Complete Adherence Research Articles

Literature Review: Effectiveness of Digital Self-Reporting on Tuberculosis Treatment Completion Adherence

Tuberculosis (TB) is a directly infectious disease caused by Mycobacterium tuberculosis. Medication adherence important to recovery TB patients. Failure of TB medication can caused spreading infection, MDR-TB (Multi Drug Resistant) to mortality. Digital based for self-reporting can help to improve medication adherence. Purpose: To determine the effectiveness of digital based self reporting that can encourage medication adherence in TB medication. Methods: Scooping review of international article with the keywords “digital health”, “tuberculosis”, “medical adherence” through the online database Scopus and Clinical Key with inclusion criteria : digital health for TB patient, SMS, VDOT, and 99DOTS use in TB medication, and article published between 2017-2022. Study did in October – December 2022 to analyze assosiated based self reporting that can encourage medication adherence in TB medication The result, a Analysis related to intervention using 99DOTS and SMS showing increased significant and unsignificant. VDOT shows increasing in TB adherence medication so that it can be recommended for apply.: Digital based self reporting that can encourage medication adherence in TB medication.

Efficacy and Feasibility of Presurgical Exercise in Bladder Cancer Patients Scheduled for Open Radical Cystectomy.

This study aimed to examine the feasibility and potential efficacy of presurgical exercise in patients with bladder cancer scheduled for open radical cystectomy with follow-up postsurgery. Prospective single-group design with assessments at baseline, presurgery, and 3 months postsurgery was used in this study. Multimodal supervised resistance and aerobic exercise was undertaken 2-3 d·wk -1 at moderate intensity for a median of 3.5 wk (interquartile range [IQR] = 1.3-5.6). Feasibility was assessed by recruitment and completion rates, patient safety, program tolerance, adherence, and compliance. Lean and fat mass were assessed by dual-energy x-ray absorptiometry, physical function by a battery of tests (chest press and leg press strength, 6-min walk test [6MWT], timed up-and-go, repeated chair rise), and quality of life (QoL), psychological distress, and body image by questionnaire. Hospital length of stay (LOS) and complications were assessed by medical records. Thirty-seven patients were referred with 20 recruited (67.3 ± 12.2 yr) and a presurgery intervention completion rate of 80% (16 of 20). The individual median program adherence was 100.0% (IQR = 89.4-100.0) with compliance of 100.0% (IQR = 90.5-100.0) for resistance exercise and 81.8% (IQR = 55.0-99.5) for aerobic exercise. There were no exercise-related adverse events. Body composition did not change presurgery; however, there were improvements ( P < 0.05) in leg press strength (16%), 6MWT distance (8%), timed up-and-go (12%), chair rise (10%), and multiple QoL domains including mental health. Median LOS was 8.0 d (IQR = 7.0, 15.0). Postsurgery, there were declines in components of QoL and apparent body image dissatisfaction. A preradical cystectomy exercise program is feasible, safe, and well tolerated with improvements in physical function and QoL. Supervised multimodal exercise in bladder cancer patients before cystectomy can enhance physical and mental health potentially buffering the effects of surgery.

Towards the revision of the Italian code of medical ethics: thoughts of an extremist.

In November 2022 the Italian medical council (Federazione nazionale degli ordini dei medici chirurghi e odontoiatri) started the revision of the Italian Code of medical ethics (Cme) with the first race dating back ten years. Since then, the Italian doctors are dealing with the scientific, ethical and economic challenges together with the more recent ones posed by the Sars-CoV-2 pandemic to the National health system underlying the ongoing crisis of the medical profession. Additionally, this critical context requires the doctors to develop new technological skills, a complete and effective adherence to the Ebm principles, a new view regarding the relationship with the other health care professionals and the related changes of clinical practices fostering a responsible use of resources. In brief, what is required nowadays from doctors is to rethink about the meaning of science, ethics, economics and public health and to make new and more appropriate connections between the instances conveyed by these different disciplines. The Cme main aim consists in providing appropriate rules in step with the current transformations of medicine and society to doctors for ethically acting in clinical practice, assuring the citizens, the institutions and law of the scientific competence, the protection of the fundamental rights of the sick person in compliance with the constitutional principles. Under this assumption and in line with the above mentioned professional crisis, at least the overall guidelines aimed to solve it should have been settled before starting the Cme review also in order to ensure the necessary coherence between the new contents drawing the doctors new social function and its codal systemisation. Unfortunately this stepwise approach was not considered.Lastly, to develop the new Cme looking towards the progress of medical profession, systematic and methodologically appropriate consultations would have been necessary to know, value and balance all the different positions of doctors, allowing them to be responsible for the change of their profession. However, such a decision was not made.

P601 Pneumococcal vaccination in patients with immunomediated inflammatory diseases (IMIDs) using a real-world multidisciplinary project

Abstract Background Vaccination is a crucial element in managing patients with IMIDs, however rates of vaccination remains suboptimal. This study assessed the adherence to pneumococcal vaccination. Methods A prospective cohort study was conducted between January 2020 and December 2021. Vaccine prescription and adherence were assessed during an Infectious Diseases (ID) consultation. Were considered pneumococcal conjugate (PCV13) and polysaccharide (PPS23) vaccines. Results There were 262 patients included (215 with inflammatory bowel disease and 47 with rheumatological diseases), 136 (52%) were male, median age was 41±15 years and 167 (64%) were on immunossuppresive therapy. At baseline, 26 (10%) patients were fully vaccinated against pneumococcal disease and for 236 (90%) vaccination was prescribed as such: PCV13 followed by PPSV23 in 86 (36%) patients, PCV13 in 126 (54%) and PPSV23 in 24 (10%). Adherence to PCV13 occurred in 185 (87%) patients and to PPSV23 in 76 (69%). In patients with both vaccines prescribed (n=86), 57 (66%) had complete adherence and the remaining had at least one of them. In this group (n=86), patients with complete adherence were older than the remaining (45±17 vs. 38±12 years, p=0.03) but no difference was found concerning the baseline disease. After the ID consultation, 175 patients from 236 (74%) became fully vaccinated against pneumococcal disease. Conclusion A multidisciplinary approach and adequate local interventions shall be considered to improve vaccine adherence. ID physicians can play a role in the process of increasing vaccine prescription and adherence.

P691 Disparate care: rates of treat to target among patients with inflammatory bowel disease

Abstract Background Inflammatory bowel diseases (IBD) therapies are limited by low response rates and risks of loss of response. Treat to target (T2T) algorithms aim to maximize the benefit of therapies by establishing a framework for assessing patient reported outcomes, biochemical evaluation (C-reactive protein (CRP) or fecal calprotectin (FC)), and structural assessment via endoscopy or enterography. There are limited data on adoption rates of T2T in real-world clinical practice. We aimed to describe rates of T2T utilization in a large regional medical system in the United States. Methods A retrospective cohort study was conducted from 2015-2021. Individuals with IBD starting a new biologic therapy were identified. Collected data included demographics, laboratory data, current medications, and procedure and imaging data. Patients were categorized based on whether they completed T2T, defined as CRP or FC testing at 2-4 months after starting a new therapy, and structural assessment, defined as colonoscopy, sigmoidoscopy, capsule endoscopy, or enterography within 6-12 months after starting a new therapy. Complete adherence was defined as both of these criteria being met. Social deprivation index (SDI), with higher values associated with higher rates of social deprivation, was derived using mail codes. T-tests, Pearson chi-square tests, ANOVA and multivariable logistic regression were used for comparisons. Results 7,962 patients were identified (Table 1). Rates of T2T were low; only 7.81% of patients completed biochemical monitoring at 2-4 months (0.83% FC, 8.65% CRP, 1.76% both), 9.80% completed structural assessment, and 3.43% completed both. In univariable logistic regression, higher age (OR 0.98, p&amp;lt;0.01), IBD type (UC OR: 0.69, p&amp;lt;0.01), having no insurance (OR 0.84, p=0.02) and low social deprivation index (SDI) (OR 1.004, p&amp;lt;0.01) were associated with lower T2T completion rates. In multivariable logistic regression, ulcerative colitis (UC), younger age, and lower SDI score were significantly associated with likelihood of completing any T2T (Table 2). When considering biochemical monitoring at 2-4 months, Asian race, UC diagnosis, age, SDI score and year were significantly associated with completion (Table 3). UC diagnosis, year and age were significantly associated with completion of structural assessment (Table 4). Conclusion Treat to target completion rates among patients with IBD starting biologic therapies were low in this large cohort. Age and UC diagnosis were negatively associated with completing T2T. Social deprivation score was positively associated with biochemical monitoring. Further research is required to understand barriers to T2T monitoring.

P622 Change in Dietary Inflammatory Index Score in patients with Crohn’s disease and healthy volunteers following the Groningen Anti Inflammatory Diet (GrAID)

Abstract Background Dietary patterns play an important role in Inflammatory Bowel Disease (IBD). The Dietary Inflammatory Index (DII) is a diet quality score that estimates the inflammatory potential of a dietary pattern on inflammatory markers. Recently, the Groningen Anti-Inflammatory Diet (GrAID) was developed to improve disease course in patients with IBD. The aim of this study is to investigate whether following the GrAID improves diet quality based on the DII compared to baseline intake in patients with Crohn’s disease (CD) and healthy volunteers (HV). Methods Between October 2021 and October 2022, patients with CD and HV completed a 12-week GrAID intervention as part of an ongoing trial: VITA-GrAID (NCT04913467). In this sub analysis, nutrient intake from a 3-day food diary was calculated at baseline (T0; habitual diet) and after 12 weeks (T3; following the GrAID), using Evry software (version 2.3.7.0). From both intakes the DII score according to the Shivappa method was calculated, based on 28 food parameters. Next, both scores were compared to the DII score of the GrAID, calculated assuming complete adherence to the GrAID. A lower DII score is regarded to having a higher anti-inflammatory potential. Paired nonparametric tests (Wilcoxon signed-rank) were performed to calculate differences between T0 and T3. Data were analysed using R (2021.09.0) and IBM SPSS Statistics 28. Results Eighteen individuals completed the 12-week GrAID intervention (12 patients with CD; and 6 HV) (table 1). Between T0 and T3, significant increases were found in fibre (16.5g), total protein (21g), total plant protein (14g), vitamin B2 (0.29ug) and beta carotene (1837ug) intake. Significant decreases were found in mono- and disaccharides (-18g), alcohol (- 5.3g), and sodium (-875mg) intake (Table 2). The median DII score at T0 was -0.112, IQR: [-1.269; 1.362] and was significantly lower at T3 (median: -2.040; IQR [-2.588; -1.417], p&amp;lt;0.05) (figure 1). Median DII score in patients with CD differed significant between T0 and T3 (0.323, IQR [-1.3897; 1.523] and -2.040, IQR [-2.665; -1.549] respectively, p&amp;lt;0.05), but not in HV (-0.692, IQR [-1.127; 0.566] and -1.998, IQR [-2.441; -1.336] respectively, p=0.09) (Figure 2). Conclusion These preliminary results show that diet quality improved in patients with CD after following the GrAID for 12 weeks. For HV, probably more participants are needed. Further research is necessary to determine whether a lower DII score will actually improve the disease course of patients with CD and the diversity of the microbiome in HV.

Prevalence of fear of COVID-19, depression, and anxiety among undergraduate students during remote classes.

During the coronavirus disease 2019 (COVID-19) pandemic, undergraduate students were exposed to symptoms of psychological suffering during remote classes. Therefore, it is important to investigate the factors that may be generated and be related to such outcomes. To investigate the association between fear of COVID-19, depression, anxiety, and related factors in undergraduate students during remote classes. This cross-sectional study included 218 undergraduate students (60.6% women and 39.4% men). Students answered a self-administered online questionnaire designed to gather personal information, pandemic exposure, physical activity level, fear of COVID-19 using the 'Fear of COVID-19 Scale', symptoms of depression using the Patient Health Questionnaire-9, and anxiety using General Anxiety Disorder-7. Undergraduate students had a high prevalence of depression and anxiety (83.0% and 76.1%, respectively) but a low prevalence of fear of COVID-19 (28.9%) during remote classes. Multivariate analysis revealed that women who reported health status as neither good nor bad and who had lost a family member from COVID-19 had the highest levels of fear. For depression and anxiety, the main related factors found were female gender, bad health status, insufficiently active, and complete adherence to the restriction measures. These findings may be used to develop actions to manage symptoms of anxiety and depression among students, with interventions through physical activity programmes to improve mental health.

Impact of Adherence to a Standardized Oxytocin Induction Protocol on Obstetric and Neonatal Outcomes

Oxytocin protocols are employed to induce uterine contractions and progressive cervical changes, but they are associated with adverse maternal and neonatal outcomes. The aim of this study was to determine whether compliance with a checklist-based protocol for oxytocin administration was associated with changes in neonatal and maternal outcomes. A retrospective cohort study of 86,786 pregnant women undergoing term (> 37 weeks) induction of labor between January 2015 and December 2017 was performed. Systemwide training in the use of an oxytocin administration protocol was provided to obstetricians and nurses. Pre-use and in-use oxytocin checklists were incorporated into each unit's policies and procedures. Subsequently, charts were reviewed and individually audited by an obstetric nurse who scored each record based on the documentation of variables in an oxytocin administration protocol and ranked adherence as complete or absent. Primary outcomes were postpartum hemorrhage, neonatal ICU (NICU) admission, and delivery by cesarean section. Bivariate analyses (t-tests) were performed on adherent and nonadherent groups for comparison of selected demographic variables and the primary outcome variables. Logistic regression was completed on the primary outcome variable with eight covariates. Among patients with complete adherence to the oxytocin administration protocol, the rate of cesarean section in the unadjusted analysis was 16.20%, compared to 18.54% for those with incomplete adherence; the rates of postpartum hemorrhage were 2.64% vs. 3.14%, respectively, and the rates of NICU admission were 3.03% vs. 3.86%, respectively. In the multivariable logistic regression, complete protocol adherence was associated with significantly lower odds of postpartum hemorrhage (adjusted odds ratio [OR] 0.85, 95% confidence interval [CI] 0.76-0.94) but higher odds of Cesarean section (adjusted OR 1.07, 95% CI 1.01-1.13); the adjusted OR for NICU admission was 0.90, which did not reach statistical significance (95% CI 0.81-1.00). Among the covariates, nulliparity and elective induction were the strongest predictors of the primary outcomes of cesarean section, postpartum hemorrhage, and NICU admission. Adherence to the oxytocin administration protocol was associated with a decrease in postpartum hemorrhage but an increased risk of delivery by cesarean section.

Prescribing Patterns of Proton Pump Inhibitors in Germany: A Retrospective Study Including 472 146 Patients.

The aims of this study were to analyze proton pump inhibitor (PPI) users in Germany, defining and classifying them in terms of treatment appropriateness, and to analyze the PPI prescription practices of healthcare providers. The updated DGVS (Deutsche Gesellschaft für Gastroenterologie, Verdauungs-und Stoffwechselkrankheiten) gastroesophageal reflux disease (GERD) treatment guideline (published March 2023) for mild heartburn symptoms recommends carrying out a probatory treatment of mild symptoms via other medication such as antacids, alginates, and H2 blockers before escalating to PPI treatments, if the patient profile allows. This retrospective cross-sectional study was based on data from the IQVIA™ Disease Analyzer database (DA) and included adult patients (18 years or older) in 1006 general and 39 gastroenterological practices in Germany who received at least 1 PPI prescription or alginate between September 2019 and September 2021 (hereinafter referred to as the index period). Analyses included indications associated with PPI prescription, co-diagnoses, co-therapies of PPI patients, duration of PPI therapy, dosages of PPI prescriptions, and proportions of practices prescribing PPIs and alginates. A total of 472 146 patients taking PPIs and 9101 patients taking alginates were available for analysis. Very few patients (4.5%) of the total cohort were treated in complete adherence to treatment guidelines. Conditions such as gastritis and duodenitis (47.2%) and reflux diseases (38.4%) were more frequently associated with PPI prescriptions. The average PPI treatment period lasted 141 days, and 36.6% of patients were treated for >6 months. High doses were prescribed relatively often (ie, 42.8% of esomeprazole prescriptions were 40 mg, 59.1% of lansoprazole prescriptions 30 mg, 28.6% of omeprazole prescriptions 40 mg). With each practice prescribing PPIs to at least 10% of their patients; 72% of general practitioners (GPs) and 8% of GENTS (Gastroenterologists) prescribed alginates. This study highlights that discrepancies exist between clinical guidelines and real-life prescribing practices of PPIs in Germany. Particular attention should be given to the incidence of patients being prescribed high-dose or long-duration PPI with mild indications. These findings are particularly apt considering the publication (March 2023) of new guidelines on the "management of gastroesophageal reflux disease and eosinophilic esophagitis," by the DGVS.

The limits and impact of communication and context in implementing social interventions in a pandemic: Ghana's free water policy revisited

The study examined the implementation of the free water intervention initiated by the government of Ghana during the peak of the Covid-19 pandemic. The study deployed a case study design within the qualitative research method. A total of 22 respondents were interviewed for the study. Findings from the study revealed that the implementation suffered some challenges which mostly stemmed from both the suddenness of the intervention and the complex context of the water sector in Ghana. The abruptness of the intervention resulted in poor communication and little or no consultation between the presidency and the implementer. The other major setback was the withdrawal of services by many tanker drivers from the supply of free water to designated Covid-19 reservoirs due to delays in reimbursement by the government. Furthermore, there was no effective monitoring mechanism to ensure complete adherence to the policy directive by both household vendors and landlords. Generally, the objective of the intervention to provide free water to all was largely ineffective due to the challenges highlighted above.

The Incidence and the Clinical Course of Retinal Complications of Intracameral Cefuroxime in Cataract Surgery

Aim. To determine the incidence and the clinical course of retinal complications of intracameral administration of cefuroxime in minimally invasive cataract surgery.Methods. From 2016 to 2021, a prospective clinical study was conducted at the Volga District Medical Center of the Federal Medical and Biological Agency of Russia, which included patients with cataract in one or two eyes to be surgically treated. All patients received 1 mg of cefuroxime injected into the anterior chamber at the end of surgery. All patients underwent ophthalmological examination including evaluation of best corrected visual acuity with determination of logarithm of minimum angle of resolution (logMAR), tonometry, biomicroscopy, and ophthalmoscopy. Each patient before and the day after surgery underwent optical coherence tomography of the retina on a spectral optical tomograph RTVue-100 (Optovue). The dynamics of the condition was evaluated on days 3 and 7 after surgery.Results. Five cases of retinal complications of intracameral cefuroxime injection were identified during the 5-year study period. According to data of optical coherence tomography, retinal edema was localized in the internal nuclear layer of the retina, and the height of serous retinal detachment in the fovea area on the next day after surgery was 315.0 ± 11.0 µm and reduced statistically significantly to 59.8 ± 42.3 µm on the 3rd day after the intervention (p = 0.043). One week later, all patients had complete retinal adherence and recovery of visual function. Retinal edema did not recur in the long term after surgery.Conclusion. Serous retinal detachment with macular edema is the most common clinically relevant complication of intracameral antibiotic prophylaxis, which develops both in compliance with the dilution protocol and in overdose, and has a favourable prognosis.

945: EARLY USE OF APRV IN CRITICALLY ILL ADULTS WITH MODERATE-TO-SEVERE ARDS: A PILOT FEASIBILITY TRIAL

Introduction: Airway pressure release ventilation (APRV) may be an alternative to low tidal volume ventilation for patients with acute respiratory distress syndrome (ARDS). We conducted an investigator-initiated, pilot feasibility randomized controlled study (RCT) comparing APRV to low tidal volume ventilation in critically ill adults with ARDS (ClinicalTrials.gov identifier NCT 04156438). Methods: Participants with moderate-to-severe ARDS admitted to an intensive care unit (ICU) in Regina, Saskatchewan, were randomized on an open-label basis to APRV or low tidal volume ventilation, over a one-year period. The primary feasibility outcomes were the informed consent rate, recruitment rate, and protocol adherence rate. A successful informed consent rate was defined as at least 70% of eligible patients approached for study participation consenting to participation. Enrollment of at least 15 participants during the one-year recruitment period was considered a successful recruitment rate. Protocol adherence was defined as the number of patient-days of complete adherence to the study protocol, with a rate of at least 80% considered successful. The secondary efficacy outcomes were 28-day mortality, in-hospital mortality, ICU length of stay, hospital length of stay, length of mechanical ventilation, and incidence of tracheostomy. Results: Due to interruptions in study recruitment from the COVID-19 pandemic, this study took place between July 1, 2020 to December 31, 2021 to ensure a one-year recruitment window. Of the 165 ARDS patients admitted to the ICU during this period, 42 (25.5%) were screened for eligibility, with 17/42 patients (40.5%) meeting the eligibility criteria. 13/17 (76.5%) secondary decision makers were approached for informed consent, with only one (7.7%) giving consent for participation. Clinical documentation limited ability to assess protocol adherence. Efficacy outcomes were not analyzed due to low recruitment. No adverse events associated with trial participation were identified. Conclusions: Our study did not meet the pre-specified feasibility outcomes for recruitment, informed consent, or protocol adherence. Future studies of ventilation strategies for ARDS at our center may need to consider the impacts of COVID-19 pandemic on recruitment strategies, institutional resources and policies.

Use of timed alarm device for pediatric daytime urinary incontinence Meta-analysis of comparative studies.

This meta-analysis aimed to determine the comparative effectiveness of timed alarm device-assisted urotherapy vs. standard urotherapy alone in managing pediatric daytime urinary incontinence (pDUI). A systematic literature search was performed in December 2021, with an update search in July 2022. Comparative studies assessing the pDUI treatment effectiveness of timed alarm device-assisted urotherapy vs. urotherapy alone were identified and evaluated according to Cochrane collaboration recommendations. The assessed outcome includes pDUI complete response and adherence rates. Relative risk (RR ) with 95% confidence intervals (CI) was extrapolated. A random-effects model was used to pool effect estimates. Heterogeneity was assessed with sensitivity and subgroup analysis performed according to study design and comparative group characteristics. GRADE criteria were used to assess evidence certainty. (PROSPEROCRD 42022299173). Four studies (three randomized controlled trials [RCTs] and one retrospective cohort) with 635 cases were included. The pooled effect estimates of pDUI complete response showed no differences between intervention groups (RR 1.20, 95% CI 0.81, 1.76). Pooled effect estimates for treatment adherence were generated from two studies, which showed significantly better adherence for the timed-alarm device group (RR 2.97, 95% CI 1.46, 6.06). Significant interstudy heterogeneity was noted; the source is likely from the study design and comparator device characteristics. The quality of evidence was assessed to be of very low certainty. Based on very low certainty evidence, timed alarm device-assisted urotherapy does not seem to have the advantage of complete treatment response over standard urotherapy alone in managing pDUI; however, a timed-alarm device is likely able to improve urotherapy treatment adherence.

Impact of antiretroviral therapy (ART) duration on ART adherence among men who have sex with men (MSM) living with HIV in Jinan of China

BackgroundConsistent and complete adherence is considered an essential requirement for patients on antiretroviral therapy (ART). This study aimed to evaluate the impact of ART duration on ART adherence, identify the trend of complete adherence, and compare the factors associated with ART adherence between short-term and long-term ART group among men who have sex with men (MSM) living with HIV in Jinan of China.MethodsMSM living with HIV aged 18 or above and currently on ART were recruited from October to December 2020 using convenience sampling. Univariate and multivariable logistic regressions were used to evaluate the impact of ART duration on adherence and compare factors associated with ART adherence between subgroups. The Mann–Kendall test was used to identify the trend of complete adherence.ResultsA total of 585 participants were included in analysis, consisting of 352 on short-term ART (ART initiation ≤ 3 years) and 233 on long-term ART (ART initiation > 3 years). Significant difference of complete ART adherence between short-term and long-term ART group was detected (79.8% vs. 69.1%, P = 0.003). Multivariable analysis showed that men with longer ART duration were less likely to report complete ART adherence (AOR = 0.88, 95% CI 0.81–0.95). A descending trend of complete adherence was identified (Z = 1.787, P = 0.037). Alcohol use and lack of medication reminders were barriers to complete adherence for both of the subgroups.ConclusionsSustained efforts to encourage maintaining adherence for a lifetime are necessary, especially for those on long-term ART. Future interventions should be tailored to subgroups with different ART duration and individuals with specific characteristics.

Protocol Adherence for Adult Sickle Cell Patients Presenting with Vaso-Occlusive Crises on a Tertiary Teaching Hospital Emergency Department

Background Patients with Sickle cell disease (SCD) suffer from frequent vaso-occlusive crises (VOC) that heavily contribute to morbidity and mortality. VOC's constitute the principal cause of emergency department (ED) presentation and hospital admission and the ED visit serves to diagnose underlying disorders, VOC complications and to institute pain relieve most often requiring intravenous opioids. The need for prompt and adequate treatment and pain relieve is reflected by standardized protocols for acute care in SCD. Adherence to these protocols has been shown to increase the quality of care, while improving overall patient pain control, decreasing frequency of ED visits and ED patient crowding and decreasing total hospital days. Several studies have demonstrated that negative health care provider attitudes interfere significantly with adequate assessment of pain and in turn may lead to insufficient treatment. We recently (October 2019) introduced novel protocols for management of SCD patients presenting with VOC's at the ED, but local the actual protocol adherence has not been evaluated. Aim Retrospective analysis of adherence to ED protocols for management of SCD patients on the ED. Methods We included all patients with SCD presenting at the ED between March 2021 and March 2022. Children and patients that presented for alternative causes than a VOC were excluded from analysis. The SCD protocol contained a circumscriptive manual with indicated timing of interventions that could be analysed for adherence. Interventions were divided into three groups: diagnostics, supportive care and analgesics. Diagnostics contained physician consultation within 60 minutes of arrival, measurement of vital parameters (SpO2, respiratory frequency, heart rate, blood pressure and body temperature), and extensive laboratory testing. In patients with chest pain it prescribed chest imaging and arterial blood gas analysis. Supportive measures included oxygen supplementation in hypoxic patients and administration of intravenous hyper hydration in absence of contraindications such as a history of fluid overload. Analgesia included treatment using a predefined personalized pain plan (PPP) if available. In all other patients, treatment consisted of acetaminophen, NSAIDs and opioids until the NRS pain score was 6 or lower or pain was deemed acceptable by the patient. Opioid treatment consisted of IV fentanyl in a maximal cumulative dose of 2 mcg/kg within the first hour followed by opioid escalation with intravenous (IV) morphine in a maximal cumulative dose of 50mg. In patients with renal failure (eGFR<30 ml/min), buprenorphine was advised instead of morphine. When analgesic treatment remained insufficient after 15 minutes the protocol prescribed consultation of the pain specialist for administration of clonidine or esketamine. Results We analyzed data from a total of 109 ED visits of 70 unique patients (median age: 31,1 years (IQR 14,0), 49.5% male) between March 2021 and March 2022 in a tertiary teaching hospital in The Netherlands. Results of protocol adherence are shown in table 1. Adherence to the complete protocol was extremely low (0.9%). For most individual components of the protocol adherence was above 50%. For fluid administration, timing of initial fentanyl and morphine escalation, adherence was 39.4%, 19.3% and 11.9%, respectively. Conclusion In patients with sickle cell disease, protocols aim to increase accuracy and speed of diagnostics and analgesia which is related to outcomes such as overall patient pain control, frequency of ED visits and total hospital days. This study evaluates protocol adherence in a large tertiary university hospital. Whereas adherence to individual components of the SCD is above 50%, total patients in which complete protocol adherence is observed is extremely low. We identify fluid administration and opioid administration as protocol components to which adherence is most insufficient. Further research on the reasons for these impaired adherence together with training of medical and nursing staff is required to improve the quality of healthcare for this patient group. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Comprehensive Nutrition Assessment in Adults with Sickle Cell Disease Using the Dietary Inflammatory Index and Healthy Eating Index

Increasing evidence shows that nutrition plays a role in the pathogenesis and progression of many diseases. Certain diets are shown to play a role in driving systemic inflammation and consequently contribute to exacerbation of disease processes. Systematic nutrition assessment in individuals with sickle cell disease (SCD) is largely unexplored and thus it is not well understood how diet impacts SCD complications and health outcomes. Therefore, the objective of this study was to assess both the inflammatory nature and quality of diet in adults with SCD. Individuals with SCD age ≥18 years were eligible for enrollment. Consented participants completed the validated diet assessment, the Block 2014 Food Frequency Questionnaire. This questionnaire has a recall period of one year and includes questions on the intake of 127 food and beverage items. Data collected from this questionnaire are sent to the developer for secondary and tertiary analyses for quantification of nutrients and food groups and the returned quantifications were used to calculate the Dietary Inflammatory Index (DII) and the Healthy Eating Index (HEI). The DII is a validated measure that quantifies the inflammatory nature of individuals' diet based on the potential of nutrients to trigger inflammation, whereas the HEI is a metric that assesses overall diet quality and several individual dietary components. DII is calculated based on the global mean intake and standard deviation (SD), and overall inflammatory effect score for specific food parameters. A total of 30 food parameters (Figure 1) were used for DII calculation in this study. Global mean intake and SD are used to calculate a Z-score for each nutrient which is then converted to the centered percentile. It is then multiplied with the overall food parameter-specific inflammatory effect score from the DII database to get a DII for each nutrient. These individual nutrient scores are summed to create the 'overall DII score' for an individual. Possible overall DII scores range from -8.87 to +7.98, with negative scores indicating an anti-inflammatory diet and positive scores indicating a pro-inflammatory diet. The HEI reflects adherence to Dietary Guidelines for Americans (DGA) and considers density-based (amounts per 1,000 kcal) intake of the following 13 components: total fruits, whole fruits, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, added sugars, saturated fats. Fruits, vegetables, and proteins are assigned a maximum of 5 points each because they are represented by two components (i.e., total fruits and whole fruits) while other food groups receive a maximum of 10 points because they are represented by one component. Maximum points are assigned if the a priori set thresholds for the specific components are met (detailed in Figure 2 legend). Final HEI is a sum of scores for each component. The HEI has a range of 0 (reflecting no adherence to DGA) to 100 (reflecting complete adherence to DGA). The mean HEI for Americans aged 19-59 years old is 57. We report the range and mean for both the DII and HEI indices. A total of 28 adults with SCD completed the Block Food Frequency questionnaire. Mean age of participants was 33.7 (SD 10.5) years with range of 19-58 years and 46.4% (n=13) were female. Figure 1 represents the DII scores for our study cohort. We found 25% (n=7) of individuals had a negative DII indicating consumption of an anti-inflammatory diet, and 75% (n=21) of individuals had a positive DII indicating consumption of a pro-inflammatory diet. The DII ranged from -5.25 to 6.55, with a median DII of 2.62 (IQR -0.49, 4.45). The mean HEI score for the study cohort was 60. Individual components of the mean HEI for SCD individuals and for average adult Americans are shown in Figure 2. Numbers in the radar graph represent the percentage of maximum possible score for each component. The majority of adults with SCD in our cohort have evidence of a pro-inflammatory diet. Our cohort had a similar HEI to average Americans, but its components vary between the food groups and require further assessment. These data are the first step to systematically assessing nutrition in individuals with SCD. Further research is necessary to investigate if nutrition impacts disease expression and health outcomes in SCD and determine whether diet is a modifiable target for interventions. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Findings from a pilot study of buprenorphine population pharmacokinetics: A potential effect of HIV on buprenorphine bioavailability

BackgroundBuprenorphine is widely used in the treatment of opioid use disorder (OUD). There are few pharmacokinetic models of buprenorphine across diverse populations. Population pharmacokinetics (POPPK) allows for covariates to be included in pharmacokinetic studies, thereby opening the potential to evaluate the effect of comorbidities, medications, and other factors on buprenorphine pharmacokinetics. This pilot study used POPPK to explore buprenorphine pharmacokinetics in patients with and without HIV receiving buprenorphine for OUD. MethodsPlasma buprenorphine levels were measured in 54 patients receiving buprenorphine for OUD just prior to and 2–5 h following regular buprenorphine dosing. A linear one-compartment POPPK model with first-order estimation was used to evaluate buprenorphine clearance (CL/F) and volume of distribution (V/F). Covariates included weight and HIV status. ResultsAll HIV+ patients reported complete past-month adherence to taking antiretroviral therapy that included either efavirenz or nevirapine. Buprenorphine CL/F was 76% higher in HIV+ patients (n = 17) than HIV- patients (n = 37). Buprenorphine V/F was 41% higher in the HIV+ patients. ConclusionsPOPPK can be used to model buprenorphine pharmacokinetics in a real-world clinical population. While interactions between ART and buprenorphine alter buprenorphine CL/F, we also found alteration in V/F. Proportionate changes in CL/F and V/F might indicate a primary effect on bioavailability (F) rather than two separate effects. These findings indicate reduced buprenorphine bioavailability in patients with HIV.

Abstract 9445: Using Latent Class Analysis to Identify Antihypertensive Adherence Trajectories: The BETTER-BP Trial

Introduction: Adherence to antihypertensive medications remains low in many patients. In this context, the BETTER-BP randomized trial was designed to test whether providing small financial rewards for medication adherence with a text message-based lottery system improves adherence and lowers blood pressure. In this preliminary analysis we characterized adherence trends from baseline to 6 months in BETTER-BP through 12/2021. Methods: Participants were recruited from two safety-net clinics in New York City (Bellevue Hospital and NYU-Brooklyn FHC). There were 101 participants with six months of complete adherence data. Mean weekly adherence was recorded through an Adheretech electronic monitoring device. Latent class mixed methods analysis was used to determine categorizable adherence trajectory trends over six months. We then investigated factors (age, sex, insurance status, comorbidity burden, depression, self-efficacy) that predicted category membership. The analysis remained blinded to treatment arm given that full enrollment was not yet complete. Results: Three distinct adherence trajectories were determined: (1) High, persistent adherence (n=53), (2) Gradually declining adherence (n=33), and (3) Early declining non-adherence (n=15). In a multivariable analysis, only self-efficacy (based on the medication adherence self-efficacy scale [MASES]) had a significant (p=0.02) association with adherence, with mean MASES scores of 81.4, 76.3 and 72.1 for clusters (1), (2) and (3) respectively. Conclusions: In this preliminary analysis, we found that the majority of participants had high persistent adherence, and that those with high self-efficacy were more likely to be members of this category. These results will need to be confirmed at trial completion (target sample N = 435). Figure 1. Mean participant adherence trajectory clusters over six months.

An exploratory assessment of the impact of a novel risk assessment test on breast cancer clinic waiting times and workflow: a discrete event simulation model

BackgroundBreast cancer clinics across the UK have long been struggling to cope with high demand. Novel risk prediction tools – such as the PinPoint test – could help to reduce unnecessary clinic referrals. Using early data on the expected accuracy of the test, we explore the potential impact of PinPoint on: (a) the percentage of patients meeting the two-week referral target, and (b) the number of clinic ‘overspill’ appointments generated (i.e. patients having to return to the clinic to complete their required investigations).MethodsA simulation model was built to reflect the annual flow of patients through a single UK clinic. Due to current uncertainty around the exact impact of PinPoint testing on standard care, two primary scenarios were assessed. Scenario 1 assumed complete GP adherence to testing, with only non-referred cancerous cases returning for delayed referral. Scenario 2 assumed GPs would overrule 20% of low-risk results, and that 10% of non-referred non-cancerous cases would also return for delayed referral. A range of sensitivity analyses were conducted to explore the impact of key uncertainties on the model results. Service reconfiguration scenarios, removing individual weekly clinics from the clinic schedule, were also explored.ResultsUnder standard care, 66.3% (95% CI: 66.0 to 66.5) of patients met the referral target, with 1,685 (1,648 to 1,722) overspill appointments. Under both PinPoint scenarios, > 98% of patients met the referral target, with overspill appointments reduced to between 727 (707 to 746) [Scenario 1] and 886 (861 to 911) [Scenario 2]. The reduced clinic demand was sufficient to allow removal of one weekly low-capacity clinic [N = 10], and the results were robust to sensitivity analyses.ConclusionThe findings from this early analysis indicate that risk prediction tools could have the potential to alleviate pressure on cancer clinics, and are expected to have increased utility in the wake of heightened pressures resulting from the COVID-19 pandemic. Further research is required to validate these findings with real world evidence; evaluate the broader clinical and economic impact of the test; and to determine outcomes and risks for patients deemed to be low-risk on the PinPoint test and therefore not initially referred.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study

To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI-0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.