Eleven-year Retrospective Study Characterizing Patients With Severe Brain Damage and Poor Neurological Prognosis -Role of Physicians’ Attitude Toward Life-Sustaining Treatment

BackgroundSevere brain hemorrhage/infarction and cardiac arrest constitute the most critical situations leading to poor neurological prognosis. Characterization of these patients is required to offer successful end-of-life care, but actual practice is affected by multiple confounding factors, including ethicolegal issues, particular in Japan and Asia. The aim of this study is to evaluate the clinical courses of patients with severe brain damage and to assess the preference of end-of-life care for these patients in Japanese hospitals.MethodsA retrospective observational study was conducted between 2008 and 2018. All intracranial hemorrhage/infarction and cardiac arrest out-patients (n=510) who were admitted to our two affiliated hospitals and survived but with poor neurologic outcomes were included. Demographic characteristics as well as prognosis and treatment policies were also assessed. Results Patients were divided into two categories; cases with absent brainstem reflex (BSR) (BSR[-]) and those with preserved BSR (BSR[+]). The survival rate was higher and the length of hospitalization was longer in patients with BSR[+] than in those with BSR[-]. Among three life-sustaining policies (i.e., aggressive treatment, withdrawal of treatment, and withholding of treatment), withholding of treatment was adopted to most patients. In BSR[-], the proportion of three treatment policies performed at the final decision did not differ from that at the initial diagnosis on neurological status (p=0.432). In contrast, this proportion tended to be altered in BSR[+] (p=0.072), with a decreasing tendency of aggressive treatment and a modest increasing tendency of withdrawal of treatment. Furthermore, the requests from patients’ families to withdraw life-sustaining treatment, including discontinuation of mechanical ventilation, increased, but actual implementation of withdrawal by physicians was less than half of the requests. ConclusionsBSR constitutes a crucial determinant of mortality and length of hospitalization in comatose patients with severe brain damage. Although the number of withdrawal of life-sustaining treatment tends to increase over time in BSR[+] patients, there are many more requests from patients’ families for withdrawal. Since physicians has a tendency to desist from withdrawing life-sustaining treatment, more in-depth communication between medical staff and patients’ families will facilitate mutual understanding over ethicolegal and religious issues and may thus improve end-of-life care.

Can We Cluster ICU Treatment Strategies for Traumatic Brain Injury by Hospital Treatment Preferences?

Background In traumatic brain injury (TBI), large between-center differences in treatment and outcome for patients managed in the intensive care unit (ICU) have been shown. The aim of this study is to explore if European neurotrauma centers can be clustered, based on their treatment preference in different domains of TBI care in the ICU. Methods Provider profiles of centers participating in the Collaborative European Neurotrauma Effectiveness Research in TBI study were used to assess correlations within and between the predefined domains: intracranial pressure monitoring, coagulation and transfusion, surgery, prophylactic antibiotics, and more general ICU treatment policies. Hierarchical clustering using Ward’s minimum variance method was applied to group data with the highest similarity. Heat maps were used to visualize whether hospitals could be grouped to uncover types of hospitals adhering to certain treatment strategies. Results Provider profiles were available from 66 centers in 20 different countries in Europe and Israel. Correlations within most of the predefined domains varied from low to high correlations (mean correlation coefficients 0.2–0.7). Correlations between domains were lower, with mean correlation coefficients of 0.2. Cluster analysis showed that policies could be grouped, but hospitals could not be grouped based on their preference. Conclusions Although correlations between treatment policies within domains were found, the failure to cluster hospitals indicates that a specific treatment choice within a domain is not a proxy for other treatment choices within or outside the domain. These results imply that studying the effects of specific TBI interventions on outcome can be based on between-center variation without being substantially confounded by other treatments. Trial registration We do not report the results of a health care intervention.

The 2021 Korean Heart Rhythm Society Guidelines for a New Approach and Integrated Management of Atrial Fibrillation

The prevalence of atrial fibrillation (AF) is gradually increasing with the aging of the population, and there is also increasing interest in AF with the development of various single-lead electrocardiography measurement methods for diagnosis. Further, the current diagnosis and treatment policies for AF do not reflect its progression and complexity. In addition, the various factors related to AF diagnosis and treatment are not simple due to the diversification of tools, advances in treatment methods, and complex mechanism of AF. Therefore, there are many challenges to developing a simple AF classification system. To overcome these, there have been a number of attempts to systematically characterize AF according to treatment and prognosis rather than using a uniform classification. Further, as mentioned in the previous AF guidelines, further research is being conducted on an integrated patient–physician approach to AF. Such an approach would be the basis for consistent treatment based on the guidelines, and would help to improve patient outcomes. Further, for the integrated management of AF patients, some changes should be made to the current approach to develop a multidisciplinary approach, including changes to the behavior of team members, patients, their family members, and physicians. The Korean Heart Rhythm will introduce an integrated approach to the classification and structure of AF management, and provide guidelines for its application in clinical practice.

Global Food Security, Economic and Health Risk Assessment of the COVID-19 Epidemic

This study addresses the complexity of global pandemic (COVID) exposures and explores how sustainable development relates to economic and health risks and food security. Multiple factor analysis (MFA) is applied to compute the links among blocks of variables, and results are validated by random sampling with bootstrapping, exhaustive and split-half techniques, and analysis of variance (ANOVA) to test the differences of the MFA factors within the different stages of competitiveness. Comparing the MFA factors suggests that higher competitiveness is correlated with better food security and natural resilience and the tremendous economic downturn; the most competitive countries have lower exposures to health risks. In addition, the risk of pandemics appears to be lower with well-established public health care (HC) system services and good health for the population. The study also underlines that the economic and health systems are unfortunately inadequate to deal with a crisis of this magnitude. Although the countries least affected by the epidemic are the most competitive, they cannot protect people and the economy effectively. Formulating appropriate global responses is a challenge, but the results may lead to more nuanced findings regarding treatment policies that can be addressed at the country level.

Single-nucleotide Polymorphisms of Artemisinin Resistance-related pfubp1 and pfap2mu Genes in Imported Plasmodium Falciparum to Wuhan, China

BackgroundMolecular markers for monitoring resistance could help improve malaria treatment policies. Delayed clearance of Plasmodium falciparum by Artemisinin-based Combination Therapies (ACTs) has been reported in several countries. In addition to the PfKelch13 (pfk13), new drug resistance genes, the ubiquitin-specific protease 1 (pfubp1) and the eadaptor protein complex 2 mu subunit (pfap2mu) have been identified as being linked to ACTs. This study investigated the prevalence of single-nucleotide polymorphisms (SNPs) in clinical P. falciparum isolates pfubp1 and pfap2mu imported from Africa and Southeast Asia (SEA) to Wuhan, China, to provide baseline data for antimalarial resistance monitoring in this region.MethodsPeripheral Blood samples were collected in Wuhan, China, from August 2011 to December 2019. The SNPs of Pfubp1 and pfap2mu of P. falciparum were determined by nested PCR and Sanger sequencing. ResultsIn total, 296 samples were collected. Subsequently, 92.23% (273/296) were successfully amplified and sequenced for the Pfubp1. There were 60.07% (164/273) wild strains and 39.93% (109/273) mutant strains. For the pfap2mu gene, it was divided into three fragments for amplification, 82.77% (245/296), 90.20% (267/296) and 94.59% (280/296) were sequenced successfully respectively. Genotypes reportedly associated with ACTs resistance detected in this study included pfubp1 D1525E as well as E1528D and pfap2mu S160N. The mutation prevalence rates were 10.99% (30/273), 13.19% (36/273) and 11.24% (30/267), respectively. These are all focused on Congo, Nigeria and Angola. And known delayed-clearance parasite mutation has also been found in SEA.ConclusionsThe existence of mutation sites of known clearance genes detected in the isolates in this study, including D1525E and E1528D in the pfubp1 gene, and S160N in the pfap2mu gene, further proved the risk of ACTs resistance. Constant vigilance is therefore needed to protect the effectiveness of ACTs, and to prevent the spread of drug-resistant P. falciparum. Further studies in malaria-endemic countries are needed to further validate potential genetic markers for monitoring parasite populations in Africa and SEA.

Classification of Aquifer Vulnerability by Using the DRASTIC Index and Geo-Electrical Techniques

Vulnerability analysis in areas vulnerable to anthropogenic pollution has become a key element of sensible resource management and land use planning. This study is intended to estimate aquifer vulnerability using the DRASTIC model and using the vertical electrical sounding (VES) and electrical conductivity (EC) outcomes. The model allows for the identification of hydrogeological environments within the scope of the research, based on a composite definition of each environment’s main geological, geoelectrical, and hydrogeological factors. The results from the DRASTIC model were divided into four equal intervals, high, medium, low, and very low drastic index values. The SW area and NE area depict drastic index values from medium to very high, making it the most vulnerable zone in the study area, while the NW and SW areas show low to very low drastic index values. In addition, the results from the VES and EC the freshwater aquifer in the NE area and brackish water in the SE area, while the rest of the area falls into the category of brackish water. Overall, it can be concluded that areas having freshwater assemblages are on the verge of becoming contaminated in the future while the rest of the NW and SW areas constitute less vulnerable zones. The validation conducted for DRASTIC and EC shows a nearly positive correlation. Wastewater treatment policies must be developed throughout the studied region to prevent contamination of the remaining groundwater.

Efficacy of Artemether-Lumefantrine for the Treatment of Plasmodium falciparum Malaria in Bohicon and Kandi, Republic of Benin, 2018–2019

In 2005, artemether-lumefantrine (AL), an artemisinin-based combination therapy, was introduced as the first-line treatment of uncomplicated Plasmodium falciparum malaria in Benin. Per World Health Organization recommendations to monitor the efficacy of antimalarial treatment, we conducted a therapeutic efficacy study with AL for uncomplicated P. falciparum malaria in Bohicon and Kandi, Benin, from 2018 to 2019. Febrile patients aged 6 to 59 months with confirmed P. falciparum monoinfection received supervised doses of AL for 3 days. We monitored patients clinically and parasitologically on days 1, 2, 3, 7, 14, 21, and 28. A molecular analysis to detect mutations in the P. falciparum Kelch propeller gene (Pfk13) gene was carried out on day 0 samples. A total of 205 patients were included in the study. In Bohicon, the uncorrected adequate clinical and parasitological response (ACPR) proportion was 91.3% (95% confidence interval [CI]: 84.6–95.8%), whereas in Kandi this proportion was 96.7% (95% CI: 90.6–99.3%). Genotype-corrected ACPR proportions were 96.3% (95% CI: 90.9–99.0%) and 96.7% (95% CI: 90.6–99.3%) in Bohicon and Kandi, respectively. On day 3, 100% of patients in Bohicon and 98.9% of patients in Kandi had undetectable parasitemia. The C580Y mutation in the Pfk13 gene was not observed. AL remains effective for P. falciparum malaria in these two sites in Benin. Monitoring antimalarial efficacy and prevalence of molecular-resistance markers in Benin should be continued to allow for early detection of antimalarial resistance and to guide treatment policies.