Effect of an interactive, educational app about venous thromboembolism and anticoagulation on patient satisfaction: A randomized controlled trial.

BACKGROUND: Adequate patient education is essential for patients to engage in shared decision-making when deciding to stop or continue anticoagulation after 3 months for venous thromboembolism (VTE). Our objectives were to evaluate the effect of an interactive, educational app on patients' level of satisfaction with information, perceived level of knowledge, decisional conflict and extent of shared decision-making when deciding on treatment duration of VTE. MATERIALS AND METHODS: This randomized controlled trial in 1 academic and 3 general Dutch hospitals included adult patients diagnosed with VTE without malignancy or prolonged anticoagulation for other indications. Patients were randomized in 1:1 ratio to receive the app (intervention group) in addition to hospital-specific standard of care. The app, created for this study, contains information on VTE and anticoagulation on an interactive timeline. In the week preceding the consultation when treatment duration is decided, patients were provided with daily videos using push notifications. Outcomes were assessed through self-reported questionnaires at baseline, 1-2 days before and 1 day after consultation. Data were analyzed using t-tests and linear mixed models for repeated measurements. RESULTS: Data of 56 patients were analyzed (mean age 57 ± 13; 27% female). On a numeric rating scale from 0 to 10, patients who received the app were 0.9 points (95%CI 0.0-1.7; p 0.04) more satisfied with the provided information. Patients who received the app experienced significantly less decisional conflict. No differences in other outcomes were observed. CONCLUSIONS: An educational app about VTE and anticoagulation increases patients' satisfaction and reduces decisional conflict when deciding on treatment duration of VTE. This study was registered in the Netherlands Trial Register (NL7037).

Prediction of disease-gene-drug relationships following a differential network analysis.

Great efforts are being devoted to get a deeper understanding of disease-related dysregulations, which is central for introducing novel and more effective therapeutics in the clinics. However, most human diseases are highly multifactorial at the molecular level, involving dysregulation of multiple genes and interactions in gene regulatory networks. This issue hinders the elucidation of disease mechanism, including the identification of disease-causing genes and regulatory interactions. Most of current network-based approaches for the study of disease mechanisms do not take into account significant differences in gene regulatory network topology between healthy and disease phenotypes. Moreover, these approaches are not able to efficiently guide database search for connections between drugs, genes and diseases. We propose a differential network-based methodology for identifying candidate target genes and chemical compounds for reverting disease phenotypes. Our method relies on transcriptomics data to reconstruct gene regulatory networks corresponding to healthy and disease states separately. Further, it identifies candidate genes essential for triggering the reversion of the disease phenotype based on network stability determinants underlying differential gene expression. In addition, our method selects and ranks chemical compounds targeting these genes, which could be used as therapeutic interventions for complex diseases.

PPARγ population shift produces disease-related changes in molecular networks associated with metabolic syndrome.

Peroxisome proliferator-activated receptor gamma (PPARγ) is a key regulator of adipocyte differentiation and has an important role in metabolic syndrome. Phosphorylation of the receptor's ligand-binding domain at serine 273 has been shown to change the expression of a large number of genes implicated in obesity. The difference in gene expression seen when comparing wild-type phosphorylated with mutant non-phosphorylated PPARγ may have important consequences for the cellular molecular network, the state of which can be shifted from the healthy to a stable diseased state. We found that a group of differentially expressed genes are involved in bi-stable switches and form a core network, the state of which changes with disease progression. These findings support the idea that bi-stable switches may be a mechanism for locking the core gene network into a diseased state and for efficiently propagating perturbations to more distant regions of the network. A structural analysis of the PPARγ-RXRα dimer complex supports the hypothesis of a major structural change between the two states, and this may represent an important mechanism leading to the differential expression observed in the core network.

[Laparoscopic cholecystectomy for acute cholecystitis]. / La colecistectomia laparoscopica nel trattamento della colecistite acuta.

BACKGROUND: The aim of this study is to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to determine the optimal timing. PATIENTS AND METHODS: The study was performed in two groups of 70 consecutive patients (similar in age and ASA classification), retrospectively reviewed, who had been diagnosed with acute cholecystitis and were underwent early or delayed laparoscopic cholecystectomy. In early group surgery took place within 48 hours of admission in hospital. The interval for delayed laparoscopic cholecystectomy was 8-12 weeks after medical treatment. RESULTS: In delayed group 21,4% of patients required urgent surgery after failure of conservative treatment. The most important significant difference is the total hospital stay: the early group had a significant shorter hospital stay (7 days) vs delayed group (13 days). Other differences were the conversion rate (8,6% in early group vs 12,7% in delayed group) and median the operation time (84 min. in early group vs 106 min. in delayed group). Post-operative complications developed in 6,3% in early group vs 2,6% in delayed group. CONCLUSION: The optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy but in our experience early laparoscopic cholecystectomy increased postoperative morbidity in hospital decreased conversion rate, median operation time and hospital stay.

[Health effects of fish oil and fish oil supplements: consumption advice sustained]. / Gezondheidseffecten van visolie en visoliepreparaten: gebruiksadvies gehandhaafd.

Omega-3 fatty acids are thought to have beneficial effects on atherosclerosis. Recently, the results ofa systematic review on the health effects of omega-3 fatty acids were published. The risk of cardiovascular death in subjects randomised to taking omega-3 fats was not significantly decreased: relative risk = 0.87 (95% CI: 0.73-1.03). In a 2004 Cochrane review, the same authors concluded that there was a significant beneficial effect on total mortality, combined cardiovascular endpoints and cancer. Inclusion of the recent 'Diet and reinfarction trial' (DART-2-trial) had a decisive negative effect on the results of the recent meta-analysis. Excluding this study resulted in a relative risk of cardiovascular death of 0.83 (95% CI: 0.75-0.91). Since the DART-2 study had methodological shortcomings, it still appears that recommending sufficient intake of omega-3 fatty acids is justifiable, preferably by eating fish but ifnecessary by using fish oil supplements, especially for patients at high risk of cardiovascular disease.

Carotid intima-media thickness at different sites: relation to incident myocardial infarction; The Rotterdam Study.

AIMS: We examined whether intima-media thickness of the common carotid artery, carotid bifurcation, internal carotid artery and the combined measure are predictive of future myocardial infarction and which of the measurements has the strongest predictive value. METHODS AND RESULTS: We used a case-cohort approach in the Rotterdam Study. Ultrasound images of the common carotid artery, carotid bifurcation and the internal carotid artery were made. We selected the first 194 myocardial infarctions in the total population (mean follow-up 4.6 years). Analyses were done using Cox regression with adjustment for age and sex. The risk ratios (RR) for myocardial infarction associated with mean maximum common carotid, bifurcation, internal carotid intima-media thickness and the combined measurements were 3.18 (95% confidence interval, 1.83-5.54), 4.11 (2.10-8.05), 5.31 (1.77-15.9) and 6.27 (3.27-12.0), respectively, for the highest compared to the lowest quartile. The RRs for myocardial infarction per standard deviation increase of common carotid, bifurcation, internal carotid artery and combined intima-media thickness were 1.44 (1.28-1.62), 1.34 (1.17-1.53), 1.12 (0.94-1.33) and 1.47 (1.31-1.65), respectively. The areas under the ROC curves for the three measurements and the combined measure were not significantly different. CONCLUSIONS: Increased carotid intima-media thickness is a strong predictor of future myocardial infarction and all measurement sites have the same ability to predict future myocardial infarction.

Carotid plaques increase the risk of stroke and subtypes of cerebral infarction in asymptomatic elderly: the Rotterdam study.

BACKGROUND: Few studies have quantified the relation between carotid plaques and stroke in asymptomatic patients, and limited data exist on the importance of location of plaques or the association with subtypes of cerebral infarction. We investigated the relationship between carotid plaques, measured at different locations, and risk of stroke and subtypes of cerebral infarction in a population-based study. Methods and Results- The study was based on the Rotterdam Study and included 4217 neurologically asymptomatic subjects aged 55 years or older. Presence of carotid plaques at 6 locations in the carotid arteries was assessed at baseline. Severity was categorized according to the number of affected sites. After a mean follow-up of 5.2 years, 160 strokes had occurred. Data were analyzed using Cox proportional hazards regression. Plaques increased the risk of stroke and cerebral infarction approximately 1.5-fold, irrespective of plaque location. Severe carotid plaques increased the risk of nonlacunar infarction in anterior (RR 3.2 [95% CI, 1.1 to 9.7]) but not in posterior circulation (RR 0.6 [95% CI, 0.1 to 4.9]). A >10-fold increased risk of lacunar infarction was found in subjects with severe plaques (RR 10.8 [95% CI, 1.7 to 69.7]). No clear difference in risk estimates was seen between ipsilateral and contralateral infarction. CONCLUSIONS: Carotid plaques increase the risk of stroke and cerebral infarction, irrespective of their location. Plaques increase the risk of infarctions in the anterior but not in the posterior circulation. It is likely that carotid plaques in neurologically asymptomatic subjects are both markers of generalized atherosclerosis and sources of thromboemboli.

Apolipoprotein E and carotid artery atherosclerosis: the Rotterdam study.

BACKGROUND AND PURPOSE: Carotid artery atherosclerosis is a strong predictor for future stroke. It is yet unclear whether the apolipoprotein E polymorphism (APOE) is related to atherosclerosis in the carotid arteries. The aim of the present study was to investigate the role of APOE in carotid artery atherosclerosis. METHODS: A population-based cross-sectional study was performed on 5401 subjects. Atherosclerosis was noninvasively assessed by the common carotid artery intima-media wall thickness and the presence of plaques in the carotid arteries. The relationship of the 6 APOE genotypes with these 2 indicators was studied with linear and logistic regression analysis, respectively, with adjustments for age and sex. RESULTS: Carriers of the E2E3 genotype had a thinner intima-media wall thickness (mean difference, -0.02 mm; 95% CI, -0.03 to -0.01 mm) and fewer plaques (odds ratio for >3 plaques at 6 sites, 0.6; 95% CI, 0.4 to 0.8) than the most common group, E3E3. The E4E4 group had slightly more atherosclerosis, but this was not statistically significant. Adjusting for the level of the apolipoprotein E protein (apoE) in serum or total or HDL cholesterol did not essentially change these findings. CONCLUSIONS: Our results suggest that APOE*4 is not an important risk factor for carotid artery atherosclerosis. The inverse relationship of E2E3 with carotid artery atherosclerosis seems to be independent of serum apoE and total and HDL cholesterol levels. However, the low frequency, together with the small effects, implies that any protective effect of E2E3 on carotid artery atherosclerosis is limited.

Is carotid intima-media thickness useful in cardiovascular disease risk assessment? The Rotterdam Study.

BACKGROUND AND PURPOSE: We determined the contribution of common carotid intima-media thickness (IMT) in the prediction of future coronary heart disease and cerebrovascular disease when added to established risk factors. METHODS: We used data from a nested case-control study comprising 374 subjects with either an incident stroke or a myocardial infarction and 1496 controls. All subjects were aged 55 years and older and participated in the Rotterdam Study. Mean follow-up was 4.2 years (range, 0.1 to 6.5 years). We evaluated which correlates of coronary heart disease and cerebrovascular disease contribute to the prediction of either a new incident myocardial infarction or a stroke. Logistic regression modeling and the area under the receiver operating characteristic curve (ROC area) were used to quantify the predictive value of the established risk factors and the added value of IMT. RESULTS: The ROC area of a model with age and sex only was 0.65 (95% CI, 0.62 to 0.69). Independent risk factors were previous myocardial infarction and stroke, diabetes mellitus, smoking, systolic blood pressure, diastolic blood pressure, and total and HDL cholesterol levels. These risk factors increased the ROC area from 0.65 to 0.72 (95% CI, 0.69 to 0.75). This model correctly predicted 17% of all subjects with coronary heart disease and cerebrovascular disease. When common carotid IMT was added to the previous model, the ROC area increased to 0.75 (95% CI, 0.72 to 0.78). When only the IMT measurement was used, the ROC area was 0.71 (95% CI, 0.68 to 0.74), and 14% of all subjects were correctly predicted. There was no difference in ROC area when different measurement sites were used. CONCLUSIONS: Adding IMT to a risk function for coronary heart disease and cerebrovascular disease does not result in a substantial increase in the predictive value when used as a screening tool.

[Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report]. / Un fibroma uterino torto associato ad ernia inguinale intasata in gravidanza. Caso clinico.

The incidence of inguinal hernias in pregnancy is 1:1000 about. Much more frequent are uterine leiomyomas, reported in 0.5-2.6% cases. We describe a rare case of a 31 old woman at the 20th week of pregnancy affected with a torsion of uterine leiomyoma associated with right inguinal incarcerated hernia, operated urgently (myomectomy and Bassini inguinal plastic).