Vaccines for older adults; the low-hanging fruit of disease prevention

Background

The COVID-19 pandemic highlighted the significance of vaccination for older adults (OA), however, more health benefits could be gained with vaccination against influenza, pneumococcal disease, herpes zoster and tetanus as their uptake remains rather low. As healthcare professionals (HCP) play an important role in the vaccination decision making of OA, this study identifies obstacles in vaccination communication between HCP and OA.

Methods

80 in-depth structured interviews have been conducted with HCPs in Hungary (HU), Italy (IT), the Netherlands (NL) and France (FR). Participants were general practitioners, medical specialists, public health physicians, occupational physicians, pharmacists, geriatricians, specialists elderly care and nurses. The interview included questions on HCPs’ perceptions regarding information provision to OA on vaccines. Data were analyzed cross-country, using thematic analysis.

Results

Preliminary results reveal that a factor hindering HCPs to initiate conversations with OA on vaccines was lack of time (FR, IT, HU, NL). In hospitals this was often due to (acute) clinical problems taking precedence over discussing vaccines (IT, NL). In ambulatory settings the high number of patients waiting to be seen prevented discussing vaccines with OA (HU). Moreover, HCPs sometimes forgot to discuss vaccines with OA (NL, HU, IT). Patient factors hindering the conversation of HCPs on OA vaccines were a negative attitude (IT, HU) and lack of understanding the information provided (IT, HU). Also, misinformation on vaccines (FR, HU), as well as anti-vax beliefs from patients (NL) or their relatives (FR, IT) hampered the conversation on vaccines. HCPs mentioned their need to learn communication skills to convince OA on vaccines (FR, IT, HU).

Conclusions

HCPs encounter various obstacles in communicating with OA about vaccines. Lack of time and not recognizing the opportunity to discuss vaccines are important barriers for initiating vaccine conversations.

Key messages

• Providing HCPs with communication strategies is important to support HCPs in discussing vaccines with OA.

• Reminder systems are important to help HCPs remember address vaccination.

In-depth phenotyping by cardiovascular magnetic resonance uncovering differences between ethnic groups in hypertensive heart disease

Background

Black African/African-Caribbean individuals with hypertension (BH) are at greater risk of heart failure than those of white European ethnicity (WH). The mechanisms underlying this dissimilarity remain poorly understood.

Purpose

To investigate the influence of ethnicity on left ventricular (LV) remodelling using multi-parametric cardiovascular magnetic resonance (CMR).

Methods

BH (n=44), WH (n=38) and healthy-volunteers (HV; n=25, 5 of black ethnicity) underwent comprehensive CMR. The exam included: i) Arterial Stiffness/Afterload pulse-wave-velocity (PWV), aortic elastance (Ea) and systemic vascular resistance (SVR) by phase-contrast velocity-encoding imaging; ii) Ventricular remodelling/Function LV and right ventricular (RV) volumes, mass, ejection fraction (EF), LV peak-filling rate by short-axis cine images; myocardial strains were measured by feature tracking; iii) Left atrial (LA) remodelling/Function volumes and functions by long-axis cine images; iv) Tissue characterisation: extracellular volume by pre/post-contrast T1-mapping and late gadolinium enhancement (LGE) for interstitial and replacement myocardial fibrosis, respectively. Multivariate linear regression models were developed to investigate how LV remodelling associates with ethnicity, arterial afterload, including elastance (Ea) and stiffness [PW], and SVR. Models were adjusted for age, gender, body-mass-index, LV volumes or function and LA volumes.

Results

Subject characteristics are summarised in the Table. PWV and Ea and SVR were greater in hypertensives, particularly in BH, than HV; this was paralleled by higher LV mass, interventricular septum thickness (IVS), LA volumes but lower LV-EF. These findings were confirmed after adjusting for age.

On the Model-1, IVS was associated with Ea (β=0.335, P=0.008) and black ethnicity (β=0.226, P=0.019) but not with SVR or PWV. For each increment of Ea there was a similar increase of IVS in BH and WH (P=0.602 for interaction), however BH had greater IVS than WH at each Ea value (Figure, fully-adjusted Model-1). On Model-2, LV end-diastolic volume was associated with Ea (β=−0.268, P=0.001), SVR (β=−0.319, P=0.019) but not with PWV or ethnicity. However, the inverse relation between LV size and Ea was significantly attenuated in BH (P=0.039 for interaction), (Figure, fully-adjusted Model-2). On model-3, LV-EF was associated with Ea (β=0.223, P=0.009) but not with ethnicity, PWV or SVR. LV-EF reduction for each Ea increment was similar for BH and WH (P=0.597 for interaction).

Conclusion

BH and WH show a distinctive LV remodelling phenotype. BH had a greater susceptibility to hypertrophy and an attenuated reduction of chamber size in response to arterial afterload. Further research to disentangle the genetic and environmental factors underlying these ethnic group-specific differences is utterly required.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Unravelling racial differences in hypertensive heart disease by multiparametric cardiovascular magnetic resonance: a phenotype-wide association study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dr Georgiopoulos was supported by the Onassis Foundation under the special grant & support program for scholars" association members

Introduction – Black Afro-Caribbean hypertensives (BAHs) are exposed to a higher risk of heart failure (HF) than white hypertensives (WHs). Arterial afterload is higher in BAHs due to increased arterial stiffness and vascular volume; BAHs develop more often left ventricular (LV) hypertrophy, dilatation and systolic dysfunction than WHs. However, it is unclear whether other racial differences concur to the more pronounced LV remodelling in BAHs.

Methods – This cross-sectional study included hypertensive patients undergoing cardiovascular magnetic resonance for their clinical work-up (1.5T Aera Siemens-Healthcare). Clinical history and haemodynamic parameters were collected in all participants; a subset of patients had complete bio-humoral assay of the renin-angiotensin-aldosterone system (RAAs). Arm cuff pressure was measured during CMR. The CMR protocol included: i) Arterial afterload / LV arterial-coupling - pulse-wave-velocity (PWV), aortic (Ea) and LV elastance (Ees) by aorta anatomic and phase-contrast velocity-encoding imaging; ii) ventricular remodelling and function - LV and right ventricular (RV) volumes, mass, EF, LV peak-filling rate by short-axis cine images; global circumferential and longitudinal strains by cine feature tracking; iii) left atrial (LA) remodelling volumes and reservoir, conduit and booster functions by long-axis cine images; iv) tissue characterisation: T2 and pre/post-contrast T1 relaxation times, extracellular volume (ECV) by single mid-ventricular short-axis T1/T2-mapping.

Results – 34 BAHs and 35 WHs (52 ± 12 vs 45 ± 14 years, P < 0.05; 61% vs 65% males P = NS) were included in the study. Baseline features are summarised in the Table. LV systolic dysfunction was more prevalent in BAH than WHs (P = 0.038). Of note, BAHs tended to have greater LV volumes and significantly higher LV mass and septal thickness than WHs. In BAHs, but not in WHs, PWV was associated with increased septal thickness after correction for blood pressure and age (β-value: 0.447, P = 0.02). Normalised RV mass was greater in BHA than WHs; RV mass suits for the identification of racial or circulating factors predisposing to hypertrophy being largely unaffected by systemic afterload. In our study LV diastolic function and LA volumes were similar between BAHs and WHs, and none of the subjects had conditions associated with pre-capillary pulmonary hypertension. Hence, higher RV-mass in BAHs pinpoints a racial susceptibility to myocardial hypertrophy. Finally, in a subset of patients with RAAs assays (n = 43), the aldosterone/renin ratio was higher in BAHs than WHs (67.04 [IQR: 19.37-209.73] vs 13.77 [IQR: 7.47-40.43], P = 0.01).

Conclusion – BAHs have heightened LV remodelling than WHs because of racial predisposition to develop hypertrophy which also encompasses derangements in RAAs. Altogether, these findings may account for the greater risk for HF in BAHs than WHs.

Cardiac magnetic resonance features of left dominant arrhythmogenic cardiomyopathy: differential diagnosis with myocarditis

Objectives

To identify potential imaging features at cardiac magnetic resonance (CMR) specific for left-dominant arrhythmogenic cardiomyopathy (LDAC) diagnosis.

Materials and methods

Between January 2011 and May 2016, we considered 36 consecutive stable patients with a recent diagnosis of significant VA and ECG morphology consistent with a LV origin, detection of potential LV arrhythmic substrate at CMR, undergoing a clinically-indicated LV endomyocardial biopsy. Exclusion criteria were history of known cardiac disease, contraindications to CMR and impaired CMR image quality. After application of these criteria, in 9 patients endomyocardial biopsy showed tissue abnormalities consistent with the diagnosis of LDAC. From the same CMR-endomyocardial biopsy registry, a second group of 9 consecutive patients with a histological diagnosis of previous myocarditis were identified.

Results

Mid-wall LGE in the interventricular septum was detected in 5 myocarditis, without findings in LDAC group (p=0.03), whereas subepicardial LGE at the level of posterolateral wall of LV was detected in 8 cases of LDAC vs. 2 cases of myocarditis (p=0.02). Fat infiltration, and particularly subepicardial posterolateral fat infiltration, was found in all LDAC patients vs. one myocarditis only (p<0.01). No differences in other CMR findings or in any clinical or echocardiographic parameters were found between patients with a biopsy consistent with LDAC vs. patients in whom biopsy suggested myocarditis.

Conclusions

In patients with significant VA and ECG morphology consistent with a LV origin, identification of morpho-functional involvement of the subepicardial layer of LV posterolateral wall at CMR (LGE, fat infiltration, wall dyskinesis) is consistent with a diagnosis of LDAC.

Funding Acknowledgement

Type of funding source: None

Information needs on vaccinations for older adults and the role of health care professionals in this

On behalf of all members of work package 4 from the VITAL project

The criterion of proportionality in the activation of Left Ventricular Assist Device implants: the method of "four boxes" to analyze the pre-implant phase

BACKGROUND

Life-saving technologies have completely changed the normal conception of medical treatments. Left Ventricular Assist Devices (LVAD) can prolong survival for patients who are not candidates for heart transplantation. In order to analyze the pre-implantation phase, which involves a shared-decision making process before activation of the device, attention should be paid to the criterion of "proportionality" in order to properly assess the risks and benefits of implantation.

AIM

The aim of our analysis is to provide an useful tool for the assessment of LVAD proportionality during the physicians' decision making.

METHODS

The method of the "four boxes", developed by Jonsen et al, was chosen to analyze the notion of proportionality and the other main ethical issues regarding LVAD activation in adult patients.

RESULTS

Medical issues are not the sole factors, which influence the choice of implantation by patients. Indeed, patient preferences, his/her quality of life, and contextual features should be taken into consideration when proposing LVADs: these factors are as important as clinical issues where outcomes are concerned.

CONCLUSIONS

In order to assess the proportionality of such a device, we present, discuss and examine, in the framework of the pre-implant phase, the content of each topic treated by the "four boxes method", that is, an essential tool for the assessment of the proportionality of the treatment for LVAD candidates.

Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients' related outcomes. A retrospective comparative study

INTRODUCTION

Lymphedema resulting from breast cancer treatment is a chronic condition that can significantly compromise quality of life. Several works have documented the efficacy of vascularized lymph node flap transfer (VLNT) for the treatment of advanced-stage lymphedema. Given that the axillary scar may contribute to the patient's existing lymphedema, the authors assumed that combining VLNT and scar release with fat graft could be an effective strategy of treatment. The purpose of this study is to compare the efficacy in the reduction of limb circumference and health-related quality of life between a combined strategy, namely, VLN transfer (VLNT) and axillary scar release with fat grafting, and only VLNT for patients affected by postmastectomy upper limb lymphedema. The idea.

MATERIALS AND METHODS

All patients with stage II and III breast cancer-related lymphedema operated between January 2012 and January 2016 were retrospectively identified, and only those treated by combined VLNT and scar release (Group A) or only VLNT (Group B) were included. The outcomes were assessed clinically by limb circumference measurement and radiologically by lymphoscintigraphy. Lymphedema-related quality of life was evaluated preoperatively and at 1 year follow-up through the LYMQOL questionnaire.

RESULTS

Thirty-nine patients met inclusion criteria (Group A = 18; Group B = 21). Mean follow-up was 29 months for Group A and 32 months for Group B. Flap survival rate was 100%, with no donor site morbidity in all patients. A statistically significant difference between the circumference reduction rates (RR) at above elbow level was observed at 3 and 6 months of follow-up comparing the two groups (p<0.00001), with higher values in Group A than in Group B. No significant difference was detected comparing RR values at above and below elbow at 12 and 24 months postoperatively. LYMQOL metrics showed significantly better scores (p<0.0001) in all domains at all follow-up appointments in Group A.

CONCLUSIONS

Patients with postmastectomy upper limb lymphedema can benefit from combined lymph node transfer and axillary scar release with fat graft, as this approach seems to fasten the onset of improvement and to have a positive impact on patients' quality of life.

Donation After Circulatory Death: When Withdrawing Life-Sustaining Treatments Is Ethically Acceptable

The possibility to determine death based on cardiocirculatory criteria in controlled cases, namely when there is a request to withhold treatment-or, more frequently, withdraw it-specifically recalls the recent Italian law on advance treatment directives and leaves the following question unanswered: Under what conditions is the patient's request legally and ethically acceptable? We present three ethical proportionality criteria for supporting physicians' decision-making facing patients' requests of treatment withdrawal, namely: 1. irreversible pathology with an ominous and worsening prognosis; 2. within an evaluation considering both clinical data and the patient's history; and 3. facing burdens that are no longer bearable. We finally argue that reflection over controlled donor may be a model for giving medicine the chance to responsibly deal with broader end-of-life issues.

"The Penitent Magdalene": Jusepe de Ribera (1591-1652)

Jusepe or Jòse de Ribera (1591-1652), known as Lo Spagnoletto ("the Little Spaniard"), has been a leading painter of the Spanish Baroque movement. In one of the portraits, de Ribera represented a scene in which the Magdalene shows a swelling at the base of the neck suggestive of a thyroid nodule.

Optimized acute stroke pathway using medical advanced regulation for stroke and repeated public awareness campaigns

OBJECTIVE

The aim of this study is to evaluate the efficiency of a specific organizational model for early stroke management associated with repeated public awareness campaigns on stroke warning signs.

METHOD

Our model is based on initial telephone triage of potential candidates for an intravenous thrombolysis by an emergency physician before a 3-party conference including basic life support team on scene and a stroke neurologist. We performed a time series analysis for a period of 5 years and a half, comparing the number of emergency telephone calls with that of intravenous thrombolysis treatment realized.

RESULTS

In our organizational model, repeated awareness public campaigns increased both the number of emergency calls for suspected stroke and the selection of potential candidates for intravenous thrombolysis. Results from the time series analysis suggest that educational campaigns are a major factor influencing our emergency medical service activity. This result is correlated with the number of performed intravenous thrombolyses by the stroke center especially within a 3-hour delay (Spearman ρ, P = .621, P = .000 and P = .439, P = .000, respectively).

CONCLUSION

Educational programs repeated each year are useful to the population for learning how to recognize stroke symptoms and send straight away an emergency call. Combining the emergency action with an early remote evaluation by the stroke center team and a direct admission in imaging department shortens the time-to-treatment delay. This model is reproducible in different health care systems.

Perfusion-weighted imaging-derived collateral flow index is a predictor of MCA M1 recanalization after i.v. thrombolysis

BACKGROUND AND PURPOSE

Recent studies highlight the role of CC in preserving ischemic penumbra. Some authors suggested the quality of CC could also impact recanalization. The purpose of this study is to test this hypothesis in patients who were treated with i.v. thrombolysis for MCA-M1 occlusion.

MATERIALS AND METHODS

A normalized index derived from Tmax maps (MR-PWI) was defined to quantify the CC deficit (nCCD) in 64 patients with stroke who underwent i.v. thrombolysis. Correlations between nCCD and parameters that may be altered by CC quality were tested (baseline NIHSS, volume of diffusion abnormalities, modified Rankin Scale at 3 months). The correlation between baseline nCCD and MCA-M1 recanalization rate at 24 hours was tested.

RESULTS

The nCCD is significantly correlated with NIHSS and with lesional volume (Pearson correlation test, positive correlations, respectively, 0.40, 0.57; P = .00089, P = 8.7e-07). The nCCD also has a significant predictive value on the full recanalization at 24 hours that decreases as TTT increases (logistic regression, P = .021). Furthermore, among patients who were treated within 3 hours, nCCD and recanalization are significantly correlated (correlation ratio test, eta2 = 0.23, P = .0023): Patients who did not achieve full recanalization have significantly higher nCCD than fully recanalized patients (Mann-Whitney U test, P = .007). In addition, the probability of full recanalization decreases as the nCCD increases (P = .021). nCCD (OR 0.988, 95% CI 0.977-0.999, P = .042) and full recanalization at 24 hours (OR 4.539, 95% CI 1.252-16.456, P = .021) are independent predictors of functional independence at 3 months.

CONCLUSIONS

The nCCD index is a predictor of full MCA-M1 recanalization in patients treated with i.v. thrombolysis.

Effectiveness and predictors of success of noninvasive ventilation during H1N1 pandemics: a multicenter study

BACKGROUND

The use of non-invasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF) due to H1N1 virus infection is controversial. In this multicenter study we aimed to assess the efficacy of NIV in avoiding endotracheal intubation (ETI) and to identify predictors of success or failure.

METHODS

In this prospective multicenter study, 98 patients with new pulmonary infiltrate(s) sustained by H1N1 virus and a PaO(2)/FiO2<300 were eligible for study; 38/98 required immediate ETI, while the others received NIV as a first line therapy; 13/60 patients failed NIV and were intubated after 5.8+5.5 hours from enrolment. The remaining 47/60 patients were successfully ventilated with NIV.

RESULTS

Hospital mortality was significantly higher in those patients who failed NIV vs. those who succeeded (53.8% vs. 2.1%; OR=0.52, P<0.001). ETI was associated with higher number of infectious complications, mainly sepsis and septic shock. The OR of having one of these events in the NIV failure group vs. NIV success was 16.7, P<0.001. According to logistic regression model, a SAPS II>29 and a PaO(2)/FIO(2)≤127 at admission and PaO2/FIO(2)≤149 after 1 hr of NIV were independently associated with the need for ETI.

CONCLUSION

The early application of NIV, with the aim to avoid invasive ventilation, during the H1N1 pandemics was associated with an overall success rate of 47/98 (48%). Patients presenting at admission with an high SAPS II score and a low PaO(2)/FiO(2) ratio and/or unable to promptly correct gas exchange are at high risk of intubation and mortality.

A case of psoriasis with secondary amyloidosis, associated symbrachydactyly of the hand and a transverse deficiency of the foot

Secondary amyloidosis is associated with a variety of chronic inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, familial Mediterranean fever, osteomyelitis, inflammatory bowel diseases and infective or neoplastic conditions. Few cases of secondary amyloidosis complicating psoriasis have been reported. We describe a 58-year-old patient with secondary amyloidosis, psoriasis, an associated symbrachydactyly of the hand and a transverse deficiency of the foot. To the best of our knowledge, no case of this association has been previously reported.