A pulmonary rehabilitation program reduces hospitalizations in chronic obstructive pulmonary disease patients: A cost-effectiveness study.

BACKGROUND: Although pulmonary rehabilitation (PR) is recommended in patients with chronic obstructive pulmonary disease (COPD), there is a scarcity of data demonstrating the cost-effectiveness and effectiveness of PR in reducing exacerbations. METHODS: A quasi-experimental study in 200 patients with COPD was conducted to determine the number of exacerbations 1 year before and after their participation in a PR program. Quality of life was measured using the COPD assessment test and EuroQol-5D. The costs of the program and exacerbations were assessed the year before and after participation in the PR program. The incremental cost-effectiveness ratio (ICER) was estimated in terms of quality-adjusted life years (QALYs). RESULTS: The number of admissions, length of hospital stay, and admissions to the emergency department decreased after participation in the PR program by 48.2%, 46.6%, and 42.5%, respectively (P < 0.001 for all). Results on quality of life tests improved significantly (P < 0.001 for the two tests). The cost of PR per patient and the cost of pre-PR and post-PR exacerbations were €1867.7 and €7895.2 and €4201.9, respectively. The PR resulted in a cost saving of €1826 (total, €365,200) per patient/year, and the gain in QALYs was+0.107. ICER was -€17,056. The total cost was <€20,000/QALY in 78% of patients. CONCLUSIONS: PR contributes to reducing the number of exacerbations in patients with COPD, thereby slowing clinical deterioration. In addition, it is cost-effective in terms of QALYs.

Recommendations by the Spanish Society of Rheumatology on risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis.

OBJECTIVE: To present recommendations based on the available evidence and the consensus of experts, for risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis. METHODS: Clinical research questions relevant to the purpose of the document were identified. These questions were reformulated in PICO format (patient, intervention, comparison, outcome or outcome) by a panel of experts, selected based on their experience in the area. A systematic review of the evidence was carried out, grading according to the GRADE criteria (Grading of Recommendations Assessment, Development, and Evaluation). Specific recommendations were then formulated. RESULTS: 6 PICO questions were proposed by the panel of experts based on their clinical relevance and the existence of recent information regarding the risk of occurrence of serious infections, the risk of reactivation of the hepatitis B virus, the risk of reactivation of the virus varicella-zoster, the risk of appearance of skin (melanoma and non-melanoma) or haematological cancer, the risk of appearance of thromboembolic disease and the risk of progression of the human papilloma virus. A total of 28 recommendations were formulated, structured by question, based on the evidence found and the consensus of the experts. CONCLUSIONS: The SER recommendations on risk management of treatment with biologic therapies and JAK inhibitors in rheumatoid arthritis are presented.

XIII International Conference on Kangaroo Mother Care - Different opinions, experiences and related KMC issues: Good practices, stabilisation concept, nutrition and basic respiratory support.

AIM: This study aimed to summarise the views and experiences of the participants in the workshop of the XIII International Conference on Kangaroo Mother Care (KMC). METHODS: The results of the discussions held during the workshop of the XIII International Conference on KMC were summarised. There were 152 participants from 47 countries. Four main KMC topics were discussed: good practices, immediate implementation, nutrition and basic ventilation. RESULTS: Several agreements were reached, namely that professional societies and governments should develop official recommendations to promote KMC as standard care for preterm and low birth weight infants and that parents should be involved as active caregivers in neonatal care units. Moreover, the criteria for referring community-born infants to KMC require standardisation. Important inequalities in resource availability among high-, middle- and low-income countries were recognised for all topics. Specific needs were identified for parenteral nutrition and fortifiers, nasal continuous positive airway pressure (nCPAP) and oxygen blenders, which are rarely available in low- and middle-income countries. Immediate implementation of KMC was discussed as a new concept. Its benefits were recognised, but its application has some variability. CONCLUSION: Adequate preterm care requires a basic neonatal package, including KMC, nCPAP, immediate management protocols and adequate nutrition and feeding strategies. The differences in resources among high-, middle- and low-income countries highlight the wide disparities in neonatal care according to the place of birth.

ASSESSMENT OF OCCUPATIONAL EXPOSURE IN THE MAIN PAEDIATRIC INTERVENTIONAL RADIOLOGY PROCEDURES.

The aim of this study is to evaluate the personal dose equivalent Hp(10) in the most frequent (non-cardiac) paediatric interventional radiology (PIR) procedures: central venous catheters (CVC), hepatic/biliary and sclerotherapy interventions. i2 active solid-state dosemeters placed over the lead apron were used to monitor the exposure of three interventional radiologists over 18 months. A database was created to register all procedures performed by each radiologist (including the type of procedure and the kerma-area product, PKA). The mean Hp(10) per procedure for CVC, sclerotherapy and hepatic/biliary interventions was respectively 0.01 ± 0.01 mSv, 0.18 ± 0.13 mSv and 0.12 ± 0.06 mSv (k = 2). A similar value of Hp(10)/PKA was found despite the type of procedure or the patient weight (~10 µSv/Gy·cm2). There was high variability among individual interventions, probably due to the variable level of complexity, which led to uncertainties in the measurements' mean higher than those associated with the dosemeter's angular and energy dependence. i2 therefore proved suitable for monitoring Hp(10) in PIR procedures.

Anthropometric Assessment of Nepali Children Institutionalized in Orphanages.

Nepal is among the world's poorest countries, and it is the third-poorest country in the South Asian region. Asia has the largest number of orphans in the world; in Nepal there are around 13,281 orphan children. The objective of this study is to evaluate the growth status of institutionalized children in Nepal through the analyses of anthropometric measures. The sample was Nepalese children aged 4 to 17, obtained from two different orphanages: in the first one, children with physical and mental disabilities coexist with children without any conditions. In the second one, there were no subjects with disabilities. Significant evidence of an association between mental and physical disability in institutionalized children and undernutrition (wasting and stunting) was found in this study. There is also weak but significant evidence of a relationship between underweight and being male. The study could help reaching a better understanding of growth status of institutionalized children in Nepal.

Characterization of Clinical MRSA Isolates from Northern Spain and Assessment of Their Susceptibility to Phage-Derived Antimicrobials.

Methicillin-resistant Staphylococcus aureus (MRSA) is a prevalent nosocomial pathogen, causing a wide range of diseases. The increased frequency of MRSA isolates in hospitals and the emergence of vancomycin resistance have sparked the search for new control strategies. This study aimed to characterize sixty-seven MRSA isolates collected from both infected patients and asymptomatic carriers in a Spanish hospital. RAPD-PCR allowed the identification of six genetic patterns. We also investigated the presence of genes involved in producing adhesins, toxins and the capsule; the biofilm; and antimicrobial resistance. A notable percentage of the isolates carried virulence genes and showed medium-high ability to form biofilms. Next, we assessed the strains' susceptibility to two phages (phiIPLA-C1C and phiIPLA-RODI) and one endolysin (LysRODI). All strains were resistant to phiIPLA-C1C, and most (70.2%) were susceptible to phiIPLA-RODI. Regarding LysRODI, all strains displayed susceptibility, although to varying degrees. There was a correlation between endolysin susceptibility and the random amplification of polymorphic DNA (RAPD) profile or the presence of some virulence genes (fnbA, eta, etb, PVL and czr), but that was not observed with biofilm-forming ability, strain origin or phage sensitivity. Taken together, these findings can help to explain the factors influencing endolysin effectiveness, which will contribute to the development of efficient therapies targeting MRSA infections.

Preliminary Assessment of Visible, Near-Infrared, and Short-Wavelength-Infrared Spectroscopy with a Portable Instrument for the Detection of Staphylococcus aureus Biofilms on Surfaces.

Bacterial biofilms constitute a major source of sanitary problems and economic losses in the food industry. Indeed, biofilm removal may require intense mechanical cleaning procedures or very high concentrations of disinfectants or both, which can be damaging to the environment and human health. This study assessed the efficacy of a technique based on spectroscopy in the visible, near-infrared, and short-wavelength infrared range for the quick detection of biofilms formed on polystyrene by the pathogenic bacterium Staphylococcus aureus. To do that, biofilms corresponding to three S. aureus strains, which differed in biofilm-forming ability and composition of the extracellular matrix, were allowed to develop for 5 or 24 h, representing an active formation stage and mature biofilms, respectively. Spectral analysis of the samples, corresponding to three biological replicates of each condition, was then performed by using a portable device. The results of these experiments showed that partial least-squares discriminant analysis of the spectral profile could discriminate between surfaces containing attached bacterial biomass and noninoculated ones. In this model, the two first principal components accounted for 39 and 19% of the variance and the estimated error rate stabilized after four components. Cross-validation accuracy of this assessment was 100%. This work lays the foundation for subsequent development of a spectroscopy-based protocol that allows biofilm detection on food industrial surfaces.

Comparative analysis of different preservation techniques for the storage of Staphylococcus phages aimed for the industrial development of phage-based antimicrobial products.

Bacteriophages have been proven as effective antimicrobial agents in the treatment of infectious diseases and in other biocontrol applications including food preservation and disinfection. The extensive use of bacteriophages requires improved methodologies for medium- and long-term storage as well as for easy shipping. To this aim, we have determined the stability of four Staphylococcus phages (phiIPLA88, phiIPLA35, phiIPLA-RODI and phiIPLA-C1C) with antimicrobial potential at different temperatures (20°C/25°C, 4°C, -20°C, -80°C, -196°C) and during lyophilization (freeze drying) using several stabilizing additives (disaccharides, glycerol, sorbitol and skim milk). Differences between phages were observed at different temperatures (20°C/25°C, 4°C and -20°C), where phages were less stable. At lower temperatures (-80°C and -196°C), all phages showed good viability after 24 months regardless of the stabilizer. Differences between phages were also observed after lyophilization although the addition of skim milk yielded a dry powder with a stable titer after 24 months. As an alternative to facilitate storage and transportation, phage encapsulation has been also explored. Phage phiIPLA-RODI encapsulated in alginate capsules retained high viability when stored at 4°C for 6 months and at 20°C for 1 month. Moreover, the spray-dryer technique allowed obtaining dry powders containing viable encapsulated phages (phiIPLA-RODI and phiIPLA88) in both skim milk and trehalose for 12 months at 4°C. Storage of phages at 20°C was less effective; in fact, phiIPLA88 was stable for at least 12 months in trehalose but not in skim milk, while phiIPLA-RODI was stable only for 6 months in either stabilizer. These results suggest that encapsulated phages might be a suitable way for shipping phages.

Real-Time Assessment of Staphylococcus aureus Biofilm Disruption by Phage-Derived Proteins.

A current focus of research is the development of new tools for removing bacterial biofilms in industrial settings. Bacteriophage-encoded proteins, such as endolysins, virion-associated peptidoglycan hydrolases, and exopolysaccharide depolymerases, have been shown to be efficient against these structures. However, the current screening techniques for the identification of antibiofilm properties of phage-derived proteins have important shortcomings. The aim of this work was to use the rapid, reproducible and accurate technology "real-time cell analyzer" for screening and comparing the antibiofilm ability of four phage-derived compounds, three lytic proteins (LysH5, CHAP-SH3b, and HydH5-SH3b) and one exopolysaccharide depolymerase (Dpo7) against Staphylococcus aureus biofilms, which have been associated with recurrent contamination of food products. The data generated after biofilm treatment allowed for the calculation of different antibiofilm parameters: (1) the minimum biofilm eradicating concentration that removes 50% of the biofilm (ranging from 3.5 ± 1.1 to 6.6 ± 0.5 µM), (2) the lowest concentration needed to observe an antibiofilm effect (∼1.5 µM for all the proteins), and (3) the specific antibiofilm activity and the percentage of biofilm removal that revealed LysH5 as the best antibiofilm compound. Overall, this technology might be used to quickly assess and compare by standardized parameters the disaggregating activity of phage antibiofilm proteins.

Hospitalization rate and costs in acute lymphoblastic leukemia of childhood in a low-income group: Financial impact in Northeast Mexico.

BACKGROUND: Acute lymphoblastic leukemia (ALL) is one of the main and most expensive and prolonged causes of hospitalization for childhood cancer. We describe the hospitalization rate and its costs for an open population with ALL in a low-middle income country. PROCEDURE: We retrospectively analyzed 449 hospital admissions for 101 pediatric patients with ALL over 8 years. Clinical files and electronic databases were scrutinized to document causes, duration, readmission rate, costs, and outcome of each admission. Hospitalizations were divided into two categories: general pediatric ward and pediatric intensive care unit (PICU). Hospitalization rates and its costs per patient were estimated considering person-time at risk. RESULTS: Patients had an admission rate of 2.09 hospitalizations per patient-year and median length of stay per admission was 5 days. Most admissions occurred during the first 2 years from diagnosis. Mean cost per day was 239 US dollars (USD) and mean cost per stay was 2,246 USD versus 1,016 and 19,004 USD (P = 0.001) in the PICU, respectively. Total hospitalization cost per patient per year (PPPY) was 5,991 USD for high-risk patients and 3,038 USD for standard-risk patients. Patients between ages 1 and 9 years had a PPPY cost of $4,057; while for children younger than 1 year or older than 9 years, it was 7,463 USD. The popular medical insurance program covered 70% of hospitalizations and 63% of its total cost; patients contributed 2%, with the hospital absorbing 35%. CONCLUSIONS: Hospitalizations for children with ALL were less expensive than in high-income countries but had a significant cost to low-income families and to the healthcare system.

HLA-DRB1 Amino Acid Positions 11/13, 71, and 74 Are Associated With Inflammation Level, Disease Activity, and the Health Assessment Questionnaire Score in Patients With Inflammatory Polyarthritis.

OBJECTIVE: Rheumatoid arthritis (RA) susceptibility HLA-DRB1 haplotypes based on amino acid positions 11/13, 71, and 74 predict radiographic damage. The mechanism of action is unknown, but it may be mediated by inflammation. We undertook this study to systematically investigate the effect of these amino acids on nonradiographic measures of disease activity/outcomes. METHODS: We tested the association of RA susceptibility HLA-DRB1 amino acids with the C-reactive protein (CRP) level, the tender joint count (TJC), the swollen joint count (SJC), the Disease Activity Score in 28 joints (DAS28), and the Health Assessment Questionnaire (HAQ) score in the Norfolk Arthritis Register (NOAR) and Early Rheumatoid Arthritis Study (ERAS) cohorts. Longitudinal modeling of disease activity/outcomes was performed using generalized linear latent and mixed models. Mediation analysis was performed using directed acyclic graphs to investigate the paths from genetic factors to outcome. RESULTS: A total of 2,158 patients were available for analysis in the NOAR cohort. Valine at position 11 showed the strongest association with the CRP level (P = 2.21 × 10-6 ), the SJC (P = 7.51 × 10-6 ), and the DAS28 (P = 0.002); it was marginally associated with the HAQ score (P = 0.044) but not with the TJC. The same amino acid and haplotype risk hierarchy observed for susceptibility and radiographic severity was observed for the CRP level and nonradiographic measures of disease activity/outcome, apart from the TJC. The results were replicated in the ERAS cohort. The effect of valine at position 11 on the SJC was mainly mediated by anti-citrullinated protein antibody status, the effect of which was mainly mediated by inflammation; however, the effect of valine at position 11 was also independent of the CRP level (P = 1.6 × 10-4 ). CONCLUSION: Genetic markers of RA susceptibility located within HLA-DRB1 determine the levels of clinical and systemic inflammation independently, and also determine all objective measures of disease activity and outcome.