Ambulatory Treatment Research Articles

The ambulatory treatment of postpartum psychosis in Israel.

Postpartum psychosis is a severe psychiatric disorder that occurs following childbirth. Due to its severity, postpartum psychosis is generally treated in an inpatient hospital setting. In this original contribution, we present the ambulatory treatment of postpartum psychosis and advocate that an ambulatory setting can be feasible under the right circumstances. In this article, we provide an overview of the Israeli legal system and its implications when treating maternal mental illness. We present the process by which we treat a woman with postpartum psychosis in an ambulatory setting. We provide a case example of the successful treatment of postpartum psychosis in an ambulatory setting and list general strategies to utilize. We demonstrate that an ambulatory approach to postpartum psychosis is not only possible, but also has significant benefits. We suggest that the ambulatory treatment of postpartum psychosis was developed in Israel as a direct result of its liberal legal system. Specifically, because of the legal system's value on patient autonomy, acute psychiatric illnesses such as postpartum psychosis are at times treated in outpatient settings. Additionally, we posit that Israel's unique culture provides the framework to support its implementation. We review the challenges of the treatment in the case example as well as other anticipated challenges that may arise with a broader application of this approach. Our hope is that this novel presentation will lead to more nuanced and holistic treatment of postpartum psychosis.

Evolving models of care for ambulatory systemic treatment.

155 Background: Increasing demand for systemic cancer treatment in Ontario, Canada, due to an aging population and therapeutic advances, is compounded by resource shortages and provider burnout heightened by the COVID-19 pandemic. This landscape has led to longer wait times, reduced services, poorer patient experiences, and widened health inequities, particularly impacting marginalized populations. In response, Ontario Health (Cancer Care Ontario) developed recommendations to optimize ambulatory systemic treatment delivery from various perspectives, including patients, providers, cancer programs, and organizations. Methods: Evidence-based recommendations were derived from a targeted literature review, current state surveys, and follow-up interviews across 16 Ontario treatment facilities. Feedback was gathered via focus groups involving patients, families, care partners, and providers. Key informants from cancer agencies in Canada and internationally were consulted through jurisdictional scans. Furthermore, focused discussions with First Nations, Inuit, Métis, urban Indigenous (FNIMUI) communities, Francophone populations, and other equity deserving groups informed the unique needs, experiences, and barriers to care of these groups. Results: Twenty-six recommendations that span various aspects of systemic treatment delivery, including referral processes, scheduling, role integration, patient education, patient and provider experiences, virtual care, and care transitions were developed. Priorities include evidence-based, person-centred care, timely access, effective collaboration, provider well-being, and technological innovation. Additionally, we highlight partnerships with FNIMUI communities, and other equity-deserving groups as strategies to address additional barriers to care. Conclusions: These recommendations strive to address challenges faced by healthcare providers and patients, ensure equitable access to care, and improve provider well-being. Engagement with FNIMUI communities and other equity-deserving groups influenced these recommendations, emphasizing the need for system-level oversight and investment to realize equitable and sustainable service delivery province-wide.

Complementary medicine use in cancer patients receiving intravenous antineoplastic treatment

ObjectiveComplementary and alternative medicine (CAM) use has grown considerably, although there is little research on the topic in Spain. The aim of this study was to determine the prevalence of complementary medicine use in adult cancer patients at the same time as they were receiving conventional treatment in a Spanish referral cancer centre. MethodAn observational, descriptive, cross-sectional study was conducted in the Ambulatory Treatment Unit during 2 consecutive weeks in March 2015. Adult patients who were receiving intravenous chemotherapy were included. Study variables were obtained from a questionnaire and medical records. Results316 patients were included. 32.3% of the patients reported complementary medicine use during this period and 89% were ingesting products by mouth, herbs and natural products being the most commonly used. 81% of patients started to use complementary medicine after diagnosis, and family/friends were the main source of information. 65% of the patients reported improvements, especially in their physical and psychological well-being. Significant predictors of CAM use were female gender (P=0.028), younger age (P<0.001), and secondary education (P=0.009). Conclusions: A large proportion of cancer patients receiving intravenous chemotherapy also use complementary medicine, which they mainly take by mouth. Due to the risk of chemotherapy-CAM interactions, it is important for health-professionals to keep abreast of research on this issue, in order to provide advice on its potential benefits and risks.

Safety of early oral ambulatory treatment of adult patients with bloodstream infections discharged from the emergency department.

This study evaluates the safety of early oral ambulatory treatment of adult patients diagnosed with bacteremia after their discharge from the emergency department. A cohort of 206 febrile ambulatory patients was assessed. Bacteremic low-risk patients were recommended an oral treatment and were compared with matched febrile non-bacteremic outpatients. Rates of 14-day mortality and unplanned re-consultations were similar and below 5% in both cohorts, highlighting the safety of oral therapy of low-risk bacteremia, even from its onset.

The Relationship between the Hospital Discharging Duration of the Patients Diagnosed with COVID-19 who had Ambulatory and Inpatient Treatment and the Frequency of Their Physical Activity before COVID-19

The Relationship between the Hospital Discharging Duration of the Patients Diagnosed with COVID-19 who had Ambulatory and Inpatient Treatment and the Frequency of Their Physical Activity before COVID-19

SAT153 A Case Of Hypoglycemia-induced Chest Pain Secondary To Adult Nesidioblastosis: A Case Report

Abstract Disclosure: O.L. Medina Espitia: None. A. Quintero Altare: None. V.A. Clavijo: None. L.C. Martínez Delgado: None. The report of the present case in the medical literature is important in itself because of the infrequency of Nesidioblastosis. Additionally, it allows us to show unusual forms of presentation such as chest pain, and dynamic electrocardiographic changes in the ST segment with negative troponin, which coincide with episodes of hypoglycemia. At admission, the patient consulted the emergency department for a clinical presentation consisting of progressive retrosternal chest pain radiating to the left cervical region associated with dyspnea for medium exertion, palpitations, and dysautonomic symptoms, given by nausea. Due to episodes of chest pain, a coronary arteriography had been performed six months before admission without evidence of obstructive lesions. During hospitalization, episodes of hypoglycemia were observed. Remarkably, it was possible to document Dynamic ST changes in all EKG leads during episodes of hypoglycemia, as shown in Figure 1. Among the differential diagnoses, hypoglycemia secondary to adrenal or thyroid dysfunction was considered a first possibility, which was ruled out in the presence of normal paraclinical tests and medications that could generate hypoglycemia (negative sulfonylurea tests) were ruled out. A fasting test was performed with results showing endogenous hyperinsulinemic hyperinsulinemia with levels of insulin in 35.5 mg/dL, C-peptide 9.34 ng/dL and blood glucose 34 mm/dL. MRI of the abdomen without lesions. Due to a history of gastric bypass, endoscopic ultrasonography was not performed, therefore pancreatic calcium stimulation test was performed with evidence of a significant delta over the territory of the splenic artery. A distal pancreatectomy was obtained. Pathology report with findings suggestive of Nesidioblastosis (Figure 2.). There was a complete resolution of episodes of hypoglycemia and chest pain for two weeks. The recurrence of hypoglycemia episodes led to ambulatory treatment, with diazoxide with complete resolution of events. Presentation: Saturday, June 17, 2023

Doppler Guided Haemorrhoidal Artery Ligation in the Management of Symptomatic Hemorrhoids

Abstract Background Hemorrhoid ligation with mucopexy is a simple, safe and cost-effective ambulatory treatment for the patients of symptomatic hemorrhoids. It can be performed on an outpatient or day care basis on grade 3 and 4 hemorrhoids to control bleeding and prolapsing hemorrhoids. Overall the results of hemorrhoid ligation and mucopexy were satisfactory with good control of patients complains. Objective To evaluate prospectively the outcome of Doppler-guided hemorrhoidal artery ligation in the management of symptomatic hemorrhoids. Patients and Methods Types of studies: A prospective study. Study setting: The study conducted in Ain Shams University Hospital (El Demerdash) under supervision of these supervisors. Study period: Six months. Results It is easy for the surgeon to learn it and acquire appropriate skills after a short learning curve. The HAL is a minimally invasive technique that is conceptually painless for patients since all maneuvers and sutures are endoanal and above the dentate line; this helps an early recovery and allows an ambulatory procedure. We must bear in mind that postoperative pain is often the most common concern for patients and professionals dealing with hemorrhoids. The results of HAL in this study show a very low postoperative pain rate (two patients_ lower than 7%); moreover, it is easily controlled with oral analgesia. One patient (3%) complained of retention of urine, which controlled easily. Conclusion Hemorrhoid ligation with mucopexy is a simple, safe and cost-effective ambulatory treatment for the patients of symptomatic hemorrhoids. It can be performed on an outpatient or day care basis on all grades of hemorrhoids to control bleeding and prolapsing hemorrhoids. Overall the results of hemorrhoid ligation and mucopexy were satisfactory with good control of patients complains.

A cost-comparative analysis of intravenous Ferric Carboxymaltose versus Iron Sucrose for the ambulatory treatment of Iron-deficiency Anemia in a major tertiary care hospital in Saudi Arabia

&lt;p class="MsoNormal" style="text-align: justify;"&gt;&lt;strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;Background:&lt;/span&gt;&lt;/strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt; The objective of this study was to compare the cost of outpatient ferric carboxymaltose (FCM; Ferinject&amp;reg;) versus Iron sucrose complex (ISC; Ferosac&amp;reg;), two prevalent intravenous iron therapy used in the treatment of iron-deficiency anemia (IDA) in the Kingdom of Saudi Arabia (KSA) from a tertiary care hospital perspective.&lt;/span&gt;&lt;/p&gt; &lt;p class="MsoNormal" style="text-align: justify;"&gt;&lt;strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;Methods:&lt;/span&gt;&lt;/strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt; A retrospective study was performed for all patients who were administered FCM in the outpatient clinical setting at Prince Sultan Military Medical City from January 1, 2019, until December 31, 2019. The descriptive data was analyzed using Microsoft Excel 2019 (Microsoft Corporation, Redmond, WA, USA). The total cost of treatment reflected the cost of drugs, the cost of disposables for each infusion, drug monitoring costs during infusion, the cost of productivity loss, and patient traveling cost.&lt;/span&gt;&lt;/p&gt; &lt;p class="MsoNormal" style="text-align: justify;"&gt;&lt;strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;Result:&lt;/span&gt;&lt;/strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt; Overall, 993 patients with IDA, treated with FCM in 1,688 outpatient visits were recruited in the study. In the outpatient setting, the per annum cost of treatment was SAR 1,434,092.50 with FCM treatment and&lt;/span&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;"&gt; &lt;/span&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;SAR 1,715,299.70 with ISC treatment, with a corresponding saving of 16.4% (SAR 281,207.20) with FCM. The cost savings with FCM treatment can be attributed to the reduced frequency of patient visits and corresponding reduction in drug monitoring costs (SAR &lt;/span&gt;&lt;span lang="EN-GB" style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-ansi-language: EN-GB; mso-fareast-language: EN-GB;"&gt;266,995.20;&lt;/span&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;77.3%), loss of productivity per year (SAR &lt;/span&gt;&lt;span lang="EN-GB" style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-ansi-language: EN-GB; mso-fareast-language: EN-GB;"&gt;163,550.20; &lt;/span&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;77.3%), and cost of transportation per year (SAR &lt;/span&gt;&lt;span lang="EN-GB" style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-ansi-language: EN-GB; mso-fareast-language: EN-GB;"&gt;573,920.00; &lt;/span&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;77.3%).&lt;/span&gt;&lt;/p&gt; &lt;p class="MsoNormal" style="text-align: justify;"&gt;&lt;strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt;Conclusion:&lt;/span&gt;&lt;/strong&gt;&lt;span style="font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-language: EN-US;"&gt; The use of FCM, as opposed to ISC resulted in a reduced number of iron infusions (4.4 visits for ISC as compared to one visit for FCM), accompanied by a reduction in the total cost. FCM may represent a cost-saving option compared with the existing alternative therapy used for the management of IDA in KSA.&lt;/span&gt;&lt;/p&gt;

Intensive neurorehabilitation and allogeneic stem cells transplantation in canine degenerative myelopathy.

Degenerative myelopathy (DM) is a neurodegenerative spinal cord disease with upper motor neurons, with progressive and chronic clinical signs, similar to amyotrophic lateral sclerosis (ALS). DM has a complex etiology mainly associated with SOD1 gene mutation and its toxic role, with no specific treatment. Daily intensive rehabilitation showed survival time near 8 months but most animals are euthanized 6-12 months after clinical signs onset. This prospective controlled blinded cohort clinical study aims to evaluate the neural regeneration response ability of DM dogs subjected to an intensive neurorehabilitation protocol with mesenchymal stem cells (MSCs) transplantation. In total, 13 non-ambulatory (OFS 6 or 8) dogs with homozygous genotype DM/DM and diagnosed by exclusion were included. All were allocated to the intensive neurorehabilitation with MSCs protocol (INSCP) group (n = 8) or to the ambulatory rehabilitation protocol (ARP) group (n = 5), which differ in regard to training intensity, modalities frequency, and MSCs transplantation. The INSCP group was hospitalized for 1 month (T0 to T1), followed by MSCs transplantation (T1) and a second month (T2), whereas the ARP group was under ambulatory treatment for the same 2 months. Survival mean time of total population was 375 days, with 438 days for the INSCP group and 274 for the ARP group, with a marked difference on the Kaplan-Meier survival analysis. When comparing the literature's results, there was also a clear difference in the one-sample t-test (p = 0.013) with an increase in time of approximately 70%. OFS classifications between groups at each time point were significantly different (p = 0.008) by the one-way ANOVA and the independent sample t-test. This INSCP showed to be safe, feasible, and a possibility for a long progression of DM dogs with quality of life and functional improvement. This study should be continued.

Real-World Implementation of a COVID-19 Monoclonal Antibody Treatment Program in a Los Angeles County Safety Net Ambulatory Healthcare System - Barriers to Treatment and Lessons Learned.

Throughout the COVID-19 pandemic, low-income, minority, and otherwise vulnerable populations have repeatedly been shown to receive unequal access to novel therapies. Addressing this inequity requires specific awareness of the barriers experienced by vulnerable patients, and systemic efforts to address these barriers to provide equitable health care. We designed and implemented an ambulatory COVID-19 treatment program expressly aimed at increasing COVID-19 treatment uptake in a safety-net healthcare system. We describe systemic and human obstacles encountered as well as strategies used to increase use of COVID-19 treatments. Thanks to these strategies, we observed an increase in monoclonal antibody acceptance rate from 29 to 69% over the course of 10 months. We found that interventions such as engaging primary care providers, creating clear-language scripts for outreach calls, assisting with logistic barriers such as transportation, and addressing medical mistrust and hesitancy among both staff and patients were critical to increasing treatment uptake among our safety-net patient population.

“It’s Like we Have Our Own Rhythm”. Music Therapeutic Affect Regulation in a Case Study of a Traumatized Patient in Mental Health Treatment

This article explores how music therapy can contribute to the treatment of individuals with affect regulation challenges related to relational traumatic experiences. Affect regulation was investigated through a case study of music therapy with a man with complex post-traumatic stress disorder. The case represents clinical work in a psychiatric hospital, on a ward for ambulatory treatment of people with severe mental illness and substance abuse challenges. Based on theories of communicative musicality, intersubjectivity and traumatology, an analysis of transcripts of music therapy improvisations and verbal interaction is presented and discussed. The method used in the study is an abductive explanatory thematic analysis grounded in hermeneutic interpretation of data. The two main themes emerging from the analysis are “Musical interaction as co-regulation” and “Music as a creative (re)source” with the subthemes “Musical interventions serves as a regulation tool”, “A process from regulation to relationship, “Musical self-agency” and “Music therapy as an experimental playground”. Further studies on affect regulation in clinical music therapy are warranted.

PN HPT™ and Striae Albae-Exploratory Interim Analysis of a Randomised Prospective Study

Introduction: The outcomes of striae albae remodelling are currently disappointing. Replenishing the fibroblast pool of nucleotide precursors through passive exposure to Polynucleotides Highly Purified Technology (PN HPT™) facilitates the dermal production of new fibres. The manuscript reports on the outcomes of a prospective study with an intradermal PN HPT™-based medical device. Methods: Intra-subject-controlled randomised real-world study to evaluate the efficacy and safety of a medical device containing 20 mg/mL of PN HPT™ (functional ingredient) intradermal gel as therapy for moderate-to-severe striae albae. Based on a preliminary sample size assessment, the study estimated the need to enrol at least 65 mature albae from 18-to-55-year-old male and female subjects seeking ambulatory treatment (mean age: 34.1 ± 10.65). Up to eight symmetrical striae albae in the target areas (breast, abdomen, buttocks, thighs) per enrolled subject underwent randomisation into the two parallel “PN HPT™ intradermal infiltration” active group and “no-treatment striae albae” intra-subject control group. Actively treated striae albae underwent a four-session intradermal therapy cycle with the PN HPT™ device. Comparative efficacy assessments, performed at the two final evaluation visits by independent evaluators: Width of actively treated and untreated control striae albae (digital calliper). Global Aesthetic Improvement Scale (GAIS) outcomes (by investigators and subjects, respectively; assessments on digital photographic documentation). Width and wrinkling of actively treated and control striae albae (quantitative Antera 3D CS skin imaging technology). Results: The digital-calliper-assessed width for the exploratory sample of the 44 actively treated striae albae (29 control striae) decreased, on average, from 4.6 ± 2.31 at the V1 baseline visit to 2.7 ± 1.42 at V5 (first follow-up visit) one month after the last PN HPT™ intradermal infiltration at V4 (–40.8% vs. baseline, p &lt;0.01). In a subset of 17 striae (7 subjects), the mean digital-calliper-assessed width was still a significant 2.0 ± 0.94 at the final V6 follow-up visit, six months after V1 and three months after V4 (–54.5% vs control striae albae at V6, p &lt;0.05). At the V5 assessment, three months after V1 and one month and a half after V4, investigators and treated subjects reported average GAIS scores of 3.8 ± 0.51 (median, 4.0) and 4.0 ± 0.66 (median, 4.0) out of 5.0 as GAIS maximum score for both. The occasional mild local pain and irritation at the injection site, expected and known in the previous PN HPT™ literature, were of no clinical significance and rapidly transitory. Discussion: PN HPT™ are an innovative option with a solid rationale for treating mature striae albae. The efficacy outcomes of PN HPT™ dermal infiltrations appear noteworthy, with excellent safety and ease of use, confirming the previous results. However, waiting for complete results and confirmation by other controlled studies is prudent.

Treatment outcomes of multidrug-resistant tuberculosis patients receiving ambulatory treatment in Shenzhen, China: a retrospective cohort study.

WHO recommended multidrug-resistant tuberculosis (MDR-TB) should be treated mainly under ambulatory model, but outcome of ambulatory treatment of MDR-TB in China was little known. The clinical data of 261 MDR-TB patients treated as outpatients in Shenzhen, China during 2010-2015 were collected and analyzed retrospectively. Of 261 MDR-TB patients receiving ambulatory treatment, 71.1% (186/261) achieved treatment success (cured or completed treatment), 0.4% (1/261) died during treatment, 11.5% (30/261) had treatment failure or relapse, 8.0% (21/261) were lost to follow-up, and 8.8% (23/261) were transferred out. The culture conversion rate at 6 months was 85.0%. Although 91.6% (239/261) of patients experienced at least one adverse event (AE), only 2% of AEs caused permanent discontinuation of one or more drugs. Multivariate analysis showed that previous TB treatment, regimens containing capreomycin and resistance to FQs were associated with poor outcomes, while experiencing three or more AEs was associated with good outcomes. Good treatment success rates and early culture conversions were achieved with entirely ambulatory treatment of MDR-TB patients in Shenzhen, supporting WHO recommendations. Advantageous aspects of the local TB control program, including accessible and affordable second-line drugs, patient support, active monitoring and proper management of AEs and well-implemented DOT likely contributed to treatment success rates.

Gender Differences in Potentially Inappropriate Medication Use among Older Adults.

Use of potentially inappropriate medication (PIMs) is a prominent concern that leads to significant medication-related issues among older adults. Notably, older women tend to utilize more medicines than men; older women frequently take more drugs. In addition, some evidence suggests that prescription PIMs vary by gender. This study examines the gender-based variation in prescribing PIM among older adults in Saudi Arabia. A cross-sectional retrospective analysis of electronic medical records from a large hospital in Saudi Arabia was carried out. Patients over the age of 65 who received ambulatory treatment were included in the study. The utilization of PIM was assessed based on Beers criteria. Descriptive statistics and logistic regression were employed to describe patterns of PIM utilization and identify factors associated with their use. All statistical analyses were performed using Version 9.4 of the Statistical Analysis Software (SAS® 9.4). The study comprised 4062 older people (age 65) who visited ambulatory care clinics; the average age was (72.6 ± 6.2) years. The majority of the study sample was women (56.8%). Among older adults, 44.7% of older men and 58.3% of older women reported having PIMs that should be avoided, indicating a higher prevalence of PIMs among women compared to men. In terms of the PIM categories used, women had a much higher utilization rate of cardiovascular and gastrointestinal drugs than men. In men, the use of PIMs was frequently associated with hypertension, ischemic heart disease, asthma, osteoarthritis, and cancer, while in women PIM use was associated with age, dyslipidemia, chronic kidney disease, and osteoporosis. This study revealed sex differences in PIM prescribing among older adults; PIM use is more common among women. Sex differences exist in clinical and socioeconomic characteristics and factors related to using potentially inappropriate medications. This study revealed essential areas that could be targeted by further interventions to improve drug-prescribing practices among older adults at risk of PIM.

Associations between physical and mental health and the utilization of ambulatory and emergency healthcare among asylum-seekers: results from a cross-sectional survey in Berlin, Germany

BackgroundDespite a high burden of chronic and mental illness, asylum-seekers show low utilization of ambulatory specialist healthcare. Forgoing timely healthcare when facing access barriers may direct them toward emergency care. This paper examines interrelations of physical and mental health and utilization of ambulatory and emergency care, and explicitly addresses associations between the different types of care.MethodsA structural equation model was applied to a sample of n = 136 asylum-seekers living in accommodation centers in Berlin, Germany. Utilization patterns of emergency care (outcome) and physical and mental ambulatory care (endogenous predictors) were estimated, while controlling for age, gender, chronic conditions, bodily pain, depression, anxiety, length of stay in Germany (exogenous predictors) and self-rated health (endogenous predictor).ResultsAssociations were observed between ambulatory care utilization and poor self-rated health (0.207, CI: 0.05; 0.364), chronic illness (0.096, CI: 0.017; 0.175) and bodily pain (0.019, CI: 0.002; 0.036); between mental healthcare utilization and anxiety (0.202, CI: 0.051; 0.352); and between emergency care utilization and poor self-rated health (0.621, CI: 0.059; 1.183), chronic illness (0.287, CI: 0.012; 0.563), mental healthcare utilization (0.842, CI: 0.148; 1.535) and anxiety (0.790, CI: 0.141; 1.438) (values in parentheses show estimated regression coefficients and 95% confidence intervals). We found no associations between the utilization of ambulatory and emergency care.ConclusionsOur study generates mixed results concerning associations between healthcare needs and ambulatory and emergency care utilization among asylum-seekers. We found no evidence that low utilization of ambulatory care contributes to emergency care utilization; neither did we find evidence that ambulatory treatment obviates the need to seek emergency care. Our results indicate that higher physical healthcare needs and anxiety are associated with more utilization of both ambulatory and emergency care; whereas healthcare needs related to depression tend to remain unmet. Both the undirected and under-utilization of health services may reflect navigation and accessibility issues. To facilitate more needs-based and effective healthcare utilization and thus contribute to health equity, support services such as interpretation and care navigation as well as outreach are warranted.

The Impact of Telemedicine on Patients with Hidradenitis Suppurativa in the COVID-19 Era.

(1) Background: Hidradenitis suppurativa is a chronic, inflammatory skin disease. It is characterized by the transformation of normal skin into skin with abscesses, nodules, tunnels, and scars. The most commonly affected areas are the armpits, groins, buttocks, and subscapular area. Patients with HS require constant care under the supervision of the outpatient clinic. Due to the COVID-19 pandemic, consultations have been introduced in the form of telemedicine. The aim of this study was to evaluate the availability of HS treatment during the COVID-19 pandemic and to assess patient satisfaction, problems with access to medical care, and the impact of the pandemic on the course of the disease. (2) Methods: An internet survey with an anonymous questionnaire was used to assess the effectiveness of telemedicine consultations. The survey consisted of 25 closed questions, and responses were kept fully anonymous. (3) Results: Most respondents reported minor problems with accessing specialized HS medical care during the COVID-19 pandemic (n = 25, 35.71%). However, 35.71% (n = 25) of them reported major problems with appointments for specialized ambulatory treatment during the last few months of the pandemic, mainly due to delayed appointments. Almost half of the respondents had been diagnosed with COVID-19 (n = 34, 48.57%), and 58.57% (n = 41) of respondents did not see a correlation between COVID-19 infection and HS progression. (4) Conclusions: Our study showed that the pandemic significantly limited access to medical advice, and patients with hidradenitis suppurativa prefer standard consultations.

Can Methotrexate Be Employed as Monotherapy for Bullous Pemphigoid? Analysis of Efficiency and Tolerance of Methotrexate Treatment in Patients with Bullous Pemphigoid.

The European Academy of Dermatology and Venerology (EADV) consensus states that the treatment of choice for bullous pemphigoid is systemic glucocorticosteroid therapy. Bearing in mind that long-term steroid therapy is associated with numerous side effects, an effective and safer treatment regimen for these patients is still being sought. A retrospective analysis was performed of the medical reports of patients with diagnosed bullous pemphigoid. The study included 40 patients with moderate or severe disease, and who had continued ambulatory treatment for at least six months. The patients were divided into two groups: one treated with methotrexate in monotherapy, or with combined methotrexate and systemic steroid therapy. A slightly better survival rate was noted in the methotrexate group. No significant differences were observed between the groups in time to achieve clinical remission. The combination therapy group demonstrated more frequent disease recurrence and exacerbations during treatment, and a higher mortality rate. None of the patients in either group presented with severe side effects related to methotrexate treatment. The treatment of bullous pemphigoid with methotrexate in monotherapy is an effective and safe therapeutic method for elderly patients.

The impact of employment on treatment completion rates with DWI offenders

Drivers under the influence of alcohol cause nearly one third of all fatal motor vehicle accidents. Ambulatory outpatient alcohol use disorder treatment has been clinically shown to increase abstinence, which could decrease the chance of subsequent DWI offences. Aiding clients in successful completion of this treatment is imperative to lower the recidivism rates of DWI offenses. The research question focused on if employment status can predict successful outpatient treatment completion in court mandated adults. The TEDS-D archival data set was used, consisting of data collected between 2006—2011 from federally funded substance abuse treatment centers throughout the USA. The variables of treatment level, gender, employment status, and age were used as controls. A logistic regression using a random sample of 4947 participants determined employment status was significant. The variable of age was also a significant predictor of treatment completion. Court and treatment agencies can use this information to offer more employment support to increase chances of treatment completion.

A co-formulation of pramlintide and insulin A21G (ADO09) improves postprandial glucose and short-term control of mean glucose, time in range, and body weight versus insulin aspart in adults with type 1 diabetes.

Pramlintide improves postprandial glucose but requires additional injections. We investigated the pharmacokinetics/pharmacodynamics, efficacy and safety of ADO09, pramlintide/insulin A21G co-formulation, in type 1 diabetes (T1D). This double-blinded, randomized, two-period cross-over study compared prandial administration of ADO09 or insulin aspart over 24 days in T1D using either ≤40 U bolus insulin per day [low-dose group (LD), n=28] or 40-75 U [high-dose group (HD), n=16]. Glycaemic responses through continuous glucose monitoring, and pharmacokinetics/pharmacodynamics profiles following mixed-meal-tolerance tests were evaluated at baseline and at the end of treatment. Glucose increments from 0 to 4h after mixed-meal-tolerance test (primary endpoint) were 39% (not statistically significantly) lower with ADO09 in the low-dose group and 69% lower in the high-dose group. Mean continuous glucose monitoring glucose during ambulatory treatment was lower with ADO09 than with aspart (LD: -8.2 ± 7.9mg/dl, p=.0001; HD: -7.0 ± 10mg/ml, p=.0127), and time-in-range (70-180 mg/dl) improved (LD: +4%, p=.0134; HD: +4%, p=.0432). Body weight declined significantly with ADO09 (LD: -0.8kg; HD: -1.6kg). Hypoglycaemic events were slightly more frequent with ADO09 versus aspart (LD: 142 vs. 115; HD: 96 vs. 79). Gastrointestinal events occurred more frequently with ADO09 but were generally transient, and no other safety signals were identified. In comparison with aspart, ADO09 was well tolerated and effective in T1D across a wide range of dosage, significantly improving the average blood glucose level and body weight during 24 days of ambulatory treatment. Meal test profiles confirmed improvement of glycaemic patterns and other responses with ADO09.

Clinical practice selectively follows acute appendicitis guidelines

IntroductionAcute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps.MethodsWe undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications.ResultsFour thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1–4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001).ConclusionsThe observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.