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Background This convergent parallel‐design mixed‐methods process evaluation of the QUARTET USA (Quadruple Ultra‐Low‐Dose Treatment for Hypertension USA) clinical trial (NCT03640312) explores patient and health care professional perceptions about the use of low‐dose quadruple therapy (LDQT) as a novel strategy for hypertension management. Methods and Results A survey of all 62 patients enrolled in the QUARTET USA trial was conducted. A subsample of 13 patients and 11 health care professionals, recruited via purposive sampling, took part in semistructured interviews. At enrollment, 68% of participants (mean [SD] age, 51.7 [11.5] years; 56% self‐identified as Hispanic: Mexican ethnicity, 16% as Hispanic: other ethnicity, 16% as Black race, 8% as White race, and 1.6% as South Asian race) reported that their current health depended on blood pressure medications, and 48% were concerned about blood pressure medications. At trial completion, 80% were satisfied with LDQT, 96% were certain the benefits of taking LDQT outweighed the disadvantages, and 96% reported that LDQT was convenient to take. Both patients and health care professionals found LDQT acceptable because it reduced patients' perceived pill burden and facilitated medication adherence. Health care professionals stated that a perceived limitation of LDQT was the inability to titrate doses. Steps to facilitate LDQT implementation include introducing stepped‐care combinations and treatment protocols, inclusion in clinical practice guidelines, and eliminating patient cost barriers. Conclusions LDQT was an acceptable strategy for hypertension treatment among patients and health care professionals involved in the QUARTET USA clinical trial. Although LDQT was generally perceived as beneficial for maintaining patients' blood pressure control and facilitating adherence, some clinicians perceived limitations in titration inflexibility, adverse effects, and costs. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03640312.

Objective: The Acute Physiology and Chronic Health Evaluation (APACHE) is a severity scoring system used to predict healthcare outcomes and make inferences regarding quality of care. APACHE was designed and validated for use in general ICU populations, but its performance in specific subgroups of ICU patients is unproven. Quantitative performance referents for severity scoring systems like APACHE have not been established. This study compares the performance of APACHE IVa in several common subgroups of ICU patients to the performance of APACHE IVa and a referent scoring system applied in a general ICU population. Design: Observational cohort. Setting: Seventeen ICUs. Patients: Adult patients meeting criteria for APACHE IVa scoring. Intervention: We designed a “two-variable severity score” (2VSS) to provide “weak” reference values for explained variance (R2) and discriminant accuracy to use in our comparisons. R2 and AUROC were calculated for 2VSS and APACHE IVa outcome predictions in the overall cohort, and for APACHE IVa in subgroups with sepsis, acute myocardial infarction, coronary artery bypass grafting, stroke, gastrointestinal bleeding, trauma, or requiring mechanical ventilation. APACHE IVa subgroup performance was compared to APACHE VIa and 2VSS performance in the overall cohort. Measurements and Main Results: APACHE IVa out-performed 2VSS in our cohort of 66,821 ICU patients (R2: 0.16 vs 0.09; AUROC: 0.89 vs 0.77). However, APACHE IVa performance was significantly diminished in subgroups with sepsis, coronary artery bypass grafting, gastrointestinal bleeding or requiring mechanical ventilation compared to its performance in the overall cohort analysis. APACHE IVa performance in patients undergoing CABG (R2: 0.03, AUROC: 0.74) failed to surpass 2VSS performance referents. Conclusions: The performance of severity scoring systems like APACHE might be insufficient to provide valid inferences regarding quality of care in select patient subgroups. Our analysis of 2VSS provides quantitative referents that could be useful in defining acceptable performance.

Alfonso Anton,1–4 Monica Fallon,3,5 Francesc Cots,2 María A Sebastian,6 Antonio Morilla-Grasa,4 Sergi Mojal,3 Xavier Castells2 1Medicine School, Universidad Internacional de Cataluña, 2Servei d’Estudies, Parc de Salut Mar, 3Instituto Hospital del Mar de Investigaciones Médicas (IMIM), 4Glaucoma Department, Instituto Catalán de Retina (ICR), 5Universidad Autónoma de Barcelona, 6Centro de Atención Primaria Larrard, Barcelona, Spain Purpose: To analyze the cost and detection rate of a screening program for detecting glaucoma with imaging devices. Materials and methods: In this cross-sectional study, a glaucoma screening program was applied in a population-based sample randomly selected from a population of 23,527. Screening targeted the population at risk of glaucoma. Examinations included optic disk tomography (Heidelberg retina tomograph [HRT]), nerve fiber analysis, and tonometry. Subjects who met at least 2 of 3 endpoints (HRT outside normal limits, nerve fiber index ≥30, or tonometry ≥21 mmHg) were referred for glaucoma consultation. The currently established (“conventional”) detection method was evaluated by recording data from primary care and ophthalmic consultations in the same population. The direct costs of screening and conventional detection were calculated by adding the unit costs generated during the diagnostic process. The detection rate of new glaucoma cases was assessed. Results: The screening program evaluated 414 subjects; 32 cases were referred for glaucoma consultation, 7 had glaucoma, and 10 had probable glaucoma. The current detection method assessed 677 glaucoma suspects in the population, of whom 29 were diagnosed with glaucoma or probable glaucoma. Glaucoma screening and the conventional detection method had detection rates of 4.1% and 3.1%, respectively, and the cost per case detected was 1,410 and 1,435€, respectively. The cost of screening 1 million inhabitants would be 5.1 million euros and would allow the detection of 4,715 new cases. Conclusion: The proposed screening method directed at population at risk allows a detection rate of 4.1% and a cost of 1,410 per case detected. Keywords: screening, glaucoma, cost, imaging devices, detection rate

Relative water content (RWC) is widely used to describe plant water status, and is commonly measured gravimetrically. The ephemeral nature of leaf fresh mass poses severe constraints for such measurements in field grown plants. These constraints can be overcome by transporting the leaves in waterproof containers into the lab. However, even then, leaves lose water, and other changes may happen. The effects of a delay on the measurement of RWC have not been quantified so far. In this study, the influence of duration of storage up to 96 h and storage temperature on RWC and its components was investigated for four species. Alnus incana subsp. rugosa (Du Roi) R.T. Clausen, Impatiens capensis Meerb., and Scirpus microcarpus J.Presl & C.Presl leaves were stored in plastic bags, whereas those of Comptonia peregrina (L.) J. M. Coult. were stored in plastic vials. RWC remained within 5% of the initial value during 24 h cool storage, but after that, larger changes were observed. The effects of storage were species specific, being most pronounced in species poorly protected against desiccation, and under warm conditions. The effects of storage were not only limited to water loss, but also included cellular degradation. In general, storage at 10°C for 24 h enables measurement of RWC for field-grown plants with accuracy of a few percent, but care has to be taken with species vulnerable to desiccation, possibly requiring faster measurement and a cooler storage temperature. Keywords: field measurement, plant water status, relative water content. Le contenu relatif en eau (RWC, acronyme de << relative water content>>) est largement utilise pour decrire le bilan hydrique d'une plante, et il est normalement mesure par gravimetrie. La nature ephemere de la masse foliaire fraiche pose des contraintes severes ti de telles mesures chez les vegetaux cultives en plein champ. Ces contraintes peuvent etre contournees en transportant les feuilles dans un recipient impermeable vers le laboratoire. Cependant, malgre cela, les feuilles perdent de l'eau et d'autres changements peuvent survenir. Les effets d'un delai dans la mesure du RWC n'ont pas ete quantifies jusqu'a present. Dans cette etude, l'influence de la duree d'un entreposage allant jusqu'a 96 h et de la temperature d'entreposage sur le RWC et ces composantes a ete examinee chez quatre especes. Les feuilles de Alnus incana subsp. rugosa (Du Roi) R.T. Clausen, Impatiens capensis Meerb. et Scirpus microcarpus J.Presl & C.Presl ont ete entreposees dans des sacs de plastique alors que les feuilles de Comptonia peregrina (L.) J.M.Coult. ont ete entreposes dans des flacons de plastique. La valeur du RWC restait a l'interieur d'une marge de 5 % de la valeur initiale durant 24 h d'entreposage au frais, mais apres ce delai, des changements plus importants etaient observes. Les effets de l'entreposage etaient specifiques a l'espece, etant plus prononces chez les especes pauvrement protegees de la dessiccation et sous des conditions plus chaudes. Les effets de l'entreposage n'etaient pas seulement limites a la perte d'eau mais incluaient aussi une degradation cellulaire. En general, un entreposage a 10°C pendant 24 h permet de mesurer le RWC chez les plantes cultivees en plein champ avec la meme precision a quelques points de pourcentage pres, mais un soin particulier doit etre apporte aux especes vulnerables a la dessiccation, qui demandent possiblement des mesures plus rapides et une temperature d'entreposage plus fraiches. [Traduit par la Redaction] Mots-cles : mesures en plein champ, bilan hydrique, contenu relatif en eau., Introduction Leaf relative water content (RWC) is commonly used to describe plant water status at a given time (Stocker 1929; Barrs 1968; Kramer 1969). It is a sensitive variable, which [...]

We report a patient with a novel presentation of anti-neutrophil cytoplasmic antibody positive (ANCA+) vasculitis of the brain and oral mucosa. ANCA+ vasculitis of the brain is usually associated with pachymeningitis and hypophysitis, and there are no cases reported with simultaneous brain and oral mucosal involvement. A 35-year-old African Zambian man presented with headache and bleeding swollen gingiva. He was myeloperoxidase (MPO) antibody positive with cytoplasmic staining. His MRI showed stable small callosal, periventricular and subcortical white matter non-enhancing lesions, without change over 15 months—compatible with vasculitis. His gingival biopsy was consistent with vasculitis. His headache and oral lesions responded to oral corticosteroids and intravenous immunoglobulin which have induced clinical remission. Our patient expands the clinical syndrome of ANCA+ MPO+ C-type vasculitis of the central nervous system with headaches complicating cerebral vasculitis and oral mucosal involvement. [ABSTRACT FROM AUTHOR]

Worldwide, cancer pain management follows the World Health Organization (WHO) three-step analgesic ladder. Using weak opioids (e.g. codeine) at step 2 is debatable with low-dose strong opioids being potentially better, particularly in low- and middle-income countries where weak opioids are expensive. We wanted to assess the efficiency, safety and cost of omitting step 2 of the WHO ladder. We carried out an international, open-label, randomised (1 : 1) parallel group trial. Eligible patients had cancer, pain ≥4/10 on a 0-10 numerical rating scale, required at least step 1 (paracetamol) of the WHO ladder and were randomised to the control arm (weak opioid, step 2 of the WHO ladder) or the experimental arm (strong opioid, step 3). Primary outcome was time to stable pain control (3 consecutive days with pain ≤3). Secondary outcomes included distress, opioid-related side-effects and costs. The primary outcome analysis was by intention to treat and the follow-up was for 20 days. One hundred and fifty-three patients were randomised (76 control, 77 experimental). There was no statistically significant difference in time to stable pain control between the arms, P = 0.667 (log-rank test). The adjusted hazard ratio for the control arm was 1.03 (95% confidence interval 0.72-1.49). In the control arm, 38 patients (53%) needed to change to a strong opioid due to ineffective analgesia. The median time to change was day 6 (interquartile range 4-11). Compared to the control arm, patients in the experimental arm had less nausea (P = 0.009) and costs were less. This trial provides some evidence that the two-step approach is an alternative option for cancer pain management. • For decades the empirical WHO 3 step analgesic ladder has remained the keystone to cancer pain management education worldwide. • Debate has existed around the need for step 2 of the analgesic ladder which consists of weak opioids, such as codeine. • We examined pain and side-effects between the standard 3 step (weak to strong opioid) and a 2 step arm (no weak opioid). • Time to pain control equal in both arms, fewer side effects in 2 step arm, 50% in control arm needed strong opioid by day 7. • Important practical implications, particularly in LMICs where weak opioids (step 2) are expensive and switching complicated. [ABSTRACT FROM AUTHOR]