Paradoxical Higher Myocardial Wall Stress and Increased Cardiac Remodeling Despite Lower Mass in Females.

Background Increased left ventricular (LV) mass is characterized by increased myocardial wall thickness and/or ventricular dilatation that is associated with worse outcomes. We aim to comprehensively compare sex-stratified associations between measures of LV remodeling and increasing LV mass in the general population. Methods and Results Participants were prospectively recruited in the National Heart Center Singapore Biobank to examine health and cardiovascular risk factors in the general population. Cardiovascular magnetic resonance was performed in all individuals. Participants with established cardiovascular diseases and abnormal cardiovascular magnetic resonance scan results were excluded. Global and regional measures of LV remodeling (geometry, function, interstitial volumes, and wall stress) were performed using conventional image analysis and novel 3-dimensional machine learning phenotyping. Sex-stratified analyses were performed in 1005 participants (57% males; 53±13 years). Age and prevalence of cardiovascular risk factors were well-matched in both sexes (P>0.05 for all). Progressive increase in LV mass was associated with increased concentricity in either sex, but to a greater extent in females. Compared with males, females had higher wall stress (mean difference: 170 mm Hg, P<0.0001) despite smaller LV mass (42.4±8.2 versus 55.6±14.2 g/m2, P<0.0001), lower blood pressures (P<0.0001), and higher LV ejection fraction (61.9±5.9% versus 58.6±6.4%, P<0.0001). The regions of increased concentric remodeling corresponded to regions of increased wall stress. Compared with males, females had increased extracellular volume fraction (27.1±2.4% versus 25.1±2.9%, P<0.0001). Conclusions Compared with males, females have lower LV mass, increased wall stress, and concentric remodeling. These findings provide mechanistic insights that females are susceptible to particular cardiovascular complications.

Candida catheter-related bloodstream infection in patients on home parenteral nutrition - Rates, risk factors, outcomes, and management.

BACKGROUND: Catheter-related bloodstream infections (CRBSIs) are life-threatening complications for home parenteral nutrition (HPN) patients. This review clarifies Candida CRBSI rates by species, risk factors, outcomes, and management to improve effectiveness of HPN programs. METHODS: A review of Candida CRBSIs in HPN patients was conducted around the following questions: 1. How often do adult and paediatric HPN patients contract Candida CRBSIs? 2. What is the proportion of different Candida species? 3. What are the risk factors? 4. How are outcomes in Candida versus other CRBSIs? 5. What are current guidelines to manage Candida CRBSIs? Specifically, should catheters be removed? What antimicrobial therapy is indicated? Are catheter lock techniques effective? RESULTS: 20 studies were included - six paediatric and 14 adult. Candida represented 9.8% of paediatric CRBSIs and 11.7% of adult CRBSIs. Paediatric candidal CRBSIs featured these species: C. albicans (46.2%), C. parapsilosis (34.6%), Candida guilliermondii (11.5%), Candida tropicalis (3.8%), and mixed or other types of Candida (3.8%). Adult candidal CRBSIs featured these species: C. albicans (37.3%), C. glabrata (33.3%), C. parapsilosis (22.4%), mixed or other types of Candida (5.7%), and C. tropicalis (1.3%). Risk factors for paediatric HPN CRBSIs include underlying haematological disease and previous fungaemia. Candida infection is associated with mortality rates around 30%. In Candida CRBSIs, major guidelines advocate catheter removal prior to systemic antifungal treatment (fluconazole, amphotericin B, echinocandins), ideally until 14 days after the first negative blood culture; some studies suggest the possibility of systemic therapy while catheters remain in-situ to preserve crucial line access. Various catheter lock solutions are effective as treatment and prophylaxis, but are not yet firmly established. CONCLUSIONS: Candida CRBSI is a significant danger to HPN patients causing high mortality; gold standard treatment is catheter removal and antifungal treatment, although treatments with catheters in-situ and catheter locks as prophylaxis appear to be gaining traction.

Future requirements for and supply of ophthalmologists for an aging population in Singapore.

BACKGROUND: Singapore's population, as that of many other countries, is aging; this is likely to lead to an increase in eye diseases and the demand for eye care. Since ophthalmologist training is long and expensive, early planning is essential. This paper forecasts workforce and training requirements for Singapore up to the year 2040 under several plausible future scenarios. METHODS: The Singapore Eye Care Workforce Model was created as a continuous time compartment model with explicit workforce stocks using system dynamics. The model has three modules: prevalence of eye disease, demand, and workforce requirements. The model is used to simulate the prevalence of eye diseases, patient visits, and workforce requirements for the public sector under different scenarios in order to determine training requirements. RESULTS: Four scenarios were constructed. Under the baseline business-as-usual scenario, the required number of ophthalmologists is projected to increase by 117% from 2015 to 2040. Under the current policy scenario (assuming an increase of service uptake due to increased awareness, availability, and accessibility of eye care services), the increase will be 175%, while under the new model of care scenario (considering the additional effect of providing some services by non-ophthalmologists) the increase will only be 150%. The moderated workload scenario (assuming in addition a reduction of the clinical workload) projects an increase in the required number of ophthalmologists of 192% by 2040. Considering the uncertainties in the projected demand for eye care services, under the business-as-usual scenario, a residency intake of 8-22 residents per year is required, 17-21 under the current policy scenario, 14-18 under the new model of care scenario, and, under the moderated workload scenario, an intake of 18-23 residents per year is required. CONCLUSIONS: The results show that under all scenarios considered, Singapore's aging and growing population will result in an almost doubling of the number of Singaporeans with eye conditions, a significant increase in public sector eye care demand and, consequently, a greater requirement for ophthalmologists.