Ankle/brachial index to everyone

Background

In the last years significant attention has been paid in identifying markers of subclinical atherosclerosis or of increased cardiovascular risk.

Method

An abnormal ankle/brachial index (ABI) identifies patients affected by lower extremity peripheral arterial disease, and even more important, represents a powerful predictor of the development of future ischemic cardiovascular events.

Conclusions

In our opinion, ABI is a cardiovascular risk prediction tool with very desirable properties that might become a routine measurement in clinical practice.

     

Endovascular treatment of lower extremity arteries is associated with an improved outcome in diabetic patients affected by intermittent claudication

Background

Lower extremity peripheral arterial disease (LE-PAD) is a highly prevalent condition among diabetic patients, associated with reduced walking capacity and a high incidence of cardiovascular events. Endovascular revascularization of lower extremities arteries improves walking performance and quality of life of diabetic patients affected by intermittent claudication, but few studies evaluated the impact of revascularization on cardiovascular outcome in this high-risk population. Accordingly, in the present study we evaluated if leg-ischemia resolution by effective lower limbs percutaneous revascularization can also impact cardiovascular outcome in a homogeneous group of diabetic patients affected by intermittent claudication.

Methods

236 diabetic patients affected by LE-PAD at stage II of Fontaine’s classification, with ankle/brachial index ≤0.90 and one or more hemodynamically significant stenosis in at least one artery of the ileo-femoro-popliteal axis were enrolled in the study. According to the Trans-Atlantic Inter Society Consensus II recommendations, 123 (52.1%) underwent percutaneous transluminal angioplasty (PTA group), while 113 (47.9%) underwent conservative medical therapy only (MT group). The incidence of major cardiovascular events (cardiovascular death, myocardial infarction, ischemic stroke, coronary or carotid revascularization) was prospectively analyzed with Kaplan-Meier curves and the risk of developing a cardiovascular event calculated by Cox analyses.

Results

No baseline difference in cardiovascular risk factors were observed between the PTA and MT groups, except for a lower prevalence of males in PTA group (74.8% vs. 85.8%, p=0.034). Furthermore, patients in the PTA group showed a worse walking capacity as expressed by maximum walking distance (108.7 ± 300.9 vs 378.4 ± 552.3 meters, p<0.001). During a median follow-up of 20 months (12.0-29.0), the incidence of cardiovascular events was markedly lower in patients in the PTA group with respect to patients in the MT group (7.3% vs. 22.1%, p=0.001), and patients of the MT group had at Cox analysis a 3.9 increased risk with respect to PTA group, after adjustment for potential confounding factors (95% CI 1.1-15.3, p=0.049).

Conclusions

The present study shows that lower limbs revascularization of diabetic patients affected by intermittent claudication, in addition to improve walking performance, is associated with a reduction in the incidence of future major cardiovascular events.

     

Spirometry in primary care: An analysis of spirometry test quality in a regional primary care asthma program

BACKGROUND:

Primary care office spirometry can improve access to testing and concordance between clinical practice and asthma guidelines. Compliance with test quality standards is essential to implementation.

OBJECTIVE:

To evaluate the quality of spirometry performed onsite in a regional primary care asthma program (RAP) by health care professionals with limited training.

METHODS:

Asthma educators were trained to perform spirometry during two 2 h workshops and supervised during up to six patient encounters. Quality was analyzed using American Thoracic Society (ATS) 1994 and ATS/European Respiratory Society (ERS) 2003 (ATS/ERS) standards. These results were compared with two regional reference sites: a primary care group practice (Family Medical Centre [FMC], Windsor, Ontario) and a teaching hospital pulmonary function laboratory (London Health Sciences Centre [LHSC], London, Ontario).

RESULTS:

A total of 12,815 flow-volume loops (FVL) were evaluated: RAP – 1606 FVL in 472 patient sessions; reference sites – FMC 4013 FVL in 573 sessions; and LHSC – 7196 in 1151 sessions. RAP: There were three acceptable FVL in 392 of 472 (83%) sessions, two reproducible FVL according to ATS criteria in 428 of 469 (91%) sessions, and 395 of 469 (84%) according to ATS/ERS criteria. All quality criteria – minimum of three acceptable and two reproducible FVL according to ATS criteria in 361 of 472 (77%) sessions and according to ATS/ERS criteria in 337 of 472 (71%) sessions. RAP met ATS criteria more often than the FMC (388 of 573 [68%]); however, less often than LHSC (1050 of 1151 [91%]; P<0.001).

CONCLUSIONS:

Health care providers with limited training and experience operating within a simple quality program achieved ATS/ERS quality spirometry in the majority of sessions in a primary care setting. The quality performance approached pulmonary function laboratory standards.     

International Scholarship Programs of the American College of Surgeons: Expansion of the Global Surgical Network

Background

The American College of Surgeons has always promoted education and collaborations with other countries and their scientific organizations. The International Guest Scholarship program was established in 1968 to support the travel of foreign surgeons to medical Institutions in the USA and Canada. The program has grown substantially over time and now includes different categories of scholarships and surgeons. The objective of this article is to describe the experiences gained by the international scholars who visited US and Canadian institutions through these ACS programs.

Study design

In order to collect information regarding these scholarships from the surgeons who have already participated in the program, an Internet-based survey was e-mailed to alumni. The surveys were constructed to gather career information on former scholars and to analyze the perceived impact of these programs on their careers.

Results

Among the international scholarships alumni, most are now Fellows of the American College of Surgeons. The majority of respondents maintained contact with their host surgeons in the USA or Canada; they began or continued research, surgical education and surgical quality improvement initiatives in their country of origin based upon their experiences as international scholars. Most of the alumni reported that the experience they had during the scholarship was inspiring, opened their minds and broadened their horizons.

Conclusions

The overall effect of ACS international scholarship program should be considered as positive, as 80–90% of respondent alumni consider their experience very helpful and feel that it provided them with opportunities that would not have been possible without it. It is incumbent upon the ACS to continue along this path by identifying funding and donation sources, as well as enriching the content and goals.

     

Trastuzumab for the treatment of non-small-cell lung cancer

OBJECTIVE: To evaluate trastuzumab for the treatment of advanced non-small-cell lung cancer (NSCLC).DATA SOURCES: Clinical literature was accessed through MEDLINE (1966-January 2003), EMBASE (1974-January 2003), International Pharmaceutical Abstracts (1970-January 2003), Proceedings of the American Society of Clinical Oncology (1995-January 2003), and Genentech. Key search terms included trastuzumab, lung cancer, Herceptin, and NSCLC.DATA SYNTHESIS: Research has revealed that NSCLC specimens may express the protein HER-2/neu. The monoclonal antibody against HER-2/neu, trastuzumab, could prove valuable for patients. An evaluation of the studies exploring trastuzumab for management of NSCLC was conducted. Phase II clinical trials reveal variable response rates from no improvement to a partial response rate of 42%. Due to a lack of clinical trials and deficiencies in the literature, the ultimate benefit of this agent remains to be proven.CONCLUSIONS: Clinical data from ongoing trials indicate potential synergy when trastuzumab is added to standard chemotherapy. The ultimate benefit in NSCLC remains to be proven.     

How to Reach the Sustainable Development Goal 1.2? Simulating Different Strategies to Reduce Multidimensional Child Poverty in Two Middle-Income Countries

Although the UN Millennium Development Goals (MDGs) have contributed to substantial progress in reducing the number of people living on less than $1.25 a day since 1990, it is now generally accepted that poverty goes beyond the simple lack of income. The new Sustainable Development Goals (SDGs) adopted by all member states of the United Nations (UN) in September 2015 call for “reducing at least by half the proportion of men, women and children of all ages living in poverty in all its dimensions according to national definitions” by 2030 (UNDESA 2016). Although there must be numerous ways of achieving this goal, research evidence on reducing multidimensional poverty is scarce. This paper investigates possible strategies for halving MD poverty among children using the case studies of Armenia and Bosnia and Herzegovina (BiH). Both Armenia and BiH conducted multidimensional child poverty studies in 2014–2016 based on nationally agreed definitions and using secondary data from representative household budget surveys. This analysis compares two approaches to halving the rate of multidimensional poverty among children aged 5–15 by employing static simulations: 1) reducing deprivation headcount in two to three key dimensions and 2) increasing monetary transfers to the consumption-poor.     

Vitamin D and COVID-19: Narrative Review after 3 Years of Pandemic

Active vitamin D [1,25(OH)₂D₃—calcitriol] is a secosteroid hormone whose receptor is expressed on all cells of the immune system. Vitamin D has a global anti-inflammatory effect and its role in the management of a SARS-CoV-2 infection has been investigated since the beginning of the COVID-19 pandemic. In this narrative review, the laboratory and clinical results of a vitamin D supplementation have been collected from both open-label and blinded randomized clinical trials. The results are generally in favor of the utility of maintaining the serum concentrations of calcifediol [25(OH)D₃] at around 40 ng/mL and of the absolute usefulness of its supplementation in subjects with deficient serum levels. However, two very recent large-scale studies (one open-label, one placebo-controlled) have called into question the contribution of vitamin D to clinical practice in the era of COVID-19 vaccinations. The precise role of a vitamin D supplementation in the anti-COVID-19 armamentarium requires further investigations in light of the breakthrough which has been achieved with mass vaccinations.     

Cutaneous collagenous vasculopathy in a pediatric patient

We report the case of a 13-year-old female who presented with punctate, erythematous macules coalescing into patches on the upper extremities and left thigh. A skin biopsy demonstrated dilated capillary-sized blood vessels in the papillary dermis consistent with a diagnosis of cutaneous collagenous vasculopathy (CCV). To our knowledge, this is the youngest patient to present with CCV and will represent the third pediatric case in the literature.