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JAMA Cardiology Jun 2024The sustainable effectiveness and safety of a nonphysician community health care practitioner-led intensive blood pressure intervention on cardiovascular disease have...
IMPORTANCE
The sustainable effectiveness and safety of a nonphysician community health care practitioner-led intensive blood pressure intervention on cardiovascular disease have not, to the authors' knowledge, been studied, especially in the older adult population.
OBJECTIVE
To evaluate such a multifaceted model with a more stringent blood pressure treatment goal (<130/80 mm Hg) among patients aged 60 years and older with hypertension.
DESIGN, SETTING, AND PARTICIPANTS
This was a 48-month follow-up study of the China Rural Hypertension Control Project (CRHCP), an open-cluster randomized clinical trial, conducted from 2018 to 2023. Participants 60 years and older and younger than 60 years with a diagnosis of hypertension from the CRHCP trial were included for analysis. Individuals were recruited from 326 villages in rural China.
INTERVENTIONS
The well-trained, nonphysician, community health care practitioner implemented a multifaceted intervention program (eg, initiation or titration of antihypertensive medications) to achieve a blood pressure level of less than 130/80 mm Hg, supervised by primary care physicians.
MAIN OUTCOMES AND MEASURES
Cardiovascular disease (a composite of myocardial infarction, stroke, heart failure requiring hospitalization, and cardiovascular disease death).
RESULTS
A total of 22 386 individuals 60 years and older with hypertension and 11 609 individuals younger than 60 years with hypertension were included in the analysis. The mean (SD) age of the participants was 63.0 (9.0) years and included 20 825 females (61.3%). Among the older individuals with hypertension, a total of 11 289 patients were randomly assigned to the intervention group and 11 097 to the usual-care group. During a median (IQR) of 4.0 (4.0-4.1) years, there was a significantly lower rate of total cardiovascular disease (1133 [2.7%] vs 1433 [3.5%] per year; hazard ratio [HR], 0.75; 95% CI, 0.69-0.81; P < .001) and all-cause mortality (1111 [2.5%] vs 1210 [2.8%] per year; HR, 0.90; 95% CI, 0.83-0.98; P = .01) in the intervention group than in the usual-care group. For patients younger than 60 years, the risk reductions were also significant for total cardiovascular disease (HR, 0.64; 95% CI, 0.56-0.75; P < .001), stroke (HR, 0.64; 95% CI, 0.55-0.76; P < .001), heart failure (HR, 0.39; 95% CI, 0.18-0.87; P = .02), and cardiovascular death (HR, 0.54; 95% CI, 0.37-0.77; P < .001), with all interaction P values for age groups greater than .05. In both age categories, the incidences of injurious falls, symptomatic hypotension, syncope, and the results for kidney outcomes did not differ significantly between groups.
CONCLUSIONS AND RELEVANCE
In both the aging and younger general population with hypertension, the nonphysician health care practitioner-led, multifaceted, intensive blood pressure intervention model could effectively and safely reduce the risk of cardiovascular disease and all-cause death.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03527719.
PubMed: 38888905
DOI: 10.1001/jamacardio.2024.1449 -
Heart (British Cardiac Society) Jun 2024
Topics: Humans; Male; Syncope; Electrocardiography; Acute Disease; Adult
PubMed: 38885970
DOI: 10.1136/heartjnl-2024-324070 -
Frontiers in Pediatrics 2024Vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) can be difficult to distinguish, given their similar clinical presentations. This study was conducted to...
BACKGROUND AND PURPOSE
Vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) can be difficult to distinguish, given their similar clinical presentations. This study was conducted to explore the clinical value of catecholamine levels in the differential diagnosis of VVS and PPS in children.
METHODS
This retrospective case-control study was conducted with data from children with VVS and PPS who underwent head-up tilt tests (HUTTs) at the Children's Hospital of Hebei Province between March 2021 and March 2023. The data collected were baseline clinical characteristics, HUTT results, serum catecholamine levels in the supine and upright positions, and 24 h urinary catecholamine concentrations. These variables were compared between the VVS and PPS groups.
RESULTS
From 328 potentially eligible cases, 54 (16.46%) cases of VVS and 24 (7.32%) cases of PPS were included in the analysis. No significant difference in age, sex, body mass index, or syncope frequency was observed between the VVS and PPS groups. The main predisposing factors for syncope were body position changes in the VSS group (83.33%) and emotional changes in the PPS group (41.67%). The episode duration was significantly shorter in the VSS group than in the PPS group (4.01 ± 1.20 vs. 24.06 ± 5.56 min, < 0.05). The recovery time was also shorter in the VVS group than in the PPS group (1.91 ± 0.85 vs. 8.62 ± 2.55 min, < 0.05). Relative to patients with PPS, those with VVS had significantly higher serum epinephrine (EP) levels in the upright position [199.35 (102.88, 575.00) vs. 147.40 (103.55, 227.25), < 0.05] and lower serum epinephrine levels in the supine position [72.70 (42.92, 122.85) vs. 114.50 (66.57, 227.50), < 0.05].
CONCLUSIONS
Serum EP levels have potential value in the differential diagnosis of VVS and PPS.
PubMed: 38884104
DOI: 10.3389/fped.2024.1281196 -
Frontiers in Pediatrics 2024Congenital Long QT Syndrome (LQTS) is common in a First Nations community in Northern British Columbia due to the founder variant p.V205M. Although well characterized...
A mild phenotype associated with p.V205M mediated long QT syndrome in First Nations children of Northern British Columbia: effect of additional variants and considerations for management.
INTRODUCTION
Congenital Long QT Syndrome (LQTS) is common in a First Nations community in Northern British Columbia due to the founder variant p.V205M. Although well characterized molecularly and clinically in adults, no data have been previously reported on the pediatric population. The phenotype in adults has been shown to be modified by a splice site variant in (p.L353L). The p.P479L metabolic variant, also common in Northern Indigenous populations, is associated with hypoglycemia and infant death. Since hypoglycemia can affect the corrected QT interval (QTc) and may confer risk for seizures (also associated with LQTS), we sought to determine the effect of all three variants on the LQTS phenotype in children within our First Nations cohort.
METHODS
As part of a larger study assessing those with LQTS and their relatives in a Northern BC First Nation, we assessed those entering the study from birth to age 18 years. We compared the corrected peak QTc and potential cardiac events (syncope/seizures) of 186 children from birth to 18 years, with and without the (p.V205M and p.L353L) and variants, alone and in combination. Linear and logistic regression and student -tests were applied as appropriate.
RESULTS
Only the p.V205M variant conferred a significant increase in peak QTc 23.8 ms ( < 0.001) above baseline, with females increased by 30.1 ms ( < 0.001) and males by 18.9 ms ( < 0.01). There was no evidence of interaction effects with the other two variants studied. Although the p.V205M variant was not significantly associated with syncope/seizures, the odds of having a seizure/syncope were significantly increased for those homozygous for p.P479L compared to homozygous wild type (Odds Ratio [OR]3.0 [95% confidence interval (CI) 1.2-7.7]; = 0.019).
CONCLUSION
While the p.V205M variant prolongs the peak QTc, especially in females, the p.P479L variant is more strongly associated with loss of consciousness events. These findings suggest that effect of the p.V205M variant is mild in this cohort, which may have implications for standard management. Our findings also suggest the p.P479L variant is a risk factor for seizures and possibly syncope, which may mimic a long QT phenotype.
PubMed: 38884101
DOI: 10.3389/fped.2024.1394105 -
MedRxiv : the Preprint Server For... Jun 2024To describe the distribution of alcohol and drug involvement in injurious falls by location and subtype of fall.
OBJECTIVE
To describe the distribution of alcohol and drug involvement in injurious falls by location and subtype of fall.
METHODS
Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset we identified 1,854,909 patients injured from falls requiring an Emergency Medical Services (EMS) response and determined the fall location (e.g. indoors or on street/sidewalk) and the EMS clinician's notation of alcohol or drug involvement. We analyzed substance involvement by fall subtype, location of fall and patient demographics.
RESULTS
Overall, for 7.4% of injurious falls there was a notation of substance use: 6.5% for alcohol alone, 0.6% for drugs and 0.3% for alcohol and drugs. 21.2% of falls that occurred on a street or sidewalk had a notation of substance use; alcohol use alone for 18.5% of falls, drugs alone for 1.7% of falls and alcohol and drugs for 0.9% of falls. Substance use prevalence was highest, at 30.3%, in the age group 21 to 64 years, for falls occurring on streets and sidewalks, without syncope or heat illness as contributing factors; alcohol use alone for 26.3%, drugs alone for 2.6%, and alcohol and drugs for 1.4%. Reported substance use involvement was more frequent for men compared to women for each location type.
CONCLUSIONS
Overall, 1-in-5 injurious falls on streets and sidewalks and requiring EMS attention involved substance use, and these numbers likely underestimate the true burden. As cities seek to expand nightlife districts, design strategies to protect pedestrians from falls should be enacted.
PubMed: 38883717
DOI: 10.1101/2024.06.03.24308063 -
Cureus May 2024A Dieulafoy lesion is an abnormal artery located in the gastric submucosa that represents a rare cause of upper gastrointestinal bleeding. These lesions typically...
A Dieulafoy lesion is an abnormal artery located in the gastric submucosa that represents a rare cause of upper gastrointestinal bleeding. These lesions typically present as massive hemorrhages in older patients, with multiple medical comorbidities. The lesions are diagnosed with endoscopy and treated with hemostasis by clip placement or coagulation. This case report is that of a rare presentation of this rare condition in a younger 18-year-old patient with no medical comorbidities. He presented with hematemesis, melena, and syncope in the setting of ibuprofen self-treatment for a recent upper viral illness. This medication use is a proposed inciting factor for the bleeding lesion, though he had a history of a splenic artery embolization following a remote motor vehicle accident, which could represent a mechanism for a rare acquired lesion. A gastroenterologist was consulted and assisted in the diagnosis and management of this patient. His lesion was identified and treated within 24 hours of his presentation.
PubMed: 38883023
DOI: 10.7759/cureus.60513 -
SAGE Open Medical Case Reports 2024Subarachnoid hemorrhage is a neurological emergency in which arterial blood accumulates in the subarachnoid space with cerebral aneurysmal rupture being the most common...
Subarachnoid hemorrhage is a neurological emergency in which arterial blood accumulates in the subarachnoid space with cerebral aneurysmal rupture being the most common cause. Subarachnoid hemorrhage is often misdiagnosed in the emergency department and mortality rates range from 8% to 67%. It may be the manifestation of the chronicity of the migraine. The difference in severity or quality compared to previous headaches, and other symptoms, particularly neck stiffness, but also seizure, syncope, focal neurological deficit, and vomiting are the key factors differentiating subarachnoid hemorrhage from the migraine. We report a case of a 37-year-old female with a previous history of migraines who presented with acute onset of excruciating headaches in the occiput associated with nausea, vomiting, and photophobia in whom a non-contrast computed tomography scan of the head showed hyper-densities involving the bilateral cerebral cortical sulcus and Sylvian fissure and the cerebral angiography showed a complex aneurysm in anterior communicating artery.
PubMed: 38881976
DOI: 10.1177/2050313X241261012 -
Practical Neurology Jun 2024Neurologists encounter a range of neurological disorders triggered by head and neck movement, reflecting an array of underlying pathologies and producing diverse... (Review)
Review
Neurologists encounter a range of neurological disorders triggered by head and neck movement, reflecting an array of underlying pathologies and producing diverse symptoms. This article provides a practically orientated review of 14 disorders and how to diagnose and manage them, including common disorders such as benign paroxysmal positional vertigo and uncommon entities such as arterial compression syndromes leading to stroke or syncope, mobile intraventricular masses and medication withdrawal states. The article considers atypical scenarios including unusual manifestations and important mimics and discusses controversial entities, as well as the risk of misattributing symptoms based on incidental imaging abnormalities. Guidelines are referenced where they exist, while in rarer situations, approaches taken in published cases are described, with the acknowledgement that management decisions are at the clinician's discretion.
PubMed: 38876781
DOI: 10.1136/pn-2024-004160 -
European Journal of Emergency Medicine... Aug 2024The European Society of Cardiology issued updated syncope guidelines in 2018 which included recommendations for managing syncope in the emergency department (ED)...
The European Society of Cardiology issued updated syncope guidelines in 2018 which included recommendations for managing syncope in the emergency department (ED) setting. However, these guidelines lack detailed process-oriented instructions regarding the fact that ED syncope patients initially present with a transient loss of consciousness (TLOC), which can have a broad spectrum of causes. This study aims to establish a European consensus on the general process of the workup and care for patients with suspected syncope and provides rules for sufficient and systematic management of the broad group of syncope (initially presenting as TLOC) patients in the ED. A variety of European diagnostic and therapeutic standards for syncope patients were reviewed and summarized in three rounds of a modified Delphi process by the European Society for Emergency Medicine syncope group. Based on a consensus statement, a detailed process pathway is created. The primary outcome of this work is the presentation of a universal process pathway for the structured management of syncope patients in European EDs. The here presented extended event process chain (eEPC) summarizes and homogenizes the process management of European ED syncope patients. Additionally, an exemplary translation of the eEPC into a practice-based flowchart algorithm, which can be used as an example for practical use in the ED, is provided in this work. Syncope patients, initially presenting with TLOC, are common and pose challenges in the ED. Despite variations in process management across Europe, the development of a universally applicable syncope eEPC in the ED was successfully achieved. Key features of the consensus and eEPC include ruling out life-threatening causes, distinguishing syncope from nonsyncopal TLOCs, employing syncope risk stratification categories and based on this, making informed decisions regarding admission or discharge.
Topics: Humans; Syncope; Emergency Service, Hospital; Consensus; Europe; Delphi Technique; Algorithms
PubMed: 38874507
DOI: 10.1097/MEJ.0000000000001146 -
Europace : European Pacing,... Jun 2024Ventricular backup leads may be considered in selected patients with His bundle pacing (HBP), but it remains unknown to what extent this is useful. A total of 184 HBP...
Ventricular backup leads may be considered in selected patients with His bundle pacing (HBP), but it remains unknown to what extent this is useful. A total of 184 HBP patients were studied. At last follow-up, 147(79.9%) patients retained His bundle capture at programmed output. HBP lead revision was performed in 5/36(13.9%) patients without a backup lead and in 3/148(2.0%) patients with a backup lead (p=0.008). One patient without a backup lead had syncope due to atrial oversensing. Thus, implantation of ventricular backup leads may avoid lead revision and adverse events in selected HBP patients.
PubMed: 38874449
DOI: 10.1093/europace/euae168