Enhancing the Management of Benign Prostatic Hyperplasia: The Role of Electronic Health Record Patient Portal Distribution of the International Prostate Symptom Score

INTRODUCTION

Recent AUA guidelines for the management of benign prostatic hyperplasia (BPH) recommend routine collection of the International Prostate Symptom Score (IPSS) data, but routine collection can be challenging to fully implement. We investigated the impact of distributing the IPSS by electronic patient portal (EPP) on IPSS completion and its impact on BPH management.

METHODS

We performed a retrospective, longitudinal study of men undergoing a new patient visit (NPV) for BPH at our academic medical center. From September 2019 to November 2022, we identified patients undergoing an NPV for BPH. Prior to January 2021, the IPSS was collected in person at NPVs via paper forms; afterwards, the IPSS was distributed before the NPV using the EPP. Our primary outcome was IPSS completion; secondary outcomes were new BPH medications and BPH surgery ordered within 6 months.

RESULTS

We identified 485 patients who underwent an NPV for BPH. EPP implementation significantly increased IPSS questionnaire completion (36.5% vs 56.9%, P < .0001). Following EPP implementation, we found that new BPH medications ordered at time of NPV decreased (10.4% vs 4.7%, P = .02). Although BPH surgery ordered within 6 months was similar, patients following EPP implementation had shorter time to BPH surgery compared to prior.

CONCLUSIONS

Our study revealed that EPP distribution of the IPSS improves IPSS collection compliance, aligning our practice closer with AUA guidelines. Routine collection of the IPSS may impact clinical practice through the detection of more severe BPH, which reduces medical BPH management and time to definitive BPH therapy. Further work is needed to confirm findings.

Validated Symptom Outcomes Following Septal Perforation Repair: Application of the NOSE-Perf Scale

OBJECTIVE

The Nasal Obstruction Symptom Evaluation (NOSE)-Perf scale was developed and validated to measure symptoms associated with nasal septal perforations. This study reports the application of the NOSE-Perf scale to evaluate symptom change following septal perforation repair.

METHODS

Patients with NOSE-Perf evaluations ≥6 months following attempted perforation closure from July 2018 to December 2021 utilizing bilateral nasal mucosal flaps with an interposition graft were eligible for study inclusion. Change in NOSE-Perf scores were noted. Patient demographics, perforation size, and concurrent functional procedures were analyzed for impact on symptom outcomes.

RESULTS

One-hundred and seventeen patients met the study criteria. Seventy-nine (67.5%) of the patients were female and the mean (range) age at surgery was 47.3 (14-78) years. Repair failure was noted in 7 (6.0%) patients. Mean (SD) preoperative NOSE-Perf score was 25.3 (95% CI, 23.5-27.1) and postoperative score was 7.9 (95% CI, 6.5-9.3). Minimal clinically important difference (MCID) was estimated and greater than 91% of patients had improvement above this threshold. Patient age, perforation size, or concurrent functional procedures did not impact outcomes. Postoperative scores at short (2-4 months), intermediate (5-8 months), and long-term (≥9 months) time periods showed significant improvement (all p < 0.001) compared to preoperative NOSE-Perf scores.

CONCLUSION

Significant reduction in nasal symptoms as measured by the NOSE-Perf scale is noted following bilateral mucosal flap repair. Although the nose does not completely normalize following repair, clinically important improvement was noted in at least 91% of patients. The NOSE-Perf scale is positioned to play a role in the standardization of septal perforation evaluation and outcomes assessment.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3067-3072, 2024.

Effect of Education on Symptom Management and Control in Cancer Patients Receiving Palliative Care

OBJECTIVE

This study aims to investigate the effect of an educational intervention on cancer patients receiving palliative care and their caregivers concerning symptom management and family needs.

METHODS

This study involved 120 participants-60 cancer patients and their respective caregivers-divided into intervention and control groups. Over a 2-week period, the intervention group received a comprehensive educational program focusing on symptom management, while the control group did not receive any educational intervention. The Edmonton Symptom Assessment System (ESAS) and Palliative Performance Scale (PPS) were used to assess patients' symptoms, their intensity, and performance, while the Family Need Scale (FNS) was utilized to evaluate caregivers' needs. These assessments were conducted at the beginning and end of the study. Primary outcomes focused on symptom assessment using ESAS and PPS, along with evaluating caregivers' needs through FNS. Secondary outcomes involved assessing participant satisfaction with the intervention.

RESULTS

At the end of the study, comparing initial and second evaluations, both ESAS and PPS scores significantly increased in the intervention and control groups (p = .003, p = .002, respectively). Additionally, a statistically significant decrease in the severity of symptoms, except for lethargy/hypokinesis, was observed in the intervention group compared to the control group. The FNS scale indicated that family needs satisfaction was higher in the intervention group compared to the control group. The data obtained demonstrated that there was a reduction the pain, fatigue, depression, anxiety, drowsiness, and shortness of breath levels in the intervention group compared to the control group, but there was no significant difference other than these symptoms.

CONCLUSIONS

The educational intervention positively impacted symptom management and family needs. Optimizing symptom control would greatly benefit palliative care patients and their caregivers.

Accessibility, Relevance, and Impact of a Symptom Monitoring Tool for Home Hospice Care: Theory Elaboration and Qualitative Assessment

BACKGROUND

Early users found Engagement and Visualization to Improve Symptoms in Oncology Care (ENVISION), a web-based application designed to improve home management of hospice patients' symptoms and support patients' and family caregivers' well-being, to be generally useful and easy to use. However, they also raised concerns about potential challenges users with limited technological proficiency might experience.

OBJECTIVE

We sought to concurrently accomplish two interrelated study aims: (1) to develop a conceptual framework of digital inclusivity for health information systems and (2) to apply the framework in evaluating the digital inclusivity of the ENVISION application.

METHODS

We engaged ENVISION users (N=34) in a qualitative study in which data were collected via direct observation, think-aloud techniques, and responses to open-ended queries. Data were analyzed via theory elaboration and basic qualitative description.

RESULTS

Accessibility, relevance, and impact were identified as 3 essential considerations in evaluating a health system's digital inclusivity. Study findings generally supported ENVISION's digital inclusivity, particularly concerning its perceived relevance to the work of family caregivers and hospice clinicians and its potentially positive impact on symptom management and quality of life. Limitations to ENVISION's digital inclusivity centered around issues of accessibility, particularly operability among individuals with limited technological knowledge and skills.

CONCLUSIONS

The Accessibility, Relevance, and Impact conceptual framework of digital inclusivity for health information systems can help identify opportunities to strengthen the digital inclusivity of tools, such as ENVISION, intended for use by a broad and diverse range of users.

Assessment of emotional distress in palliative care: Edmonton Symptom Assessment System-revised (ESAS-r) vs Distress Thermometer

OBJECTIVES

To evaluate the sensitivity and specificity of the Distress Thermometer (DT) as a screening tool for emotional distress in oncological palliative care patients and to compare the DT with the Edmonton Symptom Assessment System-revised (ESAS-r) and the gold standard to determine the most appropriate assessment method in palliative psychological care.

METHODS

Data were collected from psychological screening tests (ESAS-r and DT), and clinical interviews (gold standard) were conducted by a clinical psychologist specialist in palliative oncology from January 2021 to January 2022 in an oncology palliative care service.

RESULTS

The sample consisted of 356 first-time patients with a diagnosis of advanced cancer in palliative care. The most frequently reported oncological diagnoses were gastrointestinal tract (49.3%) and breast (18.3%). Most patients were female (n = 206; 57.9%), 60.4% were married/with a partner, 55.4% had between 6 and 9 years of schooling, and a median age of 57 (range, 46-65) years. The cutoff of the DT was 5, with a sensitivity of 75.88% and specificity of 54.3%. Emotional problems (sadness and nervousness) had a greater area under the curve (AUC) when measured using the DT than the ESAS-r; however, only in the case of the comparative sadness and discouragement was the difference between the AUC marginally significant.

SIGNIFICANCE OF RESULTS

The use of the DT as a screening tool in oncological palliative care is more effective in the evaluation of psychological needs than the ESAS-r. The DT, in addition to evaluation by an expert psychologist, allows for a more comprehensive identification of signs and symptoms to yield an accurate mental health diagnosis based on the International Classification of Diseases-11th Revision and/or Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition.

The Effect of the Neuman Systems Model-Based Training and Follow-up on Self-Efficacy and Symptom Control in Patients Undergoing Chemotherapy

In this article, the authors aimed to determine the effect of the training and follow-up based on the Neuman systems model provided to patients undergoing chemotherapy on their self-efficacy and symptom control. The study was carried out with a randomized controlled experimental study model design. The sample consisted of 102 patients including 52 in the experimental group and 50 in the control group. The data were collected using the Patient Information Form, the Cancer Behavior Inventory-Brief (CBI-B), and the Edmonton Symptom Assessment Scale (ESAS). A personal training program prepared according to the Neuman systems model was applied to the experimental group patients. In the intergroup comparison of the experimental and control group patients, there was an increase in the posttest CBI-B scores and a decrease in the ESAS scores in the experimental group compared to the control group, and the intergroup difference was statistically significant (p < .05). According to the results, to improve the self-efficacy and symptom control in patients undergoing chemotherapy, using this education and follow-up program is recommended.

Finalising the administration of co-SSPedi, a dyad approach to symptom screening for paediatric patients receiving cancer treatments

OBJECTIVES

Symptom Screening in Pediatrics Tool (SSPedi) is a validated self-report symptom screening tool for patients with cancer 8-18 years of age. Co-SSPedi is a novel dyad approach in which both child and parent complete SSPedi together. The objective was to finalise the approach to co-SSPedi administration with instruction that is easy to understand, resulting in dyads completing co-SSPedi correctly.

METHOD

We enrolled child and parent dyads, who understood English and where children (4-18 years) had cancer or were hematopoietic stem cell transplantation recipients. We provided each dyad with instruction on how to complete co-SSPedi together. Mixed methods were used to determine how easy or hard the instruction was to understand. Two raters adjudicated if co-SSPedi was completed correctly. Dyads were enrolled in cohorts of 12 evenly divided by age (4-7, 8-10, 11-14 and 15-18 years).

RESULTS

We enrolled 5 cohorts of 12 dyads, resulting in 60 dyads. Following verbal instruction provided in the first cohort, we identified the need for written instruction emphasising children should wait for parent response prior to entering scores. The instruction was iteratively refined based on qualitative feedback until the fifth cohort, where all 12 dyads found the instruction easy to understand and completed co-SSPedi correctly.

CONCLUSIONS

We developed a standard approach to dyad symptom screening named co-SSPedi with instruction that is easy to understand, resulting in correct co-SSPedi completion. Future efforts should focus on co-SSPedi validation and understanding how co-SSPedi scores compare to self- or proxy-reported symptom reporting.

The impact of routine Edmonton symptom assessment system use on receiving palliative care services: results of a population-based retrospective-matched cohort analysis

BACKGROUND

In 2007, Cancer Care Ontario began standardised symptom assessment as part of routine care using the Edmonton Symptom Assessment System (ESAS).

AIM

The purpose of this study was to evaluate the impact of ESAS on receipt of palliative care when compared with a matched group of unexposed patients.

DESIGN

A retrospective-matched cohort study examined the impact of ESAS screening on initiation of palliative care services provided by physicians or homecare nurses. The study included adult patients diagnosed with cancer between 2007 and 2015. Exposure was defined as completing ≥1 ESAS during the study period. Using 4 hard and 14 propensity score-matched variables, patients with cancer exposed to ESAS were matched 1:1 to those who were not. Matched patients were followed from first ESAS until initiation of palliative care, death or end of study.

RESULTS

The final cohort consisted of 204 688 matched patients with no prior palliative care consult. The pairs were well matched. The cumulative incidence of receiving palliative care within the first 5 years was higher among those exposed to ESAS compared with those who were not (27.9% (95% CI: 27.5% to 28.2%) versus 27.9% (95% CI: 27.5% to 28.2%)), when death is considered as a competing event. In the adjusted cause-specific Cox proportional hazards model, ESAS assessment was associated with a 6% increase in palliative care services (HR: 1.06, 95% CI: 1.04 to 1.08).

CONCLUSION

We have demonstrated that patients exposed to ESAS were more likely to receive palliative care services compared with patients who were not exposed. This observation provides real-world data of the impact of routine assessment with a patient-reported outcome.

Adaptation and Validation of the Hebrew Version of the Nasal Obstruction Symptom Evaluation (NOSE) Scale

BACKGROUND

Nasal obstruction is one of the most common complaints in the practice of rhinology.

OBJECTIVES

To adapt the Nasal Obstruction Scale Evaluation (NOSE) questionnaire to Hebrew (H-NOSE) and to assess its sensitivity and specificity.

METHODS

Candidates for surgical intervention due to isolated nasal obstruction and healthy volunteers (controls) were included in the validation. The English NOSE questionnaire was translated into Hebrew and re-translated for translation validity. Patients completed the H-NOSE questionnaire before and after surgery for nasal obstruction. The same questionnaire was completed by the controls. Test-retest reliability was performed within 2 weeks. Psychometric properties (reliability, reproducibility, validity, and responsiveness) were assessed by a test-retest procedure, internal consistency, correlation to the Hebrew Sino-Nasal Outcome Tool 22 (He-SNOT-22), and response sensitivity.

RESULTS

In total, 179 patients with nasal obstruction and 74 controls completed the questionnaire. Cronbach's alpha score was 0.93 for internal consistency. The receiver operating characteristic curve demonstrated high sensitivity and specificity (< 90%) and area under the curve was 0.97. We found no significant difference in test-retest reliability. The difference between the pre- and postoperative questionnaire scores was highly significant (13.9 ± 4.0 vs. 3.2 ± 4.1, respectively, P < 0.001).

CONCLUSIONS

The H-NOSE questionnaire demonstrated reliable internal consistency, sensitivity, specificity, and reliability. The Hebrew version differentiated between patients and heathy controls and was easy to administer. This instrument is useful for Hebrew speaking patients who undergo surgery for nasal obstruction.

Study of correlation between Visual Prostate Symptom Score and International Prostate Symptom Score in men with lower urinary tract symptoms with reference to Uroflowmetry parameters in Indian population

PURPOSE

International prostate symptom score (IPSS) is a complex questionnaire method for objective assessment of Lower urinary tract symptoms. So, there is a need to develop a simple and easy scoring system that could be easily used for illiterates and older aged patients.

MATERIALS AND METHODS

It was a prospective observational study with 202 participants, conducted at the department of urology of a tertiary care hospital in eastern India. The patients more than 50 years of age, attending urology OPD with Lower urinary tract symptoms were included in the study. Printed IPSS and VPSS questionnaires were given to the patient to answer.

RESULTS

Eighty-two percent (82%) of the higher education group and 97% of the lower education group needed assistance to answer IPSS questionnaires while 18% of the higher education group and 44% of the lower education group needed assistance to answer VPSS questionnaires. Sixty-four (64%) of patients in our study belong to the high education level while 36% of patients belong to the low education group. The mean age was 60.1 years. The mean IPSS and VPSS were 19 and 11 respectively. The mean PSA was 1.5 ng/ml. The time taken to fill VPSS questionnaire was much less than IPSS questionnaires. All the patients felt that VPSS was easier. Statistically significant (p-value < 0.05) correlation was found between total IPSS and total VPSS, Q2 IPSS and Q1 VPSS, Q7 IPSS and Q2 VPSS, Q5 IPSS and Q3 VPSS, and IPSS Qol and VPSS Qol. A negative correlation was found between Q3 VPSS and Qmax, and Q5 IPSS and Qmax.

CONCLUSIONS

VPSS can be used as an alternative tool to IPSS to assess LUTS, which uses pictograms instead of questionnaires, even in patients with limited education.

Validation of the Arabic Version of the Edmonton Symptom Assessment System

Quality cancer care is a team effort. In addition, patients' symptoms change over the course of treatment. As such, the Edmonton Symptom Assessment System (ESAS) is a simple tool designed to quickly monitor symptom change. Here, we present the results from a two-phase study aimed at validating the Arabic version of the ESAS (ESAS-A). Phase one involved the creation of two versions of the ESAS with both reverse and forward translations by bilingual, native Arabic speakers as well as evaluation by an expert panel. The reconciled version was then administered to 20 patients as a pilot from which to create the final version, which was then used with 244 patients. Phase two for the ESAS-involved an ESAS-based validation of 244 adults aged 18 years and older who were diagnosed with advanced cancer; then, further validation was completed in conjunction with two other symptom survey tools, the EORTC-Pal 15 and the HADS. The ESAS-A items possessed good internal consistency with an average Cronbach's alpha of 0.84, ranging from 0.82 to 0.85. Moreover, the results of ESAS-A showed good agreement with those of EORTC QLQ- 15 PAL (r = 0.36 to 0.69) and HADS (r = 0.60 and 0.57) regarding anxiety and depression. We found the ESAS-A to be responsive to symptom change and a median time to completion of 3.73 min. The results of our study demonstrate that the ESAS-A is a reliable, valid, and feasible tool for the purposes of monitoring symptom change over the course of cancer treatment.

The Edmonton Symptom Assessment Scale in Heart Failure: A Systematic Review

BACKGROUND

Heart failure is a troublesome condition with high healthcare utilization and cost. Most individuals with heart failure experience multiple symptoms including breathlessness, pain, depression, and anxiety.

PURPOSE

The aim of this study was to review the literature describing the use of the Edmonton Symptom Assessment Scale to assess the burden of symptoms and the impact of symptoms on heart failure outcomes including quality of life and functional outcomes.

METHODS

The search engines PubMed, Scopus, CINAHL, and Web of Science were searched from January 2001 to March 2020. A review of literature was undertaken using key terms "heart failure," "CHF," "cardiac failure," "heart decompensation," "myocardial failure," "Edmonton Symptom Assessment Scale". Hand searching of articles was also undertaken.

RESULTS

The search resulted in 33 relevant articles, which were imported into Rayyan, a Web-based systematic review software program. We present synthesis of results of studies (1) using the Edmonton Symptom Assessment Scale as an assessment of symptom burden and (2) evaluating the impact of symptom burden on quality of life and functional status.

CONCLUSION

This review highlighted the Edmonton Symptom Assessment Scale as a predictive instrument to identify symptom burden, symptom clusters, and symptom changes for patients living with heart failure. The clinical use of the Edmonton Symptom Assessment Scale may identify treatment priorities, promote self-management, inform the treatment plan, and advance effective therapeutic adjustments. The symptom burden in heart failure is high, and improving the symptom experience is an important focus of future healthcare interventions. The Edmonton Symptom Assessment Scale has utility in heart failure management due to psychometric properties and ease of administration.

CLINICAL IMPLICATIONS

The Edmonton Symptom Assessment Scale may be useful in measuring patient-reported symptom burden in patients with heart failure in the clinical setting because it correlates well with other heart failure measures on quality of life and functional outcomes and provides useful information on symptom burden.

How Does Triage by an Electronic Symptom Checker Match with Triage by a Nurse?

Omaolo© electronic symptom checkers (ESCs) have been developed to make triage for primary health care patients in Finland. Based on the analysis of the patient's responses to a set of questions, the ESC classifies him/her as emergent, urgent, not urgent, or advices on self-care. In this study the user answered the questions posed by the electronic symptom checker, after which a nurse assessed the urgency of the same user's symptom. The triage nurse was not allowed to know the result of the electronic symptom assessment until he or she had assessed the patient's condition. The level of triage was compared between ESC and nurse in each individual case. Findings from 825 individual cases were analyzed. The mean "exactly matched" for all symptom estimates was 52.6%. The mean "exactly matched" or "overconservative but suitable" for all symptom assessments was 66.6%. Safe assessments of electronic symptom checkers accounted for 98.6% of all assessments. A case was defined as "safe" if the recommendation for action given by the symptom assessment was at most one level less urgent than the nurse's triage assessment of the same case. The findings show that electronic symptom assessments are safe compared to the assessment of an experienced nurse.

Correlation of self-efficacy and symptom control in cancer patients

OBJECTIVE

This cross-sectional study was planned to evaluate the self-efficacy and symptom control of cancer patients and to determine the factors affecting them.

METHODS

The sample of the study consisted of 329 cancer patients who were treated in the Medical Oncology Clinic of a university hospital between April and June 2019 and accepted to participate in the study. Data were collected using the Patient Characteristics Information Form, Cancer Behavior Inventory-Short Version (CBI-SV), and Edmonton Symptom Assessment Scale (ESAS). Percentage, mean, Mann-Whitney U test, and Kruskal-Wallis analysis of variance were used in the analysis of the data.

RESULTS

The mean CBI-SV score of the patients was 79.10 ± 17.55. It was determined that the highest mean score of ESAS of the patients was in the symptom of fatigue (3.53 ± 2.81). Some symptoms were statistically lower in patients with good income, who are working, and who are non-smokers. Also it was determined that the self-efficacy levels of the patients with good income and quitting smoking were higher (p < 0.05). At the same time, as the patients' self-efficacy scores increased, the severity of the symptoms they experienced decreased statistically (p < 0.05).

CONCLUSION

It was found that the patients' self-efficacy score was above the moderate level, the most intense symptom experienced by the patients was fatigue, and the severity of the symptoms decreased as the patients' self-efficacy level increased. In line with these results; the symptoms, self-efficacy perceptions, and affecting factors of cancer patients should be evaluated by nurses at regular intervals, and care and consultancy services should be provided.

Validation of the Nasal Obstruction Symptom Evaluation Scale in Mexican Adults

BACKGROUND

Nasal obstruction is a feeling of impaired airflow through the nose, caused by diverse factors with high prevalence. There are numerous methods to study it, being the most important subjective instrument the Nasal Obstruction Symptom Evaluation score, NOSE, with good structural validity and internal consistency. It has been translated and validated in several languages, including European Spanish, but hasn't been validated in Mexico.

AIM

Adapt and validate the NOSE scale to the Spanish language for a Mexican adult population.

METHODS

This study was conducted from May-August 2015. The scale was translated from English to Spanish and assessed by two experts to confirm its acceptability, being retranslated later. Adult subjects with native Mexican Spanish were recruited from the outpatient clinic, with chronic rhinopathy and without evidence of respiratory pathology. Both groups filled the scale, and anthropometric data were collected. A subgroup completed the instrument again after one month. STATA 15.1 was used for analysis.

RESULTS

The sample were 261 subjects. Cronbach alpha was 0.89, intraclass correlation coefficient 0.84, agreement limits -9.62 to 16.29. There was a statistically significant difference in score between groups. The area under the ROC curve was 0.855, with 83% sensibility and 76% specificity for a 20 total score. Moderate to strong item-total association was found with Spearman. The response model showed moderate item discrimination. In the factorial analysis, one factor was found, with an Eigenvalue of 3.21.

CONCLUSION

The adaptation of the NOSE scale is reliable and valid for its application in Mexican adult population.

Long-term outcomes of Holmium laser enucleation of prostate and predictive model for symptom recurrence

INTRODUCTION AND OBJECTIVES

Holmium laser enucleation of prostate (HoLEP) represents one of the most studied surgical techniques for benign prostatic hyperplasia (BPH). Its efficacy in symptom relief has been widely depicted. However, few evidence is available regarding the possible predictors of symptom recurrence. We aimed to evaluate long-term outcomes, symptom recurrence rate, and predictors in patients that underwent HoLEP.

MATERIALS AND METHODS

We retrospectively analyzed data from patients that consecutively underwent HoLEP for BPH from 2012 to 2015 at two tertiary referral centers. Functional outcomes were evaluated by uroflowmetry parameters and International Prostate Symptom Score (IPSS) questionnaire administration at follow-up visits at 12, 24, and 60 months. The primary outcome was the symptomatic patients' rate presenting lower urinary tract symptoms (LUTS) after 60 months from surgery, defined as in case of one or more of the following: IPSS more than 7, post voidal residue (PVR) more than 20 ml, need for medical therapy for LUTS or redo surgery for bladder outlet obstruction. Multivariable logistic regression analyses evaluated predictors for being symptomatic at follow-up. Covariates consisted of: preoperative peak flow rate (PFR), PVR, and IPSS, prostate volume, age (all as continuous), and surgical technique.

RESULTS

A total of 567 patients were available for our analyses. Median prostate volume was 80cc, with a median PFR of 8 ml/s and median PVR of 100cc. One hundred and twenty-five (22%) patients were found to be symptomatic at follow-up. Redo surgery was needed for 25 (4.4%) patients. After adjusting for possible confounders, an increase in preoperative PVR (odds ratio [OR] 1.005) and IPSS (OR 1.12) resulted as independent predictors for symptom recurrence (all p < 0.001).

CONCLUSIONS

HoLEP can provide durable symptom relief regardless of the chosen technique. Patients with an important preoperative symptom burden or a high PVR should be carefully counseled on the risk of symptom recurrence.

Two Symptoms to Triage Acute Concussions: Using Decision Tree Modeling to Predict Prolonged Recovery After a Concussion

OBJECTIVE

The objective was to examine the 22 variables from the Sport Concussion Assessment Tool's 5th Edition Symptom Evaluation using a decision tree analysis to identify those most likely to predict prolonged recovery after a sport-related concussion.

DESIGN

A cross-sectional design was used in this study. A total of 273 patients (52% men; mean age, 21 ± 7.6 yrs) initially assessed by either an emergency medicine or sport medicine physician within 14 days of concussion (mean, 6 ± 4 days) were included. The 22 symptoms from the Sport Concussion Assessment Tool's 5th Edition were included in a decision tree analysis performed using RStudio and the R package rpart. The decision tree was generated using a complexity parameter of 0.045, post hoc pruning was conducted with rpart, and the package carat was used to assess the final decision tree's accuracy, sensitivity and specificity.

RESULTS

Of the 22 variables, only 2 contributed toward the predictive splits: Feeling like "in a fog" and Sadness. The confusion matrix yielded a statistically significant accuracy of 0.7636 (P [accuracy > no information rate] = 0.00009678), sensitivity of 0.6429, specificity of 0.8889, positive predictive value of 0.8571, and negative predictive value of 0.7059.

CONCLUSIONS

Decision tree analysis yielded a statistically significant decision tree model that can be used clinically to identify patients at initial presentation who are at a higher risk of having prolonged symptoms lasting 28 days or more postconcussion.

Prevalence of growth hormone deficiency in patients with unexplained chronic fatigue after undergoing bone marrow transplantation in adulthood

PURPOSE

Many patients who undergo bone marrow transplantation (BMT) in adulthood experience unexplained chronic fatigue which can have a major impact on their health-related quality of life (QoL). Pre-BMT treatment regimens increase the risk of developing acquired growth hormone deficiency (GHD), which results in a clinical syndrome with decreased energy and has additionally been linked to metabolic syndrome.

METHODS

Using the gold-standard insulin hypoglycemic test (IHT), we evaluated the prevalence of GHD in 18 post-BMT adult patients with unexplained chronic fatigue, as well as the correlation between peak serum GH response and QoL scores, the metabolic syndrome, and insulin resistance. Peak serum GH cut-point less than 3.0 ug/L was used for the diagnosis of severe GHD. The Fatigue Severity Scale and Quality of Life in Adult GHD Assessment questionnaires were used to quantify fatigue symptoms.

RESULTS

The prevalence of severe GHD within this sample of 18 patients was 50%. A trend between lower peak serum GH response and higher fatigue and QoL-AGHDA scores was observed.

CONCLUSIONS

GHD may represent a remediable contributor to post-BMT chronic fatigue in adults, further studies are needed to evaluate the potential role of screening and GH replacement therapy in this vulnerable patient population.

IMPLICATIONS FOR CANCER SURVIVORS

GHD may be a treatable explanation for disabling post-BMT fatigue pending results of intervention studies.

The Longitudinal Distribution and Stability of Curved Basilar Artery Plaque: A Study Based on HR-MRI

AIMS

This study aims to evaluate the differences in the characteristics of atherosclerotic plaques in the proximal, curved, and distal segments of the curved basilar artery (BA) through high-resolution magnetic resonance imaging(HR-MRI).

METHODS

The imaging and clinical data of 146 patients were retrospectively analyzed. On the basis of three-dimensional (3D) time -of -flight magnetic resonance angiography (3D-TOF-MRA), 51 patients with BA curvature were selected for the study. The BA plaque is divided into three groups: proximal, curved, and distal. Plaques were identified and analyzed according to spin echo acquisition imaging via T1-weighted 3D volumetric isotropic Tse acquisition (T1W-3D -VISTA), and compare the differences in clinical related factors and plaque characteristics between groups. Diffusion-weighted imaging (DWI) and/or T2WI identified brainstem infarction. The patients were divided into symptomatic and asymptomatic groups. The correlation between plaque location and symptoms was identified and analyzed.

RESULTS

Among 51 patients, a total of 376 plaques were detected. Plaques in the proximal and curved segments are more common than those in the distal segments. Proximal plaques are more likely to have intraplaque hemorrhage ( P=0.002 ＜0.05). There was no significant difference in the distribution of criminal plaques and non-criminal plaques between each group (P=0.36 ＞0.05).

CONCLUSION

Plaques in the proximal and curved segments of the BA are more common than those in the distal segments. The proximal plaque is more prone to intraplaque hemorrhage.

Use of thyroid hormones in hypothyroid and euthyroid patients: A 2020 THESIS questionnaire survey of members of the Danish Endocrine Society

PURPOSE

The standard treatment of hypothyroidism is levothyroxine (LT4), which is available as tablets or soft-gel capsules in Denmark. This study aimed to investigate Danish endocrinologists' use of thyroid hormones in hypothyroid and euthyroid patients.

METHODS

An e-mail with an invitation to participate in an online survey investigating practices about substitution with thyroid hormones was sent to all members of the Danish Endocrine Society (DES).

RESULTS

Out of 488 eligible DES members, a total of 152 (31.2%) respondents were included in the analysis. The majority (94.1%) of responding DES members use LT4 as the treatment of choice. Other treatment options for hypothyroidism are also used, as 58.6% prescribe combination therapy with liothyronine (LT3) + LT4 in their clinical practice. LT4 + LT3 combination is preferred in patients with persistent symptoms of hypothyroidism despite biochemical euthyroidism on LT4 treatment. Over half of the respondents answered that thyroid hormone therapy is never indicated for euthyroid patients, but 42.1% will consider it for euthyroid infertile women with high antibody levels. In various conditions that could interfere with the absorption of LT4, most responding Danish endocrinologists prefer tablets and do not expect a significant difference when switching from one type of tablet formulation to another.

CONCLUSION

The treatment of choice for hypothyroidism is LT4. Combination therapy with LT4 + LT3 is considered for patients with persistent symptoms. Even in the presence of conditions affecting bioavailability, responding Danish endocrinologists prefer LT4 tablets rather than newer LT4 formulations, such as soft-gel capsules.

Serum concentrations of dihydrotestosterone are associated with symptoms of hypogonadism in biochemically eugonadal men

PURPOSE

Symptoms of hypogonadism are often reported by subjects with normal serum testosterone (T) levels. We aimed to assess the association between clinical symptoms in andrological outpatients and sex steroids levels.

METHODS

This is a retrospective cross-sectional cohort study in an Academic clinic and research unit. International Index of Erectile Function (IIEF, EF domain) and Aging Males Symptoms scale (AMS) questionnaires were completed by 635 and 574 men, respectively (mean age: 47.3 ± 13.9 and 47.4 ± 13.8 years, p = 0.829), free of interfering medications with complaints possibly related to hypogonadism.

RESULTS

Serum total/free T as well as dihydro-T (DHT) was associated with IIEF-EF and AMS scores in the overall population using univariate analyses. Multivariate approaches revealed DHT concentrations in subjects with normal T levels (n = 416, Total T > 12 nmol/L) to be significant predictors of AMS scores. A 0.1 nmol/l serum DHT increase within the eugonadal range was associated with a 4.67% decrease in odds of having worse symptoms (p = 0.011). In men with biochemical hypogonadism (Total T < 12 nmol/L), total and free T rather than DHT were associated with AMS results. This association was not found for IIEF-EF scores. Indirect effects of age and BMI were seen for relations with hormone concentrations but not questionnaire scores.

CONCLUSION

DHT can be associated with symptoms of hypogonadism in biochemically eugonadal men. Serum DHT measurement might be helpful once the diagnosis of hypogonadism has been ruled out but should not be routinely included in the primary diagnostic process.

Perceived Disease Activity in Rheumatoid Arthritis: When the Physician's Gender Matters

BACKGROUND

In rheumatoid arthritis (RA), females usually have a worse prognosis. To date, the influence of physician gender in the evaluation of RA activity is still largely unknown.

OBJECTIVES

To investigate the discrepancy in RA disease activity assessment between male and female physicians and to compare patient and evaluator perception of disease activity and global health (GH) status.

METHODS

One female and one male rheumatologist evaluated 154 RA patients recording tender and swollen joint count, GH, evaluator global assessment (EGA), and patient global assessment (PGA) disease activity. A third rheumatologist calculated DAS28, CDAI, and SDAI. Difference was evaluated by Wilcoxon test. Physician-patient agreement was assessed by intraclass correlation coefficient.

RESULTS

GH, PGA, and DAS28 were higher when recorded by the female examiner. Male EGA was higher than female. Among male patients, PGA was higher when collected by the female examiner. The probability of being judged as having an active disease did not rely on physician gender. The agreement with the physician's evaluation of disease activity was high. PGA values were higher than EGA in both examiners. The physician-patient agreement was moderate for the male examiner and good for the female. The female physician had a higher agreement with both genders.

CONCLUSIONS

Subjective measure of disease activity differs between female and male rheumatologists, contributing to a different evaluation of disease activity. Patients have a higher perception of disease activity compared to physicians. The stronger agreement between female physicians and patients may be related to a more emphatic setting established by the female physician.