European Guidelines Research Articles

WP5.6 - Beyond the Left Side: Emergency Colonic Stenting for Acute Malignant Large Bowel Obstruction

Abstract Introduction Acute malignant large bowel obstruction (LBO) is traditionally treated by surgical diversion or resection in patients who are fit enough. European guidelines suggest colonic stenting as a bridge to surgery in curative disease. The aim was to examine the safety and efficacy of a change in practice from emergency laparotomy towards colonic stenting for acute malignant LBO. Methods Patients with LBO from 01/01/2019 to 31/12/2022 were included and data was obtained from the NELA database and electronic patient records. Results 42 patients underwent emergency laparotomy (EL) for LBO. 33% (14/42) patients had right-sided tumours (n=14) and/or perforated disease (n=6) where stenting was contraindicated. 28/42 patients (22% of total) went straight to EL for clinical/ organisation factors. 73 patients were stented; 44% (32/73) were at/ proximal to splenic flexure. Perforation rate was 10% (7/73) with 4/7 requiring EL. Failure rate was 14% (10/73) with 6/10 patients requiring EL. 41% (30/73) were stented with curative intent; 70% (21/30) then underwent elective resection. The rate of stoma formation and minimally invasive surgery in patients stented with curative intent was 40% (12/30) and 60% (18/30) respectively (including 9 EL following stent complications). Compared with 88% (37/42) and 19% (8/42) in patients undergoing primary EL. Conclusion Almost 2/3 of patients presenting with acute malignant LBO were suitable for stenting. Stenting reduced the need for a stoma and enabled elective minimally invasive surgery with low complication rates. This rate of colonic stenting was achievable without a 24/7 colonic stenting rota or sub-specialty cover.

Rehabilitation of oncological patients: a comparative analysis of clinical guidelines for managing oncological patients with renal parenchyma cancer, bladder cancer and female cancer in Russia, Europe, and USA

Backround. Current medicine pays significant attention to an integrated approach in managing cancer patients, from the stage of diagnosis to rehabilitation. Sections on rehabilitation have been added to respective guidelines to maintain the proper quality of life of patients and standardization of clinical protocols. Due to the different levels of medicine in Europe, Russia and USA, it is important to analyze guidelines for supporting oncological patients at the rehabilitation stage.Objective: to conduct a comparative analysis of guidelines for managing cancer patients.Material and methods. The search and selection of publications were performed according to PRISMA recommendations. In scientific databases PubMed/MEDLINE, Google Scholar, ScienceDirect, eLibrary as well as via search engines and the Rubricator of Clinical Guidelines of the Ministry of Health of Russia, 725 sources were found. After the selection procedure, 30 publications and guidelines were included in the review.Results. Rehabilitation programs are presented in many Russian, American and European guidelines for the support of cancer patients. In Russian guidelines for managing patients with renal parenchyma and bladder cancer, a significant emphasis is made on the pre-rehabilitation and using fast-track approach. A lot of attention is paid to therapeutic physical culture and instrumental methods. American and European guidelines are more detailed, in particular, protocols for the correction of certain adverse events are presented, psychological assistance and complex rehabilitation play an essential role. The absence of specialized rehabilitation program in Russian clinical guidelines for supporting oncogynecological patients, and universal character of protocols were noted. According to foreign guidelines, the rehabilitation of such patients is multidisciplinary and personalized, and is carried out in specialized centers.Conclusion. The review showed a number of deficiencies in Russian clinical guidelines. In certain documents, due attention is not paid to the provision of rehabilitation. It’s necessary to expand multidisciplinary approach in cancer patients' rehabilitation as well as the evidence base to improve Russian guidelines.

Similarities and differences between European guidelines for the management of postmenopausal osteoporosis

SummaryWe conducted a review of 10 national guidelines from five EU countries to identify similarities or differences in recommendations for the management of patients with osteoporosis. We found general alignment of key recommendations; however, there are notable differences, largely attributed to country-specific approaches to risk assessment and reimbursement conditions.IntroductionThe classification of fracture risk is critical for informing treatment decisions for post-menopausal osteoporosis. The aim of this review was to summarise 10 national guidelines from five European countries, with a focus on identifying similarities or differences in recommendations for the management of patients with osteoporosis.MethodsWe summarised the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Disease-International Osteoporosis Foundation guidelines and reviewed guidelines from France, Germany, Italy, Spain and the UK.ResultsThe approach to risk assessment differed across the guidelines. In France, and Spain, risk assessment was based on DXA scans and presence of prior fractures, whereas UK, German and Italian guidelines recommended use of a validated risk tool. These differences led to distinct definitions of very high and high-risk patients. Guidelines aligned in recommending antiresorptive and anabolic agents as pharmacologic options for the management of osteoporosis, with sequential treatment recommended. There was agreement that patients at high or very high risk of fracture or with severe osteoporosis should receive anabolic agents first, followed by antiresorptive drugs. Variations were identified in recommendations for follow up of patients on anti-osteoporosis therapies. Reimbursement conditions in each country were a key difference identified.ConclusionsCriteria for risk assessment of fractures differ across European guidelines which may impact treatment and access to anabolic agents. Harmonisation across EU guidelines may help identify patients eligible for treatment and impact treatment uptake. However, country-specific reimbursement and prescribing processes may present a challenge to achieving a consistent approach across Europe.

Advantages of Robotic Surgery for Patients of Reproductive Age with Endometrial Cancer.

This review presents current knowledge on the surgical treatment of endometrial cancer in young patients. Endometrial cancer is the most common gynecological cancer in Europe. Higher morbidity is correlated with obesity, hypertension and diabetes, which are growing worldwide. However, endometrial cancer at an early age is very rare. The first line of treatment for this cancer is radical hysterectomy, which is controversial in young women. There is an alternative method of fertility-sparing treatment. However, there is a group of young patients for whom surgical treatment is recommended. According to European guidelines, minimally invasive surgery is recommended for endometrial cancer. The aim of the study was to present the advantages of robotic surgery for endometrial cancer detected at a young age. The procedure of radical treatment with robot-assisted laparoscopy is more precise. Better visualization and stabilization of instruments allow a shorter procedure time, a brief hospital stay and fewer complications. Quality of life may be at a similar level. Incisions after trocars are painless and more esthetic than a classical wound. Bilateral adnexectomy in endometrial cancer depends on age, molecular status of the cancer, stage, genetic risk factors and individual decision. Conclusions: Robotic surgery seems to be a better surgical method for endometrial cancer in younger patients.

Comparison of American and European Guideline Recommendations for Diagnostic Workup and Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack.

Guidelines help to facilitate treatment decisions based on available evidence, and also to provide recommendations in areas of uncertainty. In this paper, we compare the recommendations for stroke workup and secondary prevention of ischemic stroke and transient ischemic attack of the American Heart Association (AHA)/American Stroke Association (ASA) with the European Stroke Organization (ESO) guidelines. The primary aim of this paper is to offer clinicians guidance by identifying areas where there is consensus and where consensus is lacking, in the absence or presence of high-level evidence. We compared AHA/ASA with the ESO guideline recommendations for 7 different topics related to diagnostic stroke workup and secondary prevention. We categorized the recommendations based on class and level of evidence to determine whether there were relevant differences in the ratings of evidence that the guidelines used for its recommendations. Finally, we summarized major topics of agreement and disagreement, while also prominent knowledge gaps were identified. In total, we found 63 ESO and 82 AHA/ASA recommendations, of which 38 were on the same subject. Most recommendations are largely similar, but not all are based on high-level evidence. For many recommendations, AHA/ASA and ESO assigned different levels of evidence. For the 10 recommendations with Level A evidence (high quality) in AHA/ASA, ESO only labeled 4 of these as high quality. There are many remaining issues with either no or insufficient evidence, and some topics that are not covered by both guidelines. Most ESO and AHA/ASA Guideline recommendations for stroke workup and secondary prevention were similar. However not all were based on high-level evidence and the appointed level of evidence often differed. Clinicians should not blindly follow all guideline recommendations; the accompanying level of evidence informs which recommendations are based on robust evidence. Topics with lower levels of evidence, or those with recommendations that disagree or are missing, may be an incentive for further clinical research.

Improved Risk Prediction Using a Refined European Guidelines Instrument in Pulmonary Arterial Hypertension Related to Congenital Heart Disease

European guidelines advocate a goal-oriented treatment approach in pulmonary arterial hypertension (PAH), based on a comprehensive risk assessment instrument, which has been validated in several PAH subgroups. We investigated its discriminatory ability, and explored tricuspid annular plane systolic excursion (TAPSE) and revised thresholds to improve its predictability within the adult congenital heart disease (CHD) population.In total, 223 adults (42±16 years, 66% female, 68% Eisenmenger) were enrolled from five European PAH-CHD expert centers. Patients were classified as ‘Low’, ‘Intermediate’, or ‘High’ risk at baseline visit and at follow-up within 4-18 months. By the general PAH guidelines instrument, survival did not differ between the risk groups (P=n.s.), mostly due to skewed group distribution. Reclassifying patients using revised thresholds for N-terminal pro-brain natriuretic peptide (NT-proBNP) and 6-minute walk distance (6MWD) (i.e., ‘Low’, ‘Intermediate’, ‘High’ as <500, 500-1400, >1400 ng/l and >400, 165-400 and <165 m, respectively) and use of TAPSE (‘Low’, ‘Intermediate’, ‘High’ as >20, 16-20 and <16mm) significantly improved discrimination between the risk groups both at baseline and follow-up (P=0.001, ROC increase from 0.648 to 0.701), reclassifying 64 (29%) patients. Irrespective of follow-up risk group, survival was better for patients with higher proportions of low-risk variables. Improvement to a ‘Low-risk’ profile at a median of 9 months follow-up provided improved survival comparable to survival of patients who remained in the ‘Low risk’ group.In conclusion, the external validity of general risk instrument for PAH appeared to be of limited discriminatory value in PAH-CHD patients. We propose a refined risk instrument with improved discrimination for PAH-CHD.

URINARY TRACT INFECTIONS AND TOTAL PROSTATE SPECIFIC ANTIGEN TPSA

Introduction: The urinary system consists of four main organs: the kidneys, ureters, bladder, and urethra, and these organs work to filter blood, remove waste, form urine, and eliminate urine from the body. In recent years there have been encouraging strides in understanding and studying the pathogenesis of urinary tract infections (UTIs) and total prostate specific antigen-TPSA. Purpose of the study: The purpose of the research will focus on biochemical markers such as: urea, creatinine, uric acid as urine degradation products and identification of parameters of diseases of the urogenital tract. Urinary status parameters will also be analyzed such as: proteinuria, hematuria, glycosuria, bilirubin, urobilinogen, pH, etc., parameters which are present during diseases and infections of the urogenital tract. The purpose of the paper will also analyze the bacteriological and virological parameters such as: ureoplasma, mycoplasma, chlamydia, toxoplasma and cytomegalovirus, which are identifying parameters for infections of the urogenital tract in different age groups and genders. This work will also consist in the measurement of total prostate specific antigen-TPSA as a main marker for the identification of prostate diseases. Material and method: In the research, a total of 50 male patients will be taken to analyze the urinary condition. Urine analyzes will be performed by collecting urine in sterile cups and using the urine microscopy method and the urine strip test using the chromatographic method, where these analyzes were performed according to the European guideline standards manual (2023). Vitek is an identification system that can identify bacteria and yeast. This test uses the biochemical reactions and nutrient utilization of the microorganism to make the identification of the bacteria and the antibiogram. The test requires that a sufficient amount of growth be obtained during a specified growth period of 18 – 70 hours. Patients of the study group for Total Prostate Specific Antigen (TPSA) were analyzed through the blood serum in ng/mL of the patients with the fluorescent immunoassay test method with Vidas Biomerie. Also 20 patients to analyze the total prostate specific antigen TPSA with serum and will be analyzed with fluorescent enzymatic immunoassay methods (Vidas). SPSS – Software package version 20.0 Numerical series were analyzed using central tendency measures (average, median, minimum values, maximum values), as well as distribution measures (standard deviation); To determine the regularity of the frequency distribution of the examined variables, the Shapiro-Wilk W Test was used; Non-parametric tests for two independent parameters were used to test the significance and difference between some numerical parameters with irregular frequency distribution (Mann Whitney U test); To determine statistical significance, a two-way analysis was used with a significance level (means) of p&lt;0.05. Results: From the results, it was found that urinary infections are frequent and appear during the attack with bacteria and viruses such as ureoplasma, mycoplasma, chlamydia and cytomegaloviruses, which are identifying parameters for infections of the urogenital tract in different age groups of the male gender. Conclusion: From the analyzes performed on patients of different age groups, we came to the conclusion that: • The parameters of the urinary system will be able to give a real picture of infectious diseases of the urinary tract. • Biochemical markers can identify the functional state of the urinary tract. • Antibiogram and cytomegaloviruses - microbiological and virological status can give an insight into the type of urinary infections. • The prostate-specific antigen TPSA can be taken as the main marker for the identification of tumoral disease of the prostate gland.

Abstract P302: Impact of Publication of Hypertension Guidelines on Inappropriate Use of Intravenous (IV) Antihypertensive Medications for Hypertensive Urgencies (HU)

Background: Hypertensive urgencies are common in hospitalized patients. In late 2017 and 2018, the publication of major U.S and European hypertension guidelines included specific recommendations against the use of IV antihypertensive medications for the management of severe acute BP elevations in the absence of acute target organ damage (HU). Aim: To study the impact of the publication of guidelines on local utilization of IV medications for HU. Methods and Results: We analyzed 224,265 non-ICU, non-obstetric, non-pediatric hospital admissions to 5 U.S. hospitals (total 2,681 beds) in a medium-sized U.S. healthcare system between January 2016 and March 2020. These included one large academic medical center with two campuses (Hosp A), one medium sized teaching community hospital (Hosp B), one small teaching community hospital (Hosp C), and two small non-teaching hospitals (Hosp D and E). Among all admitted patients, 22,929 (10.2%) developed HU (SBP&gt;180 or DBP &gt;110 mmHg sustained for at least 1 hour without evidence of acute target organ damage). A total of 2,914 HU patients (12.7%) received at least 1 intravenous medication within 6 hours of acute BP elevation, most commonly hydralazine (N 1473, 50.5%], labetalol (N 749, 25.7%) or metoprolol (N 632, 21.7%). The fraction of patients receiving IV antihypertensives decreased during the five years of the study across the five hospitals, but the absolute change was small (2016=13.7%, 2017=12.8%, 2018=12.5%, 2019=11.4%, 2020=11.7%, P value for overall change = 0.003). The Figure displays temporal trends for each hospital. There was significant heterogeneity across hospitals (P&lt;0.0001). Trends were not related to teaching (vs. nonteaching) status of each hospital. Conclusion: In a medium sized U.S. hospital system, the publication of guidelines recommending against IV antihypertensive use in HU was temporally associated with very modest reductions in IV medication use in HU. Process improvement initiatives are needed to optimize guideline-congruent practice.

Relevance of surveillance manual for the early detection of immune checkpoint inhibitor-induced myocarditis: A case series

ObjectiveThe European Cardio-Oncology Guidelines recommend regular electrocardiography and troponin testing during immune checkpoint inhibitors (ICIs) treatment, but their efficacy for monitoring ICI treatment remains unclear. This study aimed to evaluate the effectiveness of a surveillance protocol for early detection of ICI-induced myocarditis. MethodsBetween May 2014 and May 2024, patients who began treatment with ICIs at our hospital and developed ICI-induced myocarditis were included in this study. We created a straightforward management flowchart for myocarditis. The protocol was based on monitoring troponin T levels. We confirmed the efficacy of our surveillance protocol using a case series of ICI-induced myocarditis. ResultsDuring the observation period, 3481 patients were newly started on ICIs at our hospital. Five patients were previously diagnosed with myocarditis, and five patients were diagnosed with myocarditis after the implementation of the surveillance protocol. The manual enabled the early detection of myocarditis, and the mortality rate for myocarditis at our hospital improved from 60% to 0%. The incidence of conduction system disorders significantly reduced from 100% to 0% (P ​< ​0.01). After the surveillance protocol was initiated, there were no cases of myocarditis requiring immunosuppressive drugs beyond steroids. ConclusionsThis study confirmed the relevance of a troponin-based surveillance protocol for the early detection of ICI-induced myocarditis. The implementation of the surveillance protocol reduced mortality from myocarditis and significantly reduced serious complications of conduction system disorders. Although this study is a small case series of patients who developed myocarditis, we confirm the effectiveness of surveillance for myocarditis.

Factors Associated With Decision to Treat or Not to Treat Helicobacter pylori Infection in Children: Data From the EuroPedHp Registry.

European and North-American guidelines on management of H. pylori infection in children provide the option not to treat even if the infection is endoscopically confirmed. We used data from the EuroPedHp Registry to identify factors associated with therapy decisions. We included treatment-naïve patients reported between 2017 and 2020 from 30 centers in 17 European countries. Multivariable logistic regression identified factors including comorbidities within and outside the gastrointestinal (GI) tract influencing the decision for or against therapy. Of 1165 patients (52% females, median age 12.8), 28% (321/1165) reported any alarm symptom, 26% (307/1165) comorbidities, and 16% (192/1165) did not receive eradication treatment. Therapy was initiated less often in children having any GI comorbidity (57%, n = 181), particularly in those with eosinophilic esophagitis (60%, n = 35), inflammatory bowel disease (54%, n = 28), and celiac disease (43%, n = 58), compared to those with non-GI (86%, n = 126) or no comorbidity (89%, n = 858), despite similar frequencies of alarm and non-alarm symptoms, ulcers, erosions, and nodular gastritis. Patients with GI and without comorbidities remained more likely untreated in high versus low H. pylori prevalence countries (p < 0.0001). In children without comorbidities, factors favoring therapy included older age, being overweight, having symptoms, erosions, antral nodularity, and available antibiotic susceptibility results. In this cohort, H. pylori-infected children with GI comorbidities compared to no comorbidity showed 75% reduced chance of receiving eradication therapy. We found no evidence supporting different management strategies in infected patients with GI comorbidities compared to all pediatric patients with endoscopically proven H. pylori infection.

381. MULTICENTER PAN-CANADIAN EXPERIENCE OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) FOR THE TREATMENT OF ACHALASIA: A RETROSPECTIVE STUDY

Abstract Background Per oral endoscopic myotomy (POEM) has emerged as a modality for the surgical treatment of achalasia using a minimally invasive approach with similar clinical efficacy to laparoscopic Heller myotomy. Japanese, European, American and International clinical practice guidelines now cite POEM as a first line treatment for achalasia. In Canada, single-centre experiences with POEM have shown promising results. This study aims to capture the pan-Canadian national experience with POEM for the treatment of achalasia across multiple institutions. Methods This was a retrospective study of patients who underwent POEM for achalasia across four Canadian institutions (St. Joseph's Healthcare Hamilton, Kingston Health Sciences Centre, Surrey Memorial Hospital and Montreal Sacred Heart Hospital) between 2012 to 2022. Pre-operative, procedural and post-operative data was collected. Our primary outcome was the proportion of patients with normal Eckhardt score (≤ 3) at 4 weeks. Secondary outcomes included procedure related adverse events, length of stay in hospital, post-procedure lower esophageal sphincter pressures, post-procedure gastroesophageal reflux disease (GERD) and response rate at further timepoints. Outcomes are reported as either proportions (%) or medians (IQR). Results POEM was attempted in 369 patients with a success rate of 99%. The median duration of surgery was 64 (47 – 89) minutes and length of stay was ≤1 day in 88% of patients. Peri-operative complications occurred in 11% of patients, all of which were Clavien-Dindo Grade ≤III. The post-operative response rate (Eckhardt score ≤3) was 100%, 98% and 95% at 1, 6 and 12 months, respectively. Additional interventions for achalasia following POEM were required in 6% of patients. High DeMeester scores, endoscopic esophagitis and symptomatic GERD were reported in 36%, 43% and 44%, respectively. 93% of GERD was treated with PPI therapy. Conclusions POEM is safe and feasible in Canadian institutions with efficacy in keeping with current international literature.

Factors affecting treatment decisions for endoscopically resected low- and high-risk malignant colorectal polyps in a screening setting

IntroductionThe European Guidelines for colorectal cancer screening of 2006 state that only high-risk endoscopically resected malignant colorectal polyps (MCPs), defined as poor/no differentiation or positive resection margins or lymphovascular invasion, require colonic resection. MethodsA multicentre series of 954 patients with screen-detected MCP (northern Italy, 2005–2016, age 50–69) was studied to identify (1) the factors affecting the choice of colonic resection, and (2) the factors associated with deviation from the European Guidelines for low- and high-risk patients. Data analysis was based on multilevel logistic regression models. ResultsFive hundred sixty-four (59.1 %) patients underwent colonic resection. The factors significantly associated with surgical referral included: distal and rectal versus proximal tumour site (inverse association); sessile and flat versus pedunculated morphology (direct association); tumour size (direct); moderate/poor versus good differentiation (direct); adenocarcinoma of not otherwise specified type versus adenocarcinoma with a residual adenoma component (direct); positive versus negative resection margins (direct); lymphovascular invasion (direct); and high-grade versus low-grade/absent tumour budding (direct). In low-risk MCPs, tumour budding encouraged strongly the decision for surgery. In high-risk MCPs, a distal/rectal tumour site encouraged the follow-up option. ConclusionThe identification of factors associated with treatment choices other than those currently recommended may help prioritise the clinical questions in the development of future guidelines.

Myocardial Ischemic Syndromes: A New Nomenclature to Harmonize Evolving International Clinical Practice Guidelines.

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischemia, various classifications have emerged over time, often with conflicting terminology-eg, "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with "acute coronary syndromes" (ACS), the 2023 American guidelines endorsed the alternative term "chronic coronary disease." An unintended consequence of these competing classifications is perpetuation of the restrictive terms "coronary" and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes," which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischemia, and infarction.

Subchronic Effects of Tetrachloroethylene on Two Freshwater Copepod Species: Implications for Groundwater Risk Assessment.

Aliphatic chlorinated hydrocarbons, notably tetrachloroethylene (also known as perchloroethylene [PCE]), are persistent, mobile, and toxic (PMT) and/or very persistent, mobile, and toxic (vPMT) groundwater pollutants, often exceeding safe drinking water thresholds. The present study delves into the groundwater risk assessment of PCE with a novel focus on the sensitivity of stygobitic species-organisms uniquely adapted to groundwater environments. Through a comparative analysis of the subchronic effects of PCE on the locomotion behavior of two copepod species, the stygobitic Moraria sp. and the nonstygobitic Bryocamptus zschokkei, we highlighted the inadequacy of the current European predicted-no-effect concentration of PCE for groundwater ecosystems. Our findings indicate significant behavioral impairments in both species at a concentration (32 ng/L PCE) well below the threshold deemed safe, suggesting that the current European guidelines for groundwater risk assessment may not adequately protect the unique biodiversity of groundwater habitats. Importantly, B. zschokkei demonstrated sensitivity to PCE comparable to or greater than that of the target stygobitic species, suggesting its utility as a substitute species in groundwater risk assessment. The present study adds to the limited research on the ecotoxicological sensitivity of groundwater species to PMT/vPMT chemicals and highlights the need for refined groundwater risk-assessment methodologies that consider the susceptibilities of stygobitic species. Environ Toxicol Chem 2024;00:1-13. © 2024 The Author(s). Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Systolic blood pressure at age 40 and 30-year stroke risk in men and women

BackgroundAmerican and European guidelines define hypertension differently and are sex agnostic. Our aim was to assess the impact of different hypertension thresholds at the age of 40 on 30-year stroke...

Development of quality indicators for hypertension, extractable from the electronic health record of the general practitioner: a rand-modified Delphi method

BackgroundHypertension, a chronic medical condition affecting millions of people worldwide, is a leading cause of cardiovascular diseases. A multidisciplinary approach is needed to reduce the burden of the disease, with general practitioners playing a vital role. Therefore, it is crucial that GPs provide high-quality care that is standardized and based on the most recent European guidelines. Quality indicators (QIs) can be used to assess the performance, outcomes, or processes of healthcare delivery and are critical in helping healthcare professionals identify areas of improvement and measure progress towards achieving desired health outcomes. However, QIs to evaluate the care of patients with hypertension in general practice have been studied to a limited extent. The aim of our study is to define quality indicators for hypertension in general practice that are extractable from the electronic health record (EHR) and can be used to evaluate and improve the quality of care for hypertensive patients in the general practice setting.MethodsWe used a Rand-modified Delphi procedure. We extracted recommendations from European guidelines and assembled them into an online questionnaire. An initial scoring based on the SMART principle and extractability from the EHR was performed by panel members, these results were analyzed using a Median Likert score, prioritization and degree of consensus. A consensus meeting was set up in which all the recommendations were discussed, followed by a final validation round.ResultsOur study extracted 115 recommendations. After analysis of the online questionnaire round and a consensus meeting round, 37 recommendations were accepted and 75 were excluded. Of these 37 recommendations, 9 were slightly modified and 4 were combined into 2 recommendations, resulting in a list of 35 recommendations. All recommendations of the final set were translated to QIs, made up of 7 QIs on screening, 6 QIs on diagnosis, 11 QIs on treatment, 5 QIs on outcome and 6 QIs on follow-up.ConclusionsOur study resulted in a set of 35 QIs for hypertension in general practice. These QIs, tailored to the Belgian EHR, provide a robust foundation for automated audit and feedback and could substantially benefit other countries if adapted to their systems.

Applying current European periodontitis clinical practice guidelines is not feasible even for the richest countries in the world.

Clinical practice guidelines aim to enhance the quality, equality and consistency of care but often demand more time than is available, rendering adherence impractical and exceeding feasible resources. The 2017 introduction of a new periodontal classification system by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) sought to refine clinical and epidemiological practices by serving as the basis for clinical practice guidelines and epidemiological investigations around the world. Following this classification, the EFP recommends supportive periodontal care visits every 3-12 months for all periodontitis cases. Given that in Norway, approximately 72% of the adult population are identified as periodontitis cases under the current AAP/EFP case definition, this poses a significant demand on healthcare resources. We calculated that between 60% and 70% of all estimated available working hours available for adult dental care provided by dentists and dental hygienists in Norway in 2017 would be spent on supportive periodontal care visits alone if the recommendations were to be met. This situation calls for a reevaluation of disease definitions and clinical practice guidelines to ensure they are practical, financially feasible and patient-outcome relevant.

Time to intravenous diuretic administration in patients hospitalized with heart failure: An observational study.

To help establish optimized treatment strategies for congestion in patients with acute heart failure, this study aimed to provide a detailed summary of real-world diuretic use in hospitalized patients with heart failure requiring urgent therapy in Japan. This observational study used a Japanese medical records database to extract data of patients admitted to hospital with a heart failure diagnosis and an intravenous diuretic prescription from the day before admission to 2days after. Time from hospital visit to first dose, second dose, and maximum dose of intravenous diuretics were determined. Patients were grouped according to whether they received diuretic modification, defined as an intravenous diuretic dose increase or concomitant use of other diuretics. Overall, 1577 patients were included in the study (without diuretic modification, n=1140 [72.3%]; with diuretic modification, n=437 [27.7%]). The study population was 49.5% female (n=780) and the mean age±standard deviation was 80.1±12.7years. Intravenous diuretic treatment was received within 1h of their hospital visit in 43.5% of patients (686/1577) and ≤2h in 16.4% of patients (258/1577). Among 437 patients with an inadequate response following their first dose, 42.1% received an intravenous dose titration, 56.5% received combination diuretics, and 1.4% received both. Over half of the patients (59.0% [258/437]) with diuretic modification received it after the first 24h of the hospital visit. The median time from hospital visit to first dose titration was similar to time to first combination diuretic use (18.6h and 17.0h, respectively). The mean±standard deviation duration of intravenous diuretic use was significantly longer for patients with versus without diuretic modification (6.3±5.2 vs. 3.7±3.2days), and a significantly greater proportion of patients (44.6% [195/437] vs. 35.0% [399/1140]) received repeated intravenous diuretic administration. Other characteristics/outcomes of intravenous diuretic use were similar with versus without diuretic modification, including in-hospital death (15.6% [68/437] vs. 13.9% [159/1140]) and mean±standard deviation length of hospitalization (21.9±14.7days vs. 22.1±21.2days). In Japan, real-world patterns of intravenous diuretic administration for patients with heart failure remains far from the time-sensitive approach recommended in Japanese, European, and United States guidelines.

Effects of Vietnamese Balm (Elsholtzia ciliata (Thunb.) Hyland) Essential Oil on Growth Performance of Striped Catfish (Pangasianodon hypophthalmus) Juvenile stage

Graphical Abstract Highlight Research Gas chromatography-mass spectrometry identified major components of the essential oil, including (Z)-β-Farnesene (24.02%), neral (15.06%), geranial (15.02%), and β-ocimene (13.61%). Diets enriched with 5% Vietnamese balm leaf essential oils significantly improved the survival rate, feed conversion ratio, and feed efficiency. Diets enriched with 5% Vietnamese balm leaf essential oils significantly improved the weight parameters (average weight; weight gain; percentage weight gain; percentage specific growth rate; daily weight gain). Diets enriched with 5% Vietnamese balm leaf essential oils significantly improved the length parameters (average length; length gain; percentage length gain; percentage specific growth rate; daily length gain). Abstract Vietnamese balm (Elsholtzia ciliata) is a prominent herb in Vietnamese traditional medicine. This study investigated the impact of Vietnamese balm leaf essential oils on the growth of striped catfish (Pangasianodon hypophthalmus) in the juvenile stage. Essential oils were extracted using steam distillation, following European Pharmacopoeia guidelines. Gas chromatography-mass spectrometry identified the essential oil components. The experiment encompassed three treatments: 0% (control), 3%, and 5% of Vietnamese balm leaf essential oils in a completely randomized design. The results demonstrated a time and dose-dependent modulation of striped catfish growth by the essential oils. Diets enriched with 5% Vietnamese balm leaf essential oils significantly enhanced survival rate and growth, indicating potential as a fish feed additive. The essential oil yield was 0.83% dry weight, with major components including (Z)-β-Farnesene (24.02%), neral (15.06%), geranial (15.02%), and β-ocimene (13.61%). Additionally, the study emphasized the growth-promoting effects of herbal extracts on various growth parameters. Further investigations should explore the impact of Vietnamese balm essential oil on catfish immune response and disease resistance, providing a comprehensive understanding of its potential benefits.

Oligometastatic disease – a renaissance for surgery?

Abstract Half of the patients with esophageal cancer, cancer of the gastro-esophageal junction and gastric cancer present metastasis at the time of diagnosis. In addition, even patients originally thought to be free of metastasis will present metachronous metastasis in the course of the disease. These patients are considered incurable and current standard of care for metastatic esophageal, gastro-esophageal junction and gastric cancers is a systemic therapy without curative intention. However, patients presenting only a low metastatic load are now defined as oligometastatic disease and should benefit from an aggressive, multimodal therapy. We present here a review of recent publications investigating multimodal therapies for oligometastatic disease and showing that a systemic therapy combined with a resection of the primary tumor together with metastasis is associated with a better prognosis than a systemic therapy alone. We also give a precise focus on esophageal squamous cell carcinomas and adenocarcinomas of the gastro-esophageal junction and of the stomach. Interestingly, patients with oligometastatic cancer of the esophago-gastric junction can even be treated in curative intention with such a multimodal therapy as we present here in a short case report. In conclusion, new therapeutic strategies including multimodal approaches for oligometastatic disease have shown promising results in the last years and ongoing randomized prospective trials will provide us the evidence to include them in future European guidelines.