Strategies to address perceived barriers to timely kidney transplantation in the Netherlands: A qualitative study from a stakeholders' perspective

Objective

We present strategies to perceived barriers to access to kidney transplantation (KT) in the Netherlands.

Methods

This qualitative study (N = 70) includes nephrologists, social workers, surgeons, nurses, patients, former living kidney donors, policy employees, and insurance representatives. Interviews were conducted both in focus groups and individually and coded with NVivo.

Results

Participants proposed strategies within five domains. 1.Policy: Making KT guideline more visible. 2.Medical: Increase access and transparency to KT medical eligibility criteria (e.g., age, BMI) for patients and healthcare providers. 3.Psychological: Support patients who continue to use dialysis because of social interaction opportunities associated with dialysis settings to find such interaction elsewhere. Link kidney patients with fears for KT to experienced experts or trained professionals. 4.Social: Support patients with language barriers with interpreters and visual explanations. Support patients using social media, e.g. Facebook, to identify potential donors. Better expectation management to reduce reports of inadequate aftercare for living donors. 5.Economical: Solving negative economic incentives for KT by changing incentives.

Conclusion

Stakeholders see strategies for barriers in the entire care pathway.

Innovation

This large qualitative study gives an important overview which strategies stakeholders see improving access to KT. Some strategies offer opportunities to solve barriers in the short-term.

Ocular manifestations of HIV infection at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

BACKGROUND

The pattern of HIV-associated eye disease has changed with ongoing advancements in highly active antiretroviral therapy (HAART). HIV-infected individuals now live longer, enabling us to observe the long-term effects of HIV and HAART on the eye. There are few recent studies on HIV-related ocular disease in sub-Saharan Africa.

OBJECTIVES

To describe the ocular manifestations of HIV in patients attending the Nthabiseng HIV clinic at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.

METHODS

A cross-sectional study was conducted in 2021 and 2022 using convenience sampling of patients at the HIV clinic. The participants' clinical history was taken, their files were reviewed, and they underwent ocular examination. Correlation between eyes was managed by taking disease in one eye as the presence of disease in the participant. Descriptive statistics were used to summarise participant characteristics. Univariate and multivariate logistic regression models were used to assess the odds ratio (OR) of developing HIV-associated ocular diseases, and a p-value of <0.05 was used to define statistical significance.

RESULTS

There were 182 participants (139 females and 43 males), with a mean (standard deviation) age of 48.9 (10.6) years. The most common anterior segment diagnoses were conjunctival microangiopathy (34.6%), pinguecula (31.3%) and cataracts (30.2%), while the most common posterior segment finding was peripheral retinal scarring with features in keeping of previous cytomegalovirus retinitis (24.2%). Notably, only 1.1% of patients had HIV retinopathy. A CD4 count <200 cells/μL showed an increased OR for cataracts (OR 4.24; p=0.003) and any anterior segment diagnoses (OR 10.05; p=0.029), while a CD4 count ≥200 cells/μL showed an increased risk of conjunctival microangiopathy (OR 2.14; p=0.017).

CONCLUSION

With the advent of HAART, ocular manifestations of HIV are changing and the incidence of severe ocular opportunistic infections and HIV retinopathy has decreased precipitously. Although this study has shown that patients with a CD4 count <200 cells/μL are at increased risk of developing anterior ocular manifestations of HIV, including cataracts, these diseases are relatively innocuous or easily treatable. Routine ocular screening of HIV patients seems to be substantially less important now than it was in the pre-HAART era.

Stress perceived by drivers in public healthcare facilities in Negeri Sembilan during the first year of the COVID-19 pandemic

INTRODUCTION

Healthcare drivers, including ambulance drivers, were less concerned about health and safety during the COVID-19 pandemic, with not only the risk of COVID-19 infection but also a higher risk of prolonged states of alertness, stress, burnout, fatigue and road traffic accident. This study aimed to determine the prevalence of stress and its associated factors among healthcare drivers, especially during the COVID-19 pandemic.

MATERIALS AND METHODS

This study employs a crosssectional study design and utilises self-reported data obtained from locally validated personal stress inventory questionnaires. The data collection period spanned from August 1 to 31, 2020. The study sample consisted of 163 healthcare drivers affiliated with the Negeri Sembilan State Health Department. The Chi-square test and Fisher's exact test were the first used to determine the association between variables prior to conducting multiple logistic regression to predict the relationship between dependent and independent variables.

RESULTS

In COVID-19's first year, 7.4% (n = 12) of healthcare drivers reported perceived stress with ambulance drivers reporting more stress (10.6%; n = 5) than non-ambulance drivers (6.0%; n = 7). Simple statistical analysis identified perceived stress significantly associated with household income, smoking status and performing on-call. Further analysis by multiple logistic regression found that perceived stress was significantly related to smoking (aOR 19.9, 95% CI: 1.86-213.90), and performing on-call (aOR 8.69, 95% CI 1.21-62.28). Nevertheless, no association was found between perceived stress and age, ethnicity, marital status, education, household income, co-morbidities, driving assignment, employment duration, needing a part-time job or motor vehicle accident history.

CONCLUSION

The study found that the perceived stress amongst Malaysian healthcare drivers during the COVID-19 pandemic was relatively low. This could be due to fewer lifethreatening tasks, emergencies, assigned tasks and increase income due to overtime during the COVD-19 pandemic. The OSH team's efforts to provide consistent safety and health training, including stress management, may have contributed to the healthcare driver's ability to effectively manage the stressful circumstances encountered during the pandemic. In order to enhance salary competitiveness, employers should provide financial management education alongside subsidised housing and childcare provisions. Healthcare drivers who smoke should be taught different stress reduction techniques so that they can handle their stress in a healthy way.

Paving the way for solutions improving access to kidney transplantation: a qualitative study from a multistakeholder perspective

OBJECTIVES

The aim of this study was to obtain an in-depth perspective from stakeholders involved in access to kidney transplantation to pave the way for solutions in improving access to kidney transplantation. This study qualitatively explored factors influencing optimal access to kidney transplantation from a broad stakeholder perspective.

DESIGN

A qualitative study was performed using semistructured interviews both in focus groups and with individual participants. All interviews were recorded, transcribed and coded according to the principles of grounded theory.

SETTING

Participants were healthcare providers (geographically spread), patients and (former living) kidney donors, policy-makers and insurers.

PARTICIPANTS

Stakeholders (N=87) were interviewed regarding their perceptions, opinions and attitudes regarding access to kidney transplantation.

RESULTS

The problems identified by stakeholders within the domains-policy, medical, psychological, social and economic-were acknowledged by all respondents. According to respondents, more efforts should be made to make healthcare providers and patients aware of the clinical guideline for kidney transplantation. The same opinion applied to differences in medical inclusion criteria used in the different transplantation centres. Stakeholders saw room for improvement based on psychological and social themes, especially regarding the provision of information. Many stakeholders described the need to rethink the current economic model to improve access to kidney transplantation. This discussion led to a definition of the most urgent problems for which, according to the respondents, a solution must be sought to optimise access to kidney transplantation.

CONCLUSIONS

Stakeholders indicated a high sense of urgency to solve barriers in patient access to kidney transplantation. Moreover, it appears that some barriers are quite straightforward to overcome; according to stakeholders, it is striking that this process has not yet been overcome. Stakeholders involved in kidney transplantation have provided directions for future solutions, and now it is possible to search for solutions with them.

Epidemiology and risk factors of colorectal cancer in Syria: a single-center retrospective study

OBJECTIVE

Colorectal cancer represents the third most common malignancy and the second leading cause of cancer deaths worldwide. Many factors contribute to the risk of developing colorectal carcinoma including diet, lifestyle, age, and genetic abnormalities.  Recent findings have shown a considerable increase in the incidence rate of CRC in developing countries. However, there is little information regarding its incidence in the Middle East countries, including Syria. With our manuscript we aimed at presenting the first large epidemiological study regarding colorectal carcinoma incidence in Syria.

PATIENTS AND METHODS

We conducted a retrospective study on colorectal carcinoma cases at our institution from 2014 to 2018. The data include the cases that were diagnosed and recorded based on multiple parameters including gender, age, year of diagnosis, city of origin, and profession.

RESULTS

The number of colorectal cancer cases was 1,117 out of 13,589 cases of all malignant tumors recorded from 2014 to 2018, with an annual average incidence of 8.2%. There was a statistically significant difference in CRC cases according to age and gender. We also found a statistically significant difference according to physical activity and occupation.

CONCLUSIONS

These results demonstrate that risk factors related to colorectal cancer incidence in Syria mainly include male sex, age over 50 years old, and occupation with no physical activity.

A dynamic Markov model to assess the cost-effectiveness of the Kidney Team at Home intervention in The Netherlands

OBJECTIVES

The Kidney Team at Home program is an educational intervention aimed at patients with chronic kidney disease to assist them in their choice for kidney replacement therapy. Previous studies have shown that the intervention results in an increase in knowledge and communication on kidney replacement therapy, and eventually in an increase in the number of living donor kidney transplantations. The study assesses the cost-effectiveness of the intervention compared to standard care.

METHODS

A dynamic probabilistic Markov model was used to estimate the monetary and health benefits of the intervention in The Netherlands over 10 years. Data on costs and health-related quality of life were derived from the literature. Transition probabilities, prevalence, and incidence rates were calculated using a large national database. An optimistic and a pessimistic implementation scenario were compared to a base case scenario with standard care.

RESULTS

In both the optimistic and pessimistic scenario, the intervention is cost-effective and dominant compared to standard care: savings were €108,681,985 and €51,770,060 and the benefits were 1382 and 695 QALYs, respectively.

CONCLUSIONS

The superior cost-effectiveness of the intervention is caused by the superior health effects and the reduction of costs associated with transplantation, and the relatively small incremental costs of the intervention. The favorable findings of this implementation project resulted in national uptake of the intervention in The Netherlands as of 2021. This is the first time a psychosocial intervention has been implemented as part of standard care in a kidney replacement therapy program worldwide.

OP0003 DOES IMMUNOSUPPRESSIVE THERAPY IMPROVE GASTROINTESTINAL SYMPTOMS IN PATIENTS WITH SYSTEMIC SCLEROSIS?

Background

The gastrointestinal (GI) tract is frequently affected in systemic sclerosis (SSc), leading to considerable morbidity and even mortality. While important progress has been made in the last years regarding treatment of SSc, there is no disease-modifying treatment available for SSc-related GI involvement.

Objectives

We aimed to identify, in an observational cohort study of real-life patients with SSc, an association between immunosuppressive therapy and the severity of GI symptoms, measured by the University of California at Los Angeles / Scleroderma Clinical Trial Consortium Gastro-Intestinal Tract instrument 2.0 (UCLA GIT 2.0).

Methods

We selected patients from our EUSTAR centre who met the 2013 ACR/EULAR classification criteria for SSc and had at least two visits with completed UCLA GIT 2.0 questionnaires, with an interval of 12±3 months between visits. We defined the first visit with a completed UCLA GIT 2.0 questionnaire as baseline visit. Immunosuppressive therapy was defined as exposure for at least 6 months between the two visits to at least one of the following drugs, regardless of indication: mycophenolate mofetil (MMF), cyclophosphamide, methotrexate, azathioprine, leflunomide, glucocorticoids (>10mg/d prednisone-equivalent), rituximab, tocilizumab, and abatacept. The study outcome was the UCLA GIT 2.0 score at the follow-up visit. We performed multivariable linear regression with this outcome as dependent variable and immunosuppressive therapy during follow-up, immunosuppressive therapy before baseline, baseline UCLA GIT 2.0 score and several baseline parameters selected by clinical judgment as potentially influencing GI symptoms, as independent variables. Multiple imputation was implemented to handle missing values.

Results

We included 209 patients. Baseline characteristics were: 82.3% female, median (IQR) age 59.0 (48.6, 68.2) years, median disease duration 6.0 (2.7, 12.5) years, 40 (19.1%) diffuse cutaneous SSc, median baseline UCLA GIT 2.0 score 0.19 (0.06, 0.43). Of these, 71 patients were exposed to immunosuppressive therapy during the observation period: 27/71 methotrexate, 1/71 cyclophosphamide, 17/71 MMF, 3/71 leflunomide, 3/71 azathioprine, 6/71 glucocorticoids >10mg/d, 16/34 rituximab, 18/34 tocilizumab. Patients on immunosuppressive therapy during the observation period had, compared to patients without such treatment, overall more severe SSc, higher prevalence of treatment with proton pump inhibitors, similar UCLA GIT 2.0 scores at baseline and at follow up and tendentially less severe GI symptoms at baseline and follow-up by medical history. In multivariable linear regression, immunosuppressive therapy, lower body mass index, longer disease duration and lower baseline UCLA GIT 2.0 score were significantly associated with lower (better) UCLA GIT 2.0 scores at follow-up (Table 1).

Table 1.Predictors of UCLA GIT 2.0 score at follow-upEstimates95% CIpAge0.002-0.001 – 0.0060.136Sex [male]-0.056-0.172 – 0.0610.347Disease duration-0.005-0.009 – -0.0000.030Body mass index0.0140.002 – 0.0250.017UCLA GIT 2.0 total score baseline0.6900.571 – 0.809<0.001Immunosuppressive therapy during observation period-0.119-0.228 – -0.0100.032Immunosuppressive therapy before baseline0.080-0.032 – 0.1920.160Modified Rodnan Skin Score-0.001-0.008 – 0.0070.860Forced vital capacity-0.001-0.004 – 0.0010.302Erythrocyte sedimentation rate0.003-0.001 – 0.0060.116Proton pump inhibitors-0.034-0.120 – 0.0520.435(Intercept)-0.120-0.531 – 0.2910.566

Baseline factors associated with the total UCLA GIT 2.0 score at the end of the observation period. Multiple linear regression model with imputation for missing variables. N=209 patients

Conclusion

Immunosuppressive treatment was associated with lower UCLA GIT 2.0 scores, which suggests potential effects of immunosuppressants on GI manifestations in patients with SSc. These results need verification in additional studies and randomised controlled clinical trials.

References

[1]Khanna D et al. Arthritis Rheum, 2009; 61: 1257-63.

Disclosure of Interests

Lea Stamm: None declared, Alexandru Garaiman: None declared, Norina Zampatti: None declared, Mike O. Becker Speakers bureau: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Consultant of: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Grant/research support from: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Cosimo Bruni Speakers bureau: Actelion, Eli-Lilly, Boehringer-Ingelheim, Grant/research support from: Abbvie, EUSTAR, Gruppo Italiano Lotta alla Sclerodermia (GILS), SCTC, Rucsandra Dobrota Consultant of: Boehringer-Ingelheim, Grant/research support from: Iten-Kohaut Foundation, Muriel Elhai: None declared, Sherif Ismail Grant/research support from: EULAR scientific training grant for young fellows 2021, Suzana Jordan: None declared, Aurora Tatu: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Carina Mihai Speakers bureau: Boehringer-Ingelheim, Mepha, MED Talks Switzerland, Consultant of: Boehringer-Ingelheim, Janssen, Grant/research support from: Boehringer-Ingelheim, Janssen, Roche.

Salmonella-induced pulmonary and pericardial abscesses in a patient presenting with subacute cough

The non-typhoid Salmonella (NTS) species are commonly associated with gastroenteritis and other forms of intestinal disease. Thoraco-pulmonary infections are less commonly reported. We describe the case of a 66-year-old Qatari lady who presented with subacute cough. Chest imaging revealed multiple pulmonary and a pericardial cavitary lesion with air fluid levels. Bronchoalveolar lavage culture grew Salmonella species group D. The patient was treated with 4 weeks of appropriate antibiotics. Clinical and radiological improvement were documented on subsequent follow up. To our knowledge, this is the first reported case of pulmonary and pericardial salmonella abscesses in the state of Qatar.

SARS-CoV-2 associated pathogenesis, immune dysfunction and involvement of host factors: a comprehensive review

Infectious diseases, especially viral infections, have emerged as a major concern for public health in recent years. Recently emerged COVID-19, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has been declared a pandemic by World Health Organization since March 2020. It was first identified in Wuhan, China, in December 2019 and has since claimed more than a million lives. Complicated symptoms are associated with rising incidence and fatality rates, while many of the vaccine candidates are in the final stages of clinical trials. This review encompasses a summary of existing literature on COVID-19, including the basics of the disease such as the causative agent's genome characterization, modes of transmission of the virus, pathogenesis, and clinical presentations like associated immune responses, neurological manifestations, the variety of host genetic factors influencing the disease and the vulnerability of different groups being affected by COVID-19.

123 Use of The Induction Mobile Application in A Busy General Surgery Department

Introduction

Contacting other hospital professionals, or accessing local guidelines is a common task for surgeons, which is usually facilitated by inefficient switchboard and intranet systems. Induction is a mobile application which includes crowd-sourced hospital directories and local guidelines, which could theoretically expedite these tasks. To assess this, we undertook a QIP within the General Surgery department using a bespoke Induction group.

Method

A private Induction group was created with the features mentioned above. We audited Induction against local trust processes (Switchboard and Intranet Trust Guidelines). We estimated cost saving using the 2019 junior doctor pay-scales. We also surveyed our department to evaluate their experiences using the application with a Likert scale.

Results

The timesaving from using Induction compared to current methods was on average 9.93 hours/week accumulated by 16 staff members, giving an estimated cost saving of £10,636.54/year. In a qualitative analysis, respondents rated Induction 4.8/5 for speed and 3.4/5 for completeness of directory, compared to 1.5/5 and 4.5/5 respectively for switchboard. Regarding accessing clinical guidelines, respondents rated the app as ‘easier’ and ‘quicker’ than the intranet.

Conclusions

We have demonstrated significant time and cost-savings using Induction compared to standard practices. Our QIP provides a replicable model to increase efficiency in surgery departments.

Understanding the structure of a country’s health service providers for defence health engagement

There are a variety of structural and systems frameworks for describing the building blocks of country’s public health and health systems. In this paper, we propose a conceptual framework for a holistic view of a country’s health service providers in order to inform the plan for Defence Health Engagement activities with partner countries. This includes all potential government ministries involved in healthcare provision, the independent, private sector and the non-government organisation/charity sector. The framework provides a visualisation to support the analysis of a country’s health services providers. We propose that recognising and analysing the different contributions of all these national health providers is essential for understanding the wider political economy of a nation’s health systems. This can inform a plan of Defence Health Engagement for capacity building in crisis response, development and health systems strengthening.

Prevalence of Cryptosporidium spp. infection among children admitted to Hospital Tengku Ampuan Afzan

INTRODUCTION

Cryptosporidium spp. is identified as an important cause of diarrhoeal morbidity and mortality worldwide particularly in children below five years of age and immunocompromised individuals. Infections are present among cattle and humans. Until now, there is no report on its prevalence in humans in Kuantan. The aim of this study is to record the prevalence and associated risk factors of Cryptosporidium spp. infection among children admitted to Hospital Tengku Ampuan Afzan (HTAA), Kuantan.

METHODS

This is a cross-sectional study conducted among children admitted to the Paediatrics ward in HTAA between December 2017 and May 2018. Faecal samples were examined using wet smear and Modified Ziehl-Neelsen (MZN) staining techniques. Data on demography and hygiene practices was collected using a pretested questionnaire, and analysed using SPSS version 22.

RESULTS

One hundred thirty five children (95.6% were of Malay ethnicity) were included in the study. The overall prevalence of Cryptosporidium spp. infection was 25.2%. The prevalence was slightly higher in females (28.1%) than males (23.1%). The prevalence was higher than expected. This study showed that some risk factors namely children's age and trash disposal methods were significantly associated with Cryptosporidium spp. infection (p<0.05).

CONCLUSION

Higher prevalence could possibly be due to an outbreak of this infection or until now undetected.

Intranasal inoculation of recombinant DNA vaccine ABA392 against haemorrhagic septicaemia disease

We evaluate the efficacy of recombinant DNA vaccine ABA392 against haemorrhagic septicaemia infection through intranasal administration route by targeting the mucosal immunity. The DNA vaccine was constructed and subjected to animal study using the Sprague Dawley (SD) rat. The study was divided into two major parts: (i) active and (ii) passive immunization studies, involving 30 animals for each part. Each group was then divided into five test groups: two test samples G1 and G2 with 50 and 100 µg ml^-1 purified DNA vaccine; one positive control G5 with 10⁶  CFU per ml formalin-killed PMB2; and two negative controls, G3 and G4 with normal saline and pVAX1 vector. Both studies were conducted for the determination of immunogenicity by total white blood cell count (TWBC), indirect ELISA and histopathological changes for the presence of the bronchus-associated lymphoid tissue (BALT). Our findings demonstrate that TWBC, IgA and IgG increased after each of the three vaccination regimes: groups G1, G2 and G5. Test samples G1 and G2 showed significant differences (P < 0·05) compared to the negative controls, G3 and G4, but no significant differences from the positive control G5. Groups G1, G2 and G5 showed more formation of BALT compared to the negative controls, G3 and G4. Our results show that intranasal inoculation of recombinant DNA vaccine ABA392 can provoke mucosal immunity which makes it a potential prophylactic against HS. SIGNIFICANCE AND IMPACT OF THE STUDY: New approach of combating haemorrhagic septicaemia disease among bovines by recombinant DNA vaccine is crucial to overcome the loss of edible products from the infected bovines. DNA vaccine can potentially serve as a better immunogen which would elicit both cellular and humoral immunity, and it is also stable for its molecular reproduction. This research report demonstrates an effective yet simple way of administering the DNA vaccine via the intranasal route in rats, to provoke the mucosal immunity through the development of immunoglobulins IgA, IgG and bronchus-associated lymphoid tissue which guard as the first-line defence at the host's mucosal lining.

Factors influencing access to kidney transplantation: a research protocol of a qualitative study on stakeholders' perspectives

INTRODUCTION

Unequal access to kidney transplantation is suggested, but no systematic inventory exists about factors influencing access to kidney transplantation. There is an absence of any research that has combined stakeholder perspectives along the complete trajectory of transplantation. The present qualitative study explores the contributing factors from the perspectives of multiple stakeholders in this trajectory, including patients, health professionals and health insurance and financial representatives in the Netherlands. Moreover, stakeholders will be invited to suggesting strategies and solutions for handling the facilitating and hindering factors found. By means of interaction, stakeholder groups will arrive at a consensus for new policymaking in the field of a Dutch transplantation care.

METHODS AND ANALYSIS

The different stakeholders' perspectives and possible solutions will be explored by interviewing in three phases. In the first phase, stakeholders' group perspectives will be explored with individual interviews and focus group interviews without confrontation of views from other perspectives. In the second phase of focus group interviewing, perspectives will be confronted with the other stakeholders' perspectives assessed. Finally, in the third phase, stakeholders will be invited to focus group discussions for suggesting solutions to overcome barriers and promote facilitators for improving access to transplantation. Approximately, groups from six to twelve participants per focus group and four to maximal six focus groups will be held per stakeholder, depending on the level of saturation, as prescribed by grounded theory. The interviews will be audio-recorded and transcribed verbatim, and qualitative data will be analysed according to the principles of grounded theory supported by using NVivo software.

ETHICS AND DISSEMINATION

The Medical Ethical Committee of Erasmus MC, Rotterdam, The Netherlands, has approved this study. The results will be disseminated in peer-reviewed journals and major international conferences.

Cost-effectiveness of a home-based group educational programme on renal replacement therapies: a study protocol

INTRODUCTION

Living donor kidney transplantation (LDKT) is the optimal treatment for most patients with end-stage renal disease (ESRD). However, there are numerous patients who cannot find a living kidney donor. Randomised controlled trials have shown that home-based education for patients with ESRD and their family/friends leads to four times more LDKTs. This educational intervention is currently being implemented in eight hospitals in the Netherlands. Supervision and quality assessment are being employed to maintain the quality of the intervention. In this study, we aim to: (1) conduct a cost-effectiveness analysis of the educational programme and its quality assurance system; (2) investigate the relationship between the quality of the implementation of the intervention and the outcomes knowledge, communication and LDKT activities; and (3) investigate policy implications.

METHODS AND DESIGN

Patients with ESRD who do not have a living kidney donor are eligible to receive the home-based educational intervention. This is carried out by allied health transplantation professionals and psychologists across eight hospitals in the Netherlands. The cost-effectiveness analysis will be conducted with a Markov model. Cost data will be obtained from the literature. We will obtain the quality of life data from the patients who participate in the educational programme. Questionnaires on knowledge and communication will be used to measure the outcomes of the programme. Data on LDKT activities will be obtained from medical records up to 24 months after the education. A protocol adherence measure will be assessed by a third party by means of a telephone interview with the patients and the invitees.

ETHICS AND DISSEMINATION

Ethical approval was obtained through all participating hospitals. Results will be disseminated through peer-reviewed publications and scientific presentations. Results of the cost-effectiveness of the educational programme will also be disseminated to the Dutch National Health Care Institute.

TRIAL REGISTRATION NUMBER

NL6529.

Effect And Predictive Value Of Routine Preoperative Laboratory Testing For Endoscopic Retrograde Cholangiopancreatography

BACKGROUND AND AIMS

Several studies and guidelines are questioning routine preoperative laboratory tests in surgical and endoscopic procedures. Their effect in endoscopic retrograde cholangiopancreatography is not currently known. This study was carried out to evaluate the risk of adverse effects in endoscopic retrograde cholangiopancreatography and their association with preoperative lab tests.

MATERIALS AND METHODS

A single-center, prospective observational study on all 956 patients undergoing 1196 endoscopic retrograde cholangiopancreatographies in the Endoscopy Unit of Helsinki University Central Hospital from 1 March 2012 to 28 February 2013. Routine preoperative laboratory test results (basic blood count, creatinine, potassium, sodium, international normalized ratio/thromboplastin time, and amylase), health status, medication, and demographic information of all patients were analyzed in relation to adverse effects related to endoscopic retrograde cholangiopancreatography and procedural sedation.

RESULTS

Multivariate analysis showed post-endoscopic retrograde cholangiopancreatography pancreatitis (43 cases, 3.6%) to have no association with abnormal routine preoperative laboratory tests. Respiratory depression caused by sedation (128 cases, 11%) was not associated with abnormal routine preoperative laboratory tests, and anemia was found to be a slightly protecting factor. Cardiovascular depression caused by sedation was associated with thrombocytopenia (odds ratio = 1.87, p = 0.025) and, in male patients, hyponatremia (odds ratio = 3.66, p < 0.001). Incidence of other adverse effects was too low for statistical analysis.

CONCLUSION

Routine universal preoperative lab testing was not found to be successful in predicting adverse effects in endoscopic retrograde cholangiopancreatography procedures. Laboratory testing should be done focusing on each patient's individual needs.

Encapsulation of Bacillus salmalaya 139SI using double coating biopolymer technique

Sustainable crop production for a rapidly growing human population is one of the current challenges faced by the agricultural sector. However, many of the chemical agents used in agriculture can be hazardous to humans, non-targeted organism and environment. Plant growth promoting rhizobacteria have demonstrated a role in promoting plant growth and health under various stress conditions including disease. Unfortunately, bacterial viability degrades due to temperature and other environmental factors (Bashan et al., Plant Soil 378: 1-33, 2014). Encapsulation of bacteria into core-shell biopolymers is one of the promising techniques to overcome the problem. This study deals with the encapsulation of Bacillus salmalaya 139SI using simple double coating biopolymer technique which consist of brown rice protein/alginate and 0·5% low molecular weight chitosan of pH 4 and 6. The influence of biopolymer to bacteria mass ratio and the chitosan pH on the encapsulation process, physic-chemical, morphology and bioactivity properties of encapsulated B. salmalaya 139SI have been studied systematically. Based on the analysis of physico-chemical, morphology and bioactivity properties, B. salmalaya 139S1 encapsulated using double coating encapsulation technology has promising viability pre- and postfreeze-drying with excellent encapsulation yields of 99·7 and 89·3% respectively. SIGNIFICANCE AND IMPACT OF THE STUDY: The need of a simple yet effective way of encapsulating plant growth promoting rhizobacteria is crucial to further improve their benefits to global sustainable agriculture practice. Effective encapsulation allows for protection, controlled release and function of the micro-organism, as well as providing a longer shelf life for the product. This research report offers an innovative yet simple way of encapsulating using double coating technology with environmentally friendly biopolymers that could degrade and provide nutrients when in soil. Importantly, the bioactivity of the bacteria is maintained upon encapsulation.

An Empirical Study of Service Quality and Customer Satisfaction of Malaysian Air Passenger

.

Summary of the NACI Update on Herpes Zoster Vaccines

BACKGROUND

Steep increases in herpes zoster (HZ) incidence, hospitalization due to HZ and the risk of post-herpetic neuralgia as a complication of HZ occur in people over 50 years of age. Two HZ vaccines are currently authorized for use in those 50 years of age and older in Canada: a live attenuated zoster vaccine (LZV) authorized in 2008; and a recombinant subunit vaccine (RZV) authorized in October 2017.

OBJECTIVES

To review current evidence and develop guidance on whether the previously authorized LZV (Zostavax®) and/or the recently authorized RZV (Shingrix®) vaccine should be offered to Canadians 50 years of age and older: 1) at a population-level, in publicly funded immunization programs; and 2) at an individual-level, to individuals wishing to prevent HZ, or by clinicians wishing to advise individual patients about preventing HZ.

METHODS

The National Advisory Committee on Immunization (NACI) Herpes Zoster Working Group developed a predefined search strategy to identify all eligible studies, assessed their quality, and summarized and analyzed the findings. A Cost Utility Analysis of LZV and RZV was also conducted from a health care system perspective. Recommendations were proposed according to NACI's evidence-based process. The strength of these recommendations was defined, and the Grade of evidence supporting them was identified. In light of the evidence, the recommendations were then considered and approved by NACI.

RESULTS

Five recommendations were developed for public health and individual-level decision-making. 1) RZV should be offered to populations/individuals >50 years of age without contraindications (Strong NACI Recommendation, Grade A evidence). 2) RZV should be offered to populations/individuals >50 years of age without contraindications who have previously been vaccinated with LZV (Strong NACI Recommendation, Grade A evidence). Re-immunization with two doses of RZV may be considered one year after LZV (Discretionary NACI Recommendation, Grade I evidence). 3) RZV should be offered to populations/individuals >50 years of age without contraindications who have had a previous episode of HZ (Strong NACI Recommendation, Grade B evidence). Immunization with two doses of RZV may be considered one year after the HZ episode (Discretionary NACI Recommendation, Grade I evidence). 4) LZV may be considered for immunocompetent populations/individuals >50 years of age without contraindications when RZV is contraindicated, unavailable or inaccessible (Discretionary NACI Recommendation, Grade A evidence). 5) RZV (not LZV) may be considered in immunocompromised adults >50 years of age on a case-by-case basis (Discretionary NACI Recommendation, Grade I evidence).

CONCLUSION

Both vaccines have been shown to be safe and immunogenic and to reduce the incidence of HZ and post-herpetic neuralgia. Vaccine efficacy of LZV against HZ decreases with age at, and time since vaccination. The vaccine efficacy of RZV remains higher and appears to decline more slowly than vaccine efficacy of LZV across all age groups. Both vaccines are cost-effective in those 50 years of age and older compared with no vaccination, especially in those 65-79 years of age. RZV is more cost-effective than LZV.

HIV-2 Infection in Malaysia: Current situation and the use of in-house real-time reverse transcription PCR for HIV-2

HIV-2 surveillance has been carried out in Malaysia for more than 25 years ago. Tests to discriminate HIV-1 and HIV-2 are available but the options of test are limited and the need to develop a new in-house HIV-2 real-time reverse transcription PCR (RT-PCR) is crucial. A study was done on 29 samples from hospitals in Malaysia which were found to be positive screening for HIV-2 antibodies by the commercial Western Blot assay. These samples were further tested by a Western Blot assay that detects specific antibodies to HIV-2. Detection of HIV-2 genome was then performed by using a commercial kit. Fifteen samples were evaluated by using in-house real-time RT-PCR for HIV-2. Ninety-three percent (27/29) of samples have positive results for HIV-2 on HIV-2 Western Blot with only 2 samples showing indeterminate results. All samples showed negative results for HIV-2 genomes by using a PCR commercial kit and the 15 samples that were subjected to our in-house real-time RT-HIV-2 PCR were also tested negative for HIV-2 RNA. Results of HIV-2 Western Blot did not reflect the actual positivity as both HIV-1 and HIV-2 antibodies may cross-react with either viral proteins. None of the samples was confirmed positive for HIV-2 by the commercial and in-house real-time RTPCR. In-house real-time RT-HIV-2 PCR assay can be further used to confirm the presence of HIV-2 genome. Up to the year 2015, Malaysia is still free from HIV-2 infection.

A clinicopathologic study of 173 odontogenic tumours in Northern Peninsular Malaysia (2007-2014)

INTRODUCTION

The objectives of this study were to analyse, compare and contrast the demographic, clinical and pathological data of odontogenic tumours seen at a regional oral pathology centre in the Northern part of Peninsular Malaysia with other international data as an aid to clinicians in diagnosing odontogenic tumours.

MATERIALS AND METHODS

This was a descriptive, retrospective study of odontogenic tumours diagnosed from January 2007 to December 2014 at this centre. The odontogenic tumours were classified using the 2005 World Health Organization classification system.

RESULTS

Among 2,733 biopsy specimens, 173 cases were diagnosed as odontogenic tumours (6.3%), of which 171 (98.8%) are benign and 2 (1.2%) are malignant. The most frequently encountered tumour was ameloblastoma (n=96, 55.5%), followed by keratocystic odontogenic tumour (KCOT) (n=38, 22.0%) and odontomas (n=16, 9.2%). Malignant tumours accounted for 1.2% of the tumours. Most ameloblastomas and KCOTs affected the mandible preferentially. The mean age was 33.5 (± 17.8) years and 64.7% of patients were in the age group of 10 to 39. Odontogenic tumours were slightly more common in males, with a male to female ratio of 1.4:1.

CONCLUSION

The findings of this study are similar to the other studies in Asia in which the most common tumour encountered is the ameloblastoma, followed by KCOT. The most common signs and symptoms are pain and swelling, while paraesthesia and root resorption are less frequently reported. Such clinical and radiographic features should alert the clinician of a possible odontogenic tumour and though rare, malignant tumours should also be included in the differential diagnoses.

Change in Mallampati class during labor: Hypertensive versus normotensive parturients

BACKGROUND

Mallampati class has been shown to increase during labor. There are no prospective studies evaluating airway changes in hypertensive parturients during labor. The aim of our study was to observe the frequency of change in Mallampati class during labor in hypertensive compared to normotensive parturients.

METHODS

In this prospective observational cohort study, 60 parturients were enrolled and divided into two groups of 30 each: hypertensive parturients and normotensive parturients. The Mallampati class was evaluated in each parturient at two points; during early labor (cervical dilation 1-3 cm and regular contractions) taken as T1 and at 20 minutes after delivery taken as T2. The change in Mallampati class from T1 to T2 was compared between the two groups. Post-stratification chi-square test was applied and P value <.05 was considered as significant.

RESULTS

The change in Mallampati class was significantly more frequent in hypertensive group as compared to normotensive group [80% (24/30) vs 46.7% (14/30); P = .002]. Overall, an increase in Mallampati class during labor was found with statistically significant difference between the hypertensive and normotensive group [80% (24/30) vs 42.9% (12/28); P = .004]. The risk of increase in Mallampati class was 2 times higher in hypertensive women as compared to normotensive 2.44; 95% CI: 1.19 to 5.02].

CONCLUSION

Mallampati class showed 2-fold increase in hypertensive compared to normotensive parturients during labor; requiring additional caution during airway management.

Evaluation of reference values of standard semen parameters in fertile Egyptian men

The reference values of human semen, published in the WHO's latest edition in 2010, were lower than those previously reported. The objective of this study was to evaluate reference values of standard semen parameters in fertile Egyptian men. This cross-sectional study included 240 fertile men. Men were considered fertile when their wives had recent spontaneous pregnancies with time to pregnancy (TTP) ≤12 months. The mean age of fertile men was 33.8 ± 0.5 years (range 20-55 years). The 5th percentiles (95% confidence interval) of macroscopic semen parameters were 1.5 ml for volume and 7.2 for pH. The 5th percentiles of microscopic parameters were 15 million/ml for sperm concentration, 30 million per ejaculate for total sperm count, 50% for total motility, 40% for progressive motility, 62% for vitality, 4% for normal sperm forms and 0.1 million/ml for seminal leucocyte counts. In conclusion, fertile Egyptian men had higher reference values of sperm total motility, progressive motility and vitality, and lower reference values for total sperm counts as compared to those determined by the latest edition of the WHO laboratory manual in 2010. Other semen parameters were identical to those defined by the WHO 2010 manual.

Saharan dust, convective lofting, aerosol enhancement zones, and potential impacts on ice nucleation in the tropical upper troposphere

Dry aerosol size distributions and scattering coefficients were measured on 10 flights in 32 clear-air regions adjacent to tropical storm anvils over the eastern Atlantic Ocean. Aerosol properties in these regions were compared with those from background air in the upper troposphere at least 40 km from clouds. Median values for aerosol scattering coefficient and particle number concentration >0.3 μm diameter were higher at the anvil edges than in background air, showing that convective clouds loft particles from the lower troposphere to the upper troposphere. These differences are statistically significant. The aerosol enhancement zones extended ~10-15 km horizontally and ~0.25 km vertically below anvil cloud edges but were not due to hygroscopic growth since particles were measured under dry conditions. Number concentrations of particles >0.3 μm diameter were enhanced more for the cases where Saharan dust layers were identified below the clouds with airborne lidar. Median number concentrations in this size range increased from ~100 l-1 in background air to ~400 l-1 adjacent to cloud edges with dust below, with larger enhancements for stronger storm systems. Integration with satellite cloud frequency data indicates that this transfer of large particles from low to high altitudes by convection has little impact on dust concentrations within the Saharan Air Layer itself. However, it can lead to substantial enhancement in large dust particles and, therefore, heterogeneous ice nuclei in the upper troposphere over the Atlantic. This may induce a cloud/aerosol feedback effect that could impact cloud properties in the region and downwind.

Activated electric arc furnace slag as an effective and reusable Fenton-like catalyst for the photodegradation of methylene blue and acid blue 29

In this work, an activated electric arc furnace slag (A-EAFS) was investigated as an effective Fenton catalyst for the photodegradation of methylene blue (MB) and acid blue 29 (AB29). Fourier transform infrared spectroscopy and UV-visible absorption analyses indicated that A-EAFS offers additional Fe₃O₄ because of the changes in the iron oxide phase and the favorable response to visible light. It has been found that the highest degradation efficiency can reach up to 94% for MB under optimal conditions of 1 g L^-1 of A-EAFS, 20 mM H₂O₂, and pH 3. The optimal conditions for AB29 were 0.1 g L^-1 A-EAFS, 4 mM H₂O₂, and pH 3 to reach 98% degradation efficiency. Visible light enhanced the degradation of both dyes. In addition, A-EAFS, could be easily separated magnetically, exhibited good chemical stability after seven successive photodegradation cycles.

Drug resistance mutations among virological failure HIV-1 infected patients in Malaysia

The determination of HIV drug resistance mutations (DRMs) towards antiretroviral (ARV) drugs among HIV-1 treated patients with virological failure is crucial for further management of the patient. This study aimed to assess the most common genomic mutation and to analyse subtypes among the HIV-1 patients with viral load level > 1,000 copies/mL. A total of 101 virological failure HIV-1 patients from four different regions of Peninsular Malaysia with a viral load measurement facility were included in the study. Majority of patients (89.1%) have at least 1 mutation associated with clinical resistance to either protease inhibitors (PIs), nucleoside reverse transcriptase inhibitors (NRTIs) or nonnucleoside reverse transcriptase inhibitors (NNRTIs). Major resistance mutations among the patients towards NRTIs and NNRTIs were 70.3% and 18.8%, respectively. The most common mutation for NRTIs was M184V while K103N mutation was detected in the majority of patients who were treated with NNRTIs. The most commonly observed mutations for major PI and minor PI seen among the study population were V82A/T and L10V, respectively. In HIV-1 subtype analysis, CRF33_01B was the most predominant HIV-1 subtype in this study group. The vast detection of DRMs in this study emphasized the importance of genotypic resistance test in the management of HIV patients as DRMs can alter patient's susceptibility towards ARV drugs. Further study on larger number of samples is essential for the development of a database on HIV-1 DRMs among patients that experience virological failure in Malaysia.

Video-assisted thoracic surgery in a Nigerian teaching hospital: Experience and challenges

BACKGROUND

Video-assisted thoracic surgery (VATS) is well established. Its application in Nigeria has however been limited and not been reported. The aim of this study was to describe our institutional experience and challenges with VATS.

MATERIALS AND METHODS

This was a retrospective cross-sectional study of all patients that underwent VATS in our institution between March 2008 and June 2013. Data were extracted from a prospectively maintained database.

RESULTS

Two hundred and sixty-one patients were assessed as potential VATS cases. VATS was initiated in 26 patients, but completed in 25 patients (9.6%) as there was one case of conversion of a planned VATS bullectomy due to the failure of one lung ventilation. There were 12 males and 13 females. Mean age was 40.7 ± 13.9 years. The indication was interstitial lung disease in 9 patients (36%), malignant pleural effusion in 6 patients (24%), spontaneous pneumothorax in 5 patients (20%), indeterminate pulmonary nodule in 2 patients (8%), pleural endometriosis in 2 patients (8%) and bronchogenic cyst in one patient (4%). Procedures performed were lung biopsy in 13 patients (52%), pleural biopsy and pleurodesis in 6 patients (24%), bullectomy and pleurodesis in 5 patients (20%) and excision of bronchogenic cyst in one patient (4%). Mean hospital stay was 4 ± 0.7 days. There were no complications and no mortalities.

CONCLUSION

VATS is being performed in our institution with successful outcomes. The use of VATS in Nigeria is encouraged. The relatively high cost of VATS is, however, a major limitation to more widespread use.

ROBERTS SYNDROME: CLINICAL AND CYTOGENETIC STUDIES IN 8 EGYPTIAN PATIENTS AND MOLECULAR STUDIES IN 4 PATIENTS WITH GENOTYPE/PHENOTYPE CORRELATION

The Roberts syndrome (RBS) is a rare autosomal recessive disorder caused by mutation in ESCO2 gene. Among over 150 reported international cases, 16 cases are Egyptian including the presently reported patients. The current study reports 8 new Egyptian patients from 7 unrelated consanguineous families investigating clinical phenotype as well as cytogenetic changes in all cases and mutational spectrum in 4 cases. Clinical, orodental, cytogenetic and molecular studies were done to investigate genotype/phenotype correlation. Evaluation of the studied 8 patients showed that they all exhibited the main limb and craniofacial features of Roberts syndrome. Cytogenetic studies including centromeric separation and puffing by Giemsa and DAPI stains and for the first time in Egypt analysis for premature centromeric division by FISH showed consistent centromeric separation in all studied cases. Molecular studies of 4 available patients showed that they all have ESCO2 gene mutation. We conclude that RBS has a well-defined clinical spectrum. The cytogenetic changes are due to sister chromatid cohesion defects which lead to mitotic dysfunction. We confirmed previous results of lack of genotype/phenotype correlation. We also confirmed that the severity of limb malformation correlates with craniofacial manifestations. We recommend detailed evaluation of orodental changes for further definition of the phenotype and for proper patient management. We emphasize the need for further studies for the frequency of premature centromeric separation by FISH as a possible indicator of phenotypic severity.

Reclamation from palm oil mill effluent using an integrated zero discharge membrane-based process

This research emphasizes eloquently on membrane technology for treatment of palm oil mill effluent (POME) as it is the Malaysia’s largest and most important agro based industry. Findings established significant quality improvement with an efficient recovery of water from palm oil mill via innovative membrane application. Conventional bio-methods, whilst adhering to the Department of Environment’s (DOE) discharge regulations, produces brownish liquid which pales in comparison to the crystal clear water obtained through membrane treatment. The pre-treatment process consists of coagulation-flocculation using green environmental coagulant bases such as Moringa oleifera (MO) seeds. The ultrafiltration polyvinylidene difluoride (PVDF) and thin film composite (TFC) reverse osmosis were vital for the membrane processes. The system gave 99% suspended solids reduction in suspended solid and 78% of water present was successfully recovered. This technology guarantees water recovery with drinking water quality; meeting the US Environmental Protection Agency (USEPA) standard or could be recycled into the plant with sludge utilization for palm oil estates, thus enabling the concept of zero discharge to be executed in the industries. In addition, green and healthy antioxidants such as oil and beta-carotene can be recovered from POME further demonstrate. Silica gel showed better performance in separation of carotenes from oil at temperature 40°C using adsorption chromatography with 1154.55 ppm. The attractiveness of this technology, enabling the utilization of reuse of agricultural waste into potentially value added products.