Estimating Prevalence and Infection Intensity of Soil-Transmitted Helminths Using Quantitative Polymerase Chain Reaction and Kato-Katz in School-Age Children in Angola

Quantitative polymerase chain reaction (qPCR) is gaining recognition in soil-transmitted helminth (STH) diagnostics, especially for Strongyloides stercoralis and differentiating hookworm species. However, sample preservation and DNA extraction may influence qPCR performance. We estimated STH prevalence and infection intensity by using qPCR in schoolchildren from Huambo, Uige, and Zaire, Angola, and compared its performance with that of the Kato-Katz technique (here termed Kato-Katz). Stool samples from 3,063 children (219 schools) were preserved in 96% ethanol and analyzed by qPCR, of which 2,974 children (215 schools) had corresponding Kato-Katz results. Cluster-adjusted prevalence and infection intensity estimates were calculated by qPCR and Kato-Katz, with cycle threshold values converted to eggs per gram for qPCR. Cohen's kappa statistic evaluated agreement between qPCR and Kato-Katz. DNA extraction and qPCR were repeated on 191 (of 278) samples that were initially qPCR negative but Kato-Katz positive, of which 112 (58.6%) became positive. Similar prevalence for Ascaris lumbricoides (37.5% versus 34.6%) and Trichuris trichiura (6.5% versus 6.1%) were found by qPCR and Kato-Katz, respectively, while qPCR detected a higher hookworm prevalence (11.9% versus 2.9%). The prevalence of moderate- or high-intensity infections was higher by Kato-Katz than by qPCR. Agreement between qPCR and Kato-Katz was very good for A. lumbricoides, moderate for T. trichiura, and fair for hookworm. Strongyloides stercoralis prevalence was 4.7% (municipality range, 0-14.3%), and no Ancylostoma ceylanicum was detected by qPCR. Despite suboptimal performance, presumably due to fixative choice, qPCR was fundamental in detecting S. stercoralis and excluding zoonotic A. ceylanicum. Further evaluations on sample fixatives and DNA extraction methods are needed to optimize and standardize the performance of qPCR.

Impact of conflict on the elimination targets of lymphatic filariasis, schistosomiasis and soil-transmitted helminths in Cabo Delgado province, Mozambique

BACKGROUND

Mozambique has one of the highest burdens of neglected tropical diseases in Africa. Lymphatic filariasis, schistosomiasis and soil-transmitted helminths are being targeted for elimination as part of integrated mass drug administration campaigns. The progress made towards interruption of transmission has been affected by recent conflict in Cabo Delgado province. The aim of this paper was to determine the potential impact of this crisis on the neglected tropical diseases programme and the challenges in reaching the elimination goals of 2030.

METHODOLOGY

A desk-based secondary data analysis was conducted on publicly available sources of neglected tropical diseases, conflict incidents, internally displaced persons and geographical access between 2020 and 2022. Data were summarised and mapped using GIS software. A combined risk stratified assessment at district level was developed with five classifications i) Very high-risk; ii) High-risk; iii) Medium to high-risk; iv) Medium risk; and v) Not at risk due to conflict absence but co-endemic.

RESULTS

Lymphatic filariasis, schistosomiasis and soil-transmitted helminths were co-endemic in 115 out of 156 (74%) districts. Between 2020 and 2022 a total of 1,653 conflict-related incidents were reported, most of them in Cabo Delgado province (n = 1,397, 85%). A five-fold increase of internally displaced persons was recorded from April 2020 (n = 172,186) to November 2022 (n = 935,130). Geographical accessibility also deteriorated across the province with an increase from five (29%) in 2021 to seven (41%) districts in 2022 classified as hard-to-reach. The combined risk stratification identified that most districts in Cabo Delgado province had medium to high-risk (n = 7; 41%); very high-risk (n = 5, 29%); medium risk (n = 3, 18%); high-risk (n = 2, 12%).

CONCLUSION

Most of the districts of Cabo Delgado were considered to be at risk of not meeting the neglected tropical diseases road map 2030 targets due to the humanitarian crisis ongoing. There is the need for practical strategies and funding to overcome these hostile challenges.

Molecular and entomological surveillance of malaria vectors in urban and rural communities of Benguela Province, Angola

BACKGROUND

Malaria is a major public health problem in Angola, with Anopheles gambiae sensu lato (s.l.) and An. funestus s.l. being the primary vectors. This study aimed to clarify the information gaps concerning local Anopheles mosquito populations. Our objectives were to assess their abundance, geographical dispersion, and blood-feeding patterns. We also investigated their insecticide resistance. Molecular methods were used to identify sibling species, determine the origin of blood meals, measure Plasmodium falciparum infection rates, and detect the presence of knockdown resistance (kdr) mutations.

METHODS

Adult mosquitoes were collected indoors using CDC light traps from nine randomly selected households at two sentinel sites with distinct ecological characteristics. The samples were collected from 1 February to 30 June 2022. Anopheles mosquitoes were morphologically identified and subjected to molecular identification. Unfed Anopheles females were tested for the presence of P. falciparum DNA in head and thorax, and engorged females were screened for the source of the blood meals. Additionally, members of An. gambiae complex were genotyped for the presence of the L1014F and L1014S kdr mutations.

RESULTS

In total, 2226 adult mosquitoes were collected, including 733 Anopheles females. Molecular identification revealed the presence of Anopheles coluzzii, An. gambiae senso stricto (s.s.), An. arabiensis, and An. funestus s.s. Notably, there was the first record of An. coluzzii/An. gambiae s.s. hybrid and An. vaneedeni in Benguela Province. Plasmodium falciparum infection rates for An. coluzzii at the urban sentinel site and An. funestus s.s. at the rural site were 23.1% and 5.7%, respectively. The L1014F kdr mutation was discovered in both resistant and susceptible An. coluzzii mosquitoes, while the L1014S mutation was detected in An. gambiae s.s. for the first time in Benguela Province. No kdr mutations were found in An. arabiensis.

CONCLUSIONS

This study provides valuable insights into the molecular characteristics of malaria vectors from the province of Benguela, emphasising the need for continuous surveillance of local Anopheles populations regarding the establishment of both kdr mutations for tailoring vector control interventions.

Phenylpropiolic acid isolated in cryogenic nitrogen and xenon matrices: NIR and UV-induced study

Phenylpropiolic acid (C6H5C≡CCOOH, PPA) isolated in nitrogen and xenon cryogenic matrices was studied by infrared spectroscopy. The experimental studies were complemented by a series of quantum chemical calculations carried out at the density functional theory (B3LYP) and MP2 levels of theory (with different basis sets). The calculations predicted the existence of two planar PPA conformers, differing in the arrangement of the carboxylic group. The higher-energy trans-PPA conformer has a negligible population in the gas phase at room temperature and was prepared in situ in the N2 cryomatrix through vibrationally-induced rotamerization of the lower-energy cis-PPA conformer, achieved using selective narrowband infrared excitation of the OH stretching coordinate of the latter species. Broadband UV (λ > 235 nm) irradiation of matrix-isolated cis-PPA was also undertaken, leading to the observation of cis-PPA → trans-PPA isomerization. No other UV-induced photoreactions were observed. The in situ generated trans-PPA conformer was found to decay back to cis-PPA in the dark by tunneling, and its lifetimes under different experimental conditions were determined. The assignment of the infrared spectra of both conformers is presented, considerably extending the vibrational information available on this molecule.

Knowledge, attitudes, practices and acceptability of a school preventive chemotherapy programme for schistosomiasis and soil-transmitted helminths control in Angola

Schistosomiasis and soil-transmitted helminth (STH) control programs require target population engagement, assessed through knowledge, attitudes and practices (KAP) surveys. We report the results of a KAP survey of Angolan schoolchildren supported by a school preventive chemotherapy (PC) programme, without or with a school water, sanitation and hygiene (WASH) programme (PC+/WASH- and PC+/WASH+, respectively); and schoolchildren without a school PC or WASH program (PC-/WASH-). Schoolchildren from PC+/WASH- (N = 218), PC+/WASH+ (N = 250) and PC-/WASH- (N = 254) schools were interviewed. Descriptive statistics were used to report demographics and survey responses. Chi-square or Fisher's exact test was used to compare PC+/WASH- schoolchildren with (i) PC+/WASH+ and (ii) PC-/WASH- schoolchildren. A lower proportion of PC+/WASH- schoolchildren used latrines and a higher proportion practised open defecation at school compared with PC+/WASH+ schoolchildren. A lower proportion of PC+/WASH- schoolchildren always washed their hands after toileting and before meals at school compared with PC+/WASH+ schoolchildren. However, the PC+/WASH- schoolchildren reported better toileting and handwashing practices at school compared to PC-/WASH- schoolchildren. Over 90% of PC+ schoolchildren agreed with schistosomiasis and STH control and accepted schoolteacher PC delivery. Expanding the integration of both school PC and WASH programs will improve health behaviours relevant to reduce the risk of schistosomiasis and STHs in schoolchildren. This article is part of the theme issue 'Challenges and opportunities in the fight against neglected tropical diseases: a decade from the London Declaration on NTDs'.

School-based preventive chemotherapy program for schistosomiasis and soil-transmitted helminth control in Angola: 6-year impact assessment

BACKGROUND

A school preventive chemotherapy (PC) program for soil-transmitted helminths (STHs) and schistosomiasis has operated in Huambo, Uige and Zaire provinces, Angola, since 2013 and 2014, respectively; complemented by a school water, sanitation and hygiene (WASH) program in a subset of schools from 2016. Conducted in 2021, this is the first impact assessment of the school program for the control of schistosomiasis and STHs.

METHODOLOGY/PRINCIPAL FINDINGS

A two-stage cluster design was used to select schools and schoolchildren for parasitological and WASH surveys. The rapid diagnostic tests (RDTs), point of care circulating cathodic antigen (POC-CCA) and Hemastix, were used to estimate Schistosoma mansoni and Schistosoma haematobium prevalence, respectively. Kato Katz was used to detect STHs, and quantify STH and S. mansoni infections. Urine filtration was used to quantify S. haematobium infections. Prevalence, infection intensity, relative prevalence reduction and egg reduction rates were calculated for schistosomiasis and STHs. Cohen's Kappa co-efficient was used to assess agreement between RDTs and microscopy. Chi-square or Fisher's exact test was used to compare WASH indicators in WASH-supported and WASH-unsupported schools. Overall, 17,880 schoolchildren (599 schools) and 6,461 schoolchildren (214 schools) participated in the schistosomiasis and STH surveys, respectively. Prevalence of any schistosomiasis in Huambo was 29.6%, Uige 35.4%, and Zaire 28.2%. Relative reduction in schistosomiasis prevalence from 2014 for Huambo was 18.8% (95% confidence interval (CI) 8.6, 29.0), Uige -92.3% (95%CI -162.2, -58.3), and Zaire -14.0% (95%CI -48.6, 20.6). Prevalence of any STH in Huambo was 16.3%, Uige 65.1%, and Zaire 28.2%. Relative reduction in STH prevalence for Huambo was -28.4% (95%CI -92.1, 35.2), Uige -10.7% (95%CI -30.2, 8.8), and Zaire -20.9% (95%CI -79.5, 37.8). A higher proportion of WASH-supported schools had improved water sources, and toilet and handwashing facilities compared to WASH-unsupported schools.

CONCLUSIONS/SIGNIFICANCE

The limited impact this school program has had in controlling schistosomiasis and STHs identifies the need for a comprehensive understanding of individual, community, and environmental factors associated with transmission, and consideration for a community-wide control program.

Acute and chronic effects of the organophosphate malathion on the pancreatic α and β cell viability, cell structure, and voltage-gated K+ currents

Studies indicate that the pesticide malathion may have a role in diabetes. Herein, we determined the effects of different concentrations of malathion on survival, ultrastructure, and electrophysiologic islet cell parameters. Acutely, high concentrations of malathion (0.5 or 1 mM) increased cell death in rat islet cells, while low concentrations (0.1 mM) caused signs of cell damage in pancreatic α and β cells. Exposure of RINm5F cells to malathion for 24 or 48 h confirmed the reduction in β-cell viability at lower concentrations (0.001-100 µM). Chronic exposure of mouse pancreatic α and β cells to 3 nM of malathion led to increased voltage-gated K⁺ (K_v) currents in α-cells. Our findings show a time and concentration dependency for the malathion effect on the reduction of islet cell viability and indicate that pancreatic α cells are more sensitive to malathion effects on K_v currents and cell death.

Unintended intrapleural insertion of an epidural catheter in thoracic surgery: regional analgesia game over, or is there another way out?

In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia (EA) and paravertebral block (PVB) are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication. Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery (VATS). There was difficulty in epidural insertion related to patient's obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications. It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.

Exosomal glypican-1 discriminates pancreatic ductal adenocarcinoma from chronic pancreatitis

BACKGROUND AND AIMS

Pancreatic ductal adenocarcinoma (PDAC) diagnosis can be difficult in a chronic pancreatitis (CP) background, especially in its mass forming presentation. We aimed to assess the accuracy of glypican-1-positive circulating exosomes (GPC1+crExos) to distinguish PDAC from CP versus the state-of-the-art CA 19-9 biomarker.

METHODS

This was a unicentric prospective cohort. Endoscopic ultrasound with fine-needle aspiration or biopsy and blood tests (GPC1+crExos and serum CA 19-9) were performed.

RESULTS

The cohort comprised 60 PDAC and 29 CP (7 of which mass forming - MF) patients. Median levels of GPC1+crExos were significantly higher in PDAC (99.7%) versus CP (28.4%; p<0.0001) with an AUROC of 0.96 with 98.3% sensitivity and 86.2% specificity for a cut-off of 45.0% (p<0.0001); this outperforms CA 19-9 AUROC of 0.82 with 78.3% sensitivity and 65.5% specificity at a cut-off of 37 U/mL (p<0.0001). The superiority of% GPC1+crExos over CA 19-99 in differentiating PDAC from CP was observed in both early (stage I) and advanced tumors (stages II-IV).

CONCLUSION

Levels of GPC1+crExos coupled to beads enable differential diagnosis between PDAC and CP including its mass-forming presentation.

Mapping of schistosomiasis and soil-transmitted helminthiases across 15 provinces of Angola

Introduction

Schistosomiasis (SCH) and soil transmitted helminthiases (STH) have been historically recognized as a major public health problem in Angola. However, lack of reliable, country wide prevalence data on these diseases has been a major hurdle to plan and implement programme actions to target these diseases. This study aimed to characterize SCH and STH prevalence and distribution in Angola.

Methods

A country wide mapping was conducted in October 2018 (1 province) and from July to December 2019 (14 provinces) in school aged (SAC) children in 15 (of 18) provinces in Angola, using WHO protocols and procedures. A total of 640 schools and an average of 50 students per school (N = 31,938 children) were sampled. Stool and urine samples were collected and processed using the Kato-Katz method and Urine Filtration. Prevalence estimates for SCH and STH infections were calculated for each province and district with 95% confidence intervals. Factors associated with SCH and STH infection, respectively, were explored using multivariable logistic regression accounting for clustering by school.

Results

Of the 131 districts surveyed, 112 (85.5%) are endemic for STH, 30 (22.9%) have a prevalence above 50%, 24 (18.3%) are at moderate risk (prevalence 20%-50%), and 58 (44.3%) are at low risk (<20% prevalence); similarly, 118 (90,1%) of surveyed districts are endemic for any SCH, 2 (1.5%) are at high risk (>50% prevalence), 59 (45.0%) are at moderate risk (10%-50% prevalence), and 57 (43.5%) are at low risk (<10% prevalence). There were higher STH infection rates in the northern provinces of Malanje and Lunda Norte, and higher SCH infection rates in the southern provinces of Benguela and Huila.

Conclusions

This mapping exercise provides essential information to Ministry of Health in Angola to accurately plan and implement SCH and STH control activities in the upcoming years. Data also provides a useful baseline contribution for Angola to track its progress towards the 2030 NTD roadmap targets set by WHO.

Neglected Tropical Diseases (NTD) still affect nearly 1 billion people worldwide and are a major public health problem in Angola. Schistosomiasis (SCH) and soil transmitted Helminthiases (STH) affect disproportionally school aged children (SAC). In endemic areas, implementation of preventive chemoprevention through school-based Mass Drug Administration Campaigns is a key strategy used to reduce the burden of these infections. Mapping of schistosomiasis and soil transmitted helminthiases is essential to know where transmission occurs and is used to inform interventions planning. A country wide SCH and STH mapping was conducted across 15 of the 18 provinces of Angola. Parasitological analysis of nearly 32,000 children was conducted to detect SCH and STH infections and determine the prevalence of these diseases. Eighty Six percent of the mapped districts are endemic for STH and 22.9% have a prevalence above 50%. Similarly, 90% of surveyed districts are endemic for SCH. There were higher STH infection rates in the northern provinces of Malanje and Lunda Norte, and higher SCH infection rates in the southern provinces of Benguela and Huila. These results are of vital importance to map the prevalence of SCH and STH in Angola and to plan adequate interventions that support NTD control across the country.

Healthcare system delay and utilization in tuberculosis patients in Portuguese high-incidence region

Background

In Portugal, the Tâmega e Sousa region (TeS) has a high incidence of tuberculosis (TB) [27.4 and 43.8 per 100.000 inhabitants in sub-regions Baixo Tâmega (BxT) and Vale do Sousa Sul (VSS), 2017]. Delay in TB diagnosis leads to increased transmission, which may lead to more people infected. This study aimed to describe healthcare system delay among TB patients and healthcare utilization from symptoms onset to diagnosis in TeS.

Methods

We analysed pulmonary TB cases notified in BxT and VSS in 2014-7 in the national surveillance system (SVIG-TB). Concomitantly, we analysed healthcare utilisation from patients in a retrospective study (URBAN-TB) about TB delays in 2019-20. We characterised demographics of patients from each data source and comorbidities from SVIG-TB. We calculated median overall delay until diagnosis (days); and healthcare delay overall and by patient characteristics, for each sub-region. Delay was calculated only when relevant dates were recorded. Healthcare utilisation from symptoms onset to diagnosis was described using the frequency of each first contact provider and the average number of visits until diagnosis.

Results

Included 139 patients from BxT and 206 from VSS (83% male, 53% aged 40-59y, and 17% with silicosis). Global delays were 48 and 75 days (n = 57/132; BxT and VSS). Healthcare delays were 7 and 8 days (n = 76/180; BxT and VSS). In both ACES, healthcare delays were longer for patients aged 60-79y, with COPD and aged 0-19y. Healthcare utilisation analysis included 38 patients (89% male; 55% aged 40-59y; n = 17/21). Primary care (n = 15; 39%) and emergency department (ED) (n = 9; 24%) were frequent points of first contact. The average number of visits until diagnosis was higher for patients from ED (3.9) and lower for patients from TB specialised units (1.3).

Conclusions

Our results suggest that in TeS it is important to avoid ED as a point of first contact of TB patients and to facilitate the diagnosis in young, older and COPD patients.

Key messages

Emergency department is a relevant point of first contact and may be included in efforts to reduce tuberculosis delay. Policies to reduce tuberculosis delay may target younger, older and COPD patients.

Factors associated with avoidance of emergency department visits in Portugal during the pandemic

Background

Avoiding an emergency department (ED) visit risks irreversible negative consequences for patients' health. EDs are a frequent access point to the Portuguese health system. Previous studies have shown that patients may avoid visiting ED during the pandemic. This study aims to identify factors associated with avoidance of ED visits in Portugal during the COVID-19 pandemic.

Methods

We used data from a community-based survey, “COVID-19 Barometer: Social Opinion”, which includes healthcare utilisation, health status, and risk perception in Portugal from 11th April 2020 to 16th April 2021. We included respondents that reported having needed ED care. Data were collected on sociodemographics, health status (comorbidities, mental health), risk perception (COVID-19 and complications), level of trust in health services and self-assessment of the severity of the reason for ED visit. The outcome of interest was the decision to avoid ED care. We used logistic regression to identify factors associated with the decision to avoid ED.

Results

Preliminary data showed that 914 respondents reported needing ED care (74.8% female; mean age 43 years). From those, 224 (25%) decided to avoid ED care. ED visits avoidance was higher during lockdowns (28%). People reporting specific comorbidities (cardiac, autoimmune, respiratory) avoided ED more than those without them. Perception of no severe reason for ED visit, poor mental health, perception of higher risk of COVID-19 and complications, and low trust in health services response to the pandemic were associated with higher odds of ED visit avoidance.

Conclusions

People avoiding ED visits represented a considerable share. The decision to avoid ED visit was associated with clinical characteristics, but the perception of risk and assessment of the context and health system response also played a role in decision making.

Key messages

The effect of avoided ED visits on health should be a research and policy concern. People with certain comorbidities or perception of high risk of COVID-19 and complications may be closely monitored.

Resistant hypertension must be defined by ambulatory blood pressure and pulse pressure is best predictor of new cardiovascular events

Introduction

Resistant Hypertension (RH) defined by Ambulatory blood pressure monitoring (ABPM) isn't so common. Prognostic CV by ABPM of RH is uncertain.

Objective

RH Population defined by ABPM, followed 5.9±5.0 years and prognostic value of ABPM for new CV events (CVe).

Design and method

ABPM-collected 1999–2019. Identified RH patients by ABPM. Obtained anthropometric, clinic, laboratorial data from the patient and clinical records. CVe defined by: stroke (ST) (Ischemic (STisq), haemorrhagic (SThs)), Coronary Event (CD), Other CV events (OCV) (acute heart failure (HF), peripheral arterial disease (PAD). Follow-up finished with event, last evaluation of the patient or death.

Results

258 patients, follow-up – 5.9±5.0 years,158 males, mean age – 60.4±11 years. Diabetes Mellitus (DM) 45.3%, Dyslipidaemia 74.4%, Obesity 45.3%, Chronic Kidney Disease 37.2%, previous CVe (PCVe) 34.5%. Observed 68 CVe: 26 ST (21 STisq, 5 SThs), 21 CD, 21 OCV (15 HF, 6 PAD). 18 death (8 unknown, 1 infection, 2 cancer, 1 sudden death, 2 STisq, 1 CD, 3 HF). When compared those with event vs no-event (fig. 1), in T student to independent samples, those with event had larger left atrium (42.6±5.7 vs 40.2±4.7, p&lt;0.05), lower creatinine clearance (mL/min/1.73m2) (63.6±34 vs 74.5±33). PCVe was significantly more prevalent on those with event (c 9.8, p&lt;0.01). In a multivariate Cox analysis for the risk of CVe (adjusted to age, gender, DM, PCVe, glycemia, creatinine, number of antihypertensive), Day Pulse Pressure with cut-off 60mmHg was statically significant (HR 2.46 (95% CI 1.26–4.83), p&lt;0.01). In Kaplan-Meier survival curve free of events, the best CV predictor obtained was the cut-off 60mmHg of PP (24h, Day, night PP), mostly Day PP-60mmHg (log rank 9.27, p&lt;0.01) (fig. 2A). When analyzed for those who had Stroke, in the multivariate Cox analysis 24h SBP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07), and night SBP (p&lt;0.05, HR 1.03 (95% CI 1.00–1.06) were statically significant on top of age, gender, DM, PCVe, glycemia, creatinine, number of antihypertensive. In Kaplan-Meier survival curve free of events, the best CV predictor obtained was the cut-off 60mmHg PP, mostly Day PP 60mmHg (log rank 8.5 p&lt;0.01) (fig. 2B). For those who had CD in the multivariate Cox analysis, adjusted for other variables, 24h SBP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07), and night SBP (p&lt;0.05 HR1.03 (95% CI 1.00–1.06) were statically significant. In Kaplan-Meier survival curve free of events, night PP 60mmHg predicted CD events (log rank 4.42 p&lt;0.05) (fig. 2C). For OCV the multivariate Cox analysis, adjusted for other variables, 24h PP (p&lt;0.05, HR 1.04 (95% CI 1.00–1.07) and night SBP (p&lt;0.05, HR 1.03 (95% CI 1.00–1.06) were statically significant for new OCV. In Kaplan-Meier survival curve free of events, best predictor was mostly night PP 60mmHg (log rank 19, p&lt;0.001) (fig. 2D).

Conclusion

In our sample of RH the definition by ABPM is essential. PP is the key prognosis for future CVe, special if analysed by the cut of PP-60 mmHg.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier survival curves

Aerobic exercise training reduces blood pressure, angiotensin II and oxidative stress of patients with resistant hypertension: the EnRiCH trial

Introduction

Resistant hypertension is a major challenge of modern cardiovascular medicine, as it is a puzzling problem without a clear solution. Exercise training clearly reduces blood pressure (BP) and oxidative stress in patients with hypertension, however evidence is limited regarding resistant hypertension.

Purpose

To determine the effect of an aerobic exercise training program in BP, angiotensin II and oxidative stress in patients with resistant hypertension.

Methods

EnRicH is a prospective, two-center, single-blinded, randomized controlled trial with a parallel two-arm group. Sixty patients with resistant hypertension were randomly assigned in a 1:1 ratio to undergo a 12-week aerobic exercise training program (exercise) or usual care (control). The powered primary efficacy measure was 24-hour ambulatory systolic BP change from baseline. Secondary outcome measures included daytime and nighttime ambulatory BP, office BP, cardiorespiratory fitness, and oxidative stress and inflammatory biomarkers: Interferon-gamma (IFN-y), Angiotensin II, vascular endothelial growth factor (VEGF), and superoxide dismutase (SOD).

Results

Fifty-three patients (exercise n=26, control n=27) completed the study. Patients were mainly women (54.7%), with an office BP of 140.7±15.9/84.2±9.4 mm Hg and taking an average of 4.6 antihypertensive medications (median, 5; range, 3 to 7). At baseline, no differences were found between groups for the study outcomes and patient characteristics. Ambulatory systolic BP was reduced −7.1 mm Hg (95% CI, −12.8 to −1.4; P=0.015) in the exercise group (127.4±12.2 to 121.2±12.2, p=0.007) compared to control group (126.1±17.2 to 126.9±15.2, p=514) over 24-hour. In addition, 24-hour ambulatory diastolic BP (−5.1 mm Hg, −7.9 to −2.3, P=0.001), daytime ambulatory systolic (−8.4 mm Hg, −14.3 to −2.5, P=0.006), and diastolic BP (−5.7 mm Hg, −9.0 to −2.4, P=0.001) were also reduced in the exercise group compared to the control group. There were no differences in the change of nighttime ambulatory BP between groups. Cardiorespiratory fitness improved in the exercise group by 14% (4.7 ml.kg-1.min-1, P&lt;0.001), while it remained unchanged in the control group (−0.37 ml.kg-1.min-1, P=0.442). A significant between-group difference in favor of exercise group was found for IFN-y (−4.3 pg/mL, 95% CI: −7.1 to −1.5; P=0.003), Angiotensin II (−157.0 pg/mL, 95% CI: −288.1 to −25.9; P=0.020), VEGF (10.53 pg/mL, 95% CI: 0.60 to 22.54; P=0.035), and SOD (0.35 pg/mL, 95% CI: 0.10 to 0.58; P=0.009).

Conclusions

A 12-week moderate intensity aerobic exercise program reduced ambulatory BP, angiotensin II and oxidative stress in patients with resistant hypertension. The antihypertensive effects of exercise in patients with resistant hypertension may be mediated by positive changes in oxidative stress and inflammatory biomarkers.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): European Union through European Regional Development Fund – Operational Competitiveness Factors Program (COMPETE)Portuguese Government through FCT - Foundation for Science and Technology

Field Efficacy of Larvivorous Fish and Pyriproxyfen Combined with Community Engagement on Dengue Vectors in Cambodia: A Randomized Controlled Trial

Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes mosquitoes is limited. Therefore, the purpose of this trial was to estimate the impact of guppy fish in combination with the larvicide pyriproxyfen (PPF) (Sumilarv® 2MR) and communication for behavioral impact (COMBI) activities to reduce entomological indices in Cambodia. In this cluster randomized, controlled superiority trial, 30 clusters comprised of one or more villages each was allocated in a 1:1:1 ratio to receive either 1) all three interventions (guppies, PPF, and COMBI), 2) two interventions (guppies and COMBI), or 3) control (standard vector control). Entomological surveys among 40 randomly selected households per cluster were carried out quarterly. The primary outcome was the population abundance of adult female Aedes mosquitoes trapped using adult resting collections. In the primary analysis, adult female Aedes abundance and mosquito infection rates was aggregated over follow-up time points to give a single rate per cluster. These data were analyzed by negative binomial regression, yielding abundance ratios (ARs). The number of Aedes females was reduced roughly by half compared with the control in both the guppy, PPF, and COMBI arm (AR = 0.54; 95% CI, 0.34-0.85; P = 0.0073); and the guppy and COMBI arm (AR = 0.49; 95% CI, 0.31-0.77; P = 0.0021). The effectiveness demonstrated and extremely low cost of including fish rearing in community-based health structures suggest they should be considered as a vector control tool as long as the benefits outweigh any potential environmental concerns. Sumilarv® 2MR was also highly accepted and preferred over current vector control tools used in Cambodia.

May the brief physical activity assessment tool accurately measure physical activity in patients with resistant hypertension?

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FEDER Funds through the Operational Competitiveness Factors Program—COMPETE National Funds through the Portuguese Foundation for Science and Technology (FCT) “PTDC/DTP-DES/1725/2014”. SL is a PhD fellow supported by the FCT (Grant Ref: SFRH/BD/129454/2017).

Introduction

Resistant hypertension is a major health problem due to the increased risk of cardiovascular events and mortality. Physical activity and exercise reduces blood pressure in resistant hypertension and is associated with lower cardiovascular risk and mortality. It is presently recommended that physical activity assessment should be a priority in all visits to health settings

Purpose

This study aims to determine if the Brief Physical Activity Assessment Tool (BPAAT), a 2-question tool to assess physical activity, is a valid instrument to detect inactive patients with resistant hypertension. 

Methods

Sixty patients with a diagnosis of resistant hypertension were recruited. Outcome measures included clinical data, blood pressure and daily physical activity. Physical activity was objectively measured over a 7-day period with an accelerometer and subjectively assessed (self-assessment) by the BPAAT. The association between the BPAAT and accelerometry, according to the BPAAT scoring categories, was assessed bythe percentage of agreement, Cohen’s Kappa and sensitivity and specificity.

Results

Patients (33 were male) had a mean age of 59.4 ± 9.1years, were on average overweight (BMI 29.5 ± 4.5 kg/m2) and on an average of 4.5 ± 0.7 antihypertensive medications. Forty-two patients (70%) were classified as insufficiently active by the BPAAT compared to the 38 (63.3%) insufficiently active patients identified by the accelerometry data. Regarding the questionnaire’s specificity and sensitivity, the BPAAT correctly identified 32 [84.2 (73.1 – 95.3) %] of the 38 ‘insufficiently active’ patients and 12 [54.5 (34.3 – 74.7) %] of the 22 ‘sufficiently active’ patients identified by accelerometry. The agreement between BPAAT and accelerometry to identify sufficiently/insufficiently active patients, according to the BPAAT’s cut-off values was fair to moderate (Kappa = 0.403 (0.162 – 0.674), with a percentage of agreement of 73.3%.

Conclusion

The BPAAT, a 2-question tool to assess physical activity, seems to be a valid and fast solution to identify insufficiently active adults with resistant hypertension during routine clinical visits.

Higher levels of physical activity is associated with lower arterial stiffness in patients with resistant hypertension

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Portuguese Foundation for Science and Technology (FCT) European Regional Development Fund – Operational Competitiveness Factors Program (COMPETE)

Background

 Physical activity has been associated with reduced arterial stiffness in patients with hypertension. However, in resistant hypertension, a specific population with an increased risk for target organ damage, cardiovascular morbidity, and mortality, the evidence is sparse. 

Purpose

 The present study aimed to determine the association between daily physical activity and arterial stiffness in patients with resistant hypertension.

Methods

 Fifty-seven patients with resistant hypertension were recruited. Physical activity was objectively assessed during 7 consecutive days with accelerometers. Arterial stiffness was evaluated using carotid-femoral pulse wave velocity (cf-PWV) . 

Results

 Participants (50.9% men), aged 58.8 ± 9.4 years, were mainly overweight and were taking in average 4.5 antihypertensive medications. The cf-PWV showed an inverse correlation with light-intensity physical activity (r = -0.290, p = 0.029) and total daily physical activity (r = -0.287, p = 0.030). Additionally, cf-PWV tended to be inversely associated with the number of steps per day (r = -0.242, p = 0.069). Patients with higher risk of cardiovascular events (cf-PWV ≥ 10 m/s) tended to spend less time in light-intensity physical activity (324.0 ± 129.4 vs. 380.5 ± 103.1 min/day, p = 0.090) and to perform less total daily physical activity (351.5 ± 141.7 vs. 411.7 ± 109.1 min/day, p = 0.091) than participants with cf-PWV below the risk threshold value.

Conclusions

 Higher levels of total physical activity and daily levels of light-intensity were associated to lower arterial stiffness. These results emphasize the importance of physical activity as a nonpharmacological tool for patients with resistant hypertension.

Risk assessment of wildlife-watching tourism in an important endangered loggerhead turtle rookery

Wildlife-watching tourism is a non-exploitative activity that can contribute to sustainable economic development of coastal communities. However, it is important to assess the potential impact and implement best practices to mitigate any negative effects of such tourism. We studied this issue on Boa Vista (Cabo Verde), which supports around 60% of nesting activity of one of the most endangered loggerhead turtle rookeries globally. Between 2013 and 2016, authorized turtle watching involved 4942 tourists, generating a mean annual direct income of >USD 289000 and the direct creation of >250 jobs. On João Barrosa beach, which supports around 20% of nests and 48% of turtle-watching activity on the island, we tested the influence of turtle watching on nesting behavior, reproduction and nest-site fidelity. Nesting females observed by tourists spent significantly less time on nest-camouflaging behavior, although all other phases of nesting were unaffected. There were no statistically significant differences between the re-nesting frequency of females watched (n = 187) and non-watched (n = 972) by tourists. We found no evidence that the current turtle-watching intensity has an effect on turtle reproduction. Turtle poaching remains a severe threat on beaches with no turtle watching, although it has strongly decreased on beaches with tourist visits. We suggest tour guides follow best practice guidelines to minimize disturbance, specifically retreating from the immediate vicinity of a female during nest camouflaging to mitigate the observed impact.

Eliminating Plasmodium falciparum malaria: results from tailoring active case detection approaches to remote populations in forested border areas in north-eastern Cambodia

BACKGROUND

Remaining Plasmodium falciparum cases in Cambodia are concentrated in forested border areas and in remote populations who are hard to reach through passive case detection. A key approach to reach these populations is active case detection by mobile malaria workers (MMWs). However, this is operationally challenging because of changing movement patterns of the target population moving into less accessible areas. From January 2018 to December 2020, a tailored package of active case detection approaches was implemented in forested border areas of three provinces in north-eastern Cambodia to reach remote populations and support the elimination of falciparum malaria.

METHODS

Key elements of this project were to tailor approaches to local populations, use responsive monitoring systems, maintain operational flexibility, build strong relationships with local communities, and implement close supervision practices. MMWs were recruited from local communities. Proactive case detection approaches included mobile malaria posts positioned at frequented locations around and within forests, and locally informed outreach activities targeting more remote locations. Reactive case detection was conducted among co-travellers of confirmed cases. Testing for malaria was conducted independent of fever symptoms. Routine monitoring of programmatic data informed tactical adaptations, while supervision exercises ensured service quality.

RESULTS

Despite operational challenges, service delivery sites were able to maintain consistently high testing rates throughout the implementation period, with each of 45 sites testing a monthly average of 64 (SD 6) people in 2020. In 2020, project MMWs detected only 32 P. falciparum cases. Over the project period, the P. falciparum/P. vivax ratio steadily inversed. Including data from neighbouring health centres and village malaria workers, 45% (80,988/180,732) of all people tested and 39% (1280/3243) of P. falciparum cases detected in the area can be attributed to project MMWs. Remaining challenges of the last elimination phase include maintaining intensified elimination efforts, addressing the issue of detecting low parasitaemia cases and shifting focus to P. vivax malaria.

CONCLUSIONS

Reaching remote populations through active case detection should remain a key strategy to eliminate P. falciparum malaria. This case study presented a successful approach combining tailored proactive and reactive strategies that could be transferred to similar settings in other areas of the Greater Mekong Subregion.

Structural, spectroscopic, and photochemical study of ethyl propiolate isolated in cryogenic argon and nitrogen matrices

Ethyl propiolate (HC ≡ CCOOCH₂CH₃, EP) was studied experimentally by infrared spectroscopy in argon and nitrogen cryomatrices (15 K) and by quantum chemical calculations (at the DFT(B3LYP) and MP2 levels of theory). Calculations predict the existence of four conformers: two low-energy conformers (I and II) possessing the carboxylic moiety in the cis configuration (O=C-O-C dihedral equal to ~0°) and two higher-energy trans forms (O=C-O-C dihedral equal to ~180°; III and IV). The conformation of the ethyl ester group within each pair of conformers is either anti (C-O-C-C equal to 180°; in conformers I and III) or gauche (C-O-C-C equal to ±86.6° in II, and ± 92.5° in IV). The two low-energy cis conformers (I and II) were predicted to differ in energy by less than 2.5 kJ mol^-1 and were shown to be present in the studied cryogenic matrices. Characteristic bands for each one of these conformers were identified in the infrared spectra of the matrix-isolated compound and assigned taking into account the results of normal coordinate analysis, which used the geometries and harmonic force constants obtained in the DFT calculations. The two trans conformers (III and IV) were estimated to be 17.5 kJ mol^-1 higher in energy than the conformational ground state (form I) and were not observed experimentally. The unimolecular photochemistry of matrix-isolated EP (in N₂ matrix) was also investigated. In situ irradiation with UV light (λ > 235 nm) leads mainly to decarbonylation of the compound, with generation of ethoxyethyne, which in a subsequent photoreaction generates ketene (plus ethene).

Frequency and patient attributes associated with ED visits within 30 days after discharge

Background

About 20%-25% of patients return to the emergency department (ED) within 30 days after inpatient discharge. This outcome is relevant since it may signal failures in inpatient care and care transitions. However, literature on the topic is still scarce. Our study aims to describe frequency and patient attributes associated with ED visits within 30 days (30d) of inpatient discharge in one public Portuguese hospital.

Methods

The study included adult patients discharged in 2016. Admissions of deceased or transferred patients were excluded. The rate of 30d ED visits after discharge was computed for selected patient (gender and age) and admission attributes [urgent, Major Diagnostic Category (MDC)]. Number of days from discharge to ED visit was determined. Logistic regression was used to compute crude and age-gender adjusted odds-ratios (cOR, aOR) for each selected admission attribute.

Results

From the 21744 admissions included (median age: 58y; 40% male), for 5058 there was at least one ED visit within 30d after discharge (23%). The majority of ED visits were triaged urgent (n = 2286; 45%) or very urgent (n = 1499; 30%). Time to first ED visit was, on average, 11 days. The risk of ED visit was increased among men (cOR = 1.180; 95% confidence interval - 95%CI: 1.103-1.262) and patients aged 75 or older (cOR = 1.704; 95%CI: 1.557-1.866). After controlling for gender and age differences, admissions with mental diseases (aOR = 1.807; 95%CI: 1.452-2.247), respiratory diseases (aOR = 1.786; 95%CI: 1.535-2.078), endocrine diseases (aOR = 1.758; 95%CI: 1.374-2.250) showed increased risk of visiting ED after discharge.

Conclusions

ED visits after inpatient discharge are frequent and mostly due to urgent and very urgent needs. Older age, mental, respiratory and endocrine conditions are relevant patient risk factors for returning hospital for ED care shortly after discharge.

Key messages

Improved quality of inpatient care and care transitions that reduce ED visits after discharge may benefit a significant part of patients. Future initiatives to reduce adverse events after discharge may target patients with older age or with mental conditions.

Regional analysis of pediatric admissions with complex chronic conditions in mainland Portugal

Background

The expected rise in the number of children living longer with complex chronic conditions (CCC) and the social relevance of this group prompt the study of the patterns of their inpatient care utilization. We aimed to compare the utilization of inpatient care by children with CCC between regions of mainland Portugal.

Methods

Observational longitudinal retrospective study using anonymized administrative data for mainland Portuguese public hospitals. We selected admissions within the pediatric age limit (&lt;18yo), 2011-15. The variable of interest was the patient region of residence [Alentejo, Algarve, Centre, Lisbon Metropolitan Area (Lisbon MA), or North]. Variables related to condition (number and categories of CCC) and to care utilization [admission type, hospital type (I- community, II- regional, III- tertiary & university, IV- specialized), inpatient days, expenses] were described by region.

Results

A total of 64,918 pediatric admissions with CCC were included (ranging from 2,839 to 23,194 by region). The percentage of admissions with 2 or more CCC ranged from 16% to 22%. Haematologic & Immunologic and Metabolic categories were the ones with the highest range between regions (8%-19%; 5%-10%); the smallest range was seen in Cardiovascular (15%-18%). Urgent admissions ranged from 48% to 70%. Hospital type varied considerably, especially for type II (8%-69%). Median length of stay was 4-5 days, and median expense ranged from €1,256 to €1,467.

Conclusions

The utilization of inpatient care by children with CCC in mainland Portugal varied by region, mainly on type of admission, type of hospital, and distribution of CCC categories. Possible explanatory factors may include differences in CCC prevalence, patterns of care, and available care in each region.

Key messages

Differences in the percentage of urgent admissions require further analysis, aiming at reducing the disruption that healthcare needs may cause in the life of children with CCC and their families. There are considerable differences in the type of hospital where children with CCC in each region receive care. Healthcare system must ensure appropriate resources are available where needed.

Ability of the Premise Condition Index to Identify Premises with Adult and Immature Aedes Mosquitoes in Kampong Cham, Cambodia

Aedes-transmitted diseases, especially dengue, are increasing throughout the world and the main preventive methods include vector control and the avoidance of mosquito bites. A simple Premise Condition Index (PCI) categorizing shade, house, and yard conditions was previously developed to help prioritize households or geographical areas where resources are limited. However, evidence about the accuracy of the PCI is mixed. The current study aimed to contribute to a better understanding of the relevance by collecting data from 2,400 premises at four time points over 1 year in Kampong Cham, Cambodia. Regression models were then used to identify associations between PCI and Aedes adult female mosquitoes and pupae. In addition, receiver operating characteristic curves were used to measure the ability of PCI to identify premises in the top quartile of mosquito abundance. The density of adult Aedes females was positively associated with PCI at the household (ratio of means = 1.16 per point on the PCI scale) and cluster level (ratio of means = 1.54). However, the number of Aedes pupae was negatively associated with PCI at the household level (rate ratio = 0.74) and did not have a statistically significant association at the cluster level. Receiver operating characteristic curves suggest the PCI score had “rather low accuracy” (area under the ROC curve = 0.52 and 0.54) at identifying top-quartile premises in terms of adult female Aedes and pupae, respectively. These results suggest that caution is warranted in the programmatic use of PCI in areas of similar geography and mosquito abundance.

Effect of a therapeutic exercise program (FisioPausa) on the quality of life of employees from CESPU

Introduction In the context of work, labouring time is mainly spent in the sitting position and in a continuous way. This reality contributes for the increase of a sedentary lifestyle of workers, leading to health-related diseases and consequently decreasing they quality of life (QoL).

Objectives Verify the effect of a therapeutic exercise program in quality of life, and evaluate the association between different components of QoL, with back pain, physical activity and Body Mass Index (BMI).

Methodology A pré-post interventional study was realized in workers from the Cooperativa de Ensino Superior Politécnico Universitário. Fourteen participants were included and submitted to evaluations with a preliminary survey, the SF-36v2 (before and after 8 weeks of intervention) to assess the effects of the program in QoL. All the participants were submitted to a specific therapeutic exercise program of 20 minutes, twice a week, and during 8 weeks.

Results There was a general improvement in Health-Related Physical and Mental Quality of Life. These improvements were especially observed in the functional capacity with a higher median of 5.00 (p = 0,015). Although it was less evident, Vitality was the domain with higher improvements amongst all the four Mental domains (increase of 10.00 points across time, p = 0.341). Associations were observed between pain and functional capacity (p = 0,027) BMI and Mental Health (p = 0,027) and finally between Age and Mental Health (p = 0,028).

Conclusion Our therapeutic exercise program seems to have positive effect on quality of life, especially regarding functional capacity of workers. Participants with the highest pain were associated with decreased functional capacity and older people or those with higher BMI showed weaker mental health.

Evaluation of the effectiveness of community health workers in the fight against malaria in the Central African Republic (2012-2017)

BACKGROUND

This last decade's ongoing conflict in the Central African Republic (CAR) has led to gradual and continuous destruction of health services. With severe gaps in qualified health professionals, community health workers (CHWs) have become essential to ensuring health care access to the affected population. This article aims to evaluate the effectiveness of a 10-y CHW program in the CAR.

METHODS

Routine case management data from CHWs were collected in the Paoua district from January 2012 to December 2017 and analysed. Structured interviews were conducted in the Paoua and Carnot health districts among individuals from three different groups (health service beneficiaries, CHWs and health facility managers).

RESULTS

From 2012 to 2017, 353 948 people consulted for malaria suspicion with CHWs and 86% were found to be malaria positive after a rapid diagnostic test. Among those diagnosed patients, 98.5% received adequate treatment and nearly 1.5% were referred to health facilities. Also, 94.5% of respondents identified fever as the major malaria symptom. About 70% of the population could identify three malaria signs/symptoms and 84.4% accepted and used CHW services. Interviews with CHWs revealed that 45.8% of them received at least four training sessions per month as part of their capacity building.

CONCLUSIONS

CHWs can be a resourceful solution when other health professional are scarce. This study showed that CHWs are not only able to deliver curative and preventive health services, but they are also well accepted by the served communities.

Implementation of guppy fish (Poecilia reticulata), and a novel larvicide (Pyriproxyfen) product (Sumilarv 2MR) for dengue control in Cambodia: A qualitative study of acceptability, sustainability and community engagement

BACKGROUND

In Cambodia dengue vector control activities are focused on larviciding with temephos and pyrethroid based adulticide sprays to which Aedes have been shown to be increasingly resistant. A cluster randomized trial assessed the impact of using biological control tools (guppy fish, pyriproxyfen (PPF), and Communication for Behavioral Impact (COMBI) activities in combination), which would be used in a value comparison to traditional chemical control tools. Given these new intervention methods, a qualitative assessment was designed in order to represent the quality of understanding, acceptance, and implementation by participants.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 103 participants in 12 Focus Group Discussions (FGDs) and nine In-Depth Interviews (IDIs) were included in the study. The majority of participants in intervention villages (50 out of 80) preferred guppy fish over other vector control methods due to ease of use and rearing, quick reproduction and propensity to eat larvae. A substantial number of participants (11 out of 40) in intervention villages with PPF favored it due to long-lasting effectiveness, lack of smell and easy maintenance. Participants showed high demand for both interventions and were willing to pay between 100-500 riel (0.03-0.13 USD). Nearly all participants perceived that the interventions resulted in a reduction in Aedes mosquitos (both adults and immatures) and dengue cases. The presence of larvae in the water despite the use of PPF was a source of concern for some participants, although this was overcome in some cases with proper health education through health volunteers. Interpersonal communication through health volunteers was the most favorite method of transmitting prevention messages.

CONCLUSIONS/SIGNIFICANCE

The community led COMBI strategy resulted in high acceptance and perceived effectiveness of the interventions in target villages. Health volunteers are an effective and accepted channel of communication to engage communities, disseminate information and promote behavioral change at the household and community level. If shown effective through corresponding entomological surveys, the interventions should be continued and further strengthened to ensure they are accessible, available and affordable.

Low Golimumab Trough Levels at Week 6 Are Associated With Poor Clinical, Endoscopic and Histological Outcomes in Ulcerative Colitis Patients: Pharmacokinetic and Pharmacodynamic Sub-analysis of the Evolution Study

BACKGROUND AND AIMS

Golimumab has an established exposure-response relationship in patients with ulcerative colitis [UC]. However, the association of serum golimumab trough levels [TL] with objective markers of disease activity, such as endoscopic and histological activity scores and concentrations of biomarkers, remains less understood. This report describes the relationship of serum golimumab TL at the end of the induction period [Week 6] with clinical, endoscopic, histological, and biomarker parameters.

METHODS

This was an open-label, uncontrolled, prospective and interventional study. Moderate to severely active UC patients naïve to biologic therapy were treated with golimumab. Serum golimumab TL and faecal calprotectin levels were measured at baseline [Week 0 of induction] and Week 6.

RESULTS

A total of 34 patients completed the induction phase [Week 6] and were included in this analysis. Overall, 47.1% and 14.7% of patients achieved clinical response and remission with significantly higher serum golimumab TL in patients with early response or remission [3.7 μg/mL vs 1.3 μg/mL, p = 0.0013; and 3.1 μg/mL vs 1.7 μg/mL, p = 0.0164, respectively]. In addition, golimumab TL were significantly higher in patients achieving histological remission [4.2 μg/mL vs 1.7 μg/mL, p = 0.0049]. Week 6 golimumab TL were inversely correlated with the total Mayo score [rs = -0.546; p = 0.0008], the Mayo endoscopic subscore [rs = -0.381; p = 0.0262], the Geboes histological activity score [rs = -0.464; p = 0.0057], and faecal calprotectin levels [rs = -0.497; p = 0.0044].

CONCLUSIONS

A higher early exposure to golimumab is associated with a better objective response in active UC patients and appears to drive the outcome at Week 6.

The tolerability of single low dose primaquine in glucose-6-phosphate deficient and normal falciparum-infected Cambodians

Background

The WHO recommends single low-dose primaquine (SLDPQ, 0.25 mg/kg body weight) in falciparum-infected patients to block malaria transmission and contribute to eliminating multidrug resistant Plasmodium falciparum from the Greater Mekong Sub region (GMS). However, the anxiety regarding PQ-induced acute haemolytic anaemia in glucose-6-phosphate dehydrogenase deficiency (G6PDd) has hindered its use. Therefore, we assessed the tolerability of SLDPQ in Cambodia to inform national policy.

Methods

This open randomised trial of dihydroartemisinin-piperaquine (DHAPP) + SLDPQ vs. DHAPP alone recruited Cambodians aged ≥1 year with acute uncomplicated P. falciparum. Randomisation was 4:1 DHAPP+SLDPQ: DHAPP for G6PDd patients and 1:1 for G6PDn patients, according to the results of the qualitative fluorescent spot test. Definitive G6PD status was determined by genotyping. Day (D) 7 haemoglobin (Hb) concentration was the primary outcome measure.

Results

One hundred nine patients (88 males, 21 females), aged 4–76 years (median 23) were enrolled; 12 were G6PDd Viangchan (9 hemizygous males, 3 heterozygous females). Mean nadir Hb occurred on D7 [11.6 (range 6.4 ─ 15.6) g/dL] and was significantly lower (p = 0.040) in G6PDd (n = 9) vs. G6PDn (n = 46) DHAPP+SLDPQ recipients: 10.9 vs. 12.05 g/dL, Δ = -1.15 (95% CI: -2.24 ─ -0.05) g/dL. Three G6PDn patients had D7 Hb concentrations < 8 g/dL; D7-D0 Hbs were 6.4 ─ 6.9, 7.4 ─ 7.4, and 7.5 ─ 8.2 g/dL.

For all patients, mean (range) D7-D0 Hb decline was -1.45 (-4.8 ─ 2.4) g/dL, associated significantly with higher D0 Hb, higher D0 parasitaemia, and receiving DHAPP; G6PDd was not a factor. No patient required a blood transfusion.

Conclusions

DHAPP+SLDPQ was associated with modest Hb declines in G6PD Viangchan, a moderately severe variant. Our data augment growing evidence that SLDPQ in SE Asia is well tolerated and appears safe in G6PDd patients. Cambodia is now deploying SLDPQ and this should encourage other GMS countries to follow suit.

Trial registration

The clinicaltrials.gov reference number is NCT02434952.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3862-1) contains supplementary material, which is available to authorized users.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The performance of Remicade®-optimized quantification assays in the assessment of Flixabi® levels

BACKGROUND

The advent of Remicade® biosimilars, Remsima®, Inflectra® and, more recently, Flixabi®, has brought along the potential to decrease the costs associated with this therapy, therefore increasing its access to a larger group of patients. However, and in order to assure a soft transition, one must make sure the assays and algorithms previously developed and optimized for Remicade perform equally well with its biosimilars. This study aimed to: (a) validate the utilization of Remicade-optimized therapeutic drug monitoring assays for the quantification of Flixabi; and (b) determine the existence of Remicade, Remsima and Flixabi cross-immunogenicity.

METHODS

Healthy donors' sera spiked with Remicade, Remsima and Flixabi were quantified using three different Remicade-quantification assays, and the reactivity of anti-Remicade and anti-Remsima sera to Remicade and to its biosimilars was assessed.

RESULTS

The results show that all tested Remicade-infliximab-optimized assays measure Flixabi as accurately as they measure Remicade and Remsima: the intraclass correlation coefficients between theoretical and measured concentrations varied from 0.920 to 0.990. Moreover, the interassay agreement values for the same compounds were high (intraclass correlation coefficients varied from 0.936 to 0.995). Finally, the anti-Remicade and anti-Remsima sera reacted to the different drugs in a similar fashion.

CONCLUSIONS

The tested assays can be used to monitor Flixabi levels. Moreover, Remicade, Remsima and Flixabi were shown to have a high cross-immunogenicity, which supports their high similarity but prevents their switching in nonresponders with antidrug antibodies.

Resistance of Aedes aegypti (Diptera: Culicidae) Populations to Deltamethrin, Permethrin, and Temephos in Cambodia

Dengue fever is a major public health concern, including 185,000 annual cases in Cambodia. Aedes aegypti is the primary vector for dengue transmission and is targeted with insecticide treatments. This study characterized the insecticide resistance status of Ae aegypti from rural and urban locations. The susceptibility to temephos, permethrin, and deltamethrin of Ae aegypti was evaluated in accordance with World Health Organization instructions. All the field populations showed lower mortality rate to temephos compared with the sensitive strain with resistance ratio 50 (RR₅₀) varying from 3.3 to 33.78 and RR₉₀ from 4.2 to 47 compared with the sensitive strain, demonstrating a generalized resistance of larvae to the temephos in Cambodia. Ae aegypti adult populations were highly resistant to permethrin regardless of province or rural/urban classification with an average mortality of 0.02%. Seven of the 8 field populations showed resistance to deltamethrin. These results are alarming for dengue vector control, as widespread resistance may compromise the entomological impact of larval control operations. Innovative vector control tools are needed to replace ineffective pesticides in Cambodia.

Dengue knowledge, attitudes and practices and their impact on community-based vector control in rural Cambodia

BACKGROUND

Globally there are an estimated 390 million dengue infections per year, of which 96 million are clinically apparent. In Cambodia, estimates suggest as many as 185,850 cases annually. The World Health Organization global strategy for dengue prevention aims to reduce mortality rates by 50% and morbidity by 25% by 2020. The adoption of integrated vector management approach using community-based methods tailored to the local context is one of the recommended strategies to achieve these objectives. Understanding local knowledge, attitudes and practices is therefore essential to designing suitable strategies to fit each local context.

METHODS AND FINDINGS

A Knowledge, Attitudes and Practices survey in 600 randomly chosen households was administered in 30 villages in Kampong Cham which is one of the most populated provinces of Cambodia. KAP surveys were administered to a sub-sample of households where an entomology survey was conducted (1200 households), during which Aedes larval/pupae and adult female Aedes mosquito densities were recorded. Participants had high levels of knowledge regarding the transmission of dengue, Aedes breeding, and biting prevention methods; the majority of participants believed they were at risk and that dengue transmission is preventable. However, self-reported vector control practices did not match observed practices recorded in our surveys. No correlation was found between knowledge and observed practices either.

CONCLUSION

An education campaign regarding dengue prevention in this setting with high knowledge levels is unlikely to have any significant effect on practices unless it is incorporated in a more comprehensive strategy for behavioural change, such a COMBI method, which includes behavioural models as well as communication and marketing theory and practice.

TRIAL REGISTRATION

ISRCTN85307778.