It is unclear if atrial fibrillation (AF) is an independent risk factor for cognitive impairment. This review evaluates the available evidence and provides an overview of the association between AF and cognitive function. Electronic database searches, January 1990 to December 2012, identified 271 studies comparing the incidence of cognitive impairment and/or dementia in patients with/without AF. Cognitive function was diagnosed by a physician using the mini-mental state examination (MMSE) or other established diagnostic criteria. Studies with <20 participants and without direct comparison to controls in sinus rhythm were excluded. There were no restrictions on the basis of age, language or study design. Full texts of 11 studies were obtained. Eight studies (three cross-sectional, two case-control and three prospective cohorts) reported an association between cognitive decline and AF. Among cross-sectional studies, patients with AF had a 1.7 (95% CI 1.2–2.5) to 3.3 (95% CI 1.6–6.5) greater risk of cognitive impairment, and a 2.3-fold (95% CI 1.4–3.7) increased risk of dementia, compared to patients in sinus rhythm. There was marked heterogeneity in the design, size and quality of studies and reporting of the data which precluded formal meta-analysis. Eight studies reported an association between AF and cognitive impairment and/or dementia, but the magnitude of risk varied. Further large-scale prospective studies are needed to establish whether AF is a risk factor for cognitive decline, utilizing objective measures of cognitive function and neuropsychological testing, and to investigate the potential benefit of anticoagulation on reducing cognitive impairment and development of dementia.

Objective: Literature reviews suggest limited evidence of efficacy of antidepressant medication in patients with advanced cancer. This study was carried out to observe the longitudinal effect of antidepressant medication in a cohort of advanced cancer patients.

Method: Patients were recruited from hospice day care settings and followed up longitudinally by series of measures for depression for 6 months or until death.

Results: Six hundred and twenty nine patients recruited. One hundred and fifty six patients in total (25%) were receiving antidepressant medication for a median of 9.5 weeks (range 0–36 weeks) and a mean of 12.2 weeks. There was no significant difference in scores on depression measures over time for patients receiving antidepressant medication.

Conclusions: Antidepressant medication for advanced cancer patients appeared to have little impact on depression scores. We postulate the holistic approaches within hospice day care may in themselves be interventions for depression thereby masking effect of pharmacological treatment. Further research should explore multi-intervention models for management of depression in advanced cancer.

Background: Obesity is increasingly prevalent in many countries. Obesity is a major risk factor for the development of type 2 diabetes but its relationship with diabetic kidney disease (DKD) remains unclear. Some studies have suggested that the metabolic syndrome (including obesity) may be associated with DKD in type 1 diabetes.

Aim: To investigate the association between obesity and DKD.

Design: Retrospective cross-sectional study.

Methods: National Diabetes Audit data were available for the 2007–08 cycle. Type 1 and 2 diabetes patients with both a valid serum creatinine and urinary albumin:creatinine ratio were included. DKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m², albuminuria or both. Logistic regression was used to analyse associations of obesity (body mass index ≥30 kg/m²) and other variables including year of birth, year of diagnosis, ethnicity and stage of kidney disease.

Results: A total of 58 791 type 1 and 733 769 type 2 diabetes patients were included in the analysis. After adjustment, when compared with type 1 diabetes patients with normal renal function those with DKD were up to twice as likely to be obese. Type 2 DKD patients were also more likely to be obese. For example, type 2 diabetes patients with an eGFR <15 ml/min/1.73 m² and normoalbuminuria, microalbuminuria or macroalbuminuria were all more likely to be obese; odds ratios (95% CI) 1.65 (1.3–2.1), 1.56 (1.28–1.92) and 1.27 (1.05–1.54), respectively.

Conclusions: This study has highlighted a strong association between obesity and kidney disease in type 1 diabetes and confirmed their association in type 2 diabetes.

Leishmaniasis is a global term for cutaneous and visceral anthroponotic and zoonotic diseases caused by the vector-borne parasites of the genus Leishmania. These diseases afflict at least 2 million people each year with more than 350 million at risk in 98 countries worldwide. These are diseases mostly of the impoverished making prevention, diagnosis and treatment difficult. Therapy of leishmaniasis ranges from local treatment of cutaneous lesions to systemic, often toxic, therapy for disseminated cutaneous, mucocutaneous and deadly visceral disease. This review is a summary of the clinical syndromes caused by Leishmania and treatment regimens currently used for various forms of leishmaniasis.

Objective

Literature reviews suggest limited evidence of efficacy of antidepressant medication in patients with advanced cancer. This study was carried out to observe the longitudinal effect of antidepressant medication in a cohort of advanced cancer patients

Method

Patients were recruited from hospice day care settings and followed up longitudinally by series of measures for depression for 6 months or until death

Results

Six hundred and twenty nine patients recruited. One hundred and fifty six patients in total (25%) were receiving antidepressant medication for a median of 9.5 weeks ( range 0 - 36 weeks) and a mean of 12.2 weeks. There was no significant difference in scores on depression measures over time for patients receiving antidepressant medication

Conclusions

Antidepressant medication for advanced cancer patients appeared to have little impact on depression scores . We postulate the holistic approaches within hospice day care may in themselves be interventions for depression thereby masking effect of pharmacological treatment. Further research should explore multi intervention models for management of depression in advanced cancer

Aim: It is unclear if atrial fibrillation (AF) is an independent risk factor for cognitive impairment. This review evaluates the available evidence and provides an overview of the association between AF and cognitive function.

Methods: Electronic database searches, January 1990 to December 2012, identified 271 studies comparing the incidence of cognitive impairment and/or dementia in patients with/without AF. Cognitive function was diagnosed by a physician using the mini-mental state examination (MMSE) or other established diagnostic criteria. Studies with <20 participants and without direct comparison to controls in sinus rhythm were excluded. There were no restrictions on the basis of age, language or study design. Full texts of 11 studies were obtained.

Results: Eight studies (3 cross-sectional, 2 case-control, and 3 prospective cohorts) reported an association between cognitive decline and AF. Among cross-sectional studies, patients with AF had a 1.7 (95% CI 1.2-2.5) to 3.3 (95% CI 1.6-6.5) greater risk of cognitive impairment, and a 2.3-fold (95% CI 1.4-3.7) increased risk of dementia, compared to patients in sinus rhythm. There was marked heterogeneity in the design, size and quality of studies and reporting of the data which precluded formal meta-analysis.

Conclusion: Eight studies reported an association between AF and cognitive impairment and/or dementia, but the magnitude of risk varied. Further large-scale prospective studies are needed to establish whether AF is a risk factor for cognitive decline, utilising objective measures of cognitive function and neuropsychological testing, and to investigate the potential benefit of anticoagulation on reducing cognitive impairment and development of dementia.

Background:

Mortality amongst emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends.

Aim:

We studied the outcome of ST elevation myocardial infarction (STEMI) patients presenting at different times to our centre with 24/7 primary percutaneous coronary intervention (PPCI) service.

Methods

We divided all patients who underwent PPCI between Sept 2009-Nov 2011 into three groups according to the time of admission as group 1: in-hours (0800-1800 hrs weekdays), group 2: out-of-hours (1800- 0800 hrs weekdays) and group 3: weekends (Sat to Mon 0800-0800 hrs).

Results

A total of 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3 respectively. Apart from cardiogenic shock (8.9%, 5.5% and 7.7%, p=0.05) and door to balloon time (median 29, 33, 36 mins, p <0.0001), there was no significant difference noted in the baseline and procedural characteristics between the groups. In-hospital mortality (4.6%, 4.3%, 5.3%, p=0.5), 30-day mortality (6.4%, 6.3%, 7%, p=0.7), 30-day stent thrombosis (0.8%, 0.8%, 0.2%, p=0.1) and 1-year mortality (10.7%, 10.8%, 9.8%, p=0.7) were no different between the groups. On logistic regression analysis, out-of-hours and weekend admissions were not found to be a predictor of both 30-day and 1-year mortality.

Conclusion

In this consecutive series of patients admitted to a high volume PPCI centre, there was no difference in mortality when patients were admitted at different times. The involvement of senior medical staff early in the patients' admission may have contributed to these consistent outcomes.

Background

Increasing hospital or specialist volumes has been shown to improve outcomes; there are little data on volumes and outcomes in emergency medical admissions. We have examined the hospital length of stay and 30-day mortality for patients admitted under a consultant ‘of the day’ having high or low admission volumes.

Methods

An analysis was performed on all emergency medical patients admitted between 1st January 2002 and 31st December 2011, using anonymous patient data. We calculated the numbers of unique patients admitted to each ‘on call’ consultant and allocated the latter to a high (70th centile with 8/22 consultants) or low volume (14/22 consultants) category. We examined outcomes (length of stay and in-hospital 30-day mortality), by these cut-offs employing logistic regression to calculate unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI).

Results

The hospital length of stay was shorter (p<0.001) for high (median 4.2, IQR 1.7, 8.7) compared with the lower volume group (median 4.8, IQR, 1.9, 9.7). There was a reduced 30-day in hospital mortality for high volume (8.2%) compared with low volume consultants (9.6%: p < 0.01). An admission under a high volume consultant was independently predictive of survival, after adjustment for other outcome predictors including co-morbidity; the RRR was 25% (OR 0.75 (95% CI 0.68 – 0.82): p < 0.001).

Conclusion

In an era of increasing specialization, these data provide support for the concept that the frequency of being ‘on-call’ contributes to maintaining competence with an associated improvement in patient outcomes.

Bronchiectasis is a chronic debilitating condition with considerable phenotypic diversity. A vicious cycle of infection and inflammation exists in damaged airways with patients suffering from persistent cough, purulent sputum production, recurrent chest infections and general malaise. The associated burden of disease in terms of increased morbidity, reduced quality of life and the socioeconomic cost of long-term management is significant. Further research is essential to improve our understanding of the development and progression of this disease. This article reviews what is currently known about bronchiectasis, its pathophysiology, aetiology and management strategies.

As a society we have to re-imagine our health and social care models to meet the challenge of an ageing population with greater levels of chronic disease. The digital revolution offers us the potential to leverage technological innovations to develop proactive ‘connected’ health and social care models that are built around the patient’s needs to facilitate efficient management of wellness and health throughout their lifespan. However, efforts to utilize technological innovations for this purpose have not been universally successful to date, indicating that technology itself is only part of the solution. To achieve a truly connected, technology enabled, health and social care model we need to overcome some key challenges; first, we need to optimize the process of sensing data from end users in the home and community such that monitoring protocols are built around the person and designed with respect to their needs to provide for accurate and reliable harvesting of target data. We then need to gather and mine large datasets from the home and community to analyse the complex relationships between home and community acquired data and health status. Only then can we begin to design, implement and evaluate new models of care that leverage technology platforms. In meeting this challenge we can leverage technology to transform the way in which we promote and manage wellness and health throughout the lifespan.

Background: It has not been fully elucidated whether antihypertensive medication adherence affects blood pressure (BP) control in hypertension cases.

Aim: To investigate the association of adherence to antihypertensive drug regimens and BP control using data from the Combination Pill of Losartan Potassium and Hydrochlorothiazide for Improvement of Medication Compliance Trial (COMFORT) study.

Design: An observational analysis from a randomized controlled trial.

Methods: A total of 203 hypertensive subjects were randomly assigned to a daily regimen of a combination pill (losartan 50 mg/hydrochlorothiazide 12.5 mg) or two pills, an angiotensin II receptor blocker and a thiazide diuretic. Medication adherence calculated based on pill counts and BPs was evaluated at 1, 3 and 6 months after randomization.

Results: The subjects were divided into three groups according to their adherence, i.e. relatively low-adherence (<90%; n = 19), moderate-adherence (90–99%; n = 71) and high-adherence (100%; n = 113) groups. Clinical characteristics of the subjects including BP, sex, randomized treatments and past medical history did not differ significantly among the three groups. Achieved follow-up BPs over the 6-month treatment period, which were adjusted for age, sex, baseline BP and randomized treatment, were significantly higher in the low-adherence group (135/78 mmHg) compared with the high-adherence (130/74 mmHg; P = 0.02/0.02) and the moderate-adherence (128/74 mmHg; P = 0.003/0.02) groups.

Conclusions: Low adherence to an antihypertensive-drug regimen was associated with poor BP control.