Delivery Of Appropriate Therapy Research Articles

Laryngeal carcinoma with hemorraghic varicella : a rare case report

Background : Hemorrhagic varicella is a complication that usually occurs in patients with immune disorders or those on immunosuppressive therapy or hematologic malignancies such as leukemia. Purpose: This case report aimed to further examine the complications of a rarely found hemorrhagic varicella in neck head malignancies / laryngeal carcioma. Case report : This is a case report of laryngeal carcinoma with hemorrhagic varicella in a 44-year-old man. Examination of dermatological status revealed hemorrhagic, polymorphic vesicles, generalized pustular psoriasis, erosion and, crusting. Tzanck test of the scrapes of the base of lesion of the vesicles is helpful in establishing the diagnosis of varicella and discovered multinucleated giant cells (MGCs) and epithelial cells with acidophilic intranuclear inclusion bodies The patient died after 3 days of treatment in the isolation room. A previous study also reported cases of hemorrhagic varicella in a 3-year-old girl with the main complaint of pus-filled red spots throughout the body. A previous history of chickenpox was denied. The physical examination showed dark red, polymorphic lession, generalized pustular psoriasis, erosion and crusting. Hemorrhagic varicella in the head and neck malignancy is a very rare form of varicella. Clinical question: In patient with immunocompromised during chemotheraphy suffer from varicella, is it necessary to have a comprehensive diagnostic examination panel, and therapy? Review methods: Evidence-based literature search with keywords “immunocompromised” AND “Hemorrhagic varicella” was performed through Cochrane, PubMed and Medline database. Result : The literature search obtained 318 articles in PubMed, 11 articles in Medline,and none in Cochrane, which were relevant with the topic. Only 1 article screened with inclusion and exclusion criteria. A research was conducted by Elizabeth et al in Philipina (2011) on Pediatric Infectious Disease and Hematology-Oncology Services. Out of 26 immunocompromised patients who developed varicella during the study period, only 22 charts were available for review. Of these patients, 13 were male and 9 were female. The highest incidence occurred from 0 to 5 years old (41%). Twenty patients had an underlying malignancy in the form of leukemia (14%) and solid organ tumors (6%) including nasopharyngeal cancer. Diagnosis based on the characteristic generalized papulovesicular rashConclusion : This requires a comprehensive diagnostic panel test for the delivery of appropriate therapy and improved outcome.

Electrochemical point-of-care devices for the diagnosis of sepsis.

Sepsis is a life-threatening dysfunction of organ systems caused by a dysregulated immune system because of an infectious process. It remains one of the leading causes of hospital mortality and of hospital readmissions in the United States. Mortality from sepsis increases with each hour of delayed treatment, therefore, diagnostic devices that can reduce the time from the onset of a patient's infection to the delivery of appropriate therapy are urgently needed. Likewise, tools that are capable of high-frequency testing of clinically relevant biomarkers are required to study disease progression. Electrochemical biosensors offer important advantages such as high sensitivity, fast response, miniaturization, and low cost that can be adapted to clinical needs. In this review paper, we discuss the current state, limitations, and future directions of electrochemical-based point-of-care detection platforms that contribute to the diagnosis and monitoring of sepsis.

Application of PLASMIC Score in Risk Prediction of Thrombotic Thrombocytopenic Purpura: Real-World Experience From a Tertiary Medical Center in Taiwan.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder caused by severe ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) deficiency (activity <10%). Urgent intervention based on the timely evaluation of ADAMTS13 level is crucial to guide optimal therapy. The recently developed PLASMIC score based on seven items allows the rapid identification of patients at high risk for TTP due to severe ADAMTS13 deficiency. This retrospective study included 31 hospitalized patients with suspicious thrombotic microangiopathy in National Cheng Kung University Hospital from December 2016 to July 2021. Data on ADAMTS13 activity and medical and laboratory information were retrieved from medical records. The PLASMIC score could be calculated in 24 of the 31 patients with available data, and the final cohort was stratified according to the 7-point PLASMIC score. All patients with high PLASMIC score (6–7) exhibited severe ADAMTS13 deficiency (activity ≤10%). One patient with a brain tumor and a PLASMIC score of 6 did not have severe ADAMTS13 activity of ≤10%. The patients in the intermediate- and low risk groups (PLASMIC scores of 5 and 0–4, respectively) exhibited ADAMTS13 activities of above 10%. Given the role of prompt diagnosis in the timely delivery of appropriate therapy, these findings confirm and strengthen the predictive value of the PLASMIC score in patients at high risk for TTP due to severe ADAMTS13 deficiency.

Pearls from the First Gulf Cardiac Amyloidosis Summit 2021

Abstract: These proceedings from the First Gulf Cardiac Amyloidosis Summit held in June 2021 aimed to increase awareness of cardiac amyloidosis among the wider medical community in the region. Although the clinical presentation of cardiac amyloidosis is highly variable, a number of ‘red flags’ have been identified to raise suspicion of the disease and prompt further investigation. Accurate diagnosis of cardiac amyloidosis is challenging and relies on the integration of clinical, imaging and laboratory investigations. Recent imaging techniques, including bone scintigraphy together with a complete serum and urine workup, allow, in the majority of patients, accurate non-invasive diagnosis without the need for confirmatory endomyocardial biopsies. Early differential diagnosis between light-chain (AL) amyloidosis and amyloid transthyretin amyloidosis (ATTR) is critical for timely delivery of appropriate therapy. AL amyloidosis is a medical emergency requiring chemotherapy and supportive care. Treatment for ATTR-amyloidosis is most effective when administered early, before development of significant symptoms or cardiac dysfunction. Optimal management of patients involves close collaboration between multidisciplinary specialists, which may include hematologists, cardiologists, and other subspecialists, ideally at a designated specialty center with interest and expertise in amyloidosis.

Fatiga y Calidad de vida en niños, niñas y adolescentes con cáncer hematológico

Introducción: La fatiga es un problema relevante en pacientes con cáncer hematológico y puede ser un motivo de reducción importante de la calidad de vida. El objetivo del presente estudio fue realizar un estudio descriptivo de un grupo de niños y adolescentes portadores de neoplasias de origen hematológico en un centro único de referencia.&#x0D; Metodología: El presente estudio observacional tiene un corte retrospectivo, en donde se incluyeron pacientes menores a 18 años con el diagnóstico de cáncer hematológico en quienes se revisó la historia clínica y se realizó un test de calidad de vida. Se realiza un análisis de correlación entre las variables usando estadística no paramétrica.&#x0D; Resultados: ingresaron al estudio 64 pacientes. De sexo masculino (n=37) y femenino (n=27). El valor medio de fatiga fue (5.72 ± 0.53 y 5.85 ± 0.51), en actividad física y salud (1.49 ± 0.17 y 1.44 ± 0.13) en hombres y mujeres respectivamente. El valor medio de edad fue de 5.81 ± 2.46 en el rango de 2 a 10 años y 14.55 ±2.15 en el rango de 11 a 18 años. Según el rango etario existió más predominancia de fatiga en niños que en adolescentes y más en mujeres que en hombres.&#x0D; Conclusión: No se encontró relación entre las variables de estudio. Sin embargo, los hallazgos expuestos indican una marcada sensación de fatiga siendo esta moderada pudiendo convertirse en seve-ra; de igual manera se obtuvo niveles bajos y medios de calidad de vida en las similares di-mensiones incluidas en las baterías de evaluación; sugiriendo futuras investigaciones inclu-yendo colaboración de abordaje multidisciplinaria para llegar a impartir las terapias adecuadas que beneficien a los pacientes con cáncer.

Subcutaneous Implantable Cardioverter-Defibrillators in Pediatrics and Congenital Heart Disease: A Pediatric and Congenital Electrophysiology Society Multicenter Review.

The primary goal of this study was to evaluate the implant experience and midterm results of subcutaneous implantable cardioverter-defibrillators (S-ICDs) in pediatric patients and those with congenital heart disease. The S-ICD was developed to avoid the lead-related complications associated with transvenous systems. The absence of intravascular or intracardiac components offers potential advantages to pediatric patients and those with congenital heart disease. This international, multicenter, retrospective, standard-of-care study was conducted through the Pediatric & Congenital Electrophysiology Society. Complications at 30 and 360days, inappropriate shocks, and delivery of appropriate therapy were assessed. The study included 115 patients with a median follow-up of 32 (19 to 52) months. Median age was 16.7 years (14.8 to 19.3 years), 29% were female, and 55% had a primary prevention indication. Underlying disease substrate was cardiomyopathy (40%), structural heart disease (32%), idiopathic ventricular fibrillation (16%), and channelopathy (13%). The complication rate was 7.8% at 30days and 14.7% at 360days. Overall, inappropriate shocks occurred in 15.6% of patients, with no single clinical characteristic reaching statistical significance. At implant, 97.9% of patients had successful first shock conversion with 96% requiring≤65 J. Appropriate therapy was delivered to 11.2% of patients with an annual incidence of 3.9% and an acute first shock conversion success rate of 92.5%. This study found that in a heterogeneous population of pediatric patients and those with congenital heart disease, the S-ICD had comparable rates of complications, inappropriate shocks, and conversion efficacy compared with previously published studies on transvenous systems in similar populations.

Characteristics and etiology of hospitalized pediatric community-acquired pneumonia in Taiwan

Background/purposeThe purpose of this study was to determine the pathogens and to estimate the incidence of pediatric community-acquired pneumonia (CAP) in Taiwan.MethodsThis prospective study was conducted at eight medical centers from November 2010 to September 2013. Children aged 6 weeks to 18 years who met the radiologic criteria for pneumonia were enrolled. To detect classical and atypical bacteria and viruses, blood and pleural fluids were cultured, and respiratory specimens were examined by multiple conventional and molecular methods.ResultsAt least one potential pathogen was identified in 705 (68.3%) cases of 1032 children enrolled, including bacteria in 420 (40.7%) cases, virus in 180 (17.4%) cases, and mixed viral-bacterial infection in 105 (10.2%) cases. Streptococcus pneumoniae (31.6%) was the most common pathogen, followed by Mycoplasma pneumoniae (22.6%). Adenovirus (5.9%) was the most common virus. RSV was significantly associated with children aged under 2 years, S. pneumoniae in children aged between 2 and 5 years, and M. pneumoniae in children aged >5 years. The annual incidence rate of hospitalization for CAP was highest in children aged 2–5 years (229.7 per 100,000). From 2011 to 2012, significant reduction in hospitalization rates pertained in children under 5 years of age, in pneumonia caused by pneumococcus, adenovirus or co-infections and complicated pneumonia.ConclusionCAP related pathogens have changed after increased conjugated pneumococcal vaccination rates. This study described the latest incidences and trends of CAP pathogens, which are crucial for prompt delivery of appropriate therapy.

Impact of Oncology Care Model (OCM) reporting requirements on quality of care.

6620 Background: The OCM is a voluntary Center for Medicare and Medicaid Innovation alternative payment model pilot program. As of Oct 2017, OCM practices are required to report the biomarker status for NSCLC pts. Our objective was to assess the effect of OCM reporting on quality of care in aNSCLC. Methods: We developed a decision-analytic model to compare the likelihood of receiving biomarker testing and corresponding appropriate therapy. We populated the model using real-world data from pts (n=7,075) at OCM sites (n=45) and non-OCM sites (n=105) in the Flatiron Health electronic health record (EHR)-derived database. The pre-period control included pts diagnosed with aNSCLC from Jan 1, 2011 - Dec 31, 2015; the post-period included pts diagnosed Oct 2017 - Nov 2018. For OCM vs non-OCM sites, we estimated probabilities and unadjusted odds ratio (OR) of biomarker testing (EGFR, ROS1, or ALK) and subsequent delivery of appropriate therapy, defined as use of a biomarker-guided tyrosine kinase inhibitor (TKI) for positive pts, or non-TKI therapy for negative pts. Results: No differences in rates of biomarker testing or delivery of appropriate therapy were detected between OCM and non-OCM practices prior to the reporting requirement. In the post-period, OCM was associated with higher odds of biomarker testing and appropriate therapy (Table). Conclusions: To our knowledge, this is the first study of the association of OCM reporting requirements with downstream quality of care. Our results suggest that OCM documentation and reporting requirements are associated with modestly higher quality of care for pts with aNSCLC. Ongoing sensitivity analyses will determine the relative contribution of provider and practice characteristics to these findings. Careful measurement of the impact of reporting requirements is essential to measure the impact of payment reform interventions and inform policy. [Table: see text]

Improving Guideline Compliance in Australia With a National Percutaneous Coronary Intervention Outcomes Registry

Secondary prevention strategies after percutaneous coronary intervention (PCI) include statins and dual anti-platelet therapy, however there are significant gaps between guidelines and practice. Contemporary PCI practice requires comprehensive data collection to allow dynamic auditing and benchmarking of key performance and safety indices. Genesis HeartCare is Australia's largest collaborative venture of cardiologists, practising at over 40 public and private hospitals. We hypothesised that measurement and local reporting of data would improve patient outcomes through improving compliance with guideline therapies. Real-time benchmarking via a national clinical quality and outcomes register, the Genesis Cardiovascular Outcomes Registry (GCOR-PCI). GCOR-PCI prospectively collected clinical, procedural, medication and outcomes data for 6720 consecutive patients undergoing PCI from 10 private hospitals across Australia. Key performance outcomes benchmarked against the aggregated study cohort and international standards were reported to individual sites. The main outcome measure was compliance with guideline medications (statins, anti-platelet agents). Early data identified specific practice patterns associated with lower rates of statin therapy post-PCI, which led to changes in practice. Between the first and latest year of data collection there was significant improvement in the rates of statin therapy at discharge (92.1 vs. 94.4% p<0.03) and 12 months post-PCI (87.0 vs. 92.2% p<0.001) and of antiplatelet therapy at 12 months (90.7 vs. 94.3% p<0.001). This large-scale collaboration provides a platform for the development of quality improvement initiatives. Establishment of this clinical quality registry improved patient care by identifying and monitoring gaps in delivery of appropriate therapies, driving key practice change.

Increasing age does not affect time to appropriate therapy in primary prevention ICD/CRT-D: a competing risks analysis.

To evaluate the impact of age on the clinical outcomes in a primary prevention implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) population. A retrospective, multicentre analysis of patients aged 60 years and over with primary prevention ICD/CRT-D devices implanted between 1 January 2006 and 1 November 2014 was performed. Survival to follow-up with no therapy (T1), death prior to follow-up with no therapy (T2), delivery of appropriate therapy with survival to follow-up (T3), and delivery of appropriate therapy with death prior to follow-up (T4) were measured. In total, 424 patients were eligible for inclusion in the analysis, mean follow-up of 32.6 months during which time 44 patients (10.1%) received appropriate therapy. The sub-hazard ratio (SHR) for the cumulative incidence of appropriate therapy (T3) according to age at implant was 1.00 (P = 0.851; 95% CI 0.96–1.04). The SHR for cumulative incidence of death (T2) according to age at implant was 1.06 (P < 0.001; 95% CI 1.03–1.01). Age at implant, ischaemic aetiology, baseline haemoglobin, and the presence of diabetes mellitus were predictors of all-cause mortality. Age has no impact on the time to appropriate therapy, but risk of death prior to therapy increases by 6% for every year increment. As the ICD population ages, the proportion who die without receiving appropriate therapy increases due to competing risks. Characterizing competing risks predictive of death independent of ICD indication would focus therapy on those with potential to benefit and reduce unnecessary exposure to ICD-related morbidity.

Noninvasive, Highly Specific Detection of T790M-Mediated Acquired Resistance in EGFR Mutant NSCLC Using a Novel Droplet Digital PCR (ddPCR)–Based Cell-free Plasma DNA (cfDNA) Assay: Translational Research

The T790M mutation is the most common cause of acquired resistance to EGFR kinase inhibitors, occurring in more than 50% of patients. Promising mutant-specific third generation EGFR kinase inhibitors are being developed. However, selection of candidates for these therapies requires invasive re-biopsy for tissue genotyping. We recently reported on a new assay for plasma genotyping using ddPCR of cfDNA. This plasma genotyping assay has the potential to noninvasively detect T790M and accelerate delivery of appropriate therapies – potentially obviating the need for biopsy entirely.

Internet Highs—Seizures After Consumption of Synthetic Cannabinoids Purchased Online

Since 2004, a new wave of synthetic cannabinoids (SCs) known as "Spice drugs" has come under scrutiny because of their suspected link to neurological and psychiatric sequelae. These "herbal incense" or "potpourri blends" have gained popularity as a result of being more potent than natural cannabinoids, are not detected with current screening tests, and are easily modified by manufacturers to bypass legal restrictions. Unfortunately, cases of withdrawal phenomena, nausea, hypertension, and psychosis are now being reported in the medical literature. In addition, after reports in lay media of seizures and coma attributed to the consumption of the drug, anecdotal reports have emerged of similar findings in the medical literature. We report on a 48-year-old man who, after consuming the herbal blend, lost consciousness and suffered several episodes of seizures. Despite a complicated ICU stay, the patient recovered well with no subsequent neurological sequelae. The authors interpreted the history and findings consistent with the consumption of a large amount of synthetic cannabinoids leading to new-onset seizures and coma. However, at the time of admission, the lack of routine laboratory testing and treatment options delayed the diagnosis and delivery of appropriate therapy.

Potential Reductions in United States Coronary Heart Disease Mortality by Treating More Patients

Approximately one half of the recent decline observed in age-adjusted coronary heart disease (CHD) mortality rates can be attributed to the use of modern medical and surgical interventions. In 2000, however, only about 30% to 60% of eligible patients actually received the appropriate treatment. To examine the reduction in CHD mortality potentially achievable by increasing the provision of specific medical and surgical treatment to eligible patients with CHD in the United States, we integrated the data on CHD patient numbers, medical and surgical treatment uptake levels, and treatment effectiveness using a previously validated CHD policy model. We estimated the number of deaths prevented or postponed for 2000 (baseline) and for an alternative scenario (60% of eligible patients). In 2000, the treatment levels in the United States were generally poor; only 30% to 60% of eligible patients received the appropriate therapy. These treatments resulted in approximately 159,330 fewer deaths. By treating 60% of eligible patients, 297,470 fewer deaths would have been obtained (minimum 118,360; maximum 628,120), representing 134,635 less than in 2000, with approximately 32% from heart failure therapy, 30% from secondary prevention therapy, 19% from acute coronary syndrome treatment, 15% from primary prevention with statins, 0.5% from hypertension treatment, and 1% from coronary bypass surgery for chronic angina. These findings remained stable in the sensitivity analysis. In conclusion, increasing the proportion of eligible patients with CHD who received the appropriate treatment could have achieved approximately 135,000 fewer deaths in 2000, almost doubling the benefit actually achieved. Future strategies should maximize the delivery of appropriate therapies to all eligible patients with CHD and prioritize medical therapies for secondary prevention and heart failure.

FDG-PET for staging of rhabdomyosarcoma

8545 Background: Complete staging of rhabdomyosarcoma is critical for delivery of appropriate therapy. Current diagnostic tools have known limitations. We have evaluated the role of 18F fluorodeoxyglucose positron emission tomography (PET) in the staging of patients with rhabdomyosarcoma. Methods: Since 1997, 60 patients with rhabdomyosarcoma underwent 159 PET scans. Of these, 21 patients with a median age of 11 years had a PET scan as part of their initial staging evaluation, before or within 13 days of initiation of therapy. Twelve patients had alveolar and 9 had embryonal histology. Primary sites included parameningeal (11), extremity (4), trunk (3), bladder/prostate (2), and head and neck (1). Results from CT, MRI, bone scan, and pathology within 1 month of the PET were compared. Results: A total of 83 sites were evaluated. All 21 patients had positive PET scans at the primary site. Twenty six PET positive sites at primary or nodal regions were biopsied and in all sites disease was confirmed. Standardized uptake value (SUV) for the primary site at the time of diagnosis ranged from 2.4 to 12.7 (mean 5.7). All SUVs prior to therapy were ≥4. There was no significant difference in SUV when evaluated by primary site or histology. PET showed involvement of regional lymph nodes in 12 patients. Five of the 12 patients underwent lymph node biopsy, all confirming involvement. In 3 of these cases, CT or MRI failed to detect the regional involvement identified on PET. At 11 sites, CT or MRI was equivocal for detection of regional or distant spread. In these cases, PET confirmed disease in one case and excluded disease in 10 cases. PET failed to capture sites of disease visualized by CT, MRI, or bone scan at 10 sites, including pelvic, paraaortic, mediastinal, cervical and retropharyngeal lymph nodes as well as vertebral bodies. When comparing PET to the final clinical determination of disease extent, PET was 83% sensitive and 97% specific. Conclusion: These preliminary data indicate that PET is a useful adjunct in the initial staging of rhabdomyosarcoma. In 3 of 21 cases (14%), therapy was altered because of nodal disease detected only on PET. A prospective study of PET for staging of rhabdomyosarcoma is warranted. No significant financial relationships to disclose.

Respiratory syncytial virus in blood and marrow transplant recipients.

Nurses caring for blood and bone marrow transplant recipients need to understand the effects that respiratory syncytial virus (RSV) infection can have on transplant recipients, family members, and healthcare providers. With knowledge about the virulence and transmission of RSV, nurses are in a position to educate patients and family, reduce nosocomial spread of the infection, and influence clinical practice. By recognizing specific risk factors for infection, nurses can act as gatekeepers who identify candidates to screen and enhance early detection of infection. Nurses need to possess knowledge of early detection, implement clinical management strategies and precautions, and optimize delivery of appropriate therapy while maintaining a safe environment for all people involved. This article reviews RSV's clinical risk factors, transmission, signs and symptoms, diagnosis, treatment options, and impact on transplant recipients and candidates.

Results of various reconstructive procedures in bone defects of the fronto-facial area

The purpose of this study was to determine the pathogens and to estimate the incidence of pediatric community-acquired pneumonia (CAP) in Taiwan.This prospective study was conducted at eight medical centers from November 2010 to September 2013. Children aged 6 weeks to 18 years who met the radiologic criteria for pneumonia were enrolled. To detect classical and atypical bacteria and viruses, blood and pleural fluids were cultured, and respiratory specimens were examined by multiple conventional and molecular methods.At least one potential pathogen was identified in 705 (68.3%) cases of 1032 children enrolled, including bacteria in 420 (40.7%) cases, virus in 180 (17.4%) cases, and mixed viral-bacterial infection in 105 (10.2%) cases. Streptococcus pneumoniae (31.6%) was the most common pathogen, followed by Mycoplasma pneumoniae (22.6%). Adenovirus (5.9%) was the most common virus. RSV was significantly associated with children aged under 2 years, S. pneumoniae in children aged between 2 and 5 years, and M. pneumoniae in children aged >5 years. The annual incidence rate of hospitalization for CAP was highest in children aged 2–5 years (229.7 per 100,000). From 2011 to 2012, significant reduction in hospitalization rates pertained in children under 5 years of age, in pneumonia caused by pneumococcus, adenovirus or co-infections and complicated pneumonia.CAP related pathogens have changed after increased conjugated pneumococcal vaccination rates. This study described the latest incidences and trends of CAP pathogens, which are crucial for prompt delivery of appropriate therapy.

Etiology of voiding dysfunction in men less than 50 years of age

Objectives Chronic lower urinary tract symptoms in young men are often attributed to misdiagnosed chronic nonbacterial prostatitis. The purpose of this study was to analyze etiology of chronic voiding dysfunction in men less than 50 years of age. Methods The videourodynamic studies of 137 men 50 years of age or less with chronic voiding dysfunction, performed between January 1990 and October 1995, were retrospectively analyzed. Results The distribution of urodynamic abnormalities included 74 (54%) patients with primary vesical neck obstruction, 33 (24%) with obstruction localized to the membranous urethra (pseudodyssynergia), 23 (17%) with impaired bladder contractility, and the remaining 7 (5%) with an acontractile bladder. Detrusor instability was present in 67 men (49%). Conclusions Voiding dysfunction among young men is common and is often misdiagnosed. Videourodynamic evaluation is very useful in establishing the correct diagnosis and ultimately in delivery of appropriate therapy.