bluuebunny/crossref_metadata_2025 huggingface dataset:
Echocardiography
Authors: Duncan Alison
Published: May 2022

Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The most common cause of heart failure in the UK is coronary artery disease; other aetiologies include hypertension, atrial fibrillation, cardiomyopathies, valvular heart disease, pericardial disease, and intracardiac shunts. Transthoracic echocardiography has a decisive role in the diagnosis, treatment, and follow-up of patients with heart failure. Indeed, its importance was underscored in the UK 2010 National Institute for Health and Care Excellence (NICE) Guidelines for Heart Failure, and in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the diagnosis and management of heart failure. Echocardiography utilizes ultrasound, which has no known adverse biological effects, is non-invasive, and is a relatively low-cost imaging modality. The use of echocardiography in the diagnosis, therapeutic management, and serial follow-up of the increasing number of patients with heart failure has therefore potentially large health benefits with relatively low patient cost.
Nuclear medicine in heart failure
Authors: Bharadwaj Pushan , Underwood S. Richard
Published: May 2022

Nuclear medicine, sometimes known as molecular imaging, involves the characterization and measurement of biological processes in vivo using small amounts of radiolabelled tracers. It is the most sensitive imaging technique in routine use, providing images of nano- or even picomolar concentrations of the tracer. In patients with heart failure (HF), biological processes such as myocardial perfusion, metabolism (both fatty acid and glucose), injury (including necrosis and apoptosis), and innervation are relevant and can be imaged. The ideal tracer is a biological molecule labelled with an isotope of one of its constituent elements (carbon, oxygen, nitrogen, etc.), since the tracer will have biological properties identical to those of the natural compound. Such isotopes are positron emitters and are imaged by positron emission tomography (PET), which relies on detecting the synchronous 511-keV photons emitted in opposite directions when the positron annihilates with an electron in the surrounding tissue. More common tracers use foreign elements such as iodine or technetium bound to a pharmaceutical that provides useful biological properties. These radiopharmaceuticals usually emit single gamma photons that are imaged by a gamma camera, often using single photon emission computed tomography (SPECT) to produce tomograms or three-dimensional images. PET has some inherent advantages over SPECT, such as higher resolution and more reliable attenuation correction that simplifies quantification of the biological process being imaged. PET is however more expensive and, with the exception of fluorine-18, the very short-lived radionuclides have to be generated on site, requiring the additional expense of a cyclotron.
Computed tomography imaging techniques
Authors: Tops Laurens F. , de Graaf Michiel A. , Delgado Victoria , Bax Jeroen J.
Published: May 2022

In patients presenting with heart failure, assessment of underlying aetiology is critical for optimal management. To differentiate between ischaemic and non-ischaemic cardiomyopathy, invasive coronary angiography is frequently performed. This technique is currently still considered the reference standard for the detection of coronary artery disease (CAD). In patients with intermediate–high probability of CAD or in patients with documented ischaemia on non-invasive stress testing this method is recommended, especially since the technique also provides the opportunity for direct intervention. However, in patients with low–intermediate risk of CAD and no chest pain symptoms, anatomical imaging with coronary computed tomography angiography (CTA) may be more appropriate. With this technology, high-resolution images of the coronary arteries are obtained. In addition, detailed information on cardiac structures, myocardial function and to some extent also myocardial scar can be derived from cardiac computed tomography (CT). The aim of the current chapter is to provide an overview of the various applications of cardiac CT that may be relevant in the setting of heart failure.
Heart failure with preserved ejection fraction
Authors: van Heerebeek L. , Paulus Walter J.
Published: May 2022

Heart failure with preserved ejection fraction (HFpEF) represents a complex and heterogeneous clinical syndrome, which is increasingly prevalent and associated with poor outcome. In contrast to heart failure with reduced EF (HFrEF), modern heart failure pharmacotherapy does not improve outcome in HFpEF, which is related to incomplete understanding of HFpEF pathophysiology, patient heterogeneity and lack of insight into primary pathophysiological processes. Patients with HFpEF are frequently elderly females and patients have a high prevalence of non-cardiac co-morbidities, which independently adversely affect myocardial structural and functional remodelling. Furthermore, although diastolic left ventricular dysfunction represents the dominant abnormality in HFpEF, numerous ancillary mechanisms are frequently present, which also negatively impact on cardiovascular reserve. Over the past decade, clinical and translational research has lead to improved insight into HFpEF pathophysiology and the importance of co-morbidities and patient heterogeneity. Recently, a new paradigm for HFpEF has been proposed, which suggests that co-morbidities drive myocardial dysfunction and remodelling in HFpEF through coronary microvascular inflammation. In the conceptual framework of HFpEF treatment, emphasis may need to shift from a ‘one size fits all’ strategy to an individualized approach based on phenotypic patient characterization and diagnostic and pathophysiological stratification of myocardial disease processes. This chapter describes these novel insights from a pathophysiological standpoint.
Right heart failure
Authors: Clark Andrew L.
Published: May 2022

Most discussions of heart failure focus on the left ventricle and its dysfunction. The right heart is, of course, commonly affected in patients with heart failure: both by the same disease processes that affect the left heart, or as a consequence of left heart disease. The right heart itself is much less commonly affected in isolation, but patients with heart disease do frequently present with ‘right heart failure’. This chapter will focus on the miscellaneous conditions affecting predominantly the right heart. Pulmonary arterial disease, primary lung disease, some forms of congenital heart disease, valvular heart disease, and, in particular, constrictive pericarditis and their treatment will be considered.
Renal dysfunction
Authors: Green Darren , Kalra Philip A.
Published: May 2022

This chapter considers patients with both heart failure and renal dysfunction. Mortality in patients who have both renal and cardiovascular disease is much higher than in the general population. Up to 55% of patients with heart failure have evidence of chronic kidney disease (CKD) stages 3–5, and mortality rises in proportion to fall in glomerular filtration rate. In patients with heart failure, advanced CKD is as prognostically important as low left ventricular ejection fraction. Heart failure and its treatment may also play an important role in the pathophysiology of acute kidney injury, with a further associated risk of adverse outcome. Cardiovascular disease is the leading cause of death in patients with CKD, and structural cardiac abnormalities are highly prevalent in dialysis patients.
Chronic lung disease
Authors: Roversi Sara , Greenstone Michael , Hart Simon P. , Hawkins Nathaniel M.
Published: May 2022

This chapter considers patients with both heart failure and chronic lung disease. Chronic obstructive pulmonary disease (COPD) is a worldwide epidemic, characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases (mostly cigarette smoke). This disease is commonly associated with cardiac disease, including heart failure, and the presence of one will affect the prognosis, diagnosis, and treatment of the other. Prevalence estimates vary greatly across studies investigating COPD and heart failure, due to significant differences in cohort selection, population characteristics, diagnostic criteria, and measurement methods. Spirometry is constantly reported to be under-used in patients with heart failure, even in contemporary practice. Not surprisingly, prognosis is generally worse in patients with both diseases. In the heart failure population, COPD has been reported as an independent predictor of all-cause hospitalization, heart failure hospitalization, and all-cause mortality. On the other hand, cardiovascular disease is the most important cause of both morbidity and mortality in patients with mild or moderate COPD and the leading cause of hospitalization.
Pulmonary hypertension
Authors: Gibbs J. Simon R.
Published: May 2022

Pulmonary hypertension is a haemodynamic state where pulmonary artery pressure is elevated. The term ‘pulmonary hypertension’ requires qualification describing its haemodynamic pattern and the aetiology of the disease. Pulmonary hypertension affects all ages but there are gender differences in different aetiologies. The commonest causes worldwide are chronic heart disease and chronic lung disease. Care needs to be taken to make an accurate diagnosis since treatment which may be effective in one form of the disease may be ineffective or deleterious in others. Consideration of treatment with drugs specifically intended to treat pulmonary hypertension itself requires measurement of pulmonary haemodynamics at cardiac catheterization. Pulmonary hypertension often carries a poor prognosis and the presence of other chronic conditions may worsen prognosis. Patients with rare forms of pulmonary hypertension or where the diagnosis is uncertain should be referred to a specialist pulmonary hypertension centre.
Valvular heart disease
Authors: McConkey Hannah Z. R. , Prendergast Bernard
Published: May 2022

This chapter considers patients with both heart failure and valvular heart disease (VHD). As the population ages, the clinical importance and burden of VHD increases and is highly relevant to everyday cardiac care. Where symptomatology is subjective and confounded by co-morbidities, the clinician is faced with the challenge of evaluating a conundrum of complex physiological parameters while also balancing the potential risks and benefits of intervention by means of surgical valve replacement or percutaneous intervention. The emergence of transcatheter aortic valve implantation and percutaneous edge-to-edge repair for mainstream treatment of aortic stenosis and mitral regurgitation, respectively, has paved the way for a variety of innovative percutaneous options for the potential treatment of VHD. Meanwhile, there are currently no medical or pharmacological therapies to halt progression of VHD or reverse valve destruction. The chapter then considers chronic VHD and discusses cardiac physiology, clinical features, quantification using echocardiography, and clinical management for individual valve lesions.
Sleep-disordered breathing
Authors: Simonds Anita K.
Published: May 2022

This chapter discusses sleep-disordered breathing. Respiration during sleep in patients with heart failure is likely to be unstable for several reasons. Irregular breathing during sleep in heart failure patients has been observed for centuries, with Cheyne–Stokes respiration (CSR) being the classic example. A rapid increase of knowledge in sleep medicine over the last few decades has identified a range of sleep-disordered breathing conditions, all of which have relevance to the cardiac patient. Sleep-disordered breathing is a generic term used to cover the respiratory disturbances during sleep that include obstructive sleep apnoea, central sleep apnoea, CSR/periodic breathing, and obstructive and central hypoventilation. The chapter then considers the apnoea–hypopnoea index and the respiratory disturbance index.
Arrhythmias
Authors: Nisbet Ashley M. , Connelly Derek T.
Published: May 2022

Both atrial and ventricular arrhythmias are common in patients with heart failure and cardiomyopathy, regardless of underlying aetiology. Arrhythmias contribute significantly to symptoms, morbidity (including periodic decompensation), and mortality in the form of ventricular arrhythmias causing sudden cardiac death. The diagnosis and management of arrhythmias is an important element in the clinical management of patients with heart failure.
Pregnancy
Authors: Swan Lorna , Walker Niki L.
Published: May 2022

This chapter examines why heart failure is one of the commonest cardiac complications associated with pregnancy. It is the ‘common final pathway’ of many pre-existing and de-novo cardiac lesions that have either presented or decompensated during pregnancy. Its aetiology varies across the world, but, no matter the cause, pregnancy may pose a significant challenge when the circulation is ‘vulnerable’. With improvements in paediatric and adult cardiac care, there are now large populations of young women who have either stable or ‘recovered’ left ventricular dysfunction. Many of these patients are well controlled on medical therapy, and are leading lives that are difficult to differentiate from the normal population. The desire to have a family is part of that normality. However, these women do not have a normal outcome during pregnancy and access to detailed pre-conception counselling is essential for all such women of child-bearing age. The chapter then outlines the key importance of pre-conception counselling in those with known disease and the need for specialist acute care pathways for those with a new diagnosis.
Cognitive impairment
Authors: Baxter John , Young Lesley
Published: May 2022

Cognitive impairment is common in patients with heart failure. Patients admitted with decompensated heart failure that is complicated by delirium or dementia have higher inpatient mortality than heart failure patients with no cognitive impairment. Outcomes can be improved by early detection of cognitive impairment, rapid review by teams expert in the management of cognitive impairment, and addressing the underlying causes of the decline in cognition. Heart failure specialist teams need to be aware of the cardiovascular side-effects of medication used in managing patients with cognitive impairment. Heart failure specialists need to offer additional support to help patients with cognitive impairment adhere to complex therapy regimens and device management. Management of patients who have impaired capacity needs to be in the context of legal requirements for the health care system.
Inotropes, pressors, and vasodilators
Authors: Price Susanna , Uddin Shahana
Published: May 2022

There has been a perceptible change in the approach to the management of chronic heart failure, from focusing on inotropy to a predominantly neurohormonal approach to therapeutic intervention. By contrast, in acute heart failure the critical inability of the myocardium to maintain a cardiac output sufficient to meet the demands of the peripheral circulation demands urgent intervention to restore adequate perfusion. Thus, haemodynamic considerations are pivotal, and the use of inotropes, pressors, and vasodilators remains widespread. This is despite concerns about the potential of inotropic agents to increase mortality in some patient populations. Current recommendations are therefore that inotropes should be used only in selected patients and withdrawn as soon as adequate organ perfusion is restored. The present chapter reviews the pharmacology of positive inotropic drugs, the principles underlying the choice of vasoactive drugs in acute heart failure, and potential future developments in the field.
Cardiac resynchronization therapy
Authors: Haydock Paul M. , Cowburn Peter J.
Published: May 2022

This chapter examines cardiac resynchronization therapy (CRT), or biventricular pacing (BVP), which is now well established as a therapeutic option for selected, symptomatic patients with heart failure due to left ventricular systolic dysfunction and reduced ejection fraction (HFrEF) and a prolonged QRS interval. Numerous well-designed trials, in conjunction with more than a decade of clinical experience, have demonstrated the efficacy of CRT in improving symptoms, reducing hospitalizations, and prolonging survival, when combined with optimal medical therapy in this patient group. CRT improves electromechanical dyssynchrony and maximizes the efficiency of the cardiac contraction sequence, leading to an acute haemodynamic benefit and, over time, a reduction in left ventricular volumes and an increase in left ventricular ejection fraction. CRT can be delivered as a pacing system alone (CRT-P) or in addition to an implantable cardioverter–defibrillator: CRT-D. Advances in device and lead technologies continue to improve successful delivery of CRT, and modern telecommunication technologies enable remote monitoring of device variables and various surrogate markers of heart failure, potentially offering the ability to predict subclinical deterioration and thus allow for timely therapeutic intervention.
Mechanical circulatory support
Authors: Pettit Stephen
Published: May 2022

Mechanical circulatory support (MCS) describes the use of mechanical pumps to maintain blood flow around the body when the heart is unable to meet this need. MCS may be appropriate in cardiogenic shock, either as a bridge to decision, recovery, heart transplantation, or for long-term support (destination therapy). There are various techniques by which MCS may be delivered and the most appropriate technique will vary depending on the patient, pathology, clinical situation, and experience of the hospital. Adverse events during MCS are frequent despite advances in blood pump technology. Careful patient selection and meticulous care are essential to achieve acceptable long-term survival and quality of life.
Multidisciplinary heart failure management programmes
Authors: Vazir Ali , Hardman Suzanna
Published: May 2022

This chapter evaluates the multidisciplinary approach to the management of people with heart failure. A critical reading of the literature on multidisciplinary heart failure management programmes and recognition of its limitations should not in any way discourage, but rather support, the establishment of effective and responsive multidisciplinary teams for the care of people with known or suspected heart failure. To date, the emphasis has been on community-based teams, but a number of studies and emerging audit data argue powerfully, in addition, for an improvement in hospital care. Best outcomes are achieved when patients are actively identified; where ongoing care, including early echocardiography, is led by a (heart failure) cardiologist; and where patients can be managed in a specialist ward with access to a range of healthcare professionals to ensure rapid stabilization and inpatient optimization of treatment. As the patient recovers, opportunities for education arise and should be embraced. Discharge planning should include plans for primary care and cardiology review, rehabilitation, uptitration of medication, and ongoing opportunities for individual patients to understand their condition.
End of life
Authors: Johnson Miriam J.
Published: May 2022

This chapter assesses end of life care for patients with heart failure, which is not always delivered well, particularly in secondary care settings where the emphasis may still be on life-prolonging interventions. Despite observations that patients with heart failure and renal failure often died in distress, those with non-malignant disease still have unequal access to services skilled in end of life care; most patients seen by hospice services in the UK have cancer. Although this is improving, palliative care inpatients are still overwhelmingly those with cancer. To this end, a national End of Life Strategy emphasized the need to raise the standard of care of the dying to that of the best throughout the National Health Service. Ultimately, continued central drive to improve care for the dying and for those with advanced disease is seen both in the UK and in many other countries, but several challenges remain in the care of the patients with advanced non-malignant conditions such as heart failure; the main one being the difficulties that clinicians, patients, and their carers may have in recognizing the end-stage of the illness.
Quality improvement in heart failure
Authors: McDonagh Theresa A.
Published: May 2022

This chapter explores quality improvement in heart failure. Over the last thirty years, much progress has been made in the diagnosis and treatment of heart failure. Yet registries repeatedly show that uptake of known disease-modifying therapies is far short of the benchmarks set by clinical trials; and real-world outcomes are much poorer than those seen in the clinical trials. This led healthcare professionals to start focusing on quality improvement in heart failure to try and translate evidence-based-medicine for heart failure into improved outcomes for patients. Quality improvement initiatives to date include setting standards of care for heart failure; implementing multi-professional heart failure care; specialization and training for heart failure healthcare professionals; and auditing and benchmarking. An ideal heart failure service should include specialist heart failure cardiologists and nurses, function across sectors of care, incorporate heart failure clinics, and adhere to common guidelines. Ultimately, the goal of heart failure services and quality improvement programmes is to ensure that wherever patients with heart failure begins their health care journey, they see the correct people to make an accurate and timely diagnosis, instigate the most appropriate investigations to ascertain the aetiology, and facilitate the introduction of evidence-based therapy, for all patients and not just a selected few.
Demographic and epidemiological challenges
Authors: Verne Julia
Published: May 2022

This chapter provides a brief introduction to the impact of changing demography and epidemiology on modern societies. These changes are responsible for parallel changes to the experience and duration of ageing and dying and hence to the rise of modern public health and palliative care as separate and combined professional services. The chapter describes the pattern of these changes and identifies their social impact. The recent impact on these patterns of morbidity and mortality by the COVID-19 pandemic is also discussed. Implications for the value and urgency of public health palliative care approaches are described.
Palliative care
Authors: Karapliagkou Aliki
Published: May 2022

This chapter describes a practical model that redesigns and reshapes palliative care services, by inviting and organizing the coordination and interaction between specialist palliative care, generalist palliative care, compassionate communities, and the civic approach to end of life care. The seamless integration of these four components, which are already part of some end of life care systems around the world, offers the possibility of uniting professional care with community resources. The outcome of the proposed partnership is inclusive care irrespective of cause of death, and opportunities of support for the bereaved in equal measure. The chapter argues that the interdependency of these four components provides the essential ingredients that will help reshape palliative and end of life care.
A history of public health palliative care
Authors: Rumbold Bruce
Published: May 2022

This chapter outlines the international spread of the public health palliative care (PHPC) movement from its beginnings in Australia at the end of the twentieth century to the sixth international conference in 2019. PHPC is presented as a social movement within the wider palliative care field itself, interested in reforming not only specific systems of end of life care but also the societies in which this care is provided. The chapter focuses upon the dynamic networks of people and projects affiliated with the field, tracking them through the collaborations reported at the international conferences that began in 2009. The role of the Public Health Palliative Care International Council in coordinating these developments is described and, in closing, some reflections are offered on opportunities for consolidating gains already made by the PHPC movement, and its capacity to adapt to post-pandemic societies experiencing the escalating disruption of climate emergency.
Prevention and harm reduction
Authors: Sallnow Libby
Published: May 2022

The three tenets of public health action are prevention, early intervention, and harm reduction. Prevention efforts aim to stop a disease, condition, or state from occurring. Early intervention efforts aim to diagnose a disease or recognize a condition early in its course, and harm reduction efforts focus on those with an established condition or disease and aim to mitigate and reduce the impact of that condition on their lives. These approaches are well established in areas such as HIV/AIDS or cancer screening but their application to care at the end of life, dying, or grieving are less well known, despite the significant impact they can exert on mental, physical, and social well-being. Social epidemiology is the study of how social structures, institutions, and relationships influence health. The social world people inhabit and structural issues such as discrimination or disadvantage determine experiences when caring, dying, and grieving. This chapter describes the social epidemiology of caring, dying, and grieving and efforts to apply the principles of prevention and harm reduction to these often-overlooked universal experiences.
Early intervention
Authors: Rosenberg John P.
Published: May 2022

Early intervention is a core characteristic of public health, and no less so in public health palliative care. Early intervention anticipates the complex and wide-ranging experiences of people living with life-limiting illnesses, as well as those of their families, carers, and communities, as they navigate the known impacts of ageing, dying, death, bereavement, and caregiving. In this chapter, approaches to early interventions are explored at the caregiver, community, civic society, and service provider levels. Further, it considers how a partnership development method can contribute to the collaborative and participatory approaches central to public health palliative care.
Health Policy
Authors: Pettus Katherine , Dzotsenidze Pati
Published: May 2022

This chapter discusses the essential roles of global and national palliative care advocacy in laying the normative, legal, and technical groundwork for sustainable compassionate communities within national and subnational boundaries. It focuses on how evidence-based advocacy can promote the integration of palliative care into primary care to improve quality of life for patients and families in the low-, middle-, and upper middle-income countries that are the centre of the ‘pandemic of untreated [. . .] pain’. Part I discusses international law, advocacy, and palliative care praxis, Part II reviews advocacy issues for improved access to essential palliative care medicines, while Part III presents a case study of palliative care development in the Republic of Georgia, a former Soviet republic.
Health services redesign
Authors: Hodges Emma , Archer Nikki
Published: May 2022

This chapter provides practical examples of health service redesign set in the context of a helpful theoretical framework. Drawing on the experience of one English hospice, the chapter provides an overview of St Giles’ history regarding a public health approach to palliative care, and shares examples of service provision aligned to this ethos and challenges along the way. Rather than using a more traditional approach to service redesign, the examples shared demonstrate how services that operate within an organizational setting that is institutionalized are being realigned, leading to new ways of working. The chapter describes two areas of practice in order to provide case studies that describe redesign not only in a practice sense but also philosophically, and how managing the space of being both a specialist clinical provider and a community development charity creates a possible model of care. The two case studies discussed are bereavement and the dynamic of both a medicalized and sociological model followed by the opportunities and risks presented by St Giles’ involvement in social prescribing.
Public health approaches to bereavement support
Authors: Aoun Samar , Rumbold Bruce
Published: May 2022

This chapter outlines a public health approach to bereavement care. The findings of an Australian population-based survey, which challenge some of the ‘received wisdom’ in this field, are presented, exposing both the limitations of clinical services and validating community-based approaches to bereavement support. The survey shows that, for most people, the bulk of the support that is effective comes from their informal networks, and that many have an ambivalent response to the professional support offered. The clear inference is that professional services need to work collaboratively in support of these informal networks if their contribution is to be appropriate and effective. We show how a population health approach can be applied to a specific population, people living with motor neurone disease, a study that highlights the importance of third-sector organizations during caregiving and grieving. Even during the COVID-19 pandemic, public health strategies like compassionate communities retained their value and developed new approaches when face-to-face encounters were minimal and physical means for support were limited. Overall, empirical indicators and directions encourage a compassionate community approach to future bereavement support practice and policy, and these findings are now influencing practice and policy in several countries. Public health approaches to palliative care must be accompanied by public health approaches to bereavement care if we are to develop relevant, coherent, and comprehensive end of life care policies and practices.
Specialist training
Authors: Edmonds Polly
Published: May 2022

Palliative medicine became a recognized medical specialty in the UK in 1987 under the auspices of the Royal College of Physicians. Doctors in training work to a specialty curriculum. The development of a new curriculum, which will be implemented in 2022, provided the opportunity to review the public health components of the curriculum, specifically introducing the concept of health promotion and community empowerment to support people at the end of life. Significant training will be required for training supervisors and trainees to support delivery of the new curriculum, providing an opportunity to upskill the UK palliative medicine workforce.
Twenty Years of Leptosphaeria maculans Population Survey in France Suggests Pyramiding Rlm3 and Rlm7 in Rapeseed Is a Risky Resistance Management Strategy
Authors: Balesdent Marie-Hélène , Gautier Angélique , Plissonneau Clémence , Le Meur Loïc , Loiseau Alizée , Leflon Martine , Carpezat Julien , Pinochet Xavier , Rouxel Thierry
Published: May 2022

Strategies for plant resistance gene deployment aim to preserve their durability to highly adaptable fungal pathogens. While the pyramiding of resistance genes is often proposed as an effective way to increase their durability, molecular mechanisms by which the pathogen can overcome the resistance also are important aspects to take into account. Here, we report a counterexample where pyramiding of two resistance genes of Brassica napus, Rlm3 and Rlm7, matching the Leptosphaeria maculans avirulence genes AvrLm3 and AvrLm4-7, respectively, favored the selection of double-virulent isolates. We previously demonstrated that the presence of a functional AvrLm4-7 gene in an isolate masks the Rlm3-AvrLm3 recognition. Rlm7 was massively deployed in France since 2004. L. maculans populations were surveyed on a large scale (>7,600 isolates) over a period of 20 years, and resistance gene deployment at the regional scale was determined. Mutations in isolates overcoming both resistance genes were analyzed. All data indicated that the simultaneous success of Rlm7, the deployment of varieties pyramiding Rlm3 and Rlm7, along with the decrease in areas cultivated with Rlm3 only, contributed to the success of virulent isolates toward Rlm7, and more recently to both Rlm3 and Rlm7. Experimental field assays proved that resistance gene alternation was a better strategy compared with pyramiding in this context. Our study also illustrated an unusually high sequence diversification of AvrLm3 and AvrLm4-7 under such a selection pressure, and identified a few regions of the AvrLm4-7 protein involved in both its recognition by Rlm7 and in its AvrLm3-Rlm3 masking ability.

[Formula: see text] Copyright © 2022 The Author(s). This is an open access article distributed under the CC BY-NC-ND 4.0 International license .
Introducing palliative care into cancer treatment
Authors: DeSanto Logan , Evans Michael M. , Riley Kiernan , Kowalchik Kaléi , Adams Lucy , Lucey Megan , Robinson Charles C.
Published: May 2022

The implementation of palliative care into the treatment of a person with cancer offers holistic and comprehensive treatment that can address the patient's needs by improving quality of life while also alleviating symptoms.
Multiple Polymerase Chain Reaction for Direct Detection of Bloodstream Infection After Cardiac Surgery in a PICU
Authors: Checa Rosa María Calderón , Gijón Manuel , Hofheinz Sylvia Belda , Rojo Pablo
Published: May 2022

OBJECTIVES:

Nosocomial infections are a prevalent cause of death and complications in critically ill children. Conventional cultures are able to detect only up to 25% of bacteremia. Several studies have suggested that molecular tests could be a faster and effective tool for detection of bacterial infections. The objective of this study is to compare molecular tests for bacterial detection in whole blood samples, with routine blood culture for the diagnosis of nosocomial bloodstream infections (BSIs).

DESIGN:

Prospective cohort study.

SETTING:

A PICU of a tertiary center, reference for congenital heart diseases.

PATIENTS:

Children, 0–16 years, admitted to PICU between August 2016 and December 2019 after cardiac surgery were prospectively recruited. Demographic, clinical, laboratory, and microbiologic data from patient’s medical records, and laboratory and microbiologic results were collected.

INTERVENTIONS:

In all patients, blood culture and multiple polymerase chain reaction (PCR) for bacterial detection in a whole blood sample were performed.

MEASUREMENTS AND MAIN RESULTS:

Fifty-seven cases (patients with suspected infection) and 36 controls (patients with no suspected infection) were recruited during this period; 51.6% were female. Median age was 6 months (interquartile range [IQR], 0–13 mo), and median weight was 5 kg (IQR, 3.5–9.5 kg).

From the cases, 33% (19/57) had a confirmed BSI with positive blood culture; 52% were Gram-negative bacilli, and 48% were Gram-positive cocci. Thirty-three percentage (19/57) had a positive PCR with only a 26% (five cases) of concordance between PCR result and blood culture (three bacteremias for Klebsiella pneumoniae, one for Serratia marcescens, and one for Pseudomonas).

CONCLUSIONS:

Multiple PCRs in whole blood samples did not appear to be more sensitive than blood cultures in this series. Better concordance was found with Gram-negative microorganisms.
Club Cell Secretory Protein–Derived Acute Respiratory Distress Syndrome Phenotypes Predict 90-Day Mortality: A Reanalysis of the Fluids and Catheter Treatment Trial
Authors: Chase Aaron , Almuntashiri Sultan , Sikora Andrea , Zhang Duo
Published: May 2022

OBJECTIVES:

Club cell secretory protein (CC16) is a protein with potential utility as a lung-specific biomarker for acute respiratory distress syndrome. The purpose of this study was to characterize CC16 in plasma from patients enrolled in the Fluid and Catheter Treatment Trial (FACTT) to determine the prognostic value for patient outcomes in our subgroup of FACTT patients.

DESIGN:

A secondary biomarker analysis of a prospective randomized-controlled trial. The primary outcome was area under the receiver operating characteristic (AUROC) of CC16 for prediction of 90-day mortality. Secondary outcomes included differences in mortality, length of stay, and ventilator-free days (VFDs) between patients with high and low CC16. Statistical analyses were performed with IBM SPSS Statistics.

SETTING:

Single-center laboratory analysis.

SUBJECTS:

Plasma samples from 68 FACTT subjects and 20 healthy controls.

INTERVENTIONS:

CC16 was measured in patient plasma samples by enzyme-linked immunosorbent assay.

MEASUREMENTS AND MAIN RESULTS:

Subjects were an average of 48 years old (sd, 16.7 yr old) and 51.5% male. AUROC analysis of CC16 on day 1 showed an area under the ROC curve of 0.78 for prediction of mortality (odds ratio, 1.011; 95% CI, 1.003–1.021) with an optimal cutoff value of 45 ng/mL. Patients in the low CC16 group (<45 ng/mL) had lower mortality (7.5 vs 50.0%; p < 0.001) and similar VFD (11.9 vs 13.2; p = 0.638). When stratified by CC16 concentration, there was no difference between mortality in the fluid liberal (36.4 vs 58.8%; p = 0.256) or conservative (4.3 vs 11.8%; p = 0.366) groups.

CONCLUSIONS:

CC16 demonstrated an acceptable AUROC for prediction of patient mortality with a cut point of 45 ng/mL. Patients with high CC16 on day 1 had worse outcomes compared with those with low CC16, suggesting a prognostic role for this lung-specific biomarker.
Raising the Question: Medication Mix-Up or Diversion
Authors: Reilly Marie , McGivney Christine , Christiansen Audrey , Augustyn Marilyn
Published: May 2022

CASE:

Max is an 8-year-old boy with autism spectrum disorder and long-standing challenges with sleep maintenance, the latter of which persist despite behavioral intervention and environmental modification. When Max wakes in the early morning hours, he tends to wander the house, which causes his mother to be awake to monitor his safety. Given the impact of Max's fragmented sleep on his functioning and that of his family, you begin a trial of gabapentin liquid to promote sleep maintenance. Soon after, Max's mother reports that he is sleeping through the night, for the first time in his life.

Two months later, you receive a message from Max's mother requesting an early refill of his 90-day supply because of having spilled the bottle. You provide a new prescription, and Max's insurance company allows the early refill. Six weeks after that, Max's mother calls to say that she needs another gabapentin prescription because Max has run out. You confirm that she is giving the prescribed dose but are unsure as to why Max is out of medication weeks early. Given these events, you begin to question whether Max's gabapentin prescription is being diverted. What would you do next?
Changing the trajectory of clinical precepting for nurse practitioner students with the development of a preceptor resource network
Authors: Videtich Kayla , Moran Katherine , Zajac Lisa , Myers Richard
Published: May 2022

Preceptors of nurse practitioner students can be difficult to recruit and retain. Schools of nursing have deployed incentives that aim to support preceptors; however, these incentives, such as conferences, webinars, and workshops, do not always entice preceptors. The purpose of this project was to enhance the overall clinical experience for both the preceptor and the Doctor of Nursing Practice primary care nurse practitioner students through the development of an innovative preceptor resource network (PRN). The PRN was designed and developed to support preceptors in rural and/or underserved areas. The network consists of informal monthly meetings with rotating content as well as an online repository that houses resources. More than half of the invited preceptors attend the meetings each month. Preceptors' feedback indicated that the meetings assist them in their precepting and/or clinical practice, and the discussions were engaging and interesting. Schools of nursing need to deploy creative, relationship-based strategies to recruit and retain preceptors for nurse practitioner students. The development of a PRN, which facilitates discussions from a preceptor-driven agenda, rather than a top-down educational method, is an innovative approach that is worthy of further exploration and replication. The PRN is a sustainable model for preceptor support that could be used by universities across the United States and abroad.
T staging with functional and radiomics parameters of computed tomography in colorectal cancer patients
Authors: Dou Yafang , Liu Yingying , Kong Xiancheng , Yang Shangying
Published: May 2022

Preoperative T staging is closely related to operation planning and prognosis of colorectal cancer (CRC). This study aimed to re-investigate the value of computed tomography (CT) in T stage evaluation of CRC patients with both functional and radiomics parameters.

The functional and radiomics parameters of CT images and the clinical information were collected from 32 CRC patients. The radiomics parameters were measured based on manually labelled 5-mm circles using software Syngo. The radiomics parameters were computed based on labelled tumor regions using Python software package.

A total of 125 parameters were collected and analyzed by using decision tree analysis. The decision tree analysis identified 6 rules. Based on the rules, the shape elongation, flow extraction of nodule and blood volume of tumor region were found to be of significance and could define a high-risk group and a low-risk group.

This study shows the combination of functional parameters and radiomics parameters of CT is helpful for the diagnosis and T staging of CRC.
Difference in the prevalence of advanced colon adenoma between patients with gastric neoplasm and healthy people
Authors: Koh Myeongseok , Kim Min-Chan , Jang Jin Seok
Published: May 2022

We compared the prevalence of adenoma and cancerous colon polyps in patients undergoing endoscopic removal or gastric surgery for gastric adenoma or gastric cancer and in healthy individuals.

The medical records of 707 patients with gastric neoplasm and 798 age- and sex-matched healthy subjects were retrospectively analyzed between January 2010 and July 2018. The clinicopathological characteristics, prevalence of colorectal neoplasm diagnosed by colonoscopy, and risk factors for colorectal polyps were also investigated.

When comparing the two groups, the prevalence of overall colorectal polyps and its distribution was not different between the two groups (54.0% vs.49.5%, P = .079), whereas, the number of colon polyps (1.20 ± 1.71 vs 0.99 ± 1.54, P = .015) and the maximal size (3.53 ± 6.14 vs 2.08 ± 2.88, P < .001) were significantly larger in the gastric neoplasm group. The prevalence of advanced colon adenoma was significantly higher in the gastric neoplasm group (10.7% vs 3.8%, P < .001). Risk factors such as elevated glucose levels and the presence of gastric neoplasm were related to the prevalence of all colon polyps. The presence of gastric neoplasm is an important risk factor for advanced colon polyps.

Patients with gastric neoplasms had a significantly higher prevalence of advanced colon adenoma. Advanced colon adenoma is associated with the chain from benign adenomas through malignant altered adenomas to advanced colon cancer. Thus, patients with gastric neoplasm are regarded as a high-risk group for colorectal cancer and are recommended for screening colonoscopy at the time of diagnosis.
Primary ovarian abscess in virginal young woman with huge endometriosis cyst
Authors: Liu Wenhua , Zhang Zhifen , Li Dinghen
Published: May 2022

Rationale:

Primary ovarian abscess which develops as an isolated lesion without simultaneous tubal infection is a rare entity. Ovarian abscess (OA) is a serious complication of pelvic inflammatory disease (PID) rarely seen in virginal girls. Early diagnosis and treatment are essential to prevent further sequela including infertility, ectopic pregnancy, and chronic pelvic pain.

Patient concerns:

A 19-year-old virginal girl who presented with abdominal pain and pelvic mass with no risk factors.

Diagnoses:

Laparoscopic surgery was performed to confirm a primary ovarian abscess in the adolescent virginal female with a huge endometriosis cyst.

Intervention:

Ovarian abscess with extensive intestinal adhesions was determined during the laparoscopic operation. Abscess drainage and postoperative antibiotic therapy cured the patient.

Outcome:

After the surgery, the CRP level on the day of discharge was 3.18 mg/d. The histological findings revealed a cystic tissue sample with the fibrous wall infiltrated by neutrophilic granulocytes, and ectopic endometrium, suggesting abscess formation in the ovary and endometriosis cyst.

Lessons:

Although primary ovarian abscess in an adolescent virginal female is rare, given the severity of outcomes following ovarian abscess, this pathology should be considered in the differential diagnosis of virginal adolescents with fever and abdominal pain.
Peritonsillar abscess caused by Prevotella bivia during home quarantine for coronavirus disease 2019
Authors: Yamagishi Toshinobu , Arakawa Naoki , Toyoguchi Sho , Mizuno Koshi , Asami Yusuke , Yamanaka Yurika , Yamamoto Hiroki , Tsuboi Ken
Published: May 2022

Rationale:

Since late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had rapidly spread worldwide, resulting in a pandemic. Patients with coronavirus disease 2019 (COVID-19) have difficulty in visiting clinics in person during pandemic because they might be encouraged to quarantine at home with supportive care. Peritonsillar abscess rarely coexists with COVID-19; however, patients with SARS-CoV-2 infection could get co-infections or become superinfected with other microorganisms which could cause peritonsillar abscess. We herein describe a case of peritonsillar abscess caused by Prevotella bivia that occurred as a co-infection with COVID-19 during home quarantine.

Patient concerns:

A 32-year-old Asian woman who was diagnosed with COVID-19 was instructed to stay home for quarantine. Her pharyngeal discomfort worsened, and she experienced trismus and dysphagia. An emergent visiting doctor referred her to our hospital. Contrast-enhanced computed tomography showed peritonsillar abscess findings, following which we referred her to an ear, nose, throat specialist. Prevotella bivia was identified on needle aspiration pus culture; however, two sets of blood and throat cultures were negative.

Diagnosis:

A definitive diagnosis of acute COVID-19 and peritonsillar abscess due to Prevotella bivia was made.

Interventions:

An antibiotic drug, antiviral drug, and adjunctive steroid were administered intravenously.

Outcomes:

Her symptoms improved without the need for incision and drainage, and she was discharged on day 7.

Conclusion:

Patients with suspected peritonsillar abscess should be triaged and referred to ear, nose, throat specialists appropriately. Scoring systems, such as modified Liverpool peritonsillar abscess score or the guidelines criteria might be useful tools to triage patients. During the early phase of SARS-CoV-2 infection, administration of corticosteroids is not recommended. When adjunctive steroids are considered for peritonsillar abscess, prior to or simultaneous use of the antiviral agent remdesivir for COVID-19 might be recommended.