International Guidelines Research Articles

Echo triaging works. How to use international guidelines

Abstract Introduction Transthoracic echocardiography (TTE) is the first-choice non-invasive imaging modality for the assessment of cardiac structure and function due to its wide availability, speed, cost-effectiveness and reproducibility. Therefore, there is exponential increase in demand in TTE across all specialties in medicine and surgery. Hence, it is important to carefully triage patients according to current international guidelines. Purpose To reduce inappropriate TTE scans by using guideline driven indications in triaging echo scans in the UK tertiary hospital. Methods Strict list of guidelines driven indications adapted to local practice was used for triaging echo requests which included both inpatient and outpatient TTEs. The 4 objectives: appropriateness, completeness of requests as well as impact of performed studies on the follow-up and patient management plan were assessed before and after implementation of new triaging tool. To ensure similar working and staff environment was sustained we studied the pattern of referrals in the same month of the year- September. The triage process was conducted by accredited physiologists. The same month was chosen to reflect true change of practice. Change in patient management and follow up were evaluated for a minimum duration of 6-months. Results Overall there were 1112 TTEs performed in September 2022 and 1081 - in September 2023. Prospective TTE referral triaging began in March 2023. We have studied and analyzed above criteria retrospectively. In 2022 there were 18% inappropriate requests; 37% of requests lacked sufficient clinical information and 10% of studies did not lead to change in management plan according to clinical letters. There was also high proportion of inappropriate requests for inpatients (9%). Within 6 months of implementation there was a significant improvement in the appropriateness (82% vs. 99%, p<0.001), with increase in supply of adequate clinical information (63.4% vs. 86.1%, p<0.001). However, there was no significant change using TTE study results in changing patient management (10%). All inpatients had 100% appropriate requests. Conclusion The implementation of triage criteria resulted in a significant improvement in TTE referrals: both in appropriateness and completeness of requests. However, some clinicians did not use echo in patient management plan. Future research on lack of use of TTE results in clinical practice might help to utilize the limited echo capacity to full.

Effects of platelet-rich plasma combined with exercise therapy for one year on knee osteoarthritis: retrospective cohort study

BackgroundPlatelet-rich plasma (PRP) is a promising treatment for knee osteoarthritis (OA). However, exercise therapy and activities of daily living (ADL) guidance are recommended as core treatments in the Osteoarthritis Research Society International (OARSI) guidelines. However, the effects of PRP combined with exercise therapy are not fully understood. This study aimed to clarify the effectiveness of this treatment.MethodsWe assigned patients diagnosed with knee OA and treated between January 2021 and December 2022 to groups who underwent PRP + exercise (PE), PRP (P), or exercise (E) therapy. Outcomes were evaluated using Knee Injury and Osteoarthritis Outcome Scores (KOOS) before, and 1, 3, and 12 months after treatment. Within-group comparisons according to the time of each score were statistically assessed using a one-way analysis of variance, then differences were analyzed using Bonferroni multiple comparisons p < 0.05). Treatment responses were determined using Outcome Measures in Rheumatology (OMERACT)-OARSI Responder criteria.ResultsPre-treatment KOOS did not significantly differ among the groups. Pain in the PE group improved within 1 month, symptoms, ADL, and quality of life (QOL) improved after 3, months and continued for 12 months. Pain and symptoms improved in the P group within 1 month, but ADLs and the QOL did not significantly change. Pain improved after 3 months in the E group and ADL, and QOL improved by 12 months. The response among the groups was the highest for the PE, with 50.0% at 1 and 3 months, and 65.0% at 12 months.ConclusionsTherapy with PRP immediately relieved pain, whereas exercise conferred late, but enduring effects. Combining PRP with exercise conferred synergistic advantages that persisted for up to 12 months.

Sub-Saharan Africa's contribution to clinical trials in international acute coronary syndromes and heart failure guidelines

Abstract Introduction There is a growing burden of acute coronary syndrome (ACS) and heart failure (HF) in sub-Saharan Africa (SSA), yet outcomes remain poor compared to high-income countries (HICs). Global clinical guidelines are pivotal to the delivery of evidence based cardiovascular care, however their applicability to populations in SSA remains unclear. Purpose To evaluate the extent to which populations from SSA contribute to pharmacotherapeutic randomised clinical trials informing international ACS and HF clinical guidelines. Methods We extracted details on pharmacotherapeutic randomised control trials (RCTs) contributing to Class I or II guideline recommendations from the 2023 European Society of Cardiology (ESC) guidelines for ACS and the 2021 ESC guidelines for HF. Data on RCTs contributing to these guidelines were extracted from the ClinicalTrials.gov or published articles. We analysed the proportion of RCTs which had a contribution from countries in each World Bank income group. Then we specifically assessed the contribution of SSA countries to clinical trials and analysed temporal trends. Results Of 119 RCTs from the ESC HF guidelines and the 343 pharmacotherapy RCTs from the ESC ASC guidelines 75.9% were exclusively conducted in high-income countries, 22.2% of the trials included at least one site from a middle-income country and none included sites from a low-income country (figure 1). The global distribution of HF (figure 2a) and ACS (figure 2b) pharmacotherapy guidelines is demonstrated in figure 2. The only country represented from SSA was South Africa which is an upper middle-income country. A site from South Africa was included in 17 (14.2%) HF RCTs and 28 (8.2%) ACS RCTs. There has been a significant increase in the proportion HF RCTs conducted in SSA, increasing from 2.6% between 1990 and 1999 to 50% since 2020 (OR 28.8, 95% CI 2.6 – 983.4, p-value for trend&amp;lt; 0.0001). For ACS RCTs, the proportion of trials conducted in SSA increased from 1.8% pre 1990 to 23.4% during 2000-2009 (OR 15.9, 95% CI 4.2 - 112.9, p value for trend = 0.003) then declined to 11.3% from 2010-2019. Conclusions There is a marked under-representation of SSA countries in ACS and HF pharmacotherapy RCTs, despite the region's escalating cardiovascular disease burden. South Africa is the sole contributor from the region, with all other SSA countries absent. This finding could potentially affect the applicability and generalisability of global guidelines to populations in SSA with distinct clinical presentations and healthcare challenges.Figure 1 Figure 2

Temporal trends in lipid management among Korean patients following acute myocardial infarction from 2011 to 2020

Abstract Background/Purpose Real-world data trends on dyslipidaemia prevalence and lipid management for patients following acute myocardial infarction (AMI) are lacking in South Korea, one of the Asia-Pacific nations. Our study aimed to evaluate the 10-year temporal trends of dyslipidaemia prevalence and lipid management in this patient population. Methods The study utilized datasets from two Korean AMI observational cohort (2011–2020) including a total of 26,751 participants (Figure 1A). The primary endpoints were as follows: (1) absolute low-density lipoprotein cholesterol (LDL-C) target of &amp;lt;70 mg/dL; (2) relative LDL-C target of &amp;gt;50% LDL-C reduction from the baseline; (3) absolute or relative LDL-C target (American target); and (4) both absolute and relative LDL-C targets (European target). Results The prevalence of dyslipidaemia increased from 11.1% to 17.1% (Table 1, Figure 1B), while the statin prescription rates increased from 92.9% to 97.0% from 2011 to 2020. High-intensity statin use increased from 12.80% in 2012 to 69.30% in 2020 (Table 1) Interestingly, the yearlong substantial increases in the prescription rates of high-intensity statins were prominent between 2013 (21.9%) and 2014 (37.7%) and between 2018 (52.4%) and 2019 (66.1%), which may have been influenced by major revisions to the international lipid management guidelines and their adoption (Figure 1C). Ezetimibe use increased from 4.50% in 2016 to 22.50% in 2020. The achievement rate of the absolute and relative LDL-C targets increased from 41.4% and 20.8% in 2012 to 62.5% and 39.5% in 2019, respectively (Table 1). The achievement rates of the American (45.7% in 2012 to 68.6% in 2019) and European (16.5% in 2012 to 33.8% in 2019) targets showed similar increasing trends (Table 1, Figure 1D). Conclusions Despite the adoption of lipid management guidelines in clinical practice has improved, some patients some patients are unable to reduce their LDL-C concentrations to their target levels. Our real-world analyses emphasise the need for multidirectional and continued efforts to optimise lipid management and improve the clinical outcomes in these patients.Figure 1

The EU project VAXaction: tacking effectively vaccine hesitancy in Europe

Abstract The main objective of VAX-ACTION is to support EU Member States and relevant stakeholders to implement the results of tailored, evidence-based interventions aimed to reduce vaccine hesitancy. Based on the evaluation of effectiveness of these interventions, which will be conducted in selected target regions in EU member states, recommendations will be drawn through diverse dissemination strategies to allow scaling up good practices to other member States, but also to the USA and Canada, where gaps in implementation strategies also have prevented effective, evidence-based interventions aimed to better deal with vaccine hesitancy. The first phase of the research involved some relevant systematic reviews with the aim of: 1. to map public health evidence and research results on large-scale vaccination programs in Europe and north America; 2. to map interventions aimed to address vaccine hesitancy regarding new and well-stablished vaccines and vaccination programs (Covid-19, mpox, national immunizations programs for children) in Europe and north America; 3. to identify successful and unsuccessful interventions designs aimed to address vaccine hesitancy, including challenges in the implementation, evaluation designs, and the feasibility of scaling-up solutions that are context-sensitive; 4. to identify significant similarities or dissimilarities in the designs and outcomes of interventions aimed to address vaccine hesitancy in northern countries where political and academic concern towards this phenomenon is growing; 5. to identify the extent to which ‘grounding’ (bottom-up) experiences aimed to address vaccine hesitancy are evidence-based, build on current international knowledge and guidelines, and whether they are internationally reported; 6. to systematize the mapping of interventions aimed to address vaccine hesitancy in the northern hemisphere in a way that can be shared and used by third parties. This contribution will illustrate the results of the first phase of the project.

Assessing the practicality of a novel heart failure therapeutic score (QUAD Score) for drug optimisation in heart failure with a reduced ejection fraction

Abstract Introduction The 4 pillars of drug treatment for heart failure with a reduced ejection fraction (HFrEF) [Angiotensin-converting enzyme inhibitors (ACEi)/Angiotensin receptor–neprilysin inhibitors (ARNi), β-blockers (BB), Mineralocorticoid receptor antagonists (MRA), and Sodium-glucose cotransporter 2 inhibitors (SGLT2i)], are recommended by international HF guidelines to improve patient outcomes. Treatment inertia remains a challenge with non-prescription or sub-optimal dosing of these therapies. We developed a pragmatic HFrEF treatment score (QUAD score) (Figure 1) to prompt initiation and/or titration of sub-optimally dosed foundational therapies. Patients are categorized as poor (&amp;lt;8), good (8-14), and excellent (15-24) based on the dose and number of foundational drugs prescribed. This study aims to assess the practical utility of the QUAD score and its influence on treatment optimization. Methods Unwarned prescribing HCPs were approached consecutively in person, within clinical settings. Participants were told the questions were part of a research project and they provided verbal consent. Responses were anonymous and no patients were involved; therefore, verbal consent was considered proportionate and reasonable. HCPs were given an information sheet describing the QUAD score (Figure 1). They were then presented with 3 hypothetical clinical scenarios of haemodynamically stable and uncomplicated HFrEF patients with uncalculated poor, good and excellent QUAD scores. They were asked to calculate the QUAD score and if they proposed any changes to treatment. Time was recorded using a stopwatch and proposed changes were recorded. They were then invited to answer a series of follow-on questions. Results Between September 2023 and February 2024, there were 70 respondents. 71% (50) were doctors and 29% (20) allied HCPs. 83% (58) placed patients in the correct treatment grade in at least one scenario. 62.9% (44) did so for all three scenarios (Figure 2) with numerically more HCPs compared to doctors (80% vs 56% p=0.06).The median (IQR) time in seconds required to calculate the QUAD score for clinical scenarios 1,2 and 3 was 158 (100-234), 86 (54-122) and 83 (53-119) respectively. In response to the calculated QUAD score, 94.3% (66), recommended drug treatment optimisations. On a 5-point Likert scale (1 -poor, 5- excellent), 77.1% of participants rated the QUAD score ≥3 for ease of use, and 88.6% rated ≥3 as an incentive for treatment optimization. Conclusion We demonstrated the rapid clinical usability of the QUAD Score in a cohort of unselected prescribing HCPs, with a decremental calculation time with each presented clinical scenario. HCPs were also motivated to achieve further HF drug therapy optimization based on the calculated score. We conclude that the QUAD Score as a HFrEF drug therapy score may have a role in addressing treatment inertia however, it needs validation against clinically relevant outcomes in a larger cohort of HFrEF patients.

Evaluation of the biomarker-based ABC-AF-bleeding risk score and clinically based bleeding scores in 31,605 patients with atrial fibrillation treated with oral anticoagulation

Abstract Background International guidelines recommend a systematic evaluation of bleeding risk in patients with atrial fibrillation (AF) to guide oral anticoagulation. However, it remains challenging to accurately predict bleeding risk. The biomarker-based ABC-AF-bleeding risk score to predict bleeding in anticoagulated patients with AF has shown promise. Purpose To evaluate the performance of the biomarker-based ABC-AF-bleeding risk score and compare its performance with other bleeding risk scores in 31,605 patients randomized to direct oral anticoagulant or warfarin using individual patient data from three randomized clinical trials. Methods The COMBINE AF biomarker data set contains individual patient data from three pivotal randomized trials (ARISTOTLE, ENGAGE AF-TIMI 48, and RE-LY) comparing apixaban, edoxaban or dabigatran with warfarin, in patients with AF at increased risk of stroke. The ABC-AF-bleeding biomarkers were analyzed in plasma samples collected at baseline (hemoglobin, troponin T high-sensitivity, and GDF-15) using Roche Diagnostics Elecsys assays. The biomarker-based ABC-AF-bleeding risk score (Age, Biomarkers, Clinical history of prior bleeding) was calculated as previously published. The discrimination was assessed by Harrell’s c index and compared with three clinically based bleeding risk scores; HASBLED, ORBIT, and DOAC. Results During a median follow-up time of 2.0 years, a total of 1,572 ISTH major bleeding events occurred (incidence rate per 100 person-years of 2.79) including 593 gastrointestinal (1.04) and 270 intracranial (0.47) bleeding events. The biomarker-based ABC-AF-bleeding score was well calibrated for major bleeding in the total material (Figure). The c indices for major bleeding were 0.68 (95% confidence interval 0.67-0.70), for gastrointestinal bleeding 0.70 (0.68-0.72), and for intracranial bleeding 0.66 (0.63-0.69). The biomarker-based ABC-AF-bleeding risk score provided superior discrimination compared with the clinically based risk scores in the full cohort (Table). The ABC-AF-bleeding risk score also provided superior discrimination for major bleeding in clinically relevant subgroups based on age, sex, body mass index, coronary artery disease, diabetes, heart failure, kidney function, and irrespective of DOAC or VKA use. Conclusions In patients with AF treated with different types of OAC the biomarker-based ABC-AF-bleeding score provide better discrimination of the risk för major bleeding than risk scores based only on clinical factors. The results were consistent for different types of bleeding and across multiple subgroups. There was good calibration when comparing predicted vs observed rate of major bleeding. These findings support the utility of the biomarker-based ABC-AF-bleeding risk score for advancing precision medicine in patients with AF.Calibration of ABC-AF-bleeding scoreTable

Nonlinear correlation between serum vitamin D levels and the incidence of endometrial polyps in infertile women.

Are serum vitamin D levels associated with the incidence of endometrial polyps (EPs) in infertile patients? Serum 25(OH)D levels were nonlinearly correlated with the incidence of EPs in infertile women. EPs are a common condition that may affect the receptivity of the endometrium in women of reproductive age. Vitamin D regulates cell proliferation and differentiation, apoptosis, angiogenesis, anti-inflammation, and immunomodulation, in addition to its well-known functions in balancing calcium and phosphorus. Previous studies have shown that vitamin D concentrations are associated with reproductive outcomes, and that low vitamin D levels are associated with the incidence of colorectal polyps and nasal polyps. There is little evidence regarding the relationship between EPs and serum vitamin D levels. We conducted a cross-sectional study using data from Guangdong Women and Children Hospital from January 2019 to October 2023, enrolling 3107 patients. A total of 3107 infertile patients who underwent hysteroscopy were included in this study; 642 patients had endometrial polyps and 2465 had a normal uterine cavity. Hysteroscopy findings included risk of EPs, polyp size, percentage of multiple polyps, and incidence of chronic endometritis (CE). Serum vitamin D were assessed by measuring total 25(OH)D using chemiluminescence. According to international guideline recommendations for vitamin D deficiency, patients were divided into two groups: the <50 nmol/l group and the ≥50 nmol/l group. Univariable and multivariable logistic regression models, stratified analyses, and smooth curve fitting were used to examine the relationship between serum 25(OH)D levels and risk of EPs. Of all patients, 23.8% (740/3107) were vitamin D deficient (<50 nmol/l). The incidence of EPs was significantly higher in the 25(OH)D < 50 nmol/l group than in the ≥50 nmol/l group (24.9% vs 19.3%; P = 0.001). However, there were no differences in polyp size, proportion of multiple polyps, and presence of CE between the two groups. After controlling for confounders, 25(OH)D ≥ 50 nmol/l (compared with <50 nmol/l) was negatively associated with risk of EPs (adjusted OR, 0.733; 95% CI, 0.598-0.898). Other variables that had an impact on polyp incidence included BMI, type of infertility, CA125, and CD138-positive plasma cells. In addition, a linear regression model between age and serum 25(OH)D levels showed a positive linear association. Subgroup analyses were performed for different age groups, and the risk of EPs was significantly higher in the 25(OH)D < 50 nmol/l group than in the ≥50 nmol/l group, both in the younger subgroup (23.8% vs 19.1%) and in the older subgroup (28.0% vs 19.9%). The smooth curve fitting model showed a nonlinear correlation between 25(OH)D levels and risk of EPs (nonlinear P-value = 0.020), with an optimal threshold of 51.8 nmol/l for 25(OH)D levels. Moreover, subgroup smooth curve fitting models showed a nonlinear correlation between 25(OH)D levels and polyp risk in patients aged <35 years (nonlinear P-value = 0.010), whereas a linear correlation between 25(OH)D levels and polyp risk was found in patients aged ≥35 years (nonlinear P-value = 0.682). Caution should be exercised in interpreting our findings as this is a correlational study and causality cannot be inferred from our results. In addition, because of strict inclusion and exclusion criteria, our results may not be generalizable to unselected populations, including premenopausal women or women of other races. This study demonstrated for the first time that vitamin D deficiency is an independent risk factor for the incidence of EPs in infertile patients. Identifying modifiable risk factors (e.g. vitamin D deficiency) can help in the development of new strategies for treating polyps or to protect against polyp development. Further clinical intervention trials and laboratory studies are needed to evaluate the effect of vitamin D on the development of EPs and to elucidate the mechanisms. The study was funded by the National Natural Science Foundation of China (82101718) and Natural Science Foundation of Guangdong Province, China (2022A1515010776). No competing interest was involved in this study. N/A.

Emergency preparedness in healthcare systems: the “policy-effect” of COVID-19

Abstract The COVID-19 pandemic has highlighted that health services preparedness is crucial. Indeed, effective planning enables streamline operations, optimized resource allocation, and transparent communication during crises. Within this context, our analysis aims to assess EU countries’ healthcare systems preparedness, by policies analysis and capacity factor analysis, and relationship with COVID-19. We reviewed policies regarding influenza, antimicrobial resistance (AMR), and climate change in EU countries, using a web-screening of national and international authorities and institutions. Furthermore, we performed a factor analysis on WHO’s States Party Self-Assessment Reporting (SPAR) and evaluated the results using an iterated principal factor analysis with promax rotation. Few countries updated their policies after the pandemic, particularly regarding influenza plans. Italy stands out as an exception, having updated its national plan in 2021, while other countries maintain pre-COVID plans. Regarding AMR, only few countries, including Sweden, Netherlands, Malta, Germany, Spain, Belgium, and France, updated their plans post-pandemic, while Estonia and Romania lack plans entirely. Addressing the climate crisis and its impacts on health and healthcare resilience, all EU countries aligned with the EC regulation on climate action through National Energy and Climate Plans in 2023. Moreover, EU countries had average preparedness level of 75.77 (SD: 8.23), calculated on SPAR 2022, with significant disparities. Three major factors contribute to preparedness levels: planning, service delivery, and specific subtopics (e.g. food safety, radiation, infectious diseases). Our findings reveal the complexity of preparedness, showing diverse approaches across countries, despite EU regulations and WHO guidelines. International collaboration is crucial to standardize policies and enable countries to leverage successful examples, improving public health outcomes. Key messages • Health services preparedness, underscored by the COVID-19 pandemic, is crucial for effective planning and crisis management. • The analysis demonstrates varying levels of preparedness across EU countries, with differences in policy updates and adherence to international guidelines.

Proenkephalin improves risk prediction in acute coronary syndromes: derivation and external validation of the KID-ACS risk score

Abstract Background Early assessment of renal and mortality risk in patients with acute coronary syndromes (ACS) is essential to guide treatment decisions according to international guidelines. Circulating proenkephalin (PENK) is a stable opioid metabolite with fast response to changes in kidney function. Purpose This study examined the predictive value of PENK for acute kidney injury (AKI) and mortality in patients presenting with acute coronary syndromes (ACS). Methods Plasma PENK levels were measured using a validated sandwich immunoassay in a prospective multicentre ACS cohort from Switzerland (n = 4 787) and in validation cohorts from the UK (n = 1 141) and Czechia (n = 920). A biomarker-enhanced risk score for simultaneous prediction of both in-hospital acute kidney injury (AKI) and 30-day death (KID-ACS score) with model coefficients adjusted to the outcome was derived and externally validated. In the development of the in-hospital AKI model, patients from one participating study centre were reserved for external validation (Swiss validation cohort). Results Circulating PENK ranked among the top predictors of renal outcomes and mortality in patients with ACS. Accounting for established risk factors and risk models, circulating PENK levels at presentation were independently associated with in-hospital AKI (per log2 increase: adjusted odds ratio [OR] 1.56, 95% CI 1.14 – 2.12, P = 0.005) and with 30-day mortality (per log2 increase: adjusted OR 2.69, 95% CI 1.89 – 3.84, P &amp;lt; 0.001). Dynamic changes in PENK levels within the first 12-24 hours after presentation were strongly and independently associated with in-hospital AKI (increase vs. decrease: adjusted OR 2.83, 95% CI 1.98 – 4.05, P &amp;lt; 0.001). The simple 6-item KID-ACS risk score for in-hospital AKI and 30-day mortality integrates PENK levels at presentation and showed an AUC of 0.72 (95% CI 0.68 – 0.76) for in-hospital AKI, and of 0.91 (95% CI 0.87 – 0.95) for 30-day mortality in the derivation cohort. Upon external validation, KID-ACS had similarly high performance for in-hospital AKI (Swiss validation cohort: AUC 0.73, 95% CI 0.70 – 0.77; Czech validation cohort: 0.74, 95% CI 0.68 – 0.80) and 30-day mortality (UK validation cohort: AUC of 0.87, 95% CI 0.82 – 0.91; Czech validation cohort: 0.91, 95% CI 0.87 – 0.94). The simple 6-item KID-ACS score was non-inferior to established risk models and significantly outperformed the CA-AKI risk score in predicting in-hospital AKI (Zurich cohort: delta AUC 0.11, 95% CI 0.07 – 0.15, P = 0.001) and the GRACE 2.0 in predicting 30-day mortality (UK cohort: delta AUC 0.05, 95% CI 0.01 – 0.09, P = 0.027). Conclusions Circulating PENK was identified as independent predictor of in-hospital AKI and 30-day mortality in patients with ACS. The simple 6-item KID-ACS risk score integrates circulating PENK levels and provides a novel tool for simultaneous assessment of renal and mortality risk in patients presenting with ACS.Independent Predictive Value PENKPerformance and validation of KID-ACS

Right ventricular dysfunction parameters at echocardiography in patients with acute pulmonary embolism: meta-analysis of individual participant data

Abstract Background &amp; Aim Echocardiography has a crucial role for decision making on management of patient with acute pulmonary embolism (PE) according to current international guidelines. However, the definition of right ventricle dysfunction (RVD) at echocardiography requires standardization. We performed an Individual patient data meta-analysis (IPDMA) to assess the role of individual parameters of RVD and of combinations of parameters for the prediction of short-term all-cause mortality and PE-related death. Methods A systematic search was run to identify clinical studies reporting on RVD at echocardiography and on short-term clinical outcome in patients with acute PE. Individual patient data from the original studies were pooled to perform a meta-analysis (IPDMA). The study outcomes were short-term death defined as death occurring within 30 days from PE diagnosis and PE-related death. Multiple imputation was used for the management of missing data. The odds ratio for all cause and PE related mortality were calculated using generalized linear mixed effects model. Results Individual data from 9,233 patients with acute PE from 16 studies were pooled in a unique database. All cause short-term mortality occurred in 9% of patients (95% CI 0.06-0.13, I2 93%). The IPDMA was feasible for the following parameters: tricuspid anulus systolic excursion (TAPSE), estimated pulmonary artery pressure (PAP) &amp;gt;30mmHg, right to left ventricle diameter ratio (RV/LV)&amp;gt;1, hypokinesia, paradoxical septal motion, RV diameter&amp;gt;30 mm and McConnel sign. All these parameters, except for PAP&amp;gt;30mmHg and RV diameter&amp;gt;30 mm, were predictors of short-term all cause death in the overall population and in hemodynamically patients (table). All the assessed RV findings, except for the McConnell’s sign, were predictors of PE-related death (Table). The presence of one RVD parameter only was not associated with increased risk of all cause death (OR 1.22, 95% CI 0.97-1-54), while the presence of two parameters or ≥ three parameters were (OR 1.63, 95% CI 1.24-2.15; OR 2.07 95% CI 1.59-2.69, respectively). Conclusion In patients with acute PE, the majority of RVD parameter at echocardiography are predictors of short-term death and of PE-related death. The higher the number of RVD parameters the worst the prognosis. These results claim for standardization in RVD definition to guide decision making for patient management.

Risk communication with asylum-seekers: Insights from the COVID-19 Pandemic experience in Munich

Abstract Background The COVID-19 pandemic has created a ‘double crisis’ for asylum-seekers, whose lives were already in crisis. Many reports indicated the syndemic consequences on asylum seekers’ health, underscoring the need for their inclusion in risk communication (RC) and community engagement (CE) and infodemic management (IM) actions. This study aims to describe RCCE experience with asylum seekers in Munich during the COVID-19 pandemic from an expert perspective and thus gain a thorough understanding of the requirements for inclusive RCCE. Methods Our qualitative study involved people who conducted COVID-19-related RCCE for asylum-seekers. Volunteers/workers of civil society organizations and health professionals were interviewed using purposeful sampling. After reviewing international guidelines, an interview form was created. The content analysis resulted in themes and categories. Results Four of the interviewees were health managers, while 8 were working in civil society organizations. The first category of the results describes the context in which RCCE occurs; syndemic factors (uncertainty; social exclusion and stigma; precarious housing; limited access to healthcare and unmet mental health needs) and pandemic management. The second category includes determinants of RCCE from both the asylum-seeker (trust; risk perception; health literacy; language; culture and gender) and RCCE member (competences; overburden; continuity) standpoint. The third category focuses on various RCCE-IM measures, including their effectiveness and consequences. Conclusions Syndemic factors hampered the effective implementation of RCCE for asylum seekers in Munich. RCCE determinants show that pre-crisis actions are necessary for an effective response and individual interactions should accompany community-level activities, particularly for female and marginalised migrants. This study’s scope will be expanded by incorporating the IM component.

Risk communication with migrants: Lessons learned from the COVID-19 Pandemic experience in Malmö

Abstract Background During the COVID-19 pandemic, many migrants faced challenges in accessing, comprehending and implementing information, leading to mis- and disinformation and distrust. The pandemic underscored the importance of effective risk communication (RC) and community engagement (CE) that reaches all segments of society, both for managing health effects and preventing the reinforcement of discrimination and stigmatization. This study aims to describe the experience of RCCE targeting migrants in Malmö, Sweden, from an expert perspective. Further, to gain an in-depth understanding of the requirements for inclusive RCCE actions and to identify alternative or complementary strategies based on good local practices. Methods Individual interviews were conducted with experts representing civil society and public authorities who were purposely sampled based on their engagement with RCCE targeting migrants. The interview guide was based on a review of international guidelines addressing aspects of RCCE, and analysed with content analysis. Results Three key organisations working towards undocumented migrants; unaccompanied minors; and newly arrived refugees, respectively, were included. Findings are synthesized into three key insights: a) RC through trusted sources in safe spaces; b) Understanding migrant living conditions c) Promoting intersectoral collaboration and feedback loops. Experts underscored the importance of cultivating sustainable and relationships with migrant communities to effectively communicate, aiding in compliance and counter distrust. The significance of intersectoral collaboration and communication pathways was highlighted for assessing migrant specific needs and designing appropriate interventions. Conclusions Long-term trusting relationship facilitate RC. Embedding sustainability within intersectoral collaboration structures is imperative to facilitate swift mobilization during health crises, foster resilience, and counter health inequities.

The introduction of a dedicated cardiology clinic including a clinical scientist led pathway for women with turner's syndrome

Abstract Background There are more than 15,000 women living with Turner’s Syndrome (TS) in the UK, over 700 of whom are cared for within our linked Endocrinology services. Mortality is predominantly related to cardiovascular disease therefore close cardiology review with a focus on aortopathy is essential (1). However appropriate surveillance is challenging with growing pressures on all aortopathy services across the United Kingdom. Purpose To audit our current practise according to current international guidelines (2) and seek methods to improve the pathway for our growing population of TS patients including the feasibility of a Clinical Scientist led clinic, aiming to improve capacity and efficiency of our service. Methods A quality improvement project was conducted over a three-year period, piloting a dedicated clinical scientist-led clinic under close Cardiology Consultant supervision. Patients selected were deemed lower risk for cardiovascular complications according to American Heart Association (AHA) recommendations (2) (figure 1). Follow-up intervals of patients under both consultant-led and clinical scientist led pathways were analysed. Results Among a total of 226 patients analysed, 103 (46%) fell into the lowest risk category and therefore deemed suitable for prospective Clinical Scientist led pathway (figure 2). Analysis of all patients demonstrated that 60% had appropriate follow-up intervals according to guidelines, while 37% were too short and 3% were too long. A five-year projection indicated a consequential 96 unnecessary additional appointments for patients that were being seen too frequently. Further analysis showed that the time frame for follow up was too short in 25% of patients seen in the clinical scientist led clinic compared to 41% in the Consultant-led clinic. There were no aortic dissections in patients under surveillance during this period. In the last 10 years 1 patient on the waiting list for surgery (having presented with a type B dissection but requiring workup for liver cirrhosis) had a retrograde type A dissection (indexed aortic root dimension 2.4cm/m²). No other adverse events were recorded. Conclusion Auditing our service revealed safe management and improved adherence to guidelines in the clinical scientist-led clinic, identifying opportunities to optimize follow-up and enable physicians to focus upon high-risk patients. This pilot demonstrates the feasibility of a clinical scientist-led clinic in managing low risk TS patients, suggesting scalability to other conditions involving aortopathy to address capacity issues and improve pathways.

Screening for stage B heart failure in Type 2 diabetes: natriuretic peptide screening alone misses echocardiographic abnormalities

Abstract Background Heart failure (HF) often manifests as the first cardiac event in individuals with type 2 diabetes mellitus (T2DM). International guidelines recommend natriuretic peptide (NP) screening for stage B/ pre-HF in asymptomatic individuals with T2DM, with echocardiography reserved for those with elevated NPs ("NP-gated" echo approach). Whether this strategy misses individuals with echocardiographic abnormalities despite normal NPs is not fully understood. Purpose To assess the proportion of individuals with T2DM who will be classified as Stage B HF based on biomarker and echocardiography, using independent and combined screening approaches. Methods We utilised the Performance of NT-proBNP In risk Stratification for Cardiovascular Events and mortality in patients with diabetes [PISCES] study (n=765, mean age 62±9 years, 62% men), which enrolled patients with T2DM with no HF. All patients underwent laboratory-based N-terminal pro-B-type NP (NT-proBNP) testing and a point-of-care artificial intelligence echocardiography (Us2.ai). Abnormal echocardiography was defined as left ventricular ejection fraction &amp;lt;50%, left ventricular mass index ≥115(male) or ≥95g/m2(female), left atrial volume index&amp;gt;34 in sinus rhythm or &amp;gt;40mL/m2 in atrial fibrillation, relative wall thickness (RWT) &amp;gt;0.42, E/e' &amp;gt;9, peak tricuspid regurgitation velocity &amp;gt;2.8m/s, pulmonary arterial systolic pressure &amp;gt;35mmHg. Patients with T2DM were classified into either (1) Stage B(biomarker) with elevated NT-proBNP (≥125pg/mL) and normal echocardiography, or (2) Stage B(echo) with abnormal echocardiography and normal NT-proBNP, or (3) Stage B(biomarker+echo) with elevated NT-proBNP and abnormal echocardiography or (4) no abnormalities. Results Among asymptomatic patients with T2DM, the highest proportion of individuals were in Stage B(echo) (43%), followed by those with no abnormalities (37%), Stage B(biomarker+echo) (15%) and Stage B(biomarker) (5%). Patients with Stage B(echo) (vs. no abnormalities) were older (62.5 vs 59.8 years), had a higher prevalence of hypertension (78.4 vs. 72.4%), higher systolic blood pressure (135 vs. 128 mmHg), higher RWT and higher E/e’ (p&amp;lt;0.001 for all). Individuals in Stage B(biomarker+echo) (versus no abnormalities) were older, had a longer duration of T2DM, higher prevalence of hypertension, atrial fibrillation, prior CVD, highest NT-proBNP levels, lowest eGFR levels, and more echocardiography abnormalities (higher RWT and E/e’). Patients identified as Stage B(biomarker) (versus no abnormalities) had a longer duration of T2DM, higher NT-proBNP levels, higher prevalence of comorbidities and comparable echocardiographic measures. Conclusion Among asymptomatic patients with T2DM, a significant proportion have subclinical cardiac abnormalities despite a lack of diagnostic NP elevation. Instead of NP-gated echocardiography, an integrated approach using both NT-proBNP and AI echocardiography may improve the early detection of Stage B HF.

Spectrum of heart failure in 16 sub-saharan countries: drugs strategies and 8-year trends (the february study 2016-2023)

Abstract Background Heart failure (HF) is a growing public health concern in Sub-Saharan Africa (SSA). The hospital prevalence studies estimate that in SSA, HF is responsible for 9.4% to 42.5% of all medical admission. However, little is known about the management of HF in hospitalization in SSA. Purpose To describe in hospital drugs strategies and 8-year trends in Africa. Methods We conducted a transversal and longitudinal study in cardiology departments of 37 hospitals(public and private) in 16 SSA countries. The February study is an ongoing observatory included all inpatients in February from each year since 2016. Collected data included socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, medicines, length of stay were collected by the investigating physicians. HF severity was defined according to proportion of Left Ventricular Ejection Fraction(LVEF):reduced(LVEF&amp;lt;40%), mildly reduced(LVEF[41-49%] or preserved(LVEF&amp;gt;50%). All analyses were performed with random effect on countries through scripts developed in the R software(4.0.3(2020-10-10)). Results Overall, 2351 patients(57±17.5 years; 54% men) were admitted for HF in the February study. HF representing 44.6% of all patients admitted. Proportions of patients included for HF varied across countries from 28% Democratic Republic of the Congo to 75% in Guinea. At admission, 56% of patients had reduced LVEF; 12.5% had mildly reduced and 31.5% had preserved LVEF. Proportions of drug classes varied significantly according to LVEF: diuretics were significantly less prescribed in patients with preserved LVEF(65%) compared to patients with mildly reduced(77%) or reduced(73%) LVEF (P&amp;gt;0.01). The same result was observed for betablockers(BB)(30%VS46% and 46%) and angiotensin-converting enzyme inhibitors(ACEI)(50%vs77% and 71%)(p&amp;lt;0.01). Mineralocorticoid receptor antagonists were significantly more prescribed in patients with preserved LVEF(p&amp;lt;0.01). The proportion of treated with BB increased significantly over the years(p&amp;lt;0.05) from 17% in 2016 to 62% in 2023. Proportions of drugs strategies differed significantly across countries adjusted for LVEF. Drugs strategies differed significantly according to LVEF(p&amp;lt;0.01). The more reduced the LVEF, the more the drugs strategy increased. In patients with preserved LVEF, the proportion of monotherapy was 20%; this decreased to 9% in patients with reduced LVEF. Combinations of three drugs increased from 35% in patients with preserved LVEF to 46% in patients with reduced LVEF. Overall, drugs strategies differed across years(p&amp;lt;0.05): three-drug strategies increased from 35% in 2016 to 51% in 2023 and two-drug strategies decreased from 38% in 2016 to 23% in 2023. Conclusion Up-titrated strategies were prescribed according to severity of HF and access to BB increased across years according to international guidelines. However, novel drugs classes remain unavailable in SSA.

The 2021-2023 Italian influenza pandemic plan: a critical evaluation of its regional implementation

Abstract Background Influenza pandemic preparedness plans should be adopted, regularly updated in every country, and comply with international guidelines to ensure proper management of public health emergencies. In Italy, each region develops its pandemic plan based on a National Plan. This study, conducted within a project funded by the Italian Ministry of Health, aims to assess the level of compliance of these plans with the national guidelines. Methods The assessment was based on a checklist of 192 items reporting the actions prescribed by the national plan. The items were divided into macro-areas by pandemic phase: general, alert, inter-pandemic, pandemic, and transition. The compliance regarding the presence and contextualization of each item in the regional plans was evaluated. Each macro-area was further assessed for easy identification of actions, congruence with the National Plan, and contextualization in the regional healthcare system. Some analyses grouped the regions into North, Centre, and South/Islands. Results Some macro-areas, such as ‘Communication’ and ‘Prevention and Control measures,’ showed some weaknesses in all phases, especially in the northern regions, which reached levels of full compliance below 50%. Central regions were highly compliant in almost all macro-areas, especially in ‘Strategy/Governance’ (100%), ‘Supplying’ (75-100%), and ‘Surveillance’ (75-100%). Overall, contextualization was the weakest aspect in all phases, while easy identification and congruence were mainly better achieved. Only three regions fully met all the assessed parameters. Conclusions A strict surveillance and monitoring process of planned activities is necessary to strengthen the country’s preparedness. This study identified critical issues and key areas for improvement at the regional level. This might allow us to verify the correct implementation of national guidelines and define the best strategies for improving readiness for public health emergencies in the future. Key messages • Implementation of the Italian influenza pandemic plan was uneven across regions. • Identification of lacking areas of the regional implementation is essential to improving national preparedness.

Preschoolers’ Moderate-to-Vigorous Physical Activity Measured by a Tri-Axial Accelerometer: Compliance with International Guidelines and Different Cut-Points

Background/Objectives: This study aimed to investigate the effect of the most frequently used accelerometer CoPs on the quantification of active preschoolers by weekday; and to analyze children’s physical activity (PA) quantification using a vertical axis and vector magnitude (VM). Methods: A cross-sectional sample of 134 children (70 males) aged 3–5 years was studied. Height, body weight, and BMI were assessed. A tri-axial accelerometer was used for seven consecutive days of MVPA and sedentary behavior (SB). Data were analyzed using the three most used CoPs for active preschooler classification (Johansson, Butte, and Pate). A general linear model with repeated measures examined differences in PA and SB, and the agreements of all CoPs were analyzed using the Kappa index. Results: The CoPs adopted by Pate had the highest percentage of children classified as active for the weekdays (73.9%) and weekend (85.6%). The Johansson CoP classified all children as inactive. Furthermore, the prevalence of active boys was significantly higher than their female counterparts based on the Pate and Butte CoPs for the week and weekends. Conclusions: The lowest prevalence rates of active children were observed at the weekend based on all accelerometer CoPs, especially among girls. The choice of cut-points significantly affects the times calculated for different movement intensities.

Management of human epidermal growth factor receptor inhibitors-related acneiform rash: A position paper based on the first Europe/USA Delphi consensus process.

There is a need for unified guidance in the management of acneiform rash induced by epidermal growth factor receptor inhibitors (EGFRi) among dermatologists. To establish unified international guidelines for the management of acneiform rash caused by EGFR inhibitors, based on an experts' Delphi consensus. The initiative was led by five members of the European Academy of Dermatology and Venereology Task Force 'Dermatology for Cancer Patients' who developed a questionnaire that was circulated to a group of 32 supportive oncodermatology experts in Europe, Canada, Argentina, the US States and Asia. The questionnaire consisted of 84 statements in total, regarding diagnosis and treatment of EGFRi-induced acneiform rash. Experts responded to an anonymous 5-point Likert scale survey. The coordinators collected the first-round responses that were checked for consensus (≥75% agreement in positive [agree or strongly agree] or in negative [disagree or strongly disagree] vote). The statements that did not reach strong consensus in the first round were revised, according to experts' feedback, for a second-round survey. Strong consensus was reached in 75/84 (89.3%) of the statements, whilst moderate consensus was achieved in 6/84 elements. Key points include consideration of low-dose isotretinoin for refractory grade II/III acneiform rash, use of topical steroid-sparing agents like topical pimecrolimus in the maintenance phase and use of doxycycline in either 100 or 200 mg per day as prophylactic treatment. Interestingly, experts did not recommend topical antibiotics, neither for prevention, nor for treatment. Consensus failure in 3/84 objects is mostly related to the lack of robust data on these topics. This consensus offers crucial insights often overlooked by radiotherapists, general practitioners, dermatologists and oncologists, and it is expected to improve the management of oncologic patients treated with EGFRi in different settings and continents.

Guidelines for the prescription of standard hematology and biochemistry clinical laboratory tests in the intensive care unit: A scoping review protocol.

This scoping review protocol describes the strategy for a scoping review that aims to provide a comprehensive overview of published guidelines for the prescription of standard laboratory tests performed in intensive care unit (ICU) patients. The use of clinical laboratories is constantly increasing. However, there is evidence of inappropriate use. Inappropriate laboratory testing has the potential to harm patients, increase costs, burden staff, and has an environmental impact. Effective management can be achieved through demand managing strategies, such as providing guidelines on performing the appropriate test, for the right patient, at the right time. Although national and international guidelines exist for individual tests, a comprehensive summary of available recommendations for laboratory testing in the ICU is currently unavailable. This scoping review will incorporate documents that provide explicit advice on which test to perform in ICU patients. We selected 34 tests routinely ordered in the ICU. This review will consider any document type that matches our concept and context. We will consider gray literature with appropriate adherence to guidelines methodology. We will not limit the review by geographical location, but will only include articles published in English. Our scoping review will follow the Joanna Brigg Institute (JBI) methodology. We will search Medline (PubMed), Embase, Scopus, Google Scholar, and Google. Our search strategy adheres to the JBI 3-step construction approach for systematic reviews. We will search for keywords related to guidelines, laboratory testing, and the 34 selected tests. We will report our study using the S1 Checklist. Review registration number: osf.io/yfs9z.