Chiropractic Day 2023: A Report and Qualitative Analysis of How Thought Leaders Celebrate the Present and Envision the Future of Chiropractic

Objective

This study aimed to (1) collect and analyze statements about how to celebrate chiropractic in the present and roles that chiropractors may fulfill in the future, (2) identify if there was congruence among the themes between present and future statements, and (3) offer a model about the chiropractic profession that captures its complex relationships that encompass its interactions within microsystem, mesosystem, exosystem, and macrosystem levels.

Methods

For this qualitative analysis, we used pattern and grounded theory approaches. A purposive sample of thought leaders in the chiropractic profession were invited to answer the following 2 open-ended questions: (1) envision the chiropractor of the future, and (2) recommendations on how to celebrate chiropractic. Information was collected during April 2023 using Survey Monkey. The information was entered into a spreadsheet and analyzed for topic clusters, which resulted in matching concepts with social-ecological themes. The themes between the responses to the 2 questions were analyzed for congruence. We used the Standards for Reporting Qualitative Research to report our findings.

Results

Of the 54 experts invited, 32 (59%) participated. Authors represented 7 countries and have a median of 32 years of chiropractic experience, with a range of 5 to 51 years. Nineteen major topics in the future statements and 23 major topics in statements about celebrating chiropractic were combined in a model. The topics were presented using the 4 levels of the social-ecological framework. Individual (microsystem): chiropractors are competent, well-educated experts in spine and musculoskeletal care who apply evidence-based practices, which is a combination of the best available evidence, clinical expertise, and patient values. Interpersonal relationships (mesosystem): chiropractors serve the best interests of their patients, provide person-centered care, embrace diversity, equity, and inclusion, consider specific health needs and the health of the whole person. Community (exosystem): chiropractors provide care within integrated health care environments and in private practices, serve the best interests of the public through participation in their communities, participate through multidisciplinary collaboration with and within the health care system, and work together as a profession with a strong professional identity. Societal (macrosystem): chiropractors contribute to the greater good of society and participate on a global level in policy, leadership, and research. There was concordance between both the future envisioning statements and the present celebration recommendations, which suggest logical validity based on the congruence of these concepts.

Conclusion

A sample of independent views, including the perceptions from a broad range of chiropractic thought leaders from various backgrounds, philosophies, diversity characteristics, and world regions, were assembled to create a comprehensive model of the chiropractic profession. The resulting model shows an array of intrinsic values and provides the roles that chiropractors may provide to serve patients and the public. This study offers insights into the roles that future chiropractors may fulfill and how these are congruent with present-day values. These core concepts and this novel model may have utility during dialogs about identity, applications regarding chiropractic in policy, practice, education, and research, and building positive relationships and collaborations.

Impact of COVID-19 pandemic on the occurrence and outcome of cardiogenic shock complicating acute myocardial infarction

Background

The COVID-19 pandemic had influenced the patient's behavior and impacted the homeostasis to a pro-thrombotic niveau.

Aim

The study aimed to follow the impact of COVID-19 on the incidence and prognosis of cardiogenic shock complicated initially acute myocardial infarction (CS-AMI).

Methods

We used data entered into a large national all-comers registry of coronary intervention over five years. From 1/2016 to 12/2020, 50,745 AMI patients were included, and 2,822 (5.6%) initially had CS.

Results

The incidence of CS-AMI was significantly higher in the COVID period (2020) than the mean incidence in 2016–2019 (5.5% vs 6%, p=0.032). The difference was caused by significant increase of CS in acute STEMI (7.6% vs. 8.7%, p=0.011); it was 7.1% in 2016, 7.8% (2017), 7.6% (2018), 7.8% (2019), and 8.7% (2020). The CS complicated 2.3% (2016), 2.7% (2017), 2.7% (2018), 2.8% (2019), and 2.8% (2020) of NSTEMI.

The observed rise in CS-STEMI incidence each month during the pandemic compared to the average incidence in non-pandemic years correlated with the substantial increase in the number of COVID infected/hospitalized (Table 1). In these months, no changes in time delay to reperfusion layout were observed in CS-STEMI patients (Table 2).

Except of less frequent history of previous PCI (13.9% and 8.2%, p<0.001), we found no significant differences in the followed CS-STEMI patient characteristics in 2016–2019 and 2020; men 72.7% and 75.4% (p=0.1), mean age (SD) 66.3 (12.3)yrs and 66.3 (12.2) yrs, Diabetes 20.9% and 19.1% (p=0.2), CKD 5.4% and 5.7% (p=0.4), previous CABG 4.5 and 4.2% (p=0.5), left main disease (14.3% and 16%, p=0.5), one vessel disease 24.9% and 32.1% (p=0.9), pre-PCI TIMI flow 0 64.4% and 66.2% (p=0.6), post-PCI TIMI flow 3 76.7% and 76.9%.

The COVID pandemic didn't influence the proportions of pre-hospital resuscitated CS-AMI patients (57.5% and 58.7%, p=0.6) and those on mechanical ventilation (67.8% and 68.3%, p=0.8).

The 30-day mortality trend of CS-AMI was 53.7% in 2016, 51.6% (2017), 49.7% (2018), 49.3% (2019), and 47.9% (2020). And in CS-STEMI it was 50.8%, 47.1%, 46.4%, 44.1%, and 45.3% (P2019 vs. 2020 =0.8), respectively.

Conclusion

Data from a large national all-comer registry showed an increase in the proportion of patients admitted to hospitals with STEMI complicated by CS in the year of the COVID pandemic. The CS rise correlated with the increase in the COVID infected population. Factors other than the patient's cardiovascular risk profile or prolongation of a time delay to reperfusion influenced this trend. We suggest that the availability of health care and patient adherence may have affected the risks control. We did not observe any effect of the pandemic on CS-AMI mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic

All-cause mortality of patients with STEMI, cardiogenic shock and multivessel coronary disease treated with culprit vessel only versus multivessel primary PCI

Background

Patients with ST elevation myocardial infarction (STEMI) and cardiogenic shock (CS) treated with primary percutaneous coronary intervention (pPCI) have high mortality. A recent trial demonstrated that a culprit vessel-only strategy (CV-pPCI) was superior to immediate multivessel PCI (MV-pPCI) for patients with CS and multivessel coronary artery disease (MVD). Irrespective of it and current guidelines, multivessel PCI is still often used in these patients.

Purpose/Methods

The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and MVD treated with culprit vessel only pPCI or multivessel PCI during initial procedure. From 2016 to 2020, 23703 primary PCI patients with STEMI were included in the national all-comers registry of cardiovascular interventions. From them, a total of 1213 (5.1%) patients had cardiogenic shock and MVD at admission to the hospital. Initially 921 (75.9%) patients were treated with CV-pPCI and 292 (24.1%) with MV-pPCI.

Results

CV-pPCI was a preferred strategy to MV-pPCI in men (74.6% vs 25.4%; p<0,001) and women (79.8% vs 20.2%; p<0,001) with CS-STEMI and MVD. Patients with 3-vessel disease and left main disease had higher probability to be treated with MV-pPCI than patients with 2-vessel disease and without left main disease (28.5% vs 18.6%; p<0,001 and 37.7% vs 20.6%; p<0,001).The CV-pPCI and MV-pPCI group patients did not differ in age (68.1±11.2 vs 66.2±11.4 years; p=0.780), previous PCI (16.1% vs 12.0%; p=0.890) and CABG (6.2% vs 4.8%; p=0.376), chronic kidney disease (6.8% vs 8.2%; p=0.426), cardiopulmonary resuscitation (60.4% vs 58.9%; p=0.657) and pulmonary ventilation (66.8% vs 70.5%; p=0.227) at admission, localization of myocardial infarction (anterior 50.8.% vs 58.9%; p=0.671), time to reperfusion (<2 hours 5.2% vs 4.8%; p=0.722) and TIMI flow 0 before PCI (63.1% vs 64.0%; p=0.675). Based on the results of logistic regression analysis, 30-days (odds ratio, 0.99; 95% CI 0.76 to 1.29; p=0.937) and 1-year (odds ratio, 0.91; 95% CI 0.69 to 1.19; p=0.477) all-cause mortality rates were similar in CV-pPCI and MV-pPCI groups. The presence of 3-vessel disease was the strongest adjusted predictor of 30-days (odds ratio, 1.61; 95% CI 1.27 to 2.04; p<0.001) and 1-year (odds ratio, 1.64; 95% CI 1.30 to 2.08; p<0.001) all-cause mortality in patients with STEMI and CS treated with pPCI.

Conclusion

Immediate multivessel primary PCI is still used in patients with CS-STEMI and MVD in routine clinical practice. We did not find difference in 30-days and 1-year mortality among patients with CS-STEMI and MVD treated either with culprit vessel-only or multivessel primary PCI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NV19-02-00086 supported by Ministry of Health of the Czech Republic

Coronary flow reserve can explain some of FFR and iFR discrepancies. Results from international, multicenter and prospective trial

Background

The trial collected prospective data from physiology measurements of borderline lesions in five Czech, one Japan and one Argentinian cathlabs. The main purposes were to analyze diagnostic agreement between FFR (fractional flow reserve) and iFR (instantaneous wave free ratio) examinations and to find possible explanations for discrepant results.

Methods

FFR and iFR examinations were analyzed using Philips-Volcano console and coronary flow reserve (CFR) was analyzed by using Combomap machine Philips-Volcano. Hyperemia for FFR and CFR measurements was induced by intracoronary administration of adenosine. We used CFR as a truth for comparison between FFR and iFR, because CFR has higher impact on patients prognosis than pressures indices.

Results

Data were collected from February 2016 to June 2019 and the database includes 1.789 examinations from 1.492 patients (282 of them, 15.8%, with ACS). CFR were measured in 343 lesions in 293 patients. (ACS 31.2%). Overall correlation between FFR and iFR is high (R=0.86 p<0.0001). The FFR/iFR discrepancy occurred in 84 measurements (24.5%), more frequently it was FFRp (positive) / iFRn (negative) type of discrepancy (65, 18.9%) compare to FFRn/iFRp (19, 5.5%) one. There was no difference in occurrence of FFR/iFR discrepancy in stable patients and ACS ones (25.1%vs. 22.4%, p=0.59). The CFR correlated better with iFR than with FFR (R=0.56, p<0.0001 vs. R= 0.36, p<0.0001) (see table). In lesions with FFRp/iFRn type of discrepancy we found substantially higher CFR value compared to FFR/iFR agreement group (2.4±0.7 vs. 1.5±0.5, p<0.0001). Unlike to FFRn/iFRp discrepancy, where CFR value was similar with agreement group (1.4±0.1 vs. 1.5±0.1, p=0.25)

Conclusion

The FFR/iFR discrepancy occurred in almost one quarter of examinations. Correlation between CFR and iFR is better than between CFR and FFR. High flow is probably one of the main reason for FFRp/iFRn type of discrepancy.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Czech Health Research Council

Relationship between symptom-onset-to-balloon time and outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention

Background

Time delay is an important prognostic factor and indicator of quality of care for patients with AMI indicated for primary percutaneous coronary intervention (PCI).

Purpose

Assessment of total ischaemia time and its relationship to catheterization findings and the incidence of ischaemic events within 1 year in patients treated with primary PCI.

Method

The analysis included 1230 patients with AIM and primary PCI randomized in the Prague-18 study (prasugrel vs. ticagrelor). We evaluated the total ischaemia time and two the intermediate intervals: A - from the symptom onset to the arrival to the hospital and B - from the entry the hospital to balloon time. We assessed the time delay in relation to patient characteristics, PCI results and ischaemic endpoints (death, reIM, stroke) within 30 days and 1 year.

Results

Median total ischaemia time was 3.2 hours. Its prolongation resulted in more frequent incidence of TIMI flow <2 before PCI (p=0.029), TIMI flow <3 after PCI (p=0.004) and suboptimal PCI (p=0.018). The interval A was significantly prolonged in women (p=0.001) and obese patients with BMI ≥30 kg / m2 (p=0.001). The interval B <30 min was achieved in 70% of patients, only 5.3% had interval >90 min. In 717 (61,6%) patients with increased risk (at least 1 criterion: age >70 years, STEMI anterior wall or LBBB, Killip II-IV, history of MI and CABG, SBP <100 mmHG and HR >100 / min), the prolongation of total ischaemia time (≤2 vs. 2.1–4 vs. 4.1–6 vs. >6 hours) resulted in a more frequent incidence of combined ischaemic endpoints within 1 year (p=0.034) and left ventricular systolic dysfunction (p=0.028).

Conclusion

The extension of total ischaemia time in patients treated with primary PCI resulted in a more frequent suboptimal result with TIMI flow <3. Female gender, older age and obesity in women were associated with an increase in total ischaemia time. In patients with increased risk, time delay resulted in a higher incidence of combined ischaemic endpoints within 1 year and left ventricular systolic dysfunction.

Funding Acknowledgement

Type of funding source: None

BMI-referenced cut points for pedometer-determined steps per day in adults

BACKGROUND

The goal of this study was to establish preliminary criterion-referenced cut points for adult pedometer-determined physical activity (PA) related to weight status defined by body mass index (BMI).

METHODS

Researchers contributed directly measured BMI and pedometer data that had been collected (1) using a Yamax-manufactured pedometer, (2) for a minimum of 3 days, (3) on ostensibly healthy adults. The contrasting groups method was used to identify age- and gender-specific cut points for steps/d related to BMI cut points for normal weight and overweight/obesity (defined as BMI <25 and >or=25 kg/m2, respectively).

RESULTS

Data included 3127 individuals age 18 to 94 years (976 men, age = 46.8 +/- 15.4 years, BMI = 27.3 +/- 4.9; 2151 women, age = 47.4 +/- 14.9 years, BMI = 27.6 +/- 6.4; all gender differences NS). Best estimated cut points for normal versus overweight/obesity ranged from 11,000 to 12,000 steps/d for men and 8000 to 12,000 steps/d for women (consistently higher for younger age groups).

CONCLUSIONS

These steps/d cut points can be used to identify individuals at risk, or the proportion of adults achieving or falling short of set cut points can be reported and compared between populations. Cut points can also be used to set intervention goals, and they can be referred to when evaluating program impact, as well as environmental and policy changes.

[Diagnostic values of lactate dehydrogenase (LDH), creatine kinase (CK) and gamma-glutamyltransferase (gamma-GT) examinations in the course of intrahepatic cholestasis in pregnancy]

OBJECTIVE

The activity of LDH, CK and gamma-GT in blood serum of women with intrahepatic cholestasis in pregnancy was investigated. Diagnosis of intrahepatic cholestasis was based on anamnesis, clinical examination and laboratory tests.

METHODS

41 women with intrahepatic cholestasis (the study group) and 30 healthy women (the control group) entered the study. All women were in the third trimester of pregnancy. The prevalence rate of intrahepatic cholestasis in pregnancy in our Department is 1%. All women of the study group presented an intensive pruritus and had negative hepatitis B antigen. They also presented negative results of laboratory tests, clinical examination and anamnesis concerning other hepatitis.

RESULTS

There was no significant difference in mean gestational age between study and control group (35.1 +/- 2.8 vs 36.0 +/- 3.0 weeks). The results of biochemical tests in study vs control group: 1) total bilirubin 33.3 +/- 18.8 vs 8.55 +/- 3.4 mumol/L; p < 0.001, 2) direct bilirubin 25.6 +/- 14.2 vs 1.7 +/- 1.7 mumol/L; p < 0.001, 3) indirect bilirubin 7.7 +/- 2.22 vs 8.5 +/- 3.4 mumol/L; NS, 4) alkaline phosphatase (AP) 168.4 +/- 61.2 vs 96.8 +/- 14.9 IU/L; p < 0.001, 5) heat-stable AP 99.8 +/- 38.7 vs 64.1 +/- 20.9 IU/L; p < 0.001, 6) bile acid 28.6 +/- 20.0 vs 4.5 +/- 1.5 mumol/L; p < 0.001, 7) AlAT 158 +/- 00 vs 5 +/- 3 IU/L; p < 0.001, 8) AspAT 97 +/- 31 vs 8 +/- 3 IU/L; p < 0.001, 9) de Ritis ratio AspAT/AlAT 0.61 +/- 0.31 vs 1.6 +/- 0.4; p < 0.001, 10) total protein 61.8 +/- 5.6 vs 66.0 +/- 6.0 G/L; p < 0.001, 11) albumine 450 +/- 34.8 vs 484.0 +/- 37.7 mumol/L, 12) Fe++ 26.0 +/- 3.8 vs 12.71 +/- 2.15 mumol/L; p < 0.001, 13) total cholesterol 8.81 +/- 1.87 vs 6.68 +/- 1.04 mmol/L; p < 0.001, total LDL 6.80 +/- 1.57 vs 4.80 +/- 0.81 G/L; p < 0.001, 15) LDH 211 +/- 48 vs 134 +/- 33 UI/L; p < 0.001, 16) CK 51.0 +/- 33 vs 45 +/- 14 UI/L; NS, 17) gamma-GT 49 +/- 22 vs 23 +/- 8 UI/L; p < 0.001.

CONCLUSIONS

An increase of LDH is related to the significant impairment of hepatocytes. An increase of gamma-GT confirms the retention of bile in intrahepatic ducts. CK does not present prognostic value in intrahepatic cholestasis in pregnancy.

[The influence of chosen hormones on lipids and its correlation during normal pregnancy]

OBJECTIVES

Lipids and hormones levels in nonpregnant and pregnant with uneventful gestation (from I, II, III trimester) were estimated and its correlation was evaluated.

METHODS

The study group consisted of 219 women: 49 nonpregnant and 170 pregnant women (35 in I trimester, 35 in II and 100 in III trimester of gestation). All subjects were healthy. Following parameters were measured in blood serum: total lipids, LDL total fraction, (beta-lipoproteids), cholesterol both total and free, HDL cholesterol, LDL cholesterol. Percentage of free cholesterol contained on total cholesterol was evaluated. HPL and estrogens levels were estimated.

RESULTS

Serum levels of total lipids, phosphlipids, triglicerides, total fraction of LDL and its contains of cholesterol increase with gestational age (p < 0.001). During pregnancy positive correlation between estrogens, HPL and triglycerides was also observed (p < 0.001). Additionally in II trimester positive correlation of total cholesterol, phospholipids and HPL was noted (respectively r = 0.469 p < 0.001 and r = 0.452 p < 0.01).

CONCLUSIONS

In case of women with uneventful pregnancy positive correlation between estrogens and total lipids, total fractions LDL and triglycerides was stated. Also positive correlation among lipids parameters and HPL concentration was noted. No correlation between HPL and free cholesterol, LDL, HDL cholesterol nor between estrogens and total cholesterol, free cholesterol and LDL cholesterol was found. Lipids status in case of nonpregnant women is multihormonaly influenced.