A nomogram prediction model for mild cognitive impairment in non-dialysis outpatient patients with chronic kidney disease

BACKGROUND

The high prevalence of mild cognitive impairment (MCI) in non-dialysis individuals with chronic kidney disease (CKD) impacts their prognosis and quality of life.

OBJECTIVE

This study aims to investigate the variables associated with MCI in non-dialysis outpatient patients with CKD and to construct and verify a nomogram prediction model.

METHODS

416 participants selected from two hospitals in Chengdu, between January 2023 and June 2023. They were categorized into two groups: the MCI group (n = 210) and the non-MCI (n = 206). Univariate and multivariate binary logistic regression analyses were employed to identify independent influences (candidate predictor variables). Subsequently, regression models was constructed, and a nomogram was drawn. The restricted cubic spline diagram was drawn to further analyze the relationship between the continuous numerical variables and MCI. Internally validated using a bootstrap resampling procedure.

RESULTS

Among 416 patients, 210 (50.9%) had MCI. Logistic regression analysis revealed that age, educational level, occupational status, use of smartphones, sleep disorder, and hemoglobin were independent influencing factors of MCI (all p<.05). The model's area under the curve was 0.926,95% CI (0.902, 0.951), which was a good discriminatory measure; the Calibration curve, the Hosmer-Lemeshow test, and the Clinical Decision Curve suggested that the model had good calibration and clinical benefit. Internal validation results showed the consistency index was 0.926, 95%CI (0.925, 0.927).

CONCLUSION

The nomogram prediction model demonstrates good performance and can be used for early screening and prediction of MCI in non-dialysis patients with CKD. It provides valuable reference for medical staff to formulate corresponding intervention strategies.

Outpatient management of essential hypertension: a review based on the latest clinical guidelines

Background: Essential hypertension, a prevalent cardiovascular condition, poses a significant health burden worldwide. Based on the latest American clinical guidelines, half of adults in the United States have hypertension. Of these, only about a half are treated and about a quarter are adequately controlled for hypertension. Given its impact on morbidity and mortality, ensuring effective management of high blood pressure is crucial to reduce associated risks and improve patient outcomes.Objective: This review aims to provide a comprehensive and up-to-date summary of the latest cardiology guidelines and evidence-based research on essential hypertension, with a focus on guiding outpatient clinical practice.Methods: The review evaluates both non-pharmacological approaches and pharmacological interventions to offer clinicians practical insights. Notably, it emphasizes the importance of individualized treatment plans tailored to patients' specific risk profiles and comorbidities.Results: By consolidating the latest advancements in hypertension management, this review provides clinicians with an up-to-date reference, offering a nuanced understanding of treatment goals and strategies.Conclusion: Through the incorporation of evidence-based recommendations, healthcare practitioners can optimize patient care, mitigate potential complications, and improve overall outcomes in essential hypertension.

Association between endocrine and neuropsychological endophenotypes and gambling disorder severity

BACKGROUND

Neurobiological characteristics have been identified regarding the severity of gambling disorder (GD). The aims of this study were: (1) to examine, through a path analysis, whether there was a relationship between neuroendocrine features, potentially mediational GD variables, and GD severity, and (2) to associate neuroendocrine variables, with GD severity-related variables according to gambling preferences.

METHODS

The sample included 297 outpatients with GD. We analyzed endocrine concentrations of different appetite-related hormones (ghrelin, liver antimicrobial peptide 2 [LEAP-2], leptin, adiponectin), and neuropsychological performance (working memory, cognitive flexibility, inhibition, decision making, premorbid intelligence). Path analysis assessed mechanisms between neuroendocrine features and GD severity, including mediational GD variables (impulsivity traits and gambling-related cognitive distortions). Partial correlations evaluated the associations between neuroendocrine variables, including impulsivity traits, and variables related to GD severity (DSM-5, South Oaks Gambling Screen, illness duration, and gambling-related cognitive distortions).

RESULTS

Lower adiponectin concentrations predicted greater GD severity, while higher LEAP-2 concentrations predicted more gambling-related cognitive distortions. Likewise, better neuropsychological performance directly predicted GD severity, but worse neuropsychological performance was associated with GD severity through the mediational variables of impulsivity traits and gambling-related cognitive distortions. Also, in non-strategic individuals with GD, poor working memory was associated with gambling expectancies and predictive control. In strategic individuals with GD, poor cognitive flexibility was associated with illusion of control, predictive control, and inability to stop gambling.

CONCLUSIONS

These results provide updated information about the comprehension of the interaction between neuroendocrine features, clinical variables, and severity of GD. Thus, neurobiological functions seem to be strongly related to GD severity.

Prevalence of urogenital disease in male adolescent outpatient visits. A descriptive, cross-sectional study

Introduction. The male genital exam is a simple and quick assessment to look for urogenital disease. Data on the prevalence of urogenital disease in male adolescents are limited. Our objective was to describe the prevalence of urogenital disease in male adolescents. Population and methods. Descriptive, cross-sectional study conducted at the Department of Adolescence of a public hospital in the City of Buenos Aires. The medical records of male patients aged 9 to 20 years seen between 2008 and 2018 were retrospectively reviewed; all those with a genital exam were included. Data on age, pubertal stage, orchidometry, and urogenital disease before adolescence and at the time of consultation were recorded. The prevalence was described as percentage and 95% confidence interval (CI). As per estimations, 1167 medical records had to be included to establish the population sample. Results. A total of 2129 medical records were assessed and 1429 were included. No genital exam had been conducted in 686 cases. The median age of the population was 12 years (interquartile range: 11-14 years). Urogenital disease before adolescence was detected in 72 boys (5.7%; 95% CI: 4.5- 7.2). Urogenital disease was found in 272 adolescents (14.8%; 95% CI: 13.1-16.7); the most common conditions were balanopreputial adhesions in 5.3% (95% CI: 4.2-6.6), varicocele in 2.7% (95% CI: 2-3.7), and phimosis in 1.8% (95% CI: 1.2-2.6). Conclusions. A genital exam allowed to detect that 14.8% of adolescent boys had a urogenital disease. The most common conditions were balanopreputial adhesions, varicocele, and phimosis.

High persistence and low treatment rates of metabolic syndrome in patients with mood and anxiety disorders: A naturalistic follow-up study

BACKGROUND

Patients with affective and anxiety disorders are at risk of metabolic syndrome (MetS) and, consequently, cardiovascular disease and premature death. In this study, the course and treatment of MetS was investigated using longitudinal data from a naturalistic sample of affective- and anxiety-disordered outpatients (Monitoring Outcome of psychiatric PHARmacotherapy [MOPHAR]).

METHODS

Demographics, clinical characteristics, medication use, and MetS components were obtained for n = 2098 patients at baseline and, in a FU-subsample of n = 507 patients, after a median follow-up (FU) of 11 months. Furthermore, pharmacological treatment rates of MetS were investigated at baseline and FU. Finally, demographic and clinical determinants of change in MetS (component) scores were investigated.

RESULTS

At baseline, 34.6 % of n = 2098 patients had MetS, 41.4 % of whom received treatment. Of patients with persisting MetS, 46.1 % received treatment for one (or more) MetS component(s) at baseline, and 56.6 % received treatment at FU. Treatment rates of solely elevated blood pressure and reduced HDL-cholesterol did significantly, but modestly, improve. Higher age, male sex, smoking behavior, low education, diabetes, and depressive versus anxiety disorder were predictors of worse outcome at FU on at least one MetS component.

LIMITATIONS

We did not have data on lifestyle interventions as a form of treatment, which might partly have explained the observed low pharmacotherapeutic treatment rates.

CONCLUSION

MetS (components) show high persistence rates in affective- and anxiety-disordered patients, and are, despite adequate monitoring, undertreated over time. This indicates that adherence and implementation of monitoring protocols should be crucially improved in psychiatric outpatients in secondary care.

Association between self-perceived consultation time and understanding of the prescribed treatment: An analysis of a national survey in Peru

OBJECTIVE

To assess the relationship between the self-perceived consultation time and the knowledge of the proposed treatment.

METHODS

Secondary data from a 2015 national survey of health services in Peru were analyzed. The self-perceived consultation time was calculated by asking how long it took from when you entered the consultation until you departed. It was then categorized as low, medium, and high. Five self-reported questions were used to construct a knowledge of the prescribed treatment. Adjusted regression models from the Poisson family models were used to evaluate the relationship. We report adjusted prevalence ratios (aPR) with their 95% confidence intervals (95%CI).

RESULTS

A total of 9939 outpatients were analyzed, with 58% women; the average age was 44 years; and 45.4% had higher education. Using low self-perceived consultation time as references, medium and high consultation times were associated with understanding the prescribed treatment (aPR=1.17; 95%CI, 1.04-1.33 and aPR=1.30; 95%CI, 1.20-1.40, respectively).

CONCLUSION

Patients who reported a medium and high self-perceived consultation time better understood the prescribed treatment.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should strive to maximize consultation time to ensure effective communication and improve patient knowledge of treatments, improving overall patient satisfaction and health outcomes.

Differentiating hidradenitis suppurativa flare from infection in the emergency department and recommendations for transitioning care to the outpatient setting

Hidradenitis suppurativa is a painful and often progressive inflammatory skin condition that presents with papules, nodules, abscesses, and tunnels in the axillary, inframammary and anogenital regions. HS can be difficult to differentiate from a skin infection, such as a bacterial abscess. However, differentiation between the two is important as management of hidradenitis suppurativa often requires long-term follow-up and specialist care. Emergency physicians should be aware of how to differentiate acute hidradenitis suppurativa flares from similarly presenting conditions, particularly skin and soft tissue infection, when encountered in the emergency department and what steps should be taken to adequately bridge care to the outpatient setting.

Identifying unique subgroups in suicide risks among psychiatric outpatients

BACKGROUND

The presence of psychiatric disorders is widely recognized as one of the primary risk factors for suicide. A significant proportion of individuals receiving outpatient psychiatric treatment exhibit varying degrees of suicidal behaviors, which may range from mild suicidal ideations to overt suicide attempts. This study aims to elucidate the transdiagnostic symptom dimensions and associated suicidal features among psychiatric outpatients.

METHODS

The study enrolled patients who attended the psychiatry outpatient clinic at a tertiary hospital in South Korea (n = 1, 849, age range = 18-81; 61% women). A data-driven classification methodology was employed, incorporating a broad spectrum of clinical symptoms, to delineate distinctive subgroups among psychiatric outpatients exhibiting suicidality (n = 1189). A reference group of patients without suicidality (n = 660) was included for comparative purposes to ascertain cluster-specific sociodemographic, suicide-related, and psychiatric characteristics.

RESULTS

Psychiatric outpatients with suicidality (n = 1189) were subdivided into three distinctive clusters: the low-suicide risk cluster (Cluster 1), the high-suicide risk externalizing cluster (Cluster 2), and the high-suicide risk internalizing cluster (Cluster 3). Relative to the reference group (n = 660), each cluster exhibited distinct attributes pertaining to suicide-related characteristics and clinical symptoms, covering domains such as anxiety, externalizing and internalizing behaviors, and feelings of hopelessness. Cluster 1, identified as the low-suicide risk group, exhibited less frequent suicidal ideation, planning, and multiple attempts. In the high-suicide risk groups, Cluster 2 displayed pronounced externalizing symptoms, whereas Cluster 3 was primarily defined by internalizing and hopelessness symptoms. Bipolar disorders were most common in Cluster 2, while depressive disorders were predominant in Cluster 3.

DISCUSSION

Our findings suggest the possibility of differentiating psychiatric outpatients into distinct, clinically relevant subgroups predicated on their suicide risk. This research potentially paves the way for personalizing interventions and preventive strategies that address cluster-specific characteristics, thereby mitigating suicide-related mortality among psychiatric outpatients.

Opioid craving does not incubate over time in inpatient or outpatient treatment studies: Is the preclinical incubation of craving model lost in translation?

Within addiction science, incubation of craving is an operational label used to describe time-dependent increases in drug seeking during periods of drug deprivation. The purpose of this systematic review was to describe the preclinical literature on incubation of craving and the clinical literature on craving measured over extended periods of abstinence to document this translational homology and factors impacting correspondence. Across the 44 preclinical studies that met inclusion criteria, 31 reported evidence of greater lever pressing, nose pokes, spout licks, or time spent in drug-paired compartments (i.e., drug seeking) relative to neutral compartments after longer periods of abstinence relative to shorter periods of abstinence, labelled as "incubation of craving." In contrast, no clinical studies (n = 20) identified an increase in opioid craving during longer abstinence periods. The lack of clinical evidence for increases in craving in clinical populations weakens the translational utility of operationalizing the time-dependent increase in drug-seeking behavior observed in preclinical models as models of incubation of "craving".

Preventing Readmissions of Hepatic Encephalopathy: Strategies in the Acute Inpatient, Immediate Postdischarge, and Longitudinal Outpatient Setting

Hepatic encephalopathy (HE) is a strong predictor of early hospital readmission in patients with cirrhosis. Early hospital readmission increases health care costs and is associated with worse survival. Herein we provide an overview of strategies to prevent hospital readmissions in patients with HE, divided into 3 contexts: (a) acute inpatient, (b) immediate postdischarge, and (c) longitudinal outpatient setting.

[Overview of hospital city repay for paediatric preparations initiated within the Marseille Public University Hospital system]

OBJECTIVES

Hospital internal-use pharmacies are required to make pharmaceutical preparations in order to obtain a medication in a dosage and/or Galenic form (FG) suitable for pediatric use. The aim of this study is to assess the procedures for continuing pharmaceutical preparations initiated within the Assistance Publique des Hôpitaux de Marseille in an outpatient setting.

METHODS

Hospital discharge prescriptions and/or consultation prescriptions involving paediatric magistral preparations and issued by our Hospital Centre were collected from two pharmacies with significant preparation activity at national level. An analysis of regulatory compliance was carried out, as well as a comparison of the formulation of preparations made in the outpatient setting and in the hospital.

RESULTS

Au total, 45 prescriptions were collected, representing 52 preparation lines. The regulatory analysis revealed that all the prescriptions contained at least one non-conformity, 60.8% of which related to drug treatments. The prepared FG differed in the outpatient setting compared to the hospital in 46.2% of cases, and in 56% of cases, the vehicle and concentration of the active ingredient used differed when the FG was a liquid oral form.

CONCLUSIONS

The lack of clear and complete hospital prescriptions makes it difficult to carry out treatment initiated in hospital in the outpatient setting. The multiplicity of information systems between hospitals and outpatient settings are obstacles to the interoperability needed to coordinate patient treatment, particularly in paediatrics. The quality of discharge prescriptions needs to be improved to optimise the patient care pathway.

Development and validation of a medication-based risk prediction model for acute kidney injury in older outpatients

BACKGROUND

Older adults are at an increased risk of acute kidney injury (AKI), particularly in community settings, often due to medications. Effective prevention hinges on identifying high-risk patients, yet existing models for predicting AKI risk in older outpatients are scarce, particularly those incorporating medication variables. We aimed to develop an AKI risk prediction model that included medication-related variables for older outpatients.

METHODS

We constructed a cohort of 2,272,257 outpatients aged ≥65 years using a national claims database. This cohort was split into a development (70%) and validation (30%) groups. Our primary goal was to identify newly diagnosed AKI within one month of cohort entry in an outpatient context. We screened 170 variables and developed a risk prediction model using logistic regression.

RESULTS

The final model integrated 12 variables: 2 demographic, 4 comorbid, and 6 medication-related. It showed good performance with acceptable calibration. In the validation cohort, the area under the receiver operating characteristic curve value was 0.720 (95% confidence interval, 0.692-0.748). Sensitivity and specificity were 69.9% and 61.9%, respectively. Notably, the model identified high-risk patients as having a 27-fold increased AKI risk compared with low-risk individuals.

CONCLUSION

We have developed a new AKI risk prediction model for older outpatients, incorporating critical medication-related variables with good discrimination. This tool may be useful in identifying and targeting patients who may require interventions to prevent AKI in an outpatient setting.

Association of clinical characteristics, depression remission and suicide risk with discrepancies between self- and clinician-rated suicidal ideation: Two large naturalistic cohorts of outpatients with depression

Clinician- and self-rating of suicidal ideation (SI) are often discrepant. The aim of this study was to determine: 1) Association between discrepant self- and clinician-rated SI with clinical characteristics, depression remission and SA (SA) risk; 2) which SI assessment (self or clinician) predicted depression remission and risk of SA. LUEUR and GENESE are two large, prospective, naturalistic cohorts of French adult outpatients with unipolar depression treated and followed for 6 weeks. SI presence was assessed and defined with a score to the suicidal item of the Montgomery-Åsberg Depression Rating Scale ≥3. Discordant SI was defined as SI detection by only one of the two evaluators (patient or clinician). In both cohorts, 49.3 % (GENESE) and 34 % (LUEUR) patients had discordant SI. Clinical characteristics were more severe, and risk of SA was higher in patients with current SI (concordant and discordant) than in patients without SI and in the concordant than in the discordant group. Prediction of the risk of SA and of depression non-remission was comparable by the two ratings. Patients with SI (concordant and discordant) have more severe clinical characteristics and patients with concordant SI are the most at risk of SA during the follow-up. It is crucial to assess SI and to improve how it is evaluated.

Relationships between long-term exposure to major PM2.5 constituents and outpatient visits and hospitalizations in Guangdong, China

Ambient fine particulate matter (PM2.5) has attracted considerable attention due to its crucial role in the rising global disease burden. Evidence of health risks associated with exposure to PM2.5 and its major constituents is important for advancing hazard assessments and air pollution emission policies. We investigated the relationship between exposure to major constituents of PM2.5 and outpatient visits as well as hospitalizations in Guangdong Province, China, where 127 million residents live in a severe PM2.5 pollution environment. An approach that integrates the generalized weighted quantile sum (gWQS) regression with the difference-in-differences (DID) approach was used to assess the overall mixture effects and relative contributions of each constituent. We observed significant associations between long-term exposure to the mixture of PM2.5 constituents (WQS index) and outpatient visits (IR%, percentage increases in risk per unit WQS index increase:1.73, 95%CI: 1.72, 1.74) as well as hospitalizations (IR%:5.15, 95%CI: 5.11, 5.20). Black carbon (weight: 0.34) and nitrate (weight: 0.60) respectively exhibited the highest contributions to outpatient visits and hospitalizations. The overall mixture effects on outpatient visits and hospitalizations were higher with increased summer air temperatures (IR%: 7.54, 95%CI: 7.33, 7.74 and IR%: 9.55, 95%CI: 8.36, 10.75, respectively) or decreased winter air temperatures (IR%: 1.88, 95%CI: 1.68, 2.08 and IR%: 4.87, 95%CI: 3.73, 6.02, respectively). Furthermore, the overall mixture effects on outpatient visits and hospitalizations were significantly higher in populations with higher socioeconomic status (P < 0.01). It's crucial to address the primary sources of nitrate precursor substances and black carbon (mainly traffic-related and industrial-related air pollutants) and consider the complex interaction effects between air temperature and PM2.5 in the context of climate change. Of particular concern is the need to prioritize healthcare demands in economically disadvantaged regions and to address the health inequalities stemming from the uneven distribution of healthcare resources and PM2.5 pollution.

Evaluation of a Clinical Decision Support System and an Automated Electronic Health Record Alert on Outpatient Prescribing of Cefdinir

Acute bacterial upper respiratory infections are common indications for antibiotics in pediatrics, and many prescriptions may be inappropriate. Novel approaches to outpatient antimicrobial stewardship interventions are needed. This quasi-experimental study of an order set and best practice advisory alert targeting cefdinir prescriptions demonstrated an 8.4% decrease in cefdinir prescribing (P ≤ .001).

Effect of converting from propofol to remimazolam with flumazenil reversal on recovery from anesthesia in outpatients with mental disabilities: a randomized controlled trial

BACKGROUND

General anesthesia is often necessary for dental treatment of outpatients with mental disabilities. Rapid recovery and effective management of postoperative nausea and vomiting (PONV) are critical for outpatients. This study aimed to investigate the effect of transitioning from propofol to remimazolam with flumazenil reversal administered toward the end of surgery during propofol-based total intravenous anesthesia (TIVA) on recovery.

METHODS

Adults with mental disabilities scheduled to undergo dental treatment were randomly assigned to receive either propofol-based TIVA (Group P) or propofol-remimazolam-based TIVA with flumazenil reversal (Group PR). Propofol was replaced with remimazolam 1 h before the end of surgery in Group PR; moreover, 0.5 mg of flumazenil was administered after the neuromuscular blockade reversal agent. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). The secondary outcomes included time to eye-opening, time to extubation, occurrence of PONV, and quality of recovery.

RESULTS

Fifty-four patients were included in this study. The duration of stay in the PACU in Group PR was significantly shorter than that in Group P (mean difference, 8.7 min; confidence interval [95% CI], 3.3-14.2; P = 0.002). Group PR exhibited a shorter time to eye opening (mean difference, 5.4 min; 95% CI, 3.3-8.1; P < 0.001) and time to extubation (mean difference, 5.5 min; 95% CI, 3.6-7.9; P < 0.001) than Group P. Neither group required the administration of rescue analgesics, and the incidence of PONV was not reported.

CONCLUSIONS

Transitioning from propofol to remimazolam 1 h before the end of surgery followed by flumazenil reversal reduced the duration of stay in the PACU and the time to eye opening and extubation without affecting the incidence of PONV and quality of recovery.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service (KCT0007794), Clinical trial first registration date: 12/10/2022.

Sex differences of post-Covid patients undergoing outpatient pulmonary rehabilitation

BACKGROUND

Following years of pandemic severe acute respiratory syndrome coronavirus 2 infections labelled Covid-19, long lasting impairment summarized as post-Covid syndrome (PCS) challenges worldwide healthcare. Patients benefit from rehabilitation programs, but sex specific aspects of improvement remain little understood. The aim of the study was to assess whether women and men differ in response to outpatient pulmonary rehabilitation for PCS.

METHODS

263 (54.4% female) patients partaking in outpatient pulmonary rehabilitation (OPR) due to PCS between March 2020 and July 2022 were included in a prospective observational cohort study. Outcomes were assessed at baseline and before discharge from OPR and included six-minute walking distance (6MWD), 1-second forced expiratory volume (FEV1), diffusion capacity for carbon monoxide, maximal inspiratory pressure (MIP), dyspnea (medical research council scale), and post-Covid functional status scale (PCFS). Sexspecific changes in outcomes following OPR were assessed by linear mixed model and presented as mean differences (MD) with 95% confidence intervals. Linear regression was applied to test whether 6MWD correlates with PCFS and the minimal clinically important difference (MCID) in 6MWD regarding an improvement of at least one point in PCFS was computed with logistic regression.

RESULTS

Significant improvement throughout OPR was observed for all outcomes (all p < 0.0001). Despite less severe Covid-19 infections, PCFS scores remained higher in females after OPR (p = 0.004) and only 19.4% of women compared to 38.5% of men achieved remission of functional impairment. At baseline as well as after OPR, females showed higher symptom load compared to men in dyspnea (p = 0.0027) and scored lower in FEV1 (p = 0.009) and MIP (p = 0.0006) assessment. Performance in 6MWD was comparable between men and women. An increase of 35 m in 6MWD was computed as minimal clinically important difference to improve functional impairment.

CONCLUSION

Both subjective symptoms such as fatigue and dyspnea and objective impairment in performance in pulmonary function were more frequently observed among women. Despite improvement throughout OPR in both women and men, the sex-gap in symptom load could not be closed as women less often achieved remission from functional impairment due to PCS. Intensified treatment of these symptoms should be considered in women undergoing rehabilitation for PCS.

The effectiveness of Forensic Outpatient Systemic Therapy in the treatment of juvenile antisocial behavior: A study protocol of a Multiple Case Experimental Design

BACKGROUND

Juvenile antisocial behavior can have long-lasting and devastating effects for juveniles themselves, victims, and society. Evidence-based treatment is vital. Forensic Outpatient Systemic Therapy (Forensische Ambulante Systeem Therapie; FAST) is a promising treatment for juveniles showing severe antisocial behavior including aggression, (domestic) violence, and delinquent behavior. FAST has a flexible intensity and length, addresses individual and systemic risk and protective factors, and is responsive to the abilities of the client (system), intervention characteristics all considered crucial for effective treatment. The current study will investigate whether FAST is effective in reducing aggression of the juvenile, reaching client formulated subgoals, and improving family functioning. Processes of change will be examined, as well as mediation by reaching client formulated subgoals and improved family functioning.

METHODS

A Multiple Case Experimental Design (MCED) with an ABC design will be performed (A = baseline, B = intervention, and C = follow-up). Juveniles with primary aggression and/or anger problems (N = 15) and their caregiver(s) will be recruited. Data collection will consist of self-report questionnaires and case file analysis. Participants fill out frequent short self-report questionnaires (twice a week during phase A, every other week during phase B, and every week during phase C) and two main questionnaires at the start of the intervention and immediately after intervention end, thereby covering a period of 5 to 11 months. Both visual and statistical analyses will be performed.

DISCUSSION

This study will generate robust knowledge and inform clinical practice on the effectiveness, processes of change, and mediating mechanisms of FAST, aiming to improve the treatment of future families within youth forensic care.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov on 28/08/2023, protocol ID 60-63600-98-1138a.

Evaluation of a manualised neurofeedback training in psychosomatic-psychotherapeutic outpatient treatment (Neuro-pp-out): study protocol for a clinical mixed-methods pilot study

INTRODUCTION

Electroencephalographic neurofeedback (NFB), as a non-invasive form of brainwave training, has been shown to be effective in the treatment of various mental health disorders. However, only few results regarding manualised and standardised NFB trainings exist. This makes comparison as well as replication of studies difficult. Therefore, we developed a standard manual for NFB training in patients with mental health disorders attending a psychosomatic outpatient clinic. The current study aims at investigating the conduction of a standardised manual for NFB training in patients with mental health disorders. If successful, the study provides new opportunities to investigate NFB in a more controlled and comparable manner in clinical practice.

METHODS AND ANALYSIS

30 patients diagnosed with a mental health disorder will be included. After the educational interview, patients will undergo baseline diagnostics (T0). The subsequent intervention consists of 10 sessions of NFB training aiming at increasing sensorimotor rhythm and alpha-frequency amplitudes and decreasing theta-frequency and high beta-frequency amplitudes to induce relaxation and decrease subjective stress. All patients will undergo a post-treatment diagnostic assessment (T1) and a follow-up assessment 8 weeks following the closing session (T2). Changes in amplitude bands (primary outcome) will be recorded with electroencephalography during pre-assessments, post-assessments and follow-up assessments and during NFB sessions. Physiological (respiratory rate, blood volume pulse, muscle tension) and psychometric parameters (distress, perceived stress, relaxation ability, depressive and anxiety symptoms, insomnia, self-efficacy and quality of life) will be assessed at T0, T1 and T2. Moreover, satisfaction, acceptance and usability will be assessed at T1 after NFB training. Further, qualitative interviews about the experiences with the intervention will be conducted with NFB practitioners 6 months after the study starts. Quantitative data will be analysed using repeated measures analysis of variance as well as mediation analyses on mixed linear models. Qualitative data will be analysed using Mayring's content analysis.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the Medical Faculty of the University of Duisburg-Essen (23-11140-BO) and patient enrolment began in April 2023. Before participation, written informed consent by each participant will be required. Results will be published in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Prospectively registered on 28 March 2023 in the German clinical trials register, DRKS00031497.

Schema therapy versus treatment as usual for outpatients with difficult-to-treat depression: study protocol for a parallel group randomized clinical trial (DEPRE-ST)

BACKGROUND

About one third of patients with depression are in a condition that can be termed as "difficult-to-treat". Some evidence suggests that difficult-to-treat depression is associated with a higher frequency of childhood trauma and comorbid personality disorders or accentuated features. However, the condition is understudied, and the effects of psychotherapy for difficult-to-treat depression are currently uncertain. The aim of this trial is to investigate the beneficial and harmful effects of 30 sessions of individual schema therapy versus treatment as usual for difficult-to-treat depression in the Danish secondary, public mental health sector.

METHODS

In this randomized, multi-centre, parallel-group, superiority clinical trial, 129 outpatients with difficult-to-treat depression will be randomized (1:1) to 30 sessions of individual schema therapy or treatment as usual; in this context mainly group-based, short-term cognitive behaviour or psychodynamic therapy. The primary outcome is the change from baseline in depressive symptoms 12 months after randomization, measured on the observer-rated 6-item Hamilton Rating Scale for Depression. The secondary outcomes are health-related quality of life assessed with the European Quality of Life 5 Dimensions 5 Level Version, functional impairment assessed with the Work and Social Adjustment Scale, psychological wellbeing assessed with the WHO-5 Well-being Index, and negative effects of treatment assessed with the Negative Effects Questionnaire. Exploratory outcomes are improvement on patient self-defined outcomes, personal recovery, anxiety symptoms, anger reactions, metacognitive beliefs about anger, and perseverative negative thinking. Outcomes will be assessed at 6, 12, and 24 months after randomization; the 12-month time-point being the primary time-point of interest. Outcome assessors performing the depression-rating, data managers, statisticians, the data safety and monitoring committee, and conclusion makers for the outcome article will be blinded to treatment allocation and results. To assess cost-effectiveness of the intervention, a health economic analysis will be performed.

DISCUSSION

This trial will provide evidence on the beneficial and harmful effects, as well as the cost-effectiveness of schema therapy versus treatment as usual for outpatients with difficult-to-treat depression. The results can potentially improve treatment for a large and understudied patient group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05833087. Registered on 15th April 2023 (approved without prompts for revision on 27th April 2023).

Prevalence of suicidal ideation in German psychotherapy outpatients: A large multicenter assessment

BACKGROUND

Suicidal ideation is a major concern in clinical practice. Yet, little is known about prevalence rates of suicidal ideation in patients undergoing outpatient psychotherapeutic treatment. Therefore, the aim of the current study is to assess the prevalence of suicidal ideation in a large sample of psychotherapy outpatients in Germany. The data analyzed in this study is taken from the KODAP-project on the coordination of data collection and analysis at German university-based research and training outpatient clinics for psychotherapy.

METHODS

A total of N = 10,357 adult outpatients (64.4 % female; age: M(SD) = 35.94 (13.54), range: 18-92 years of age) starting cognitive-behavioral therapy at one of 27 outpatient clinics in Germany were included in the current study. Prevalence of suicidal ideation was assessed with the Suicide Item (Item 9) of the Beck-Depression Inventory II.

RESULTS

Suicidal ideation was reported by 36.7 % (n = 3795) of the participants. Borderline Personality Disorder, Posttraumatic Stress Disorder, and recurrent Major Depression were the diagnoses most strongly associated with the presence and severity of suicidal ideation.

LIMITATION

Suicide ideation was assessed only with the respective item of the Beck Depression Inventory II.

CONCLUSION

Suicidal ideation is very common among adult patients who start psychotherapy in Germany. A well-founded knowledge of risk assessment in suicidal patients and suicide-specific treatment options is therefore highly relevant.

Can we predict a "tsunami"? Symptomatic and syndromal density, mood instability and treatment intensity in people with bipolar disorders under a strict and long lockdown

BACKGROUND

Converging evidence supports the involvement of circadian rhythm disturbances in the course and morbidity of bipolar disorders (BD). During 2020, lockdown measures were introduced worldwide to contain the health crisis caused by the COVID-19 pandemic. As a result, chronobiological rhythms were critically disrupted and illness outcomes were expected to worsen. The current study aimed to explore changes in morbidity among BD patients living under lockdown.

METHODS

Ninety BD outpatients under naturalistic treatment conditions were followed from March to September 2020 using a mood chart technique. Different treatment and illness variables, including mood instability, were assessed and compared with the outcomes obtained during the same 28-week period in 2019.

RESULTS

For most clinical variables, no significant differences were observed between time periods. A slight decrease was found in symptom intensity (from 15.19 ± 20.62 to 10.34 ± 15.79, FDR-adjusted p = 0.04) and in the number of depressive episodes (from 0.39 ± 0.74 to 0.22 ± 0.63, FDR-adjusted p = 0.03), whereas the intensity of pharmacological treatment remained unchanged. Previous illness course predicted mood outcomes during the confinement.

LIMITATIONS

Follow-up periods were relatively short. Further, actigraphy or other methods capable of ensuring significant changes in physical activity were not used.

CONCLUSIONS

In line with other studies, our findings show no worsening in the clinical morbidity of BD patients during lockdown. This conspicuous contrast between our initial predictions and the observed findings highlights the fact that we are still far from being able to provide accurate predictive models for BD.

Preventing Pediatric Medical Traumatic Stress in a Pediatric Urology Outpatient Setting: Application of the Pediatric Psychosocial Preventative Health Model (PPPHM)

OBJECTIVE

The objectives of this topical review are to (1) increase understanding of pediatric medical traumatic stress (PMTS) in pediatric urology populations through literature review, (2) identify a theoretical model to guide prevention of PMTS in this population, and (3) provide clinical care recommendations based on the model identified. Authors introduce a new term "uropsychology" to describe psychological practice that specializes in the treatment of urology patients.

METHODS

Pediatric uropsychologists from 5 pediatric medical care centers gathered to discuss their experience with treating PMTS in their settings and to review existing literature related to PMTS in pediatric urology, PMTS in other populations, and established models for prevention. Authors provide recommendations based on literature review for preventing PMTS in a pediatric urology population.

RESULTS

Gaps in the evidence base for preventing PMTS in this population are identified. Authors provide a series of clinical care recommendations, utilizing clinical experience, and the Pediatric Psychosocial Preventative Health Model (PPPHM) as a framework.

CONCLUSIONS

While there is limited research on PMTS in pediatric urology populations, urologic interventions can be perceived as invasive, painful, distressing, and traumatic. Application of the PPPHM can guide prevention and intervention efforts. Future research is needed to characterize PMTS in this population, evaluate the efficacy of trauma-informed prevention and intervention practices, and develop screening measures that accurately identify at-risk patients. Authors recommend intradisciplinary collaboration among uropsychologists, urology specialists, and patients and families to create formal standards of care, avenues for other future research, and equitable access to uropsychology care.

The effectiveness of online group mindfulness-based cognitive therapy for outpatients with depression in China

OBJECTIVES

With the development of online technology and the increase in real-world needs, conducting psychotherapy on online platforms has become a popular trend. The present study followed the schedule and content of Mindfulness-based Cognitive Therapy (MBCT), and only changed the treatment format (from offline to online) to investigate the effectiveness of online group MBCT for Chinese outpatients with depression.

METHODS

The study used before-and-after controlled design, and included 88 depressed outpatients, of which 75 formally underwent a 10-week online group MBCT. The 24-item Hamilton Depression Scale (HAMD-24), Hamilton Anxiety Scale (HAMA), Self-Depression Rating Scale (SDS), Mindful Attention Awareness Scale (MAAS), and Self-Acceptance Questionnaire (SAQ) were administered to patients one week prior to treatment, the fifth week of treatment, and the tenth week of treatment. Repeated-measures data were processed using linear mixed-effects models.

RESULTS

75 patients (85.23 %) attended >4 sessions, 44 of whom were taking psychotropic medication during treatment. HAMD-24 and HAMA scores decreased significantly in both medicated and unmedicated patients (w10 < w1, p < 0.05). HAMD-24 and HAMA scores declined more rapidly in patients taking medication, with significant decreases in the fifth week (w5 < w1, p < 0.05). The remarkable effectiveness of treatment (HAMD-24 score reduction >50 %) was >30 %, but there were no significant changes in patients' SDS, MAAS, or SAQ scores.

CONCLUSIONS

This study supports the effectiveness of online group MBCT for outpatients with depression and the adherence of depressed patients to participate in online group MBCT was high.

Prospective external validation of the FluScore risk score for influenza in outpatients

BACKGROUND

Testing for influenza in patients with acute lower respiratory tract infection (LRTI) is common and in some cases is performed for all patients with LRTI. A more selective approach to testing could be more efficient.

METHODS

We used data from two prospective studies in the US primary and urgent care settings that enrolled patients with acute LRTI or influenza-like illness. Data were collected in the 2016, 2019, 2021, and 2022 flu seasons. All patients underwent polymerase chain reaction (PCR) testing for influenza and the FluScore was calculated based on patient-reported symptoms at their initial visit. The probability of influenza in each risk group was reported, as well as stratum-specific likelihood ratios (SSLRs) for each risk level.

RESULTS

The prevalence of influenza within risk groups varied based on overall differences in flu seasons and populations. However, the FluScore exhibited consistent performance across various seasons and populations based on the SSLRs. The FluScore had a consistent SSLR range of 0.20 to 0.23 for the low-risk group, 0.63 to 0.99 for the moderate-risk group, and 1.46 to 1.67 for the high-risk group. The diagnostic odds ratio based on the midpoints of these ranges was 7.25.

CONCLUSIONS

The FluScore could streamline patient categorization, identifying patients who could be exempted from testing, while identifying candidates for rapid influenza tests. This has the potential to be more efficient than a "one size fits all" test strategy, as it strategically targets the use of tests on patients most likely to benefit. It is potentially usable in a telehealth setting.

Real-world evidence of treatment patterns and survival of metastatic gastric cancer patients in Germany

BACKGROUND

Patients with metastatic gastric cancer (mGC) have poor prognosis. This real-world study aimed to describe treatment regimens and survival of mGC patients.

METHODS

A retrospective analysis was conducted using anonymized German claims data (AOK PLUS) covering a period from 2010 to 2021. The study population included newly diagnosed mGC cases identified from 2011 to 2020. The index date was defined as the first diagnosis of metastasis on or after gastric cancer diagnosis. Therapy regimens were identified based on inpatient and outpatient data, and subsequently stratified by line of treatment. Survival analyses were conducted using the Kaplan-Meier method.

RESULTS

The cohort consisted of 5,278 mGC incident cases (mean age: 72.7 years; male: 61.9%). Nearly half of the incident cases received mGC-related treatment (49.8%). Treated patients were more often male, younger, and had fewer comorbidities compared to untreated patients. Of the 2,629 mGC patients who started the first line of treatment (1LOT), 32.8% switched to 2LOT, and 10.2% reached 3LOT. Longer survival time was observed among disease-specific treated cases compared with untreated cases (median real-world overall survival (rwOS): 12.7 months [95%CI 12.1 - 13.3 months] vs. 3.7 months [95%CI 3.4 - 4.0 months]).

CONCLUSION

Systemic therapy was not received in almost half of the mGC patients. In those patients, a very short median rwOS was observed. Treatment patterns were generally in line with the guideline recommendations, however, therapy switching rates and poor prognosis indicate high unmet needs also in the treated population.

Outpatient geriatric health care in the German federal state of Mecklenburg-Western Pomerania: a population-based spatial analysis of claims data

BACKGROUND

Due to unidentified geriatric needs, elderly patients have a higher risk for developing chronic conditions and acute medical complications. Early geriatric screenings and assessments help to identify geriatric needs. Holistic and coordinated therapeutic approaches addressing those needs maintain the independence of elderly patients and avoid adverse effects. General practitioners are important for the timely identification of geriatric needs. The aims of this study are to examine the spatial distribution of the utilization of outpatient geriatric services in the very rural Federal State of Mecklenburg-Western Pomerania in the Northeast of Germany and to identify regional disparities.

METHODS

Geographical analysis and cartographic visualization of the spatial distribution of outpatient geriatric services of patients who are eligible to receive basic geriatric care (BGC) or specialized geriatric care (SGC) were carried out. Claims data of the Association of Statutory Health Insurance Physicians in Mecklenburg-Western Pomerania were analysed on the level of postcode areas for the quarter periods between 01/2014 and 04/2017. A Moran's I analysis was carried out to identify clusters of utilization rates.

RESULTS

Of all patients who were eligible for BGC in 2017, 58.3% (n = 129,283/221,654) received at least one BCG service. 77.2% (n = 73,442/95,171) of the patients who were eligible for SGC, received any geriatric service (BGC or SGC). 0.4% (n = 414/95,171) of the patients eligible for SGC, received SGC services. Among the postcode areas in the study region, the proportion of patients who received a basic geriatric assessment ranged from 3.4 to 86.7%. Several regions with statistically significant Clusters of utilization rates were identified.

CONCLUSIONS

The widely varying utilization rates and the local segregation of high and low rates indicate that the provision of outpatient geriatric care may depend to a large extent on local structures (e.g., multiprofessional, integrated networks or innovative projects or initiatives). The great overall variation in the provision of BGC services implicates that the identification of geriatric needs in GPs' practices should be more standardized. In order to reduce regional disparities in the provision of BGC and SGC services, innovative solutions and a promotion of specialized geriatric networks or healthcare providers are necessary.

Network analysis on psychopathological symptoms, psychological measures, quality of life and COVID-19 related factors in Chinese psychiatric patients in Hong Kong

BACKGROUND

Psychiatric patients are susceptible to adverse mental health impacts during COVID-19, but complex interplays between psychopathology and pandemic-related variables remain elusive. This study aimed to investigate concomitant associations between psychopathological symptoms, psychological measures and COVID-19 related variables in Chinese psychiatric patients during the peak of fifth pandemic wave in Hong Kong.

METHODS

We employed network analysis to investigate inter-relationships among psychopathological symptoms (including depression, anxiety, post-traumatic stress disorder-like [PTSD-like] symptoms, insomnia, psychotic symptoms), cognitive complaints, health-related quality of life, loneliness, resilience and selected pandemic-related factors in 415 psychiatric outpatients between 28 March and 8 April, 2022. Network comparisons between genders, diagnosis (common mental disorders [CMD] vs. severe mental disorders [SMD]), and history of contracting COVID-19 at fifth wave were performed as exploratory analyses.

RESULTS

Our results showed that anxiety represented the most central node in the network, as indicated by its highest node strength and expected influence, followed by depression and quality of life. Three comparatively strong connections between COVID-19 and psychopathological variables were observed including: fear of contagion and PTSD-like symptoms, COVID-19 stressor burden and PTSD-like symptoms, and COVID-19 stressor burden and insomnia. Network comparison tests revealed significant network structural difference between participants with history of contracting COVID-19 and those without, but showed no significant difference between genders as well as between CMD and SMD patients.

CONCLUSIONS

Our findings suggest the pivotal role of anxiety in psychopathology network of psychiatric patients amidst COVID-19. Pandemic-related variables are critically associated with trauma/stress and insomnia symptoms. Future research is required to elucidate potential network structural changes between pandemic and post-COVID periods.

A cross-sectional study on the proper administration of eye medications and its determinants among outpatients attending Brhan Aini Ophthalmic National Referral Hospital in Asmara, Eritrea

OBJECTIVE

This study aimed to assess the administration technique of eye medications, its determinants and disposal practices among ophthalmic outpatients.

DESIGN

An analytical cross-sectional study was conducted.

SETTING

Brhan Aini Ophthalmic National Referral Hospital in Asmara, Eritrea.

PARTICIPANTS

Samples of ophthalmic outpatients aged >18 years who visited Brhan Aini Ophthalmic National Referral Hospital in Asmara, Eritrea. Systematic random sampling was used to select the study participants.

DATA COLLECTION AND ANALYSIS

Data were collected from August 2021 to September 2021, using an interview-based questionnaire. The collected data were entered and analysed using CSPro (V.7.3) and SPSS (V.26), respectively. Descriptive statistics and independent samples t-test were performed. P-values less than 0.05 were considered as significant.

RESULTS

A total of 333 respondents with a mean age of 56.4 (SD: 18.76) years were recruited in the study. More than half of the respondents (57.4%) did not have any information on the time interval between two successive eye medications. However, only 16.5% of the respondents managed to close their tear ducts after the administration of eye medication. The mean (SD) score for proper administration of eye medication was 4.16 (1.07) out of 7.0. Female sex (p=0.002), the absence of glaucoma (p=0.035) and the presence of cataract (p=0.014) were significant determinants of the proper administration technique of eye medication. The most favoured disposal practice for unused and/or expired eye medications was disposing of regular garbage (79.9%).

CONCLUSION

This research revealed that there was an inappropriate administration technique and disposal practices of eye medications among ophthalmic outpatients. This requires immediate attention from policy-makers, programme managers and healthcare professionals to ensure the appropriate use of eye medications by the patients.

Anxiety and depression symptoms in adolescents and young adults with juvenile idiopathic arthritis: results of an outpatient screening

BACKGROUND

Previous studies have shown that growing up with rheumatic conditions can fuel dissatisfaction and psychological distress, which in turn affects disease self-management and treatment adherence. Primary objective of this study was to estimate the prevalence of anxiety and depression symptoms in adolescents and young adults (AYA) with juvenile idiopathic arthritis (JIA) and to identify correlates of conspicuous screening results.

METHODS

Initiated as part of the COACH multicenter observational study, outpatients aged 12 to 21 years participating in the National Pediatric Rheumatological Database (NPRD) were prospectively screened for mental health using the Patient Health Questionnaire-9 (PHQ-9) and the Generalised Anxiety Disorder Scale-7 (GAD-7).

RESULTS

Data from 1,150 adolescents with JIA (mean age 15.6 ± 2.2 years; mean disease duration 7.2 ± 4.9 years, 69% female, 43% oligoarthritis, 26% polyarthritis) were analysed. Overall, 32.7% (n = 316) of AYA showed conspicuous screening results, of whom 30.4% reported clinically relevant suicidal or self-harm thoughts. About 19% of screened patients showed moderate to severe depressive or anxious symptoms. AYA with conspicuous screening results were older (15.8 vs. 15.2 years; p < 0.0001), more often female (81% vs. 64%; p < 0.0001) and more often overweight (25% vs. 17%; p = 0.006). They had higher disease activity (physician global assessment on NRS 0-10; 1.7 vs. 1.2; p < 0.0001), more functional limitations (CHAQ; 0.44 vs. 0.14; <0.0001) and rated their health status worse (NRS 0-10; 3.5 vs. 1.8; p < 0.0001) than AYA with inconspicuous screening results. Females (OR 2.33 [CI 1.53-3.56]; p < 0.0001), older age (OR 1.09 [CI 1.01-1.18]; p = 0.026), patients with more functional limitations (OR 3.36 [CI 1.98-5.72]; p < 0.0001), and patients with worse subjective health status (OR 1.17 [CI 1.07-1.27]; p < 0.0001) were more likely to have a conspicuous screening result. Regular sports participation was associated with a lower likelihood of conspicuous screening result (OR 0.69 [CI 0.49-0.98]; p = 0.039).

CONCLUSIONS

A large-scale outpatient screening of AYA with JIA in Germany shows a high prevalence of anxiety and depression symptoms. The need for routine screening for early detection of mental health problems became apparent.

[Preliminary observation of wearable balance diagnosis and treatment system in evaluating dynamic and static balance function in patients with vestibular vertigo]

A newly developed wearable balance diagnosis and treatment system was studied to evaluate the indexes of the abnormal balance function in patients with vestibular vertigo. A cross-sectional study was carried out. A total of 30 patients diagnosed with non-acute vestibular vertigo in the outpatient department of Eye, Ear, Nose and Throat Hospital Affiliated to Fudan University from July 2022 to May 2023 were selected as the vertigo group, including 13 males and 17 females, and aged (45.7±13.9) years. Meanwhile, 20 healthy controls (8 males and 12 females) were included as the control group, with a mean age of (43.6±8.0) years. The static balance and limits of stability (LOS) function of all subjects were assessed with wearable balance diagnosis and treatment system developed under the leadership of Eye & ENT Hospital of Fudan University. In the static balance test, the ratio of eyes open with cushions to eyes open without cushions in the vertigo group was less than that of the control group[1.20% (0.92%, 1.53%) vs 1.49% (1.22%, 1.81%), P=0.008], indicating that patients with non-acute vestibular vertigo may compensate static balance ability earlier. In vertigo group, the directional control in 8 directions, the maximum excursion in anterior, posterior, right anterior and right posterior directions, the endpoint excursion in the posterior, right posterior, and left posterior directions were all smaller than those of the control group (all P<0.05). The reaction time in the left posterior direction of vertigo group was longer than that of the control group (all P<0.05). Those results indicated that the directional control, maximum excursion and endpoint excursion of LOS could be considered as important reference indexes for dynamic balance function.

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

BACKGROUND

Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients.

METHODS

We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics.

RESULTS

There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation.

CONCLUSIONS

Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.

Exploring viral aetiology in upper respiratory tract infections: insights from metagenomic next-generation sequencing in Swiss outpatients before and during the SARS-CoV-2 pandemic

AIMS OF THE STUDY

Upper respiratory tract infections are among the most common reasons for primary care consultations. They are diagnosed predominantly based on clinical assessment. Here, we investigated the benefit of viral metagenomic next-generation sequencing (mNGS) in an outpatient setting.

METHODS

This prospective cross-sectional study included immunocompetent patients with acute upper respiratory tract infections. General practitioners collected pharyngeal swabs and demographic and clinical data. Specimens were analysed using viral mNGS and conventional tests.

RESULTS

Two hundred seventy-seven patients were recruited by 21 general practitioners between 10/2019 and 12/2020, of which 91% had a suspected viral aetiology. For 138 patients (49.8%), mNGS identified one or more respiratory viruses. The mNGS showed a high overall agreement with conventional routine diagnostic tests. Rhinoviruses were the most frequently detected respiratory viruses (20.2% of patients). Viral mNGS reflected the influenza wave in early 2020 and the SARS-CoV-2 pandemic outbreak in Switzerland in March 2020. Notably, rhinoviruses continued to circulate despite non-pharmaceutical hygiene measures.

CONCLUSIONS

Viral mNGS allowed the initial diagnosis to be retrospectively re-evaluated. Assuming reduced turnaround times, mNGS has the potential to directly guide the treatment of upper respiratory tract infections. On an epidemiological level, our study highlights the utility of mNGS in respiratory infection surveillance, allowing early detection of epidemics and providing information crucial for prevention.

Feasibility of outpatient daycase local anaesthestic Rezūm™ without sedation

BACKGROUND

Rezūm™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring.

METHODS

We propose an outpatient daycase method of delivering Rezūm™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra.

RESULTS

Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation.

CONCLUSIONS

We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Detection and Characterization of Bacterial and Viral Acute Gastroenteritis among Outpatient Children under 5 Years Old in Guangzhou, China

Acute gastroenteritis (AGE) in children can be attributed to a multitude of bacterial and viral pathogens. The objective of this study was to investigate the epidemiology of bacterial and viral AGE in children and to compare clinical characteristics between single and multiple enteric pathogen infections. A total of 456 stool samples were collected from outpatient children under 5 years old with AGE, which were subsequently analyzed for nine bacteria and three viruses using the Luminex xTAG® Gastrointestinal Pathogen Panel. The presence of at least one pathogen was detected in 260 cases (57.0%), with Salmonella being the predominant agent, followed by norovirus, Campylobacter, and rotavirus. A total of 69 cases (15.1%) exhibited positive results for two or more enteric pathogens. Although certain co-infections demonstrated significant differences in primary clinical features compared with mono-infections, no statistical variance was observed in terms of disease severity. In outpatient children from southern China, Salmonella emerged as the most prevalent causative agent of AGE, succeeded by norovirus and Campylobacter. This study underscores the burden posed by coinfections and highlights the clinical characteristics associated with AGE when accompanied by coinfections among children under 5 years old.

COVID-19 hospitalization risk after outpatient nirmatrelvir/ritonavir use, January to August 2022, North Carolina

BACKGROUND

In the USA, nirmatrelvir/ritonavir is authorized for the treatment of mild-to-moderate COVID-19 in patients at least 12 years of age, at high risk for progression to severe COVID-19.

OBJECTIVES

To estimate the impact of outpatient nirmatrelvir/ritonavir on COVID-19 hospitalization risk in a US healthcare system.

METHODS

We conducted a cohort study using electronic health records among outpatients with a positive SARS-CoV-2 PCR test between January and August 2022. We evaluated the association of nirmatrelvir/ritonavir therapy with time to hospitalization by estimating adjusted HRs and assessed the impact of nirmatrelvir/ritonavir on predicted COVID-19 hospitalizations using machine-learning methods.

RESULTS

Among 44 671 patients, 4948 (11%) received nirmatrelvir/ritonavir, and 201 (0.4%) were hospitalized within 28 days of COVID-19 diagnosis. Nirmatrelvir/ritonavir recipients were more likely to be older, white, vaccinated, have comorbidities and reside in areas with higher average socioeconomic status. The 28 day cumulative incidence of hospitalization was 0.06% (95% CI: 0.02%-0.17%) among nirmatrelvir/ritonavir recipients and 0.52% (95% CI: 0.46%-0.60%) among non-recipients. For nirmatrelvir/ritonavir versus no therapy, the age-adjusted HR was 0.08 (95% CI: 0.03-0.26); the fully adjusted HR was 0.16 (95% CI: 0.05-0.50). In the machine-learning model, the primary features reducing predicted hospitalization risk were nirmatrelvir/ritonavir, younger age, vaccination, female gender and residence in a higher socioeconomic status area.

CONCLUSIONS

COVID-19 hospitalization risk was reduced by 84% among nirmatrelvir/ritonavir recipients in a large, diverse healthcare system during the Omicron wave. These results suggest that nirmatrelvir/ritonavir remained highly effective in a setting substantially different than the original clinical trials.

Barriers to use of interpreters in outpatient mental health care: Exploring the attitudes of psychotherapists

The support of professional interpreters is an essential component of adequate mental health care for migrants with limited language proficiency. Nevertheless, for varied reasons, only a small proportion of outpatient psychotherapists provide interpreter-mediated psychotherapy for migrants. This study explored the perspectives of psychotherapists who have not worked with professional interpreters in outpatient mental health care to identify factors that may prevent the use of interpreters in outpatient care and explore possible incentives to provide interpreter-mediated psychotherapy for migrants with limited language proficiency. Semi-structured interviews were conducted with 13 outpatient psychotherapists in Northern Germany who had not yet worked with professional interpreters in outpatient care. The interviews were audio recorded, transcribed and analysed using a structured content analysis approach. The psychotherapists named structural as well as subjective barriers and concerns. Findings suggest that improving structural factors, such as secure funding, minimal additional work, better preparation and training could facilitate the integration of professional interpreters into everyday treatment. Psychotherapists also mentioned concerns about their own confidence (e.g., insecurities regarding the triadic situation), the patient (e.g., reduced openness), the interpreter (e.g., doubts about suitability, motivation and empathy), as well as the therapeutic process (e.g., unclear allocation of roles). However, positive aspects and opportunities of interpreter-mediated psychotherapy were also described. These could be enhanced by the presence of conducive factors, such as existing trust between all parties and professional cooperation between interpreter and psychotherapist.

COVID-19 vaccination and infection status: a cross-sectional survey of patients with rheumatic diseases in China

To evaluate the vaccination status and clinical practice of patients with rheumatic diseases (RD) during the COVID-19 pandemic in China and to explore the impact of vaccination on infection severity in patients with RD. A cross-sectional survey was conducted among RD patients in outpatient and inpatient settings of the Rheumatology and Immunology Department in our hospital. Participants' characteristics, vaccination status, COVID-19 infection status, and medication for acute COVID-19 were collected. A total of 749 valid surveys were included in the study. A total of 271 (36.2%) patients were not vaccinated, and 478 (63.8%) patients received at least one dose of COVID-19 vaccine. 83.3% of patients were vaccinated with inactivated vaccines. Several patients with RD experienced the disease flare (57, 11.9%) and some adverse reactions (31, 6.5%) after COVID-19 vaccination. The COVID-19 infection rate was 84.1% in our study, which was not reduced by vaccination. However, vaccinated patients with RD showed decreased frequencies of pneumonia and hospitalization, compared with those of unvaccinated patients. Independent factors associated with hospitalization were COVID-19 vaccination (OR = 0.422, 95% CI 0.227-0.783), advanced age (OR = 1.070, 95% CI 1.046-1.095), ILD (OR = 1.245, 95% CI 1.082-1.432), and glucocorticoid (OR = 4.977, 95% CI 2.326-10.647). Adverse reactions to vaccines and disease flare are not common in RD patients. Although COVID-19 vaccination could not reduce the risk of COVID-19 infection in RD patients, it may effectively decrease the frequencies of pneumonia and hospitalization after infection. It is recommended that patients with RD should receive COVID-19 vaccination if there are no contraindications because the benefits outweigh the risks.

Racial, ethnic, and biologic sex disparities in outpatient laboratory monitoring of isotretinoin use: a cross-sectional study

BACKGROUND

Isotretinoin is commonly used for the treatment of acne. Despite high efficacy, isotretinoin has a side effect profile that prompts regular outpatient laboratory monitoring. Emerging evidence suggests clinically significant lab abnormalities are rare. Racial, ethnic, and biologic sex disparities in laboratory monitoring of isotretinoin have yet to be characterized.

METHODS

This study explores disparities in laboratory monitoring of patients prescribed isotretinoin, factoring in the COVID-19 pandemic given its impacts on laboratory monitoring. Two populations were evaluated: all patients taking isotretinoin, and patients taking isotretinoin with no metabolic, cardiovascular, hematologic, hepatic, or renal comorbidities. The latter population was included to screen out patients who might receive increased laboratory testing for conditions besides isotretinoin use.

RESULTS

Our data reveal that African-American, Asian, and Hispanic patients prescribed isotretinoin were more likely than Caucasian patients to receive orders for outpatient laboratory monitoring. These disparities persisted independent of comorbidities that may prompt additional testing, suggesting that non-Caucasian patients bear an additional testing burden even when their comorbidities were matched to their peers. Disparities persisted in the setting of reduced laboratory monitoring due to the COVID-19 pandemic.

CONCLUSIONS

These data reveal that patients of color are more likely to receive outpatient laboratory monitoring for isotretinoin prescriptions. There is an opportunity for testing standardization to improve medication access, decrease burden and costs for patients and the healthcare system, and decrease racial disparities in prescribing and monitoring of isotretinoin. Dermatology clinics may benefit from standard operating procedures outlining for whom regular monitoring is needed.

Sick leave before, during, and after short-term outpatient psychotherapy: a cohort study on sick leave days and health care costs between behavioral and psychodynamic psychotherapies on anonymized claims data

BACKGROUND

Sick leave due to mental disorders poses a relevant societal and economic burden. Research on sick leave over a patient journey of individuals who received one of two treatment approaches - either behavioral (BT) or psychodynamic (PDT) psychotherapy - is scarce.

METHODS

We conducted a cohort study on anonymized German claims data for propensity-score matched patients who received short-term outpatient BT or PDT. We analyzed sick leave days and direct health care costs one year before, during, and one year after psychotherapy.

RESULTS

We analyzed data of patients who received BT and PDT, with N = 14 530 patients per group after matching. Patients showed sick leave days per person year of 33.66 and 35.05 days before, 35.99 and 39.74 days during, and 20.03 and 20.95 days after BT and PDT, respectively. Sick leave rates were overall higher in patients who received PDT. Both patient groups showed reductions of roughly 14 sick leave days per year, or 40%, from before to after therapy without a difference between BT and PDT (difference-in-difference [DiD] = -0.48, 95%-confidence interval [CI] -1.61 to 0.68). Same applies to direct health care costs which reduced in both groups by roughly 1800 EUR (DiD = 0, 95%-CI -158 to 157).

CONCLUSIONS

Results suggest similar reductions in sick leave days and direct health care costs from before to after BT and PDT. As sick leave is discussed to serve as an indicator of overall health and functioning in mental disorders, both treatments may have a similar positive impact on mental health.

QuickStroop Predicts Time to Development of Overt Hepatic Encephalopathy and Related Hospitalizations in Patients With Cirrhosis

Cirrhosis-related neurocognitive impairment caused by covert or minimal hepatic encephalopathy (CHE) affects psychosocial function, increases risk of overt hepatic encephalopathy (OHE) development, and worsens survival.1,2 However, detection in clinical practice is challenging.2 One modality used for screening and prediction of outcomes related to cirrhosis is the EncephalApp Stroop, but it can require up to 10 minutes. Furthermore, the assessment comprises of distinct stages of difficulty, with an easier "Off" stage and a more challenging "On" stage.3 To alleviate these concerns, QuickStroop, which takes <1 minute, was developed. This uses only the first 2 runs of the Off stage of the EncephalApp Stroop, where number signs presented in red, green, or blue need to be matched quickly to their respective colors.4 A prior study showed these versions were comparable cross-sectionally to diagnose CHE.4 However, the utility of QuickStroop to predict cirrhosis-related outcomes is unclear.5-7 Our aim was to determine the ability of QuickStroop to determine time to development of OHE and OHE-related hospitalizations, all-cause hospitalizations, and death in outpatients with cirrhosis.

Pattern of Prescribing Analgesics and Their Response in Cancer Patients Attending Outpatient Department of Palliative Care Service in Two Teaching Hospitals of Bangladesh

Palliative care is a valued aspect of clinical care which is an urgent humanitarian need for people worldwide with cancer and other chronic fatal diseases. Patients experience many different symptoms including severe pain in advanced cancer. Palliative care focuses on relief from symptoms, pain and stress by using different analgesics and adjuvant. The goal of palliative care is to improve the quality of life. So, this prospective observational study was carried out to assess pattern of drugs used and their response to pain in cancer patients attending out-patient department of palliative care service in two teaching hospitals of Bangladesh. One hundred forty (140) cancer patients were purposively selected who attended in out-patient department of palliative care unit in Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) from July 2018 to June 2019. Outcome variables were commonly presenting complaints, pain intensity, commonly prescribed drugs and analgesic prescription according to WHO three-step analgesic ladder, etc. The mean age ±SD of the respondents was 51.30±15.38 years, male-female ratio 1:1. Common sites of cancer were alimentary origin (20.0%), genitourinary system (17.86%), hepatobiliary system (11.43%), respiratory system (10.71%). The prescribed drugs were analgesics (96.4%), PPIs (74.3%), laxatives (62.1%), anti-emetics (38.6%), multivitamins (32.9%), H2 antagonists (17.1%), sedatives (17.1%), and corticosteroids (8.6%). Level 1 analgesics (Paracetamol or other NSAIDs) were prescribed to 42.65%, level 2 analgesics (Tramadol) were prescribed to 50.00% patients and level 3 analgesics (Morphine) were prescribed to 51.42% patients. The relation between and receiving three levels of analgesic prescriptions was statistically significant. The association between level of analgesic prescription was significant with site of cancer (p<0.001) and intensity of pain (p<0.001). This study showed that morphine was prescribed to more than half of the patients. Other level of analgesics were also used either single or in combination. Younger and male patients were treated more with level III analgesics. Prescribing analgesics were dependent on sites of cancer and intensity of pain.

A Prospective Multicenter Standard of Care Study of Outpatient Laparoscopic Sleeve Gastrectomy

A global shift is occurring as hospital procedures move to ambulatory surgical settings. Surgeons have performed outpatient sleeve gastrectomy (SG) in bariatric surgery since 2010. However, prospective trials are needed to ensure its safety before widespread adoption.

PURPOSE

The study aimed to present a comprehensive report on the prospective data collection of 30-day outcomes of outpatient primary laparoscopic SG (LSG). This trial seeks to assess whether outpatient LSG is non-inferior to hospital-based surgery in selected patients who meet the outpatient surgery criteria set by the American Society for Metabolic and Bariatric Surgery.

MATERIALS AND METHODS

This study is funded by the Society of American Gastrointestinal and Endoscopic Surgeons and has been approved by the Advarra Institutional Review Board (Pro00055990). Cognizant of the necessity for a prospective approach, data collection commenced after patients underwent primary LSG procedures, spanning from August 2021 to September 2022, at six medical centers across the USA. Data centralization was facilitated through ArborMetrix. Each center has its own enhanced recovery protocols, and no attempt was made to standardize the protocols.

RESULTS

The analysis included 365 patients with a mean preoperative BMI of 43.7 ± 5.7 kg/m2. Rates for 30-day complications, reoperations, readmissions, emergency department visits, and urgent care visits were low: 1.6%, .5%, .2%, .2%, and 0%, respectively. Two patients (0.5%) experienced grade IIIb complications. There were no mortalities or leaks reported.

CONCLUSION

The prospective cohort study suggests that same-day discharge following LSG seems safe in highly selected patients at experienced US centers.

Hospital outpatient department billing is a poor indicator of primary care practice integration with hospital systems

OBJECTIVE

To test the reliability of Medicare claims in measuring vertical integration. We assess the accuracy of a commonly used measure of integration, primary care physician (PCP) practices billing Medicare as a hospital outpatient department (HOPD) in claims.

DATA SOURCES AND STUDY SETTING

Medicare fee-for-service claims, IQVIA, and CPC+ practice surveys for this study.

STUDY DESIGN

We compare measures of integration from Medicare claims to self-reported indicators of integration from IQVIA and a survey of CPC+ participating practice sites.

DATA COLLECTION/EXTRACTION METHODS

We measure integration by using site-of-service billing in the 100% sample of Medicare Carrier claims from 2017-2020. In the IQVIA SK&A (2017-2018), OneKey (2019-2020), and practice survey data (2017-2019), we use self-reported responses to measure integration.

PRINCIPAL FINDINGS

We find that currently most PCP practices sites that report themselves as being integrated with a health system do not bill as an HOPD. In 2017, 11% of CPC+ practices were identified as being vertically integrated in claims, while the equivalent numbers in SK&A and surveys were 52% and 54% integration, respectively. A t-test found that both datasets significantly differed from claims (Survey: 41.3%-45.1%; SK&A: 45.3%-51.1%); this gap persists in 2018-2019.

CONCLUSION

Measuring physician-hospital vertical integration accurately is integral to determining consolidation. The overwhelming majority of PCP practice sites not billing as an HOPD may reflect Medicare regulatory changes that have reduced the financial incentives for doing so. These findings have implications for researchers that study the growth in PCP-hospital integration in health care markets.

Evaluation of enoxaparin for bridging of warfarin in outpatients with left ventricular assist devices (LVADs)

BACKGROUND

Patients with left ventricular assist devices (LVADs) require systemic anticoagulation. The use of enoxaparin for bridging to warfarin remains understudied in this population.

METHODS

This single-center retrospective study was performed to characterize enoxaparin use and associated thrombotic and bleeding outcomes in adult outpatients with LVADs from January 2018 to July 2021.

RESULTS

Fifty-four enoxaparin bridging events were evaluated in 49 patients. Most patients with HeartMate II (HM2) and HeartWare (HVAD) devices received enoxaparin dosed 1 mg/kg every 12 h. In patients with HeartMate 3 (HM3) devices, an equal number of patients received 0.5 mg/kg every 12 h and 1 mg/kg every 12 h, with a smaller subset receiving intermediate doses. The median duration of bridging was 6 days (4-8 [IQR]). One major bleeding event required discontinuation of enoxaparin and hospitalization in a patient with an HM3 device. Thrombotic events occurred in four patients with two incidents of pump thrombosis requiring pump exchange and two ischemic strokes. All thrombotic events occurred in patients with HVAD or HM2 devices.

CONCLUSION

These results suggest that enoxaparin bridging in LVAD patients was well-tolerated with low bleeding and thrombotic rates, particularly with the HM3 device.

Implementation of a Perinatal Substance Use Screening Protocol in the Outpatient Setting

OBJECTIVE

To implement the 5Ps Screen for Alcohol/Substance Use tool and the screening, brief intervention, and referral to treatment (SBIRT) process into clinical practice to determine if enhanced training would improve perinatal providers' adherence to universal screening.

DESIGN

A quality improvement project using a pre- and postintervention design.

SETTING/LOCAL PROBLEM

Three community-based, outpatient obstetrics and gynecology clinics in southeastern Massachusetts. The local problem identified was that no validated screening tool was being used for universal screening of substance use in pregnancy.

INTERVENTIONS/MEASUREMENTS

Training consisted of two phases that reviewed the SBIRT process, the 5Ps screening tool, brief intervention conversations, and the process for referral to treatment. Pre- and postimplementation screening rates were compared and analyzed using descriptive statistics and chi-square tests of independence.

RESULTS

Preimplementation screening rates were 14.4%. Screening rates measured 1 month after implementation were 44.6% (p < .001). Universal screening was not achieved.

CONCLUSION

Short-term improvement in screening for perinatal substance use was observed. Whether these results are sustainable beyond the project time frame is unknown. Future work should examine longer-term outcomes and continued barriers to universal uptake of the screening protocol.