Differences In Clinical Management Research Articles

Venous Thromboembolism in Pancreatic Cancer: Unraveling the Paradox of Mortality and Hospitalization Outcomes

Background: Pancreatic cancer is known for its aggressive nature and poor prognosis, with a five-year survival rate of less than 10%. Patients diagnosed with pancreatic cancer face a myriad of complications, one of the most significant being venous thromboembolism (VTE). VTE primarily includes deep venous thrombosis (DVT) and pulmonary embolism (PE), and it represents a major cause of morbidity and mortality in this patient population. The increased risk of VTE in pancreatic cancer patients is attributed to multiple factors. Malignancy itself is a well-recognized hypercoagulable state, largely due to the secretion of pro-coagulant factors by tumor cells. Additionally, pancreatic cancer can induce a systemic inflammatory response, leading to widespread activation of pro-coagulant factors and platelets. This hypercoagulable state is further exacerbated by factors such as immobilization, surgery, chemotherapy, and the presence of central venous catheters, which are common in these patients. Several studies have highlighted the prevalence of VTE in pancreatic cancer patients, suggesting that up to 20-30% of these patients may develop VTE at some point during their disease course. The management of VTE in pancreatic cancer patients is complex, as it requires a balance between preventing thrombosis and minimizing the risk of bleeding, particularly in the context of anticoagulant therapy. Methods: We analyzed real-world evidence from the 2021 Nationwide Inpatient Sample database the Agency of Healthcare Research and Quality (AHRQ). The study included all hospitalized pancreatic cancer patients with both a primary diagnosis of venous thromboembolism. We conducted a comparative analysis of demographic characteristics and clinical outcomes between a cohort of pancreatic cancer patients with VTE as a primary diagnosis and those without VTE. Results: In 2021, there were 76,315 patients with a discharge diagnosis of pancreatic cancer. 2,580 patients (3.38%) had a relevant diagnosis of VTE or PE at the time of hospitalization. The mean age for patients in both the VTE and non-VTE groups was 68 years. 51.1 percent of patients in the VTE group were female compared to 46.5 percent of patients in the non-VTE group (p<0.0001). The mortality rate was 8.62% in the non-VTE group, compared to 6.78% in the VTE group (p<0.0001). Furthermore, patients with pancreatic cancer who developed venous thromboembolism (VTE) were found to have no significant difference in mortality compared to those without VTE during the index hospitalization (p<0.179) after adjusting for sex, race, and age. The odds ratio for length of stay in the VTE group was 1.57 (95% CI: 0.75-3.32, p = 0.230). This suggests that there is no statistically significant difference in hospital stay duration between patients with pancreatic cancer who develop VTE and those who do not. The mean total hospitalization charges for the VTE group was $59,556 and $74,249 for the non-VTE group. Discussion: The presence of VTE in hospitalized pancreatic cancer patients is a critical factor that influences clinical management but does not necessarily worsen the short-term prognosis or increase hospitalization duration. Differences in clinical management between the two groups could also contribute to our findings. Patients who develop VTE may receive more intensive monitoring and treatment, potentially improving their overall outcomes. Conversely, variations in the use of prophylactic anticoagulation and differences in the aggressiveness of VTE treatment could impact mortality and length of stay, independent of the presence of VTE. The non-significant difference in length of stay between the VTE and non-VTE groups may reflect hospital practices and discharge criteria rather than patient outcomes. Hospitals with varying policies on discharge timing and criteria can influence length of stay without directly correlating with mortality. Furthermore, differences in post-hospitalization care and follow-up may play a role, as patients discharged sooner might receive better outpatient care, which is not captured in the dataset. Further research should aim to include a sensitivity analysis and more covariates related to disease severity, co-morbidities, and treatment specifics. This can improve the adjustment for confounding factors and provide a more comprehensive understanding of the factors influencing mortality and length of stay.

Differentiating extradural head and neck arterial fenestrations from other intraluminal abnormalities

Background and PurposeArterial fenestrations are a benign entity arising from a failure of fetal fusion. However, fenestrations in the head and neck may be misinterpreted as carotid webs or dissections. Given differences in clinical management, the differentiation of these entities is imperative. We aim to document the prevalence of these entities on CTA imaging and highlight imaging features for confident differentiation. Materials and MethodsWe retrospectively reviewed head and neck CTA studies performed at our institution over an 18-month period. The extradural common carotid, internal carotid, external carotid, and vertebral arteries were inspected for intraluminal abnormalities. These abnormalities were classified as fenestration, web, or dissection. Location and associated non-atherosclerotic calcification, pseudoaneurysm, or thrombosis were also documented. ResultsA total of 1800 head and neck CTAs were examined. Normal extradural arteries were seen in 1731 patients (1731/1800; 96.2 %). An intraluminal abnormality was evident in the remaining 69 patients (69/1800; 3.8 %). There were 16 carotid webs (16/1800; 0.9 %), 46 dissections (46/1800; 2.6 %), and 7 fenestrations (7/1800; 0.4 %). An associated non-atherosclerotic pattern of calcification was only identified in a single fenestration case (1/7; 14.3 %). Thrombosis was not identified in any fenestration case. ConclusionArterial fenestrations of the extradural head and neck arterial vasculature are evident on 0.4 % of CTAs. It is important to differentiate these benign entities from carotid webs and arterial dissections. With the appropriate knowledge and interpretive tools, characteristic imaging findings on CTA can be used for reliable differentiation.

Clinical impact of using [18F]AlF-NOTA-octreotide PET/CT instead of [68Ga]Ga-DOTA-SSA PET/CT: Secondary endpoint analysis of a multicenter, prospective trial.

[18F]AlF-NOTA-octreotide ([18F]AlF-OC) is a promising alternative for [68Ga]Ga-DOTA-somatostatin analogs (SSAs) in positron emission tomography (PET) imaging of the somatostatin receptor (SSTR). Our aim is to assess changes in TNM staging and differences in patient management between [18F]AlF-OC PET/CT and [68Ga]Ga-DOTA-SSA PET/CT in the work-up of neuroendocrine tumor (NET) patients. Patients who underwent both [18F]AlF-OC and [68Ga]Ga-DOTA-TATE or [68Ga]Ga-DOTA-NOC PET/CT in our multicenter study (Pauwels et al., J Nucl Med.2023;63:632-638) with a NET were included for analysis. TNM staging was determined and compared for both tracers. For each patient, the blinded [68Ga]Ga-DOTA-SSA or [18F]AlF-OC PET/CT images were presented in random order at a multidisciplinary team board. The images were presented together with clinical information and compared with previous SSTR and [18F]FDG PET/CT imaging. After a consensus decision for patient management was recorded, the board was presented with the PET/CT images from the other SSTR tracer and a decision was made for the second tracer. Differences in management were classified as major if it entailed an intermodality change and minor if it led to an intramodality change. Compared with [68Ga]Ga-DOTA-SSA, the use of [18F]AlF-OC led to a change in 16/75 patients: TNM staging changes in 10/75 patients (13.3%; downstaging in 3/10, upstaging in 7/10) and differences in clinical management were seen in 10/75 patients (13.3%), leading to a major difference in 7/10 cases and a minor change in 3/10 cases. All 10 cases with a difference in patient management between both PET tracers were caused by additional lesion detection by [18F]AlF-OC. The use of [18F]AlF-OC did not impact TNM staging or clinical management in the large majority of the patients (86.7%), further validating the potential for routine clinical use of [18F]AlF-OC PET/CT as an alternative for [68Ga]Ga-DOTA-SSA PET/CT. The trial is registered under ClinicalTrials.gov identifier NCT04552847 and EudraCT 2020-000549-15.

Impact of Insurance Status on Clinical Management and Outcomes of Patients with ST-Segment Elevation Myocardial Infarction: Findings from the Kuwait Catheterization Laboratory Project Registry.

Emerging evidence from various countries suggests that ST-segment elevation myocardial infarction (STEMI) patients with differing health-care insurance types experience discrepancies in clinical management and outcomes. Kuwait government provides free essential treatments and medications to noninsured patients with certain emergency conditions. We aimed to compare differences in clinical management and in-hospital and 30-day outcomes in STEMI patients with different insurance types in Kuwait. Data were derived from Kuwait Catheterization Laboratory Project (Kuwait CLAP) registry. Adult patients (≥18 years) diagnosed with STEMI were enrolled in Kuwait CLAP registry between February 2020 and February 2021. Patients were categorized into insured and noninsured. The coprimary outcomes were the in-hospital and 30-day mortality in insured versus noninsured patients with STEMI. In-hospital and 30-day adverse cardiac outcomes were also compared. Of 668 patients with STEMI, 116 (17%) were insured and 552 (83%) were not insured. Three (2.6%) of the insured and 9 (1.6%) of the noninsured patients suffered in-hospital mortality, while no patients in the insured group and four patients (0.7%) patients in the noninsured group suffered 30-day mortality, with no significant difference between the two groups (P = 0.447 and P = 1, respectively). The rates of in-hospital complications and 30-day adverse events were similar between the two groups. Our findings suggest no differences in acute or short-term outcomes among patients with different insurance status in Kuwait. These findings are reassuring knowing that the free essential services provided by Kuwait government for STEMI patients did not compromise the outcomes of noninsured compared to insured patients.

Dementia-Related Disparities in Adult Day Centers: Results of a Bivariate Analysis.

Adult day services (ADS) are a valuable resource for people living with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD) and serve a large population of late-life immigrants, often with limited English proficiency (LEP). This secondary data analysis examined potential disparities in diagnosis, dementia severity, medical complexity, and dementia-related behavioral problems in persons with AD/ADRD with LEP within the ADS setting. The current study used data from TurboTAR, the electronic health record for ADS in California. Bivariate analyses were conducted to examine differences in clinical management for those with and without LEP. Of 3,053 participants included in the study, 42.3% had LEP. Participants with LEP had higher rates of emergency department use and medication mismanagement. However, due to non-standard data collection, there was a significant amount of missing data on language preference (38.1%) and race/ethnicity (46.5%). Although these findings suggest LEP may play a role in the clinical management of persons with AD/ADRD in ADS, missing data caused by lack of standardized collection compromise the results. It is essential to improve data collection practices in ADS on language, race, and ethnicity to help identify health disparities and promote equitable care for marginalized older adults. [Journal of Gerontological Nursing, 50(4), 42-47.].

EPITRANS. Quality assessment of the epilepsy transition process

ObjectiveTo analyze the differences in clinical management during the epilepsy transition process from pediatric to adult care and to determine the quality of life and degree of satisfaction of patients and caregivers during the transition. MethodsThis is a longitudinal study including patients with epilepsy transferred from pediatric to adult epilepsy care between 2013 and 2017. Patients had a minimum follow-up of 3 years before the transition visit and at least 3 years consulting in the adults section. Clinical characteristics were retrieved from the medical chart. Quality of life and satisfaction questionnaires were administered by online access to patients and caregivers at the end of the adult follow-up period. Results99 patients (50.5 % women, mean transition age 16.5 ± 1 years old) were included. Before the transition visit, 90 % of patients received a transition discussion and 88 % had a formal clinical report. In the pediatric period, patients were visited more frequently, had more EEGs and genetic studies, and were seen by the same neuropediatrician (P<0.05). In the adult period, patients underwent a larger number of prolonged video EEGs and were prescribed polytherapy more often (P<0.05). Quality of life remained steady during the entire transition, but satisfaction with the care received was significantly higher during the pediatric period. ConclusionsSignificant differences were seen in epilepsy care during transition from pediatric to adult management, and this had an impact on the degree of satisfaction reported by patients and caregivers. Our results provide evidence of the potential value of development and early implementation of a protocolled transition program.

EXPLORING THE ROLE OF CENTRAL VENOUS OXYGEN SATURATION IN THE EVALUATION AND MANAGEMENT OF SEVERE HYPOXEMIA IN MECHANICALLY VENTILATED PATIENTS.

Background: Although central venous oxygen saturation (ScvO 2 ) has been used as an endpoint for the treatment of circulatory shock, its role in guiding the evaluation and treatment of patients with severe hypoxemia remains to be assessed. The aim of this study was to assess the incidence of low ScvO 2 in a cohort of hypoxemic patients and the association of this finding with differences in clinical management and patient outcomes. Methods: Retrospective review of data from adult intensive care unit patients with hypoxemia who required invasive mechanical ventilation for over 24 h and had at least one ScvO 2 measured within 6 h of a PaO 2 /FiO 2 ratio <200. Results: Of 442 mechanically ventilated patients with severe hypoxemia, 249 (56%) had an ScvO 2 <70%. When compared with patients with ScvO 2 ≥70%, those with low ScvO 2 had worse systemic oxygenation and hemodynamic parameters and were more likely to receive red blood cell transfusions (31.7% vs. 18.1%, P = 0.001), epinephrine (27.3% vs. 16.6%, P = 0.007), and inodilators. Outcomes such as median intensive care unit length of stay (7.5 vs. 8.3 days, P = 0.337) and hospital mortality (39.8% vs. 35.7%, P = 0.389) were not different between groups. When stratified by the central venous-to-arterial CO 2 difference (∆PCO 2 ), patients with a low ScvO 2 and normal ∆PCO 2 had lower median PaO 2 and hemoglobin levels and received more red blood cell transfusions, whereas those with an increased ∆PCO 2 had a lower pulse pressure and cardiac index and were more likely to receive epinephrine and milrinone. Conclusion: Low ScvO 2 is frequently observed in mechanically ventilated patients with severe hypoxemia, and these patients receive different interventions. Clinicians often use therapies targeting systemic oxygen delivery to correct low ScvO 2 . Prospective research is needed to identify patients with severe hypoxemia that might benefit from interventions targeting systemic oxygen delivery.

Physical Examination in Medical Oncology Guiding the Development of a Protocol for Teleoncology Care in a Public Health Care Oncology Service.

We aimed to define clinical variables that could predict changes in physical examination (PE) findings and consequently lead to significant differences in clinical management. This knowledge is important because of the growing popularity of teleoncology consultations, in which there is no possibility of PE, aside from inspection. This prospective study was conducted in two public hospitals in Brazil. Clinical variables and findings of PE, as well as the management plan determined at the end of the medical appointment, were systematically recorded. A total of 368 in-person clinical evaluations of patients with cancer were included. PE was normal or had alterations already seen in previous consultations in 87% of the cases. Among patients with new changes in PE (n = 49), cancer treatment was maintained in 59%, complementary examinations and specialist appointments were requested in 31%, and oncological therapy was modified directly after PE in 10%. Of the total 368 visits, only 12 (3%) had a change in oncological management, five directly after PE abnormalities and 7 after complementary assessment. The presence of symptoms and reasons for consultation other than follow-up showed a positive association with alterations in PE and consequent changes in clinical management by univariate and multivariate analysis (P < .05). Considering changes in clinical management, PE on every encounter for medical oncology surveillance visits may not be necessary. We envision that teleoncology will be a safe modality in most cases, given the large percentage of asymptomatic patients with no changes in PE during face-to-face care. However, for patients with advanced disease and symptoms, however, we suggest priority for in-person care.

Targeted Transcriptional Analysis of IgA Vasculitis, IgA Nephropathy, and IgA-Dominant Infection-Related Glomerulonephritis Reveals Both Distinct and Overlapping Immune Signatures.

IgA vasculitis (IgAV), IgA nephropathy (IgAN), and IgA-dominant infection-related glomerulonephritis (IgA-IRGN) have shared histopathologic features but differences in clinical management and prognosis. The most serious IgAV organ involvement is in the kidneys (IgAV nephritis). In this study, we hypothesized that targeted immune transcript profiling could aid in 1) predicting development of IgAV nephritis in patients with cutaneous IgAV, and 2) differentiating IgAN, IgAV, and IgA-IRGN. RNA was extracted from 24 formalin-fixed paraffin-embedded tissue specimens (16 kidney, 8 skin) from 21 patients with IgAV nephritis (n=7), IgAN (n=5), and IgA-IRGN (n=4), and IgAV skin biopsies from patients with (n=3) and without (n=5) IgAV nephritis. Differential gene expression and gene set enrichment analysis were performed on a total of 594 transcripts (Nanostring immunology panel) profiled using the nCounter system. Skin biopsies in IgAV patients who develop kidney involvement exhibit reduced S100A8/S100A9, IL9, and KIR expression. The kidney tissue immune transcriptomes of IgAN, IgAV, and IgA-IRGN are largely overlapping. IgA-IRGN kidney biopsies are, however, uniquely enriched for transcripts involved in granulocyte chemotaxis. This study identifies immune transcript signatures that may predict IgAV nephritis in skin biopsies and distinguish IgA-IRGN from IgAN and IgAV in kidney biopsies.

Management and outcomes of patients with chest pain and psychiatric disorders in the era of high-sensitivity cardiac troponins.

The management of patients with psychiatric disease and chest pain in the emergency department (ED) in the era of high-sensitivity cardiac troponin assays is unexplored. To investigate differences in management and outcomes comparing patients with versus without psychiatric disorders who present with chest pain in the ED. All visits to seven different EDs in Sweden from 9 December 2010 to 31 December 2016 by patients with chest pain were included. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to estimate differences in clinical management. Hazard ratios with 95% CIs were used for comparisons of all-cause mortality and risk of cardiovascular events. Altogether, 216,653 visits were identified, of which 40,054 (18%) occurred in patients with psychiatric disorders. The risk of a myocardial infarction (MI) was reduced almost by half in patients with an affective (OR 0.63; 95% CI: 0.59-0.68) or psychotic disorder (OR 0.57; 95% CI: 0.47-0.70). These patients were less likely to be treated with any cardiovascular medication or to undergo percutaneous coronary intervention. Contrastingly, patients with psychiatric disease had a 1.8- to 2.6-fold increased risk of being diagnosed with an MI registered after the index visit but within 30 days. Patients with psychiatric disease and chest pain undergo less intense investigation and are less likely to receive cardiovascular medications compared with patients without psychiatric disease, even in the presence of myocardial injury. In addition, they experience a higher risk of being diagnosed with an MI within 30 days after a visit with no MI.

Shedding a Light on the Challenges of Adolescents and Young Adults with Rhabdomyosarcoma.

Rhabdomyosarcoma (RMS) is a typical tumour of childhood but can occur at any age. Several studies have reported that adolescent and young adult (AYA) patients with RMS have poorer survival than do younger patients. This review discusses the specific challenges in AYA patients with pediatric-type RMS, exploring possible underlying factors which may influence different outcomes. Reasons for AYA survival gap are likely multifactorial, and might be related to differences in tumor biology and intrinsic aggressiveness, or differences in clinical management (that could include patient referral patterns, time to diagnosis, enrolment into clinical trials, the adequacy and intensity of treatment), as well as patient factors (including physiology and comorbidity that may influence treatment tolerability, drug pharmacokinetics and efficacy). However, improved survival has been reported in the most recent studies for AYA patients treated on pediatric RMS protocols. Different strategies may help to further improve outcome, such as supporting trans-age academic societies and national/international collaborations; developing specific clinical trials without upper age limit; defining integrated and comprehensive approach to AYA patients, including the genomic aspects; establishing multidisciplinary tumor boards with involvement of both pediatric and adult oncologists to discuss all pediatric-type RMS patients; developing dedicated projects with specific treatment recommendations and registry/database.

Impact of amyloid PET in the clinical care of US Veterans in a Tertiary Memory Disorders Clinic

AbstractBackgroundPrior studies assessing the clinical impact of amyloid PET have been limited to assessments before and after the scan. We aim to characterize the impact of amyloid PET in a veterans population with cognitive decline by comparing differences in clinical management within two years of follow‐up.MethodsThe current retrospective observational study includes all patients seen for an initial evaluation for cognitive complaints in the Memory Disorders Clinic at the VA Boston Healthcare System from October 2016 to January 2020. Clinical impact outcomes within two years of follow‐up were compared between patients with and without an aPET scan. Poisson regressions, negative binomial regressions, and binomial logistic regression were used for the analysis. Age, cognitive syndrome, follow‐up time, clinical diagnosis after initial evaluation and MoCA scores were used as covariates. Additionally, propensity score matching was performed to balance confounders between the two groups. To further understand the clinical impact outcomes in the aPET group, multiple regressions were performed within the group.ResultsFive‐hundred‐sixty‐five veterans were included in the analysis. Thirty‐five percent of patients underwent aPET imaging in addition to routine diagnostic workup. The study was positive in 72 patients (36.56%). Having an aPET, in addition to the usual diagnostic workup, was associated with a longer follow‐up time, and a higher diagnostic variability at follow‐up. We did not find an association between aPET use and the number of additional diagnostic studies ordered, early cholinesterase inhibitors prescription, or referrals to social work, research and clinical trials. When analyzing the same clinical utility outcomes within the group with an aPET, we found that a positive result was associated with fewer additional diagnostic tests, less diagnostic variability at follow up visits, more cholinesterase inhibitors prescription, and more research referrals.ConclusionsIn medically complex populations, aPET positivity might be lower than prior studies have described, used more to “rule out” than confirm the diagnosis of Alzheimer’s disease. This lower positivity rate results in less robust differences in classically explored clinical impact variables when comparing patients with and without an aPET.

IPSS-M Applicability and Clinical Impact in Decision-Making Process in Real-Life Clinical Practice

Background: Disease specific prognostic scores play a key role in risk-stratification and treatment decision-making process in Myelodysplastic Syndromes (MDS). An updated version of the International Prognostic Scoring System-Revised (IPSS-R), based on classical clinical variables-and molecular data (IPSS-M), has been recently proposed. Since some of the genes included in the IPSS-M are unfrequently mutated in MDS and, therefore, not commonly assessed in routine diagnostic laboratories (ex. MLL-PTD), we aimed to analyze the applicability of the new IPSS-M in a "real-life” setting. Methods: We retrospectively collected clinical (including treatment), cytogenetic and molecular data from our real-life cohort of patients with MDS from a single institution. Inclusion criteria were MDS and MDS/MPN (< 13 x109/L leukocytes) diagnosed between 2018 and 2022 with molecular data from a commercial NGS panel containing myeloid-related genes. This panel comprises 27 out of 32 genes included in the IPSS-M, not analyzing MLL-PTD, BCORL1, ETNK1, GNB1, and PPM1D. Patients were classified according to IPSS-R and IPSS-M, and differences for risk stratification were evaluated in each patient to assess clinical implications of score-related variability. Results: From a total of 208 patients diagnosed with MDS during the study period, 126 (60.6%) patients were finally selected based on the availability of molecular data at the time of diagnosis. Despite the lack of 5 genes belonging to the IPSS-M, the IPSS-M calculator assigned a score for each patient as well as a range for best-worst potential scores. The mean difference between the assigned score and the lowest and highest ones was 0.15 (±0,8) and 1.75 (±0.37), respectively (Figure 1). The assigned score was closer to the best potential lowest score, due to the fact that mutations in the missing genes in our NGS panel are rarely mutated in MDS. Overall, 42.9% (54/126) of the patients became reclassified to a different risk category when IPSS-M was calculated (Figure 2). However, in only 17.4% (22/126) of patients these changes were considered relevant from the therapeutic standpoint, namely patients considered as low risk who may have benefited from a more intensive treatment, and vice versa. Of these, 11.9% (15/126) cases were upgraded and 5.6% (7/126) were downgraded. Nonetheless, and after analyzing each patient individually following our institution's guidelines, only 12/126 (9.5%) of patients would have been managed differently if IPSS-M had been initially applied, mainly because part of the higher risk patients resulted not candidate to intensive care due to age and comorbidities. Conclusions: According to our cohort of MDS patients, the proportion of cases who might benefit from the re-stratification according to the IPSS-M, in terms of potential differences in clinical management, is lower than initially expected. In spite of that, information derived from the NGS molecular should be the basis for different treatment approaches in the future. FIGURE LEGENDS: Figure 1. IPSS-M range variability. The y-axis represents the IPSS-M score value. Each patient is represented by 3 dots in the x-axis including a dot for the IPSS-M calculated score (orange) and the range from the lowest/best IPSS-M (green) and the highest/worst IPSS-M (red). Patients are ordered from lowest to highest IPSS-M calculated score. Figure 2. IPSS-M recategorization. Each IPSS-R category in our cohort is represented by a bar, which is then color coded according to the number of patients that are re-classified according to the IPSS-M categories (moderate low and moderate high are merged into one category in IPSS-M). Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Features of clinical complexity in european patients with atrial fibrillation: a report from the ESC-EHRA EORP atrial fibrillation general long-term registry

Abstract Introduction There is increasing concern regarding the burden of clinical complexity, beyond thromboembolic risk, in patients with atrial fibrillation (AF). Also, clinical complexity is heterogenous and entails differential impact on the patients' clinical course. Purpose To explore different complexity features in AF patients in determining differences in clinical management and outcomes. Methods We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Features of complexity were analysed in the context of the following high-risk groups: i) only CHA2DS2-VASc ≥2; ii) history of stroke/bleeding; iii) chronic kidney disease (creatinine clearance &amp;lt;60 mL/min, CKD); iv) frail (frailty index ≥0.25); v) ≥2 criteria. All these groups were compared to a low-risk group (CHA2DS2-VASc 0–1). We examined use of oral anticoagulant (OAC) and the risks of a composite outcome of all-cause death and major adverse cardiovascular events. Results A total of 10285 patients (mean [SD] age 68.8 [11.5] years, 4107 [39.9%] females) were included in the analysis. Of these, 3944 (38.3%) had only CHA2DS2-VASc ≥2; 412 (4.0%); history of stroke/bleeding; 1480 (14.4%) CKD; 1007 (9.8%) were frail; 1315 (12.8%) had ≥2 criteria; and 2127 (20.7%) were low-risk. After adjustment for age, sex, type of AF and EHRA score, compared to low-risk patients, all the other groups were associated with OAC prescription but with progressively lower odds ratio, while those ≥2 criteria which were least likely prescribed with OAC (Table 1). After a mean (SD) 634.5 (223.0) days of follow-up, a total of 1432 events were recorded. After adjustment for confounders, Cox regression analysis found that all the complexity groups were associated with a higher risk of the composite outcome across the groups (Figure 1). In patients with available data about ABC (Atrial fibrillation Better Care) pathway adherence, the latter adherence was associated a significant incidence rate reduction (IRR) compared to non-ABC adherence in those with ≥2 criteria of clinical complexity (IRR 0.46, 95% CI 0.30–0.71), and in the CKD complexity group (IRR 0.57, 95% CI 0.41–0.81). Conclusions In a large contemporary cohort of European AF patients, features of clinical complexity affect differently prescriptions of OAC. All the subgroups of clinical complexity were associated with a higher risk of adverse outcomes, which were reduced by adherence to ABC pathway. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and PfizerAlliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck &amp; Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022).

Predictors of Acute Care Reutilization in Pediatric Patients With Amoxicillin-Associated Reactions

Amoxicillin-associated reactions (AARs) contribute to substantial health care utilization, with a reutilization rate of 10% in pediatric emergency department (ED) and urgent care (UC) settings. To identify predictors of ED/UC reutilization by examining patients' clinical features and providers' management of AARs. Through a retrospective chart review of 668 patients presenting with AARs over 2 years to the pediatric ED/UC, we examined clinical features associated with ED/UC reutilization, including rash phenotype, systemic symptoms (fever, angioedema, joint involvement, gastrointestinal symptoms), and providers' management (pharmacologic treatment and counseling). We then constructed a statistical model to predict ED/UC reutilization using stepwise backward model selection. ED/UC reutilizers were more likely to be male (P=.008) and have fever (P= .0001), angioedema (P < .0001), joint involvement (P < .0001), and gastrointestinal symptoms (P= .0001) during their AAR course. Rash phenotypes differed between groups (P < .0001), as ED/UC reutilizers more frequently exhibited urticaria. However, there were no differences in clinical management between groups, including pharmacologic recommendations, at the initial ED/UC encounter. In addition, our statistical model identified younger patients <2 years of age as more likely to reutilize ED/UC resources if providers did not document specific return precautions (odds ratio, 3.6; 95% confidence interval, 1.7-7.7). Recognition of clinical features and treatment gaps associated with ED/UC reutilization will guide interventions to optimize care in children presenting with AARs, such as improved anticipatory guidance and early allergy consultation. Prospective studies are needed to determine whether these interventions will reduce ED/UC reutilization and facilitate timely allergy testing.

Immunohistochemistry in melanocytic lesions: Updates with a practical review for pathologists.

This review provides a summary of the immunohistochemical markers pertinent to the diagnosis of melanocytic lesions. There is considerable morphologic overlap between benign and malignant melanocytic lesions, and given the significant differences in clinical management, the diagnostic workup becomes crucial. Immunohistochemistry aids in the distinction between various melanocytic proliferations and recent contributions to the literature have furthered our optimization of panels in the diagnostic workup. In recent years, SOX10 has been considered as the optimal marker for melanocytic lesions given the similar sensitivity but higher specificity than S100. HMB-45 is less sensitive than S100 but demonstrates utility in confirmation of deceptively banal small cell and nevoid melanoma variants where deep nests of melanocytes are highlighted. Melan-A (MART-1) and MiTF show similar sensitivity to S100 however there is a lack of expression in spindle cell and desmoplastic melanomas.

Differences in time-critical interventions and radiological examinations between adult and older trauma patients: A national register-based study.

Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients hold important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations. Retrospective analysis of the Norwegian Trauma Registry for 2015 through 2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score of 9 or greater were included, dichotomized into age groups 16 years to 64 years and 65 years or older. Prehospital and emergency department clinical management, advanced airway management, chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests. There were 9543 patients included, of which 28% (n = 2711) were 65 years or older. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.57-0.71), conveyed by air ambulance (OR, 0.65; 95% CI, 0.58-0.73), and transported directly to a trauma center (OR, 0.86; 95% CI, 0.79-0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with New Injury Severity Score of 25 or greater, showing lower rates for older adults (advanced airway management: OR, 0.60; 95% CI, 0.47-0.76; chest decompression: OR, 0.46; 95% CI, 0.25-0.85; x-ray chest: OR, 0.54; 95% CI, 0.39-0.75; x-ray pelvis: OR, 0.69; 95% CI, 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups. Older trauma patients were less likely to receive advanced prehospital care compared with younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities. Therapeutic/Care Management; Level III.

CT imaging findings of renal epithelioid lipid-poor angiomyolipoma.

To identify specific imaging and clinicopathological features of a rare potentially malignant epithelioid variant of renal lipid-poor angiomyolipoma (E-lpAML). A total of 20 patients with E-lpAML and 43 patients with other lpAML were retrospectively included. Multiphase computed tomography (CT) imaging features and clinicopathological findings were recorded. Independent predictors for E-lpAML were identified using multivariate logistic regression and were used to construct a diagnostic score for differentiation of E-lpAML from other lpAML. The E-lpAML group consisted of 6 men and 14 women (age median ± SD: 39.45 ± 15.70, range: 16.0-68.0years). E-lpAML tended to appear as hyperdense mass lesions located at the renal sinus (n = 8, 40%) or at the renal cortex (n = 12, 60%), with a "fast-in and slow-out" enhancement pattern (n = 20, 100%), cystic degeneration (n = 18, 90%), "eyeball" sign (n = 11, 55%), and tumor neo-vasculature (n = 15, 75%) on CT. Multivariate logistic regression analysis showed that the independent predictors for diagnosing E-lpAML were cystic degeneration on CT imaging and CT value of the tumor in corticomedullary phase of enhancement. A predictive model was built with the two predictors, achieving an area under the curve (AUC) of 93.5% (95% confidence interval (95%CI): 84.3-98.2%) with a sensitivity of 95.0% (95%CI: 75.1-99.9%) and a specificity of 83.72% (95%CI: 69.3-93.2%). We identified specific CT imaging features and predictors that could contribute to the correct diagnosis of E-lpAML. Our findings should be helpful for clinical management of E-lpAML which could potentially be malignant and may require nephron-sparing surgery while other lpAML tumors which are benign require no intervention. • It is important to differentiate renal epithelioid lipid-poor angiomyolipoma (E-lpAML) from other lpAML because of differences in clinical management. • E-lpAML tumors tend to be large hyperdense tumors in the renal sinus with cystic degeneration and "fast-in and slow-out" pattern of enhancement. • Our CT imaging-based predictive model was robust in its performance for predicting E-lpAML from other lpAML tumors.

Clinical Decision Support for Symptom Management in Lung Cancer Patients: A Group RCT

ContextClinical guidelines are available to enhance symptom management during cancer treatment but often are not used in the practice setting. Clinical decision support can facilitate the implementation and adherence to clinical guidelines. and improve the quality of cancer care. ObjectivesClinical decision support offers an innovative approach to integrate guideline-based symptom management into oncology care. This study evaluated the effect of clinical decision support-based recommendations on clinical management of symptoms and health-related quality of life (HR-QOL) among outpatients with lung cancer. MethodsTwenty providers and 179 patients were allotted in group randomization to attention control (AC) or Symptom Assessment and Management Intervention (SAMI) arms. SAMI entailed patient-report of symptoms and delivery of recommendations to manage pain, fatigue, dyspnea, depression, and anxiety; AC entailed symptom reporting prior to the visit. Outcomes were collected at baseline, two, four and six-months. Adherence to recommendations was assessed through masked chart review. HR-QOL was measured by the Functional Assessment of Cancer Therapy-Lung questionnaire. Descriptive statistics with linear and logistic regression accounting for the clustering structure of the design and a modified chi-square test were used for analyses. ResultsMedian age of patients was 63 years, 58% female, 88% white, and 32% ≤high school education. Significant differences in clinical management were evident in SAMI vs. AC for all target symptoms that passed threshold. Patients in SAMI were more likely to receive sustained-release opioids for constant pain, adjuvant medications for neuropathic pain, opioids for dyspnea, stimulants for fatigue and mental health referrals for anxiety. However, there were no statistically significant differences in HR-QOL at any time point. ConclusionSAMI improved clinical management for all target symptoms but did not improve patient outcomes. A larger study is warranted to evaluate effectiveness.

Implications of Myocardial Infarction on Management and Outcome in Cardiogenic Shock.

BackgroundThe randomized DOREMI (Dobutamine Compared to Milrinone) clinical trial evaluated the efficacy and safety of milrinone and dobutamine in patients with cardiogenic shock. Whether the results remain consistent when stratified by acute myocardial infarction remains unknown. In this substudy, we sought to evaluate differences in clinical management and outcomes of acute myocardial infarction complicated by cardiogenic shock (AMICS) versus non‐AMICS.Methods and ResultsPatients in cardiogenic shock (n=192) were randomized 1:1 to dobutamine or milrinone. The primary composite end point in this subgroup analysis was all‐cause in‐hospital mortality, cardiac arrest, non‐fatal myocardial infarction, cerebrovascular accident, the need for mechanical circulatory support, or initiation of renal replacement therapy (RRT) at 30‐days. Outcomes were evaluated in patients with (n=65) and without (n=127) AMICS. The primary composite end point was significantly higher in AMICS versus non‐AMICS (hazard ratio [HR], 2.21; 95% CI, 1.47–3.30; P=0.0001). The primary end point was driven by increased rates of all‐cause mortality, mechanical circulatory support, and RRT. No differences in other secondary outcomes including cardiac arrest or cerebrovascular accident were observed. AMICS remained associated with the primary composite outcome, 30‐day mortality, and RRT after adjustment for age, sex, procedural contrast use, multivessel disease, and inotrope type.ConclusionsAMI was associated with increased rates of adverse clinical outcomes in cardiogenic shock along with increased rates of mortality and initiation of mechanical circulatory support and RRT. Contrast administration during revascularization likely contributes to increased rates of RRT. Heterogeneity of outcomes in AMICS versus non‐AMICS highlights the need to study interventions in specific subgroups of cardiogenic shock.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT03207165.