Appropriate use of medication among home care adult cancer patients at end of life: a retrospective observational study

BACKGROUND

Medications are commonly used for symptom control in cancer patients at the end of life. This study aimed to evaluate medication utilization among home care palliative patients with cancer at the end of life and assess the appropriateness of these medications.

METHOD

This retrospective observational study included adult cancer patients who received home care in 2020. Medications taken during the last month of the patient's life were reviewed and classified into three major categories: potentially avoidable, defined as medications that usually have no place at the end of life because the time to benefit is shorter than life expectancy; medications of uncertain appropriateness, defined as medications that need case-by-case evaluation because they could have a role at the end of life; and potentially appropriate, defined as medications that provide symptomatic relief.

RESULTS

In our study, we enrolled 353 patients, and 2707 medications were analyzed for appropriateness. Among those, 1712 (63.2%) were classified as potentially appropriate, 755 (27.9%) as potentially avoidable, and 240 (8.9%) as medications with uncertain appropriateness. The most common potentially avoidable medications were medications for peptic ulcers and gastroesophageal reflux disease (30.5%), vitamins (14.6%), beta-blockers (9.8%), anticoagulants (7.9%), oral antidiabetics (5.4%) and insulin products (5.3%). Among the potentially appropriate medications, opioid analgesics were the most frequently utilized medications (19.5%), followed by laxatives (19%), nonopioid analgesics (14.4%), gamma-aminobutyric acid analog analgesics (7.7%) and systemic corticosteroids (6%).

CONCLUSION

In home care cancer patients, approximately one-third of prescribed medications were considered potentially avoidable. Future measures to optimize medication use in this patient population are essential.

Analyzing the dynamic patterns of COVID-19 through nonstandard finite difference scheme

This paper presents a novel approach to analyzing the dynamics of COVID-19 using nonstandard finite difference (NSFD) schemes. Our model incorporates both asymptomatic and symptomatic infected individuals, allowing for a more comprehensive understanding of the epidemic's spread. We introduce an unconditionally stable NSFD system that eliminates the need for traditional Runge-Kutta methods, ensuring dynamical consistency and numerical accuracy. Through rigorous numerical analysis, we evaluate the performance of different NSFD strategies and validate our analytical findings. Our work demonstrates the benefits of using NSFD schemes for modeling infectious diseases, offering advantages in terms of stability and efficiency. We further illustrate the dynamic behavior of COVID-19 under various conditions using numerical simulations. The results from these simulations demonstrate the effectiveness of the proposed approach in capturing the epidemic's complex dynamics.

Serum Interleukin-1 Levels Are Associated with Intracranial Aneurysm Instability

Serum interleukin-1 (IL-1) are possibly indicative of the inflammation in the intracranial aneurysm (IA) wall. This study aimed to investigate whether IL-1 could discriminate the unstable IAs (ruptured intracranial aneurysms (RIAs) and symptomatic unruptured intracranial aneurysms (UIAs)) from stable, asymptomatic UIAs. IA tissues and blood samples from 35 RIA patients and 35 UIA patients were collected between January 2017 and June 2020 as the derivation cohort. Blood samples from 211 patients with UIAs were collected between January 2021 and June 2022 as the validation cohort (including 63 symptomatic UIAs). Blood samples from 35 non-cerebral-edema meningioma patients (non-inflammatory control) and 19 patients with unknown-cause subarachnoid hemorrhage (hemorrhagic control) were also collected. IL-1β and IL-1.ra (IL-1 receptor antagonist) were measured in serum and IA tissues, and the IL-1 ratio was calculated as log10 (IL-1.ra/IL-1β). Based on the derivation cohort, multivariate logistic analysis showed that IL-1β (odds ratio, 1.48, P = 0.001) and IL-1.ra (odds ratio, 0.74, P = 0.005) were associated with RIAs. The IL-1 ratio showed an excellent diagnostic accuracy for RIAs (c-statistic, 0.91). Histological analysis confirmed the significant correlation of IL-1 between serum and aneurysm tissues. IL-1 ratio could discriminate UIAs from non-inflammatory controls (c-statistic, 0.84), and RIAs from hemorrhagic controls (c-statistic, 0.95). Based on the validation cohort, the combination of IL-1 ratio and PHASES score had better diagnostic accuracy for symptomatic UIAs than PHASES score alone (c-statistic, 0.88 vs 0.80, P < 0.001). Serum IL-1 levels correlate with aneurysm tissue IL-1 levels and unstable aneurysm status, and could serve as a potential biomarker for IA instability.

Time to Recurrence of Ameloblastoma and Associated Factors in a Multi-institutional Black Patient Cohort

Ameloblastoma is a highly recurrent odontogenic neoplasm with variable global distribution. However, impact of race and ethnicity on ameloblastoma recurrence are still unclear. The primary aim of this study was to assess duration of time between primary and recurrent ameloblastomas in a predominantly Black multi-institutional patient cohort and secondarily to determine whether recurrent ameloblastomas are more readily discovered when clinically-symptomatic rather than by radiographic surveillance. A retrospective cross-sectional design was used to evaluate demographic, clinical, and pathological information on recurrent ameloblastomas patients. Outcome variable was time to recurrence, determined as period between the diagnosis of primary and recurrent ameloblastomas. We assessed associations between outcome variable and race, time lapse between primary and recurrent ameloblastomas and clinical symptoms of recurrent ameloblastomas at time of diagnosis. Among 115 recurrent ameloblastomas identified, 90.5% occurred in adults, 91.3% in Blacks, and similarly, 91.3% were conventional ameloblastomas. About 41% affected the posterior mandible. 93.9% were clinically symptomatic at time of presentation while 6.1% non-symptomatic lesions were discovered by routine diagnostic radiology. Median time to presentation of recurrent tumor was significantly longer in females (90 months, p = 0.016) and clinically symptomatic group of ameloblastoma patients (75 months, p = 0.023). Ameloblastoma recurrence was distinctively high in Black patients, occurred faster in males than females and was located mostly in the posterior mandible. Concomitant with delayed access to healthcare of Black individuals, routine post-surgical follow-up is essential because time lag between primary and recurrence tumors was longer in clinically symptomatic ameloblastomas at the time of diagnosis.

Neutrophil-to-lymphocyte ratio associated with symptomatic saccular unruptured intracranial aneurysm

BACKGROUND AND PURPOSE

Whether symptomatic unruptured intracranial aneurysms (UIAs) lead to change in circulating inflammation remains unclear. This study aims to evaluate the role of hematological inflammatory indicators in predicting symptomatic UIA.

METHODS

Adult patients diagnosed with saccular intracranial aneurysm from March 2019 to September 2023 were recruited retrospectively. Clinical and laboratory data, including the white blood cells (WBC), neutral counts (NEUT), lymphocyte counts (LYM), and monocyte counts (MONO) of each patient, were collected. The neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) were calculated as NLR = NEUT/LYM, LMR = LYM/MONO, SII = PLT*NEUT/LYM. The hematological inflammatory indicators were compared in symptomatic saccular and asymptomatic UIA patients. Multivariable logistic regression analyses were performed to explore the factors predicting symptomatic UIA.

RESULTS

One hundred and fifty UIA patients with a mean age of 58.5 ± 12.4 were included, of which 68% were females. The NLR and LMR were significantly associated with symptomatic UIA, and the association remained in small UIAs (< 7 mm). The multiple logistic regression analysis showed that NLR was independently associated with symptomatic UIA. On ROC curve analysis, the optimal cutoff value of NLR to differentiate symptomatic from asymptomatic was 2.38. In addition, LMR was significantly associated with symptomatic UIA smaller than 7 mm.

CONCLUSION

There was a significant correlation between NLR and symptomatic UIA. The NLR was independently associated with symptomatic UIA.

Malaria Prevalence in Asymptomatic and Symptomatic Children Living in Rural, Semi-Urban and Urban Areas in Eastern Gabon

BACKGROUND

Malaria remains a major public health issue in the world despite a decline in the disease burden. However, though symptomatic malaria is diagnosed and treated, asymptomatic infections remain poorly known and support transmission. This study assessed the prevalence of symptomatic and asymptomatic Plasmodium spp. infections in three areas in Gabon to monitor and evaluate the impact of malaria.

METHODS AND RESULTS

A cross-sectional study was conducted in three areas of Gabon. Febrile and afebrile children aged 6 months to 15 years were included in this study. Malaria prevalence was determined by microscopy of and using rapid diagnostic test (RDT). Plasmodium spp. species were identified by PCR according to the Snounou method. The data were recorded in Excel, and the statistical analyses were performed using the software R version R 64 × 3.5.0. A total of 2381(333 asymptomatic and 107 symptomatic) children were included. The overall prevalence of malaria was 40% (952/2381), with the majority (77% symptomatic and 98% asymptomatic) of infections caused by Plasmodium falciparum. A high prevalence of malaria was found in infected children in rural and semi-rural areas. In these two areas, a higher prevalence of Plasmodium malariae was observed in asymptomatic. Furthermore, mixed infections were more prevalent in asymptomatic children than in symptomatic.

CONCLUSION

This study showed that the prevalence of Plasmodium spp. infection varied according to the regions. The main species was Plasmodium falciparum, but in asymptomatic children the prevalence of Plasmodium malariae was high in rural areas. To help fight malaria more effectively asymptomatic infections should be taken into account and treated.

Effect of second booster vaccinations and prior infection against SARS-CoV-2 in the UK SIREN healthcare worker cohort

Background

The protection of fourth dose mRNA vaccination against SARS-CoV-2 is relevant to current global policy decisions regarding ongoing booster roll-out. We aimed to estimate the effect of fourth dose vaccination, prior infection, and duration of PCR positivity in a highly-vaccinated and largely prior-COVID-19 infected cohort of UK healthcare workers.

Methods

Participants underwent fortnightly PCR and regular antibody testing for SARS-CoV-2 and completed symptoms questionnaires. A multi-state model was used to estimate vaccine effectiveness (VE) against infection from a fourth dose compared to a waned third dose, with protection from prior infection and duration of PCR positivity jointly estimated.

Findings

1298 infections were detected among 9560 individuals under active follow-up between September 2022 and March 2023. Compared to a waned third dose, fourth dose VE was 13.1% (95% CI 0.9 to 23.8) overall; 24.0% (95% CI 8.5 to 36.8) in the first 2 months post-vaccination, reducing to 10.3% (95% CI -11.4 to 27.8) and 1.7% (95% CI -17.0 to 17.4) at 2-4 and 4-6 months, respectively. Relative to an infection >2 years ago and controlling for vaccination, 63.6% (95% CI 46.9 to 75.0) and 29.1% (95% CI 3.8 to 43.1) greater protection against infection was estimated for an infection within the past 0-6, and 6-12 months, respectively. A fourth dose was associated with greater protection against asymptomatic infection than symptomatic infection, whilst prior infection independently provided more protection against symptomatic infection, particularly if the infection had occurred within the previous 6 months. Duration of PCR positivity was significantly lower for asymptomatic compared to symptomatic infection.

Interpretation

Despite rapid waning of protection, vaccine boosters remain an important tool in responding to the dynamic COVID-19 landscape; boosting population immunity in advance of periods of anticipated pressure, such as surging infection rates or emerging variants of concern.

Funding

UK Health Security Agency, Medical Research Council, NIHR HPRU Oxford, Bristol, and others.

Clinicoradiologic Risk Stratification and Outcome Assessment in Symptomatic Intracranial Arachnoid Cyst Managed Over Fifteen Years

BACKGROUND

Arachnoid cysts (ACs) are developmental anomalies formed by splitting the arachnoid membrane's layers. ACs contribute around 2% of all intracranial space-occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratification with a possible role in outcome prediction. The present study describes the management strategies and outcomes in symptomatic intracranial ACs.

METHODS

All biopsy-proven symptomatic patients who underwent surgical management over last 15 years were included in this study (January 2008-December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradiologic improvement was evaluated at 3 months follow-up visit.

RESULTS

A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n = 59, 54.6%) were higher than the infratentorial ACs (n = 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompression (P= 0.23).

CONCLUSIONS

ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms.

A systematic review of the symptomatic management of Lhermitte's phenomenon

INTRODUCTION

Lhermitte's phenomenon (LP) is a transient shock-like sensation that radiates down the spine into the extremities, usually with neck flexion. The potential efficacy and tolerability of various symptomatic therapies in the management of LP have not been systematically reviewed previously.

METHOD

A systematic review was conducted using PubMed, EMBASE, and the Cochrane Library from inception to August 2022 for peer-reviewed articles describing the treatment of patients with Lhermitte's phenomenon. The review adheres to the PRISMA guidelines and was registered on PROSPERO.

RESULTS

This systematic review included sixty-six articles, which included 450 patients with LP. Treatment of the underlying cause varied by aetiology. Whilst LP is most commonly considered in the context of structural pathology of the cervical cord, medication-induced LP was a common theme in the literature. The most common cause of medication-induced LP was platinum-based chemotherapy agents such as cisplatin and oxaliplatin. In medication-induced LP, symptoms typically resolved with cessation of the causative agent. Non-pharmacological treatment options were associated with mild-moderate symptomatic improvement. The most commonly used agents to treat patients with LP were carbamazepine and gabapentin, which resulted in variable degrees of symptomatic benefit.

CONCLUSIONS

No randomised studies currently exist to support the use of symptomatic therapies to treat LP. Observational data suggest that some therapies may yield a symptomatic benefit in the management of LP. However, this systematic review identified a significant paucity of evidence in the literature, which suggests that further controlled studies are needed to investigate the optimal management of this common neurologic phenomenon.

Safety and efficacy of enterprise stenting for symptomatic atherosclerotic severe posterior circulation stenosis

PURPOSE

To investigate the safety and efficacy of Enterprise stent angioplasty and risk factors for the prognoses in treating symptomatic severe posterior circulation atherosclerotic stenosis (SSPCAS).

MATERIALS AND METHODS

Patients with SSPCAS who were treated with the Enterprise stent angioplasty were retrospectively enrolled. The clinical data, peri-procedural complications, postoperative residual stenosis, in-stent restenosis and recurrent stroke at follow-up were analyzed.

RESULTS

262 patients with 275 stenotic lesions treated with the Enterprise stent angioplasty were enrolled. The stenosis degree was reduced from 86.3 ± 6.2% before to 19.3 ± 5.4% after stenting. Complications occurred in 14 (5.3%) patients. Clinical follow-up was performed in 245 (93.51%) patients for 16.5 ± 7.3 months. During 1 year follow-up, 7 patients (2.9%) had recurrent symptoms, including 4 patients with stenting in the intracranial vertebral artery and 3 in the basilar artery. Imaging follow-up was conducted in 223 (85.11%) patients. In-stent restenosis was present in 35 patients (15.7%), with the restenosis rate of 26.4% (n = 23) in the intracranial vertebral artery, which was significantly (P < 0.001) greater than in the basilar artery (8.8%). Six patients (17.1%) with in-stent restenosis were symptomatic. The stenotic length was the only significant (P = 0.026 and 0.024, respectively) independent risk factor for 1 year stroke or death events and in-stent restenosis.

CONCLUSION

The Enterprise stent can be safely and efficaciously applied in the treatment of symptomatic severe posterior circulation atherosclerotic stenosis, with a relatively low rate of in-stent restenosis and recurrent stroke within 1 year. The stenotic length was the only significant independent risk factor for 1 year stroke or death events and in-stent restenosis.

High baseline frequencies of natural killer cells are associated with asymptomatic SARS-CoV-2 infection

This study tested the hypothesis that high frequencies of natural killer (NK) cells are protective against symptomatic SARS-CoV-2 infection. Samples were utilized from the COVID-19 Health Action Response for Marines study, a prospective, observational study of SARS-CoV-2 infection in which participants were enrolled prior to infection and then serially monitored for development of symptomatic or asymptomatic infection. Frequencies and phenotypes of NK cells (CD3-CD14-CD19-CD56+) were assessed by flow cytometry. Individuals that developed asymptomatic infections were found to have higher pre-infection frequencies of total NK cells compared to symptomatic individuals (10.61% [SD 4.5] vs 8.33% [SD 4.6], p = 0.011). Circulating total NK cells decreased over the course of infection, reaching a nadir at 4 weeks, while immature NK cells increased, a finding confirmed by multidimensional reduction analysis. These results indicate that NK cells likely play a key role in controlling the severity of clinical illness in individuals infected with SARS-CoV-2.

The quantity and quality of anti-SARS-CoV-2 antibodies show contrariwise association with COVID-19 severity: lessons learned from IgG avidity

Gaining more appreciation on the protective/damaging aspects of anti-SARS-CoV-2 immunity associated with disease severity is of great importance. This study aimed to evaluate the avidity of serum IgG antibodies against SARS-CoV-2 spike (S) and nucleocapsid (N) in hospitalized symptomatic COVID-19 patients and asymptomatic RT-PCR-confirmed SARS-CoV-2 carriers as well as to compare antibody avidities with respect to vaccination status, vaccination dose and reinfection status. Serum levels of anti-S and anti-N IgG were determined using specific ELISA kits. Antibody avidity was determined by urea dissociation assay and expressed as avidity index (AI) value. Despite higher IgG levels in the symptomatic group, AI values of both anti-S and anti-N IgG were significantly lower in this group compared to asymptomatic individuals. In both groups, anti-S AI values were elevated in one-dose and two-dose vaccinees versus unvaccinated subjects, although significant differences were only detected in the symptomatic group. However, anti-N avidity showed no significant difference between the vaccinated and unvaccinated subgroups. Almost all vaccinated patients of different subgroups (based on vaccine type) had higher anti-S IgG avidity, while the statistical significance was detected only between those receiving Sinopharm compared to the unvaccinated subgroup. Also, statistically significant differences in antibody AIs were only found between primarily infected individuals of the two groups. Our findings indicate a key role for anti-SARS-CoV-2 IgG avidity in protection from symptomatic COVID-19 and calls for the incorporation of antibody avidity measurement into the current diagnostic tests to predict effective immunity toward SARS-CoV-2 infection or even for prognostic purposes.

Incidence of symptomatic gallstones after bariatric surgery: the impact of expectant management

BACKGROUND

Bariatric surgery is the most effective treatment for sustained weight reduction and obesity-related comorbidities. The development of gallstones as a result of rapid weight loss is a well-known consequence of bariatric procedures. It remains unclear, if there is an increased risk of these gallstones becoming symptomatic.

METHODS

A retrospective analysis of 505 consecutive patients submitted to either Roux-en-Y Gastric Bypass or Sleeve Gastrectomy between January and December 2019 was performed. The aim of our study was to determine the incidence of symptomatic cholelithiasis in asymptomatic patients with their gallbladder in situ after bariatric surgery and to identify potential risk factors for its development.

RESULTS

Of the 505 patients included, 79 (15.6%) underwent either previous cholecystectomy. (n = 67, 84.8%) or concomitant cholecystectomy during bariatric surgery (n = 12, 15.2%). Among the remaining 426 (84.4%) patients, only 8 (1.9%) became symptomatic during the 12-month follow-up period. When compared with patients who remained asymptomatic, they had a higher median preoperative BMI (47.0 vs. 42.8, p = 0.046) and prevalence of cholelithiasis on preoperative ultrasound (62.5% vs. 10.7%, p = 0.001). Multivariate analysis revealed preoperative BMI and cholelithiasis on preoperative ultrasound as independent risk factors for symptomatic biliary disease (OR 1.187, 95%CI 1.025-1.376, p = 0.022 and OR 10.720, 95%CI 1.613-71.246, p = 0.014, respectively).

CONCLUSION

Considering a low incidence of symptomatic gallstones after bariatric surgery, concomitant cholecystectomy should only be performed in symptomatic patients undergoing bariatric surgery. Preoperative factors, such as a higher BMI and positive ultrasound for cholelithiasis, may be related to the development of symptomatic gallstones.

Symptomatic calcifying odontogenic cyst in the maxilla, a case report with a literature review

INTRODUCTION

Calcifying odontogenic cysts (COC) are rare lesions classified as developmental cysts and occur mostly in the maxillary and mandibular bone. Some of the COCs are related to odontogenic lesions.

CASE PRESENTATION

We report a 60-year-old man with COC of the maxillary bone, presenting after tooth extraction. The patient has a palpable tender mass at the right upper tooth area. Imaging shows a well-defined radiolucency in the 7-3 tooth area of the right upper jaw. The combination of radiologic data and histopathologic findings was in keeping with the calcifying odontogenic cyst. Total enucleation is the chosen treatment for COC. No recurrence is proved by X-ray imaging after 1-year follow-up.

DISCUSSION

COC is a rare entity of odontogenic cysts and needs an exact diagnosis by pathology examination to estimate behavior.

CONCLUSION

Our case report offers significant data that could help clinicians and surgeons as well as pathologists with the diagnosis and management of these lesions.

Patient-reported outcome measures show FIT as an acceptable investigation to rule out colorectal cancer in the two-week wait cohort

INTRODUCTION

Use of faecal immunochemical testing (FIT) for symptomatic patients is increasing. FIT is recommended as a triage tool from primary care to the two-week wait (TWW) suspected cancer pathway, but there is still little known about patient attitudes.

AIM

The aim of this study was to explore patient opinions of FIT and how it might be applied in the TWW pathway.

METHODS

A telephone survey was conducted for patients from the TWW pathway who had undergone both conventional colonic investigation and FIT. Five questions explored expectations, attitudes towards results and experience of the investigations using a Likert scale 1-5. Differences in opinion were compared using median and mode scores and visualised using bar charts.

RESULTS

One hundred and nine TWW patients agreed to answer the five questions. All had taken a stool sample for FIT, 50 underwent colonoscopy, 51 had a CT colonography and 8 underwent flexible sigmoidoscopy. Most patients (85%) scored 5 (completely satisfied) with these conventional colonic investigation methods they underwent for ruling out colorectal cancer (median 5). However, 30% of patients scored 5 (completely satisfied) if using a negative FIT to not require additional colonic investigation. The median score to perform FIT was 5 (very easy) compared with a median of 4 (easy) to undergo the other colonic investigations.

CONCLUSIONS

Symptomatic patients can perform FIT with little difficulty, and often would have been happy to avoid conventional colonic investigations with a negative result. However, shared decision-making should be employed to identify those who would be dissatisfied with relying on FIT for further investigation decisions.

The importance of hypophosphatemia in the clinical management of primary hyperparathyroidism

AIM

The levels of serum phosphorus (P) are low or low-normal in primary hyperparathyroidism (PHPT), and there is an inverse relationship between the levels of parathormone (PTH) and P. However, when considering the diagnostic and surgical indication criteria of PHPT, serum P levels are generally ignored. The aim of this study was to retrospectively evaluate the association of serum P levels with the clinical outcomes of PHPT.

MATERIALS AND METHODS

A retrospective evaluation was made of the data of 424 consecutive patients (370 females, 54 males) with PHPT who presented at our centre.

RESULTS

The mean age of the study population was 57 ± 11.68 years. The mean P was 2.57 ± 0.53 mg/dl. Asymptomatic disease was determined in 199 (47%) patients. Male patients had significantly lower levels of P. Symptomatic patients and patients with renal stones, vitamin D < 20 µg/l, calcium level ≥ 11.2 mg/dl, 24 h urinary calcium > 400 mg/day, or hypomagnesemia, were seen to have significantly lower levels of P (p < 0.05). Hypophosphatemia (hypoP) was found in 202 of 424 patients (47%), and these patients had a higher rate of symptomatic disease (63% to 44%, p < .0001). Of the 61 (88%) patients with moderate hypoP, 54 (88%) had at least one of the surgical criteria. A statistically significant increase in the incidence of hypoP was determined in symptomatic and male patients. In the patients with hypoP, serum PTH and urine calcium levels were found to be higher, and lumbar T-scores and serum vitamin D levels were lower. The patients with hypoP had higher rates of renal stones and osteoporosis (p < 0.05).

CONCLUSIONS

The current study results show that hypoP is associated with a higher risk of osteoporosis and renal stones in PHPT patients. Even if patients are asymptomatic, moderate hypoP may be associated with poor outcomes of PHPT. Therefore, moderate hypoP may be a new criterion for parathyroidectomy, regardless of hypercalcemia level.

Short jump vein graft for the treatment of symptomatic Riles type 1A occlusion of common carotid artery: case report and review of literature

A 62-year-old man was presented with transient ischemic attack 1 day after percutaneous coronary intervention. Magnetic resonance imaging demonstrated fresh cerebral infarction in the left hemisphere. Digital subtraction angiography showed left Riles type 1A common carotid artery occlusion (CCAO). Blood flow in the internal carotid artery (ICA) was derived from the external carotid artery, which came through the anastomosis between the left occipital artery and a muscular branch of left vertebral artery. We performed short jump graft from CCA to ICA using saphenous vein, followed by ligation of CCA. The graft remained patent at the 1-year follow-up.

A comparison of SARS-CoV-2 rapid antigen testing with realtime RT-PCR among symptomatic and asymptomatic individuals

BACKGROUND

Identification of SARS-CoV-2 positive patients with rapid and cost-effective test methods is the key for isolating infected individuals, interrupting the transmission chain, and thus, containment of the CoVID-19 disease. In this regard, Rapid Antigen Test (RAT) plays an important role at point of care testing but the low sensitivity attributing towards escape of positive cases is reported as a major disadvantage of RAT which led us to evaluate a RAT kit among symptomatic and asymptomatic individuals suspected of CoVID-19.

METHODS

We analyzed 329 parallel nasopharyngeal swabs for RAT (Zydus Cadila, India) at the point of collection in a hospital-based facility and RealTime RT-PCR in the laboratory. The performance parameters were analyzed by evaluating the specificity, sensitivity, Negative Predictive Value (NPV), Positive Predictive Value (PPV), and Kappa coefficient.

RESULTS

The sensitivity and specificity were found to be 75.17% and 98.89% respectively. Positive Predictive value was 98.25% and the negative predictive value was 82.79%. The accuracy between the two techniques was found to be 88.14% with a kappa coefficient of 0.756 (SE: 0.036 and CI at 95%: 0.686 to 0.826) with a good strength of agreement (0.61-0.80) between the two testing techniques. Among the false-negative cases, 22 (59.5%) were asymptomatic having the Cycle Threshold (Ct) range 27 to 32.9 including 12 cases with a history of close contact with the known positive cases (i.e. household contact). The remaining 15 cases (40.5%) were symptomatic having low to moderate Ct values.

CONCLUSION

It is observed from the results that the false negative result for symptomatic individuals is a matter of concern as it was noted in 4 cases of our study subjects who required hospitalisation later. Also the positives among asymptomatic contacts are important from epidemiological point of view for isolation and curtailing the infection from spreading in a community. These results support the fact that RAT showing sensitivity below 80% can be used for mass screening purposes with provision for additional testing in case of false negative with symptomatic individuals. Also false-negative results should be interpreted cautiously considering the epidemiological link as well as the clinical condition of the patients.

Prospective population-level validation of the Abbott ID NOW severe acute respiratory syndrome coronavirus 2 device implemented in multiple settings for testing asymptomatic and symptomatic individuals

OBJECTIVE

Diagnostic evaluation of the ID NOW coronavirus disease 2019 (COVID-19) assay in various real-world settings among symptomatic and asymptomatic individuals.

METHODS

Depending on the setting, the ID NOW testing was performed using oropharyngeal swabs (OPSs) taken from patients with symptoms suggestive of COVID-19, asymptomatic close contacts, or asymptomatic individuals as part of outbreak point prevalence screening. From January to April 2021, a select number of sites switched from using OPS to combined oropharyngeal and nasal swab (O + NS) for ID NOW testing. For every individual tested, two swabs were collected by a health care worker: one swab (OPS or O + NS) for ID NOW testing and a separate swab (OPS or nasopharyngeal swab) for RT-PCR.

RESULTS

A total of 129 112 paired samples were analysed (16 061 RT-PCR positive). Of these, 81 697 samples were from 42 COVID-19 community collection sites, 16 924 samples were from 69 rural hospitals, 1927 samples were from nine emergency shelters and addiction treatment facilities, 23 802 samples were from six mobile units that responded to 356 community outbreaks, and 4762 O + NS swabs were collected from three community collection sites and one emergency shelter. The ID NOW assay sensitivity was the highest among symptomatic individuals presenting to community collection sites (92.5%; 95% CI, 92.0-93.0%) and the lowest for asymptomatic individuals associated with community outbreaks (73.9%; 95% CI, 69.8-77.7%). Specificity was >99% in all populations tested.

DISCUSSION

The sensitivity of ID NOW severe acute respiratory syndrome coronavirus 2 testing is the highest when used in symptomatic community populations not seeking medical care. Sensitivity and positive predictive value drop by approximately 10% when tested on asymptomatic populations. Using combined oropharyngeal and nasal swabs did not improve the performance of ID NOW assay.

CT perfusion alterations in patients with symptomatic and asymptomatic unilateral middle cerebral artery severe stenosis or occlusion

OBJECTIVE

To investigate the changes in CT perfusion between symptomatic and asymptomatic patients with unilateral middle cerebral artery severe stenosis or occlusion.

METHODS

A total of 64 consecutive patients with unilateral middle cerebral artery severe stenosis or occlusion admitted to the First Affiliated Hospital of Xinxiang Medical College from January 2019 to March 2022 were retrospectively analyzed and divided into the symptomatic group (n=33), and the asymptomatic group (n=31). Clinical data of the two groups were collected. Multivariate logistic regression analysis was performed to analyze the factors of symptomatic and asymptomatic MCA stenosis. A t-test was performed to compare the differences in cerebral perfusion parameters between the two groups.

RESULTS

Multivariate logistic regression analysis indicated that glycosylated hemoglobin levels and high-density lipoprotein cholesterol levels were associated with the development of asymptomatic MCA severe stenosis or occlusion (odds ratio =1.591 and 0.04, respectively). There were significant differences in CBV, MTT, and TTP between symptomatic and asymptomatic groups (P<0.05). The CBF of the affected side in the symptomatic group was lower than that of the unaffected side (P<0.05), whereas the asymptomatic group in CBF was not. Compared with the asymptomatic group, the CBF, MTT, and TTP of the affected side were significantly different (P<0.05). In contrast, the cerebral perfusion parameters of the unaffected side were not significantly different (P>0.05).

CONCLUSION

The use of CT perfusion imaging to analyze the alterations in cerebral perfusion parameters in patients with symptomatic and asymptomatic MCA severe stenosis or occlusion was helpful in clinical diagnosis and selecting treatment strategies and judging the development of the disease.

Symptomatic and Asymptomatic SARS-CoV-2 Infection and Follow-up of Neutralizing Antibody Levels

OBJECTIVE

To investigate neutralizing antibody levels in symptomatic and asymptomatic patients with coronavirus disease 2019 (COVID-19) at 6 and 10 months after disease onset.

METHODS

Blood samples were collected at three different time points from 27 asymptomatic individuals and 69 symptomatic patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Virus-neutralizing antibody titers against SARS-CoV-2 in both groups were measured and statistically analyzed.

RESULTS

The symptomatic and asymptomatic groups had higher neutralizing antibodies at 3 months and 1-2 months post polymerase chain reaction confirmation, respectively. However, neutralizing antibodies in both groups dropped significantly to lower levels at 6 months post-PCR confirmation.

CONCLUSION

Continued monitoring of symptomatic and asymptomatic individuals with COVID-19 is key to controlling the infection.

Management of Patients with Uncomplicated Symptomatic Isolated Mesenteric Artery Dissection: a Multicentre Experience

OBJECTIVE

Isolated mesenteric artery dissection (IMAD) is an increasingly diagnosed disease. However, multicentre studies to support clinical decision making are limited. This multicentre retrospective study aimed to investigate the characteristics, treatment options, and outcomes of IMAD.

METHODS

Data from consecutively enrolled patients with IMAD between October 2009 and May 2021 at three hospitals were collected retrospectively. One hundred and ninety uncomplicated symptomatic IMAD patients were divided into two groups: conservative (n = 141) and operative (n = 49). The costs, length of hospital stay, factors affecting outcomes, symptom relief, and complete remodelling of superior mesenteric artery (SMA) were analysed between the two groups.

RESULTS

Compared with patients who received operative treatment, patients receiving conservative treatment had shorter hospital stays (8.2 ± 4.6 vs. 11.9 ± 6.4 day, p < .020) and lower hospital costs (14 900 ± 1 048 vs. 60 400 ± 7 733 yuan, p < .001). In contrast, patients receiving operative treatment showed higher complete SMA remodelling (95.9% vs. 51.8%, p < .001). The cumulative rate of symptom relief was similar between the groups (p = .71). The rates were 78% vs. 79%, 87% vs. 87%, 89% vs. 87% at one, 12, and 60 months in the conservative and operative groups, respectively. Further subgroup analysis showed that endovascular treatment of IMAD had the advantage of shorter hospital stays than open surgery (10.7 ± 4.5 vs. 25.2 ± 9.4 days, p < .010). Univariable analysis showed that Sakamoto type II was associated with failed complete SMA remodelling (odds ratio 0.34; 95% confidence intervals 0.13 - 0.91; p = .031).

CONCLUSION

IMAD patients achieved good long term survival and symptom relief regardless of the treatment. Sakamoto type II IMAD is a risk factor for failed complete SMA remodelling. Although endovascular treatment provided a higher rate of complete SMA remodelling, the conservative group had statistically significantly shorter hospital stays, lower hospital costs, and similar cumulative rates of symptom relief. Therefore, this study supports conservative treatment as the main strategy for uncomplicated symptomatic IMAD patients.

Acute abdominal pain due to sigmoid volvulus with persistent descending mesocolon: a case report

Background

Persistent descending mesocolon, an anomaly of fixation of the mesentery of the descending colon, can sometimes cause complications such as intestinal obstruction and intussusception. We present the first reported case of sigmoid volvulus with persistent descending mesocolon.

Case presentation

An 82-year-old Japanese man had intermittent lower abdominal pain. Abdominal computed tomography showed dilation and a shift to the right side of the sigmoid colon, but no findings of volvulus. The next day, he presented continuous lower abdominal pain with bloody stool. A second abdominal computed tomography showed strangulation and dilation of the sigmoid colon, with shift from the right side of the abdominal cavity to the pelvic space. This suggested the descending colon was running to the medial side with sigmoid volvulus. Emergency surgery was performed for volvulus with persistent descending mesocolon. Operative findings revealed dilation of the sigmoid colon with a partial poorly colored region and strangulation that caused volvulus. After releasing the strangulation of the sigmoid colon, the descending colon was revealed to be running more to the medial side, with adherence to small intestinal mesentery. There was no Toldt’s fusion fascia at the descending colon. Persistent descending mesocolon was therefore diagnosed due to abnormality of fixation of the descending colon. The sigmoid colon, including the poorly colored region, was resected and reconstructed, while the inferior mesenteric and left colonic arteries were preserved because of the complexity of the vascular system running around the descending and sigmoid colon due to the shortened mesentery. These findings were pathologically compatible with circulatory compromise and intestinal degeneration due to sigmoid volvulus. The patient had no complications after discharge, including in relation to defecation.

Conclusion

Persistent descending mesocolon can occasionally cause acute abdominal symptoms requiring immediate treatment. A computed tomography finding of the descending colon running more to the medial side than ordinary cases can aid diagnosis of persistent descending mesocolon.

[Symptomatic arachnoid cyst in an elderly patient who developed motor aphasia]

The patient was an 83-year-old woman with a history of breast cancer, distal right radial edge bone fracture, and cervical spine symptoms who had been diagnosed with an arachnoid cyst 9 years previously. She was examined by a nearby doctor, because of an approximately 1-year history of reduced verbal output; she also begun experiencing difficulties with walking. However, she was diagnosed with aging, a history of cervical spondylosis, and the effects of past fractures.At the time of this consultation, she was conscious and lucid, with mild right-sided hemiparesis, was unable to write, and had mild motor aphasia. Head magnetic resonance imaging revealed an arachnoid cyst (longer axis: 10 cm) in the left frontal lobe that did not take up contrast media. There was also a midline shift. The cause of the right hemiparesis and motor aphasia was probably compression of the left frontal lobe by the arachnoid cyst.We performed excision of the cyst wall by craniotomy and placed a cyst-peritoneal shunt under general anesthesia. At approximately one week after surgery, the patient was able to write and her motor aphasia improved. She was discharged 20 days after the operation.It is rare for an arachnoid cyst to increase in size after childhood. In the present case, surgical treatment led to a good outcome in an elderly patient with a symptomatic arachnoid cyst. Arachnoid cysts rarely increase in size. These cysts may become symptomatic in elderly people after lying clinically dormant for a long time.

Decision Aids for Determining Facility Versus Non-Facility-Based Exercise in Those with Symptomatic Peripheral Artery Disease

Purpose of Review

This paper sought to provide rationale for determining when a patient with symptomatic peripheral artery disease (PAD) might be referred for home-based versus facility-based exercise therapy.

Recent Findings

Multiple randomized controlled studies have embedded supervised, structured exercise therapy as a class IA recommended therapy for those with symptomatic PAD. More recently, there is interest in non-facility-based exercise training as an alternative. The current literature is mixed on the effectiveness of non-facility-based training and is influenced by the amount of contact with clinical staff providing some supervision (e.g., occasional facility-based exercise or coaching phone calls), and the intensity (e.g., performed intermittently by inducing pain or continually and not inducing pain) and frequency (e.g., 12-week common supervised exercise program or those longer than 24 weeks) of exercise. Certainly, the data suggests non-facility-based exercise, while possibly improving walking performance, is inferior to facility-based supervised exercise training. Comprehensive data is lacking on utilization of supervised exercise therapy in those with symptomatic PAD, but is likely <2% of those eligible who participate. This suggests a possible important role for alternatives including non-facility-based (e.g., home, fitness center).

Summary

Exercise training in the supervised, facility-based setting appears to be greatly underutilized. Non-facility-based exercise may help to overcome some of the most common barriers to participating in facility-based exercise including those related to motivation, transportation, and proximity. However, facility-based training is considered the gold standard so decisions about allowing a patient to exercise train at home must take into account issues including disease severity, patient motivation and available exercise resources, mobility and balance, cognitive function, and other medical concerns (e.g., symptomatic coronary artery disease or heart failure).

Circulating Biomarkers Predict Symptomatic but Not Asymptomatic Carotid Artery Stenosis

BACKGROUND

Subjects exposed to risk factors such as age, gender, hypertension, diabetes mellitus, and smoking are prone to atherosclerotic events.

AIMS

The main aim of this longitudinal cohort study was to determine whether the role of novel plasma biomarkers for atherosclerotic carotid artery disease is different in subjects developing symptomatic carotid artery stenosis (CAS), as opposed to those with incident asymptomatic CAS.

METHODS

The following biomarkers were measured in 5,550 middle-aged subjects in a population-based cohort study: C-reactive protein (CRP), lipoprotein-associated phospholipase A2 mass and activity, proneurotensin, midregional proadrenomedullin (MR-proADM), midregional proatrial natriuretic peptide (MR-proANP), N-terminal pro-B-type natriuretic peptide (NT pro-BNP), copeptin, and cystatin C. After exclusion of those with prevalent CAS, subjects were thereafter followed in national patient registers for 23.4 (interquartile range 19.5-24.3) years regarding incident symptomatic and asymptomatic CAS.

RESULTS

Among 110 patients with confirmed incident CAS, 56 were symptomatic and 54 were asymptomatic. When including conventional risk markers in a Cox regression analysis, NT pro-BNP (hazard ratio [HR] 1.59; 95% confidence interval [CI]: 1.20-2.11), MR-proADM (HR 1.40; CI: 1.13-1.73), cystatin C (HR 1.21; CI: 1.02-1.43), and CRP (HR 1.53; CI: 1.13-1.73) were independently associated with incident symptomatic CAS, whereas no plasma biomarker was associated with incident asymptomatic CAS.

CONCLUSION

Plasma biomarkers NT pro-BNP, MR-proADM, cystatin C, and CRP were independently associated with incident symptomatic CAS, whereas no such association could be demonstrated with incident asymptomatic CAS. As these biomarkers indicate future development of clinically relevant atherosclerotic CAS, their potential utility in relation to intensified preventive measures and selection of potential candidates for carotid surgery should be further evaluated.

An Audit of Systemic Therapy in Medullary Carcinoma Thyroid

There is a paucity of evidence of the impact of sorafenib on MCT and it is the preferred therapy used in India. We decided to do an audit of all patients of MCT who were referred to us for systemic therapy. The objective of this exercise was to identify the treatment pattern, outcomes, and adverse events with therapy in MCT. Baseline demographics (age, gender, ECOG PS, comorbidities, habits), tumor details (site of metastasis), previous treatment details, clinical features at metastasis (symptomatic or asymptomatic), the pattern of treatment, adverse events (CTCAE version 4.02), date of progression, date of death and status, and follow-up were extracted from the rare tumor database and electronic medical records. Out of 75 patients referred for therapy for MCT, 47 (62.7%) patients were considered for immediate tyrosine kinase inhibitors as they had symptomatic status and 28 (37.3%) patients were kept on observation due to the asymptomatic nature of the disease. Out of the 28 patients, 15 (53.6%, n = 28) patients were subsequently started on TKI while in 13 (46.4%, n = 28) patients observation was continued. In the overall cohort, the median PFS was 18.9 months (95% CI 11.9-29.9) and OS was 26.6 months (95% CI 14.4-39.0). Among variables tested, only female gender had an impact on PFS (hazard ratio = 0.364 95% CI 0.148-0.895; P = 0.028) and the absence of lung metastasis had a positive impact on OS (hazard ratio = 0.443 95% CI 0.207-0.95; P = 0.037). Most commonly used TKI was sorafenib (n = 61) and sunitinib in 1 patient. The most common adverse events with TKI were palmo-plantar dysesthesia (50, 80.6%) and oral mucositis (25, 40.2%). The strategy of treating symptomatic MCT and observing in asymptomatic MCT is associated with reasonable PFS and OS. Sorafenib is the most commonly used TKI in our setup and provides similar outcomes as globally.

Platelet Biomarkers in Patients with Atherosclerotic Extracranial Carotid Artery Stenosis: A Systematic Review

OBJECTIVE

The aim was to enhance understanding of the role of platelet biomarkers in the pathogenesis of vascular events and risk stratifying patients with asymptomatic or symptomatic atherosclerotic carotid stenosis.

DATA SOURCES

Systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

REVIEW METHODS

A systematic review collated data from 1975 to 2020 on ex vivo platelet activation and platelet function/reactivity in patients with atherosclerotic carotid stenosis.

RESULTS

Forty-three studies met the inclusion criteria; the majority included patients on antiplatelet therapy. Five studies showed increased platelet biomarkers in patients with ≥ 30% asymptomatic carotid stenosis (ACS) vs. controls, with one neutral study. Preliminary data from one study suggested that quantification of "coated platelets" in combination with stenosis severity may aid risk stratification in patients with ≥ 50% - 99% ACS. Platelets were excessively activated in patients with ≥ 30% symptomatic carotid stenosis (SCS) vs. controls (≥ 11 positive studies and one neutral study). Antiplatelet-High on Treatment Platelet Reactivity (HTPR), previously called "antiplatelet resistance", was observed in 23% - 57% of patients on aspirin, with clopidogrel-HTPR in 25% - 100% of patients with ≥ 50% - 99% ACS. Aspirin-HTPR was noted in 9.5% - 64% and clopidogrel-HTPR in 0 - 83% of patients with ≥ 50% SCS. However, the data do not currently support the use of ex vivo platelet function/reactivity testing to tailor antiplatelet therapy outside of a research setting. Platelets are excessively activated (n = 5), with increased platelet counts (n = 3) in recently symptomatic vs. asymptomatic patients, including those without micro-emboli on transcranial Doppler (TCD) monitoring (n = 2). Most available studies (n = 7) showed that platelets become more reactive or activated following carotid endarterectomy or stenting, either as an acute phase response to intervention or peri-procedural treatment.

CONCLUSION

Platelets are excessively activated in patients with carotid stenosis vs. controls, in recently symptomatic vs. asymptomatic patients, and may become activated/hyper-reactive following carotid interventions despite commonly prescribed antiplatelet regimens. Further prospective multicentre studies are required to determine whether models combining clinical, neurovascular imaging, and platelet biomarker data can facilitate optimised antiplatelet therapy in individual patients with carotid stenosis.

Combining the quantitative faecal immunochemical test and full blood count reliably rules out colorectal cancer in a symptomatic patient referral pathway

PURPOSE

Faecal Immunochemical Test (FIT) has proven utility for Colorectal Cancer (CRC) detection in symptomatic patients. Most studies have examined FIT in symptomatic patients subsequently referred from primary care. We investigated associations between CRC and FIT in both referred and non-referred symptomatic patients.

METHODS

A retrospective, observational study of all patients with a FIT submitted Aug 2018 to Jan 2019 in NHS GG&C was performed. Referral to colorectal/gastroenterology and decision to perform colonoscopy were recorded. FIT results were grouped as f-Hb < 10/10-149/150-399/ ≥ 400 μg/g. The MCN cancer registry identified new cases of CRC. Covariables were compared using the χ2 test. Multivariate binary logistic regression identified independent predictors of CRC.

RESULTS

A total of 4968 patients were included. Raised FIT correlated with decision to refer (p < 0.001) and scope (p < 0.001). With 23-month median follow-up, 61 patients were diagnosed with CRC. These patients were older (median 69 vs 59 years, cancer and no cancer respectively, p = 0.001), more likely to be male (55.7% vs 42.1%, p = 0.033), and to report rectal bleeding (51.7% vs 36.1%, p = 0.013). FIT (< 10 µg/g 8.2% vs 76.7% and ≥ 400 µg/g 55.7% vs 3.8%, p < 0.001) and anaemia (45.9% vs 19.7%, p < 0.001) were associated with CRC. On multivariate analysis, age (p = 0.023), male sex (p = 0.04), FIT (≥ 400 OR 54.256 (95% CI:20.683-142.325; p < 0.001)), and anaemia (OR 1.956 (1.071-3.574; p = 0.029)) independently predicted CRC. One patient (0.04%) with a negative FIT and normal haemoglobin had CRC.

CONCLUSION

GP referral and secondary care investigation patterns were influenced by FIT. The combination of normal Hb and f-Hb excluded CRC in 99.96% of cases, providing excellent reassurance to those prioritising access to endoscopy services.

Nasopharyngeal microbiome reveals the prevalence of opportunistic pathogens in SARS-CoV-2 infected individuals and their association with host types

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is causing a severe global health emergency owing to its highly infectious nature. Although the symptoms of SARS-CoV-2 are well known but its impact on nasopharyngeal microbiome is poorly studied. The present cross-sectional study was intended to understand the perturbation in the nasopharyngeal microbiome composition within the infected (n = 63) and non-infected (n = 26) individuals using 16S rRNA gene based targeted amplicon sequencing and their association with host types and the prevalence of opportunistic pathogens at the stage of infection. The results confirmed that number of OTUs were significantly (p < 0.05) decreased in the SARS-CoV-2 infected individuals in comparison to non-infected individuals. Pairwise Wilcoxon test showed a significant (p < 0.05) increase in the abundance of Proteobacteria in infected individuals compared to non-infected ones and vice-versa for Fusobacteria and Bacteroidetes. Similarity percentage (SIMPER) analysis showed the increment in the abundance of opportunistic pathogens (Haemophilus, Stenotrophomonas, Acinetobacter, Moraxella, Corynebacterium 1, Gemella, Ralstonia, and Pseudomonas) involved in secondary infection. Furthermore, this study highlighted the microbial community structure of individuals within and across the families. In this study, we also performed the assesment of microbiome associated with host types (age and genders) and COVID-19 conditions (symptomatic and asymptomatic). The data suggested that the host types/conditions during the COVID-19 infection are potential factors in enrichment of specific bacterial communities in upper respiratory tract.

Plasmodium falciparum msp1 and msp2 genetic diversity in parasites isolated from symptomatic and asymptomatic malaria subjects in the South of Benin

Symptomatic and asymptomatic malaria patients are considered as the reservoirs of human Plasmodium. In the present study, we have evaluated the Plasmodium falciparum merozoite surface protein-1 (Pfmsp1) and protein-2 (Pfmsp2) genetic diversity among the symptomatic and asymptomatic malaria infection from health facilities in Cotonou, Benin Republic. A cross-sectional study recruited 158 individuals, including 77 from the asymptomatic and 81 from the symptomatic groups. The parasites were genotyped using Nested Polymerase Chain Reaction. Samples identified as Plasmodium falciparum were genotyped for their genetic diversity. No significant difference was observed in the overall multiplicity of infection (MOI) between the asymptomatic and symptomatic groups. In the symptomatic group, the overall frequency of K1, MAD20, and RO33 allelic family was more predominant (98.5%) followed by 3D7 (87.3%) and FC27 (83.1%). However, in asymptomatic group, the K1 alleles were the most prevalent (100%) followed by FC27 (89.9%), 3D7 (76.8%), MAD20 (60.5%), and RO33 (35.5%). The frequency of multiple allelic types (K1+MAD20+RO33) at the Pfmsp1 loci in the symptomatic infections was significantly higher when compared to that of the asymptomatic ones (97% vs. 34%, p < 0.05), whereas no difference was observed in the frequency of multiple allelic types (3D7 and FC27) at the Pfmsp2 loci between the two groups. The high presence of msp1 multiple infections in the symptomatic group compared to asymptomatic ones suggests an association between the genetic diversity and the onset of malaria symptoms. These data can provide valuable information in the development of a vaccine that could reduce the symptomatic disease.

Single versus multiple and incidental versus symptomatic subsegmental pulmonary embolism: clinical characteristics and outcome

It remains unexplored if the clinical picture and outcome of subsegmental pulmonary embolism (SSPE) differ between single versus multiple, and incidental versus symptomatic embolism. Consecutive patients anticoagulated for SSPE at the Mayo Thrombophilia Clinic (03/01/2013-12/31/2020) were followed forward to assess venous thromboembolism (VTE) recurrence, mortality, major bleeding, and clinically relevant non-major bleeding (CRNMB); expressed as a rate per 100 person-years. Among 3878 VTE patients, 1541 had pulmonary embolism including 224 (14.6%) with SSPE either single (n = 139) or multiple (n = 85; 46 bilateral and 39 unilateral emboli); 134 had incidental and 90 symptomatic SSPE. Patients with single were less often symptomatic and less often had coexisting DVT than multiple SSPE. Patients with incidental had a two-fold higher frequency of cancer compared to symptomatic SSPE. During the study period, 1 patient with single and 2 with multiple SSPE had VTE recurrence (rate of 1.14 vs 3.63, p = 0.280). Single SSPE patients experienced 2 episodes of major bleeding (rate of 2.36) while the multiple SSPE group had no major bleeding. Seven patients in each group had CRNMB events (rate of 8.20 vs 13.58 for single and multiple SSPE, respectively, p = 0.282). Patients with single SSPE had a higher death rate compared to multiple SSPE (43.07 vs 22.22, p = 0.031) but no difference was noted after adjusting for cancer (p = 0.388). Also, incidental had similar clinical outcomes to symptomatic SSPE.Interpretation Anticoagulated SSPE patients with single and multiple as well as incidental and symptomatic have a different clinical profile but similar clinical outcomes.

Effectiveness and Tolerability of Trimetazidine 80 Mg Once Daily in Patients with Stable Angina Uncontrolled with Bisoprolol-Based Therapy: The Modus Vivendi Observational Study

Introduction

Modus Vivendi was conducted in routine clinical practice to evaluate the effect of adding trimetazidine 80 mg once daily (TMZ 80 OD) to treat patients with persistent symptoms despite treatment with background antianginal therapies including maximally tolerated bisoprolol.

Methods

This multicenter, prospective, observational, open-label, uncontrolled study recruited adult outpatients with a confirmed diagnosis of stable angina to whom physicians had decided to prescribe TMZ 80 OD. All patients were symptomatic despite treatment, including maximally tolerated doses of bisoprolol. Data on number of angina attacks, use of short-acting nitrates, and quality of life (QoL) were collected at baseline (V1) and at 1-month (V2) and 3-month (V2) follow-up visits. Two sub-analyses assessed efficacy in patients who remained on a stable bisoprolol dose throughout the study, and in patients in whom background antianginal therapy was known.

Results

A total of 1939 patients were recruited (57.2% women). The mean age was 65.6 ± 8.8 years; 73.8% had class II and 26.2% class III angina. At V1, the mean number of angina attacks per week was 6.2 ± 6.5 despite antianginal therapy including maximally tolerated bisoprolol dosage. Following the addition of TMZ 80 OD, this decreased to 3.4 ± 4.2 attacks per week at V2, and 1.6 ± 2.6 at V3 (P < 0.05 at V2 and V3), with concomitant reductions in short-acting nitrate use (P < 0.05). Significant improvements in QoL were observed throughout the study. Subgroup analyses showed that the addition of TMZ 80 OD to guideline-recommended antianginal therapy was associated with significant reductions in the mean number of weekly angina attacks and consumption of short-acting nitrates and improvements in QoL whether patients were treated with maximally tolerated bisoprolol and TMZ 80 OD alone, or maximally tolerated bisoprolol and TMZ 80 OD on top of other antianginal therapies. Treatment was well tolerated.

Conclusion

The study findings support the addition of TMZ 80 OD to bisoprolol with or without other antianginal therapies for patients with persistent angina.

Trial Registration

This study was retrospectively registered under the number ISRCTN29992579.

Physician-Modified Endografts Versus Chimney/Snorkel for Ruptured and Symptomatic Juxtarenal and Paravisceral Aneurysms in the Vascular Quality Initiative

OBJECTIVES

Ruptured and symptomatic juxtarenal and paravisceral aneurysms present technical challenges during endovascular repair. We sought to compare physician modification and fenestrated (PMEG) versus chimney/periscope/snorkel (CHIMPS) repair techniques for the treatment of ruptured and symptomatic paravisceral and juxtarenal aortic aneurysms (r/sPJAA).

METHODS

Patients in the thoracic and complex endovascular aneurysm module of the Vascular Quality Initiative (VQI) national registry undergoing CHIMPS and PMEG for r/sPJAA were included. Patients who underwent thoracic aneurysm repair with only celiac intervention or who had coverage or occlusion only of one renal or visceral branch vessel were excluded. One-year mortality was the primary outcome. Secondary outcomes included peri- and postoperative endoleak, hospital and ICU length of stay, reintervention, and other local and systemic complications.

RESULTS

A total of 81 CHIMPS and 47 PMEG patients were identified. Patients undergoing PMEG were more frequently symptomatic, had a history of CHF and were taking aspirin, statin and P2Y12 antiplatelet medications. Patients undergoing CHIMPS presented more frequently with rupture. There was no significant survival advantage for CHIMPS over PMEG patients (P = 0.5). There were no apparent long-term differences in the numbers of endoleaks or in the rates of subsequent reinterventions between the two groups.

CONCLUSIONS

It does not appear that the procedure type (CHIMPS versus PMEG) is associated with postoperative survival in patients with r/sPJAA. Not surprisingly, survival is associated with postoperative complications, particularly myocardial infarction and intestinal ischemia. Further research should evaluate reasons for failure to rescue from and the impact of postoperative complications on the postoperative survival after endovascular repair of r/sPJAA.

The Role of Ivabradine in Managing Symptomatic Patients with Chronic Coronary Syndromes: A Clinically Oriented Approach

Angina is a significant contributor to disability and impairment in quality of life in patients with chronic coronary syndromes (CCS). An elevated heart rate (HR) may trigger myocardial ischemia by increasing oxygen consumption and decreasing the diastolic time, compromising the coronary flow. HR-lowering strategies offer symptom control and prevent cardiovascular events in subgroups of patients with CCS. However, the best therapeutic approach to achieve the desired HR in patients with CCS can be challenging based on efficacy and tolerability. Guidelines usually propose β-blockers and/or non-dihydropyridine calcium channel blockers (CCB) for angina patients with elevated HR. Nonetheless, there is no clear evidence of greater antianginal efficacy of this strategy versus an alternative HR-lowering agent. Ivabradine reduces the HR by blocking the I_f current in the sinoatrial node without affecting myocardial contractility or vascular tone. The magnitude of the HR reduction by ivabradine is proportional to the initial HR, which decreases the risk of significant bradycardia. Ivabradine increases the diastolic time and the coronary flow reserve to a greater extent than β-blockers and favors collateralization, improving the regional blood flow. We present two clinical cases of patients with symptomatic CCS in whom HR control with ivabradine was fundamental for symptom control and improvement in left ventricular (LV) function. An earlier combination of ivabradine plus β-blockers would have provided more rapid symptom control and improved LV function in the first case. In the second case, the primary mechanism responsible for angina was most likely a coronary vasomotor abnormality, in which the use of β-blockers aggravated the discomfort. The combination of a dihydropyridine CCB plus ivabradine was highly influential in symptom control. Due to its effects beyond HR reduction and good tolerability, ivabradine should be considered an essential ally in managing patients with angina and high HR with or without LV dysfunction.

Stratifying outcome based on the Oswestry Disability Index for operative treatment of adult spinal deformity on patients 60 years of age or older: a multicenter, multi-continental study on Prospective Evaluation of Elderly Deformity Surgery (PEEDS)

BACKGROUND CONTEXT

Patients with adult spinal deformity suffer from disease related disability as measured by the Oswestry Disability Index (ODI) for which surgery can result in significant improvements.

PURPOSE

The purpose of this study was to show the change in overall and individual components of the ODI in patients aged 60 years or older following multi-level spinal deformity surgery.

STUDY DESIGN

Prospective, multicenter, multi-continental, observational longitudinal cohort study PATIENT SAMPLE: Patients ≥60 years undergoing primary spinal fusion surgery of ≥5 levels for coronal, sagittal or combined deformity.

OUTCOME MEASURES

Oswestry Disability Index (ODI) METHODS: : Patients completed the ODI pre-operatively for baseline, then at 10 weeks, 12 months and 24 months post-operatively. ODI scores were grouped into deciles, and change was calculated with numerical score and improvement or worsening was further categorized from baseline as substantial (≥20%), marginal (≥10-<20%) or no change (within 10%).

RESULTS

Two-hundred nineteen patients met inclusion criteria for the study. The median number of spinal levels fused was 9 [Q1=5.0, Q3=12.0]. Two-year mean (95% CI) ODI improvement was 19.3% (16.7%; 21.9%; p<.001) for all age groups, with mean scores improved from a baseline of 46.3% (44.1%; 48.4%) to 41.1% (38.5%; 43.6%) at 10 weeks (p<.001), 28.1% (25.6%; 30.6%) at 12 months (p<.001), and 27.0% (24.4%; 29.5%) at 24 months (p<.001). At 2 years, 45.5% of patients showed 20% or greater improvement in ODI, 23.7% improved between 10% and 20%, 26.3% reported no change (defined as±10% from baseline), 4.5% of patients reported a worsening between 10% to 20%, and none reported worsening greater than 20%. 59.0% of patients were severely disabled (ODI >40%) pre-operatively, which decreased to 20.2% at 2 years. Significant improvement was observed across all 10 ODI items at 12 and 24 months. The largest improvements were seen in pain, walking, standing, sex life, social life and traveling.

CONCLUSIONS

In this prospective, multicenter, multi-continental study of patients 60 years or older undergoing multi-level spinal deformity surgery, almost 70% of patients reported significant improvements in ODI without taking into account surgical indications, techniques or complications. Clear data is presented demonstrating the particular change from baseline for each decile of pre-operative ODI score, for each sub-score, and for each age group.

Performance of SARS-CoV-2 antigen testing in symptomatic and asymptomatic adults: a single-center evaluation

BACKGROUND

Antigen testing offers rapid and inexpensive testing for SARS-CoV-2 but concerns regarding performance, especially sensitivity, remain. Limited data exists for use of antigen testing in asymptomatic patients; thus, performance and reliability of antigen testing remains unclear.

METHODS

148 symptomatic and 144 asymptomatic adults were included. A nasal swab was collected for testing by Quidel Sofia SARS IFA (Sofia) as point of care. A nasopharyngeal swab was also collected and transported to the laboratory for testing by Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV RT-PCR (Cepheid).

RESULTS

Overall, Sofia had good agreement with Cepheid (> 95%) in adults, however was less sensitive. Sofia had a sensitivity of 87.8% and 33.3% for symptomatic and asymptomatic patients, respectively. Among symptomatic patients, testing > 5 days post symptom onset resulted in lower sensitivity (82%) when compared with testing within 5 days of symptom onset (90%). Of the four Sofia false-negative results in the asymptomatic cohort, 50% went on to develop COVID-19 disease within 5 days of testing. Specificity in both symptomatic and asymptomatic cohorts was 100%.

CONCLUSIONS

Sofia has acceptable performance in symptomatic adults when tested < 5 days of symptom onset. Caution should be taken when testing patients with ≥ 5 days of symptoms. The combination of low prevalence and reduced sensitivity results in relatively poor performance of in asymptomatic patients. NAAT-based diagnostic assays should be considered in when antigen testing is unreliable, particularly in symptomatic patients with > 5 days of symptom onset and asymptomatic patients.

Performance of SARS-CoV-2 antigen testing in symptomatic and asymptomatic adults: a single-center evaluation

Background

Antigen testing offers rapid and inexpensive testing for SARS-CoV-2 but concerns regarding performance, especially sensitivity, remain. Limited data exists for use of antigen testing in asymptomatic patients; thus, performance and reliability of antigen testing remains unclear.

Methods

148 symptomatic and 144 asymptomatic adults were included. A nasal swab was collected for testing by Quidel Sofia SARS IFA (Sofia) as point of care. A nasopharyngeal swab was also collected and transported to the laboratory for testing by Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV RT-PCR (Cepheid).

Results

Overall, Sofia had good agreement with Cepheid (> 95%) in adults, however was less sensitive. Sofia had a sensitivity of 87.8% and 33.3% for symptomatic and asymptomatic patients, respectively. Among symptomatic patients, testing > 5 days post symptom onset resulted in lower sensitivity (82%) when compared with testing within 5 days of symptom onset (90%). Of the four Sofia false-negative results in the asymptomatic cohort, 50% went on to develop COVID-19 disease within 5 days of testing. Specificity in both symptomatic and asymptomatic cohorts was 100%.

Conclusions

Sofia has acceptable performance in symptomatic adults when tested < 5 days of symptom onset. Caution should be taken when testing patients with ≥ 5 days of symptoms. The combination of low prevalence and reduced sensitivity results in relatively poor performance of in asymptomatic patients. NAAT-based diagnostic assays should be considered in when antigen testing is unreliable, particularly in symptomatic patients with > 5 days of symptom onset and asymptomatic patients.

Modelling and analysis of a SEIQR model on COVID-19 pandemic with delay

This paper deals with mathematical modelling and analysis of a SEIQR model to study the dynamics of COVID-19 considering delay in conversion of exposed population to the infected population. The model is analysed for local and global stability using Lyapunov method of stability followed by Hopf bifurcation analysis. Basic reproduction number is determined, and it is observed that local and global stability conditions are dependent on the number of secondary infections due to exposed as well as infected population. Our study reveals that asymptomatic cases due to exposed population play a vital role in increasing the COVID-19 infection among the population.

Evaluation of molecular testing for Mycoplasma genitalium for symptomatic women

Mycoplasma genitalium is an emerging cause of sexually transmitted infections (STI) with a capacity to rapidly develop antibiotic resistance. The aim of this work was to carry out an evaluation and descriptive analysis of routine molecular testing of M. genitalium in symptomatic women at the Rotunda Hospital, Dublin January 2018-December 2019. 1972 specimens were tested from1291 individual symptomatic female patients > 18 years old. The median age was 29 (range 18-71). There were 10 confirmed positive specimens (0.77%); median patient age 26 (range 18-34); seven were obstetrics/gynaecology patients and three were attendees at a sexual assault treatment unit (SATU). The prevalence of positive cases in the ≥ 18 ≤ 30-year-old age group (n = 683) was six times that of the ≥ 30 year-old age group (n = 608) at 1.3% versus 0.2%. Patient symptoms included: discharge in five (50%); pelvic pain on examination in five (50%); abdominal pain in two (20%); pelvic bleeding in two (20%); dyspareunia in two (20%) patients. Co-infections were present in three patients (30%). Macrolide resistance was detected in two positives (28.6%). This initial pilot study prompts the following recommendations which require further study and consideration: 1. promotion of M. genitalium status to notifiable disease; 2 widespread screening of female population not warranted; 3. M. genitalium testing for women symptomatic for STIs; 4. antibiotic resistance testing of all positive cases. 5. Further research into other potential risk groups.

Symptomatic and restorative therapies in neuromyelitis optica spectrum disorders

Neuromyelitis optica spectrum disorders (NMOSD) are a group of autoimmune inflammatory conditions that primarily target the optic nerves, spinal cord, brainstem, and occasionally the cerebrum. NMOSD is characterized by recurrent attacks of visual, motor, and/or sensory dysfunction that often result in severe neurological deficits. In recent years, there has been a significant progress in relapse treatment and prevention but the residual disability per attack remains high. Although symptomatic and restorative research has been limited in NMOSD, some therapeutic approaches can be inferred from published case series and evidence from multiple sclerosis literature. In this review, we will discuss established and emerging therapeutic options for symptomatic treatment and restoration of function in NMOSD. We highlight NMOSD-specific considerations and identify potential areas for future research. The review covers pharmacologic, non-pharmacologic, and neuromodulatory approaches to neuropathic pain, tonic spasms, muscle tone abnormalities, sphincter dysfunction, motor and visual impairment, fatigue, sleep disorders, and neuropsychological symptoms. In addition, we briefly discuss remyelinating agents and mesenchymal stem cell transplantation in NMOSD.

Role of Total Thyroidectomy in Painful (Symptomatic) Hashimoto's Thyroiditis: Descriptive Study

Hakura Hashimoto described Hashimoto's Thyroiditis (HT) in 1912. In HT, there occurs formation of antibodies against the self (thyroid), which causes enlargement of the thyroid gland as a whole and decreased thyroid hormone levels. Most of the patients with HT are given medical line of management (hypo/hyperthyroidism). The indications for surgical line of management for HT are due to pressure symptoms over the trachea and oesophagus, pain in the thyroid gland and for chance of malignancy. Surgical treatment gives complete relief from pain and pressure symptoms and also prevents the risk of malignancy. To evaluate the outcome and complications of total thyroidectomy in painful (symptomatic) Hashimoto's thyroiditis. It was a Hospital based Descriptive study conducted in tertiary care teaching hospital by ENT Department, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry from Nov 2017 to May 2019. Sample size was 30. All patients with symptomatic (painful) HT was given trail of medical therapy (steroids and NSAIDS), following repeated attempts of failed medical therapy, surgical management (total thyroidectomy) was preferred. Visual Analog Scale (VAS) was used to assess the pain grading pre and post operatively. MS Excel and SPSS trial version 20 software was used to analyze the data. The Wilcoxan Signed Ranked test was used as test of significance to identify the difference between ordinal variables. In this study, all the 30 patients had pain as the predominant symptom. Visual Analog Scale was used to grade the pain in all the patients preoperatively and 2 weeks postoperatively. All the patients had significant reduction in the pain following total thyroidectomy, when compared to pre-operative VAS grading. Total thyroidectomy is the technique of choice in surgical treatment of symptomatic Hashimoto's thyroiditis (pain, tenderness and pressure symptoms) which warrants a radical and definitive control of the disease, without any risk of relapse and without the side effects of medical management. Moreover in longstanding cases of HT, the risk of malignant transformation is prevented due to total thyroidectomy. In experienced hands it assures total relief of compressive and painful symptoms and low incidence of/nil major complications.

Symptomatic and asymptomatic peripheral artery disease and the risk of abdominal aortic aneurysm: The Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND AND AIMS

Symptomatic peripheral artery disease (PAD) is a risk factor for abdominal aortic aneurysm (AAA). However, data on the association of asymptomatic PAD with AAA are limited. We explored the association of symptomatic and asymptomatic PAD with AAA.

METHODS

We primarily assessed a prospective association of symptomatic (based on clinical history) and asymptomatic (ankle-brachial index ≤0.9) PAD at baseline (1987-89 [ages 45-64 years]) with incident AAA in a biracial community-based cohort, the Atherosclerosis Risk in Communities Study. We secondarily investigated a cross-sectional association of PAD with ultrasound-based AAA (diameter≥3.0 cm) (2011-13 [ages 67-91 years]).

RESULTS

Of 14,148 participants (55.1% female, 25.5% black, 0.9% with symptomatic PAD) in our prospective analysis (median follow-up 22.5 years), 530 (3.7%) developed incident AAA. Symptomatic PAD had a higher hazard ratio (HR) of incident AAA [4.91 (95%CI 2.88-8.37)], as did asymptomatic PAD with ABI≤0.9 [2.33 (1.55-3.51)], compared to the reference ABI>1.1-1.2 in demographically-adjusted models. Crude 15-year cumulative incidence of AAA in these three groups were 12.3%, 3.9%, and 1.5%, respectively. The associations remained significant after accounting for other potential confounders [corresponding HR 2.96 (95%CI 1.73-5.07) and 1.52 (95%CI 1.00-2.30), respectively]. The cross-sectional analysis demonstrated similar patterns with ultrasound-based AAA [odds ratio 2.46 (95%CI 1.26-4.81) for symptomatic PAD and 3.98 (1.96-8.08) for asymptomatic PAD in a demographically-adjusted model].

CONCLUSIONS

Our prospective and cross-sectional data show elevated risk of AAA in both symptomatic and asymptomatic PAD. Our data support the current recommendation of AAA screening in symptomatic PAD patients and suggest the potential extension to asymptomatic PAD patients as well.

Prevalence and risk factors of intestinal protozoan infection among symptomatic and asymptomatic populations in rural and urban areas of southern Algeria

BACKGROUND

Intestinal parasitic infections are amongst the most common infections worldwide and have been identified as one of the most significant causes of morbidity and mortality among disadvantaged populations. This comparative cross-sectional study was conducted to assess the prevalence of intestinal protozoan infections and to identify the significant risk factors associated with intestinal parasitic infections in Laghouat province, Southern Algeria.

METHODS

A comparative cross-sectional study was conducted, involving 623 symptomatic and 1654 asymptomatic subjects. Structured questionnaires were used to identify environmental, socio demographic and behavioral factors. Stool specimens were collected and examined using direct wet mount, formalin-ether concentration, xenic in vitro culture and staining methods.

RESULTS

A highly significant difference of prevalence was found between symptomatic (82.3%) and asymptomatic subjects (14.9%), with the majority attributable to protozoan infection. The most common species in the symptomatic subjects were Blastocystis spp. (43.8%), E. histolytica/dispar (25.4%) and Giardia intestinalis (14.6%) and more rarely Enterobius vermicularis (02.1%), Teania spp. (0.6%) and Trichuris trichiura (0.2%), while in asymptomatic population Blastocystis spp. (8%), Entamoeba coli (3.3%) and Entamoeba histolytica/dispar (2.5%) were the most common parasites detected with no case of helminth infection. Multivariate log-linear analysis showed that contact with animals was the main risk factor for transmission of these protozoa in both populations. Furthermore, living in rural areas was significantly associated with combined protozoan infection in the asymptomatic population, whereas, in the symptomatic population an increasing trend of protozoan infection was detected in the hot season. In addition, Blastocystis spp. and G. intestinalis infection were found to be associated with host sex and contact with animals across the study period.

CONCLUSIONS

Based on these results, several strategies are recommended in order to effectively reduce these infections including good animal husbandry practices, health education focused on good personal hygiene practices and adequate sanitation.

Symptomatic subclavian steal syndrome: Report of four Moroccan cases and literature review

Introduction

Subclavian steal syndrome (SSS) is the hemodynamic phenomenon of blood flow reversal in the vertebral artery due to significant stenosis or occlusion of the proximal ipsilateral subclavian artery.

Materials and methods

Four patients with subclavian steal syndrome were treated in our center. Percutaneous radial approach was used for angioplasty, primary stenting of subclavian artery was performed, surgical techniques in particular carotid-subclavian bypass and carotid-subclavian transposition were used.

Results

We report the cases of four patients, three of which are male, with an average age of 60 years. All of them were symptomatic. Diagnosis was made by duplex ultrasound, supplemented by CT-angiography and arteriography. Endovascular treatment was attempted in all four patients, which was successful in two patients, who underwent primary stenting, and failed for the two others, for whom surgical treatment was considered. One had a subclavio-carotid bypass graft with a polytetrafluorethylene (PTFE) prosthesis and the other had a subclavio-carotid transposition. The technical results were satisfactory in all patients with symptoms resolution. The postoperative evolution was without notable complications and the postoperative checkups were satisfactory.

Discussion

There are excellent screening tools and effective medical therapies which can be instituted if the SSS is diagnosed early. When the need for revascularization arises, percutaneous modalities are favored given their proven long-term efficacy, decreased morbidity and mortality, and cost-effectiveness. Nevertheless, large, prospective, randomized and controlled trials are needed to compare the long-term patency rates between the endovascular and surgical techniques.

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SSS is caused by the reversal of blood flow in the vertebral artery.

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Doppler ultrasound is the ultimate screening tool for diagnosis.

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Treatment of symptomatic SSS is always indicated.

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Endovascular approach is the first-line treatment.

Clinical Outcomes in Asymptomatic and Symptomatic Atrial Fibrillation Presentations in GARFIELD-AF: Implications for AF Screening

BACKGROUND

Asymptomatic atrial fibrillation is often detected incidentally. Prognosis and optimal therapy for asymptomatic compared with symptomatic atrial fibrillation is uncertain. This study compares clinical characteristics, treatment, and 2-year outcomes of asymptomatic and symptomatic atrial fibrillation presentations.

METHODS

Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) is a global, prospective, observational study of newly diagnosed atrial fibrillation with ≥1 stroke risk factors (http://www.clinicaltrials.gov, unique identifier: NCT01090362). Patients were characterized by atrial fibrillation-related symptoms at presentation and the CHA₂DS₂-VASc score. Two-year follow-up recorded anticoagulation patterns (vitamin K antagonist, direct oral anticoagulants, parenteral therapy) and outcomes (stroke/systemic embolism, all-cause mortality, and bleeding).

RESULTS

At presentation, of 52,032 eligible patients, 25.4% were asymptomatic and 74.6% symptomatic. Asymptomatic patients were slightly older (72 vs 70 years), more often male (64.2% vs 52.9%), and more frequently initiated on anticoagulation ± antiplatelets (69.4% vs 66.0%). No difference in events (adjusted hazard ratios, 95% confidence interval) for nonhemorrhagic stroke/systemic embolism (1.19, 0.97-1.45), all-cause mortality (1.06, 0.94-1.20), or bleeding (1.02, 0.87-1.19) was observed. Anticoagulation was associated with comparable reduction in nonhemorrhagic stroke/systemic embolism (0.59, 0.43-0.82 vs 0.78, 0.65-0.93) and all-cause mortality (0.69, 0.59-0.81 vs 0.77, 0.71-0.85) in asymptomatic versus symptomatic, respectively.

CONCLUSIONS

Major outcomes do not differ between asymptomatic and symptomatic atrial fibrillation presentations and are comparably reduced by anticoagulation. Opportunistic screening-detected asymptomatic atrial fibrillation likely has the same prognosis as asymptomatic atrial fibrillation at presentation and likely responds similarly to anticoagulation thromboprophylaxis.

SARS-CoV-2 quantitative real time PCR and viral loads analysis among asymptomatic and symptomatic patients: an observational study on an outbreak in two nursing facilities in Campania Region (Southern Italy)

BACKGROUND

In December 2019 an outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 was first observed in Wuhan, China. The virus has spread rapidly throughout the world creating a pandemic scenario. Several risk factors have been identified, such as age, sex, concomitant diseases as well as viral load. A key point is the role of asymptomatic people in spreading SARS-CoV-2. An observational study in Southern Italy was conducted in order to elucidate the possible role of asymptomatic individuals related to their viral loads in the transmission of the virus within two nursing facilities.

METHODS

Oro-nasopharyngeal swabs from 179 nursing health care workers and patients were collected. SARS-CoV-2 RT-qPCR was performed and viral loads were calculated by using standard curve. A statistical correlation between viral loads, the presence/absence of symptoms, age and sex variables was investigated.

RESULTS

SARS-CoV-2 was confirmed in the 50.8 % (n = 91) of the cases. Median age of positive individuals resulted higher than negative ones. Over 65 year as well as female individuals showed higher susceptibility to SARS-CoV-2 infection, OR = 3.93 and 2.86, respectively. Among 91 tested positive, the 70.3 % was symptomatic while the 29.7 % was asymptomatic. Median viral loads of asymptomatic individuals were found statistically significant higher than symptomatic ones (p = 0.001), while no influence was observed in age and sex variables. The presence of comorbidities was 8.9 folds higher in patients who showed and developed symptoms compared to non-symptomatic ones. Moreover, higher viral loads were found in patients who remained asymptomatic than pre-symptomatic (p = 0.022).

CONCLUSIONS

A range from 9.2 to 69 % of confirmed SARS-CoV-2 cases remains asymptomatic, moreover, sporadic transmissions from asymptomatic people are reported, that makes their involvement an important issue to take into account in the spreading control of the virus. An asymptomatic clinical course was observed in the 29.7 % of positive individuals, moreover, median viral loads resulted to be statistically significant when compared to symptomatic ones. Surely, such a relevant frequency should not be ignored in relation to the spread of the disease in an environment which has not only important intrinsic (age, sex, concomitant diseases) but also extrinsic factors such as high population density and close contacts.

SARS-CoV-2 quantitative real time PCR and viral loads analysis among asymptomatic and symptomatic patients: an observational study on an outbreak in two nursing facilities in Campania Region (Southern Italy)

BACKGROUND

In December 2019 an outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 was first observed in Wuhan, China. The virus has spread rapidly throughout the world creating a pandemic scenario. Several risk factors have been identified, such as age, sex, concomitant diseases as well as viral load. A key point is the role of asymptomatic people in spreading SARS-CoV-2. An observational study in Southern Italy was conducted in order to elucidate the possible role of asymptomatic individuals related to their viral loads in the transmission of the virus within two nursing facilities.

METHODS

Oro-nasopharyngeal swabs from 179 nursing health care workers and patients were collected. SARS-CoV-2 RT-qPCR was performed and viral loads were calculated by using standard curve. A statistical correlation between viral loads, the presence/absence of symptoms, age and sex variables was investigated.

RESULTS

SARS-CoV-2 was confirmed in the 50.8 % (n = 91) of the cases. Median age of positive individuals resulted higher than negative ones. Over 65 year as well as female individuals showed higher susceptibility to SARS-CoV-2 infection, OR = 3.93 and 2.86, respectively. Among 91 tested positive, the 70.3 % was symptomatic while the 29.7 % was asymptomatic. Median viral loads of asymptomatic individuals were found statistically significant higher than symptomatic ones (p = 0.001), while no influence was observed in age and sex variables. The presence of comorbidities was 8.9 folds higher in patients who showed and developed symptoms compared to non-symptomatic ones. Moreover, higher viral loads were found in patients who remained asymptomatic than pre-symptomatic (p = 0.022).

CONCLUSIONS

A range from 9.2 to 69 % of confirmed SARS-CoV-2 cases remains asymptomatic, moreover, sporadic transmissions from asymptomatic people are reported, that makes their involvement an important issue to take into account in the spreading control of the virus. An asymptomatic clinical course was observed in the 29.7 % of positive individuals, moreover, median viral loads resulted to be statistically significant when compared to symptomatic ones. Surely, such a relevant frequency should not be ignored in relation to the spread of the disease in an environment which has not only important intrinsic (age, sex, concomitant diseases) but also extrinsic factors such as high population density and close contacts.