Utility of irritable bowel syndrome subtypes and most troublesome symptom in predicting disease impact and burden.

BACKGROUND: Little is known about the characteristics of individuals with irritable bowel syndrome (IBS) according to stool subtype or the most troublesome symptom reported by the individual, or whether these are useful in predicting the impact of IBS. METHODS: We collected demographic, gastrointestinal, and psychological symptoms, healthcare usage and direct healthcare costs, impact on work and activities of daily living, and quality of life data from individuals with Rome IV-defined IBS. KEY RESULTS: We recruited 752 people with Rome IV IBS. Individuals with IBS-D reported a poorer disease-specific quality of life than those with IBS-C or IBS-M (mean (SD) IBS-QOL 45.3 (23.0) for IBS-D, vs. 52.3 (19.9) for IBS-C, vs. 49.4 (22.0) for IBS-M, p = 0.005). Mean (SD) IBS-QOL scores were also lower amongst those who reported diarrhea (44.8 (22.3)) or urgency (44.6 (22.3)) as their most troublesome symptom, compared with those reporting abdominal pain (52.2 (22.9)), constipation (49.5 (21.8)), or abdominal bloating or distension (50.4 (21.3)). However, there were no differences in mean EQ-5D scores, IBS severity, levels of anxiety, depression, somatoform symptom-reporting, or gastrointestinal symptom-specific anxiety. Direct healthcare costs of IBS were similar across all subtypes and all most troublesome symptom groups, although some differences in work productivity and social leisure activities were detected. CONCLUSIONS AND INFERENCES: There appears to be limited variation in the characteristics of individuals with Rome IV IBS based on both stool subtypes and most troublesome symptom reported, suggesting that gastrointestinal symptoms alone have limited ability to predict disease impact and burden.

Direct oral anticoagulant use in hospitalized patients with atrial fibrillation across body mass index categories: design and rationale for a retrospective cohort study.

Background: Atrial fibrillation (AF) and obesity are common conditions globally; yet, there remains suboptimal pharmacological management contributing to high rates of hospitalization in patients with AF. The altered pathophysiology of both obese and underweight individuals may influence the pharmacology of medications, including those used to manage AF. This, in turn, increases the risk of adverse events and impacts patient risk for stroke and rehospitalization. Despite the well-established complications of obesity, research investigating the relationship between obesity and AF is scant. Objectives: The primary aim of this study is to describe cardiovascular-related hospitalization in AF patients according to BMI categories. A secondary aim is to describe anticoagulant and antiarrhythmic prescribing practice patterns in patients with AF, according to the BMI category. Design: A retrospective, exploratory descriptive observational cohort study, using routinely collected electronic medical record data from five public hospitals within a single health district, with a population dominantly that is culturally and linguistically diverse, and has a low socioeconomic status. Methods and analysis: Data extraction will include a 24-month period (January 2017 to December 2018) with a 12-month follow-up. All adult (⩾18 years) patients at discharge diagnosed with AF, prescribed any oral anticoagulant and/or oral rate/rhythm control agent, will be eligible for inclusion. Ethics and dissemination: Ethics approval from the health district and the University of Wollongong has been granted. Findings will seek to demonstrate associations between management strategies and patient outcomes, as well as describe patterns of acute care management from prescribers. These data will be used to inform and generate hypotheses for large-scale studies examining the impact of body weight on anticoagulation prescribing at national and global scales.

Background: Across the world, two of the most common conditions include obesity and a heart disease that causes irregular heartbeat which is known as Atrial Fibrillation (AF). As a result of the excessive over or underweight of an individual with AF, can affect how some of the medications used manage AF work, in turn potentially affecting their health. Purpose: The main purpose of this study is to describe how often people with AF end up in the hospital because of heart-related problems based on their weight category. We also want to describe how doctors prescribe blood thinners and medicines that control the heart rhythm, in patients with AF based on their body weight. Design and method: To do this we will examine old electronic medical records over a two-year period, from January 2017 to December 2018 from five public hospitals, and we will see what happens after one year if they were hospitalised. These hospitals serve a diverse population with a mix of languages and cultures and are low-income earning households. We will only examine the electronic medical records of adults (18 years and over) who were diagnosed with AF and were prescribed blood thinners and/or heart rate or rhythm-controlling medications at the time of leaving the hospital. All adult (⩾18 years) patients at discharge diagnosed with AF, prescribed any oral anticoagulant and/or oral rate/rhythm control agent, will be eligible for inclusion. We have already gotten approval from the hospital and the University of Wollongong to conduct this study ethically. We anticipate that the results from this study will help us understand how different treatments and body weights are connected, and this knowledge can be used to plan bigger studies on a national and global scale to improve how we care for people with irregular heartbeats.

Designing a study that examines the use of blood thinners in hospitalised patients with irregular heartbeat at different body weights.

Frailty and oral anticoagulant prescription in adults with atrial fibrillation: A systematic review.

Objectives: The objectives of this study were to determine the prevalence of frailty in the context of atrial fibrillation (AF); to identify the most commonly used frailty instruments in AF; and to describe the effect of frailty on non-vitamin K oral anticoagulant (NOAC) prescription for stroke prevention in adults with AF. Methods: A systematic search of databases, including Medline, Embase, Web of Science, Cochrane Library, Scopus, and CINAHL, was conducted using search terms including "atrial fibrillation," "frailty," and "anticoagulation." A narrative synthesis was undertaken. Results: A total of 92 articles were screened, and 12 articles were included. The mean age of the participants (n = 212,111) was 82 years (range = 77-85 years) with 56% of participants identified as frail and 44% identified non-frail. A total of five different frailty instruments were identified: the Frailty Phenotype (FP; n = 5, 42%), the Clinical Frailty Scale (CFS; n = 4, 33%), Cumulative Deficit Model of Frailty (CDM; n = 1, 8%), Edmonton Frail Scale (n = 1, 8%) and the Resident Assessment Instrument - Minimum Data Set (RAI-MDS 2.0; n = 1, 8%). Frailty was identified as an important barrier to anticoagulant therapy with 52% of the frail population anticoagulated vs 67% non-frail. Conclusion: Frailty is an important consideration in anticoagulation decision making for stroke prevention in patients with AF. There is scope to improve frailty screening and treatment. Frailty status is an important risk marker and should be considered when evaluating stroke risk alongside congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65-74 years, sex category (CHA2DS2-VASc) and Hypertension, Abnormal renal/liver function, Stroke, Bleeding, Labile, Elderly, and Drugs (HAS-BLED) scores.

A Systematic Review and Meta-Analysis of Prevalence, Characteristics, and Impact of Mitral Annular Calcification on Outcomes After Transcatheter Aortic Valve Implantation.

There is a paucity of data on the prognostic impact of mitral annular calcification (MAC) in patients who underwent transcatheter aortic valve implantation (TAVI) with conflicting results being reported by the studies that are published. Therefore, we performed a meta-analysis to assess the short-term and long-term outcomes of MAC in patients after TAVI. Of 25,407 studies identified after the initial database search, 4 observational studies comprising 2,620 patients (2,030 patients in the nonsevere MAC arm and 590 patients in the severe MAC arm) were included in the final analysis. Compared with patients with nonsevere MAC, the severe MAC group was associated with significantly higher incidences of overall bleeding (0.75 [0.57 to 0.98], p = 0.03, I2 = 0%) at 30 days. However, no significant difference was observed between the 2 groups for the rest of the 30-day outcomes: all-cause mortality (0.79 [0.42 to 1.48], p = 0.46, I2 = 9%), myocardial infarction (1.62 [0.37 to 7.04], p = 0.52, I2 = 0%), cerebrovascular accident or stroke (1.22 [0.53 to 2.83], p = 0.64, I2 = 0%), acute kidney injury (1.48 [0.64 to 3.42], p = 0.35, I2 = 0%), and pacemaker implantation (0.70 [0.39 to 1.25], p = 0.23, I2 = 68%). Similarly, follow-up outcomes also showed no significant difference between the 2 groups: all-cause mortality (0.69 [0.46 to 1.03], p = 0.07, I2 = 44%), cardiovascular mortality (0.52 [0.24 to 1.13], p = 0.10, I2 = 70%) and stroke (0.83 [0.41 to 1.69], p = 0.61, I2 = 22%). The sensitivity analysis, however, demonstrated significant results for all-cause mortality (0.57 [0.39 to 0.84], p = 0.005, I2 = 7%) by removing the study by Okuno et al5 and cardiovascular mortality (0.41 [0.21 to 0.82], p = 0.01, I2 = 66%) by removing the study by Lak et al.7 In conclusion, our meta-analysis corroborates the notion that isolated MAC is not an independent predictor of long-term mortality after TAVI and determines severe MAC to be a predictor of mortality at follow-up because of the higher incidence of mitral valve dysfunction associated with it.

Practices, beliefs, and attitudes of clinicians in prescribing direct oral anticoagulants for obese adults with atrial fibrillation: a qualitative study.

BACKGROUND: Atrial fibrillation (AF) and obesity affect over 60 and 650 million people, respectively. AIM: This study aimed to explore clinician practices, beliefs, and attitudes towards the use of direct oral anticoagulants (DOACs) in obese adults (BMI ≥ 30 kg/m2) with AF. METHOD: Semi-structured interviews via video conference were conducted with multidisciplinary clinicians from across Australia, with expertise in DOAC use in adults with AF. Clinicians were invited to participate using purposive and snowball sampling techniques. Data were analysed in NVIVO using thematic analysis. RESULTS: Fifteen clinicians including cardiologists (n = 5), hospital and academic pharmacists (n = 5), general practitioners (n = 2), a haematologist, a neurologist and a clinical pharmacologist participated. Interviews were on average 31 ± 9 min. Key themes identified were: Health system factors in decision-making Disparities between rural and metropolitan geographic areas, availability of health services, and time limitations for in-patient decision-making, were described; Condition-related factors in decision-making Clinicians questioned the significance of obesity as part of decision-making due to the practical limitations of dose modification, and the rarity of the extremely obese cohort; Decision-making in the context of uncertainty Clinicians reported limited availability, reliability and awareness of primary evidence including limited guidance from clinical guidelines for DOAC use in obesity. CONCLUSION: This study highlights the complexity of decision-making for clinicians, due to the limited availability, reliability and awareness of evidence, the intrinsic complexity of the obese cohort and limited guidance from clinical guidelines. This highlights the urgent need for contemporary research to improve the quality of evidence to guide informed shared decision-making.

Visual outcome of cataract surgery in a tertiary care teaching hospital.

Objectives: To review the visual outcomes after cataract surgery in a tertiary care teaching hospital, Isra University Hyderabad. Methods: This retrospective clinical study was carried out for six months at Isra University Hyderabad from December 2020-May 2021. Total patients included were 982. The data comprised of patients who underwent cataract surgery from Sept 2018 - Aug 2020. Individuals over 40 years were included and who returned for out-patient appointments. Visual acuity before and six weeks after cataract surgery were noted and categorized according to World Health Organization criteria (i-e Good, Moderate and Poor).. Data analysis was done with the help of SPSS version 22.0. Results: Out of 982 patients who underwent Phacoemulsification at Isra University Hospital, the operated eyes were 483 right and 499 left respectively. Meanwhile, 966 had good visual acuity six weeks after the surgery, while 16 had moderate visual acuity noted after six weeks. Conclusion: Clinical audit of cataract surgeries by measuring visual acuity postoperatively is an excellent approach in improving the outcomes and maintaining the good care facilities at a tertiary care hospital.

Effectiveness of Direct Oral Anticoagulants in Obese Adults With Atrial Fibrillation: A Systematic Review of Systematic Reviews and Meta-Analysis.

Background: Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia. Obesity is an independent risk factor for AF. Anticoagulants have been strongly recommended by all international guidelines to prevent stroke. However, altered pathophysiology in obese adults may influence anticoagulant pharmacology. Direct oral anticoagulants (DOACs) in the context of obesity and AF have been examined in recent systematic reviews. Despite the similarities in included studies, their results and conclusions do not agree. Methods and Results: The protocol for this review was registered with PROSPERO (CRD42020181510). Seven key electronic databases were searched using search terms such as "atrial fibrillation," "obese,*" "overweight," "novel oral anticoagulant," "direct oral anticoagulant," "DOAC," "NOAC," "apixaban," dabigatran," "rivaroxaban," and "edoxaban" to locate published and unpublished studies. Only systematic reviews with meta-analyses that examined the effect of DOACs in overweight or obese adults with AF, published in the English language, were included. A total of 9,547 articles were initially retrieved. After removing the duplicates, title and abstract review and full-text review, five articles were included in the systematic review. From these only RCTs were included in the meta-analyses. There was disagreement within the published systematic reviews on DOACs in obesity. The results from our meta-analysis did not show any significant difference between all body mass index (BMI) groups for all outcomes at both 12 months and for the entire trial duration. Non-significant differences were seen among the different types of DOACs. Conclusion: There was no difference between the BMI classes in any of the outcomes assessed. This may be due to the limited number of people in the trial that were in the obese class, especially obese class III. There is a need for large prospective trials to confirm which DOACs are safe and efficacious in the obese class III adults and at which dose.

Comparison of efficacy of combination therapy of an Intravitreal injection of bevacizumab and photocoagulation versus Pan Retinal Photocoagulation alone in High risk Proliferative Diabetic Retinopathy.

OBJECTIVE: To compare efficacy of intravitreal bevacizumab augmented with Panretinal photocoagulation versus Panretinal photocoagulation alone in high risk proliferative diabetic retinopathy. METHODS: This is Randomized clinical control trial study conducted at ISRA University Hospital, Hyderabad from July 2018 to December 2018. A total of 76 eyes were randomized into two groups, 38 eyes undergone PRP plus intravitreal bevacizumab, while 38 eyes had PRP alone. Status of neovessels was assessed before and after treatment with the help of fundus fluorescein angiography. Neovessels at disc (NVD's) and neovessels elsewhere (NVE's) were assessed with the disc surface diameter. RESULTS: Seventy-six eyes were enrolled in this randomized clinical trial into two groups consecutively, that all completed the six months follow-up. In the PRP group mean BCVA (logMAR) worsened significantly from mean 0.30±0.07 to mean 0.40±0.04 at a 30th day and mean 0.40±0.04 at day 90. While BCVA become improved from 0.30±0.05 to 0.1±0.03 at week four and 0.1±0.02 at week 12 in PRP-Plus group. There was significant change in regression of NVES in PRP only group at week 4 is 2.25±0.75 (p=0.00004) and at 12 weeks 2.00±0.50 (p=0.00002), while in PRP + intravitreal bevacizumab group at 4th week was 1±0.5 (p =0.0001) and at 12th week was 0.75±0.25 (p=0.0001). CONCLUSION: Intravitreal Bevacizumab augmented with PRP is more effective in early regression of neovessels in high risk PDR patients.

Vitrectomy With Epiretinal Membrane Peeling Alone Verses Combined With Internal Limiting Membrane Peeling For Idiopathic Epiretinal Membrane.

BACKGROUND: The objective of this study was to determine and compare the structural and functional outcome in eyes who underwent Pars Plana Vitrectomy (PPV) with Epiretinal Membrane (ERM) peeling alone verses combined Epiretinal membrane with Internal Limiting Membrane (ILM) peeling for Idiopathic Epiretinal Membrane along with the rate of recurrence. METHODS: It was an interventional randomized study, conducted at Al-Ibrahaim Eye Hospital, Malir, Karachi, for two-year period from 1st August 2016 to 1st August 2018. A total of forty-four eyes of 44 patients were divided into two groups equally. Group A contains 22 eyes of 22 patients who underwent PPV with ERM peeling alone. Group B also contains 22 eyes of 22 patients who underwent PPV with ERM and ILM peeling. The follow up period was 1 year. The patients having best corrected visual acuity (BCVA) less than 6/18 or symptom of metamorphopsia were included in our study. The best corrected visual acuity (BCVA) and central macular thickness (CMT) were recorded at 3, 6 and 12-month follow up. RESULTS: In group A, the mean preoperative BCVA was 0.148 Log MAR (6/36 Snellen chart). The mean postoperative BCVA at 3, 6, and 12 months was 0.32 (6/18), 0.49 (6/12 P), and 0.50 (6/12), respectively. In group B, the mean preoperative best corrected visual acuity was 0.161 Log MAR (6/36 P Snellen chart). The mean postoperative BCVA at 3, 6, and 12 months was 0.36 (6/18 P), 0.51 (6/12), and 0.51 (6/12) respectively. The mean preoperative Central Macular Thickness (CMT) was 398.9 µm in group A and 384.7 µm in group B. The mean CMT in group A was 271.4, 236.7, and 229.8 µm at 3, 6, and 12 months, respectively. In group B, the mean CMT was 272.1, 233.8, and 220.4 µm at 3, 6, and 12 months, respectively. No significant difference was found in the visual outcome and central macular thickness between the two groups. CONCLUSIONS: Pars plana vitrectomy along with ERM peeling alone or combined with ILM peeling is a safe procedure. Both methods were effective functionally and structurally in the treatment of idiopathic ERM, however, no significant difference and no recurrence of ERM was observed in either group.

Giant Leiomyosarcoma Arising in Posterior Thigh: Management of a Rare Case.

Leiomyosarcoma, primarily a tumor of smooth muscle origin, frequently originates from the uterus, retroperitoneum, and intra-abdominal region. Rarely, the tumor may arise from the conjunctiva, inferior vena cava, or oral cavity. Here we report a case of a 65-year-old male patient who presented with a swelling in the posterior thigh for six months. The swelling was progressively increasing in size for the last two months. Examination of thigh showed a swelling of 20×30 cm in size, which was firm, non-compressible, immobile, and not transilluminating. CT scan showed no metastasis in the liver, lung, or bone. The histopathology report showed poorly differentiated leiomyosarcoma involving the muscles of the posterior compartment of the left thigh. The tumor was resected, and the patient was referred to rehabilitation clinic. Early diagnosis of such cases is essential to improve the outcome in patients as these tumors can metastasize early.

Addressing Multimorbidity and Polypharmacy in Individuals With Atrial Fibrillation.

PURPOSE OF REVIEW: The objectives of this review were to (1) discuss how multimorbidity and polypharmacy contributes to the complexity of management among individuals with AF and (2) identify any interventions to manage polypharmacy in relation to AF. RECENT FINDINGS: Based on the four landmark clinical trials of novel anticoagulants, the most common comorbidities with AF are hypertension, heart failure, diabetes, stroke and myocardial infarction. Polypharmacy was also found prevalent in 76.5% of patients with AF, with a median of six drugs per patient. Despite the consequences of polypharmacy in AF, there is very little evidence-based intervention designed to manage it. Hence, there is a need for further research to examine interventions to manage polypharmacy in relation to AF. Atrial fibrillation (AF) is the most common type of cardiac arrhythmia requiring treatment in adults. Due to the structural and/or electrophysiological abnormalities that occur in AF, patients are managed through the use of prophylactic anticoagulant and rate and/or rhythm control medications. However, these medications are considered high risk and can increase the chances of medication misadventure. Additionally, AF rarely occurs in isolation and is known to coexist with multiple other medical comorbidities, i.e. multimorbidity. This also increases the number of medications, i.e. polypharmacy and pill burden which results in treatment non-compliance to prescribed therapy.

Knowledge, Attitude and Practices Regarding Benign Testicular Disorders in the Educated Young Men of Pakistan.

Background It has been seen that despite the increasing incidence of benign testicular disorders (BTDs), little work has been done towards its awareness among the male populace. Also, the trend of not seeking help in this regard is concerning. In this study, we aim to better perceive the level of understanding and common practices regarding BTDs among educated young men. Methods A cross-sectional study was carried out among two groups of ages 14-20 and 21-28 years. The inclusion criterion was that of educated males in an urban setting. Data were collected through a standardized questionnaire using cluster sampling by independent interviewers. The questionnaire consisted of four parts dealing with demographics, knowledge, attitudes and practices. Chi-square and Mann-Whitney U test were used as the primary statistical tests. Results The sample population consisted of an equal number of participants between the ages of 14 and 20, and between 21 and 28 years (n = 200, 50%). About half the participants (n = 215, 53.8%) were not familiar with the term BTDs. The majority (n = 324, 78.8%) of participants were not aware of symptoms of BTDs. Three-fourth of the participants believed that the subject is considered taboo in Pakistan (n = 307, 73.6%) while a majority of participants (n = 340, 85%) believed media coverage can help spread awareness of BTDs. A huge number (n = 268, 67%) thought that BTDs can cause fertility problems while one-third of them would not perform testicular self-examination (TSE) in case of pain or swelling in the scrotal region (n = 119, 29.8). The level of education and age were significantly associated with the knowledge regarding symptoms and types of BTDs. Conclusion Knowledge of BTDs and practices of TSE in the young educated men of Karachi are alarmingly poor. Therefore, there is an urgent need to create awareness at all levels using different strategies and platforms.