Association of chronic self-perceived stress with mortality and health status outcomes in patients with peripheral artery disease: insights from the portrait registry

Title from PDF of title page viewed January 15, 2020Thesis advisor: Kim SmolderenVitaIncludes bibliographical references (page 50-56)Thesis (M.S.)--School of Medicine. University of Missouri--Kansas City, 2019The prevalence of peripheral artery disease (PAD) is increasing worldwide and is estimated to affect about 360 million patients by 2030. Patients with PAD are at a higher risk of premature mortality and suffer from disability and functional impairment, both of which contribute to the direct and indirect socioeconomic burden of PAD. These trends are occurring despite emphasis towards control of traditional risk factors and interventions to decrease the impact of PAD on patient outcomes. Hence it is critical to identify and study novel risk factors that could impact outcomes in patients with PAD. Chronic mental stress could be one such factor. Mental stress is a potent cardiovascular risk factor and has been associated with development and progression of coronary disease and worse outcomes, including higher risk of mortality and poorer quality of life in patients after a myocardial infarction. However, there is paucity of evidence for the association of chronic mental stress with outcomes in PAD. To address this critical gap in understanding the link between mental stress and outcomes in PAD, we used data from the Patient-centered Outcomes Related to Treatment practices in peripheral Arterial disease: Investigating Trajectories (PORTRAIT), an international registry of patients presenting with symptoms of PAD. Mental stress was quantified at baseline, 3-, 6- and 12-month follow-up using the validated 4-item Perceived Stress Scale (PSS-4). For each patient available PSS-4 scores from all time points were averaged to quantify a subject’s average exposure to mental stress over one year. To examine the association of chronic stress with longitudinal mortality and health status outcomes, we did two separate landmark analysis. First to examine the impact of chronic stress on mortality we did a landmark analysis starting at 12-month follow-up. For each patient we defined chronic stress to be average of PSS-4 score at baseline through 12-months. Cox regression models adjusting for patients’ demographics (age, sex, race), comorbid conditions (diabetes, hypertension, history of myocardial infarction, congestive heart failure, smoking status), baseline ankle-brachial index, invasive treatment for PAD, socioeconomic indicators (highest education level, avoidance of care due to cost and end of the month resources), were used to assess an independent association of average stress (over first year of follow-up) with all-cause mortality over the subsequent four years. Second, to examine the association of chronic stress with 12-month health status outcomes we defined chronic stress exposure to be average PSS-4 score across baseline, 3- and 6-month follow-up assessments. This quantified a patient’s exposure to chronic stress over first 6-months of follow-up. Health status was quantified at baseline and 12-months. PAD specific health status was assessed using the PAD Questionnaire (PAQ). Generic health status was assessed using the EuroQoL Visual Analog Scale (EQ5D VAS). Hierarchical multivariable regression models, with random effects for site and adjustment for country, patients’ demographics, comorbid conditions, baseline ABI, treatment strategy and socioeconomic status-were used to examine independent association of average stress (baseline to 6-months) on recovery in health status at 12-months. In in patients in whom accurate assessment of chronic mental stress and mortality could be made (n=757, mean age 68.5 ± 9.7, 42% females, 28% non-Caucasians), higher average stress scores over 12-months were associated with greater hazards of mortality, in the adjusted model (hazard ratio per +1 unit increase in average PSS-4 1.08, 95% CI 1.01, 1.16 p=0.03). Similarly, in patients who had complete assessment of chronic stress over 6-months and health status at baseline and 12-month follow-up (n=1060, mean age 67.7, 37% females, 17.7% non-Caucasian) higher averaged stress scores over 6-months were associated with poorer PAQ summary score at 12-months in completely adjusted models (-1.4 points per +1-point increase in average PSS-4 95% CI -2.1, -0.6 p <0.001). Chronic stress in patients with PAD, is independently associated with higher mortality risk and poorer health status outcomes. These results set the stage for exploring interventions to examine if strategies to reduce chronic stress in patients with PAD improves outcomesIntroduction -- Methodology -- Results -- Discussion -- Appendi

Catheter Related Infections in Medical Intensive Care Units

To determine the frequency of different isolates from samples taken from catheter tips of tracheal suction catheters, endotracheal tubes and central venous pressure line catheters among the patients of medical intensive care unitsMethods: In this descriptive cross sectional study a total of 200 patients were checked for bacterial or fungal growth. Included samples were 140 from suction catheters, 51 from endotracheal tubes and 9 from CVP catheters cultured for bacterial or fungal growth. Different organisms were identified on the basis of colony morphology, Colony staining and Biochemical reactions.Results: Out of 200 patients, majority (72.5%) patients were found to be positive for bacterial or fungal growth. Out of which 89(62.2%) were male and 54(37.8%) were females. One hundred and one (69.7%), 38(26.2%), 6(4.1%) growth cultures were obtained from samples of tracheal suction catheter tips, ETT tips and CVP catheter tips respectively. Microorganisms isolated were Acinetobacter species 62(42.8%), Klebsiella species 43(29.7%), Pseudomonas species 19(13.1%), E.coli 8(5.5%), MRSA 5(3.4%), Candida albicans 4(2.8%), Proteus 2(1.4%) and Staphylococcus aureus 2(1.4%).Conclusion: Acinetobacter, Klebsiella and Pseudomonas were the most frequent infectious agents isolated from catheter tips in settings of medical intensive care units

Cardiovascular Aspects of Patients with Chronic Kidney Disease and End-Stage Renal Disease

Chronic kidney disease (CKD) is a globally recognized public health concern. Multiple studies have shown the association of CKD with cardiovascular mortality that persists after adjustment for traditional cardiovascular disease (CVD) risk factors. CKD causes accelerated coronary artery disease (CAD). In this chapter, we discuss the pathophysiological mechanisms that play a role in increasing CVD risk in patients with CKD. Further we delve into some commonly encountered challenges related to CVD in patients with CKD. These include revascularization challenges, contrasted induced nephropathy and alterations in traditional risk factors for CVD in renal transplant patients

Comparison of Efficacy of Febuxostat with Allopurinol in Lowering Serum Urate Levels

To compare the efficacy of Febuxostat with Allopurinol in lowering serum urate levelsMethods: In this randomized controlled trial a total of 60 patients with hyperuricemia above 18 years of age were included. Thirty patients were given Allopurinol and 30 patients were given Febuxostat for 4 weeks. Hyperuricemia was defined as serum uric acid level of greater than 6mmol/L. Uric acid was measured at 2 and 4 weeks from start of treatment. Chi-square test was applied to compare the efficacy of drugs among the two groups.Results: After 4 weeks of therapy uric acid reduced to &lt;6mg/dl successfully in 42/60 patients (70 %) . In Febuxostat group 26/30 (86.7%) patients responded to treatment with uric acid levels &lt;6mg/dl while in Allopurinol group 16/30 (53.3%) patients showed uric acid &lt;6mg/dl with a significant p= 0.005 . Febuxostat was effective in 22/25 (88%) of male (mean age 57.50 ± 8.695years) and 4/5(80%) of female(mean age 57.75 ± 8.578 years)patients while Allopurinol was effective in 12/23 (52.2%) of males (mean age 56.33 ± 11.758 years ) and 4/7 (57.1%) of females (mean age 54.25 ± 8.770 years ) .Conclusion: The efficacy of treatment was significantly higher in Febuxostat group as compared to the Allopurinol grou

Rate-latency optimization for NB-IoT with adaptive resource unit configuration in uplink transmission

Narrowband Internet of Things (NB-IoT) is a cellular IoT communication technology standardized by 3rd Generation Partnership Project (3GPP) for supporting massive machine type communication and its deployment can be realized by a simple firmware upgrade on existing long term evolution (LTE) networks. The NB-IoT requirements in terms of energy efficiency, achievable rates, latency, extended coverage, make the resource allocation, in a limited bandwidth, even a more challenging problem w.r.t. to legacy LTE. The allocation, done with subcarrier (SC) granularity in NB-IoT, should maintain adequate performance for the devices while keeping the power consumption as low as possible. Nevertheless, the optimal solution of the resource allocation problem is typically unfeasible since nonconvex, NP-hard and combinatorial because of the use of binary variables. In this article, after the formulation of the optimization problem, we study the resource allocation approach for NB-IoT networks aiming to analyze the tradeoff between rate and latency. The proposed suboptimal algorithm allocates radio resource (i.e., SCs) and transmission power to the NB-IoT devices for the uplink transmission and the performance is compared in terms of latency, rate, and power. By comparing the proposed allocation to a conventional round robin (RR) and to a brute-force approach, we can observe the advantages of the formulated allocation problem and the limited loss of the suboptimal solution. The proposed algorithm outperforms the RR by a factor 2 in terms of spectral efficiency and, moreover, the study includes techniques that reduce the dropped packets from 29% to 1.6%

Melatonin downregulates the increased hepatic alpha-fetoprotein expression and restores pancreatic beta cells in a streptozotocin-induced diabetic rat model: a clinical, biochemical, immunohistochemical, and descriptive histopathological study

BackgroundDiabetes mellitus (DM) is a chronic metabolic disorder. Hepatopathy is one of the serious effects of DM Melatonin (MT) is a potent endogenous antioxidant that can control insulin output. However, little information is available about the potential association between melatonin and hepatic alpha-fetoprotein expression in diabetes.ObjectiveThis study was conducted to assess the influence of MT on diabetes-related hepatic injuries and to determine how β-cells of the pancreas in diabetic rats respond to MT administration.Materials and methodsForty rats were assigned to four groups at random (ten animals per group). Group I served as a normal control group. Group II was induced with DM, and a single dose of freshly prepared streptozotocin (45 mg/kg body weight) was intraperitoneally injected. In Group III, rats received 10 mg/kg/day of intraperitoneal melatonin (IP MT) intraperitoneally over a period of 4 weeks. In Group IV (DM + MT), following the induction of diabetes, rats received MT (the same as in Group III). Fasting blood sugar, glycosylated hemoglobin (HbA1c), and serum insulin levels were assessed at the end of the experimental period. Serum liver function tests were performed. The pancreas and liver were examined histopathologically and immunohistochemically for insulin and alpha-fetoprotein (AFP) antibodies, respectively.ResultsMT was found to significantly modulate the raised blood glucose, HbA1c, and insulin levels induced by diabetes, as well as the decreased alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Furthermore, MT attenuated diabetic degenerative changes in the pancreas and the hepatic histological structure, increased the β-cell percentage area, and decreased AFP expression in the liver tissue. It attenuated diabetes-induced hepatic injury by restoring pancreatic β-cells; its antioxidant effect also reduced hepatocyte injury.ConclusionCollectively, the present study confirmed the potential benefits of MT in downregulating the increased hepatic alpha-fetoprotein expression and in restoring pancreatic β-cells in a streptozotocin-induced diabetic rat model, suggesting its promising role in the treatment of diabetes

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.Peer reviewe

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised