Patient Counseling Research Articles

A Guide for Implementing DPYD Genotyping for Systemic Fluoropyrimidines into Clinical Practice.

The safety of systemic fluoropyrimidines (e.g., 5-fluorouracil, capecitabine) is impacted by germline genetic variants in DPYD, which encodes the dihydropyrimidine dehydrogenase (DPD) enzyme that functions as the rate-limiting step in the catabolism of this drug class. Genetic testing to identify those with DPD deficiency can help mitigate the risk of severe and life-threatening fluoropyrimidine-induced toxicities. Globally, the integration of DPYD genetic testing into patient care has varied greatly, ranging from being required as the standard of care in some countries to limited clinical use in others. Thus, implementation strategies have evolved differently across health systems and countries. The primary objective of this tutorial is to provide practical considerations and best practice recommendations for the implementation of DPYD-guided systemic fluoropyrimidine dosing. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to cover topics including the clinical evidence supporting DPYD genotyping to guide fluoropyrimidine therapy, regulatory guidance for DPYD genotyping, key stakeholder engagement, logistics for DPYD genotyping, development of point-of-care clinical decision support tools, and considerations for the creation of sustainable and scalable DPYD genotype-integrated workflows. This guide also describes approaches to counseling patients about DPYD testing and result disclosure, along with examples of patient and provider educational resources. Together, DPYD testing and clinical practice integration aim to promote safe prescribing of fluoropyrimidine therapy and decrease the risk of severe and life-threatening fluoropyrimidine toxicities.

Defining Substantial Clinical Benefits of PROMIS Pain Interference and Physical Function in Patients Undergoing Lumbar and Thoracolumbar Spine Surgery.

Prospective cohort study. This study aims to define Substantial Clinical Benefit (SCB) thresholds for PROMIS physical function (PF) and pain interference (PI) in lumbar or thoracolumbar spine surgery population. Patient-reported outcome measures (PROMs) are widely used in spine surgery to assess treatment efficacy. SCB is a relatively new concept that represents a substantial improvement perceived by the patient. This is a prospective study that included adults aged 21-85 years, undergoing lumbar/ thoracolumbar surgery for degenerative spine disease, and reporting at least 3/10 back or leg pain on a numeric rating scale. PROMs including Oswestry Disability Index, PROMIS PF, and PROMIS PI were collected preoperatively and at one year postoperatively. The North American Spine Surgery Patient Satisfaction (NASS) Index was collected one year postoperatively. SCB thresholds of absolute and percentage changes were calculated using anchor-based methods with ODI and NASS index as anchors. ROC analysis was used to determine optimal SCB cutoffs. We included 137 patients. Using a fixed 19-point reduction in ODI as an anchor yielded SCB thresholds of 6.8 and 11.3 points for PROMIS PF and PI respectively. When using a dynamic anchor based on preoperative disability (50% ODI improvement), SCB thresholds were defined as achieving 18 and 27% of maximum possible improvement for PROMIS PF and PI respectively. Using NASS index, thresholds were 11 points or 24% for PROMIS PF, and 11.2 points or 21% for PROMIS PI. ROC values ranged from 0.81 to 0.9, with the dynamic ODI anchor cutoffs demonstrating the best discrimination. Our study is the first to define SCB thresholds for PROMIS PF and PROMIS PI using both fixed and dynamic cutoffs based on preoperative disability in lumbar and thoracolumbar patients. These thresholds will help in patient counseling and outcome evaluation for spine surgery research.

The Impact of Tele pharmacy in Rural Healthcare

In many nations, the rapid expansion of information and telecommunication technology use has a significant impact on healthcare delivery. Geographical and demographic characteristics, however, frequently make it difficult for rural areas and residents to access healthcare services. Telepharmacy, a relatively new term for pharmaceutical services, allows a qualified pharmacist to provide healthcare services, including medication reviews, patient counseling, and prescription verification, to patients who live far from a hospital, pharmacy, or healthcare facility. Economic benefits, patient satisfaction due to medication access and information in rural areas, easy access to healthcare services in remote and rural locations, effective patient counseling, and a lack of local pharmacists and pharmacy services are just a few of the well-known advantages of telepharmacy. Although telepharmacy is an excellent idea, its implementation can occasionally be difficult. There are hazards and legal issues that come with implementing these techniques that must be resolved. Significant time, money, and effort are required for the technology, software, connectivity, and operational costs associated with telepharmacy startup. One of the main obstacles to telepharmacy services for rural hospitals with fewer patients seems to be cost.Furthermore, there are still issues with the execution and uniformity of the telepharmacy law. A properly-designed system, however, has the power to transform pharmacy practice in ways that benefit rural communities as well as the hospitals or retail pharmacies that provide these services.

Identifying At-Risk Populations for Reoperations, Readmissions, and Interventions in MBSAQIP Using a Novel Inpatient Postoperative Care Metric.

Metabolic and bariatric surgery (MBS) is increasingly used for obesity and metabolic disease, with safety profiles showing it is among the safest major operations. The last 20 + years have noted significantly improved safety that has been accompanied by decreasing length of stay and select populations electing for outpatient surgery, leading to continued decreases in cost. Regardless, readmissions and complications still occur, requiring inpatient postoperative care (IP-POC). The current study aimed to identify and characterize at-risk populations for MBS-related IP-POC. The 2015-2021 MBSAQIP (n = 1,346,468 records) was used to extract 973,520 primary cases of laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, duodenal switch, and associated IP-POC. Conversions, pediatric cases, and < 30-day follow-up were excluded. IP-POC severity scores were calculated by summing readmissions (1 point), interventions (5 points), and reoperations (15 points). Risk factors associated with IP-POC were identified using zero-inflated Poisson models. GERD, COPD, smoking, and type of MBS procedure were significantly associated with increased IP-POC incidence and severity. Male sex was associated with increased severity but a lower likelihood of IP-POC, while Black and Hispanic race predicted increased IP-POC likelihood but not severity. ROC curve analysis identified IP-POC score thresholds of ≥ 6 and ≥ 10 as significantly associated with MACE (OR 2.4) and 30-day mortality (OR 4.7). The weighted IP-POC model demonstrated associations between preoperative characteristics and increased IP-POC likelihood and severity. These findings add to the current understanding of MBS patient care dynamics, and can be used to improve patient counseling, refine postoperative protocols, and optimize resource allocation.

P-1879. Change in Healthcare Professional’s Identification, Counseling, and Adherence with Black Women for Long-Acting Cabotegravir (CAB LA) for PrEP Across Women’s Health, Primary Care, and Infectious Diseases Sites: Findings from the EBONI Study

Abstract Background The CDC estimates that 400,000 Black women would benefit from PrEP but only 1% obtain a prescription for it in the US. Ensuring equitable access requires expanding delivery outside of infectious disease clinics and equipping healthcare professionals (HCPs) with strategies to support Black women’s PrEP use. EBONI is a phase 4 gender-concordant, implementation science trial evaluating the delivery of CAB LA, a new PrEP modality, to Black cisgender and transgender women in 15 US women’s health, primary care, and infectious disease sites. We present changes in HCPs’ perceptions of identifying, counseling, and supporting CAB LA use in Black women after four months of study implementation. Methods Shifts from baseline (BL) to Month 4 (M4) in HCPs’ appropriateness, acceptability, feasibility and patient identification, counseling and adherence were assessed via surveys completed by a longitudinal sample of HCPs (N=65). At M4, a cross-sectional sample HCPs (N=69) evaluated usefulness of patient support tools. Descriptive statistics are reported. Results Table 1 presents demographics. HCPs reported high levels of appropriateness, acceptability, and feasibility of CAB LA (BL mean scale scores ≥4.6; M4 mean scale scores ≥4.3). Concerns decreased between BL and M4 for the perceived factors related to patient identification, counseling, and adherence (Table 2). HCPs reported feeling “extremely positive”/ “positive” about implementing CAB LA into care at BL (90.8%) and M4 (87.7%). At M4, of HCPs (50%) who completed the PrEP Education Training for Black Women training, most “completely agreed”/“agreed” the training would be useful to their practice (88%), helped them address patient HIV concerns effectively (84%), and improved their likelihood of providing PrEP (84%). Among HCPs (68.8%) that used a shared decision tool, most completely agreed/agreed the tool was easy to implement (82%) and supported conversations with Black women (82%). Conclusion HCPs across women’s health, primary care, and infectious disease clinics maintained high appropriateness, acceptability, and feasibility after four months of integrating CAB LA into care. Effective tools exist to support HCPs in identifying, counseling, and supporting CAB LA use in Black women. Disclosures Dylan M. Baker, MBBS, ViiV Healthcare: Grant/Research Support Katherine L. Nelson, PhD, MPH, GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee Yolanda Lawson, MD, Gilead: Honoraria|Gilead: Meeting and travel support|National Medical Association: Board Member|ViiV Healthcare: Advisor/Consultant|ViiV Healthcare: Grant/Research Support Alftan Dyson, PharmD, GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee Deanna Merrill, PharmD, MBA, AAHIVP, GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee Lisa Petty, MT(ASCP), GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee Peter Jeffery, BSc, PgDip, GSK: Complimentary Worker Kenneth Sutton, MA, GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee Kimberley Brown, PharmD, GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee Maggie Czarnogorski, MD MPH, GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee Nanlesta Pilgrim, PhD, GSK: Stocks/Bonds (Public Company)|ViiV Healthcare: Employee

The Modified Frailty Index Predicts Outcomes in Immediate Implant-Based Breast Reconstruction.

Risk stratification is a crucial tool to help in surgical planning and counseling. Historically, this has been measured by age, BMI, smoking status, or medical comorbidities. Frailty, the combined burden of the patient's comorbidities and risk factors, has gained traction as a method of combining disparate risk factors into one number. The modified 5-factor frailty index (mFI-5) is simple to calculate and takes only moments to assign a risk level to a patient. This study aimed to study the application and efficacy of the mFI-5 as a measurement of operative risk in immediate breast reconstruction. A total of 650 patients undergoing breast reconstruction at our institution were identified. Patients were divided into 5 mFI-5 groups based on their associated comorbidities. Surgical outcomes were compared using the χ2 or Fisher exact tests for categorical variables and t tests for continuous variables. There were 452 patients stratified into the mFI-5 0 group, 155 patients into the mFI-5 1 group, 40 patients into the mFI-5 2 group, and 3 patients into the mFI-5 3 group. There were no patients in our cohort in either the mFI-5 4 or 5 groups. In comparison of the mFI-5 0 group to 1 group, there was a significant difference in postoperative day of infection (32.06 vs. 21.5 days. respectively; P = 0.049). When comparing to the mFI-5 2 group, there was a significant difference in overall complications on univariate analysis (P = 0.012), minor infections on univariate and multivariate analysis (P = 0.050 and P < 0.001), seroma formation on univariate analysis (P = 0.017), hematoma formation (P < 0.001), return to OR (P < 0.001), and replaced implant (P < 0.001) on multivariate analysis. When comparing the mFI-5 1 group to the mFI-5 2 group, there was a significant difference between overall complications on both univariate and multivariate analyses (P = 0.012 and P = 0.041) and minor infections on univariate analysis (P = 0.032). The modified 5-factor frailty index is effective in predicting increased complication risks seen after IBR and may be helpful for surgeons when counseling patients and assessing overall operative risk.

P-1420. Tracking Shadows: Loss to Follow-up in Persons Living with HIV

Abstract Background During the year 2020, HIV viral suppression was 89.4% in clients throughout the United States who receive care through the Ryan White HIV/AIDS program (RYHAP). This was a significant increase compared to 69.5% in 2010. Likewise, Wayne State University (WSU) Tolan Park Infectious Disease Clinic, which is also funded by RYHAP noted a 5% increase in the rate of viral suppression in 2020 compared to the previous year. Eighty-six percent of Tolan Park clients across all Ryan White programs were virally suppressed, eighty-seven percent of women and youth were virally suppressed. However, there was a decline in the overall patient pool in 2019. The goal of this study was to locate those lost-to-care as part of the WSU Tolan Park clinic. Methods Clinicians reviewed a list of clients who were lost-to-care during 2019. These clients were individually called by nurse practitioners, patient advocates or early intervention staff (EIS) to re-engage in medical care. The quality improvement team then discussed feedback from staff and clients regarding barriers to medical care. Results We contacted a total of 310 clients. Out of these, 40 (13%) were lost-to-care. Among the remaining clients, 95 (31%) were deceased, 64 (21%) were in-care at other clinics, 63 (20%) were currently in-care at Tolan park clinic, 41 (13%) had confirmed clinic appointments and 7 (2%) were out-of-state or incarcerated. Of the 40 clients returned to care at the Tolan Park clinic, route cause analysis revealed the main barriers to care including poor mental health, lack of transportation, schedule conflicts, relocation, poor financial resources, inadequate medication adherence and clinic fatigue. Conclusion We report a significant number of patients who were lost-to-care at the WSU Tolan Park clinic. Our patients continue to experience poor mental health, poor medication adherence and several socioeconomic barriers that limit their access to continuity of care. Our results highlight the need for better tracking services and strategies to minimize the loss to follow-up in HIV clinics. Disclosures All Authors: No reported disclosures

The Role of Environmental Factors Prior to Diagnosis on the Activity and Severity of Inflammatory Bowel Diseases-Results From the Prospective Population-Based Copenhagen Inflammatory Bowel Disease Inception Cohort.

The influence of environmental factors on the severity of early inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), is unclear. Herein, we aimed to investigate the role of environmental factors in the initial phenotype, activity, and severity of IBD. Copenhagen IBD Inception Cohort is a prospective population-based cohort of patients with newly diagnosed IBD between May 2021 and May 2023. Data on environmental factors were captured at IBD diagnosis using International Organisation of IBD (IOIBD) and HeartDiet questionnaires. Environmental factors' influence on outcome was analyzed and odds ratios (aOR) were adjusted for age, gender, and disease characteristics (adjusted OR, aOR [95% confidence interval]). In total, 208 and 128 patients with incident UC and CD, respectively, were included. Active smoking was associated with increased risk of CD-related hospitalization (aOR=2.84 [1.03; 7.88]) and stricturing phenotype (aOR=5.28 [1.76; 15.85]) but lower risk of severe UC course (aOR=0.28 [0.08; 0.95]). Further, previous smoking was not associated with negative effects in patients with CD in terms of early need for biologics, surgery, or hospitalization. In terms of diets, daily consumption of fruits (aOR=0.27 [0.07; 0.99]) or vegetables (aOR=0.27 [0.09; 0.80]) was inversely associated with stricturing CD, whereas whole meal bread was associated with reduced risk of severe CD activity (aOR=0.40 [0.16; 0.98]). This prospective population-based study highlighted several environmental factors associated with the initial severity and activity of IBD, emphasizing their pivotal role in the initial disease burden and giving guidance to personalized patient counseling.

Complication Rates Following Endoscopic Sinus Surgery for Chronic Sinusitis.

Endoscopic sinus surgery (ESS) is a minimally invasive procedure indicated for medically refractory chronic sinusitis (CRS). As with any surgical procedure, there are potential risks and complications. The purpose of this study is to report skull base, orbital, and hemorrhagic-associated complication rates following ESS. A retrospective query on the TriNetX platform identified patients diagnosed with CRS who subsequently underwent ESS in the last 20 years. Outcomes analyses were performed to determine the incidence of skull base (cerebrospinal fluid rhinorrhea, bacterial meningitis, dural tear), orbital (diplopia, optic nerve injury, blindness, epiphora, orbital hemorrhage, canthotomy/canthoplasty), and hemorrhagic (epistaxis, carotid artery injury, blood transfusion) complications within 30 days postoperatively. Kaplan-Meier Analysis estimated survival probability from each complication type. Outcome rates were also compared between female and male patients. A total of 116 669 patients from 55 healthcare organizations fit the study criteria. The average age at surgery was 47.9 ± 17.9 years. The gender distribution of the cohort was 50% female and 48% male. The risk of skull base, orbital, and hemorrhagic complications within 30 days of the surgery was found to be 0.212%, 0.741%, and 3.00%, respectively. Kaplan-Meier Analysis revealed that survival probability from each complication type was 99.783%, 99.260%, and 96.903%, respectively. Comparison of outcome risks stratified by gender revealed no major differences for skull base and orbital complications; however, males exhibited a significantly higher risk of hemorrhagic complications (3.2% vs 2.8%, P < .0001). The study supports ESS as a safe procedure for the management of CRS. Though rare, hemorrhagic complications are more common than orbital and skull base complications. Hemorrhagic complications are also more common in men than women. These findings provide insights for counseling patients about ESS risks and benefits.

P-1547. Real-World Patient Insights Inform an Action-Oriented Healthcare Professional (HCP) Educational Initiative to Address Gaps in Uncomplicated Urinary Tract Infection (uUTI) Management

Abstract Background uUTIs are among the most common outpatient infections and reasons for antibiotic use. This project aimed to understand the real-world burden of UTIs on patients, uncover HCP challenges in uUTI management, and educate HCPs to improve knowledge of guidelines and align clinical practices with patient priorities.Table 1.Demographics of Women Who Experience UTIs Who Participated in the Patient Survey (N = 413). Methods Patient surveys were distributed nationwide to women who experience UTIs (Table 1). Baseline HCP surveys were administered in 6 clinics that treat UTIs in the southeast US (Table 2). Survey outcomes informed live education sessions with each clinic from 10/2023 – 2/2024, featuring pre-/post-session surveys and team-based action planning.Table 2.HCP Baseline Survey Participant Demographics (N = 94). Results Outcomes from the patient survey revealed the extensive burden of UTIs on quality of life (N = 413, Fig 1). Patients experienced 4 UTIs in the last year on average and reported the most difficult aspect of experiencing UTIs was fear of recurrence (49%), with 79% of patients seen in urology clinics and 66% of patients seen in infectious disease clinics agreeing they were frequently concerned about recurrence versus 58% of patients seen in other clinics (p &amp;lt; .001 and p = .217, respectively). HCPs (N = 94) also reported their top challenge in uUTI care was management of persistent or recurrent infections (54%) and felt they could most improve on antibiotic stewardship (47%) and aligning clinic protocols with the latest guidelines (42%). HCP education sessions led to improvements in knowledge and confidence in uUTI management. After sessions, more HCPs correctly selected 5 days of nitrofurantoin as a first-line uUTI treatment (85% vs 61%, p &amp;lt; .001) and reported high confidence in applying the latest guidelines (72% vs 40%, p &amp;lt; .001) than before. Patient survey data presented to HCPs during sessions showed patients thought their care teams could most improve on counseling about antibiotic side effects (50%) and education about risks of frequent antibiotic use (47%). In response, 93% of HCPs committed to counseling patients about antibiotic use and UTI prevention and clinic action plans included expansion of patient education efforts.Figure 1.Real-World Patient Insights on UTI Burden. Conclusion This initiative offers real-world insights on the burden of UTIs on patients and demonstrates the potential impact of patient-informed education on HCP knowledge and clinical practice in uUTI care. Disclosures Kalpana Gupta, MD MPH, GlaxoSmithKline: Advisor/Consultant|Iterum Therapeutics: Advisor/Consultant|PhenUtest Diagnostics: Advisor/Consultant|Qiagen: Advisor/Consultant|Up to Date: Royalties|Utility Therapeutics: Advisor/Consultant Kara Cossis, MPH, PA-C, Amgen: Honoraria|Astellas: Advisor/Consultant|AstraZeneca: Advisor/Consultant|Bayer: Advisor/Consultant|Janssen: Advisor/Consultant|Myriad: Advisor/Consultant|Tolmar: Advisor/Consultant

Nurse Perspectives on Labor Union Participation Prior to Implementation of a Collective Bargaining Agreement: A Qualitative Study.

Background: Patient advocacy is a duty for professional nurses; however, not all nurses are empowered to advocate for meeting patients' needs. Participation in labor unions may serve as a venue for nurses with limited institutional decision-making authority to advocate for patient needs; however, unionization can be a time-intensive and fraught process. Purpose: This study examined how nurses participating in a new union in an urban United States hospital described their reasons for participating in a labor union during collective bargaining. Methods: Content analysis of participant's interviews that took place between January and March 2023, after the nurses voted to unionize and collective bargaining had commenced but progress had stalled, and before additional actions (e.g., informational picketing, labor strikes) were authorized by union members. Findings: Content analysis generated three themes: (a) systemic barriers to advocacy, (b) unionization as an advocacy method, and (c) professional empowerment through unionization. Nurses in this study perceived barriers to meeting patient care needs that were insufficiently addressed prior to unionization. They described their motivation to participate in the union due to their desire to advocate despite adversity and finding empowerment through union activities. Implications for Practice: This study highlights the need for equity in decision-making authority and greater opportunities for nurses to effect workplace changes.

A Prototype "Smart" 3-Dimensionally Printed Model Showcasing Interactivity: Implementing Voice Command for the Ventricular and Cisternal Systems.

The next step in the evolution of static 3-dimensionally (3D) printed models may be the creation of "smart" models, where subcomponents can be seamlessly interacted with through a feedback mechanism, with potential applications in trainee education and patient counseling. Considering the complexity of the ventricular and cisternal systems, they were chosen for segmentation, using Materialize InPrint with outward hollowing using 2.5-mm wall thickness. After 3D printing, dedicated holes were drilled for placement of wired light emitting diodes (LEDs) in anatomical landmarks and connected to an Arduino Uno microcontroller. This was coupled to a Bluetooth transceiver for communication via an Android cellular device. C++ was used to match each LED to a particular pin number on the Arduino board. When the user verbalizes a structure, the Bluetooth sends a command to the Arduino, where the code looks for the "trigger word," subsequently sending a signal to illuminate the corresponding LED. The system requires wireless/cellular data for communication with the voice recognition engine on the Google server. The described method may serve as a prototype for when 3D printers are capable of simultaneously printing conductive material or wiring along with the main material within a model to allow for integration of feedback devices.

Pre-operative Emergency Department Usage Is a Sentinel Marker of Worsened Posterior Lumbar Interbody Fusion Outcome.

Utilization of the emergency department (ED) is associated with medical and social comorbidities. These factors may also be associated with medical complications after complex surgeries. This study investigated how pre-operative ED use increases risk of posterior lumbar interbody fusion (PLIF) complications. We identified adult PLIF patients between 2016-2019 in the PearlDiver Claims Database. Clinical variables including Pre-operative ED use within 180 days were collected using International Classification of Disease (ICD-10) codes. Risk difference was calculated, and multivariable regression was performed. This study included 13,010 (21.1%) patients who went to the ED before surgery and 48,065 (78.9%) who did not. Having a pre-operative ED visit significantly increased risk of a post-operative ED visit by 28.7 percentage points, 90-day readmission by 3.8 percentage points, and 30-day major-medical complications by 3.4 percentage points. Risk of these outcomes increased in a dose-dependent fashion. Compared to patients with zero pre-operative ED visits, patients who had six or more pre-operative ED visits had an 82.0 percentage point increase in risk for a post-operative ED visit, a 46.5 percentage point increase for six or more ED visits, a 6.1 percentage point increase for major medical complications, and 10.6% increase for readmission. Patients with any pre-operative ED visit had an increased risk for post-operative ED use, readmission, and medical complications. The risk difference increased with each additional pre-operative visit. Patient counseling and protocols that reduce preventable ED visit in the pre-operative period may reduce a patient's risk for costly post-operative complications.

Tumour size is associated with growth rates of >0.5 cm/year and delayed intervention in small renal masses in patients on active surveillance.

To evaluate the association between tumour size and the growth rate (GR) of small renal masses (SRMs) in patients managed by active surveillance (AS). We queried the prospective, multi-institutional Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry for patients on AS with an imaging interval of ≥6 months, identifying 456 patients. We tracked tumour size over time; a GR >0.5 cm/year was defined as a GR event. We used multivariable recurrent events and time-to-event Cox regression modelling to evaluate the association between tumour size and GR events (primary outcome) and tumour size and delayed intervention (DI; secondary outcome). We tested tumour size as a continuous variable and dichotomised tumour size by predefined (2-cm) and calculated (2.9-cm) cutoffs. We calculated the cutoff using maximally selected rank statistics and time to progression, defined according to the DISSRM registry. The median (interquartile range) follow-up of patients on AS was 40.1 (26.4-71.2) months, during which 128 patients (28%) had ≥1 GR event, and 80 (18%) underwent DI. Larger tumour size was an independent predictor for GR events and DI when tested as a continuous and a dichotomous variable in multivariable analyses (all P < 0.05). The association was strongest when accounting for the change in tumour size over time and when applying the 2.9-cm cutoff. The study is limited by the mixed tumour pathology inert to SRMs. Larger tumour size was independently associated with GR events and DI for patients with SRMs on AS. A 2.9-cm cutoff may provide valuable information for patient counselling.

Exploring the Social Media Discussion of Breast Cancer Treatment Choices: Quantitative Natural Language Processing Study.

Early-stage breast cancer has the complex challenge of carrying a favorable prognosis with multiple treatment options, including breast-conserving surgery (BCS) or mastectomy. Social media is increasingly used as a source of information and as a decision tool for patients, and awareness of these conversations is important for patient counseling. The goal of this study was to compare sentiments and associated emotions in social media discussions surrounding BCS and mastectomy using natural language processing (NLP). Reddit posts and comments from the Reddit subreddit r/breastcancer and associated metadata were collected using pushshift.io. Overall, 105,231 paragraphs across 59,416 posts and comments from 2011 to 2021 were collected and analyzed. Paragraphs were processed through the Apache Clinical Text Analysis Knowledge Extraction System and identified as discussing BCS or mastectomy based on physician-defined Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) concepts. Paragraphs were analyzed with a VADER (Valence Aware Dictionary for Sentiment Reasoning) compound sentiment score (ranging from -1 to 1, corresponding to negativity or positivity) and GoEmotions scores (0-1) corresponding to the intensity of 27 different emotions and neutrality. Of the 105,231 paragraphs, there were 7306 (6.94% of those analyzed) paragraphs mentioning BCS and mastectomy (2729 and 5476, respectively). Discussion of both increased over time, with BCS outpacing mastectomy. The median sentiment score for all discussions analyzed in aggregate became more positive over time. In specific analyses by topic, positive sentiments for discussions with mastectomy mentions increased over time; however, discussions with BCS-specific mentions did not show a similar trend and remained overall neutral. Compared to BCS, conversations about mastectomy tended to have more positive sentiments. The most commonly identified emotions included neutrality, gratitude, caring, approval, and optimism. Anger, annoyance, disappointment, disgust, and joy increased for BCS over time. Patients are increasingly participating in breast cancer therapy discussions with a web-based community. While discussions surrounding mastectomy became increasingly positive, BCS discussions did not show the same trend. This mirrors national clinical trends in the United States, with the increasing use of mastectomy over BCS in early-stage breast cancer. Recognizing sentiments and emotions surrounding the decision-making process can facilitate patient-centric and emotionally sensitive treatment recommendations.

Obstetrical Catastrophe: Ruptured UterusIncidence, Risk Factors, Fetomaternal Outcome and Management in Ad-Din Women’s Medical College and Hospital, Dhaka, Bangladesh

Background: A ruptured uterus is a catastrophic condition. It is associated with a high incidence of fetal and maternal mortality and morbidity. Objective: To determine the incidence, risk factors, maternal and fetal outcome, and management of uterine rupture in Ad-din Women’s Medical College and Hospital, Dhaka, Bangladesh. Materials and Methods: This prospective observational study of patients with ruptured uterus from July 2022 to June 2023 admitted at Gynaecology and Obstetrics department of Ad-din Women’s Medical College and Hospital, Dhaka. All the cases of ruptured uterus who were either admitted with ruptured uterus or who developed it in hospital were included in the study. Patients were initially assessed in emergency and labor wards, and relevant sociodemographic data, obstetric history, and previous antenatal and surgical history were recorded. Ways of management, and maternal and fetal outcomes were taken for analysis. Results: There were 45 cases of ruptured uterus out of a total of 17,288 deliveries over one year with a prevalence of 0.26%. The most common age group was 30-35 years, and most of the patients 37(82.2%) had a history of previous cesarean section. A maximum of 24 (53.3%) rupture of the uterus was found &gt;36-40 weeks. Subtotal hysterectomy was done in 4 (8.9%) patients, and Subtotal hysterectomy with the repair of the bladder was done in 2 (4.4%) patients, out of 45 patients, 4 (8.9%) patients developed acute renal failure and maternal death was found 4 (8.9%) patients. IUFD was found in 21 (46.7%) babies, 10 (22.2%) babies needed NICU and neonatal death was found in 4 (8.9%) babies. Conclusion: Uterine rupture is a preventable obstetric complication that carries severe risks both to the mother and to the baby. Proper antenatal care, appropriate counseling of patients with a history of previous caesarian section for hospital delivery, and training of skilled birth attendants can reduce maternal and perinatal mortality and morbidity due to ruptured uterus. The Journal of Ad-din Women's Medical College; Vol. 12 (2), July 2024; p 5-10

A Framework to Optimize Primary Care of Older Surgical Patients

An increasing number of older adults are undergoing surgery. Older adults face significant challenges throughout the spectrum of perioperative care. No frameworks exist to support primary care clinicians in helping older adults navigate perioperative care beyond preoperative medical clearance. We aimed to develop a framework to assist primary care clinicians in surgical care navigation for older patients. This qualitative study used semistructured interviews with a sample of geriatricians from across the US between January and June 2022. Interviews were conducted one on one via an online video conferencing platform without observers present. Demographics of participants were analyzed using descriptive statistics. Directed content analysis of interview data was used to examine how primary care clinicians can optimally support older patients throughout the perioperative process. This qualitative study included 24 geriatricians, 16 (67%) women, with median time in practice of 12.4 years (IQR, 5.0-24.5 years). Of those, 11 (46%) worked at an academic or tertiary referral center. Qualitative analysis identified 7 actions that geriatricians perform when caring for patients through the surgical continuum: conduct risk-benefit analysis of surgical referral, elicit and communicate patient goals, prepare patient and family for surgical consultation, set realistic expectations, assist with decision about surgery, advocate for patient and family, and coordinate postoperative care. In this qualitative study of geriatricians, 7 key domains of perioperative care for older adults were identified. The resulting framework can be used by primary care clinicians as they help their older patients navigate surgical care.

Optimizing iron absorption: Superiority of alternate day dosing

Dear Madam, Pakistan is one of the leading countries in iron deficiency and iron deficiency anaemia, ranking 2nd in South Asia, involving 53% of children under the age of 5 years along with 41.7% of women of reproductive age.[1] Last assessed by the National Nutritional Survey (year of the survey?). Pakistan had suffered a total economic loss, over 10 year period of 12.25 billion dollars which makes it essential to focus on controlling risk factors to prevent this prevailing issue.[2] This can be done by the use of iron supplements. In a randomised double-blind placebo-controlled study, patients receiving iron supplementation on alternative days for 6 months as opposed to consecutive day-intake for 90 followed by a placebo for a subsequent 90 days were studied. While the baseline variables showed little difference amongst the two groups, after 6 months the prevalence of iron deficiency was 11.4% in the consecutive day group versus 3% in the alternative day group (P= 0.049.) Despite the variation in serum ferritin at days 46 and 93, 4 months post treatment, median serum ferritin remained higher in the alternate day group as compared to the consecutive day group(P=0.03.). At equal iron doses, in consecutive and alternate day groups, the latter experienced fewer gastrointestinal adverse effects. Serum hepcidin was consistently higher in the consecutive-day group at various points (P &lt; 0.001), with a significant difference at the end of treatment. This can be attributed to the upregulation of serum hepcidin by acute intake of iron doses and the resulting increase in liver stores over the course of 3 months.[3] This corroborated previous research that dosing oral iron intake in this method held superiority in efficacy and in lowering iron deficiency amongst individuals. The general population should be aware of the correct use of iron supplements to ensure maximum efficacy as awareness has been found to significantly impact adherence. .[4] Studies in Pakistan have not investigated this aspect of iron supplementation and it is essential that such aspects be explored in a third world country like Pakistan as alternate day iron supplementation would prove to be more economical for patients. Also, reduced Gastrointestinal side effects would improve patient compliance leading to more favourable results. Moreover, physicians should also be made aware to ensure proper counselling of patients leading to favourable outcomes.

Frequency and Molecular Characteristics of Mismatch Repair-deficient Status among Multiple Synchronous Colorectal Cancers

Mismatch repair (MMR)-deficient (dMMR) colorectal cancer (CRC) have been largely categorized into three subtypes: MLH1-methylated, Lynch syndrome (LS)-associated, and Lynch-like syndrome (LLS)-associated. No studies have examined the prevalence and subtypes of synchronously diagnosed dMMR CRCs in detail. Therefore, this study aimed to examine the frequency and molecular characteristics of the dMMR status among multiple synchronous CRCs to clarify the clinical significance of identifying patients with such tumors. Immunohistochemistry (IHC) of MMR proteins (MLH1, MSH2, MSH6, and PMS2) was performed for surgically and endoscopically resected (in conjunction with surgical resection) lesions from consecutive patients with initially diagnosed multiple synchronous CRCs between July 2014 and June 2020. When necessary, MLH1-methylation analysis and testing of germline and somatic MMR genes were performed. In total, 133 patients (33 females) had 309 lesions. The combinations of synchronous tumor sites were the left-sided colon/rectum only (n=67, 50.4%), both the right-sided colon and left-sided colon/rectum (n=42, 31.6%), and the right-sided colon only (n=24, 18.0%). IHC showed a loss of expression of at least one MMR protein in 10 (7.5%) of 133 patients and 17 (5.5%) of 309 lesions. Molecular analysis revealed that these 10 patients were categorized as having MLH1-methylated (n=5, 3.8% of all patients), LS-associated (n=4, 3.0%), or LLS-associated (n=1, 0.8%) CRC. Our data will be useful for genetic counseling in patients with synchronous CRCs suspected of having LS. Screening for LS using IHC for MMR proteins in individuals with multiple synchronous CRCs is an effective approach.

Radiotherapy toxicities: mechanisms, management, and future directions.

For over a century, radiotherapy has revolutionised cancer treatment. Technological advancements aim to deliver high doses to tumours with increased precision while minimising off-target effects to organs at risk. Despite advancements such as image-guided, high-precision radiotherapy delivery, long-term toxic effects on healthy tissues remain a great clinical challenge. In this Review, we summarise common mechanisms driving acute and long-term side-effects and discuss monitoring strategies for radiotherapy survivors. We explore ways to mitigate toxic effects through novel technologies and proper patient selection and counselling. Additionally, we address policies and management strategies to minimise the severity and impact of toxicity during and after treatment. Finally, we examine the potential advantages of emerging technologies and innovative approaches to improve conformity, accuracy, and minimise off-target effects.