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Forensic Science International Jul 2024To summarize recent cases of fatal insulin poisoning both domestically and internationally, thereby offering valuable insights for the forensic identification of insulin...
PURPOSE
To summarize recent cases of fatal insulin poisoning both domestically and internationally, thereby offering valuable insights for the forensic identification of insulin overdose cases.
METHODS
Literature published since 2000 on fatal insulin overdose were systematically searched and screened. Data encompassing variables such as year, age, sex, cause of death, scene conditions, occupations, medical histories of victims and perpetrators, autopsy timing, dosage and administration methods, forensic pathology, and toxicological analysis, were compiled for rigorous statistical analysis.
RESULTS
Among the 29 fatal cases of insulin poisoning, suicides and homicides accounted for 55.2 % and 41.4 %, respectively. Precisely 34.5 % of victims or perpetrators were associated with the medical industry, 27.6 % had diabetes, and 24.1 % had mental illnesses such as depression. Intravenous injection resulted in quicker death than did subcutaneous injection. In some cases, immunohistochemical staining of insulin and protamine at injection sites yielded positive results. The average molar ratio of insulin to C-peptide in post-mortem blood was 13.76 ± 5.167, indicating a significant diagnostic value for insulin poisoning.
CONCLUSION
Assessment of cases of fatal insulin overdose should be thorough, incorporating case investigation, scene examination, medical records review, autopsy findings, pathological examinations, and laboratory tests, alongside considering the condition of the body and timing of death autopsy. Using mass spectrometry to detect insulin proves valuable, particularly in cases of poor body preservation.
PubMed: 38954875
DOI: 10.1016/j.forsciint.2024.112126 -
JMIR Perioperative Medicine Jul 2024Exposure to opioids after surgery is the initial contact for some people who develop chronic opioid use disorder. Hence, effective postoperative pain management, with...
BACKGROUND
Exposure to opioids after surgery is the initial contact for some people who develop chronic opioid use disorder. Hence, effective postoperative pain management, with less reliance on opioids, is critical. The Perioperative Opioid Quality Improvement (POQI) program developed (1) a digital health platform leveraging patient-survey-reported risk factors and (2) a postsurgical pain risk stratification algorithm to personalize perioperative care by integrating several commercially available digital health solutions into a combined platform. Development was reduced in scope by the COVID-19 pandemic.
OBJECTIVE
This pilot study aims to assess the screening performance of the risk algorithm, quantify the use of the POQI platform, and evaluate clinicians' and patients' perceptions of its utility and benefit.
METHODS
A POQI platform prototype was implemented in a quality improvement initiative at a Canadian tertiary care center and evaluated from January to September 2022. After surgical booking, a preliminary risk stratification algorithm was applied to health history questionnaire responses. The estimated risk guided the patient assignment to a care pathway based on low or high risk for persistent pain and opioid use. Demographic, procedural, and medication administration data were extracted retrospectively from the electronic medical record. Postoperative inpatient opioid use of >90 morphine milligram equivalents per day was the outcome used to assess algorithm performance. Data were summarized and compared between the low- and high-risk groups. POQI use was assessed by completed surveys on postoperative days 7, 14, 30, 60, 90, and 120. Semistructured patient and clinician interviews provided qualitative feedback on the platform.
RESULTS
Overall, 276 eligible patients were admitted for colorectal procedures. The risk algorithm stratified 203 (73.6%) as the low-risk group and 73 (26.4%) as the high-risk group. Among the 214 (77.5%) patients with available data, high-risk patients were younger than low-risk patients (age: median 53, IQR 40-65 years, vs median 59, IQR 49-69 years, median difference five years, 95% CI 1-9; P=.02) and were more often female patients (45/73, 62% vs 80/203, 39.4%; odds ratio 2.5, 95% CI 1.4-4.5; P=.002). The risk stratification was reasonably specific (true negative rate=144/200, 72%) but not sensitive (true positive rate=10/31, 32%). Only 39.7% (85/214) patients completed any postoperative quality of recovery questionnaires (only 14, 6.5% patients beyond 60 days after surgery), and 22.9% (49/214) completed a postdischarge medication survey. Interviewed participants welcomed the initiative but noted usability issues and poor platform education.
CONCLUSIONS
An initial POQI platform prototype was deployed operationally; the risk algorithm had reasonable specificity but poor sensitivity. There was a significant loss to follow-up in postdischarge survey completion. Clinicians and patients appreciated the potential impact of preemptively addressing opioid exposure but expressed shortcomings in the platform's design and implementation. Iterative platform redesign with additional features and reevaluation are required before broader implementation.
PubMed: 38954808
DOI: 10.2196/54926 -
Urogynecology (Philadelphia, Pa.) Jun 2024Guideline-recommended medications for overactive bladder and urge urinary incontinence (OAB/UUI) are effective but have high costs and side effects. Little is known...
IMPORTANCE
Guideline-recommended medications for overactive bladder and urge urinary incontinence (OAB/UUI) are effective but have high costs and side effects. Little is known about patient concerns regarding these medications when prescribed by their primary care providers (PCPs).
OBJECTIVE
The aim of the study was to describe PCP-patient interactions when prescribing medications for OAB/UUI, specifically clinical concerns, cost and authorization issues, and mode of communication for these interactions.
STUDY DESIGN
Using electronic health records, we identified a retrospective cohort of women aged 18-89 years who were prescribed a medication for OAB/UUI during a primary care office visit from 2017 to 2018. We examined the electronic health record from initial prescription through 15 subsequent months for documentation of prior authorization requests and patient concerns about cost, side effects, or ineffectiveness. The association of patient demographics, comorbidity, and medication class with these concerns was examined with logistic regression models.
RESULTS
Overall, 46.2% of patients (n = 123) had 1 or more OAB/UUI medication concerns, and 52 reported outside an office visit. Only higher comorbidity was associated with reduced concern of any type. Although the overall percent age of patients reporting concerns was similar by medication type, the patterns of concern type varied. Compared with those taking short-acting antimuscarinics, patients taking long-acting antimuscarinics other than oxybutynin were less likely to have side effect concerns (adjusted odds ratio 0.35, 95% CI 0.16-0.78) and more likely to have cost concerns (adjusted odds ratio 5.10, 95% CI 1.53-17.03).
CONCLUSIONS
Patient concerns regarding OAB/UUI medications were common in primary care practices and frequently reported outside of office visits. However, the patterns of concerns (cost vs side effects) varied between medication classes.
PubMed: 38954604
DOI: 10.1097/SPV.0000000000001540 -
Journal of Obstetrics and Gynaecology :... Dec 2024Adolescent pregnancy is defined as pregnancy occurring in young women between the ages of 10 and 19 years. Adolescent pregnancies, which are among the social... (Comparative Study)
Comparative Study
BACKGROUND
Adolescent pregnancy is defined as pregnancy occurring in young women between the ages of 10 and 19 years. Adolescent pregnancies, which are among the social healthcare concerns in developed and developing countries, have negative effects on maternal and infant health. Pregnancy in adolescence puts the health of both the mother and child at risk, as adolescent pregnancies have higher rates of eclampsia, systemic infection, low birth weight, and preterm delivery compared to other pregnancies. In this study, the effects of education level, smoking, and marital status on maternal and foetal outcomes in adolescent pregnancies were evaluated.
METHODS
The records of a total of 960 pregnant women (480 pregnant adolescents aged 15-19 years and 480 pregnant adult women aged 20-26 years) were examined retrospectively. The demographic data of the groups and maternal and foetal outcomes of the pregnancies were compared. A logistic regression model was established as a statistical method for reducing confounding effects.
RESULTS
Unmarried women were statistically significantly more prevalent in the adolescent group (38.3% vs. 7.3%). Among the considered risk factors, preeclampsia (2.9% vs. 0.8%) and smoking (29.8% vs. 9.8%) were statistically significantly more common in the adolescent group. When the groups were compared in terms of risk factors in pregnancy, it was found that pregnancy in adolescence was associated with a 3.04-fold higher risk of smoking, 5.25-fold higher risk of being unmarried, 3.50-fold higher risk of preeclampsia, and 1.70-fold higher risk of intrauterine growth retardation (IUGR).
CONCLUSIONS
This study demonstrates an increased risk of preeclampsia, IUGR, and smoking during pregnancy in adolescent pregnant women. These findings can be used to identify adolescent pregnancies requiring specific assistance and to take measures to reduce the probability of adverse outcomes.
Topics: Humans; Female; Pregnancy; Pregnancy in Adolescence; Adolescent; Retrospective Studies; Young Adult; Turkey; Adult; Risk Factors; Smoking; Pregnancy Outcome; Pre-Eclampsia; Marital Status; Educational Status; Pregnancy Complications
PubMed: 38954590
DOI: 10.1080/01443615.2024.2364787 -
IEEE Journal of Biomedical and Health... Jul 2024The real-world Electronic Health Records (EHRs) present irregularities due to changes in the patient's health status, resulting in various time intervals between...
The real-world Electronic Health Records (EHRs) present irregularities due to changes in the patient's health status, resulting in various time intervals between observations and different physiological variables examined at each observation point. There have been recent applications of Transformer-based models in the field of irregular time series. However, the full attention mechanism in Transformer overly focuses on distant information, ignoring the short-term correlations of the condition. Thereby, the model is not able to capture localized changes or short-term fluctuations in patients' conditions. Therefore, we propose a novel end-to-end Deformable Neighborhood Attention Transformer (DNA-T) for irregular medical time series. The DNA-T captures local features by dynamically adjusting the receptive field of attention and aggregating relevant deformable neighborhoods in irregular time series. Specifically, we design a Deformable Neighborhood Attention (DNA) module that enables the network to attend to relevant neighborhoods by drifting the receiving field of neighborhood attention. The DNA enhances the model's sensitivity to local information and representation of local features, thereby capturing the correlation of localized changes in patients' conditions. We conduct extensive experiments to validate the effectiveness of DNA-T, outperforming existing state-of-the-art methods in predicting the mortality risk of patients. Moreover, we visualize an example to validate the effectiveness of the proposed DNA.
Topics: Humans; Electronic Health Records; Algorithms
PubMed: 38954562
DOI: 10.1109/JBHI.2024.3395446 -
JMIR Research Protocols Jul 2024Starting in 2010, the epidermal growth factor receptor (EGFR) kinase inhibitors erlotinib and gefitinib were introduced into routine use in Aotearoa New Zealand (NZ) for...
Erlotinib or Gefitinib for Treating Advanced Epidermal Growth Factor Receptor Mutation-Positive Lung Cancer in Aotearoa New Zealand: Protocol for a National Whole-of-Patient-Population Retrospective Cohort Study and Results of a Validation Substudy.
BACKGROUND
Starting in 2010, the epidermal growth factor receptor (EGFR) kinase inhibitors erlotinib and gefitinib were introduced into routine use in Aotearoa New Zealand (NZ) for treating advanced lung cancer, but their impact in this setting is unknown.
OBJECTIVE
The study described in this protocol aims to understand the effectiveness and safety of these new personalized lung cancer treatments and the contributions made by concomitant medicines and other factors to adverse outcomes in the general NZ patient population. A substudy aimed to validate national electronic health databases as the data source and the methods for determining patient eligibility and identifying outcomes and variables.
METHODS
This study will include all NZ patients with advanced EGFR mutation-positive lung cancer who were first dispensed erlotinib or gefitinib before October 1, 2020, and followed until death or for at least 1 year. Routinely collected health administrative and clinical data will be collated from national electronic cancer registration, hospital discharge, mortality registration, and pharmaceutical dispensing databases by deterministic data linkage using National Health Index numbers. The primary effectiveness and safety outcomes will be time to treatment discontinuation and serious adverse events, respectively. The primary variable will be high-risk concomitant medicines use with erlotinib or gefitinib. For the validation substudy (n=100), data from clinical records were compared to those from national electronic health databases and analyzed by agreement analysis for categorical data and by paired 2-tailed t tests for numerical data.
RESULTS
In the validation substudy, national electronic health databases and clinical records agreed in determining patient eligibility and for identifying serious adverse events, high-risk concomitant medicines use, and other categorical data with overall agreement and κ statistic of >90% and >0.8000, respectively; for example, for the determination of patient eligibility, the comparison of proxy and standard eligibility criteria applied to national electronic health databases and clinical records, respectively, showed overall agreement and κ statistic of 96% and 0.8936, respectively. Dates for estimating time to treatment discontinuation and other numerical variables and outcomes showed small differences, mostly with nonsignificant P values and 95% CIs overlapping with zero difference; for example, for the dates of the first dispensing of erlotinib or gefitinib, national electronic health databases and clinical records differed on average by approximately 4 days with a nonsignificant P value of .33 and 95% CIs overlapping with zero difference. As of May 2024, the main study is ongoing.
CONCLUSIONS
A protocol is presented for a national whole-of-patient-population retrospective cohort study designed to describe the safety and effectiveness of erlotinib and gefitinib during their first decade of routine use in NZ for treating EGFR mutation-positive lung cancer. The validation substudy demonstrated the feasibility and validity of using national electronic health databases and the methods for determining patient eligibility and identifying the study outcomes and variables proposed in the study protocol.
TRIAL REGISTRATION
Australian New Zealand Clinical Trials Registry ACTRN12615000998549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368928.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)
DERR1-10.2196/51381.
Topics: Humans; Erlotinib Hydrochloride; Gefitinib; Lung Neoplasms; ErbB Receptors; Retrospective Studies; New Zealand; Mutation; Female; Male; Protein Kinase Inhibitors; Antineoplastic Agents; Cohort Studies; Middle Aged; Aged
PubMed: 38954434
DOI: 10.2196/51381 -
Drugs & Aging Jul 2024The objective of this review is to summarize and appraise the research methodology, emerging findings, and future directions in pharmacoepidemiologic studies assessing... (Review)
Review
The objective of this review is to summarize and appraise the research methodology, emerging findings, and future directions in pharmacoepidemiologic studies assessing the benefits and harms of pharmacotherapies in older adults with different levels of frailty. Older adults living with frailty are at elevated risk for poor health outcomes and adverse effects from pharmacotherapy. However, current evidence is limited due to the under-enrollment of frail older adults and the lack of validated frailty assessments in clinical trials. Recent advancements in measuring frailty in administrative claims and electronic health records (database-derived frailty scores) have enabled researchers to identify patients with frailty and to evaluate the heterogeneity of treatment effects by patients' frailty levels using routine health care data. When selecting a database-derived frailty score, researchers must consider the type of data (e.g., different coding systems), the length of the predictor assessment period, the extent of validation against clinically validated frailty measures, and the possibility of surveillance bias arising from unequal access to care. We reviewed 13 pharmacoepidemiologic studies published on PubMed from 2013 to 2023 that evaluated the benefits and harms of cardiovascular medications, diabetes medications, anti-neoplastic agents, antipsychotic medications, and vaccines by frailty levels. These studies suggest that, while greater frailty is positively associated with adverse treatment outcomes, older adults with frailty can still benefit from pharmacotherapy. Therefore, we recommend routine frailty subgroup analyses in pharmacoepidemiologic studies. Despite data and design limitations, the findings from such studies may be informative to tailor pharmacotherapy for older adults across the frailty spectrum.
PubMed: 38954400
DOI: 10.1007/s40266-024-01121-0 -
Cancer Causes & Control : CCC Jul 2024Sexual and gender minority (SGM) populations experience cancer treatment and survival disparities; however, inconsistent sexual orientation and gender identity (SOGI)...
PURPOSE
Sexual and gender minority (SGM) populations experience cancer treatment and survival disparities; however, inconsistent sexual orientation and gender identity (SOGI) data collection within clinical settings and the cancer surveillance system precludes population-based research toward health equity for this population. This qualitative study examined how hospital and central registry abstractors receive and interact with SOGI information and the challenges that they face in doing so.
METHODS
We conducted semi-structured interviews with 18 abstractors at five Surveillance, Epidemiology, and End Results (SEER) registries, as well as seven abstractors from commission on cancer (CoC)-accredited hospital programs in Iowa. Interviews were transcribed, cleaned, and coded using a combination of a priori and emergent codes. These codes were then used to conduct a descriptive analysis and to identify domains across the interviews.
RESULTS
Interviews revealed that abstractors had difficulty locating SOGI information in the medical record: this information was largely never recorded, and when included, was inconsistently/not uniformly located in the medical record. On occasion, abstractors reported situational recording of SOGI information when relevant to the patient's cancer diagnosis. Abstractors further noticed that, where reported, the source of SOGI information (i.e., patient, physician) is largely unknown.
CONCLUSION
Efforts are needed to ensure standardized implementation of the collection of SOGI variables within the clinical setting, such that this information can be collected by the central cancer registry system to support population-based equity research addressing LGBTQ + disparities.
PubMed: 38954307
DOI: 10.1007/s10552-024-01897-x -
Bulletin of Experimental Biology and... Jul 2024We studied the effect of Refralon on the electrophysiological properties of the supraventricular myocardium against the background of adrenergic (epinephrine) influence...
We studied the effect of Refralon on the electrophysiological properties of the supraventricular myocardium against the background of adrenergic (epinephrine) influence in the zone of the pulmonary veins, the area where 50-90% of atrial arrhythmias is triggered. The experiments were carried out on isolated tissue preparations of Wistar rats. The multichannel microelectrode array technique was used to record action potentials simultaneously in the atrium and in the ostium and distal parts of the pulmonary veins. Epinephrine application (12-50 nM) led to depolarization of the resting potential and the conduction block in the distal part of the pulmonary veins. Refralon (30 μg/kg) restored the resting potential in the distal part of the pulmonary veins. Against the background of epinephrine, Refralon did not significantly change the duration of the action potential at 90% repolarization in comparison with control. At the same time, the comparison drug E-4031 against the background of epinephrine significantly increased the duration of action potential in the atrium and in the ostium of the pulmonary veins, and sotalol increased it only in the ostium. Neither E-4031, nor sotalol restored conduction in their distal part. Refralon has a biphasic effect under conditions of adrenergic stimulation: the fast component is responsible for stabilizing the resting potential in the pulmonary vein and reduces the dispersion of action potential duration in the atrium and pulmonary vein and is also quickly washed away, and the slow component is responsible for the increase of the action potential duration and is slowly washed away.
PubMed: 38954299
DOI: 10.1007/s10517-024-06131-x -
Journal of Cancer Survivorship :... Jul 2024This study aimed to investigate the impact of nutritional status and frailty phenotype and the predictors of temporal changes on health-related quality of life (HRQoL)...
Factors influencing health-related quality of life in patients with bladder or kidney cancer: a prospective cohort study of the impact of nutritional status and frailty phenotype.
PURPOSE
This study aimed to investigate the impact of nutritional status and frailty phenotype and the predictors of temporal changes on health-related quality of life (HRQoL) of patients with bladder or kidney cancer.
METHODS
Frailty phenotype, Patient-Generated Subjective Global Assessment, and Quality-of-life questionnaire Core-30 were applied twice to patients diagnosed with bladder or kidney cancer. Patients also completed a sociodemographic questionnaire, and clinical data were collected from records.
RESULTS
Sixty-two individuals completed the study, mostly male, with a mean age of 62.5 (± 11.4) years. The median time of follow-up was 14.5 months. Role functioning, emotional functioning, and fatigue improved over time (p < 0.05). The factors that negatively affected the long-term quality of life summary score were being female, malnourished, pre-frail and frail, cancer treatment, performance status, and lower income. Using the multivariate model, being malnourished (β = - 7.25; 95% CI, - 10.78 to - 3.71; p < 0.001), frail (β = - 7.25; 95% CI, - 13.39 to - 1.11; p = 0.021), and each one-point increase in performance status (β = - 6.9; 95% CI, - 9.54 to - 4.26; p < 0.001), were the ones that most negatively impacted the HRQoL between the two assessments.
CONCLUSION
This study confirmed that frailty, nutritional status, and performance status are the main predictors of HRQoL of patients with bladder or kidney cancer over time.
IMPLICATIONS FOR CANCER SURVIVORS
These findings may be the first step towards highlighting the importance of preventing malnutrition and frailty, in favor of a better long-term QoL for cancer patients.
PubMed: 38954250
DOI: 10.1007/s11764-024-01637-9