Validating the Prognostic Utility of the ABCD-GENE Score in Asian Patients with Acute Coronary Syndrome Patients on Clopidogrel.

Background: The ABCD-GENE score, which links cytochrome P450 2C19 (CYP2C19) phenotype and high platelet reactivity (HPR) to the risk of major adverse cardiovascular events (MACE) in clopidogrel users, has been validated in white and Japanese populations. The prognostic implications of the score in other Asian cohorts, however, have been largely unchartered. The aim of this study was to validate the prognostic utility of the ABCD-GENE score in a heterogeneous Asian acute coronary syndrome (ACS) cohort. Methods and Results: In this single-centre, retrospective cohort evaluation of 423 ACS patients, the objectives were to characterise the best cut-off score for MACE prognostication by comparing the adjusted 1-year risk of MACE between groups above and below the candidate cut-off scores using Cox regression; and for on-clopidogrel HPR prediction using receiver operating characteristic (ROC) analysis and Youden's index. In the adjusted Cox model, an ABCD-GENE score cut-off at 10 points significantly predicts the 1-year risk of MACE (adjusted HR 3.771; 95% CI [1.041-13.661]). Female sex, baseline LDL, history of ACS and angiotensin receptor blocker use were additional independent predictors of MACE. On ROC analysis the ideal cut-off for HPR prediction was 7 points. However, that did not independently predict the 1-year risk of MACE (adjusted HR 1.595; 95% CI [0.425-5.989]). Conclusion: The original ABCD-GENE score 10-point cut-off moderately predicts MACE in a heterogeneous, Asian ACS population at 1 year. Additional predictors of MACE were also identified in the present cohort, and these findings should be prospectively validated in larger ACS cohorts.

An unusual case of anti-MOG CNS demyelination with concomitant mild anti-NMDAR encephalitis.

We report the case of a patient who presented with progressive unsteadiness and narcoleptic attacks followed by behavioral change and psychosis, without visual disturbances or seizures. MRI revealed multiple areas of fluid attenuation inversion recovery (FLAIR) high-intensity lesions involving the cerebellum, brainstem, thalamus and third ventricular peri-ependymal region consistent with demyelination. Both the serum myelin oligodendrocyte glycoprotein-antibodies (MOG-Abs) and cerebral spinal fluid (CSF) anti-N-methyl-d-as-partate receptor (NMDAR) antibodies were positive using transfected cell based assays. The patient presented simultaneously with symptoms of MOG antibody disease and anti-NMDAR encephalitis, an unusual clinical scenario, indicating the co-existence of the two disorders.

"Experience Isn't Everything": How Emotion Affects the Relationship Between Experience and Cue Utilization.

OBJECTIVE: This research examined whether negative and positive arousal emotions modify the relationship between experience level and cue utilization among anesthetists. BACKGROUND: The capacity of a practitioner to form precise associations between clusters of features (e.g., symptoms) and events (e.g., diagnosis) and then act on them is known as cue utilization. A common assumption is that practice experience allows opportunities for cue acquisition and cue utilization. However, this relationship is often not borne out in research findings. This study investigates the role of emotional state in this relationship. METHOD: An online tool (EXPERTise 2.0) was used to assess practitioner cue utilization for tasks relevant to anesthesia. The experience of positive and negative arousal emotions in the previous three days was measured, and emotion clusters were generated. Experience was measured as the composite of practice years and hours of practice experience. The moderating role of emotion on the relationship between experience and cue utilization was examined. RESULTS: Data on 125 anesthetists (36% female) were included in the analysis. The predicted interaction between arousal emotions and the experience level emerged. In particular, post hoc analyses revealed that anxiety-related emotions facilitated the likelihood of high cue utilization in less experienced practitioners. CONCLUSION: The findings suggest a role for emotions in cue use and suggest a functional role for normal range anxiety emotions in a simulated work-relevant task. APPLICATION: This research illustrates the importance of understanding the potentially functional effects common negative arousal emotions may have on clinical performance, particularly for those with less experience.

Positive Affect Is Associated With Reduced Fixation in a Realistic Medical Simulation.

OBJECTIVE: This study extends previous research by exploring the association between mood states (i.e., positive and negative affect) and fixation in practicing anesthetists using a realistic medical simulation. BACKGROUND: The impact of practitioner emotional states on fixation is a neglected area of research. Emerging evidence is demonstrating the role of positive affect in facilitating problem solving and innovation, with demonstrated implications for practitioner fixation. METHOD: Twelve practicing anesthetists (4 females; Mage= 39 years; SD = 6.71) were involved in a medical simulation. Prior to the simulation, practitioners rated the frequency they had experienced various positive and negative emotions in the previous three days. During the simulation, the patient deteriorated rapidly, and anesthetists were observed for their degree of fixation. After the simulation, practitioners indicated the frequency of these same emotions during the simulation. RESULTS: Nonparametric correlations were used to explore the independent relationships between positive and negative affect and the behavioral measures. Only positive affect impacted the likelihood of fixation. Anesthetists who reported more frequent recent positive affect in the three days prior to the simulation and during the simulation tended to be less fixated as judged by independent raters, identified a decline in patient oxygen saturation more quickly, and more rapidly implemented the necessary intervention (surgical cricothyroidotomy). CONCLUSION: These findings have some real-world implications for positive affect in patient safety. APPLICATION: This research has broad implications for professions where fixation may impair practice. This research suggests that professional training should teach practitioners to identify their emotions and understand the role of these emotions in fixation.

Crime victimization and the implications for individual health and wellbeing: A Sheffield case study.

Public health and criminology have developed largely independently of one another at the research and policy levels so that the links between crime victimization and health status are not well understood. Although it is not difficult to support the idea of crime as a threat to the health of individuals and the wider community, the difficulty lies in quantifying the impact of crime on public health, while controlling other variables, including gender and ethnicity. We report the results of a study, the goals of which were to: develop an understanding conceptually of the relationships between different types of crime (violent and non-violent) and health; explore the impact of victimization on quality of life and physical and psychological wellbeing; investigate the role of social and demographic factors in shaping any relationships. The study is based on 840 responses from a postal survey administered to 4,100 households in Sheffield, England, located primarily in deprived areas where overall crime rates were high. Non-violent crimes were more frequently reported than violent crimes and in general, inner city neighbourhoods were associated with higher violent crime rates. Out of 392 victims of crime, 27% of individuals detailed physical injuries resulting directly from a crime event and 31% had taken some medical steps to treat a crime-related injury. 86% experienced at least one psychological or behavioural change, including stress, sleeping difficulties, loss of confidence, and depression. Logistic regression models estimated victimization risk based on various social and demographic variables. Violent crimes were consistently linked with higher odds of seeking medical treatment and a higher likelihood of experiencing psychological ill health effects or behavioural changes. In comparison, victims of non-violent or property crimes were not significantly associated with mental health or behavioural/lifestyle effects.

Association between Total Daily Doses with duration of hospitalization among readmitted patients in a multi-ethnic Asian population.

Increased length of stay (LOS) in the hospital incurs substantial financial costs on the healthcare system. Multiple factors are associated with LOS. However, few studies have been done to associate the impact of Total Daily Doses (TDD) and LOS. Hence, the aim of this study is to examine the association between patients' LOS upon readmission and their TDD before readmission. A retrospective cross-sectional study of readmission cases occurring from 1st January to 31st March 2013 was conducted at a regional hospital. Demographics and clinical variables were collected using electronic medical databases. Univariable and multiple linear regressions were used. Confounders such as comorbidities and drug related problems (DRP) were controlled for in this study. There were 432 patients and 649 readmissions examined. The average TDD and LOS were 18.04 ± 8.16 and 7.63 days ± 7.08 respectively. In the univariable analysis, variables that were significantly associated with the LOS included age above 75 year-old, race, comorbidity, number of comorbidities, number of medications, TDD and thrombocytopenia as DRPs. In the multiple linear regression, there was a statistically significant association between TDD (ß = 0.0733, p = 0.030) and LOS. Variables that were found significant were age above 75 year-old (ß = 1.5477, p = 0.008), Malay (ß = -1.5123, p = 0.033), other races (ß = -2.6174, p = 0.007), depression (ß = 2.1551, p = 0.031) and thrombocytopenia as a type of DRP (ß = 7.5548, p = 0.027). When TDD was replaced with number of medications, number of medications (ß = 0.1487, p = 0.021), age of 75 year-old (ß = 1.5303, p = 0.009), Malay (ß = -1.4687, p = 0.038), race of others (ß = -2.6499, p = 0.007), depression (ß = 2.1951, p = 0.028) and thrombocytopenia as a type of DRP (ß = 7.5260, p = 0.028) were significant. In conclusion, a significant relationship between TDD and number of medications before readmission and the LOS upon readmission was established. This finding highlights the importance of optimizing patients' TDD in the attempt of reducing their LOS.

Association between number of doses per day, number of medications and patient's non-compliance, and frequency of readmissions in a multi-ethnic Asian population.

OBJECTIVE: To investigate whether number of doses per day and number of medications are significantly associated with the number of readmissions and to study the association of readmission frequency with other medical and socio-demographic variables. METHODS: Retrospective cross-sectional study involving 432 patients who were readmitted within 15 days of previous hospital discharge between January 1, 2013 and March 31, 2013. Relevant medical records were collected from the national electronic databases of every public tertiary hospital in Singapore. Significant variables (p < 0.05) were identified using forward selection and modeled using generalized linear mixed models. RESULTS: A total of 649 unplanned readmissions were reviewed. At a multivariable level, number of readmission was significantly associated with the number of medications (p = 0.002) and number of doses per day (p = 0.003) after adjusting for race, liver disease, schizophrenia and non-compliance. CONCLUSION: Complex medication regimen (i.e. multiple medications and multiple doses per day) is a statistically significant predictor of number of readmissions. Simplifying therapeutic regimens with alternatives such as longer-acting or fixed-dose combination drugs may facilitate better patient adherence and reduce costly readmissions.

High thoracic/cervical epidural blood patch for spontaneous cerebrospinal fluid leak: a new challenge for anesthesiologists.

Spontaneous cerebral spinal fluid leakage is increasingly recognized as a cause of headache due to low intracranial pressure. The site of leakage can be identified with radionuclide cisternography, and anesthesiologists are increasingly requested to provide epidural blood patch for their management. This series of case reports demonstrates some of the issues relating to the management of this condition.