Clinical profile, prognosis and post COVID-19 syndrome among UNRWA staff in Jordan: A clinical case-series study

BACKGROUND

The clinical manifestations of Corona Virus Disease of 2019 (COVID-19) varied from patient to patient with evidence of multi-organ involvement. Many patients continue to have a wide range of symptoms for variable periods of time. The long-term effects of COVID-19 infection (post COVID-19 illness or syndrome) are not yet fully explored. This study aims to shed light on the clinical manifestations of the acute COVID-19 infection as well as post COVID-19 syndrome among the United Nations Relief and Works Agency for Palestine Refugee (UNRWA) staff in Jordan.

METHODS

A clinical case-series was conducted on a sample of COVID-19 positive employees of the UNRWA staff in Jordan. A structured questionnaire based mainly on World Health Organization (WHO) Case Report Form (CRF) verified tool for post COVID-19 was used. A sample of 366 out of a total of 1322 confirmed cases was systemically selected and included in the present study. Data were collected from UNRWA medical records and phone interviews. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software.

RESULTS

The calculated Case Fatality Ratio was 0.7%. The incidence of COVID-19 among UNRWA staff in Jordan during the period of our study was 20.1%. A total of 366 respondents, 220 (60.1%) females and 146 (39.9%) males were included in the study. The mean (SD) age was 44.2 (8.0) years. Most of the infected (97.8%) developed acute COVID-19 symptoms. Fatigue, fever, joint pain, loss of smell and taste, and cough were the most common symptoms. According to WHO clinical classification of acute illness severity, 65.0% had mild illness. Only 28.7% of all subjects fully recovered from the infection, while most of them (71.3%) continued to suffer from many symptoms. Persistent fatigue (39.7%), shortness of breath (SOB) with activity (18.8%), anxiety (17.4%), forgetfulness (16.9%), trouble in concentrating (16.7%), and depressed mood (15.8%) were the most frequently reported.

CONCLUSION

Post COVID-19 illness was very common (71.3%) calling for UNRWA to continue assessment of post COVID-19 syndrome and the medical and psychological needs of affected staff. Despite vaccination, only 2.2% of the infected were asymptomatic. Reinfection was unusually high (24%).

Evaluating the performance of artificial intelligence software for lung nodule detection on chest radiographs in a retrospective real-world UK population

OBJECTIVES

Early identification of lung cancer on chest radiographs improves patient outcomes. Artificial intelligence (AI) tools may increase diagnostic accuracy and streamline this pathway. This study evaluated the performance of commercially available AI-based software trained to identify cancerous lung nodules on chest radiographs.

DESIGN

This retrospective study included primary care chest radiographs acquired in a UK centre. The software evaluated each radiograph independently and outputs were compared with two reference standards: (1) the radiologist report and (2) the diagnosis of cancer by multidisciplinary team decision. Failure analysis was performed by interrogating the software marker locations on radiographs.

PARTICIPANTS

5722 consecutive chest radiographs were included from 5592 patients (median age 59 years, 53.8% women, 1.6% prevalence of cancer).

RESULTS

Compared with radiologist reports for nodule detection, the software demonstrated sensitivity 54.5% (95% CI 44.2% to 64.4%), specificity 83.2% (82.2% to 84.1%), positive predictive value (PPV) 5.5% (4.6% to 6.6%) and negative predictive value (NPV) 99.0% (98.8% to 99.2%). Compared with cancer diagnosis, the software demonstrated sensitivity 60.9% (50.1% to 70.9%), specificity 83.3% (82.3% to 84.2%), PPV 5.6% (4.8% to 6.6%) and NPV 99.2% (99.0% to 99.4%). Normal or variant anatomy was misidentified as an abnormality in 69.9% of the 943 false positive cases.

CONCLUSIONS

The software demonstrated considerable underperformance in this real-world patient cohort. Failure analysis suggested a lack of generalisability in the training and testing datasets as a potential factor. The low PPV carries the risk of over-investigation and limits the translation of the software to clinical practice. Our findings highlight the importance of training and testing software in representative datasets, with broader implications for the implementation of AI tools in imaging.

Non-invasive detection of severe PH in lung disease using magnetic resonance imaging

Introduction

Severe pulmonary hypertension (mean pulmonary artery pressure ≥35 mmHg) in chronic lung disease (PH-CLD) is associated with high mortality and morbidity. Data suggesting potential response to vasodilator therapy in patients with PH-CLD is emerging. The current diagnostic strategy utilises transthoracic Echocardiography (TTE), which can be technically challenging in some patients with advanced CLD. The aim of this study was to evaluate the diagnostic role of MRI models to diagnose severe PH in CLD.

Methods

167 patients with CLD referred for suspected PH who underwent baseline cardiac MRI, pulmonary function tests and right heart catheterisation were identified. In a derivation cohort (n = 67) a bi-logistic regression model was developed to identify severe PH and compared to a previously published multiparameter model (Whitfield model), which is based on interventricular septal angle, ventricular mass index and diastolic pulmonary artery area. The model was evaluated in a test cohort.

Results

The CLD-PH MRI model [= (-13.104) + (13.059 * VMI)-(0.237 * PA RAC) + (0.083 * Systolic Septal Angle)], had high accuracy in the test cohort (area under the ROC curve (0.91) (p < 0.0001), sensitivity 92.3%, specificity 70.2%, PPV 77.4%, and NPV 89.2%. The Whitfield model also had high accuracy in the test cohort (area under the ROC curve (0.92) (p < 0.0001), sensitivity 80.8%, specificity 87.2%, PPV 87.5%, and NPV 80.4%.

Conclusion

The CLD-PH MRI model and Whitfield model have high accuracy to detect severe PH in CLD, and have strong prognostic value.

Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair

OBJECTIVE

The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively.

METHODS

A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment.

RESULTS

Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results.

CONCLUSIONS

EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.

Quantitative CT Evaluation of Small Pulmonary Vessels Has Functional and Prognostic Value in Pulmonary Hypertension

Background The in vivo relationship between peel pulmonary vessels, small pulmonary vessels, and pulmonary hypertension (PH) is not fully understood. Purpose To quantitatively assess peel pulmonary vessel volumes (PPVVs) and small pulmonary vessel volumes (SPVVs) as estimated from CT pulmonary angiography (CTPA) in different subtypes of PH compared with controls, their relationship to pulmonary function and right heart catheter metrics, and their prognostic value. Materials and Methods In this retrospective single-center study performed from January 2008 to February 2018, quantitative CTPA analysis of total SPVV (TSPVV) (0.4- to 2-mm vessel diameter) and PPVV (within 15, 30, and 45 mm from the lung surface) was performed. Results A total of 1823 patients (mean age, 69 years ± 13 [SD]; 1192 women [65%]) were retrospectively analyzed; 1593 patients with PH (mean pulmonary arterial pressure [mPAP], 43 mmHg ± 13 [SD]) were compared with 230 patient controls (mPAP, 19 mm Hg ± 3). The mean vessel volumes in pulmonary peels at 15-, 30-, and 45-mm depths were higher in pulmonary arterial hypertension (PAH) and PH secondary to lung disease compared with chronic thromboembolic PH (45-mm peel, mean difference: 6.4 mL [95% CI: 1, 11] [P < .001] vs 6.8 mL [95% CI: 1, 12] [P = .01]). Mean small vessel volumes at a diameter of less than 2 mm were lower in PAH and PH associated with left heart disease compared with controls (1.6-mm vessels, mean difference: -4.3 mL [95% CI: -8, -0.1] [P = .03] vs -6.8 mL [95% CI: -11, -2] [P < .001]). In patients with PH, the most significant positive correlation was noted with forced vital capacity percentage predicted (r = 0.30-0.40 [all P < .001] for TSPVVs and r = 0.21-0.25 [all P < .001] for PPVVs). Conclusion The volume of pulmonary small vessels is reduced in pulmonary arterial hypertension and pulmonary hypertension (PH) associated with left heart disease, with similar volume of peel vessels compared with controls. For chronic thromboembolic PH, the volume of peel vessels is reduced. In PH, small pulmonary vessel volume is associated with pulmonary function tests. Clinical trial registration no. NCT02565030 Published under a CC BY 4.0 license Online supplemental material is available for this article.

Validation of Artificial Intelligence Cardiac MRI Measurements: Relationship to Heart Catheterization and Mortality Prediction

Background Cardiac MRI measurements have diagnostic and prognostic value in the evaluation of cardiopulmonary disease. Artificial intelligence approaches to automate cardiac MRI segmentation are emerging but require clinical testing. Purpose To develop and evaluate a deep learning tool for quantitative evaluation of cardiac MRI functional studies and assess its use for prognosis in patients suspected of having pulmonary hypertension. Materials and Methods A retrospective multicenter and multivendor data set was used to develop a deep learning-based cardiac MRI contouring model using a cohort of patients suspected of having cardiopulmonary disease from multiple pathologic causes. Correlation with same-day right heart catheterization (RHC) and scan-rescan repeatability was assessed in prospectively recruited participants. Prognostic impact was assessed using Cox proportional hazard regression analysis of 3487 patients from the ASPIRE (Assessing the Severity of Pulmonary Hypertension In a Pulmonary Hypertension Referral Centre) registry, including a subset of 920 patients with pulmonary arterial hypertension. The generalizability of the automatic assessment was evaluated in 40 multivendor studies from 32 centers. Results The training data set included 539 patients (mean age, 54 years ± 20 [SD]; 315 women). Automatic cardiac MRI measurements were better correlated with RHC parameters than were manual measurements, including left ventricular stroke volume (r = 0.72 vs 0.68; P = .03). Interstudy repeatability of cardiac MRI measurements was high for all automatic measurements (intraclass correlation coefficient range, 0.79-0.99) and similarly repeatable to manual measurements (all paired t test P > .05). Automated right ventricle and left ventricle cardiac MRI measurements were associated with mortality in patients suspected of having pulmonary hypertension. Conclusion An automatic cardiac MRI measurement approach was developed and tested in a large cohort of patients, including a broad spectrum of right ventricular and left ventricular conditions, with internal and external testing. Fully automatic cardiac MRI assessment correlated strongly with invasive hemodynamics, had prognostic value, were highly repeatable, and showed excellent generalizability. Clinical trial registration no. NCT03841344 Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Ambale-Venkatesh and Lima in this issue. An earlier incorrect version appeared online. This article was corrected on June 27, 2022.

Right ventricular remodelling in pulmonary arterial hypertension predicts treatment response

OBJECTIVES

To determine the prognostic value of patterns of right ventricular adaptation in patients with pulmonary arterial hypertension (PAH), assessed using cardiac magnetic resonance (CMR) imaging at baseline and follow-up.

METHODS

Patients attending the Sheffield Pulmonary Vascular Disease Unit with suspected pulmonary hypertension were recruited into the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral Centre) Registry. With exclusion of congenital heart disease, consecutive patients with PAH were followed up until the date of census or death. Right ventricular end-systolic volume index adjusted for age and sex and ventricular mass index were used to categorise patients into four different volume/mass groups: low-volume-low-mass, low-volume-high-mass, high-volume-low-mass and high-volume-high-mass. The prognostic value of the groups was assessed with one-way analysis of variance and Kaplan-Meier plots. Transition of the groups was studied.

RESULTS

A total of 505 patients with PAH were identified, 239 (47.3%) of whom have died at follow-up (median 4.85 years, IQR 4.05). The mean age of the patients was 59±16 and 161 (32.7%) were male. Low-volume-low-mass was associated with CMR and right heart catheterisation metrics predictive of improved prognosis. There were 124 patients who underwent follow-up CMR (median 1.11 years, IQR 0.78). At both baseline and follow-up, the high-volume-low-mass group had worse prognosis than the low-volume-low-mass group (p<0.001). With PAH therapy, 73.5% of low-volume-low-mass patients remained in this group, whereas only 17.4% of high-volume-low-mass patients transitioned into low-volume-low-mass.

CONCLUSIONS

Right ventricular adaptation assessed using CMR has prognostic value in patients with PAH. Patients with maladaptive remodelling (high-volume-low-mass) are at high risk of treatment failure.

Machine learning cardiac-MRI features predict mortality in newly diagnosed pulmonary arterial hypertension

Aims

Pulmonary arterial hypertension (PAH) is a rare but serious disease associated with high mortality if left untreated. This study aims to assess the prognostic cardiac magnetic resonance (CMR) features in PAH using machine learning.

Methods and results

Seven hundred and twenty-three consecutive treatment-naive PAH patients were identified from the ASPIRE registry; 516 were included in the training, and 207 in the validation cohort. A multilinear principal component analysis (MPCA)-based machine learning approach was used to extract mortality and survival features throughout the cardiac cycle. The features were overlaid on the original imaging using thresholding and clustering of high- and low-risk of mortality prediction values. The 1-year mortality rate in the validation cohort was 10%. Univariable Cox regression analysis of the combined short-axis and four-chamber MPCA-based predictions was statistically significant (hazard ratios: 2.1, 95% CI: 1.3, 3.4, c-index = 0.70, P = 0.002). The MPCA features improved the 1-year mortality prediction of REVEAL from c-index = 0.71 to 0.76 (P ≤ 0.001). Abnormalities in the end-systolic interventricular septum and end-diastolic left ventricle indicated the highest risk of mortality.

Conclusion

The MPCA-based machine learning is an explainable time-resolved approach that allows visualization of prognostic cardiac features throughout the cardiac cycle at the population level, making this approach transparent and clinically interpretable. In addition, the added prognostic value over the REVEAL risk score and CMR volumetric measurements allows for a more accurate prediction of 1-year mortality risk in PAH.

Severe pulmonary hypertension associated with lung disease is characterised by a loss of small pulmonary vessels on quantitative computed tomography

Background

Pulmonary hypertension (PH) in patients with chronic lung disease (CLD) predicts reduced functional status, clinical worsening and increased mortality, with patients with severe PH-CLD (≥35 mmHg) having a significantly worse prognosis than mild to moderate PH-CLD (21-34 mmHg). The aim of this cross-sectional study was to assess the association between computed tomography (CT)-derived quantitative pulmonary vessel volume, PH severity and disease aetiology in CLD.

Methods

Treatment-naïve patients with CLD who underwent CT pulmonary angiography, lung function testing and right heart catheterisation were identified from the ASPIRE registry between October 2012 and July 2018. Quantitative assessments of total pulmonary vessel and small pulmonary vessel volume were performed.

Results

90 patients had PH-CLD including 44 associated with COPD/emphysema and 46 with interstitial lung disease (ILD). Patients with severe PH-CLD (n=40) had lower small pulmonary vessel volume compared to patients with mild to moderate PH-CLD (n=50). Patients with PH-ILD had significantly reduced small pulmonary blood vessel volume, compared to PH-COPD/emphysema. Higher mortality was identified in patients with lower small pulmonary vessel volume.

Conclusion

Patients with severe PH-CLD, regardless of aetiology, have lower small pulmonary vessel volume compared to patients with mild-moderate PH-CLD, and this is associated with a higher mortality. Whether pulmonary vessel changes quantified by CT are a marker of remodelling of the distal pulmonary vasculature requires further study.

CMR Measures of Left Atrial Volume Index and Right Ventricular Function Have Prognostic Value in Chronic Thromboembolic Pulmonary Hypertension

Providing prognostic information is important when counseling patients and planning treatment strategies in chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to assess the prognostic value of gold standard imaging of cardiac structure and function using cardiac magnetic resonance imaging (CMR) in CTEPH. Consecutive treatment-naive patients with CTEPH who underwent right heart catheterization and CMR between 2011 and 2017 were identified from the ASPIRE (Assessing-the-Specturm-of-Pulmonary-hypertensIon-at-a-REferral-center) registry. CMR metrics were corrected for age and sex where appropriate. Univariate and multivariate regression models were generated to assess the prognostic ability of CMR metrics in CTEPH. Three hundred and seventy-five patients (mean+/-standard deviation: age 64+/-14 years, 49% female) were identified and 181 (48%) had pulmonary endarterectomy (PEA). For all patients with CTEPH, left-ventricular-stroke-volume-index-%predicted (LVSVI%predicted) (p = 0.040), left-atrial-volume-index (LAVI) (p = 0.030), the presence of comorbidities, incremental shuttle walking test distance (ISWD), mixed venous oxygen saturation and undergoing PEA were independent predictors of mortality at multivariate analysis. In patients undergoing PEA, LAVI (p < 0.010), ISWD and comorbidities and in patients not undergoing surgery, right-ventricular-ejection-fraction-%predicted (RVEF%pred) (p = 0.040), age and ISWD were independent predictors of mortality. CMR metrics reflecting cardiac function and left heart disease have prognostic value in CTEPH. In those undergoing PEA, LAVI predicts outcome whereas in patients not undergoing PEA RVEF%pred predicts outcome. This study highlights the prognostic value of imaging cardiac structure and function in CTEPH and the importance of considering left heart disease in patients considered for PEA.

Imaging and Risk Stratification in Pulmonary Arterial Hypertension: Time to Include Right Ventricular Assessment

Background

Current European Society of Cardiology and European Respiratory Society guidelines recommend regular risk stratification with an aim of treating patients with pulmonary arterial hypertension (PAH) to improve or maintain low-risk status (<5% 1-year mortality).

Methods

Consecutive patients with PAH who underwent cardiac magnetic resonance imaging (cMRI) were identified from the Assessing the Spectrum of Pulmonary hypertension Identified at a Referral centre (ASPIRE) registry. Kaplan-Meier survival curves, locally weighted scatterplot smoothing regression and multi-variable logistic regression analysis were performed.

Results

In 311 consecutive, treatment-naïve patients with PAH undergoing cMRI including 121 undergoing follow-up cMRI, measures of right ventricular (RV) function including right ventricular ejection fraction (RVEF) and RV end systolic volume and right atrial (RA) area had prognostic value. However, only RV metrics were able to identify a low-risk status. Age (p < 0.01) and RVEF (p < 0.01) but not RA area were independent predictors of 1-year mortality.

Conclusion

This study highlights the need for guidelines to include measures of RV function rather than RA area alone to aid the risk stratification of patients with PAH.

Capacity planning for acute hospital inpatient care and adult critical care in England: a descriptive study using hospital administrative data

Background

At the beginning of the COVID-19 pandemic in March and April, 2020, there was a focus on accommodating an anticipated surge of patients with COVID-19 in acute hospitals. We aimed to estimate the potential for freeing up capacity in acute hospitals in England.

Methods

In this descriptive study, we used admitted patient and adult critical care records from Hospital Episode Statistics (a database containing details of attendances at National Health Service acute hospitals in England) from 2018/19 to estimate historical numbers of inpatients. Each admission was grouped into emergency, maternity, and elective, with elective split by the presence or absence of cancer in the primary diagnosis. We further stratified the population by age and frailty, which we estimated with an index using International Statistical Classification of Diseases and Related Health Problems (tenth revision) codes in diagnosis fields. We used the (then current) National Institute for Health and Care Excellence (NICE) 2020 guidance on critical care pathways as a framework to examine four scenarios that limited access to beds for specific patient groups. This study was approved by the Secretary of State and the Health Research Authority under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 to hold confidential data and analyse them for research purposes (CAG ref 15/CAG/0005). We have approval to use these data for research into the quality and safety of health care, from the London–South East Ethics Committee (REC ref 20/LO/0611).

Findings

Between April 1, 2018, and March 31, 2019, 8 957 521 adults were admitted (7 372 040 [82·3%] emergency, 295 598 [3·3%] elective with cancer, 850 964 [9·5%] elective without cancer, and 438 919 [4·9%] maternity admissions), and 974 038 critical care episodes were recorded. Our analysis suggested that up to 70% of all acute inpatient beds could be released if only maternity, cancer, and emergency patients younger than 65 years were admitted; if non-frail patients aged 65 years and older were also admitted, 41% of beds could be freed up. Similarly, if only maternity, cancer, and emergency patients younger than 65 years were admitted to critical care beds, that might free up to 56% of adult critical care beds; if non-frail patients aged 65 years and older were also admitted, 30% of critical care beds could be freed up.

Interpretation

Given a crisis in health-care capacity, it seemed appropriate to model some difficult options based on NICE guidelines. We identified scope for freeing up total acute and critical care beds by postponing elective non-cancer admissions as a short-term measure during the first wave of COVID-19 (March to June, 2020) in England. The NICE guidelines were criticised by patient groups and have since been updated (NG191). Administrative data can inform planning for future crises albeit with limitations on estimating individual patient need, and deep social and ethical considerations. Our estimates were incorporated into a modelling tool for hospital provision during the pandemic.

Funding

Dr Foster Intelligence.

The impact of e-health system implementation on UNWRA health services: an observational study

BACKGROUND

The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary-health-care services to more than 5 million Palestinian refugees in five operational fields (Jordan, Syria, Lebanon, West Bank, and Gaza) through 144 health centres. UNRWA developed its electronic health records (e-Health) system to improve monitoring and facilitation of health services provided to Palestinian refugees. By the end of 2017, the system had been deployed in 129 health centres, included the health files of 3 million patients, and managed more than 8 million visits per year. We assessed whether preventive-health-care services had improved following implementation of the system.

METHODS

This observational study used three key performance indicators to assess preventive-health-care services reported in UNRWA's annual reports in 2012-17: the percentage of targeted people aged 40 years and older screened for diabetes; the percentage of pregnant women with a livebirth who attended at least four antenatal visits; and the prevalence of growth problems (underweight, stunting, wasting, and overweight or obesity) in children younger than 5 years. Simple descriptive analysis was conducted with Microsoft Excel 2010. Ethical approval was obtained from the UNRWA Headquarters Department of Health.

FINDINGS

Screening for diabetes significantly increased from 13% in 2012 to 21% in 2017 (p<0·0001) since the e-Health system started sending alerts to clerks at health centres. The percentage of pregnant women with a livebirth who attended at least four antenatal visits, increased from 87% in 2012 to 92% in 2017, when the e-Health System allowed health-care providers to log all pregnant women who missed their appointments to enable follow-up. Additionally, an electronic maternal and child health mobile application, sends regular reminders to mothers about appointments for themselves and their children. The percentages of underweight, stunting, wasting, and overweight or obesity among children younger than 5 years increased respectively from 3%, 4%, 2%, and 2% in 2014 to 5%, 7%, 4%, and 5% in 2017, but this was due to the increased detection of growth problems through the e-Health system.

INTERPRETATION

The e-Health system improved detection and monitoring by UNRWA health-care providers and access to health services for Palestinian refugees in all three indicator categories. This study has several limitations. It is an observational study based on assessing health records of children rather than a prospective study over time. The focus of the study was to assess the impact of the eHealth system on health-care delivery and not to assess the changes in health-care delivery itself. The electronic health records that were reviewed are for the Palestine refugees who are registered at UNRWA health clinics and not for other refugees or residents of the five countries. Strengths of the study are that it is based on electronic health records which contain data recorded by the treating staff; the e-health system used by UNRWA clinics staff is centralised and the data are aggregated agency wide; and the growth monitoring indicators used by UNRWA were derived from the WHO Multi-center Growth Reference Study to assess the growth of children from birth up to age 5 years.

FUNDING

None.

Non-communicable diseases among Palestinian refugees from Syria: a cross-sectional study on prevalence, case management, access to and utilisation of UNRWA Health Services

BACKGROUND

As of Feb 14, 2014, UNRWA had registered almost 53 000 Palestinian refugees from Syria (PRS) who had fled to Lebanon as the result of the conflict in Syria. Half of the PRS had gone to one of the 12 Palestinian camps, which are overcrowded and of poor infrastructure. Consequently, there is concern for the wellbeing of PRS; in particular, their health status and access to medical care. Little attention has been given to non-communicable diseases (NCDs) in the acute phases of emergencies. Therefore, an assessment of the prevalence of NCDs among PRS, as well as the patterns of use of available health care services by PRS, is warranted.

METHODS

A cross-sectional study was conducted in April, 2018, with 1100 PRS residing inside and outside refugee camps across all governorates of Lebanon. A listing of all PRS families was the sampling frame. A random sample of families was selected and contacted, and then one adult randomly selected from each family was approached for data collection. Pregnant women and participants who were too ill to participate were excluded. After obtaining informed verbal consent, we did face-to-face interviews to collect data on household details (such as type of settlement, source of income) and sociodemographic information, major NCDs (for the household representative), lifestyle behaviours, and health-care use. We invited all participants to UNRWA clinics for physical and biochemical measurements. The study protocol was approved by the Institutional Review Board of the American University of Beirut.

FINDINGS

We surveyed 959 PRS (59% male [465], 82% married [785], mean age 43 years [SD 12]). A quarter of those interviewed had at least one NCD; the most prevalent were hypertension (23%; 221 of 959), rheumatic diseases (17%; 166), cardiovascular diseases (CVDs, 13%; 126), diabetes (13%; 124), and chronic respiratory diseases (CRDs) (10%; 100). All these NCDs were more prevalent among PRS inside camps than in those residing outside camps, except for diabetes. Most participants who had been diagnosed with NCDs were adhering to their prescribed medications (90-98%). However, of those reporting CVDs, only 56% (71 of 126) had attended at least one follow-up appointment, and of those reporting rheumatic diseases, only 33% (55 of 166) had attended at least one follow-up appointment. About half of participants reported that they checked their blood pressure (55%; 528 of 959) or blood glucose (45%; 430). 111 of 221 (50%) participants with hypertension monitored their blood pressure, and 78 of 124 (63%) participants with diabetes monitored their blood glucose. 133 participants attended UNRWA clinics for measurements; 40% (54) had obesity (>30 kg/cm²), 10% (13) had elevated blood pressure, 12% (16) had stage 1 hypertension, and 8% (10) had stage 2 hypertension. Most participants had normal glucose (67%; 89 of 133), cholesterol (65%; 87), triglyceride (58%; 77), and glycosylated haemoglobin levels (64; 85). A substantial proportion of participants who were tested had undiagnosed diabetes (14%; 33 of 108 reporting no diabetes), undiagnosed hypertension (23%; 19 of 81), uncontrolled diabetes (79% of participants with diabetes; 19 of 24), or uncontrolled hypertension (64% of participants with hypertension; 29 of 45).

INTERPRETATION

Further study is needed to understand why the prevalence of NCDs among PRS residing in Palestinian camps is higher than among those living outside, and to understand whether and why access to medicines is a problem, particularly outside camps. The burden of NCDs among PRS is high and their access to services is not optimal; therefore UNRWA should pay special attention to NCD services in this population. UNRWA should invest in efforts to increase awareness of free blood pressure and blood glucose monitoring services in its clinics, and could actively offer free testing in public areas inside camps. Doctors at UNRWA clinics should recommend that patients monitor their disease more frequently and educate them on how to do so. A limitation of the study was the low percentage of participants who attended UNRWA clinics for physical and biochemical measurements.

FUNDING

UNRWA.

Myocardial T1-mapping and extracellular volume in pulmonary arterial hypertension: A systematic review and meta-analysis

INTRODUCTION

Elevated myocardial T₁-mapping and extracellular volume (ECV) measured on cardiac MR (CMR) imaging is associated with myocardial abnormalities such as oedema or fibrosis. This meta-analysis aims to provide a summary of T₁-mapping and ECV values in pulmonary arterial hypertension (PAH) and compare their values with controls.

METHODS

We searched CENTRAL, MEDLINE, Embase, and Web of Science in August 2020. We included CMR studies reporting T₁-mapping or ECV values in adults with any type of PAH. We calculated the mean difference of T₁-values and ECV between PAH and controls.

RESULTS

We included 12 studies with 674 participants. T₁-values were significantly higher in PAH with the highest mean difference (MD) recorded at the RV insertion points (RVIP) (108 milliseconds (ms), 95% confidence intervals (CI) 89 to 128), followed by the RV free wall (MD 91 ms, 95% CI 56 to 126). The pooled mean T₁-value in PAH at the RVIP was 1084, 95% CI (1071 to 1097) measured using 1.5 Tesla Siemens systems. ECV was also higher in PAH with an MD of 7.5%, 95% CI (5.9 to 9.1) at the RV free wall.

CONCLUSION

T₁ mapping values in PAH patients are on average 9% higher than healthy controls when assessed under the same conditions including the same MRI system, magnetic field strength or sequence used for acquisition. The highest T₁ and ECV values are at the RVIP. T₁ mapping and ECV values in PH are higher than the values reported in cardiomyopathies and were associated with poor RV function and RV dilatation.

Repeatability and sensitivity to change of non-invasive end points in PAH: the RESPIRE study

End points that are repeatable and sensitive to change are important in pulmonary arterial hypertension (PAH) for clinical practice and trials of new therapies. In 42 patients with PAH, test–retest repeatability was assessed using the intraclass correlation coefficient and treatment effect size using Cohen’s d statistic. Intraclass correlation coefficients demonstrated excellent repeatability for MRI, 6 min walk test and log to base 10 N-terminal pro-brain natriuretic peptide (log₁₀NT-proBNP). The treatment effect size for MRI-derived right ventricular ejection fraction was large (Cohen’s d 0.81), whereas the effect size for the 6 min walk test (Cohen’s d 0.22) and log₁₀NT-proBNP (Cohen’s d 0.20) were fair. This study supports further evaluation of MRI as a non-invasive end point for clinical assessment and PAH therapy trials.

Trial registration number NCT03841344.

Patterns of thromboembolic pulmonary vascular disease in COVID-19

SARS-CoV-2 (COVID-19) is associated with increased thrombosis. Here, we demonstrate patterns of pulmonary vascular disease in COVID-19 including classical acute pulmonary embolism and subsegmental perfusion defects in the absence of acute pulmonary embolism suggestive of microvascular thrombosis.

Cardiac Magnetic Resonance in Pulmonary Hypertension-an Update

PURPOSE OF REVIEW

This article reviews advances over the past 3 years in cardiac magnetic resonance (CMR) imaging in pulmonary hypertension (PH). We aim to bring the reader up-to-date with CMR applications in diagnosis, prognosis, 4D flow, strain analysis, T1 mapping, machine learning and ongoing research.

RECENT FINDINGS

CMR volumetric and functional metrics are now established as valuable prognostic markers in PH. This imaging modality is increasingly used to assess treatment response and improves risk stratification when incorporated into PH risk scores. Emerging techniques such as myocardial T1 mapping may play a role in the follow-up of selected patients. Myocardial strain may be used as an early marker for right and left ventricular dysfunction and a predictor for mortality. Machine learning has offered a glimpse into future possibilities. Ongoing research of new PH therapies is increasingly using CMR as a clinical endpoint.

SUMMARY

The last 3 years have seen several large studies establishing CMR as a valuable diagnostic and prognostic tool in patients with PH, with CMR increasingly considered as an endpoint in clinical trials of PH therapies. Machine learning approaches to improve automation and accuracy of CMR metrics and identify imaging features of PH is an area of active research interest with promising clinical utility.

Cardiac-MRI Predicts Clinical Worsening and Mortality in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis

Objectives

This meta-analysis evaluates assessment of pulmonary arterial hypertension (PAH), with a focus on clinical worsening and mortality.

Background

Cardiac magnetic resonance (CMR) has prognostic value in the assessment of patients with PAH. However, there are limited data on the prediction of clinical worsening, an important composite endpoint used in PAH therapy trials.

Methods

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Web of Science databases were searched in May 2020. All CMR studies assessing clinical worsening and the prognosis of patients with PAH were included. Pooled hazard ratios of univariate regression analyses for CMR measurements, for prediction of clinical worsening and mortality, were calculated.

Results

Twenty-two studies with 1,938 participants were included in the meta-analysis. There were 18 clinical worsening events and 8 deaths per 100 patient-years. The pooled hazard ratios show that every 1% decrease in right ventricular (RV) ejection fraction is associated with a 4.9% increase in the risk of clinical worsening over 22 months of follow-up and a 2.1% increase in the risk of death over 54 months. For every 1 ml/m² increase in RV end-systolic volume index or RV end-diastolic volume index, the risk of clinical worsening increases by 1.3% and 1%, respectively, and the risk of mortality increases by 0.9% and 0.6%. Every 1 ml/m² decrease in left ventricular stroke volume index or left ventricular end-diastolic volume index increased the risk of death by 2.5% and 1.8%. Left ventricular parameters were not associated with clinical worsening.

Conclusions

This review confirms CMR as a powerful prognostic marker in PAH in a large cohort of patients. In addition to confirming previous observations that RV function and RV and left ventricular volumes predict mortality, RV function and volumes also predict clinical worsening. This study provides a strong rationale for considering CMR as a clinically relevant endpoint for trials of PAH therapies.

Assessment of the knowledge, attitudes, and practices (KAP) among UNRWA* health staff in Jordan concerning mental health programme pre-implementation: a cross-sectional study

BACKGROUND

Mental health is a major public health priority, especially among refugees. The United Nations Relief and Works Agency for Palestine Refugees (UNRWA) started to integrate mental health and psychosocial support (MHPSS) into its primary healthcare services in Jordan in late 2017. In this study, we aimed to assess of the knowledge, attitudes, and practices (KAP) among UNRWA health staff (HS) in Jordan concerning mental health programme pre-implementation, and their perceived barriers about this MHPSS programme.

METHODS

A cross-sectional study was conducted among doctors, dentists, nurses, and midwives who work at 16 of the 25 UNRWA health centres in Jordan. The assessment was made using a validated self-administered questionnaire. Data analysis was performed using SPSS (version 22).

RESULTS

Of the participants, 73% (161 of 220) believed that their knowledge of MHPSS programmes was insufficient, with no significant difference (p = 0·116) between different categories of staff. Furthermore, 88% (194 of 220) said that they needed more training, 67% (147 of 220) reported that the number of mental health cases is increasing, and 50% (110 of 220) that dealing with these cases is difficult. Reflecting on the past 12 months, 31% of staff (69 out of 220) reported meeting between one and ten children, and 45% (100 out of 220) reported meeting between one and ten adults suspected of having mental illnesses. The most suspected condition was depression (84%; 150 of 220), followed by epilepsy (64%; 140 of 220). The main perceived barriers to implementation included the limited availability of MHPSS policies (87%; 192 of 220), MH professionals (86%; 190 of 220), resources (86%; 189 out of 220), and lack of privacy (14%; 31 out of 220).

CONCLUSIONS

Most health staff had positive attitudes towards MHPSS programme implementation but felt they lacked the required knowledge. There is a need for training and clear technical guidelines. Perceived barriers to MHPSS programme implementation were consistent with the previous studies and need to be tackled with a structured plan of action.

OP0024 USE OF HYDROXYCHLOROQUINE AND RISK OF HEART FAILURE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Hydroxychloroquine (HCQ) is a disease-modifying anti-rheumatic drug (DMARD) used as a long-term treatment for rheumatoid arthritis (RA) patients. Cardiotoxicity is a rare but potentially life-threatening side effect of HCQ and may present as conduction disorders, cardiomyopathy, and resulting heart failure (HF). The evidence of cardiotoxicity associated with the use of HCQ largely relies on case reports and case series while large cohort studies on the subject are lacking.

Objectives:

To examine the relationship between the use of HCQ and risk of developing HF in RA.

Methods:

In this nested case-control study, cases were Olmsted county, Minnesota residents with incident RA (based on 1987 ACR criteria) in 1980-2013 who developed HF after RA incidence. Each case was matched on year of birth, sex and year of RA incidence with an RA control who did not develop HF. Each non-HF control was assigned an index date corresponding to the HF diagnosis date of the case. Controls were allowed to later become cases to avoid bias. HF was defined using the Framingham criteria. Data on HCQ use including start and stop dates and dose changes was manually abstracted via medical record review, and used to calculate HCQ duration and cumulative dose. Age-adjusted logistic regression models were used to examine the association between HCQ and HF.

Results:

From a cohort of 1078 subjects, the study identified 143 RA cases diagnosed with HF (mean age 65.8, 62% females) and 143 non-HF RA controls (mean age 64.5, 62% female). Cases and controls had similar RA duration, proportion of patients positive for rheumatoid factor (RF) and/ or cyclic citrullinated antibody (CCP), body mass index, and smoking status (Table). The duration of HCQ use prior to the diagnosis of HF was 2.8 years in cases and 2.6 years in controls. A total of 71 cases and 69 controls used HCQ at some time before index date. Among these, the median (interquartile range) duration of HCQ use was 2.8 (0.6, 10.0) years for cases and 2.5 (0.7, 8.2) for controls. The median cumulative dose of HCQ was 371 g and 302 g in cases and controls, respectively, with 55% of cases receiving a cumulative dose of ≥ 300 g compared to 54% in controls. HCQ cumulative dose was not associated with HF (Odds Ratio [OR]: 0.96 per 100g increase in cumulative dose, 95% confidence interval [95% CI]: 0.90-1.03). Likewise, no association was found for patients with a cumulative dose ≥300g (OR 0.92, 95% CI 0.41-2.08). The duration of use of HCQ prior to index was not associated with HF (OR 0.98, 95% CI 0.91-1.05). Retinal toxicity rates were similar in cases and controls.

Table 1.

Characteristics of patients with rheumatoid arthritis with and without heart failure.

VariableHFnon-HFAge at RA diagnosis (years)65.8 ± 12.364.5 ± 12.5Female62%62%RA duration at baseline (years)11.3 ± 8.510.3 ± 8.2RF positive66%65%CCP positive46%53%RF/ CCP positive68%66%BMI (at RA diagnosis)28.6 ± 6.527.7 ± 5.4Smoking status at RA incidenceFormer45%41%Current22%22%

Conclusion:

Use of HCQ was not associated with development of HF in patients with RA in this study. While there was no statistically significant association between the cumulative dose of HCQ and HF, the confidence interval for HCQ dose ≥300 g was wide suggesting that more studies are needed to understand the impact of higher doses of HCQ on development of HF in RA.

Disclosure of Interests:

Ahmed Sorour: None declared, Youssef Shahin: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, Reto Kurmann: None declared, Sara Achenbach: None declared, Rekha Mankad: None declared, Elena Myasoedova: None declared

Diagnostic accuracy of CT pulmonary angiography in suspected pulmonary hypertension

Objectives

Computed tomography (CT) pulmonary angiography is widely used in patients with suspected pulmonary hypertension (PH). However, the diagnostic and prognostic significance remains unclear. The aim of this study was to (a) build a diagnostic CT model and (b) test its prognostic significance.

Methods

Consecutive patients with suspected PH undergoing routine CT pulmonary angiography and right heart catheterisation (RHC) were identified. Axial and reconstructed images were used to derive CT metrics. Multivariate regression analysis was performed in the derivation cohort to identify a diagnostic CT model to predict mPAP ≥ 25 mmHg (the existing ESC guideline definition of PH) and > 20 mmHg (the new threshold proposed at the 6th World Symposium on PH). In the validation cohort, sensitivity, specificity and compromise CT thresholds were identified with receiver operating characteristic (ROC) analysis. The prognostic value of the CT model was assessed using Kaplan-Meier analysis.

Results

Between 2012 and 2016, 491 patients were identified. In the derivation cohort (n = 247), a CT model was identified including pulmonary artery diameter, right ventricular outflow tract thickness, septal angle and left ventricular area. In the validation cohort (n = 244), the model was diagnostic, with an area under the ROC curve of 0.94/0.91 for mPAP ≥ 25/> 20 mmHg respectively. In the validation cohort, 93 patients died; mean follow-up was 42 months. The diagnostic thresholds for the CT model were prognostic, log rank, all p < 0.01.

Discussion

In suspected PH, a diagnostic CT model had diagnostic and prognostic utility.

Key Points

• Diagnostic CT models have high diagnostic accuracy in a tertiary referral population of with suspected PH.

• Diagnostic CT models stratify patients by mortality in suspected PH.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06846-1) contains supplementary material, which is available to authorized users.

Perioperative, Postoperative, and Long-Term Outcomes Following Open Surgical Repair of Ruptured Abdominal Aortic Aneurysm

We investigated factors that affected perioperative, postoperative, and long-term outcomes of patients who underwent open emergency surgical repair of ruptured abdominal aortic aneurysms (RAAA). All patients who underwent open emergency surgical repair from 1990 to 2011 were included (463 patients; 374 [81%] male; mean age 74.7 ± 8.7years). Logistic and Cox regression analyses were performed to explore the association of variables with outcomes. Preoperatively, median (interquartile range) hemoglobin was 11.2 (9.5-12.8) g/dL, and median creatinine level was 140 (112-177) µmol/L. Intraoperatively, the median operative time was 2.25 (2-3) hours, and median estimated blood loss was 1.5 (0.5-3) L; 250 (54%) patients required intraoperative inotropes, and a median of 6 (4-8) units of blood was transfused. Median length of hospital stay was 11 (7-20) days. In-hospital mortality rate was 35.6%, and 5-year mortality was 48%. Age, distance traveled, operation duration, postoperative myocardial infarction (MI), and multi-organ failure (MOF) were predictors of in-hospital mortality and long-term outcome. Additionally, postoperative acute renal failure predicted in-hospital mortality. In patients with RAAA undergoing open surgical repair, the strongest predictors of in-hospital mortality and long-term outcome were postoperative MOF and MI and operative duration.

IodiNe Subtraction mapping in the diagnosis of Pulmonary chronIc thRomboEmbolic disease (INSPIRE): Rationale and methodology of a cross-sectional observational diagnostic study

Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe but treatable disease that is commonly underdiagnosed. Computed tomography lung subtraction iodine mapping (CT-LSIM) in addition to standard CT pulmonary angiography (CTPA) may improve the evaluation of suspected chronic pulmonary embolism and improve the diagnostic pick up rate. We aim to recruit 100 patients suspected of having CTEPH and perform CT-LSIM scans in addition to the current gold standard test of nuclear medicine test (lung single photon emission computed tomography (SPECT) imaging) as a pilot study which will contribute to and inform the definitive trial. The diagnostic accuracy of CT-LSIM and lung SPECT will be compared. The primary outcome of the full definitive study is non-inferiority of CT-LSIM versus lung SPECT imaging.

Model to improve cardiometabolic risk factors in Palestine refugees with diabetes mellitus attending UNRWA health centers

Introduction The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is the main primary healthcare provider and provides assistance and protection to around 5 million Palestine refugees in Jordan, Lebanon, Syria, West Bank and Gaza. Diabetes mellitus (DM) is a common problem among Palestine refugees, with a prevalence of 11.0%. In 2014, UNRWA embarked on a diabetes campaign to assist both patients with DM and staff in improving diabetes care management, by building the capacity of UNRWA's health staff and improving the knowledge and lifestyle behaviors among Palestine refugees with DM. Method Using a quasiexperimental study, we randomly selected 50 patients with diabetes from the 32 largest UNRWA health centers (HC); a total of 1600 participants were enrolled. Each HC conducted weekly group sessions for 6 months, including education, healthy cooking, and physical exercise. Body measurements, 2-hour postprandial glucose test, blood pressure and session attendance were collected on a weekly basis. Demographical data, pre/postquestionnaires and cholesterol levels were collected before and after the campaign. Paired t-test in SPSS V.21 was used. Results Out of 1600 patients, 1598 (1186 (74.0%) females and 412 (26.0%) males) completed the campaign; 576 (36.0%) patients had diabetes type 2 (DMII), 960 (60.0%) had DMII and hypertension and 62 (4.0%) had diabetes type 1 (DMI). After the campaign, the average weight loss was 2.6 kg (95% CI 2.4 to 2.7). In addition, 22% lost ≥5%, 25% lost 3%-5%, and 30% lost 1%-3% of their weight. Significant improvements were seen in blood glucose, cholesterol and waist circumference (WC) (p≤0.001 for all). The session attendance rate was 70.6% in total. Conclusions This campaign focused on raising healthy lifestyle awareness and practices among Palestine refugees with DM. It was associated with reduction cardiometabolic risk factors. Similar campaigns need to be sustained and expanded. Local community and non-governmental organization partnerships observed during the campaign should be strengthened and sustained.

Health and dignity of Palestine refugees at stake: a need for international response to sustain crucial life services at UNRWA

The UN Sustainable Development Goals affirm equality and dignity as essential to the enjoyment of basic human rights, including the right to the highest attainable standard of physical and mental health, which promotes global solidarity among all people, including refugees. The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has provided support to Palestine refugees in Jordan, Lebanon, Syria, the Gaza Strip, and the West Bank since the 1950s. Today, however, conflict and violence, occupation, high levels of poverty, and other social determinants of health jeopardize the wellbeing of Palestine refugees. Health concerns include non-communicable diseases, mental health conditions, and access to hospital care. Additionally, UNRWA is continuing to face a severe funding crisis. Using a historical and health policy perspective, this Health Policy examines UNRWA strategies that facilitate continuous provision of health-care services for Palestine refugees. Given the increasingly volatile environment faced by this population, a multifaceted international response is needed to enable UNRWA to deliver sustainable services to Palestine refugees and avert further loss of life, dignity, and hope, pending a just and lasting solution to their plight in accordance with applicable international law and UN General Assembly resolutions.

Development and Deployment of an e-Health System in UNRWA Healthcare Centers (HCs): The Experience and Evidence

UNRWA recognized the need to develop and introduce eHealth programme based on needs assessment. The web-based e-Health application was developed and deployed in 116 out of 143 HCs in the five fields of operation. Evaluation of the application revealed positive outcomes in terms of reporting requirements, statistics, time saving, efficiency, drug compliance and workflow in general.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Diabetes mellitus and treatment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan

SETTING

Six primary health care clinics in Jordan, serving Palestine refugees diagnosed with diabetes mellitus (DM).

OBJECTIVES

To report on the number and characteristics of new DM patients registered in the second quarter of 2013 and of all DM patients ever registered by 30 June 2013, with treatment outcomes and cumulative burden of late-stage complications.

DESIGN

A descriptive cohort study using routine data collected through e-Health.

RESULTS

Of the 288 new patients in Q2 2013 and 12 548 patients ever registered with DM by 30 June 2013, smoking, physical inactivity and obesity were recorded in 19%, 50% and 47%, respectively. In Q2 2013, 9740 (78%) patients attended a clinic, with >99% having undergone disease control measures: of these, 72% had postprandial blood glucose ⩽ 180 mg/dl, 71% had blood cholesterol < 200 mg/dl, 82% had blood pressure < 140/90 and 40% had body mass index < 30 kg/m(2). Late-stage complications were present in 1130 (11.6%) patients who attended a clinic, with cardiovascular disease and stroke being the most common. Several differences in outcomes were found between males and females.

CONCLUSION

There is a high burden of disease due to DM at primary health care clinics in Jordan. Cohort analysis using e-Health is a vital way to assess management and follow-up.

Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012

Objectives

The purpose of this study is to describe trends in the utilization of antihypertensive medications, overall and by type of medication, specifically thiazide diuretics, as well as uncontrolled hypertension, in the Palestine refugee population in Jordan between 2008 and 2012.

Methods

We analyzed aggregate procurement data on antihypertensive medications derived from the United Nations Relief and Works Agency (UNRWA) pharmacy records between 2008 and 2012. Antihypertensive medications were aggregated and utilization was calculated overall and for specific types of antihypertensive medications (e.g. β-blockers, diuretics). We used the WHO (World Health Organization) defined daily dose (DDD) methodology, often used to evaluate drug utilization patterns using aggregate data, to calculate utilization defined as DDDs per 100 persons with hypertension. In addition, UNRWA medical records were used to measure the prevalence of uncontrolled hypertension in the primary care setting. Uncontrolled hypertension was defined as a systolic/diastolic blood pressure ≥140/90 in at least 2 out of 3 readings, one of which is the most recent reading, during the year for a patient diagnosed with hypertension.

Results

Overall, total utilization of antihypertensive medications has not changed between 2008 and 2012; hypertensive patients persistently used at least 2 antihypertensive medications daily (range 200–280 DDDs/100 patients with hypertension) during this five-year period. However, there is significant variation in utilization patterns by type of antihypertensive medication. While Angiotensin Converting Enzyme Inhibitors (ACE-I) were persistently the most commonly used antihypertensive medication, there utilization significantly (P < 0.05) declined by 26%. However, there was a statistically significant increase of 124% in the utilization of thiazide diuretics. Further, the prevalence of uncontrolled hypertension has also declined at a rate of 3% annually between 2008 and 2012.

Conclusion

Our findings indicate that the STGs for hypertension management implemented in 2009 as part of UNRWA's essential drug program have increased the utilization of thiazide diuretics, and potentially contributed to improvements in hypertension control. This study also demonstrates that feasibility of drug utilization studies in monitoring and evaluating trends in the use of essential medications in low-resource settings.

Diabetes care in refugee camps: the experience of UNRWA

United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) was established in 1949 and has delivered health care services for over 65 years. The epidemiological transition in disease burden is changing the context in which UNRWA's health programme operates and poses new challenges that require new ways of providing health services. Hypertension and diabetes are two major health problems for Palestine refugees. UNRWA has been providing diabetes and hypertension care since 1992 in its primary health care centres. Of late, through a structured process of care delivery the UNRWA health system is making significant strides in addressing diabetes and hypertension and consequently the nine voluntary global targets as envisaged in the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020. Given that most developing countries either have no or only rudimentary services for diabetes and hypertension at the primary care level and may face similar resource and capacity constraints, UNRWA's efforts can serve as a model and inspiration to set up similar initiatives.

Supervised exercise program improves aerobic fitness in patients awaiting abdominal aortic aneurysm repair

BACKGROUND

Aerobic fitness is an important predictor of postoperative outcome in major surgery. In this study, we assess the effects of a period of preoperative exercise on aerobic fitness as measured by cardiopulmonary exercise testing (CPET) in patients scheduled for abdominal aortic aneurysm (AAA) repair.

METHODS

As part of a randomized trial, the first patients recruited in the intervention group were enrolled in a supervised exercise program of six week duration. Treadmill CPET parameters were measured before and after exercise preoperatively for these patients. These parameters were as follows: peak oxygen uptake (VO2 peak), anaerobic threshold (AT), and ventilator equivalents for oxygen and carbon dioxide (VE/VO2 and VE/VCO2, respectively). Total exercise time and the time at which AT was achieved were also recorded. A comparison between pre- and postexercise parameters was made to detect for a possible improvement in aerobic fitness.

RESULTS

Twenty patients with AAA (17 men; mean age: 74.9 ± 5.9 years) were included in this study. Thirty-five percent of patients had a history of ischemic heart disease, 25% of obstructive airway disease, and 15% of cerebral vascular events. Seventy percent were previous smokers, and 15% were current smokers. Fifty-five percent of patients were taking aspirin and 75% were undergoing statin therapy. The median (interquartile range) VO2 peak at baseline was 18.2 (15.4-19.9) mL/kg/min, and after exercise was 19.9 (17.1-21.1; P = 0.048). Median AT at baseline was 12.2 (10.5-14.9), and 14.4 (12.3-15.4) after exercise (P = 0.023). Time of exercise tolerated also improved from a median of 379 to 604 sec (P = 0.001). No significant changes were seen in VE/VO2, VE/VCO2, or the time at which AT was achieved.

CONCLUSION

This study shows that cardiopulmonary aerobic fitness improves after a period of supervised exercise in patients scheduled for AAA repair. This is justification for a randomized trial to assess whether this affects morbidity and mortality after AAA repair.

Electrical stimulation vs. standard care for chronic ulcer healing: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

We conducted a systematic review to investigate the effect of electrical stimulation on ulcer healing compared to usual treatment and/or sham stimulation. This systematic review also aimed to investigate the effect of different types of electrical stimulation on ulcer size reduction.

MATERIALS AND METHODS

MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to October 2013 on randomised controlled trials (RCTs), in English and on human subjects, which assessed the effect of electrical stimulation on ulcer size as compared to standard care and/or sham stimulation. Data from included RCTs were pooled with use of fixed and random effects meta-analysis of the weighted mean change differences between the comparator groups. Heterogeneity across studies was assessed with the I(2) statistic.

RESULTS

Twenty-one studies were eligible for inclusion in the meta-analysis. In six trials (n = 210), electrical stimulation improved mean percentage change in ulcer size over total studies periods by 24·62%, 95% confidence interval (CI) 19·98-29·27, P < 0·00001 with no heterogeneity. In three trials (n = 176), electrical stimulation insignificantly improved mean weekly change in ulcer size by 1·64%, 95% (CI) -3·81 to 7·09, P = 0·56 with significant heterogeneity (I(2) = 96%, P < 0·00001). In six trials (n = 266), electrical stimulation decreased ulcer size by 2·42 cm(2), 95% (CI) 1·66-3·17, P < 0·00001, with significant heterogeneity. In one trial (n = 16), electrical stimulation also insignificantly improved the mean daily percentage change in ulcer size by 0·63%, 95% (CI) -0·12 to 1·37, P = 0·10, with significant heterogeneity.

CONCLUSIONS

Electrical stimulation appears to increase the rate of ulcer healing and may be superior to standard care for ulcer treatment.

What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment?

OBJECTIVE

In a primary healthcare clinic in Jordan to determine: (i) treatment outcomes stratified by baseline characteristics of all patients with diabetes mellitus (DM) ever registered as of June 2012 and (ii) in those who failed to attend the clinic in the quarter (April-June 2012), the number who repeatedly did not attend in subsequent quarters up to 1 year later, again stratified by baseline characteristics.

METHOD

A retrospective cohort study with treatment outcome data collected and analysed using e-health and the cohort analysis approach in UNRWA Nuzha Primary Health Care Clinic for Palestine refugees, Amman, Jordan.

RESULTS

As of June 2012, there were 2974 patients with DM ever registered, of whom 2246 (76%) attended the clinic, 279 (9%) did not attend, 81 (3%) died, 67 (2%) were transferred out and 301 (10%) were lost to follow-up. A higher proportion of males and patients with undetermined or poor disease control failed to attend the clinic compared with those who attended the clinic. Of the 279 patients who did not attend the clinic in quarter 2, 2012, 144 (52%) were never seen for four consecutive quarters and were therefore defined as lost to follow-up. There were a few differences between patients who were lost to follow-up and those who re-attended at another visit that included some variation in age and fewer disease-related complications amongst those who were lost to follow-up.

CONCLUSION

This study endorses the value of e-health and cohort analysis for monitoring and managing patients with DM. Just over half of patients who fail to attend a scheduled quarterly appointment are declared lost to follow-up 1 year later, and systems need to be set up to identify and contact such patients so that those who are late for their appointments can be brought back to care and those who might have died or silently transferred out can be correctly recorded.

Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan

OBJECTIVE

The aim of this study was to use E-Health to report on 12-month, 24-month and 36-month outcomes and late-stage complications of a cohort of Palestine refugees with diabetes mellitus (DM) registered in the second quarter of 2010 in a primary healthcare clinic in Amman, Jordan.

METHOD

Retrospective cohort study with treatment outcomes censored at 12-month time points using E-Health in UNRWA's Nuzha Primary Health Care Clinic.

RESULTS

Of 119 newly registered DM patients, 61% were female, 90% were aged ≥40 years, 92% had type 2 DM with 73% of those having hypertension and one-third of patients were newly diagnosed. In the first 3 years of follow-up, the proportion of clinic attendees decreased from 72% to 64% and then to 61%; the proportion lost to-follow-up increased from 9% to 19% and then to 29%. At the three time points of follow-up, 71-78% had blood glucose ≤180 mg/dl; 63-74% had cholesterol <200 mg/dl; and about 90% had blood pressure <140/90 mmHg. Obesity remained constant at 50%. The proportion of patients with late-stage complications increased from 1% at baseline to 7% at 1 year, 14% at 2 years and 15% at 3 years.

CONCLUSION

Nuzha PHC Clinic was able to monitor a cohort of DM patients for 3 years using E-Health and the principles of cohort analysis. This further endorses the use of cohort analysis for managing patients with DM and other non-communicable diseases.

Randomized clinical trial of angiotensin-converting enzyme inhibitor, ramipril, in patients with intermittent claudication

Background

The aim was to investigate the effect of ramipril on clinical parameters in patients with peripheral arterial disease.

Methods

Patients with intermittent claudication were randomized to receive ramipril or placebo for 24 weeks in a double-blind study. Outcome measures were walking distance, arterial stiffness measurement and quality of life (QoL).

Results

A total of 33 patients were included (25 men; mean(s.d.) age 64·6(7.8) years); 14 received ramipril and 19 placebo. After 24 weeks, ramipril improved maximum treadmill walking distance by an adjusted mean (95 per cent confidence interval, c.i.) of 131 (62 to 199) m (P = 0·001), improved treadmill intermittent claudication distance by 122 (56 to 188) m (P = 0·001) and improved patient-reported walking distance by 159 (66 to 313) m (P = 0·043) compared with placebo. Ramipril reduced carotid femoral pulse wave velocity by –1·47 (95 per cent c.i. –2·40 to –0·57) m/s compared with placebo (P = 0·002). Resting ankle : brachial pressure index (ABPI) improved slightly in both ramipril and placebo groups (0·02 (95 per cent c.i. –0·08 to 0·11) versus 0·03 (–0·05 to 0·10); P = 0·830). Ramipril had a slight, non-significant effect on QoL physical domains compared with placebo.

Conclusion

Ramipril improved walking distance in patients with claudication; however, this improvement was not related to improved ABPI but might have been due to ramipril reducing arterial stiffness. Registration number: NCT01037530 (http://www.clinicaltrials.gov).

Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan

OBJECTIVE

To illustrate the method of cohort reporting of persons with diabetes mellitus (DM) in a primary healthcare clinic in Amman, Jordan, serving Palestine refugees with the aim of improving quality of DM care services.

METHOD

A descriptive study using quarterly and cumulative case findings, as well as cumulative and 12-month analyses of cohort outcomes collected through E-Health in UNRWA Nuzha Primary Health Care Clinic.

RESULTS

There were 55 newly registered patients with DM in quarter 1, 2012, and a total of 2851 patients with DM ever registered on E-Health because this was established in 2009. By 31 March 2012, 70% of 2851 patients were alive in care, 18% had failed to present to a healthcare worker in the last 3 months and the remainder had died, transferred out or were lost to follow-up. Cumulative and 12-month cohort outcome analysis indicated deficiencies in several components of clinical care: measurement of blood pressure, annual assessments for foot care and blood tests for glucose, cholesterol and renal function. 10-20% of patients with DM in the different cohorts had serious late complications such as blindness, stroke, cardiovascular disease and amputations.

CONCLUSION

Cohort analysis provides data about incidence and prevalence of DM at the clinic level, clinical management performance and prevalence of serious morbidity. It needs to be more widely applied for the monitoring and management of non-communicable chronic diseases.