Clinical Categories Research Articles

Proposal for a Two-Tier Re-classification of Stage IV/M1 domain of Renal Cell Carcinoma into M1 ("Oligometastatic") and M2 ("Polymetastatic") subdomains: Analysis of the Registry for Metastatic Renal Cell Carcinoma (REMARCC).

We hypothesized that two-tier re-classification of the "M" (metastasis) domain of the Tumor-Node-Metastasis (TNM) staging of Renal Cell Carcinoma (RCC) may improve staging accuracy than the current monolithic classification, as advancements in the understanding of tumor biology have led to increased recognition of the heterogeneous potential of metastatic RCC (mRCC). Multicenter retrospective analysis of patients from the REMARCC (REgistry of MetAstatic RCC) database. Patients were stratified by number of metastases into two groups, M1 (≤3, "Oligometastatic") and M2 (>3, "Polymetastatic"). Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS). Cox-regression and Kaplan-Meier (KMA) analysis were utilized for outcomes, and receiver operating characteristic analysis (ROC) was utilized to assess diagnostic accuracy compared to current "M" staging. 429 patients were stratified into proposed M1 and M2 groups (M1 = 286/M2 = 143; median follow-up 19.2 months). Cox-regression revealed M2 classification as an independent risk factor for worsened all-cause mortality (HR=1.67, p=0.001) and cancer-specific mortality (HR=1.74, p<0.001). Comparing M1-oligometastatic vs. M2-polymetastatic groups, KMA revealed significantly higher 5-year OS (36% vs. 21%, p<0.001) and 5-year CSS (39% vs. 17%, p<0.001). ROC analyses comparing OS and CSS, for M1/M2 reclassification versus unitary M designation currently in use demonstrated improved c-index for OS (M1/M2 0.635 vs. unitary M 0.500) and CSS (M1/M2 0.627 vs. unitary M 0.500). Subclassification of Stage "M" domain of mRCC into two clinical substage categories based on metastatic burden corresponds to distinctive tumor groups whose oncological potential varies significantly and result in improved predictive capability compared to current staging.

Trichoscopy pattern and evaluation of serum vitamin D status in alopecia areata

BackgroundVitamin D (VD) insufficiency has been linked to a number of autoimmune illnesses including, alopecia areata (AA). To distinguish between clinically common hair problems, trichoscopy is a beneficial non-invasive, rapid, and affordable procedure that is yet neglected. Objectiveto evaluate trichoscopic patterns and severity in various clinical categories of AA considering vitamin D level (VDL). Also, focusing on specific patterns of trichoscopy in AA related to VDL. Subject and methodsSeverity of Alopecia Tool (SALT) was used to clinically assess patients with AA scores. Trichoscopic patterns were analyzed concerning VDL and disease severity. The VDL was estimated for 59 patients and 60 healthy controls. ResultsVDL was higher in healthy controls than in AA patients. The most common trichoscopic findings seen in our study were yellow dots (77.97%), followed by black dots (67.8%), and broken hairs (59.32%). Short vellus hairs and yellow dots were the most common in remitting AA. In progressive AA, the most common findings were broken hairs, yellow dots, and tapering hairs. VDL was significantly higher in both mild and moderate AA. ConclusionsVDL was significantly lower in severe AA and active progressive disease. Trichoscopic features could predict disease activity and VDL in patients with AA. Broken and tapering hairs will be more represented in patients with progressive disease. Short vellus hairs were seen more in stable or remitting disease. Furthermore, black dots and broken hairs were more prevalent in AA with deficient VDL.

Olfaction and Anxiety Are Differently Associated in Men and Women in Cognitive Physiological and Pathological Aging.

Olfaction impairment in aging is associated with increased anxiety. We explored this association in cognitively healthy controls (HCs), Mild Cognitive Impairment (MCI) and Parkinson's disease (PD) patients. Both olfaction and anxiety have sex differences, therefore we also investigated these variances. Investigate the association of olfaction with anxiety in three distinct clinical categories of aging, exploring the potential role of sex. 117 subjects (29 HCs, 43 MCI, and 45 PD patients) were assessed for olfaction and anxiety. We used regression models to determine whether B-SIT predicted anxiety and whether sex impacted that relationship. Lower olfaction was related to greater anxiety traits in all groups (HCs: p = 0.015; MCI: p = 0.001 and PD: p = 0.038), significantly differed by sex. In fact, in HCs, for every unit increase in B-SIT, anxiety traits decreased by 7.63 in men (p = 0.009) and 1.5 in women (p = 0.225). In MCI patients for every unit increase in B-SIT, anxiety traits decreased by 1.19 in men (p = 0.048) and 3.03 in women (p = 0.0036). Finally, in PD patients for every unit increase in B-SIT, anxiety traits decreased by 1.73 in men (p = 0.004) and 0.41 in women (p = 0.3632). Olfaction and anxiety are correlated in all three distinct diagnostic categories, but differently in men and women.

Interleukins in serum and bronchoalveolar lavage in patients with chronic obstructive pulmonary disease or bronchial asthma after pulmonary tuberculosis or pneumonia

The spread of respiratory diseases has become a topical issue of modern medicine. The prevalence of the diseases caused the rising rates of disability and mortality among people affected by respiratory diseases. The clinical course of respiratory diseases includes the disorders of general and local adaptive and protective mechanisms and cell-mediated connections. Objective — to determine the interleukin profile of serum and bronchoalveolar lavage for the verification of chronic obstructive pulmonary disease (COPD) or bronchial asthma in patients with pulmonary tuberculosis or pneumonia with bronchial obstruction syndrome. Materials and methods. 67 patients affected by chronic obstructive pulmonary disease and 33 patients diagnosed with bronchial asthma who were hospitalized in the Pulmonology Lviv Regional Diagnostic Center during 2015—2020, were examined. The patients were verified with a non-complicated tuberculosis without any destructive changes evident in the lungs (the first or third clinical category of patients), the community-acquired pneumonia with the bronchial obstruction syndrome. Pro-inflammatory interleukins IL-1β, IL-2, IL-6, TNF-α and anti-inflammatory IL-4 in serum and bronchoalveolar lavage were revealed during the lobar and tertiary bronchi fiber-optic bronchoscopy. Results and discussion. The interleukins misbalance was evident: the decrease in IL-1β and IL-2 and the increase in IL-6 and TNF-α by 4.5 times as compared to the unaffected donors was revealed in the patients with chronic obstructive pulmonary disease. The significant decrease in IL-4 was revealed pointing at the high probability of the severe and prolonged COPD and leading to frequent exacerbation and compilations of the disease. By contrast, the patients diagnosed with bronchial asthma showed higher IL-1β and IL-2 as compared to the unaffected patients; the level of IL-6 was higher as compared to the COPD patients, while TNF-α was lower. The patients with bronchial asthma showed higher IL-4 than the unaffected donors and the patients with COPD. Conclusions. The intensity of interleukins expression (especially pro-inflammatory) revealed the level of inflammation based on the acute-phase proteins in the proteolytic-antiproteolytic balance, which may be also used as the additional criteria for the differential diagnostics and justification for the treatment optimization.

Adherence to antidiabetic drug therapy and reduction of fatal events in elderly frail patients

BackgroundTo evaluate the protective effect of oral antidiabetic drugs in a large cohort of elderly patients with type 2 diabetes differing for age, clinical status, and life expectancy, including patients with multiple comorbidities and short survival.MethodsA nested case–control study was carried out by including the cohort of 188,983 patients from Lombardy (Italy), aged ≥ 65 years, who received ≥ 3 consecutive prescriptions of antidiabetic agents (mostly metformin and other older conventional agents) during 2012. Cases were the 49,201 patients who died for any cause during follow-up (up to 2018). A control was randomly selected for each case. Adherence to drug therapy was measured by considering the proportion of days of the follow-up covered by the drug prescriptions. Conditional logistic regression was used to model the risk of outcome associated with adherence to antidiabetic drugs. The analysis was stratified according to four categories of the clinical status (good, intermediate, poor, and very poor) differing for life expectancy.ResultsThere was a steep increase in comorbidities and a marked reduction of the 6-year survival from the very good to the very poor (or frail) clinical category. Progressive increase in adherence to treatment was associated with a progressive decrease in the risk of all-cause mortality in all clinical categories and at all ages (65–74, 75–84 and ≥ 85 years) except for the frail patient subgroup aged ≥ 85 years. The mortality reduction from lowest to highest adherence level showed a tendency to be lower in frail patients compared to the other categories. Similar although less consistent results were obtained for cardiovascular mortality.ConclusionsIn elderly diabetic patients, increased adherence to antidiabetic drugs is associated with a reduction in the risk of mortality regardless of the patients’ clinical status and age, with the exception of very old patients (age ≥ 85 years) in the very poor or frail clinical category. However, in the frail patient category the benefit of treatment appears to be less than in patients in good clinical conditions.

Development and validation of a machine learning ASA-score to identify candidates for comprehensive preoperative screening and risk stratification

ObjectiveThe ASA physical status (ASA-PS) is determined by an anesthesia provider or surgeon to communicate co-morbidities relevant to perioperative risk. Assigning an ASA-PS is a clinical decision and there is substantial provider-dependent variability. We developed and externally validated a machine learning-derived algorithm to determine ASA-PS (ML-PS) based on data available in the medical record. DesignRetrospective multicenter hospital registry study. SettingUniversity-affiliated hospital networks. PatientsPatients who received anesthesia at Beth Israel Deaconess Medical Center (Boston, MA, training [n = 361,602] and internal validation cohorts [n = 90,400]) and Montefiore Medical Center (Bronx, NY, external validation cohort [n = 254,412]). MeasurementsThe ML-PS was created using a supervised random forest model with 35 preoperatively available variables. Its predictive ability for 30-day mortality, postoperative ICU admission, and adverse discharge were determined by logistic regression. Main resultsThe anesthesiologist ASA-PS and ML-PS were in agreement in 57.2% of the cases (moderate inter-rater agreement). Compared with anesthesiologist rating, ML-PS assigned more patients into extreme ASA-PS (I and IV), (p < 0.01), and less patients in ASA II and III (p < 0.01). ML-PS and anesthesiologist ASA-PS had excellent predictive values for 30-day mortality, and good predictive values for postoperative ICU admission and adverse discharge. Among the 3594 patients who died within 30 days after surgery, net reclassification improvement analysis revealed that using the ML-PS, 1281 (35.6%) patients were reclassified into the higher clinical risk category compared with anesthesiologist rating. However, in a subgroup of multiple co-morbidity patients, anesthesiologist ASA-PS had a better predictive accuracy than ML-PS. ConclusionsWe created and validated a machine learning physical status based on preoperatively available data. The ability to identify patients at high risk early in the preoperative process independent of the provider's decision is a part of the process we use to standardize the stratified preoperative evaluation of patients scheduled for ambulatory surgery.

Integrating polygenic and clinical risks to improve stroke risk stratification in prospective Chinese cohorts.

The utility of the polygenic risk score (PRS) to identify individuals at higher risk of stroke beyond clinical risk remains unclear, and we clarified this using Chinese population-based prospective cohorts. Cox proportional hazards models were used to estimate the 10-year risk, and Fine and Gray's models were used for hazard ratios (HRs), their 95% confidence intervals (CIs), and the lifetime risk according to PRS and clinical risk categories. A total of 41,006 individuals aged 30-75 years with a mean follow-up of 9.0 years were included. Comparing the top versus bottom 5% of the PRS, the HR was 3.01 (95%CI 2.03-4.45) in the total population, and similar findings were observed within clinical risk strata. Marked gradients in the 10-year and lifetime risk across PRS categories were also found within clinical risk categories. Notably, among individuals with intermediate clinical risk, the 10-year risk for those in the top 5% of the PRS (7.3%, 95%CI 7.1%-7.5%) reached the threshold of high clinical risk (⩾7.0%) for initiating preventive treatment, and this effect of the PRS on refining risk stratification was evident for ischemic stroke. Even among those in the top 10% and 20% of the PRS, the 10-year risk would also exceed this level when aged ⩾50 and ⩾60 years, respectively. Overall, the combination of the PRS with the clinical risk score improved the risk stratification within clinical risk strata and distinguished actual high-risk individuals with intermediate clinical risk.

Noninferiority of Artificial Intelligence–Assisted Analysis of Ki-67 and Estrogen/Progesterone Receptor in Breast Cancer Routine Diagnostics

Image analysis assistance with artificial intelligence (AI) has become one of the great promises over recent years in pathology, with many scientific studies being published each year. Nonetheless, and perhaps surprisingly, only few image AI systems are already in routine clinical use. A major reason for this is the missing validation of the robustness of many AI systems: beyond a narrow context, the large variability in digital images due to differences in preanalytical laboratory procedures, staining procedures, and scanners can be challenging for the subsequent image analysis. Resulting faulty AI analysis may bias the pathologist and contribute to incorrect diagnoses and, therefore, may lead to inappropriate therapy or prognosis. In this study, a pretrained AI assistance tool for the quantification of Ki-67, estrogen receptor (ER), and progesterone receptor (PR) in breast cancer was evaluated within a realistic study set representative of clinical routine on a total of 204 slides (72 Ki-67, 66 ER, and 66 PR slides). This represents the cohort with the largest image variance for AI tool evaluation to date, including 3 staining systems, 5 whole-slide scanners, and 1 microscope camera. These routine cases were collected without manual preselection and analyzed by 10 participant pathologists from 8 sites. Agreement rates for individual pathologists were found to be 87.6% for Ki-67 and 89.4% for ER/PR, respectively, between scoring with and without the assistance of the AI tool regarding clinical categories. Individual AI analysis results were confirmed by the majority of pathologists in 95.8% of Ki-67 cases and 93.2% of ER/PR cases. The statistical analysis provides evidence for high interobserver variance between pathologists (Krippendorff's α, 0.69) in conventional immunohistochemical quantification. Pathologist agreement increased slightly when using AI support (Krippendorff α, 0.72). Agreement rates of pathologist scores with and without AI assistance provide evidence for the reliability of immunohistochemical scoring with the support of the investigated AI tool under a large number of environmental variables that influence the quality of the diagnosed tissue images.

Abstract P2-03-22: Assessment of the relationship between duration of treatment with hormonal therapy and the detection of ESR1 mutations in hormone-receptor positive, HER2 negative, breast cancer

Abstract Background Hormonal therapeutic agents such as the selective estrogen receptor modulator, tamoxifen, as well as the aromatase inhibitors (AIs), anastrozole, exemestane, and letrozole, are a mainstay in the treatment of patients with hormone-receptor positive (HR+) breast cancer. Despite the effectiveness of hormonal therapy in the treatment of patients with HR+ breast cancer, acquired resistance to both AIs and tamoxifen does occur, often associated with mutations of the estrogen receptor 1 (ESR1). Although the acquisition of ESR1 mutations in patients with HR+ breast cancer treated with hormonal therapy has been established as a mechanism of resistance, there is a paucity of data on the relationship between the duration of treatment with hormonal therapies and the development of ESR1 mutations. Using a cohort of patients with HR+ breast cancer who underwent next generation sequencing (NGS) as part of routine clinical care, we aim to assess the relationship between the duration of exposure to aromatase inhibitors and the detection of ESR1 mutations. The results of this study will further our understanding of ESR1-mutations and provide insight into strategies to optimize therapy for patients with HR+ breast cancers. Methods This is a retrospective analysis of patients 18 years of age or older treated at a single academic cancer center in the USA, diagnosed with HR+, HER2-negative breast cancer and who have received somatic NGS as part of clinical care over a six-year period through July 2019. Demographic, disease-related, and treatment related variables were collected along with genomic testing variables (ie. ESR1-mutation status) for each patient who met the inclusion criteria. Two patient groups were formed on the basis of ESR1-mutation status (present vs. absent) and compared on the basis of duration of treatment with AI, and other clinical and demographic categories. Results A total of 247 patients who were diagnosed with HR-positive, HER2-negative breast cancer and received NGS were identified and are included in this analysis. A total of 138 (56%) patients were assessed via tissue based NGS and 109 (44%) by liquid biopsy. The median age at time of sequencing was 58 years [57 years (ESR1-absent) vs. 60 years (ESR1-present); p =0.009]. The majority of patients were white (83%) and post-menopausal (57%). Invasive ductal carcinoma was the most common histological type (82%). Nearly all (96%) patients had stage IV disease at time of sequencing and ESR1 mutations were found exclusively in those with stage IV disease. ESR1 mutations were identified in 62 patients (25%). The median duration of treatment with aromatase inhibitors prior to testing was 19.3 months in both groups (ESR1 mutations absent vs. detected). There was no difference in prior tamoxifen use between groups (absent 43%, present 48%; p=0.48). In patients tested by tissue based NGS, ESR1 mutations were more frequently detected in metastatic sites (28% vs. 13%; p=0.03). Twenty-two patients for whom NGS did not identify an ESR1 mutation prior to July 2019 received subsequent NGS testing. Of these 22 patients, six (27%) had ESR1 mutations detected by subsequent NGS. In these six patients, ESR1-mutations were detected by NGS a median of 2.2 years (range 1.7 years to 2.6 years) after prior NGS. Conclusion There was no difference in duration of treatment with aromatase inhibitor therapy in patients with ESR1 mutations vs. those without ESR1 mutations detected by NGS. Patients with ESR1 mutations tended to be older. Although the detection of ESR1 mutations is associated with acquired therapy resistance and progression on treatment, a longer duration of treatment may make the emergence of ESR1 mutations more likely. These counterbalancing factors may have contributed to the results reported here. Citation Format: Hannah Ayettey-Anie, Kamran A. Ahmed, Iman Washington, Kosj Yamoah, Todd Knepper. Assessment of the relationship between duration of treatment with hormonal therapy and the detection of ESR1 mutations in hormone-receptor positive, HER2 negative, breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-03-22.

Implementation of Incidental Liver Lesion Clinically Integrated Workflow Increases Compliance With ACR Follow-Up Guidelines, Closing Care Gaps

ObjectiveFollow established management guidelines from the ACR and improve adherence to follow-up recommendations for incidental liver lesions (ILLs) for all patients undergoing CT abdomen and pelvis with contrast (CTAPw) examinations, with advocacy from a multidisciplinary care team. MethodsA mandatory structured radiology reporting module was developed for use in CTAPw reports for ILL recommendations. Data from the electronic medical record describing patients with radiology-reported ILLs and their clinical risk diagnosis categories were tabulated in a queryable electronic database. A nurse co-ordinator initiated workflow to communicate the need for ILL follow-up MRI to ordering physicians and primary care providers. MRIs were ordered by the ILL team. An interactive process was undertaken with continuous review to improve identification of eligible patients and adherence to recommendations. ResultsDuring the initial launch phase from December 2020 to March 2021, 1,577 ILLs were detected on 20,667 CTAPw examinations, and for those with the characterize now recommendation, 36 of 114 (31.6%) received follow-up in 30 days. Between January 2021 and June 2022, 117,520 CTAPws were performed and 4,371 ILLs were detected. Using the ILL workflow, in the MRI now cohort, follow-up occurred within 30 days in 202 of 542 (36.2%) patients, and a total of 368 of 542 (67.9%) patients have completed their follow-up to date. DiscussionUsing a focused effort to close a gap in ILL care, adherence to follow-up recommendations improved over the long term, although there remains a gap in adherence to short-term interventions. A multidisciplinary approach, radiology reporting, and software solutions were leveraged to improve a complex process.

Use of Artificial Intelligence in the Classification of Elementary Oral Lesions from Clinical Images.

Artificial intelligence has generated a significant impact in the health field. The aim of this study was to perform the training and validation of a convolutional neural network (CNN)-based model to automatically classify six clinical representation categories of oral lesion images. The CNN model was developed with the objective of automatically classifying the images into six categories of elementary lesions: (1) papule/nodule; (2) macule/spot; (3) vesicle/bullous; (4) erosion; (5) ulcer and (6) plaque. We selected four architectures and using our dataset we decided to test the following architectures: ResNet-50, VGG16, InceptionV3 and Xception. We used the confusion matrix as the main metric for the CNN evaluation and discussion. A total of 5069 images of oral mucosa lesions were used. The oral elementary lesions classification reached the best result using an architecture based on InceptionV3. After hyperparameter optimization, we reached more than 71% correct predictions in all six lesion classes. The classification achieved an average accuracy of 95.09% in our dataset. We reported the development of an artificial intelligence model for the automated classification of elementary lesions from oral clinical images, achieving satisfactory performance. Future directions include the study of including trained layers to establish patterns of characteristics that determine benign, potentially malignant and malignant lesions.

In cats undergoing midline ovariohysterectomy, is the use of local anaesthesia with bupivacaine associated with a reduction in postoperative pain score?

PICO question In cats undergoing midline ovariohysterectomy, is the use of local anaesthesia with bupivacaine via intraperitoneal or subcutaneous injections, in comparison with the use of a control substance or other analgesic measure, associated with a reduction in postoperative pain score? Clinical bottom line The category of research question: Treatment. The number and type of study designs that were critically appraised: Three studies were critically appraised in this Knowledge Summary. They included two prospective, blinded, randomised, controlled clinical trials and one prospective randomised, blinded clinical trial. Strength of evidence: Weak. The outcomes reported: Bupivacaine does not eliminate postoperative pain in cats undergoing ovariohysterectomies; minimal evidence was found to suggest that it was better at reducing postoperative pain scores in comparison to other analgesics. However, bupivacaine may provide analgesic benefits to cats when administered via intraperitoneal or subcutaneous injections as local anaesthesia and in combination with other analgesic agents. The need for postoperative rescue analgesia was minimised when bupivacaine was administered prior to or during the ovariohysterectomy. Conclusion: When compared to a control, pain scores for the participating cats were lower after administration of bupivacaine, however, statistical significance was only reached in one of the studies. Additionally, other medications were found to lower the post operative pain score to a greater effect. However, bupivacaine administration is cheap and simple to perform, so it’s use as part of a multimodal analgesic protocol is supported. Confounding factors within the studies may have altered the perceived effectiveness of the analgesic properties of bupivacaine though, so further investigation involving larger cohorts with standardised controls would be prudent. How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Variations in Chronic Obstructive Pulmonary Disease Outpatient Care in Respiratory Clinics: Results From the 2021 EPOCONSUL Audit

IntroductionThe aim of our work has been to describe the results of the clinical audit carried out in 2021 and to compare the results with 2015 EPOCONSUL audit. MethodsEPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to patients with a diagnosis of chronic obstructive pulmonary disease (COPD) in respiratory clinics in Spain with prospective recruitment between April 15, 2021, and January 31, 2022. ResultsA total of 45 hospitals participated in the 2021 audit and 4.225 clinical records of patients were evaluated. Clinical phenotype according to the Spanish National Guidelines for COPD care (GesEPOC) was reported in 63.1% of the audited patients, and the COPD type assessment for the Global initiative for chronic Obstructive Lung Disease (GOLD) was present in 38.3%. There was an improved compliance with clinical practice guideline (CPG) recommendations in the 2021 audit with respect to the 2015 audit. There was an increase in the proportion of cases with alfa-1-antitrypsin serum level testing available (audit 1: 18.9%; audit 2: 38.7%, p<0.001) and 6-min walk test carried out (audit 1: 24%; audit 2: 45.2%, p<0.001). However, these significant variations adherence to CPG recommendations were not reached for the clinical evaluation and therapeutic intervention category when adjusting for patient and resource variables. ConclusionsThe 2021 EPOCONSUL audit showed increased adherence to recommendations although they seem to be related to the availability of resources for care. These results should be taken into account in order to establish improvements in resources to achieve a better quality of care.

Comprehensive medication management: Review and recommendations for quality measures

AbstractComprehensive medication management (CMM) provided by a clinical pharmacist can improve the quality of care and reduce health care costs through the optimization of medication use and a significant reduction in medication‐related problems. As demonstrated by multiple research studies and detailed in published use cases, CMM should be an essential practice for improving population health. This narrative review discusses the limitations of the current evidence and recommends structure, process, and outcome measures to ensure that the key elements of CMM that drive the observed benefits are implemented with fidelity to address the goals of the quadruple aim. The proposed outcome measures are further sub‐classified into economic, clinical, and humanistic categories. Several medication‐related measures are recommended to help define the importance and value of CMM as a key component of population health management.

Did the UK's public health shielding policy protect the clinically extremely vulnerable during the COVID-19 pandemic in Wales? Results of EVITE Immunity, a linked data retrospective study

IntroductionThe UK shielding policy intended to protect people at the highest risk of harm from COVID-19 infection. We aimed to describe intervention effects in Wales at 1 year. MethodsRetrospective comparison of linked demographic and clinical data for cohorts comprising people identified for shielding from 23 March to 21 May 2020; and the rest of the population. Health records were extracted with event dates between 23 March 2020 and 22 March 2021 for the comparator cohort and from the date of inclusion until 1 year later for the shielded cohort. ResultsThe shielded cohort included 117,415 people, with 3,086,385 in the comparator cohort. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). People in the shielded cohort were more likely to be female, aged ≥50 years, living in relatively deprived areas, care home residents and frail. The proportion of people tested for COVID-19 was higher in the shielded cohort (odds ratio [OR] 1.616; 95% confidence interval [CI] 1.597–1.637), with lower positivity rate incident rate ratios 0.716 (95% CI 0.697–0.736). The known infection rate was higher in the shielded cohort (5.9% vs 5.7%). People in the shielded cohort were more likely to die (OR 3.683; 95% CI: 3.583–3.786), have a critical care admission (OR 3.339; 95% CI: 3.111–3.583), hospital emergency admission (OR 2.883; 95% CI: 2.837–2.930), emergency department attendance (OR 1.893; 95% CI: 1.867–1.919) and common mental disorder (OR 1.762; 95% CI: 1.735–1.789). ConclusionDeaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders; however, lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.

Omicron COVID-19 variant outcomes and vaccination in non-severe and non-critical patients at admission.

The clinical data of patients infected with the Omicron variant virus in Zhejiang Province from January to 14 May 2022 were collected retrospectively. We analyzed the differences in symptoms, clinical categories of COVID-19, length of hospital stay, and time for clearance of Omicron variant viral RNA in the sputum among the groups receiving a different number of vaccine doses. The analysis showed that as the number of vaccine doses increased, the frequency of clinical symptoms, such as fever and fatigue, decreased and the frequency of patients with moderate infections gradually decreased. At the same time, the length of hospital stay was significantly shortened. Based on the multivariate analysis, one vaccine dose [odds ratio (OR): 0.21, 95% confidence interval (CI): 0.08-0.56, p = 0.002], two vaccine doses (OR: 0.54, 95% CI: 0.33-0.88, p = 0.013), and three vaccine doses (OR: 0.40, 95% CI: 0.24-0.64, p < 0.001) shortened the length of hospitalization than those with no vaccination. The persistence of the virus in the sputum was significantly shortened with one vaccine dose (OR: 0.36, 95% CI: 0.15-0.89, p = 0.027), two vaccine doses (OR: 0.46, 95% CI: 0.27-0.78, p = 0.004), and three vaccine doses (OR: 0.38, 95% CI: 0.22-0.64, p < 0.001) than those with no vaccination. Therefore, we concluded that vaccination was an effective way to protect people against infection with the Omicron variant. Indeed, on the premise of the current routine recommendation of vaccination, three vaccines were necessary for people to be protected against the Omicron variant.

Measuring Self–Serving Cognitive Distortions in School Dropout Adolescents (Boys)

Adolescence is an important period in the life span which includes physical, and psychological changes. These changes can be difficult for an adolescent to adjust which can lead to different adversities. Sometimes overcoming such adversities can be problematic and leads to cognitive distortions known as biased thinking. Aim: the study aims to measure self-serving cognitive distortions in school drop -out boys. Sample: The sample size is n-40, and the samples were collected from various places in Madurai District, Tamil Nadu using the Purposive sampling method. Materials: informed consent form, socio-demographic variables, and the How I think questionnaire ( Barriga, et al, 2001). Results: From the results, it was found that the scoring for the dimensions Self-centered, blaming others, minimizing/mislabeling, assuming the worst, oppositional defiance, physical aggression, lying, and stealing fall under the clinical category which means there exists externalizing psychopathology. The study shows that the samples tend to engage in deviant behavior like aggression, violent behaviors, stealing, substance use, and criminal behavior

Evaluation of three commercial methods of susceptibility testing for ceftolozane/tazobactam against carbapenem-resistant Pseudomonas aeruginosa

IntroductionCeftolozane/tazobactam has shown excellent activity against Pseudomonas aeruginosa, but this drug is not always included in commercial panels. The aim of the study was to evaluate the performance of 2 gradient strips (BioMérieux and Liofilchem) and a commercial microdilution panel (Sensititre, EURGNCOL panel) using this combination against carbapenem-resistant P. aeruginosa isolates. MethodsThree commercial methods were tested with 41 metallo-beta-lactamase-producing and 59 non-carbapenemase-producing P. aeruginosa isolates. Broth microdilution was used as reference. ResultsAll carbapenemase-producing isolates and only one non-producing isolate were resistant to this antibiotic. Both essential agreement and bias were outside the acceptance intervals since MIC values were higher than reference values for all three methods. The Kappa index indicated poor or weak agreement. Changes in clinical categories were observed in 3 isolates. ConclusionsThe three methods yielded poor agreement with the reference. Despite the differences in MIC values, fewer than 3% involved category changes.

The Impact of Virtual Care in an Emergency Department Observation Unit.

We report the impact of telemedicine virtual rounding in emergency department observation units (EDOU) on the effectiveness, safety, and cost relative to traditional observation care. In this retrospective diff-in-diff study, we compared observation visit outcomes from 2 EDOUs before (pre) and after (post) full adoption of telemedicine rounding tele-observation (tele-obs) with usual care in control EDOU and care in a hospital bed in an integrated health system without tele-obs. Tele-obs physicians did not work at the control hospital. Outcomes were the length of stay, total direct costs, admission status, and adverse events (ICU and death). Difference-in-differences modeling evaluated outcomes with covariates including age, sex, payer type, and clinical classification software diagnostic category. Data from a system data warehouse and a cost accounting database were used. Of the 20,861 EDOU visits, 15,630 (74.9%) were seen in the preperiod and 6,657 (31.9%) in control EDOU. Of 23,055 non-EDOU inpatient visits assigned to observation status (nonobservation unit), 76% were seen in the preperiod. Adjusted length of stay was not significantly different for tele-obs and control EDOUs (26.4 hours versus 23.5 hours), which remained lower than in hospital settings (37.9 hours). The pre-post diff-in-diff was not significant (P=.78). Inpatient admission status was similar for tele-obs and control EDOUs (20.9% versus 22.4.%) and lower than in hospital settings (30.3%). Prepost odds ratios for inpatient admission and adverse outcomes did not change significantly for all study groups. Adjusted costs increased over time for all settings; however, the prepost median cost change was not significantly different between tele-obs EDOUs and control EDOUs ($162.5 versus $235) and was lower than the change for control hospital settings ($783). Median tele-obs EDOU cost over both periods ($1,541) remained significantly lower than hospital costs ($2,413). Using tele-obs to manage observation patients in an ED observation unit was not associated with significant differences in length of stay, admission status, measured adverse events, or total direct cost.

SG-APSIC1208: Association between severity of COVID-19 pneumonia and vaccination status in a tertiary-care teaching hospital in Malaysia

Background and objectives: Since the introduction of the COVID-19 vaccine through the National COVID-19 Immunization Program in Malaysia in February 2021, the number of cases of severe COVID-19 and mortality have progressively decreased. We explored the association between vaccination status, type of vaccine, and the highest COVID-19 clinical category. Methods: Patients were recruited via the electronic medical record (EMR) at University Malaya Medical Centre (UMMC) from July 2021 onward. Included patients were aged ≥18 years old with positive SARS-CoV-2 RT-PCR results from respiratory samples (naso-oropharyngeal swab, saliva, or sputum). Patient demographic data, COVID-19 clinical category, vaccination status, and type of vaccine received were recorded. Results: In total, 1,391 positive SARS-CoV-2 PCR results were reviewed; 1,188 patients (85%) with complete data were analyzed. These patients’ median age was 50 years. The proportions of patients COVID-19 clinical categories were as follows: category 1 (4.04%), category 2 (28.37%), category 3 (10.7%), category 4 (30.6%), and category 5 (2.6%). The mortality rate was 21.5%. As of July 2021, only 16.8% of patients were fully vaccinated, 30.3% were vaccinated, 31.5% unvaccinated, and 21.5% had unknown vaccination status. In total 364 patients with category 4 COVID-19 (4.4%; P &lt; .001) were fully vaccinated and no patients who were fully vaccinated had category 5 COVID-19 (P = .011). Furthermore, 40.8% of patients who died had unknown vaccination status (P &lt; .01); 28.1% of patients who died were unvaccinated (P = .015); 25.3% of patients who died were partially vaccinated (P = .036); and 0.4% of patients who died were fully vaccinated (P &lt; .001). For category 4 and 5 illness and death, there were no significant differences between the type of vaccine received (Pfizer-BioNTechR, Astra ZenecaR and Coronavac/SinovacR) and severe COVID-19. Conclusions: The completion of 2 doses of government-approved COVID-19 vaccination is paramount in preventing severe COVID-19 disease and death. Rapid rollout and equitable distribution of vaccination should be initiated. Vaccine hesitancy should be promptly addressed to ensure vaccination uptake.