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Medicine Feb 2024As the second leading cause of death and disability worldwide, stroke is mainly caused by atherosclerosis and cardiac embolism, particularly in older individuals.... (Review)
Review
INTRODUCTION
As the second leading cause of death and disability worldwide, stroke is mainly caused by atherosclerosis and cardiac embolism, particularly in older individuals. Nevertheless, in young and otherwise healthy individuals, the causes of stroke can be more diverse and may include conditions such as patent foramen ovale, vasculitis, coagulopathies, genetic factors, or other undetermined causes. Although these other causes of stroke account for a relatively small proportion compared to ischemic stroke, they are becoming increasingly common in clinical practice and deserve attention. Here, we present a rare female patient with polycythemia vera (PV) who was admitted to the hospital as a stroke patient without any previous medical history.
PATIENT CONCERNS
A 40-year-old young woman felt sudden dizziness and slow response. After 4 days of being admitted, she developed blurry vision on the right.
DIAGNOSES
Cranial magnetic resonance imaging revealed aberrant signals in the left temporal and parietal lobe, as well as multiple small focal signal abnormalities were observed in the left frontal lobe. Magnetic resonance angiography revealed partial stenosis of the left internal carotid artery. The patient's blood routine examination revealed a significant elevation in complete blood counts, particularly the increase in red blood cells, as well as prolonged clotting time. An abdominal ultrasound and abdomen computed tomography showed splenomegaly. The outcome of the genetic testing was positive for the Janus kinase JAK2 exon V617F mutation (JAK2/V617F). The patient was diagnosed with PV-related stroke.
INTERVENTIONS
The patient was treated with phlebotomy, cytoreductive therapy, and low-dose aspirin antiplatelet therapy and was regularly followed up in hematology and neurology clinics after discharge.
OUTCOMES
The patient's red blood cell, leukocyte, and thrombocyte counts had fully normalized, with her hemoglobin level measuring at 146 g/L and hematocrit value at 43%. Furthermore, there had been a significant improvement in neurological symptoms.
LESSONS
PV, a rare hematological disorder, can present with ischemic stroke as the initial performance, and the diagnosis mainly relies on routine blood tests, bone marrow biopsies, and genetic test. Therefore, clinicians should pay attention to PV, a low-prevalence disease, when encountering stroke in youth.
Topics: Female; Humans; Young Adult; Aged; Adolescent; Adult; Male; Polycythemia Vera; Ischemic Stroke; Janus Kinase 2; Bone Marrow; Mutation
PubMed: 38363912
DOI: 10.1097/MD.0000000000036953 -
JMIR Diabetes Mar 2024Diabetes and hypertension are some of the most prevalent and costly chronic conditions in the United States. However, outcomes continue to lag behind targets, creating...
BACKGROUND
Diabetes and hypertension are some of the most prevalent and costly chronic conditions in the United States. However, outcomes continue to lag behind targets, creating further risk of long-term complications, morbidity, and mortality for people living with these conditions. Furthermore, racial and ethnic disparities in glycemic and hypertension control persist. Flexible telehealth programs leveraging asynchronous care allow for increased provider access and more convenient follow-up, ultimately improving critical health outcomes across demographic groups.
OBJECTIVE
We aim to evaluate the 12-month clinical outcomes of participants in the 9amHealth web-based clinic for diabetes and hypertension. We hypothesized that participation in the 9amHealth program would be associated with significant improvements in glycemic and blood pressure (BP) control across a diverse group of individuals.
METHODS
We enrolled 95 patients in a completely web-based care clinic for diabetes and hypertension who received nutrition counseling, health coaching, and asynchronous physician consultations for medication prescribing. Patients received standard or cellular-connected glucose meters and BP cuffs in order to share data. Laboratory tests were completed either with at-home phlebotomy draws or a self-administered test kit. Patients' first and last hemoglobin A (HbA) and BP results over the 12-month period were compared, and analyses were repeated across race and ethnicity groups.
RESULTS
Among all 95 patients, the average HbA decreased by -1.0 (from 8.2% to 7.2%; P<.001) over 12 months of program participation. In those with a baseline HbA >8%, the average HbA decreased by -2.1 (from 10.2% to 8.1%; P<.001), and in those with a baseline HbA >9%, the average HbA decreased by -2.8 (from 11% to 8.2%; P<.001). Among participants who identified as a race or ethnicity other than White, the HbA decreased by -1.2 (from 8.6% to 7.4%, P=.001). Further examination of subgroups confirmed HbA lowering within each race or ethnicity group. In the overall population, the average systolic BP decreased by 17.7 mm Hg (P=.006) and the average diastolic BP decreased by 14.3 mm Hg (P=.002). Among participants self-identifying as a race or ethnicity other than White, the results similarly showed a decrease in BP (average reduction in systolic BP of 10 mm Hg and in diastolic BP of 9 mm Hg).
CONCLUSIONS
A fully web-based model leveraging all-asynchronous physician review and prescribing, combined with synchronous and asynchronous coaching and nutrition support, was associated with clinically meaningful improvement in HbA and BP control over a 12-month period among a diverse group of individuals. Further studies should prospectively evaluate the effectiveness of such models among larger populations, assess the longer-term sustainability of these outcomes, and explore financial models to make these types of programs broadly accessible.
PubMed: 38363585
DOI: 10.2196/53835 -
Journal of Hospital Medicine Apr 2024Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days...
BACKGROUND
Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure.
OBJECTIVE
To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes.
DESIGN, SETTINGS AND PARTICIPANTS
We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality.
MAIN OUTCOME AND MEASURES
We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups.
RESULTS
We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.
Topics: Humans; Child; Phlebotomy; Cross-Sectional Studies; Length of Stay; Pneumonia; Hospitals
PubMed: 38348499
DOI: 10.1002/jhm.13282 -
Saudi Journal of Kidney Diseases and... Jul 2023Pain at the injection site is one of the most common complaints in the clinic and is the most important symptom affecting the quality of life of hemodialysis (HD)... (Randomized Controlled Trial)
Randomized Controlled Trial
Comparing the Effect of Local Application of Peppermint and Cold Compresses on the Severity of Pain from Venipuncture in Dialysis Patients: A Parallel Randomized Clinical Trial Study.
Pain at the injection site is one of the most common complaints in the clinic and is the most important symptom affecting the quality of life of hemodialysis (HD) patients. The aim of this study was to determine the effect and compare the topical application of peppermint and cold compresses on the intensity of pain caused by the insertion of a needle into the fistula of HD patients. In this parallel randomized clinical trial, 99 HD patients were assigned to three groups receiving peppermint, a cold compress, or a control using six blocks. For the peppermint group, 20 min before the needle's insertion, a peppermint gel was used; for the cold compress group, an ice pack was used; and for the control group, the usual method was applied. The patients' pain was assessed with the Visual Analog Scale immediately after the needle's insertion. The results showed that after the intervention, the mean and standard deviation of the pain score in the intervention groups receiving peppermint (4.81 ± 1.13) or a cold compress (4.78 ± 1.13) were significantly less than those of the control group (8.42 ± 1.22) (P <0.001), but there was no statistically significant difference between the peppermint group and the cold compress group (P = 0.91). The use of peppermint, which is a cheap and uncomplicated herbal medicine, and a cold compress, which is easy to use and available, is recommended to reduce the severity of pain caused by venipuncture in HD patients.
Topics: Humans; Phlebotomy; Mentha piperita; Quality of Life; Renal Dialysis; Pain
PubMed: 38345583
DOI: 10.4103/1319-2442.395444 -
Journal of Clinical Apheresis Feb 2024Donor vein assessment for the selection of good quality veins is crucial for a successful apheresis procedure. This study intends to find out the effectiveness of a vein... (Observational Study)
Observational Study
INTRODUCTION
Donor vein assessment for the selection of good quality veins is crucial for a successful apheresis procedure. This study intends to find out the effectiveness of a vein assessment scoring tool (VST) used and found to be effective in selecting whole blood donors to reduce the difficulty in identifying good quality veins for the plateletpheresis procedure.
MATERIALS AND METHODS
This was a prospective observational study on platelet apheresis donors with the application of a VST consisting of three vein descriptor parameters (vein visibility, vein palpability, and vein size) with 5 Likert-type responses constituting a score of 0-12 for each arm. Two vein assessors independently evaluated the vein in both arms and marked their responses blinded from each other as well from the principal investigator. The scores were then calculated and analyzed at the end of the study for their association with phlebotomy and procedural outcomes.
RESULTS
A total of 190 donors were recruited. The mean scores for the arms with successful and failed phlebotomy were 9.1 and 9.4 (SD 2.3), respectively. The intra-class correlation Alpha Cronbach value was 0.834 and 0.837 for total scoring in the left arm and right arm, respectively, between the two assessors. Scores neither showed a correlation with other outcomes like low flow alarms, hematoma formation, number of phlebotomy attempts, and procedure completion.
CONCLUSION
The study showed that the vein score tool did not truly predict the phlebotomy outcome in apheresis donors, though there was a good degree of inter-assessor reliability.
Topics: Humans; Plateletpheresis; Reproducibility of Results; Veins; Blood Donors; Phlebotomy
PubMed: 38334167
DOI: 10.1002/jca.22106 -
CPT: Pharmacometrics & Systems... Mar 2024Polycythemia vera (PV) is a chronic myeloproliferative neoplasm characterized by excessive levels of platelets (PLT), white blood cells (WBC), and hematocrit (HCT)....
Polycythemia vera (PV) is a chronic myeloproliferative neoplasm characterized by excessive levels of platelets (PLT), white blood cells (WBC), and hematocrit (HCT). Givinostat (ITF2357) is a potent histone-deacetylase inhibitor that showed a good safety/efficacy profile in PV patients during phase I/II studies. A phase III clinical trial had been planned and an adaptive dosing protocol had been proposed where givinostat dose is iteratively adjusted every 28 days (one cycle) based on PLT, WBC, and HCT. As support, a simulation platform to evaluate and refine the proposed givinostat dose adjustment rules was developed. A population pharmacokinetic/pharmacodynamic model predicting the givinostat effects on PLT, WBC, and HCT in PV patients was developed and integrated with a control algorithm implementing the adaptive dosing protocol. Ten in silico trials in ten virtual PV patient populations were simulated 500 times. Considering an eight-treatment cycle horizon, reducing/increasing the givinostat daily dose by 25 mg/day step resulted in a higher percentage of patients with a complete hematological response (CHR), that is, PLT ≤400 × 10 /L, WBC ≤10 × 10 /L, and HCT < 45% without phlebotomies in the last three cycles, and a lower percentage of patients with grade II toxicity events compared with 50 mg/day adjustment steps. After the eighth cycle, 85% of patients were predicted to receive a dose ≥100 mg/day and 40.90% (95% prediction interval = [34, 48.05]) to show a CHR. These results were confirmed at the end of 12th, 18th, and 24th cycles, showing a stability of the response between the eighth and 24th cycles.
Topics: Humans; Carbamates; Polycythemia Vera; Computer Simulation
PubMed: 38327117
DOI: 10.1002/psp4.13087 -
NEJM Evidence Jun 2023BACKGROUND: Whether phlebotomy alone can adequately maintain target hematocrit in patients with low-risk polycythemia vera (PV) remains elusive. METHODS: In a phase 2... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND: Whether phlebotomy alone can adequately maintain target hematocrit in patients with low-risk polycythemia vera (PV) remains elusive. METHODS: In a phase 2 open-label randomized trial, we compared ropeginterferon alfa-2b (ropeg; 100 μg every 2 weeks) with phlebotomy only regarding maintenance of a median hematocrit level (≤45%) over 12 months in the absence of progressive disease (primary end point). In follow-up, crossover to the alternative treatment group was allowed if the primary end point was not met. RESULTS: In total, 127 patients were enrolled (ropeg: n=64; standard group: n=63). The primary end point was met in 81% and 51% in the ropeg and standard groups, respectively. Responders continued the assigned treatment until month 24 and maintained response in 83% and 59%, respectively (P=0.02). Ropeg responders less frequently experienced moderate/severe symptoms (33% vs. 67% in the standard group) and palpable splenomegaly (14% vs. 37%) and showed normalization of ferritin levels and blood counts. Nonresponders at 12 months crossed over to the standard (n=9) or ropeg (n=23) group; in patients switched to ropeg only, 7 of 23 met the response criteria in 12 months, and phlebotomy need was high (4.7 per patient per year). Discontinuation because of adverse events occurred in seven patients treated with ropeg. CONCLUSIONS: In this 24-month trial, ropeg was superior to phlebotomy alone in maintaining hematocrit on target. No dose-limiting side effects or toxicities were noted; 9.2% of patients on ropeg and no patients on standard treatment developed neutropenia. (Funded by AOP Health and others; ClinicalTrials.gov number, NCT03003325.)
Topics: Humans; Polycythemia Vera; Polycythemia; Thrombocytosis; Thrombosis; Leukocytosis
PubMed: 38320126
DOI: 10.1056/EVIDoa2200335 -
Clinical Advances in Hematology &... 2024Polycythemia vera is a Philadelphia chromosome-negative myeloproliferative neoplasm characterized by the clonal proliferation of hematopoietic cells, leading to the... (Review)
Review
Polycythemia vera is a Philadelphia chromosome-negative myeloproliferative neoplasm characterized by the clonal proliferation of hematopoietic cells, leading to the overproduction of erythrocytes and the elaboration of inflammatory cytokines. Management is aimed at reducing the risk of thromboembolic events, alleviating the symptom burden, decreasing splenomegaly, and potentially mitigating the risk of disease progression. Existing treatment options include therapeutic phlebotomy and cytoreductive agents including hydroxyurea, pegylated recombinant interferon alpha 2a, ropegylated recombinant interferon alpha 2b, and ruxolitinib. We review risk factors for both thrombotic events and disease progression in patients with polycythemia vera. We discuss existing and novel therapeutic approaches to mitigate the risk of disease-related complications and progression.
Topics: Humans; Polycythemia Vera; Goals; Erythrocytes; Risk Factors; Interferon alpha-2; Disease Progression
PubMed: 38294739
DOI: No ID Found -
BMC Nephrology Jan 2024Obstructive sleep apnea is a known risk factor for the progression of chronic kidney disease. To find early signs of the progression in subjects with obstructive sleep... (Observational Study)
Observational Study
PURPOSE
Obstructive sleep apnea is a known risk factor for the progression of chronic kidney disease. To find early signs of the progression in subjects with obstructive sleep apnea., we assessed the diurnal variation of kidney biomarkers.
METHODS
A prospective observational study was conducted at Kangwon National University Hospital, Chuncheon, South Korea. All participants underwent in-laboratory polysomnography and phlebotomy in the evening before the polysomnography and in the morning after the polysomnography. Kidney biomarkers, including serum creatinine, blood urea nitrogen, and serum cystatin C, were measured. Delta kidney biomarkers were calculated by subtracting the evening level of the biomarkers from the morning level.
RESULTS
Twenty-six of 50 participants had severe obstructive sleep apnea. Delta cystatin C was significantly correlated with apnea-hypopnea index, oxygen desaturation index, and total arousal index with coefficients of -0.314, -0.323, and -0.289, respectively. In participants without severe obstructive sleep apnea, the morning cystatin C level (0.84 ± 0.11 mg/L) was significantly higher than the evening cystatin C level (0.81 ± 0.11 mg/L) (P = 0.005). With severe obstructive sleep apnea, the cystatin C levels were not different between the morning (0.85 ± 0.11 mg/L) and the evening (0.85 ± 0.10 mg/L).
CONCLUSIONS
Cystatin C level was increased in the morning in participants without severe obstructive sleep apnea, but not in participants with severe obstructive sleep apnea.
Topics: Humans; Cystatin C; Sleep Apnea, Obstructive; Circadian Rhythm; Polysomnography; Biomarkers
PubMed: 38287274
DOI: 10.1186/s12882-024-03472-7 -
BMC Infectious Diseases Jan 2024Dried blood spot (DBS) testing provides an alternative to phlebotomy and addresses barriers to accessing healthcare experienced by some key populations. Large-scale...
BACKGROUND
Dried blood spot (DBS) testing provides an alternative to phlebotomy and addresses barriers to accessing healthcare experienced by some key populations. Large-scale evaluations of DBS testing programs are needed to understand their feasibility. This study evaluated the implementation of a state-wide DBS HIV and hepatitis C virus (HCV) testing pilot.
METHODS
The New South Wales (NSW) DBS Pilot is an interventional cohort study of people testing for HIV antibody and/or HCV RNA from DBS samples in NSW, Australia. Participants at risk of HIV/HCV participated in testing via: 1) self-registration online with a DBS collection kit delivered and returned by conventional postal service; or 2) assisted DBS sample collection at 36 community health sites (including drug treatment and harm-minimisation services) and prisons. Participants received results by text (HIV antibody/ HCV RNA not detected) or a healthcare provider (HIV antibody/ HCV RNA detected). The RE-AIM framework was used to evaluate reach, effectiveness, adoption, and implementation.
RESULTS
Reach: Between November 2016 and December 2020, 7,392 individuals were tested for HIV and/or HCV (21% self-registration, 34% assisted in community, and 45% assisted in prison).
EFFECTIVENESS
Of 6,922 people tested for HIV (19% men who have sex with men, 13% living outside major cities, 21% born outside Australia), 51% (3,521/6,922) had no HIV test in the past two years, 0.1% (10/6,922) were newly diagnosed with HIV, and 80% (8/10) initiated HIV treatment within six months. Of 5,960 people tested for HCV (24% women, 35% Aboriginal and/or Torres Strait Islander, 55% recently injected drugs), 15% had detectable HCV RNA (878/5,960), and 45% (393/878) initiated treatment within six months. Adoption: By the end of 2020, DBS via assisted registration was available at 36 community sites and 21 prisons.
IMPLEMENTATION
90% of DBS cards arriving at the laboratory had the three full spots required for testing; the proportion was higher in assisted (94%) compared to online (76%) registration.
CONCLUSIONS
This study demonstrated the feasibility of DBS testing for HIV and HCV in key populations including Aboriginal and Torres Strait Islander peoples, men who have sex with men, people who inject drugs, and demonstrated the utility of DBS in the prison setting.
Topics: Male; Humans; Female; New South Wales; Cohort Studies; Dried Blood Spot Testing; Homosexuality, Male; Sensitivity and Specificity; Sexual and Gender Minorities; Hepatitis C; Hepacivirus; RNA, Viral; HIV Antibodies; HIV-1; HIV Infections
PubMed: 38287234
DOI: 10.1186/s12879-024-08989-8