Combined Medical Therapy Research Articles

Lemierre syndrome due to Klebsiella pneumoniae: a rare case report with review of literature

Lemierre’s syndrome, a forgotten clinical entity, is characterised by septic thrombophlebitis of the internal jugular vein due to oropharyngeal infection. In the past, it was mainly associated with Fusobacterium necrophorum infections. We present a unique case report of Lemierre’s syndrome due to Klebsiella pneumoniae. Patient reported with progressive swelling involving right side of the neck that eventually increased in size. After confirming the diagnosis through CECT, patient was managed through combined medical and surgical therapy in the form of incision and drainage, targeted antibiotic therapy, glycaemic control and anticoagulation therapy. This case report highlights the association of poor glycaemic control in the pathogenesis and the isolation of Klebsiella pneumoniae as the rare organism of Lemierre’s syndrome.

The 'Prostate Embolisation AS first-line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial' (P-EASY ADVANCE): a randomised controlled trial of prostate embolisation vs medication for BPH.

To compare prostate artery embolisation (PAE) to the combination of tamsulosin and dutasteride therapy as a potential first-line therapy for obstructive benign prostatic hyperplasia (BPH) in treatment-naïve patients in the 'Prostate Embolisation AS first-line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial' (P-EASY ADVANCE). A total of 39 men with enlarged prostates, moderate-severe lower urinary tract symptoms (LUTS) and obstructed/equivocal urodynamic studies (UDS), and who had no prior treatment for BPH, were randomised to receive either combined medical therapy with tamsulosin and dutasteride (medication) or PAE. Follow-up UDS, International Prostate Symptom Score (IPSS), uroflowmetry and ultrasound were performed at short- to medium-term intervals following interventions and compared to baseline. The medication and PAE treatment groups had similar baseline characteristics, including prostate volumes (87.8 and 85.4 mL respectively), maximum urinary flow rate (Qmax; 6.5 and 6.6 mL/s, respectively), IPSS (19.5 and 21, respectively) and obstructed UDS (79% and 74%, respectively). Both interventions improved voiding and bladder outflow obstruction from baseline, with more patients unobstructed after PAE (63%) compared to medication (28%) (P = 0.03). PAE patients had significantly greater reductions in prostate size (P < 0.001), incomplete emptying (P = 0.002), total IPSS (P = 0.032), Qmax (P = 0.006) and quality of life (P = 0.001). Altered ejaculation, erectile dysfunction and nausea were more common in the medication group. Prostate artery embolisation was more effective than combined medical therapy at reducing urinary obstruction, decreasing prostate volume and improving LUTS in patients with BPH who had not previously been treated. This is the first randomised control study to compare PAE and combined medical therapy in exclusively treatment-naïve patients and raises the potential of PAE as an alternative early treatment option for BPH. Further randomised comparative trials are planned to further validate the role of PAE in mitigating obstructive BPH.

PRODUCTION RISK FACTORS AND SPINE INJURIES IN GARMENT WORKERS

Garment workers are exposed to various factors in the work environment, classified as physical and ergonomic. Occupational injuries of the spine develop as a result of the action of harmful production factors, the most important of which are overstrain, vibrations and an unfavorable production microclimate. The aim of the study is to improve the health and prevention of spine injuries among garment workers. The subject of the study is 75 cases of spine injuries in garment workers. The persons were hospitalized in University Hospital - Pleven during the period 2019-2023. Clinical, laboratory, functional, imaging and statistical research methods were used. Treatment with medication and physical factors was carried out. In 93% of the patients, an improvement in clinical syndromes and the performance of activities of daily living was found. 7% of the examined persons required surgical treatment. Conclusions: Spinal injuries are a current health problem among garment workers. Combined medication and physical therapy is an effective and practically applicable therapeutic approach for the investigated disabilities.

The improvement of pain symptoms in patients with burning mouth syndrome through combined laser and medication therapy.

The etiology of Burning Mouth Syndrome (BMS) remains unclear. To explore the differences in the therapeutic efficacy of pain improvement between medication therapy and laser therapy in patients with BMS. 45 BMS patients were randomly divided into three groups: The Combination therapy group (Group A, n= 15), The Medication therapy group (Group B, n= 15), and the Laser therapy group (Group C, n= 15). The pain condition of the patients was evaluated using the Numeric Rating Scale (NRS), and the improvement in pain before and after treatment was compared among the three groups. All three groups (A, B, and C) showed a significant reduction in NRS scores after treatment, with statistically significant differences observed among the different groups. Group A exhibited the most significant improvement, with a statistically significant difference before and after treatment. Laser and medication therapy are effective methods for reducing oral burning pain * symptoms, and their combined use yields more significant therapeutic effects.

Latest pharmaceutical approaches across the spectrum of heart failure.

Despite major advances in prevention and medical therapy, heart failure (HF) remains associatedwith high morbidity and mortality, especially in older and frailer patients. Therefore, acomplete, guideline-based treatment is essential, even in HF patients with conditionstraditionally associated with a problematic initiation and escalation of the medical HFtherapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects areovercome by the overall decrease of the absolute risk. Furthermore, since the latestdata suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i,beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups ofpatients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medicaltherapy across the HF spectrum. In particular, the use of SGLT2i was recentlyextended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preservedtrials. Moreover, the indication for other conservative treatments in HF patients, suchas the intravenous iron supplementation, was accordingly strengthened in the latestguidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.

Effects of combined electroacupuncture and medication therapy on the RhoA/ROCK-2 signaling pathway in the striatal region of rats afflicted by cerebral ischemia

ObjectiveTo investigate the effects of electroacupuncture(EA), gastrodin(Gas), and their combination on the signaling pathways involving Ras homologous gene family member A (RhoA) and Rho-associated frizzled helix protein kinase (ROCK-2) within the striatal region of rats subjected to cerebral ischemia. Additionally, we aim to elucidate the therapeutic effects and potential underlying mechanisms associated with the concurrent application of electroacupuncture and medication in the treatment of cerebral ischemia. MethodsRats were randomly assigned to one of five groups, namely, the sham operation (Sham) group, model group, EA group, Gas group, and the EA combined with Gas group (referred to as the "EA+Gas group"). Each group consisted of ten rats. Following the induction of cerebral ischemia, the EA group and EA+Gas group received EA stimulation at the Baihui(GV20) and Zusanli(ST36) acupoints for 30 min per session, administered once daily for 14 consecutive days. The Gas group and EA+Gas group were intraperitoneally injected with Gas at a dosage of 10 mg/kg, also administered once daily for 14 consecutive days. Nissl staining was employed to observe morphological alterations in the striatal nerve cells of rats in each group. Immunohistochemistry and western blot techniques were employed to evaluate the expression levels of striatal RhoA and ROCK-2 proteins. ResultsIn comparison to the Sham group, the model group exhibited a substantial reduction in the number of striatal nerve cells on the ischemic side, accompanied by notable changes in cell morphology, characterized by reduced cytoplasm, defective and atrophied cytosol, solidified nuclei, loosely arranged cells, and enlarged intercellular spaces. Additionally, there was a notable increase in the positive expression of RhoA and ROCK-2. In contrast, when compared to the model group, the EA, Gas, and EA+Gas groups demonstrated an elevated number of normal nerve cells within the ischemic striatal region, with a significant improvement in cell count and morphology. Furthermore, positive expression levels of RhoA and ROCK-2 were notably reduced in these groups. Compared with the EA group or the GAS group, the number of normal nerve cells in the striatum on the ischemic side of the EA+GAS group was further increased, and the positive expression level of RhoA and ROCK-2 were both further reduced. ConclusionThe protective mechanism underlying the therapeutic efficacy of EA combined with Gas against cerebral ischemic striatal injury in rats may be associated with the inhibition of the activation of the RhoA/ROCK-2 signaling pathway. Importantly, the therapeutic effects observed with the combination of electroacupuncture and medication were superior to those achieved with EA alone or the sole administration of Gas.

Initial antibiotic therapy for postoperative moderate or severe diabetic foot infections: Broad versus narrow spectrum, empirical versus targeted.

To retrospectively evaluate clinical and microbiological outcomes after combined surgical and medical therapy for diabetic foot infections (DFIs), stratifying between the empirical versus the targeted nature, and between an empirical broad versus a narrow-spectrum, antibiotic therapy. We retrospectively assessed the rate of ultimate therapeutic failures for each of three types of initial postoperative antibiotic therapy: adequate empirical therapy; culture-guided therapy; and empirical inadequate therapy with a switch to targeted treatment based on available microbiological results. We included data from 332 patients who underwent 716 DFI episodes of surgical debridement, including partial amputations. Clinical failure occurred in 40 of 194 (20.6%) episodes where adequate empirical therapy was given, in 77 of 291 (26.5%) episodes using culture-guided (and correct) therapy from the start, and in 73 of 231 (31.6%) episodes with switching from empirical inadequate therapy to culture-targeted therapy. Equally, a broad-spectrum antibiotic choice could not alter this failure risk. Group comparisons, Kaplan-Meier curves and Cox regression analyses failed to show either statistical superiority or inferiority of any of the initial antibiotic strategies. In this study, the microbiological adequacy of the initial antibiotic regimen after (surgical) debridement for DFI did not alter therapeutic outcomes. We recommend that clinicians follow the stewardship approach of avoiding antibiotic de-escalation and start with a narrow-spectrum regimen based on the local epidemiology.

De-escalation of Oxygen Therapy and Medication in Patients With Chronic Thromboembolic Pulmonary Hypertension After Balloon Pulmonary Angioplasty.

There is no consensus on the adjustment of home oxygen therapy (HOT) and pulmonary hypertension (PH)-specific medications after balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to examine the status of de-escalation and discontinuation of HOT and PH-specific medications post-BPA and clarify its effect on hemodynamics, biomarkers, and long-term outcomes. From November 2012 to May 2018, 135 consecutive patients with CTEPH who underwent BPA at a single university hospital were enrolled (age, 63.5 ± 13.5 years; World Health Organization functional class (WHO-FC) II, III, IV; 34, 92, 9). The mean pulmonary arterial pressure decreased from 37.7 ± 11.3 to 20.4 ± 5.1 mm Hg 1 year post-BPA (P < 0.01). The proportion of patients who required HOT and combination medical therapy (≥ 2 PH-specific medications) decreased 1 year post-BPA (from 58.5% to 7.4% and from 40.0% to 10.4%, respectively). Baseline factors influencing the requirement of HOT and combination medical therapy post-BPA were almost identical (ie, lower exercise capacity and pulmonary diffusion capacity and worse hemodynamics). Regardless of their discontinuation, the improved hemodynamics, functional capacity (WHO-FC), and biomarkers (B-type natriuretic peptide and high-sensitivity troponin T) were almost maintained, and no adverse 1-year clinical outcomes (all-cause death and PH-related hospitalization) were observed. Most patients with CTEPH discontinued HOT and PH-specific combination medical therapy post-BPA, which was not associated with the deterioration of hemodynamics, functional capacity, or biomarkers. No long-term adverse outcomes were observed.

Pediatric Sinogenic Subdural Empyema: Case Report and Operative Technique

Intracranial complications of sinusitis in the pediatric age are rare but potentially life threatening. They usually occur with nonspecific symptoms such as headache, fever, nausea and vomiting rather than a classic neurological presentation, but they may evolve in few hours, leading to significant morbidity with permanent brain damage and sometimes to death. For this reason, early diagnosis and prompt treatment are essential. Our case demonstrates a sinogenic subdural empyema in an immunocompetent young boy who reached our Emergency Department due to a continuous right-sided headache, unresponsive to pain relievers. The clinical history and the diagnostic process are described: at first, laboratory exams, neurologic and otolaryngological assessment were performed, together with a cranial CT scan showing an inflammatory involvement of the right frontal, ethmoidal and maxillary sinuses. Intravenous antibiotic therapy was initiated. After a few hours the patient showed a sudden worsening of his clinical conditions: he was drowsy with left lower extremity hyposthenia and ipsilateral deep tendon reflexes absence. Considering the patient’s aggravated clinical presentation an emergent MRI with contrast enhancement was conducted, showing left midline shift, a widening of the liquor space on the right frontal and parietal convexity and noticeable meningeal enhancement after contrast injection. After a Neurosurgical and ENT evaluation the patient was taken to the operating room for a combined craniotomy and trans-nasal endoscopic drainage of the empyema. We present the surgical procedure with a pictorial step-by-step description. After the surgical procedure the patient’s condition gradually improved. He regained full neurological function, was accompanied by a rehabilitation team on recovering full force on the left extremities. At discharge the patient had no apparent neurological deficits. Subdural empyema is a rare but severe complication of pediatric sinusitis. Early diagnosis with combined medical and surgical therapies play a key role to reduce morbidity and mortality.

Non-surgical treatment of hidradenitis suppurativa: the role of cryotherapy.

Hidradenitis suppurativa is a chronic and recurrent inflammatory disease with a great impact on a patient's quality of life, due to the painful involvement of very sensitive areas, such as the groin, mammary area, and genitals, with malodourous discharge. Multiple treatment options are available; however, no single treatment is effective for all patients, and usually, a combination of medical therapy with various surgical and physical procedures is provided. Cryotherapy is not a routine technique to treat HS, although usually available in the majority of medical clinics, and is cheaper than laser and surgical treatments. The aim of this study was to evaluate the effectiveness of cryotherapy on persistent HS nodules, to reduce the burden of local disease. Retrospective observational study in all patients treated with liquid nitrogen cryotherapy for persistent nodules of hidradenitis suppurativa in the last 2 years, with at least 6 months of follow-up after the procedure. Disease severity was assessed with Hurley staging and sonographic staging according to SOS-HS (18 MHz probe, Esaote-MyLab™). The results were scored with a 0-3 points scale, as complete remission (3), partial response (2 to 1), or no response (0), after one session of treatment. Local cleansing and antiseptic treatment after the procedure was the same as previously performed in each patient, not to influence recovery. In total, 23 patients were included, with a total of 71 persistent nodules treated with a single cryotherapy session. The treatment has been effective in 63 out of 71 nodules treated (88.7%), and the patients attested that they recommend the treatment, the discomfort during recovery was minimal, and the management was not different from daily routine. Persistence was considered as having a failure rate (11.3% overall) and occurred in 7.5% of the nodules of the axillary region, 18.2% on the groin, and 11.2% for nodules of the gluteal region. Cryotherapy is a simple and effective procedure for the treatment of persistent nodules of HS not responding to medical therapy, and it is a valid alternative to local surgery or laser ablation.

When Surgery Won’t Cut It: Successful Management of Eruptive Squamous Atypia With Combination Medical Therapy

The term eruptive squamous atypia (ESA) is used to describe squamous proliferations that do not present with high-grade histologic features and for which surgical management may exacerbate the condition. Non-surgical management of ESA with radiation, local or systemic chemotherapy, retinoids, or immunotherapy have been reported with variable success. In contrast, combination treatment with retinoids, immunomodulatory or chemotherapeutic agents may result in a more durable response. We report a case of recalcitrant ESA of the lower extremities where complete clinical remission was induced with triple combination medical management with intralesional 5-fluorouracil, field treatment with topical 5-fluorouracil and imiquimod, and oral acitretin. Our case adds to the literature supporting combination medical therapy for challenging cases of ESA.

Various Treatment Modalities in COVID-19 Associated Facial Mucormycosis and the Need for its Surgical Management: A Systematic Review.

Mucormycosis emerged as a wildfire in post-covid-19 infected patients. Most frequently involved sites of mucormycosis are rhino-orbital, rhino-sinusal and rhino-orbito-cerebral. The hallmark sign of mucormycosis is tissue necrosis, which is often a late sign. The fatality rate of mucormycosis is 46% globally. Despite early aggressive combined surgical and medical therapy, the prognosis of mucormycosis is poor. We searched the electronic database of PubMed, web of science, Embase, Scopus and Google Scholar from Jan 2020 until December 2021 using keywords. We retrieved all the granular details of original research articles, case reports/series of patients with rhino-orbito-cerebral mucormycosis (ROCM), and COVID-19 reported worldwide. Subsequently, we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, treatment given and its outcome in people with COVID-19. (Prospero registration-CRD42021256830, June 4, 2021). Overall, 544 rhino-orbito-cerebral mucormycosis patients were included in our review with a history of Covid-19 infection. Out of which 410 patients had diabetes mellitus which has proven to be major contributing immunocompromised disease. Other diseases like hypertension, chronic kidney diseases, hypothyroidism, etc., were also attributed as an immunocompromised disease causing increased number of covid associated mucormycosis cases. We found out that total number of patients alive after taking only antifungal drug treatment were 25 in number, whereas total number of patients alive when antifungal drugs were combined with surgical intervention were 428 which was significantly higher. Our systematic review concluded that surgical debridement should be performed whenever feasible in parallel to antifungal treatment in order to reduce the mortality rate of COVID-19 associated rhino-orbito-cerebral mucormycosis patients.

Voice Hoarseness with Reflux as a Suspected Etiology: Incidence, Evaluation, Treatment, and Symptom Outcomes

PurposeTo describe the clinical evaluation course, treatments, and outcomes of patients with a primary complaint of hoarseness due to suspected laryngopharyngeal reflux (LPR). MethodsA retrospective chart review was conducted of patients with a primary complaint of hoarseness with acid reflux as the suspected cause at a single institution between October 2011 and March 2020 who underwent clinical evaluation, treatment, and follow-up. Data collected included diagnostic procedures and treatments received, subjective symptom outcomes, and final diagnosis as determined by the treating physician. ResultsA total of 134 patients met the inclusion criteria. Videostroboscopy was the most performed procedure (n = 59, 44%) followed by endoscopy (n = 38, 28%) and pH monitoring (n = 28, 21%). Three patients were removed for statistical analysis of treatment differences and outcomes due to variant treatment plans. Most patients received sole medical management (n = 86, 66%), 7 patients received only voice therapy (5%), and 10 patients underwent surgical management (8%). Several patients received combined medical management and voice therapy (n = 21, 16%). Final diagnoses included gastroesophageal reflux disease (GERD) (25%), followed by multifactorial causes (17%) and dysphonia with unclear etiology (13%). Among all patients, 82 (61%) reported symptom improvement. Twenty-eight patients were diagnosed with LPR or LPR with GERD (21%), and 22 reported symptom improvement (79%). There was a statistically significant relationship between a final diagnosis with a reflux component and symptom improvement (p = .038). There was no statistically significant difference between treatment types and symptom outcomes both within the total patient population (p = .051) and patients diagnosed with a reflux condition (p = .572). ConclusionLPR remains a difficult diagnosis to establish and represents a minority of patients with voice complaints. Despite varying evaluation and treatment modalities, most patients with LPR improved during their treatment and evaluation period without a clear association with any specific type of treatment. Further studies should explore diagnostic criteria for LPR, the necessary and efficient clinical evaluation to establish a diagnosis, and possible beneficial treatments.

A rationale for dedicated trials of combination therapy in heart failure.

As heart failure (HF) enters a new era with high level of evidence supporting the use of individual drug therapies, we put forth a rationale for the need for dedicated investigation of the safety, tolerability, and practicalities associated with combination medical therapy. Being able to tailor therapies via combination approaches might offer a way to maximize benefits of available therapies and also facilitate compliance. The evidentiary bar to support multi-drug regimens should be raised in HF for a variety of reasons: (1) Pivotal HF randomized controlled trials (RCTs) to date have not traditionally tested and proven safety and efficacy of drug combinations, (2) HF patients have variable disease trajectories, (3) There is hesitancy by clinicians and patients to using multiple drugs and such trials may build confidence in their use, and (4) HF therapies have overlapping side effects. Similar to combination therapies being developed and tested in adjacent fields of medicine, HF care too would greatly benefit from dedicated investigations of combination treatment approaches. Personalizing precision medicine with combination therapies has the potential to further improve outcomes and facilitate optimal implementation of disease-modifying therapies in HF.

Digital cognitive behavior therapy for insomnia improving sleep quality: a real-world study

BackgroundDigital cognitive behavior therapy for insomnia (dCBT-I) is an effective treatment in alleviating insomnia. This study examined the effect of dCBT-I for improving sleep quality in patients with insomnia complaints from a clinical population in a real-world setting.MethodsThe study included 6,002 patients aged 18 years and above with primary complaints of dissatisfying sleep from a sleep clinic in a psychiatric hospital from November 2016 to April 2021. Patients were diagnosed with insomnia, anxiety disorders, or anxiety comorbid with insomnia or depression according to ICD-10. A mobile app was developed for self-reported assessment and delivering dCBT-I interventions and treatment prescriptions to participants. The primary outcome was change in global sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). At 8- and 12-week follow-up, 509 patients were reassessed. Data were analyzed with non-parametric tests for repeated measures.ResultsPatients treated with dCBT-I monotherapy were younger, with a more frequent family history of insomnia compared to those with medication monotherapy and those with combined dCBT-I and medication therapy. Improvements of sleep quality from baseline to 8-week follow-up were significant in each treatment type. Compared to 8-week follow-up, PSQI scores at 12-week were significantly decreased in the depression group receiving combined therapy and in the anxiety group treated with dCBT-I monotherapy and with combined therapy. A time-by-treatment interaction was detected in anxiety patients indicating differential reduction in PSQI scores over time between different treatment options.ConclusionThe current findings suggest dCBT-I is a practical and effective approach for lessening insomnia symptoms, especially for patients with anxiety symptoms suggesting with a more extended intervention period (i.e., 12 weeks).Trial registrationChinese Clinical Trial Registry (ChiCTR1900022699).

Balloon pulmonary angioplasty: are we there yet? Lessons learned and unanswered questions.

Evidence supporting the use of balloon pulmonary angioplasty #BPA, which has drastically changed management of non-operable chronic thromboembolic pulmonary hypertension #CTEPH, and rationale for a future multimodal approach with combined medical therapy https://bit.ly/3F7ccKD.

A cost-effectiveness analysis of pharmacotherapy versus prostatic urethral lift as initial therapy for patients with moderate benign prostatic hyperplasia

ABSTRACT Aim The objective of this study was to evaluate the cost-effectiveness of an upfront minimally invasive surgical procedure, the prostatic urethral lift (PUL), as an initial treatment for patients with moderate benign prostatic hyperplasia (BPH), against current first-line pharmacotherapy with combination medical therapy. Method A micro-simulation model was developed using TreeAge Pro to compare two treatment strategies – initial treatment with combination medical therapy (alpha-blocker + 5-ARI) versus an upfront prostatic urethral lift procedure. The impact on disease progression, costs, and quality-adjusted life-years (QALYs) was analyzed. A Markov model and probabilistic sensitivity analysis were used to estimate the costs and effects of the different strategies. The cost-effectiveness of the strategies at different willingness-to-pay (WTP) thresholds was then examined. Results Incremental costs (versus no prostatic urethral lift) were S$13,600 (1 year) and S$8,700 (5 years). Incremental QALYs were 0.07 (1 year) and 0.22 (5 years). An upfront PUL procedure was more expensive but also more effective than pharmacotherapy, with an incremental cost per QALY gain of approximately S$39,400. It is a cost-effective treatment option at the willingness-to-pay threshold of S$50,000. Conclusion Prostatic urethral lift is a cost-effective initial treatment option for men with moderate symptoms of benign prostatic hyperplasia.

PO214 / #734 OUTCOMES OF SPINAL CORD STIMULATION FOR REFRACTORY ANGINA: E-POSTER VIEWING

Refractory angina is defined as a chronic condition characterized by the presence of angina due to coronary insufficiency which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. Prevalence in the United States is estimated to be between 300,000-900,000. Spinal cord stimulation for refractory angina pain relief was first described in 1987 but is still not widely used in North America. We report our experience with this treatment.

A mixed-methods study to identify key priorities around improving team-based care coordination for patients receiving combination IV and oral systemic anti-cancer therapy.

52 Background: When combination medical therapy incorporates both IV and oral anti-cancer agents, patients may experience compound side effects and face challenges with treatment adherence. To assess how community cancer programs may improve care coordination for patients receiving combination IV/oral systemic therapy, the Association of Community Cancer Centers (ACCC) conducted a mixed-methods study that involved healthcare professionals (HCPs), patients and caregivers. Methods: The study followed a sequential quantitative-qualitative design to answer questions around the barriers or challenges associated with combination IV/oral systemic therapy. The quantitative phase included an online survey of HCPs (by ACCC) and a survey of patients and caregivers (by Edge Research, in collaboration with several patient advocacy organizations). In the quantitative phase, the survey results were contextualized through two HCP focus groups and individual HCP interviews. Results: Comparing and contrasting the patient survey (n = 113) and HCP survey (n = 157) results revealed insights around the following themes: Top Challenges: Patients felt their top challenges were side effects (57.5%); inconvenience going to medical appointments (37.2%); and financial burden (36.3%). HCPs perceived top challenges as cost of care to the patient (24.0%); coordination and delivery of oral agents (22.1%); and health insurance coverage (21.9%). In focus groups, HCPs explained how they were investing significant staffing resources to prevent and mitigate financial toxicity, especially for patients receiving oral therapies. Methods of Communication: 35.4% of patients “highly preferred” using email to communicate with HCPs about their combination regimens. However, HCPs felt that email was one of the least effective methods of communicating with patients. In focus groups, HCPs agreed that email is convenient when communicating about non-urgent matters. However, they were concerned that some patients may use email to communicate about urgent issues. Treatment-related AEs: When patients experienced treatment-related AEs, 30.1% said their clinicians tried a dose modification or hold. HCPs had mixed perceptions regarding the effectiveness of dose holidays. Those who felt this was highly effective included: advanced practice providers (42.9%), nurses (28.1%); oncologists (16.7%); and pharmacists (16.7%). Conclusions: This study identifies opportunities to improve care coordination for patients receiving combination IV/oral systemic anti-cancer regimens. These findings may inform the creation and dissemination of effective practices and quality improvement projects. These results may also help cancer programs tailor resources and incorporate proactive steps to address some of the key challenges patients may face.

The Multidisciplinary Management of Perianal Fistulas in Crohn's Disease: A Systematic Review.

Perianal fistulas in Crohn's disease (CD) are often recurring and challenging to treat. This systematic review aimed to evaluate the medical, surgical, and combination treatment options and provide an overview of their efficacy. We performed this systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Our group searched PubMed, Medline, PubMed Central, Google Scholar, and ScienceDirect for articles within the last ten years using different terms and criteria mentioned in detail in the search strategy and eligibility criteria sections. Initially, 739 records were retrieved, out of which we excluded 731 records for various reasons, such as irrelevant titles and abstracts and low scores on quality assessment tools. The evidence for combination (surgical and medical) therapy is superior to that for medical and surgical treatments individually. In contrast, the studies on medical and surgical treatments individually reported varied evidence and efficacy for their respective options.