International Recommendations Research Articles

Exchangeable copper for patients with Wilson disease at follow-up: Rethinking normal ranges or changing methodology.

Determining suitable copper parameters for monitoring Wilson disease remains a topic of ongoing discussion. International recommendations currently rely on the combination of urinary copper excretion and nonspecific liver markers when considering therapy and time elapsed since diagnosis. The emergence of exchangeable copper (CuEX) as a novel measurement reflecting the "free copper pool" held promise as a valuable target to ensure metabolic stability during follow-up, although the validation of target ranges remains unknown. We aimed to evaluate CuEX quantification in repeated samples from 92 real-world patients with Wilson disease during a 2-year period. Patients were classified as "stable" if a diagnosis had been made more than 1 year before and were compliant with stable anti-copper drug and dose. Otherwise, patients were classified as "nonstable." Two hundred and thirteen CuEX samples were obtained per clinical practice. Overall, 57% of CuEX measurements fell below the reference "range of normality," whereas only 34% were within and 9% were above normal levels. There was no association of CuEX levels with therapy, elapsed time from diagnosis, or clinical stability, although most of the samples above normality corresponded to nonstable patients. Only 23.4% of the CuEX samples were aligned with data obtained from concomitant urinary copper excretion. Our findings suggest that CuEX is a suboptimal tool for assessing copper homeostasis when used alone and should be used with caution if no additional information is available. Normal reference intervals for Wilson disease-treated patients should be redefined, as most CuEX quantifications fell in the lower range, with no sign of overtreatment in these patients.

Legal regulation of rehabilitation in the field of health care

The article notes that the law guarantees everyone the right to health care and medical assistance. A full-scale invasion calls for the development and updating of legal acts on ensuring a person’s right to medical assistance, in particular, to the provision of rehabilitation services. It is noted that rehabilitation assistance is aimed at a number of main areas, firstly, at supporting the functions of the patient’s body during the exacerbation of chronic diseases. Secondly, for warning, early diagnosis of disorders of the organs and systems of the patient’s body. The third direction is aimed at full or partial restoration of damaged organs or systems and compensation of lost functions of affected organs or systems. The fourth direction is related to the prevention and reduction of the degree of disability. The author emphasizes that the lack of competent and effective medical rehabilitation in Ukraine is a multifactorial problem: there is an insufficient number of inpatient and outpatient rehabilitation departments; lack of medical personnel - rehabilitation specialists, psychologists; there is not enough rehabilitation equipment; there is a need for adequate educational programs for physicians. In the article, the author emphasizes that one of the tasks of the state is to help persons with disabilities realize their constitutional rights; implementation of state policy in the field of rehabilitation of persons with disabilities, support for their integration into society, and the full-scale war on the territory of Ukraine causes an increasing urgency and need for the rehabilitation of persons injured as a result of hostilities. Such factors of the population’s health, such as the increase in morbidity, injuries, temporary loss of working capacity, premature mortality of the population require the development of the rehabilitation medicine market of Ukraine and its legal regulation. The article notes that the positive aspects are the development of new medical rehabilitation technologies, including those based on telemedicine and IT technologies, the preparation of new professional standards for medical rehabilitation at the modern level in accordance with international recommendations. All this requires the effective functioning of the system, which first of all requires the improvement and development of regulatory and legal support in the field of rehabilitation.

Management of severe ANCA-associated glomerulonephritis: comparison of international recommendations and narrative review

Severe kidney injury in ANCA-associated vasculitis remains a major challenge for healthcare practitioners due to the difficulty in defining the term and the limitations in the evidence base associated with the exclusion of the most severely ill patients from majority of clinical trial protocols. The ACR/VF, EULAR, and KDIGO recommendations intended to answer the questions regarding the management of this patient’s population, but some recommendations on both initial and supportive therapy, provided be the expert panels, differ, which increase the number of treatment options, but also leads to the uncertainty of the expected effect of the treatment. Kidney biopsy plays an important role in identifying patients with a favorable and unfavorable kidney prognosis. Timely histological assessment is necessary not only to confirm the diagnosis, but also to decide whether to intensify therapy if active changes are detected, or, conversely, to discontinue immunosuppressive treatment and switch to renal replacement therapy if chromic changes dominate and the extrarenal manifestations are quiescent. Several scoring systems for assessing kidney damage and risks in the in ANCA-associated vasculitis were proposed during the last decade. Glucocorticoid’s dosing and the choice between cyclophosphamide and rituximab for the initial therapy remains controversial, and the most controversial issue to date remain the indications for the plasma exchange usage. New treatment options for ANCA-associated nephritis, such as the usage of complementblocking therapy are likely to improve the prognosis for the patients with severe renal damage, taking into account the maximum effect on renal function restoration in this particular category.

A review of small cetacean hunts in Greenland

Seven odontocete species are targeted by hunters in Greenland. Beluga (Delphinapterus leucas) and narwhal (Monodon monoceros) are hunted under annual quotas. Atlantic white-sided dolphin (Lagenorhynchus acutus), white beaked dolphin (Lagenorhynchus albirostris), harbour porpoise (Phocoena phocoena), killer whale (Orcinus orca) and long-finned pilot whale (Globicephala melas) are hunted without quotas. From 1993–2023, 109, 645 small cetaceans have been recorded in the North Atlantic Marine Mammal Commission (NAMMCO) catch database as hunted in Greenland. The hunt follows the scientific advice in 3 out of 25 populations considered: the hunt is higher than the advice for 12 and there has been no assessment or advice for 10. Population trends are unknown for 14 populations, while numbers are stable or increasing in 6 and decreasing in 4. One population has been extirpated by hunting. Catches of all small cetaceans have increased since data records are available, including for narwhal and beluga since quotas have been in place. In some cases, insufficient monitoring and inaccurate reporting occur and there is a lack of data to assess struck and lost rates and times to death. Narwhals are experiencing significant declines in abundance due to hunting, particularly in East Greenland, where recovery may be compromised. To ensure the protection of small cetaceans in Greenland, management is required for all hunts, consistent with international conservation management recommendations. Measures should ensure sustainability, include stuck and lost and additional anthropogenic threats, be precautionary, based upon up-to-date knowledge of population status and trends and consider welfare aspects and recovery rates.

History of housing policy’s formation and development in Ukraine

The purpose of this article is to reveal specific features of the history of the formation and development of housing policy in Ukraine from the ХІХ century to the present time has been researched. Obtaining research results became possible due to the application of general philosophical and special methods of scientific cognition. The factors that influenced the development of housing policy have been established. It has been clarified that the problem of providing housing historically was initially considered as the problem of an individual person, and only later – one of the issues of the state policy. Such key stages of the development of housing policy as the initiation of housing policy in the ХІХ century, the development of housing policy after the First and Second World Wars, modern challenges of housing policy have been analyzed. It has been emphasized that international standards and recommendations for the formation of housing policy were formed at the beginning of the ХХ century. It has been established that there was a large-scale reconstruction of the housing stock and the construction of typical multi-apartment buildings after the end of the Second World War. It has been emphasized that Ukraine's housing policy after obtaining independence in 1991 had undergone significant changes. It was confirmed by the massive privatization of housing by Ukrainian citizens and the growth of the share of the private housing stock. The authors have offered own periodization of the stages for the formation and development of housing policy in Ukraine, starting from the ХІХ century and up to nowadays. The importance of the historical approach for further development of housing policy, taking into account economic, social and political aspects, has been emphasized.

GROSS ALPHA/BETA ACTIVITY DETERMINATIONIN DRINKING WATER PROFICIENCY TESTS

Water intended for drinking purposes has to be analyzed first for gross alpha/beta activity according to national and international standards and recommendations. According to Albanian legislation, Article 6, the gross alpha/beta radioactivity concentration in water, should be below the level of 0.1 Bq/L and 1 Bq/L respectively for human consumption. Our laboratory participated in an interlaboratory comparison organized by IAEA Terrestrial Environmental Laboratory under suggestion of ALMERA members. Proficiency Test among environmental radioactivity monitoring laboratories for the determination of gross alpha/beta activity concentration in drinking water and contaminated surfaces (2018, 2020). Independent standard methods were used for the reference value determination. Each sample was pretreated on site with nitric acid until reaching a pH level below 2. By creating relatively non-polar surfaces, this procedure avoids a loss of radionuclide fractions due to absorption into the walls of the containers.The Gross alpha/beta activity measurements were done using gas-flow proportional counter (GPC) method. The total dissolved solids should not exceed a surface density of 5 mg/cm2 for gross alpha determination and 10 mg/cm2 for gross beta determination The performance of participating laboratories was evaluated with respect to the reference values using relative deviations. The results presented from our laboratory in both inter comparisons (IAEA-TEL-2018-03) and (IAEA-TEL-2020-03) were all acceptable. The laboratory for the measurement of gross alpha/beta radioactivity and our Institute as a part of Tirana University is in the process of accreditation, so far the participation in the inter comparisons exercise is very important.

The role of the central bank of Iraq in confronting economic crime

The Central Bank of Iraq has made strenuous efforts to combat economic crime in Iraq, represented by financial and administrative corruption, money laundering and terrorist financing issues, as it is the highest regulatory and supervisory authority over the work of financial institutions, banks and banks, through issuing laws and legislation that have limited this crime, in addition to complying with international laws and recommendations issued in this regard, by Iraq's compliance with financial transparency, financial disclosure and accountability. It has also used advanced technological methods and effective regulatory and supervisory systems in its efforts to combat this crime, and the activation of the law (Where did you get this from?) contributed to increasing the role of the Central Bank of Iraq in monitoring economic crime. As the highest authority in managing financial and monetary affairs in Iraq, it may publish in its annual reports on an ongoing basis statistics related to corruption, money laundering and terrorist financing issues, and these reports are subject to periodic follow-up by international financial and monetary institutions, including the World Bank, the International Monetary Fund, the Financial Action Task Force (FATF), and other relevant institutions. This enabled it to achieve tangible success in reducing corrupt practices and illegal financial activities, and it was able to get off the monitoring and follow-up list. This is a clear indication of the escalation of local efforts in cooperation with these institutions. Despite the presence of some obstacles, it has achieved tangible progress in combating corruption

Rapid analysis of amatoxins in human urine by means of affinity column chromatography and liquid chromatography-high-resolution tandem mass spectrometry

Analysis of amatoxins is of great importance as these cyclic peptides contribute to a high number of fatalities each year. Development of analytical approaches needs to focus on rapid, sensitive, and reliable methods. By establishing an affinity column chromatography-based assay using the monoclonal amanitin antibody AMA9G3 and liquid chromatography (LC) coupled to high-resolution mass spectrometry (HRMS) for the trace detection of α-, β-, and γ-amanitin in human urine samples to confirm ingestion, we report the first approach that extents the current status of amatoxin analysis. The presented procedure allows detection of amatoxins in human urine down to 1 ng/mL. The method was successfully validated qualitatively for α- and γ-amanitin according to international recommendations. A proof of concept was performed by analyzing 37 urine samples after suspected amatoxin consumption submitted for regular clinical toxicological analysis. Using this antibody-based enrichment strategy, acute amatoxin intoxications can be determined within 90 min and due to the high sensitivity and selectivity, a comparable approach using target specific antibodies may also be used for other toxicological relevant peptides.

Treatment of spondyloarthritis with disease-modifying anti-rheumatic drugs during pregnancy and breastfeeding: comparing the recommendations and guidelines of the principal societies of rheumatology.

This paper aims to provide an overview of the use of treatments available for axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) during pregnancy and breastfeeding, according to current national recommendations and international guidelines, as well as data on the impact on pregnancy outcomes of paternal exposure to treatment. We performed a narrative review of national and international recommendations and guidelines on the reproductive health of patients suffering from rheumatic diseases. The last updated recommendations and guidelines were considered source data. We reported updated information regarding the treatment of axSpA and PsA with nonsteroidal anti-inflammatory drugs, intra-articular glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and targeted synthetic DMARDs during the preconception period, pregnancy, and breastfeeding, as well as data related to paternal exposure. We highlighted any medications that should be discontinued and/or not used in the reproductive age group and also treatments that may be continued, avoiding the withdrawal of drugs that can be used in the different phases, thus preventing the risk of increasing disease activity and flares before, during, and after pregnancy in SpA patients. The best management of pregnancy in patients with SpA is based on knowledge of updated drug recommendations, a careful and wise evaluation of the risks/benefits of starting or continuing treatment from the SpA diagnosis in a woman of childbearing age through pregnancy and lactation, and sharing therapeutic choices with other healthcare providers (in particular, gynecologists/obstetricians) and the patient.

Rotation or change of biotherapy after TNF blocker treatment failure for axial spondyloarthritis: the ROC-SpA study, a randomised controlled study protocol

IntroductionAxial spondyloarthritis (axSpA) is a chronic inflammatory disease characterised by inflammatory low back pain. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as a first treatment in axSpA. In case of inadequate...

Hybrid Simulation of Therapeutic Appointment — a New Step in Creating Effective Training for Practical Healthcare

The main difference of the author's educational program "Therapeutic patient at an outpatient appointment" is the introduction of simulation technologies. The course structure includes 5 days of training, during which sequential and joint use of interactive lectures is used, based on international recommendations and treatment protocols of the Republic of Kazakhstan, as well as the development of practical skills on modern simulation equipment.

The Europeanization of Sports Associations Welcoming Migrants: International Recommendations, Local Contexts and Transnational Practices in Germany, France and England

ABSTRACT This article examines the impact of European recommendations, local contexts and transnational exchanges on sports programs for welcoming migrants. The “sport model” promoted by European institutions, which is not very restrictive, contrasts with the reality of highly differing national and local policies and contexts. Despite this, we discovered numerous transnational relationships among members of these sport programs in three European countries (England, France, and Germany). Analyzed from the concept of social figurations developed by Norbert Elias and allowing the interdependence of relationships, we show that these interactions help legitimize and disseminate “good ways of doing things” across borders. This horizontal sharing of norms and beliefs reveals finally the diffusion, from the bottom up, of an “informal Europeanization” of welcoming migrants through sport. In addition, migrants express an alternative, transnational and informal culture in sport, which also calls for the establishment of intercultural relations with the local population, which are often limited.

Pregnancy outcomes among women with inflammatory bowel disease: A UK tertiary centre experience.

Optimal management of inflammatory bowel disease (IBD) in pregnancy is associated with better pregnancy outcomes. We describe management of IBD during pregnancy and maternal and fetal outcomes of patients from a tertiary UK IBD centre. This is a retrospective observational cohort study of all pregnancies occurring between 2015 and 2021 in a large tertiary IBD centre in the UK. IBD activity and management prior to, during and after pregnancy were recorded along with pregnancy and neonatal outcomes. Associations between IBD-focused interventions and any adverse pregnancy outcomes, as well as the association between IBD severity and treatments and adverse maternofetal outcomes were assessed. Pregnancies in 130 women with IBD were included for analysis. The mean maternal age at delivery was 30.5 (± 4.7) years. At conception, 73 women (56.2%) were in clinical remission and 24 (18.4%) were treated with a biologic agent. Active disease during pregnancy, measured by physician global assessment, was less frequent in women who were in clinical remission at conception, compared to those not in remission at conception (16/73 21.9% vs. 39/49 79.6%; data insufficient for eight women). Active IBD at conception was associated with pre-term birth (p = 0.04). Maternal corticosteroid use in any trimester was associated with low birth weight (T1 p = 0.02; T2 p = 0.005; T3 p = 0.007). Active disease (p = 0.008) and steroid use in the third trimester (p = 0.05) were both associated with neonatal infections up to sixmonths after birth. Women in clinical remission at the time of conception have favorable outcomes, consistent with prospective observational studies. Our observations emphasize the importance of high quality IBD care for women pre and post-partum in line with international recommendations.

Recommendations for the implementation and conduct of multidisciplinary team meetings for those providing endometriosis and adenomyosis care - a Delphi consensus of the European Endometriosis League (EEL).

The treatment of endometriosis and adenomyosis requires a complex, multidisciplinary approach. Some centres have established multidisciplinary teams (MDT) and regular meetings. There are currently no international data or recommendations. To examine existing MDT meetings and define consensus recommendations to support implementation and conduct. Online questionnaires were sent through the European Endometriosis League (EEL) based on a Delphi protocol. After a literature review and assessment of existing MDT meetings, essential aspects for consensus statements were identified. The consensus statements were evaluated using a 5-point Likert scale with the possibility to modify them. Results were analysed between rounds and reported to the respondents. Consensus, defined as ≥70% agreement, concluded the Delphi process when achieved in the majority of statements. Prevalence and type of existing MDT meetings and recommendations. In round 1, 69 respondents participated, with 49.3% (34) having an MDT meeting at their institutions, of which 97% are multidisciplinary. 50 % meet once a month and 64.7% indicated that less than 25% of their patients are discussed. Throughout the three rounds, 47 respondents from 21 countries participated. During the process, 82 statements were defined, with an agreement of 92.7% on the statements. This study assessed existing MDT meetings for endometriosis and adenomyosis and developed recommendations for their implementation and conduct. The consensus group supports the strengths of MDT meetings, highlighting their role in offering guideline-based, multidisciplinary, and personalised care. This study presents the first international data and recommendations on MDT meetings for endometriosis and adenomyosis.

Minor surgical procedures during immune tolerance induction in people with hemophilia A and inhibitors: results from the Brazilian Immune Tolerance (BrazIT) study cohort

IntroductionSurgeries are implicated in the development of anti-factor VIII (FVIII) neutralizing antibodies (inhibitors) in hemophilia A individuals with immune tolerance induction (ITI) treatment being the recommended therapy to eradicate these inhibitors. We evaluated the association of surgical procedures performed during ITI and treatment outcome. MethodsPatients were treated according to the Brazilian ITI Protocol with outcomes being defined as successful (i.e., recovered responsiveness to exogenous FVIII) and failed (i.e., unresponsiveness to exogenous FVIII thus requiring bypassing agents for bleeding control). Surgical procedures during induction therapy were managed following international recommendations. ResultsTreatment success rate was 68.7 % in 163 patients; 33 (20.2 %) were submitted to 43 (96 %) minor and two major surgeries. Personal, hemophilia, inhibitor, and treatment characteristics were similar between patients submitted to surgical procedures or not while on ITI; the success rates were 72.7 % and 67.7 % (p-value = 0.577), respectively. ConclusionNo association was found between having a minor surgical procedure and ITI treatment outcome.

The Efficacy and Safety of Antifungal Agents for Managing Oral Candidiasis in Oncologic Patients: A Systematic Review With Network Meta-Analysis.

This study aimed at synthesizing the available evidence on the comparative safety and efficacy of antifungal agents for preventing or treating oral candidiasis (OC) in oncologic patients. A systematic review following international recommendations was performed (PROSPERO CRD42024507745). A comprehensive search was conducted in PubMed, Scopus, and Web of Science (Feb 2024) to retrieve randomized controlled trials evaluating the clinical effects of antifungal agents in the management of OC in this vulnerable population. Network meta-analyses were performed to evaluate the most prevalent outcomes, with findings reported as odds ratios (ORs) with 95% confidence intervals (CIs). Overall, 24 trials were included, of which 10 addressed OC treatment and 14 disease prophylaxis (n=3449 patients). Fluconazole had the most significant rates of clinical cure when compared to placebo (OR 0.09 [95% CI 0.01-0.69]), amphotericin B (0.21 [95% CI 0.07-0.65]) and itraconazole (OR 0.58 [95% CI 0.34-0.99]); ketoconazole was also superior to placebo for this outcome (OR 0.10 [95% CI 0.03, 0.36]). All antifungal agents presented significantly higher rates of prophylaxis success compared to the absence of an active agent. While these therapies were generally considered safe, only four studies provided data on adverse events, primarily related to gastrointestinal issues. In oncologic patients, azoles (fluconazole, ketoconazole) should be used as a first-line approach for OC treatment. The selection of antifungal agents for diseaseprophylaxis should consider, among others, patients' clinical characteristics and preferences. Economic and quality of life-related outcomes should be further addressed in future studies.

Reproductive Rights Under International Regulations and Recommendations for Vietnam

Reproductive Rights Under International Regulations and Recommendations for Vietnam

ADHD in children and adolescents: Guideline-based online assessment in the consortium project INTEGRATE-ADHD.

The consortium project INTEGRATE-ADHD compared administrative data on the presence of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents with the results of a parent survey and a comprehensive clinical assessment based on the S3 guideline of the Association of the Scientific Medical Societies in Germany (AWMF). Due to the COVID-19 pandemic, the clinical assessment was carried out online. The article describes how a guideline-based clinical assessment of ADHD can be implemented in an online setting. A specially developed diagnostic matrix is presented to illustrate the assessment procedures and the diagnostic decision-making process. The matrix is intended to help the diagnostician to gain an overview of the numerous individual findings that have been collected using different assessment perspectives and methods (e.g. diagnostic interviews, rating scales, performance tests) in order to make a well-founded and transparent diagnostic decision. The consortium project INTEGRATE-ADHD has shown that an online assessment can be implemented in a guideline-compliant manner and allows a valid clinical decision. The diagnostic strategy is discussed with reference to international guidelines and recommendations for online diagnostics (e.g. aspects of feasibility, acceptability and safety of the assessment procedures). The challenges and opportunities of using online assessments in clinical practice are also described.

Association of Cartilage, Synovial Fluid and Membrane Pathological Findings in Serbian Mountain Horses Without Signs of Lameness

Abstract Osteoarthritis (OA) in horses often affects the metacarpal/metatarsophalangeal (MCP/MTP) joints and its detection in the early stages is crucial for effective management. I t was hypothesized that the extent of cartilage damage positively correlates with synovial membrane (SM) and synovial fluid (SF) pathological findings in the MCP/MTP joints of Serbian mountain horses that transported heavy loads but did not show signs of lameness. The study was conducted on 32 MCP/MTP joints of eight horses between seven to 12 years of age. Horse limbs were transferred from the abattoir to the necropsy room and SF was sampled. Its appearance, total nucleated cell count (TNCC), mononuclear cell count (MNC), total proteins (TP), and haptoglobin (Hp) were determined. Samples of SM were collected from the dorsal palmar/plantar pouch for histology. A macroscopic examination of gross condylar pathology of the third metacarpal/metatarsal bone was performed with Indian Ink staining. Scoring was done based on Osteoarthritis Research Society International recommendations. SF was clear, pale yellow, and mostly fairly viscous. Half of the samples had TNCC above, and all had TP within the reference range. Hp values were below the reference range and were omitted from further analyses. TNCC correlated with MNC (ρs=0.81, P<0.001), microscopic (ρs=0.62, P=0.003) and macroscopic scores (ρs=0.47, P=0.008). In addition, MNC correlated with macroscopic scores (ρs=0.40, P=0.03). All pathological findings were mild and their correlation indicated that these processes are interrelated and that could be ascribed to early OA.

Monitoring of adverse effects of antituberculosis drugs: case study of hepatic cytolysis and skin reactions

Introduction. Tuberculosis remains a major public health issue worldwide. Progress in treatment, particularly with the emergence of anti-tuberculosis drugs, has been significant. However, identifying the drugs responsible for adverse effects is crucial to establish a practical approach in clinical situations, including the assessment and monitoring of these effects. Methods. This case study describes the monitoring and management of adverse effects of anti-tuberculosis drugs in patients at the Tuberculosis and Respiratory Diseases Control Department (SCTMR) in Sidi Bel Abbes (Algeria). Results. The observed effects include nine cases of hepatic cytolysis and two cases of skin reactions. This work revealed a predominantly high intrinsic imputability of anti-tuberculosis drugs, with a rating of I3 (C2S2) for six cases and I5 (C2S3) for five cases. The therapeutic interventions implemented and their compliance with international recommendations are discussed. Discussion. SCTMR specialists generally follow international recommendations to manage adverse effects of antituberculosis drugs. However, the high imputability of anti-tuberculosis drugs indicates that they are strongly incriminated in the occurrence of these adverse effects. Conclusion. Adverse effects of anti-tuberculosis treatment are not rare, requiring rigorous clinical, biological and pharmacovigilance monitoring. These surveillances can reduce mortality and morbidity associated with tuberculosis treatment. A government commitment is essential to revitalize the national pharmacovigilance center and improve the detection of serious adverse effects.