Main Indications Research Articles

Arrhythmia detection using an implantable loop recorder after a negative electrophysiology study in Brugada syndrome: Observations from a multicenter international registry

BackgroundRisk stratification in Brugada syndrome (BrS) remains controversial. In this respect, the role of the electrophysiology study (EPS) has been a subject of debate. In some centers, it is common practice to use an implantable loop recorder (ILR) after a negative EPS to help in risk stratification. However, the diagnostic value of this approach has never been specifically addressed. ObjectiveThe aim of this study was to describe the baseline characteristics and the main findings of a diagnostic workup strategy with an ILR after a negative EPS in BrS. MethodsWe conducted a retrospective international registry including patients with BrS and negative EPS (ie, noninducible ventricular tachycardia or ventricular fibrillation) before ILR monitoring. ResultsThe study included 65 patients from 8 referral hospitals in The Netherlands, Spain, and the United Kingdom (mean age, 39 ± 16 years; 72% male). The main indication for ILR monitoring was unexplained syncope/presyncope (66.2%). During a median follow-up of 39.0 months (Q1 25.0–Q3 47.6 months), 18 patients (27.7%) experienced 21 arrhythmic events (AEs). None of the patients died during follow-up. Bradyarrhythmias were the most common finding (47.6%), followed by atrial tachyarrhythmias (38.1%). Only 3 patients presented with ventricular arrhythmias. AEs were considered incidental in 12 patients (66.7%). In 11 patients (61.1%), AEs led to specific changes in treatment. ConclusionThe use of ILR after a negative EPS in BrS is a safe strategy that reflected the high negative predictive value of EPS for ventricular arrhythmia in this syndrome. In addition, it allowed the detection of AEs in a significant proportion of patients, with therapeutic implications in most of them.

Combined ACL and Anterolateral Ligament Reconstruction Using an Adjustable-Loop Fixation Device: Surgical Technique

Background: There are several techniques for the combined reconstruction of the anterior cruciate ligament (ACL) and the anterolateral ligament (ALL), but none have shown superiority. This study aims to present a surgical technique that theoretically reduces some of the risks reported in these procedures. Indications: The main indications for the ALL reconstruction include chronic ACL injuries, revision ACL reconstruction, acute ACL injuries in patients with high-grade pivot-shift (grades 2 or 3), patients involved in pivoting sports, and generalized ligament hyperlaxity or knee hyperextension. Technique Description: Hamstring tendon autografts are used for the ACL and ALL reconstruction; a common femoral ACL and ALL tunnel is made outside-in, making a short socket. A continuous looped hamstring tendon autograft attached to one button is used. The ACL is fixed with an adjustable-loop button. Through small incisions, the tibial fixation of both grafts is performed with bioabsorbable screws. Results: We present a 19-year-old professional soccer player with an acute ACL tear, with no associated meniscal or chondral lesions. Owing to his young age and high-risk sports practice, a combined ACL and ALL reconstruction was performed. The combined ACL and ALL reconstruction with a single femoral tunnel using the hamstrings tendons graft is a well-established procedure for ACL augmentation, reducing failure rates for certain risk groups, with excellent outcomes reported. The use of an adjustable-loop button on the femur is a viable option for this kind of reconstruction with postoperative stability comparable to the interference screw, classically used for this kind of reconstruction. Discussion/Conclusion: This technique has some advantages, such as the use of a short outside-in femoral socket, thus theoretically improving healing. In addition, this lowers the risk of lateral collateral ligament injury, and since the ileotibial band graft is not used, the risk of injuring the lateral inferior genicular vessels and the peroneal nerve is theoretically reduced. Besides, using an adjustable-loop cortical button in the femur can theoretically reduce potential complications such as screw migration, soft-tissue impingement, femoral-site pain, and implant removal. Finally, the reconstruction is done with small incisions, improving the aesthetic result and postoperative pain. Considering all the aforementioned factors, this technique theoretically offers some benefits. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Competence of radiologists in cardiac CT and MR imaging in Europe: insights from the ESCR Registry

RationaleTo provide an overview of the current status of cardiac multimodality imaging practices in Europe and radiologist involvement using data from the European Society of Cardiovascular Radiology (ESCR) MRCT-registry.Materials and methodsNumbers on cardiac CT and MRI examinations were extracted from the MRCT-registry of the ESCR, entered between January 2011 and October 2023 (n = 432,265). Data collection included the total/annual numbers of examinations, indications, complications, and reporting habits.ResultsThirty-two countries contributed to the MRCT-registry, including 29 European countries. Between 2011 and 2022, there was a 4.5-fold increase in annually submitted CT examinations, from 3368 to 15,267, and a 3.8-fold increase in MRI examinations, from 3445 to 13,183. The main indications for cardiac CT were suspected coronary artery disease (CAD) (59%) and transcatheter aortic valve replacement planning (21%). The number of patients with intermediate pretest probability who underwent CT for suspected CAD showed an increase from 61% in 2012 to 82% in 2022. The main MRI indications were suspected myocarditis (26%), CAD (21%), and suspected cardiomyopathy (19%). Adverse event rates were very low for CT (0.3%) and MRI (0.7%) examinations. Reporting of CT and MRI examinations was performed mainly by radiologists (respectively 76% and 71%) and, to a lesser degree, in consensus with non-radiologists (19% and 27%, respectively). The remaining examinations (4.9% CT and 1.7% MRI) were reported by non-radiological specialties or in separate readings of radiologists and non-radiologists.ConclusionsReal-life data on cardiac imaging in Europe using the largest available MRCT-registry demonstrate a considerable increase in examinations over the past years, the vast majority of which are read by radiologists. These findings indicate that radiologists contribute to meeting the increasing demands of competent and effective care in cardiac imaging to a relevant extent.Clinical relevance statementThe number of cardiac CT and MRI examinations has risen over the past years, and radiologists read the vast majority of these studies as recorded in the MRCT-registry.Key Points• The number of cardiac imaging examinations is constantly increasing.• Radiologists play a central role in providing cardiac CT and MR imaging services to a large volume of patients.• Cardiac CT and MR imaging examinations performed and read by radiologists show a good safety profile.Graphical

Echographic Screening for Fetal Malformations at the Gynecological and Obstetric Clinic of the Aristide Le Dantec Hospital: Review from 2016 to 2018

Introduction: Congenital malformations affect around 3% to 4% of live births and 20% of stillbirths. They represent 20 to 30% of the causes of infant mortality in the countries of the European Community. It is estimated that 5 to 10% of malformations are due to exogenous or environmental causes and 12 to 30% to genetic or endogenous causes (gene mutations or chromosomal anomalies). In almost 60% of cases, the actual origin of the malformation remains unknown. Nevertheless, the origin of these anomalies is still being researched, and numerous diagnostic tools are available to practitioners to improve antenatal screening and pregnancy monitoring. However, obstetric ultrasound remains the primary tool for antenatal screening and monitoring of congenital malformations. Methodology: Our main objective was to evaluate the practice of ultrasound screening for foetal malformations at the Gynaecology and Obstetrics Clinic at Hopital Aristide Le Dantec from 1 February 2016 to 31 December 2018. We conducted a retrospective study of ultrasound screening for foetal malformations. Results: At the end of our study, 869 obstetric ultrasounds met our inclusion criteria. We had 837 singleton pregnancies (96.3%), 31 twin pregnancies (3.6%) and 1 trimellar pregnancy (0.1%). We noted 35 cases of foetal malformations, an incidence of 4.02%. All cases of malformations were diagnosed in singleton pregnancies. The average age of the patients was 29 years, with extremes of 18 and 45 years. Primiparous women were the most represented in our study (62.5%). The majority of patients were from Dakar. A history of recurrent miscarriage was found in 7 patients (20%) and there was one case of fetal death in utero during the previous pregnancy. There was no family history of malformations. Consanguinity was found in 11 cases (31.4%). Only 2 patients were found to have taken medication, one for insulin and the other for an unspecified drug. There was no evidence of toxic intake. Fetal malformations were observed in the 3rd trimester in 23 cases (42.9%). There were 11 cases in the 2nd trimester (31.4%) and only 1 case in the 1st trimester. Cranioencephalic malformations were detected in almost half of the cases (42.8%), i.e. 15 cases. There were 8 cases of polymalformative syndromes, i.e. 22.8%. Digestive malformations were represented in 3 cases, i.e. 8.6%, as were cardiac malformations in 3 cases. Pulmonary malformations and limb malformations accounted for 5.7% and 2 cases each. Renal malformations and orofacial malformations also accounted for 1 case each, 2.9% respectively. Among the 15 cases of malformations of the nervous system, ventricular dilatation ranked first with 10 cases representing 66.6%, followed by anencephaly and cystic hygroma with 2 cases each representing 13.3% and finally dolichocephaly with 1 case representing 6.7%. We found 8 different cases of polymalformative syndromes. These syndromes were labelled in 2 cases and unlabelled in the 6 others. There was 1 case of trisomy 21 and 1 case of trisomy 13. The other cases of polymalformative syndromes were not clearly labelled. A combination of cerebral, $cardiac and/or renal malformations were reported. Digestive malformations were noted in 3 cases (8.6%), including 2 dilatations of the coves (megacolon) and 1 case of omphalocele. Pericarditis, atrial septal defect and transposition of the great vessels were the cardiac malformations found in a total of 3 cases (8.6%). Two cases of achondroplasia were found in our series (5.7%). They were all associated with oligohydramnios. There were 2 cases of pulmonary hypoplasia (5.7%). These were associated with anamnios and a medullary syndrome in one of the cases. Cleft lip and palate and polycystic kidney disease were present in one case each (2.9%). The pregnancy resulted in vaginal delivery in 21 cases (60%), caesarean section in 13 cases (37.1%) and in 1 case the mode of delivery was not specified. The main indication for Caesarean section was hydrocephalus (61.5%). The anomaly and the type of malformation were announced in 85.5% of cases. A referral for fetal ultrasound was suggested in 5.7% of patients and fetal MRI in 2.9%. Concordance between antenatal and postnatal diagnosis was achieved in 18 cases (51.4%). The pregnancy resulted in vaginal delivery in 21 cases (60%), caesarean section in 13 cases (37.1%) and in 1 case the mode of delivery was not specified. The main indication for Caesarean section was hydrocephalus (61.5%). The anomaly and the type of malformation were announced in 85.5% of cases. A referral for fetal ultrasound was suggested in 5.7% of patients and fetal MRI in 2.9%. Concordance between antenatal and postnatal diagnosis was achieved in 18 cases (51.4%). Neonatal mortality accounted for 62.9% of the series, with 22 cases. Conclusion: Fetal malformations were detected with a concordance of 51.4% between antenatal and postnatal diagnosis. Neonatal mortality was high. A major preoccupation should be the strengthening of cytogenetic diagnosis and management resources, and raising awareness of the origins of congenital malformations.

Amazonian useful plants described in the book “Le Pays des Amazones” (1885) of the Brazilian propagandist Baron de Santa-Anna Nery: a historical and ethnobotanical perspective

BackgroundFrederico José de Santa-Anna Nery (1848–1901) was a Brazilian Baron who referred to himself as a "volunteer propagandist" for Brazil in Europe, serving as an immigration agent to publicize the living conditions in the Amazon region, advocating for its development and modernization at the end of the nineteenth century. Santa-Anna Nery’s most famous book is "Le Pays des Amazones" (The Lands of the Amazons), first published in 1885, which the author dedicated a chapter to introduce and report on the Amazonian useful plant species and its relationship with humans. The aim of this work is to understand the historical context and ethnobotanical value of the plant species in the Brazilian Amazon at the end of the nineteenth century through an analysis of the book “Le Pays des Amazones” (1885) by Baron de Santa-Anna Nery, as well as to bring to light the historical importance of this very influential propagandist, who has been forgotten nowadays.MethodsThe original book “Le Pays des Amazones” (1885), as well as the original 3rd edition and its translated version into Portuguese, was carefully analyzed and all information about plants was systematized, with botanical names being updated. Finally, using the scientific name of medicinal plants alone or in combination with their traditional use, a search was carried out in databases in order to indicate current pharmacological studies that provide evidence about the described traditional uses.ResultsA total of 156 plant species were identified in the book, although 132 species had their scientific names updated. These species belong to 45 different families, with Fabaceae and Arecaceae the most represented, and 109 plants are Brazilian native. Considering only the 36 medicinal plants, the main medicinal indications reported were astringent, purgative/laxative, stimulant and tonic, vermifuge, febrifuge, sudorific, emetic, diuretic and antidysenteric. Regarding other useful plants (non-medicinal), 97 species were cited for food, constructions and buildings, spices and condiments, ornaments and objects, carpentry, textile fibers, gums, oils, balms and essences, pigments and tanning, hunting and fishing.ConclusionsWhen the book “Le Pays des Amazones” is analyzed from a timeless perspective, with a particular focus on historical ethnobotany, it is possible to observe the economic, social, and political importance of many useful plants for the Amazon at the end of the nineteenth century and how the relationship between local people, indigenous communities, and immigrants was established with plant biodiversity.

Postoperative Complications of Transvesical Adenomectomy of the Prostate in the Urology Department of the Centre Hospitalier Universitaire GABRIEL TOURE in Bamako

Objective: To study postoperative complications of transvesical adenomectomy of the prostate in the urology department of the Gabriel TOURE University Hospital in Bamako. Patients and Methods: This was a prospective, cross-sectional, descriptive study conducted over 12 months, from December 1, 2022 to November 30, 2023. It covered all patients admitted, operated on and followed up in the Urology Department of CHU Gabriel Touré for benign prostatic hypertrophy and having a complete medical record. Results: Out of 102 patients operated on for prostate adenoma in the urology department of CHU Gabriel Touré, 26 cases of postoperative complications (POC) were recorded, representing a frequency of 25.49%. The average age of our patients was 71.38 years. Urinary bilharziasis was the main urological antecedent in 50% of patients, while inguinal hernia repair was the most common surgical antecedent, accounting for 27% of cases. Pollakiuria was the main reason for consultation (46.15%). Urinary tract infection was found in 57.69% of patients, with Escherichia coli the main germ involved (34.61%). The mean ultrasound prostate weight was 63.82g, with a mean total PSA level of 2.98ng/ml. Preoperative catheterization was strongly associated with postoperative complications (37.21%). The main indication for surgery was complicated BPH (infectious complication: 38.46%). The average duration of bladder irrigation was 2.3 days. Parietal suppuration was the main postoperative complication (30.77%). Postoperative indwelling catheterization lasted an average of 16 days. The average hospital stay was 7.3 days for patients with CPO versus 5 days for other patients. The mortality rate was estimated at 3.84%. Conclusion: In our context, transvesical adenomectomy of the prostate is still the most common surgical treatment for benign prostatic hyperplasia. Postoperative complications are dominated by parietal suppuration.

Antibiotic therapy in pediatric outpatient ENT infections

Inflammatory diseases of the ENT organs are currently the most common pathology in children. Diseases of the nasal cavity and paranasal sinuses occupy the leading place in the structure of primary morbidity, averaging 55.5%. In the paediatric population, ENT pathology develops more often as a secondary bacterial complication of a previous viral infection of the upper respiratory tract. Bacterial otorhinolaryngological complications often require the prescription of antibacterial drugs. In outpatient practice, the choice of rational and safe therapy is of utmost importance. The article presents clinical cases of ENT diseases in children and algorithms for the choice of initial antibacterial therapy. Recommended drugs for the treatment of ENT diseases and the main indications for their administration are presented. Most national and international guidelines recommend amoxicillin as a first-line drug for the treatment of major respiratory pathogens (S. pneumoniae, H. influenzae, S. pyogenes) and bacterial complications of ENT diseases in children, taking into account its low toxicity, cost and convenient form of administration. In case of ineffective therapy or in the presence of risk factors for drug resistance of pathogens, semi-synthetic penicillins in combination with β-lactamase inhibitors are recommended.

Amplatzer or Figulla Flex II Occluder: a comparative study of outcomes after transcatheter patent foramen ovale closure.

Percutaneous closure of a patent foramen ovale (PFO) for the prevention of recurrent paradoxical thromboembolic events has been shown to be safe and effective in randomized controlled trials. However, it remains uncertain if differences in the structure and design of the occluder devices impact the outcomes. The aim of this study was to compare results of percutaneous PFO closure using 2 widely used double-disc occluders. Consecutive patients who underwent percutaneous PFO closure with the Abbott Amplatzer occluder (APO) or the Occlutech Figulla-Flex-II occluder (OPO) at the Heart Center Lucerne between February 2017 and December 2022 were included in a registry. The primary endpoint was effective closure of the PFO, defined as a residual shunt grade 0 or 1, assessed by contrast echocardiogram at 6-month follow-up. Secondary endpoints included procedural efficacy/safety and major adverse cardiovascular events during the hospital stay and at 6-month follow-up. One hundred ninety-three consecutive patients (mean age 51.7 ± 12.5 years; 39% women; Risk of Paradoxical Embolism (RoPE) score = 7, IQR = 6-8) underwent percutaneous PFO closure with the APO (120 patients, 62.2%) or the OPO (73 patients, 37.8%). Main indications for closure were crypotogenic stroke in 168 patients (87.1%) and peripheral embolism in 13 patients (6.7%). At baseline, right-to-left shunt (RLS) greater than or equal to grade 2 was present in 189 patients (97.9%). Immediate procedural success was 99.5%. In 1 patient, an air embolism occurred during positioning of the APO occluder with transient chest pain and electrocardiogram changes, but without further sequelae to the patient. At 6-month follow-up, effective closure was achieved in 185 patients (95.8%; APO: 96.6% vs OPO: 94.5%, P = .30). Rates of atrial fibrillation and recurrent thromboembolic events were 4.2 and 0.5%, respectively. PFO closure is safe and effective when performed with either the self-expanding Abbott Amplatzer or Occlutech Figulla Flex II PFO occluder.

Conversion from twice-daily everolimus to once-daily sirolimus in long-term stable liver transplant recipients

BackgroundAfter organ transplantation, strategies for simplifying the therapeutic regimen may improve adherence and prevent acute organ rejection and/or late graft loss. The present study aimed to evaluate the safety and efficacy of conversion from everolimus (EVR) twice daily to sirolimus (SIR) once daily in a large cohort of liver transplantation (LT) patients. MethodsWe included 108 LT patients with at least 12 months of post-transplant follow-up and no rejection episodes in the last year. Conversion was based on a 1:1 ratio (but eventually adapted to available formulations of SIR). ResultsThe median age at the time of conversion was 68.9 years (range: 26.1–83.6); 75.0% were men. The main indications for mTOR inhibitor use were renal failure (38.9%) and/or a history of malignancy (37.0%). Median conversion time after LT was 14.8 years (range: 2.3–31.5). The median dose of EVR and SIR (initially) was 1.50 mg/day (range: 0.5–4.5). The mean follow-up after conversion was 15.8±4.4 months. Median serum EVR/SIR trough levels before/after conversion were 3.85 ng/mL vs. 6.32 ng/mL (p < 0.05), i.e. a 1:1.64 ratio. At the end of follow-up after conversion, the median dose of SIR was 1.25 mg/day (range: 0.5–3.5), and the mean serum SIR trough level was 5.23 ng/mL; 9 patients (8.3%) had returned to EVR, because of side effects (mainly digestive), that resolved thereafter. No biopsy-proven acute rejection episode was observed. Finally, 87.1% of patients considered the conversion beneficial and the cost was reduced by 50.3%. ConclusionThe results of our study indicate that conversion from once-daily EVR to once-daily SIR in stable LT patients is safe, but needs dose adaptations and careful monitoring.

Real-life practice of reflectance confocal microscopy in France: A prospective multicenter study

BackgroundStudies demonstrating the potential utility of reflectance confocal microscopy (RCM) have been performed under experimental conditions. ObjectiveTo provide an overview of RCM practice in real-life. MethodsA multicenter, prospective study carried out in 10 university dermatology departments in France. Results0verall, 410 patients were enrolled. Half of the patients (48%) were referred by private-practice dermatologists. They were referred for diagnosis (84.9%) or pre-surgical mapping (13%). For diagnosis, the lesions were located on the face (62%), arms and legs (14.9%), and trunk (13,6%), and pre-surgical mapping was almost exclusively on the face (90.9%). Among those referred for diagnosis, the main indication was suspicion of a skin tumor (92.8%). Of these,50.6% were spared biopsies after RCM. When RCM indicated surgery, histology revealed malignant lesions in 72.7% of cases. The correlation between RCM and histopathology was high, with a correlation rate of 82.76% and a kappa coefficient of 0.73 (0.63; 0.82). Limitations: This study was performed in the settings of French tertiary referral hospitals. Conclusion: This study shows that in real-life RCM can be integrated into the workflow of a public private network, which enables a less invasive diagnostic procedure for patients.

Risk Factors for Recurrence of Primary Sclerosing Cholangitis after Liver Transplantation: Single-Center Data.

Primary sclerosing cholangitis (PSC), comprising 5-15% of European liver transplantation (LT) cases, poses a significant challenge due to the risk of post-transplant disease recurrence (rPSC). This single-center study aimed to determine the rPSC rate and long-term post-LT outcomes in PSC patients and to identify potentially modifiable risk factors of rPSC. All PSC patients receiving LT at Padua Hospital from 1993 to 2021 were included. Recipient data were collected pre-LT, at LT, and during the follow-up. Donor and LT features were recorded. The rPSC rate was assessed according to Mayo Clinic criteria. Patient and graft survival were reported. Thirty-three patients were included. The main indication of LT was decompensated cirrhosis (70%). Nine patients (27%) developed rPSC during a median follow-up of 59 months (45-72). A longer cold ischemia time (p = 0.026), donor female gender (p = 0.049), inflammatory bowel disease reactivation (IBD) post LT (p = 0.005) and hepaticojejunostomy (p = 0.019) were associated with a higher risk of rPSC. Graft and patient survival at 1, 5 and 10 years post LT, 94%, 86%, 74% and 97%, 89%, 77% respectively, were not affected by rPSC development. Specific donor and surgical features might increase the risk of rPSC. Identifying predictive factors for rPSC to prevent graft loss is challenging but could lead to a more personalized organ allocation and follow-up in PSC transplanted patients. IBD reactivation might have a pathogenic role in rPSC. In our single-center experience, rPSC did not affect patient and graft survival.

Baseline Characteristics of Fabry Disease "Amenable" Migalastat Patients in Argentinian Cohort.

Fabry disease (FD) is a multisystem lysosomal storage disorder induced by genetic variants in the alpha-galactosidase A (αGalA) gene. Some FD patients have GLA variants with a reduction in overall αGalA enzymatic activity due to mutated proteins with reduced stability, caused by protein misfolding and premature degradation, but the αGalA catalytic activity remains conserved ("amenable" genetic variants). To correct this misfolding and to prevent premature degradation, migalastat, a small iminosugar molecule was developed. We report the clinical characteristics of FD "amenable" cohort patients from Argentina, prior to starting treatment with migalastat. Seventeen Fabry adult patients were recruited from 13 Argentinian Centers; 8 males (47.1%) and 9 females (52.9%) were included. All genotypes included were missense-type "amenables" mutations. Some classic FD typical early manifestations were more frequent in patients with "classic" versus "late-onset" FD phenotype (pain, p=0.002; cornea verticillata, p=0.019). There was a statistically significant difference in estimated glomerular filtration rate in the "classic" versus "late-onset" phenotype (p=0.026) but no difference between genders (p=0.695). Left ventricular mass was similar between genders (p=0.145) and phenotypes (p=0.303). Cardiovascular risk factors were present among "late-onset" females (obesity 50% and smoke 25%). In patients who started "de novo" migalastat, the main indications were (i) heart disease, (ii) kidney damage, and (iii) pain, while in "switched from prior enzyme replacement therapy" patients, the most frequent indication was "patient decision;" this coincides with publications by other authors.

Clinical implementation of preemptive pharmacogenomics in psychiatry

Pharmacogenomics (PGx) holds promise to revolutionize modern healthcare. Although there are several prospective clinical studies in oncology and cardiology, demonstrating a beneficial effect of PGx-guided treatment in reducing adverse drug reactions, there are very few such studies in psychiatry, none of which spans across all main psychiatric indications, namely schizophrenia, major depressive disorder and bipolar disorder. In this study we aim to investigate the clinical effectiveness of PGx-guided treatment (occurrence of adverse drug reactions, hospitalisations and re-admissions, polypharmacy) and perform a cost analysis of the intervention. We report our findings from a multicenter, large-scale, prospective study of pre-emptive genome-guided treatment named as PREemptive Pharmacogenomic testing for preventing Adverse drug REactions (PREPARE) in a large cohort of psychiatric patients (n=1076) suffering from schizophrenia, major depressive disorder and bipolar disorder. We show that patients with an actionable phenotype belonging to the PGx-guided arm (n=25) present with 34.1% less adverse drug reactions compared to patients belonging to the control arm (n=36), 41.2% less hospitalisations (n=110 in the PGx-guided arm versus n=187 in the control arm) and 40.5% less re-admissions (n=19 in the PGx-guided arm versus n=32 in the control arm), less duration of initial hospitalisations (n=3305 total days of hospitalisation in the PGx-guided arm from 110 patients, versus n=6517 in the control arm from 187 patients) and duration of hospitalisation upon readmission (n=579 total days of hospitalisation upon readmission in the PGx-guided arm, derived from 19 patients, versus n=928 in the control arm, from 32 patients respectively). It was also shown that in the vast majority of the cases, there was less drug dose administrated per drug in the PGx-guided arm compared to the control arm and less polypharmacy (n=124 patients prescribed with at least 4 psychiatric drugs in the PGx-guided arm versus n=143 in the control arm) and smaller average number of co-administered psychiatric drugs (2.19 in the PGx-guided arm versus 2.48 in the control arm. Furthermore, less deaths were reported in the PGx-guided arm (n=1) compared with the control arm (n=9). Most importantly, we observed a 48.5% reduction of treatment costs in the PGx-guided arm with a reciprocal slight increase of the quality of life of patients suffering from major depressive disorder (0.935 versus 0.925 QALYs in the PGx-guided and control arm, respectively). While only a small proportion (∼25%) of the entire study sample had an actionable genotype, PGx-guided treatment can have a beneficial effect in psychiatric patients with a reciprocal reduction of treatment costs. Although some of these findings did not remain significant when all patients were considered, our data indicate that genome-guided psychiatric treatment may be successfully integrated in mainstream healthcare. European Union Horizon 2020.

Suppressive antibiotic therapy for infectious endocarditis

ObjectivesSuppressive antibiotic therapy (SAT) is a long-term antibiotic strategy at times applied when an indicated surgical management of infective endocarditis (IE) is not possible. Our aim was to describe the characteristics and outcomes of patients having received SAT for IE. MethodsWe conducted a retrospective, observational study at Strasbourg University Hospital, France between January 2020 and May 2023. We reviewed all medical files taken into consideration at weekly meetings of the local Multidisciplinary Endocarditis Team (MET) during the study period. We included patients having received SAT following the MET evaluation. The primary endpoint was all-cause mortality at most recent follow-up. Secondary endpoints included all-cause mortality at 3 and 6 months, infection relapse, and tolerance issues attributed to SAT. ResultsThe MET considered 251 patients during the study time, among whom 22 (9 %) had received SAT. Mean age was 77.2 ± 12.3 years. Patients were highly comorbid with a mean Charlson index score of 6.6 ± 2.5. Main indication for SAT was surgery indicated but not performed or an infected device not removed (20/22). Fourteen patients had prosthetic valve IE, including 9 TAVIs. Six patients had IE affecting cardiac implantable electronic devices. Staphylococcus aureus and enterococci were the main bacteria involved (6/22 each). Median follow-up time was 249 days (IQR 95–457 days). Mortality at most recent follow-up was 23 % (5/22). Three patients (14 %) presented tolerance issues attributed to SAT, and two patients suffered late infectious relapse. ConclusionMortality at most recent follow-up was low and tolerance issues were rare for patients under SAT, which might be a palliative approach to consider when optimal surgery or device removal is not possible.

Lived experiences of women during induction of labour at a tertiary hospital in Ghana: A qualitative study.

Induction of labour (IOL) has become a major and vital maternal health intervention to facilitate childbirth and minimize the rising caesarean section rates globally. However, there is limited information to facilitate appropriate client counselling, birth preparedness and informed decision making although the procedure has inherent tendency for adverse maternal/perinatal outcomes. Given the need for optimal client education and shared decision making in maternal health, this study explored women's knowledge and their lived experiences of IOL. This qualitative study used in-depth interviews, conducted at the largest teaching hospital in Ghana. Purposive sampling was used to recruit the study participants. Data analysis was performed based on thematic content using inductive framework synthesis. We included 17 women who had undergone IOL, delivered and discharged. Most participants(52.9%) were ≥30 years old, married(88.2%), and 41.1% had no previous childbirth experience. The main indications of IOL were postdate(47%), pre-eclampsia(29%) and gestational diabetes mellitus(11.8%). Data synthesis resulted in three broad themes: women's knowledge on IOL, women's experiences of care and women's difficult experiences including coping mechanisms. We determined mixed responses concerning the themes explored: adequate versus inadequate knowledge; positive versus negative experiences of care and satisfaction. Nearly all women mentioned vaginal examination as their most difficult experience due to severe pain, extreme discomfort, and being psychologically traumatic. The main coping strategy the women developed to navigate the traumatic vaginal examination was by "psyching" themselves. Our study indicates women encounter significant negative and positive experiences during IOL and childbirth in Ghana with vaginal examination cited as the most painful experience. Appropriate antenatal counselling, women empowerment and pre-labour education on childbirth processes and expectations are recommended to enhance birth preparedness and complication awareness. Health system improvement and regular refreshers courses for health workers are urgently required to promote positive women's experiences of care during labour induction and childbirth.

The outcomes of treatment for homebound adults with complex medical conditions in a hospital-at-home unit in the southern district of Israel

BackgroundA model of hospital-at-home services called the Home Care Unit (“the unit”) has been implemented in the southern region of the Clalit Healthcare Services in Israel. The aim of the present study was to characterize this service model.MethodsA retrospective cross-over study. included homebound patients 65 years of age and above who were treated for at least one month in the framework of the unit, between 2013 and 2020. We compared the hospitalization rate, the number of hospital days, the number of emergency room visits, and the cost of hospitalization for the six-month period prior to admission to the unit, the period of treatment in the unit, and the six-month period following discharge from the unit.ResultsThe study included 623 patients with a mean age of 83.7 ± 9.2 years with a mean Mini-mental State Examination (MMSE) score of 12.0 ± 10.2, a mean Charlson Comorbidity Index (CCI) of 3.7 ± 2.2 and a Barthel Index score of 23.9 ± 25.1. The main indications for admission to the unit were various geriatric syndromes (56.7%), acute functional decline (21.2%), and heart failure (12%). 22.8% died during the treatment period and 63.4% were discharged to ongoing treatment by their family doctor after their condition stabilized. Compared to the six months prior to admission to the unit there was a significant decrease (per patient per month) in the treatment period in the number of days of hospitalization (2.84 ± 4.35 vs. 1.7 ± 3.8 days, p < 0.001) and in the cost of hospitalization (1606 ± 2170 vs. 1066 ± 2082 USD, p < 0.001).ConclusionsTreatment of homebound adults with a high disease burden in the setting of a hospital-at-home unit can significantly reduce the number of hospital days and the cost of hospitalization. This model of service for homebound patients with multiple medical problems maintained a high level of care while reducing costs. The results support the widespread adoption of this service in the community to enable the healthcare system to respond to the growing population of elderly patients with medical complexity.

Retrospective analysis of regional anaesthesia in hip surgery: A clinical audit

IntroductionTotal hip arthroplasty is one of the most frequent surgical interventions in the hospital setting. Nonetheless, the ideal method to manage post-operative pain is still unknown. Multimodal analgesia techniques based on regional anaesthesia are amongst the most promising solutions. ObjectivesThe aim of this study was to evaluate postoperative pain after total hip arthroplasty according to whether peripheral nerve block was performed (femoral block, fascia iliaca block and pericapsular nerve group block). Intravenous morphine consumption during the patient’s stay in the post-anaesthesia care unit was measured, as well as the number of opioid rescues at 24 and 48 h post intervention. As secondary objectives, the prevalence of nerve injury, prolonged quadricipital block, and morphine consumption were established according to other variables of interest. Materials and methodsIn this observational retrospective study, data was collected from the electronic medical record of 656 traumatological surgery patients from April 2018 to August 2020, with the following inclusion criteria: over 18 years old, ASA I–III, primary total hip arthroplasty under general anaesthesia or subarachnoid anaesthesia (only with hyperbaric bupivacaine) and use of levobupivacaine for peripheral nerve block. ResultsA total of 362 patients were selected. The main surgical indication was coxarthrosis (61.3%), followed by hip fracture (22.6%). Peripheral nerve blocks were performed on 169 patients (66.3% femoral, 27.7% PENG, and 6.0% fascia iliaca). Mean postoperative opioid consumption in PACU was lower in patients in who received a PENG (2.2 mg) or a femoral (3.27 mg) block, compared to those who received neither (6.69 mg). There were no differences in opioid rescues at 24 and 48 h after the procedure. Nerve injury incidence was low (.8%), and not associated with nerve blocks. The incidence of prolonged quadricipital paralysis was also low (1.3%), and was mainly associated with femoral nerve block (75% of cases). ConclusionsThis retrospective study supports the use of regional blocks as opioid-sparing techniques, highlighting their role in rapid functional recovery with no motor impairment.

An agro-meteorological hazard analysis for risk management in a Mediterranean area: a case study in Southern Italy (Campania Region)

Agriculture is highly dependent on environmental, climate and weather conditions and on extreme weather events leading to natural disasters. Such events are more and more frequent in Italy, and in the last decades huge public investments were dedicated to risk management policies in agriculture. In order to set an adequate weather-related risk assessment, a robust analysis of the hazard is needed, which requires an agro-meteorological approach to detect the potential impacts of weather extremes on agricultural activities. With the aim of assessing the effectiveness of the current risk management policy in catching the main hazards, specific agro-meteorological indices were applied to highlight occurrence, trends, and spatial patterns of extreme events. The analysis was based on reanalysis datasets and focused on a study area in Southern Italy (Campania region) during the 1981–2021 period. The findings are reported in terms of maps and statistics aggregated at administrative unit level (5 provinces) and show a general intensification of weather extremes in the last decades, both in frequency and intensity of the events. The main indications refer to growth rates of heavy precipitation, potentially leading to flood, locally exceeding 3–4 mm/year, an increasing number of months with severe/extreme droughts, mainly concentrated during the growing season. An upward trend was also observed for days with extreme maximum temperatures, which already exceeded or approached 50% between June and September in the 1981–2021 period in most areas. Maximum temperatures above 35 °C are becoming more frequent and in the inner areas they were reached in 10 days in the 2021 summer quarter. On the other hand, no significant trends were detected for late frosts. In terms of policy implications, the results seem to suggest that some extreme weather events can no longer be considered as exceptional at the present time and in a trend perspective, making them less suitable to be addressed through the risk management tools based almost exclusively on the strategy of transferring risks (insurances and more recent mutual funds) both for farmers and for the allocation of public resources. Therefore, the need is underlined for improving the design of the risk management policies to increase farms’ resilience and adaptation to climate change. Moreover, the study highlights the information potential of agro-meteorological indices in supporting evidence-based decision making in agriculture.

Bisphosphonate treatment for skeletal complications in paediatric cancer-Experience from a single tertiary centre.

The aim was to analyse the use and safety of bisphosphonate treatment for metabolic bone complications in paediatric cancer patients. We retrospectively describe our experience with bisphosphonate treatment in 25 childhood cancer patients (aged <18 years) in a single tertiary hospital between 1999 and 2020. The most common primary diagnosis was acute lymphoblastic leukaemia (n = 16) and Hodgkin lymphoma (n = 3). Eleven patients (44%) had received allogeneic stem cell transplantation and two patients autologous stem cell transplantation. Sixteen patients (64%) had been treated with radiotherapy, either total-body (n = 11) or local (n = 5). The main indication for bisphosphonates was osteoporosis with vertebral compression fractures in 13/25, osteonecrosis in 6/25 and hypercalcaemia in 2/25. The bisphosphonate treatment was started on average 13 (range 0-76) months after the diagnosis of the bone complication. Bisphosphonate treatment lasted between weeks (hypercalcaemia) to 5 years (severe osteoporosis). Mild, non-symptomatic hypophosphatemia (n = 8), hypocalcaemia (n = 6) and moderate, transient pain (n = 6) were the most common adverse effects. No severe side effects were observed even when bisphosphonates were administered concomitantly with chemotherapy. Bone mineral density significantly improved with the bisphosphonate treatment (mean lumbar spine Z-score -1.17 vs. -0.07, p < 0.001). Bisphosphonate treatment was well tolerated in this paediatric patient cohort.

Vaginal hysterectomy at federal teaching hospital, Katsina: A five-year review.

Even though the vaginal route is said to be the gynaecologist route of surgery, abdominal hysterectomy remains the predominant method of uterine removal in most parts of the world, despite the evidence of the safety of vaginal hysterectomy. The study aims to determine the prevalence, socio-demographic variables, indications as well as outcome of vaginal hysterectomy at Federal Teaching Hospital (FTH) Katsina, during the 5-year study period. A five-year retrospective study on vaginal hysterectomy was conducted in Federal Teaching Hospital, Katsina from 1st January 2015 to 31st December 2019. The rate of hysterectomies (Abdominal & Vaginal) was 21.6% of the total major gynaecological surgeries performed during the study period. Vaginal hysterectomy accounted for 6.7%. The mean age and parity of the patients were 56.06+/- 9.55 years and 10.17+/- 4.57 respectively. The commonest indication was Utero-vaginal Prolapse (88.9%) and 80.5% (29) of the patients had no complications. Most of the patients (94.4%) were discharged within 7 days of surgery and there was no fatality. The rate of vaginal hysterectomy in our centre is low. Most of the patients were grand multiparous with the main indication being Uterovaginal prolapse. It is associated with favourable outcomes and very low complication rates.