Identification and diagnosis of Secondary Progressive Multiple Sclerosis during the clinical encounter: Results from a physician survey

BACKGROUND

It is difficult to characterize the transition from relapsing-remitting multiple sclerosis (RRMS) to secondary progressive MS (SPMS), due to symptomatic variability across patients. Diagnosis of SPMS is prolonged and often established retrospectively, as it is based on patient clinical history and symptoms. This cross-sectional study aimed to identify MS neurologist reported clinical indicators deemed important in diagnosing SPMS in clinical practice.

METHODS

A web-based quantitative survey was conducted among MS-treating neurologists across the United States in January 2019. The questionnaire comprised of 17 questions evaluating primary clinical indicators used by neurologists in assessing patient progression to SPMS. Treatment approach and factors influencing treatment decision-making following SPMS diagnosis were also analyzed in the survey.

RESULTS

Overall, 300 neurologists completed the survey; most of the respondents were general MS-treating neurologists (63%) and from private care setting (58%). The overall respondents as well as MS-focused neurologists ranked patient history (45% and 42%, respectively) and patients' neurological exam (39% and 44%, respectively) as -primary clinical indicators of SPMS diagnosis. 57% of neurologists always or mostly switched disease modifying therapies after progression to SPMS, and mostly considered 3-6 months' assessment interval to diagnose SPMS.

CONCLUSION

The survey indicated that neurologists are able to recognize signs of SPMS within six months of symptomatic assessment. The diagnosis is primarily based on patient history among MS-treating neurologists. Therefore, continued education to neurologists may facilitate early diagnosis and timely introduction of effective treatment to manage the progression of SPMS.

Kerala Atrial Fibrillation Registry: a prospective observational study on clinical characteristics, treatment pattern and outcome of atrial fibrillation in Kerala, India, cohort profile

PURPOSE

Limited published data exist on the clinical epidemiology of atrial fibrillation (AF) in South Asia including India. Most of the published data are from the Western countries and the Far East. The Kerala AF registry was initiated to collect systematic, prospective data on clinical characteristics, risk factors, treatment pattern and outcomes of consecutive AF patients who consulted cardiologists across the state of Kerala, India.

PARTICIPANTS

All newly diagnosed and previously reported patients aged ≥18 years with documented evidence of AF on ECG were included. Patients with transient AF due to infection, acute myocardial infarction, alcohol intoxication, metabolic abnormalities and AF seen in postoperative cases and critically ill patients with life expectancy less than 30 days were excluded.

FINDINGS TO DATE

A total of 3421 patients were recruited from 53 hospitals across Kerala from April 2016 to April 2017. There were 51% (n=1744) women. The median age of the cohort was 65 (IQR 56-74) years. Hypertension, diabetes mellitus and dyslipidaemia were present in 53.8%, 34.5% and 42.2% patients, respectively. Chronic kidney disease was observed in 46.6%, coronary artery disease in 34.8% and heart failure (HF) in 26.5% of patients. Mean CHA₂DS₂-VASc score of the cohort was 2.9, and HAS-BLED score was 1.7. Detailed information of antithrombotic and antiarrhythmic drugs was collected at baseline and on follow-up. During 1-year follow-up, 443 deaths (12.9%) occurred of which 332 (9.7%) were cardiac death and 63 (1.8%) were due to stroke. There were 578 (16.8%) hospitalisations mainly due to acute coronary syndrome, arrythmias and HF.

FUTURE PLANS

Currently, this is the largest prospective study on AF patients from India, and the cohort will be followed for 5 years to observe the treatment patterns and clinical outcomes. The investigators encourage collaborations with national and international AF researchers.

TRIAL REGISTRATION NUMBER

CTRI/2017/10/010097.

Determining the cost of obesity and its common comorbidities from a commercial claims database

What is already known about this subject Obesity is highly prevalent and costly in the US. Obesity often leads to other comorbid conditions, including diabetes and hypertension. Obesity prevention efforts can reduce healthcare costs. What this study adds Obesity combined with other comorbidities significantly increases healthcare costs per patient visit. The combination of obesity and depression exacerbates costs. The most expensive series of chronic conditions in this study included obesity, diabetes, hypertension and depression. Our objectives were to determine payments made by commercial healthcare providers in the US for adults diagnosed with obesity, and those comorbid with any combination of selected chronic conditions. Using a commercial claims and encounters database (n = 3,562,717), we evaluated an adult study population that had at least one in-patient visit, outpatient visit or emergency department visit, and received a primary or secondary diagnosis of obesity. Persons were categorized by one or more comorbid diagnoses for diabetes mellitus, hypertension, depression or congestive heart failure. We adjusted for age and gender, and calculated the mean total net expenditures (in 2012, $US) for each combination of comorbid conditions based on individual visits to an in-patient, outpatient or emergency department setting. Among 50,717 claims with diagnosis of obesity, the mean net expenditure for in-patient and outpatient services was $ 1907 per patient per visit. Persons diagnosed with obesity and other comorbidities observed an increase in total net expenditures. Obesity and congestive heart failure observed the highest increase among single comorbidities at $ 5275. For persons with obesity and two other comorbidities, diabetes mellitus and depression was the highest at $ 15,226. The most expensive condition was obesity, diabetes mellitus, hypertension and depression at $ 15,733. Compared with average medical claims, persons diagnosed with obesity and other common chronic conditions experience significant increases in medical costs. These costs are often driven higher by time spent as in-patients. By controlling and reducing the prevalence of obesity, we may see significant decreases in medical expenditures.

Primary malignant tumors of orofacial region at Benghazi, Libya: a 17 years review

The aim of this study was to systematically analyze the clinical presentations of orofacial malignant tumors in a Libyan population over a period of 17 years and compare the results with the reports from other countries. During the study period, tumors of epithelial origin were found in 160 patients (82%), followed by tumors of immune system, 22 (11%) and tumors of mesenchymal origin, 14 (7%). Of the total malignant tumors, 115 were men and 81 were women and the male to female ratio was 1.41:1. Malignant non-odontogenic tumors were seen in 194 patients (99%) and malignant odontogenic tumors were seen in 2 patients (1%). Among the epithelial tumors, squamous cell carcinoma (50.6%) was the most common neoplasm, followed by mucoepidermoid carcinoma (15%) and adenoid cystic carcinoma (8.7%). The incidence of oral malignancy is impressively low with respect to the corresponding levels in other countries in Africa and some European countries.

Evaluation of health and pharmacy benefit information in health plan information packages

Consumers have ready access to their health plan information packages, and the utility of this source in providing information about health and pharmacy benefits to consumers should be evaluated. A preliminary evaluation using a sample of student consumers enrolled in a variety of health plans was conducted. Findings revealed that consumer information is lacking in areas related to the definition of pharmacy benefit terminology, cost sharing for medications and services, provider selection, and referral processes. Managed care decision makers will benefit from understanding the informational needs of their members and from designing health care benefit information to accommodate these needs.

An organizational tool to describe and evaluate group performance in the health care setting

OBJECTIVE

To develop and test a tool for evaluating the performance of working groups in the institutional health care setting and to discuss its utility for pharmacists and other health care providers.

DESIGN

A model for understanding how groups make decisions in health care settings was developed based on theories derived from organizational research. Our general group decision-making model was based on data collected from a national survey of members of hospital pharmacy and therapeutics (P&T) committees. Members were asked to describe how they interacted when making decisions regarding whether to add or delete drugs from their hospital's formulary. The relationships were examined using structural equation modeling.

SETTING

Large teaching hospitals.

PARTICIPANTS

Key members of P&T committees.

MAIN OUTCOME MEASURES

Committee members' responses about committee structure, organizational environment, quality of their interactions with each other, and the committee's decision-making abilities. Individual responses were aggregated into group measures to improve reliability and validity.

RESULTS

Responses were received from 114 of the 222 hospitals surveyed (51.3%), and analysis was conducted on 95 hospitals (42.8%) for which three or more group members responded. Positive interactions among group members had the greatest influence on the group's decision-making abilities (beta = 0.92). These interactions were facilitated by a well-designed group (gamma = 0.71) and the support of the environment within which the committee operates (gamma = 0.29).

CONCLUSION

The general group decision-making model tested in this study may be useful in understanding how the internal processes of health care groups such as P&T committees influence group performance and, hence, group outputs. Health care providers who apply a systematic approach to assessing group performance will find this model useful because it provides a starting point for examining the process, a way to show interrelationships among various group activities, and a guide to which strategies may be most effective for improving the decision-making process.

Environmental physiology of the mole crab Emerita asiatica, at a power plant discharge area on the east coast of India

Cage experiments at the discharge area of Madras Atomic Power Station (MAPS) facilitated studies of thermal tolerance in Emerita asiatica. At the laboratory, oxygen consumption at various temperatures and varying salinities was also investigated. In the field 100% mortality of crabs was recorded at the Condenser Cooling Water Pumps (CCWP) discharge site compared to no mortality at the Processed Sea Water Pumps (PSWP) site. This observation implicated temperature as a stress factor at the CCWP outfall, because other factors, including residual chlorine and water velocity, were the same at the PSWP and CCWP sites. Laboratory experiments on tolerance revealed that 38.5 degrees C was lethal to mole crabs. The time taken for 100% mortality decreased as the temperature increased from 35 to 40 degrees C. Oxygen metabolism showed a progressive increase with temperature from 29 to 36 degrees C, and declined at 37 degrees C. The influence of salinity on oxygen consumption was marginal at salinities of 20 to 35 per thousand but, when reduced to 15 per thousand, the oxygen consumption declined. The present study thus indicates that temperature could be the lethal factor, determining the distribution of mole crabs near the power station, where water temperature can exceed 40 degrees C.

Rectal varices in extrahepatic portal hypertension

Rectal varices, as distinct from haemorrhoids, occur due to high pressure in the inferior mesenteric venous system in patients with portal hypertension. The exact prevalence of rectal varices in extrahepatic portal hypertension is unknown. To determine this, 116 patients with extrahepatic portal hypertension were studied for the presence of rectal varices. These lesions were found in 103 (88.8%) patients. Bleeding from rectal varices occurred in 14.6% of patients. Massive bleeding requiring hospitalization and blood transfusion was not encountered. It is concluded that rectal varices are common in extrahepatic portal hypertension. Bleeding from them is uncommon, and often mild and self-limiting. The available literature is reviewed and the importance of recognizing the condition stressed.

Unusual presentations of duodenal tuberculosis

Gastrointestinal tuberculosis is still rampant in underdeveloped countries and can mimic other gastrointestinal (GI) disorders. Herein we report four cases of isolated proximal duodenal tuberculosis, without involvement of other parts of the GI tract. The clinical presentation in three of them resembled that of peptic ulcer disease, and one had features of gastric outlet obstruction. On investigation, one of these patients had a pyeloduodenal fistula. The limitations of clinical evaluation, radiology, and endoscopy are stressed, and the value of surgical biopsy is highlighted.

Randomised double blind placebo controlled clinical trial of sucralfate and ranitidine in chronic duodenal ulcer

A double blind, randomised, placebo controlled clinical trial was carried out in endoscopically proved chronic duodenal ulcer patients to compare the efficacy of sucralfate and ranitidine. Sucralfate 1 g four times daily and ranitidine 150 mg twice daily were found to be equally effective in inducing ulcer healing (73.1% and 82.1% respectively) during the 6-week treatment period. The rate of recurrence of the ulcer within six months after the initial treatment (84.2% and 82.6%) was also comparable in the sucralfate and ranitidine groups. Sucralfate and ranitidine are equally effective in ulcer healing and prevention of ulcer relapse.

Tricalcium phosphate ceramic as immediate root implants for the maintenance of alveolar bone in partially edentulous mandibular jaws. A clinical study

This study was undertaken to probe the efficacy of tricalcium phosphate ceramic (TCP) as an immediate root implant in the maintenance of alveolar bone. Three patients had five TCP root implants placed in fresh extraction sockets with soft tissue closure. The control and implant areas were evaluated at the 20th and 78th week on the basis of radiographic and clinical measurements. Tricalcium phosphate ceramic root implants in extraction sockets produced a significant increase in height and width of alveolar bone compared with control sites. It is believed that this method is a more effective and efficient procedure to preserve alveolar bone for the retention of dentures than other methods.

Corticosteroid treatment increases parasite numbers in murine giardiasis

Corticosteroid therapy is known to be hazardous in patients with occult infection but the mechanism by which the host parasite relationship is altered by steroids is not known. We have used an intestinal protozoal parasite, Giardia muris, to examine the effects of corticosteroids on the number of parasites in the intestine in the course of a primary infection. A single injection of cortisone acetate, subcutaneously, one day before oral inoculation of CBA mice with 1000 cysts of Giardia muris, resulted in significantly higher trophozoite counts in animals studied at one, two, three, four, and eight weeks post-infection, when they were compared with saline injected controls. Recrudescence of occult infection was also achieved by cortisone acetate treatment of mice which had been infected with Giardia muris eight months previously. Clinical studies are required to establish if recrudescence of occult protozoal infection is an important cause of morbidity when immunosuppressive therapy is given to patients in areas where giardiasis is endemic.

Comparative study of the methylglucamine salts of iodamide and iothalamate in clinical urography

In a comparative urographic study of the methylglucamine salts of iodamide (Uromiro 300) and iothalamate (Conray 280) the following conclusions have been made: (i) In subjects with radiologically normal kidneys and a creatinine clearance greater than 70 ml/min total urogram scores and nephrogram scores were higher with iodamide (not statistically significant). The improvement in performance was more marked in the nephrographic phase. (ii) In patients with radiologically normal kidneys and a spectrum of normal and abnormal renal function, total urogram scores and nephrogram scores showed no significant dependance on creatinine clearance. (iii) No correlations of note were observed between urographic performance and physical or biochemical parameters for either contrast medium. (iv) Side effects encountered in the study were mild and there were no significant differences between the contrast media in either the incidence or severity of the side effects. (v) Post-injection blood pressure profiles showed no significant differences between the media. (vi) Induced electrocardiographic abnormalities were uncommon and mild occurring in seven patients following iothalamate and three patients following iodamide.