Frequent Clinical Assessment Research Articles

Exploring the association of adverse drug reactions with medication adherence and quality of life among hypertensive patients: a cross-sectional study.

Effective hypertension management requires medication adherence to prevent complications. However, adverse drug reactions (ADRs) can undermine adherence and negatively affect patients' quality of life. Limited research has explored the association between ADRs, medication adherence, and health-related quality of life (HRQoL) in individuals with hypertension. To investigate the association between ADRs, medication adherence, and HRQoL among patients with hypertension. A cross-sectional study using telephone interviews and medical record reviews was conducted in 11 primary care facilities in Indonesia. The causality of reported ADRs was assessed using the Naranjo algorithm, validated by a panel of experts in pharmacy practice and medication safety. The severity of ADRs was classified using the Hartwig scale. Adherence to antihypertensive drugs was estimated using the Medication Adherence Report Scale-5 (MARS-5). The EuroQoL EQ-5D-5L was used to measure HRQoL. The association between ADRs and medication adherence was assessed using multivariate logistic regression, while the association with HRQoL was evaluated through the Tobit regression model. A total of 507 patients were included in this study. We found that 20.32% (n = 103) of the patients experienced ADRs, with the most commonly reported ADRs being polyuria and urgency, gastrointestinal symptoms, leg swelling, dizziness/hypotension, palpitations, and dry cough. The majority experienced mild ADRs (n = 75, 72.82%), while 27.18% (n = 28) had reactions of moderate severity. Experiencing ADRs was associated with reduced medication adherence (adjusted odds ratio (OR) 7.15, 95% CI 4.07-12.55) and decreased HRQoL (coefficient: - 0.037). Patients experiencing ADRs were seven times more likely to be non-adherent to their medication regimen and reported a reduced quality of life compared to those without ADRs, placing them at a higher risk of suboptimal treatment outcomes. This finding highlights the need for additional monitoring and education for patients affected by ADRs, particularly through more frequent clinical and laboratory assessments, timely management of ADRs, and personalized education on the importance of adherence to prevent hypertension-related complications.

Using the Progression Independent of Relapse Activity Framework to Unveil the Pathobiological Foundations of Multiple Sclerosis.

Progression independent of relapse activity (PIRA), a recent concept to formalize disability accrual in multiple sclerosis (MS) independent of relapses, has gained popularity as a potential clinical trial outcome. We discuss its shortcomings and appraise the challenges of implementing it in clinical settings, experimental trials, and research. The current definition of PIRA assumes that acute inflammation, which can manifest as a relapse, and neurodegeneration, manifesting as progressive disability accrual, can be disentangled by introducing specific time windows between the onset of relapses and the observed increase in disability. The term PIRMA (progression independent of relapse and MRI activity) was recently introduced to indicate disability accrual in the absence of both clinical relapses and new brain and spinal cord MRI lesions. Assessing PIRMA in clinical practice is highly challenging because it necessitates frequent clinical assessments and brain and spinal cord MRI scans. PIRA is commonly assessed using Expanded Disability Status Scale, a scale heavily weighted toward motor disability, whereas a more granular assessment of disability deterioration, including cognitive decline, using composite measures or other tools, such as digital tools, would possess greater utility. Similarly, using PIRA as an outcome measure in randomized clinical trials is also challenging and requires methodological considerations. The underpinning pathobiology of disability accumulation, that is not associated with relapses, may encompass chronic active lesions (slowly expanding lesions and paramagnetic rim lesions), cortical lesions, brain and spinal cord atrophy, particularly in the gray matter, diffuse and focal microglial activation, persistent leptomeningeal enhancement, and white matter tract damage. We propose to use PIRA to understand the main determinant of disability accrual in observational, cohort studies, where regular MRI scans are not included, and introduce the term of "advanced-PIRMA" to investigate the contributions to disability accrual of the abovementioned processes, using conventional and advanced imaging. This is supported by the knowledge that MRI reflects the MS pathogenic mechanisms better than purely clinical descriptors. Any residual disability accrual, which remains unexplained after considering all these mechanisms with imaging, will highlight future research priorities to help complete our understanding of MS pathogenesis.

Optimal follow-up schedule for patients taking PCSK9 monoclonal antibodies in a health system: Analysis of specialty pharmacy clinical interventions.

The objective of this study was to determine if and when it is clinically appropriate to consider a reduction in the frequency of health-system specialty pharmacy (HSSP) clinical pharmacist assessments for patients taking a proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody (mAb) after they are deemed clinically stable on therapy. A single-center, retrospective, observational study of adult patients on PCSK9 mAb therapy enrolled in the University of Rochester Specialty Pharmacy Cardiology Patient Management Program was performed between October 24, 2016, and April 30, 2022. The primary outcome was the number of clinical pharmacist interventions per interval within the baseline 12 months compared to 12-month intervals for up to 72 months after initiation of PCSK9 mAb therapy. A total of 368 patients on PCSK9 mAb therapy were included in the study. A significantly lower percentage of patients had more than 2 interventions during the 12- to 24-month interval (24.3%) as compared to the baseline 12-month interval (80.2%) (P < 0.001); this represented a 70% reduction in the chance of a patient requiring more than 2 interventions (relative risk, 0.30; 95% CI, 0.24-0.38). A similar trend was demonstrated in the 24- to 36-month and 36- to 48-month intervals when compared to the first year of therapy. The most commonly documented clinical pharmacist interventions were in the categories of safety (29.2%), effectiveness (28.4%), and adherence (19.9%). Patients beyond 1 year of PCSK9 mAb therapy required less clinical pharmacist interventions. Therefore, stable patients receiving a PCSK9 mAb may be considered for less frequent clinical assessments to allow for HSSP growth to nontraditional clinical areas.

The physical and developmental outcomes of children whose mothers are substance abusers: Analysis of associated factors and the impact of early intervention.

Maternal illicit drug use is associated with negative physical and developmental outcomes for their born children. We aim to find out the incidence of different developmental problems in a cohort of Chinese children born to drug-abusing mothers, compare the physical health and developmental outcomes of the subjects recruited in the Integrated Program to the Comprehensive Child Development Service (CCDS), and to study the potential factors on their associations. A retrospective longitudinal cohort study with frequent clinical assessments of the children's physical and developmental outcomes in a HKSAR's regional hospital from birth until 5 years old. 123 Children in Integrated Program were compared with 214 children in CCDS between 1 January 2008 and 28 February 2019. Cox regression analysis was performed to determine the possible factors associated with the developmental outcomes. Developmental delay was detected in 129 children (38.9%). CCDS group has significantly higher incidence of cognitive delay (p = < 0.001), language delay (p = < 0.001), motor delay (p = < 0.001), social delay (p = 0.002), and global delay (p = 0.002). On Cox multivariable regression analysis, integrated program (HRadj 0.53, 95% C. I. 0.34-0.84), social support (HRadj 0.45, 95% C.I. 0.25-0.80), and maternal abstinence from drug use up to 2-year post-delivery (HRadj 0.62, 95% C.I. 0.40-0.95) were significant protective factors, while male gender (HRadj 1.73, 95% C.I. 1.18-2.54) was a significant risk factor. CCDS achieves early engagement of drug-abusing expectant mothers during pregnancy, and an early integrated program with multidisciplinary collaboration was an independent factor in improving the developmental outcomes of these vulnerable children.

548 A 10-Year Longitudinal Cohort Study Assessing Growth Rates and Surveillance Intervals for Common Iliac Artery Aneurysms

Abstract Aim The European Society for Vascular Surgery defines common iliac artery (CIA) aneurysms as greater than 1.8cm in men and 1.5cm in women. Their reported growth rate is 1–4mm/year depending on their diameter. This study aimed to assess the natural history and surveillance intervals for CIA aneurysms as intervention threshold is based on low-quality evidence. Method Patients diagnosed with an IAA at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included diameter-based mean aneurysm growth rates and median surveillance intervals. Statistical analysis with SPSS® was performed using chi-squared tests. Results Of the 203 patients included, 90.6% were men and median (IQR) age at detection was 77 (71–83). IAA were located in the CIA (85.2%), IIA (21.7%) and EIA (2.0%) with the majority being asymptomatic (78.8%). CT was most frequently used as the imaging modality for IAA surveillance (66.3%), followed by ultrasound scan (29.8%) and MRA (3.9%). Growth rate for CIA aneurysms measuring 1.0–1.9cm were -2.1mm/year, 2.0–2.9cm were 0.8mm/year, 3.0–3.9cm were 3.5mm/year, 4.0–4.9cm were 9.4mm/year, 5.0–5.9cm were 2.9mm/year and &amp;gt;6.0cm were 13.8mm/year. Median surveillance intervals for CIA aneurysms at 1.0–1.9cm were 12-monthly, 2.0–2.9cm were 11-monthly, 3.0–3.9cm were 5-monthly, 4.0–4.9cm were 5-monthly, 5.0–5.9cm were 5.5-monthly and &amp;gt;6.0cm were 14.5-monthly. Mean(SD) CIA diameter at rupture was 4.6 (2.4)cm. Conclusions CIA aneurysms demonstrate faster growth rates as they enlarge and may require more frequent clinical assessments, surveillance, and consideration for repair prior to rupture.

O072 A 10-year longitudinal cohort study assessing growth rates and surveillance intervals for common iliac artery aneurysms

Abstract Introduction European Society for Vascular Surgery defines common iliac artery (CIA) aneurysms as greater than 1.8cm in men and 1.5cm in women. Reported growth rate is 1–4mm/year depending on their diameter. This study assessed the natural history and surveillance intervals for CIA aneurysms as intervention threshold is based on low-quality evidence. Methods Patients with an IAA at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included diameter-based mean aneurysm growth rates and median surveillance intervals. Statistical analysis with SPSS® was performed using chi squared tests. Results Of 203 patients included, 90.6% were men and median (IQR) age at detection was 77(71–83). IAA were located in the CIA (85.2%), IIA (21.7%) and EIA (2.0%) with the majority being asymptomatic (78.8%). CT was most frequently used as the imaging modality for IAA surveillance (66.3%), followed by ultrasound scan (29.8%) and MRA (3.9%). Growth rate for CIA aneurysms measuring 1.0–1.9cm were -2.1mm/year, 2.0–2.9cm were 0.8mm/year, 3.0–3.9cm were 3.5mm/year, 4.0–4.9cm were 9.4mm/year, 5.0–5.9cm were 2.9mm/year and &amp;gt;6.0cm were 13.8mm/year. Median surveillance intervals for CIA aneurysms at 1.0–1.9cm were 12-monthly, 2.0–2.9cm were 11-monthly, 3.0–3.9cm were 5-monthly, 4.0–4.9cm were 5-monthly, 5.0–5.9cm were 5.5-monthly and &amp;gt;6.0cm were 14.5-monthly. Mean (SD) CIA diameter at rupture was 4.6 (2.4)cm. Conclusion CIA aneurysms demonstrate faster growth rates as they enlarge and may require more frequent clinical assessments, surveillance and consideration for repair prior to rupture. Take-home message CIA aneurysms demonstrate faster growth rates as they enlarge and may require more frequent clinical assessments, surveillance and consideration for repair prior to rupture.

COVID-19 and Light Chain Amyloidosis, Adding Insult to Injury

Light chain (AL) amyloidosis is a potentially fatal disease of monoclonal plasma cells that leads to accumulation of light chain amyloid fibrils, organ damage, and the manifestations of clinical disease. Meanwhile, coronavirus disease 2019 (COVID-19) is a disease caused by infection with the severe acute respiratory syndrome coronavirus 2 virus, with the potential to cause severe systemic illness and death. There is significant overlap in the demographics and comorbidities observed in AL amyloidosis and those associated with highest risk for severe morbidity and mortality due to COVID-19. This overlap creates unique challenges in caring for patients with AL amyloidosis, which are further compounded by the immunosuppressive nature of anti-plasma cell therapies, the need for frequent clinical assessments, and the exclusion of AL amyloidosis patients from initial COVID-19 vaccine trials. Herein, we highlight many of the relevant concerns related to COVID-19 and the treatment of AL amyloidosis, summarize a general approach for AL amyloidosis management amidst the ongoing COVID-19 pandemic, and discuss current guidance about COVID-19 vaccination of patients with AL amyloidosis.

Impact of Smoking History on Pulmonary Metastasis-free Survival in Patients With Soft-tissue Sarcoma.

Although smoking history is predictive of poor pulmonary metastasis-free survival (PMFS) in patients with epithelial tumors, the impact of smoking history on PMFS in those with soft-tissue sarcoma (STS) is not known. Patients undergoing treatment for STS at our institutes between 2008 and 2017 were enrolled. Patients were excluded if they had metastatic lesion, or had a histopathological classification demonstrating small round-cell sarcoma. The impact of smoking history on PMFS and overall survival was examined with multivariate analysis using a Cox proportional hazards model. A total of 250 patients were retrospectively reviewed. Patients with smoking history had worse PMFS on multivariate analysis (hazard ratio=2.00, 95% confidence interval=1.12-3.60). On the other hand, smoking history did not significantly affect overall survival (hazard ratio=1.26, 95% confidence interval=0.61-2.58). Patients with STS need to be followed-up by frequent clinical assessments if they have a smoking history.

O07 The increase in erythrocyte mean corpuscular volume by methotrexate is potentiated by hydroxychloroquine and is an early indicator of clinical response in rheumatoid arthritis

Background/Aims Rheumatologists are facing a significant challenge in the management of early rheumatoid arthritis (RA) due to limitations placed on outpatient visits during the COVID-19 pandemic. Frequent clinical assessments of disease activity are recommended during implementation of the treat to target strategy to achieve remission. A biomarker indicating response to methotrexate during the early phase of therapy could complement clinical examination. Methotrexate increases erythrocyte mean corpuscular volume (MCV), which is measured routinely, prompting us to investigate whether changes in MCV could act as an early indicator of response. Methods Patients with early RA who were started on methotrexate therapy were included from two independent cohorts. The larger cohort (discovery cohort, n = 655) was used to build the model and the second cohort (validation cohort, n = 225) was applied to test the prediction of the model. Conventional statistical, and machine learning approaches were adopted to identify key determinants that influence the potential relationship between MCV and clinical response, defined as attainment of remission or low disease activity, at six months after starting methotrexate. Results A LASSO penalised logistic regression model was built with the discovery cohort [area under the receiver operating characteristics (AUROC) curve = 0.76], where change of MCV from three months [Odds ratio (OR) 1.53 (95% CI 1.38-1.70)], concomitant use of hydroxychloroquine [OR 2.16 (95% CI 1.52 - 3.07, p < 0.001)], and seropositivity [OR 1.83 (95% CI 1.12 - 3.03, p = 0.02)] were associated with favourable methotrexate response [accuracy 81% (95% CI 76%-86%) of the model testing against discovery model]. Different machine learning classification methods were applied. Random forest exhibited the maximum accuracy and AUROC (89%, and 86%, respectively), confirming the above three predictors as the most significant. Two latent classes (class 1: smaller MCV increase and class 2: greater MCV increase) were identified based on the MCV changes over six months. Class 1 had fewer responders and a lower number of patients on hydroxychloroquine compared to class 2. The earliest time point of significant difference of MCV between responders and non-responders was three months [mean difference 1.43 (95% CI 0.57-2.3)]. Combination hydroxychloroquine and methotrexate caused the greatest increase in MCV with a difference between responders and non-responders at 2 months. Change of MCV at three months showed AUROC of 0.75 to predict treatment response to the combination of methotrexate and hydroxychloroquine at six months with an optimal cut-point of MCV 3.5 fL (95% CI 3.5-3.6) with 71% sensitivity and 75%, specificity. Conclusion Our data provides mechanistic insight into the synergistic clinical benefit of concomitant hydroxychloroquine with methotrexate, boosting the rise in erythrocyte MCV which could serve as an early biomarker of treatment response. Disclosure M.R. Shipa: Grants/research support; Versus arthritis. S. Yeoh: Grants/research support; Royal College of Physicians, Rosetrees Trust, NIHR University College London Hospitals Biomedical Research Centre, UCLH Charities. A. Embleton-Thirsk: None. D. Mukerjee: None. M.R. Ehrenstein: Grants/research support; University College London Hospital Biomedical Research Centre.

Negative drift of sedation depth in critically ill patients receiving constant minimum alveolar concentration of isoflurane, sevoflurane, or desflurane: a randomized controlled trial

BackgroundIntensive care unit (ICU) physicians have extended the minimum alveolar concentration (MAC) to deliver and monitor long-term volatile sedation in critically ill patients. There is limited evidence of MAC’s reliability in controlling sedation depth in this setting. We hypothesized that sedation depth, measured by the electroencephalography (EEG)-derived Narcotrend-Index (burst-suppression N_Index 0—awake N_Index 100), might drift downward over time despite constant MAC values.MethodsThis prospective single-centre randomized clinical study was conducted at a University Hospital Surgical Intensive Care Unit and included consecutive, postoperative ICU patients fulfilling the inclusion criteria. Patients were randomly assigned to receive uninterrupted inhalational sedation with isoflurane, sevoflurane, or desflurane. The end-expiratory concentration of the anaesthetics and the EEG-derived index were measured continuously in time-stamped pairs. Sedation depth was also monitored using Richmond-Agitation-Sedation-Scale (RASS). The paired t-test and linear models (bootstrapped or multilevel) have been employed to analyze MAC, N_Index and RASS across the three groups.ResultsThirty patients were recruited (female/male: 10/20, age 64 ± 11, Simplified Acute Physiology Score II 30 ± 10). In the first 24 h, 21.208 pairs of data points (N_Index and MAC) were recorded. The median MAC of 0.58 ± 0.06 remained stable over the sedation time in all three groups. The t-test indicated in the isoflurane and sevoflurane groups a significant drop in RASS and EEG-derived N_Index in the first versus last two sedation hours. We applied a multilevel linear model on the entire longitudinal data, nested per patient, which produced the formula N_Index = 43 − 0.7·h (R2 = 0.76), showing a strong negative correlation between sedation’s duration and the N_Index. Bootstrapped linear models applied for each sedation group produced: N_Index of 43–0.9, 45–0.8, and 43–0.4·h for isoflurane, sevoflurane, and desflurane, respectively. The regression coefficient for desflurane was almost half of those for isoflurane and sevoflurane, indicating a less pronounced time-effect in this group.ConclusionsMaintaining constant MAC does not guarantee stable sedation depth. Thus, the patients necessitate frequent clinical assessments or, when unfeasible, continuous EEG monitoring. The differences across different volatile anaesthetics regarding their time-dependent negative drift requires further exploration.Trial registration: NCT03860129.

Literature-based considerations regarding organizing and performing cardiac surgery against the backdrop of the coronavirus pandemic

BackgroundThe ongoing coronavirus disease 2019 (Covid-19) pandemic presents challenges for surgeons of all disciplines, including cardiologists. The volume of cardiac surgery cases has to comply with the mandatory constraints of healthcare capacities. The treatment of Covid-19-positive patients must also be considered. Unfortunately, no scientific evidence is available on this issue. Therefore, this study aimed to offer some consensus-based considerations, derived from available scientific papers, regarding the organization and performance of cardiac surgery against the backdrop of the Covid-19 pandemic.MethodsKey recommendations were extracted from recent literature concerning cardiac surgery.RESULTSː Reducing elective cardiac procedures should be based on frequent clinical assessment of patients on the waiting list (every one or two weeks) and the current local status of the Covid-19 pandemic. Screening tests at admission for every patient are broadly recommended. Where appropriate, alternative treatment methods can be considered, including percutaneous techniques and minimally invasive surgery, if performed by experienced cardiac surgery teams.ConclusionsThere is little evidence on the strategies to organize cardiac surgery in the Covid-19 pandemic. Most authors agree on reducing elective operations based on patients’ clinical condition and the status of the Covid-19 pandemic. Admission screenings and the use of percutaneous or minimally invasive approaches should be preferred to reduce in-hospital stays.

Influence of Framing: Recruitment to a Diabetes Disease Management Program From an Emergency Department Improves Enrollment and Outcomes

IntroductionDisease management programs (DMPs) provide education, self-management skills, care coordination, and frequent clinical assessment and medication adjustment. Our health system’s diabetes mellitus (DM) DMP recruited patients from an emergency department (ED) and outpatient settings (primary care physicians’ [PCP] and endocrinologists’ offices; cold calling patients with poorly-controlled diabetes). We investigated whether recruitment to a DMP from an ED is feasible and effective, hypothesizing such patients would have better enrollment rates, future A1c control, and ED utilization because their receptiveness to change was “framed” by their ED visit. “Framing” is the notion that the same problem presented using a different context impacts response to the information. Being told in an acute-care ED setting one has newly-diagnosed or poorly-controlled DM, or DM-related complications may influence desire/commitment to enroll in the DMP and make lifestyle/medication changes. That is, acute illness or acute setting may influence/”frame” willingness to enroll and improve glycemic control. MethodsWe captured all DMP recruitees’ demographic, medical, insurance, A1c, and recruitment venue characteristics and evaluated future enrollment rates, A1c, and ED utilization from any ED in our health system. We analyzed pre- vs. post-recruitment changes in A1c and ED visit rates, comparing patients recruited from the ED who enrolled, patients recruited from the ED who did not enroll, patients recruited from outpatient settings who enrolled, and patients recruited from outpatient settings who did not enroll. Continuous enrollment predictor and outcome variables were compared using the Mann-Whitney test; categorical outcome variables were compared using Fisher’s exact test.ResultsThere were no statistically significant differences in characteristics (including mean baseline A1c [~11.4%]) among patients recruited from the ED, clinics, or cold calling. Twenty-five percent of all ED-recruited patients enrolled vs. 35% from outpatient settings. When a recruiter familiar with the DMP was in the ED, 41% of ED patients enrolled vs. 12% at other times (p=0.0001). Nearly 84% of ED visits were for direct DM-related causes (eg, diabetic ketoacidosis, hyperosmolar hyperglycemic state) or complications with a well-established link to diabetes (eg, acute coronary syndrome, stroke, wound infection); there was no statistically-significant difference in enrollment rates between patients whose ED visit was vs. was not for a DM-related complaint (53.8% vs. 60.0%, p=0.8018). No other variables, including whether the patient had newly diagnosed DM, were associated with enrollment. Enrollees with worse baseline glycemic control (A1c ≥11%) had a greater median A1c decrease (3.5% vs. 1.9%) vs. those with less-poor baseline glycemic control (A1c <11%) or those declining the program (p=0.05). Post-recruitment ED visits-per-patient-per-month decreased among patients recruited from the ED (-0.08), but not among those recruited from outpatient settings. (+0.08), p<0.0001).ConclusionED recruitment to a diabetes DMP is feasible and effective. An ED-based diabetes DMP recruiter had enrollment rates substantially greater than a cold-calling DMP recruiter, comparable to enrollment rates from PCPs and endocrinologists, suggesting the importance of the recruitment framing/context. ED-recruited patients achieved substantial improvements in A1c and future ED visit rates.

Heart Sound Analysis in Individuals Supported With Left Ventricular Assist Devices

LVADs are surgically implanted mechanical pumps that improve survival rates of individuals with advanced heart failure. LVAD therapy is associated with high morbidity, which can be partially attributed to challenges with detecting LVAD complications before adverse events occur. Current methods used to monitor for complications with LVAD support require frequent clinical assessments at specialized LVAD centers. Analysis of recorded precordial sounds may enable real-time, remote monitoring of device and cardiac function for early detection of LVAD complications. The dominance of LVAD sounds in the precordium limits the utility of routine cardiac auscultation of LVAD recipients. In this work, we develop a signal processing pipeline to mitigate sounds generated by the LVAD. We collected in vivo precordial sounds from 17 LVAD recipients, and contemporaneous echocardiograms from 12 of these individuals, to validate heart valve closure timings. We characterized various acoustic signatures of heart sounds extracted from in vivo recordings, and report preliminary findings linking fundamental heart sound characteristics and level of LVAD support. Mitigation of LVAD sounds from precordial sound recordings of LVAD recipients enables analysis of intrinsic heart sounds. These findings provide proof-of-concept evidence of the clinical utility of heart sound analysis for bedside and remote monitoring of LVAD recipients.

Resorption of maxillary first permanent molars by impacted maxillary second premolars: A case series

Although rare, resorption of the first permanent molar caused by impaction of the second premolar does occur. Three paediatric patients with impacted upper second premolars, distinct symptoms and signs of resorption are described. One case with clear resorption of the upper molar on initial presentation was managed immediately with extraction of the first permanent molar. Eruption of the impacted premolars was monitored in the other two cases, but symptom changes and sectional cone beam computed tomography (CBCT) highlighted resorption of the first permanent molars. In both cases the resorbed first permanent molars required extraction. Frequent clinical and radiographic assessment is imperative in such cases, along with consideration for the use of CBCT. CPD/Clinical Relevance: Many dental health professionals are unaware that resorption of maxillary molars induced by impacted premolars is possible, thus, this phenomenon is not monitored, resulting in misdiagnosis and avoidable patient morbidity.

Fluid, electrolyte and early nutritional management in the preterm neonate with very low birth weight

Abstract Water and electrolytes are major constituents of the body in the preterm infant and undergo rapid changes in content and distribution within the body compartments during the first few days of postnatal adaptation. The changes can be amplified by the severity of the functional immaturity of organs and adverse environmental factors. A clear understanding of fetal physiology and postnatal adaptation, along with frequent and structured clinical assessment, is necessary to guide optimal fluid and electrolyte supplementation. An accurate fluid and electrolyte prescription is critical to delivery of optimum early nutrition. While survival of premature infants has leapt forward with widespread use of antenatal corticosteroids, postnatal surfactant and advances in respiratory support modalities, further improvement is dependent on multiple marginal gains. Meticulous attention to maintain a physiological milieu in the ex utero environment and providing high quality early nutrition to prevent catabolism and promote early growth have been shown to have a positive impact in reducing neonatal morbidities and improving long-term outcomes. This review offers a simple overview of the physiological changes during postnatal adaptation in the preterm infant. It provides practical guidance on fluid, electrolyte and nutritional management in the first few days following birth including advice about clinical assessment and preventative measures. A self-assessment exercise is also included.

Addition of tumour infiltration depth and extranodal extension improves the prognostic value of the pathological TNM classification for early‐stage oral squamous cell carcinoma

AimsIn the 8th edition of the American Joint Committee on Cancer TNM staging manual, tumour infiltration depth and extranodal extension are added to the pathological classification for oral squamous cell carcinoma. The currently available 8th TNM validation studies lack patients with conservative neck treatment, and changes in the classification especially affect patients with small tumours. The aim of this study was to determine the potential impact of the changes in the 8th edition pTNM classification on the prognosis and treatment strategy for oral squamous cell carcinoma in a well‐defined series of pT1–T2 patients with long‐term follow‐up.Methods and resultsTwo hundred and eleven first primary pT1–T2 oral squamous cell carcinoma patients, with surgical resection as primary treatment, were analysed retrospectively. One hundred and seventy‐three patients underwent a neck dissection, and 38 patients had frequent clinical neck assessments. Long‐term follow‐up (median 64 months) and reassessed tumour infiltration depth were available. Classification according to the 8th edition criteria resulted in 36% total upstaging with the T classification and 16% total upstaging with the N classification. T3‐restaged patients (n = 30, 14%) had lower 5‐year disease‐specific survival rates than T2‐staged patients (81% versus 67%, P = 0.042). Postoperative (chemo)radiotherapy could have been considered in another seven (3%) patients on the basis of the 8th edition criteria.ConclusionsAddition of tumour infiltration depth and extranodal extension in the 8th TNM classification leads to the identification of oral squamous cell carcinoma patients with a worse prognosis who might benefit from an improved postoperative treatment strategy.

329 Emergency Providers and Documentation of Interfacility Transferred Aortic Disease Patients

Patients with aortic disease (AoD) are often transferred from community emergency departments (EDs) to tertiary referral facilities for higher levels of care. Currently, there exist frameworks for documentation in compliance with the Health Insurance Portability and Accountability Act (HIPAA) from the American College of Emergency Physicians (ACEP) and Society of Critical Care Medicine (SCCM). These recommendations include documentation of consultation with the accepting physicians and presence of transfer consent. Additionally, the 2010 American Heart Association’s (AHA) guideline recommends fast reduction of systolic blood pressure (SBP) to ≤ 120mm Hg, heart rate (HR) ≤ 60 beats/minute (bpm), and pain management. Therefore, documenting these measures shows proper treatment of patients in the EDs. This study aims to: a) assess the compliance of ED charts containing required HIPAA elements and clinical assessments for this critically ill group of transferred AoD patients; b) to identify demographic or clinical factors associated with inadequate documentation. This is a retrospective study of AoD patients transferred to a quaternary academic referral center between 01/01/2011 and 09/30/2015. Patients were identified by ICD-9 billing codes of 441.XX. Exclusion criteria were a) not a direct interfacility transfer from a referring ED unit and b) no ED documentation. Primary outcome was percentage of charts with HIPAA compliance. Secondary outcome was percentage of charts with good clinical practice, defined as presence of triage SBP and HR, as well as ≥ 2 clinical assessments for SBP and HR both before and after AoD diagnosis. Outcomes were dichotomized (Good vs. Bad documentation). Stepwise backward regression was performed using sixteen demographic and clinical independent variables. We electronically identified 565 patients, of which 285 patients were included in analysis. One hundred and fifty-nine (56%) of the patients’ charts contained elements meeting HIPAA requirement for transfer of critically ill patients. One hundred and sixty (56%) of the patients’ charts had triage SBP and HR, as well as ≥ 2 clinical assessments before and after AoD diagnosis. Among 16 demographic and clinical factors, only Emergency Severity Index (ESI) was associated with poor HIPAA documentation, with a correlation coefficient (cc) of 0.0951 and p=0.007. For clinical documentation, three variables were negatively associated with poor documentation of frequent clinical assessment: sex (cc = -0.184, p=0.022), age (cc = -0.101, p=0.038), triage SBP (cc = -0.214, p<0.01), while triage time of day was positively associated with poor clinical documentation (cc = 0.204, p=0.011). ED provider documentation for critically ill patients with AoD is poor. Although certain demographic and clinical factors may be associated with poor documentation, emergency providers should thoroughly document their care for critically ill patients, for both clinical and legal reasons.

Risk Reduction Strategies in Breast Cancer Prevention.

Evaluating the risk of breast cancer makes it possible to identify women with a high risk of developing breast cancer in the future. Adopting a healthier lifestyle, involving diet and exercise, is one way of reducing this risk-but there are other, non-modifiable risk factors, such as family history, genetics and diagnosis of premalignant lesions. In this high-risk population, the tracking must be rigorous and involve the participation of the patient herself, earlier and more frequent clinical assessment, and the use of imaging screening. Agents such as tamoxifen, raloxifene and aromatase inhibitors may be used in chemoprevention and may reduce the risk substantially. The risks and benefits must be assessed, and one must discuss with the patient her adverse events and the decision regarding the best treatment. Women who carry the BRCA1/2 mutation (very high risk) can benefit from prophylactic surgical interventions, such as bilateral mastectomy and/or bilateral salpingo-oophorectomy. This group of patients must be monitored by a multidisciplinary team, providing explanations prior to surgery regarding the surgical treatment offered, the reconstruction techniques, and the risks and complications.

23 Right ventricular outflow tract elan conduit: the five year scotland experience

Background The management of the right ventricular outflow tract (RVOT) is a common feature in congenital cardiac surgery. A number of valved conduits are available. We reviewed the outcomes of the Vascutek RVOT Elan Conduit in patients from a specialist congenital surgical centre. Methods Between 2010 and 2011, 25 patients (13 male, mean age: 25.5 years) received an Elan conduit in the RVOT position. 24 reported previous open cardiac surgery. Most common diagnosis was Tetralogy of Fallot (n=19 (76%)). Results The mean follow up period was 4.96 years. 24 (96%) patients were alive at the time of censorship. 16 adverse events were noted and defined as haemodynamically significant conduit and/or valve stenosis (n=12), death (n=1) and bacterial endocarditis (n=3). 12 (48%) patients required re-intervention (10 transcatheter pulmonary valve replacements [8 Medtronic Melody and 2 Edwards Sapien] and 2 surgical pulmonary homografts). Mean time to re-intervention 1.7 years (range 0.25 – 4.36 years) Conclusion This review of RVOT Elan conduits demonstrates that in a significant proportion of patients there is short interval to re-intervention due to haemodynamically significant conduit and/or valve stenosis. (Figures 1 and 2) The conduit was technically attractive for transcatheter intervention. Other centres have published favourable results in the first 12 months after surgery. There are no other reported outcomes after this period. Our review suggests that ongoing frequent clinical assessment is required and should continue beyond the first 12 months. The Elan conduit is no longer in production and the search for the ideal valved RVOT conduit continues at a time when homograft availability is becoming an increasing challenge.

Evaluating machine learning algorithms estimating tremor severity ratings on the Bain–Findley scale

Tremor is a debilitating symptom of some movement disorders. Effective treatment, such as deep brain stimulation (DBS), is contingent upon frequent clinical assessments using instruments such as the Bain–Findley tremor rating scale (BTRS). Many patients, however, do not have access to frequent clinical assessments. Wearable devices have been developed to provide patients with access to frequent objective assessments outside the clinic via telemedicine. Nevertheless, the information they report is not in the form of BTRS ratings. One way to transform this information into BTRS ratings is through linear regression models (LRMs). Another, potentially more accurate method is through machine learning classifiers (MLCs). This study aims to compare MLCs and LRMs, and identify the most accurate model that can transform objective tremor information into tremor severity ratings on the BTRS. Nine participants with upper limb tremor had their DBS stimulation amplitude varied while they performed clinical upper-extremity exercises. Tremor features were acquired using the tremor biomechanics analysis laboratory (TREMBAL). Movement disorder specialists rated tremor severity on the BTRS from video recordings. Seven MLCs and 6 LRMs transformed TREMBAL features into tremor severity ratings on the BTRS using the specialists’ ratings as training data. The weighted Cohen’s kappa () defined the models’ rating accuracy. This study shows that the Random Forest MLC was the most accurate model ( = 0.81) at transforming tremor information into BTRS ratings, thereby improving the clinical interpretation of tremor information obtained from wearable devices.