Ambulatory Patients Research Articles

Six-minute walk test as outcome measure of fatigability in adults with spinal muscular atrophy treated with nusinersen.

Fatigue (subjective perception) and fatigability (objective motor performance worsening) are relevant aspects of disability in individuals with spinal muscular atrophy (SMA). The effect of nusinersen on fatigability in SMA patients has been investigated with conflicting results. We aimed to evaluate this in adult with SMA3. We conducted a multicenter retrospective cohort study, including adult ambulant patients with SMA3, data available on 6-minute walk test (6MWT) and Hammersmith Functional Motor Scale-Expanded (HFMSE) at baseline and at least at 6 months of treatment with nusinersen. We investigated fatigability, estimated as 10% or higher decrease in walked distance between the first and sixth minute of the 6MWT, at baseline and over the 14-month follow-up. Forty-eight patients (56% females) were included. The 6MWT improved after 6, 10, and 14 months of treatment (p < 0.05). Of the 27 patients who completed the entire follow-up, 37% improved (6MWT distance increase ≥30 m), 48.2% remained stable, and 14.8% worsened (6MWT distance decline ≥30 m). Fatigability was found at baseline in 26/38 (68%) patients and confirmed at subsequent time points (p < 0.05) without any significant change over the treatment period. There was no correlation between fatigability and SMN2 copy number, sex, age at disease onset, age at baseline, nor with 6MWT total distance and baseline HFMSE score. Fatigability was detected at baseline in approximately 2/3 of SMA3 walker patients, without any correlation with clinical features, included motor performance. No effect on fatigability was observed during the 14-month treatment period with nusinersen.

Therapeutic inertia and contributing factors among ambulatory patients with hypertension

BackgroundTherapeutic inertia refers to the failure of healthcare providers to initiate or intensify therapy based on current evidence-based guidelines, even when the desired treatment goal is not achieved. Despite poorly controlled hypertension, clinicians often hesitate to intensify treatment. Therapeutic inertia is currently receiving more attention as a significant reason for clinicians’ inability to effectively manage hypertension. However, in our setting, there is limited knowledge about therapeutic inertia and its contributing factors.ObjectivesThe aim of this study was to investigate therapeutic inertia and contributing factors among ambulatory patients with hypertension.MethodA prospective observational study was conducted at the cardiac clinic of Ayder comprehensive specialized hospital in the Tigray region of northern Ethiopia. Patients were recruited into the study during their medication refilling appointments using a simple random sampling technique. All patients were followed for a minimum of 6 months to assess therapeutic inertia, which was defined as the healthcare providers’ failure to initiate or intensify therapy based on current evidence-based guidelines when therapeutic goals were not achieved. Data were collected through patient interviews and review of their medical records. We utilized binary logistic regression analysis to determine factors associated with therapeutic inertia.ResultThe study included 282 participants, with an equal male-to-female ratio. The mean age of the participants was 56.6 ± 12.3 years. Among all participants, a majority (67.4%) had uncontrolled hypertension. The study revealed that 72% of patients with uncontrolled hypertension experienced therapeutic inertia. In response to this issue, we recommended dose escalation for 73% of the patients and the initiation of additional drug therapy for 27% of them. Multivariable analysis indicated that having three or more medications (AOR = 4.74, 95%CI = 1.94–11.61) and having stage II hypertension (AOR = 3.06, 95%CI = 1.32–7.08) were identified as independent predictors of therapeutic inertia.ConclusionThe findings of our study indicated that a large proportion of the patients had poorly controlled hypertension, and a significant number of these patients also demonstrated therapeutic inertia. The number of medications and stage II hypertension were identified as independent predictors of therapeutic inertia. Therefore, it is crucial to prioritize patients at risk of therapeutic inertia and provide them with additional support. Moreover, practice based training should be given to clinicians in order to enhance treatment intensification and overall treatment outcome among ambulatory patients with hypertension.

Insomnia in ambulatory care: A clinical review.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. One-third to one-half of ambulatory care patients report insomnia. The objective of this clinical review is to detail the many causes and evidence-based treatment options for insomnia in outpatients and to recommend screening and summarize evidence for the place in therapy of prescription and nonprescription treatments. This work provides an overview of the literature on insomnia regarding causes, patient assessment, and nonpharmacological and pharmacological treatments. Patients who present with insomnia should be assessed for sleep apnea, restless legs syndrome, narcolepsy, and all contributing medications as well as medical, psychiatric, and substance use disorder diagnoses. The type of insomnia, namely difficulty falling asleep, difficulty maintaining sleep, and early morning awakening with resulting functional impairment, should be documented in addition to whether insomnia is short term or persistent. Cognitive behavioral therapy for insomnia (CBT-I) or digital CBT-I is first-line treatment for all patients with insomnia irrespective of the cause or type. Nonprescription treatments such as antihistamines or melatonin are for select populations. Prescription hypnotics are best utilized on an as-needed basis or for nightly use for less than 6 weeks. Z-hypnotics are safe and effective for insomnia in persons with depression or an anxiety disorder but should be avoided in older individuals or if there is respiratory or cognitive impairment. Orexin receptor antagonists are effective for sleep initiation and maintenance in healthy persons or if there is mild cognitive impairment, but they require further study in individuals with psychiatric and medical diagnoses. Trazodone is the most prescribed off-label treatment due to its efficacy for sleep initiation and maintenance and its lack of abuse potential. Insomnia treatment should be guided by patient age, diagnoses, and type of insomnia. Pharmacological treatments should be used at the lowest effective dose for the shortest duration of time.

Barriers and facilitators to implementation of intravenous cardiovascular treatments in ambulatory settings.

Intravenous (IV) therapies have transformed the management of various cardiovascular conditions in ambulatory patients. However, uptakeof these therapies in ambulatory care settings has several barriers. In this systematic scoping review, we aimed to identify the barriers and facilitators that influence the implementation of current IV therapies in ambulatory settings. We searched MEDLINE, Embase and CINAHL databases from inception to September 2023 for studies on barriers and facilitators of IV therapy uptake in ambulatory patients. We classified the identified factors and performed a thematic analysis. Fifteen studies, primarily conducted in North America and Europe, were included. Methodologies varied, precluding quantitative synthesis. Key barriers were identified across several levels. At the medication level, barriers included the need for multiple vials and lengthy preparation. Patient-level barriers included adverse effects, infections, painful venous access and non-adherence. Clinician-level barriers included understaffing, time constraints and safety concerns. Institutional barriers ranged from staff or equipment shortages to liability concerns and complex logistics. Healthcare system barriers included financial constraints and limited care delivery services. Facilitators included evidence-based indications, patient education and comfort, staff experience, guidance documents, safe settings, favourable insurance policies and supportive guidelines. As novel IV treatments emerge, addressing barriers and leveraging facilitators preemptively can enhance the successful implementation of IV therapies and improve clinical outcomes in ambulatory settings.

Increased cGMP improves microvascular exercise training adaptations independent of endothelial nitric oxide synthase.

Impaired microvascular function is a hallmark of pre-diabetes. With development of atherosclerosis this impaired microvascular function can result in diminished capacity for ambulation and is a risk factor for Type 2 Diabetes. Dynamic changes in vascular tone are determined, in large part, by the eNOS/NO/cGMP axis. We used gain of function of the eNOS/NO/cGMP axis in diet-induced obese (DIO) mice and reduced function in lean mice to test the hypothesis that functionality of this vascular control mechanism parallels the benefits of an exercise training regimen. DIO mice have lower exercise capacity than lean mice and were used for pharmacological gain of function. The PDE-5a inhibitor - sildenafil - increases cGMP and was administered to DIO mice daily. In sedentary mice, we find that sildenafil does not improve exercise capacity. In contrast, it amplifies the microcirculatory effects of exercise training. Sildenafil synergizes with exercise training to improve performance during an incremental exercise test. Improved exercise performance was accompanied by increased skeletal muscle capillary flow velocity and capillary density measured via intravital microscopy. Loss of function was tested in lean mice hemizygous for endothelial cell (EC) specific eNOS creating an EC-eNOS knockdown (KD). EC-eNOS KD decreases capillary density and exercise tolerance in sedentary mice; however, it did not prevent exercise-training induced improvements in endurance capacity. These data show that 1) increasing cGMP with sildenafil enhances microcirculatory function and exercise work tolerance that results from training; 2) eNOS KD does not prevent the microcirculatory or improvements in exercise tolerance with training. PDE-5a inhibitors combined with physical exercise are a potential mechanism for improving ambulation in patients with circulatory limitations.

Flap‐Based Lower Extremity Reconstruction in the Elderly—Is It Safe and Does Age Impact Ambulation?

ABSTRACTIntroductionLower extremity (LE) reconstruction in the elderly population presents a multifaceted challenge, primarily due to age‐related degenerative changes, comorbidities, and functional decline. Elderly individuals often encounter conditions such as osteoarthritis, osteoporosis, and cardiovascular and peripheral artery disease (PAD), which can severely compromise the structural integrity and function of the lower limbs. As such, we aim to assess postoperative complications and functional recovery following LE reconstruction in elderly patients.MethodsPatients ≥ 18 years who underwent post‐traumatic LE reconstruction with flap reconstruction at a Level 1 trauma center between 2007 and 2022 were included. Patient demographics, flap/wound characteristics, complications, and ambulation for the elderly (≥ 60 years old) and the control (&lt; 60 years old) cohorts were recorded. The primary outcome was final ambulation status, modeled with logistic regression. Secondary outcomes included postoperative complications.ResultsThe mean ages of the control (n = 374) and elderly (n = 49) groups were 37.4 ± 12.6 and 65.8 ± 5.1 years, respectively. Elderly patients more frequently required amputation after flap surgery (p = 0.002). There was no significant difference between the two cohorts in preoperative ambulation status (p = 0.053). Postoperatively, 22.4% of elderly patients were independently ambulatory at final follow‐up, compared to 49.5% of patients &lt; 60. Of the elderly, 14.3% could ambulate with an assistance device (cane, walker, etc.), compared to 26.5% in the control group. A wheelchair was required for 46.9% of elderly patients, significantly higher than the 22.7% of those &lt; 60 years of age (p &lt; 0.001). Multivariate regression confirmed an association between older age and nonambulatory final status (p = 0.033).ConclusionLE reconstruction can likely be performed safely in patients 60 years of age or older. However, older age is independently associated with significantly worse postoperative ambulation. Preoperative assessment, including gait and muscle strength, and early initiation of postoperative rehabilitation can potentially improve ambulation in elderly individuals undergoing LE reconstruction.

Using Patient Experience Surveys to Identify Potential Diagnostic Safety Breakdowns: A Mixed Methods Study.

One in 20 outpatients in the United States experiences a diagnostic error each year, but there are no validated methods for collecting feedback from patients on diagnostic safety. We examined patient experience surveys to determine whether patients' free text comments indicated diagnostic breakdowns. Our objective was to evaluate associations between patient-perceived diagnostic breakdowns reported in free text comments and patients' responses to structured survey questions. We conducted an exploratory mixed methods study using data from patient experience surveys collected from adult ambulatory care patients March 2020 to June 2020 in a large U.S. health system. Data analysis included content analysis of qualitative data and statistical analysis of quantitative data. In 2525 surveys with negative comments, 619 patients (24.5%) identified diagnostic breakdowns, including issues with accuracy (n = 282, 46%), timeliness (n = 243, 39%), or communication (n = 290, 47%); some patients (n = 181) reported breakdowns in multiple categories. Patients who gave a low average score (50 or less on a 100-point scale) on provider questions were almost seven times more likely to perceive a diagnostic breakdown than patients who scored their provider higher. Similarly, patients who gave a low average score on practice-related questions were twice as likely to perceive a diagnostic breakdown. Patient feedback in routinely collected patient experience surveys is a valuable and actionable information source on diagnostic breakdowns in the ambulatory setting. The more easily monitored structured survey data provide a screening method to identify encounters that may have included a patient-perceived diagnostic breakdown and therefore require further examination.

A Quality Improvement Project Aimed at Reducing Patient Falls in Ambulatory Clinics

Introduction Patient falls in ambulatory settings are uniquely challenging in that patients have more autonomy during outpatient visits and are not always easily identified as at risk for falling. Falls result in patient harm and dissatisfaction, loss of revenue, and a potential impact to the reputation of the health system. Objectives The primary objective of this study was to describe the work done to reduce falls risk for ambulatory patients. Methods This was a quality improvement project that used traditional improvement methodology to perform root cause analysis and process mapping, and to test and implement change strategies. Results The falls rate for ambulatory patients fell from 0.050 in fiscal year (FY) 2022 to 0.039 in FY23, a 22% reduction. The falls rate for ambulatory patients has continued to decrease; the current annual falls rate for FY24 is 0.030, a 37% reduction from FY21 rate 0.051, when a sentinel fall prompted root cause analysis and team focus. Conclusion While the initial intervention was only moderately successful, it led to a renewed focus on the risk of patient falls, which resulted in additional interventions and ultimately a reduction in high harm falls and the annual falls rate.

Early follow-up of outpatients with oral anticancer therapy in the ONCORAL multidisciplinary community-hospital program.

Healthcare professionals are faced with the new challenges of preventing and managing drug-related problems (DRPs) with oral anticancer therapy (OAT): side-effects, drug-drug interactions (DDIs), non-adherence, or medication errors. This study aims to assess the impact of ONCORAL, a real-life multidisciplinary care plan for cancer patients based on community and hospital follow-up, for the first OAT cycle. A prospective cohort study was conducted between October 1, 2021 and October 1, 2022 including all outpatients starting OAT treatment. During the first OAT cycle, the program consists of 6 weekly scheduled face-to-face or phone consultations to prevent and manage DRPs. Nurse and pharmacist interventions (NPIs) are realized to optimize treatments (primary outcomes). Secondary outcomes included the relative dose intensity (RDI) of the first cycle. A total of 562 NPIs were performed by the ONCORAL team: that is, 87.1% of the 209 patients included, for a mean of 3.1 ± 2.2 NPIs/patient. NPIs-concerned DRPs detected by the nurse and pharmacist (346, 61.6%), symptoms and/or adverse effects reported as PROs by the patient or family (138, 24.6%), or pathway issues (78, 13.9%). Seventy-three DDIs were detected and managed during medication review, in a quarter of patients (n = 54/209), leading to the discontinuation of a daily concomitant medication in 30 cases. The mean RDI at the end of the first cycle, calculated for 209 patients, was 83.1 ± 23.9% (17.56-144.23). In these ambulatory cancer patients, the interest in tailored monitoring of DRPs as a whole, including the prevention and management of drug interactions in addition to symptoms and adverse effects, is highlighted.

Anticoagulation for the Prevention of Arterial Thromboembolism in Cancer Patients by Primary Tumor Site: A Systematic Review and Meta-Analysis of Randomized Trials.

Incidence of arterial thromboembolism (ATE) among ambulatory cancer patients varies by primary tumor site. However, it is unclear whether this alters the benefit-to-harm profile of prophylactic anticoagulation for ATE prevention. Therefore, we systematically evaluated the efficacy and safety of anticoagulants for ATE prevention among ambulatory cancer patients according to the primary tumor site. We conducted a systematic review using Medline, Embase, SCOPUS, and CENTRAL, and included randomized trials comparing prophylactic anticoagulation to no anticoagulation among ambulatory cancer patients who initiated tumor-directed systemic therapy. Incidence of symptomatic ATE (acute ischemic stroke, acute myocardial infarction or peripheral artery occlusion) and major bleeding, as well as risk differences (RDs) attributable to anticoagulation were meta-analyzed by primary tumor site using random-effects modeling. We included 10 randomized controlled trials with 9,875 patients with follow-up ranging from 3.3 to 68 (median 6.6) months. While prophylactic anticoagulation did not reduce ATE risks overall (RD -0.49%; 95% CI -0.49% to 0.01%; I2=0%), it conferred a protective effect among pancreatic cancer patients (RD -3.2%; 95%CI -5.7% to -0.8%; I2=0%) without a detectable increase in major bleeding (RD -1.4%; 95% CI -4.6% to 1.8%; I2=0%). Prophylactic anticoagulation was not associated with ATE risk reduction in other tumor sites. Based on available evidence, prophylactic anticoagulation did not reduce ATE risk among ambulatory cancer patients overall. However, we observed lower incidence of ATE among pancreatic cancer patients randomized to receive anticoagulation. Prophylactic anticoagulant use to reduce ATEs in pancreatic cancer should be evaluated in future research.

Perceived Usefulness of Robotic Technology for Patient Fall Prevention.

Technology has the potential to prevent patient falls in healthcare settings and to reduce work-related injuries among healthcare providers. However, the usefulness and acceptability of each technology requires careful evaluation. Framed by the Technology Acceptance Model (TAM) and using the Adaptive Robotic Nursing Assistant (ARNA) to assist with patient ambulation, the present study examined the perceived usefulness of robots in patients' fall prevention with implications for preventing associated work-related injuries among healthcare providers. Employing an experimental design, subjects were undergraduate nursing students (N = 38) and one external subject (not a nursing student) who played the role of the patient. Procedures included subjects ambulating a simulated patient in three ways: (a) following the practice of a nurse assisting a patient to walk with the patient wearing a gait belt; (b) an ARNA-assisted process with the gait belt attached to ARNA; (c) an ARNA-assisted process with a subject walking a patient wearing a harness that is attached to ARNA. Block randomization was used with the following experimental scenarios: Gait Belt (human with a gait belt), "ARNA + Gait Belt" (a robot with a gait belt), and "ARNA + Harness" (a robot with a harness). Descriptive statistics and a multiple regression model were used to analyze the data and compare the outcome described as the Perceived Usefulness (PU) of a robot for patient walking versus a human "nurse assistant" without a robot. The independent variables included the experimental conditions of "Gait Belt," "ARNA + Gait Belt," and "ARNA + Harness," the subject's age, race, and previous videogame playing experience. Results indicated that PU was significantly higher in the Gait Belt + ARNA and Harness + ARNA conditions than in the Gait Belt condition (p-value <.01 for both variables). In examining potential influencing factors, the effects of race (White, African American, and Asian), age, and previous video-playing experience were not statistically significant (p-value >.05). Results demonstrated that using robot technology to assist in walking patients was perceived by subjects as more useful in preventing falls than the gait belt. Patient fall prevention also has implications for preventing associated work-related injuries among healthcare providers. Understanding the effects of a subject's perceptions can guide further development of assistive robots in patient care. Robotic engineers and interdisciplinary teams can design robots to accommodate worker characteristics and individual differences to improve worker safety and reduce work injuries.

Preliminary Insights Into Early Ambulation and Hemostasis After Atrial Fibrillation Ablation Using the Perclose Vascular Closure Device.

The introduction of the Perclose vascular closure device (VCD) for atrial fibrillation (AF) ablation procedures in Japan is expected to facilitate early ambulation. The study population comprised 554 patients undergoing AF ablation, of whom 377 successfully underwent Perclose VCD deployment at the end of the procedure. At 4 h after the procedure, 94% (353/377 patients) achieved early hemostasis and 57% (213/377 patients) achieved early ambulation. Notably, 0.5% (2/377 patients) developed acute deep vein thrombosis. The Perclose VCD demonstrated promising efficacy in achieving early hemostasis, potentially facilitating early ambulation and discharge in appropriate patients.

The Association of Dietary Micronutrient Intake and Systemic Inflammation among Patients with Type 2 Diabetes: A Cross-Sectional Study.

Inflammation contributes to the pathogenesis of type 2 diabetes (T2DM). This study sought to document how the systemic biomarkers of inflammation varied based on food choices among patients with T2DM. This cross-sectional study enrolled ambulatory patients with T2DM. Demographic and clinical information was collected. Five drops of fingerstick blood were collected using an absorbent paper device (HemaSpot HFR). C-reactive protein (CRP), serum amyloid A protein (SAA), and fibrinogen were measured using a Luminex assay. Patient-generated 7-day food diaries were analyzed using a validated food processor software. Data were analyzed by Pearson's correlation tests, linear regression and logistic regression with the significance level set at 0.05. Among the 71 participants, 43 (60.6%) were females. The average age and duration of T2DM were 64.1 ± 10.3 and 15.8 ± 9.1 years, respectively. In a simple linear regression run with selected micronutrients, iron [F (1, 53) = 5.319, p < 0.05, adj. R2 = 0.074] significantly predicted plasma CRP. This significance was lost with multiple linear regressions including age, gender, BMI, T2DM duration, T2DM complications, glycohemoglobin A1c (HbA1c) and other micronutrients. The average intake of most micronutrients by the participants was below the recommended daily intake. A higher intake of iron-rich foods was associated with higher levels of systemic inflammation in a simple linear regression model, but the association was not present after adjusting for patient factors like age, gender, BMI and T2DM-related variables. This relationship needs to be explored further given the key role of inflammation in the pathogenesis of T2DM and its associated complications.

Bladder drainage methods for acute urinary retention due to benign prostatic hyperplasia: patient-preference analysis

Introduction. Currently, the classical management of acute urinary retention creates a certain discomfort for the patient and leads to explore alternative method of management, such as intermittent catheterization, including focusing on the patient opinions.Objective. To assess the preference of high-risk patients for acute urinary retention relative to bladder drainage in the occurrence of acute urinary retention.Materials &amp; methods. A survey was conducted among 200 ambulatory male patients. All the participants were tested to assess their mental status and ability to perform self-intermittent catheterization before filling out the questionnaire. The questionnaire included questions about the preferred method of bladder drainage for acute urinary retention, as well as factors influencing the patient's choice of self-intermittent catheterization in case of non-recovery. After completing the questionnaire, all the patients were shown a video on self-catheterization and asked to re-take the questionnaire after watching it. This allowed evaluating the impact of the training video on patients' preferences and their confidence in performing self-catheterization.Results. Among the 200 patients, 151 (75.5 %) preferred intermittent catheterization, while 40 (25.5 %) chose an indwelling urinary catheter. Additionally, 152 (76 %) patients opted for intermittent catheterization until the planned surgery, and 48 (24 %) selected a suprapubic catheter. The main factors influencing the patient choice of intermittent catheterization were: the desire to restore bladder function faster (on the first or second day) in 96 (63.2 %) patients; unwillingness to stay in the hospital in 56 (36.8 %); the desire to return to work in 22 (14.5 %); avoiding the use of a suprapubic catheter in 51 (33.5 %). After watching the video, there was a statistically significant change in patients' assessments of their ability to perform self-intermittent catheterization (p &lt; 0.001).Conclusion. The patient's choice of the intermittent catheterization is significantly influenced by the patient self-confidence in the ability to practice self-intermittent catheterization and the demonstration of the video tutorial. Due to the high efficiency and safety of intermittent catheterization, this method should be introduced into clinical practice based on the proposed algorithm.

Factors associated with musculoskeletal pain in ambulatory individuals with spinal cord injury

Background: Such myriad consequences of musculoskeletal pain were common and distorted the level of functioning after spinal cord injury (SCI). No known data identifies pain-related factors in ambulatory individuals with SCI. Objective: To examine the risk factors for musculoskeletal pain in ambulatory patients with SCI. Materials and methods: A total of 138 ambulatory participants with SCI were interviewed and evaluated for their demographics, SCI traits, levels of locomotor disability (Functional Independence Measure-Locomotor), and data on musculoskeletal pain, including area, cause, and severity of pain using a body chart diagram and Visual Analogue Scale. Then, logistic regression was used to analyze risk factors associated with musculoskeletal pain. Results: Precisely, 55.07% of the 138 ambulatory individuals with SCI reported musculoskeletal pain. The common top three areas of pain include the lower back (27%), hip (23%) and shoulder (15%). Factors associated with musculoskeletal pain include being a man and FIM-L 6 in which males had OR=3.56 (95% CI, 1.62-7.84; p=0.002) and FIM-L 6 had OR=2.57 (95% CI, 1.08-6.10; p=0.032). Conclusion: The present findings revealed that musculoskeletal pain is highly prevalent in ambulatory individuals with SCI. Ambulatory individuals with SCI who are males and able to walk at least 50 meters while using gait devices are most concerned about musculoskeletal pain problems.

A study of nonglaucomatous optic neuropathies in a teaching hospital in Western Maharashtra

Background: Nonglaucomatous optic neuropathy (NGON) is defined as clinical evidence of optic nerve impairment without glaucomatous field/disc changes. Etiology is diverse and elusive in many patients. Causes of NGON include traumatic, compressive, inflammatory, demyelinating, toxic, nutritional, hereditary, vascular, infiltrative, and idiopathic. NGON disorders can be misdiagnosed as glaucoma and can be preventable or life-threatening. In some, fellow eye involvement is common. This can lead to inadequate management and influence prognosis which can be prevented by multispecialty approach. Physicians and ophthalmologists must be vigilant against threatening NGON forms. It is essential to track burden as most literature focused on particular NGON subtype. Aim: The aim was to study the clinical presentation of NGON in a teaching hospital. Setting and Design: This was a prospective, hospital-based, cross-sectional, observational study. Materials and Methods: A total of 86 eyes of 61 NGON patients were studied from January 2021 to June 2022 in a tertiary care hospital. Detailed history and comprehensive ophthalmic examination were performed in ambulatory patients. Nonambulatory patients were examined using torchlight. Ancillary investigations were performed, to confirm the clinical diagnosis wherever applicable. Statistical Analysis: Microsoft Excel was used for statistical analysis. Results: The mean age of study patients was 44.87 ± 16.05 years with a male: female ratio of 2.8:1. Unilateral eye involvement was seen in 36 (59.02%). Best-corrected visual acuity = 3/60–1/60 was noted in 41 (47.67%) patients. Red-green defect and contrast sensitivity were reduced by 59.30% and 66.28%, respectively. Relative afferent pupillary defect (RAPD) was noted in 52.46% of patients with Grade 5 RAPD in 40.63%. The most common visually evoked potential type and visual field defect noted were axonal and central scotoma (n = 31 [36.05%] and n = 26 [30.23%]), respectively. Traumatic optic neuropathy was diagnosed in 15 (24.59%) followed by inflammatory optic neuritis in 11 (18.04%) patients. Conclusion: Diagnosing cause of NGON in clinical practice is challenging, but emerging burden cannot be neglected. Knowledge of various NGON types helps narrow differential diagnoses and execute efficient, targeted workup. Timely recognition alters visual, neurological prognosis and saves the lives of patients sometimes.

Automated Urine Screening and Residual Antimicrobial Activity Test for Rapid Diagnosis of Urinary Tract Infections in Ambulatory Patients: A Laboratory Evaluation of HB&amp;L Uroquattro Instrument

Automated Urine Screening and Residual Antimicrobial Activity Test for Rapid Diagnosis of Urinary Tract Infections in Ambulatory Patients: A Laboratory Evaluation of HB&amp;L Uroquattro Instrument

Integration of Patient Reported Quality-of-life Data into Risk Assessment in Heart Failure

Optimal management of outpatients with heart failure (HF) requires serially updating the estimates of their risk for adverse clinical outcomes to guide treatment. Patient-reported outcomes (PROs) are becoming increasingly used in clinical care. The purpose of this study was to determine whether the inclusion of PROs can improve the risk prediction for HF hospitalization and death in ambulatory patients with HF. We included consecutive patients with HF with reduced ejection fraction (HFrEF) and HF with preserved EF (HFpEF) seen in a HF clinic between 2015 and 2019 who completed PROs as part of routine care. Cox regression with a least absolute shrinkage and selection operator regularization and gradient boosting machine analyses were used to estimate risk for a combined outcome of HF hospitalization, heart transplant, left ventricular assist device implantation, or death. The performance of the prediction models was evaluated with the time-dependent concordance index (Cτ). Among 1165 patients with HFrEF (mean age 59.1 ± 16.1, 68% male), the median follow-up was 487 days. Among 456 patients with HFpEF (mean age 64.2 ± 16.0 years, 55% male) the median follow-up was 494 days. Gradient boosting regression that included PROs had the best prediction performance - Cτ 0.73 for patients with HFrEF and 0.74 in patients with HFpEF, and showed very good stratification of risk by time to event analysis by quintile of risk. The Kansas City Cardiomyopathy Questionnaire overall summary score, visual analogue scale and Patient Reported Outcomes Measurement Information System dimensions of satisfaction with social roles and physical function had high variable importance measure in the models. PROs improve risk prediction in both HFrEF and HFpEF, independent of traditional clinical factors. Routine assessment of PROs and leveraging the comprehensive data in the electronic health record in routine clinical care could help more accurately assess risk and support the intensification of treatment in patients with HF.

Robotic exoskeleton-assisted gait training in patients with motor incomplete myelopathy

Objectives: To assess the effect of gait training with robotic exoskeleton-assisted rehabilitation systems on gait parameters, balance, and overall disability in motor incomplete myelopathy. Design: Prospective pre-post study. Setting: Neurological rehabilitation unit in a tertiary university teaching hospital. Participants: Thirty-four motor incomplete myelopathy patients [22 males, mean age 36.7 y (12.7)] were included in this prospective, pre-post study. Twenty-two had nontraumatic etiology, and 17 had tetraplegia. American Spinal Injury Association impairment scale suggested 23 as C and 11 as American Spinal Injury Association impairment scale-D. The mean duration of the lesion was 333 days. Intervention: Twenty-four sessions of robotic gait training (1-h session, 5–6 sessions/wk) for 4–6 weeks. Outcome measures: Gait speed was assessed using a 10-meter walk test (10MWT), endurance with a 2-minute walk test (2MWT) and 6-minute walk test (6MWT), walking ability by Walking Index in Spinal Cord Injury-walking index for spinal cord injury II, functionality using Spinal cord Independence Measure-SCIM III, and balance by Timed-up-and-go (TUG) test. Results: At baseline, 20 patients were nonwalkers-NWB, and 14 were walkers-WB. The walking index for spinal cord injury II and SCIM III suggested significant improvement in both groups by the end of the study (P&lt;0.05). Among the WB group, 10MWT, 2MWT, and TUG showed significant improvement (P=0.004, 0.02, and 0.01, respectively) with training. Patients in NWB group were able to perform 10MWT, 2MWT, 6MWT, and TUG by the end of the study. Conclusions: Gait training with robotic exoskeleton-assisted rehabilitation systems can lead to a significant improvement in gait endurance, speed, balance, and functional outcomes in individuals with incomplete myelopathy. The effect is more pronounced among already ambulatory patients.

Analysis of excessive corticosteroid use as an indicator of poor quality of care in patients with inflammatory bowel disease

&amp;lt;p&amp;gt;&amp;lt;strong&amp;gt;Aim &amp;lt;/strong&amp;gt;To evaluate the clinical impact of corticosteroids (CS) overuse in inflammatory bowel disease (IBD) patients. Excessive use of CS could delay more efficacious treatment and may indicate poor quality of care.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Method &amp;lt;/strong&amp;gt;This is a two-phase study that used Steroid Assessment Tool (SAT) to measure corticosteroid exposure in IBD patients. In the first phase data from 211 consecutive ambulatory patients with IBD (91 with ulcerative colitis, 115 with Crohn&amp;#039;s disease, and five with unclassified inflammatory bowel disease) were analyzed by SAT. In the second phase, one year after data entry, clinical outcome of patients with cortico-steroids overuse was analysed.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Results &amp;lt;/strong&amp;gt;Of the 211 IBD patients, 132 (62%) were not on corticosteroids, 45 (22%) were cortico-steroid-dependent and 34 (16%) used corticosteroids appropriately, according to the European Crohn&amp;#039;s and Colitis Organization guidelines. In the group of patients with ulcerative colitis, 57 (63%) were not on cortico-steroids, 18 (20%) were corticosteroid-dependent, and 16 (16%) used cortico-steroids appropriate-ly; in the group of patients with Crohn&amp;#039;s disease 70 (61%), 27 (23%) and 18 (16%), respectively. Overall, 24 (out of 45; 53%) patients with IBD could avoid the overuse of cortico-steroids if they had a timely change of the treatment, surgery or entered a clinical trial.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Conclusion &amp;lt;/strong&amp;gt;An excessive corticosteroid use can be recognized on time using the SAT. We have proven that excessive corticosteroid use could be avoided in almost half of cases and thus the overuse of CS may indicate poor quality of care in those patients.&amp;lt;/p&amp;gt;