Clinical Practice Research Articles

Progress of systematic psychological interventions in elderly patients with femoral fractures: A comprehensive review

This review aims to gain a deeper understanding of the psychological state of elderly patients with femoral fractures and provide more theoretical and practical support for clinical treatment and care. Through a literature analysis, we found that elderly patients with femoral fractures face various psychological issues such as anxiety, depression, sleep disorders, and social isolation. The application of systematic nursing interventions in clinical practice, including cognitive-behavioral therapy, mindfulness therapy, family therapy, art therapy, interpersonal therapy, emotion-focused therapy, and relaxation training, has yielded significant results. Systematic psychological interventions can improve the psychological state and quality of life of elderly patients with femoral fractures. Therefore, promoting the application and practice of systematic psychological interventions in the clinical care of elderly patients with fractures will provide more effective psychological services to a wider group of patients with fractures in the future.

Expert consensus on diagnosis and treatment of spontaneous intracranial hypotension(2024)

Spontaneous intracranial hypotension is a disease characterized by orthostatic headache caused by spinal cerebrospinal fluid leakage. Patients have to remain bedridden, which significantly affects their quality of life. In severe cases, complications such as subdural hematomas may occur. Clinical practice reveals a high rate of misdiagnosis and insufficient implementation of diagnostic and treatment measures. To improve clinical physicians' understanding of spontaneous intracranial hypotension and to standardize the diagnosis and treatment, the Neurologist Branch of the Chinese Medical Doctor Association and the Headache and Sensory Disorders Committee of the Chinese Research Hospital Association organized experts to develop a total of 30 recommendations on the clinical identification, examination processes, diagnostic criteria, treatment, and follow-up of spontaneous intracranial hypotension based on domestic and international clinical practices and recent literature evidence after extensive discussions.

Association between intercellular adhesion molecule-1 to depression and blood-brain barrier penetration in cerebellar vascular disease

BACKGROUND Cerebral small vessel disease (CSVD) is a prevalent cerebrovascular disease in clinical practice that is often associated with macrovascular disease. A clear understanding of the underlying causes of CSVD remains elusive. AIM To explore the association between intercellular adhesion molecule-1 (ICAM-1) and blood-brain barrier (BBB) penetration in CSVD. METHODS This study included patients admitted to Fuyang People’s Hospital and Fuyang Community (Anhui, China) between December 2021 and March 2022. The study population comprised 142 patients, including 80 in the CSVD group and 62 in the control group. Depression was present in 53 out of 80 patients with CSVD. Multisequence magnetic resonance imaging (MRI) and dynamic contrast-enhanced MRI were applied in patients to determine the brain volume, cortical thickness, and cortical area of each brain region. Moreover, neuropsychological tests including the Hamilton depression scale, mini-mental state examination, and Montreal cognitive assessment basic scores were performed. RESULTS The multivariable analysis showed that age [P = 0.011; odds ratio (OR) = 0.930, 95% confidence interval (CI): 0.880-0.983] and ICAM-1 levels (P = 0.023; OR = 1.007, 95%CI: 1.001-1.013) were associated with CSVD. Two regions of interest (ROIs; ROI3 and ROI4) in the white matter showed significant (both P < 0.001; 95%CI: 0.419-0.837 and 0.366-0.878) differences between the two groups, whereas only ROI1 in the gray matter showed significant difference (P = 0.046; 95%CI: 0.007-0.680) between the two groups. ICAM-1 was significantly correlated (all P < 0.05) with cortical thickness in multiple brain regions in the CSVD group. CONCLUSION This study revealed that ICAM-1 levels were independently associated with CSVD. ICAM-1 may be associated with cortical thickness in the brain, predominantly in the white matter, and a significant increase in BBB permeability, proposing the involvement of ICAM-1 in BBB destruction.

Exploring the views and experiences of professionals using PBS and emotional development assessment for individuals with an intellectual disability: a case study

Purpose The purpose of this paper was to investigate the utility of including emotional development (ED) assessment into a Positive Behaviour Support (PBS) approach in clinical practice with a patient with an intellectual disability (ID) and challenging behaviour. Design/methodology/approach Interviews were conducted with four staff involved in the care of the patient. The interviews were transcribed and analysed using thematic analysis and three reflective sessions were completed with the lead psychologist of the service. Findings Using thematic analysis, four themes were identified: getting everyone around the table: a collaborative approach, complementary approaches: a feedback loop, helping to make sense of the individual and ensuring a voice for service users. Research limitations/implications This was a case study selected from routine clinical practice and as such generalisability may be limited. This case study was designed as an exploration of the potential benefits of incorporating ED alongside PBS for ID and provides a basis for future research. Practical implications This study highlights the value of integration of ED assessment for people with ID and challenging behaviour within a healthcare team. Originality/value There is a lack of literature relating to ED and challenging behaviour within an ID population, particularly exploring ED within a PBS framework. This study provides a starting point for exploring how practice can be improved through incorporating ED assessment for individuals with ID and challenging behaviour.

Correction to: 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Correction to: 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Unraveling the complexities of adolescent depression: A call for action

The adolescent years are a period of profound change, both physically and psychologically. For many, these years are marked by excitement and exploration, but for others, they are fraught with challenges that can lead to significant mental health issues. Depression, in particular, has become an increasingly prevalent concern among adolescents worldwide, and its multifaceted etiology requires a comprehensive approach to understanding and intervention. A recent study on the relationships among negative life events, dysfunctional attitudes, social support, and depressive symptoms in Chinese adolescents offers valuable insights into the complex interplay between various factors contributing to adolescent depression. The authors explore a moderated mediation model to better understand how these factors interact with and contribute to the onset of depression. This article aims to delve into the key findings of the study, highlight its implications for clinical practice, and encourage further research in this critical area.

Diagnostic and prognostic value of time to positivity in blood cultures. An opinion paper

Time to positivity (TTP) refers to the duration required for a microbiological culture test to indicate a positive result, marking the onset of detectable bacterial or fungal growth in the sample. Numerous variables, including patient characteristics, infection source, former antimicrobial therapy, blood sample volume, and sample transportation time can influence the value of TTP. Several studies have been conducted on bloodstream infections, whereas studies on the clinical significance of yeast TTP are quite limited in the literature. Furthermore, many studies are retrospective and have a small sample size. In this opinion paper, we have formulated some questions and attempted to provide answers based on the available literature and our perspective. The objective of this opinion paper is to summarise current knowledge based on the literature, aiming to offer a critical perspective, particularly on aspects with weaker evidence, which could guide future studies in this area. We believe that TTP of blood cultures appears to exhibit considerable potential and may prove to be a valuable tool in clinical practice for estimating patient mortality risk and guiding antimicrobial therapy choices. Topics discussed include the diagnostic and prognostic role of TTP in Gram-positive and Gram-negative bacteremias and in candidemias, and the significance of differential time to positivity (DTTP). In summary, our opinion is that, based on the available literature, it is not possible to determine whether TTP provides prognostic information, particularly concerning candidemia. Therefore, clinical decisions cannot be systematically based on this parameter.

Integration of palliative rehabilitation in cancer care: a multinational mixed method study

Abstract Background Incurable cancer is a major contributor to societal suffering and disability, and palliative rehabilitation is recommended to be integrated within and between cancer services at all healthcare levels. However, little knowledge exists on how integration of palliative rehabilitation in cancer is understood and achieved in clinical practice. INSPIRE (Integrated short-term palliative rehabilitation to improve quality of life and equitable care access in incurable cancer) is a large European-funded project that aims to promote quality of life through a novel rehabilitation model for people disabled by advanced cancer. Aim To compare the existing integration of palliative rehabilitation in cancer within official documents and in clinical practice across five European countries including United Kingdom, France, Denmark, Norway, and Italy. Methods Mixed methods study with a concurrent research design, comprising a document analysis (N = 23), stakeholder interviews (N = 22), and an online survey (N = 225). Data from each sub-study were analysed separately before results were merged. Results There was limited integration of palliative rehabilitation in cancer in official documents and in clinical practice, though some indicators of integration, including participation in multidisciplinary teams and adherence to standardised pathways, were identified in the survey. Notably, integration of palliative rehabilitation in cancer in clinical practice was observed within limited organisations in secondary healthcare systems, without widespread adoption. Although palliative rehabilitation in cancer as a concept was sparingly used by stakeholders, they recognised the need for a comprehensive approach including multidisciplinary teams that aligns with the individual patient’s needs and goals. Moreover, the ambiguous distinction between the terms ‘palliative rehabilitation’ and ‘palliative care’, insufficient funding, lack of well-defined care pathways and competence gaps among healthcare professionals represented barriers to integration of palliative rehabilitation in cancer into clinical practice. Conclusion Integration of palliative rehabilitation in cancer was limited in the five EU partnership countries investigated. Clarifying the concept of palliative rehabilitation, including adoption of the concept into official documents and delineating it from palliative care, is essential for more successful integration. This can possibly be achieved by addressing the barriers identified and fostering close collaboration across disciplines.

Technical feasibility of automated blur detection in digital mammography using convolutional neural network

Abstract Background The presence of a blurred area, depending on its localization, in a mammogram can limit diagnostic accuracy. The goal of this study was to develop a model for automatic detection of blur in diagnostically relevant locations in digital mammography. Methods A retrospective dataset consisting of 152 examinations acquired with mammography machines from three different vendors was utilized. The blurred areas were contoured by expert breast radiologists. Normalized Wiener spectra (nWS) were extracted in a sliding window manner from each mammogram. These spectra served as input for a convolutional neural network (CNN) generating the probability of the spectra originating from a blurred region. The resulting blur probability mask, upon thresholding, facilitated the classification of a mammogram as either blurred or sharp. Ground truth for the test set was defined by the consensus of two radiologists. Results A significant correlation between the view (p < 0.001), as well as between the laterality and the presence of blur (p = 0.004) was identified. The developed model AUROC of 0.808 (95% confidence interval 0.794–0.821) aligned with the consensus in 78% (67–83%) of mammograms classified as blurred. For mammograms classified by consensus as sharp, the model achieved agreement in 75% (67–83%) of them. Conclusion A model for blur detection was developed and assessed. The results indicate that a robust approach to blur detection, based on feature extraction in frequency space, tailored to radiologist expertise regarding clinical relevance, could eliminate the subjectivity associated with the visual assessment. Relevance statement This blur detection model, if implemented in clinical practice, could provide instantaneous feedback to technicians, allowing for prompt mammogram retakes and ensuring that only high-quality mammograms are sent for screening and diagnostic tasks. Key Points Blurring in mammography limits radiologist interpretation and diagnostic accuracy. This objective blur detection tool ensures image quality, and reduces retakes and unnecessary exposures. Wiener spectrum analysis and CNN enabled automated blur detection in mammography. Graphical Abstract

Study the role of xanthine oxidase inhibitor, allopurinol in experimentally induced steatohepatitis

Nonalcoholic steatohepatitis (NASH) is a chronic liver disease which can lead to cirrhosis and hepatic failure. It is observed in patients with both type 1 and type 2 diabetes mellitus (T1DM, T2DM). Allopurinol, a xanthine oxidase inhibitor that is widely used in clinical practice, has been demonstrated to reduce hepatic oxidative stress and attenuate acute liver injury which may be through activation of antioxidant pathways. This work aimed at investigating the role of Allopurinol (ALP) in attenuation of type 1 diabetes associated with Nonalcoholic fatty liver disease (NAFLD) and exploring the possible molecular mechanism by which ALP attenuates NASH in type 1 diabetes. Forty-five adult male albino rats were included in the study. They were randomly allocated to 3 equal groups: group I (control), Group II (diabetic animals), Group III (diabetic animals with allopurinol treatment). At the end of this experimental study measurements of serum glucose, ALT, AST, cholesterol, triglyceride, serum levels of uric acid, malondialdehyde (MDA), serum superoxide dismutase (SOD) were done. Histological analysis of liver tissue to diagnose steatohepatitis and gene expression of nuclear factor-erythroid-2- related factor-2 (Nrf2) & TNFα were done. Diabetic rates treated with allopurinol (group III) showed decrease in serum levels of ALT, AST, cholesterol, uric acid and MDA compared to diabetic rat group. As regards TNF, gene expression was significantly decreased in group III compared to group II. This study also demonstrated that Nrf2α was significantly increased in group III compared to group II. Allopurinol also, ameliorated the histopathological changes observed in group II. In conclusion, allopurinol treatment increases the Nrf2 gene expression in the liver of STZ-induced diabetic rats and ameliorates steatohepatitis through modulation of TNF-α gene expression. Allopurinol could be a candidate for prevention or treatment of NAFLD.

Using the PROMOTE Screener to Identify Psychosocial Risk Factors for Prenatal Substance Use

Introduction There is an urgent need to improve the identification of psychosocial vulnerabilities in clinical practice (eg, stress, unstable living conditions) and examine their contribution to prenatal substance use, especially for legal substances such as alcohol, tobacco, and recently, cannabis. Methods We conducted a retrospective chart review of 1842 patients who completed the PROMOTE screening instrument during their first prenatal visit to outpatient clinics of a New York State health system in 6/2019–11/2020. The PROMOTE includes 18 core items to assess psychosocial vulnerabilities including the NIDA Quick Screen assessing past year substance use. Outcomes were tobacco, cannabis, and alcohol use during pregnancy based on electronic medical record abstraction including clinical notes, self-report, or urine toxicology. Results A total of 188 (10.2%) patients used at least 1 substance prenatally, including 132 (7.2%) tobacco, 50 (2.7%) cannabis, and 45 (2.4%) alcohol. Two of the NIDA Quick Screen items (past year tobacco use and past year illegal drug use) were associated in the bivariate analysis with greater use risk of all 3 substances. Additional risk factors uniquely associated with specific prenatal substance use variables include low education predicting tobacco use (adjusted odds ratio [AOR] = 2.74, 95% confidence interval [CI] = 1.43–5.23), being unpartnered predicting cannabis use (AOR = 3.37, 95% CI = 1.21–9.39), and major life events predicting alcohol use (AOR = 3.25, 95% CI = 1.439–7.38). Conclusions Utilizing brief psychosocial self-screening instruments such as the PROMOTE can help identify and refer at-risk patients to appropriate care. Particular attention should be paid to life context including partner support, emotional health, stress, and past year substance use.

Evolution of dosimetric parameters through PRRT and potential impact on clinical practice: data from the prospective phase II LUMEN study

Evolution of dosimetric parameters through PRRT and potential impact on clinical practice: data from the prospective phase II LUMEN study

MS brain health quality standards: a survey on the reality in clinical practice in Germany

Abstract Background The quality of treatment is especially critical in the context of complex and chronic diseases such as multiple sclerosis (MS). The Brain Health Initiative, an independent international consortium of neurologists, reached a consensus on time-based quality standards prioritizing brain health-focused care for people with MS. Objectives To gain deeper insights into the transferability of these quality standards to a specific area, we conducted a survey among MS experts across various MS centers in Germany. Methods Participants were asked about time frames considered high standards and those currently being implemented in daily routine based on their experience. Results The results reveal a large gap between ideal conceptions and their adaptation in the real world, mostly due to a lack of resources. Conclusions Nevertheless, these guidelines and recommendations can be aspired to as ideals. Consensual and inclusive clinical pathways complemented by measurable quality indicators are needed to improve care and approach these ideals. Neither exists in the current management of MS.

Dupilumab Improves Patient-Reported Outcomes as Early as 1 Month among Adults with Prurigo Nodularis in Clinical Practice: Initial Results from the RELIEVE-PN Study

Introduction: Dupilumab is a monoclonal antibody approved in the United States (US) for patients aged ≥18 years with prurigo nodularis (PN). This analysis evaluated the real-world initial impact of dupilumab therapy on symptoms and treatment satisfaction among US adults with PN. Methods: RELIEVE-PN is an ongoing longitudinal prospective patient survey study assessing the real-world effectiveness of dupilumab in the treatment of adult patients with PN. Adults with PN were recruited through the US dupilumab patient support program and surveyed before (baseline) and 1 month after dupilumab initiation. PN symptoms over the last 7 days were assessed using the worst-itch numeric rating scale (WI-NRS), average-itch NRS, skin pain NRS, and skin burning or stinging/tingling NRS (range 0 [no symptom] to 10 [most severe symptom] for all). Treatment satisfaction with current therapy was evaluated using a 7-point Likert scale from “extremely satisfied” to “extremely dissatisfied”. Results: Of 84 patients (mean age, 57.5 years; 79.8% female; 83.3% White) completing the baseline survey and initiating dupilumab, 62 (mean age, 56.4 years; 77.4% female; 83.9% White) completed the Month 1 survey. At baseline, mean (SD) WI-NRS, average itch NRS, skin pain NRS, and skin burning/tingling NRS were 7.70 (2.24), 6.45 (2.25), 5.06 (2.87), and 5.51 (3.02), respectively. By month 1, mean (SD) WI-NRS, average itch NRS, skin pain NRS, and skin burning or stinging/tingling NRS improved to 5.56 (2.89), 4.35 (2.23), 3.40 (2.46), and 3.76 (2.60), respectively (p<0.001 for all). Additionally, significantly more patients reported they were satisfied with current PN treatment(s) at 1 month after dupilumab treatment initiation vs prior to starting dupilumab (77.4% vs 13.1%; p<0.001). Conclusion: Early results from the RELIEVE-PN study demonstrate improvement in symptoms and patient satisfaction with therapy as early as 1-month from treatment initiation of dupilumab. Further comparative research is needed to confirm these findings. Acknowledgment: Research was funded by Sanofi and Regeneron Pharmaceuticals Inc.

Comparison of Effects between Nasal Bi-Level Positive Airway Pressure and Nasal Synchronized Intermittent Mandatory Ventilation in Neonatal Respiratory Distress Syndrome

Aims/Background Neonatal respiratory distress syndrome (NRDS) is characterized by progressive aggravation and rapid progression of respiratory distress, with a high incidence rate among premature infants. If left untreated, NRDS results in a poor prognosis. In recent years, various respiratory support modalities have received extensive attention in clinical practice. The therapeutic effect of different respiratory support modes on NRDS has gradually become the focus of clinical research. The aim of this study was to explore the therapeutic effects of nasal bi-level positive airway pressure (nBiPAP) and nasal synchronized intermittent mandatory ventilation (nSIMV) on NRDS. Methods This study retrospectively analyzed the clinical data of 157 newborns with NRDS in the Mudanjiang Medical University Affiliated Second Hospital from January 2021 to December 2023, finally including 153 cases after excluding 4 cases with missing clinical data. According to the non-invasive ventilation method, these newborns were categorized into a nBiPAP group (receiving nBiPAP treatment, n = 77) and an nSIMV group (receiving nSIMV treatment, n = 76). The blood gas indices, using time of ventilator, hospitalization time, therapeutic effects, and incidence of complications were compared between the two groups. Results The PaCO2, PaO2, and pH levels in the nBiPAP group were basically consistent with those in the nSIMV group before and after treatment (p > 0.05). The use time of ventilator, hospitalization time, and therapeutic effects in the nBiPAP group were similar to those in the nSIMV group (p > 0.05). Additionally, both groups demonstrated no significant difference in the incidence of complications such as intraventricular hemorrhage, apnea, necrotizing enterocolitis, and feeding intolerance (p > 0.05). The incidence rates of ventilator-associated lung injury and neonatal bronchopulmonary dysplasia in the nBiPAP group were lower than those in the nSIMV group, with a significant difference (p < 0.05). Conclusion Both nBiPAP and nSIMV have shown good effects in treating NRDS, with nBiPAP showing a significant advantage in reducing the incidence rates of complications such as ventilator-associated lung injury and neonatal bronchopulmonary dysplasia.

Manualised Attachment-Based Interventions for Improving Caregiver-Infant Relationships: A Two-Stage Systematic Review

Abstract As attachment-based interventions can improve caregiver-infant relationships and their subsequent psychological outcomes, the identification of relevant and effective interventions can facilitate their implementation into clinical practice. This systematic review aimed to a) provide an overview of manualised attachment-based interventions, without video-feedback as the main component, for caregivers and infants from conception to two years, and b) determine which of these interventions were effective in demonstrating improvements in caregiver-infant relational outcomes. To identify eligible interventions and their empirical evidence base, two search stages were conducted for 1) relevant interventions and 2) studies of interventions identified in the first stage that focussed on caregiver-infant relational outcomes. All studies included in Stage 2 were quality assessed and findings analysed. Twenty-six interventions were eligible for inclusion at Stage 1 but studies reporting on relational outcomes were identified for 16 interventions only. Forty studies reporting on those 16 interventions met inclusion criteria and were synthesised at Stage 2. Most studies were of good quality. Observer-rated measures were used in 90% of studies. There was evidence for these interventions in relation to improving caregiver-infant relational outcomes: 80% of studies reported a statistically significant positive change in a relational outcome for the intervention compared to pre-intervention or control group. The most promising evidence was identified for Attachment and Biobehavioral Catch-Up (ABC), Minding the Baby (MTB) and Circle of Security (COS). This systematic review offers guidance to healthcare professionals, commissioners and policymakers within perinatal sectors in relation to the training, delivery and implementation of evidenced manualised attachment-based interventions.

Results of a Phase 2 Multicenter Study to Evaluate the Efficacy of VP-315, an Investigational Therapy for Basal Cell Carcinoma

Introduction: VP-315 is an intratumorally injected, chemotherapeutic oncolytic peptide in development as a non-surgical immunotherapeutic agent to be utilized as first line therapy in a primary or neoadjuvant setting for patients with basal cell carcinoma (BCC). Objective: In Part 2 of this study, the secondary objective was to evaluate the effect of various dosing regimens on the antitumor efficacy of VP-315 in a larger population of adult subjects with biopsy proven BCC. Methods: Eighty-two (82) subjects with up to 2 target BCC tumors (total 91 tumors) were treated intratumorally with VP-315 for up to 2 weeks. Cohort 3 was not enrolled based on results from Cohorts 1-2. Each 7-day treatment week was comprised of 2 or 3 consecutive treatment days followed by a no-treatment period of at least 4 days. Dosing scheme: Cohort 1: (n=6) Tumor injected 3 days consecutively (3X/week 4 mg loading dose Day 1 followed by 8 mg dose). Cohort 2: (n=3) Tumor injected 3 days consecutively (3X/week 8 mg dose). Cohort 4: (n=36) Each tumor was injected 2 days consecutively (2X/week 8 mg split dose*). Cohort 5: (n=37) Each tumor was injected 3 days consecutively (3X/week 8 mg split dose*). * Dose split into 2 injections, 30% injected initially; 70% injected 15-30 minutes later. Efficacy endpoints included histological clearance of target tumor(s) and estimate of remaining tumor volume (tumor size reduction) at excision (Week 12-13). Results: Eighty-two (82) subjects (n=92 lesions) completed treatment for BCC with VP-315 in Part 2. Approximately 51% of tumors achieved complete histologic clearance. All tumors treated had a reduction in tumor size. Overall tumor size reduction was 86%. Tumor size reduction in subjects who still had any residual tumor was 71%. Conclusion: Complete histological clearance in a majority of VP-315 treated tumors could eliminate the need for surgical intervention in those patients in clinical practice. In subjects with residual tumor burden, the substantial reduction in tumor size after VP-315 treatment would markedly reduce the surgical incision area and the amount of potential post-surgical scarring. Based on the favorable results, further research using VP-315 as a potential non-surgical immunotherapy for BCC as a first line therapy in a primary or neoadjuvant setting is warranted.

Evaluation of the Impact of Monitoring for Tumor Lysis During Venetoclax Ramp-Up in Chronic Lymphocytic Leukemia in Routine Clinical Practice

PURPOSE Venetoclax has made a significant impact in the treatment of chronic lymphocytic leukemia (CLL) due to its ability to induce deep and durable remissions with a finite duration of oral therapy. However, it can lead to tumor lysis syndrome (TLS) which is mitigated with dose escalation strategies. Patients who initiate venetoclax need to follow rigorous, and potentially burdensome, TLS monitoring during dose ramp-up. The frequency with which this rigorous monitoring leads to therapeutic interventions in clinical practice has not been well described. We conducted a study to assess the incidence of TLS and interventions needed after initiation of venetoclax in patients with CLL. METHODS Adult patients with CLL who started treatment with venetoclax between July 2017 and March 2021 at Levine Cancer Institute were included in this study. Adherence to the venetoclax package insert (PI) for tumor lysis monitoring, incidence of laboratory as well as clinical TLS, and interventions resulting from the monitoring of TLS were collected. RESULTS We report outcomes on 73 consecutive patients with CLL who initiated venetoclax. The majority of patients had low (49%) or medium (44%) tumor burden. During venetoclax ramp-up, 66% of patients adhered strictly to TLS monitoring as per the venetoclax PI. One patient developed laboratory TLS, and no patients developed clinical TLS. Six patients received unplanned interventions to treat TLS; all had medium or high tumor burden. There were no unplanned interventions in patients with low tumor burden. CONCLUSION In patients with low and medium tumor burden CLL who start venetoclax, the incidence of TLS is very low, and interventions are uncommonly needed.

Incremental clinical value of intraplaque neovascularization in predicting recurrent ischemic stroke

AbstractObjectiveCarotid intraplaque neovascularization (IPN) detected by contrast‐enhanced ultrasound (CEUS) is a risk factor for recurrent ischemic stroke. However, it is still unclear whether IPN can be used to accurately identify patients with recurrent ischemic stroke in clinical practice. Herein, we investigated the clinical predictive value of IPN for recurrent ischemic stroke in a real‐world setting.MethodsWe enrolled 200 patients with ischemic stroke and atherosclerotic carotid stenosis who were followed up for 2 years. The endpoint was recurrent ischemic stroke. Cox regression and subgroup analyses were employed to assess whether treatment affected the relationship between IPN and recurrent ischemic stroke. The net classification index (NRI) and integrated discriminant improvement index (IDI) were used to validate the additional clinical value of IPN in identifying recurrent ischemic stroke.ResultsDuring the 2‐year follow‐up, 36 patients experienced recurrent ischemic stroke. Cox regression analyses showed that IPN (grade 2), hypoechoic plaque, high homocysteine levels, and smoking were independent risk factors for recurrent ischemic stroke. Additional IPN evaluation may increase the NRI (0.512; 95% confidence interval [CI]: 0.083–0.624) and IDI (0.151; 95% CI: 0.010–0.213) for identifying high‐risk patients with recurrent ischemic stroke. In addition, in the subgroup undergoing revascularization, the proportion of IPN (grade 2) was significantly higher in patients with recurrent ischemic stroke than in patients with nonrecurrent ischemic stroke (p = 0.001).InterpretationIn clinical settings, IPN, assessed by CEUS, may provide additional clinical value for predicting recurrent ischemic stroke, helping to identify patients with ischemic stroke who require close follow‐up.

Laboratory findings predictive of critical illness in hospitalized COVID-19 patients in Tunisia

Background COVID-19 disease has spread rapidly worldwide, causing high mortality. Accessible biomarkers capable of early identification of patients at risk of severe form are needed in clinical practice. The aim of the study was to determine the biological markers that predict a critical condition. Methods Retrospective study including patients with confirmed COVID-19 hospitalized between September 2020 and June 2021. The primary endpoint was progression to critical status within 7 days from admission. We defined two groups: Critical group: Patients who developed a critical condition or died or transferred to the ICU before or at 7th day. Non-critical group: Patients who remained in non-critical respiratory status until 7th day or discharged before or at 7th day. Results Our study included 456 patients, with a sex ratio of 1.32 and an average age of 62 years. At the 7th day of hospitalization, 115 (25.2%) patients were in the critical group and 341 (74.8%) patients were in the non-critical group. The univariate logistic regression indicated that laboratory findings between non-critical and critical groups showed that C-reactive protein (CRP) (p=0.047), D-Dimer (p=0.011), creatinine (0.026), creatine kinase (p=0.039), lactate dehydrogenase (p=0.04), and troponin (p=0.001) were all higher among patients in critical group. However, lymphocyte (p<0.001) and platelet (p<0.001) counts were significantly lower among the critical group. Multivariate logistic regression model, identified four independent risk factors: lymphopenia (OR=2.771, 95%CI=1.482-5.181, p=0.001), Neutrophil to Lymphocyte Ratio (NLR) (OR=2.286, 95%CI=1.461-3.578, p<0.001), thrombocytopenia (OR=1.944, 95%CI=1.092-3.459, p=0.024), and CRP>71.5 (OR=1.598, 95% CI=1.042-2.45, p=0.032) were associated to critical group. Conclusions Our results show the predictive value of lymphopenia, thrombocytopenia, high NLR and CRP levels to evaluate the prognosis of COVID-19 pneumonia. A prognostic score could be proposed for guiding clinical care and improving patient outcomes.