Different patient versus provider perspectives on living with Cushing's disease

CONTEXT

Patients with Cushing's disease (CD) face challenges living with and receiving appropriate care for this rare, chronic condition. Even with successful treatment, many patients experience ongoing symptoms and impaired quality of life (QoL). Different perspectives and expectations between patients and healthcare providers (HCPs) may also impair well-being.

OBJECTIVE

To examine differences in perspectives on living with CD between patients and HCPs, and to compare care goals and unmet needs.

DESIGN

Memorial Sloan Kettering Pituitary Center established an annual pituitary symposium for pituitary patients and HCPs. Through anonymous pre-program surveys distributed at the 2020 and 2022 symposia, patients and HCPs answered questions related to their own sense, or perception of their patients' sense, of hope, choice, and loneliness in the context of living with CD.

PARTICIPANTS

From 655 participants over two educational events, 46 patients with CD and 116 HCPs were included. Median age of both groups was 51 years. 78.3% of the patients were female vs. 53.0% of the HCPs.

RESULTS

More patients than HCPs reported they had no choices in their treatment (21.7% vs. 0.9%, P < 0.001). More patients reported feeling alone living with CD than HCPs' perception of such (60.9% vs. 45.5%, P = 0.08). The most common personal care goal concern for patients was 'QoL/mental health,' vs. 'medical therapies/tumor control' for HCPs. The most common CD unmet need reported by patients was 'education/awareness' vs. 'medical therapies/tumor control' for HCPs.

CONCLUSIONS

CD patients experience long term symptoms and impaired QoL which may in part be due to a perception of lack of effective treatment options and little hope for improvement. Communicating experiences and care goals may improve long term outcomes for CD patients.

Identification of demyelinating lesions and application of McDonald criteria when confronted with white matter lesions on brain MRI

INTRODUCTION

White matter lesions (WML) on magnetic resonance imaging (MRI) are common in clinical practice. When analyzing WML, radiologists sometimes propose a pathophysiological mechanism to explain the observed MRI abnormalities, which can be a source of anxiety for patients. In some cases, discordance may appear between the patient's clinical symptoms and the identification of the MRI-appearing WML, leading to extensive diagnostic work-up. To avoid misdiagnosis, the analysis of WML should be standardized, and a consensual MRI reading approach is needed.

OBJECTIVE

To analyze the MRI WML identification process, associated diagnosis approach, and misinterpretations in physicians involved in WML routine practice.

METHODS

Through a survey distributed online to practitioners involved in WML diagnostic work-up, we described the leading causes of MRI expertise misdiagnosis and associated factors: clinical experience, physicians' subspecialty and location of practice, and type of device used to complete the survey. The survey consisted of sixteen T2-weighted images MRI analysis, from which ten were guided (binary response to lesion location identification), four were not shown (multiple possible answers), and two were associated with dissemination in space (DIS) McDonald criteria application. Two independent, experienced practitioners determined the correct answers before the participants' completion.

RESULTS

In total, 364 participants from the French Neuro Radiological (SFNR), French Neurological (SFN), and French Multiple Sclerosis (SFSEP) societies completed the survey entirely. According to lesion identification, 34.3% and 16.9% of the participants correctly identified juxtacortical and periventricular lesions, respectively, whereas 56.3% correctly identified non-guided lesions. Application of the 2017 McDonald's DIS criteria was correct for 35.3% of the participants. According to the global survey scoring, factors independently associated with correct answers in multivariate analysis were MS-expert subspecialty (P<0.001), young clinical practitioners (P=0.02), and the use of a computer instead of a smartphone to perform WML analysis (P=0.03).

CONCLUSION

Our results highlight the difficulties regarding WML analysis in clinical practice and suggest that radiologists and neurologists should rely on each other to ensure the diagnosis of multiple sclerosis and related disorders and limit misdiagnoses.

Critical Appraisal of Histologic Grading for Mucoepidermoid Carcinoma of Salivary Gland: Is an Objective Prognostic 2-tiered Grading System Possible?

Multiple 3-tiered grading systems exist for mucoepidermoid carcinoma (MEC), leading to controversial results on the frequency and prognostic values of each grade. We aimed to identify prognostic histologic factors and to evaluate grading schemes in this retrospective study of 262 resected primary head and neck MECs. The rate of nodal metastasis was 8.4%. Large tumor size, tumor fibrosis, infiltrative border, lymphovascular invasion, perineural invasion, atypical mitosis, mitotic index (MI) ≥4/2 mm 2 (4/10 HPFs), necrosis, and pT4 stage were associated with increased risk of nodal metastasis. The 5-year recurrence-free survival (RFS) was 95%. Significant prognostic factors for RFS included infiltrative border, tumor-associated lymphoid stroma, architectural patterns (macrocystic, microcystic, and noncystic), anaplasia, atypical mitosis, MI, necrosis, lymphovascular invasion, margin, pT stage, and tumor size. Nuclear anaplasia, high mitotic rate, and ≥25% microcystic component were significant independent prognostic factors on multivariate survival analysis. There was no significant difference between low-grade (LG) and intermediate-grade (IG) MECs in terms of risk of nodal metastasis and outcomes using all 4 known grading systems. Rather, high-grade MEC was consistently associated with an increased risk of nodal metastasis at presentation and decreased RFS and distant metastasis-free survival (DMFS) compared with the LG/IG MECs. We therefore recommend simplifying MEC grading to a 2-tiered grading scheme using MI and/or tumor necrosis. Using a 2-tiered grading, high-grade histology independently predict RFS, and is associated with a 25% risk of nodal metastasis, a 5-year RFS of 76%, and a 5-year DMFS of 76%, whereas LG MEC has a nodal metastasis rate of 7.0%, 5-year RFS of 97% and 5-year DMFS of 99%.

The Association Between Herpes Simplex Virus and Alzheimer's Disease: A Systematic Review

Alzheimer's disease (AD) is a significant public health concern, affecting more than 6 million Americans; and currently, there are no cure or effective treatment options. The underlying etiology and pathogenesis are not fully understood, presenting a barrier to therapy. A substantial amount of data exists associating infection with Herpes simplex virus 1 (HSV-1) and AD. This review of published studies highlights the epidemiological associations between HSV-1 and AD. A systematic search of PubMed, Embase, and Web of Science was conducted on January 6, 2022, using PRISMA guidelines. Articles that presented epidemiological data correlating HSV-1 with AD were included. Bibliographies were screened for additional relevant articles as well. After review, 21 studies were included: 2 review articles and 19 population-based studies including case control, cohort, and cross-sectional studies.  The quantitative data derived from the studies in this report substantiate a relationship between infection with HSV-1 and AD. Based on these results, it may be of reasonable benefit to more consistently treat latent or active HSV-1 infection with anti-viral medications to potentially reduce the risk of AD. Furthermore, a prospective randomized controlled clinical trial could elucidate the benefit of anti-viral therapy to prevent or limit AD.J Drugs Dermatol. 2023;22(10):1046-1052     doi:10.36849/JDD.6785.

Therapeutic inefficacy of protocol driven intravenous unfractionated heparin infusion in the current era

Unfractionated heparin (UFH) is commonly used for several life-threatening conditions requiring anticoagulant therapy but failure to reach therapeutic levels in 24 h can be associated with adverse outcomes. Use of low molecular weight heparin (LMWH) may provide an alternative while providing superior outcomes as compared to UFH. We studied 100 patients who underwent UFH therapy for >24 h and found that theoretically 80 % were eligible for LMWH therapy. Only 29 % and 40 % of the total aPTT draws were in the therapeutic window within the first 24 h and at 25-48 h respectively. This study reports that a vast majority of patients remain outside of therapeutic aPTT within first 24-48 h when anticoagulated with UFH. With high eligibility for LMWH therapy, its substitution can potentially lead to better patient outcomes, higher levels of therapeutic efficacy, and decrease in hospital resources.

Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Aqua polo: Preliminary feasibility and efficacy study of a programme of adapted, supervised water polo to reduce fatigue and improve women's psychological and social recovery after breast cancer treatment: A mixed-methods design

Physical activity has been shown to have many benefits, including reducing cancer-related fatigue (CRF) and improving psychological and physical recovery from breast cancer. Some authors have shown the benefits of aquatic practice, while others have detailed the benefits of group and supervised practice. We hypothesize that an innovative sports coaching proposal could allow a significant adherence of patients and contribute to their health improvement. The main objective is to study the feasibility of an adapted water polo programme (aqua polo) for women after breast cancer. Secondarily we will analyse the effect of such a practice on patients' recovery and study the relationship between coaches and participants. The use of mixed methods will allow us to question the underlying processes precisely. This is a prospective, non-randomized, monocentric study with a sample of 24 breast cancer patients after treatment. The intervention is a 20 week programme (1 session per week) of aqua polo in a swim club facility, supervised by professional water-polo coaches. The variables measured are patient participation, quality of life (QLQ BR23), CRF (R-PFS) and post-traumatic growth (PTG-I) as well as different variables to observe physical capacity (strength with dynamometer, step-test and arm amplitude). The quality of the coach-patient relationship will be evaluated (CART-Q) to explore its dynamics. Participatory observations and interviews will be carried out to report on the interactions between the coach and the participants during the sessions.

Registration number and name of trial registry

No. EudraCT or ID-RCB: 2019-A03003-54 and NCT: NCT04235946.

Outcomes for Organ Preservation with Chemoradiation Therapy for T4 Larynx and Hypopharynx Cancer

OBJECTIVE

Limited data is available to guide non-surgical management of Stage T4 larynx and hypopharynx cancer patients who have inoperable disease or refuse surgery. We aim to review the nonoperative management of T4 laryngeal and hypopharyngeal cancer and report the long-term therapeutic and functional outcomes.

METHODS

We reviewed the nonoperative management of T4 laryngeal (n = 44) and hypopharyngeal (n = 53) cancer from 1997 to 2015 and performed a univariate analysis (UVA).

RESULTS

The 2-/5-year OS rates were 73%/38% for larynx patients and 52%/29% for hypopharynx patients. Locoregional failure (LRF) occurred in 25% and 19% of larynx and hypopharynx patients, respectively. On UVA of the larynx subset, N3 nodal status and non-intensity-modulated radiation therapy were negatively associated with OS; treatment with radiation therapy alone impacted disease-free survival; and age >70 was associated with LRF. On UVA of the hypopharynx subset, only T4b status significantly impacted OS. In the larynx and hypopharynx groups, 68% and 85% received a percutaneous endoscopic gastrostomy (PEG) tube and 32% and 40% received a tracheostomy tube, respectively. At the last follow-up visit, 66% of our larynx cohort had neither tracheostomy or PEG placed and 40% of our hypopharynx cohort had neither.

CONCLUSION

We report better than previously noted outcomes among T4 larynx and hypopharynx patients who have unresectable disease or refuse surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1138-1145, 2023.

Detections of organophosphate and pyrethroid insecticide metabolites in urine and sweat obtained from women during infrared sauna and exercise: A pilot crossover study

Synthetic pesticides such as organophosphates and pyrethroids are commonly used worldwide yet the metabolic and long-term human health effects of these environmental exposures are unclear. Urinary detections of metabolites involving both classes of insecticides have been documented in various global populations. However, reports documenting similar detections in human sweat are sparse. In this study, the concentrations of four insecticide metabolites were measured using liquid chromatography coupled with tandem mass spectrometry in repeated sweat and urine collections (n = 85) from 10 women undergoing three interventions (control, infrared sauna and indoor bicycling) within a single-blinded randomised crossover trial. The Friedman test with post-hoc two-way analysis of variance, the related-samples Wilcoxon signed rank test and the Spearman's rank-order correlation test were used to analyse the results. Organophosphate metabolites were detected in 84.6% (22/26) and pyrethroids in 26.9% (7/26) of the collected sweat samples (pooled per individual, per intervention). Urinary concentrations of three of the four metabolites marginally increased after infrared sauna bathing: 3,5,6-trichloro-2-pyridinol (z = 2.395, p = 0.017); 3-phenoxybenzoic acid (z = 2.599, p = 0.009); and trans-3-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid (z = 2.090, p = 0.037). Urinary 3-phenoxybenzoic acid also increased after exercise (z = 2.073, p = 0.038) and demonstrated the most temporal variability (days to weeks) of any of the urinary metabolites. Definitive sweat/urine correlations were not demonstrated. These results indicate metabolites from organophosphate and pyrethroid pesticides can be detected in human sweat and this raises intriguing questions about perspiration and its role in the metabolism and excretion of synthetic pesticides.

Diversity in U.S. Cardiovascular Trainees and Leadership Where we are and What the Future Holds

Cardiovascular (CV) outcomes can be improved with commonality between provider and patient regarding gender and race/ethnicity. Slow growth in CV care provider diversity is an obstacle for women and underrepresented groups. The hope for more equitable outcomes is unlikely to be realized unless trends change in selection of CV fellows and program directors (PDs). We investigate longitudinal trends of gender and racial/ethnic composition of CV FITs. De-identified demographic data were compiled in a descriptive cross-sectional study from AAMC of internal medicine (IM) residents and CV FITs from 2011 through 2021 to evaluate gender and race/ethnicity trends among CV trainees. Trends of CV fellows who later became program directors were analyzed. In the US between 2011 and 2021, 53% of IM residents were male while 40% female (7% unreported). Among CV FITs, 78% were male and 21% female. Races/ethnicities among CV FITs consisted of 36% non-Hispanic white, 28% non-Hispanic Asian, 5% Hispanic, 4%Black, and 25% were classified within other race/ethnicity categories. The proportion who became CV program directors followed similarly: 79% of PDs were male and 21% female. Demographic profiles for CV FITs have not significantly changed over the past decade despite increased diversity among IM residents. Efforts to improve diversity of CV FITs and PDs need to be analyzed. Slow growth of diversity in CV FITs is outpaced by rising patient diversity, leading to disparities in care and poorer CV outcomes for women and underrepresented minorities. Recruiting, training, and retaining diverse CV FITs is necessary.

Sex Differences in Periprocedural and Long-Term Outcomes Following Transcatheter Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis

BACKGROUND

Atrial fibrillation (AF) is among the most common arrhythmias associated with an increased risk of cardioembolic phenomena, including stroke. Percutaneous left atrial appendage occlusion (LAAO) has proven beneficial in reducing stroke and mortality in patients with atrial fibrillation who have contraindications to anticoagulation. However, the sex differences in outcomes following LAAO have not been studied systematically.

METHODS

Electronic databases PUBMED, Embase, and Web of Science were systematically searched until March 2022 for studies evaluating patient outcomes following LAAO for AF. The primary outcomes of interest were the risks of periprocedural stroke, major bleeding, pericardial complications, and all-cause mortality. Secondary outcomes included stroke risks, major bleeding, device-related thrombus, cardiovascular and all-cause mortality on long-term follow-up. A random-effects model meta-analysis was conducted, and heterogeneity was assessed using the I-squared test.

RESULTS

Sixteen studies were included in the final analysis encompassing 111,775 patients, out of which 45,441 (40.7 %) were women. Women had a significantly higher risk of peri-procedural complications including all-cause mortality [relative risk (RR), 95 % confidence intervals (CI); RR 1.94, 95 % CI 1.40-2.69], stroke [RR 1.85, 95 % CI 1.29-2.67], major bleeding [RR 1.63, 95 % CI 1.08-2.44], and pericardial events [RR 1.80, 95 % CI 1.58-2.05]. However, there were no statistically significant differences between sexes in terms of risk of stroke, major bleeding, device-related thrombus, cardiovascular and all-cause mortality on long-term follow-up.

CONCLUSION

Among patients undergoing LAAO implantation, women were at higher risk of periprocedural complications than men. This risk was not significant on long-term follow-up.

The effect of the right care, right place, right time (R3) initiative on Medicare health service use among older affordable housing residents

OBJECTIVE

To determine the effect of an affordable housing-based supportive services intervention, which partnered with health and community service providers, on Medicare health service use among residents.

DATA SOURCES

Analyses used aggregated fee-for-service Medicare claims data from 2017 to 2020 for beneficiaries living in 34 buildings in eastern Massachusetts.

STUDY DESIGN

Using a quasi-experimental design, a "difference-in-differences" framework was employed to isolate changes in outcomes, focusing on changes in pre- and post-intervention health service use across two stages of the intervention. Phase 1 encompassed the initial implementation period, and Phase 2 introduced a strategy to target residents at high risk of poor health outcomes. Key health service outcomes included hospitalizations, 30-day hospital readmission, and emergency department use.

DATA COLLECTION

Medicare claims data for 10,412 individuals were obtained from a Quality Improvement Organization and aggregated at the building level.

PRINCIPAL FINDINGS

Analyses for Phase 1 found that hospital admission rates, emergency department admissions and payments, and hospital readmission rates grew more slowly for intervention sites than comparison sites. These findings were strengthened after the introduction of risk-targeting in Phase 2. Compared to selected control buildings, residents in intervention buildings experienced significantly lower rates of increases in inpatient hospitalization rates (-16% vs. +6%), hospital admission days (-25% vs. +29%), average hospital days (-12% vs. +14%), hospital admission payments (-22% vs. +33%), and 30-day hospital readmission rates (-22% vs. +54%). When accounting for the older age of the intervention residents, the size of the decline recorded in emergency department admissions was 6.7% greater for the intervention sites than the decline in comparison sites.

CONCLUSIONS

A wellness-focused supportive services intervention was effective in reducing select health service use. The introduction of risk-targeting further strengthened this effect. Age-friendly health systems would benefit from enhanced partnerships with affordable housing sites to improve care and reduce service use for older residents.

Glycemic index and insulin index after a standard carbohydrate meal consumed with live kombucha: A randomised, placebo-controlled, crossover trial

Introduction

Kombucha is a complex probiotic beverage made from fermented tea, yet despite extensive historical, anecdotal, and in-vivo evidence for its health benefits, no controlled trials have been published on its effect on humans.

Methods

We conducted a randomised placebo-controlled, cross-over study that examined the Glycemic Index (GI) and Insulin Index (II) responses after a standardised high-GI meal consumed with three different test beverages (soda water, diet lemonade soft drink and an unpasteurised kombucha) in 11 healthy adults. The study was prospectively registered with the Australian New Zealand Clinical Trials Registry (anzctr.org.au: 12620000460909). Soda water was used as the control beverage. GI or II values were calculated by expressing the 2-h blood glucose or insulin response as a percentage of the response produced by 50 g of glucose dissolved in water.

Results

There was no statistically significant difference in GI or II between the standard meal consumed with soda water (GI: 86 and II: 85) or diet soft drink (GI: 84 and II: 81, (p = 0.929 for GI and p = 0.374 for II). In contrast, when kombucha was consumed there was a clinically significant reduction in GI and II (GI: 68, p = 0.041 and II: 70, p = 0.041) compared to the meal consumed with soda water.

Discussion

These results suggest live kombucha can produce reductions in acute postprandial hyperglycemia. Further studies examining the mechanisms and potential therapeutic benefits of kombucha are warranted.

Spontaneous immortalization of chicken fibroblasts generates stable, high-yield cell lines for serum-free production of cultured meat

Cellular agriculture could meet growing demand for animal products, but yields are typically low and regulatory bodies restrict genetic modification for cultured meat production. Here we demonstrate the spontaneous immortalization and genetic stability of fibroblasts derived from several chicken breeds. Cell lines were adapted to grow as single-cell suspensions using serum-free culture medium, reaching densities of 108 × 10⁶ cells per ml in continuous culture, corresponding to yields of 36% w/v. We show that lecithin activates peroxisome proliferator-activated receptor gamma (PPARγ), inducing adipogenesis in immortalized fibroblasts. Blending cultured adipocyte-like cells with extruded soy protein, formed chicken strips in which texture was supported by animal and plant proteins while aroma and flavour were driven by cultured animal fat. Visual and sensory analysis graded the product 4.5/5.0, with 85% of participants extremely likely to replace their food choice with this cultured meat product. Immortalization without genetic modification and high-yield manufacturing are critical for the market realization of cultured meat.

Patient selection for long-term secondary prevention with ticagrelor: insights from PEGASUS-TIMI 54

AIM

In patients with prior myocardial infarction (MI) on aspirin, the addition of ticagrelor reduces ischaemic risk but increases bleeding risk. The simultaneous assessment of baseline ischaemic and bleeding risk may assist clinicians in selecting patients who are most likely to have a favourable risk/benefit profile with long-term ticagrelor.

METHODS AND RESULTS

PEGASUS-TIMI 54 randomized 21 162 prior MI patients, 13 956 of which to the approved 60 mg dose or placebo and who had all necessary data. The primary efficacy endpoint was cardiovascular death, MI, or stroke, and the primary safety outcome was TIMI major bleeding; differences in Kaplan-Meier event rates at 3 years are presented. Post-hoc subgroups based on predictors of bleeding and ischaemic risk were merged into a selection algorithm. Patients were divided into four groups: those with a bleeding predictor (n = 2721, 19%) and then those without a bleeding predictor and either 0-1 ischaemic risk factor (IRF; n = 3004, 22%), 2 IRF (n = 4903, 35%), or ≥3 IRF (n = 3328, 24%). In patients at high bleeding risk, ticagrelor increased bleeding [absolute risk difference (ARD) +2.3%, 95% confidence interval (CI) 0.6, 3.9] and did not reduce the primary efficacy endpoint (ARD +0.08%, 95% CI -2.4 to 2.5). In patients at low bleeding risk, the ARDs in the primary efficacy endpoint with ticagrelor were -0.5% (-2.2, 1.3), -1.5% (-3.1, 0.02), and -2.6% (-5.0, -0.24, P = 0.03) in those with ≤1, 2, and 3 risk factors, respectively (P = 0.076 for trend across groups). There were significant trends for greater absolute risk reductions for cardiovascular death (P-trend 0.018), all-cause mortality (P-trend 0.027), and net outcomes (P-trend 0.037) with ticagrelor across these risk groups.

CONCLUSION

In a post-hoc exploratory analysis of patients with prior MI, long-term ticagrelor therapy appears to be best suited for those with prior MI with multiple IRFs at low bleeding risk.

CLINICAL TRIAL REGISTRATION

NCT01225562 ClinicalTrials.gov.

BUILDING CAPACITY FOR PATIENT-CENTERED OUTCOMES RESEARCH IN AGING RESEARCH: TRAINING ACROSS THE CONTINUUM

Patient-centered outcomes research (PCOR) models are increasingly used to ensure stakeholders inform evidence-based systems of care. Unfortunately, older adults are often left out of PCOR, leading to continued health and service disparities. The Aging PCOR Learning Collaborative was funded by the Patient-Centered Outcomes Research Institute in 2020 to conduct a series of training activities to change how older adults are viewed and engaged in research. Training was extended to Gerontology students, researchers new to engagement, established researchers, and to older adults to advance the strategies needed to infuse PCOR within aging research design and implementation. Project staff analyzed data relevant to these activities, which demonstrated the project’s reach to over 300 older adults, researchers, funders, and academic leaders. This session will review the steps required to implement training, our project reach, outputs, and mid-term outcomes, providing one of the first glimpses into how to measure this shift in our research paradigm.

HOUSING AND COMMUNITY PARTNER VIEWS ON THE BENEFITS OF THE R3 PROGRAM

Housing with services programs have potential to benefit residents and operators of affordable senior housing communities. This study aimed to understand housing and community partner views on the benefits of the R3 program. Data derived from 31 interviews with R3 program managers and wellness team members, executives and direct service staff at the intervention sites, and community partners. Overwhelmingly positive overall assessments of the R3 program were reported. Concrete benefits to residents included receiving additional attention and support; connecting with family and health care resources; enhancing group programming; preventing ambulance transports; helping with transitions; and improving health and quality of life. Psychosocial benefits to residents included: empowering program participants; providing socio-emotional support; and alleviating psychosocial distress. Benefits to housing sites included augmenting staffing levels, skills, and capabilities; proactively tracking and responding to resident needs; lowering resident turnover; and learning from and adopting procedures and processes underlying the R3 philosophy.

TARGETING PARTICIPANTS AT HIGH RISK FOR ADVERSE HEALTH OUTCOMES IN THE R3 PROGRAM

The R32 program seeks to ensure that individuals at high risk for adverse health outcomes are identified, engaged, and linked to needed services. The program pays particular attention to identifying individuals with risks related to mental health, memory, nutrition, food insecurity, and emergency department or inpatient hospitalizations. Key performance indicators were tracked, including the number and proportion of participants whose needs were addressed by R32. Results indicate that the program has succeeded in engaging the vast majority (>90%) of individuals with specific risk factors and connecting them with needed services. Viewed in the context of managed care plans, this level of performance is noteworthy and would earn the program a 5 Star rating – the highest rating available. Findings underscore the strong advantage offered by having a wellness nurse and wellness coordinator embedded on site in senior housing and using this platform to manage prevention and care services to residents.

THE EXPERIENCES OF PROGRAM PARTICIPANTS WITH THE R3 PROGRAM

The voluntary nature of the R3 program means that the experiences of residents who enroll in the program are critical to program success. Surveys were distributed to participants and non-participants in the intervention and control buildings during R32. Findings indicate that most enrollees are interacting with R32 staff; they trust them and feel that they provide important information; and they feel safer, less alone, and healthier because of their participation in the program. Roughly nine-in-ten are satisfied with the program and three in five would recommend it to a friend. Fully one-third believe that the program is helping them avoid medical emergencies necessitating a trip to the emergency room. When faced with a serious medical concern, residents in R32 buildings are far less likely to view calling 911 or going to the emergency room for treatment as a way to address their issue compared to individuals living in control buildings.

THE IMPACT OF THE R3 PROGRAM ON HEALTH SERVICES UTILIZATION AND COSTS

Relatively few housing with services evaluations use rigorous designs when assessing program impacts on health services utilization. This study thus employed a pre/post difference-in-difference quasi-experimental design, including building-level comparisons using Medicare fee-for-service claims data across two stages of the R3 intervention. Intervention sites included seven buildings with roughly 1,200 individuals. Key outcomes included hospital admissions, 30-day hospital readmission, and emergency department admissions. Results indicate that adding the R3 intervention to low-income housing sites led to meaningful reductions in service utilization and costs when compared to buildings where the program was not operating. The introduction of risk-targeting in the second stage of the intervention further strengthened this effect. Findings demonstrate that residents of affordable senior housing communities, who tend to be in poorer health than their counterparts in the community, benefit from the R3 program and that additional investment in this type of initiative would benefit the health care system.

ACHIEVING SUSTAINABILITY IN HOUSING WITH SERVICES: INSIGHTS FROM R3 PROGRAM

There has been a long-standing interest in developing housing models that integrate the supportive services that older people need to remain at home as long as possible. This approach has boomed for better-off people who can afford the cost of private-pay independent living and assisted living environments. For those with fewer resources, however, options are limited, given that they are largely dependent on public financing. This study focuses on how to develop sustainable models of housing with services for low-income older people. Using data from 31 key informant interviews and three focus groups, it reports and analyzes expert perspectives on how programs such as R3 can achieve financial sustainability. Four major themes emerged: (1) funding as the key to sustaining housing with services; (2) funding housing with services through participating health plans; (3) other potential funding sources for housing with services; and (4) gaining buy-in for housing with services.

Potential Role of Insulin-Like Growth Factors in Myofascial Pain Syndrome: A Narrative Review

ABSTRACT

Insulin-like growth factors have diverse functions in skeletal muscles by acting through multiple signaling pathways, including growth regulation and differentiation, anti-inflammation, and antioxidation. Insulin-like growth factors have anti-inflammatory effects and also play roles in nociceptive pathways, determining pain sensitivity, in addition to their protective role against ischemic injury in both the nervous system and skeletal muscle. In skeletal muscle, insulin-like growth factors maintain homeostasis, playing key roles in maintenance, accelerating muscle regeneration, and repair processes. As part of their maintenance role, increased levels of insulin-like growth factors may be required for the repair mechanisms after exercise. Although the role of insulin-like growth factors in myofascial pain syndrome is not completely understood, there is evidence from a recent study that insulin-like growth factor 2 levels in patients with myofascial pain syndrome are lower than those of healthy individuals and are associated with increased levels of inflammatory biomarkers. Importantly, higher insulin-like growth factor 2 levels are associated with increased pain severity in myofascial pain syndrome patients. This may suggest that too low or high insulin-like growth factor levels may contribute to musculoskeletal disorder process, whereas a midrange levels may optimize healing without contributing to pain hypersensitivity. Future studies are required to address the mechanisms of insulin-like growth factor 2 in myofascial pain syndrome and the optimal level as a therapeutic agent.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

A 2-4 keV multilayer mirrored channel for the NIF Dante system

During inertial confinement fusion experiments at the National Ignition Facility (NIF), a capsule filled with deuterium and tritium (DT) gas, surrounded by a DT ice layer and a high-density carbon ablator, is driven to the temperature and densities required to initiate fusion. In the indirect method, 2 MJ of NIF laser light heats the inside of a gold hohlraum to a radiation temperature of 300 eV; thermal x rays from the hohlraum interior couple to the capsule and create a central hotspot at tens of millions degrees Kelvin and a density of 100-200 g/cm³. During the laser interaction with the gold wall, m-band x rays are produced at ∼2.5 keV; these can penetrate into the capsule and preheat the ablator and DT fuel. Preheat can impact instability growth rates in the ablation front and at the fuel-ablator interface. Monitoring the hohlraum x-ray spectrum throughout the implosion is, therefore, critical; for this purpose, a Multilayer Mirror (MLM) with flat response in the 2-4 keV range has been installed in the NIF 37° Dante calorimeter. Precision engineering and x-ray calibration of components mean the channel will report 2-4 keV spectral power with an uncertainty of ±8.7%.

Active Surveillance of Papillary Thyroid Cancer: Frequency and Time Course of the Six Most Common Tumor Volume Kinetic Patterns

Background: The change in size of the papillary thyroid cancer (PTC) nodule during active surveillance has traditionally been characterized as either stable, increasing, or decreasing based on changes in maximal tumor diameter or tumor volume. More recently, it has been observed that the changes in tumor size observed during observation are more complex with tumor volume kinetic patterns that can be characterized either as stable (Pattern I), early increase in volume (Pattern II), later increase in volume (Pattern III), early increase in volume followed by stability (Pattern IV), stability followed by an increase in volume (Pattern V), or a decrease in tumor volume (Pattern VI). Methods: The frequency, time course, and clinical correlates of these six tumor volume kinetic patterns were analyzed in a cohort of 483 patients with low-risk PTC up to 1.5 cm in maximal diameter followed with active surveillance at our center for a median of 3.7 years. Results: The cumulative incidence of an increase in tumor volume for the entire cohort was 15.9% [confidence interval (CI) 11.8-20.0] at 5 years. At 5 years, most tumors demonstrated stability (78.8%, Pattern I) with 10.0% showing early growth (Pattern II), 4.1% late growth (Pattern III), 1.9% growth then stability (Pattern IV), 0.6% stability then growth (Pattern V), and 5.6% with a decrease in tumor volume (Pattern VI). Tumor volume doubling time during exponential growth significantly differed across the kinetic patterns, with median values of 2.4, 7.1, and 3.3 years for Patterns II, III, and IV, respectively (p < 0.01). Similarly, the time to a change in tumor volume was significantly different across the kinetic patterns, with median values of 1.5, 3, 1.6, 4.7, and 4.1 years for Patterns II, III, IV, V, and VI, respectively (analysis of variance, p < 0.01). Clinical correlates at baseline were not associated with tumor volume kinetic pattern. Conclusions: These six kinetic tumor volume patterns provide a comprehensive description of the changes in PTC tumor volume observed during the first 5 years of active surveillance.

Efficacy and safety outcomes of ultrasound assisted thrombolysis versus standard catheter direct thrombolysis in patients with submassive or massive pulmonary embolism: an updated meta-analysis

Background

The use of catheter-based thrombolysis in comparison to systemic thrombolytics has emerged as a potentially lifesaving therapy for patients with sub massive or massive pulmonary embolism (PE). The addition of ultrasound waves to accelerate lytic dispersion in ultrasound assisted thrombolysis (USAT) has been proposed to improve outcomes as compared to standard catheter-directed thrombolysis (SCDT). These two modalities have been compared in small studies, but larger population data on the outcomes of these therapies is still lacking.

Purpose

To assess the efficacy and safety of USAT versus SCDT in patients with submassive or massive pulmonary embolism.

Methods

A review of electronic databases (PubMed, Scopus, Embase, and Cochrane) was performed using keywords USAT, SCDT and PE and studies were included if efficacy and safety outcomes were compared between the two types of therapies. Efficacy outcomes that were evaluated included the reduction in right ventricle/left ventricle ratio (RV/LV ratio), pulmonary artery systolic pressure (PASP) and Miller score. Safety outcomes that were evaluated included major bleeding, mortality and length of ICU stay. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for continuous variables. Risk ratio (RR) and 95% CI were reported for dichotomous variables using the random effects model in comprehensive meta-analysis and RevMan 5.4.1 softwares.

Results

Six studies with a total of 381 patients (USAT n=204; SCDT n=177) were included. No statistical difference in efficacy outcomes of USAT over SCDT was noted in the degree of RV/LV ratio reduction (SMD: −0.507; CI: −1.386–0.373; p&gt;0.05; I2=92%), PASP reduction (SMD: 0.037; CI: −0.404–0.478; p&gt;0.05; I2=59%), or Miller score reduction (SMD: 0.303; CI: −0.481– 1.087; p&gt;0.05; I2=82%). Safety outcomes were also not statistically different with similar rates of major bleeding (RR: 1.44; CI: 0.54–3.85; p&gt;0.05; I2=4%), mortality (RR: 1.46; CI: 0.35–6.05; p&gt;0.05; I2=0%) and length of ICU stay (SMD: −0.01; CI: −0.29–0.27; p&gt;0.05; I2=31%) in both treatment groups.

Conclusion

Our data suggest that despite the technological advancement of USAT, there is no additional benefit over SCDT in terms of efficacy and safety. Further studies are warranted for both procedures investigating financial and clinical outcomes in real world practice.

Funding Acknowledgement

Type of funding sources: None.

Lipoprotein(a), cardiovascular events, and benefit of P2Y12 inhibition: insights from the PEGASUS-TIMI 54 trial

Background

Lp(a) plays a causal role in atherogenesis and may exert pro-thrombotic effects by inhibiting fibrinolysis owing to its structural homology with plasminogen. Patients with higher Lp(a) concentrations may derive greater benefit from anti-thrombotic therapy.

Purpose

We assessed whether patients with higher Lp(a) derive greater risk reduction from P2Y12 inhibition with ticagrelor vs. placebo on a background of aspirin therapy.

Methods

Lp(a) concentration was measured (Randox) in a prospective nested cohort of 8,967 pts enrolled in PEGASUS-TIMI 54, a randomized trial of ticagrelor vs. placebo in patients 1–3 years post MI (median follow-up: 2.7 y). Lp(a) was dichotomized at 200 nmol/L as an established threshold of risk. The prespecified MACE endpoint was CV death, MI or stroke, with KM rates reported at 3y. Cox proportional hazards were used to assess the relationship between Lp(a), MACE and treatment benefit. Models were adjusted for relevant baseline characteristics including apolipoprotein B.

Results

The median Lp(a) was 29 (25th-75th percentile: 12–137) nmol/L. A total of 1,053 pts (11.7%) had a high Lp(a) (≥200 nmol/L). In the pooled trial population, high Lp(a) concentration was associated with a 29% higher risk of MACE (9.1% vs 7.6%; adjusted hazard ratio [adj HR] 1.29, 95% confidence interval [CI] 1.02–1.62; p=0.03), including a 37% higher risk of MI (6.9% vs. 5.3%; adj HR 1.37, 95% CI 1.05–1.79; p=0.02). The hazard ratios for MACE with ticagrelor vs. placebo were 0.73 (95% CI 0.48–1.11) for patients with higher Lp(a) and 0.88 (95% CI 0.74–1.05) for patients with lower Lp(a) (p-interaction=0.41; Figure 1). The absolute risk reductions were 2.4% and 1.2%, respectively.

Conclusion

Lp(a) above 200 nmol/L identifies patients with prior MI at increased risk of MACE who may derive greater absolute risk reduction from treatment with ticagrelor. These exploratory observations provide insights for therapeutics that are evaluating the clinical benefit of Lp(a) reduction.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The PEGASUS-TIMI 54 trial was funded by AstraZeneca

T677T Methylenetetrahydrofolate Reductase Single Nucleotide Polymorphisms Increased Prevalence in a Subgroup of Infertile Patients with Endometriosis

<b><i>Background:</i></b> Approximately 10% (190 million) of women worldwide are affected by endometriosis, ectopic deposits of endometrial tissue that create a major source of pain that affects lifestyle and reproductive function. The pathogenesis of endometriosis is an estrogen-dependent inflammatory process, influenced/catalyzed by oxidative stress and consequently defective methylation, with biochemical features centered around the folate and one-carbon cycles. We aimed to determine whether a link could be found between the two major methylenetetrahydrofolate reductase single nucleotide polymorphisms (MTHFR SNPs), c.677C&gt;T and c.1298A&gt;C, involved in methylation process/epigenetic marking failures, and endometriosis. <b><i>Material and Methods:</i></b> We studied a population of 158 patients in a group of &gt;1500 referred for treatment of infertility. All the patients had experienced &gt;2 failed assisted reproductive technology cycles and/or &gt;2 miscarriages, a classical cohort for investigation in our group. Patients with endometriosis had at least stage 2+ disease confirmed by laparoscopy. <b><i>Results:</i></b> The prevalence of the homozygous c.677C&gt;T isoform is doubled in the endometriosis group, 21.5% versus 10.2% in the non-endometriosis group (<i>p</i> &gt; 0.01). Symmetrically, the percentage of patients in the endometriosis group with the wild type MTHFR significantly decreased by one-half (8.2%-17.2%) in the non-endometriosis group (<i>p</i> &lt; 0.001). <b><i>Conclusion:</i></b> Determination of MTHFR c.677C&gt;T should not be overlooked in patients with harmful endometriosis affecting their fertility. As folates metabolism is impaired in these MTHFR SNPs carrier patients, co-treatment with 5-methyl folate may constitute a successful (co)-treatment modality.

Endoscopic Endonasal Repair of Recurrent Cerebrospinal Fluid Leak With Adipofascial Anterolateral Thigh Free Flap: Case Report and Review of Literature

Background. Cerebrospinal fluid leaks are the most common complication of endoscopic endonasal skull base tumor resection. The workhorse nasoseptal flap or other vascularized intranasal flaps may not be a viable option in patients who have previously undergone surgery or local radiation; in these cases, pericranial flaps may also be unavailable. Free flap reconstruction in patients undergoing endoscopic resection is challenging because of limited exposure. The transmaxillary approach has recently been reported for free flap reconstruction of these defects. This report describes a patient with a pituitary tumor who underwent craniotomy and resection of a pituitary mass via an endoscopic endonasal approach. Postoperatively, the patient developed a high flow cerebrospinal fluid leak that did not resolve with lumbar drain and attempts at endoscopic revision of nasoseptal flap. An adipofascial anterolateral thigh free flap was harvested, based on the descending branch of the lateral circumflex femoral vessels. An upper gingivobuccal sulcus incision was used to access the maxilla. Openings were created in the anterior and medial maxillary sinus to create a passage to the sphenoid sinus. The flap was inset into the defect via this transmaxillary channel. The pedicle was tunneled subcutaneously through the cheek to recipient facial vessels. The procedure resulted in complete resolution of cerebrospinal fluid rhinorrhea and pneumocephalus. Imaging at 18 months showed the flap in good position. This report describes the technique in detail along with a review of the current literature.

Multimodality Imaging of Constrictive Pericarditis: Pathophysiology and New Concepts

Purpose of Review

The unique pathophysiological changes of constrictive pericarditis (CP) can now be identified with better imaging modalities, thereby helping in its early diagnosis. Through this review, we outline the pathophysiology of CP and its translation into symptomology and various imaging findings which then are used for both diagnosis and guiding treatment options for CP.

Recent Findings

Multimodality imaging has provided us with the capability to recognize early stages of the disease and identify patients with a potential for reversibility and can be treated with medical management. Additionally, peri-procedural planning and prediction of post-operative complications has been made possible with the use of advanced imaging techniques.

Summary

Advanced imaging has the potential to play a greater role in identification of patients with reversible disease process and provide peri-procedural risk stratification, thereby improving outcomes for patients with CP.

Red Light Phototherapy Using Light-Emitting Diodes Inhibits Melanoma Proliferation and Alters Tumor Microenvironments

Background

Total annual cancer rates have decreased due to improved treatment and prevention. However, the incidence of melanoma is rising, and not all patients respond to immune and targeted approaches. Therefore, we sought to determine the efficacy of red light (RL) phototherapy in preclinical models of melanoma.

Methods

Melanoma cells (A375, B16F10, MNT-1) were irradiated with RL. Melanoma proliferation, apoptosis, oxidative stress, and p53 phosphorylation were measured in vitro. In C57BL/6 mice, phototherapy safety, B16F10 tumor growth, and immunocyte infiltration were assessed following RL.

Results

In vitro, 640 J/cm² RL decreased cellular proliferation without increasing apoptosis, while 1280 J/cm² increased apoptosis. RL increased intracellular reactive oxygen species generation and p53 phosphorylation. In animal models, 2560 J/cm² RL significantly prevented melanoma growth and increased the expression of CD103+ dendritic cells. 1280 and 1920 J/cm² RL decreased tumor volume, but not significantly. RL did not cause skin inflammation or erythema in normal skin.

Conclusion

RL represents a potentially safe and effective melanoma therapeutic. RL prevented tumor growth and increased the expression of immune markers, such as CD103, that are associated with favorable melanoma outcomes. Further research is needed to determine the optimal clinical treatment regimen for melanoma using RL.

A pilot study of neoadjuvant cemiplimab with platinum-doublet chemotherapy and cetuximab in patients with resectable, locally advanced head and neck squamous cell carcinoma (HNSCC)

TPS6109

Background: Definitive treatment of locally advanced HNSCC can require radical surgery and reconstruction often resulting in unacceptable functional consequences. Radiotherapy, often with concurrent chemotherapy, is administered postoperatively to achieve the best chance for cure. Induction chemotherapy has previously been shown to reduce the extent of surgical resection and need for adjuvant radiation (RT). The purpose of this trial is to evaluate if an induction regimen combining cytotoxic chemotherapy, EGFR targeting, and immune checkpoint blockade can pathologically downstage resectable HNSCC sufficiently to decrease surgical morbidity and justify omission of adjuvant RT-based therapy. Compared to standard docetaxel, cisplatin, and 5-FU (TPF), docetaxel, cisplatin, and cetuximab (TPC) has been shown to be a therapeutic alternative with a more favorable toxicity profile. Targeting PD-1 alone can induce significant pathologic responses in resectable HNSCC patients. Combining PD-1 inhibitors with cetuximab has shown promising activity in incurable HNSCC; cetuximab may optimize the tumor immune microenvionment for PD-1 therapy by stimulating IFN-gamma secretion to increase dendritic cell maturation and CD8 T cell expression of PD1. Based on this rationale, we are evaluating the novel induction regimen of platinum, docetaxel, cetuximab plus cemiplimab (anti-PD1 antibody). Methods: This is a 10-patient pilot study for locally advanced, resectable HNSCC patients for whom standard management requires adjuvant RT +/- chemotherapy. Patients will receive neoadjuvant treatment with a loading dose of cetuximab and cemiplimab followed by 3 cycles of cisplatin or carboplatin, docetaxel, cetuximab and cemiplimab followed by definitive surgical resection of the primary site +/- neck dissection(s). Post-operative RT +/- radiosensitizing agent(s) will be administered per standard of care (SOC) based on pathologic staging (rather than clinical staging at presentation). If the pathologic stage following induction and surgery is ypT0-2N0 without adverse features, adjuvant RT will not be administered and 6 months of adjuvant cemiplimab will be given. Otherwise, patients will receive SOC adjuvant RT-based treatment. The primary endpoint is safety and tolerability. Secondary endpoints include feasibility assessed by the number of patients whose definitive surgery was delayed due to toxicity and quantifying the number in whom clinical to pathologic downstaging is achieved and the planned surgery and/or need for adjuvant-RT based therapy is modified. Exploratory endpoints include evaluating the association between biomarkers in the tumor microenvironment and peripheral blood with pathologic response. 8 of 10 patients have been enrolled. Clinical trial information: NCT04722523.

The involvement and autonomy of young children undergoing elective paediatric cardiac surgery: a qualitative study

Background

Standards generally reported in the literature about informing children and respecting their consent or refusal before elective heart surgery may differ from actual practice. This research aims to summarize the main themes in the literature about paediatric anaesthesia and compare these with research findings on how health professionals counsel young children before elective heart surgery, respect their consent or refusal, and maintain patient-centred care.

Methods

This qualitative research involved: literature reviews about children’s consent to surgery and major interventions; observations of wards, clinics and medical meetings in two paediatric cardiology departments, October 2019 to February 2020; audio-recorded semi-structured interviews with 45 hospital staff, including 5 anaesthetists, and related experts, November 2019 to April 2021; interviews with 16 families, with children aged 6- to 15-years and their parents shortly after elective heart surgery, and some months later (reported in other papers); thematic data analysis; and research reports on how different professions contribute to children’s informed decisions for heart surgery.

Results

The medical, ethics and English legal literature tend to assume legal minors cannot refuse major recommended treatment, and cannot consent until they are 12 years or older. Little is said about informing pre-competent children. If children resist, some anaesthetists rely on sedation and distraction, and avoid much informed discussion, aiming to reduce peri-operative anxiety. However, interviewees reported informing young children, and respecting their consent or refusal before elective surgery. They may delay elective surgery and provide further information and support, aiming to reduce fear and promote trust. Six years of age was commonly cited as the threshold for respecting consent to heart transplantation.

Conclusion

Differing views about younger children’s competence, anxiety and best interests support different reactions to children’s consent and refusal before elective heart surgery. This paper reports the zero-restraint policy followed for over a decade in at least one leading surgery centre. The related law and literature need to be updated, to take more account of evidence of actual practice.

Heart rate recovery is improved after locomotor training in persons with incomplete spinal cord injury: implications for health and prevention

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Heart rate recovery after exercise provides meaningful information about physical fitness and prognosis in both health and disease. A more rapid decrease in heart rate after exercise has been associated with higher levels of fitness as well as better health and survival. In fact, heart rate recovery (HRR) ≤ 12 beats at one minute after maximal and sub-maximal exercise is a significant prognostic index of poorer health and survival. However, little research has examined HRR in persons with spinal cord injury (SCI) despite the need for a responsive measure of fitness and health in this population.

Purpose

The purpose of this study was to examine HRR before and after locomotor training (LT) in persons with SCI.

Methods

Twenty-nine subjects with incomplete SCI performed LT 5 days per week for 12 weeks using one of four training approaches: treadmill-based training with manual assistance (TMM), treadmill-based training with stimulation (TMS), over-ground training with stimulation (OGS), and treadmill-based training with robotic assistance (TMR). Before and after 12 weeks of LT the HRR was measured one minute after 2-3 minutes of walking at each subject’s maximal capacity. Heart rate data was captured via a recording band placed on each subjects’ chest that transmitted wireless signals to a data collection system which recorded heart rate data continuously.

Results

The peak HR during maximal walking of the cohort before and after LT was 75 ±15% and 71 ±14% of the age-predicted maximal HR, respectively. Fifteen of the 29 subjects (52%) had an abnormal HRR (≤ 12 beats) at baseline; following LT, HRR was improved in 11/15 (73%) of these subjects. In addition, 50% of subjects with a normal baseline HRR improved HRR after LT. There was no significant difference in HRR among training approaches at baseline or after LT.

Conclusions

Twelve weeks of LT was associated with an improvement in HRR in almost three-quarters of the subjects with an abnormal HRR at baseline, and HRR improved in one-half of the subjects with a normal HRR at baseline. These findings suggest that HRR may be of value for tracking fitness and prognosis in persons with SCI. Further investigation of HRR in subjects with SCI is warranted.

Analysis of Reddit Reveals Dupilumab Questions Among Atopic Dermatitis Patients

BACKGROUND

Atopic dermatitis patients are turning to social media to seek guidance and source medical information. Reddit, the seventh most visited website in the US, contains the popular “eczeMABs” subreddit, a forum dedicated to discussing monoclonal antibody therapy for atopic dermatitis.

OBJECTIVE

To uncover atopic dermatitis patients’ dupilumab-related information needs.

METHODS

The authors analyzed all questions posted on the “eczeMABs” subreddit. Each question was then separated into categories and subcategories for analysis.

RESULTS

262 questions from 189 posts were analyzed. The greatest proportion of questions was related to side effects (36.3%), with patients most frequently inquiring about flares (25/95), ocular effects (17/95), and dry skin (10/95). Usage instructions (13.4%) and general experience (8.0%) were common question categories as well.

LIMITATIONS

The questions of the “eczeMABs” subreddit subscribers may not reflect the questions of all atopic dermatitis patients.

CONCLUSION

Reddit provides valuable insight into atopic dermatitis patient gaps in knowledge regarding dupilumab therapy. Physicians can use this knowledge to better address the information needs of patients, potentially leading to better outcomes and more informed, empowered patients. J Drugs Dermatol. 2022;21(3):292-294. doi:10.36849/JDD.5942.

[Long-term medical complications of Holocaust trauma]

Holocaust survivors are currently confronted with the problems inherent to ageing such as illness, frailty, dependency and isolation. A study was carried out to assess the long-term medical consequences of the Holocaust trauma.

A survey of elite and pre-elite athletes' perceptions of key support, lifestyle and performance factors

Background

Success at the elite level in sport is often attributed to physical prowess, technical skill, and mental attitude. However, underpinning these factors are various lifestyle, support and social factors that may contribute to successful performance, but which may be absent from athlete development programs.

Methods

An online survey was used to investigate athlete perceptions of lifestyle practices and support services amongst 135 Australian Olympic, Paralympic, National, and state-level athletes across 25 Olympic sports.

Results

International athletes perceived psychological skills and attributes, along with strong interpersonal relationships as vital to their success, and they also rated ‘Recovery practices’ as very important and made extensive use of available support services. These athletes also indicated that they would have liked access to these services earlier in their careers, a wish that was reiterated by the sub-elite athletes. Furthermore, athletes wanted greater knowledge, mentoring, and autonomy earlier in their careers, and the importance of ‘athlete wellbeing’ as well as ‘athletic performance’ was evident in a number of contexts.

Conclusions

An athlete development system into which these are included may assist in generating an environment that facilitates athlete success, repeated podium performances, retain athletes in high-performance sport for longer, encourage human-flourishing, wellbeing and smooth transitions for retiring athletes.