Local recurrence following a complete radiologic response in hepatocellular carcinoma patients: comparison of transarterial chemoembolisation and transarterial radioembolisation

AIM

To evaluate and compare the rates of local recurrence in hepatocellular carcinoma (HCC) patients who undergo selective transarterial radioembolisation (TARE) or transarterial chemoembolisation (TACE) and achieve a complete response (CR) radiologically.

MATERIALS AND METHODS

All patients undergoing treatment with TARE or TACE at a single academic institution were reviewed retrospectively. Those who had been treated previously, presented with multifocal disease, had non-selective TARE or TACE, or did not achieve a complete response (CR) radiologically were excluded.

RESULTS

In total 110 patients were included (TACE n=60 [54.5%]; TARE n=50 [45.5%]). TARE patients were older (66.4 ± 9.4 versus 61.2 ± 5.6 years, p<0.001) and had larger tumours (4.4 ± 2.2 versus 3 ± 1.4 cm, p=0.002). TACE patients were significantly more likely to suffer a local recurrence (31/60, 51.7% versus 9/50, 18%, p<0.001) and had a significantly shorter time to recurrence (median 8.3 {interquartile range [IQR]}: 12 versus median 17.9 [IQR: 23.5] months, p=0.001). A local time to progression (TTP) Kaplan-Meier curve demonstrated TACE patients had a significantly shorter local TTP (hazard ratio [HR]: 7.2; 95% confidence interval [CI]: 3.64-14.24; p<0.001) and treatment modality (TACE or TARE; HR: 0.05; 95% CI: 0.005-0.5; p=0.01) was found to be associated with local recurrences on multivariate Cox proportional HR analysis. When overall TTP was evaluated, again TACE patients were found to have a significantly shorter TTP (HR: 2.13 [1.28-3.53], p=0.004).

CONCLUSION

In HCC patients undergoing selective treatment who achieve a CR radiologically, those treated with TARE may be less likely to suffer recurrence, either local or general, than those treated with TACE.

Intrapartum Risk Factors and Prediction of Obstetric Hemorrhage-Related Morbidity

OBJECTIVE

 The aim of this study was to assess whether inclusion of intrapartum risk factors improves our obstetric hemorrhage risk stratification tool in predicting obstetric hemorrhage, transfusion, and related severe morbidity.

STUDY DESIGN

 This is a retrospective cohort study using all live deliveries at a single institution over a 2-year period (n = 5,332). Obstetric hemorrhage risk factors, hemorrhage burden, and severe maternal morbidity index outcomes were assessed through chart abstraction. Hemorrhage risk was assessed at (1) "time of admission" through chart abstraction and (2) "predelivery" by calculation after inclusion of all abstracted intrapartum risk factors. Admission high risk was compared with predelivery high risk for sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio in predicting obstetric hemorrhage, obstetric hemorrhage requiring transfusion, and obstetric hemorrhage-related severe morbidity. Significance levels were calculated using descriptive statistical methods including chi-squared tests and McNemar's tests.

RESULTS

 The sensitivities of the risk assessment tool using admission risk classification for high-risk patients is 25% for obstetric hemorrhage, 37% for obstetric hemorrhage requiring transfusion, and 22% for obstetric hemorrhage-related severe morbidity. After intrapartum factor inclusion, the sensitivities increase to 55% for obstetric hemorrhage, 59% for obstetric hemorrhage requiring transfusion, and 47% for obstetric hemorrhage-related severe morbidity. This "predelivery" risk assessment is significantly more sensitive across all three end points (p < 0.001 for all three outcomes). While the positive likelihood ratios for obstetric hemorrhage are equal on admission and predelivery (2.10 on admission and predelivery), they increase after intrapartum factor inclusion for obstetric hemorrhage requiring transfusion and obstetric hemorrhage-related severe morbidity (on admission, 2.74 and 1.6, respectively, and predelivery: 4.57 and 3.58, respectively).

CONCLUSION

 Inclusion of intrapartum risk factors increases the accuracy of this obstetric hemorrhage risk stratification tool in predicting patients requiring hemorrhage management with transfusion and obstetric hemorrhage-related severe morbidity.

KEY POINTS

· There are little data to validate intrapartum hemorrhage risk reassessment.. · Including intrapartum factors improves risk stratification for transfusion and related morbidity.. · Future research should clinically validate risk reassessment in the intrapartum period..

Assessing Time to Removal of Tunneled Dialysis Catheters after Arteriovenous Access Creation

BACKGROUND

Tunneled dialysis catheters (TDCs) are a temporary bridge until definitive arteriovenous (AV) access is established. Our objective was to evaluate the time to TDC removal in patients who underwent AV access creations with TDCs already in place.

METHODS

A single-center analysis of all AV access creations in patients with TDCs was performed (2014-2020). Primary outcome was time to TDC removal after access creation.

RESULTS

There were 364 AV access creations with TDCs in place. The average age was 58 years, 44% of patients were female, and 64% were Black. The median time to TDC removal was 113 days (range, 22-931 days) with 71.4% having a TDC >90 days after access creation. Patients with TDC >90 days were often older (60 vs. 54.7), had hypertension (98.1% vs. 93.3%), were diabetic (65.4% vs. 47.1%), and had longer average time to maturation (107.1 vs. 55.4 days, P < 0.001) and first access (114 vs. 59.4 days, P < 0.001). Multivariable analysis showed that older age was associated with prolonged TDC placement (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005) and prosthetic graft use was associated with shorter TDC indwelling time (OR 0.09, 95% CI 0.04-0.23, P ≤ 0.001). Kaplan-Meier analysis showed that 87% of TDCs were removed at 1 year.

CONCLUSIONS

The majority of patients with TDCs who underwent AV access creation had prolonged TDC placement. Prosthetic graft use was associated with shorter catheter times. Close follow-up after access placement, improving maturation times, and access type selection should be considered to shortened TDC times.

Breast Cancer Screening and BI-RADS Scoring Trends Before and During the COVID-19 Pandemic in an Academic Safety-Net Hospital

BACKGROUND

Little is known about how the COVID-19 pandemic affected screening mammography rates and Breast Imaging Reporting and Data Systems (BI-RADS) categorizations within populations facing social and economic inequities. Our study seeks to compare trends in breast cancer screening and BI-RADS assessments in an academic safety-net patient population before and during the COVID-19 pandemic.

PATIENTS AND METHODS

Our single-center retrospective study evaluated women ≥ 18 years old with no known breast cancer diagnosis who received breast cancer screening from March 2019-September 2020. The screening BI-RADS score, completion of recommended diagnostic imaging, and diagnostic BI-RADS scores were compared between the pre-COVID-19 era (from 1 March 2019 to 19 March 2020) and COVID-19 era (from 20 March 2020 to 30 September 2020).

RESULTS

Among the 11,798 patients identified, screened patients were younger (median age 57 versus 59 years, p < 0.001) and more likely covered by private insurance (35.9% versus 32.3%, p < 0.001) during the COVID-19 era compared with the pre-COVID-19 era. During the pandemic, there was an increase in screening mammograms categorized as BI-RADS 0 compared with the pre-COVID-19 era (20% versus 14.5%, p < 0.0001). There was no statistically significant difference in rates of completion of diagnostic imaging (81.6% versus 85.4%, p = 0.764) or assignment of suspicious BI-RADS scores (BI-RADS 4-5; 79.9% versus 80.8%, p = 0.762) between the two eras.

CONCLUSIONS

Although more patients were recommended to undergo diagnostic imaging during the pandemic, there were no significant differences in race, completion of diagnostic imaging, or proportions of mammograms categorized as suspicious between the two time periods. These findings likely reflect efforts to maintain equitable care among diverse racial groups served by our safety-net hospital.

Pre-Pandemic and Recent Oral and Medical Health Care Utilization among Young American Indian Children and Their Caregivers

Children from diverse ethnic groups are at significantly increased risk for dental caries. In particular, American Indian (AI) children have the highest incidence of detal caries of any ethnic group. The COVID-19 pandemic dramatically restricted health care access, including preventive oral health care. Given this context, it is unclear whether or not preventive oral health care for AI children has resumed since lockdown. To address this question, we surveyed adult AI caregivers (N = 152) of children aged 0-5 years, assessing recent (12-month) and pre-COVID (for caregivers of children aged 3-5 years) preventive oral and medical health services. We also examined medical health care access and utilization among caregivers. Among children aged 3-5 years old, both pre-pandemic and past year medical care utilization were generally high (80 and 90%, respectively) as was any oral health care utilization (64 & 78%, respectively). Oral health check-ups were more common over the last year (62%) compared to pre-COVID (44%). Recent health care utilization among children 1-5 years old in this sample were generally comparable to national estimates, except for higher reported preventive medical care (99% vs. 87.6%, respectively) and higher preventive oral care (96% vs. 59.6%, respectively). More caregivers reported delaying or foregoing needed health care due to COVID (28-38%) versus due to cost (8-17%). In this survey of AI caregivers, recent child preventive health care utilization was high, and changes in utilization following the lockdown phases of the pandemic were comparable for oral and medical health care.

Group B Streptococcus Infection and Obstetric Hemorrhage Risk

OBJECTIVE

To elucidate the association between GBS infection and maternal risk for obstetric hemorrhage (OBH) and OBH-related morbidities (OBH-M).

METHODS

This was a retrospective cohort study of all deliveries with a documented GBS status at a single large academic medical center from 2018 to 2019. GBS status was determined by either urine culture or rectovaginal culture collected during the antepartum period. The primary outcomes were quantitative blood loss (QBL), OBH, and a composite of OBH-M. Secondary outcomes were individual components of the OBH-M composite and frequency of hemorrhage-related interventions utilized intrapartum and postpartum. A stratified analysis was conducted examining only patients who were diagnosed intrapartum with an intrapartum intraamniotic infection (III).

RESULTS

Of 4679 pregnant individuals who delivered a live infant between January 1, 2018 and January 1,2019 with a documented GBS status, 1,487 were identified as GBS positive (+) and 3192 were identified as GBS negative (-). The GBS + group did not have significantly higher QBL (p = 0.29) or rate of OBH (p = 0.35). There were no significant differences by GBS status in OBH morbidity (p = 0.79) or its individual components or frequency of individual pharmacologic or non-pharmacologic OBHrelated interventions. There were also no significant differences by GBS status among patients with an III.

CONCLUSIONS FOR PRACTICE

GBS infection at the time of delivery was not associated with increased risk for OBH or OBH-M. Further research is needed to further explore the relationship between peripartum infections and OBH risk.

Association between duration of intrapartum oxytocin exposure and obstetric hemorrhage

PURPOSE

Prolonged duration of intrapartum oxytocin exposure is included as a risk factor within widely adopted obstetric hemorrhage risk stratification tools. However, the duration of exposure that confers increased risk is poorly understood. This study aimed to assess the association between duration of intrapartum oxytocin exposure and obstetric blood loss, as measured by quantitative blood loss, and hemorrhage-related maternal morbidity.

METHODS

This was a retrospective cohort study of all deliveries from 2018 to 2019 at a single medical center. We included patients who had received any intrapartum oxytocin, and we categorized them into 1 of 5 groups: > 0-2, ≥ 2-4, ≥ 4-6, ≥ 6-12, and ≥ 12 h of intrapartum oxytocin exposure. The primary outcomes were mean quantitative blood loss, proportion with obstetric hemorrhage (defined as quantitative blood loss ≥ 1000 mL), and proportion with obstetric hemorrhage-related morbidity, a composite of hemorrhage-related morbidity outcomes. Secondary outcomes were hemorrhage-related pharmacologic and procedural interventions. A stratified analysis was also conducted to examine primary and secondary outcomes by delivery mode.

RESULTS

Of 5332 deliveries between January 1, 2018 and December 31, 2019 at our institution, 2232 (41.9%) utilized oxytocin for induction or augmentation. 326 (14.6%) had exposure of > 0-2 h, 295 (13.2%) ≥ 2-4 h, 298 (13.4%) ≥ 4-6 h, 562 (25.2%) ≥ 6-12 h, and 751 (33.6%) ≥ 12 h. Across all deliveries, there was higher mean quantitative blood loss (p < 0.01) as well as increased odds of obstetric hemorrhage (adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.21-1.91) for those with ≥ 12 h of oxytocin compared to all groups between > 0-12 h of exposure. In our stratified analysis, ≥ 12 h of oxytocin exposure was associated with higher mean quantitative blood loss (p = 0.04) and odds of obstetric hemorrhage in vaginal deliveries (aOR 1.47, 95% CI: 1.03-2.11), though not in cesarean deliveries (aOR 1.16, 95% CI 0.82-1.62). There were no differences in proportion with obstetric hemorrhage-related morbidity across all deliveries (p = 0.40) or in the stratified analysis.

CONCLUSION

Intrapartum oxytocin exposure of ≥ 12 h was associated with increased quantitative blood loss and odds of obstetric hemorrhage in vaginal, but not cesarean, deliveries.

Spontaneous renal tumour regression following an aortic dissection

Spontaneous tumour regression is a rare but well-documented phenomenon, especially for renal cell carcinomas. We describe the case of a 60-year-old male who presented with chest pain and shortness of breath. He was diagnosed with a large type A aortic dissection and an incidental right renal mass, highly suspicious of a renal cell carcinoma. Following repair of the dissection, subsequent imaging showed that the renal mass had largely resolved. Spontaneous tumour regression is commonly thought to occur through immunological mechanisms. A vascular cause of tumour regression through infarction is postulated in this case. Although angioembolisation is a well-recognised management option in the context of palliative treatment of symptomatic renal tumours, this case suggests an extended role for angioembolisation in the treatment of small renal masses.

Hospital-based opioid treatment: Expanding and sustaining the model in Texas

This Brief Report includes follow-up data about the sustainability and expansion of the Buprenorphine Team (B-Team), a hospital-based opioid treatment (HBOT) program. Between September 2018 and January 2023, the B-Team started 398 patients with opioid-use disorder (OUD) on buprenorphine therapy and coordinated outpatient care for 353 patients before discharge. Two-hundred and forty-nine of these patients were scheduled for follow-up at our partner addiction treatment clinic. Retention rates at our partner clinic remain relatively high: 73 patients (36% of eligible patients) continued to attend appointments between 6 and 12 months, and 40 of 180 patients (22%) who have been discharged from the hospital for at least 1 year continued to attend appointments. This model has been adopted at three additional Texas hospitals, resulting in rapid growth: 1037 patients were started on buprenorphine across these four sites during 2021-2022. Our longitudinal results support HBOT as an effective model for treating patients with OUD.

Factors associated with uptake of guideline-recommended cardiovascular implantable electronic device management: a nationwide, retrospective cohort study

Clinical guidelines recommend device removal for cardiovascular implantable electronic device (CIED) infection management. In this retrospective, nationwide cohort, 60.8% of CIED infections received guideline-concordant care. One-year mortality was higher among those without procedural management (25% vs 16%). Factors associated with receipt of device procedures included pocket infections and positive microbiology.

Continuing Professional Development for Radiation Oncologists: Where are the Gaps and Barriers?

PURPOSE/OBJECTIVE(S)

Continuing professional development (CPD) involves continuing medical education (CME), as well as educational activities to enhance research, teaching and leadership skills. Although CPD has been well explored in other specialties, the literature pertaining to radiation oncology is lacking. We sought to evaluate current CPD practices of radiation oncologists (RO) and identify unmet needs and barriers.

MATERIALS/METHODS

An online survey on CPD was developed in English and French, approved by ethics board, and emailed to all RO departments across Canada. Respondents' current practices, preferences, barriers, and needs were explored across the CPD domains of CME, research, teaching and administrative skills.

RESULTS

One-hundred twenty-four radiation oncologists completed the survey with representation across all listed disease sites and provinces. Respondents had an average 13.6 years of experience as staff (6 months to 38 years) and 96% were affiliated with a university. ROs indicated the most helpful resources for CME were reading journal articles (27%), attending tumor boards (25%), conferences (19%), informal discussion with colleagues (11%), free online websites (e.g., NCCN) (4%) and Twitter (3.5%). Lack of time was unanimously regarded as a barrier for CME. Other barriers included growing clinical workloads, expanding literature, and a lack of renumeration for CME. The mean score was 3.5/5, between "neutral" and "satisfied" for "satisfaction that CME needs are met" on a 5-point Likert scale. Seventy-six percent of respondents are currently engaged in research, with 46% involved as a research supervisor. However, only 35% had protected time for research (ranging from 10-80% FTE). Time (89%), funding (63%) and human resources (63%) were cited as barriers. Respondents wanted to improve skills in statistical analysis, clinical trial design and grant writing. Most researchers (78%) were comfortable with quantitative methodologies. Conversely, only 35% were comfortable with qualitative methods. Nearly all respondents (98%) were involved with clinical teaching. While the majority of respondents were satisfied with their teaching ability, many wanted to improve skills in coaching, providing feedback and delivering lectures. The preferred learning formats for improving these skills were either workshops at conferences or online. Half of the respondents are currently in an administrative/leadership role, and of those that are not, only 30% were interested in pursuing future leadership positions. The main barriers cited were time and the experience required.

CONCLUSION

Overall satisfaction scores for current CME practices were mediocre amongst Canadian radiation oncologists - a group that is mostly in university-affiliated/academic practices with 98% involved in clinical teaching. There are notable barriers and unmet needs in research, teaching and administration - highlighting potential areas for future CPD initiatives in radiation oncology.

Assessing the Compliance and Accuracy of a National Australian Head and Neck Cancer (HNC) Database

PURPOSE/OBJECTIVE(S)

Accurate cancer databases enable auditing of patient management, and this knowledge facilitates optimizing care. A multi-institutional organization, the largest single provider of radiation oncology services in Australia, has developed its own national database (ND). All patients are entered on the ND as a prerequisite for generating a radiotherapy prescription. A significant component of the ND is automated, but manual input from the treating radiation oncologist (RO) is also required. The purpose of this study was to assess the compliance and accuracy of the data entered on this ND for head and neck cancer (HNC) patients.

MATERIALS/METHODS

We included all HNC patients with either oral cavity cancer or oropharynx cancer (ICD-10 coding) treated between September 2021 and September 2022 to assess compliance. We randomly selected 25% of these cases and assigned them to 3 HNC ROs to manually review the accuracy of all clinical data points.

RESULTS

There were 166 HNC patients, 139 oropharynx and 27 oral cavity. Compliance in the 166 patients was excellent (94% or higher) for the majority of data points - age, gender, diagnosis ICD code, diagnosis date, laterality, TNM classification, radiotherapy dose, fractionation and technique and start and completion dates. Compliance was good (85% or more) for smoking history, use of chemotherapy, and p16 status (oropharynx). Compliance was poor (43%) for specific chemotherapy regimens. Accuracy was high (92% or higher) for diagnosis ICD code, smoking history, use of chemotherapy; good (87% or higher) for p16 status (oropharynx), laterality and histopathology; and poor for date of diagnosis (75%), TNM classification (62%) and specific chemotherapy regimens (29%).

CONCLUSION

The ND is a powerful tool for assessing patient care. Overall, compliance was very good. Accuracy was very good for most items, and we have highlighted areas where improvements can be made. This study shows that a compliant and accurate ND is achievable and supports the next goal of additional items to be included in the ND, specifically patient outcome data.

Accelerating Solutions for the Overdose Crisis: an Effectiveness-Implementation Hybrid Protocol for the HEAL Prevention Cooperative

Given increasing opioid overdose mortality rates in the USA over the past 20 years, accelerating the implementation of prevention interventions found to be effective is critical. The Helping End Addiction Long-Term (HEAL) Prevention Cooperative (HPC) is a consortium of research projects funded to implement and test interventions designed to prevent the onset or escalation of opioid misuse among youth and young adults. The HPC offers a unique opportunity to synthesize and share lessons learned from participating research projects' varied implementation experiences, which can facilitate quicker integration of effective prevention interventions into practice. This protocol paper describes our hybrid approach to collecting and analyzing information about the implementation experiences of nine of the HPC research projects while they maintain their focus on assessing the effectiveness and cost-effectiveness of prevention interventions. To better understand implementation within this context, we will address five research questions: (1) What were the context and approach for implementing the prevention interventions, and how was the overall implementation experience? (2) How representative of the target population are the participants who were enrolled and retained in the research projects' effectiveness trials? (3) For what purposes and how were stakeholders engaged by the research projects? (4) What are the adaptable components of the prevention interventions? And finally, (5) how might implementation of the prevention interventions vary for non-trial implementation? This work will result in intervention-specific and general practical dissemination resources that can help potential adopters and deliverers of opioid misuse prevention make adoption decisions and prepare for successful implementation.

SGLT2 inhibitor ertugliflozin decreases elevated intracellular sodium, and improves energetics and contractile function in diabetic cardiomyopathy

BACKGROUND

Elevated myocardial intracellular sodium ([Na+]i) was shown to decrease mitochondrial calcium ([Ca2+]MITO) via mitochondrial sodium/calcium exchanger (NCXMITO), resulting in decreased mitochondrial ATP synthesis. The sodium-glucose co-transporter 2 inhibitor (SGLT2i) ertugliflozin (ERTU) improved energetic deficit and contractile dysfunction in a mouse model of high fat, high sucrose (HFHS) diet-induced diabetic cardiomyopathy (DCMP). As SGLT2is were shown to lower [Na+]i in isolated cardiomyocytes, we hypothesized that energetic improvement in DCMP is at least partially mediated by a decrease in abnormally elevated myocardial [Na+]i.

METHODS

Forty-two eight-week-old male C57BL/6J mice were fed a control or HFHS diet for six months. In the last month, a subgroup of HFHS-fed mice was treated with ERTU. At the end of the study, left ventricular contractile function and energetics were measured simultaneously in isolated beating hearts by 31P NMR (Nuclear Magnetic Resonance) spectroscopy. A subset of untreated HFHS hearts was perfused with vehicle vs. CGP 37157, an NCXMITO inhibitor. Myocardial [Na+]i was measured by 23Na NMR spectroscopy.

RESULTS

HFHS hearts showed diastolic dysfunction, decreased contractile reserve, and impaired energetics as reflected by decreased phosphocreatine (PCr) and PCr/ATP ratio. Myocardial [Na+]i was elevated > 2-fold in HFHS (vs. control diet). ERTU reversed the impairments in HFHS hearts to levels similar to or better than control diet and decreased myocardial [Na+]i to control levels. CGP 37157 normalized the PCr/ATP ratio in HFHS hearts.

CONCLUSIONS

Elevated myocardial [Na+]i contributes to mitochondrial and contractile dysfunction in DCMP. Targeting myocardial [Na+]i and/or NCXMITO may be an effective strategy in DCMP and other forms of heart disease associated with elevated myocardial [Na+]i.

Randomised controlled trial of the short-term effects of osmotic-release oral system methylphenidate on symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder: CIAO-II study

BACKGROUND

Research has shown that 20-30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders.

AIMS

To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD.

METHOD

We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16-25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression.

RESULTS

In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI -2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm.

CONCLUSIONS

ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.

Remote mental health care interventions during the COVID-19 pandemic: An umbrella review

Mitigating the COVID-19 related disruptions in mental health care services is crucial in a time of increased mental health disorders. Numerous reviews have been conducted on the process of implementing technology-based mental health care during the pandemic. The research question of this umbrella review was to examine what the impact of COVID-19 was on access and delivery of mental health services and how mental health services have changed during the pandemic. A systematic search for systematic reviews and meta-analyses was conducted up to August 12, 2022, and 38 systematic reviews were identified. Main disruptions during COVID-19 were reduced access to outpatient mental health care and reduced admissions and earlier discharge from inpatient care. In response, synchronous telemental health tools such as videoconferencing were used to provide remote care similar to pre-COVID care, and to a lesser extent asynchronous virtual mental health tools such as apps. Implementation of synchronous tools were facilitated by time-efficiency and flexibility during the pandemic but there was a lack of accessibility for specific vulnerable populations. Main barriers among practitioners and patients to use digital mental health tools were poor technological literacy, particularly when preexisting inequalities existed, and beliefs about reduced therapeutic alliance particularly in case of severe mental disorders. Absence of organizational support for technological implementation of digital mental health interventions due to inadequate IT infrastructure, lack of funding, as well as lack of privacy and safety, challenged implementation during COVID-19. Reviews were of low to moderate quality, covered heterogeneously designed primary studies and lacked findings of implementation in low- and middle-income countries. These gaps in the evidence were particularly prevalent in studies conducted early in the pandemic. This umbrella review shows that during the COVID-19 pandemic, practitioners and mental health care institutions mainly used synchronous telemental health tools, and to a lesser degree asynchronous tools to enable continued access to mental health care for patients. Numerous barriers to these tools were identified, and call for further improvements. In addition, more high quality research into comparative effectiveness and working mechanisms may improve scalability of mental health care in general and in future infectious disease outbreaks.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Intrapartum magnesium sulfate exposure and obstetric hemorrhage risk

BACKGROUND

The gold standard intrapartum treatment for preeclampsia with severe features is magnesium sulfate in order to provide prophylaxis against eclampsia. However, though magnesium sulfate is known to have a relaxant effect on uterine muscle, there have been variable reports in the literature in regard to the association between magnesium and obstetric hemorrhage (OBH).

OBJECTIVE

We aim to compare OBH incidence in patients with hypertensive disease of pregnancy (HDP) with or without exposure to intrapartum magnesium sulfate.

METHODS

We performed a retrospective cohort study of all deliveries at our institution associated with a diagnosis of hypertensive disease of pregnancy (HDP) (e.g. chronic and gestational hypertension, preeclampsia with or without severe features, eclampsia, or HELLP) from January 1, 2018 to December 31, 2019. The category of HDP diagnosis was determined by a detailed chart review by trained chart abstractors. The primary outcome was total quantitative blood loss (QBL) and the rate of obstetric hemorrhage. Secondary outcomes included a composite of obstetric hemorrhage-related maternal morbidity outcomes (OBH-M), the individual composite components and the incidence of additional hemorrhage-related interventions (e.g. uterotonics and surgical interventions). We also examined the same primary and secondary outcomes in a stratified analysis based on delivery mode (i.e. vaginal deliveries only and cesarean deliveries only).

RESULTS

Of 791 patients with a diagnosis of HDP, 411 patients received magnesium sulfate for eclampsia prophylaxis and 380 patients did not receive magnesium sulfate. For all delivery modes, there was a significantly higher QBL (p < .01), increased rate of OBH (p = .04) and increased OBH-M (p < .01) in deliveries associated with intrapartum exposure to magnesium compared to those without. However, our stratified analysis by delivery mode demonstrated that magnesium-related hemorrhage risk only persisted for vaginal deliveries (QBL p < .01; OBH aOR 1.47, 95% CI: 0.75-2.85; OBH-M aOR 1.47, 95% CI 1.00-7.55) with no significant hemorrhage-related differences among cesareans with or without magnesium exposure (QBL p = .51; OBH aOR 1.45, 95% CI: 0.85-2.47; OBH-M 1.50 95% CI: 0.70-3.23).

CONCLUSION

Intrapartum exposure to magnesium sulfate use was associated with an increase in QBL and risk of OBH-M in vaginal deliveries, but not associated with any hemorrhage-related outcome differences in cesarean deliveries. More research is needed to explore the effects of hypertensive disease, magnesium exposure, and delivery mode on obstetric hemorrhage risk.

Whole genome and transcriptome analysis enhances precision cancer treatment options

BACKGROUND

Recent advances are enabling delivery of precision genomic medicine to cancer clinics. While the majority of approaches profile panels of selected genes or hotspot regions, comprehensive data provided by whole genome and transcriptome sequencing and analysis (WGTA) presents an opportunity to align a much larger proportion of patients to therapies.

PATIENTS AND METHODS

Samples from 570 patients with advanced or metastatic cancer of diverse types enrolled in the Personalized OncoGenomics (POG) program underwent WGTA. DNA-based data, including mutations, copy number, and mutation signatures, were combined with RNA-based data, including gene expression and fusions, to generate comprehensive WGTA profiles. A multidisciplinary molecular tumour board used WGTA profiles to identify and prioritize clinically actionable alterations and inform therapy. Patient responses to WGTA-informed therapies were collected.

RESULTS

Clinically actionable targets were identified for 83% of patients, 37% of whom received WGTA-informed treatments. RNA expression data were particularly informative, contributing to 67% of WGTA-informed treatments; 25% of treatments were informed by RNA expression alone. Of a total 248 WGTA-informed treatments, 46% resulted in clinical benefit. RNA expression data were comparable to DNA-based mutation and copy number data in aligning to clinically beneficial treatments. Genome signatures also guided therapeutics including platinum, PARP inhibitors, and immunotherapies. Patients accessed WGTA-informed treatments through clinical trials (19%), off-label use (35%), and as standard therapies (46%) including those which would not otherwise have been the next choice of therapy, demonstrating the utility of genomic information to direct use of chemotherapies as well as targeted therapies.

CONCLUSIONS

Integrating RNA expression and genome data illuminated treatment options that resulted in 46% of treated patients experiencing positive clinical benefit, supporting the use of comprehensive WGTA profiling in clinical cancer care.

CLINICAL TRIAL NUMBER

NCT02155621.

Motivations for concurrent use of uppers and downers among people who access harm reduction services in British Columbia, Canada: findings from the 2019 Harm Reduction Client Survey

INTRODUCTION

An increase in crystal methamphetamine (methamphetamine) use during the overdose epidemic is being observed in British Columbia (BC), Canada, and across North America. Concurrent use (ie, using uppers and downers one after the other or together) can increase the risk of fatal and non-fatal opioid overdose.

OBJECTIVES

We investigated motivations for concurrent use of uppers and downers, specifically how (eg, in what order) and why people use concurrently, to identify potential interventions to prevent overdose and other harms.

SETTING AND PARTICIPANTS

The 2019 Harm Reduction Client Survey was administered across 22 harm reduction supply distribution sites in BC (n=621). This thematic analysis examined 307 responses by people who affirmed concurrent use to classify order and reasons for using uppers and downers concurrently.

RESULTS

Of the 307 people who responded 'yes' to concurrent use, 179 (58.3%) used downers then uppers, 76 (24.8%) used uppers then downers and 184 (59.9%) mixed uppers and downers together. Four main reasons for concurrent use emerged: self-medication, availability and preference, drug effects/properties, and financial and life situation. People who mixed drugs together predominantly wanted to achieve desired drug effects/properties, such as a specific high or balancing stimulating and sedating effects.

CONCLUSIONS

The ongoing rise in overdoses in BC is multifactorial, and the recent parallel increases in methamphetamine use and concurrent use with opioids may contribute. Qualitative interviews may further elucidate reasons for concurrent use. Addressing reasons for concurrent use identified in this study through harm reduction strategies and education may affect the rates of overdose morbidity and mortality.

Opinions of stakeholders about integrating pharmacists into Community Mental Health Teams

Introduction

Pharmacists are routinely involved in optimising medicines for mental health patients during inpatient admissions through attending ward rounds and providing a clinical pharmacy service. (1) Despite literature demonstrating the benefits, specialist pharmacists are not routinely integrated in Community Mental Health Teams (CMHTs) (2) and there is little research to identify the barriers to pharmacists’ integration. The opinions of stakeholder who influence the design of community mental health services, are key to understanding these issues.

Aim

To explore the views of relevant stakeholders in one health board (HB) in Wales, regarding integration of pharmacists into CMHTs, and to make recommendations to overcome identified barriers to integration.

Methods

Semi-structured interviews using open questions with key stakeholders within two CMHTs and the HB’s adult mental health clinical board. Participants were selected purposively to allow recruitment of individuals who would provide insight into the proposed question(s). Written, informed consent was obtained. A deductive approach was used to define interview questions. Interviews were transcribed and analysed thematically using an inductive approach to explore the data without any pre-conceived ideas and identify additional key themes. The study was registered with the HB.

Results

Interviews (3 pharmacists, 2 consultant psychiatrists, 1 integrated manager, 2 clinical nurse leads and 2 general managers) lasted between 30-45 minutes. Analysis revealed five main themes; relationship with the pharmacist, including previous experiences and individual pharmacist’s personal attributes; CMHT workload relevant to pharmacists’ skills; workforce and financial pressures; the need for ongoing support for and from pharmacists; and pharmacists’ expertise including non-medical prescribing. Previous experience of working with specialist mental health pharmacist influenced participants’ views, those with limited experience were less clear about what a pharmacist’s role would be in CMHTs“…we haven’t had specialist pharmacist linked to us ………“Always can get in touch with pharmacy by e-mail or phone. Can see advantage of a pharmacist in the building, the medics would really like that it wouldn’t need to be every week maybe a morning every two weeks. We know where pharmacy are, not a dire need. Others identified a clear role for pharmacists, “running clinic for us especially when we have referrals from GP purely asking for medication reviews having [pharmacist] here the benefit surpasses most of the options we can offer through medic”. Participants believed pharmacists needed training in risk assessment and consultation skills and they should be prescribers to contribute effectively. Nine participants had worked previously with pharmacists, all advocated their integration into CMHTs.

Conclusion

This small-scale study suggests there is a desire to integrate pharmacists into CMHTs with a strong emphasis on their role in addressing medicine-related workload pressures. Positive relationships formed from prior experience of working with pharmacists strongly influenced support for integration. There are potential roles for pharmacists that would improve timeliness and quality of care for people supported by CMHTs. Resource constraints such as lack of funding and availability of appropriately trained pharmacists need to be resolved. Further work is necessary to investigate how these barriers can be addressed and to evaluate the cost-effectiveness of any pharmacy service delivered.

References

(1) Royal Pharmaceutical Society England (2018). No health without mental health: How can pharmacy support people with mental health problems? London. Royal Pharmaceutical Society England

(2) Robinson, J. (2017). Challenging the Stigma. The Pharmaceutical Journal, November 2017, Vol 299, No 7907, [online] | DOI: 10.1211/PJ.2017.20203915 [Accessed 1 Mar. 2019]

Community based participatory research approaches to combat oral health inequities among American Indian and Alaska Native populations

American Indian and Alaska Native (AI/AN) communities have experienced a history of systemic racism and still face significant oral health disparities. These disparities extend to the youngest community members in the form of early childhood caries (ECC). Although behavior and biology contribute to ECC, the conditions where people live, grow, and work, and the systems and political and economic forces that shape individual health outcomes, are thought to greatly impact ECC among AI/AN populations. To address ECC in AI/AN communities, we used a community based participatory approach that incorporated social determinants of health. We found that implementing culturally-tailored, culturally-centered, and AI/AN-created materials for ECC interventions is viewed favorably by community members and tribal leaders. Because of the complexity of ECC in AI/AN communities we adopted a bundled approach of best practices to reduce ECC including: (1) incorporating locally, contextually, and culturally relevant strategies to present recommended ECC prevention approaches; (2) employing AI/AN community members as educators; (3) utilizing motivational interviewing with expectant mothers; and (4) providing fluoride varnish. Our work underscores the importance of developing trusting partnerships with each other and with our communities, drawing upon the insights of community advisory board members, and eliciting formative assessment data from tribal members to gain a more holistic understanding of our participants' lived experience to design relevant intervention materials. Incorporating local knowledge and situating Western oral health prevention approaches within culturally aligned frameworks can enhance partnerships and create sustainable materials for community work.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

A case of premature ventricular contractions-related cardiomyopathy

Premature ventricular contractions (PVCs) are heart beats initiated in the ventricles instead of in the sinoatrial node. A high burden of PVCs can lead to a cardiomyopathy, characterised by reduced left ventricular (LV) systolic dysfunction. We present a case of PVC-related cardiomyopathy where the 65-year-old male was initially seen by his primary care provider for recent onset chest pain and dizziness. His transthoracic echocardiogram showed mild concentric LV hypertrophy and mildly reduced systolic function (LV ejection fraction 43%). There was also mild right ventricular (RV) systolic dysfunction. He was started on a beta-blocker and an angiotensin-converting enzyme inhibitor. A 24-hour Holter monitor showed a very high burden of PVCs (32% of all beats). He continued to have frequent PVCs and his echocardiogram did not improve. He was eventually referred for a PVC ablation. Following the ablation, a repeat Holter monitor showed a marked reduction in PVC burden (<1% of beats) and his echocardiogram had normalised.

Increasing fatty acid oxidation elicits a sex-dependent response in failing mouse hearts

BACKGROUND

Reduced fatty acid oxidation (FAO) is a hallmark of metabolic remodeling in heart failure. Enhancing mitochondrial long-chain fatty acid uptake by Acetyl-CoA carboxylase 2 (ACC2) deletion increases FAO and prevents cardiac dysfunction during chronic stresses, but therapeutic efficacy of this approach has not been determined.

METHODS

Male and female ACC2 f/f-MCM (ACC2KO) and their respective littermate controls were subjected to chronic pressure overload by TAC surgery. Tamoxifen injection 3 weeks after TAC induced ACC2 deletion and increased FAO in ACC2KO mice with pathological hypertrophy.

RESULTS

ACC2 deletion in mice with pre-existing cardiac pathology promoted FAO in female and male hearts, but improved cardiac function only in female mice. In males, pressure overload caused a downregulation in the mitochondrial oxidative function. Stimulating FAO by ACC2 deletion caused unproductive acyl-carnitine accumulation, which failed to improve cardiac energetics. In contrast, mitochondrial oxidative capacity was sustained in female pressure overloaded hearts and ACC2 deletion improved myocardial energetics. Mechanistically, we revealed a sex-dependent regulation of PPARα signaling pathway in heart failure, which accounted for the differential response to ACC2 deletion.

CONCLUSION

Metabolic remodeling in the failing heart is sex-dependent which could determine the response to metabolic intervention. The findings suggest that both mitochondrial oxidative capacity and substrate preference should be considered for metabolic therapy of heart failure.

Cardiovascular Complications of Acetylcholinesterase Inhibitors in Patients with Alzheimer's Disease: A Narrative Review

While acetylcholinesterase inhibitors are used to treat a wide range of patients with Alzheimer's disease, acetylcholinesterase inhibitor use has also been associated with a variety of cardiovascular complications, including bradycardia and syncope. Herein, we review the pathophysiology and clinical evidence for cardiovascular complications caused by acetylcholinesterase inhibitors in patients being treated for dementia and discuss options for their management.

A retrospective single-site data-linkage study comparing manual to electronic data abstraction for routine post-operative nausea and vomiting audit

BACKGROUND

Post-operative nausea and vomiting (PONV) is a common cause of patient dissatisfaction following anaesthesia. Audit of adherence to PONV prevention guidelines is resource intensive when performed by manual chart extraction. Electronic audit can require costly anaesthetic and medical records.

OBJECTIVE

In our single-site study we sought to compare manual and electronic PONV audits by utilizing existing non-anaesthetic electronic medical records to avoid expensive additional software.

METHODS

The audits were performed from 13 January 2020 to 1 February 2020 for surgical inpatients. Two PONV periods were captured-the post-anaesthetic recovery unit and on the ward (to 24 h). Electronic PONV was defined as the administration of an anti-emetic medication. A 6-month electronic PONV rate was also calculated.

RESULTS

Manual audit captured 142 patients and electronic audit captured 294 patients, over the same time period. The manual PONV rate was 10% (95% confidence interval (CI) 5-16%) in the post-anaesthetic recovery unit and 20% (95% CI 14-28%) the next day. The electronic rate was 5% (95% CI 3-8%) in the post-anaesthetic recovery unit and 15% (11-19%) in a 24-h period. The 6-month electronic audit found 3510 patients, with a post-anaesthetic recovery unit and 24-h PONV rates of 5% (4-6%) and 14% (13-16%), respectively. Electronic audit did not identify 5.8% of PONV patients in the manual audit.

CONCLUSION

Electronic audit enrolled more patients and identified a lower PONV rate than manual audit, likely from less enrolment bias. Electronic audit was easily repeated over a 6-month period. While electronic PONV audit is possible without additional software, an electronic anaesthetic chart would greatly improve audit quality.