Epinephrine before advanced airway placement may improve patient outcomes in out-of-hospital cardiac arrest: Study

Japan: Administration of intravenous (IV) epinephrine before placement of an advanced airway may be the optimal treatment sequence for improved patient outcomes in patients with out-of-hospital cardiac arrest (OHCA), a recent study has shown. The findings were published online in JAMA Network Open on February 19, 2024.

The cohort study of 259 237 Japanese adult patients with OHCA for whom emergency medical services personnel administered IV epinephrine and/or placed an advanced airway revealed that epinephrine as a first strategy was linked with a higher likelihood of 1-month survival in both shockable and nonshockable rhythms than advanced airway management as the first strategy.

Out-of-hospital cardiac arrest is an important public health problem, with high rates of mortality worldwide. Emergency medical services (EMS) play an important role in providing initial treatment for OHCA patients as a part of the chain of survival.

As a part of pre-hospital care, advanced life support interventions, advanced airway management (AAM) (endotracheal intubation and supraglottic airway insertion) and epinephrine administration are commonly performed for out-of-hospital cardiac arrest, but there seems no clarity on the optimal sequence of these interventions. Therefore, Masashi Okubo, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and colleagues aimed to evaluate the association of the sequence of epinephrine administration and AAM with patient outcomes after OHCA in a cohort study.

For this purpose, the researchers analyzed the nationwide, population-based OHCA registry in Japan and included adults with OHCA for whom emergency medical services personnel administered epinephrine and/or placed an advanced airway between 2014 and 2019.

The primary outcome was 1-month survival. Secondary outcomes included 1-month survival with favourable functional status and prehospital return of spontaneous circulation.

The researchers performed inverse probability of treatment weighting (IPTW) and propensity scores for shockable and non-shockable initial rhythm subcohorts to control imbalances in measured cardiac arrest characteristics, patient demographics, and bystander and prehospital interventions.

The researchers reported the following findings:

  • Of 259,237 eligible patients (median age, 79 years), 58.7% were male. A total of 8.3% of patients had an initial shockable rhythm, and 91.7% had an initial nonshockable rhythm.
  • Using IPTW, all covariates between the epinephrine-first and AAM-first groups were well balanced, with all standardized mean differences less than 0.100.
  • After IPTW, the epinephrine-first group had a higher likelihood of 1-month survival for both shockable (odds ratio [OR], 1.19) and non-shockable (OR, 1.28) rhythms compared with the AAM-first group.
  • For the secondary outcomes, the epinephrine-first group experienced an increased likelihood of favourable functional status and prehospital return of spontaneous circulation for both shockable and non-shockable rhythms compared with the AAM-first group.

The findings suggest that administration of epinephrine first for adult OHCA is associated with an increased likelihood of 1-month survival, 1-month survival with favourable functional status, and prehospital return of spontaneous circulation (ROSC) among Japanese patients with shockable and non-shockable rhythms compared with an AAM-first strategy.

“Our study results, along with the currently available evidence, suggest that IV epinephrine administration may be more beneficial than AAM for adult patients with OHCA, indicating that prioritizing epinephrine administration over AAM might be reasonable,” the researchers wrote.

Reference:

Okubo M, Komukai S, Izawa J, et al. Sequence of Epinephrine and Advanced Airway Placement After Out-of-Hospital Cardiac Arrest. JAMA Netw Open. 2024;7(2):e2356863. doi:10.1001/jamanetworkopen.2023.56863

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Pitavastatin promising for reducing risk of cardiovascular disease in people with HIV: REPRIEVE substudy

USA: A recent analysis of the REPRIEVE trial revealed pitavastatin to be promising in reducing noncalcified coronary plaque as well as markers of lipid oxidation and arterial inflammation among people with HIV at low to moderate cardiovascular (CV) risk. The study findings were published online in JAMA Cardiology.

The substudy of the REPRIEVE randomized clinical trial (RCT) comprising 611 people with HIV (PWH) showed that the pitavastatin arm had a significant 7% relative reduction in noncalcified plaque compared with the placebo arm. Pitavastatin use was linked with decreased oxidized low-density lipoprotein cholesterol (LDL-C) and lipoprotein-associated phospholipase A2.

Previous studies have shown that people with HIV are at a 1.5-fold to 2-fold risk of major adverse cardiovascular events (MACE), including stroke and myocardial infarction, and develop coronary artery disease (CAD) at an earlier age versus people without HIV. Premature CAD in PWH is characterized by increased noncalcified coronary plaque, which may contribute to increased CV events. As PWH are more likely to die of non–HIV-related causes, including cardiovascular disease, it is critical to develop a strategy to improve CAD and CV outcomes in people with HIV.

REPRIEVE is a phase 3 multicenter randomized clinical trial of oral pitavastatin calcium, 4 mg per day, versus matched placebo for primary prevention of atherosclerotic CVD (ASCVD) events in people with HIV at low to moderate risk for ASCVD. The trial showed that over a median of 5.1 years, an effect beyond that anticipated from LDL cholesterol reduction alone.

Against the above background, Michael T. Lu, Massachusetts General Hospital, Harvard Medical School, Boston, and colleagues designed the mechanistic substudy embedded within REPRIEVE to determine potential statin effects to reduce noncalcified plaque progression and volume as evaluated by entry and 2-year coronary computed tomography angiography (CTA). Moreover, the substudy sought to identify effects on lipid parameters and circulating biomarkers of inflammation.

The study included PWH without known CVD who were taking antiretroviral therapy and had low to moderate 10-year CVD risk.

The study led to the following findings:

  • Of 804 enrolled persons, 774 had at least one evaluable CTA.
  • Plaque changes were assessed in 611 who completed both CT scans. Of 611 analyzed participants, 84.0% were male, the mean age was 51 years, and the median (10-year CVD risk was 4.5%. 302 were included in the pitavastatin arm and 309 in the placebo arm.
  • The mean noncalcified plaque volume decreased with pitavastatin compared with placebo (mean change, −1.7 mm3 vs 2.6 mm3; baseline adjusted difference, −4.3 mm3; 7% greater reduction than placebo).
  • A larger effect size was seen among the subgroup with plaque at baseline (−8.8 mm3).
  • Progression of noncalcified plaque was 33% less likely with pitavastatin compared with placebo (relative risk, 0.67).
  • Compared with placebo, the mean low-density lipoprotein cholesterol decreased with pitavastatin (mean change: pitavastatin, −28.5 mg/dL; 95% CI, −31.9 to −25.1; placebo, −0.8; 95% CI, −3.8 to 2.2).
  • The pitavastatin arm had a reduction in both oxidized low-density lipoprotein (−29% vs −13%) and lipoprotein-associated phospholipase A2 (−7% vs 14%) compared with placebo at 24 months.

“In people with HIV at low to moderate CVD risk, 24 months of pitavastatin reduced noncalcified plaque volume and progression, and markers of lipid oxidation and arterial inflammation,” the researchers wrote. “These changes may contribute to the observed MACE reduction in REPRIEVE.”

Reference:

Lu MT, Ribaudo H, Foldyna B, et al. Effects of Pitavastatin on Coronary Artery Disease and Inflammatory Biomarkers in HIV: Mechanistic Substudy of the REPRIEVE Randomized Clinical Trial. JAMA Cardiol. Published online February 21, 2024. doi:10.1001/jamacardio.2023.5661

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Intravascular imaging significantly improves outcomes in CV stenting procedures over conventional angiography: Study

Using intravascular imaging to guide stent implantation during percutaneous coronary intervention (PCI) in heart disease patients significantly improves survival and reduces adverse cardiovascular events compared to angiography-guided PCI alone, the most commonly used method.

These are the results from the largest and most comprehensive clinical study of its kind comparing two types of intravascular imaging methods (intravascular ultrasound, or IVUS, and optical coherence tomography, or OCT) with angiography-guided PCI. The study, published Wednesday, February 21, in The Lancet, is the first to show that these two methods of high-resolution imaging can reduce all-cause death, heart attacks, stent thrombosis, and the need for revascularization.

“Our study, representing a synthesis of all early and recent clinical studies, has shown for the first time that the routine use of intravascular imaging guidance improves survival and enhances all aspects of the safety and effectiveness of coronary stenting, even with excellent contemporary drug-eluting stents,” says first author Gregg W. Stone, MD. Dr. Stone is Director of Academic Affairs for the Mount Sinai Health System, and Professor of Medicine (Cardiology), and Population Health Science and Policy, at the Icahn School of Medicine at Mount Sinai.

“Prior studies had shown benefits of intravascular imaging, but never to this extent,” Dr. Stone adds. “The addition of four recent trials in which 7,224 patients were enrolled now shows that intravascular imaging reduces all-cause death and all heart attacks across the wide range of patients who undergo stent treatment. As such, the routine use of intravascular imaging to guide stent implantation is one of the most effective therapies we have to improve the prognosis of patients with coronary artery disease.”

Patients with coronary artery disease-plaque buildup inside the arteries that leads to chest pain, shortness of breath, and heart attack-often undergo PCI, a non-surgical procedure in which interventional cardiologists use a catheter to place stents in the blocked coronary arteries to restore blood flow. Interventional cardiologists most commonly use angiography to guide PCI, which involves a special dye (contrast material) and X-rays to see how blood flows through the heart arteries to highlight any blockages.

Angiography has limitations, however, making it difficult to determine the true artery size and the makeup of the plaque, and is suboptimal in identifying whether the stent is fully expanded post-PCI and in detecting other conditions that affect the early and late outcomes of the procedure. Intravascular ultrasound was introduced more than 30 years ago to provide a more accurate and specific picture of the coronary arteries. Even though studies have shown that IVUS-guided PCI is superior to angiography-guided PCI and reduces cardiovascular events, it is only used in roughly 15 to 20 percent of PCI cases in the United States, since the images may be difficult to interpret and the procedure is not fully reimbursed.

Optical coherence tomography uses light instead of sound to create images of the blockages. OCT images are much higher in resolution, more accurate, and more detailed compared to IVUS, and easier to interpret. However, as a newer technique, OCT is used in only 3 percent of PCI cases, partly because of a lack of study data-a limitation this new study has addressed.

In their study, the researchers analyzed data from 15,964 patients undergoing PCI from 22 trials in hundreds of centers from the United States, Europe, Asia, and elsewhere between March 2010 and August 2023. Patients underwent either angiography-guided PCI or intravascular imaging-guided PCI using either IVUS or OCT. During follow-up ranging from 6-60 months with a mean of two years, patients who received intravascular imaging guidance experienced a 25 percent reduction in all-cause death, 45 percent reduction in cardiac death, 17 percent reduction in all myocardial infarctions, and 48 percent reduction in stent thrombosis compared with angiography guidance. The study also found that intravascular imaging reduced target vessel myocardial infarction by 18 percent and target lesion revascularization by 28 percent. The outcomes were similar for OCT-guided and IVUS-guided PCI.

“With these results, we now need to shift from performing more studies to determine whether intravascular imaging is beneficial, to increasing efforts to overcome the remaining impediments to the routine use of OCT and IVUS, including better training of physicians and staff and increasing reimbursement,” Dr. Stone said. “In this regard, we now have better ‘hard evidence’ that intravascular imaging guidance of PCI procedures makes a greater impact to improving our patients’ lives than other routine therapies which are more widely used and reimbursed.”

Reference:

Prof Gregg W Stone, Evald H Christiansen, Lene N Andreasen, Prof Akiko Maehara, Yousif Ahmad, Intravascular imaging-guided coronary drug-eluting stent implantation: an updated network meta-analysis, The Lancet, https://doi.org/10.1016/S0140-6736(23)02454-6.

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Good news-MS drugs taken while breastfeeding may not affect child development

Certain medications for multiple sclerosis (MS) called monoclonal antibodies, taken while breastfeeding, may not affect the development of a child during the first three years of life, according to a preliminary study released today, March 4, 2024. The study will be presented at the American Academy of Neurology’s 76th Annual Meeting taking place April 13–18, 2024, in person in Denver and online. The study examined four monoclonal antibodies for MS: natalizumab, ocrelizumab, rituximab and ofatumumab.

MS is a disease in which the body’s immune system attacks myelin, the fatty white substance that insulates and protects the nerves. Symptoms may include fatigue, numbness, tingling or difficulty walking.

“Most monoclonal antibody medications for multiple sclerosis are not currently approved for use while a mother is breastfeeding,” said study author Kerstin Hellwig, MD, of Ruhr University in Bochum, Germany. “Yet MS can develop during the childbearing years of life. Since the risk of MS relapses increases after giving birth, some mothers may need or want to restart these therapies, so it is important to determine whether these medications, through breast milk, have a negative impact on a child’s development.”

For the study, researchers used the German MS and Pregnancy Registry to identify 183 infants born to mothers taking monoclonal antibodies while breastfeeding. Of this group, 180 had mothers with MS and the three had mothers with neuromyelitis optica spectrum disease (NMOSD). NMOSD is also a demyelinating disease, but it is rare and specifically affects the optic nerve, spinal cord or brain.

The infants were compared to another 183 infants, matched for exposure to MS medications shortly before or during pregnancy, born to mothers with the same diseases who did not take monoclonal antibodies while breastfeeding.

Of those exposed to MS medications, 125 were exposed to natalizumab, 34 to ocrelizumab, 11 to rituximab and 10 to ofatumumab. Two infants were first exposed to natalizumab and then ocrelizumab. One infant was exposed to rituximab and then ocrelizumab.

The first exposures to the medications through breastfeeding ranged from the day a child was born to the ninth month of life. Infants were breastfed for an average of five-and-a-half months while their mothers took these medications.

For all infants, researchers then examined the number of hospital stays, antibiotic use, developmental delays such as problems with social and fine motor skills and delayed speech development, and the infants’ weight at follow-up visits during the first three years of life.

After comparing infants exposed to the medications to infants not exposed, researchers found no differences in their health or development.

“Our data show infants exposed to these medications through breastfeeding experienced no negative effects on health or development within the first three years of life,” Hellwig said.

A limitation of the study was that only about a third of the infants were followed for the full three years. Therefore, Hellwig said, the results for the third year of life are less meaningful than for years one and two.

Reference:

Good news-MS drugs taken while breastfeeding may not affect child development, American Academy of Neurology, Meeting: 2024 American Academy of Neurology’s 76th Annual Meeting.

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Rusfertide effective for controlling RBCs overproduction in polycythemia vera: NEJM

USA: A recent multi-centre clinical trial published in the New England Journal of Medicine has shed light on the efficacy and safety of rusfertide, a hepcidin mimetic, in patients with phlebotomy-dependent polycythemia vera.

Marina Kremyanskaya, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, and colleagues revealed that in patients with polycythemia vera, rusfertide treatment was linked with a mean hematocrit of less than 45% during the 28-week dose-finding period, and during the 12-week randomized withdrawal period, percentage of patients with a response was greater with rusfertide than with placebo.

“A novel treatment for polycythemia vera, a potentially fatal blood cancer, demonstrated the ability to control the overproduction of red blood cells, the hallmark of this malignancy and many of its debilitating symptoms,” the researchers reported.

Polycythemia vera is a chronic myeloproliferative neoplasm characterized by erythrocytosis. Rusfertide is an injectable peptide mimetic of the master iron regulatory hormone hepcidin, which restricts the availability of iron for erythropoiesis. There is no information on the efficacy and safety of rusfertide in patients with phlebotomy-dependent polycythemia vera.

The researchers enrolled patients in a 28-week dose-finding assessment of rusfertide in part 1 of the international, phase 2 REVIVE trial. Part 2 was a double-blind, randomized withdrawal period in which patients were assigned 1:1 to receive rusfertide or placebo for 12 weeks.

The primary efficacy endpoint was a response, defined by hematocrit control, phlebotomy absence, and completion of the trial regimen during part 2. Patient-reported outcomes were evaluated using the modified Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) patient diary (scores vary from 0 to 10, with higher scores indicating greater severity of symptoms).

The study led to the following findings:

  • In part 1 of the trial, seventy patients were enrolled, and 59 were assigned to receive rusfertide (30 patients) or placebo (29 patients) in part 2. The estimated mean number of phlebotomies per year was 8.7±2.9 during the 28 weeks before the first dose of rusfertide and 0.6±1.0 during part 1 (estimated difference, 8.1 phlebotomies per year).
  • The mean maximum hematocrit was 44.5±2.2% during part 1 as compared with 50.0±5.8% during the 28 weeks before the first dose of rusfertide.
  • During part 2, a response was observed in 60% of the patients who received rusfertide as compared with 17% of those who received a placebo.
  • Between baseline and the end of part 1, rusfertide treatment was associated with a decrease in individual symptom scores on the MPN-SAF in patients with moderate or severe symptoms at baseline.
  • During parts 1 and 2, grade 3 adverse events occurred in 13% of the patients, and none of the patients had a grade 4 or 5 event.
  • Injection-site reactions of grade 1 or 2 in severity were common.

“Rusfertide is a potentially effective treatment option for achieving and sustaining hematocrit control in polycythemia vera, reducing the use of phlebotomy and the occurrence of debilitating disease-related symptoms,” the researchers wrote.

“For patients with polycythemia vera, the hepcidin mimetic rusfertide, which restricts the availability of iron, might be effective for controlling erythrocytosis,” they concluded.

Reference:

Kremyanskaya, M., et al. (2024) Rusfertide, a Hepcidin Mimetic, for Control of Erythrocytosis in Polycythemia Vera. New England Journal of Medicine. doi.org/10.1056/NEJMoa2308809.

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AI Tool Enhances Accuracy in Diagnosing Acute Otitis Media in children, reveals JAMA study

Acute otitis media (AOM) is a common childhood illness, but accurately diagnosing it can be challenging. Traditional methods have shown low accuracy, prompting the development of artificial intelligence (AI) tools to improve diagnostic precision. In a recent study, researchers aimed to develop and validate an AI decision-support tool to interpret otoscopic videos of the tympanic membrane, potentially enhancing the accuracy of AOM diagnosis. They found  that AI Tool  may enhance accuracy in Diagnosing Acute Otitis Media in children.

This study was published in JAMA Pediatrics by Nader Sheikh and colleagues. Despite being frequently diagnosed in children, the accuracy of AOM diagnosis remains suboptimal. This leads to potential overdiagnosis or underdiagnosis, impacting patient care and healthcare resources. AI-based approaches offer promising solutions to improve diagnostic accuracy and streamline clinical decision-making in AOM.

The study analyzed otoscopic videos of the tympanic membrane captured using smartphones during outpatient clinic visits in Pennsylvania from 2018 to 2023. Children presenting for sick visits or wellness visits were included in the study. Two AI models were developed: a deep residual-recurrent neural network and a decision tree network. The models were trained to predict AOM vs. no AOM based on features of the tympanic membrane observed in the videos. The accuracy of the AI models was compared, and a noise quality filter was trained to assess the adequacy of video segments for diagnostic purposes.

Key Findings:

  • The deep residual-recurrent neural network and the decision tree network exhibited almost identical diagnostic accuracy.

  • The neural network algorithm classified tympanic membrane videos into AOM vs. no AOM categories with a sensitivity of 93.8% and specificity of 93.5%, while the decision tree model had a sensitivity of 93.7% and specificity of 93.3%.

  • Bulging of the tympanic membrane was the feature most closely aligned with the predicted diagnosis of AOM, present in all cases where AOM was predicted in the test set.

The study demonstrates the high accuracy of the AI algorithm in diagnosing AOM based on tympanic membrane features observed in otoscopic videos. This suggests that the AI tool, along with a medical-grade application for image acquisition and quality filtering, could be utilized in primary care or acute care settings to aid in automated diagnosis of AOM and treatment decisions. This advancement has the potential to improve clinical outcomes and optimize healthcare resource utilization in managing AOM in children.

Reference:

Shaikh, N., Conway, S. J., Kovačević, J., Condessa, F., Shope, T. R., Haralam, M. A., Campese, C., Lee, M. C., Larsson, T., Cavdar, Z., & Hoberman, A. Development and validation of an automated classifier to diagnose acute otitis media in children. JAMA Pediatrics,2024. https://doi.org/10.1001/jamapediatrics.2024.0011

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Perioperative adjunctive esketamine during cesarean delivery mitigates depressive symptoms: JAMA

Postpartum depression (PPD) is a prevalent mental health condition affecting numerous women during the perinatal and postpartum periods which poses significant risks to both maternal and infant well-being. A recent study published in the Journal of American Medical Association revealed that esketamine administration significantly decreased the postpartum depression incidence and improved depressive symptoms during the initial postpartum period.

The study was conducted at Fujian Provincial Hospital from January 2022 to January 2023 and involved a total of 298 women. The participants of this study were aged 18 to 40 years who were undergoing elective cesarean deliveries. This single-center, double-blind, placebo-controlled, randomized clinical trial investigated the effectiveness of esketamine with emerging antidepressant properties in controlling PPD symptoms.

The participants were randomly assigned to receive either esketamine or a placebo following cesarean delivery. The esketamine group received a single intravenous injection of 0.25 mg/kg of esketamine immediately after delivery, this was followed by additional doses as an adjuvant in patient-controlled intravenous analgesia for 48 hours post-surgery, while the control group received saline.

The primary outcomes were assessed using the Edinburgh Postnatal Depression Scale (EPDS) at postpartum day 7 with positive screening for PPD defined as a score of 10 or more points on the EPDS. The results indicated a significant reduction in depression symptoms among patients who were administered esketamine when compared to the control group at postpartum day 7.

While the esketamine group expressed lower depression symptom scores and reduced pain levels, these benefits did not extend uniformly across all the postpartum assessments. There were no significant differences in PPD screening results or changes in EPDS scores between the groups at later follow-up points. The outcomes of this study emphasized the potential of esketamine as a perioperative intervention for preventing early postpartum depression.

Reference:

Chen, Y., Guo, Y., Wu, H., Tang, Y.-J., Sooranna, S. R., Zhang, L., Chen, T., Xie, X.-Y., Qiu, L.-C., & Wu, X.-D. (2024). Perioperative Adjunctive Esketamine for Postpartum Depression Among Women Undergoing Elective Cesarean Delivery. In JAMA Network Open (Vol. 7, Issue 3, p. e240953). American Medical Association (AMA). https://doi.org/10.1001/jamanetworkopen.2024.0953

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Case of total knee arthroplasty for knee osteoarthritis associated with abnormal patellar tendon deformity: a report

Case of total knee arthroplasty for knee osteoarthritis associated with abnormal patellar tendon deformity suggests a report published in the Journal of Surgical Case Reports.

There have been no earlier reports of knee osteoarthritis with valgus knee deformity in which the patellar tendon infiltrates the tibial bone marrow instead of attaching to the tibial tubercle. A 73-year-old Asian woman had been undergoing conservative treatment, but the pain gradually worsened, and she was referred to our hospital for TKA. The patient had no specific history of trauma to the knee but had undergone a surgery for gastric cancer 3 years before.

This case report describes a total knee arthroplasty (TKA) performed for the treatment of a primary knee osteoarthritis resulting from a valgus knee joint position attributed to an abnormality of the patellar ligament attachment. During a TKA, the tendon tissue in the tibial medullary canal interfered with the reamer used to prepare for the stem extensions needed to improve the fixation of the component on the tibia, which had a cortical defect. The arthroplasty succeeded, and good clinical results have been maintained over the 3 years since the surgery. Surgeons should consider careful preoperative examinations by magnetic resonance imaging or CT when an abnormal bone defect is observed at the tibial tubercle on plain X-ray images.

Reference:

Satoshi Miyamoto, Shin Sasaki, Hiroyuki Kojin, Ken Okazaki, Total knee arthroplasty for knee osteoarthritis associated with abnormal patellar tendon deformity: a case report, Journal of Surgical Case Reports, Volume 2024, Issue 3, March 2024, rjae102, https://doi.org/10.1093/jscr/rjae102

Keywords:

total knee arthroplasty, knee osteoarthritis, abnormal, patellar tendon deformity, Journal of Surgical Case Reports, Satoshi Miyamoto, Shin Sasaki, Hiroyuki Kojin, Ken Okazaki, Total knee arthroplasty, patellar tendon deformity, valgus knee deformity, total knee arthroplasty, magnetic resonance imaging, diagnostic, radiologic, examination, knee region,knee

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Post‐load glucose more reliable test than HbA1c for predicting adverse pregnancy outcomes: Study

Iran: A recent study published in the Journal of Diabetes Investigation has shown post-load glucose to be the most reliable test for predicting adverse pregnancy outcomes. Fasting blood sugar was of more predictive value than first-trimester HbA1c.

The study suggests that post-load plasma glucose (PLPG) provides greater reliability than HbA1c in assessing APO risk.

Adverse outcomes of gestational diabetes mellitus (GDM) can impact both maternal and fetal health. Hyperglycemia is suggested to be the underlying cause of several GDM complications. However, a screening of pregnant women for maternal hyperglycemia showed a spectrum of glucose intolerance.

Studies have investigated the association of hemoglobin A1c (HbA1c), fasting plasma glucose, insulin resistance, and oral glucose tolerance with adverse obstetric outcomes. Debate exists on the relationship of adverse pregnancy outcomes with glycemic levels in early pregnancy. In particular, the association of maternal blood glucose concentrations with adverse pregnancy outcomes (APO) risk in women with GDM remains controversial.

Against the above background, Elham Toghraee, Shiraz University of Medical Sciences, Shiraz, Iran, and colleagues aimed to investigate the association of maternal characteristics, including post-load glucose and first-trimester HbA1c test results with adverse pregnancy outcomes in women without GDM.

For this purpose, the researchers explored a dataset (January 2011 and September 2017) from a hospital prenatal clinic to find the important predictors of adverse pregnancy outcomes using maternal characteristics and glucose assessments in mothers without gestational diabetes.

The investigators used two machine learning algorithms to capture nonlinearity in selecting important maternal characteristics and developed predictive models for each outcome. 1,618 pregnant women were included in the analytic dataset with a mean age of 26.8 years and gravida of 1.7.

The study revealed the following findings:

  • Important associations were detected between maternal features and primary cesarean section, fetal distress, premature rupture of membranes, macrosomia, small or large for gestational age, APGAR <7 at 1 or 5 min, hyperbilirubinemia, and poly- or oligo-hydramnios.
  • The predictive models showed good performance and large areas under the curves (0.732, 0.765, 0.646, 0.651, 0.730, 0.646, 0.684, 0.716, and 0.678, respectively). Specifically, they had high positive likelihood ratios.

In conclusion, the findings showed differences in the predictive power of post-load glucose and first-trimester HbA1c test results for adverse pregnancy outcomes. Overall, PLPG1 or PLPG2 showed greater importance scores than hemoglobin A1c for all outcomes. Furthermore, fasting blood sugar outranked HbA1c in most of the importance ratings.

“We also recommend that future studies of pregnancy outcomes use data analysis techniques capable of capturing nonlinearity and complex interactions,” the researchers wrote.

Reference:

Rajabi, S. K., Toghraee, E., & Nejatipour, G. Post-load glucose is a stronger predictor of adverse pregnancy outcomes than first-trimester HbA1c in women without gestational diabetes. Journal of Diabetes Investigation. https://doi.org/10.1111/jdi.14181

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Morning Bright Light Therapy Not Superior to placebo red light for treatment of Depression among adolescents: JAMA

Major depressive disorder (MDD) is prevalent among adolescents and often leads to significant psychosocial impairment. With conventional treatment yielding insufficient responses, adjunctive therapies are sought. A recent study investigated the effectiveness of morning bright light therapy as an adjunct to inpatient treatment for adolescents with major depressive disorder (MDD). Despite expectations, the study found no superiority of bright light therapy over placebo red light therapy in reducing depressive symptoms.

This study aimed to investigate the efficacy of morning bright light therapy as an adjunct to inpatient treatment for adolescent MDD. The study was published in the journal JAMA Psychiatry by Tanja L. and colleagues. In a double-blind, placebo-controlled randomized trial conducted across four university hospitals in Germany, 227 adolescent inpatients aged 12 to 18 with major depressive disorder were randomized to receive either morning bright light therapy or placebo red light therapy in addition to standard inpatient treatment over four weeks.

The key findings of the study were:

  • 224 patients were included in the intention-to-treat analysis, with a mean baseline Beck Depression Inventory-II (BDI-II) score of 37.3.

  • After four weeks, BDI-II scores were significantly reduced by a mean of -7.5 (95% CI, -9.0 to -6.0; Hedges g = 0.71), with no significant difference between the bright light therapy and placebo groups.

  • Loss to follow-up was 31% at 16 weeks and 49% at 28 weeks, with 10 serious adverse events reported but not related to study treatment.

Contrary to expectations, morning bright light therapy did not show superiority over placebo red light therapy as an adjunct to standard inpatient treatment for adolescent major depressive disorder. Both groups experienced significant symptom reduction, highlighting the effectiveness of standard treatment modalities.

Reference:

Legenbauer, T., Kirschbaum-Lesch, I., Jörke, C., Kölch, M., Reis, O., Berger, C., Dück, A., Schulte-Markwort, M., Becker-Hebly, I., Bienioschek, S., Schroth, J., Ruckes, C., Deuster, O., & Holtmann, M. Bright light therapy as add-on to inpatient treatment in youth with moderate to severe depression: A randomized clinical trial. JAMA Psychiatry (Chicago, Ill.),2024. https://doi.org/10.1001/jamapsychiatry.2024.0103

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