Immunisation coverage and factors associated with incomplete immunisation in children under two during the COVID-19 pandemic in Sierra Leone

BACKGROUND

Routine childhood immunisation is one of the most important life-saving public health interventions. However, many children still have inadequate access to these vaccines and millions remain (partially) unvaccinated globally. As the COVID-19 pandemic disrupted health systems worldwide, its effects on immunisation have become apparent. This study aimed to estimate routine immunisation coverage among children under two in Sierra Leone and to identify factors associated with incomplete immunisation during the COVID-19 pandemic.

METHODS

A cross-sectional household survey was conducted in three districts in Sierra Leone: Bombali, Tonkolili and Port Loko. A three-stage cluster sampling method was followed to enrol children aged 10-23 months. Information regarding immunisation status was based on vaccination cards or caretaker's recall. Using WHO's definition, a fully immunised child received one BCG dose, three oral polio vaccine doses, three pentavalent vaccine doses and one measles-containing vaccine dose. Following the national schedule, full immunisation status can be achieved at 9 months of age. Data were weighted to reflect the survey's sampling design. Associations between incomplete immunisation and sociodemographic characteristics were assessed through multivariable logistic regression.

RESULTS

A total of 720 children were enrolled between November and December 2021. Full vaccination coverage was estimated at 65.8% (95% CI 60.3%-71.0%). Coverage estimates were highest for vaccines administered at birth and decreased with doses administered subsequently. Adjusting for age, the lowest estimated coverage was 40.7% (95% CI 34.5%-47.2%) for the second dose of the measles-containing vaccine. Factors found to be associated with incomplete immunisation status were: living in Port Loko district (aOR = 3.47, 95% CI = 2.00-6.06; p-value < 0.001), the interviewed caretaker being Muslim (aOR = 1.94, 95% CI = 1.25-3.02; p-value = 0.015) and the interviewed caretaker being male (aOR = 1.93, 95% CI = 1.03-3.59, p-value = 0.039).

CONCLUSION

Though full immunisation coverage at district level improved compared with pre-pandemic district estimates from 2019, around one in three surveyed children had missed at least one basic routine vaccination and over half of eligible children had not received the recommended two doses of a measles-containing vaccine. These findings highlight the need to strengthen health systems to improve vaccination uptake in Sierra Leone, and to further explore barriers that may jeopardise equitable access to these life-saving interventions.

Coverage of intermittent preventive treatment of malaria in infants after four years of implementation in Sierra Leone

BACKGROUND

Intermittent Preventive Treatment of malaria in infants (IPTi) is a malaria control strategy consisting of the administration of an anti-malarial drug alongside routine immunizations. So far, this is being implemented nationwide in Sierra Leone only. IPTi has been renamed as Perennial Malaria Chemoprevention -PMC-, accounting for its recently recommended expansion into the second year of life. Before starting a pilot implementation on PMC, the currently implemented strategy and malaria prevalence were assessed in young children in selected areas of Sierra Leone.

METHODS

A cross-sectional, community-based, multi-stage cluster household survey was conducted from November to December 2021 in selected districts of the Northern and northwestern provinces of Sierra Leone among 10-23 months old children, whose caretakers gave written informed consent to participate in the survey. Coverage of IPTi and malaria prevalence-assessed with rapid diagnostic tests-were calculated using percentages and 95% confidence intervals weighted for the sampling design and adjusted for non-response within clusters. Factors associated with RDT + and iPTi coverage were also assessed.

RESULTS

A total of 720 children were recruited. Coverage of three IPTi doses was 50.57% (368/707; 95% CI 45.38-55.75), while prevalence of malaria infection was 28.19% (95% CI 24.81-31.84). Most children had received IPTi1 (80.26%, 574/707; 95% CI 75.30-84.44), and IPTi2 (80.09%, 577/707; 95% CI 76.30-83.40) and over half of the children also received IPTi3 (57.72%, 420/707; 95% CI 53.20-62.11). The uptake of each IPTi dose was lower than that of the vaccines administered at the same timepoint at all contacts.

CONCLUSION

In Sierra Leone, half of the children received the three recommended doses of IPTi indicating an increase in its uptake compared to previous data of just a third of children receiving the intervention. However, efforts need to be made in improving IPTi coverage, especially in the planned expansion of the strategy into the second year of life following recent WHO guidelines.

P2 IMPACT OF CATHETER ABLATION ON ARRHYTHMIC STORM: A SINGLE–CENTER EXPERIENCE

Background

Arrhythmic storm (AS) is a medical emergency whom management is multidisciplinary and includes antiarrhythmic medications, sedation and mechanical circulatory support, as well as catheter ablation, a procedure that is gaining growing relevance in clinical practice, supported by guidelines.

Methods and Aims

It is a retrospective observational study of patients admitted to Cardiology Department of Ospedale dell’Angelo for AS from 2016 to 2021. The primary endpoint was the rate of arrhythmic recurrences and their clinical predictors; the secondary endpoint was a composite of all– cause death, LVAD or cardiac transplant. Successful CA was defined as no inducibility of any VT at the end of the procedure.

Result

We evaluated 74 patients. Catheter ablation (CA) was performed in 56 patients, while in the other 18 patients, the treatment of the arrhythmic emergency was limited to medical therapy. At a median follow–up of 10 months (range 4–36 months), the overall arrhythmic recurrence rate was 39.1% and AS recurrence occurred in 11% of patients; the incidence of the composite end–point of all–cause death, LVAD implant or cardiac transplant was 20.2%. B–blockers (85% vs 100%, p = 0.025) and successful CA (60% vs 88.6%, p = 0.021) were associated with less arrhythmic recurrences. At multivariate analysis, a successful CA was an independent predictor of arrhythmic recurrence free survival (HR 0.32, [0.11–0.94], p = 0.039), and of ICD shocks free survival (HR 0.087, [0.02–0.37], p = 0.001). ICD shocks at admission (8.06 ± 9.8 vs 3.18 ± 4.24, p = 0.005), NYHA class III–IV (46.6% vs 5%, p = 0.001), medical treatment (53.3% vs 83%, p = 0.031), ICD shocks during follow–up (53.3% vs 18,6%, p = 0.004) and AS recurrence (33.3% vs 10.1%, p = 0.039) were associated with an increased rate of the secondary endpoint.

Conclusions

In our real world experience of patients admitted for AS, CA was a predictor of arrhythmic recurrence free survival and may have a role in improving quality of life and prognosis by reducing ICD shocks. CA was an independent predictor of the reduced incidence of all–cause death, LVAD implant or cardiac transplant, although this finding might reflect a more severe cardiac disease of the medically treated patients than a real benefit of CA on mortality.

Usefulness of late gadolinium enhancement cardiac magnetic resonance to predict appropriate therapies in implantable cardioverter defibrillator patients in primary prevention

Background

The scar and the amount of border zone measured by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) has been proposed as an independent predictor of ventricular arrhythmias in patients with ischemic and non-ischemic cardiomyopathy. However, at the present time, the guidelines are based only on the ejection fraction to recommend an implantable cardioverter defibrillator (ICD) in primary prevention, and only a minority of these patients receive appropriate therapies. So, prevention needs to be improved.

Purpose

To identify predictors of appropriate therapies in patients with a primary prevention ICD using cardiac magnetic resonance imaging and a dedicated software (ADAS-3D) to characterize the scar.

Methods

Patients who underwent a LGE-MR prior to ICD implantation in primary prevention were retrospectively included. Clinical and cardiac imaging characteristics were collected. The myocardium was segmented with ADAS-3D software in 10 layers (from endocardium to epicardium). The scar, border zone, core and conducting channels were automatically measured in grams by the software.

Results

Since 2008 to 2017, 206 patients were included. Mean age was 67±28 years, 80% men, mean ejection fraction 26%±9, 52% with ischemic cardiomyopathy and 48% non-ischemic. The primary endpoint was appropriate therapies and/or sudden cardiac death (SCD). Median follow-up was 46.33 months. 46 patients (22%) reached the primary endpoint. Greater scar mass (36.05 grams vs 21.5 grams; HR 1.04; 95% CI (1.03–1-05), p&lt;0.001), core mass (9.8 grams vs 5.6 grams; HR 1.06; 95% CI (1.04–1-09), p&lt;0.001), border zone mass (26.2 grams vs 15.9 grams; HR 1.05; 95% CI (1.04–1-09), p&lt;0.001) and channel mass (3.0 grams vs 1.6 grams; HR 1.15 95% CI (1.06–1.25), p&lt;0.001) were associated with appropriate therapies and SCD. A border zone mass &gt;5.3 grams was independently associated with the primary endpoint (HR: 4.77; 95% CI (1.15–19.73), p=0.03).

Conclusions

The amount of border zone, core and channel mass measured by LGE-MR and ADAS software are independent predictors of appropriate therapies and SCD in patients with ICD in primary prevention.

Scar characterization

Funding Acknowledgement

Type of funding source: None

Clinical Features Associated with Strongyloidiasis in Migrants and the Potential Impact of Immunosuppression: A Case Control Study

Strongyloides stercoralis is a widely distributed nematode more frequent in tropical areas and particularly severe in immunosuppressed patients. The aim of this study was to determine factors associated with strongyloidiasis in migrants living in a non-endemic area and to assess the response to treatment and follow-up in those diagnosed with the infection. We performed a multicenter case-control study with 158 cases and 294 controls matched 1:2 by a department service. Participants were recruited simultaneously at six hospitals or clinics in Spain. A paired-match analysis was then performed looking for associations and odds ratios in sociodemographic characteristics, pathological background, clinical presentation and analytical details. Cases outcomes after a six-month follow-up visit were also registered and their particularities described. Most cases and controls came from Latin America (63%-47%) or sub-Saharan Africa (26%-35%). The number of years residing in Spain (9.9 vs. 9.8, p = 0.9) and immunosuppression status (30% vs. 36.3%, p = 0.2) were also similar in both groups. Clinical symptoms such as diffuse abdominal pain (21% vs. 13%, p = 0.02), and epigastralgia (29% vs. 18%, p < 0.001); along with a higher eosinophil count (483 vs. 224 cells/mL in cases and controls, p < 0.001) and the mean total Immunoglobulin E (IgE) (354 U/L vs. 157.9 U/L; p < 0.001) were associated with having strongyloidiasis. Finally, 98.2% percent of the cases were treated with ivermectin in different schedules, and 94.5% met the cure criteria at least six months after their first consultation. Abdominal pain, epigastralgia, eosinophilia, increased levels of IgE and Latin American origin remain the main features associated with S. stercoralis infection, although this association is less evident in immunosuppressed patients. The appropriate follow-up time to evaluate treatment response based on serology titers should be extended beyond 6 months if the cure criteria are not achieved.

129Magnetic resonance predictors of ventricular tachycardia recurrence after radiofrequency substrate ablation: septal and transmural channels

 

Ventricular tachycardia (VT) substrate-based ablation has become a gold standard in patients with structural heart disease. Success of VT ablation is related with mortality reduction.

Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is a powerful technique to assess substrate of VT. Myocardial fibrosis is electrically inert (Core) but it is surrounded by a ‘‘border-zone (BZ)’’ where normal cardiomyocytes intermingle with dense bundles of fibrosis. Slow impulse conduction in the BZ allows for the re-entry circuits leading to VT. Both the presence and extent of LGE have been associated with VT and SCD risk. LGE-CMR tissue characterization can be depicted as pixel signal intensity (PSI) maps and can guide VT ablation.

The aim of this study was to analyze possible VT recurrence predictors in a long term follow-up of patients that underwent VT ablation (endo and/or epicardial) related with LGE-CMR PSI maps.

We analyzed 234 consecutive patients (age: 63.2 ± 14 years, follow-up: 3.14 years ±1.8) undergoing VT ablation with scar-dechannelling technique at a single center from 2013 to 2018.  110 patients underwent a preprocedural LGE-CMR, and in 94 patients (85,5%) a CMR-aided ablation using the PSI maps was performed.

All LGE-CMR images were semi-automatically processed using a dedicated software. PSI-based algorithm was applied to characterize the hyperenhanced area as core or BZ, using fixed threshold of the maximum intensity. A LV 3D shell was obtained and were imported into the navigation system. In the PSI maps, heterogenous tissue channels were defined as a continuous corridor of BZ surrounded by scar core or an anatomic barrier that connects 2 areas of healthy tissue.

Results

Overall recurrence of VT was 41.8 %. There was ICD shock reduction, from 43,6% to a 28,2% (ICD shocks before ablation 2,23 ± 7,32, after: 1,10 ± 2,92).

Left ventricle mass predicted significantly VT recurrence (Mean 168,3 ± 53,3 vs 152,3 ± 46,4 g, HR 1,02 [1,01-1,02], p &lt; 0.001). LGE distribuition was predictive of VT recurrence when a more than 40% of the interventricular septum was involved (62,5% vs 37,8%; HR 1,6 [1,01-1,02]; p = 0,044). No differences in recurrence were found among the patterns of LGE distribution (transmural/epicardial/subendocardial or peculiar segments localizations). The amount of BZ and the total amont of Core + BZ was related with VT recurrence (BZ 26,6 ± 13,9 vs 19,56 ± 9,69 g, HR 1,03 [1,01-1,06], p = 0,012; total Core + BZ 37,1 ± 18,2 vs 29,0 ± 16,3 g, HR 1,02 [1,00-1,04], p = 0,033). Finally VT recurrence was higher in patients with channels with transmural path (66,7% vs 31,4%, HR 3,25 [1,70-6,23], p &lt; 0,001) or midmural channels (54,3% vs 27,6%, HR 2,49 [1,21–5,13], p = 0,013).

CMR-aided scar dechanneling is a helpful and feasible technique which could identify patients with high risk of VT recurrence. High left ventricular mass, septal LGE distribution, transmural and midmural heterogeneous tissue channels were predictive factors of post ablation VT recurrence.

Abstract Figure. VTchannel & heterogeoneus tissue channel

P1163Correction of septal flash excursion with his bundle pacing

Funding Acknowledgements

Grant from the Catalan Society of Cardiology

Background

His bundle pacing (HBP) directly stimulates the conduction system and could therefore correct asynchrony and evolve as a more physiological pacing approach. Septal flash (SF) is a fast contraction and relaxation of the septum occurring during the isovolumetric contraction period. It is a specific marker of cardiac dyssynchrony.  

Purpose

Evaluate whether HBP corrects SF in patients with an indication for CRT or RV pacing.

Methods

A cohort of 20 consecutive patients undergoing HBP at our center was analyzed. HBP indications were:  Group A (n = 3): left bundle branch block (LBBB) and left ventricular (LV) dysfunction (LV ejection fraction [LVEF] &lt; 35%); Group B (n = 14): LV dysfunction (LVEF &lt; 50%) and atrio-ventricular block requiring permanent pacing; Group C (ablate&pace, n = 3): atrio-ventricular node ablation due to rapid atrial fibrillation.

Patients in groups B and C had a RV backup lead implanted, in line with current recommendations. The presence of SF was analyzed in 2D-echocardiography at 15 days post-implant. SF excursion was quantified using M-mode in parasternal short and long axis views as the highest amplitude of the early inward motion. Baseline SF excursion was determined during intrinsic rhythm (group A) or RV pacing (groups B and C). For each patient, the pair of measurements (baseline, HBP) in the axis with the highest baseline SF was selected.

Results

Mean LVEFs were 21 ± 8%, 32 ± 6%, and 41 ± 18% for groups A, B and C, respectively. HBP shortened QRS duration by 42 ± 15 ms and 45 ± 23 ms in groups A (Baseline QRS - HBP QRS) and B + C (RV pacing QRS - HBP QRS), respectively. At baseline, all patients except 1 had SF (Fig. 1A). The mean SF excursion was 4.3 ± 1.9 mm, with SF excursion being larger in group A than in the RV-paced groups (6.3 ± 1.5 mm vs. 3.9 ± 1.8 mm for groups A and B + C, respectively, p = 0.04). HBP abolished SF in 3 patients (15%) and, on average, decreased SF excursion by 2.3 mm (95% CI 1.3-3.2), irrespective of pacing indication (Fig. 1B). The degree of SF excursion reduction after HBP significantly correlated with QRS shortening (r = 0.53, p = 0.024) (Fig 1C).

Conclusions

In conclusion, we show that HBP results in acute correction or decrease of SF, thereby improving LBBB- or RV-induced mechanical dyssynchrony.

Abstract Figure. Septal Flash and His pacing

P575Usefulness of late gadolinium enhancement cardiac magnetic resonance to predict appropriate therapies in implantable cardioverter defibrillator patients in primary prevention

Funding Acknowledgements

No funding acknowledgements

OnBehalf

VT and sudden cardiac death

Background

  The scar and the amount of border zone measured by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) has been proposed as an independent predictor of ventricular arrhythmias in patients with ischemic and non-ischemic cardiomyopathy. However, at the present time, the guidelines are based only on the ejection fraction to recommend an implantable cardioverter defibrillator (ICD) in primary prevention, and only a minority of these patients receive appropriate therapies. So, prevention needs to be improved.

Purpose

To identify predictors of appropriate therapies in patients with a primary prevention ICD using cardiac magnetic resonance imaging and a dedicated software (ADAS-3D) to characterize the scar.

Methods

All consecutive patients who underwent a LGE-MR prior to ICD implantation in primary prevention were prospectively included.  Clinical and cardiac imaging characteristics were collected. The myocardium was segmented with ADAS-3D software in 10 layers (from endocardium to epicardium). The scar, border zone, core and conducting channels were automatically measured in grams by the software.

Results

Since 2008 to 2017, 206 patients were included. Mean age was 67 +/- 28 years, 80% men, mean ejection fraction 26%+/-9, 52% with ischemic cardiomyopathy and 48% non-ischemic. The primary endpoint was appropriate therapies and/or sudden cardiac death (SCD). Median follow-up was 46,33 months.  46 patients (22%) reached the primary endpoint. Greater scar mass  (36,05 grams vs 21,5 grams; HR 1.04; 95% CI (1.03-1-05), p &lt;0.001), core mass (9,8 grams vs 5,6 grams; HR 1.06; 95% CI (1.04-1-09), p &lt;0.001),  border zone mass (26,2 grams vs 15,9 grams; HR 1.05; 95% CI (1.04-1-09), p &lt;0.001) and channel mass (3,0  grams vs 1,6 grams; HR 1.15 95% CI (1.06-1.25), p &lt;0.001) were associated with appropriate therapies and SCD.  A border zone mass &gt;5.3 grams was independently associated with the primary endpoint (HR: 4.77; 95% CI (1.15-19.73), p = 0.03).

Conclusions

 The amount of border zone, core and channel mass measured by LGE-MR and ADAS software are independent predictors of appropriate therapies and SCD in patients with ICD in primary prevention.

Abstract Figure. Scar characterization

45Improving the optimization of cardiac resynchronization therapy: Does multipoint left ventricular pacing shorten the paced-QRS duration compared to the fusion-optimized intervals method?

Funding Acknowledgements

Cardiac Pacing Scholarship from the Spanish Society of Cardiology (SEC)

Background

Electrocardiogram-based optimization of cardiac resynchronization therapy (CRT) using the fusion-optimized intervals (FOI) method has demonstrated to improve both acute hemodynamic response and left ventricle (LV) reverse remodeling compared to nominal programming of CRT. FOI optimizes the atrioventricular (AV) and ventriculo-ventricular (VV) intervals to achieve the shortest paced-QRS duration. The recent development of multipoint pacing (MPP) enables the activation of the LV from 2 locations, also shortening the QRS duration compared to conventional biventricular pacing.

Purpose

To determine if MPP reduces the paced-QRS duration compared to FOI optimization. 

Methods

This prospective clinical study included 25 consecutive patients who successfully received a CRT with MPP pacing capability. All patients were in sinus rhythm and had an PR interval below 250 ms. The QRS duration was measured with a 12-lead digital electrocardiography (screen speed of 200 mm/s) at baseline and using 3 different configurations: MPP, FOI and a combined FOI-MPP strategy. In MPP, the intervals were (based on previous studies): 1) AV 130 ms, 2) Right ventricular (RV)-LV2 (Δ1) 5 ms, and 3) LV1-LV2 (Δ2) 5 ms. In FOI, AV and VV intervals were optimized to achieve fusion between intrinsic conduction and biventricular pacing. In FOI-MPP, the Δ2 was set at 5 ms, while AV and Δ1 intervals were optimized using the FOI method. The CRT device was programmed with the configuration that achieved a greater paced-QRS shortening. After 45 days, battery life was estimated.

Results

  Mean age was 65 ± 10 years, 20 were men (80%) and baseline QRS duration was 177 ± 17 ms. The FOI method bested nominal MPP (QRS shortened by 58 ± 16 ms vs 43 ± 16 ms, respectively, p = 0.002). Adding MPP to the narrowest QRS by FOI did not result in further shortening (FOI: 58 ± 16 ms vs FOI-MPP: 59 ± 13 ms, p = 0.81). The final configuration was FOI method alone in most cases (n = 16, 64%) and FOI-MPP in all others (n = 9, 36%; figure). In total, 10 out of 25 patients (40%) were not candidates to MPP due to: 1) pacing thresholds exceeding 3.5 V/0.4 ms at the distal or proximal electrode (8, 32%), and 2) phrenic stimulation (2, 8%). Estimated battery longevity was longer in patients receiving FOI as compared to MPP (8.3 ± 2.1 years vs. 6.2 ± 2.2 years, p = 0.04).

Conclusion

In CRT, the FOI method is not improved by coupling with MPP.  Up to 40% of patients are not candidates for MPP due to high thresholds or phrenic stimulation. The use of MPP in unselected patients would result in a decrease of battery longevity, without any additional benefit over FOI.

Abstract Figure.

P1129Bipolar voltage cut-off validation in electroanatomical voltage mapping to identify scar and conduction channels in ventricular tachycardia ablation: need for new cut-off in NICM

Background/Introduction

Substrate-guided techniques have changed the approach and results of ventricular tachycardia (VT) ablation and electroanatomical voltage mapping (EAVM) constitutes a diagnostic and therapeutic cornerstone in this field. In current practice normal myocardium is typically characterized by bipolar voltage &gt; 1.5 mV, dense scar &lt; 0.5 mV, and border zone (BZ) tissue by the range between 0.5 to 1.5 mV. Of note, evidence for these cut-off values has been derived in humans from small observational studies and in animals. Furthermore, some studies suggest that only the 60% of not transmural endocardial scars and the 35% of not endocardial scars are detected without any adjustment of these values. New voltage cut-off values are needed.

Purpose

The purpose of this study is to adjust voltage cut off in order to establish the threshold that more accurately define the pathological substrate in VT ablation. Additionally, predictors of usefulness of current thresholds are analyzed.

Methods

EAVM were created with CARTO3 System and Sensor-Force catheter (Navistar Smart-Touch and Pentaray). We delineated the conducting channels by analyzing the late potentials activation. Based on these channels we looked for the best cut-off values to detect these channels. We describe the baseline characteristics, the best cut-off values for border zone and scar core in our series and we analyzed the accuracy of the current established values to detect the arrhythmogenic VT substrate

Results

We investigated 51 patients (74,5% males; 41,2% ischemic cardiomyopathy, mean LVEF 38,6% +/-13,6) with sustained monomorphic VT submitted to ablation during 2016 and 2017. The range of the voltage adjustment was from 0,01-1 mV for core area and 0,2-6mV as maximum, with an average of 0,31-1,42mV. Using currently accepted bipolar voltage cut-off &lt;0.5 mV the core scar was correctly identified in 80,4% of patients: 90,4% in ischemic and 73,3% in NICM. Regarding BZ, using classical cut off (0.5-1.5mV) only 56,9 % of the cases were well identified: interestingly, accuracy was worse in NICM (46,6%) than in ischemic patients (71,4%) (p = 0,07).

Conclusions EAVM is very important to detect scar and channels in VT ablation, but several elements can affect it and recently the traditional voltage values have been questioned. Our study suggests how the threshold as currently applied in daily practice could be acceptable to detect the core scar area, but it has to be reconsidered in NICM, especially regarding the border zone. An evident trend (p = 0,07) suggests a better accuracy of current values to define VT substrate in ischemic patients than in NICM.

Abstract Figure. Channel Identification

Self-perception of olfactory dysfunction is associated with history of Traumatic Brain Injury: post-hoc analysis from the OLFACAT survey

BACKGROUND: Traumatic brain injury (TBI) is one of the main causes of smell loss. However, epidemiological studies evaluating the incidence in general population are scarce. The aim of this analysis is to investigate the prevalence of TBI-induced olfactory dysfunction (OD) in a general-based population study. METHODOLOGY: A cross-sectional population-based survey was distributed to general population (260,000 households) through the newspaper. The survey included four microencapsulated odorants (smell test) to assess smell loss and two self-administered questionnaires (odour description and epidemiology/health status). Participants were divided into two groups, with or without a history of TBI. RESULTS: From 10,783 returned surveys, 9,348 were analysed. The survey profile was a 43-year old woman with medium-high educational level, living in a city. The overall prevalence of TBI was 5% (N=464, 44.5±14.1 years old, 57% females). Recorded causes of TBI were traffic, domestic, or work accidents. Subjects with TBI reported a poorer subjective smell self-perception compared to non-TBI participants, and a decreases ability to identify mercaptan (odour added to gas used in cities). Although, using the smell test, both groups showed similar smell capacities. CONCLUSIONS: Subjects with TBI history report a higher frequency of self-perceived OD, and a decrease ability to smell the odour added to domestic gas. Having said that, the prevalence of OD, according to the smell test, was similar in both groups.

Multiplexing detection of IgG against Plasmodium falciparum pregnancy-specific antigens

Background

Pregnant women exposed to Plasmodium falciparum generate antibodies against VAR2CSA, the parasite protein that mediates adhesion of infected erythrocytes to the placenta. There is a need of high-throughput tools to determine the fine specificity of these antibodies that can be used to identify immune correlates of protection and exposure. Here we aimed at developing a multiplex-immunoassay to detect antibodies against VAR2CSA antigens.

Methods and findings

We constructed two multiplex-bead arrays, one composed of 3 VAR2CSA recombinant-domains (DBL3X, DBL5Ɛ and DBL6Ɛ) and another composed of 46 new peptides covering VAR2CSA conserved and semi-conserved regions. IgG reactivity was similar in multiplexed and singleplexed determinations (Pearson correlation, protein array: R² = 0.99 and peptide array: R² = 0.87). IgG recognition of 25 out of 46 peptides and all recombinant-domains was higher in pregnant Mozambican women (n = 106) than in Mozambican men (n = 102) and Spanish individuals (n = 101; p<0.05). Agreement of IgG levels detected in cryopreserved plasma and in elutions from dried blood spots was good after exclusion of inappropriate filter papers. Under heterogeneous levels of exposure to malaria, similar seropositivity cutoffs were obtained using finite mixture models applied to antibodies measured on pregnant Mozambican women and average of antibodies measured on pregnant Spanish women never exposed to malaria. The application of the multiplex-bead array developed here, allowed the assessment of higher IgG levels and seroprevalences against VAR2CSA-derived antigens in women pregnant during 2003–2005 than during 2010–2012, in accordance with the levels of malaria transmission reported for these years in Mozambique.

Conclusions

The multiplex bead-based immunoassay to detect antibodies against selected 25 VAR2CSA new-peptides and recombinant-domains was successfully implemented. Analysis of field samples showed that responses were specific among pregnant women and dependent on the level of exposure to malaria. This platform provides a high-throughput approach to investigating correlates of protection and identifying serological markers of exposure for malaria in pregnancy.

A direct comparison of real time PCR on plasma and blood to detect Plasmodium falciparum infection in children

Background

Estimation of Plasmodium falciparum parasitaemia can vary with the method used and time of sampling. Quantitative real time PCR (qPCR) on whole blood or plasma samples has previously been shown to be more sensitive than thick film microscopy. However the efficiencies of each method have not been compared using samples obtained from infants less than one year old.

Methods

A multiple of statistical approaches were used to compare the performance of qPCR on whole blood or plasma to detect the 18 S ribosomal gene of P. falciparum in 548 samples from children aged 2.5 or 24 months. Parasite prevalence in matched samples was compared using Mcnemar’s test and agreement of positive results quantified as Kappa scores. Parasite prevalences between different age groups were compared by Fisher’s test. Results from analyses by thick film microscopy were also available from children at 24 months and their correlation to each qPCR method examined by the Spearman’s test. Finally the association of P. falciparum infection with the incidence of multiple malaria episodes from contact to 24 months of age was evaluated using negative binomial regression.

Results

These analyses showed that qPCR from whole blood detected approximately 3-fold more cases of infection than plasma qPCR. Both qPCR methods agreed well with each other although qPCR from plasma had a greater agreement with microscopy (96.85%) than did qPCR from blood (69.7%). At 24 months the prevalence of infection detected by all methods was associated with anaemia (p < 0.05).

Conclusions

The data presented here demonstrates that low levels of parasitaemia are better detected by qPCR using parasite DNA from whole blood than from plasma. However plasma samples provide a viable substitute when parasite smears are unavailable.

A country-wide malaria survey in Mozambique. I. Plasmodium falciparum infection in children in different epidemiological settings

Background

Across tropical Africa the bulk of malaria-related morbidity and mortality is particularly high during childhood. Classical malariometric surveys have relied on assessing malaria infection prevalence. The last comprehensive evaluation of the malaria situation in Mozambique was carried out during the 1950s. This study aims to characterize the malaria transmission intensities and to estimate the disease burden that may help guide control programme.

Methods

Between February 2002 and April 2003, a house-to-house survey, was carried out in 24 districts randomly selected. A total of 8,816 children aged below 10 years old were enrolled. Finger prick and blood collection were performed to prepare thick and thin films for malaria parasite species identification, density and haemoglobin concentration. Axillary temperature was also measured. Prevalence of infection, parasite density and anaemia were estimated for age groups category in each region/stratum. Comparisons between proportions were made using Chi-square test or Fisher exact. Relationship between age groups, region/stratum and parasite prevalence, density was determined using linear regression. All survey mean estimations were adjusted for sampling weights, clustering and stratification.

Results

Malaria parasite prevalence was 58.9% (5.190/8.816), the majority of blood smears 52.4% (4,616/8,816) were due to Plasmodium falciparum and geometric mean parasite density was 1,211 parasites/μl (95% CI, 1,141 – 1.286). Gametocytes prevalence, only for P. falciparum was 5.6% (518/8,816). The burden was highest in the northern regions and in the coastal stratum. Parasite infection and geometric mean parasite density peaked during the second year of life and thereafter decreased with increasing age. Mean haemoglobin concentrations was 9.9 g/dl (95% CI 9.5 – 10.2). Anaemia prevalence was 69.8% (6.257/8.816) and among anaemic children 11.5% (743/6.257) were severely anaemic. Anaemia rose dramatically during the first year of life to peak among children in the 12 – 23 months age group. Highest levels of anaemia were recorded in both northern and central-northern regions 77.9% and 79.4% respectively.

Conclusion

This survey confirms that malaria especially that caused by P. falciparum, remains endemic throughout the country. The burden of malaria disease and anaemia-related malaria during childhood constitute a major public health problem and warrant integrated and collaborative interventions towards its control.

Osteopontin and alphavbeta3 integrin expression in the endometrium of infertile and fertile women

Osteopontin and its receptor alpha(v)beta(3) integrin have recently been proposed as a major complex to promote embryo attachment, and thus they would be useful as markers of endometrial receptivity. In the current study alpha(v)beta(3) integrin and osteopontin expression and co-expression in in-phase and out-of-phase endometrial biopsies from normal healthy women (n = 12) and infertile patients (n = 107) were investigated. Two endometrial biopsies (post-ovulatory day +6 to +8, and 4 days later) were performed during a single menstrual cycle in each subject. Oestradiol and progesterone serum concentrations were quantified on the same days as endometrial sampling. No statistically significant difference regarding alpha(v)beta(3) integrin and osteopontin expression and their coexpression was found between fertile controls and infertile patients irrespective of endometria being in-phase or out-of-phase, infertility factors detected or whether patients became spontaneously pregnant or not. Although a co-ordinate high concentration of both glycoproteins on post-ovulatory day 8 onwards was observed, there was an evident lack of temporal co-expression of these markers during the implantation window. It is concluded that the functional significance of the osteopontin:alpha(v)beta(3) integrin complex as a marker of endometrial receptivity and implantation potential in women seems to be untenable.

Management of sleep apnea: concordance between nonreference and reference centers

BACKGROUND

When a disorder is as prevalent as sleep apnea-hypopnea syndrome (SAHS), different medical levels and approaches should be involved in facilitating the diagnosis, at least, of patients with symptoms that disrupt social or working life, and of risk groups such as professional drivers. We sought to analyze the degree of concordance between management and treatment decisions for SAHS patients at sleep reference centers (RCs) and at non-RCs (NRCs).

MATERIALS AND METHODS

Eighty-eight consecutive patients with suspected SAHS were referred by family doctors to the NRC. The patients were studied randomly at the RC, using full polysomnography, and at the NRC, employing respiratory polygraphy. The concordance in the therapeutic approach between both centers was analyzed via the outcomes, and the physiologic variables of the sleep studies were also evaluated.

RESULTS

The concordance in the final clinical decision was substantial. There was a good agreement with respect to apnea-hypopnea index as a categoric variable and as a continuous variable.

CONCLUSIONS

These results suggest that respiratory physicians with simple sleep studies are able to manage a large number of patients with SAHS.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT 00424658.

High-risk cervical epithelial neoplasia grade 1 treated by loop electrosurgical excision: follow-up and value of HPV testing

OBJECTIVE

This study was undertaken to evaluate the value of high-risk human papillomavirus (HPV) testing in the follow-up of cervical intraepithelial neoplasia grade 1/low-grade squamous intraepithelial lesion treated by loop electrosurgical excision procedure because of the risk criteria established by the American Society for Colposcopy and Cervical Pathology (ie, unsatisfactory colposcopy or positive endocervical curettage, persistence of cervical intraepithelial neoplasia grade 1/low-grade squamous intraepithelial lesion, or high-risk HPV infection for longer than 2 years and older than 40 years).

STUDY DESIGN

Seventy-seven women with cervical intraepithelial neoplasia grade 1/low-grade squamous intraepithelial lesion treated by loop electrosurgical excision procedure and followed-up with colposcopy, cytology, and high-risk HPV detection using Hybrid Capture II.

RESULTS

More than 67% (67.6%) of women had cervical intraepithelial neoplasia grade 1 in the specimen; 22% a cervical intraepithelial neoplasia grade 2-3; and 10.4% had no lesion. Pretreatment HPV testing was positive in 100% of cervical intraepithelial neoplasia grade 2-3, in 93.5% of cervical intraepithelial neoplasia 1, and in 14.3% of cases with no lesion (P < .01). Pretreatment high-risk HPV testing was positive in all cases eventually developing residual/recurrent disease. Fifty percent of women with pretreatment viral load more than 100 relative light units had residual/recurrent disease develop. Posttreatment high-risk HPV testing during the follow-up reached a sensitivity and negative predictive value of 100% for detecting residual/recurrent disease.

CONCLUSION

Patients with low-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia grade 1 and risk factors have a significant risk of harboring a cervical intraepithelial neoplasia grade 2-3 lesion. A conservative approach should be considered when basal high-risk HPV test is negative. High pretreatment high-risk HPV loads should be considered a risk factor for developing residual/recurrent disease. Posttreatment Hybrid Capture II has an extremely high sensitivity for detecting recurrences.

Improved preoperative iron status assessment by soluble transferrin receptor in elderly patients undergoing knee and hip replacement

A poor preoperative haemoglobin (Hb) status is frequently encountered among adult patients scheduled for corrective surgery of the locomotive system, representing the main risk factor for blood transfusion. The soluble transferrin receptor (sTfR) has become a highly specific parameter for the detection of iron deficits as it can differentiate between iron deficiency anaemia and anaemia of chronic disease, because of the lack of effect by associated inflammation, unlike ferritin. The objectives of this study were to evaluate patients with the prevalence of risk for transfusion, the effect of inflammation on ferritin (F) values and functional iron deficiency in elderly patients with advanced degenerative arthropathy scheduled for hip or knee replacement. This observational, prospective study included patients over 50 years, operated for hip or knee replacements between April and June 2004. Of 218 patients studied, 87 (39%) presented with Hb levels between 10 and 13 g/dl. The prevalence of functional iron deficit was 27% (sTfR > 1.76 mg/l), while only 8.6% of patients displayed F levels below normal. As expected, C-reactive protein levels were elevated in 24.8% of patients and erythrocyte sedimentation rate was elevated in 50%. These inflammatory markers did not correlate with levels of either F or sTfR. Multiple factors can affect F levels, such as the inflammatory status of osteoarthritis in the elderly, obesity, nonsteroidal anti-inflammatory drugs therapy and low physical performance. As sTfR is not affected by inflammation, it has emerged as a primary parameter for the evaluation of iron status during preoperative assessment among patients scheduled for arthroplasty surgery. Our data strongly suggest that sTfR measurement contributes to improve patient management.

Pre- and post-conization high-risk HPV testing predicts residual/recurrent disease in patients treated for CIN 2–3

OBJECTIVE

To evaluate whether high-risk human papillomavirus (HR-HPV) detection and viral load prior to treatment and status of cone margins can predict residual/recurrent disease as well as the ability of current diagnostic tools to identify residual/recurrent disease during follow-up of high-grade cervical intraepithelial neoplasia (CIN) treated by conization using loop electrosurgical procedure (LEEP).

METHODS

Two hundred and three women (mean age 38.6 +/- 9.7; range 22-83) with CIN2-3 treated by LEEP conization and confirmed in the surgical specimen, attending follow-up visits were included. Age, HR-HPV detection and viral load determined by HybridCapture 2, and cone margins were evaluated as possible predictors of residual/recurrent disease. Value of single and repeated cytology as well as HR-HPV detection and viral load during follow-up were analyzed as screening tools of recurrence.

RESULTS

Residual/recurrent disease was demonstrated by colposcopy guided biopsy in 36 patients (17.7%). High HR-HPV load (>1000 RLU) prior to LEEP and positive cone margins were significantly associated with higher risk of recurrence (31.8% vs. 9.4%, P = 0.005; and 36.4% vs. 11.9%, P < 0.001 respectively). HR-HPV detection at 6-12 m after LEEP showed higher sensitivity than a single or repeated cytology (97.2% vs. 83.3% and 94.4% respectively) although it showed less specificity (81.4% vs. 92.2% and 82.6%). The combination of HR-HPV detection and the first cytology during follow-up detected all patients with residual/recurrent disease (sensitivity 100%, negative predictive value 100%) with an acceptable specificity (76.6%).

CONCLUSION

The inclusion of HR-HPV testing with cytology in follow-up of patients treated for CIN2-3 would allow for fewer post-treatment visits and avoid unnecessary cytologies. High HR-HPV load prior to LEEP or positive margins should be considered as risk factors for developing residual/recurrent disease.

MR imaging of temporomandibular joint dysfunction: a pictorial review

Temporomandibular joint (TMJ) dysfunction is a common condition that is best evaluated with magnetic resonance (MR) imaging. The first step in MR imaging of the TMJ is to evaluate the articular disk, or meniscus, in terms of its morphologic features and its location relative to the condyle in both closed- and open-mouth positions. Disk location is of prime importance because the presence of a displaced disk is a critical sign of TMJ dysfunction. However, disk displacement is also frequently seen in asymptomatic volunteers, so that other findings may be required to help make the diagnosis. These findings include thickening of an attachment of the lateral pterygoid muscle, rupture of retrodiskal layers, and joint effusion and can serve as indirect early signs of TMJ dysfunction. It is important for the radiologist to detect early MR imaging signs of dysfunction, thereby avoiding the evolution of this condition to its final stage, an advanced and irreversible phase that is characterized by osteoarthritic changes such as condylar flattening or osteophytes. Further studies conducted with the latest MR imaging techniques will allow a better understanding of the sources of TMJ pain and of any discrepancy between imaging findings and patient symptoms.

The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study

OBJECTIVE

To evaluate the effect of therapeutic education and functional readaptation (TEFR) on health-related quality of life (HRQL) in patients diagnosed with osteoarthritis on a waiting list for total knee replacement (TKR).

METHODS

Randomized controlled trial of 9 months duration was conducted. One hundred consecutive outpatients (71 females, mean age 71 years (range 50-86), mean disease duration 11.84+/-10.52 months) were included. Patients were randomized in two groups. The intervention group received TEFR added to conventional (pharmacological) treatment (n=51). The control group received conventional (pharmacological) treatment only (n=49). The main outcome variable was self-reported HRQL measured by the Spanish version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were general HRQL measured by Short Form Health Survey general questionnaire (SF-36), number of visits to general physicians and their cost. Assessments were done at baseline and at 9 months.

MAIN RESULTS

Eighty patients completed the study. Significant improvement in the WOMAC function was found at 9 months in the TERF group with respect to the control group (P=0.035). Consumption of analgesics increased significantly in the TERF group compared with controls (P=0.036). Significant improvements in pain (P=0.027) measured by WOMAC and in bodily pain (P=0.043) and physical function (P=0.031), measured by SF-36, were observed in the intervention group with respect to baseline.

CONCLUSIONS

The function dimension measured by WOMAC of patients who received both pharmacological treatment and TERF improved with respect to the control group receiving only pharmacological treatment. This suggests that a program of TEFR during the period on the waiting list for TKR may reduce the negative impact of this situation.

Laser-assisted uvulopalatoplasty for snoring: does it meet the expectations?

The high prevalence of habitual snoring (35% of the general population) and the increasing demand for an effective treatment have led, in the last decade, to the generalisation of laser-assisted uvulopalatoplasty (LAUP). However, acceptable studies on its effectiveness are lacking. The present randomised, placebo-controlled study included 25 nonapnoeic and mild obstructive sleep apnoea snorers to evaluate LAUP effectiveness for snoring. Group I received a one-stage LAUP treatment and group II a placebo (simulated snore surgery followed by an oral placebo). Before each treatment and 3 months after, the variables and procedures assessed were: body weight; sleepiness (Epworth sleepiness scale); quality of life (SF-36); subjective snoring intensity (0-10 analogue scale); objective snoring intensity (average decibel intensity); snoring index (number of snores per hour); and apnoea/hypopnea index. No differences were observed in body weight, sleepiness, quality of life, subjective and objective intensity, and frequency of snoring, and apnoea/hypopnea index between the groups before and 3 months after treatment. In conclusion, this study provides evidence of the lack of effectiveness of one-stage laser-assisted uvulopalatoplasty for snoring in nonapnoeic and mild obstructive sleep apnoea patients, with the result that it does not meet the expectations generated by the procedure.

The effects of short-term iron supplementation on iron status in infants in malaria-endemic areas

Iron deficiency and Plasmodium falciparum malaria are the two main causes of anemia in young children in region endemic for this disease. The impact on iron status of prophylactic oral iron supplementation (2 mg/kg/day from two to six months of age) and the duration of this effect were assessed in a group of 832 Tanzanian infants exposed to P. falciparum malaria. Iron parameters and red blood cell indices were assessed at 2, 5, 8, and 12 months of age. Infants who received iron supplements had a significantly lower prevalence of iron deficiency (P < 0.01 at 5 months and P < 0.001 at 8 and 12 months). Red blood cell indices (mean corpuscular volume, mean cell hemoglobin, and mean cell hemoglobin concentration) were increased in children receiving iron supplementation and they did not differ between those protected and unprotected against malaria. The prevalence of ferropenia was similar in children protected against malaria and in those who were not protected and did not receive iron supplements (34.7% versus 37.3% at 12 months of age). We concluded that iron supplementation between the ages of 2-6 months improves iron status at least up to 12 months of age. Malaria infection does not contribute to iron deficiency.

Integrin expression in normal and out-of-phase endometria

Integrins have recently been proposed as having a major role in endometrial receptivity. Different patterns of integrin expression have been described during the normal endometrial cycle, and the co-expression of several integrins, mainly alpha1, alpha4 and beta3 has been considered as specific to the 'window of implantation'. In the present study 55 infertile patients underwent two endometrial biopsies during a single menstrual cycle. An early biopsy was done on postovulatory days 6-8, and a late biopsy was performed on postovulatory days 10 to 12. Histological dating as well as immunohistochemical evaluation of alpha1, alpha4, beta1, beta3, beta5, alpha(v)beta3 integrin expression and oestrogen and progesterone receptors were determined in all endometrial biopsies. Oestradiol and progesterone serum concentrations in serum were evaluated on the same days of the endometrial samplings. Nine out of the 55 midluteal biopsies (16.4%) showed out-of-phase endometria, but all biopsies were in phase in the late luteal phase. Differences in integrin expression between in- and out-of-phase biopsies were observed only for alpha(v)beta3 integrin glandular expression during the midluteal phase. Alpha(v)beta3 integrin glandular expression was found in all late luteal phase biopsies. Alpha(v)beta3 expression was closely correlated with histological maturation of the endometrium appearing suddenly at postovulatory day 6-7 and being expressed by all endometria dated as postovulatory day > or = 8, irrespective of midluteal endometrial biopsies being in phase or out of phase. No differences in integrin expression were detected between patients with or without endometriosis or between patients who became spontaneously pregnant and those who did not. In conclusion, further studies are necessary before patterns of integrin expression may offer an alternative to predict uterine receptivity and implantation potential.

Does the use of contraception reduce the risk of pregnancy-induced hypertension?

To estimate the impact of the exposure to spermatozoa on the risk of developing pregnancy-induced hypertension, the duration of sexual cohabitation with the father and the use of contraceptive methods were evaluated among 113 primigravid women with pregnancy-induced hypertension and 109 age- and parity-matched controls. The duration of unprotected sexual cohabitation was approximately 50% shorter in women with pregnancy-induced hypertension (2.3 versus 4.7, P < 0.0001), regardless of the contraceptive method previously used. However, the duration of oral contraception use was similar in cases and controls (22.1 versus 23.4 months). Also, of the total group of women who developed pregnancy-induced hypertension, 85.5% (97) became pregnant during the first 3 months of unprotected sexual intercourse in comparison with 54.1% (59) in the control group (P < 0.0001). Results suggest that the risk of pregnancy-induced hypertension in primigravidae is reduced with duration of sexual cohabitation, and therefore with exposure to paternal spermatozoa. However, the protective effect of exposure is not achieved while using oral contraceptives. Considering the present options for nulliparous women, contraception does not appear to be a viable public health policy to reduce the risk of pregnancy induced hypertension.