MRI and clinicopathological correlation of childhood primary central nervous system angiitis

AIM

To review the long-term clinical and imaging follow-up of eight children with histopathologically proven childhood primary central nervous system angiitis (cPACNS).

MATERIALS AND METHODS

Eight children (5-17 years, five female and three male patients) with biopsy-proven cPACNS vasculitis were reviewed retrospectively. All children were followed at the Children's Hospital of Eastern Ontario. Magnetic resonance imaging (MRI) images of the brain parenchyma and vessel pattern of the arteries of the circle of Willis were reviewed at baseline and follow-up(s). All MRI images were correlated with clinical and histopathological findings.

RESULTS

Seven (87.5%) children demonstrated parenchymal abnormalities: five of the seven (71.4%) presented with non-haemorrhagic lesions, one (14.3%) presented with a parenchymal bleed, and one (14.3%) showed diffuse oedema. One child remained negative for brain parenchymal abnormality at baseline and follow-up. Of the seven children with a parenchymal abnormality, parenchymal enhancement was seen in two (28.5%) and leptomeningeal enhancement was seen in one child. Only two children had positive diffusion-weighted imaging (DWI) restriction at baseline. Five of the seven children (71.4%) showed no magnetic resonance angiography (MRA) abnormalities at baseline. In one, MRA detected complete absence of flow. Follow-up MRA (24-74 months) demonstrated that five of the seven (71.4%) children had progressive paucity of the peripheral vascularity. Two children (28.5%) with shorter-term follow-up (7 and 13 months) did not demonstrate MRA changes.

CONCLUSION

Long-term follow-up MRA demonstrated progressive paucity of peripheral vessels, which could be secondary to the inflammation affecting the peripheral vasculature causing reduction in vessel lumen size beyond the resolution of the maximum intensity projection (MIP) reconstruction.

Abstract TP387: An Interdisciplinary Approach to Improving Acute Treatment- Implementation of the Rapid Acute Stroke Protocol

Background: Recent emergence of evidence for the effectiveness of intra-arterial treatment (IAT) of acute ischemic stroke secondary to large vessel occlusion (LVO) has prompted hospitals to examine the efficiency of their initial evaluation process. Mount Sinai Hospital has taken an interdisciplinary approach to hyper acute stroke care. It streamlined its process focusing on rapid triage of stroke, stroke team assessment, IV tPA administration and detection of LVO.

Rapid Acute Stroke Protocol (RASP), including early stroke team activation by the triage nurse was implemented in December 2014. Triage nurses were trained in the identification of stroke and stroke team activation. Feedback was provided to nursing leadership and individual participants on every treated case. A ‘team member of the month’ was established to promote ongoing enthusiasm and team rapport.

We hypothesized that the combination of new evidence and the introduction of RASP would increase the number of patients treated, decrease time to stroke team assessment and door to puncture (DTP) time.

Method: In this retrospective review of 51 consecutive patients with AIS treated with IAT from January 2014 until July 2015, the population was divided into two cohorts. Cohort 1 included patients treated from January 2014 through November 2014, prior to RASP initiation. Cohort 2 included patients treated from December 2014 through July 2015. Outcomes included number of patients treated, arrival to stroke team assessment, and DTP time.

Results: In cohort 1, .9 cases per month were treated with IAT compared to 5.1 per month in cohort 2, a 5.2 fold increase. A greater percentage of these patients arrived in the ED via inter-hospital transfer 56% vs 30%. There was a decrease in arrival time to stroke team assessment for cohort 2 vs cohort 1 (3 vs 9 minutes) and a reduction of 46.6% from DTP time (79 minutes vs 148 minutes p=<.001).

Conclusion: These findings demonstrate how an interdisciplinary approach to hyper acute care can have a dramatic effect on the stroke patient. Improved prenotification by EMS or the originating hospital contributed to immediate stroke team availability. However, key to RASP was empowering the triage nurse with the responsibility of stroke recognition and activation of the stroke code.

Operational Definition of Active and Healthy Ageing (AHA): A Conceptual Framework

Health is a multi-dimensional concept, capturing how people feel and function. The broad concept of Active and Healthy Ageing was proposed by the World Health Organisation (WHO) as the process of optimizing opportunities for health to enhance quality of life as people age. It applies to both individuals and population groups. A universal Active and Healthy Ageing definition is not available and it may differ depending on the purpose of the definition and/or the questions raised. While the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) has had a major impact, a definition of Active and Healthy Ageing is urgently needed. A meeting was organised in Montpellier, France, October 20-21, 2014 as the annual conference of the EIP on AHA Reference Site MACVIA-LR (Contre les Maladies Chroniques pour un Vieillissement Actif en Languedoc Roussillon) to propose an operational definition of Active and Healthy Ageing including tools that may be used for this. The current paper describes the rationale and the process by which the aims of the meeting will be reached.

Statin utilisation patterns in older Australians living in residential care: 1-year prevalence study

Despite controversy over the risks and benefits of statin therapy, statins continue to be commonly used medicines by older people. In a cohort study of participants aged ≥70 years (n = 540) living in residential care, Sydney, we found that the proportion of statin users decreased gradually from the baseline of 33.1% to 31.3% at 6 months (P = 0.13) and to 28.7% over 1 year (P = 0.002). Prevalence of statin use decreased with increasing age, with individuals aged ≥90 years being more likely to discontinue or deprescribe statins. The patterns of statin use did not change according to increasing baseline dose or baseline indication.

Efficient, quality-assured data capture in operational research through innovative use of open-access technology

Ensuring quality of data during electronic data capture has been one of the most neglected components of operational research. Multicentre studies are also challenged with issues about logistics of travel, training, supervision, monitoring and troubleshooting support. Allocating resources to these issues can pose a significant bottleneck for operational research in resource-limited settings. In this article, we describe an innovative and efficient way of coordinating data capture in multicentre operational research using a combination of three open access technologies-EpiData for data capture, Dropbox for sharing files and TeamViewer for providing remote support.

Operational research capacity building in Asia: innovations, successes and challenges of a training course

A structured training course on operational research (OR) based on the model created by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières was conducted in the South Asian region in 2012. Many innovations were introduced into the administration, structure and content of the course. Of 12 participants, 11 successfully completed all pre-defined milestones. Several challenges were identified. The main challenges included shortage of time, especially for data analysis and interpretation, and insufficient numbers of experienced facilitators. Appropriate modifications have been made to the structure and processes of the next course scheduled for 2013. We describe these modifications and the innovations, successes and challenges of this model of training.

Epidemiology and interaction of diabetes mellitus and tuberculosis and challenges for care: a review

The global burden of diabetes mellitus (DM) is immense, with numbers expected to rise to over 550 million by 2030. Countries in Asia, such as India and China, will bear the brunt of this unfolding epidemic. Persons with DM have a significantly increased risk of developing active tuberculosis (TB) that is two to three times higher than in persons without DM. This article reviews the epidemiology and interactions of these two diseases, discusses how the World Health Organization and International Union Against Tuberculosis and Lung Disease developed and launched the Collaborative Framework for the care and control of TB and DM, and examines three important challenges for care. These relate to 1) bi-directional screening of the two diseases, 2) treatment of patients with dual disease, and 3) prevention of TB in persons with DM. For each area, the gaps in knowledge and the priority research areas are highlighted. Undiagnosed, inadequately treated and poorly controlled DM appears to be a much greater threat to TB prevention and control than previously realised, and the problem needs to be addressed. Prevention of DM through attention to unhealthy diets, sedentary lifestyles and childhood and adult obesity must be included in broad non-communicable disease prevention strategies. This collaborative framework provides a template for action, and the recommendations now need to be implemented and evaluated in the field to lay down a firm foundation for the scaling up of interventions that work and are effective in tackling this dual burden of disease.

LED fluorescence microscopy increases the detection of smear-positive pulmonary tuberculosis in medical colleges of India

In July 2012, light-emitting diode fluorescence microscopy (LED-FM) replaced conventional light microscopy using Ziehl-Neelsen stain in the detection of sputum-positive pulmonary tuberculosis in 190 microscopy centres of medical colleges operating under India's Revised National Tuberculosis Control Programme. We compared the performance of LED-FM (July-December 2012) to that of conventional microscopy (July-December 2011) across 190 sites. Of 222 658 patients examined using conventional microscopy, 28 042 (12.6%) were smear-positive, while of 224 714 examined using LED-FM, 33 552 (14.9%) were smear-positive, an additional yield of 5251 cases after adjusting for the increase in patients examined. We recommend replacing conventional microscopy with LED-FM in high workload microscopy centres in India.

Use of Multicriteria Risk Ranking of Zoonotic Diseases in a Developing Country: Case Study of Mongolia

Many developing countries face significant health burdens associated with a high incidence of endemic zoonoses and difficulties in integrated control measures for both the human and animal populations. The objective of this study was to develop and apply a multicriteria ranking model for zoonoses in Mongolia, a country highly affected by zoonotic disease, to inform optimal resource allocation at the national level. Diseases were evaluated based on their impact on human health, livestock sector health and the wider society through affects on the economic value of livestock, as well as the feasibility of control in both the human and livestock population. Data on disease in Mongolia were collected from various government departments including the Mongolian State Central Laboratory, the Mongolian Department of Veterinary and Animal Breeding, the Mongolian Ministry of Health, Mongolian National Center for Communicable Diseases, the National Center for Zoonotic Disease and expert opinion from a workshop with a number of Mongolian Government officials and researchers. A combined score for both impact of the disease and feasibility of its control was calculated. Five zoonotic diseases were determined to be of high priority from this assessment (i.e. ovine brucellosis, echinococcosis (hydatids), rabies, anthrax and bovine brucellosis). The results supported some of the findings for high-priority diseases (namely brucellosis, rabies and anthrax) from a previous priority setting exercise carried out in Mongolia in 2011, but also identified and ranked additional animal diseases of public health importance. While the process of model development was largely Mongolian specific, the experience of developing and parameterizing this multicriteria ranking model could be replicated by other countries where zoonoses have substantive impacts on both animal and human health.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Introducing holmium laser enucleation of the prostate alongside transurethral resection of the prostate improves outcomes of each procedure

INTRODUCTION

Holmium laser enucleation of the prostate (HoLEP) is recognised as an alternative to transurethral resection of the prostate (TURP). HoLEP has been demonstrated to be at least as effective as TURP with less morbidity but its introduction to practice has been limited in part by the learning curve of a novel procedure. This study examined the effects of introducing HoLEP alongside an established practice of TURP on early morbidity and length of hospital stay (LOS).

METHODS

A retrospective review of all patients who underwent HoLEP and TURP between April 2007 and July 2011 was undertaken. HoLEP was introduced in April 2008; patients undergoing TURP before this were considered as a historical control group. Data were collected concerning resection/enucleation weight, blood transfusions and LOS.

RESULTS

Overall, 772 patients underwent HoLEP or TURP within the 52-month study period: 164 underwent TURP prior to the introduction of HoLEP (TURP-A), 425 had TURP after the introduction of HoLEP (TURP-B) and 183 underwent HoLEP. The mean removed weight was 24g (standard deviation [SD]: 21g) for TURP-A, 19g for TURP-B (SD: 16g) and 38g (SD: 32g) for HoLEP (p<0.005). Blood transfusion rates were 5.5%, 2.2% and 1.6% for the TURP-A, TURP-B and HoLEP groups respectively (p<0.05). For TURP-A patients, the mean LOS was 5.6 days (SD: 3.5 days, 95% confidence interval [CI]: 5.3-6.0 days). The mean LOS for TURP-B patients was 4.4 days (SD: 4.4 days, 95% CI: 4.2-4.8 days). HoLEP patients had a mean LOS of 3.0 days (SD: 3.0 days, 95% CI: 2.6-3.4 days).

CONCLUSIONS

The introduction of HoLEP alongside TURP is associated with lower rates of blood transfusion and shorter LOS for all patients. This is likely to be due to the use of HoLEP rather than TURP in patients with larger prostates, who are more likely to have complications.

Does increased sunlight exposure work as a strategy to improve vitamin D status in the elderly: a cluster randomised controlled trial

SUMMARY

Sunlight exposure by improving vitamin D status could be a simple public health strategy in reducing falls among frail elder people. In a randomised controlled trial, adherence to sunlight exposure was low (median adherence, 26%) and no effect of increased UV exposure on falls risk was observed (incidence rate ratio (IRR) 1.06, P = 0.73).

INTRODUCTION

This study aimed to determine whether increased sunlight exposure was effective to improve vitamin D status and reduce falls in the elderly.

METHODS

In a cluster randomised controlled trial (NCT00322166 at ClinicalTrials.gov), 602 residents aged 70 or more (mean age, 86.4 years; 71% female) were recruited from 51 aged care facilities in Northern Sydney, Australia. Participants were randomised by facility to receive either increased sunlight exposure (additional 30-40 min/day in the early morning) with (UV+) or without (UV) calcium supplementation (600 mg/day) or neither (control) for a year. The co-primary endpoints were change in serum 25 hydroxy vitamin D (25OHD) and falls incidence after 12 months.

RESULTS

Adherence to sunlight exposure was low (median adherence, 26%; IQR, 7%-45%). Serum 25OHD levels were low at baseline (median, 32.9 nmol/L) and increased only slightly depending on the number of sunlight sessions attended over 12 months (P = 0.04). During the study, 327 falls occurred in 111 (54%) subjects in the control group, 326 falls in 111 (58%) subjects in the UV only group and 335 falls in 108 (52%) subjects in the UV+ group. By intention-to-treat analysis, there was no significant effect of increased UV exposure on falls risk (IRR, 1.06; 95% CI, 0.76-1.48; P = 0.73). However, in 66 participants who attended ≥130 sessions per year (adherence, ≥50% of 260 sessions-five per week), falls were significantly reduced (IRR, 0.52; 95% CI, 0.31-0.88; P = 0.01) compared with the control group.

CONCLUSIONS

Increased sunlight exposure did not reduce vitamin D deficiency or falls risk in frail older people. This public health strategy was not effective most likely due to poor adherence to the intervention.