Pre-operative expectations of patients with degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network.

BACKGROUND: Despite an abundance of literature on degenerative cervical myelopathy (DCM), little is known about pre-operative expectations of these patients. PURPOSE: The primary objective was to describe patient pre-operative expectations. Secondary objectives included identifying patient characteristics associated with high pre-operative expectations and to determine if expectations varied depending on myelopathy severity. STUDY DESIGN: This was a retrospective study of a prospective multicenter, observational cohort of patients with DCM. PATIENT SAMPLE: Patients who consented to undergo surgical treatment between January 2019 and September 2022 were included. OUTCOMES MEASURES: An 11-domain expectation questionnaire was completed pre-operatively whereby patients quantified the expected change in each domain. METHODS: The most important expected change was captured. A standardized expectation score was calculated as the sum of each expectation divided by the maximal possible score. The high expectation group was defined by patients who had an expectation score above the 75th percentile. Predictors of patients with high expectations were determined using multivariable logistic regression models. RESULTS: There were 262 patients included. The most important patient expectation was preventing neurological worsening (40.8%) followed by improving balance when standing or walking (14.5%), improving independence in everyday activities (10.3%), and relieving arm tingling, burning and numbness (10%). Patients with mild myelopathy were more likely to select no worsening as the most important expected change compared to patients with severe myelopathy (p<.01). Predictors of high patient expectations were: having fewer comorbidities (OR -0.30 for every added comorbidity, 95% CI -0.59 to -0.10, p=.01), a shorter duration of symptoms (OR 0.92, 95% CI 0.35-1.19, p=.02), no contribution from "failure of other treatments" on the decision to undergo surgery (OR 1.49, 95% CI 0.56-2.71, p=.02) and more severe neck pain (OR 0.19 for 1 point increase, 95% CI 0.05-0.37, p=.01). CONCLUSIONS: Most patients undergoing surgery for DCM expect prevention of neurological decline, better functional status, and improvement in their myelopathic symptoms. Stopping neurological deterioration is the most important expected outcomes by patients.

Effect of Dosage Reduction of Hypoglycemic Multidrug Regimens on the Incidences of Acute Glycemic Complications in People With Type 2 Diabetes Who Fast During Ramadan: A Randomized Controlled Trial.

Objective: We aimed to investigate the effect of dosage reduction of four hypoglycemic multidrug regimens on the incidences of acute glycemic complications in people with type 2 diabetes who fast during Ramadan. Methods: We conducted an open-label, parallel-group, randomized controlled trial at a tertiary care center in Amman, Jordan. We recruited adults with type 2 diabetes who expressed an intention to fast during Ramadan and were adherent to one of four regimens-namely: metformin and glimepiride; metformin and vildagliptin; metformin and insulin glargine U100; or, metformin, insulin glargine U100, and human regular insulin. We randomly assigned participants in a 2:1 ratio to low- or regular-dosage therapy. The primary outcomes were the incidences of hypoglycemia and hyperglycemia during the 29 days of Ramadan 2017, and the secondary outcomes were the incidences of diabetic ketoacidosis and hyperosmolar hyperglycemic state during the same period. Results: We randomly assigned 687 participants to low-dosage therapy (n = 458) or regular-dosage therapy (n = 229) and included 678 (452 and 226, respectively) in the final analysis. The incidence of hypoglycemia was lower in the low-dosage group compared with the regular-dosage group (19 [4.2%] vs. 52 [23.0%], respectively; OR, 0.15 [95% CI, 0.08-0.26]; P < 0.001). The incidence of hyperglycemia did not differ between the low- and regular-dosage groups (319 [70.6%] vs. 154 [68.1%], respectively; OR, 1.12 [95% CI, 0.79-1.58]; P = 0.5). No participants experienced diabetic ketoacidosis or hyperosmolar hyperglycemic state. Each 1% decrease in the baseline HbA1c concentration was associated with a 19.9-fold (95% CI, 9.6-41.5; P < 0.001) increase in the odds of hypoglycemia, and each 1% increase in the baseline HbA1c concentration was associated with a 15.7-fold (95% CI, 10.0-24.6; P < 0.001) increase in the odds of hyperglycemia. Conclusion: Dosage reduction decreases the incidence of hypoglycemia without a concomitant increase in the incidences of hyperglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state in people with type 2 diabetes who fast during Ramadan. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04237493.

Possible Mode of Spread of Hepatitis B and Hepatitis C in Chronic Liver Disease Patients Presenting at CMH Lahore Medical College and Institute of Dentistry.

Introduction Chronic hepatitis B and C are the leading causes of chronic liver disease and a significant cause of mortality and morbidity worldwide. Hepatitis B is a preventable disease with vaccination, which is available worldwide. About 257 million people are affected worldwide with hepatitis B and around 71 million people with hepatitis C, and Pakistan is the second most prevalent country with hepatitis C. The possible mode of spread of hepatitis B and C in chronic liver disease patients presenting at CMH medical wards and dental clinics was evaluated. Among various types of hepatitis, A, B, and C are the most common. The course of disease followed by hepatitis A is short term, but when we talk about the common types, which are B and C, the disease is chronic and, moreover, the complications associated with these types are more severe too. Materials and methods The study was carried out at the medical wards and dental clinics of CMH Lahore Medical College. A total of 240 patients were evaluated for the possible mode of spread of hepatitis B and C. A detailed history regarding the use of needles, surgical procedures, including dental treatment, unsterilized razors for shaving (barbers'), blood transfusions, tattooing, and mode of delivery in females, was evaluated and data were interpreted. Aims and objectives To observe the mode of spread of hepatitis B and C among patients of CMH Lahore Medical College and Institute of Dentistry. Results The results of our study revealed that the most common mode of spread of disease in males was exposure to infected blades and instruments at barbers' shops. In females, blood transfusion and caesarian section, especially in rural areas, remained the most common possible cause of spread. A small number of patients was not aware of the possible mode of transmission, whereas a few others did not seek treatment for the disease. Conclusion From our study, we can conclude that a substantial number of patients with chronic liver disease have exposure to various risk factors. Exposure to the unsterilized equipment of barbers and improperly screened blood remains the main cause of the spread of hepatitis B and C in males whereas surgical procedures related to gynecological procedures and blood transfusions remain the second most common cause. Dental procedures in the hands of trained dental professionals/dentists carry less danger of transmitting the disease but carry an equally high incidence if quacks do the dental procedures.

Heart Failure in Relation to Anthracyclines and Other Chemotherapies.

Anthracyclines are the cornerstone of therapy for a wide range of solid and hematologic malignancies; however, their use is limited by the risk of chemotherapy-induced cardiotoxicity leading to cardiomyopathy and heart failure. The incidence of cardiotoxicity in the literature depends on the definition being used, anthracycline dose, duration of follow-up, and surveillance methods used to identify cardiac injury. The reported risk of clinical heart failure has been around 2% to 4% with low-dose anthracycline regimens, whereas the incidence of cardiac injury defined by an abnormal increase in cardiac biomarkers has been reported as high as 35%. Multiple mechanisms have been proposed for anthracycline cardiotoxicity, including the deleterious effects of oxidative stress and reactive oxygen species and the inhibition of topoisomerase II beta, which leads to cardiomyocyte death. In addition, genetic susceptibility is an emerging field that is currently generating active research. The risk factors associated with anthracycline cardiotoxicity include lifetime cumulative dose, age, prior cardiac dysfunction, and the presence of cardiovascular risk factors, in particular hypertension. In this review, we summarize the incidence, mechanisms, and risk factors for anthracycline-mediated left ventricular dysfunction and discuss the role of risk stratification and early detection in patient management.

Heart Failure in Relation to Tumor-Targeted Therapies and Immunotherapies.

Tumor-targeted therapies such as trastuzumab have led to significant improvements in survival of human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, these therapies have also been associated with significant left ventricular dysfunction. The incidence of trastuzumab-induced heart failure has decreased significantly since the initial reports, in large part due to improved screening, closer monitoring for early changes in left ventricular function, and a significant decrease in the concurrent administration of anthracyclines. The mechanism of trastuzumab cardiotoxicity is still not well understood, but current knowledge suggests that ErbB2 inhibition in cardiac myocytes plays a key role. In addition to trastuzumab and other HER2-targeted agents, vascular endothelial growth factor inhibitors, proteasome inhibitors, and immune checkpoint inhibitors are all additional classes of drugs used with great success in the treatment of solid tumors and hematologic malignancies. Yet these, too, have been associated with cardiac toxicity that ranges from a mild asymptomatic decrease in ejection fraction to fulminant myocarditis. In this review, we summarize the cardiotoxic effects of tumor-targeted and immunotherapies with a focus on HER2 antagonists.

Consanguinity and the Risk of Hashimoto's Thyroiditis.

BACKGROUND: Hashimoto's thyroiditis (HT) is the most common autoimmune thyroid disease that may lead to hypothyroidism due to progressive destruction of the thyroid. The etiology of HT is unclear. However, it is associated with multiple genetic predispositions. Consanguinity has been associated with an increased susceptibility to different inherited conditions. This study investigated the association between consanguinity and risk of HT for the first time. METHODS: Using a case-control study design, 298 HT patients were compared with two subject groups: (i) 299 participants with non-HT hypothyroidism, and (ii) 298 healthy control participants. The three groups were age and sex matched. Presence of consanguinity among the parents was compared in these groups, and odds ratios (OR) were calculated to establish a correlation. RESULTS: Consanguinity significantly increased the risk of HT (compared with healthy subjects; OR = 3.3; p < 0.0001). In addition, consanguinity was a significant risk factor for HT compared with non-HT hypothyroidism patients (OR = 2.8; p < 0.0001). However, the prevalence of consanguinity was not significantly different in non-HT hypothyroidism patients and healthy subjects. CONCLUSIONS: The results suggest that the risk for HT is increased in consanguineous unions, but no significant increase in the risk of non-HT hypothyroidism was observed. However, for more precise risk estimates, larger studies that include different populations may be helpful. These findings highlight the health impact of consanguinity and have applications in empiric risk estimations in genetic counseling, particularly in countries with high rates of consanguineous marriages.

Do heart failure patients understand their diagnosis or want to know their prognosis? Heart failure from a patient's perspective.

The management of heart failure has evolved to become a multidisciplinary affair. Constraints of time and resources limit the amount of counselling that is given to heart failure patients in hospital and, with the advent of community heart failure specialist nurses, there is a trend to move more of these services into the community. Most heart failure patients are elderly and may find the information given to them, at the time of diagnosis and later on at home by heart failure nurses, difficult to grasp. In this study, patients' perspectives of a diagnosis of heart failure, their understanding of the diagnosis as well as what being diagnosed with heart failure means to them were recorded. Patients were questioned on whether the news of the heart failure diagnosis was broken to them in a sympathetic manner and how they felt about the information provided at diagnosis.

Evaluation of functional improvement in older patients with cognitive impairment, depression and/or delirium admitted to a geriatric convalescence hospitalization unit.

Cognitive impairment, depression and delirium are problems of high prevalence in older patients. The geriatric convalescence unit (GCU) is a hospitalization facility offering an interdisciplinary geriatric intervention program that may be more appropriate for these patients. This study intended to analyze the functional improvement (FI) in older patients with cognitive impairment, depression and/or delirium admitted to a GCU. A group of 107 patients received specific nurse care, habitually performed in GCU and they also were included in a rehabilitation program. Cognitive impairment, depression and delirium were diagnosed according to standardized protocols. The analyzed variables were: age, functional status (Barthel index) before admission (BBA), at admission (BA) and at discharge(BD), diagnostic categories, cognitive function (mini mental state examination: MMSE) and post-discharge destination. The corrected Heinemann index (CHI) was used to evaluate FI obtained during GCU-stay, where CHI = 100 x (BD-BA)/(BBA-BA), and the efficiency index(El) was used to analyze the relationship between FI and the length of stay in the GCU,where El = (BD-BA)/(days in GCU). According to CHI, patients were divided in three groups. Group I: CHI = 0 or negative (patients who lost functional capacity during hospitalization,those who died or were transferred to hospital owing to acute deterioration. Group II: CHI < 35 % (high FI). Mean age was 77.6 +/- 9.1 years, the diagnostic categories were: fractures/orthopedics 49 (45.7 %), neurological 27(25.2 %), pulmonary/cardiologic 6 (5.6 %) and other cases 25 (23.3 %). Mean MMSE and BA scores were 16.9 +/- 9.4 and 29.6 +/- 18.9, respectively. Post-discharge destinations were:63 patients (58.8 %) returned home, 28 (26.1 %) were definitively institutionalized, 11 (10.2%) died and finally 5 (4.6 %) were transferred to acute care hospital. In-Group I, there were 35 patients (32.7 %) with a mean value of the El = 0.12 +/-1.1; in Group II, 13 (12.1 %) and 0.26 +/- 0.38; in Group III, 59 (55.1 %) and 0.94 +/- 0.97, respectively. In spite of the presence of cognitive impairment, depression and/or delirium, a high proportion of patients (67.2 %)obtained a significant improvement in their functional capacity.35 % (moderate FI). Group III: CHI >/=