[Artificial intelligence to support telemedicine in Africa]

Telemedizin findet seit Jahrzehnten Anwendung im Alltag von Dermatologen. Insbesondere in afrikanischen Ländern mit begrenzter medizinischer Versorgung, zu überbrückenden geografischen Distanzen und einem zwischenzeitlich relativ gut ausgebauten Telekommunikationssektor liegen die Vorteile auf der Hand. Nationale und internationale Arbeitsgruppen unterstützen den Aufbau von teledermatologischen Projekten und bedienen sich in den letzten Jahren zunehmend KI(künstliche Intelligenz)-gestützter Technologien, um Ärzte vor Ort zu unterstützen. Vor diesem Hintergrund stellen ethnische Variationen eine besondere Herausforderung in der Entwicklung automatisierter Algorithmen dar. Um die Genauigkeit der Systeme weiter zu verbessern und globalisieren zu können, ist es wichtig, die Zahl der verfügbaren klinischen Daten zu erhöhen. Dies kann nur mit der aktiven Beteiligung der lokalen Gesundheitsversorger sowie der dermatologischen Gemeinschaft gelingen und muss stets im Interesse des einzelnen Patienten erfolgen.

Non-alcoholic fatty liver disease increases the prevalence of maintenance haemodialysis in patients with chronic kidney disease

AIM

To investigate the association between non-alcoholic fatty liver disease (NAFLD) and incidence of maintenance haemodialysis in patients with chronic kidney disease (CKD).

METHODS

We enrolled patients diagnosed with CKD between 2001 and 2007. The patients were categorized into two groups based on abdominal ultrasound finding, namely those with NAFLD and those without NAFLD. The disease (maintenance haemodialysis)-free survival rate was estimated using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses was used to evaluate the hazard ratios of covariates for the incidence of maintenance haemodialysis.

RESULTS

A total of 161 patients (61 with NAFLD and 100 without NAFLD) were enrolled. The mean age was 69.3 years. The mean follow-up was 7.4 years. The patients with NAFLD had an increased incidence of maintenance haemodialysis (39.3 % vs 24.0 %; p=0.0396) and inferior disease-free survival rate (p=0.006). Furthermore, diabetes (p=0.0126) and proteinuria (p=0.0003) were identified as significant predictors of CKD progression.

CONCLUSION

NAFLD was associated with an increased incidence of maintenance haemodialysis and inferior disease-free survival rate. NAFLD may impair renal function and patients with renal impairment should be monitored carefully (Tab. 3, Fig. 1, Ref. 25) Keywords: non-alcoholic fatty liver disease, haemodialysis, chronic kidney disease, proteinuria.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of hepatocellular carcinoma (HCC) was published in 2018, and covered the diagnosis, management, treatment and follow-up of early, intermediate and advanced disease. At the ESMO Asia Meeting in November 2018 it was decided by both the ESMO and the Taiwan Oncology Society (TOS) to convene a special guidelines meeting immediately after the Taiwan Joint Cancer Conference (TJCC) in May 2019 in Taipei. The aim was to adapt the ESMO 2018 guidelines to take into account both the ethnic and the geographic differences in practice associated with the treatment of HCC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with intermediate and advanced/relapsed HCC representing the oncology societies of Taiwan (TOS), China (CSCO), India (ISMPO) Japan (JSMO), Korea (KSMO), Malaysia (MOS) and Singapore (SSO). The voting was based on scientific evidence, and was independent of the current treatment practices, the drug availability and reimbursement situations in the individual participating Asian countries.

Underestimated fracture risk in postmenopausal women-application of the hybrid intervention threshold

This study evaluated the fragility fracture risk of Taiwanese postmenopausal women with osteopenia. With the incorporation of FRAX and hybrid intervention threshold (HIT), 25% of the participants had high fracture risk. We suggest intervention for fragility fracture for postmenopausal women should be guided by FRAX and HIT instead of bone mineral density alone.

INTRODUCTION

To explore the risk of fragility fracture in Taiwanese postmenopausal women with osteopenia using the hybrid intervention threshold (HIT) and Fracture Risk Assessment tool (FRAX).

METHODS

The Taiwan Osteoporosis Association (TOA) conducted a nationwide bone mineral density (BMD) survey between 2008 and 2011 using a bus equipped with a dual-energy X-ray absorptiometry (DXA) machine. All participants completed a structured questionnaire, which included the elements in the FRAX. Based on the results, the group made up of postmenopausal women with osteopenia was identified. In order to explore the risk of fragility fracture by HIT and FRAX among Taiwan postmenopausal women with osteopenia, the 10-year probability of fracture (FRAX score) and individual intervention threshold (IIT) in this group were calculated. If the FRAX score of a participant was higher than or equal to the IIT or fixed intervention threshold (FIT), the participant was considered as above the HIT (HIT could be reached by being over a threshold at either major osteoporotic fracture or hip fracture) and categorized as having a high FRAX fracture risk.

RESULTS

A total of 13,068 postmenopausal women were enrolled in the program. A total of 5743 (43.9%) participants had osteopenia, of which 1434 (25.0%) had high FRAX fracture risk.

CONCLUSIONS

One quarter of Taiwanese postmenopausal women with osteopenia had high fragility fracture risk evaluated by FRAX and HIT. Due to the poor sensitivity of BMD for fragility fracture, we suggest that intervention for fragility fracture for postmenopausal women should also be guided by FRAX and HIT instead of BMD alone.

Antiplatelet agents for the secondary prevention of ischaemic stroke in patients with or without renal dysfunction

BACKGROUND AND PURPOSE

Studies on using antiplatelet agents for secondary prevention in ischaemic stroke patients with renal dysfunction are limited. The Taiwan Stroke Registry database was used to compare the efficacy of antiplatelet agents.

METHODS

From the Taiwan Stroke Registry data, 39 174 acute ischaemic stroke patients were identified and were classified into three groups by antiplatelet agent: aspirin, clopidogrel and dual antiplatelet therapy (DAPT) with a combination of aspirin and clopidogrel. The re-stroke incidence and 1-year mortality were stratified by estimated glomerular filtration rate (eGFR) levels at admission: ≥90, 60-89 and <60 ml/min/1.73 m² or on dialysis.

RESULTS

Compared to the aspirin group, the re-stroke differences were not statistically significant for the clopidogrel group [adjusted subhazard ratio 0.95, 95% confidence interval (CI) 0.84-1.08] and the DAPT group (adjusted subhazard ratio 1.03, 95% CI 0.77-1.39) after controlling for the competing risk of death. The mortality rate increased as the eGFR level declined. In addition, compared to patients taking aspirin, there was no statistically significant difference in overall 1-year mortality for the clopidogrel group (adjusted hazard ratio 1.11, 95% CI 0.95-1.29) and for the DAPT group (adjusted hazard ratio 1.01, 95% CI 0.67-1.54). The results were consistent in different subgroups stratified by eGFR levels.

CONCLUSIONS

There was no difference in the risks of recurrent stroke and 1-year mortality amongst ischaemic stroke patients with or without renal dysfunction receiving antiplatelet agents with aspirin, clopidogrel or dual agents with a combination of aspirin and clopidogrel, regardless of their renal dysfunction status.

Position Statement on Atopic Dermatitis in Sub-Saharan Africa: current status and roadmap

BACKGROUND

The first International Society of Atopic Dermatitis (ISAD) global meeting dedicated to atopic dermatitis (AD) in Sub-Saharan Africa (SSA) was held in Geneva, Switzerland in April 2019. A total of 30 participants were present at the meeting, including those from 17 SSA countries, representatives of the World Health Organization (WHO), the International Foundation for Dermatology (IFD) (a committee of the International League of Dermatological Societies, ILDS www.ilds.org), the Fondation pour la Dermatite Atopique, as well as specialists in telemedicine, artificial intelligence and therapeutic patient education (TPE).

RESULTS

AD is one of the most prevalent chronic inflammatory skin diseases in SSA. Besides neglected tropical diseases (NTDs) with a dermatological presentation, AD requires closer attention from the WHO and national Departments of Health.

CONCLUSIONS

A roadmap has been defined with top priorities such as access to essential medicines and devices for AD care, in particular emollients, better education of primary healthcare workers for adequate triage (e.g. better educational materials for skin diseases in pigmented skin generally and AD in particular, especially targeted to Africa), involvement of traditional healers and to a certain extent also patient education, bearing in mind the barriers to effective healthcare faced in SSA countries such as travel distances to health facilities, limited resources and the lack of dermatological expertise. In addition, several initiatives concerning AD research in SSA were discussed and should be implemented in close collaboration with the WHO and assessed at follow-up meetings, in particular, at the next ISAD meeting in Seoul, South Korea and African Society of Dermatology and Venereology (ASDV) meeting in Nairobi, Kenya, both in 2020.

Is serum uric acid a predictive factor for stroke in men with hypertriglyceridemia?

OBJECTIVE

This study investigated the association between serum uric acid (sUA) and stroke risk in men with hypertriglyceridemia.

METHODS

Between 2002 and 2012, male patients with pure hypertriglyceridemia and a triglyceride (TG) level ≥ 150 mg/dL were enrolled. Eligible patients were categorized into two groups according to their sUA levels (≥ and < 8 mg/dL). Clinical characteristics and comorbidities that are risk factors for stroke were recorded and compared between the groups.

RESULTS

A total of 265 male patients (95 with sUA ≥ 8 mg/dL and 170 with sUA < 8 mg/dL) were enrolled. The incidence of ischemic type of stroke was significantly higher in patients with sUA ≥ 8 mg/dL (p = 0.038), particularly in the age range of 45-65 years. Multivariate Cox proportional analyses confirmed that age (p = 0.003) and UA (p = 0.019) were major predictive factors for stroke free (ischemic type of stroke) survival.

CONCLUSION

Among men with hypertriglyceridemia, the incidence rate of ischemic type of stroke significantly increased with sUA levels ≥ 8 mg/dL, particularly in men aged 45 to 65 years. Hyperuricemia is considered a potential predictive factor for ischemic type of stroke and may indicate the need for preventive management in patients with hypertriglyceridemia (Tab. 3, Fig. 1, Ref. 28).

Combination immunosuppressant therapy and lupus nephritis outcome: a hospital-based study

Lupus nephritis (LN) is the leading cause of mortality in lupus patients. This study aimed to investigate the treatment outcome and renal histological risk factors of LN in a tertiary referral center. Between 2006 and 2017, a retrospective observational study enrolled 148 biopsy-proven LN patients. After propensity score matching, 75 cases were included for further analysis. The classification and scoring of LN were assessed according to the International Society of Nephrology/Renal Pathology Society. Treatment response was evaluated by daily urine protein and urinalysis at two years after commencing induction treatment and the development of end-stage renal disease (ESRD). In total, 50.7% patients achieved complete remission (CR) or partial remission (PR), while 49.3% patients were categorized as nonresponders. Therapeutic responses in terms of CR/PR rates were associated with Systemic Lupus Erythematosus Disease Activity Index scores (odds ratio (OR): 1.34, 95% confidence interval (CI): 1.12-1.60, p = 0.001). Moreover, higher baseline creatinine levels (hazard ratio (HR): 2.10, 95% CI: 1.29-3.40, p = 0.003), higher renal activity index (HR: 1.30, 95% CI: 1.07-1.58, p = 0.008) and chronicity index (HR: 1.40, 95% CI: 1.06-1.85, p = 0.017) predicted ESRD. Among pathological scores, cellular crescents (HR: 4.42, 95% CI: 1.01-19.38, p = 0.049) and fibrous crescents (HR: 5.93, 95% CI: 1.41-24.92, p = 0.015) were independent risk factors for ESRD. In conclusion, higher lupus activity was a good prognostic marker for renal remission. Renal histology was predictive of ESRD. Large-scale prospective studies are required to verify the efficacy of mycophenolate in combination with azathioprine or cyclosporine in LN patients.

Screen-Round–Based Risk Strategies for Population-Based Mammography Screening

Background: The widespread use of organized screening strategies of mammography screening at population level stood a chance of reducing the threat to women's life from breast cancer. However, such a population-wide strategy is often faced with the questions like “How many rounds of mammography screening are require before detecting cancer in question?” and “Can the attendee be classified the low risk after several negative screening rounds?” In addition to the concerns on resource allocation for the purpose of planning an efficient population-based screening program, the recent emergence in precision medicine also makes it attractive for considering such a risk-based decision on breast cancer prevention under the context of mass screening. Aim: To quantify number of screen rounds required for detecting an asymptomatic cancer in question and dispensing with further invitation to screen. Methods: By applying a series of Bayesian negative–binomial family–based stochastic process models taking sensitivity and specificity into account, we elucidated the aforementioned issues based on the empirical data on population-based breast cancer screening program in Finland with international collaboration. The Finnish nationwide biennial mammographic screening program was implemented and targeted to women aged 50-59 years since 1988. The panel data on the regular invitation of eligible population by Pirkanmaa screening center excluding the women who had been diagnosed by breast cancer before their first invitation were enrolled in this study. Results: Based on the estimated results, we are able to determine the rounds of screens required before detecting an asymptomatic breast cancer according to the risk profile determined by age and the performance of screening tool. Based on the empirical data, an average of 2.77 (95% CI, 2.61-2.91) screen rounds will be required to detect an asymptomatic breast cancer cases. A woman may not be invited after a series of negative findings of 8 rounds of screen. Considering the sensitivity of 83% (95% CI, 61%–95%), the required screen rounds become 2.81 (95% CI, 2.65-2.94). The screening rounds required for the young (<55 years) and the old (≥55 years) age group, the corresponding figures was 2.81 (95% CI, 2.55-3.11) and 2.76 (95% CI, 2.43-3.05). Conclusion: We quantified the screen round, 2.77 on average, required to detect an asymptomatic breast cancer and 8 rounds of screen to dispense with further invitation based on the risk and the performance of screening tool. The findings may aid in risk-based interscreening interval determination but also provide information on resources required by different screening policies with target population with different risk levels.