Venous thromboembolism and underutilisation of anticoagulant thromboprophylaxis in hospitalised patients with inflammatory bowel disease

Background: Venous thromboembolism (VTE) is a well-recognised extra-intestinal manifestation of inflammatory bowel disease (IBD). Despite the widespread support for anticoagulant prophylaxis in hospitalised IBD patients, the utilisation and efficacy in clinical practice are unknown. Aims: The aim of this study was to assess the prevalence and clinical features of VTE among hospitalised IBD patients and ascertain whether appropriate thromboprophylaxis had been administered. Methods: All patients with a discharge diagnosis of Crohn disease or ulcerative colitis and VTE were retrospectively identified using International Classification of Diseases, tenth revision codes from medical records at our institution from July 1998 to December 2009. Medical records were then reviewed for clinical history and utilisation of thromboprophylaxis. Statistical analysis was performed by Mann-Whitney test and either χ2 tests or Fisher's exact tests. Results: Twenty-nine of 3758 (0.8%) IBD admissions suffered VTE, 13 preadmission and 16 during admission. Of these 29 admissions (in 25 patients), 24% required intensive care unit and 10% died. Of the 16 venous thrombotic events that occurred during an admission, eight (50%) did not receive anticoagulant thromboprophylaxis and eight (50%) occurred despite thromboprophylaxis. Most thromboembolism despite prophylaxis occurred post-intestinal resection (n = 5, 63%). Conclusion: Thromboprophylaxis is underutilised in half of IBD patients suffering VTE. Prescription of thromboprophylaxis for all hospitalised IBD patients, including dual pharmacological and mechanical prophylaxis in postoperative patients, may lead to a reduction in this preventable complication of IBD. © 2014 Royal Australasian College of Physicians.

Prospective progression from high-prevalence disorders to bipolar disorder: exploring characteristics of pre-illness stages

BACKGROUND: Identification of risk factors within precursor syndromes, such as depression, anxiety or substance use disorders (SUD), might help to pinpoint high-risk stages where preventive interventions for Bipolar Disorder (BD) could be evaluated.

METHODS: We examined baseline demographic, clinical, quality of life, and temperament measures along with risk clusters among 52 young people seeking help for depression, anxiety or SUDs without psychosis or BD. The risk clusters included Bipolar At-Risk (BAR) and the Bipolarity Index as measures of bipolarity and the Ultra-High Risk assessment for psychosis. The participants were followed up for 12 months to identify conversion to BD. Those who converted and did not convert to BD were compared using Chi-Square and Mann Whitney U tests.

RESULTS: The sample was predominantly female (85%) and a majority had prior treatment (64%). Four participants converted to BD over the 1-year follow up period. Having an alcohol use disorder at baseline (75% vs 8%, χ(2)=14.1, p<0.001) or a family history of SUD (67% vs 12.5%, χ(2)=6.0, p=0.01) were associated with development of BD. The sub-threshold mania subgroup of BAR criteria was also associated with 12-month BD outcomes. The severity of depressive symptoms and cannabis use had high effects sizes of association with BD outcomes, without statistical significance.

CONCLUSIONS AND LIMITATIONS: The small number of conversions limited the power of the study to identify associations with risk factors that have previously been reported to predict BD. However, subthreshold affective symptoms and SUDs might predict the onset of BD among help-seeking young people with high-prevalence disorders.

The role of parity in gestational weight gain and postpartum weight retention

OBJECTIVES: Parity, excessive gestational weight gain (GWG), and postpartum weight retention (PPWR) have been identified as risk factors for maternal obesity. The aim of this study was to explore whether GWG and PPWR at 6 and 12 months after birth differed for primiparous and multiparous Australian women. METHODS: One hundred thirty-eight Australian women provided weight measures in early to mid pregnancy (M = 16.7 weeks, SD = 2.3), late pregnancy (M = 37.7 weeks, SD = 2.4), 6 months postpartum (M = 6.1 months, SD = 1.4), and 12 months postpartum (M = 12.6 months, SD = 0.7). Height, parity, and demographic information were also collected. Prepregnancy body mass index (BMI), total GWG, incidence of excessive GWG, as well as change in BMI and BMI category from prepregnancy to 6 and 12 months postpartum were computed. Differences between primiparous and multiparous women were compared using analysis of covariance (controlling for age, prepregnancy BMI, and GWG) and χ(2) test of independence. RESULTS: Seventy women (50.7%) were primiparous and 68 women (49.3%) were multiparous. Primiparous women were more likely to retain weight at 12 months postpartum than multiparous women (p = .021; Cohen's d = .24). This difference was not reflected when analyzing change in BMI categories from prepregnancy to the postpartum. CONCLUSIONS: Evidence for the role of parity in PPWR is inconclusive. Future research should consider the temporal development of PPWR in primiparous and multiparous women, leading to tailored care in the postpartum period to help women return to a healthy prepregnancy weight.

Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction

BACKGROUND: Heart failure is associated with high mortality and hospital readmissions. Beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) can improve survival and reduce hospital readmissions and are recommended as first-line therapy in the treatment of heart failure. Evidence has also shown that there is a dose-dependent relationship of these medications with patient outcomes. Despite this evidence, primary care physicians are reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration (NLT) is one such strategy. OBJECTIVES: To assess the effects of NLT of beta-adrenergic blocking agents, ACEIs, and ARBs in patients with heart failure with reduced ejection fraction (HFrEF) in terms of safety and patient outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL Issue 11 of 12, 19/12/2014), MEDLINE OVID (1946 to November week 3 2014), and EMBASE Classic and EMBASE OVID (1947 to 2014 week 50). We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources. We used no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing NLT of beta-adrenergic blocking agents, ACEIs, and/or ARBs comparing the optimisation of these medications by a nurse to optimisation by another health professional in patients with HFrEF. DATA COLLECTION AND ANALYSIS: Two review authors (AD & JC) independently assessed studies for eligibility and risk of bias. We contacted primary authors if we required additional information. We examined quality of evidence using the GRADE rating tool for RCTs. We analysed extracted data by risk ratio (RR) with 95% confidence interval (CI) for dichotomous data to measure effect sizes of intervention group compared with usual-care group. Meta-analyses used the fixed-effect Mantel-Haenszel method. We assessed heterogeneity between studies by Chi(2) and I(2). MAIN RESULTS: We included seven studies (1684 participants) in the review. One study enrolled participants from a residential care facility, and the other six studies from primary care and outpatient clinics. All-cause hospital admission data was available in four studies (556 participants). Participants in the NLT group experienced a lower rate of all-cause hospital admissions (RR 0.80, 95% CI 0.72 to 0.88, high-quality evidence) and fewer hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72, moderate-quality evidence) compared to the usual-care group. Six studies (902 participants) examined all-cause mortality. All-cause mortality was also lower in the NLT group (RR 0.66, 95% CI 0.48 to 0.92, moderate-quality evidence) compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving NLT of beta-adrenergic blocking agents, ACEIs, and ARBs. Only three studies (370 participants) reported outcomes on all-cause and heart failure-related event-free survival. Participants in the NLT group were more likely to remain event free compared to participants in the usual-care group (RR 0.60, 95% CI 0.46 to 0.77, moderate-quality evidence). Five studies (966 participants) reported on the number of participants reaching target dose of beta-adrenergic blocking agents. This was also higher in the NLT group compared to usual care (RR 1.99, 95% CI 1.61 to 2.47, low-quality evidence). However, there was a substantial degree of heterogeneity in this pooled analysis. We rated the risk of bias in these studies as high mainly due to a lack of clarity regarding incomplete outcome data, lack of reporting on adverse events associated with the intervention, and the inability to blind participants and personnel. Participants in the NLT group reached maximal dose of beta-adrenergic blocking agents in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event. AUTHORS' CONCLUSIONS: Participants in the NLT group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting NLT as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions. Despite evidence of a dose-dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving outcomes in patients with HFrEF, the translation of this evidence into clinical practice is poor. NLT is one strategy that facilitates the implementation of this evidence into practice.

A strategy for involving general practitioners in smoking control

OBJECTIVE: In 1991, the Victorian Smoking and Health Program introduced a simple intervention strategy for general practitioners that could be integrated conveniently and inexpensively into the routine care of patients who smoke. The aim of this study was to determine whether there had been a change over time in whether or not GPs advised their patients not to smoke. METHOD: The extent to which smokers remembered GPs talking to them about smoking was assessed in population-based surveys of adults in Victoria in 1990 (prior to the implementation of the intervention) and in 1992, 1994 and 1996. RESULTS: Over time there was a significant increase in the proportion of smokers who reported that their GP had provided them with help or information to stop smoking (chi 2 = 17.58, p < 0.001). In 1996, 9% of smokers said their doctor had advised them to contact Quit. CONCLUSION: Levels of recalled advice and provision of information regarding smoking cessation have increased by 10% over the past six years. However, nearly half the smokers in this study reported that they had been given inappropriate advice or no advice at all. IMPLICATIONS: A brief intervention by GPs, supplemented by appropriate referrals, has the potential to assist significant numbers of smokers to quit and may be more practical for GPs who are unable to personally provide all of the support smokers may need to quit.

Use of eye care services by people with diabetes: the Melbourne Visual Impairment Project

AIM: The use of eye care services by people with and without diabetes was investigated in the Melbourne Visual Impairment Project (VIP), a population based study of eye disease in a representative sample of Melbourne residents 40 years of age and older. METHODS: A comprehensive interview was employed to elicit information on history of diabetes, medication use, most recent visit to an ophthalmologist and optometrist, and basic demographic details. Presence and extent of diabetic retinopathy was determined by dilated fundus examination. RESULTS: The Melbourne VIP comprised 3271 people who ranged in age from 40 to 98 years; 46.2% of them were male. Of 3189 people who had the fundus examination and knew their diabetes status, 162 (5.1%) reported having been previously diagnosed with diabetes and, of these, 37 (22.2%) were found to have diabetic retinopathy. Seven people (4.3%) had developed diabetes before age 30. The mean duration of diabetes was 9.2 years. People with diabetes were significantly more likely to have visited an ophthalmologist ever or in the past 2 years than people without diabetes. However, 31.8% of people with diabetes had never visited an ophthalmologist. The proportion of people who had never seen an ophthalmologist was 47.1% for people without diabetes, 34.2% for people with diabetes but without diabetic retinopathy, and 25% for people with diabetic retinopathy. Sixty one per cent of people with diabetic retinopathy had seen an ophthalmologist in the past year and a further 3% within the past 2 years. People with diabetes were not significantly more likely to have visited an optometrist than people without diabetes (p = 0.51). Overall, 37.7% of people with diabetes and 32.9% of people without diabetes had visited an optometrist within the past year (chi 2 = 2.25, 1 df, p = 0.13). Information concerning retinal examinations was available for 135 individuals (83.3% of people with diabetes). Only 74 (54.8%) could recall ever having a dilated fundus examination; 10 (14%) by an optometrist, 62 (86%) by an ophthalmologist, and five (7%) by a general practitioner. Of those 68 people who had seen an ophthalmologist in the past 2 years, 48 (71%) reported a dilated fundus examination during that time. This compares with 28 (43%) reported dilated fundus examinations in the 65 people who had seen an optometrist in the past 2 years. This finding is statistically significant (chi 2 = 10.2, 1 df, p < 0.005). CONCLUSION: These results indicate that nearly half of people with diabetes in Melbourne are not receiving adequate screening or follow up for diabetic retinopathy, despite universal health care.

A process evaluation of the Supermarket Healthy Eating for Life (SHELf) randomized controlled trial

BACKGROUND: Supermarket Healthy Eating for Life (SHELf) was a randomized controlled trial that operationalized a socioecological approach to population-level dietary behaviour change in a real-world supermarket setting. SHELf tested the impact of individual (skill-building), environmental (20 % price reductions), and combined (skill-building + 20 % price reductions) interventions on women's purchasing and consumption of fruits, vegetables, low-calorie carbonated beverages and water. This process evaluation investigated the reach, effectiveness, implementation, and maintenance of the SHELf interventions.

METHODS: RE-AIM provided a conceptual framework to examine the processes underlying the impact of the interventions using data from participant surveys and objective sales data collected at baseline, post-intervention (3 months) and 6-months post-intervention. Fisher's exact, χ (2) and t-tests assessed differences in quantitative survey responses among groups. Adjusted linear regression examined the impact of self-reported intervention dose on food purchasing and consumption outcomes. Thematic analysis identified key themes within qualitative survey responses.

RESULTS: Reach of the SHELf interventions to disadvantaged groups, and beyond study participants themselves, was moderate. Just over one-third of intervention participants indicated that the interventions were effective in changing the way they bought, cooked or consumed food (p < 0.001 compared to control), with no differences among intervention groups. Improvements in purchasing and consumption outcomes were greatest among those who received a higher intervention dose. Most notably, participants who said they accessed price reductions on fruits and vegetables purchased (519 g/week) and consumed (0.5 servings/day) more vegetables. The majority of participants said they accessed (82 %) and appreciated discounts on fruits and vegetables, while there was limited use (40 %) and appreciation of discounts on low-calorie carbonated beverages and water. Overall reported satisfaction with, use, and impact of the skill-building resources was moderate. Maintenance of newly acquired behaviours was limited, with less than half of participants making changes or using study-provided resources during the 6-month post-intervention period.

CONCLUSIONS: SHELf's reach and perceived effectiveness were moderate. The interventions were more effective among those reporting greater engagement with them (an implementation-related construct). Maintenance of newly acquired behaviours proved challenging.

Compositional nutrient diagnosis of corn using the Mahalanobis distance as nutrient imbalance index

Parent, L. E., Natale, W. and Ziadi, N. 2009. Compositional nutrient diagnosis of corn using the Mahalanobis distance as nutrient imbalance index. Can. J. Soil Sci. 89: 383-390. Compositional nutrient diagnosis (CND) provides a plant nutrient imbalance index (CND - r(2)) with assumed chi(2) distribution. The Mahalanobis distance D(2), which detects outliers in compositional data sets, also has a chi(2) distribution. The objective of this paper was to compare D(2) and CND - r(2) nutrient imbalance indexes in corn (Zea mays L.). We measured grain yield as well as N, P, K, Ca, Mg, Cu, Fe, Mn, and Zn concentrations in the ear leaf at silk stage for 210 calibration sites in the St. Lawrence Lowlands [2300-2700 corn thermal units (CTU)] as well as 30 phosphorus (2300-2700 CTU; 10 sites) and 10 nitrogen (1900-2100 CTU; one site) replicated fertilizer treatments for validation. We derived CND norms as mean, standard deviation, and the inverse covariance matrix of centred log ratios (clr) for high yielding specimens (>= 9.0 Mg grain ha(-1) at 150 g H(2)O kg(-1) moisture content) in the 2300-2700 CTU zone. Using chi(2) = 17 (P < 0.05) with nine degrees of freedom (i.e., nine nutrients) as a rejection criterion for outliers and a yield threshold of 8.6 Mg ha(-1) after Cate-Nelson partitioning between low- and high-yielders in the P validation data set, D(2) misclassified two specimens compared with nine for CND -r(2). The D(2) classification was not significantly different from a chi(2) classification (P > 0.05), but the CND - r(2) classification differed significantly from chi(2) or D(2) (P < 0.001). A threshold value for nutrient imbalance could thus be derived probabilistically for conducting D(2) diagnosis, while the CND - r(2) nutrient imbalance threshold must be calibrated using fertilizer trials. In the proposed CND - D(2) procedure, D(2) is first computed to classify the specimen as possible outlier. Thereafter, nutrient indices are ranked in their order of limitation. The D(2) norms appeared less effective in the 1900-2100 CTU zone.

INHERITANCE of CUCUMBER TOLERANCE TO ZUCCHINI YELLOW MOSAIC VIRUS

Studies were carried out in Brazil to study the inheritance of tolerance to Zucchini yellow mosaic virus (ZYMV) in cucumber cv. Formosa. This cultivar was individually crossed with two cucumber lines from different varietal types (L(b) from a Brazilian type, and L(j) from a Japanese type), both susceptible to the virus. Two experiments, one for each line, were separately carried out, where 6 treatments (parents, generations F1, F2 and F1BC1 for both parents) were evaluated in a randomized block design with 5 repetitions. Cotyledons of 2-week-old cucumber seedlings were inoculated with ZYMV. Only the plants that did not show symptoms up to 63 days post inoculation were considered as tolerant. A chi-square (chi(2)) analysis for assessing segregation from F2 and both F1BC1, led to the conclusion that the tolerance found in cv. Formosa is determined by a recessive gene.

No relationship found between point heteroplasmy in mitochondrial DNA control region and age range, sex and haplogroup in human hairs

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Effect of intravenous alizapride on spinal morphine-induced pruritus

Background. This double-blind study was undertaken to determine whether alizapride inhibits spinal morphine-induced pruritus.Methods. Eighty-four patients undergoing Caesarean section under spinal anaesthesia (100 mg of hyperbaric lidocaine 5% plus morphine 0.2 mg) were randomly allocated to one of two groups. just after birth, alizapride-50 mg (alizapride group) or metoclopramide 10 mg (metoclopramide group) were injected i.v. Patients were assessed after surgery for pruritus (absent, mild, moderate or severe) or other untoward symptoms.Results. In the metoclopramide group, pruritus was absent in 5 (12%) patients, mild in 23 (55%), moderate in 11 (26%), and severe in 3 (7%), while in the alizapride group, these incidences were, respectively, 5 (12%), 33 (79%), 4 (10%), and 0 (P=0.045, chi(2)-test). There was no difference in the incidence of side-effects, which were all minor.Conclusions. Alizapride reduced the severity of morphine-induced pruritus.

Helicobacter pylori and EBV in gastric carcinomas: Methylation status and microsatellite instability

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Effect of hormone therapy on postural balance in postmenopausal women

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Influence of Hydatidiform Mole Follow-Up Setting on Postmolar Gestational Trophoblastic Neoplasia Outcomes A Cohort Study

OBJECTIVE: To assess the influence of hydatidiform mole (HM) management setting (reference center versus other institutions) on gestational trophoblastic neoplasia (GTN) outcomes. METHODS: This cohort study included 270 HM patients attending Botucatu Trophoblastic Diseases Center (BTDC, São Paulo State University, Brazil) between January 1.990 and December 2009 (204 undergoing evacuation and entire postmolar follow-up at BTDC and 66 from other institutions [OIs]). GTN characteristics and outcomes were analyzed and compared according to HM management setting. The confounding variables assessed included age, gravidity, parity, number of abortions and HM type (complete or partial). Postmolar GTN outcomes were compared using Mann-Whitney's test, chi(2) test or Fisher's exact test.RESULTS: Postmolar GTN occurred in 34 (34/204= 16.7%) BTDC patients and in 27 (27/66=40.9%) of those initially treated in other institutions. BTDC patients showed lower metastasis rate (5.8% vs. 48%, p = 0.003) and lower median FIGO (2002) score (2.00 0.00, 3.001 vs. 4.00 [2.00, 7.00], p = 0.003]. Multiagent chemotherapy to treat postmolar GTN was required in 2 BTDC cases (5.9%) and in 8 OI cases (29.6%) (p = 0.017). Median time interval between molar evacuation and chemotherapy onset was shorter among BTDC patients (7.0 [6.0, 10.0] vs. 10.0[7.0, 16.0], p = 0.040). CONCLUSION: BTDC patients showed GTN characteristics indicative of better prognosis. This underscores the importance of GTD specialist centers. (J Reprod Med 2012;57:305-309)

Body dysmorphic disorder among dermatologic patients: Prevalence and clinical features

Background: An impairing preoccupation with a nonexistent or slight defect in appearance is the core symptom of body dysmorphic disorder (ODD), a psychiatric condition common in dermatology settings.Objective: We sought to determine the prevalence of ODD in dermatologic patients, comparing general and cosmetic settings, and describing some demographic and clinical characteristics.Methods: In all, 300 patients were consecutively assessed. Screening and diagnoses were performed with validated instruments plus a best estimate diagnosis procedure. The final sample comprised 150 patients in the cosmetic group, 150 patients in the general dermatology group, and 50 control subjects. Standard statistical analyses were performed (chi(2), nonparametric tests, logistic regression).Results: The current prevalence was higher in the cosmetic group (14.0%) compared with general (6.7%) and control (2.0%) groups. No patient had a previous diagnosis. Frequently the reason for seeking dermatologic treatment was not the main ODD preoccupation. Patients with ODD from the cosmetic group were in general unsatisfied with the results of dermatologic treatments.Limitations: Cross-sectional study conducted in a university hospital is a limitation. It is uncertain if the findings can be generalized. Retrospective data regarding previous treatments are not free from bias.Conclusions: BUD is relatively common in a dermatologic setting, especially among patients seeking cosmetic treatments. These patients have some different features compared with general dermatology patients. Dermatologists should be aware of the clinical characteristics of ODD to identify and refer these patients to mental health professionals. (J Am Acad Dermatol 2010;63:235-43.)