State of the Art Review: Emerging Therapies: The Use of Insulin Sensitizers in the Treatment of Adolescents with Polycystic Ovary Syndrome (PCOS)

PCOS, a heterogeneous disorder characterized by cystic ovarian morphology, androgen excess, and/or irregular periods, emerges during or shortly after puberty. Peri- and post-pubertal obesity, insulin resistance and consequent hyperinsulinemia are highly prevalent co-morbidities of PCOS and promote an ongoing state of excess androgen. Given the relationship of insulin to androgen excess, reduction of insulin secretion and/or improvement of its action at target tissues offer the possibility of improving the physical stigmata of androgen excess by correction of the reproductive dysfunction and preventing metabolic derangements from becoming entrenched. While lifestyle changes that concentrate on behavioral, dietary and exercise regimens should be considered as first line therapy for weight reduction and normalization of insulin levels in adolescents with PCOS, several therapeutic options are available and in wide use, including oral contraceptives, metformin, thiazolidenediones and spironolactone. Overwhelmingly, the data on the safety and efficacy of these medications derive from the adult PCOS literature. Despite the paucity of randomized control trials to adequately evaluate these modalities in adolescents, their use, particularly that of metformin, has gained popularity in the pediatric endocrine community. In this article, we present an overview of the use of insulin sensitizing medications in PCOS and review both the adult and (where available) adolescent literature, focusing specifically on the use of metformin in both mono- and combination therapy

EPIdemiology of Surgery-Associated Acute Kidney Injury (EPIS-AKI) : Study protocol for a multicentre, observational trial

More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

QALY: Quality Adjusted Life Year

Nufusun yaslanmasi ve yaslilik donemi hastaliklar ile kronik hastaliklarin one cikmasi verilen saglik hizmetlerinin sadece saglik duzeyi uzerine degil yasam kalitesine etkisinin de onemli bir cikti olarak degerlendirilmesini getirmistir. Aslinda bu yaklasim Dunya Saglik Orgutunun (WHO), 1946 yilinda sagligi “yalnizca hastalik ve sakatligin olmayisi degil, fiziksel, ruhsal ve sosyal yonden tam bir iyilik hali” olarak tanimlamasina uyan ve bu ogeleri daha tam ve kapsamli karsilayan bir yaklasim olmustur. QALY (Quality Adjusted Life Year), “Kaliteye Ayarli Yasam Yili” anlamina gelen sozcuklerin kisaltmasindan olusmaktadir. Her bir omur senesini yasam kalitesi ile birlikte ele alan bir olcektir. Hem yasam beklentisindeki artisi, hem de yasam kalitesindeki farklilasmayi olcer. Amac, bircok farkli durumdaki saglik kazanimlarinin ortak bir olcekle degerlendirilerek basit bir birimle ifade edilmesi ve bircok boyutun tek bir endekste toplanmasidir. QALY terimi sinirli saglik kaynaklarinin alternatif saglik programlari arasinda dagitilmasi sirasinda karar vericilere yardimci olan analizlerde kazanimlarin verimliligini daha dogru olcmek icin gelistirilmis bir kavramdir. Saglik hizmetleri finansmaninda kullanilan kaynaklar, dunyadaki diger ulkelerde oldugu gibi ulkemizde de sinirlidir. Mevcut kaynaklarin yetersizligi, bunlarin mumkun olan en iyi sekilde kullanilmasi sorumlulugunu da beraberinde getirmektedir. [Med-Science 2012; 1(3.000): 232-243

Acute effect of joint distraction exercises with elastic band on maximal strength performance in adult male athletes.

This study is a cross-sectional study. Athletes with at least four years of strength training experience will be included in the study. This study will evaluate the effect of joint distraction exercises supported with elastic bands on maximal strength. The training protocol will be performed by coaches with at least 15 years of personal trainer experience, having NASM (CPT, WFS) and ISSA (SCS) coaching certifications

An analysis of analogies used in secondary chemistry textbooks

1st World Conference on Information Technology (WCIT) -- OCT 06-10, 2010 -- Bahcesehir Univ, Istanbul, TURKEYWOS: 000299159800050Analogies have been an important part of chemistry education for many years. Especially, analogies have been used to teach abstract concepts like chemical equilibrium, nature of matter and chemical bonding. Accordingly, analogies plays central role in supporting the understanding of complex concepts and topics. One of the main sources of analogies is textbooks. The purpose of this study to examine analogies found in the 9th and 10th the grades chemistry textbooks. As a result of this study, it was found that the use of the analogies were limited in both 9th and 10th grades chemistry textbooks. Also, it was determined that these analogies were very simple. (C) 2010 Published by Elsevier Ltd. Selection and/or peer-review under responsibility of the Guest Editor

Investigation Studies in the Life Experiences of Families of Children with Autism Spectrum Disorders: A Meta-Synthesis Study

Qualitative studies that involved the parents of children diagnosed with autism spectrum disorders tend to focus on the adaptation efforts of parents after learning of the diagnosis and their experiences at the time. Identifying experiences that are associated with their child's ASD and the factors that affect their experiences are important to determine the needs of parents who have children with ASD. The present study uses a meta-synthesis method in a review of qualitative studies to investigate the experiences of parents of children with ASD, with the aim to identify common conclusions. The present study makes a review of 18 studies, selected from national and international literature and published between 2008 and 2017, that met the criteria of the study. All of the studies adopted a phenomenology pattern as a qualitative research method to investigate the life experiences of parents of children with ASD, and an overall assessment of the reviewed studies revealed the following four salient themes: the effects of cultural differences on experiences, coping strategies, labeling and advocacy. Further research may focus on such factors as culture and advocacy, both of which influence the parental experience