A Markov model of Diabetic Retinopathy Progression for the Economic Evaluation of a novel DR prognostic device, CHERE Working Paper 2007/14

The initial diagnosis of Diabetic Retinopathy (DR) is often in the advance stages of the condition, as patients are only promoted for an examination when sight has been affected. An innovative prognostic technique has recently been made available which can non-invasively detect the damaging effects of high blood glucose before the development of clinical symptoms. This innovation offers the opportunity to patients to make the necessary behavioural and medicinal modification to prevent further progress of the disease. This paper reports the development of a Markov model which emulates the natural progression of Diabetic Retinopathy based on data from clinical trials. The purpose of such a model is to estimate the chronic cost and health outcomes of DR, and it may be modified to reflect the potential changes in current practice or condition changes, hence allowing for an economic evaluation of the DR prognostic test. The implications and limitations of the model were also discussed in the paper.Diabetic retinopathy, economic evaluation

Incident and recurrent major depressive disorder and coronary artery disease severity in acute coronary syndrome patients

There is recent evidence that acute coronary syndrome (ACS) patients with first time incident major depressive disorder (MDD) and those with recurrent MDD represent different subtypes among individuals with ACS and comorbid depression. However, few studies have examined whether or not these subtypes differ in coronary artery disease (CAD) severity. We assessed whether those with incident MDD (in-hospital MDD and negative for history of MDD) or recurrent MDD (in-hospital MDD and a positive history of MDD) differ in angiographically documented CAD severity. Within 1 week of admission for ACS, 88 patients completed a clinical interview to assess current and past diagnosis of MDD. CAD severity was assessed in all patients by coronary angiography. A hierarchical regression analysis showed that neither in-hospital MDD status, nor history of MDD were significant predictors of CAD severity, but the interaction term between in-hospital MDD status and history of MDD was a significant predictor of CAD severity, after controlling for age, sex and ethnicity. Follow-up analyses showed that patients with first time, incident MDD had significantly more severe CAD compared to patients with recurrent MDD (p = 0.043). To conclude, our study adds to the growing evidence that patients with incident MDD should be considered as a clinically distinct subtype from those with recurrent MDD. Possible mechanisms for differing CAD severity by angiogram between these two subtypes are proposed and implications for prognosis and treatment are discussed

Ten Year Real World Experience with Ultrafiltration for the Management of Acute Decompensated Heart Failure

Background: Randomized controlled trials (RCT) of ultrafiltration (UF) have demonstrated conflicting results regarding its efficacy and safety. Objective: We reviewed 10 years of data for adjustable UF during heart failure hospitalizations in a real world cohort. Methods: We performed a retrospective, single center analysis of 335 consecutive patients treated with adjustable rate UF using the CHF Solutions Aquadex Flex Flo System from 2009 to 2019. Results: Compared to previous RCTs investigating UF, our cohort was older, with worse renal impairment and more antecedent HF hospitalizations in the year preceding therapy. Mean fluid removal with UF was 14.6 l. Mean weight loss with UF was 15.6 lbs (range 0.2–57 lbs) and was sustained at 1–2 week follow-up. Mean creatinine change upon stopping UF, at discharge and follow-up (mean 30 days) was +0.11 mg/dl, +0.07 mg/dl and +0.11 mg/dl, respectively. HF rehospitalizations at 30 days, 90 days and 1 year were 12.4 %, 14.9 % and 27.3 % respectively. On average patients had 1.74 fewer hospitalizations for HF in the year following UF when compared to 12 months preceding UF. Major bleeding defined as requiring discontinuation of anticoagulation occurred in 3.6 % of patients. Conclusions: Compared with previous UF trials, our study demonstrates that UF compares favorably for HF rehospitalizations, renal function response, and weight/volume loss. Importantly, our real world experience allowed for the adjustment of UF rate during therapy and we believe this is a major contributor to our favorable outcomes. In clinical practice, UF can be a safe and effective strategy for decongestion

Preventing misdiagnosis of ambulatory hypertension: algorithm using office and home blood pressures

Objectives—An algorithm for making a differential diagnosis between sustained and white coat hypertension (SH and WCH) has been proposed–patients with office hypertension undergo home blood pressure monitoring (HBPM) and those with normal HBP levels undergo ambulatory blood pressure monitoring (ABPM). We tested whether incorporating an upper office blood pressure (OBP) cutoff in the algorithm, higher than the traditional 140/90 mmHg, reduces the need for HBPM and ABPM. Methods—229 normotensive and untreated mildly hypertensive participants (mean age 52.5 ± 14.6, 54% female) underwent OBP measurements, HBPM, and 24-hour ABPM. Using the algorithm, sensitivity (SN), specificity (SP), and positive and negative predictive values (PPV, NPV) for SH and WCH were assessed. We then modified the algorithm utilizing a systolic and diastolic OBP cutoff at a SP of 95% for ambulatory hypertension –those with office hypertension but OBP levels below the upper cutoff undergo HBPM and subsequent ABPM if appropriate. Results—Using the original algorithm, SN and PPV for SH were 100% and 93.8%. Despite a SP of 44.4%, NPV was 100%. These values correspond to SP, NPV, SN, and PPV for WCH respectively. Using the modified algorithm, the diagnostic accuracy for SH and WCH did not change. However, far fewer participants needed HBPM (29 vs. 84) and ABPM (8 vs. 15). Conclusions—In this sample, the original and modified algorithms are excellent at diagnosing SH and WCH. However, the latter requires far fewer subjects to undergo HBPM and ABPM. These findings have important implications for the cost-effective diagnosis of SH and WCH

Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? No

Background: The purported relationship between cervical manipulative therapy (CMT) and stroke related to vertebral artery dissection (VAD) has been debated for several decades. A large number of publications, from case reports to case–control studies, have investigated this relationship. A recent article suggested that case misclassification in the case–control studies on this topic resulted in biased odds ratios in those studies. Discussion: Given its rarity, the best epidemiologic research design for investigating the relationship between CMT and VAD is the case–control study. The addition of a case-crossover aspect further strengthens the scientific rigor of such studies by reducing bias. The most recent studies investigating the relationship between CMT and VAD indicate that the relationship is not causal. In fact, a comparable relationship between vertebral artery-related stroke and visits to a primary care physician has been observed. The statistical association between visits to chiropractors and VAD can best be explained as resulting from a patient with early manifestation of VAD (neck pain with or without headache) seeking the services of a chiropractor for relief of this pain. Sometime after the visit the patient experiences VAD-related stroke that would have occurred regardless of the care received. This explanation has been challenged by a recent article putting forth the argument that case misclassification is likely to have biased the odds ratios of the case–control studies that have investigated the association between CMT and vertebral artery related stroke. The challenge particularly focused on one of the case–control studies, which had concluded that the association between CMT and vertebral artery related stroke was not causal. It was suggested by the authors of the recent article that misclassification led to an underestimation of risk. We argue that the information presented in that article does not support the authors’ claim for a variety of reasons, including the fact that the assumptions upon which their analysis is based lack substantiation and the fact that any possible misclassification would not have changed the conclusion of the study in question. Conclusion: Current evidence does not support the notion that misclassification threatens the validity of recent case–control studies investigating the relationship between CMT and VAD. Hence, the recent re-analysis cannot refute the conclusion from previous studies that CMT is not a cause of VAD.https://doi.org/10.1186/s12998-016-0124-

Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients The ROADMAP Study 2-Year Results

OBJECTIVES The authors sought to provide the pre-specified primary endpoint of the ROADMAP (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients) trial at 2 years. BACKGROUND The ROADMAP trial was a prospective nonrandomized observational study of 200 patients (97 with a left ventricular assist device [LVAD], 103 on optimal medical management [OMM]) that showed that survival with improved functional status at 1 year was better with LVADs compared with OMM in a patient population of ambulatory New York Heart Association functional class IIIb/IV patients. METHODS The primary composite endpoint was survival on original therapy with improvement in 6-min walk distance \u3e= 75 m. RESULTS Patients receiving LVAD versus OMM had lower baseline health-related quality of life, reduced Seattle Heart Failure Model 1-year survival (78% vs. 84%; p = 0.012), and were predominantly INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile 4 (65% vs. 34%; p \u3c 0.001) versus profiles 5 to 7. More LVAD patients met the primary endpoint at 2 years: 30% LVAD versus 12% OMM (odds ratio: 3.2 [95% confidence interval: 1.3 to 7.7]; p = 0.012). Survival as treated on original therapy at 2 years was greater for LVAD versus OMM (70 +/- 5% vs. 41 +/- 5%; p \u3c 0.001), but there was no difference in intent-to-treat survival (70 +/- 5% vs. 63 +/- 5%; p = 0.307). In the OMM arm, 23 of 103 (22%) received delayed LVADs (18 within 12 months; 5 from 12 to 24 months). LVAD adverse events declined after year 1 for bleeding (primarily gastrointestinal) and arrhythmias. CONCLUSIONS Survival on original therapy with improvement in 6-min walk distance was superior with LVAD compared with OMM at 2 years. Reduction in key adverse events beyond 1 year was observed in the LVAD group. The ROADMAP trial provides risk-benefit information to guide patient- and physician-shared decision making for elective LVAD therapy as a treatment for heart failure. (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients [ROADMAP]; NCT01452802

Movement of Walleyes in Lakes Erie and St. Clair Inferred from Tag Return and Fisheries Data

Lake Erie walleyes Sander vitreus support important fisheries and have been managed as one stock, although preliminary tag return and genetic analyses suggest the presence of multiple stocks that migrate among basins within Lake Erie and into other portions of the Great Lakes. We examined temporal and spatial movement and abundance patterns of walleye stocks in the three basins of Lake Erie and in Lake St. Clair with the use of tag return and sport and commercial catchâ perâ unit effort (CPUE) data from 1990 to 2001. Based on summer tag returns, western basin walleyes migrated to the central and eastern basins of Lake Erie and to Lake St. Clair and southern Lake Huron, while fish in the central and eastern basins of Lake Erie and in Lake St. Clair were primarily caught within the basins where they were tagged. Seasonal changes in sport and commercial effort and CPUE in Lake Erie confirmed the walleye movements suggested by tag return data. Walleyes tagged in the western basin but recaptured in the central or eastern basin of Lake Erie were generally larger (or older) than those recaptured in the western basin of Lake Erie or in Lake St. Clair. Within spawning stocks, female walleyes had wider ranges of movement than males and there was considerable variation in movement direction, minimum distance moved (mean distance between tagging sites and recapture locations), and mean length among individual spawning stocks. Summer temperatures in the western basin often exceeded the optimal temperature (20â 23°C) for growth of large walleyes, and the migration of western basin walleyes might represent a sizeâ dependent response to warm summer temperatures. Cooler temperatures and abundant softâ rayed fish probably contributed to an energetically favorable foraging habitat in the central and eastern basins that attracted large walleyes during summer.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141620/1/tafs0539.pd