Disease Guidelines Research Articles

Expanding the imaging armamentarium for the diagnosis of prosthetic aortic graft infection.

In their study published in this issue of the European Journal of Cardio-Thoracic Surgery, Tsuda et al. [1] evaluated the role of 18-fluorodeoxyglucose positron emission tomography (18-F-FDG PET) in the diagnosis of prosthetic aortic graft infection. Their retrospective review of 71 patients who underwent 18-FDG PET imaging after aortic repair showed that patients with aortic graft infection had a higher maximum standardized uptake value (SUVmax) than patients without infection (8.64 vs 3.40, P < 0.01) and that SUVmax value differed between the early postoperative period and long-term follow-up. The authors propose a cut-off value for SUVmax of 4.5 for suspicion of graft infection immediately after endovascular repair and subsequently using stepwise cuff-off values of 6.5 at 1 year, 5.5 at 3 years and 5.0 thereafter. Aortic graft infection is an uncommon complication, and its diagnosis and treatment can be challenging. The recent American Heart Association aortic disease guideline [2] provides recommendations for the diagnosis and management of prosthetic aortic graft infection. The diagnostic recommendations state that the sensitivity and specificity of diagnosis are enhanced by the use of cross-sectional imaging with computed tomography angiography combined with 18-FDG PET or magnetic resonance imaging of tagged white blood cells. Furthermore, the Management of Aortic Graft Infection Collaboration (MAGIC) group has proposed clinical/surgical, radiological, and laboratory diagnostic criteria for aortic graft infection, among which suspicious metabolic activity on 18-FDG PET is a minor criterion [3]. The MAGIC criteria were shown to have with good sensitivity and specificity in the prospective Vascular Graft Cohort study (VASGRA) [3]. Importantly, FDG-PET interpretation can be limited in patients with natural inflammation or malignancy that can affect its diagnostic accuracy for infection, as well as differences among centres and practitioners in their methods of image acquisition, processing and interpretation [4].

Investigating antibiotic use in Gaza Strip hospitals: A retrospective cross-sectional analysis.

Rates of antimicrobial resistance in the Gaza Strip are rising while regulations on antibiotics use are weakly implemented. This study aimed to investigate antibiotic use in hospitals utilizing World Health Organization (WHO) hospital, prescribing, and patient care indicators. A retrospective study was conducted at Al Shifa medical complex (SMC), Nasser Medical Complex (NMC), and European Gaza Hospital (EGH). Data for hospital indicators were collected from drug inventory records and by interviewing hospital pharmacy managers, while data for prescribing and patient care indicators were collected from medical records from all departments. WHO standard data collection forms and formulas to calculate quantitative indicators were used. Standard treatment guidelines for infectious diseases were unavailable. The availability of key antibiotics on the day of the investigation was 58.62%, 90.9%, and 44.82%, and antibiotics were out of stock for 120.5, 63.3, and 119.8 days/year in SMC, NMC, and EGH, respectively. A total of 1400 patients' records were screened; 68.2% of patients were prescribed antibiotics with an average duration of 3 days. The number of antibiotics prescribed was 1.26/hospitalization, 55% were prescribed by generic name, 98% were consistent with the essential medicine list, and 94.7% were given parenterally. Ceftriaxone was the most commonly used antibiotic (47.5%). Adherence rates to STGs for Caesarean section antibiotic prophylaxis and for pneumonia were 43% and 6.3%, respectively. About 97% of doses of prescribed antibiotics were administered and patients on antibiotics stayed in the hospital for 4.1 days. Antibiotic utilization patterns are less than optimal. Strategies to improve antibiotic use in the investigated hospitals are needed.

Knowledge of cardiovascular disease risk factors, practice, and barriers of community pharmacists on cardiovascular disease prevention in North West Ethiopia

BackgroundIn Ethiopia, there are no adequate studies made on the knowledge and practice of CVD and its risk factors among community pharmacists. Thus, this study aimed to assess knowledge of cardiovascular disease risk factors, practice, and barriers of community pharmacists on cardiovascular disease prevention. MethodsA Cross-sectional study was conducted on a total of 81 community pharmacists from the first march to May 30, 2020, at Gondar town. Data was entered to EPI-INFO 7 and exported to SPSS software for windows version 20 for analysis. The results are presented by using tables and figures. The chi-square test was applied to test the relationship between Knowledge and independent variables. P-value ≤ 0.05 was considered as statistical significance. ResultOf the participants, 45 (55.6%) of them were found knowledgeable about cardiovascular disease. On the other hand, only 18.5%, 77.8%, and 93.8% of the study participants respectively were aware of CVD risk factors like symptoms of heart disease, the connection of family history of heart disease, and the connection between old age and heart disease. Only 21% of the study participants had known the existence of HTN guidelines in Ethiopia. X2 statistical analysis showed that there was no statistically significant association between age (P = 0.82), gender (P = 0.661). Marital statuses (P > 0.50), number of years of practice (P = 0.796) and cardiovascular disease. The main barriers to the prevention of CVD for community pharmacists were, lack of time (18.5%), inability to identify targeted patients (65.4%), lack of knowledge (23%), and lack of communication (26%). ConclusionThe overall assessment of the pharmacists demonstrated that more than half of the participants were found knowledgeable. However, only a small proportion of the study participants had known about the existence of National guidelines for cardiovascular disease in particular and non-communicable disease in general. Therefore, the provision of government policy that will regulate their training, certification, and practice for CVD screening and as well as provide a framework of incentives are recommended.

A Review of the use of Rational and Quality Antibiotics in a Nigerian Tertiary Institution

Purpose: The study reviewed the use of rational and quality antibiotics at the Federal Medical Centre, Yenagoa, Bayelsa State. Three objectives and three research questions were drafted for the study, respectively.&#x0D; Methodology: The study used a retrospective descriptive survey that lasted four months. The study relied on secondary data, which was gathered from the folders of 583 patients. From January 1, 2019 to April 30, 2019, all patients with complete information admitted to medical, surgical, and paediatric wards, as well as obstetrics and gynaecology wards, had their folders reviewed. A self-developed checklist was used to assess critical aspects of antibiotic utilisation and the use of generic names in antibiotic prescribing, a self-developed checklist was used. The data collected were collated, coded and analysed using descriptive statistics of frequency, percentage, charts, and tables.&#x0D; Findings: The findings showed that out of the total folders (n=583) reviewed, the socio-demographic information showed that majority of the patients (42.2%) who received prescribed antibiotics were adult female. On the age category, out of the total folders (n=583) reviewed, majority of the folders (114) showed that those within the ages of 21-30 years represents over 19.0%. The antibiotics prescribed from the four (4) different departments showed that 26.7% of antibiotics were prescribed and utilized in medical wards. The level of compliance with some standard practices, shows that pneumonia test conducted, was highest in surgery ward, this represents 82.8%, the sensitivity test conducted, was highest in paediatric ward (46.4%). Out of the total antibiotics prescribed (n=1164), generic names were used for 59.6% cases, while 73.2% of the antibiotic prescribed were in the EDL authorised list. The results revealed that cephalosporins were the most commonly prescribed class of antibiotics, 384 (34%) followed by the nitroimidazoles 346 (29.7%) and penicillin’s 138 (11.9%). Inappropriate antibiotic prescription was found to be 58.7% among the total prescribed antibiotics (n=1164). Based on the results and findings in the study, it is safe to conclude that the majority of antibiotics utilised were over prescribed, with high inappropriate use. The lack of generic use in antibiotic prescriptions and the overuse of antibiotics remain a problem in tertiary hospitals across Nigeria.&#x0D; Recommendation: This study recommend that prescriptions should be prescribed with slips duly signed by a doctor and approved by a pharmacist before the administration of such drugs. Also, all public hospitals in Nigeria should develop local treatment guidelines using national and international policy guidelines for local infectious disease.

Gastrointestinal Microbiota and Breast Cancer Chemotherapy Interactions: A Systematic Review.

Breast cancer is the most common type of cancer in women besides basal cell and squamous cell skin cancer. The current systemic therapy guidelines for this heterogeneous disease are mainly based on the molecular subtypes. However, more research is required to improve rates of therapy resistance and prevent side effects. Previous studies have shown that the human gut microbiota may have an important role in carcinogenesis as well as therapy outcomes, but this factor has not yet been integrated into therapy protocols. This systematic review aims to analyze how response rates and side effect profiles of breast cancer systemic therapies may be affected by the gastrointestinal microbiota. A literature search was performed using multiple databases and keywords related to gastrointestinal microbiota, breast cancer, and anticancer drugs. Studies were excluded if they primarily focused on diseases other than breast cancer. Abstracts, reviews, meta-analyses, and animal experiments were also excluded. After screening, nine studies met all selection criteria and included a total of 566 participants. Most studies described the impact of the gut microbiota on therapy response, but a few additionally discussed chemotherapy side effects, probiotics, or antibiotics. In general, diversity and specific microbiota were linked to chemotherapy response as well as prognosis. Microbiota diversity was also predictive of side effects such as neurological symptoms, weight gain, and constipation. The diversity and composition of gastrointestinal microbiota may serve as biomarkers and provide pathways for the optimization of chemotherapy in breast cancer patients.

Quantification of Emphysema in Chronic Obstructive Pulmonary Disease by Volumetric Computed Tomography of Lung

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with small airway inflammation and emphysema. Emphysema is permanent enlargement of air spaces distal to terminal bronchioles accompanied by destruction of alveolar walls. These morphological changes can be studied on quantitative computed tomography (CT). Thirty-four patients diagnosed to have COPD as per Global Initiative for Chronic Obstructive Lung Disease guidelines underwent chest CT using full inspiration with low dose radiation protocol. Pulmo-CT software was used to analyse the scans. The primary aim was to quantify emphysema and emphysema clusters and secondary aim was to assess correlation between percentage emphysema and lung function. Their mean [standard deviation (SD)] age was 66.4 (7.0) years; 11 (32.4%) were current smokers (median pack years 45.5). Their mean (SD) forced expiratory volume in the first second (FEV1%) was 55.6 (17.6), mean (SD) %emphysema was 26.8 (11.1), mean (SD) lung density was -848.35 (29.5) Hounsfield units (HU), median (interquartile range) %cluster class 4 emphysema was 22.4 (13.5-32.6). There was no significant difference in %low attenuation volume (%LAV) in current and exsmokers (p=0.4); across various severity grades of COPD (p=0.15). Further, no significant correlation was observed between %emphysema and post-bronchodilator FEV1%. Volumetric CT can detect and quantify emphysema. Majority of emphysema clusters in COPD are >25mm. The %emphysema does not correlate to the severity of the disease. Quantitative CT is a good objective method to study emphysema and can be used to phenotype COPD radiologically.

Sino-Nasal Status in Patients with Chronic Obstructive Pulmonary Disease

Background. Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease with serious impact on quality of life (QoL). There are limited studies available supporting coexistence of sino-nasal involvement in COPD. Methods. A prospective study was conducted to evaluate sino-nasal status in patients with COPD (n=100) presenting to the Department of Respiratory Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur from July 2011 to October 2012. COPD was diagnosed based on the Global initiative on Obstructive Lung Disease (GOLD) guidelines. Sino-nasal status was assessed by detailed history, radiograph of the para-nasal sinuses (PNS), nasal endoscopy and mucociliary clearance time. Results. Sino-nasal symptoms were present in 74 patients with COPD; nasal discharge (75.7%) being the most common. Tobacco smokers with COPD had a higher occurrence of sino-nasal symptoms (76.8%). Radiograph of para-nasal sinuses showed that maxillary sinus was most commonly involved. Nasal endoscopy revealed discharge in 63.5% cases. Nasal mucociliary clearance time was delayed (>11 to >40 min) in 98% cases. Nasal mucociliary clearance time was significantly delayed (>20 min) in COPD patients who were tobacco smokers as compared to non-smokers (53.7% versus 16.7%) and also related with increasing severity of COPD. Conclusions. Our observations suggest that sino-nasal involvement and delayed mucociliary clearance are common in patients with COPD, especially in tobacco smokers. Assessment of upper airway involvement in all the patients with COPD can help better therapeutic intervention and improvement in QoL.

Longitudinal, Real-World Data Reveal Treatment Effectiveness in Idiopathic Multicentric Castleman Disease and Support Current Treatment Guidelines

Background: Idiopathic multicentric Castleman disease (iMCD) is an immunologic disorder with unknown etiology that is diagnosed in approximately 1200 individuals in the US annually. Presentation is heterogeneous - ranging from mild/moderate constitutional symptoms to severe multi-organ dysfunction. Treatment guidelines were developed by an international expert panel in 2017 based on the review of a limited number of clinical trials and small case series. Siltuximab, a monoclonal antibody against interleukin-6 (IL6) approved for the treatment of iMCD, is recommended first-line based on evidence from its phase II trial. High-dose steroids and cytotoxic chemotherapy are recommended for patients with severe disease who progress on anti-IL6 therapy. For patients with mild/moderate disease not responding to IL6 blockade, rituximab +/- immunomodulators is recommended. While concurrent steroids are recommended in some cases, steroid monotherapy is discouraged. Limited data exist on the effectiveness of these agents beyond siltuximab. Herein, we evaluate treatment regimens administered to a cohort of 83 iMCD patients with longitudinal treatment and response data. Methods: A review of cases in the ACCELERATE natural history registry by a panel of experts led to the identification of 83 patients with confirmed iMCD. Longitudinal treatment and response data were abstracted from medical records. Durable treatment response was defined as the best response according to the change in the proportion of abnormal clinical/laboratory criteria sustained for at least 1 year. Severity at the time of treatment initiation was defined as ≥2 of renal failure, fluid accumulation, severe anemia, pulmonary involvement, or hospitalization. Survival analysis for time-to-next-treatment, a proxy for time to treatment failure, was performed on regimens categorized in the guidelines: siltuximab +/- best supportive care (BSC), tocilizumab +/- BSC, rituximab +/- BSC, chemotherapy +/- other agents, and steroid monotherapy. BSC includes steroids, transfusions, and other supportive modalities. Log rank test was used to determine differences across treatment regimens, and pairwise comparisons were Bonferroni corrected. Results: Approximately half (47%) of the patients were female, with a mean (SD) age at diagnosis of 35.9 (16.2). A total of 261 regimens were administered across the cohort. Of the 41 patients who received siltuximab +/-BSC, 44% (N=18) achieved a durable response. Durable response rates to other treatments included: tocilizumab +/-BSC: 41% (7/17); rituximab +/-BSC: 23% (6/26); chemotherapy +/-BSC: 38% (8/21); steroid monotherapy: 6% (2/32). Steroid monotherapy was significantly less likely to induce a durable response than siltuximab +/-BSC (p=0.02). Notably, response rates were significantly lower across modalities in severe compared to mild/moderate disease (p=0.004). We also found that the treatment regimen significantly predicts time-to-next-treatment (p<0.0001, Figure 1). Median time-to-next-treatment for siltuximab +/-BSC is 742 days (95% CI: 1.26, no upper limit), tocilizumab +/-BSC is 689 days (234, no upper limit), rituximab +/- BSC is 153 days (116, 399), chemotherapy +/- other agents is 463 days (107, 791), and steroid monotherapy is 64 days (36,129). Pairwise comparison demonstrated that siltuximab +/-BSC, tocilizumab +/-BSC, and chemotherapy each have a significantly longer time-to-next-treatment compared with steroids (p<0.05). Further, siltuximab +/- BSC also had a significantly longer time-to-next-treatment than rituximab +/-BSC (p=0.02). There were no other differences between regimens. Discussion: Though guidelines were developed in 2017, this is the first systematic assessment of iMCD treatment regimens included in these guidelines. We found differences in durable response rates and in time-to-next-treatment between regimen approaches. Patients on steroids alone require additional drug-intervention a median of 2 months after treatment start, while patients treated on siltuximab +/-BSC remained on treatment for a median of 2 years before additional interventions were added. Our results support current recommendations to administer siltuximab first-line and limit steroid monotherapy use. These results also demonstrate that additional agents are needed for refractory patients, who have few options and are at risk of death due to progression. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The association between total cholesterol and cognitive impairment in chronic obstructive pulmonary disease patients

AimChronic obstructive pulmonary disease (COPD) is primarily a respiratory system disorder associated with extrapulmonary conditions. Cognitive impairment (CoI) is very common among COPD patients This study sought to investigate the association between CoI and clinical parameters, inflammatory markers and lipid profiles in a COPD patient population. MethodsThe study population included 111 stable COPD patients. COPD was diagnosed according to Global Initiative for Chronic Obstructive Lung Disease guideline. Total complete blood count test and biochemical measurements including lipid profile were performed. Afterwards, all patients underwent neuropsychological assessment including Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index and Montreal Cognitive Assessment (MoCA) tests. ResultsThe patients were categorized into two groups according to their MoCA test score: MoCA score ≤ 21 (CoI) (n = 69) and MoCA score > 21 (normal cognition) (n = 42). Total cholesterol (TC) levels were significantly lower in patients with CoI compared to patients with normal cognition. Inflammation related parameters including C-reactive protein were similar among groups. Multivariate logistic regression analysis yielded education, HADS score and TC (OR:1.02, 95% CI:1.00–1.04, p = 0.025) as independent predictors of MoCA score. ConclusionTC independently associates with CoI in COPD patients. There is comparable inflammatory status in COPD patients with CoI compared to COPD patients with normal cognition.

The policy environment of self-care: a case study of the Philippines.

Self-care is the ability and empowerment of individuals to maintain health through informed health-care decisions, with or without the support of a health provider. High-income countries have made advances to their conceptualization, research and institutionalization of self-care, given its reported benefits to patients, the health system and economy. A similar undertaking in low- and middle-income countries (LMICs) with already fragile health systems is warranted as highlighted by the coronavirus disease 2019 pandemic. Our article therefore aimed to describe and analyse the policy environment of self-care using the Philippines as a case study, which may have relevance to other similar countries and settings that are transitioning towards Universal Health Care (UHC) to reform and strengthen their primary care systems. We conducted 13 key informant interviews and 2 focus group discussions among representatives from the government, the pharmaceutical retail/industry, community retail pharmacy, primary health physicians and health workers, an infirmary administrator and patients and/or patient advocates. We triangulated our qualitative data with findings from our policy review. We found a total of 13 relevant policies on self-care in the Philippines recently drafted and/or implemented from 2016 to 2021 that fall under the broad categories of unifying frameworks and road maps, capacity building and institutional streamlining, regulations and disease guidelines. Our case study highlights the role of the UHC Law as a driver for self-care and patient empowerment towards better health outcomes with its passage resulting in the promulgation of self-care-related policies. Our findings also suggest that changes in the local policy and built environment, and the formal educational and health systems, are needed to foster a culture of responsible self-care. There are notable exemplars in advancing self-care in the region, including Thailand, from which LMICs like the Philippines can draw lessons to make progress on institutionalizing self-care and, ultimately, realizing UHC and Health For All.

A multicenter study of genetic testing for Parkinson’s disease in the clinical setting

Parkinson’s disease (PD) guidelines lack clear criteria for genetic evaluation. We assessed the yield and rationale of genetic testing for PD in a routine clinical setting on a multicenter cohort of 149 early-onset and familial patients by exome sequencing and semi-quantitative multiplex ligation-dependent probe amplification of evidence-based PD-associated gene panel. We show that genetic testing for PD should be considered for both early-onset and familial patients alike, and a clinical yield of about 10% in the Caucasian population can be expected.

Home delivery of ART: could this be a reality in South Africa?

Differentiated models of care for HIV treatment are now well established in South Africa. The National Adherence Guidelines for HIV, tuberculosis, and non-communicable diseases clearly outline policy and service-delivery procedures for a number of models.1,2 While some models are targeted at children and adolescents or those patients who are struggling with adherence or who have disengaged with care, most models include only adult patients who have successfully navigated HIV services for 6 months or more and are considered to be established on antiretroviral therapy (ART).

TO STUDY THE IMPACT OF MODIFIED PULMONARY REHABILITATION PROGRAMME ON IMPROVEMENT OF MORBIDITIES IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENTS

Background : Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality throughout the world. It is characterized by slow emptying of the lung during forced expiration and measured by FEV1/FVC ratio. Objectives: To assess the difference in the patient's level of symptoms (MMRC Grading), psychological assessment (PHQ9),objective parameters (6 Minute Walk Test, Spirometry) after giving modied pulmonary rehabilitation. Material and Methods:An analytical study was carried out on 150 participants attending our hospital who were enrolled after their informed and written consent, Demographic data, history, physical examination, and psychological assessment were conducted of all the patients. The total duration of the study is of 18 months. Out of that one patient is followed for 12 weeks during which during the rst 6 weeks of the study patients were given pharmacotherapy as per Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and for the next 6 weeks patients were given pharmacotherapy with pulmonary rehabilitation. Results: Out of 150 patients , the majority of the patients presented with MMRC grade 2 or 3 at the initiation of study and at the end of the study, their grades were improved. The value of spirometry testing, 6 Minute walk test, and the PHQ9(Psychological assessment) score was also improved at the end of the study as compared to the initiation of the study. Conclusion: Pulmonary rehabilitation plays a sentinel role in management of COPD and it increases the survival of COPD patients

Prevalence of chronic obstructive pulmonary disease (COPD) among rural population: A national survey in Bangladesh.

In Bangladesh, there is a scarcity of nationally representative data on the burden of chronic obstructive pulmonary disease (COPD). To estimate the COPD prevalence in rural settings, this cross-sectional, population-based study was conducted in all eight administrative divisions of Bangladesh, and involved adults aged 40 years and above. By using multi-stage random sampling, 2,458 individuals were enrolled. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines were used to diagnose COPD based on post-bronchodilator lung function, while additional participant data was gathered through computer-assisted personal interviews. A 2% COPD prevalence (95% CI: 1.45, 2.55) was found in the study sample with a statistically significant difference between males (2.7%; 95% CI: 1.8, 3.6) and females (1.2%; 95% CI: 0.59, 1.81). Increasing age significantly inflated the odds of having COPD irrespective of sex (OR: 1.03; 95% CI: 1.00, 1.05; P value < 0.05). Furthermore, prevalence of COPD was higher among manual workers, cigarette smokers, and those that used the indoor kitchen and did not have a primary education. Sex-based analysis showed that smokeless tobacco consumption was significantly associated with COPD occurrence among males (OR: 2.14; 95% CI: 1.05, 4.37; P value < 0.05), but not females. Further, using an indoor kitchen increased the odds of developing COPD by 400% among female participants (OR: 4.39; 95% CI: 1.37, 14.10; P value < 0.05). This study provides a comprehensive sex-based estimation of COPD prevalence among rural population and imparts significant contribution to the growing database on COPD prevalence in Bangladesh.

Safe prevention of Clostridium difficile using infectious disease guidelines at an urban hospital in North Carolina

Clostridium difficile causes nearly 500 000 annual infections in the USA. A total of 15 000–30 000 US deaths annually and greater than US$4.8 billion dollars are related to Clostridium...

Investigation of ocular microstructural changes according to disease severity in patients with chronic obstructive pulmonary disease

ObjectifVérifier les variations de l’épaisseur des couches de fibres nerveuses rétiniennes (RNFL) et de la densité vasculaire dans la rétine et le disque optique en présence de bronchopneumopathie chronique obstructive (BPCO). MéthodesAinsi, 66 patients présentant une BPCO et 54 sujets sains appariés pour l’âge et le sexe ont pris part à cette étude transversale prospective. Les patients présentant une BPCO ont été divisés en 3 sous-groupes (atteinte légère, modérée ou grave) d'après les paramètres spirométriques figurant dans les lignes directrices de la Global Initiative for Chronic Obstructive Lung Disease. On a eu recours à l'angiographie-tomographie par cohérence optique (OCTA) pour mesurer l’épaisseur des RNFL, l'aire de la zone fovéale avasculaire (ZFA) de même que la densité vasculaire du plexus capillaire superficiel, du plexus capillaire profond et du plexus capillaire péripapillaire radial. Les résultats ont ensuite été comparés d'un groupe à l'autre. RésultatsOn n'a noté aucune différence significative entre les patients du groupe BPCO et les sujets témoins en ce qui a trait à l'aire de la ZFA ou à l’épaisseur des RNFL (p = 0,891 et p = 0,896, respectivement). La densité vasculaire des patients du sous-groupe BPCO grave était moins élevée dans le plexus capillaire superficiel, comparativement aux autres groupes, mais la différence n’était pas significative (p > 0,05). La densité vasculaire dans le plexus capillaire profond ne différait pas significativement d'un groupe à l'autre dans la région fovéale (p > 0,05), mais était significativement moins élevée dans tous les quadrants parafovéaux chez les patients présentant une BPCO grave. La densité vasculaire dans le plexus capillaire péripapillaire radial était également moins élevée en présence de BPCO grave, surtout dans la région péripapillaire (p = 0,044). ConclusionBien que la BPCO soit d'abord et avant tout une affection pulmonaire, les tissus de l’œil semblent compter parmi ceux qui sont touchés pendant l’évolution naturelle de la maladie. Les effets sont plus prononcés en présence de BPCO grave et se manifestent dans le plexus capillaire profond et dans le plexus capillaire péripapillaire radial.

Disparities in Loss to Follow-Up Among Adults With Congenital Heart Disease in North Carolina.

The AHA/ACC Adult Congenital Heart Disease guidelines recommend that most adults with congenital heart disease (CHD) follow-up with CHD cardiologists every 1 to 2 years because longer gaps in care are associated with adverse outcomes. This study aimed to determine the proportion of patients in North Carolina who did not have recommended follow-up and to explore predictors of loss to follow-up. Patients ages ≥18 years with a healthcare encounter from 2008 to 2013 in a statewide North Carolina database with an ICD-9 code for CHD were assessed. The proportion with cardiology follow-up within 24 months following index encounter was assessed with Kaplan-Meier estimates. Cox regression was utilized to identify demographic factors associated with differences in follow-up. 2822 patients were identified. Median age was 35 years; 55% were female. 70% were white, 22% black, and 3% Hispanic; 36% had severe CHD. The proportion with 2-year cardiology follow-up was 61%. Those with severe CHD were more likely to have timely follow-up than those with less severe CHD (72% vs 55%, P < .01). Black patients had a lower likelihood of follow-up than white patients (56% vs 64%, P = .01). Multivariable Cox regression identified younger age, non-severe CHD, and non-white race as risk factors for a lower likelihood of follow-up by 2 years. 39% of adults with CHD in North Carolina are not meeting AHA/ACC recommendations for follow-up. Younger and minority patients and those with non-severe CHD were particularly vulnerable to inadequate follow-up; targeted efforts to retain these patients in care may be helpful.

Sensitivity of TTFields Dose Distribution in the Lungs to the Deviations in Array Placement

<h3>Purpose/Objective(s)</h3> Tumor Treating Fields (TTFields) are an anti-mitotic novel therapy, utilizing low-intensity alternating electric fields to arrest cell proliferation. The effect of TTFields is dose dependent: higher field intensities correlate with better survival rates for patients. TTFields are currently FDA-approved for treating Glioblastoma Multiforme (GBM) and Malignant Pleural Mesothelioma (MPM). The technology is currently begin tested for other diseases, such as Non-Small Cell Lung Cancer. TTFields are delivered using two pairs of arrays, placed on the patient's skin. The distribution of the fields is determined by the electric properties of the tissues and by the geometry of the patient and the system. Thus, the location of the arrays on the patient's body has a significant influence on the TTFields dose that is received at the tumor. The array layout (TAL) is prescribed according to clinical guidelines for thoracic disease, taking into account the size of the patient. However, actual placement of the arrays may pose challenges. Lung cancer patients also have shunts that may overlap the location of the arrays. In addition, areas with skin damage due to surgery or radiation therapy may prevent placing the arrays on their location, ultimately resulting in different field distributions than expected. In this work, we examined the sensitivity of the field distribution in the lungs to the array placement. <h3>Materials/Methods</h3> Using a simulation platform, we have simulated the electric field distribution within a healthy human model (Duke, by ITI'S foundation, Zurich). We applied boundary conditions on surfaces of different sizes adhered to the model's skin. The surfaces where in different sizes (25% to 121% of the area of the actual arrays used for the thorax) and locations (top of the lung, center and lower). We then analyzed the field distribution in the lungs resulting from each placement and compared it to the distribution from a surface roughly at the size of the real-world arrays. We also analyzed the resistance of the model in each case since this has implications on actual current delivery. <h3>Results</h3> Analysis of the resistance showed that it is highly sensitive to the size of the arrays, with resistance increasing by up to 2.5-fold from the baseline size. However, the array location had little impact on the resistance, with a span of 3Ω over a resistance of 45Ω for the smallest arrays, which showed the highest variability. The lung region with higher field intensities has moved with the array location, and in general stayed near the centerline connecting the arrays. However, therapeutic levels may still be reached outside this area, but field intensities will decrease as we go further from the arrays. <h3>Conclusion</h3> Our results show that the field intensities in the lungs are sensitive to the location of the arrays. Nevertheless, as the arrays get larger, the regions being treated effectively stayed nearly the same.

Examining Array Layouts for Targeting a Single Lung with TTFields

<h3>Purpose/Objective(s)</h3> Tumor Treating Fields (TTFields) are an anti-mitotic novel therapy, utilizing low-intensity alternating electric fields to arrest cell proliferation. TTFields are currently FDA-approved for treating Glioblastoma Multiforme (GBM) and Malignant Pleural Mesothelioma (MPM). The effect of TTFields is dose dependent: higher field intensities correlate with better survival rates for patients. TTFields are delivered using two pairs of arrays, placed on the patient's skin. The distribution of the fields is determined by the electric properties of the tissues and by the geometry of the patient and the system. Thus, the location of the arrays on the patient's body has a significant influence on the TTFields dose he or she may get. The array layout (TAL) is prescribed according to clinical guidelines for thoracic disease, taking into account the size of the patient. These guidelines are meant to target both lungs as a whole. However, in MPM patients, the disease is usually concentrated in one lung. In this study, we examined how placing one channel over a single lung and modifying the lateral channel will affect field distribution in the lungs. <h3>Materials/Methods</h3> To test new layouts, we placed cylinders imitating the arrays on the skin of a realistic human computerized model. We then used a simulation platform to simulate the TTFields distribution resulting from the different layouts. We tested the recommended layout by the guidelines, in which all four arrays are placed on the front and back of the thorax and are coupled in a cross formation (i.e., posterior left with anterior right and vice versa). We then compared this to layouts where one channel is focused around the right lung (front and back), paired with a layout in which one array is placed at the front or back of the left lung and the other under the right armpit. A current of 4A was set for channels consisting 20-disks arrays while a current of 2.6A was set for channels consisting at least one 13-disks array. For each layout, we calculated the average field intensity delivered to each lung. <h3>Results</h3> For patients receiving the recommended layout, average field intensity resulting from the recommended layout was 1.69 V/cm for each lung. The modified layouts provided 1.6-1.68 V/cm for the right lung, and 0.88-0.99 V/cm to the left lung. In terms of local minimum power density (LMiPD), the recommended layout provided 0.83 mW/cm³ for both lungs, while the modified layouts provided 0.62-0.81 mW/cm³ and 0.22-0.27 mW/cm³ to the right and left lungs, respectively. <h3>Conclusion</h3> Our results show that for patients eligible to be treated with the large cross layout, the modified single-lung layouts are not expected to provide a benefit in terms of TTFields dose. This is due the need for smaller arrays under the armpits, which reduces the expected output current from the device. However, further investigation is required for patients that are prescribed smaller arrays according to the guidelines.

The burden of disease due to COVID-19 in Sweden: a disability-adjusted life years (DALY) study

Abstract Background Many countries have been severely affected by the COVID-19 pandemic, including Sweden, which has been in the spotlight regarding its policies and their impact on mortality and morbidity. Therefore, it is of high interest to measure the disease burden of COVID-19 in terms of disability-adjusted life years (DALYs). DALYs have two main components: the years of life lost through premature death (YLL) and the number of years lived with disability (YLD). This study aims to measure DALYs due to COVID-19 in Sweden. Methods This study used data from the nationwide multi-register observational study SCIFI-PEARL (Swedish COVID-19 Investigation for Future Insights - a Population Epidemiology Approach using Register Linkage) covering the entire Swedish population. The methodology used in the modelling and calculation of DALYs was based on the Global Burden of Disease guidelines, using Sweden-specific life tables for estimated life expectancies. Results In Sweden, 152877 DALYs were lost to COVID-19 between March 2020 and October 2021, corresponding to 1447/ 100 000, 99,3% of which was attributed to YLL. DALYs loss occurred mainly among elderly groups with 66,78 % of DALYs being attributed to individuals above 70 years old. 57,6% of the lost DALYs occurred among men that lost more DALYs compared to females in all age groups. Conclusions Similar to other countries, the burden of COVID-19 in Sweden is concentrated mainly among the elderly, which contributed to the highest DALY loss due to mortality. Yet, DALY loss remains lower for COVID-19 compared to other major non-communicable diseases such as cardiovascular diseases and neoplasms. The contribution of YLD was minimal. However, YLD due to post-Covid is not well understood and long-term disability is likely still underestimated. Key messages • The burden of COVID-19 was mainly due to premature mortality in the older age groups. • More research is needed especially on post-COVID disability to derive better estimates of YLD.