14; n=11, 418) scholastic performance of adults with psychiatric disorders (n=194, 1.7, particularly with schizophrenia (n=86, 0.8%), comparing the results with those of their normative peers. The researchers examined report cards of eighth-graders at state secular schools in Jerusalem over a ten-year period (1978-1988), applying ANOVA and logistic regression models to evaluate associations between school performance and subsequent psychiatric hospitalization. The findings indicated that participants hospitalized with varied psychiatric disorders had lower grades in mathematics, gym, handcraft and academic core subjects, with significantly lower overall scores. Amended logistic regression models indicate that reduced performance (in mathematics, gym, handcraft and overall scores) was correlated with an increasing likelihood of hospitalization for the psychiatric disorders group and the subgroup with schizophrenia-related ailments. These results imply that eighth-grade school performance in core subjects is poorer among persons later hospitalized with psychiatric disorders than that of their classmates.