Clinical characteristics and outcomes in Asian patients with heart failure with mildly reduced ejection fraction.

Introduction: Data on heart failure (HF) with mildly reduced ejection fraction (HFmrEF) is still emerging, especially in Asian populations. This study aims to compare the clinical characteristics and outcomes of Asian HFmrEF patients with those of HF patients with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Methods: Patients admitted nationally for HF between 2008 and 2014 were included in the study. They were categorised according to ejection fraction (EF). Patients with EF <40%, EF 40%-49% and EF ≥50% were categorised into the following groups: HFrEF, HFmrEF and HFpEF, respectively. All patients were followed up till December 2016. Primary outcome was all-cause mortality. Secondary outcomes included cardiovascular death and/or HF rehospitalisations. Results: A total of 16,493 patients were included in the study - HFrEF, n = 7,341 (44.5%); HFmrEF, n = 2,272 (13.8%); and HFpEF n = 6,880 (41.7%). HFmrEF patients were more likely to be gender neutral, of mid-range age and have concomitant diabetes mellitus, hyperlipidaemia, peripheral vascular disease and coronary artery disease (P < 0.001). The two-year overall mortality rates for HFrEF, HFmrEF and HFpEF were 32.9%, 31.8% and 29.1%, respectively. HFmrEF patients had a significantly lower overall mortality rate compared to HFrEF patients (adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.83-0.95; P < 0.001) and a significantly higher overall mortality rate (adjusted HR 1.25, 95% CI 1.17-1.33; P < 0.001) compared to HFpEF patients. This was similarly seen with cardiovascular mortality and HF hospitalisations, with the exception of similar HF hospitalisations between HFmrEF and HFpEF patients. Conclusion: HFmrEF patients account for a significant burden of patients with HF. HFmrEF represents a distinct HF phenotype with high atherosclerotic burden and clinical outcomes saddled in between those of HFrEF and HFpEF. Further therapeutic studies to guide management of this challenging group of patients are warranted.

When Objective Ambivalence Predicts Subjective Ambivalence: An Affect-Cognition Matching Perspective.

Understanding when people are likely to feel ambivalent is important, as ambivalence is associated with key attitude outcomes, such as attitude-behavior consistency. Interestingly, the presence of conflicting positive and negative reactions (objective ambivalence) is weakly related to feeling conflicted (subjective ambivalence). We tested a novel situation that can influence the correspondence between objective and subjective ambivalence: whether a message and a recipient's topic match in affective versus cognitive orientation. When a person encounters a message with an affective or cognitive match to the topic, conflicting reactions may be more accessible, increasing feelings of ambivalence. Across five studies, greater objective-subjective ambivalence correspondence occurred with an affective-cognitive match between message and topic orientation. Studies 4 and 5 also demonstrated that this primarily occurred when the message was counterattitudinal. This work contributes to the literature explaining the gap between measures of objective and subjective ambivalence as well as how messages can influence attitude strength properties.

Defensive Confidence and Certainty in Unchanged Attitudes: The Role of Affect-Cognition Matching.

Despite much prior research on matching appeals to the affective-cognitive orientation of attitudes, little attention has focused on the consequences of affect-cognition (mis)matching when individuals resist persuasion. We propose that unlike a matched attack, an attack that is mismatched to the affective-cognitive orientation of attitudes would result in low defensive confidence individuals holding onto their unchanged attitudes with less certainty than high defensive confidence individuals. As hypothesized, low defensive confidence participants were less certain after an affective than a cognitive attack for a cognitive issue (Study 1), and the opposite was true for an affective issue (Study 2). Both patterns occurred again when the affective-cognitive orientation of attitudes was manipulated (Study 3) or measured as an individual difference (Study 4). Moreover, perceived knowledge mediated the effects on attitude certainty (Study 4). We end by discussing implications for our understanding of affect-cognition matching and attitude certainty.

Polarization of Attitudes as a Function of Mortality Salience: A Meta-Cognitive Analysis / Polarización de las Actitudes Como Resultado de Hacer Saliente la Mortalidad: un Análisis Meta-Cognitivo

Background: The present study analyzes how attitudes can polarize afterreminders of death in the context of persuasion, and proposes that a meta-cognitive process (i.e., self-validation) can serve as a compensatory copingmechanism to deal with mortality salience. Method: Participants were firstasked to read either a strong or a weak resume of a job applicant. Next,they listed their initial thoughts about that applicant. Then, they were askedto think about of their own death (i.e., mortality salience condition) versusbeing asked to think about of being cold (i.e., control condition). Finally,participants reported the confidence in their thoughts, as well as theirattitudes towards the applicant. Results: Participants who were assigned tothe mortality salience (vs. control) condition showed greater impact of theirpreviously generated thoughts on their subsequent attitudes. Additionally,as hypothesized, this effect of attitude polarization was mediated by changesin thought confidence. Conclusions: Attitudes unrelated to mortality canbe polarized by reminders of death and this effect can operate through ameta-cognitive process of thought validation. Implications for persuasion,self-validation, and beyond are discussed.

Antecedentes: la presenteinvestigación analiza cómo las actitudes se polarizan como resultado dehacer saliente la mortalidad en el contexto de la persuasión y propone queun proceso meta-cognitivo (i.e., la auto-validación) puede servir comoun mecanismo compensatorio de afrontamiento ante la idea de la muerte.Método: los participantes fueron asignados aleatoriamente a leer uncurrículum que incluía información muy convincente o información pococonvincente sobre un candidato a un puesto de trabajo. A continuación, escribieron los pensamientos que tuvieron sobre el candidato. Después, realizaron una tarea que implicó pensar en la idea de su propia muerte (i.e.,condición de mortalidad) o pensar en la idea de tener frío (i.e., condiciónde control). Finalmente, los participantes informaron de la confianza que tuvieron en sus pensamientos, así como de las actitudes que se formaron hacia el candidato. Resultados: los participantes de la condición demortalidad (vs. control) mostraron un mayor impacto de sus pensamientosiniciales sobre sus actitudes. Además, este efecto de polarización fuemediado por la confianza en los pensamientos. Conclusiones: las actitudesno relacionadas con la mortalidad pueden polarizarse al hacer salientela mortalidad y este efecto puede ocurrir a través de un proceso meta-cognitivo de validación del pensamiento.

Meta-analysis on continuous nerve monitoring in thyroidectomies.

In the last decade, the introduction of continuous intraoperative recurrent laryngeal nerve (RLN) monitoring (C-IONM) has enabled the operator to verify the functional integrity of the vagus nerve-recurrent laryngeal nerve (VN-RLN) axis in real-time. We aim to present the current evidence on C-IONM utility for thyroid surgery by conducting the first meta-analysis on this technique. A systematic review of literature was conducted by two independent reviewers via Ovid in the Medline, EMBASE, and Cochrane reviews databases. The search was limited to human subject research in peer-reviewed articles of all languages published between Jan 1946 and April 2020. Medical subject headings (MeSH) terms utilized were thyroid surgery, thyroidectomies, recurrent laryngeal nerve, vagal nerve, monitor, and stimulation. Thirty-eight papers were identified from Ovid, another six papers were identified by hand-search. A random effect meta-analysis was performed with assessment of heterogeneity using the I2 value. A total of 23 papers that investigated the use of continuous vagal nerve monitoring during thyroid surgery were identified. The proportion of nerves at risk (NAR) with temporary RLN paralysis postoperation was 2.26% (95% CI: 1.6-2.9, I2  = 37). The proportion of NAR with permanent RLN palsy postoperation was 0.05% (95% CI: 0.08-0.2, I2  = 0). In this meta-analysis, there is one case of temporary vagal nerve paralysis secondary to VN electrode dislodgement, and a case of hemodynamic instability manifested in bradycardia and hypotension in the initial phase of surgery shortly after calibration. C-IONM is a safe and effective means by which RLN paralyses in thyroid surgery can be reduced.

Efficacy and safety of multiple intra-articular corticosteroid injections for osteoarthritis-a systematic review and meta-analysis of randomized controlled trials and observational studies.

OBJECTIVES: To investigate the efficacy and safety of multiple intra-articular corticosteroid (IACS) injections for the treatment of OA. METHODS: We conducted electronic searches of several databases for randomized controlled trials (RCTs) and observational studies. Standard mean difference was calculated for efficacy, whereas hazard ratio (HR) was used for adverse effects. Results were combined using the random effects model. Heterogeneity was measured using I2 statistics. RESULTS: Six RCTs were included for efficacy assessment. The use of multiple IACS appeared to be better than comparator (standard mean difference for pain -0.47, 95% CI -0.62, 0.31). However, there was considerable heterogeneity (I2 92.6%) and subgroup analysis by comparator showed no separation of regular IACS from placebo, though timing of pain assessments was questionable. Fourteen RCTs and two observational studies were assessed for the safety of multiple IACS. Minor local adverse events were similar in both groups. One RCT found that regular IACS every 3 months for 2 years caused greater cartilage loss compared with saline injection (-0.21 vs 0.10 mm). One cohort study found that multiple IACS injections associated with worsening of joint space narrowing (HR 3.02, 95% CI 2.25, 4.05) and increased risk of joint replacement (HR 2.54, 95% CI 1.81, 3.57). CONCLUSION: Multiple IACS injections are no better than placebo for OA pain according to current evidence. The preliminary finding of a detrimental effect on structural OA progression warrants further investigation. Efficacy and safety of multiple IACS reflecting recommended best practice has yet to be assessed.

Comparison of early versus late laser goniopuncture following deep sclerectomy for the management of open-angle glaucoma.

PURPOSE: To compare the outcome of early versus late Nd:YAG laser goniopuncture (LGP) after deep sclerectomy with mitomycin C (DSMMC) for open-angle glaucoma (OAG). METHODS: A retrospective study of consecutive OAG eyes that underwent a LGP following DSMMC was recruited between June 2012 and November 2015. Success was defined as intraocular pressure (IOP) less than 21, 18 or 15 mm Hg with a reduction of more than 20% IOP from baseline without (complete success) or with medications (qualified success). RESULTS: 99 eyes with OAG that underwent DSMMC were recruited into the study. Of these, 49 eyes (49.49%) had undergone LGP post-DSMMC. IOP was significantly reduced following LGP from 28.4 to 11.8 mm Hg. Comparison of Kaplan-Meier survival curves out to 60 months after LGP showed a trend towards better outcomes in the late LGP group with the only statistically significant difference noted for qualified success with IOP target <15 mm Hg. Complications were few with no difference noted between early and late LGP groups. CONCLUSION: There appears to be a trend towards late LGP being more effective after DSMMC when compared with early LGP; this however was not significant. This study corroborates previous published data confirming LGP is an effective and safe procedure for lowering IOP post-DSMMC procedure.

POPPER MACULOPATHY: LONG-TERM FOLLOW-UP AND CASE SERIES.

PURPOSE: To report a case series of popper maculopathy. METHODS: Clinical history, examination findings, retinal imaging, and progress of the disease are described. RESULTS: Four male patients with a mean age of 37 years (range 25-48) and different duration of popper use (ranging from first time user to chronic user) presented with central scotomata, phosphenes, or photophobia. Optical coherence tomography in all cases demonstrated subfoveal disruption of the ellipsoid zone. Three cases also showed hyperreflectivity of the ellipsoid zone, and one case had a foveal detachment. Chronic user of poppers was associated with more severe macular changes. One patient had a 3-year follow-up and demonstrated complete resolution of signs on retinal imaging after ceasing popper use. CONCLUSION: Popper maculopathy may show complete resolution of signs on long-term follow-up, even after chronic popper ingestion.

Light-induced Amaurosis: A Rare Manifestation of Internal Carotid Artery Stenosis.

Light-induced amaurosis (LIA) is a rare presentation of internal carotid artery (ICA) stenosis. This report documents a 74-year-old Caucasian male who presented with profound right monocular vision loss, occurring on every occasion upon entering brightly lit environments. This was managed successfully with a right carotid endarterectomy. This case is presented to highlight the recognition and understanding of LIA and its importance for preservation of vision and prevention of ICA-related stroke.

Presumed choroidal metastasis from soft tissue myoepithelial carcinoma.

PURPOSE: To report a case of presumed choroidal metastasis from soft tissue myoepithelial carcinoma and highlight challenges in its diagnosis. OBSERVATIONS: A 52-year-old man was referred with a two-week history of photopsia in his left eye. His background medical history included known soft tissue myoepithelial carcinoma metastatic to his bone, lung, liver and chest wall. A large, raised, yellow choroidal lesion was identified nasal to and abutting the optic disc. This lesion demonstrated growth 1 month after presentation. The patient died with widespread metastatic disease 5 months after initial presentation. CONCLUSION AND IMPORTANCE: Soft tissue myoepithelial carcinoma can rarely metastasise to the choroid and present as a rapidly-growing, yellow, echodense tumour with serous retinal detachment. MRI brain can assist in tumour evaluation and monitoring progression, while immunoperoxidase stains and molecular testing can assist with diagnosis. The condition has an aggressive natural history and poor prognosis.

How do specialist trainee doctors acquire skills to practice patient-centred care? A qualitative exploration.

OBJECTIVES: The importance of patient-centred care (PCC) has been increasingly recognised. However, there is limited work exploring what doctors actually understand by PCC, and how they perceive they acquire PCC skills in the workplace. The objectives of our study were to explore (1) what UK doctors, in specialist training, perceive to be the essential components of PCC, (2) if/how they acquire these skills, (3) any facilitators/barriers for engaging in PCC and (4) views on their PCC training. DESIGN: Qualitative study using in-depth individual semi-structured interviews with UK specialist trainees. Interview transcripts were thematically analysed. SETTING AND PARTICIPANTS: Thirty-one specialist trainee doctors, with at least 4 years postgraduate experience, were interviewed. Participants worked in various medical specialities within the Medical Directorate of an acute hospital in the East Midlands of England. RESULTS: Interview data were transcribed verbatim and categorised into three main themes. The first theme was 'Understanding PCC' where the doctors gave varied perspectives on what they understood by PCC. Although many were able to highlight key components of PCC, there were also some accounts which demonstrated a lack of understanding. The second theme was 'Learning PCC skills: A work in progress'. Learning to be patient-centred was perceived to be an ongoing process. Within this, trainee doctors reported 'on-the-job' learning as the main means of acquiring PCC skills, but they also saw a place for formal training (eg, educational sessions focussing on PCC, role play). 'Delivering PCC: Beyond the physician' referred to the many influences the doctors reported in learning and delivering PCC including patients, the organisation and colleagues. Observing consultants taking a patient-centred approach was cited as an important learning tool. CONCLUSIONS: Our findings may assist clinical educators in understanding how trainee doctors perceive PCC, and the factors that influence their learning, thereby helping them shape PCC skills training.

Rapid "epiretinal membrane" development following intravitreal bevacizumab for Coats' disease.

PURPOSE: To report a case of rapid "epiretinal membrane" ("ERM") development following intravitreal bevacizumab for juvenile Coats' disease. OBSERVATIONS: A 7-year old boy was followed for four years with asymptomatic stage 2 Coats' disease in his left eye. At age 11, he developed symptomatic cystoid macular edema. Argon laser photocoagulation to the leaking aneurysms failed to improve his vision, which had symptomatically declined to 20/30. Four-months after laser, a single injection of intravitreal bevacizumab was given. Rapid development of an "ERM" was noticed on his first post-injection follow-up at 4 weeks. By 8-weeks post-injection the visual acuity had deteriorated to 20/400. 25 + gauge pars plana vitrectomy with "ERM" peeling was performed, with recovery of vision to 20/30 at the 4 months post-operative visit. CONCLUSIONS AND IMPORTANCE: Intravitreal bevacizumab may induce rapidly progressive "ERM" in patients with juvenile Coats' disease.

Evaluation of the Early to Mid-term Efficacy and Safety of Deep Sclerectomy without an Intrascleral Spacer for Open-angle Glaucoma in an Australian Population.

PURPOSE: This study aims to evaluate the early to the midterm efficacy of deep sclerectomy (DS) without an intra-scleral spacer for open-angle glaucoma (OAG) patients. MATERIALS AND METHODS: Retrospective study of 99 eyes (88 patients) with open-angle glaucoma who underwent DS were recruited in a consecutive order following informed consent. Intraocular pressure (IOP) was collected up to 60 months post operation (mean 19.87 ± 15.13 months). Criteria of success were defined as the qualified success (QS) or complete success (CS) with IOP level less than 21, 18 and 15 mm Hg and a reduction of more than 20% IOP from baseline. QS includes additional medication post-DS, while CS requires no other medications or surgery post-DS. Further analysis includes comparing the criteria of success based on several factors. The data were analyzed using statistical package for social sciences (SPSS version 21) statistical software. RESULTS: The QS at 60 months for IOP less than 21, 18 and 15 mm Hg is 71.3% (45.12 ± 2.46), 63.9% (40.41 ± 2.75) and 48.7% (35.62 ± 2.85), respectively. The CS at 60 months for IOP less than 21, 18 and 15 mm Hg are 69.3% (47.51 ± 2.77), 57.9% (40.41 ± 2.75) and 45.2% (35.62 ± 2.85), respectively. There was no significant difference between QS and DS post-DS based on the level of experience of the surgeons; intraoperation complication; age and gender. There was a significant reduction in IOP post operation (p < 0.001). CONCLUSION: DS is observed to be an effective surgical method with a favorable safety profile to manage patients with open-angle glaucoma. It has a better safety profile compared to trabeculectomy (TE) and can be performed by surgeons of different experience safely and successfully. CLINICAL SIGNIFICANCE: To our knowledge, this is the first report of DS in an Australian population with up to 60 months of follow-up. It is an effective procedure for IOP control in patients with OAG and has fewer complications compared to TE. DS is less popular than TE primarily due to a perceived steep learning curve, but most of the literature on DS describe single surgeon results. Our study compared the outcome of five surgeons with a variety of experience and found no significant differences in the rate of success for all levels of IOP. HOW TO CITE THIS ARTICLE: Hui MM, Clement CI. Evaluation of the Early to Mid-term Efficacy and Safety of Deep Sclerectomy without an Intrascleral Spacer for Open-angle Glaucoma in an Australian Population. J Curr Glaucoma Pract 2018;12(3):107-112.

The Singapore Paediatric Triage Scale Validation Study.

INTRODUCTION: This study aimed to determine the usefulness and validity of the triaging scale used in our emergency department (ED) by analysing its association with surrogate clinical outcome measures of severity consisting of hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalisation. METHODS: A retrospective observational study was conducted of the performance markers of the Singapore Paediatric Triage Scale (SPTS) to identify children who needed immediate and greater care. All children triaged and attended to at the paediatric ED at KK Women's and Children's Hospital, Singapore, from 1 January 2014 to 31 December 2014 were included. Data was retrieved from the Online Paediatric Emergency Care system, which is used for patients' care from initial triaging to final disposition. RESULTS: Among 172,933 ED attendances, acuity levels 1, 2 plus, 2 and 3 were seen in 2.3%, 26.4%, 13.5% and 57.8% of patients, respectively. For admissions, triage acuity level 1 had a strong positive predictive value (79.5%), while triage acuity level 3 had a strong negative predictive value (93.7%). Fewer patients with triage acuity level 3 (6.3%) were admitted as compared to those with triage acuity level 1 (79.5%) (p < 0.001). There was a correlation between triage level and length of ED stay. CONCLUSION: The SPTS is a valid tool for use in the paediatric emergency setting. This was supported by strong performance in important patient outcomes, such as admission to hospital, ICU admissions and length of ED stay.

The Singapore Paediatric Triage Scale Validation Study

<p><b>INTRODUCTION</b>This study aimed to determine the usefulness and validity of the triaging scale used in our emergency department (ED) by analysing its association with surrogate clinical outcome measures of severity consisting of hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalisation.</p><p><b>METHODS</b>A retrospective observational study was conducted of the performance markers of the Singapore Paediatric Triage Scale (SPTS) to identify children who needed immediate and greater care. All children triaged and attended to at the paediatric ED at KK Women's and Children's Hospital, Singapore, from 1 January 2014 to 31 December 2014 were included. Data was retrieved from the Online Paediatric Emergency Care system, which is used for patients' care from initial triaging to final disposition.</p><p><b>RESULTS</b>Among 172,933 ED attendances, acuity levels 1, 2 plus, 2 and 3 were seen in 2.3%, 26.4%, 13.5% and 57.8% of patients, respectively. For admissions, triage acuity level 1 had a strong positive predictive value (79.5%), while triage acuity level 3 had a strong negative predictive value (93.7%). Fewer patients with triage acuity level 3 (6.3%) were admitted as compared to those with triage acuity level 1 (79.5%) (p < 0.001). There was a correlation between triage level and length of ED stay.</p><p><b>CONCLUSION</b>The SPTS is a valid tool for use in the paediatric emergency setting. This was supported by strong performance in important patient outcomes, such as admission to hospital, ICU admissions and length of ED stay.</p>