Effect of remote ischemic preconditioning on clinical outcomes in patients undergoing coronary artery bypass graft surgery (ERICCA): rationale and study design of a multi-centre randomized double-blinded controlled clinical trial

Background

Novel cardioprotective strategies are required to improve clinical outcomes in high risk patients undergoing coronary artery bypass graft (CABG)?±?valve surgery. Remote ischemic preconditioning (RIC), in which brief episodes of non-lethal ischemia and reperfusion are applied to the arm or leg, has been demonstrated to reduce perioperative myocardial injury following CABG?±?valve surgery. Whether RIC can improve clinical outcomes in this setting is unknown and is investigated in the effect of remote ischemic preconditioning on clinical outcomes (ERICCA) trial in patients undergoing CABG surgery. (ClinicalTrials.gov Identifier: NCT01247545).

Methods

The ERICCA trial is a multicentre randomized double-blinded controlled clinical trial which will recruit 1,610 high-risk patients (Additive Euroscore ≥?5) undergoing CABG?±?valve surgery using blood cardioplegia via 27 tertiary centres over 2?years. The primary combined endpoint will be cardiovascular death, non-fatal myocardial infarction, coronary revascularization and stroke at 1?year. Secondary endpoints will include peri-operative myocardial and acute kidney injury, intensive care unit and hospital stay, inotrope score, left ventricular ejection fraction, changes of quality of life and exercise tolerance. Patients will be randomized to receive after induction of anesthesia either RIC (4 cycles of 5?min inflation to 200?mmHg and 5?min deflation of a blood pressure cuff placed on the upper arm) or sham RIC (4 cycles of simulated inflations and deflations of the blood pressure cuff).

Implications

The findings from the ERICCA trial have the potential to demonstrate that RIC, a simple, non-invasive and virtually cost-free intervention, can improve clinical outcomes in higher-risk patients undergoing CABG?±?valve surgery.     

Perineal ultrasound in the study of urethral mobility: proposal of a normal physiological range

The aim of the study was to determine, using perineal ultrasound, the physiological range for urethral mobility in normal women. Sixty healthy women were enrolled. The ultrasound parameters obtained with a perineal "static" and "dynamic" evaluation method were: pubic-urethral distance and inclination angle of the urethral axis. We propose a physiological range of pubic-urethral distance under stress in young women between 10 and 15 mm, the inclination angle of the urethral axis is between 60 and 100 degrees . In peri-post-menopause women we establish a non-rigid range of mobility in relation to age and parity: between 15 and 18 mm for the pubis-urethra distance and 80 degrees and 120 degrees for the angle of the urethral axis. Defining a range of normality for urethral mobility through ultrasound is useful for further studying therapeutic choices and help to identify the surgical correction and post-operative follow-up.     

Prophylaxis and treatment of pregnant women for emerging infections and bioterrorism emergencies

Emerging infectious disease outbreaks and bioterrorism attacks warrant urgent public health and medical responses. Response plans for these events may include use of medications and vaccines for which the effects on pregnant women and fetuses are unknown. Healthcare providers must be able to discuss the benefits and risks of these interventions with their pregnant patients. Recent experiences with outbreaks of severe acute respiratory syndrome, monkeypox, and anthrax, as well as response planning for bioterrorism and pandemic influenza, illustrate the challenges of making recommendations about treatment and prophylaxis for pregnant women. Understanding the physiology of pregnancy, the factors that influence the teratogenic potential of medications and vaccines, and the infection control measures that may stop an outbreak will aid planners in making recommendations for care of pregnant women during large-scale infectious disease emergencies.     

Prevalence of non-communicable diseases and access to care among non-camp Syrian refugees in northern Jordan

Background

Tackling the high non-communicable disease (NCD) burden among Syrian refugees poses a challenge to humanitarian actors and host countries. Current response priorities are the identification and integration of key interventions for NCD care into humanitarian programs as well as sustainable financing. To provide evidence for effective NCD intervention planning, we conducted a cross-sectional survey among non-camp Syrian refugees in northern Jordan to investigate the burden and determinants for high NCDs prevalence and NCD multi-morbidities and assess the access to NCD care.

Methods

We used a two-stage cluster design with 329 randomly selected clusters and eight households identified through snowball sampling. Consenting households were interviewed about self-reported NCDs, NCD service utilization, and barriers to care.We estimated the adult prevalence of hypertension, diabetes type I/II, cardiovascular- and chronic respiratory conditions, thyroid disease and cancer and analysed the pattern of NCD multi-morbidities. We used the Cox proportional hazard model to calculate the prevalence ratios (PR) to analyse determinants for NCD prevalence and logistic regression to determine risk factors for NCD multi-morbidities by calculating odds ratios (ORs).

Results

Among 8041 adults, 21.8%, (95% CI: 20.9–22.8) suffered from at least one NCD; hypertension (14.0, 95% CI: 13.2–14.8) and diabetes (9.2, 95% CI: 8.5–9.9) were the most prevalent NCDs. NCD multi-morbidities were reported by 44.7% (95% CI: 42.4–47.0) of patients. Higher age was associated with higher NCD prevalence and the risk for NCD-multi-morbidities; education was inversely associated.Of those patients who needed NCD care, 23.0% (95% CI: 20.5–25.6) did not seek it; 61.5% (95% CI: 54.7–67.9) cited provider cost as the main barrier. An NCD medication interruption was reported by 23.1% (95% CI: 20–4-26.1) of patients with regular medication needs; predominant reason was unaffordability (63.4, 95% CI: 56.7–69.6).

Conclusion

The burden of NCDs and multi-morbidities is high among Syrian refugees in northern Jordan. Elderly and those with a lower education are key target groups for NCD prevention and care, which informs NCD service planning and developing patient-centred approaches.Important unmet needs for NCD care exist; removing the main barriers to care could include cost-reduction for medications through humanitarian pricing models. Nevertheless, it is still essential that international donors agencies and countries fulfill their commitment to support the Syrian-crisis response.

     

Counselling in humanitarian settings: a retrospective analysis of 18 individual-focused non-specialised counselling programmes

Background

Médecins Sans Frontières (MSF) provides individual counselling interventions in medical humanitarian programmes in contexts affected by conflict and violence. Although mental health and psychosocial interventions are a common part of the humanitarian response, little is known about how the profile and outcomes for individuals seeking care differs across contexts. We did a retrospective analysis of routine programme data to determine who accessed MSF counselling services and why, and the individual and programmatic risk factors for poor outcomes.

Methods

We analysed data from 18 mental health projects run by MSF in 2009 in eight countries. Outcome measures were client-rating scores (1–10 scale; 1 worst) for complaint severity and functioning and counsellor assessment. The effect of client and programme factors on outcomes was assessed by multiple regression analysis. Logistic regression was used to assess binary outcome variables.

Results

48704 counselling sessions were held with 14963 individuals. Excluding women-focused projects, 66.8% of patients were women. Mean (SD) age was 33.3 (14.1) years. Anxiety-related complaints were the most common (35.0%), followed by family-related problems (15.7%), mood-related problems (14.1%) and physical complaints (13.7%). Only 2.0% presented with a serious mental health condition. 27.2% did not identify a traumatic precipitating event. 24.6% identified domestic discord or violence and 17.5% psychological violence as the precipitating event. 6244 (43.9%) had only one session. For 91% of 7837 who returned, the counsellor reported the problem had decreased or resolved. The mean (SD) complaint rating improved by 4.7 (2.4) points (p?<?0.001) and by 4.2 (2.3, p?<?0.001) for functional rating. Risk factors for poorer outcomes were few sessions, non-conflict setting (stable or societal violence settings), serious mental health condition, or attending a large, recently opened project.

Conclusions

The majority of clients accessing counselling services present with anxiety related complaints. Attrition rates were high. Good outcomes were recorded among those who attended for more than one visit. Lessons learned included the importance of adaptation of approach in non-conflict contexts such as societal violence or post-conflict contexts. There is a need for further research to evaluate the intervention against a control group.

     

Conservative treatment of early endometrial cancer: preliminary results of a pilot study

Objective

Frozen section is an important diagnostic tool to determine the nature of the ovarian masses intraoperatively. The optimal surgical treatment can be achieved by classifying the masses as benign, borderline and malignant. The aim of this retrospective study was to evaluate the accuracy of frozen section diagnosis of ovarian neoplasms and to determine the effects of Gynecologic (Gyn) pathologist or non-Gyn pathologist on frozen section diagnosis.

Material and methods

Intraoperative frozen section diagnosis was retrospectively evaluated in 578 patients operated with the suspicion of ovarian neoplasms. We compared the results of frozen section diagnosis by Gyn pathologists (Group 1) and by non-Gyn (Group 2) pathologists.

Results

In 23 patients (3.9%), the tissues were other than ovary. No opinion could be obtained on frozen sections of 14 cases (2.4%). The sensitivities for benign, borderline and malignant tumors for frozen section diagnoses of Gyn pathologists were 99.7%, 89.5%, and 96.3% respectively. The corresponding specificities were 97.6%, 85% and 99%, respectively. Group 2 pathologists had sensitivities and specificities of 97%, 50%, 84.6% and 95.2%, 96.2% and 94.5% for benign, borderline and malignant tumors, respectively. The overall accuracy rate of frozen section was 97.1%.

Conclusion

Intraoperative frozen section diagnosis has a high accuracy rate for ovarian pathologies. Those rates do increase even more if it is evaluated by the Gyn pathologists.     

Factors Related to Fetal Death in Pregnant Women with Cholera,Haiti, 2011–2014

We assessed risk factors for fetal death during cholera infection and effect of treatment changes on these deaths. Third trimester gestation, younger maternal age, severe dehydration, and vomiting were risk factors. Changes in treatment had limited effects on fetal death, highlighting the need for prevention and evidence-based treatment.