Clinical Awareness Research Articles

Expansion of outreach to native Hawaii and Pacific Islander communities to increase breast cancer screening and clinical trial awareness in underserved and rural Oahu.

e13725 Background: Multiple barriers exist in the enrollment of racial and ethnic minority groups into breast cancer screening and clinical trials. Such barriers include the lack of knowledge, mistrust, and access. To increase participation of rural-dwelling Native Hawaiian/Pacific Islanders (NHPI) and other underserved minority groups in breast cancer screening and clinical trials, a pilot project was developed to augment community engagement, provide education, and gain insights into the cancer screening/clinical trial process. Our objective was to engage rural Oahu's underserved communities in breast cancer screening and facilitate enrollment into the Digital Tomosynthesis Mammography and Digital Mammography in Screening Patients of Breast Cancer Trial (TMIST) utilizing a team comprising of a cultural congruent and gender concordant Community Health Educator (CHE) and medical oncology health care provider. Methods: We reviewed the community activities over the course of a year. The CHE facilitated outreach by speaking at numerous church events and other community gatherings. Results: Participants did not respond favorably to surveys on social determinants of health. Common reasons for their reluctance included lack of perceived importance and medical mistrust. When discussing verbiage that was intimidating or confusing such as clinical trial protocol consent language, TMIST study participants conveyed a strong sense of dehumanization. Conclusions: A total of 93 women were screened for the TMIST clinical trial. Of those, 13 were enrolled in TMIST and 31 participants received mammograms. Participant insight highlighted the importance of education using culturally sensitive language and community engagement to combat the lack of knowledge and mistrust. Continued development of education materials centered around community involvement will improve the accrual of NHPI participation in breast cancer screening/clinical trials. We hope this project established a basis for equity in communities with low breast cancer screening and clinical trial participation rates. We intend to build upon the community partnerships forged during this pilot project.

Maxillary osteonecrosis related to post-COVID-19: A report of case series and 6-month follow-up

ObjectivePost-COVID-19-related osteonecrosis of jaws (PCRONJ) has emerged as a complication observed in patients recovered from COVID-19 infection, but PCRONJ has been understudied in the literature. We aimed to report a case series of PCRONJ, including diagnosis, treatment procedures, and discussion about related factors. MethodsWe prospectively evaluated PCRONJ patients at the National Hospital of Odonto-Stomatology in Ho Chi Minh, Vietnam. Patients’ demographics, medical history, COVID-19 treatment, clinical and preclinical features, and clinical outcomes were reported. ResultsDuring a six-month period, nine patients were included in this study. The mean age was 53.7 years and 56 % of patients were male. All patients were diagnosed with PCRONJ at the maxillary, diabetic and administered corticosteroids to manage COVID-19 prior to this infection. The mean time from COVID-19 recovery to the onset of symptoms was 4.6 weeks. 89 % of patients underwent tooth extractions following tooth mobility examination. Clinically, mobility of dentoalveolar maxillae, in combination with necrotic bone exposure and/or inflammatory signs were observed in all cases. Radiographically, bone destruction located in maxillae and surrounding structures reflected the extension of lesions. Surgical treatment was applied for all cases to debride the necrotic bone. All patients exhibited well-healing, and an improved quality of life after discharge. ConclusionsPCRONJ should be distinguished from other forms of osteonecrosis of the jaws due to its distinct features. Multiple risk factors complicate the refinement of the likelihood of PCRONJ but warrant awareness for clinicians. An early diagnosis would help to plan a timely treatment and for optimal clinical outcomes.

Etiological spectrum and diagnostic challenges of short-duration fever in West Bengal (India). A cross-sectional tertiary care study

IntroductionThe scarcity of epidemiological data on acute febrile illnesses from South Asia impairs evidence-based clinical decision-making. Our study aimed to explore the etiological spectrum of short-duration fever in patients admitted to a tertiary care hospital in West Bengal, India. MethodsWe conducted a cross-sectional study from May 2021 to April 2022 involving 150 adult patients presenting with a fever lasting less than two weeks at Burdwan Medical College and Hospital (West Bengal, India). We performed comprehensive clinical assessments, including microbiological, serological, and other specific investigations, to identify the causes of the fever. ResultsThe demographic profile predominantly included individuals aged 21–40 years, with a male-to-female ratio of 1.9:1; 60.7% of participants were from rural areas. The primary etiological agents identified were scrub typhus (25.3%), dengue (15.3%), and enteric fever (13.3%). Notably, 80% of patients presented with non-localizing symptoms, while 14.7% had respiratory symptoms. Blood cultures pinpointed Salmonella typhi and Staphylococcus aureus in a minority of cases (3.3%); malaria, primarily Plasmodium vivax, was diagnosed in 12% of the cases. ConclusionOur findings highlight the complexity of diagnosing short-duration fevers, dominated by a wide range of etiological agents, with a notable prevalence of scrub typhus. These results underscore the urgent need for enhanced diagnostic facilities, including the availability of scrub typhus testing at primary healthcare centers. We recommend empirical doxycycline therapy for suspected cases and emphasize the need for further research to develop management guidelines for acute febrile illnesses. This study also highlights the importance of raising both community and clinician awareness to prevent irrational antibiotic use.

Delirium in the United States: Results From the 2023 Cross-Sectional World Delirium Awareness Day Prevalence Study

Delirium is an acute brain dysfunction associated with an increased risk of mortality and future dementia. To describe the prevalence of clinically documented delirium in the United States on World Delirium Awareness Day2023. This is a sub-analysis of a prospective, cross-sectional, online, international survey. All health care settings were eligible, with the exception of operating rooms and outpatient clinics. Health care clinicians, administrators, and researchers completed the survey. The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. and 8:00 p.m. on March 15, 2023. Secondary outcomes were related to health care delivery. Descriptive statistics are reported. Differences between unit types (non-intensive care unit vs intensive care unit) were examined for all outcomes. Ninety-one hospital units reported on 1318/1213 patients. The prevalence of clinically documented delirium was 16.4% (n= 216/1318) at 8:00 a.m. and 17.9% (n= 217/1213) at 8:00 p.m. (P=0.316) and significantly differed between age groups, reported discipline, unit, and hospital types. Significant differences were identified between non-intensive care unit and intensive care unit settings in the use of delirium-related protocols, nonpharmacologic and pharmacologic management, educational processes, and barriers to evidence-based delirium care. To our knowledge, this is the first epidemiologic survey of clinically documented delirium across two time points in the United States. Delirium remains a significant burden and challenge for health care systems. The high percentage of units using delirium management protocols suggests administrator and clinician awareness of evidence-based strategies for its detection and mitigation. We provide recommendations for future studies and quality improvement projects to improve clinical recognition and management of delirium.

Awareness of peripheral IV catheters among nurses, physicians, and trainees: A prospective cohort study

Peripheral intravenous catheters (PIVs) are the most frequently used invasive device in hospitalized patients. These devices are not benign and are associated with complications. However, clinician awareness of them is variable and poorly understood. We conducted a prospective, multicenter, observational point prevalence study to assess awareness of PIV presence among clinicians caring for hospitalized patients in 4 hospitals between May 2018 and February 2019 located in Michigan, USA. We first assessed patients for thepresence of a PIV then interviewed their providers. Differences in awareness by provider type were assessed via χ² tests; P<.05 was considered statistically significant. Analyses were performed on Stata MP v16. A total of 1,385 patients and 4,003 providers were interviewed. Nurses had the greatest awareness of overall PIV presence, 98.6%, while attendings were correct 88.1% of the time. Nurses were more likely to correctly assess PIV presence and exact location than physicians (67.7% vs<30% for all others). Awareness of PIV presence did not significantly vary in patients on contact precautions or those receiving infusions. Given the ubiquity of PIVs and known complications, methods to increase awareness to ensure appropriate care and removal are necessary.

Perspectives of facilitators and barriers to cancer clinical trial participation: A mixed-methods study.

e23206 Background: Inclusive clinical trials (CT) are integral to ensure that all patients benefit from advancements in cancer treatment. Having a diverse makeup of CT participants is imperative. Yet nationally, only 5% of trial participants are racial/ethnic minorities despite persistent disparities in cancer incidence and mortality. Determining the barriers and facilitators to CT participation will inform strategies to advance CT diversity, and cancer care equity. Methods: We conducted a mixed methods study exploring perceived barriers and facilitators to CT participation. We asked CT staff and Black adult cancer patients who enrolled in a CT to engage in semi-structured focus groups or interviews via Zoom. Based on emergent themes and data from extant literature we developed and deployed to CT staff a 24 item 5-point Likert style (strongly disagree – strongly agree) survey regarding clinician, institution, and patient-level factors impacting CT participation; one item ranked overall CT participation barriers. Results: Ten patients and thirteen CT staff participated in the focus groups and interviews. Table 1 presents major themes that emerged. CT survey respondents (N = 30) included clinicians (40%) and research associates (43%) and roughly half (55%) were White, non-Hispanic. The majority (80%) responded that their personal skills and confidence with enrolling diverse patients were high. The top ranked barriers to CT enrollment were travel distance (77%) and added financial burden (60%). Facilitators were altruism (70%) and clinician awareness of available trials (73%). Most (60%) endorsed perceptions that enrolling racial/ethnic patients was more challenging than White and that patient attributes (e.g., higher education, timeliness to appointments increased adherence to CTs protocols. Conclusions: Complex, multi-level factors influence CT enrollment and diversity with patient level factors of most concern. Multi-level approaches both internally and community-focused are necessary for CT participation and diversity. Efforts are necessary to mitigate implicit bias among CT staff, particularly as it relates to perceptions of patient attributes. To advance cancer care, CT participation equity must remain a priority.

Effect of real-time data-driven physician engagement on appropriate precision oncology testing.

11168 Background: Precision medicine is a paradigm shift in healthcare: 24% of all FDA approvals are precision medicines, with 67% of new approvals relying on companion or complementary testing or on diagnostics prior to clinical use. Yet a recent publication indicates that approximately 64% of potentially eligible patients could be lost due to various clinical practice gaps along patient journey (Sadik et al JCO 2022). Low prevalence biomarker testing is proven to be one of the critical determinants of missed therapy, potentially due to poor physician awareness. The increasingly advanced machine learning (ML) and natural language processing (NLP)-based ability to label, analyze, and segment data can be utilized to monitor and influence testing behavior in real-time. We hypothesize that a real-time data-driven physician-targeted digital engagement can increase biomarker testing rate and in turn enhance patient identification for precision therapies. Methods: Unstructured real-world, real-time biomarker testing reports were collected from 494 laboratories across the US. These testing reports were first curated, labeled and extracted via ML and NLP-based technologies to allow data analysis and reveal testing behavior. Suboptimal testing behavior was defined as no requisition of the selected novel biomarker as part of the diagnostic workups. Physicians who identified as having suboptimal testing behavior were selected as candidates to receive a personalized digital engagement over a 4-week period. The digital engagement's purpose was to raise clinical awareness towards the novel biomarker testing. The follow-up testing behavior was analyzed again over laboratory reports collected from 26-weeks’ time after the initial engagement. Results: 822 physicians were identified with suboptimal testing behavior and selected to receive 4 weeks' follow-up digital engagement. 271 out of 822 (33%) recipients were successfully engaged shown as open and read the digital communication. 42 (~15%) physicians reacted to the communications and ordered the new test at least once during this period. The initial 4 weeks' engagement was observed to be the most impactful, when 23 out of the 42 (~55%) physicians ordered the novel biomarker test for the first time.71 new therapy-eligible patients were identified via data-driven targeted physician digital engagement during the 26 weeks’ follow-up period. Conclusions: This study illustrates the value of data in influencing or reinforcing testing behaviors and emphasizes the value of data-driven physician-targeted digital engagement in addressing clinical practice gaps which in turn, drive patient identification to match potential eligible precision therapies.

Clinico-Biochemical Spectrum of Pakistani Patients with Glutaric Aciduria Type 1 (GA1): Experience from a Specialised Biochemical Genetics Laboratory in Pakistan.

To evaluate the clinical, radiological, and biochemical features of glutaric aciduria Type 1 (GA1) patients identified through urine organic acid testing at a biochemical genetics laboratory (BGL) in Pakistan. Observational study. Place and Duration of the Study: Department of Pathology and Laboratory Medicine, The Aga Khan University Hospital, Karachi, Pakistan, from January 2013 to December 2022. Medical charts and urine organic acid (UOA) chromatograms of the patients presenting at the BGL from January 2013 to December 2022 were reviewed. Brain imaging was obtained where available. Variables were noted as per the objective and descriptive statistics were obtained. GA1 was found in 64 (0.4%) patients out of a total of 16,094 UOA requests for high-risk screening cases. The age of diagnosis ranged between one month and three years. The brain MRI findings revealed characteristic abnormalities such as cerebral atrophy, expanded CSF spaces, white matter abnormalities, and a distinct bat wings appearance, in cohesion with the results of biochemical testing. Sixty-four cases of GA1 from a single centre indicate a high frequency of the disorder in Pakistan. Late diagnosis emphasises the need for increased clinical awareness and preferably newborn screening to ensure optimal outcomes. Glutaric aciduria Type 1 (GA1), Brain imaging, UOA analysis, Glutaryl-CoA dehydrogenase (GCDH), Pakistan.

Childhood gratification syndrome: Demystifying the clinical conundrum with a narrative literature review of the past 5 decades.

Childhood gratification syndrome (CGS) refers to self-stimulatory or masturbatory behaviors in children, which may have an onset as early as in infancy (IGS). The aim of this review is to understand the various clinical manifestations of CGS/IGS and their clinical differentiation from commonly misdiagnosed neurological and physical illnesses and to formulate a preliminary approach to their diagnosis and management. This narrative review is based on a search of literature over the past 50 years (1972-2022) in three online databases (PubMed/Medline, Embase, and Google Scholar). The behaviors are episodic, occurring for brief periods, involving posturing, stereotypical limb movements, pubic pressure with autonomic hyperactivity, and postepisodic lethargy. They mimic seizures, movement disorders, abdominal pain, and tics. The paper also highlights the gap in the current knowledge to guide future research in the area. CGS usually represents nonpathological "pleasure-seeking" habits of childhood, but at times, it may become problematic for the child and his family. A careful history and videotape analysis of the events confirms the diagnosis and behavioral therapy with parental reassurance as the mainstay of treatment. A better understanding and clinical awareness of the CGS are necessary to prevent misdiagnosis and delay in appropriate intervention.

#2590 Electrolyte abnormalities in HIV patients with CKD

Abstract Background and Aims Individuals with HIV infection and CKD are prone to various water &amp; electrolyte disorders with previous studies showing prevalence of 70%. Many of these disturbances remain clinically silent until they reach an advanced stage, emphasizing the need for a high level of clinical suspicion and awareness, as they contribute to both morbidity and mortality. The prevalence of CKD in HIV patients has been increasing, yet data on electrolyte disturbances is sparse. The study we conducted aims to determine electrolyte imbalances in this population. Method Prospective observational single center study for a period of 2 years including HIV seropositive patients &amp;gt;18 years of age who were screened for CKD as per KDIGO definition (eGFR &amp;lt; 60 ml/min/1.73 m2 or significant proteinuria &amp;gt; 300 mg/day for more than 3 months). Demographic features, laboratory investigations for serum electrolytes including Sodium, Potassium, Phosphorous &amp; Calcium levels were done at baseline with follow up at 3, 6 &amp; 12 months. Results Out of 695 HIV patients screened, 56 who had CKD were included in our study. The average age was 53.8 ± 11.3 years, including 41 males (73.2%). Median creatinine at baseline was 1 (1.3) mg/dL, &amp; median eGFR was 59 (24.82) ml/min/1.73 m2 (Table 1). Commonest abnormality at baseline was hyponatremia (53.6%), and only 8.9% had severe hyponatremia (&amp;lt;125 mmol/L). Other abnormalities prevalent were hypocalcemia (35.7%) and hypophosphatemia (46.4%). Follow up details are presented in Table 2. Conclusion CKD was prevalent in 56 (8%) of our patients. Dyselectrolytemias were seen in 91% of study population. Hyponatremia (89.2%) was the commonest electrolyte imbalance followed by Hypophosphatemia (62.5%) &amp; Hypocalcemia (57.1%). Notably, our study identified a significantly higher incidence of hypocalcemia, and hypophosphatemia compared to other studies.

A ten-year literature review of oral malignant melanoma cases: A meta-analysis study

AimOral malignant melanoma (OMM) is a rare and aggressive malignant tumour arising from the proliferation of melanocytes and accounts for only 0.5 % of all oral malignancies. It is invasive and tends to metastasise. The aim of this study is to determine the patient profile of OMM and to provide information about the clinical features and treatment plans of the disease. Materials and MethodsThe Pubmed database was searched for OMM cases published as case reports in the last 10 years. The search was limited to English and open-access case reports. A total of 49 OMMs in 45 patients from 43 case reports were analyzed. In addition to the age, gender, smoking and alcohol consumption habits of the patients, data on the signs and symptoms of OMM, location of the lesion, imaging modalities used in diagnosis and treatment, lymph node involvement, presence of metastasis, survival time, and treatment modalities were recorded. ResultsIn OMM cases, 18 (40 %) of the patients were female, 27 (60 %) were male, and the mean age was 53.13 ± 16.09 years. The most common symptom was "swelling" (n = 23, 33.8 %) and the most common finding was "hyperpigmentation" (n = 40, 24.4 %). The most common site of OMM was the maxilla (n = 21, 46.7 %). According to the rate of use of imaging modalities in the cases, it was determined that "advanced imaging modalities" were mostly used (n = 24, 53.3 %). It was determined that 22.2 % (n = 10) of the patients died within the first 5 years. Combined treatment (n = 21, 46.5 %) were mostly applied to the patients. ConclusionOMM is more common in the maxilla, in males and in the fifth decade of life, and advanced imaging modalities are most commonly used to detect the disease. Because of its poor prognosis, knowing the patient profile and common clinical features of OMM will increase the clinical awareness of physicians.

#1280 Temporal trends in chronic kidney disease and mortality after acute kidney injury

Abstract Background and Aims In 2015, the International Society of Nephrology formulated the “0by25” initiative, which aims to eliminate all preventable deaths due to acute kidney injury (AKI) by 2025. Numerus publications have added focus to the importance of clinical awareness and improved treatment for AKI. Ideally, this should translate to lower rates of AKI-associated adverse outcomes such as chronic kidney disease (CKD) and death. To our knowledge, there are no studies describing temporal trends in the incidence of CKD following AKI. Moreover, only a few studies have examined the temporal trends in mortality following AKI and these studies included highly selected groups of patients not representative of general hospitalized patients and to an even lesser degree the general population. Hence, further examination of the prognosis after AKI is required to understand temporal trends in the quality of care for AKI and establish a foundation for both preventive and therapeutic measures. Therefore, we examined the temporal trends in CKD and mortality after AKI in Denmark. Method We identified adult individuals with AKI from 1 January 2007 to 31 December 2018 using population-based plasma creatinine (pCr) data covering both the primary care and hospital settings. AKI was defined in accordance with the Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. CKD after AKI was defined as ≥2 eGFR measurements from primary care or planned outpatient hospital visits &amp;lt;60 mL/min/1.73 m2 separated by a period of ≥90 days or by a hospital diagnoses code related to chronic dialysis or kidney transplantation. Information on all-cause death was obtained from the Danish Civil Registration System. Annual crude and sex-and-age-standardized 1-year incidence rates of CKD and mortality after AKI were estimated using direct standardization. Results During the 2007-2018 period, 406,207 AKIs were identified in 274,269 distinct Danish residents. The mean age at the time of first AKI was 72 years (IQR, 61; 81) and 137,185 (50%) of first-time AKIs occurred in males. Twenty-eight percent of individuals had a Charlson Comorbidity Index (CCI) score of 0, while 42% had a CCI score of 1-2, and 30% a CCI score ≥3. The mean age, sex, and CCI score distributions were stable across the study period. The age- and sex-standardized incidence rate of CKD after AKI ranged from 102 (95% CI, 99-106) per 1000 person-years in 2018 to 126 (95% CI, 119-133) per 1000 person-years in 2014. Besides a peak in 2014, the incidence of CKD after AKI showed little variation throughout the period. The age-and sex-standardized mortality rate after AKI ranged from 317 (95% CI, 311-323) per 1000 person-years in 2018 to 392 (95% CI, 379-406) per 1000 person-years in 2007. From 2007 to 2013 there was a stable decline in the mortality rate after AKI. From 2014 to 2018 the rate showed little variation. Conclusion The rate of CKD after AKI was stable throughout the period, while there was a decline in mortality after AKI, especially in the years from 2007 to 2013. The decline in mortality after AKI is encouraging; however, the stable rate of CKD after AKI, despite increasing knowledge on AKI treatment and CKD prevention, warrants an evaluation of the contemporary quality of care for AKI in Denmark.

Impact of peri-operative frailty and operative stress on post-discharge mortality, readmission and days at home in Medicare beneficiaries.

Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress. This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure. In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category. These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty.

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration

BackgroundDespite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.MethodsWe conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.ResultsWe conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.ConclusionsThe diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Determining the future role of clinical practice guidelines: The experience of Australia and New Zealand.

There has been recent discussion in Australia and New Zealand concerning the utility of Clinical Practice Guidelines (CPGs) and the role of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in their development. The College Board therefore established a Steering Group (SG) to oversee an exploration of options and produce recommendations about contemporary approaches to the development of high-quality evidence-based clinical practice guidance for psychiatry. This paper outlines the SG's conclusions and recommendations, as well as the underlying methods and reasoning. In particular, we discuss best practice and recent developments in the synthesis of research evidence. Account has been taken of the opportunities offered by digital technologies, the proliferation of clinical evidence and awareness of the gains to be made by increased inclusion of lived-experience perspectives. It is recommended that the broader concept of best practice resources (BPRs) as now emphasised in so many fields of service is the most appropriate starting point for the College's role in this area especially as the expertise of the College and its fellows lends itself to the development of a range of BPRs. In conclusion, contemporary guidance needs to be tailored to the requirements of the practitioners seeking it, to articulate the real-world needs and experiences of patients, and to be delivered in a contemporary format that is responsive to rapidly emerging evidence. The experience in Australia and New Zealand may have implications elsewhere for the development of CPGs and BPRs more broadly.

Deficiency of leucine-rich repeat kinase 2 aggravates thioacetamide-induced acute liver failure and hepatic encephalopathy in mice

BackgroundHepatic encephalopathy (HE) is closely associated with inflammatory responses. However, as a crucial regulator of the immune and inflammatory responses, the role of leucine-rich repeat kinase 2 (LRRK2) in the pathogenesis of HE remains unraveled. Herein, we investigated this issue in thioacetamide (TAA)-induced HE following acute liver failure (ALF).MethodsTAA-induced HE mouse models of LRRK2 wild type (WT), LRRK2 G2019S mutation (Lrrk2G2019S) and LRRK2 knockout (Lrrk2−/−) were established. A battery of neurobehavioral experiments was conducted. The biochemical indexes and pro-inflammatory cytokines were detected. The prefrontal cortex (PFC), striatum (STR), hippocampus (HIP), and liver were examined by pathology and electron microscopy. The changes of autophagy-lysosomal pathway and activity of critical Rab GTPases were analyzed.ResultsThe Lrrk2−/−-HE model reported a significantly lower survival rate than the other two models (24% vs. 48%, respectively, p < 0.05), with no difference found between the WT-HE and Lrrk2G2019S-HE groups. Compared with the other groups, after the TAA injection, the Lrrk2−/− group displayed a significant increase in ammonium and pro-inflammatory cytokines, aggravated hepatic inflammation/necrosis, decreased autophagy, and abnormal phosphorylation of lysosomal Rab10. All three models reported microglial activation, neuronal loss, disordered vesicle transmission, and damaged myelin structure. The Lrrk2−/−-HE mice presented no severer neuronal injury than the other genotypes.ConclusionsLRRK2 deficiency may exacerbate TAA-induced ALF and HE in mice, in which inflammatory response is evident in the brain and aggravated in the liver. These novel findings indicate a need of sufficient clinical awareness of the adverse effects of LRRK2 inhibitors on the liver.

Homeless people: a review of personality disorders.

Personality disorders in homeless people pose a challenge to the medical community and society, requiring specialized approaches for these super-difficult patients. The prevalence of personality disorders is higher in homeless populations than in the general population. However, there is a knowledge gap regarding personality disorders among people experiencing homelessness, and the implications of this lack of recognition are substantial. This paper provides a brief narrative review of personality disorders among homeless individuals. The primary importance and specificity of these disorders in this population remain unexplored. We searched PubMed and Web of Science databases in February and November 2023 using the keywords 'homeless' and 'personality disorder', and selected fifty-eight studies to be included in this literature review. The main themes of the results were personality disorders in homeless individuals and comorbid psychiatric disorders; risk factors and other psychological and behavioral data; clinical and intervention outcomes; and challenges linked to assessment, treatment, and intervention. The homeless population experiences significant diagnostic variability and the diagnosis of personality disorders is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. A future challenge is to raise clinical awareness and optimize research knowledge, assessment, and intervention in personality disorders among homeless individuals with comorbid psychiatric disorders.

Evaluating precision medicine tools in cystic fibrosis for racial and ethnic fairness.

Patients with cystic fibrosis (CF) experience frequent episodes of acute decline in lung function called pulmonary exacerbations (PEx). An existing clinical and place-based precision medicine algorithm that accurately predicts PEx could include racial and ethnic biases in clinical and geospatial training data, leading to unintentional exacerbation of health inequities. We estimated receiver operating characteristic curves based on predictions from a nonstationary Gaussian stochastic process model for PEx within 3, 6, and 12 months among 26,392 individuals aged 6 years and above (2003-2017) from the US CF Foundation Patient Registry. We screened predictors to identify reasons for discriminatory model performance. The precision medicine algorithm performed worse predicting a PEx among Black patients when compared with White patients or to patients of another race for all three prediction horizons. There was little to no difference in prediction accuracies among Hispanic and non-Hispanic patients for the same prediction horizons. Differences in F508del, smoking households, secondhand smoke exposure, primary and secondary road densities, distance and drive time to the CF center, and average number of clinical evaluations were key factors associated with race. Racial differences in prediction accuracies from our PEx precision medicine algorithm exist. Misclassification of future PEx was attributable to several underlying factors that correspond to race: CF mutation, location where the patient lives, and clinical awareness. Associations of our proxies with race for CF-related health outcomes can lead to systemic racism in data collection and in prediction accuracies from precision medicine algorithms constructed from it.

Factors Associated With Extrapulmonary Tuberculosis in Southeastern Mexico: A Case-Control Study.

Extrapulmonary tuberculosis (EPTB) is a disease that can affect any organ or tissue. Due to its potential to cause more dangerous sequelae and the barriers to its timely diagnosis, greater clinical awareness of this disease is crucial.This study aimedto identify the factors associated with EPTB in the population of Oaxaca, Mexico. This is an unpaired case-control study. The cases were patients with EPTB+ while the controls were patients with pulmonary tuberculosis (PTB+) registered in the Tuberculosis Epidemiological Surveillance System. Sociodemographic, clinical, and microbiological variables were recovered. Bivariate analyses were performed and logistic regression analyses were performed to calculate the odds ratio (OR). A total of 75 EPTB+ cases and 300 PTB+ controls were included. Of the total sample, 57.1% were men and 60.3% indigenous. The most frequent clinical presentations of EPTB+ were nodal (21.3%), miliary (21.3%), and breast (20.0%). According to logistic regression analysis, age <40 years (OR: 2.25(95% CI: 1.13-4.49), female sex (OR: 1.92(95% CI: 1.03-3.56)], urban residence (OR: 2.25 (95% CI: 1.11-4.55)), comorbidity with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (OR: 3.46 (95% CI: 1.31-9.10)), dyspnea (OR: 2.67 (1.22-5.82)), and adenopathy (OR: 3.38 (95% CI: 1.42-8.06)) were positively associated with EPTB+. These results can serve as a basis for screening EPTB+, thus improving the preventive and diagnostic capacity of local health services, taking as a starting point women under 40 years of age and patients with HIV/AIDS in urban areas, as well as the presence of adenopathy and dyspnea as clinical characteristics of the disease.

Disseminated Talaromyces marneffei infection initially presenting as cutaneous and subcutaneous lesion in an HIV-Negative renal transplant recipient: a case report and literature review

BackgroundThe incidence of Talaromyces marneffei (T. marneffei) infection has increased in recent years with the development of organ transplantation and the widespread use of immunosuppressive agents. However, the lack of clinical suspicion leading to delay or misdiagnosis is an important reason for the high mortality rate in non-human immunodeficiency virus (HIV) and non-endemic population. Herein, we report a case of disseminated T. marneffei infection in a non-HIV and non-endemic recipient after renal transplant, who initially presented with skin rashes and subcutaneous nodules and developed gastrointestinal bleeding.Case presentationWe describe a 54-year-old renal transplantation recipient presented with scattered rashes, subcutaneous nodules and ulcerations on the head, face, abdomen, and right upper limb. The HIV antibody test was negative. The patient had no obvious symptoms such as fever, cough, etc. Histopathological result of the skin lesion sites showed chronic suppurative inflammation with a large number of fungal spores. Subsequent fungal culture suggested T. marneffei infection. Amphotericin B deoxycholate was given for antifungal treatment, and there was no deterioration in the parameters of liver and kidney function. Unfortunately, the patient was soon diagnosed with gastrointestinal bleeding, gastrointestinal perforation and acute peritonitis. Then he rapidly developed multiple organ dysfunction syndrome and abandoned treatment.ConclusionsThe risk of fatal gastrointestinal bleeding can be significantly increased in kidney transplant patients with T. marneffei infection because of the long-term side effects of post-transplant medications. Strengthening clinical awareness and using mNGS or mass spectrometry technologies to improve the detection rate and early diagnosis of T. marneffei are crucial for clinical treatment in non-HIV and non-endemic population.