Occurrence Of First Symptoms Research Articles

No reimbursement policy and implantable loop recorders in the real world setting

Abstract Background Prolonged heart rhythm evaluation is indicated in patients with suspected arrhythmias. Routine electrocardiographic Holter monitoring is often associated with poor adherence and may lead to little to no clinically relevant findings. Implantable loop recorders (ILRs) are small, subcutaneous cardiac devices providing semi-continuous electrocardiographic recording. Despite strong evidence supporting their effectiveness, ILRs are yet to be fully reimbursed by the National Health Fund- the public insurer in Poland. Purpose We aimed to investigate the feasibility, as well as the diagnostic yield of ILRs in a real world setting of a tertiary cardiovascular center. Methods We retrospectively analyzed data of consecutive patients admitted for ILR implantation between March 2013 nad November 2023. Hospitalization and procedural costs were covered by the clinic's statutory and hospital funds and not by the National Health Fund, the public payer. All patients were remotely monitored for device follow-up. Baseline demographic characteristics, as well as data regarding observation period, clinical outcomes and safety were collected. Results Data for 51 ILR implants in 50 patients was assessed. Insertion success rate was 100% on first attempt with no complications. Mean age was 54,43 ±18,56 years old. 52,94% of patients were female. Coronary artery disease was present in 21,57% patients, hypertension in 50,98%, diabetes in 13,73%. The indications for ILR implantation were unexplained syncope (n= 42; 82,35%), palpitations (n= 16; 31,37%), ischemic stroke of unknown origin (n= 6; 11,76%), monitoring of ventricular arrhythmia (n= 2; 3,92%). Mean time between occurrence of first symptoms and ILR implantation was 80,86 ±112,95 months. Mean monitoring period was 1067,62 ±668,89 days. 23 (45,1%) patients had an actionable event detected. Mean time to clinical outcome was 190,34 ±514,85 days. Based on the obtained recordings, in 13 (25,49%) patients a cardiac electronic device was implanted and 6 (11,76%) underwent an electrophysiological procedure. Time to intervention was 435,17 ± 542,9 days and 338,8 ± 273,44 days, respectively. ILR prompted medication modification in 14 (27,45%) patients. Antiarrhythmic drugs were modified in 6 (11,76%) patients. Oral anticoagulation was initiated in 3 (5,88%) patients. Mean time to any pharmacotherapy modification was 654,68 ± 604,32 days. Skin infections occurred in 2 patients, leading to early device removal. Conclusions This is the first study to present a comprehensive evaluation of ILR patients in Poland, along with a substantial observation period. We report a high prevalence of treatable cardiac conditions in patients with previous unsuccessful diagnostic work up. In the light of the upcoming favourable changes in governmental healthcare policy, demonstrating evidence supporting ILR application in everyday clinical practice is crucial for advocating their wider utilization and reimbursement.

Evaluating the burden of endogenous Cushing’s syndrome using a web-based questionnaire and validated patient-reported outcome measures

IntroductionEndogenous Cushing’s syndrome (CS) is a rare endocrine condition caused by chronic oversecretion of cortisol, resulting in a diverse constellation of symptoms. This study examined the ongoing burden of illness (BOI), from the first appearance of symptoms through treatment, which is currently not well evaluated.MethodsA quantitative, cross-sectional, web-enabled survey including 5 validated patient reported outcomes (PRO) measures was conducted in patients with CS who had been diagnosed ≥ 6 months prior and who had received ≥ 1 treatment for their endogenous CS at the time of the survey.ResultsFifty-five patients participated in this study; 85% were women. The mean age was 43.4 ± 12.3 years (± standard deviation, SD). On average, respondents reported a 10-year gap between the first occurrence of symptoms and diagnosis; 80% underwent surgical treatment for CS. Respondents experienced symptoms on 16 days in a typical month, and their health-related quality of life was moderately impacted based on the CushingQoL score. Weight gain, muscle fatigue, and weakness were the most common symptoms and 69% percent of patients reported moderate or severe fatigue using the Brief Fatigue Inventory. Following treatment, the occurrence of most symptoms declined over time, although anxiety and pain did not significantly decrease. Overall, 38% of participants reported an annual average of 25 missed workdays due to CS symptoms.ConclusionsThese results demonstrate a BOI in CS despite ongoing treatment and illustrate the need for interventions to address persistent symptoms, particularly weight gain, pain, and anxiety.

Impact of COVID-19 before and after 2020 on Retinal Detachment Management in a Tertiary Eye Hospital in Germany

Introduction: COVID-19 has had a tremendous impact on our everyday life. A growing body of evidence indicates that subsequent lockdowns and fear of exposure may have impacted patient care. We analyzed data on incidence and time to surgery in cases of rhegmatogenous retinal detachments (RRD) at three defined time points before, during, and 1 year after the first lockdown period in Germany. Methods: In this single-center study, we identified all patients who were admitted and treated for a primary RRD in April and May 2020, the time of the first lockdown period in Germany, and compared them with cases of the same time period in the years 2019 and 2021. The time from first occurrence of symptoms to surgery as well as visual outcome was analyzed. Results: A total of 192 patients presented to our tertiary academic referral center with a RRD during the months of April and May in 2019 (72 patients), 2020 (62 patients), and 2021 (58 patients) and were included in this study. There were no significant differences with regard to gender and age. In 2019, the time interval between occurrence and presentation to our hospital amounted to a mean of 5.96 days and in 2021 to mean of 5.45 days. However, in 2020, the time between occurrence and presentation was significantly longer with a mean of 15.36 days. The number of patients presenting with a macula-on retinal detachment was also lowest in 2020 (39.2%) compared to 2019 (50.7%) and 2021 (50.0%). Furthermore, with 1.24 logMAR the mean BCVA upon initial presentation was lower in 2020 compared to 0.93 logMAR in 2019 and 1.06 logMAR in 2021. Six to twelve weeks following surgery, visual acuity had improved in 56.1% of patients in 2019 and 60.0% of patients in 2021 as compared to 59.0% in 2020. Conclusion: We found significant differences in terms of elapsed time from first symptoms to surgical management for patients in 2020 in comparison with the same time period in 2019 and 2021. Less strict lockdown policies appear to impact patient behavior and patient care. Further measures, such as questionnaires, might help address which measures may provide safer circumstances for patients to consult health care providers in the case of future strict lockdowns.

SLITRK2, an X-linked modifier of the age at onset in C9orf72 frontotemporal lobar degeneration.

The G4C2-repeat expansion in C9orf72 is the most common cause of frontotemporal dementia and of amyotrophic lateral sclerosis. The variability of age at onset and phenotypic presentations is a hallmark of C9orf72 disease. In this study, we aimed to identify modifying factors of disease onset in C9orf72 carriers using a family-based approach, in pairs of C9orf72 carrier relatives with concordant or discordant age at onset. Linkage and association analyses provided converging evidence for a locus on chromosome Xq27.3. The minor allele A of rs1009776 was associated with an earlier onset (P = 1 × 10-5). The association with onset of dementia was replicated in an independent cohort of unrelated C9orf72 patients (P = 0.009). The protective major allele delayed the onset of dementia from 5 to 13 years on average depending on the cohort considered. The same trend was observed in an independent cohort of C9orf72 patients with extreme deviation of the age at onset (P = 0.055). No association of rs1009776 was detected in GRN patients, suggesting that the effect of rs1009776 was restricted to the onset of dementia due to C9orf72. The minor allele A is associated with a higher SLITRK2 expression based on both expression quantitative trait loci (eQTL) databases and in-house expression studies performed on C9orf72 brain tissues. SLITRK2 encodes for a post-synaptic adhesion protein. We further show that synaptic vesicle glycoprotein 2 and synaptophysin, two synaptic vesicle proteins, were decreased in frontal cortex of C9orf72 patients carrying the minor allele. Upregulation of SLITRK2 might be associated with synaptic dysfunctions and drives adverse effects in C9orf72 patients that could be modulated in those carrying the protective allele. How the modulation of SLITRK2 expression affects synaptic functions and influences the disease onset of dementia in C9orf72 carriers will require further investigations. In summary, this study describes an original approach to detect modifier genes in rare diseases and reinforces rising links between C9orf72 and synaptic dysfunctions that might directly influence the occurrence of first symptoms.

Paracoccidioidomycosis Diagnosed in Europe-A Systematic Literature Review.

Paracoccidioidomycosis is a systemic mycosis that is endemic in geographical regions of Central and South America. Cases that occur in nonendemic regions of the world are imported through migration and travel. Due to the limited number of cases in Europe, most physicians are not familiar with paracoccidioidomycosis and its close clinical and histopathological resemblance to other infectious and noninfectious disease. To increase awareness of this insidious mycosis, we conducted a systematic review to summarize the evidence on cases diagnosed and reported in Europe. We searched PubMed and Embase to identify cases of paracoccidioidomycosis diagnosed in European countries. In addition, we used Scopus for citation tracking and manually screened bibliographies of relevant articles. We conducted dual abstract and full-text screening of references yielded by our searches. To identify publications published prior to 1985, we used the previously published review by Ajello et al. Overall, we identified 83 cases of paracoccidioidomycosis diagnosed in 11 European countries, published in 68 articles. Age of patients ranged from 24 to 77 years; the majority were male. Time from leaving the endemic region and first occurrence of symptoms considerably varied. Our review illustrates the challenges of considering systemic mycosis in the differential diagnosis of people returning or immigrating to Europe from endemic areas. Travel history is important for diagnostic-workup, though it might be difficult to obtain due to possible long latency period of the disease.

A Germany-wide survey study on the patient journey of patients with hereditary angioedema

BackgroundHereditary angioedema (HAE) is a rare genetic disease and characterized by clinical features such as paroxysmal, recurrent angioedema of the skin, the gastrointestinal tract, and the upper airways. Swelling of the skin occurs primarily in the face, extremities and genitals. Gastrointestinal attacks are accompanied by painful abdominal cramps, vomiting and diarrhea. Due to the low prevalence and the fact that HAE patients often present with rather unspecific symptoms such as abdominal cramps, the final diagnosis is often made after a long delay. The aim of this German-wide survey was to characterize the period between occurrence of first symptoms and final diagnosis regarding self-perceived health, symptom burden and false diagnoses for patients with HAE.ResultsOverall, 81 patients with HAE were included and participated in the telephone-based survey. Of those, the majority reported their current health status as “good” (47.5%) or “very good” (13.8%), which was observed to be a clear improvement compared to the year before final diagnosis (“good” (16.3%), “very good” (11.3%)). Edema in the extremities (85.2%) and in the gastrointestinal tract (81.5%) were the most currently reported symptoms and occurred earlier than other reported symptoms (mean age at onset 18.1 and 17.8 years, respectively). Misdiagnoses were observed in 50.6% of participating HAE patients with appendicitis and allergy being the most frequently reported misdiagnoses (40.0 and 30.0% of those with misdiagnosis, respectively). Patients with misdiagnosis often received mistreatment (80.0%) with pharmaceuticals and surgical interventions as the most frequently carried out mistreatments (65.6 and 56.3% of those with mistreatment, respectively). The mean observed diagnostic delay was 18.1 years (median 15.0 years). The diagnostic delay was higher in older patients and index patients.ConclusionsThis study showed that self-perceived status of health for patients is much better once the final correct diagnosis has been made and specific treatment was available. Further challenge in the future will still be to increase awareness for HAE especially in settings which are normally approached by patients at occurrence of first symptoms to assure early referral to specialists and therefore increase the likelihood of receiving an early diagnosis.

Exhaled Breath Analysis for Assessment of IBD (Inflammatory Bowel Disease) Based on Electronic Nose System

Introduction The diagnosis and differentiation of IBD (Inflammatory Bowel Disease) lacks a single gold standard. IBD commonly suffers from a delay in time from first occurrence of symptoms to diagnosis, especially in young patients with ileal disease, which hinders our ability to alter the progression of disease. Also, once the diagnosis of IBD is made its sub categorization into CD (Crohn’s Disease) or UC (ulcerative colitis) is critical for determining the optimal treatment strategy. It is important to identify at risk population that could benefit from a therapeutic approach [1]. Metabolomics studies have recently enter the field of IBD. A variety of studies have been conducted to be significantly different between CD, UC and heathy controls [2]. Limitation for use of metabolomics markers would be too time-consuming and expensive for assessment of IBD or invasive testing in cases. An ideal approach regarding IBD assessment is that breath metabolome offers great potential with simply, easy to use, non-invasive, cheap, rapid and reproducible [3]. An electronic nose system, which is an instrument comprises an array of chemical sensors with partial specificity and an appropriate pattern recognition system capable of recognition simple or complex odors [4], has been suggested a potential alternative as a novel approach for breath analytic technique.In this presentation, we introduce exhaled breath analysis for assessment of IBD from controls and CD from UC using an electronic nose system incorporating a solid-phase micro extraction (SPME) technique. Method We have been developed an electronic nose system composed one chip type array of chemical sensors, chamber, data acquisition system with microprocessor, and sampling system for SPME fiber operation for non-invasive heath care monitoring. The 2x4 sensor array in the system consisted of three oxides of SnO2, NiO2, and In2O3 using Au, Pt, and Pd as catalyst and fabricated on one chip by glancing angle deposition method [5]. A chamber was used to maintain the stable operating temperature of sensor array, and SPME fiber used transferring of exhaled breath samples for measurement. Figure 1 is shown electronic nose system which has been used for experimental work in the hospital. The collection of exhaled breath for IBD patients (23 CD, 32 UC) and 15 controls was carried out using tedlar bag in connection with mouthpiece having a saliva trap to prevent humidity. The SPME fiber coated 85μm Polyacrylate was inserted into the tedlar bag and exposed to the collected breath at an ambient temperature. The system exposed the fiber to the heated sensor array desorbing the volatile off the fiber directly onto the sensors in the chamber. The collection and measurement of expiration were conducted in a hospital after approval of the IRB (Institutional Review Board) at Dongsan Medical Center, Deagu, Korea. Results and Conclusions The primary result for collected data from electronic nose system is shown at Figure 2 using Linear Discriminant Analysis (LDA) algorithm. As shown in Figure 2, IBD patients and controls are distinguished, especially IBD subgroup between CD and UC is well separated each other. However, some samples from UC subgroup are mixed with controls. In this study, we implemented an electric nose system by fabricating a one chip sensors array incorporating SPME sampling technique. Throughout the experimental result, we investigate the possibility of classification between IBD including 2 subgroup discrimination and controls. However, we need more research to improve discrimination regarding UC and controls following by optimal VOCs markers between UC and control including instrument control.

Salivary Gland Disorders in Children and Adolescents: A 15-year Experience.

Introduction Diseases of the salivary glands are rare in children and adolescents, with the exception of viral-induced infections. Objective To determine the clinical course of the disease, the diagnostic procedures, the treatment and the outcome of all children and adolescents affected with salivary gland diseases at our clinic over a period of 15 years. Methods A retrospective chart review including a long-term follow-up was conducted among 146 children and adolescents treated for salivary gland disorders from 2002 to 2016. Results Diagnosing acute sialadenitis was easily managed by all doctors regardless of their specialty. The diagnosis of sialolithiasis was rapidly made only by otorhinolaryngologists, whereas diagnosing juvenile recurrent parotitis imposed difficulties to doctors of all specialties – resulting in a significant delay between the first occurrence of symptoms and the correct diagnosis. The severity-adjusted treatment yielded improvements in all cases, and a full recovery of 75% of the cases of sialolithiasis, 73% of the cases of juvenile recurrent parotitis, and 100% of the cases of acute sialadenitis. Conclusions Due to their low prevalence and the lack of pathognomonic symptoms, salivary gland diseases in children and adolescents are often misdiagnosed, resulting in an unnecessarily long period of suffering despite a favorable outcome following the correct treatment.

Cysts associated with intramedullary ependymomas of the spinal cord: clinical, MRI and oncological features.

Few published articles have explicitly focused on cysts associated with intramedullary (IM) ependymomas. The objective was to assess the clinical, MRI, and oncological results of patients operated for an IM ependymoma associated with a cystic portion. During the study period, 23 IM tumors resected were cystic ependymomas. The modified McCormick scale was used to assess the neurological function of patients. The diagnosis of cystic spinal cord tumor was made on preoperative MRI. Two types of cysts were identified according to their location: either intra-tumoral cysts (ITC) or satellite cysts (SC). ITC (52.2%) were more frequent than SC (21.7%), but 26.1% of patients presented both. ITC were enhanced by gadolinium while SC were not. The solid portion of ependymomas with ITC was significantly larger than the one of ependymomas with SC (p = 0.002). The mean time to the first occurrence of symptoms was significantly shorter in patients with neurological deficit than those without a deficit (p = 0.04). GTR was achieved in 78.2% of cases. Complete excision of the cysts was easier when they were larger (p = 0.006). Sixty percent of cysts disappear postoperatively. Persistence of satellite cysts despite GTR of the tumor, and with no recurrence of a tumor on the post-operative MRI, was observed for 3 patients. ITC and SC are different in location, volume, gadolinium enhancement. Their surgical management is different since ITC are resected while SC are drained. Cystic recurrence and/or persistence are not synonymous with tumor recurrence.

Standards Used by a Clinical and Scientific Endometriosis Center for the Diagnosis and Therapy of Patients with Endometriosis

Endometriosis is one of the most common benign gynecological diseases. The extremely heterogeneous complex of symptoms complicates the diagnosis and treatment of this disease. In most patients, there is a latency period of several years between the first occurrence of symptoms and the definitive diagnosis. This paper aims (1) to evaluate standards for the diagnosis and treatment of patients with (symptoms suspicious for) endometriosis in terms of feasibility, and (2) to assess the potential use of data collected by a certified clinical and scientific endometriosis center to answer scientific questions. Standards for outpatient consultations were developed for a special endometriosis outpatient clinic. Between January 2014 and December 2017, a total of 1715 outpatients with a suspicion of endometriosis presented to this special endometriosis outpatient clinic; the diagnosis and treatment of patients was carried out in accordance with the developed standards. Data of this patient cohort obtained from patient records created during outpatient consultations and from a questionnaire recorded in an Oracle-based database was analyzed. The patient cohort was also compared with another patient cohort who had attended different outpatient clinics and had been diagnosed intraoperatively with endometriosis. 41.8% of patients examined during special outpatient consultations had surgery for suspicion or recurrence of endometriosis. Endometriosis was confirmed in 81.5% of cases. Pain symptoms were the main indication for surgery in 70.1% of cases compared to 45.1% of cases in the comparison group. The structured approach used in the special endometriosis outpatient clinic is a key aspect of the care provided by the certified clinical and scientific endometriosis center. It ensures that patients are diagnosed and treated in accordance with guideline recommendations, that diagnosis and treatment comply with certification requirements, and that the collected data can be used to answer scientific questions.

The economic burden of chronic thromboembolic pulmonary hypertension in Russian Federation.

The aim of current study was to estimate the economic burden of the chronic thromboembolic pulmonary hypertension (CTEPH) in Russia based on patient registry. Cost of illness study was based on data derived from CTEPH patient registry that was developed at the Division of hypertension of FSBI "National Medical Research Center of Cardiology". Demographic and clinical patient characteristics were analyzed with descriptive statistic methods. Cost of illness study was performed from the state perspective and with bottom-up approach. Bootstrapping was used for calculation of average costs per patient/year. Within the study direct costs (medical costs: outpatient, inpatient, emergency, PAH-specific therapy, concomitant therapy; non-medical costs: pension due to disability status, payments for patients on sick-leave) and indirect costs (loss in GDP) were estimated. Overall, 113 CTEPH patients (67 women and 46 men) from 33 Russian regions were included, mean age of patients with CTEPH was 54.6±13.95 years. Most of the patients (55%) were in able-bodied age. It was found that about half of patients with diagnosed CTEPH had a disability. Average duration of disease at the time of analysis was 6.88±11.41 years. Period from the first occurrence of symptoms to the confirmation of diagnosis of CTEPH was 2.58±5.21 years on average. More than 70% of patients had III and IV FC (WHO) at the time of diagnosis. Mean number of outpatient visits was 1.97±1.65 per patient/year, and inpatient visits were reported for 59% of patients. About 54% of patients used PAH-specific therapy, moreover 46% patients had interruptions of PAH-specific therapy (58.4±66.3 days). The total costs of CTEPH per patient/year were calculated as 805,901 RUB. The overall burden of CTEPH in Russia for total CTEPH population (470 patients) was 379 million RUB per year. CTEPH is the rare disease that is characterized with later diagnosis due to absence of disease-specific symptoms. Therefore economic burden of the CTEPH is significantly low in comparison to widespread cardiovascular diseases. Development of network of expert PH-centers and increase of the access for PAH-specific therapy will help to increase the quality of health care for patients with CTEPH.

PHS49 - Health Utility of Hospitalized Stroke Patients in Vietnam, Comparing Early Stage to Discharge

Evidence on health utility of stroke patients at intensive care units is very limited but would be useful as an input parameter for modelling cost-effectiveness of cardiovascular prevention and care. This study aims to provide evidence on health utility of such patients at different time points after hospital admission. Stroke patients admitted into Thai Nguyen National Hospital who were able to respond in an interview were invited to participate in a survey using EQ-5D. Health utility was estimated by applying a previously published algorithm. Patients were interviewed at two time points: the 5th day after first occurrence of symptoms, and on the day of hospital discharge. Patients with both cerebral infarction and cerebral hemorrhage were excluded. 148 patients were interviewed. The mean number of inpatient days was 9.5±2.5. The mean utility of interviewed patients was 0.26 on the 5th day and 0.39 on the day of discharge. The mean difference between these two measurements was statistically significant (p=0.00). Among patients with a history of a previous stroke, the difference between the two measurements (5th day and discharge) appeared to be lower than among patients without such history, but the difference was not statistically significant (p=0.6). The difference between the two measurements was not significantly different when patients with cerebral infarction and those with cerebral hemorrhage patients were compared. However, the health utility at the day of discharge from hospital was higher among cerebral infarction patients (0.42) than among patients with cerebral hemorrhage (0.23) (p=0.001). Health utilities found among stroke patients during their stay in hospital was low as compared to other studies. Utilities in cerebral infarction patients were higher than in patients with cerebral hemorrhage. The mean utility improvement during intensive care unit was 0.13. Our results can be used for cost-effectiveness analysis of cardiovascular interventions.

Red Flags: Clinical Signs for Identifying Autoimmune Encephalitis in Psychiatric Patients.

Autoimmune mechanisms causing diverse psychiatric symptoms are increasingly recognized and brought about a paradigm shift in neuropsychiatry. Identification of underlying antibodies against neuronal ion channels or receptors led to the speculation that a number of patients go misdiagnosed with a primary psychiatric disease. However, there is no clear consensus which clinical signs in psychiatric patients should prompt further investigations including measurement of anti-neuronal autoantibodies. We therefore aimed to analyze the presenting symptoms in patients with autoimmune encephalitis and the time between symptom onset and initiation of antibody diagnostics. For this, we recruited 100 patients from the Charité Center for Autoimmune Encephalitis between May and October 2016, including all types of autoimmune encephalitides. Psychiatric abnormalities were the most common clinical symptoms and were the presenting sign in 60%. One-third of patients were initially hospitalized in a psychiatric ward. All patients positive for antibodies against the N-methyl-d-aspartate receptor showed behavioral changes, hallucinations, memory deficits, catatonia, or delusions. Patients positive for antibodies against other cell surface or intracellular antigens were often hospitalized with a psychosomatic diagnosis. The time between occurrence of first symptoms and antibody testing was often alarmingly prolonged. In patients with symptom onset between 2013 and 2016, the mean delay was 74 days, in cases diagnosed between 2007 and 2012 even 483 days, suggesting though that increased awareness of this novel disease group helped to expedite proper diagnosis and treatment. By analyzing the medical records in detail, we identified clinical signs that may help to assist in earlier diagnosis, including seizures, catatonia, autonomic instability, or hyperkinesia. Indeed, reanalyzing the whole cohort using these “red flags” led to a 58% reduction of time between symptom onset and diagnosis. We conclude that the timely diagnosis of an autoimmune psychiatric disease can be facilitated by use of the described clinical warning signs, likely enabling earlier immunotherapy and better prognosis. Also, the threshold for cerebrospinal fluid analysis and autoantibody testing should be low.

Being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy: a phenomenological study

To explore the experiences of being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy. Overt hepatic encephalopathy is a common complication in patients with liver cirrhosis. It is associated with decreased quality of life for patients, and presents a major burden for caregivers. The involvement of informal caregivers in medical care is recommended, but it has not been clearly described. An understanding of the experience of caregivers is needed to improve the support provided to them by healthcare professionals. A qualitative, interpretative, phenomenological approach was used. Twelve informal caregivers participated in qualitative interviews. The analysis followed the six steps of the interpretative phenomenological approach. Caregivers' experiences were described using five themes: (1) feeling overwhelmed by their loved one having unexplainable symptoms and behaviours; (2) learning that this and previous experiences were complications of liver disease; (3) becoming aware of the symptoms of hepatic encephalopathy; (4) having feelings of being tied down and (5) experiencing and overcoming obstacles in working with healthcare professionals. This study provides insight into caregivers' experiences and the consequences for their lives. The first occurrence of symptoms was a shock, but receiving the diagnosis was seen as an important step in understanding and learning. Caregivers provide daily assessments of their relatives' conditions, and they feel responsible for medication management. Over time, the caregivers impressively showed how they were able to incorporate their personal experiences into caregiving and to accept more accountability in managing the disease. Nurses should acknowledge caregivers as experts in caring for their loved ones. Nurses can assist caregivers in managing an episode of hepatic encephalopathy and can provide individualised interventions to ease the future burden.

Real‐time PCR detection of Erwinia amylovora on blossoms correlates with subsequent fire blight incidence

Fire blight is the most devastating bacterial disease of rosaceous plants. Forecasting fire blight infections is important to allow for countermeasures that reduce economic damage in pome fruit production. Current computerized forecasting models are solely based on physical factors such as temperature and moisture, but not on the actual presence of the pathogen Erwinia amylovora. Although the inoculum concentration is considered to be crucial for infection and disease outbreak, most current approaches used for identification of fire blight inoculum including morphological, biochemical, serological, and DNA‐based methods are nonquantitative. Based on a real‐time PCR approach previously published, an improved protocol to be used directly on whole bacteria in the field is described. The method allows for early detection and quantification of the pathogen prior to the occurrence of first symptoms. There is a clear correlation between bacterial abundance and subsequent disease development. However, in some cases, no disease symptoms could be observed despite a pathogen load of up to 3·4 × 106 cells per blossom. Integration of the amount of pathogen detected into refined prediction algorithms may allow for the improvement of applied forecasting models, finally permitting a better abatement of fire blight.

Severe adverse effects of bromocriptine in lactation inhibition: a pharmacovigilance survey.

To assess the nature and conditions of the occurrence of adverse drug reactions (ADRs) of bromocriptine, which is used to inhibit lactation. Observational study. Cases from the French pharmacovigilance database and the marketing authorisation holders. Serious ADRs reported between 1994 and 2010 in association with bromocriptine used for lactation inhibition in France. Each case was checked to confirm the bromocriptine indication, the seriousness of the ADR, the modalities of bromocriptine use, and to identify possible associated predisposing factors. Number and description of serious ADRs, with a particular focus on misuse and associated predisposing factors. Among 105 serious ADRs, including two fatal cases, the most frequent were cardiovascular (70.5%), neurological (14.3%), and psychiatric (8.6%) disorders. Cardiovascular disorders primarily consisted of ischaemic manifestations (n = 47): acute ischaemic stroke (n = 18, one death), myocardial infarction (n = 11, one death), and reversible postpartum cerebral angiopathy (n = 10). Misuse was identified in 52 cases (70.3%) of cardiovascular disorders, and mostly consisted of bromocriptine continuation despite the occurrence of first symptoms suggesting an ADR or the absence of a progressive titration of bromocriptine. About half of these women had cardiovascular predisposing factors, mainly tobacco smoking, overweight or obesity, or a history of hypertension or pre-eclampsia. This survey, together with published data, provides further evidence that serious ADRs still occur after bromocriptine use in lactation inhibition, and that most of these ADRs could have been avoided. The use of bromocriptine should therefore be limited to cases where no other options are available to inhibit lactation.

English

BACKGROUND: Serum ferritin, which measures stored iron, is an inflammatory marker and a potential novel risk factor for CAD. Its role in coronary artery disease like acute myocardial infarction has generated considerable interest in recent times. There is a plethora of articles reporting the relationship between serum ferritin and acute myocardial infarction but with conflicting and contradictory results. AIMS AND OBJECTIVES: 1) To compare serum ferritin levels in cases of coronary artery disease with those of controls, in order to assess the relationship of serum ferritin with coronary artery disease. 2) To compare serum ferritin levels in cases of unstable angina with those of AMI (NSTEMI & STEMI) and healthy controls. MATERIAL AND METHODS: In this hospital based case-control study, 30 cases of acute myocardial infarction, 30 cases of unstable angina admitted to hospital in SGRD & Rand 30 age, sex and haemoglobin matched healthy controls were enrolled. Patients were allocated into 2 equal groups- Unstable Angina and AMI (NSTEMI & STEMI).Serum ferritin was estimated in cases of acute myocardial infarction on fifth day following occurrence of first symptom and on day 1 in patients in control group. Data was compiled and statistically analyzed. RESULTS: In this study, it was observed that the mean serum ferritin levels in controls were comparatively higher (165.13 ± 104.17 ng/ml) than that in the patients with Acute Myocardial Infarction (81.83 ± 97.46ng/ml) and Unstable Angina (90.24 ± 41.88ng/ml). Although the value of mean serum ferritin was within normal limits in both the groups under but it was higher in controls as compared to that in patients with Acute Myocardial Infarction and Unstable Angina and this difference was statistically highly significant (p<0.001). When levels of mean serum ferritin in patients with AMI and UA were compared, the difference was not statistically significant. CONCLUSION: The present study concluded that the risk of coronary artery disease is inversely proportional to the serum ferritin level because the mean serum ferritin levels were statistically lower in cases of AMI and UA as compared to those of control group. However, there was no difference of levels between AMI and UA.

New onset atrial fibrillation and long-term risk of heart failure in the general population: the Rotterdam study

Purpose: Chronic heart failure is often a manifestation of long-standing underlying cardiac conditions, such as coronary heart disease (CHD) and left ventricular hypertrophy (LVH). Atrial fibrillation (AF) is a well-recognized consequence of heart failure which can be prevented by timely pharmacological treatment. However, limited data exists on the role of AF in the etiology of heart failure in the general population. We sought to evaluate the long-term risk of heart failure associated with new onset AF; in addition, we evaluated the interplay between AF and other cardiac conditions (CHD and LVH) in the development of heart failure. Methods: Within the Rotterdam Study, a prospective population-based cohort, we followed 6178 persons (mean age 68.6 years, 41% men) free of heart disease at baseline (1990-1993) for the occurrence of AF, CHD (defined as myocardial infarction or revascularization), and heart failure. We constructed time-dependent Cox models adjusted for traditional cardiovascular risk factors to study the effect of newly-diagnosed AF (and CHD) during follow-up and subsequent heart failure risk. Since both AF and heart failure can have a substantial time-lag between the occurrence of first symptoms and clinical diagnosis, we modeled various time-lags of up to 5 years since first diagnosis of AF in order to ascertain that AF preceded heart failure symptoms. Results: During a median 14.2 years of follow-up 584 diagnoses of AF were made and 994 participants developed heart failure. New onset AF was associated with an increased risk of heart failure (adjusted HR 3.16 [95% CI: 2.63-3.79]), which persisted even 5 years after AF diagnosis (adjusted HR 2.60 [95% CI: 1.88-3.58]). Regarding the interplay between AF and CHD, the presence of AF only, CHD only, and concomitant AF and CHD showed a graded increase in heart failure risk (adjusted HRs 3.52 [95% CI: 2.85-4.34], 4.30 [95% CI: 3.40-5.45], and 6.23 [95% CI: 3.56-10.88], respectively). A similar graded increase in risk estimates was observed for the presence of ECG detected LVH and concurrent AF. Population attributable risks were 12.2% for AF, 6.3% for CHD, and 5.2% for LVH. Conclusions: New onset AF was a strong risk factor for incident heart failure in the general population, with long-term relative risks close to those of manifest CHD. Absolute and relative risk estimates were especially high for persons with concomitant AF and CHD. Persons with AF may well constitute an important part of the general population that could potentially benefit from timely introduced intensive preventive measures to reduce the growing burden of chronic heart failure.

OP0241-PARE Time to diagnosis and quality of life people with diagnosed rheumatoid arthritis in poland

BackgroundEarly diagnosis of rheumatoid arthritis (RA) and appropriate treatment are the conditions, that slow process of a long-term disease leading to disability. As a consequence, the RA prevents the normal...

Characteristics and pattern of rhegmatogenous retinal detachment in pakistan.

To determine the presenting characteristics of rhegmatogenous retinal detachment (RRD) in a consecutive series of Pakistani patients. Case series. Layton Rahmatullah Benevolent Trust (LRBT), Lahore, from June 2010 to October 2011. A total of 107 eyes underwent RRD surgery. Detailed diagrams were drawn pre-operatively for all. Other recorded details included, bio-data, age, gender, visual acuity, autorefractometery, predisposing risk factors, lens state and duration of symptoms. The data was analyzed with respect to age and gender distribution, frequency of various risk factors for RRD, duration of RRD and its various presenting characteristics. Mean age of the patients were 33.1 ± 1.5 years, 85% were males. Bilateral RRD was discovered in 2.8% patients. No identifiable risk factor for RRD was present in 28%, while in rest of the 72% eyes, the commonest risk factors were intraocular surgery, trauma and peripheral myopic degeneration in decreasing order of frequency. There were 70.1% phakic, 23.4% pseudophakic and 6.5% aphakic eyes. Majority (93.5%) presented with macula off detachment. There was an overall average time lapse of 97.24 ± 16.95 days between presenting and first occurrence of symptoms. In 31.8% of eyes no break could be found pre-operatively, while 38.3% had 1 and 29.9% eyes had ³ 2 breaks. Majority of the primary breaks were horse-shoe tears (42.1%). Total RRD was found in 35.5% eyes. Infero-temporal and supero-temporal were the most frequently involved quadrants (93.5% and 86.9% respectively). Intraocular surgery, trauma and lattice degeneration in myopia are established common risk factors for RRD. These patients deserve meticulous fundus examination with indentation indirect ophthalmoscopy by trained professionals.