First-line Strategy Research Articles

Covid-19 Detection on X-ray Images using Machine Learning

The Severe Acute Respiratory Syndrome Covid (SARS-CoV-2) is answerable for the eruption of a respiring ailment that begun in China and has because pollute various nations. Generally, nasopharyngeal rRT-PCR has happened handled to form a dispassionate disease.2 Be that as it may, it isn't famous either the contamination maybe pursued in instances from various fields, so it yes grant permission be spread through few various alternative from respiring mist sprayers. We resolved the biodistribution of SARS-CoV-2 in miscellaneous tissues of inpatients accompanying Coronavirus disorder 2019 (Covid) declared by SARS-CoV-2 announcement and insolvent unhappy seeing subordinate belongings and radiology. With the end goal of recognition, we utilize the RF, DT, Naive Bayes, KNN, and Voting Classifier (GBDT + DT) calculations in this work. With a waiver of informed assent, the taking part clinics' morals payments endorsed this review. The typical arrangement precision of the proposed framework for Coronavirus seriousness discovery was 97.84 percent, which is higher than the characterization exactness of existing techniques. Clinical experts can accurately distinguish assets and treatment plans thanks to this. As a first-line identification strategy for seriousness risk, this work assists clinical experts with arranging patient consideration and decide if ICU offices and ventilator support are required. A PC supported framework that makes it more straightforward to make a treatment plan for the day to day deluge of numerous patients would obviously be a significant resource during these tempestuous times.

Effects of a Low-FODMAP Diet on Irritable Bowel Syndrome in Both Children and Adults-A Narrative Review.

Irritable bowel syndrome is a typical gastrointestinal disease that causes bloating, flatulence, abdominal pain, diarrhoea, constipation, or alteration of the last two in adults and children. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) is one of the potential treatment strategies to reduce abdominal symptoms and increase the quality of life. The present narrative review aims to present a general overview of current studies that have evaluated the efficacy of a low-FODMAP diet against other diets in gastrointestinal symptoms, nutrient intake in adults and children, and lifestyle quality. The research was performed using seven searchable databases, which included the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Excerpta Medica Database (EMBASE), Medline, PubMed, Scopus, and Web of Science, up to March 2023. In conclusion, there is significant evidence that the follow-up of a low-FODMAP diet might be a feasible first-line therapeutic strategy to reduce stomach discomfort, pain, bloating, and quality of life for patients with irritable bowel syndrome.

Treatment strategy for late-life depression.

With the unprecedented aging of the world's population, the number of elderly patients with depression is expected to increase. However, management and treatment of late-life depression (LLD) is more difficult than in early adults. Prior to treatment, diagnosis must take into account the differentiation from, and comorbidity with, organic brain diseases such as dementia and delirium, as well as depression caused by other physical diseases or medications. As clinical features of LLD, treatment response tends to be poor in older patients and recurrence rates are higher than those in early adult patients, therefore psycho-social interventions on the basis of the patient's background and condition are important for LLD. The first-line treatment strategy generally depends on the severity of the depression. Systematic psychotherapies, including cognitive behavioral therapy and problem-solving therapy, have been reported to reduce depressive symptoms in LLD. Regarding pharmacotherapy, newer antidepressants are recommended for LLD, but careful attention to adverse events is required. Treatment using neuromodulation is also reported to be useful for LLD. In the current review, for further-line treatment, treatment strategies were divided according to the level of first-line treatment response. Evidence indicates that LLD is more heterogeneous than depression in younger adults, therefore when treating LLD patients it is necessary to take various conditions and situations into consideration, and to provide detailed treatment that is tailored to each patient.

Heterogeneity in management of category II fetal tracings: data from a multihospital healthcare system

Electronic fetal monitoring is widely used to identify and intervene in suspected fetal hypoxia and/or acidemia. Category II fetal heart rate tracings are the most common class of fetal monitoring in labor, and intrauterine resuscitation is recommended given the association of category II fetal heart rate tracings with fetal acidemia. However, limited published data are available to guide intrauterine resuscitation technique selection, leading to heterogeneity in the response to category II fetal heart rate tracings. This study aimed to characterize approaches to intrauterine resuscitation in response to category II fetal heart rate tracings. This was a survey study administered to labor unit nurses and delivering clinicians (physicians and midwives) across 7 hospitals in a Midwestern healthcare system spanning 2 states. The survey posed 3 category II fetal heart rate tracing scenarios (recurrent late decelerations, minimal variability, and recurrent variable decelerations) and asked participants to select first- and second-line intrauterine resuscitation management strategies. The participants were asked to quantify the level of influence certain factors have on their choice using a scale from 1 to 5. Intrauterine resuscitation strategy selection was compared by clinical role and hospital type (nurses vs delivering clinicians and university-affiliated hospital vs non-university-affiliated hospital). Of 610 providers invited to take the survey, 163 participated (response rate of 27%): 37% of participants from university-affiliated hospitals, 62% of nurses, and 37% of physicians. Maternal repositioning was the most selected first-line strategy, regardless of the type of category II fetal heart rate tracing. First-line management varied by clinical role and hospital affiliation for each fetal heart rate tracing scenario, particularly for minimal variability, which was associated with the most heterogeneity in the first-line approach. Previous experience and recommendations from professional societies were the most influential factors in intrauterine resuscitation selection overall. Of note, 16.5% of participants reported that published evidence did not influence their choice at all. Participants from a university-affiliated hospital were more likely than participants from a non-university-affiliated hospital to consider patient preference when selecting an intrauterine resuscitation technique. Nurses and delivering clinicians differed significantly in the rationale for management choices: nurses were more often influenced by advice from other healthcare providers on the team (P<.001), whereas delivering clinicians were more influenced by literature (P=.02) and ease of technique (P=.02). There was significant heterogeneity in the management of category II fetal heart rate tracing. In addition, motivations for choice in intrauterine resuscitation technique varied by hospital type and clinical role. These factors should be considered when creating fetal monitoring and intrauterine resuscitation protocols.

Discussion on how to optimize active surveillance for low-risk papillary thyroid microcarcinoma in China

Active surveillance, as a first-line treatment strategy for low-risk papillary thyroid microcarcinoma, has been recommended by guidelines worldwide. However, active surveillance has not been widely accepted by doctors and patients in China. In view of the huge challenges faced by active surveillance, doctors should improve their understanding of the "low risk" of papillary thyroid micropapillary cancer, identify some intermediate or high-risk cases, be familiar with the criteria and methods of diagnosis for disease progression, and timely turn patients with disease progression into more active treatment strategies. By analyzing the long-term cost-effectiveness of active surveillance, it is clear that medical expense is only one cost form of medical activities, and the health cost (thyroid removal and surgical complications) paid by patients due to"over-diagnosis and over-treatment" is the most important. Moreover, the weakening of the patients' social function caused by surgical procedures is a more hidden and far-reaching cost. The formulation of health economic policies (including medical insurance) should promote the adjustment of diagnosis and treatment behavior to the direction which is conducive to the long-term life and treatment of patients, improving the overall health level of society and reducing the overall cost. At the same time, doctors should stimulate the subjective initiative of patients, help them fully understand the impact of various treatment methods on their psychological and physical status, support patients psychologically, and strengthen their confidence in implementing active surveillance. By strengthening multi-disciplinary treatment team and system support, doctors can achieve risk stratification of papillary thyroid microcarcinoma, accurate judgment of disease progress, timely counseling for psychological problems, and long-term adherence to active surveillance. Improving the treatment level of advanced thyroid cancer is the key point of improve the prognosis. It is important to promote the development of active surveillance for low-risk papillary thyroid microcarcinoma. In the future, it is necessary to carry out multi-center prospective research and accumulate research evidence for promoting the standardization process of active surveillance. Standardized active surveillance will certainly benefit specific papillary thyroid microcarcinoma patients.

EUS-guided gastroenterostomy for management of malignant gastric outlet obstruction: a prospective cohort study with matched comparison with enteral stenting

Retrospective studies on malignant gastric outlet obstruction (mGOO) highlighted several advantages of EUS-guided gastroenterostomy (EUS-GE) over enteral stenting (ES). However, no prospective evidence is available. The aim of this study was to report on clinical outcomes of EUS-GE in a prospective cohort study, with a subgroup comparison versus ES. All consecutive patients endoscopically treated for mGOO between December 2020 and December 2022 in a tertiary, academic center were enrolled in a prospective registry (Prospective Registry of Therapeutic Endoscopic Ultrasound [PROTECT]; NCT04813055) and followed up every 30 days to register efficacy/safety outcomes. EUS-GE and ES cohorts were matched according to baseline frailty and oncologic disease. A total of 104 patients were treated for mGOO during the study; 70 (58.6% male subjects; median age, 64 [interquartile range, 58-73] years; 75.7% pancreatic cancer, 60.0% metastatic cancer) underwent EUS-GE via the wireless simplified technique. Technical success was 97.1% and clinical success was 97.1% after a median of 1.5 (interquartile range, 1-2) days. Adverse events occurred in 9 (12.9%) patients. After a median follow-up of 105 (49-187) days, symptom recurrence was 7.6%. In the matched comparison versus ES (28 patients per arm), EUS-GE-treated patients experienced higher and faster clinical success (100% vs 75.0%, P= .006), reduced recurrences (3.7% vs 33.3%, P= .02), and a trend toward shorter time to chemotherapy. In this first, prospective, single-center comparison, EUS-GE showed excellent efficacy in treating mGOO, with an acceptable safety profile and long-term patency, and several clinically significant advantages over ES. While awaiting randomized trials, these results might endorse EUS-GE as first-line strategy for mGOO, where adequate expertise is available.

Central extracorporeal circulatory life support (cECLS) in selected patients with critical cardiogenic shock.

Percutaneous extracorporeal life support (pECLS) is increasingly applied in cardiogenic shock (CS) despite a lack of evidence from randomized trials. The in-hospital mortality rate of pECLS still reaches up to 60%, while vascular access site complications remain a shortcoming. Surgical approaches with central cannulation for ECLS (cELCS) have emerged as a bail-out option. To date, no systematic approach exists that allows a definition of inclusion or exclusion criteria for cECLS. This single-center, retrospective, case-control study includes all patients fulfilling criteria for CS at the West German Heart and Vascular Center Essen/Germany between 2015 and 2020 who underwent cECLS (n = 58), excluding post-cardiotomy patients. Seventeen patients received cECLS (29.3%) as a first-line treatment strategy and 41 patients as a second-line strategy (70.7%). The main complications leading to the use of cECLS as a second-line strategy were limb ischemia (32.8%) and ongoing insufficient hemodynamic support (27.6%). The first-line cECLS cohort showed a 30-day mortality rate of 53.3% that was constant during follow-up. The 30-day mortality rate of secondary cECLS candidates was 69.8% and the rate at 3 and 6 months was 79.1%. Younger patients (<55 years) were more likely to exhibit survival benefit with cECLS (p = 0.043). Surgical cECLS in CS is a feasible therapy for highly selected patients with hemodynamic instability, vascular complications, or peripheral access site limitations as complementary strategy in experienced centers.

Embolization as stand-alone strategy for pediatric low-grade brain arteriovenous malformations

ObjectivesWe evaluated the safety and efficacy of endovascular embolization as first-line stand-alone strategy for the treatment of low-grade brain arteriovenous malformations (bAVMs) (Spetzler Martin [SM] grade I and II) in pediatric patients. In addition, we assessed the predictors of procedure-related complications and radiographic complete obliteration in a single session. Material and methodsWe conducted a single center retrospective cohort study of all pediatric (≤18 years) patients who underwent embolization as a stand-alone strategy for low-grade bAVMs between 2010 and 2022. Safety was measured by procedure-related complications and mortality. Efficacy was defined as complete angiographic obliteration after the last embolization session. ResultsSixty-eight patients (41 females; median age 14 years) underwent a total of 102 embolization sessions. There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Six procedure-related complications (5.8% of procedures) were observed and no deaths were reported. All the complications were intraoperative nidus ruptures. A single draining vein was the only significant predictor of procedure-related complications (OR=0.10; 95% CI 0.01 – 0.72; p=0.048). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (51%) the bAVM was completely occluded in one session. The bAVM nidal size was a predictor of complete obliteration in one session (OR=0.44; 95% CI, 0.21–0.80; p=0.017). ConclusionEndovascular treatment as a stand-alone strategy for pediatric low-grade bAVMs is an adequate first-line approach in high volume centers with endovascular expertise. Nidal size evaluation is relevant in order to optimize patient selection for embolization as a stand-alone treatment modality.

The language of vaccination campaigns during COVID-19

Understanding what makes communication effective when designing public health messages is of key importance. This applies in particular to vaccination campaigns, which aim to encourage vaccine uptake and respond to...

Development of a Tailored Mobile Phone-Based Intervention to Facilitate Parent-Child Communication and Build Human Papillomavirus Vaccine Confidence: Formative Qualitative Study.

Human papillomavirus (HPV) vaccine hesitancy is on the rise, and provider communication is a first-line strategy to address parental concerns. The use of the presumptive approach and motivational interviewing by providers may not be enough to influence parental decision-making owing to the providers' limited time, self-efficacy, and skills to implement these strategies. Interventions to enhance provider communication and build parental HPV vaccine confidence have been undertested. Delivering tailored patient education to parents via mobile phones before they visit the health care provider may address time constraints during clinic visits and positively affect vaccine uptake. This study aimed to describe the development and evaluate the acceptability of a mobile phone-based, family-focused intervention guided by theory to address concerns of HPV vaccine-hesitant parents before the clinic visit, as well as explore intervention use to facilitate parent-child communication. The health belief model and theory of reasoned action guided intervention content development. A multilevel stakeholder engagement process was used to iteratively develop the HPVVaxFacts intervention, including a community advisory board review, a review by an advisory panel comprising HPV vaccine-hesitant parents, a health communications expert review, semistructured qualitative interviews with HPV vaccine-hesitant parents (n=31) and providers (n=15), and a content expert review. Inductive thematic analysis was used to identify themes in the interview data. The qualitative interviews yielded 4 themes: overall views toward mobile device use for health information, acceptability of HPVVaxFacts, facilitators of HPVVaxFacts use, and barriers to HPVVaxFacts use. In parent interviews after reviewing HPVVaxFacts prototypes, almost all parents (29/31, 94%) stated they intended to have their child vaccinated. Most of the parents stated that they liked the added adolescents' corner to engage in optional parent-child communication (ie, choice to share and discuss information with their child; 27/31, 87%) and shared decision-making in some cases (8/31, 26%). After incorporating all input, the final intervention consisted of a 10-item survey to identify the top 3 concerns of parents, followed by tailored education that was mapped to each of the following concerns: evidential messages, images or graphics to enhance comprehension and address low literacy, links to credible websites, a provider video, suggested questions to ask their child's physician, and an optional adolescents' corner to educate the patient and support parent-child communication. The multilevel stakeholder-engaged process used to iteratively develop this novel intervention for HPV vaccine-hesitant families can be used as a model to develop future mobile health interventions. This intervention is currently being pilot-tested in preparation for a randomized controlled trial aiming to increase HPV vaccination among adolescent children of vaccine-hesitant parents in a clinic setting. Future research can adapt HPVVaxFacts for other vaccines and use in other settings (eg, health departments and pharmacies).

MP31-10 MANAGEMENT OF MYCOTIC PSEUDOANEURYSMS IN RENAL TRANSPLANT PATIENTS - A LITERATURE REVIEW AND PROPOSAL FOR A NOVEL MANAGEMENT PATHWAY

You have accessJournal of UrologyCME1 Apr 2023MP31-10 MANAGEMENT OF MYCOTIC PSEUDOANEURYSMS IN RENAL TRANSPLANT PATIENTS - A LITERATURE REVIEW AND PROPOSAL FOR A NOVEL MANAGEMENT PATHWAY Alexandra Bain, Gerrit Winkelaar, and Max Levine Alexandra BainAlexandra Bain More articles by this author , Gerrit WinkelaarGerrit Winkelaar More articles by this author , and Max LevineMax Levine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vascular complications represent the main cause of early graft loss in renal transplantations—with less than 1% of these cases developing mycotic pseudoaneurysms. The morbidity and mortality associated with this complication is significant with an overall mortality rate of 15-20% and a graft loss rate of 55-70%. Currently the gold standard treatment for mycotic pseudoaneurysms is undefined. Recently there have been three renal transplant patients at the University of Alberta Hospital who developed mycotic pseudoaneurysms with different surgical repairs and outcomes. We performed a quality assurance review and a literature review of the surgical management of mycotic pseudoaneurysms. Based on this review, we have proposed a novel management pathway which may help reduce post-operative complications. METHODS: The databases MEDLINE and SCOPUS were searched for all case reports describing management of mycotic pseudoaneurysms in renal transplant patients between years 1990-2022. RESULTS: Twenty-two articles were reviewed which described forty-one case reports of mycotic pseudoaneurysms in renal transplant recipients. Repair techniques included patch repair in 61% of cases (25/41), endovascular stenting in 22% of cases (9/41), and extra-anatomical bypass in 12% of cases (5/41), 5% of patients (2/41) had a post-mortem diagnosis. The failure rates of patch repair resulting in death or repeat surgery was 44% (11/25), failure rates for stents was 22% (2/9), failure rates of extra-anatomical bypass was 0%. Every patient who required a takeback operative procedure was managed with an extra-anatomical bypass. Overall patient mortality was 17% (7/41), overall graft loss rate was 68% (28/41). CONCLUSIONS: Considering the high failure rates of patch repairs and endovascular stents, we suggest the first-line strategy for repair should be an extra-anatomical bypass with the assistance of Vascular Surgery when possible. If an extra-anatomical bypass cannot be performed, we suggest a wide surgical debridement with autologous in-line reconstruction. These surgical approaches may help decrease the incidence of surgical failure rates and mortalities. Having a standardized management pathway utilized by Transplant Urology and Vascular Surgery may allow for improved patient surgical outcomes and graft survival outcomes in the future. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e433 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandra Bain More articles by this author Gerrit Winkelaar More articles by this author Max Levine More articles by this author Expand All Advertisement PDF downloadLoading ...

Effectiveness and safety of first-line immune checkpoint inhibitors for patients with extensive-stage small cell lung carcinoma: A systematic review and network meta-analysis

ObjectiveIn recent years, the introduction of immune checkpoint inhibitors (ICIs) has revolutionized the treatment of extensive-stage small cell lung carcinoma (ES-SCLC), but the optimal combination of ICI and standard chemotherapy strategy is yet to be established. The aim of this network meta-analysis (NMA) was to identify which first-line combination strategy is optimal for patients with ES-SCLC. MethodsPubMed, Embase, Cochrane Library, and the proceedings of international conferences, including American Society of Clinical Oncology and European Society for Medical Oncology meetings, were searched for randomized controlled trials (RCTs) published through October 31, 2022. The collected primary outcomes were overall survival (OS), progression-free survival (PFS), and grade 3–5 treatment-related adverse events (TRAEs). ResultsOur NMA study included six phase 3 and three phase 2 RCTs including 4037 patients and 10 first-line regimens. Regarding effectiveness, the addition of programmed cell death 1 (PD-1) or programmed cell death ligand 1 (PD-L1) inhibitors to standard chemotherapy provided greater efficacy than chemotherapy alone. However, cytotoxic T lymphocyte-associated antigen-4 inhibitors were not associated with satisfactory prognoses. Serplulimab plus carboplatin–etoposide (vs. standard chemotherapy, hazard ratio [HR] = 0.63; 95% CI = 0.49–0.82) and nivolumab plus platinum–etoposide (HR = 0.65; 95% confidence interval [CI] = 0.46–0.91) displayed the greatest benefit regarding OS. In terms of PFS, serplulimab plus carboplatin–etoposide yielded the best benefit of all treatments (HR = 0.48; 95% CI = 0.39–0.6). The combination of ICIs and chemotherapy caused more toxicity in general, but durvalumab plus platinum–etoposide (odds ratio [OR] = 0.98; 95% CI = 0.68–1.4), atezolizumab plus carboplatin–etoposide (OR = 1.04; 95% CI = 0.68–1.6), and adebrelimab plus platinum–etoposide (OR = 1.02; 95% CI = 0.52–2) displayed similar safety as standard chemotherapy. Subgroup analysis by race illustrated that serplulimab plus carboplatin–etoposide was associated with the best OS in Asian patients. And in non-Asian patients, the combination of PD-1/PD-L1 inhibitors and chemotherapy (pembrolizumab plus platinum–etoposide, durvalumab plus platinum–etoposide, and durvalumab and tremelimumab plus platinum–etoposide) displayed superiority to standard chemotherapy. ConclusionsThe results of our NMA study suggested that serplulimab plus carboplatin–etoposide and nivolumab plus platinum–etoposide are associated with the best OS as first-line treatments for patients with ES-SCLC. Serplulimab plus carboplatin–etoposide was associated with the best PFS. In Asian patients, serplulimab plus carboplatin–etoposide had the best OS. Systematic review registrationThis study is registered with PROSPERO, number CRD42022345850.

A Real-world Study on the Expression Characteristics of PD-L1 in Patients with Advanced EGFR Positive NSCLC and Its Relationship with the Therapeutic Efficacy of EGFR-TKIs

Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) is the first choice for first-line treatment of advanced patients with EGFR positive non-small cell lung cancer (NSCLC). For advanced NSCLC patients with negative drive gene and positive programmed cell death ligand 1 (PD-L1) or highly expressed NSCLC patients, the first-line treatment recommends immune checkpoint inhibitors (ICIs) monotherapy or ICIs combined chemotherapy. Therefore, the first-line treatment strategy for advanced NSCLC patients with EGFR positive at different PD-L1 expression levels is worth further exploring. Many previous studies have suggested that the expression of PD-L1 is obviously affected by EGFR mutation, and the expression of PD-L1 is likely to be related to the mechanism of EGFR-TKIs resistance. The purpose of this study was to analyze the expression characteristics of PD-L1 in patients with advanced EGFR positive NSCLC and its relationship with the efficacy of EGFR-TKIs. 159 patients with newly diagnosed advanced NSCLC with EGFR positive (including 141 patients with EGFR sensitive mutations) were enrolled to analyze the relationship between clinicopathological characteristics and PD-L1 expression. The factors affecting the therapeutic effect of EGFR-TKIs in 141 patients with EGFR sensitive mutations were also explored. The PD-L1 expression of the included patients was classified according to the tumor promotion score (TPS): negative (TPS<1%) accounted for 47.2%, low expression (1%≤TPS<50%) accounted for 32.1%, and high expression (TPS≥50%) accounted for 20.7%. Among them, patients with solid predominant cancer cell pathomorphology classification are more likely to have high expression of PD-L1, accounting for 52.9% (P<0.0001). The median progression-free survival (mPFS) of patients with PD-L1 negative expression, low expression and high expression who received first generation EGFR-TKIs treatment were 12.4 months, 10.5 months and 3.7 months, respectively, with significant statistical difference (P<0.0001). During the EGFR-TKIs treatment, patients with a history of radiotherapy for lung lesions have a longer PFS benefit than those without a history of radiotherapy (mPFS: 17.0 months vs 9.3 months, P<0.0001). The expression level of PD-L1 in advanced EGFR positive NSCLC patients was significantly correlated with the pathomorphology classification of cancer cells. The efficacy of EGFR-TKIs in patients with PD-L1 overexpression NSCLC was significantly poor. PFS can be significantly prolonged during targeted therapy combined with radiotherapy of lung lesions.

A120 ENDOSCOPIC CLOSURE TECHNIQUES FOLLOWING ACUTE IATROGENIC PERFORATION -- AN UPDATED SYSTEMATIC REVIEW

Abstract Background Iatrogenic perforation is arguably the most feared adverse event associated with endoscopy. Current American Society for Gastrointestinal Endoscopy (ASGE) and European Society of Gastroenterology Endoscopy (ESGE) guidelines recommend endoscopic closure as the first-line treatment strategy. Historically, this has been achieved using through-the-scope clips (TTSC). Given the emergence of alternative endoscopic closure techniques including over-the-scope clips (OTSC) and endoscopic suturing, we sought to provide an updated review of the literature. Purpose To review endoscopic closure techniques following iatrogenic perforation during screening or therapeutic endoscopy. Method Based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, an electronic search of MEDLINE and EMBASE from June 1st, 1946 – Oct 10th, 2022 was performed. Inclusion criteria was limited to English full-text original citations, with case reports, and cohorts with &amp;lt; 3 patients excluded. Our primary objective was to assess complete defect closure after attempted endoscopic treatment. Outcomes were stratified by modality (TTSC, OTSC, endoscopic suturing) and chronologically based on a previous well received systematic review. Result(s) A total of 2549 citations were identified in our electronic search, of which 34 were included representing 830 perforations. Overall, successful endoscopic closure was achieved in 763 cases (91.9%). When stratified by endoscopic closure techniques, range estimates for successful endoscopic closure was 71% – 100%, 57% - 100%, and 100% for TTSC, OTSC and endoscopic suturing respectively. When stratifying chronologically, an improvement in TTSC closure was identified. Conclusion(s) Endoscopic defect closure, including TTSC, OTSC and endoscopic suturing, are effective in the management of iatrogenic perforations with increasing TTSC performance over time. It remains the primary treatment strategy for iatrogenic perforation. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Partner Alliance to Enhance Efficacy and Adherence of CBT-I.

Cognitive behavioral therapy for insomnia (CBT-I) is now widely recognized as the first-line management strategy for insomnia, both for insomnia in its "pure" form, and when comorbid with a physical or psychological illness. However, there is a definite need to develop and test both alternative and adjunct interventions to CBT-I, before implementing them into routine practice. The aim of this article is to provide a narrative review of the literature with regard to what is known about the influence of partners on sleep, insomnia, and its management.

Korean Medication Algorithm Project for Bipolar Disorder 2022: Comparisons with Other Treatment Guidelines.

The objective of this study was to compare recommendations of the Korean Medication Algorithm Project for Bipolar Disorder 2022 (KMAP-BP 2022) with other recently published guidelines for treating bipolar disorder. We reviewed a total of six recently published global treatment guidelines and compared treatment recommendation of the KMAP-BP 2022 with those of other guidelines. For initial treatment of mania, there were no significant differences across treatment guidelines. All guidelines recommended mood stabilizer (MS) or atypical antipsychotic (AAP) monotherapy or a combination of an MS with an AAP as a first-line treatment strategy in a same degree for mania. However, the KMAP-BP 2022 recommended MS + AAP combination therapy for psychotic mania, mixed mania and psychotic depression as treatment of choice. Aripiprazole, quetiapine and olanzapine were the first-line AAPs for nearly all phases of bipolar disorder across guidelines. Some guideline suggested olanzapine is a second-line options during maintenance treatment, related to concern about long-term tolerability. Most guidelines advocated newer AAPs (asenapine, cariprazine, long-acting injectable risperidone, and aripiprazole once monthly) as first-line treatment options for all phases while lamotrigine was recommended for depressive and maintenance phases. Lithium and valproic acid were commonly used as MSs in all phases of bipolar disorder. KMAP-BP 2022 guidelines were similar to other guidelines, reflecting current changes in prescription patterns for bipolar disorder based on accumulated research data. Strong preference for combination therapy was characteristic of KMAP-BP 2022, predominantly in the treatment of psychotic mania, mixed mania and psychotic depression.

Exercise in the Prevention and Treatment of Type 2 Diabetes.

Type 2 diabetes is a systemic, multifactorial disease that is a leading cause of morbidity and mortality globally. Despite a rise in the number of available medications and treatments available for management, exercise remains a first-line prevention and intervention strategy due to established safety, efficacy, and tolerability in the general population. Herein we review the predisposing risk factors for, prevention, pathophysiology, and treatment of type 2 diabetes. We emphasize key cellular and molecular adaptive processes that provide insight into our evolving understanding of how, when, and what types of exercise may improve glycemic control. © 2023 American Physiological Society. Compr Physiol 13:1-27, 2023.

The effects of exercise therapy feedback on subjective treatment outcome and patient satisfaction: study protocol for a mono-centric, randomized, controlled trial in orthopedic rehabilitation (FeedYou)

BackgroundThe disease burden of musculoskeletal disorders necessitates multidisciplinary and patient-centered models of care. Exercise therapy represents a first-line treatment strategy and a central component of medical rehabilitation. In order to realize the goals of long-term physical activity and participation as proposed by the ICF, exercise therapy can be supplemented by interventional techniques from the field of psychotherapy. Although psychotherapist feedback has been shown to improve therapeutic outcome and patient satisfaction, feedback use in exercise therapy is mostly limited to motor learning and exercise instruction. The present paper therefore describes the use of multidimensional exercise therapy feedback in medical rehabilitation. The aims of the trial presented in this study protocol are to evaluate the effects of this novel feedback approach on rehabilitation outcomes in comparison to usual care.MethodsThe study is designed as a prospective, mono-centric, randomized controlled, superiority trial (RCT) with two parallel groups and three measuring points: T0 = start of three-week inpatient rehabilitation, T1 = end of three-week inpatient rehabilitation, T2 = 12-week follow-up. In total, 132 patients suffering from chronic neck, shoulder and/or lumbar spine disorders will be recruited. The intervention involves multidimensional exercise therapy feedbacks during the initial and final physical therapist examination, as well as short exercise therapy feedbacks during the course units of the mandatory group-based exercise therapy program. Primary outcomes are the subjective treatment outcome, assessed by BPI and indication-specific questionnaires, as well as patient satisfaction, assessed by ZUF-8 and an intervention-specific questionnaire. The final data collection is expected by May 2023.DiscussionThis study may provide a valuable insight into the effectiveness of multidimensional exercise therapy feedback to improve treatment outcomes and patient satisfaction in medical rehabilitation. This could contribute to rehabilitation quality assurance and the long-term physical activity behavior of rehabilitation patients.Trial registration The trial has been registered with the German Clinical Trial Register (DRKS) under the Registration Number DRKS00027263.

Cost-effectiveness analysis of anlotinib versus sunitinib as first-line treatment for metastatic renal cell carcinoma in China.

Sunitinib was approved several years ago as a first-line drug for treating metastatic renal cell carcinoma (mRCC); however, its high price and broad side effects when administered at the standard dose have limited its clinical use. A clinical trial (NCT02072031) confirmed that anlotinib could be used as the first-line treatment for mRCC. This study was conducted to evaluate the cost-effectiveness of anlotinib as a first-line treatment for mRCC compared to that of sunitinib in China. A Markov model was established to compare the cost-effectiveness of anlotinib with that of sunitinib. Clinical data were obtained from a multi-center phase II trial (clinical trial information: NCT02072031). Utility values were obtained from the literature. Total costs were calculated from a Chinese societal perspective. A sensitivity analysis was conducted to assess the model uncertainty. The life-year (LY), quality-adjusted life-year (QALY), and incremental cost-effectiveness ratio were calculated. The base-case analysis over a lifetime horizon of 10 years showed that the anlotinib group had 2.196 LYs and 1.487 QALYs at a total cost of $68,597.84. The sunitinib group had 2.194 LYs and 1.432 QALYs at a total cost of $88,060.02. This resulted in incremental cost-effectiveness ratios (ICER) of anlotinib versus sunitinib of $-9,210,858.93 per LYs and $-354,117.07 per QALYs, suggesting that anlotinib is a more effective and less costly strategy than sunitinib. Anlotinib may be a more cost-effective first-line treatment strategy for mRCC than sunitinib in China.

Phase III FIRE-4 study (AIO KRK-0114): Evaluation of first-line treatment efficacy of FOLFIRI/cetuximab in patients with RAS-WT mCRC receiving the first cycle of treatment with chemotherapy only.

100 Background: FIRE-4 (AIO KRK-0114) is performed in RAS wild-type (wt) mCRC patients. This randomized study tests the efficacy of early switch maintenance during 1st-line therapy (part 1) and re-challenge with cetuximab (part 2) in later-line treatment. In part 1, all patients received first-line induction treatment with FOLFIRI plus cetuximab (FOLFIRI/Cet). In arm A, patients were randomized to continue FOLFIRI/Cet until progression or intolerable toxicity. In arm B, patients received FOLFIRI/Cet for 8-12 cycles, after which maintenance therapy with 5-FU/FA plus bevacizumab (5-FU/Bev) was applied. The first randomization evaluates the question if an early switch from cetuximab to bevacizumab during maintenance therapy may prolong PFS. The study protocol explicitly allowed a first cycle of chemotherapy to be applied before randomization. Methods: Within this randomized, controlled, open-label phase-III study, patients received FOLFIRI (irinotecan plus 5-FU/FA) plus cetuximab every two weeks at the standard dosing schedule. In arm A, FOLFIRI plus cetuximab was continued until progression or intolerable toxicity. De- and re-escalation was allowed according to the local standard of care. In arm B, patients received 8 cycles of FOLFIRI plus cetuximab (in case of tumor response) or 12 cycles (in case of stable disease) followed by maintenance with 5-FU/FA plus bevacizumab (5mg/kg) until disease progression or intolerable toxicity. Overall survival after second randomization (part 2) is evaluated as a primary endpoint. Here, we report PFS in first-line (part 1) as a secondary study endpoint of the study. Other secondary endpoints included ORR, OS, safety, and tolerability. Results: From August 2015 to January 2021, 672 patients were randomized, and 656 patients were assigned to treatment in 120 German and 10 Austrian centers (327 arm A and 329 in arm B). Of those, 205 patients received one cycle of FOLFIRI alone before randomization. In both arms, ORR was comparable for patients receiving cetuximab from the first cycle when compared to those receiving one cycle of chemotherapy only (arm A: 58.7% vs 62.9% (p = 0.54), arm B 60.2% vs 55.6% (p = 0.48). PFS was also not influenced in both arms (arm A: 10.8mo vs. 10.6mo (p = 0.91); arm B 11.2mo vs. 11.4mo (p = 0.62)). Preliminary results suggest that also OS (event rate 38.3%) was not influenced by one cycle applied without cetuximab (arm A: 33.7 mo vs. 29.1 mo (p = 0.20); arm B: 35.6 mo vs. 28.9 mo (p = 0.13)). Conclusions: Application of one initial cycle with chemotherapy alone did not influence the efficacy of a first-line strategy of FOLFIRI plus cetuximab. If RAS mutational analysis is not timely available, a start with FOLFIRI alone adding cetuximab in cycle 2 seems to be safe with respect of overall efficacy. Clinical trial information: NCT02934529 .