Cost-Benefit Analysis of the CT of the Face in the Evaluation of Traumatic Facial Fractures in an Appalachian Tri-state Geriatric Population.

OBJECTIVE: This study aimed to evaluate the cost vs. benefits of the CT face imaging study in the trauma workup of those over the age of 65. METHODS: We performed a retrospective chart review of 169 trauma patients in our trauma database aged 65 years or older who underwent a CT of the head, a CT of the face, or a CT of the head and CT of the face that resulted in findings of a facial fracture from 2017-2022. Injuries and the treatment they received were documented. If a patient underwent both a CT of the face and a CT of the head, then the author first viewed the CT of the head, documented any injury, and then recorded treatment based on the CT of the head. The CT of the face was then viewed, injuries were recorded, and treatment based on the CT of the face was documented. Statistical analysis was then performed using the paired T-test, McNemar test, and number needed to harm analysis. RESULTS: Of the 169 patients sampled, 159 underwent both CT of the head and the face. There were no patients who underwent a CT of the face exclusively, and only 10 patients underwent a CT of the head exclusively. Of the 159 that had both a CT of the head and the face, the average number of injuries noted on CT of the head + CT of the face vs. CT of the head was 2.42 vs. 1.36, P<.0.0001. The number needed to avoid missing a surgical facial fracture when only a CT of the head was obtained was 14.68. CONCLUSION: The risks of missing a surgical facial fracture outweigh the monetary, radiation, and patient-desired necessity benefits of only performing a CT of the head. A CT of the face should be included in the trauma workup for those over the age of 65 when facial fractures are suspected.

Impact of Safety Device Features Upon Motor Vehicle Collision Facial Fracture Traumas: A Five-Year Retrospective Study in the Appalachian Tri-State Area.

Motor vehicle collisions (MVCs) represent a significant public health concern, contributing to substantial morbidity and mortality globally. Despite advancements in vehicle safety technology, the impact of safety measures on facial fractures in MVCs remains poorly understood, especially in regions with diverse road conditions like the Appalachian tri-state area. This retrospective study analyzed data from two regional level II trauma centers in Appalachia, focusing on MVC-related facial fractures and safety device usage from January 2017 to December 2021. Descriptive statistics and logistic regression models were employed to assess associations between safety devices and injury outcomes. The study comprised 85 participants, categorized into groups based on safety device usage. Results indicated no significant differences in demographic characteristics, injury severity, surgical intervention rates, or specific facial fractures among groups. These findings challenge some previous research suggesting the protective effects of safety devices on facial fractures in MVCs, underscoring the complex nature of injury prevention in this context. While limitations such as retrospective data collection and sample size constrain generalizability, this study contributes valuable insights for informing injury prevention strategies and trauma care practices in Appalachia and beyond.

Age-Related Patterns of Traumatic Facial Fractures in the Appalachian Tri-state Area: A Five-Year Retrospective Study.

Introduction Traumatic facial injuries, leading to facial fractures represent a significant subset of traumatic events, with age emerging as a crucial determinant influencing both their etiology and outcomes. Understanding the age-related patterns of traumatic facial fractures is essential for developing targeted prevention and management strategies. In this context, the Appalachian tri-state area stands as an underexplored region concerning this issue, necessitating comprehensive research to elucidate the nuances of age-related traumatic facial fractures within this geographic context. Methods This retrospective study delves into the age-related patterns of traumatic facial fractures within the Appalachian tri-state area, drawing upon patient records from Cabell Huntington Hospital and Saint Mary's Medical Center spanning a five-year period. The study cohort encompasses 623 patients categorized into three age groups: individuals aged <22 years, those aged 22-65 years, and individuals over 65 years. Data analysis involves meticulous examination of mechanisms of injury, injury severity scores (ISSs), hospital length of stay, and the prevalence of surgical interventions across different age cohorts. Results Out of 623 patients, 104 (16.7%) were under 22 years old, 367 (58.9%) were between 22 and 65 years old, and 152 (24.4%) were over 65 years old. The majority were male (70%). Falls were the most common cause of facial fractures in patients over 65 (78%), while assaults were predominant in the 22-65 age group (24%), and motor vehicle collisions (MCVs) in those under 22 (34%). The median ISS and hospital stay durations were similar across age groups. 28% of patients underwent surgery, with significant variation among age groups (p<0.001): 38% for <22 years, 33% for 22-65 years, and 11% for >65 years. Mandibular fractures were more prevalent in younger patients, with rates of 12% for <22 years compared to 5.3% for >65 years. Logistic regression analysis revealed that patients aged 22-65 had 4.10 times higher odds (95% CI=2.38, 7.45, p<0.001) of undergoing surgery, while those under 22 had 5.14 times higher odds (95% CI=2.73, 10.0, p<0.001) compared to those over 65. Significant associations were found for mandibular and bilateral mandibular outcomes in patients aged 22-65 years. Discussion These findings underscore the imperative for tailored prevention strategies and age-specific treatment protocols to optimize patient outcomes. Fall prevention initiatives for the elderly and interventions addressing sports-related injuries for younger individuals are paramount. Moreover, the study highlights the necessity of specialized care protocols for elderly patients to minimize hospital stay durations and manage age-related comorbidities effectively. Moving forward, further research should address limitations, validate findings, and explore the efficacy of specific interventions, thereby paving the way for enhanced preventive measures and management strategies tailored to the diverse age cohorts affected by traumatic facial fractures in the Appalachian region.

A Comparative American Board of Surgery In-Training Examination (ABSITE) Performance Analysis Between International vs. Domestic Graduates and Doctor of Medicine (MD) vs. Doctor of Osteopathic Medicine (DO) Medical Degrees.

Introduction The American Board of Surgery (ABS) plays a pivotal role in certifying surgeons in the United States, with the American Board of Surgery In-Training Examination (ABSITE) serving as a critical assessment tool for general surgery residents aspiring for certification. The aim of this study is to compare the performance of international medical graduates (IMGs) to their domestic counterparts and assess the impact of different medical degrees on ABSITE scores. Notably, ABSITE scores often dictate the trajectory of a surgical career, including opportunities for fellowship placements in specialized fields such as plastic surgery. Methods This study focused on general surgery residents enrolled at Marshall University from 2014 to 2022. Data encompassing ABSITE scores, TrueLearn quiz percentages, and TrueLearn mock exam results were collected for analysis. Descriptive statistics summarized sample characteristics, and linear mixed models were employed to address correlations. Statistical analyses were conducted using the Statistical Analysis System (SAS) (version 9.4; SAS Institute Inc., Cary, NC, USA), with significance defined by a two-sided test with p < 0.05. Results Among the 48 participants, comprising 24 non-international medical graduates (nIMGs) and 24 IMGs, IMGs demonstrated superior performance across various metrics. They exhibited higher quiz percentages (67% vs. 61%; p = 0.0029), mock Exam 1 scores (64% vs. 58%; p = 0.0021), mock Exam 2 scores (66% vs. 58%; p = 0.0015), ABSITE scores (560 vs. 505; p = 0.010), and ABSITE percentages (74% vs. 68%; p = 0.0077) compared to nIMGs. Analysis between Doctor of Osteopathic Medicine (DO) and Doctor of Medicine (MD) participants revealed no statistically significant differences in performance metrics, highlighting the comparability of these medical degrees in the context of ABSITE scores and related assessments. Discussion/conclusion This study underscores the superior performance of IMGs over nIMGs in ABSITE examinations, shedding light on the critical role of ABSITE scores in shaping surgical careers. Higher scores correlate with enhanced opportunities for coveted fellowship placements, particularly in specialized fields like plastic surgery. Understanding these dynamics is crucial for resident training and navigating the competitive landscape of surgical sub-specialization. Future research endeavors can delve deeper into the factors influencing ABSITE performance, thereby facilitating the development of targeted interventions to support residents in achieving their career aspirations.

Navigating the American Board of Surgery In-Training Examination (ABSITE) Success: Insights From Pre-assessment Practices in Preparing Surgical Residents for Competitive Sub-specialties.

Introduction The American Board of Surgery In-Training Examination (ABSITE) is a critical tool in assessing surgical residents' readiness for board certification and clinical practice. While various factors influencing ABSITE performance have been examined, the impact of innovative educational resources, such as TrueLearn, remains underexplored. TrueLearn's adaptive learning algorithms and comprehensive question banks offer a promising adjunct to traditional study methods. This study investigates the relationship between TrueLearn utilization and ABSITE performance among general surgery residents. Methods This retrospective study, ethically approved by the Marshall University Institutional Review Board (IRB No. 2097669-1), analyzed the performance of general surgery residents at Marshall University from 2014 to 2022. Data were collected on ABSITE scores. Additionally, quiz percentages (Quiz %) and scores from two mock exams (Exam 1 and Exam 2), all provided by the TrueLearn platform, were included in the analysis. Descriptive statistics summarized the sample characteristics. Linear mixed models were employed to examine the associations between TrueLearn engagement and ABSITE performance, accounting for the correlated nature of the data and addressing any missing data at random. Statistical analyses were conducted using the Statistical Analysis System (SAS, version 9.4; SAS Institute Inc., Cary, NC), with significance defined as a p-value < 0.05. Results The study cohort included 58 residents from 2016 to 2022. Linear mixed model analysis revealed significant positive correlations between TrueLearn Quiz %, Exam 1 scores, and Exam 2 scores with ABSITE performance. A 1% increase in Quiz % was associated with a 0.77-point rise in ABSITE scores (95% CI: 0.65, 0.89; p < 0.0001). For Exam 1, each point increase corresponded to a 6.36-point increase in ABSITE scores (95% CI: 5.01, 7.7; p < 0.0001), while Exam 2 scores showed a 3.8-point increase per point (95% CI: 2.74, 4.86; p < 0.0001). Discussion and conclusion Our findings underscore the significant impact of TrueLearn engagement on ABSITE performance, with higher quiz percentages and mock exam scores predictive of better ABSITE outcomes. This suggests that regular use of TrueLearn's educational resources enhances residents' knowledge and exam readiness. These results advocate for the integration of innovative educational tools such as TrueLearn into surgical training programs to optimize study strategies and improve exam performance. However, the study's retrospective design and single-institution focus limit the generalizability of the findings. Future research should explore these relationships in diverse settings and specialties and consider additional factors influencing ABSITE performance. This study highlights the positive association between TrueLearn utilization and ABSITE performance among general surgery residents, emphasizing the importance of innovative educational resources in surgical training. By enhancing engagement with platforms such as TrueLearn, surgical programs can improve residents' readiness for high-stakes examinations, ultimately contributing to the development of proficient surgical practitioners.

Burn Mortality in an Appalachian Referral Center: An Examination of Mortality Prediction Scores in a 13-Year Retrospective Study.

Introduction Burn injuries have profound implications, prompting the use of various mortality scoring systems. This study aimed to evaluate their effectiveness within our Appalachian burn referral center, which serves as the sole burn center in the state of West Virginia. Given this unique status, understanding the efficacy of mortality scoring systems within our center is crucial for resource allocation and optimizing patient outcomes in our region. Methods A retrospective analysis of patients admitted to Cabell Huntington Hospital Burn Intensive Care Unit (BICU) from January 2010 to June 2023 was conducted, assessing Baux (B), revised Baux (rB), Belgian Outcome in Burn Injury (BOBI), and Abbreviated Burn Severity Index (ABSI) scores. Logistic regression and receiver operating characteristic analysis were employed to examine survival status and determine optimal cut points. Results Among 1,104 patients, 57 died (5% mortality rate). Deceased patients had significantly higher B/rB/BOBI scores (mean: 98/98/92) than survivors (45/46/4.19) (p < 0.001), with ABSI showing no significance (p = 0.079). Each one-point increase in B/rB/BOBI scores correlated with a 1.09/1.09/2.34 times higher mortality risk (p < 0.001). The AUC for B score in predicting mortality was 0.926 (95% CI: 0.890, 0.962), with sensitivity and specificity values of 0.789 and 0.92, respectively, and an optimal cutoff point of 79. The AUC for the rB score was 0.927 (95% CI: 0.892, 0.962), with sensitivity and specificity values of 0.789 and 0.926, respectively, and an optimal cutoff point of 80. The AUC for the BOBI score was 0.901 (95% CI: 0.865, 0.937), with sensitivity and specificity values of 0.895 and 0.775, respectively, and an optimal cutoff point of 2. For patients with B scores above 79, their odds of mortality were 42.6 times higher than those with B scores of 79 or lower (95% CI: 22.6, 85.6, p < 0.001). Similarly, for patients with rB scores exceeding 80, their odds of mortality were 42.9 times higher than those with rB scores of 80 or lower (95% CI: 22.9, 84.8, p < 0.001). Finally, for patients with BOBI scores greater than 2, their odds of mortality were 17.8 times higher than those with BOBI scores of 2 or lower (95% CI: 9.88, 33.4, p < 0.001). Conclusion Our study underscores the vital role of mortality scoring systems in guiding clinical decision-making and resource allocation for burn patients, particularly within the Appalachian region served by the Cabell Huntington Hospital BICU. By leveraging tools such as the Baux, revised Baux, and BOBI scores, healthcare providers can identify high-risk patients early in their treatment course, facilitating personalized interventions and improving overall patient outcomes. Moreover, our findings highlight the significance of age and total body surface area burned as key determinants of mortality risk, emphasizing the need for tailored approaches to care for elderly patients and those with extensive burns. Continued research and refinement of mortality scoring systems are essential to further enhance their effectiveness and ensure optimal patient care in the challenging field of burn management.

Bridging the Gap: Understanding Appalachian Patient Satisfaction in Cosmetic Rhinoplasty.

Rhinoplasty is a surgical procedure aimed at correcting both functional and aesthetic nasal deformities, addressing issues such as trauma-induced disfigurements and patient dissatisfaction with nasal appearance. Patient satisfaction is a critical outcome measure in rhinoplasty, reflecting the success of the procedure and the quality of care provided. This study investigates factors influencing patient satisfaction among Appalachian patients undergoing rhinoplasty for aesthetic reasons, considering the unique healthcare challenges faced by rural populations. A modified Rhinoplasty Outcome Evaluation questionnaire was utilized to assess patient satisfaction. Descriptive statistics and regression analyses were performed to analyze demographic characteristics, complications, re-operations, and satisfaction scores among rural and urban participants. While no significant differences were found in demographic characteristics, trends in satisfaction scores suggest potential disparities between rural and urban populations. Rural patients exhibited marginally lower satisfaction scores and higher rates of complications and re-operations, highlighting the need for targeted interventions in rural healthcare settings. Addressing geographic barriers, enhancing preoperative education and postoperative support, and fostering interdisciplinary collaboration are essential strategies to improve patient satisfaction and outcomes in rhinoplasty procedures, particularly in rural communities. Further research with larger sample sizes and qualitative methods is warranted to explore the underlying factors contributing to patient satisfaction disparities and to inform evidence-based interventions aimed at narrowing healthcare disparities and advancing health equity in rhinoplasty care.

The Impact of the Fungal Priority Pathogens List on Medical Mycology: A Northern European Perspective.

Fungal diseases represent a considerable global health concern, affecting >1 billion people annually. In response to this growing challenge, the World Health Organization introduced the pivotal fungal priority pathogens list (FPPL) in late 2022. The FPPL highlights the challenges in estimating the global burden of fungal diseases and antifungal resistance (AFR), as well as limited surveillance capabilities and lack of routine AFR testing. Furthermore, training programs should incorporate sufficient information on fungal diseases, necessitating global advocacy to educate health care professionals and scientists. Established international guidelines and the FPPL are vital in strengthening local guidance on tackling fungal diseases. Future iterations of the FPPL have the potential to refine the list further, addressing its limitations and advancing our collective ability to combat fungal diseases effectively. Napp Pharmaceuticals Limited (Mundipharma UK) organized a workshop with key experts from Northern Europe to discuss the impact of the FPPL on regional clinical practice.

Breast Augmentation Patient Satisfaction in an Appalachian Region.

The prevalence of cosmetic plastic surgeries, including breast augmentation, has risen significantly, with breast augmentation being among the most sought-after procedures. However, there's a dearth of research on patient outcomes and satisfaction, particularly in rural areas like the Appalachian region. This retrospective study aimed to fill this gap by examining patient satisfaction and complications following breast augmentation surgery among rural Appalachian patients in the tri-state (West Virginia, Kentucky, and Ohio) area. A total of 63 patients who underwent primary breast augmentation at a regional referral center from June 2014 to December 2022 were included in the study. Patient records were reviewed and data on demographics, complications, re-operations, and satisfaction scores were analyzed. Results revealed no significant differences between rural and urban populations in terms of demographic characteristics, complication rates, re-operation rates, or satisfaction scores. Logistic regression models confirmed that rural/urban status did not significantly influence the likelihood of complications, re-operations, or satisfaction. Despite the study's limitations, including a small sample size and single-center design, the results indicate that rural Appalachian patients receive surgical care comparable to their urban counterparts and experience similar benefits from breast augmentation surgery. Recognizing the distinctive healthcare needs and obstacles faced by rural communities is essential for mitigating healthcare disparities and enhancing overall health outcomes. Future research and healthcare initiatives should prioritize improving access to care, fostering patient-centered approaches, and addressing systemic challenges in healthcare delivery across rural Appalachia.

Aspergillus fumigatus-a systematic review to inform the World Health Organization priority list of fungal pathogens.

Recognizing the growing global burden of fungal infections, the World Health Organization established a process to develop a priority list of fungal pathogens (FPPL). In this systematic review, we aimed to evaluate the epidemiology and impact of invasive infections caused by Aspergillus fumigatus to inform the first FPPL. The pre-specified criteria of mortality, inpatient care, complications and sequelae, antifungal susceptibility, risk factors, preventability, annual incidence, global distribution, and emergence were used to search for relevant articles between 1 January 2016 and 10 June 2021. Overall, 49 studies were eligible for inclusion. Azole antifungal susceptibility varied according to geographical regions. Voriconazole susceptibility rates of 22.2% were reported from the Netherlands, whereas in Brazil, Korea, India, China, and the UK, voriconazole susceptibility rates were 76%, 94.7%, 96.9%, 98.6%, and 99.7%, respectively. Cross-resistance was common with 85%, 92.8%, and 100% of voriconazole-resistant A. fumigatus isolates also resistant to itraconazole, posaconazole, and isavuconazole, respectively. The incidence of invasive aspergillosis (IA) in patients with acute leukemia was estimated at 5.84/100 patients. Six-week mortality rates in IA cases ranged from 31% to 36%. Azole resistance and hematological malignancy were poor prognostic factors. Twelve-week mortality rates were significantly higher in voriconazole-resistant than in voriconazole-susceptible IA cases (12/22 [54.5%] vs. 27/88 [30.7%]; P = .035), and hematology patients with IA had significantly higher mortality rates compared with solid-malignancy cases who had IA (65/217 [30%] vs. 14/78 [18%]; P = .04). Carefully designed surveillance studies linking laboratory and clinical data are required to better inform future FPPL.

Pichia kudriavzevii (Candida krusei): A systematic review to inform the World Health Organisation priority list of fungal pathogens.

In response to the growing global threat of fungal infections, in 2020 the World Health Organisation (WHO) established an Expert Group to identify priority fungi and develop the first WHO fungal priority pathogen list (FPPL). The aim of this systematic review was to evaluate the features and global impact of invasive infections caused by Pichia kudriavzevii (formerly known as Candida krusei). PubMed and Web of Science were used to identify studies published between 1 January 2011 and 18 February 2021 reporting on the criteria of mortality, morbidity (defined as hospitalisation and length of stay), drug resistance, preventability, yearly incidence, and distribution/emergence. Overall, 33 studies were evaluated. Mortality rates of up to 67% in adults were reported. Despite the intrinsic resistance of P. kudriavzevii to fluconazole with decreased susceptibility to amphotericin B, resistance (or non-wild-type rate) to other azoles and echinocandins was low, ranging between 0 and 5%. Risk factors for developing P. kudriavzevii infections included low birth weight, prior use of antibiotics/antifungals, and an underlying diagnosis of gastrointestinal disease or cancer. The incidence of infections caused by P. kudriavzevii is generally low (∼5% of all Candida-like blood isolates) and stable over the 10-year timeframe, although additional surveillance data are needed. Strategies targeting the identified risk factors for developing P. kudriavzevii infections should be developed and tested for effectiveness and feasibility of implementation. Studies presenting data on epidemiology and susceptibility of P. kudriavzevii were scarce, especially in low- and middle-income countries (LMICs). Thus, global surveillance systems are required to monitor the incidence, susceptibility, and morbidity of P. kudriavzevii invasive infections to inform diagnosis and treatment. Timely species-level identification and susceptibility testing should be conducted to reduce the high mortality and limit the spread of P. kudriavzevii in healthcare facilities.

Fusarium species,Scedosporium species, and Lomentospora prolificans: A systematic review to inform the World Health Organization priority list of fungal pathogens.

Recognizing the growing global burden of fungal infections, the World Health Organization established a process to develop a priority list of fungal pathogens (FPPL). In this systematic review, we aimed to evaluate the epidemiology and impact of infections caused by Fusarium spp., Scedosporium spp., and Lomentospora prolificans to inform the first FPPL. PubMed and Web of Sciences databases were searched to identify studies published between January 1, 2011 and February 23, 2021, reporting on mortality, complications and sequelae, antifungal susceptibility, preventability, annual incidence, and trends. Overall, 20, 11, and 9 articles were included for Fusarium spp., Scedosporium spp., and L. prolificans, respectively. Mortality rates were high in those with invasive fusariosis, scedosporiosis, and lomentosporiosis (42.9%-66.7%, 42.4%-46.9%, and 50.0%-71.4%, respectively). Antifungal susceptibility data, based on small isolate numbers, showed high minimum inhibitory concentrations (MIC)/minimum effective concentrations for most currently available antifungal agents. The median/mode MIC for itraconazole and isavuconazole were ≥16 mg/l for all three pathogens. Based on limited data, these fungi are emerging. Invasive fusariosis increased from 0.08 cases/100 000 admissions to 0.22 cases/100 000 admissions over the time periods of 2000-2009 and 2010-2015, respectively, and in lung transplant recipients, Scedosporium spp. and L. prolificans were only detected from 2014 onwards. Global surveillance to better delineate antifungal susceptibility, risk factors, sequelae, and outcomes is required.

Mapping the Burden of Fungal Diseases in the United Arab Emirates.

The United Arab Emirates has very little data on the incidence or prevalence of fungal diseases. Using total and underlying disease risk populations and likely affected proportions, we have modelled the burden of fungal disease for the first time. The most prevalent serious fungal conditions are recurrent vulvovaginitis (~190,000 affected) and fungal asthma (~34,000 affected). Given the UAE's low prevalence of HIV, we estimate an at-risk population of 204 with respect to serious fungal infections with cryptococcal meningitis estimated at 2 cases annually, 15 cases of Pneumocystis pneumonia (PCP) annually, and 20 cases of esophageal candidiasis in the HIV population. PCP incidence in non-HIV patients is estimated at 150 cases annually. Likewise, with the same low prevalence of tuberculosis in the country, we estimate a total chronic pulmonary aspergillosis prevalence of 1002 cases. The estimated annual incidence of invasive aspergillosis is 505 patients, based on local data on rates of malignancy, solid organ transplantation, and chronic obstructive pulmonary disease (5.9 per 100,000). Based on the 2022 annual report of the UAE's national surveillance database, candidaemia annual incidence is 1090 (11.8/100,000), of which 49.2% occurs in intensive care. Fungal diseases affect ~228,695 (2.46%) of the population in the UAE.

The impact of permanent pacemaker implantation on long-term survival after cardiac surgery: A systematic review and meta-analysis.

OBJECTIVES: The long-term impact of permanent pacemaker (PPM) implantation on survival after cardiac surgery remains ill defined. We aimed to investigate the effect of PPM on survival and explore factors driving outcomes using meta-regression according to the type of surgery. METHODS: MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials were searched through October 2023 to identify studies reporting the long-term outcomes of PPM implantation. The primary outcome was all-cause mortality during follow-up. The secondary outcome was heart failure rehospitalization. The subgroup analysis and meta-regression analysis were performed according to the type of surgery. RESULTS: A total of 28 studies met the inclusion criteria. 183,555 patients (n = 6298; PPM, n = 177,257; no PPM) were analyzed for all-cause mortality, with a weighted median follow-up of 79.7 months. PPM implantation was associated with increased risks of all-cause mortality during follow-up (hazard ratio, 1.22; confidence interval, 1.08-1.38, P < .01) and heart failure rehospitalization (hazard ratio, 1.24; confidence interval, 1.01-1.52, P = .04). Meta-regression demonstrated the adverse impact of PPM was less prominent in patients undergoing mitral or tricuspid valve surgery, whereas studies with a greater proportion with aortic valve replacement were associated with worse outcomes. Similarly, a greater proportion with atrioventricular block as an indication of PPM was associated with worse survival. CONCLUSIONS: PPM implantation after cardiac surgery is associated with a greater risk of long-term all-cause mortality and heart failure rehospitalization. This impact is more prominent in patients undergoing aortic valve surgery or atrioventricular block as an indication than those undergoing mitral or tricuspid valve surgery.

The incidence and prevalence of serious fungal diseases in Tunisia.

With increasing concern about the negative health impact of fungal disease, there is a need to survey what is and is not known about the epidemiology of these infections in Tunisia. We have estimated the incidence and prevalence of the most serious fungal diseases in Tunisia for the first time. Using published literature from Tunisia, or if absent other countries, we have estimated the burden of life-threatening fungal infections and those causing significant morbidity, using deterministic modeling, based on populations at greatest risk. An estimated 250,494 (2.12% of the Tunisian population) are affected by a serious fungal disease annually. Invasive and chronic pulmonary aspergillosis are relatively common with 708 and 2090 patients affected, partly linked to the prevalence of chronic obstructive pulmonary disease (COPD). Fungal asthma (allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization) have an estimated prevalence of 38,264 (5.8% of the adult asthma population). Fungal keratitis probably affects 1,761 eyes annually, often leading to uniocular blindness. Candidaemia and Candida peritonitis probably affect at least 680 people annually, with a high mortality. Recurrent vulvovaginal candidiasis probably affects over 200,000 women. While fungal diseases are regularly diagnosed in Tunisia, epidemiological studies with denominators are uncommon. Some fungal diseases are poorly addressed with the current diagnostic portfolio, and surveillance is lacking. Studies on these diseases and the implementation of a national program of surveillance are required.

Triazole antifungal drug interactions-practical considerations for excellent prescribing.

Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.