The Inlet and Outlet Ratio: Retrospective and Prospective Study on an Improved Diagnostic Ultrasound Tool for Carpal Tunnel Syndrome.

PURPOSE This study hypothesized that ratios of sonographic cross-sectional areas (CSAs) throughout the median nerve provide a more reliable tool for diagnosing carpal tunnel syndrome (CTS) than a single CSA value. We first tested this hypothesis in a retrospective cohort and subsequently confirmed it in a prospective blinded case-control series. METHODS Seventy patients were included in the retrospective study, and 50 patients and matched controls were included for the prospective study. We evaluated 4 CSAs, at the forearm, inlet, tunnel, outlet, and their ratios (Rforearm, Rinlet, Routlet, Routlet forearm) to evaluate compression of the median nerve. All patients underwent nerve conduction studies. For the prospective cohort, Disabilities of the Arm, Shoulder, and Hand scores and Boston Carpal Tunnel Questionnaire scores were evaluated, and ultrasound was performed by 2 examiners for each participant. RESULTS The Boston and Disabilities of the Arm, Shoulder, and Hand scores showed worse subjective function in patients with CTS than in controls. Three ultrasonography parameters (CSAs at the inlet, Rinlet, and Routlet) correlated significantly with subjective function. Age and Rinlet were significantly correlated with severity of CTS in the nerve conduction studies. In both the retrospective and prospective patient groups, the numbers of CSAs at the inlet and outlet were significantly higher than that of CSAs at the tunnel, whereas in the control group, no such compression was found. Of the single measurements, CSAs at the inlet had the best diagnostic performance with an optimized cutoff of 11.75 mm2. The Rinlet and Routlet ratios performed even better and showed the highest adjusted odds ratios for predicting CTS of all parameters (cutoff Rinlet, 1.25; Routlet, 1.45). Inter-observer correlation was generally high, with better values for single CSAs than for ratios. CONCLUSIONS The 3 CSA measurements of the median nerve and the associated ratios improved diagnostic power for ultrasonography in CTS in our study. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic I

Risk Assessment Models for Venous Thromboembolism in Medical Inpatients.

IMPORTANCE Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking. OBJECTIVES To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included. EXPOSURES At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM. MAIN OUTCOMES AND MEASURES Symptomatic VTE within 90 days. RESULTS Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score. CONCLUSIONS AND RELEVANCE This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies

Prediction of in-hospital bleeding in acutely ill medical patients: External validation of the IMPROVE bleeding risk score.

INTRODUCTION Pharmacological thromboprophylaxis slightly increases bleeding risk. The only risk assessment model to predict bleeding in medical inpatients, the IMPROVE bleeding risk score, has never been validated using prospectively collected outcome data. METHODS We validated the IMPROVE bleeding risk score in a prospective multicenter cohort of medical inpatients. Primary outcome was in-hospital clinically relevant bleeding (CRB) within 14 days of admission, a secondary outcome was major bleeding (MB). We classified patients according to the score in high or low bleeding risk. We assessed the score's predictive performance by calculating subhazard ratios (sHRs) adjusted for thromboprophylaxis use, positive and negative predictive values (PPV, NPV), and the area under the receiver operating characteristic curves (AUC). RESULTS Of 1155 patients, 8 % were classified as high bleeding risk. CRB and MB within 14 days occurred in 0.94 % and 0.47 % of low-risk and in 5.6 % and 3.4 % of high-risk patients, respectively. Adjusted for thromboprophylaxis, classification in the high-risk group was associated with an increased risk of 14-day CRB (sHR 4.7, 95 % confidence interval [CI] 1.5-14.5) and MB (sHR 4.9, 95%CI 1.0-23.4). PPV was 5.6 % and 3.4 %, while NPV was 99.1 % and 99.5 % for CRB and MB, respectively. The AUC was 0.68 (95%CI 0.66-0.71) for CRB and 0.73 (95%CI 0.71-0.76) for MB. CONCLUSION The IMPROVE bleeding risk score showed moderate to good discriminatory power to predict bleeding in medical inpatients. The score may help identify patients at high risk of in-hospital bleeding, in whom careful assessment of the risk-benefit ratio of pharmacological thromboprophylaxis is warranted

Widely differing screening and treatment practice for osteoporosis in patients with inflammatory bowel diseases in the Swiss IBD cohort study.

Low bone mineral density (BMD) and osteoporosis remain frequent problems in patients with inflammatory bowel diseases (IBDs). Several guidelines with nonidentical recommendations exist and there is no general agreement regarding the optimal approach for osteoporosis screening in IBD patients. Clinical practice of osteoporosis screening and treatment remains insufficiently investigated.In the year 2014, a chart review of 877 patients included in the Swiss IBD Cohort study was performed to assess details of osteoporosis diagnostics and treatment. BMD measurements, osteoporosis treatment, and IBD medication were recorded.Our chart review revealed 253 dual-energy x-ray absorptiometry (DXA) scans in 877 IBD patients; osteoporosis was prevalent in 20% of tested patients. We identified widely differing osteoporosis screening rates among centers (11%-62%). A multivariate logistic regression analysis identified predictive factors for screening including steroid usage, long disease duration, and perianal disease; even after correction for all risk factors, the study center remained a strong independent predictor (odds ratio 2.3-21 compared to the center with the lowest screening rate). Treatment rates for patients with osteoporosis were suboptimal (55% for calcium, 65% for vitamin D) at the time of chart review. Similarly, a significant fraction of patients with current steroid medication were not treated with vitamin D or calcium (treatment rates 53% for calcium, 58% for vitamin D). For only 29% of patients with osteoporosis bisphosphonate treatment was started. Treatment rates also differed among centers, generally following screening rates. In patients with longitudinal DXA scans, calcium and vitamin D usage was significantly associated with improvement of BMD over time.Our analysis identified inconsistent usage of osteoporosis screening and underuse of osteoporosis treatment in IBD patients. Increasing awareness of osteoporosis as a significant clinical problem in IBD patients might improve patient care

Modeling an America's Cup Regatta as a Sequential Stochastic Game

The main objective of this thesis is to model a regatta in the America’s Cup, and more precisely the first leg of the race, where the two competing sailboats have to move upwind. During the race, each crew attempts to be the first to reach the end of this leg, and is allowed to hinder its opponent as long as certain rules are respected. A boat which finishes this leg first is often able to manage its lead until the end of the regatta. An essential ingredient of the problem is the study of different maneuvers that the boats can execute during the race, as well as the effect generated by the presence of a boat on the wind around it. Indeed, a boat located just behind its opponent will receive less wind in its sails, and its speed will consequently be reduced. The boats considered in our model are of the type Class America, which were in used in the America’s Cup between 1982 and 2007. The race can hence be viewed as a game between two players which are assumed to be identical, in which each of them can make decisions sequentially. The goal of each player is to finish the first upwind leg with the largest lead possible over the opponent. The boats progress in an environment in which the wind fluctuates unpredictably. Thus, the game is a sequential stochastic game, in which each player will try to determine a sequence of actions which is the most favorable on average. A mathematical study of this kind of game will be done, and a strategy will be built by using tools of dynamic programming. A theorem will prove that this strategy is optimal, in the sense that no player has interest to deviate from this strategy. The last part of this thesis consists of applying the mathematical study of sequential stochastic games in the context of a sailing regatta. Given the current positions of the boats as well as the current state of the wind, a set of available actions and reactions for the boats can be defined. Each choice will bring the boats up to some new positions, where a new decision process will begin in a new state of the wind. Once the rules of the game are established, the objective is to define an algorithm which allows to build a strategy which will be an approximation of the optimal strategy. The implementation of this algorithm could produce a tool for decision support, that the crew could use on board during the regatta

Uveitis manifestations in patients of the Swiss Inflammatory Bowel Disease Cohort Study

Background The knowledge about risk factors for the onset of uveitis manifestations in patients with inflammatory bowel disease (IBD) is still limited. Here, we aimed to provide an overview of the clinical factors associated with the onset of uveitis in the Swiss IBD Cohort Study (SIBDCS). Methods We included epidemiological and clinical data from 1840 patients with Crohn's disease (CD) and 1426 patients with ulcerative colitis (UC) followed up in the SIBDCS between 2006 and 2018. Associations between disease characteristics and uveitis were assessed in univariate and multivariate analyses. Results Overall, we identified 285 patients with uveitis. Uveitis was more frequent in patients with CD (11.1%; 205 of 1635) than UC (5.6%; 80 of 1346; odds ratio 2.11, p < 0.001). The occurrence of uveitis manifestations in patients with UC and CD was significantly associated with the onset of other extraintestinal manifestations, also in multivariate analyses. The onset of uveitis was associated with the hallmark features of severe disease in both CD and UC, including a higher clinical disease activity index and the use of immunomodulators or calcineurin inhibitors. In CD, uveitis was more frequent in females and showed a positive correlation with a positive family history of IBD. Conclusions Our data demonstrate that uveitis in IBD occurs more often in CD as well as in women and is associated with a more severe disease course. This might guide physicians' awareness in at-risk patients to the presence of uveitis extraintestinal manifestations and help to improve patient care

Effects of anti-TNF therapy and immunomodulators on anxiety and depressive symptoms in patients with inflammatory bowel disease: a 5-year analysis.

Background and aims Anxiety and depression are prevalent in patients with inflammatory bowel diseases (IBD), especially during IBD flares. IBD therapies can profoundly affect the mood of patients with IBD. We aimed to determine the long-term impact of anti-tumor necrosis factor (anti-TNF) and immunomodulators (IM) on anxiety and depressive symptoms in IBD patients. Methods We compared three treatment groups with IM only (group A), anti-TNF ± IM (group B) and no such therapy (group C). Patients completed the hospital anxiety and depression scale (HADS) at 1 year, 3 years, and 5 years after start of treatment. Results In total, 581 patients with IBD (42.9% Crohn's disease, 57.1% ulcerative colitis/IBD unclassified) participated in this study. Effects of treatment were analyzed in a mixed effects model, with and without correction for confounders. Compared with group C, group B showed a significant treatment-related improvement in both anxiety and depressive symptoms within the first 2.5 years and also thereafter. Group A showed a significant long-term improvement of anxiety and both short-term and long-term improvement in depressive symptoms. The significance of these results was maintained after correction for confounders, including corticosteroid treatment. Additionally, both groups A and B showed a significant decrease in disease activity in the first 2.5 years after start of treatment and also thereafter. Anti-TNF and IM treatment were associated with a similarly significant decrease in anxiety and depressive symptoms over an observation period of up to 5 years. Conclusion Besides a clear benefit for disease activity, anti-TNF and IM apparently improve the mood of patients with IBD

Risk factors for gallstones and kidney stones in a cohort of patients with inflammatory bowel diseases

Gallstones and kidney stones are known complications of inflammatory bowel diseases (IBD). Risk factors have been insufficiently studied and explanatory studies date back up to 30 years. It remains unclear, whether improved treatment options also influenced risk factors for these complications.Identifying risk factors for gallstones and kidney stones in IBD patients.Using data from the Swiss Inflammatory Bowel Disease Cohort Study we assessed associations of diseases characteristics with gallstones and kidney stones in univariate and multivariate logistic regression analyses.Out of 2323 IBD patients, 104 (7.8%) Crohn's disease (CD) and 38 (3.8%) ulcerative colitis (UC) patients were diagnosed with gallstones. Significant risk factors for gallstones were diagnosis of CD, age at diagnosis, disease activity and duration, NSAID intake, extra-intestinal manifestations and intestinal surgery. Kidney stones were described in 61 (4.6%) CD and 30 (3.0%) UC patients. Male gender, disease activity, intestinal surgery, NSAID usage and reduced physical activity were significant risk factors. Hospitalization was associated with gallstones and kidney stones. The presence of gallstones increased the risk for kidney stones (OR 4.87, p<0.001).The diagnosis of CD, intestinal surgery, prolonged NSAID use, disease activity and duration and bowel stenosis were significantly associated with cholecystonephrolithiasis in IBD

Adverse metabolic outcomes in the early and late postpartum after gestational diabetes are broader than glucose control

Introduction: Gestational diabetes mellitus is associated with an increased cardiovascular risk. To better target preventive measures, we performed an in-depth characterization of cardiometabolic risk factors in a cohort of women with gestational diabetes in the early (6–8 weeks) and late (1 year) postpartum.Research design and methods: Prospective cohort of 622 women followed in a university gestational diabetes clinic between 2011 and 2017. 162 patients who attended the late postpartum visit were analyzed in a nested long-term cohort starting in 2015. Metabolic syndrome (MetS) was based on the International Diabetes Federation definition, and then having at least two additional criteria of the MetS (blood pressure, triglycerides, high-density lipoprotein (HDL) cholesterol, plasma glucose above or below the International Diabetes Federation cut-offs).Results: Compared with prepregnancy, weight retention was 4.8±6.0 kg in the early postpartum, and the prevalence of obesity, pre-diabetes, MetS-body mass index (BMI) and MetS-waist circumference (WC) were 28.8%, 28.9%, 10.3% and 23.8%, respectively. Compared with the early postpartum, weight did not change and waist circumference decreased by 2.6±0.6 cm in the late postpartum. However, the prevalence of obesity, pre-diabetes, MetS-WC and MetS-BMI increased (relative increase: 11% for obesity, 82% for pre-diabetes, 50% for MetS-WC, 100% for MetS-BMI; all p≤0.001). Predictors for obesity were the use of glucose-lowering treatment during pregnancy and the prepregnancy BMI. Predictors for pre-diabetes were the early postpartum fasting glucose value and family history of diabetes. Finally, systolic blood pressure in pregnancy and in the early postpartum, the 2-hour post oral glucose tolerance test glycemia and the HDL-cholesterol predicted the development of MetS (all pConclusions: The prevalence of metabolic complications increased in the late postpartum, mainly due to an increase in fasting glucose and obesity, although weight did not change. We identified predictors of late postpartum obesity, pre-diabetes and MetS that could lead to high-risk identification and targeted preventions.</p