Self-reported sleep disturbances among people who have had a stroke: a cross-sectional analysis
1. This cross-sectional cohort study determined that there was an increased relative risk of sleep disturbances in adults who have previously suffered a stroke compared to those who have not.Â
Evidence Rating Level: 2 (Good)
The experience of sleep disturbances for stroke patients is thought to be an important factor contributing to low mood, fatigue, impaired activities of daily living, and overall poorer post-stroke rehabilitation. Despite this, previous research has not adequately quantified the prevalence of sleep disturbances in this population. In this cross-sectional, population-based study, data was collected from the 2017-2018 Canadian Community Health Survey. 46,404 individuals were included in this study, 682 of whom reported a previous stroke. Four types of sleep disturbances were self-reported, including difficulty staying awake, abnormally short (<5 hr) or long (>9hr) sleep duration, difficulty falling or staying asleep, and lack of refreshing sleep. Authors adjusted for confounding variables, including diabetes status, age, sex, highest level of education, body mass index, physical activity level, and other self-reported chronic conditions. Relative risk was greater for all four types of sleep disturbances in the stroke group, with the greatest effect found on the ability to stay awake (RR 2.16, 95% confidence interval 1.59-2.94). It is important to note that this study does not define whether the increased prevalence of sleep disturbances in the stroke population existed prior to stroke occurrence; as such, no conclusions regarding causation can be made. Regardless, this study demonstrates an association between stroke and sleep disturbances and outlines the importance of screening for sleep issues in this patient population. Future research in this field may determine whether impaired sleep is more significant as a risk factor or result of stroke, as well as the extent to which impaired sleep impacts stroke rehabilitation.
Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting
1. Among patients aged 15-49 with early pregnancy loss, those diagnosed in the emergency department were less likely to receive surgical or medical management compared to those diagnosed in outpatient settings.Â
Evidence Rating Level: 2 (Good)
Early pregnancy loss (EPL), defined as a spontaneous abortion before 20 weeks gestation, is the most common form of pregnancy loss, affecting approximately 10% of clinically recognized pregnancies. Many patients present to the emergency department when EPL is suspected. Anecdotally, patients complain that care received in the ED for EPL is poorer for emotional support, follow-up, and access to surgical and medical management options (active management) compared to outpatient settings; however, no prior study has determined whether management for EPL differs between the ED and outpatient clinics. In this retrospective cohort study, a nationwide insurance claims database in the US, the IBM MarketScan Research Database, was used to collect data on 117,749 pregnant individuals aged 15-49 from 2015-2019, who presented to the emergency department or an outpatient clinic for the initial management of EPL. 17.7% of patients presented to the ED, while 82.3% presented to outpatient clinics. The adjusted odds ratio for receiving active vs. expectant management in the ED compared to outpatient clinics was 0.46 (95% CI 0.44-0.47). Complications within 6 weeks of EPL management differed between the two groups as well, with the ED group having a significantly greater risk of inpatient hospitalization, hemorrhage requiring transfusion, and intrauterine infection (p <0.001), though complication rates were low overall regardless of care setting. A limitation of this study is the use of the insurance claims database to collect data, as only patients with private insurance coverage were included, which accounts for just 62% of the US population. This in turn, may impact the generalizability of results to the total population. Overall, this study finds that patients with EPL cared for in the ED were less likely to receive active management compared to outpatient clinics. Further research may explore whether there are barriers present in emergency departments limiting the ability to provide patient-centered EPL care.
1. In this retrospective cohort study, rates of inferior vena cava (IVC) filter retrieval were improved when implanting physician teams adopted an active surveillance strategy.Â
Evidence Rating Level 2: (Good)
Retrievable inferior vena cava filters are effective tools for the prevention of venous thromboembolism-related morbidity and mortality when anticoagulation is contraindicated. Retrievable IVC filters provide the greatest benefit to patients when removed within 90 days, with longer delays contributing to complications, such as filter fracture (up to 21%) and vessel or organ perforation (up to 12.4%). This retrospective cohort study assessed the medical records of 699 patients from a single institution with IVC filters placed between June 2011 and September 2019 to determine whether active surveillance by implanting physicians improved retrieval rates of IVC filters compared to passive surveillance. Prior to 2016, retrieval was organized passively via letters mailed to patients and physicians. Following 2016, physicians adopted an active surveillance model, whereby eligibility for retrieval was discussed with patients over the phone periodically by the implanting physician team. In this study, 55.2% of patients were followed by passive surveillance, and 44.8% were followed by active surveillance. With the adoption of active surveillance in 2016, filter retrieval increased from 48.7% to 61.4% per year, p<0.001. This study demonstrates that a significant increase in IVC filter removal was observed when the implanting physician team assumed the active surveillance model. This finding suggests that rates of IVC filter retrieval should improve if more physicians choose an active surveillance approach.
1. In a large prospective study, risk burden and genetic predisposition acted synergistically to significantly increase the risk of developing atrial fibrillation.Â
Evidence Rating Level: 1 (Excellent)
Atrial fibrillation (AF) is one of the most common cardiac arrhythmias and is associated with a high risk of thromboembolism and death. This study aims to identify the effects of both risk factor burden and genetic predisposition on the 10-year risk of developing atrial fibrillation. 352,804 participants aged 40-69 were enrolled in this study between 2006 and 2010 from the UK biobank. A polygenic risk score was calculated for each participant, using 165 known genetic risk markers for atrial fibrillation. Risk factor burden was determined by BMI, diabetes mellitus, alcohol use, smoking, blood pressure, and cardiac history (MI or CHF). Participants were divided into three age groups: 40-49, 50-59, and 60-69. A lower risk factor burden was significantly associated with a later onset of atrial fibrillation (p<0.001). In each age category, risk factor burden and genetic predisposition acted synergistically to significantly increase the AF risk (p <0.05). The greatest AF risk was found for those aged 60-69 with elevated risk factor profile and genetic predisposition (10-year risk 11.1%, 95% CI 10.72-11.49). In comparison, participants aged 60-69 with an elevated risk factor burden and low genetic predisposition had a 3.91% 10-year risk of developing AF (95% CI 3.68-4.14). Overall, this study demonstrates that risk burden and genetic predisposition act synergistically to increase the risk of developing AF. In the clinical setting, identifying younger individuals with a strong genetic predisposition for AF may be a beneficial preventative strategy, providing the opportunity for early intervention to reduce risk factor profile and 10-year AF risk.
1. In this prospective population-based study, the likelihood of becoming pregnant or fathering a child was lower for those conceived via assisted reproductive technologies (ART) compared to natural conception, though the rates of perinatal complications were similar between both groups.Â
Evidence Rating Level: 2 (Good)
Little is known regarding the fertility rates and pregnancy outcomes of people born via artificial reproductive technology (ART). In this prospective population-based study, the Medical Birth Registry of Norway was used to collect data on people born in Norway between 1984 and 2002. 531,015 liveborn girls and 561,136 liveborn boys are included in this registry, with 4763 girls and 5083 boys conceived via ART. ART was defined as the use of in vitro fertilization and embryo transfer. The study assessed the likelihood of becoming pregnant or fathering a child, as well as several pregnancy complications and outcomes, including the use of ART, hypertensive disorders of pregnancy and pre-eclampsia, birth weight, placental weight, preterm birth, gestational age, delivery by cesarean section, congenital malformations, low 5 minute Apgar score, transfer to NICU, and offspring sex. The likelihood of having a registered pregnancy was lower in the ART group compared to the non-ART group, with a minimally adjusted hazard ratio of 0.71 (95% CI 0.65-0.77). Similarly, the likelihood of fathering a child was lower for those conceived via ART, with an unadjusted hazard ratio of 0.79 (95% CI 0.71-0.87). Neonates of women conceived by ART had an increased risk of a low 5-minute Apgar score, with an adjusted odds ratio of 1.86 (95% CI 1.20-2.89), and decreased likelihood of male sex, with an odds ratio of 0.79 (95% CI 0.67-0.93). For all other pregnancy complications and outcomes assessed, there was no significant difference between both groups. Overall, this study determined that those conceived via ART were less likely to have a registered pregnancy or father a child, but further research is needed to fully understand the fertility differences between these two groups. As well, this study determined that there is little difference in pregnancy outcomes or rates of complications for those conceived via ART compared to natural conception. However, further research is needed to determine why the risk of having a neonate with a low 5-minute Apgar score is greater for those conceived via ART.
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