Influence of anticardiolipin and anti-β2 glycoprotein I antibody cutoff values on antiphospholipid syndrome classification

Background: Anticardiolipin (aCL) and anti-beta 2 glycoprotein I (a beta 2GPI) immunoglobulin (Ig) G/IgM antibodies are 2 of the 3 laboratory criteria for classification of antiphospholipid syndrome (APS). The threshold for clinically relevant levels of antiphospholipid antibodies (aPL) for the diagnosis of APS remains a matter of debate. The aim of this study was to evaluate the variation in cutoffs as determined in different clinical laboratories based on the results of a questionnaire as well as to determine the optimal method for cutoff establishment based on a clinical approach.Methods: The study included samples from 114 patients with thrombotic APS, 138 patients with non-APS thrombosis, 138 patients with autoimmune disease, and 183 healthy controls. aCL and a beta 2GPI IgG/IgM antibodies were measured at 1 laboratory using 4 commercial assays. Assay-specific cutoff values for aPL were obtained by determining 95th and 99th percentiles of 120 compared to 200 normal controls by different statistical methods.Results: Normal reference value data showed a nonparametric distribution. Higher cutoff values were found when calculated as 99th rather than 95th percentiles. These values also showed a stronger association with thrombosis. The use of 99th percentile cutoffs reduced the chance of false positivity but at the same time reduced sensitivity. The decrease in sensitivity was higher than the gain in specificity when 99th percentiles were calculated by methods wherein no outliers were eliminated.Conclusions: We present cutoff values for aPL determined by different statistical methods. The 99th percentile cutoff value seemed more specific. However, our findings indicate the need for standardized statistical criteria to calculate 99th percentile cutoff reference values.Background: Anticardiolipin (aCL) and anti-beta 2 glycoprotein I (a beta 2GPI) immunoglobulin (Ig) G/IgM antibodies are 2 of the 3 laboratory criteria for classification of antiphospholipid syndrome (APS). The threshold for clinically relevant levels of antiphospholipid antibodies (aPL) for the diagnosis of APS remains a matter of debate. The aim of this study was to evaluate the variation in cutoffs as determined in different clinical laboratories based on the results of a questionnaire as well as to determine the optimal method for cutoff establishment based on a clinical approach.Methods: The study included samples from 114 patients with thrombotic APS, 138 patients with non-APS thrombosis, 138 patients with autoimmune disease, and 183 healthy controls. aCL and a beta 2GPI IgG/IgM antibodies were measured at 1 laboratory using 4 commercial assays. Assay-specific cutoff values for aPL were obtained by determining 95th and 99th percentiles of 120 compared to 200 normal controls by different statistical methods.Results: Normal reference value data showed a nonparametric distribution. Higher cutoff values were found when calculated as 99th rather than 95th percentiles. These values also showed a stronger association with thrombosis. The use of 99th percentile cutoffs reduced the chance of false positivity but at the same time reduced sensitivity. The decrease in sensitivity was higher than the gain in specificity when 99th percentiles were calculated by methods wherein no outliers were eliminated.Conclusions: We present cutoff values for aPL determined by different statistical methods. The 99th percentile cutoff value seemed more specific. However, our findings indicate the need for standardized statistical criteria to calculate 99th percentile cutoff reference values.A

Intravascular absorption syndrome : case report of a life-threatening complication during hysteroscopy

A 40-year old, healthy woman underwent hysteroscopic endometrial ablation with a bipolar electrocautery using 0.9% saline as distension fluid. After 45 minutes of surgery, arterial oxygen saturation decreased and liquid was obstructing the laryngeal mask. With an estimated total fluid deficit of 5000 mL, fluid overload was suspected and the patient's trachea was intubated. Furosemide was given intravenously and a urinary catheter was inserted. The intra-abdominal pressure, measured through the urinary catheter, was 28 mmHg. As ventilation became unfeasible, the patient became cyanotic and no clear pulse could be detected, cardiopulmonary resuscitation was started. In order to decrease the abdominal pressure, a laparotomy was performed and extracorporeal membrane oxygenation was started to increase the arterial oxygenation. After one week in the Intensive Care Unit, the patient was extubated and gradually recovered without further complications nor residual morbidity. The pathophysiological aspects of the evolution to severe pulmonary edema due to massive fluid translocation during operative hysteroscopy, and the rationale behind the successful interventions are being discussed. Close continuous monitoring of the amount of fluid deficit should be performed to avoid severe fluid overload during operative hysteroscopy. Extracorporeal membrane oxygenation can be life-saving to bridge the period of desaturation until standard treatment suffices to provide adequate oxygenation

The Effect of Volunteer Demographics on Nonprofit Volunteer Retention

Nonprofit organizations rely upon volunteers to assist in achieving their mission and reaching strategic operational goals. As the volunteer population in the United States has decreased, nonprofit organizations are challenged to recruit and retain volunteers. To improve operational efficiencies in nonprofit volunteer management, organizations need to implement more effective strategies to assign roles to volunteers and develop a better understanding of how those roles fit into volunteers\u27 lives and the value systems of individual volunteers. The functional theory of volunteer behavior characterizes the values, understanding, social, career, protective, and enhancement functions as they relate to an individual\u27s motivation for volunteering. To investigate how active volunteer demographics related to self-reported ratings of personal and social motivational functions, a multivariate analysis of variance, with designated follow-up post hoc tests, was used to address the research questions and associated hypotheses to provide a basis to make comparative statistical analysis to determine volunteer needs, values, and purpose based on age cohort, sex, race/ethnicity, and socioeconomic status. It was found that the functional aspect, career, was a significant determinate when focused on the demographics of age, gender, and socioeconomic status. Additionally, an interaction emerged with sex and age with career, social, understanding, and enhancement functional aspects. The results of the study will foster positive social change by increasing the understanding of how volunteer behavior impacts volunteer retention and recruitment, facilitating nonprofit organizations in their ability to effectively match volunteer skills with assignment, thereby maximizing their impact and longevity within the organization

Medication adherence to inhalation therapy and the risk of COPD exacerbations:a systematic review with meta-analysis

Background Assessing medication adherence is crucial in chronic obstructive pulmonary disease (COPD) management to prevent exacerbations. However, it is unclear whether this association between adherence and exacerbations is influenced by the adherence assessment methods or thresholds used. Electronic healthcare databases are valuable to study exacerbations and adherence in real life. We aimed to systematically review the literature to identify adherence assessment methods and thresholds used in healthcare databases when investigating the association between medication adherence and COPD exacerbations and to meta-analyse the associated effect sizes. Method MEDLINE, Web of Science and Embase were searched for peer-reviewed articles, written in English, published up to 10 October 2022 (PROSPERO: CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. A qualitative approach described the adherence assessment methods and thresholds used. A quantitative approach (meta-analysis using random effects model) estimated the association between adherence and the risk of COPD exacerbations. Results Eight studies were included in the systematic review of which five studies were included in the meta-analysis. The medication possession ratio (MPR) and the proportion of days covered (PDC) were the adherence assessment methods used and 0.80 was always used as threshold to differentiate good from poor adherence. Adherence and exacerbations were mostly measured over the same time period. Poor adherence (MPR or PDC&lt;0.80) was significantly associated with a higher COPD exacerbation risk (OR 1.40, 95% CI 1.21 to 1.62, I 2=85%), regardless of the adherence assessment method used. Results were consistent when stratified by exacerbation severity. Poor adherence was also associated with a time-dependent risk of COPD exacerbations (incidence rate ratio 1.31, 95% CI 1.17 to 1.46). Conclusion Our systematic review with meta-analysis demonstrated a 40% increased risk of COPD exacerbations in case of poor adherence to inhaler medication.</p

Methods to assess COPD medications adherence in healthcare databases:a systematic review

Background: The Global Initiative for Chronic Obstructive Lung Disease 2023 report recommends medication adherence assessment in COPD as an action item. Healthcare databases provide opportunities for objective assessments; however, multiple methods exist. We aimed to systematically review the literature to describe existing methods to assess adherence in COPD in healthcare databases and to evaluate the reporting of influencing variables. Method: We searched MEDLINE, Web of Science and Embase for peer-reviewed articles evaluating adherence to COPD medication in electronic databases, written in English, published up to 11 October 2022 (PROSPERO identifier CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. Methods to assess initiation (dispensing of medication after prescribing), implementation (extent of use over a specific time period) and/or persistence (time from initiation to discontinuation) were listed descriptively. Each included study was evaluated for reporting variables with an impact on adherence assessment: inpatient stays, drug substitution, dose switching and early refills. Results: 160 studies were included, of which four assessed initiation, 135 implementation and 45 persistence. Overall, one method was used to measure initiation, 43 methods for implementation and seven methods for persistence. Most of the included implementation studies reported medication possession ratio, proportion of days covered and/or an alteration of these methods. Only 11% of the included studies mentioned the potential impact of the evaluated variables. Conclusion: Variations in adherence assessment methods are common. Attention to transparency, reporting of variables with an impact on adherence assessment and rationale for choosing an adherence cut-off or treatment gap is recommended.</p

Lower extremity near-infrared spectroscopy after popliteal block for orthopaedic foot surgery

BACKGROUND: Noninvasive measurement of cutaneous tissue oxygenation using near-infrared spectroscopy (NIRS) has become common in peri-operative care. Following institution of peripheral nerve blocks, neurovascular alterations in the blocked region have been described. OBJECTIVE: The primary aim of this study encompassed the assessment of the influence of a popliteal block on changes in regional oxygen saturation (SrO(2)), and the location of most prominent changes. METHOD: We conducted a prospective randomised controlled trial. Hundred twenty patients who received a popliteal block for foot surgery were included. Popliteal block was performed under echographic guidance. The patients were randomized in 3 groups according to the location of the SrO(2) electrodes on the legs. Bilateral SrO(2) measurements were performed simultaneously. SrO(2) in the operated leg and in the control leg was measured at baseline and 1, 5, 10, 15, and 30 minutes after the perineural injection. We quantified the evolution in SrO(2) by calculating over time the differences in SrO(2) values between the operated and control leg (=ΔSrO(2)). RESULTS: At 30 minutes, ΔSrO(2) increased significantly (p<0.05) at the plantar side of the foot (11.3% ± 2.9%), above the ankle (4.9% ± 1.3%) and the popliteal fossa (3.6% ± 1.2%). CONCLUSION: At 30 minutes after institution of the popliteal block, ΔSrO(2) was most prominent at the plantar side of the foot as compared with measurement performed above the ankle or under the knee

Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment of High-Risk Patients

In hospitalized patients, cardiorespiratory collapse mostly occurs after a distinct period of deterioration. This deterioration can be discovered by a systematic quantification of a set of clinical parameters. The combination of such a detection system—to identify patients at risk in an early stage —and a rapid response team—which can intervene immediately—can be implemented to prevent life-threatening situations and reduce the incidence of in-hospital cardiac arrests outside the intensive care setting. The effectiveness of both of these systems is influenced by the used trigger criteria, the number of rapid response team (RRT) activations, the in- or exclusion of patients with a DNR code >3, proactive rounding, the team composition, and its response time. Each of those elements should be optimized for maximal efficacy, and both systems need to work in tandem with little delay between patient deterioration, accurate detection, and swift intervention. Dependable diagnostics and scoring protocols must be implemented, as well as the organization of a 24/7 vigilant and functional experienced RRT. This implies a significant financial investment to provide an only sporadically required fast intervention and sustained alertness of the people involved

Iron overload in polytransfused patients without heart failure is associated with subclinical alterations of systolic left ventricular function using cardiovascular magnetic resonance tagging

BACKGROUND: It remains incompletely understood whether patients with transfusion related cardiac iron overload without signs of heart failure exhibit already subclinical alterations of systolic left ventricular (LV) dysfunction. Therefore we performed a comprehensive evaluation of systolic and diastolic cardiac function in such patients using tagged and phase-contrast CMR. METHODS: 19 patients requiring regular blood transfusions for chronic anemia and 8 healthy volunteers were investigated using cine, tagged, and phase-contrast and T2* CMR. LV ejection fraction, peak filling rate, end-systolic global midventricular systolic Eulerian radial thickening and shortening strains as well as left ventricular rotation and twist, mitral E and A wave velocity, and tissue e' wave and E/e' wave velocity ratio, as well as isovolumic relaxation time and E wave deceleration time were computed and compared to cardiac T2*. RESULTS: Patients without significant iron overload (T2* > 20 ms, n = 9) had similar parameters of systolic and diastolic function as normal controls, whereas patients with severe iron overload (T2* 20 ms) or normal controls. Patients with moderate iron overload (T2* 10-20 ms, n = 5), had preserved ejection fraction (59 ± 6%, p = NS vs. pts. with T2* > 20 ms and controls), but showed reduced maximal LV rotational twist (1.8 ± 0.4 degrees). The magnitude of reduction of LV twist (r = 0.64, p < 0.001), of LV ejection fraction (r = 0.44, p < 0.001), of peak radial thickening (r = 0.58, p < 0.001) and of systolic (r = 0.50, p < 0.05) and diastolic twist and untwist rate (r = -0.53, p < 0.001) in patients were directly correlated to the logarithm of cardiac T2*. CONCLUSION: Multiple transfused patients with normal ejection fraction and without heart failure have subclinical alterations of systolic and diastolic LV function in direct relation to the severity of cardiac iron overload. Among all parameters, left ventricular twist is affected earliest, and has the highest correlation to log (T2*), suggesting that this parameter might be used to follow systolic left ventricular function in patients with iron overload