1st Choice Research Articles

Real World Management of Multiple Myeloma in Asia: Treatment Pattern and Cost

Introduction:Multiple myeloma (MM) is the second most common hematologic malignancies in the world. New approved therapeutic agents have improved the survival rates of myeloma patients. However, it is often unclear what is the best treatment in different settings, and the treatment cost is rising. In this study, we assess the way MM is treated in a developed country in Asia.Methods:A retrospective study of newly diagnosed MM patients from June 2009 to April 2017 from Singapore was conducted. The analysis focused on the age of patient, medication regimes used for different lines of treatment, whether autologous stem cell transplant (SCT) was received and the estimated cost of treatment. Treatment free period (TFP) was measured as time from the end date of previous treatment to the start date for the next treatment. The time to next treatment (TTNT) was measured from the start date of the first treatment to the start date of the next line of treatment.Results:A total of 143 patients were included in the analysis. Among the 96 (67.1%) patients under 65 years old, only 73 (76%) received autologous SCT treatment. Overall, 56 (39.2%) of the patients progressed and received second (2nd) line treatment, while 21 (14.7%) and 9 (6.3%) received 3rd and 4th line treatment respectively. The most frequently used drugs for 1st line treatment were Bortezomib (75.5%), Dexamethasone (87.4%), Thalidomide (63.6%) and Cyclophosphamide (53.8%). This reflects that the 2 most commonly used regimens for 1st line treatment are VCD and VTD. For 2nd line treatment, Lenalidomide (50%) and Dexamethasone (94.6%) were the main drugs used, reflecting that RD was the predominant regimen used in this phase. For 3rd line treatment, Dexamethasone (100%), Pomalidomide (38.1%), Cyclophosphamide (33.3%) and Lenalidomide (33.3 %) were the main drugs used.Focusing on individual drugs, while Lenalidomide was only used 7.7% of the time for 1st line treatment, usage increased to 50% and 33.3% for 2nd and 3rd line treatment respectively. For Pomalidomide, while usage was low at 0% and 7.1% for 1st and 2nd line treatment respectively, it increased to 38.1% for 3rd line treatment. Bortezomib, Thalidomide and Cyclophosphamide were predominantly used as 1st line treatment choices, with usage rates of 75.5%, 63.6% and 53.8% respectively. Their usage rates were significantly reduced in 2nd and 3rd line treatment.The average treatment cost per TFP (weeks) among 56 patients who progressed to 2nd line treatment was $673.81/week. The average cost increased to $2,239/week and $11,556.56/week for the patients who received 3rd and 4th line treatment respectively. For SCT patients (30 patients progressed to 2nd line, 7 patients to 3rd line, and 4 patients to 4th line), the average cost per TFP was $705.87/week, $2,078.66/week and $35,854.20/week for 2nd, 3rd and 4th line of treatment respectively. For non-SCT patients (26 patients progressed to 2nd line, 14 patients to 3rd line, and 5 patients to 4th line), the average cost per TFP was $603.64/week, $2,333.25/week and $5,959.72/week for 2nd, 3rd and 4th line of treatment respectively.The average TTNT per patient for 1st, 2nd and 3rd treatment line progression was 128.8, 58.7 and 75.5 weeks respectively. The average TTNT per SCT patient was 142.4, 65.6 and 74.9 weeks for 1st, 2nd and 3rd treatment line progression respectively, as compared to 113.1, 55.2 and 75.9 weeks for non-SCT patients. Overall, the average treatment cost per week of TTNT was $409.18, $798.10 and $2,167.92 for 1st, 2nd and 3rd treatment line progression respectively - the average cost for SCT patients was $496.91, $736.23 and $2,855.34, while the average cost for non-SCT patients was $281.81, $834.81 and $1,625.58 respectively.Conclusions:Treatment for multiple myeloma remains expensive. While the benefits of subsequent lines of treatment decreases, the average treatment cost increases. With the increasing availability of expensive but yet more effective treatments, these could be incorporated early into the treatment regimen to maximise therapeutic benefit. Despite the higher cost of these drugs, cost-effectiveness could be improved, or at least remain similar if TTNT can be greatly prolonged. [Display omitted] DisclosuresChng:Janssen China R&D: Research Funding.

S2k-Leitlinie: Status Epilepticus im Erwachsenenalter

Diese S2k-Leitlinie (LL) zum Status epilepticus (SE) im Erwachsenenalter schreibt die letzte DGN-LL zum SE von 2012 fort. Neue Definitionen und Evidenz wurden bei der Erstellung der LL und des Clinical Pathway berücksichtigt. Jeder epileptische Anfall, der länger als 5 Minuten anhält (oder ≥ 2 Anfälle über einen Zeitraum von mehr als 5 Minuten ohne Wiedererlangen des neurologischen Ausgangsstatus), soll als SE behandelt werden.In der Diagnostik sollte initial eine CCT oder, wenn möglich, eine MRT erfolgen. Das EEG spielt bei der Diagnosestellung und beim Therapiemonitoring von non-konvulsiven SE und zum Ausschluss bzw. Nachweis psychogener nichtepileptischer Anfälle eine wesentliche Rolle. Der prognostische Einfluss von insbesondere entzündlichen Begleiterkrankungen (z. B. Pneumonie) wurde besser belegt, weshalb entsprechende Laborparameter auch im Verlauf kontrolliert werden sollten und ggf. frühzeitig eine antibiotische Therapie initiiert werden sollte.Die Therapie erfolgt in 4 Stufen: 1. Initialer SE: Gabe eines ausreichend hoch dosierten Benzodiazepins i. m., i. v. oder i. n.; 2. Benzodiazepin-refraktärer SE: 1. Wahl ist die i.v. Gabe von Levetiracetam oder Valproat; 3. Refraktärer SE (RSE) und 4. Superrefraktärer SE (SRSE): I.v. Propofol oder Midazolam alleine oder in Kombination oder Thiopental in anästhetischen Dosen. Beim fokalen non-konvulsiven RSE kann unter Umständen auf die Einleitung eines therapeutischen Komas verzichtet werden. Bei SRSE sollte die ketogene Diät zum Einsatz kommen. I.v. Ketamin oder inhalatives Isofluran kann erwogen werden. In Einzelfällen kann die elektrokonvulsive Therapie und, bei resektabler epileptogener Zone, ein Epilepsie chirurgischer Eingriff erwogen werden. I.v. Allopregnanolon oder die Hyperthermie sollen nicht eingesetzt werden.

The level of competence of graduating nursing students in 10 European countries-Comparison between countries.

AimTo analyse graduating nursing students’ self‐assessed competence level in Europe at graduation, at the beginning of nursing career.DesignAn international cross‐sectional evaluative design.MethodsData were collected in February 2018–July 2019 from graduating nursing students in 10 European countries. Competence was assessed with a validated instrument, the Nurse Competence Scale (NCS). The sample comprised 3,490 students (response rate 45%), and data were analysed statistically.ResultsIn all countries, graduating nursing students assessed their competence as good (range 50.0–69.1; VAS 0–100), albeit with statistically significant differences between countries. The assessments were highest in Iceland and lowest in Lithuania. Older students, those with working experience in health care, satisfied with their current degree programme, with excellent or good study achievements, graduating to 1st study choice and having a nursing career plan for future assessed their competence higher.

Role of Ultrasonographic Examination of the Knee in Evaluation of Meniscal Injury in Correlation with Magnetic Resonance Imaging

Background: meniscal tear is one of the most common injuries of knee joint. MRI is considered to be 1st choice to diagnose meniscal tear. The question of the study is, if we can use U/S as screening tool for meniscal injuries before MRI. Aim of the Work: to determine the clinical usefulness of ultrasonography for diagnosis of meniscal pathology in patients with acute knee pain and to compare its diagnostic accuracy to MRI in a clinical setting. Patients and Methods: this study was carried out in Radiology department, Benha University hospitals. Forty patients with clinical suspicion of post-traumatic meniscal injury were submitted to the following: i. data collection, ii. Clinical examination, iii. Ultrasound examination, iv. MRI examination. Data management and statistical analysis were done using SPSS vs.25. (IBM, Armonk, New York, USA). Results: the overall accuracy of ultrasound examination for meniscal tears was 85.2% while the overall accuracy of ultrasound examination for meniscal degeneration was 70.6% Conclusion: ultrasound appears to be useful for the screening of meniscal tears.

Structural Antibiotic Surveillance and Stewardship via Indication-Linked Quality Indicators: Pilot in Dutch Primary Care.

Insight into antibiotic prescribing quality is key to general practitioners (GPs) to improve their prescribing behavior and to national antibiotic surveillance and stewardship programs. Additionally to numbers of prescribed antibiotics, quality indicators (QIs) linked to the clinical indication for prescribing are urgently needed. The aim of this proof of concept study was to define indication-linked QIs which can be easily implemented in Dutch primary care by collaborating with data-extraction/processing companies that routinely process patient data for GP practices. An expert group of academic and practicing GPs defined indication-linked QIs for which outcomes can be derived from routine care data. QI outcomes were calculated and fed back to GPs from 44 practices, associations between QI outcomes were determined, and GPs’ opinions and suggestions with respect to the new set were captured using an online questionnaire. The new set comprises: (1) total number of prescribed antibiotics per 1000 registered patients and percentages of generally non-1st choice antibiotics; (2) prescribing percentages for episodes of upper and lower respiratory tract infection; (3) 1st choice prescribing for episodes of tonsillitis, pneumonia and cystitis in women. Large inter-practice variation in QI outcomes was found. The validity of the QI outcomes was confirmed by associations that were expected. The new set was highly appreciated by GPs and additional QIs were suggested. We conclude that it proved feasible to provide GPs with informative, indication-linked feedback of their antibiotic prescribing quality by collaborating with established data extraction/processing companies. Based on GPs’ suggestions the set will be refined and extended and used in the near future as yearly feedback with benchmarking for GPs and for national surveillance and stewardship purposes.

Locoregional management of in-transit metastasis in melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline.

The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastasis (itm) from melanoma. The guideline was developed by the Program in Evidence-Based Care (pebc) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group. Recommendations were drafted by a Working Group based on a systematic review of publications in the medline and embase databases. The document underwent patient- and caregiver-specific consultation and was circulated to the Melanoma Disease Site Group and the pebc Report Approval Panel for internal review; the revised document underwent external review. "Minimal itm" is defined as lesions in a location with limited spread (generally 1-4 lesions); the lesions are generally superficial, often clustered together, and surgically resectable. "Moderate itm" is defined as more than 5 lesions covering a wider area, or the rapid development (within weeks) of new in-transit lesions. "Maximal itm" is defined as large-volume disease with multiple (>15-20) 2-3 cm nodules or subcutaneous or deeper lesions over a wide area.■ In patients presenting with minimal itm, complete surgical excision with negative pathologic margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered.■ In patients presenting with moderate unresectable itm, consider using this approach for localized treatment: intralesional interleukin 2 or talimogene laherparepvec as 1st choice, topical diphenylcyclopropenone as 2nd choice, or radiation therapy as 3rd choice. Evidence is insufficient to recommend intralesional bacille Calmette- Guérin or CO2 laser ablation outside of a research setting.■ In patients presenting with maximal itm confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference.■ In cases in which local, regional, or surgical treatments for itm might be ineffective or unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered.

An analysis of contributing factors of head and neck space infections of odontogenic origin: A long-term retrospective clinical study (including COVID-19 pandemic period).

The purpose of this study is to investigate predisposing factors for the head and neck infections (HNIs), regarding to the demographic data, anatomical spaces, microbiology and antibiotic sensitivity for affected patients. A 13-year of retrospective study evaluating 470 patients with HNIs, treated as inpatient management in the Department of Oral and Maxillofacial Surgery of KyungHee University school of Dentistry, Seoul, Korea, from January 2009 to February 2022. Statistical analysis of demographic, time-related, anatomic, microbiologic, and treatment variables were investigated for each patient. The frequency of HNIs was significantly higher in 50's in males, followed by 70's in females. High Severity score (SS) were significantly associated with increased LOH (Length of hospital stay) and LOM (Length of medication), while LOH showed more intensive relationship compared with LOM. The most frequently involved space in abscess was submandibular space, though incidence and severity of HNIs shows declining tendency throughout 13-year research. Streptococcus viridans was the most predominant species isolated from pus culture growth, and a combination of ampicillin and sulbactam was the 1st choice of antibiotics intravenously. According to the comparison analysis between recommended antibiotics from resistance testing result and clinically administered antibiotics, final coincidence rate was estimated about 55%. Due to HNIs being multifactorial, predicting progression and management of HNIs is still a challenge for oral and maxillofacial surgeons. The present study showed several predisposing factors of SHNIs and their correlations, which could contribute to earlier diagnosis and more effective treatment planning for clinicians, thereby leading to the improvement of prognosis for patients, ultimately.

Implementation and evaluation of an antimicrobial stewardship programme in companion animal clinics: A stepped-wedge design intervention study.

To curb increasing resistance rates, responsible antimicrobial use (AMU) is needed, both in human and veterinary medicine. In human healthcare, antimicrobial stewardship programmes (ASPs) have been implemented worldwide to improve appropriate AMU. No ASPs have been developed for and implemented in companion animal clinics yet. The objective of the present study was to implement and evaluate the effectiveness of an ASP in 44 Dutch companion animal clinics. The objectives of the ASP were to increase awareness on AMU, to decrease total AMU whenever possible and to shift AMU towards 1st choice antimicrobials, according to Dutch guidelines on veterinary AMU. The study was designed as a prospective, stepped-wedge, intervention study, which was performed from March 2016 until March 2018. The multifaceted intervention was developed using previous qualitative and quantitative research on current prescribing behaviour in Dutch companion animal clinics. The number of Defined Daily Doses for Animal (DDDAs) per clinic (total, 1st, 2nd and 3rd choice AMU) was used to quantify systemic AMU. Monthly AMU data were described using a mixed effect time series model with auto-regression. The effect of the ASP was modelled using a step function and a change in the (linear) time trend. A statistically significant decrease of 15% (7%-22%) in total AMU, 15% (5%-24%) in 1st choice AMU and 26% (17%-34%) in 2nd choice AMU was attributed to participation in the ASP, on top of the already ongoing time trends. Use of 3rd choice AMs did not significantly decrease by participation in the ASP. The change in total AMU became more prominent over time, with a 16% (4%-26%) decrease in (linear) time trend per year. This study shows that, although AMU in Dutch companion animal clinics was already decreasing and changing, AMU could be further optimised by participation in an antimicrobial stewardship programme.

Application of different fish sampling gear in Korean reservoirs and the analysis of sampling efficiencies

The key objectives of this research were to establish fish monitoring methodologies and sampling efficiency strategies through the analysis of relations between fish species (compositions) and different kinds of sampling gear for lentic ecosystem health assessments. During the study, 81 species of fish and 53,792 individuals were sampled from the thirty reservoirs. When we tested the efficiency of combinations of multiple sampling gears, the combination of the cast net (CN) and kick net (KN) was most cost-effective, based on the sampling time elapsed and total cost of the sampling. This combination (1st choice method) sampled 74 fish species and 21,321 individuals and showed even better results than the combination of four types of gear (2nd choice method), which included the CN, fyke net (FN), trammel net (TN), KN, although 80 species and 52,242 individuals were sampled from the 2nd method. Overall, our preliminary data suggest that the lentic ecosystem health assessment (LEHA) model developed for national-level surveys may be used as an efficient tool for LEHA and the combined use of the CN and KN was more cost-effective than the 2nd choice method of four types of sampling gear (CN, FN, TN, and KN).

Trends of prescribing antibiotics in various dental diseases at different private clinical setups of Sialkot, Pakistan.

Objectives: Antibiotics widely used now a day in dental practice for treatment of acute odontogenic, non-odontogenic infections and as a prophylactic purpose for focal infections in patients at possibility for infective endocarditis development as well as prevention of surgical infection of wound and controlling of orofacial infections. Studies of prescribing trends provide information about the quality & pattern of use causes of drug use, and their outcomes. The main objective of this study was to assist trends and the rational utilization of antibiotics in dental practice. Study Design: Descriptive study. Settings: The current study was conducted among the different private dental clinical settings of Sialkot. Period: Eight months study (Jan-Aug 2018). Material and Methods: Sample size was 700 prescriptions which were gathered during. A purposive sampling was used for collection of prescription. A proforma was used for recording all required demographic & prescribing data was designed to collect all information associated to antibiotic prescribing trend. The data was collected, compiled, & analysed on MS Excel and descriptive statistics was used for analysing the result of the study. Results: A total of 700 prescriptions were collected from various Dental clinics. Among the study, 58.7% patients were male and 41.3 % females and more frequent age group was 51-68 (37%). Mostly patients have pervious medication history (38.8%) and most common diagnosis was periodontal abscess (16.6%) observed during our study followed by pulpitis (15.9%). The trend observed was that majority 35.3% would prescribe antibiotics for patients who presented with elevated body temperature. Commonly 5 drugs per prescription prescribed (26.7%) least numbers of drugs prescribed per prescription is 2(5.9%). Total 3445 drugs were prescribed in 700 prescriptions. Analgesics are frequently prescribed drug category (22.3%) followed by antibiotics (21.8%) Amoxicillin and clavulanic acid was mostly used (31.9%) in these dental centres. Conclusion: This study show that most prevalent dental disease for which doctors prescribed antibacterial was periapical or periodontal abscess and Amoxicillin and clavulanic acid used as a 1st choice for oral infections.

EP1.12-01 Does PCI Still Have a Role in Limited SCLC?

Prophylactic cranial irradiation (PCI) has long been an integral part of treatment protocols for limited stage small cell lung cancer (SCLC). PCI stands for "prophylactic” while it may be not really prophylactic, rather therapeutic for un-detectable brain disease. A survey of 39 questions was conducted on the online platform “Survey Monkey” for practicing oncologists, radiotherapists, pulmonologists and thoracic surgeons. The aim of this survey is to establish a practice baseline for a future multicenter study of overall survival (OS) benefits of PCI versus MRI follow-up in limited SCLC. 41 respondents participated from 14 European countries (26 oncology centers) and from 4 US radiotherapy centers: medical oncologists (31%), radiation oncologist (25%), pulmonologists (34%). Brain imaging at diagnosis of SCLC is performed by MRI in 83% and CT with contrast in 49%. Brain follow up after chemotherapy is performed by MRI in 49%, CT with contract in 41%, and no imaging in asymptomatic patients in 20%. PCI is recommended to 67% of patients and performed immediately after the last chemotherapy in 37%, or 2 months after chemotherapy in 49%. The most important criteria whether patient needs PCI are performance status and response to chemotherapy. The most common schedule of PCI is 25Gy in 10 fractions, 41% of respondents. In case of a single brain metastasis after PCI the 1st choice of treatment is SRS, in 93%. Regarding the role of PCI 46% of respondents think that PCI prevents brain metastases from occurring, and 54% think that PCI treats occult brain metastases. The lack of clinical trials about PCI for limited SCLC patients is undisputed. Our survey shows practice patterns to PCI for patients with limited SCLS depends on Institution and/or specialty. These results establish a practice baseline for a multicentral trial of PCI versus MRI observation, and 93% of our respondents agreed to take part in this trial.

Time trends, seasonal differences and determinants of systemic antimicrobial use in companion animal clinics (2012-2015)

Any antimicrobial use (AMU) in humans and animals selects for antimicrobial resistance (AMR) and responsible AMU should therefore be promoted both in human and veterinary medicine. Insight into current AMU in companion animal clinics is necessary to be able to optimise antimicrobial (AM) prescribing behaviour. The objective of this study was to describe systemic AMU in 44 Dutch companion animal clinics over a 3-year time period (2012–2015), using retrospectively collected data. The number of Defined Daily Doses for Animals (DDDAs) per month and per clinic were calculated from prescription data for total, 1st, 2nd and 3rd choice AMU (classification according to Dutch policy on veterinary AMU). Time trends, seasonality and the influence of potential determinants (e.g., the number of dogs, cats and rabbits per clinic and other clinic characteristics) were explored using statistical modelling. Overall, the findings show that total AMU decreased over time and a shift in used classes of antimicrobials towards more 1st choice AMs was visible. Mean total AMU decreased from 1.82 DDDA/year in 2012–2013 to 1.56 DDDA/year in 2014-2015. Aminopenicillins, with and without clavulanic acid, accounted for the largest group of antimicrobials used; 38.7% (2012–2013), 40.2% (2013–2014) and 39.3% (2014–2015) of total AMU, respectively. Strong seasonal differences in AMU were found, with highest AMU in July-August and lowest in February-March. The distribution of different animal species per clinic appeared to affect AMU as well. In clinics with a larger proportion of dogs, 2nd choice AMU was significantly higher, whereas in clinics with a larger proportion of rabbits, 2nd choice AMU was significantly lower. Despite the decrease of AMU during the study period, there is still room for improvement left, especially with regard to the antimicrobial classes prescribed. According to Dutch classification of veterinary AMU, 1st choice AMs should be used as empirical therapy. A decrease in 2nd (might select for ESBL-producing bacteria) and 3rd choice AMU (i.e. fluoroquinolones and 3rd generation cephalosporins) should be aimed for.

The Role of Ultrasound in Evaluation of Meniscal Injury

Background: meniscal tear is one of the most common injuries of knee joint , MRI is considered to be 1st choice to diagnose meniscal tear. The Question of the study is if we can use U/S as screening tool for Meniscal injuries before MRI. Aim of the Work: to determine the clinical usefulness of ultrasonography for diagnosis of meniscal pathology in patients with acute knee pain and compare its diagnostic accuracy to MRI in a clinical setting. Patients and Methods: this study was carried out in Radiology department, Ain Shams University hospitals. 15 patients with MRI proven Meniscal tear underwent knee ultrasound examination. Results: the overall sensitivity of ultrasound examination for meniscal tears was 77%. Conclusion: ultrasound appears to be useful for the screening of meniscal tears but detection of the morphology of meniscal tears seems insufficient.

Gut Incretin Release as a Mediator of Metabolic Effects of Metformin in Type 2 Diabetic Patients with Chronic Heart Failure

Introduction: Metformin (MET) is a 1st choice drug used in patients with type 2 diabetes (DM). Treatment with MET in patient with DM and heart failure (HF) is associated with better cardiovascular outcomes, but mechanisms of MET-mediated effects are unexplained. Our aim was to evaluate the effects of MET on substrate metabolism, cardiac function and structure in patient with DM and HF. Methods: 40 patients with DM and stable chronic HF (age: 59 ± 9 years) were studied in a random sequence cross-over clinical study testing the effect of 3-month usage of MET vs. placebo. The subjects were randomized to MET (2 g/day) or to placebo group. After the three months of treatment the medication was changed and the treatment continued for next 3 months. At the beginning and the end of each intervention period (3 times in total) the panel of various metabolic and cardiovascular tests was done: echocardiography, spiroergometry and meal test with evaluation of several variables like incretins (GLP-1 and peptide YY) and parameters of oxidative stress (MCP-1, TNFα). Results: Compared to placebo, MET was accompanied with significantly higher increase of selected gut-related hormones. GLP-1 area-under-curve increased during the meal test (MET vs. PL: 8571.39±6899.57 vs. 5665.82±4580.57pmol.hour.l-1; p<0.01). Also the peptide YY area-under-curve increased during the meal test (MET vs. PL: 29809.67±13442.43 vs. 23636.21±8183.08pmol.hour.l-1; p<0.05). MCP-1 showed inconsistent trend to increase during meal test. Fasted levels of TNFα were higher after MET, but there was no change during the meal test compared to placebo. MET therapy led to reduction of HbA1C (p<0.001) and reduced glucose area-under-curve (p<0.001) during glucose tolerance test. MET had neutral effect on cardiac structure and function. Conclusions: Our results suggest that metabolic effects of MET might be mediated by improvement of gut endocrine function. MET had neutral effect on cardiac function or structure. Disclosure E. Stolarikova: None. J. Kopecky: None. J. Veleba: None. K. Velebova: None. L. Belinova: None. V. Melenovsky: None. J. Kopecky: None. T. Pelikanova: None.

간세포암종에서 초치료로 양성자를 사용하여 양호한 결과를 보인 증례 1예

간세포암종에서 초치료로 양성자를 사용하여 양호한 결과를 보인 증례 1예

Cultural reflections in practicing exposure therapy for social anxiety

Evidence-based practice of exposure therapy has long been adopted as an effective therapy for treating anxiety disorders including social anxiety. In many situations, it is the chosen therapy for such a debilitating disease. Due to its proven efficacy and readiness applicability, it has proven to be the 1st choice of therapy for social anxiety across different life spans from adolescents to geriatrics. Yet, cross-cultural differences have seldom been considered in the approach towards managing social anxiety. Many differences lie between populations and countries in defining what is accepted and what is not with regard to social interactions. Even across the one country, many differences may color the perception of appropriate social communication. Hence, no one-size-fits all can be adopted here. Some interactions are accepted and encouraged while others are basically banned. Thus, during the application of exposure therapy, therapists should modify the conceptual framework while still trying to abide with the fundamental notion of therapy of exposure experiments. In doing this, many therapists may be challenged in their work. While still lacking a strong body of research, clinical experience can provide us with some helpful innovations for successful practice. Our aim is to provide therapists and psychiatrists across the Arab world with tools for applying successful therapy for social anxiety. A series of case studies are discussed to present some innovations in applying Cognitive Behavior Therapy for patients suffering from social inhibitions. Moreover, essentials of past research are reviewed and needs for further research directions in the field are discussed.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

Development and validation of an automatic method to detect the latest contracting viable left ventricular segments to assist guide CRT therapy from gated SPECT myocardial perfusion imaging

ObjectivesThe purpose of this study is to use ECG-gated SPECT MPI to detect the latest contracting viable left ventricular (LV) segments to help guide the LV probe placement used in CRT therapy and to validate segment selection against the visual integration method by experts. MethodsFor each patient, the resting ECG-gated SPECT MPI short-axis images were sampled in 3D to generate a polar map of the perfusion distribution used to determine LV myocardial viability, and to measure LV synchronicity using our phase analysis tool. In the visual integration method, two experts visually interpreted the LV viability and mechanical dyssynchrony from the short-axis images and polar maps of viability and phase, to determine the latest contracting viable segments using the 17-segment model. In the automatic method, the apical segments, septal segments, and segments with more than 50% scar were excluded as these are not candidates for CRT LV probe placement. Amongst the remaining viable segments, the segments, whose phase angles were within 10° of the latest phase angle (the most delayed contracting segment), were identified for potential CRT LV probe placement and ranked based on the phase angles of the segments. Both methods were tested in 36 pre-CRT patients who underwent ECG-gated SPECT MPI. The accuracy was determined as the percent agreement between the visual integration and automatic methods. The automatic method was performed by a second independent operator to evaluate the inter-operator processing reproducibility. ResultsIn all the 36 patients, the LV lead positions of the 1st choices recommended by the automatic and visual integration methods were in the same segments in 35 patients, which achieved an agreement rate of 97.2%. In the inter-operator reproducibility test, the LV lead positions of the 1st choices recommended by the two operators were in the same segments in 25 patients, and were in the adjacent segments in 7 patients, which achieved an overall agreement of 88.8%. ConclusionsAn automatic method has been developed to detect the latest contracting viable LV segments to help guide the LV probe placement used in CRT therapy. The retrospective clinical study with 36 patients suggests that this method has high agreement against the visual integration method by experts and good inter-operator reproducibility. Consequently, this method is promising to be a clinical tool to recommend the CRT LV lead positions.

Assessment of Table Olives’ Organoleptic Defect Intensities Based on the Potentiometric Fingerprint Recorded by an Electronic Tongue

Table olives are prone to the appearance of sensory defects that decrease their quality and in some cases result in olives unsuitable for consumption. The evaluation of the type and intensity of the sensory negative attributes of table olives is recommended by the International Olive Council, although not being legally required for commercialization. However, the accomplishment of this task requires the training and implementation of sensory panels according to strict directives, turning out in a time-consuming and expensive procedure that involves a degree of subjectivity. In this work, an electronic tongue is proposed as a taste sensor device for evaluating the intensity of sensory defects of table olives. The potentiometric signal profiles gathered allowed establishing multiple linear regression models, based on the most informative subsets of signals (from 24 to 29 recorded during the analysis of olive aqueous pastes and brine solutions) selected using a simulated annealing meta-heuristic algorithm. The models enabled the prediction of the median intensities (R 2 ≥ 0.942 and RMSE ≤ 0.356, for leave-one-out or repeated K-fold cross-validation procedures) of butyric, musty, putrid, winey-vinegary, and zapateria negative sensations being, in general, the predicted intensities within the range of intensities perceived by the sensory panel. Indeed, based on the predicted mean intensities of the sensory defects, the electrochemical-chemometric approach developed could correctly classify 86.4% of the table olive samples according to their trade category based on a sensory panel evaluation and following the International Olive Council regulations (i.e., extra, 1st choice, 2nd choice, and olives that may not be sold as table olives). So, the satisfactory overall predictions achieved demonstrate that the electronic tongue could be a complementary tool for assessing table olive defects, reducing the effort of trained panelists and minimizing the risk of subjective evaluations.

Results of a prospective multicenter non-interventional study in adult outpatients with acute sinusitis treated with Flemoclav Solutab® in routine clinical practice in Russia (FlemENT)

Background. According to Russian clinical guidelines, amoxicillin/clavulanic acid is an antibiotic of the 1st choice in treatment of adult outpatients with acute sinusitis with suspected or confirmed bacterial etiology. The growth of bacterial resistance causes reasonable concern of otorhinolaryngologists about the efficacy of commonly used antibiotics in the routine clinical practice. Objective. The objective of this study was to evaluate the clinical success rate and tolerability of acute sinusitis treatment with Flemoclav Solutab® as initial antibiotic treatment in adult outpatients with acute sinusitis in routine clinical practice. Methods. A prospective multi-center study. The study covered adult outpatients with acute sinusitis with suspected or confirmed bacterial etiology treated with Flemoclav Solutab® and included the assessment of effectiveness and tolerability of Flemoclav Solutab® in the patients with acute sinusitis. Besides, the clinical effectiveness of treatment with this antibiotic in the subgroups of patients aged 65 years or older, smokers and non-smokers was assessed. Clinical success was determined as the complete resolution of all the symptoms and clinical signs of acute bacterial sinusitis that did not require supplementary of alternative antimicrobial therapy. In period of October 2015 to February 2016 eighty otorhinolaryngologists from various regions of Russia examined 893 adult outpatients (346 men and 547 women) with acute sinusitis treated with the antibiotic Flemoclav Solutab®. Clinical recovery confirmed by the data of all the examinations was achieved in 97.2% [(868/893), 95% CI 96.1 – 98.3%]. In the subgroup of patients aged 65 years or older the clinical success rate was 98.5% [(128/130), 95% CI 96.3 – 100%], in the subgroup of non-smokers clinical success was 97.3% [(690/709), 95% CI 96.1 – 98.5], in the subgroup of smokers clinical success was 96.7% [(178/186), 95% CI 94.2–99.3%]. Twenty five cases of adverse drug reactions (ADR) were recorded in 20 (2.2%) patients, of them 22 non-serious ADRs were in 17 (1.9%) patients and 3 serious ADRs were in 3 (0.3%) patients. Conclusion. The study proved high clinical success of acute sinusitis treatment with Flemoclav Solutab® in adult outpatients, including the patients aged 65 years or older, smokers and non-smokers. Antimicrobial treatment with Flemoclav Solutab® was well tolerated.

Evaluation of the Imatinib Treatment of Patients with Chronic Myeloid Leukemia (CML). a Retrospective Study from Algerian Working Group on CML (GAT-LMC)

Introduction: The advent of anti-tyrosine kinase has revolutionized the treatment of chronic myeloid leukemia. Indeed, from 2000, the IMATINIB has become internationally the gold standard of treatment for CML chronic phase, while the allogeneic bone marrow transplant was previously, the 1st intention choice, when an HLA-matched donor is available. The aim of this study is to evaluate the efficiency and the toxicity of a treatment with Imatinib(copy), drug used in Algeria to treat patients with a CML chronic phase. The main objective is to evaluate the overall survival and the progression-free survival to these patients.Materials and methods: This is a longitudinal study, National, multicenter, retrospective, which included Algerian patients with chronic phase CML and treated with Imatinib between January 2007 and December 2013. A technical form was established and distributed to different hematology services nationwide, to collect and analysis the following data: Patient’s general characteristics, disease circumstances of discovery, clinical and para-clinical examinations at diagnosis (blood count, blood smear, bone marrow aspiration, karyotype, molecular biology, Sokal prognostic classification score and Eutos score). The treatment: Imatinib 400 mg / d, a therapeutic assessment is made according to the ELN recommendations adapted to our conditions and capabilities in Algeria: The complete hematologic response (CHR) at 03 months and molecular response and / or cytogenetic and / or Fish at 03, 06.12, 18.24 months and more according to capabilities. At 03mois and / or 6 months we search a bcr / abl rate <10%. At 12 months we research a major molecular response (MMR), defined by a bcr / abl ratio lower than 0, 1% according to the ELN. A ratio between 0.1 to 1% is considered a good response according to GAT-LMC (the CML study Algerian group) so the Imatinib treatment is continued. The median follow-up of patients in December 2014 is 48 months (12-84 months). Overall survival and progression-free survival are determined by using the Kaplan-Meier method. The descriptive analysis of the quantitative variables by calculating averages, medians and the qualitative variables, by using percentages and 95% confidence interval. The Chi2 test is used to compare between two variables.Results: From 1024 collated sheets, 1007 are assessable; the median age of patients was 45.7 years (06-87 years), it’s about 516 men and 491 women with a sex ratio M / F 1.05. The Diagnosis of CML is done by cytogenetic examination in 337 patients (33%), by Fish 214 patients (21%) and by molecular biology in 401 patients (39%). The prognostic classification (PC), according to the Sokal score, found a low risk in 18.7%, 55.5% as intermediate and a high risk in 25.8%. The Eutos score is less than 87 in 97% and more than 87 in 03%. A CHR at 03mois was found in 907 patients (90.1%). There is no correlation between the RHC at 03 months and the SOKAL PC (p = 0.23), by cons we found a significant correlation with the Eutos score (p <10-3). Molecular assessment at 03 and 06 months is performed in 222 patients and a bcr / abl ratio <10% was found in 66.5%. A molecular evaluation at 12 months showed an MMR in 55.4%. Cytogenetic evaluation (FISH) has found a 28.6% CCyR at 3 months, 45% at 6 months, 64.2% at 12 months (IRIS = 68%), 75.7% at 18 months (IRIS = 76.2%) and 85% at 24 months. Overall survival was 84% at 08 years and it is significantly correlated to Sokal score (p <10-6). A failure to TRT was found in 11.5% of the cases and a 10, 1% relapse rate, related to non-adherence to TRT in 50% of the cases and a lack of monitoring by a regular molecular control in the other half of the cases. Event-free survival at 08 years was 76%. A good clinical and biological tolerance is noted in 90% of the cases. Only 8% of patients were switched to a 2nd generation TKIs because of intolerance. A non-adherence to TRT was found in 14.4%.Conclusion: Imatinib, used in Algeria, is a very interesting molecule both efficiency side and tolerance level. However, we must ensure a molecular monitoring for a patients optimal follow up, and an adequate patient education for a better adherence. DisclosuresNo relevant conflicts of interest to declare.