Patient satisfaction with therapeutic interventions is an important outcome of care. Although generic measures of patient satisfaction exist, there is no validated scale for measuring patient satisfaction with epilepsy surgery. We aimed to systematically obtain patient-identified factors related to satisfaction with epilepsy surgery as a means of informing clinicians about the ways that patients evaluate outcomes of their treatment and as a conceptual basis for the future development of epilepsy surgery patient satisfaction scales. Focus group discussions with epilepsy surgery patients (n=9) were conducted to identify themes relevant to patient satisfaction with epilepsy surgery and to draft initial items of importance. Consensus methodology (Delphi technique) was used to obtain expert opinion (n=13) to refine the items. Member-checking with focus group participants was performed to ensure the identified items were relevant, clear, and inclusive. A list of 31 items embodied 12 themes related to patient-reported satisfaction with epilepsy surgery. These included adverse effects, medical care or rehabilitation, seizure control, post-operative recovery, anti-seizure medication, independence, seizure worry, ability to drive, social relationships, self-confidence, improved cognitive function, and improved physical health. This study used a systematic approach to identify factors that are important to patients when assessing satisfaction with epilepsy surgery. This knowledge can assist clinicians caring for these patients and is also a critical step towards the validation of a formal scale to assess satisfaction with epilepsy surgery.
The incidence and prevalence of psychiatric disorders are elevated in the IBD population.
Read moreThe haemodynamic profile of COVID-19 patients needing mechanical ventilation is characterized by combined cardiopulmonary alterations. Low pulmonary vascular resistance, coherent with a blunted hypoxic vasoconstriction, is associated with high cardiac output and post-capillary pulmonary hypertension, that could eventually contribute to lung stiffness and promote a vicious circle between the lung and the heart.
: The Lancet Commission on Hypertension identified that a key action to address the worldwide burden of high blood pressure (BP) was to improve the quality of BP measurements by using BP devices that have been validated for accuracy. Currently, there are over 3000 commercially available BP devices, but many do not have published data on accuracy testing according to established scientific standards. This problem is enabled through weak or absent regulations that allow clearance of devices for commercial use without formal validation. In addition, new BP technologies have emerged (e.g. cuffless sensors) for which there is no scientific consensus regarding BP measurement accuracy standards. Altogether, these issues contribute to the widespread availability of clinic and home BP devices with limited or uncertain accuracy, leading to inappropriate hypertension diagnosis, management and drug treatment on a global scale. The most significant problems relating to the accuracy of BP devices can be resolved by the regulatory requirement for mandatory independent validation of BP devices according to the universally-accepted International Organisation for Standardization Standard. This is a primary recommendation for which there is an urgent international need. Other key recommendations are development of validation standards specifically for new BP technologies and online lists of accurate devices that are accessible to consumers and health professionals. Recommendations are aligned with WHO policies on medical devices and universal healthcare. Adherence to recommendations would increase the global availability of accurate BP devices and result in better diagnosis and treatment of hypertension, thus decreasing the worldwide burden from high BP.
Both the general population and patients with PsA have experienced increasing rates of first arthroplasty from 1995 to 2010, although the overall incidence rate was significantly higher for those with PsA.
Read moreObjective: The combination of neprilisin and angiotensin receptor inhibition (Sacubitril/Valsartan, i.e. ARNI) is recommended in heart failure guidelines for patients in NYHA class II-III with reduced left ventricular ejection fraction (LVEF). Sacubitril/Valsartan increases survival and quality of life. Moreover, due to its cardiac and hemodynamic effects, it could also affect exercise tolerance. Design and method: We studied the effects of ARNI on cardiopulmonary exercise test (CPET) in 35 patients [67 ± 11 years; Left ventricular ejection fraction (LVEF) 31 ± 6%; NT-proBNP 1822 ± 1651 pg/ml; ICD/CRT 26/35], being treated with increasing doses of Sacubitril/Valsartan up to the maximum tolerated dose (318 ± 36 mg/die) without side effects. In addition to CPET, plasma levels of pro-BNP, renal function, plasma electrolytes, echocardiocolorDoppler were performed at baseline and at 6 months follow-up. Results: No variations of renal function and/or kaliemia were observed, while NT-proBNP levels decreased significantly. Most CPET variables were improved by ARNI: an increase in peak VO2 (from 15.8 ± 3.4 to 17.0 ± 4.0 ml/Kg/min, p < 0.05) and in O2 pulse (from 11.5 ± 2.5 to 12.6 ± 2.4 ml/beat, p < 0.05), together with a decrease in VEVCO2 slope (from 35.2 ± 11.2 to 33.1 ± 12.3, p < 0.05) were observed. In addition, a significant relationship (p < 0.05) was present between the amount of increase in LVEF and that of O2 pulse in all patients (see Figure).Conclusions: Already in the short term, ARNI favourably affect global cardiopulmonary response to exercise in heart failure patients.
Read moreComplexity decomposition by DFA describes autonomic alterations in HRV in low-level paraplegia better than traditional indices, probably pointing out a loss of system complexity in the sitting posture and an impaired sympatho/vagal modulation in the supine position.
Read moreSignal detection concepts help to avoid the "clinician's illusion" in which aspects of functioning of the body's defenses are mistaken for a disease entity or defect. These principles emphasize inevitable difficulties that are encountered in attempts to conceptualize depressive disorders without reference to the environment in which they occur, and without addressing possible stochastic (randomly varying) elements. Because of the "clinicians illusion", current research priorities, as well as diagnosis and treatment strategies, may be flawed.
Read moreTreatment of obstructive sleep apnoea (OSA) has been shown to reduce blood pressure (BP). However, the effect size is modest and treatment of OSA is not recommended as the only treatment target when treating hypertension. The aim of this systematic review and meta-analysis was to identify potential predictors for BP response in patients with OSA undergoing CPAP treatment. A systematic search was conducted in three databases (MEDLINE, Embase and Web of Science) between January 1st 1960 to December 31st 2017 using terms exploring three domains (obstructive sleep apnoea, CPAP, clinical trial) Out of 2445 articles, 59 RCTs were included (n=7,329 subjects) comparing CPAP with control groups. CPAP was associated with a net reduction in systolic BP of -2.12 (95% CI -2.82 to -1.42) mmHg and in diastolic BP of -1.97 (95% CI -2.46 to -1.48) mmHg, favouring treatment of OSA using CPAP (both p-values <0.001). The subgroup analysis showed that systolic BP reduction was greater in subjects younger than 60 years (-2.88 fro age 40-50, -2.78 for age 50-60 and -0.61 for age more than 60 years, p=0.007) and in patients with controlled BP at baseline versus uncontrolled BP(-1.45 vs -4.14, p=0.002) (Figure 1). Younger patients (< 60 years) with uncontrolled blood pressure at baseline are more likely to experience significant BP reductions with CPAP therapy. Phenotypisation of specific cohorts of patients can guide clinicians to target OSA treatment and help to optimise patients’ cardiovascular risk.
Read moreObjective: Diagnosis of heart failure with preserved ejection fraction (HFpEF) is complex, especially in its earlier, pre-clinical stage. Stress tests have been suggested as possible tools to improve the diagnosis of HFpEF, albeit with contrasting and debated evidences. We sought to evaluate the diagnostic performance of stress tests in consecutive ambulatory patients evaluated for exertional breathlessness. Design and method: Retrospective analysis of data in patients with unexplained dyspnea who underwent 1) echocardiography at rest and 2) exercise echo combined with cardiopulmonary exercise test (CPET). Diastolic function at rest and at exercise was scored according to 2016 ASE/EACVI criteria. Exercise oscillatory ventilation (EOV+) was chosen as a CPET marker of high filling pressure during effort. Diagnosis of HFpEF was established by a right heart catheterization (RHC) demonstrating a pulmonary artery wedge pressure (PAWP) > 15 mmHg at rest and/or a PAWP>=25 mmHg at peak exercise. Results: 72 patients in sinus rhythm with normal left ventricular ejection fraction (68+/-10 years old, 68% females, BMI 27+/-5 Kg/m2) were evaluated. At rest, 82% of patients had either normal diastolic function or grade I diastolic dysfunction or indeterminate diastolic function, while 18% had estimation of high filling pressure (figure 1). Exercise stress echo was positive in 5 cases (7%), while diastolic function during effort resulted “indeterminate” in 93% of patients. EOV+ was found in 15 cases (21%), i.e. in 4/5 patients with positive exercise echocardiography and in 11/67 with indeterminate diastolic function at exercise. Twenty patients (26%) underwent RHC as clinically indicated, including 19 RHC during exercise (figure 1). RHC revealed HFpEF in 17 cases (85%). Both exercise echo and EOV+ at CPET had a 100% specificity and positive predictive value to noninvasively detect HFpEF. However, sensitivity of exercise echo was only 13%, compared with 53% of EOV+ at CPET (p < 0.05).Conclusions: Our preliminary results: confirm the limitations of echocardiography for the diagnosis of HFpEF; suggest that EOV+ at CPET may have higher sensitivity than exercise echocardiography for the noninvasive detection of HFpEF, maintaining an excellent specificity.
Read moreObjective: An echocardiographic diastolic stress test (DST) may be useful in subjects with unexplained exertional breathlessness. The E/e′ ratio and tricuspid regurgitant jet velocity (TRV) are used to differentiate normal vs abnormal responses. However, absence of flow-corrected estimates of pulmonary pressure may reduce the diagnostic performance of the test. We sought to compare flow-corrected and flow-uncorrected estimates of pulmonary pressure during exercise in consecutive patients undergoing a DST, using as gold-standard reference exercise right heart catheterization (RHC). Design and method: Retrospective analysis of patients undergoing a DST. Echo estimates of mean pulmonary artery pressure (PAP) and cardiac output (Q) were used to generate PAP/Q relationship during exercise. The slope of the latter and the ratio between mean PAP and Q at peak exercise (TPR) were used as flow-corrected estimates of abnormal response of the pulmonary circulation. In a subset of patients, P/Q slope and TPR obtained at RHC were compared with echocardiographic results. Results: Out of 38 patients with tricuspid regurgitation during exercise, all had TRV > 2.8 m/s so that none could be classified to have normal diastolic function at exercise; 92% had “indeterminate” diastolic function. When a flow-corrected estimate of PAP was used, the DST could be defined “normal” in 6 cases (17%, with both TPR < 3 and P/Q slope <3). P/Q slope and TPR were both >3 in 18 subjects, nine of whom underwent also exercise RHC, allowing confirmation of HFpEF in 78% of them. When comparing the results of the 15 patients undergoing both DST and exercise RHC, we found a correlation between invasive measurements and non-invasive estimate of P/Q slope (R = 0.70) and TPR (R = 0.66). Echocardiographic estimates of P/Q slope and TPR were accurate as compared with RHC measurements, but showed large confidence intervals (figure 1).Conclusions: Our preliminary data suggest that flow-corrected estimates of pulmonary pressure might provide additional pathophysiological information during a noninvasive DST, but suffer of large limits of agreement as compared with RHC.
Read morePhysical comorbidities are associated with an apparent increase in MS disability progression. Appropriate management of comorbidities needs to be determined to optimize outcomes.
Read moreOverall, the symptom scales for depression and anxiety were similar in their psychometric properties. The anxiety scales did not perform as well as the depression scales. Alternate cut-points may be more relevant when these scales are used in an IBD sample.
Read moreHigh blood pressure (BP) is a highly prevalent modifiable cause of cardiovascular disease, stroke, and death. Accurate BP measurement is critical, given that a 5-mmHg measurement error may lead to incorrect hypertension status classification in 84 million individuals worldwide. This position statement summarizes procedures for optimizing observer performance in clinic BP measurement, with special attention given to low-tomiddle- income settings, where resource limitations, heavy workloads, time constraints, and lack of electrical power make measurement more challenging. Many measurement errors can be minimized by appropriate patient preparation and standardized techniques. Validated semi-automated/automated upper arm cuff devices should be used instead of auscultation to simplify measurement and prevent observer error. Task sharing, creating a dedicated measurement workstation, and using semi-automated or solar-charged devices may help. Ensuring observer training, and periodic re-training, is critical. Low-cost, easily accessible certification programs should be considered to facilitate best BP measurement practice.
Read moreThis single-center study suggested that CAS is a safe and effective treatment for patients with symptomatic carotid artery stenosis, who recently underwent PTCA for ACS, requiring uninterrupted dual antiplatelet therapy.
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