Antimony Selenide Solar Cells Fabricated by Hybrid Reactive Magnetron Sputtering

The fabrication of Sb2Se3 thin-film solar cells deposited by a pulsed hybrid reactive magnetron sputtering (PHRMS) was proposed and examined for different growth conditions. The influence of growth temperature and Se pulse period were studied in terms of morphology, crystal structure, and composition. The Sb2Se3 growth showed to be dependent on the growth temperature, with a larger crystal size for growth at 270 °C. By controlling the Se pulse period, the crystal structure and crystal size could be modified as a function of the supplied Se amount. The solar cell performance for Sb2Se3 absorbers deposited at various temperatures, Se pulse periods and thicknesses were assessed through current-voltage characteristics. A power conversion efficiency (PCE) of 3.7% was achieved for a Sb2Se3 solar cell with 900 nm thickness, Sb2Se3 deposited at 270 °C and Se pulses with 0.1 s duration and period of 0.5 s. Finally, annealing the complete solar cell at 100 °C led to a further improvement of the Voc, leading to a PCE of 3.8%, slightly higher than the best reported Sb2Se3 solar cell prepared by sputtering without post-selenization.

[Guidelines for the Diagnosis and Treatment of Spontaneous Intracranial Hypotension]

Spontaneous intracranial hypotension (SIH) is a syndrome characterized by disabling orthostatic headache, due to reduced cerebrospinal fluid (CSF) volume probably caused by a CSF fistula. It affects mostly women of working-age, although it is probably underdiagnosed. The aim of this article is to present a practical approach to the diagnosis and treatment of SIH. After a description of its symptoms and signs, we present a step-by-step approach to the confirmation of the diagnosis and treatment, considering different clinical scenarios. This is intended to guide clinical decision making, through a systematized and individualized management, aimed at the best interest of the patient.

X-linked myotubular myopathy: a clinical report and a review of the mild phenotype

INTRODUCTION

X-linked myotubular myopathy is a rare centronuclear myopathy that affects approximately 1 in 50,000 male newborns caused by pathogenic variants in the myotubularin 1 gene (MTM1). The clinical severity varies, however the need for ventilatory support occurs almost invariably.

CASE REPORT

We report the case of a 4-year-old boy presenting mild muscle hypotonia at 12 months-old, expressive language disorder, global developmental delay, and a sensory processing disorder. Clinical exome sequencing identified the hemizygous variant c.722G>A p.(Arg241His) in exon 9 of the myotubularin 1 gene (NM_000252.2). The mother is a heterozygous carrier of the same variant. A diagnosis of a mild form of maternal inherited X-linked myotubular myopathy was established. The child presented significant improvement with speech, occupational, and physical therapies, with no respiratory intercurrences or ventilator dependency.

CONCLUSION

The presentation of a mild form of this myotubular myopathy, being less commonly reported, added challenge to the diagnosis. The combination of mild hypotonia, feeding difficulties and expressive language disorder should raise suspicion of a neuromuscular disease. There is a lack of verified motor or developmental scores specific to this myopathy to further determine prognosis and need of other therapies. While currently the severity myotubular myopathy is classified according to ventilator dependency, this may be insufficient and unapplicable to milder cases. There is an evident need for a grading system for mild and moderate cases assessing muscle weakness and fatigue, daily life limitations, motor developmental delay, early phenotypical scores, or recurrent respiratory infections.

Visual impairment in mucopolysaccharidosis VI

Mucopolysaccharidosis (MPS) VI is a rare genetic disease characterized by deficient activity of N-acetylgalactosamine 4-sulfatase, leading to the systemic deposition of glycosaminoglycans. Ocular involvement is classically characterized by progressive corneal clouding, ocular hypertension (OHT), and optic neuropathy. Although corneal clouding can be solved with penetrating keratoplasty (PK), visual impairment usually remains, being frequently attributed to glaucoma. The purpose of this study was to retrospectively describe a series of MPS VI patients with optic neuropathy in order to deepen the knowledge regarding the causes of severe visual impairment among these patients. We present five genetically confirmed clinical cases of MPS VI, treated with enzymatic replacement therapy, and with regular systemic and ophthalmologic follow-up. Corneal clouding was a common early presenting feature, leading to PK in four patients. During their follow-up, all patients developed very low visual acuities regardless of corneal grafts outcomes and controlled intraocular pressure (IOP). Furthermore, all patients exhibited optic atrophy and imagiological evidence of significant subarachnoid space enlargement and consequent optic nerve thickness reduction, suggesting compression of the optic nerve in a retro-ocular location as the cause of optic neuropathy. Although optic neuropathy in MPS VI is commonly attributed to glaucoma due to OHT, by describing a series of five MPS VI patients, we provided evidence that, differently from glaucoma, compression of optic nerve in a retro-ocular location is crucial for the development of optic neuropathy, at least in some cases. We propose the denomination of posterior glaucoma and suggest it as an important cause of optic neuropathy, leading to severe visual impairment and blindness among these patients.

Shorter cardiac rehabilitation programs: taking time is taking effectiveness?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Due to the covid-19 outbreak, cardiac rehabilitation programs (CRP) underwent most needed adaptions to stay operative. To face all the requests and guarantee sanitary measures, we reduced the duration of the program from about 12 weeks to about 8 weeks, so we could have smaller groups but still respond to all patients who had been referred. However, it is still unclear whether less hours of contact and exercise sessions can achieve the same results as traditional CRP.

Objective

To analyse the effectiveness of shorter duration CRP on risk factor control and exercise tolerance after concluding the program.

Methods

Observational single center study including two groups of patients who underwent CRP: one group who had been in 12 weeks-CRP before the pandemic sprout and another group enrolled in an 8-week program after April 2021. Albeit differences in their duration, both CRP had the same structure: observation by cardiologist, physiatrist, specialist nurse, exercise (aerobic and strength exercises) and educational sessions, as well as nutrition and psychologist consultation.

Results

A total of 114 pts were analysed (mean age 62,4±11,6 years, 85.1% men, 86% with ischemic heart disease). Main comorbidities were hypertension (68,4%), dyslipidaemia (70%) and diabetes (30,7%). 78 pts completed a longer programme with 12 weeks duration while 36 underwent a shorter CRP with 8 weeks. There were no statistically significant differences between both groups regarding population demographics, aetiology, LVEF and co-morbidities.

After CRP, there was significant improvement in risk factor control (mainly lipidic profile and weight) and echocardiographic parameters in both groups. We noted an important reduction in LDL levels (85±42.6mg/dL before CRP and 67.68±28.45mg/dL after), approaching the guideline recommended levels (<55mg/dL): 29.8% before vs 42.6% after (p=0.079), with no difference between the two groups (p=0,65). Significant improvement of LVEF was also observed (53% to 57%, p <0.001) without difference between the two groups (p=0.112).

Exercise tolerance improved similarly in both groups, assessed by the time of exercise stress test: we registered a global increase of 65 ± 1.38s after CRP, with no difference between the two groups (p = 0.157).

Conclusion

Shorter duration CRP showed similar results concerning risk factor control, echocardiographic LVEF and exercise tolerance improvement, suggesting that they can be an effective alternative when needed.

Very acute benefits on physical performance in elderly patients who undergone TAVI

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) emerged as a safe and efficient procedure in patients with high or prohibitive surgical risk or in older patients. The prevalence of severe aortic stenosis is growing up, given de aging of population. These patients are much often frailty and experience low levels of physical activity and functional capacity as a result of their aortic valve disease and comorbidities. When untreated severe aortic stenosis has a poor prognosis so it is of utmost importance to restore the normal hemodynamic condition and consequently to improve functional capacity.

Aim

To assess the acute benefits (in 1 moth) of TAVI on functional capacity and physical performance.

Methods

Single center prospective study of patients submitted to TAVi between April 2021 and September 2021. Patients were evaluated at baseline (before TAVI) and one month after the procedure. To assess physical activity and functional capacity it was used the International Physical Activity Questionnaire (IPAQ) and the short physical performance battery (SPPB) which is a group of measures that combines the results of the gait speed (two timed trials of a 4-m walk – fastest recorded), chair stand (time to raise for a chair 5 times) and balance tests (ability to stand for 10 seconds with feet in 3 different positions). Additionally, patients were submitted to handgrip strength test. Paired sample t-test and Wilcoxon test were used to statistical analysis.

Results

We included 20 patients, with a mean age of 85±5,86 years, 40% (8) male. 19 patients undergone TAVI due severe native aortic stenosis and 1 due to bioprosthetic aortic valve dysfunction. The vascular access site was transfemoral in 19 patients and transapical in 1 patient.

No patient had vigorous physical activity either before or after TAVI, but the daily sitting time was lower after the procedure (mean time: 634 versus 570 minutes), however not statistically significant. Regarding the results of SPPB patients experience improvements in balance (p=0,035) and chair stand (time to raise for a chair 5 times: 19,04 versus 17,05 seconds), p=0,01.

Patients tended to be faster in 4m velocity test, however with no statistical difference (8,49 versus 6,6 seconds). No statistical differences were also observed in handgrip strength test.

Conclusion

In an elderly population, TAVI appears to have an early and beneficial effect (in 1 moth) on some domains oh physical activity and functional capacity.

PURA syndrome in a child with severe developmental delay: a challenging diagnosis

INTRODUCTION

PURA syndrome is a rare autosomal dominant condition caused by de novo pathogenic variants in PURA gene and characterized by a multisystemic phenotype that includes global neurodevelopmental delay, early hypotonia, absence of speech, feeding difficulties, hypersomnolence, epilepsy and movement disorders.

CASE REPORT

We report a 9-year-old girl with hypotonia and feeding difficulties with failure to thrive since the neonatal period. At the age of 3 years motor and intellectual delay were evident, she had a wide-based gait, no speech and an exaggerated acoustic startle response. She developed hand-mouthing stereotypies and epilepsy at 6 years old. The 24 hours continuous electroencephalogram monitoring revealed global slow activity and frequent epileptiform activity in left temporal and centrotemporal areas. The brain MRI revealed delayed myelination. At 6 years old the clinical exome sequencing identified a heterozygous pathogenic variant in the PURA gene, c.153delA p.(Leu54CysfsTer24).

CONCLUSION

PURA syndrome has clinical features similar to other neurological disorders but the association with some clinical features, not as common in other neurological entities, like never being able to speak but being able to follow simple orders and exaggerated acoustic startle response, should raise the suspicion of PURA syndrome and genetic analysis must be performed to confirm the diagnosis and provide early multidisciplinary intervention.

Aphasia assessment: impact of material on naming performance

BACKGROUND

Naming and lexical retrieval difficulties are common symptoms of aphasia. Naming abilities are usually evaluated by means of real objects or pictures or line drawings that are printed.

OBJECTIVE

The aim of this study was to investigate whether the ability to name objects among individuals with aphasia is influenced by the dimensions of the visual stimuli and to understand whether the order of presentation of the stimuli, number of years of education and length of time post-onset are involved in the success of naming.

METHODS

The naming abilities of healthy controls and patients with acute or chronic aphasia due to stroke were assessed through presentation of two sets of 24 stimuli consisting of real objects and color photographs of the same objects presented on a screen. The results obtained under these two conditions were compared by means of within-subject paired ANOVA, controlling for presentation order.

RESULTS

40 patients (62.4 ± 17.3 years old; 70% females; mean education level of 8.5 ± 5.3 years; and 60% evaluated within the first eight days after stroke) and 50 controls that were age, gender and education-matched were included. Object naming was significantly better than naming color photographs among the patients (p = 0.001), but no differences were observed among the controls. Age, education, length of time post-onset and presentation sequence did not have any impact on naming performance.

CONCLUSION

These results suggest that use of digital color photographs for naming objects in assessment of aphasia may be associated with lower naming performance, compared with use of real objects. This needs to be taken into account when different forms of stimuli are presented in sequential aphasia evaluations.

Hypoalbuminaemia and One-Year Mortality in Haemodialysis Patients with Heart Failure: A Cohort Analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) and heart failure (HF) has been rising over the past decade, with a prevalence close to 40%. Cardiovascular disease and malnutrition are common comorbidities and known risk factors for mortality in haemodialysis (HD) patients. We aimed to evaluate the one-year mortality rate after dialysis induction, and the impact of serum albumin levels on survival outcomes, in patients with CKD and HF.

METHODS

This was a retrospective analysis of patients with CKD and HF who underwent chronic HD between January 2016 and December 2019 in a tertiary-care Portuguese hospital. Variables were submitted to univariate and multivariate analysis to determine factors predictive of one-mortality after HD start.

RESULTS

In total, 204 patients were analysed (mean age 75.1 ± 10.3 years). Within the first year of HD start, 28.7% of patients died. These patients were significantly older [79.8 ± 7.2 versus 72.9 ± 10.9 years, p < 0.001; OR 1.08 (1.04-1.13), p < 0.001] and had a higher mean Charlson Index [9.0 ± 1.8 versus 8.3 ± 2.0, p = 0.015; OR 1.22 (1.04-1.44), p = 0.017], lower serum creatinine [5.1 ± 1.6 mg/dL versus 5.8 ± 2.0 mg/dL; p = 0.021; OR 0.80 (0.65-0.97), p = 0.022], lower albumin levels [3.1 ± 0.6 g/dL versus 3.4 ± 0.6 g/dL, p < 0.001; OR 0.38 (0.22-0.66), p = 0.001] and started haemodialysis with a central venous catheter more frequently [80.4% versus 66.2%, p = 0.050]. Multivariate analysis identified older age [aOR 1.07 (1.03-1.12), p = 0.002], lower serum creatinine [aOR 0.80 (0.64-0.99), p = 0.049] and lower serum albumin [aOR 0.41 (0.22-0.75), p = 0.004] as predictors of one-year mortality.

CONCLUSION

In our cohort, older age, lower serum creatinine and lower serum albumin were independent risk factors for one-year mortality, highlighting the prognostic importance of malnutrition in patients starting chronic HD.

Impact of Chronic RAAS Use in Elderly COVID-19 Patients: A Retrospective Analysis

Corona Virus Disease-19 (COVID-19) recently emerged as a global pandemic. Advanced age is the most important risk factor for increased virus susceptibility and worse outcomes. Many older adults are currently treated with renin–angiotensin–aldosterone system (RAAS) inhibitors and there is concern that these medications might increase the risk of mortality by COVID-19. This is a retrospective cohort of 346 patients older than 65 years with COVID-19, at the Department of Medicine of the Centro Hospitalar Universitário Lisboa Norte, in Portugal, hospitalized between March 2020 and August 2020. Mean age was 80.9 ± 8.7 years old. Most patients had arterial hypertension (n = 279, 80.6%), almost half (n = 161, 46.5%) had cardiovascular disease and approximately one-third of patients had heart failure (n = 127, 36.7%) or diabetes Mellitus (n = 113, 32.7%). Ninety-eight patients (28.3%) had chronic kidney disease and almost half of the patients (49.4%) were chronically under renin–angiotensin–aldosterone system (RAAS) inhibitors. Twenty percent of patients died during hospitalization. In a multivariate analysis, older age (OR 1.11, 95% CI 1.04, 1.18, p = 0.002), absence of baseline medication with RAAS inhibitors (OR 0.27, 95% CI 0.10, 0.75, p = 0.011), higher serum ferritin (OR 1.00, 95% CI 1.00, 1.00, p = 0.003) and higher lactate levels (OR 1.08, 95% CI 1.02, 1.14, p = 0.006) were independent predictors of mortality. Older age, higher serum ferritin and lactate levels at admission were found to be independent predictors of mortality and might act as early predictors of worsening disease in clinical practice. Chronic treatment with RAAS inhibitors appeared to be protective, supporting guidelines in not discontinuing such drugs.

ANCA Vasculitis Recurrence in Hemodialysis Patients: The Role of Rituximab

Antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) is characterized by systemic inflammation and is the most common cause of new-onset glomerulonephritis in adults older than 50 years. Renal disease secondary to AAV can lead to chronic kidney disease (CKD) requiring renal replacement therapy in approximately 20-25% of patients. Relapses are infrequent in the population on dialysis, and treatment guidelines do not specify these patients. Reports regarding the clinical course, survival, or relapse rate after beginning dialysis are scarce. The authors present 3 cases of CKD patients on hemodialysis who presented with AAV relapse, successfully treated with rituximab, and provide a literature review on relapse treatment.

RHOBTB2 p.Arg511Trp Mutation in Early Infantile Epileptic Encephalopathy-64: Review and Case Report

Early infantile epileptic encephalopathy-64 (EIEE 64), also called RHOBTB2-related developmental and epileptic encephalopathy (DEE), is caused by heterozygous pathogenic variants (EIEE 64; MIM#618004) in the Rho-related BTB domain-containing protein 2 (RHOBTB2) gene. To date, only 13 cases with RHOBTB2-related DEE have been reported. We add to the literature the 14th case of EIEE 64, identified by whole exome sequencing, caused by a heterozygous pathogenic variant in RHOBTB2 (c.1531C > T), p.Arg511Trp. This additional case supports the main features of RHOBTB2-related DEE: infantile-onset seizures, severe intellectual disability, impaired motor functions, postnatal microcephaly, recurrent status epilepticus, and hemiparesis after seizures.

227 Is the antral follicle count on a random day of the oestrous cycle correlated with superovulatory responses in Santa Inês ewes?

Antral follicle count (AFC) performed after an oestrus synchronization protocol has been studied as a tool to select ewes with high potential for invivo embryo production (Pinto et al. 2018 Theriogenology 113, 146-152). However, it would be interesting to know whether AFC assessed on a random day of the oestrous cycle correlates with the superovulatory response. The present study was conducted to evaluate the correlation between AFC at the beginning of progesterone (P4)-based oestrus synchronization protocol used as basis of superovulatory treatment and the number of corpora lutea (CL) 12h before recovery of embryos in Santa Inês ewes. The study was conducted during September and October in northeast Brazil (03°40′26″S and 40°14′20″W) using 8 adult Santa Inês ewes. On a random day of oestrous cycle (Day 0) all ewes received an intravaginal device (CIDR) of progesterone (0.3g, Eazi-breed, Zoetis), which remained for 9 days. On Day 7, the pFSH (133mg, Folltropin V, Vetoquinol) treatment began, with 6 decreasing doses (25, 25, 15, 15, 10, and 10%) injected IM at 12-h intervals. On Day 9, 2 equal doses of D-cloprostenol were injected at a 12-h interval (37.5µg, Prolise, Agener União). All ewes showed oestrus and were mated by fertile rams. Flunixin meglumine (24.9 mg; Banamine, MSD Animal Health) was administered IM on Days 12, 13, and 15. On Day 16, non-surgical embryo recovery (NSER) was performed after cervical dilation using D-cloprostenol and oestradiol benzoate at 16h and oxytocin 20min before. Transrectal B-mode ultrasound evaluations (Z5 Vet, Mindray), frequency 7.5MHz, were performed on Day 0 and 7 and 12h before NSER to evaluate the ovarian population present. Pearson correlation analysis (P&lt;0.05) was performed using Bioestat 5.3 software. The number of AFC per ewe at the beginning of the protocol and on Day 7 were 9.9±2.7 and 11±3.2, respectively. The numbers of CL, recovered embryos, and viable embryos were 14.0±3.5, 8.2±10.9, and 6.0±11.0, respectively. There was no correlation of AFC on a random day of oestrous cycle with the number of AFC on Day 7 (P=0.42), number of corpora lutea (P=0.44), number of recovered embryos (P=0.18), or number of viable embryos (P=0.11) in superovulated ewes. In conclusion, we did not find significant correlations between AFC on a random day of oestrous cycle and the superovulatory/embryos response in Santa Inês ewes. Financial support for this study was provided by Embrapa (02.13.06.026.00.02 and 02.13.06.026.00.04) and FAPEMIG (PPM 00201-17).

Ménétrier's disease : a case of successful treatment using long-acting octreotide

The authors describe a 31 years old male, admitted for hematemesis, epigastric pain and lower limb edema. Laboratorial data showed haemoglobin 18.4g/dl, total proteins 2.8g/dl, albumin 1.6g/dl and hipogammaglobulinaemia. 24h urinary proteins were normal. HIV and CMV serology were negative. Upper GI endoscopy revealed markedly enlarged gastric folds covered by abundant exudative fluid. Endoscopic ultrasound showed ascites, pleural effusion and gastric wall thickening with mucosa expansion and intact submucosa. In gastric biopsies foveolar hyperplastic and regenerative mucosa were observed being suggestive of Ménétrier´s disease. Helicobacter pylori was not detected. Albumin replacement and diuretics corrected anasarca and long-acting octreotide was instituted. Nine months later, the patient was asymptomatic, serum proteins were normal (albumin 4.6g/dl and total proteins 6.5g/dl), signs of endoscopic improvement were observed with marked reduction in gastric folds and mucosal inflammation and no ultrastructural changes were detected in gastric specimens sent for electron microscopy. Ménétrier´s Disease (MD) is a rare form of hypertrophic gastropathy characterized by massive enlargement of gastric folds causing marked protein exudation. The increase in tight junction diameter is the most consistent ultraestrutural change. Octreotide is a somatostatin analogue that acts by modulating TGFαEGFR pathway, which has been associated with the pathogenic mechanisms. As well as other cases reported in literature, this case report highlights the potential of long-acting octreotide for MD treatment avoiding more expensive therapies like cetuximab and gastrectomy.

Guidance to 2018 good practice: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma

Aims

Mobile Airways Sentinel NetworK (MASK) belongs to the Fondation Partenariale MACVIA-LR of Montpellier, France and aims to provide an active and healthy life to rhinitis sufferers and to those with asthma multimorbidity across the life cycle, whatever their gender or socio-economic status, in order to reduce health and social inequities incurred by the disease and to improve the digital transformation of health and care. The ultimate goal is to change the management strategy in chronic diseases.

Methods

MASK implements ICT technologies for individualized and predictive medicine to develop novel care pathways by a multi-disciplinary group centred around the patients.

Stakeholders

Include patients, health care professionals (pharmacists and physicians), authorities, patient’s associations, private and public sectors.

Results

MASK is deployed in 23 countries and 17 languages. 26,000 users have registered.

EU grants (2018)

MASK is participating in EU projects (POLLAR: impact of air POLLution in Asthma and Rhinitis, EIT Health, DigitalHealthEurope, Euriphi and Vigour).

Lessons learnt

(i) Adherence to treatment is the major problem of allergic disease, (ii) Self-management strategies should be considerably expanded (behavioural), (iii) Change management is essential in allergic diseases, (iv) Education strategies should be reconsidered using a patient-centred approach and (v) Lessons learnt for allergic diseases can be expanded to chronic diseases.

Adjustable transobturator male system (ATOMS®) as treatment of stress urinary incontinence secondary to transurethral resection of the prostate

OBJECTIVES

Feasibility study to evaluate efficacy and safety of Adjustable Transobturator Male System (ATOMS^®) for male stress urinary incontinence (SUI) after transurethral resection of the prostate.

MATERIALS AND METHODS

Twenty patients were implanted ATOMS^® for SUI caused by transurethral resection of the prostate with or without radiotherapy. Incontinence severity was evaluated as mild (2 pads/day), moderate (3-5 pads/day) or severe (≥6pads/day), and dryness as none or one security pad/day. Changes in pad-test and pad-count after adjustment were investigated, together with operative parameters, patient satisfaction with the procedure, and number and grade of complications (Clavien-Dindo).

RESULTS

Median age was 76.5years. Five patients received previous pelvic radiation (3 prostate, 2 rectal cancer) and 2 (10%) previous failed artificial urinary sphincter with urethral erosion and mechanical failure, respectively. Preoperative SUI was mild in 4 (20%), moderate in 7 (35%) and severe in 9 (45%). Median filling of the system was 13.5ml. Median pad-test decreased from 375±855ml baseline to 10±31.5ml and pad-count from 4±3 to 0±1.5 after adjustment (1±3fillings). Postoperative SUI distribution was mild in 2 (10%), moderate in one (5%) and severe in 2 (10%). Satisfaction rate was 80%, equal for transurethral resection of the prostate with/without previous radiotherapy. No patient had urinary retention after catheter removal. Complications presented in 3 (15%) patients, all minor. After median 38.5mo follow-up no system has been removed, 19 (95%) self-considered better than before and 11 (55%) very much better.

CONCLUSION

Based on short-term efficacy and patient satisfaction ATOMS^® can be considered a realistic alternative for SUI after transurethral resection of the prostate, even after irradiation. Absence of urethral erosion and very limited problems make this alternative especially attractive for cases with diminished dexterity, advanced age and previous failed treatments.

MASK 2017: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma multimorbidity using real-world-evidence

mHealth, such as apps running on consumer smart devices is becoming increasingly popular and has the potential to profoundly affect healthcare and health outcomes. However, it may be disruptive and results achieved are not always reaching the goals. Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best evidence-based approach to care pathways suited to real-life using mobile technology in allergic rhinitis (AR) and asthma multimorbidity. Patients largely use over-the-counter medications dispensed in pharmacies. Shared decision making centered around the patient and based on self-management should be the norm. Mobile Airways Sentinel networK (MASK), the Phase 3 ARIA initiative, is based on the freely available MASK app (the Allergy Diary, Android and iOS platforms). MASK is available in 16 languages and deployed in 23 countries. The present paper provides an overview of the methods used in MASK and the key results obtained to date. These include a novel phenotypic characterization of the patients, confirmation of the impact of allergic rhinitis on work productivity and treatment patterns in real life. Most patients appear to self-medicate, are often non-adherent and do not follow guidelines. Moreover, the Allergy Diary is able to distinguish between AR medications. The potential usefulness of MASK will be further explored by POLLAR (Impact of Air Pollution on Asthma and Rhinitis), a new Horizon 2020 project using the Allergy Diary.

Treatment of allergic rhinitis using mobile technology with real-world data: The MASK observational pilot study

BACKGROUND

Large observational implementation studies are needed to triangulate the findings from randomized control trials as they reflect "real-world" everyday practice. In a pilot study, we attempted to provide additional and complementary insights on the real-life treatment of allergic rhinitis (AR) using mobile technology.

METHODS

A mobile phone app (Allergy Diary, freely available in Google Play and Apple App stores) collects the data of daily visual analog scales (VAS) for (i) overall allergic symptoms, (ii) nasal, ocular, and asthma symptoms, (iii) work, as well as (iv) medication use using a treatment scroll list including all medications (prescribed and over the counter (OTC)) for rhinitis customized for 15 countries.

RESULTS

A total of 2871 users filled in 17 091 days of VAS in 2015 and 2016. Medications were reported for 9634 days. The assessment of days appeared to be more informative than the course of the treatment as, in real life, patients do not necessarily use treatment on a daily basis; rather, they appear to increase treatment use with the loss of symptom control. The Allergy Diary allowed differentiation between treatments within or between classes (intranasal corticosteroid use containing medications and oral H1-antihistamines). The control of days differed between no [best control], single, or multiple treatments (worst control).

CONCLUSIONS

This study confirms the usefulness of the Allergy Diary in accessing and assessing everyday use and practice in AR. This pilot observational study uses a very simple assessment (VAS) on a mobile phone, shows novel findings, and generates new hypotheses.

Geolocation with respect to personal privacy for the Allergy Diary app - a MASK study

Background

Collecting data on the localization of users is a key issue for the MASK (Mobile Airways Sentinel networK: the Allergy Diary) App. Data anonymization is a method of sanitization for privacy. The European Commission's Article 29 Working Party stated that geolocation information is personal data.To assess geolocation using the MASK method and to compare two anonymization methods in the MASK database to find an optimal privacy method.

Methods

Geolocation was studied for all people who used the Allergy Diary App from December 2015 to November 2017 and who reported medical outcomes. Two different anonymization methods have been evaluated: Noise addition (randomization) and k-anonymity (generalization).

Results

Ninety-three thousand one hundred and sixteen days of VAS were collected from 8535 users and 54,500 (58.5%) were geolocalized, corresponding to 5428 users. Noise addition was found to be less accurate than k-anonymity using MASK data to protect the users' life privacy.

Discussion

k-anonymity is an acceptable method for the anonymization of MASK data and results can be used for other databases.

Simultaneously elevated FeNO and blood eosinophils relate to asthma morbidity in asthmatics from NHANES 2007-12

BACKGROUND

Fraction of exhaled nitric oxide (FeNO) and blood eosinophil (B-Eos) count are biomarkers for type 2 inflammation. However, they signal different inflammatory pathways. Simultaneously elevated, they are related to more asthma events in a general population and among younger asthmatics.

OBJECTIVE

To investigate if simultaneously elevated FeNO and B-Eos relate to asthma outcomes and lung function among subjects with asthma at a wide age span, and how different cut-offs for the markers affect these relations.

METHOD

FeNO, B-Eos and forced expiratory volume in 1 second (FEV₁ ) were assessed in 1419 subjects with asthma, aged 6-79 years old, from the National Health and Nutrition Examination Survey (NHANES) 2007-12. Elevated levels were defined as FeNO ≥20 p.p.b. for children <12 years and ≥25 p.p.b. for subjects ≥12 years and B-Eos count ≥300 cells/μL. Additional analyses were performed for the cut-offs FeNO >35/30 and >50/35 p.p.b., and for B-Eos ≥400 and ≥ 500 cells/μL, as well as for different age subgroups (6-17, 18-44, >44 years old). Asthma events during the past year were self-reported.

RESULTS

Subjects with simultaneously elevated FeNO and B-Eos compared with normal levels of both markers had a higher adjusted odds ratio (aOR (95%CI)) for having FEV₁ <80% of predicted (2.15 (1.28-3.59), wheeze disturbing sleep (1.88 (1.27, 2.78)) but did not differ regarding asthma attacks past year. Elevated B-Eos, but not FeNO, was related to higher aOR for asthma attack (1.57 (1.14, 2.18) or emergency room (ER) visit due to asthma (1.88 (1.33, 2.64) when elevated FeNO and elevated B-Eos were studied as independent predictors.

CONCLUSION

Simultaneously elevated FeNO and B-Eos related to reduced lung function in asthmatics, wheezing symptoms, but not to a history of asthma attacks. Asthma attacks and ER-visit due to asthma were related to increased B-Eos levels.

Cognitive functioning in chronic post-stroke aphasia

There is a minimal amount of knowledge regarding the cognitive abilities of people with aphasia. We evaluated the performance of individuals with chronic aphasia (AP) and control participants without aphasia (CP) with left hemisphere stroke in a battery of nonverbal cognitive tests and its relationship with aphasia severity, comprehension abilities, and speech fluency in a prospective cross-sectional study. Cognitive evaluation comprised 10 nonverbal tests. Scores were converted to age and education adjusted standard scores. Forty-eight AP and 32 CP were included. AP average scores were below normal range in three tests: Camel and Cactus Test, immediate recall of 5 Objects Test and Spatial Span. The mean test scores were significantly lower in AP than in CP, except in four tests. Aphasia severity and verbal comprehension ability correlated significantly with semantic memory, constructive abilities and attention/processing speed tests. Subjects with nonfluent aphasia had lower scores than CP in memory, executive functions and attention tests, while subjects with fluent aphasia showed lower scores in memory tests only. On average half of the individuals with aphasia exhibit results within the normal range. Nonetheless, their performance was worse than that of controls, despite the fact that many tests do not correlate with the severity of language disorder.

The Allergic Rhinitis and its Impact on Asthma (ARIA) score of allergic rhinitis using mobile technology correlates with quality of life: The MASK study

Mobile technology has been used to appraise allergic rhinitis control, but more data are needed. To better assess the importance of mobile technologies in rhinitis control, the ARIA (Allergic Rhinitis and its Impact on Asthma) score ranging from 0 to 4 of the Allergy Diary was compared with EQ-5D (EuroQuol) and WPAI-AS (Work Productivity and Activity Impairment in allergy) in 1288 users in 18 countries. This study showed that quality-of-life data (EQ-5D visual analogue scale and WPA-IS Question 9) are similar in users without rhinitis and in those with mild rhinitis (scores 0-2). Users with a score of 3 or 4 had a significant impairment in quality-of-life questionnaires.

CHRODIS criteria applied to the MASK (MACVIA-ARIA Sentinel NetworK) Good Practice in allergic rhinitis: a SUNFRAIL report

A Good Practice is a practice that works well, produces good results, and is recommended as a model. MACVIA-ARIA Sentinel Network (MASK), the new Allergic Rhinitis and its Impact on Asthma (ARIA) initiative, is an example of a Good Practice focusing on the implementation of multi-sectoral care pathways using emerging technologies with real life data in rhinitis and asthma multi-morbidity. The European Union Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) has developed a checklist of 28 items for the evaluation of Good Practices. SUNFRAIL (Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community dwelling persons of EU Countries), a European Union project, assessed whether MASK is in line with the 28 items of JA-CHRODIS. A short summary was proposed for each item and 18 experts, all members of ARIA and SUNFRAIL from 12 countries, assessed the 28 items using a Survey Monkey-based questionnaire. A visual analogue scale (VAS) from 0 (strongly disagree) to 100 (strongly agree) was used. Agreement equal or over 75% was observed for 14 items (50%). MASK is following the JA-CHRODIS recommendations for the evaluation of Good Practices.

Validation of the MASK-rhinitis visual analogue scale on smartphone screens to assess allergic rhinitis control

BACKGROUND

Visual Analogue Scale (VAS) is a validated tool to assess control in allergic rhinitis patients.

OBJECTIVE

The aim of this study was to validate the use of VAS in the MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) app (Allergy Diary) on smartphones screens to evaluate allergic rhinitis symptoms and disease control.

METHODS

Each user filled 4 different VAS measuring overall, nasal, ocular, and asthma symptoms at least once. Following COSMIN guidelines, we evaluated internal consistency, (Cronbach's alpha coefficient and test-retest), reliability (intraclass correlation coefficients), sensitivity, and acceptability of the MASK-Rhinitis VAS.

RESULTS

Between 1 August 2015 and 31 July 2016, the app was used 14 612 times in 15 countries. A total of 1225 users used it more than once, during the evaluated period. The tool resulted to be statistically satisfactory, showing excellent internal consistency (Cronbach's test > 0.84, test-retest > 0.7), reliability (>0.9), and acceptability. In addition, the tool had a good sensitivity when users (n = 521) answered the VAS twice in less than 3 hours.

CONCLUSIONS AND CLINICAL RELEVANCE

The MASK-rhinitis VAS is a reliable and valid tool to assess allergic control on smartphone screens, at the population level.

Work productivity in rhinitis using cell phones: The MASK pilot study

Allergic rhinitis often impairs social life and performance. The aim of this cross-sectional study was to use cell phone data to assess the impact on work productivity of uncontrolled rhinitis assessed by visual analogue scale (VAS). A mobile phone app (Allergy Diary, Google Play Store and Apple App Store) collects data from daily visual analogue scales (VAS) for overall allergic symptoms (VAS-global measured), nasal (VAS-nasal), ocular (VAS-ocular) and asthma symptoms (VAS-asthma) as well as work (VAS-work). A combined nasal-ocular score is calculated. The Allergy Diary is available in 21 countries. The app includes the Work Productivity and Activity Impairment Allergic Specific Questionnaire (WPAI:AS) in six EU countries. All consecutive users who completed the VAS-work from 1 June to 31 October 2016 were included in the study. A total of 1136 users filled in 5818 days of VAS-work. Symptoms of allergic rhinitis were controlled (VAS-global <20) in approximately 60% of the days. In users with uncontrolled rhinitis, approximately 90% had some work impairment and over 50% had severe work impairment (VAS-work >50). There was a significant correlation between VAS-global calculated and VAS-work (Rho=0.83, P<0.00001, Spearman's rank test). In 144 users, there was a significant correlation between VAS-work and WPAI:AS (Rho=0.53, P<0.0001). This pilot study provides not only proof-of-concept data on the work impairment collected with the app but also data on the app itself, especially the distribution of responses for the VAS. This supports the interpretation that persons with rhinitis report both the presence and the absence of symptoms.