Inform Clinical Decision-making Research Articles

Go with the Flow? Considerations for Blood Flow Restriction Training in People with Neurologic Conditions

Abstract Blood flow restriction training (BFRT) with low intensity resistance or aerobic exercise can improve muscle strength and aerobic capacity, respectively. Furthermore, low intensity BFRT with resistance or aerobic exercise can be as effective as training at higher intensities without BFR in healthy adult populations. The clinical use of BFRT is therefore becoming increasingly common, particularly in otherwise healthy adults recovering from musculoskeletal injury or orthopedic surgery, for whom training at high intensities is not indicated. People with neurologic conditions may also benefit from training at lower intensities, as many individuals with neurologic conditions may not tolerate higher intensities for a variety of reasons, including advanced mobility restrictions, extreme weakness, severe fatigue, and/or pain. Indeed, more and more rehabilitation clinicians are beginning to use BFRT with their patients who have neurologic conditions even though there is very little evidence to support its safety, feasibility, or efficacy in those populations. In this perspective, we propose that BFRT can be an important alternative to conventional exercise training approaches for some individuals with neurologic conditions, and in the right circumstances can be delivered both safely and effectively. This perspective will also provide considerations and decision-making strategies that can help inform clinical decisions for rehabilitation practitioners considering the use of BFRT in their patients with neurologic conditions.

Genomic Epidemiology of Antimicrobial Resistance: Tracking the Global Spread of Resistant Pathogens

The rapid development and spread of antimicrobial resistance have been one of the most prominent health crises globally, which significantly challenges treating infectious diseases. This paper will address the contribution that genomic epidemiology makes to track and understand the global spread of antimicrobial-resistant pathogens. Genomic epidemiology, an area combining pathogen genomics with epidemiological data, allows for an extremely powerful approach in the identification of resistance mechanisms and tracing transmission routes for guiding public health interventions. This review Emphasizes major bacterial pathogens, such as Escherichia coli, Staphylococcus aureus, and Klebsiella pneumoniae, which harbor major resistance genes: blaCTX-M, mecA, and blaKPC. These genes contribute to the worldwide dissemination of resistance, mainly through mechanisms involving horizontal gene transfer and selective antibiotic pressure. Thus, genomic surveillance, phylogenetic analysis, and bioinformatics approaches allow for the pinpointing of transmission hotspots, mapping of resistance gene distribution, and tracking of emerging resistant strains in real time. It also provides information on how genomic data are being used to improve antimicrobial stewardship programs and inform clinical treatment decisions. Public health responses can further be tailored by recognizing regional resistance patterns, hence enhancing interventions. However, several challenges persist—for example, the need for standardized sharing of data, interpretation of genomic data, and integration of these insights into public health systems, especially in low-resource settings. This abstract highlights the transformative impact of genomic epidemiology in the management of the AMR crisis while emphasizing the continued need for global cooperation, enhanced data infrastructures, and policy initiatives to ensure the effective use of genomic data in public health.

Treatment Patterns and Clinical Outcomes in Patients with Hodgkin Lymphoma from Saudi Arabia, Türkiye, and South Africa: Subgroup Analysis from the International, Multi-center, Retrospective BHOLISTIC Study.

B-HOLISTIC was a real-world, retrospective study of treatment patterns and clinical outcomes in Hodgkin lymphoma (HL) in regions outside Europe and North America. This subgroup analysis reports findings from Saudi Arabia, Türkiye, and South Africa. Patients aged ≥18 years and diagnosed with stage IIB-IV classical HL receiving frontline chemotherapy (frontline cHL) and/or relapsed/refractory HL (RRHL) from January 2010-December 2013 were assessed. The primary endpoint was progression-free survival (PFS) in patients with RRHL. Overall, 694 patients (RRHL: n=178; frontline cHL: n=653) were enrolled. Among patients with RRHL, >80% received first salvage chemotherapy. The most common first salvage regimens were etoposide, methylprednisolone, cytarabine, cisplatin (ESHAP) in Saudi Arabia (78.3%) and dexamethasone, cytarabine, cisplatin (DHAP) in Türkiye (36.1%) and South Africa (40%). Median PFS (95% confidence interval [CI]) in the RRHL group was 5.1 (3.0-15.9), 19.7 (7.5-not reached), and 5.2 (1.1- 10.1) months in Saudi Arabia, Türkiye, and South Africa, respectively. The 5-year PFS and overall survival (95% CI) rates in patients with RRHL were 33.2% (21.6-45.2) and 78.2% (65.9-86.5) in Saudi Arabia, 42.5% (29.5-54.9) and 79.4% (67.2-87.5) in Türkiye, and 13.1% (4.2-27.0) and 53% (35.5-67.8) in South Africa, respectively. This study showed that the clinical outcomes in Türkiye and Saudi Arabia were generally comparable with Western countries during the study period, although Saudi Arabia had lower PFS rates. Conversely, the clinical outcomes in South Africa were suboptimal, emphasizing the need for novel therapies and improved progression to stem cell transplantation. Additionally, these data may serve as a control group for future studies in these countries and inform clinical decision-making.

Torsemide versus furosemide in patients with heart failure: a systematic review and meta-analysis

Abstract Introduction Loop diuretics are essential agents in the management of fluid overload conditions, heart failure and renal dysfunction. Despite their widespread use, there is ongoing debate regarding the relative efficacy, safety, and clinical outcomes associated with furosemide and torsemide. By systematically analyzing existing literature, this study seeks to provide a comprehensive evaluation of the comparative effectiveness and safety profiles of these two medications , Helping to inform clinical decision-making and contribute to the optimization of diuretic therapy in patients with heart and kidney diseases. Methods We searched PubMed, Scopus, WOS, and Cochrane until February 2024 for relevant studies comparing the torsemide and furosemide in Heart failure patients. Outcomes of interest were all-cause mortality, cardiovascular mortality, all-cause hospitalization, hospitalization for HF, and improvement of ≥ 1 in NYHA functional class. Results 16 studies were included in this meta-analysis with a total of 12545 patients, There were no significant results between the two drugs in all-cause mortality, cardiovascular mortality or all-cause hospitalization, torsemide showed a reduction in hospitalization from heart failure (RR 0.85, 95% CI [0.71 to 1.02]), torsemide showed a significant improvement of ≥ 1 in NYHA functional class (OR 1.60, 95% CI [1.18, 2.17]). Conclusion There was no difference between torsemide and furosemide when it comes to all-cause and cardiovascular mortality, but torsemide showed better results in reducing hospitalization rates and and improving quality of life.Hospitalization from heart failureImprovement ≥ 1 in NYHA class

--Connecting Transcriptomics with Computational Modeling to Reveal Developmental Adaptations in Pediatric Human Atrial Tissue.

Nearly 1% of babies are born with congenital heart disease (CHD) - many of whom will require heart surgery within the first few years of life. A detailed understanding of cardiac maturation can help to expand our knowledge on cardiac diseases that develop during gestation, identify age-appropriate drug therapies, and inform clinical care decisions related to surgical repair and postoperative management. Yet, to date, our knowledge of the temporal changes that cardiomyocytes undergo during postnatal development is limited. In this study, we collected right atrial tissue samples from pediatric patients (n=117) undergoing heart surgery. Patients were stratified into five age groups. We measured age-dependent adaptations in cardiac gene expression, and used computational modeling to simulate action potential and calcium transients. Enrichment of differentially expressed genes (DEGs) revealed age-dependent changes in several key biological processes (e.g., cell cycle, structural organization), cardiac ion channels, and calcium handling genes. Gene-associated changes in ionic currents exhibited age-dependent trends, with changes in calcium handling (INCX) and repolarization (IK1) most strongly associated with an age-dependent decrease in the action potential plateau potential and increase in triangulation, respectively. We observed a shift in repolarization reserve, with lower IKr expression in younger patients, a finding potentially tied to an increased amplitude of IKs that could be triggered by elevated sympathetic activation in pediatric patients. Collectively, this study provides valuable insights into age-dependent changes in human cardiac gene expression and electrophysiology, shedding light on molecular mechanisms underlying cardiac maturation and function throughout development.

A prediction model for electroconvulsive therapy effectiveness in patients with major depressive disorder from the Dutch ECT Consortium (DEC).

Reliable predictors for electroconvulsive therapy (ECT) effectiveness would allow a more precise and personalized approach for the treatment of major depressive disorder (MDD). Prediction models were created using a priori selected clinical variables based on previous meta-analyses. Multivariable linear regression analysis was used, applying backwards selection to determine predictor variables while allowing non-linear relations, to develop a prediction model for depression outcome post-ECT (and logistic regression for remission and response as secondary outcome measures). Internal validation and internal-external cross-validation were used to examine overfitting and generalizability of the model's predictive performance. In total, 1892 adult patients with MDD were included from 22 clinical and research cohorts of the twelve sites within the Dutch ECT Consortium. The final primary prediction model showed several factors that significantly predicted a lower depression score post-ECT: higher age, shorter duration of the current depressive episode, severe MDD with psychotic features, lower level of previous antidepressant resistance in the current episode, higher pre-ECT global cognitive functioning, absence of a comorbid personality disorder, and a lower level of failed psychotherapy in the current episode. The optimism-adjusted R² of the final model was 19%. This prediction model based on readily available clinical information can reduce uncertainty of ECT outcomes and hereby inform clinical decision-making, as prompt referral for ECT may be particularly beneficial for individuals with the above-mentioned characteristics. However, despite including a large number of pretreatment factors, a large proportion of the variance in depression outcome post-ECT remained unpredictable.

Enhancing patient-centered care: a randomized study on G-CSF administration preferences in chemotherapy-induced neutropenia.

Chemotherapy-induced neutropenia poses a significant risk to cancer patients, with pegfilgrastim being commonly used for its prevention. While pegfilgrastim can be administered via prefilled syringe or pen device, patient preferences and experiences with these delivery methods remain unclear. We conducted a prospective, open-label, randomized, observational trial (NCT05910164) at the Rafael Institute, France, comparing patient preferences for pegfilgrastim administration using a prefilled syringe versus a prefilled pen device. Patients undergoing chemotherapy and requiring pegfilgrastim were enrolled and randomized 1:1 to receive either syringe or pen first, with crossover administration. Questionnaires assessed patient preferences, learning experiences, autonomy, pain levels, emotional responses, satisfaction with nursing care, and empowerment. Among 150 randomized patients (mean age 58years; 69% female), both groups showed a preference for the pen device, with significantly higher mean scores favoring pen administration (4.94 ± 1.70 vs. 4.27 ± 1.84; p = 0.00106). Patients reported significantly lower perceived pain with pen administration and stronger positive emotions compared to syringe use. Satisfaction with nursing care was higher with syringe use. Empowerment levels were similar across groups but significantly stronger when using the pen in complete autonomy. A preference for pegfilgrastim administration via the pen device was observed, though this may have been influenced by the administration sequence and the absence of syringe self-administration. The insights gained can help inform clinical decision-making and improve patient-centered care in managing chemotherapy-induced neutropenia. NCT05910164 on June 15, 2023.

Efetividade e segurança do uso do ar ambiente em comparação ao oxigênio a 100% em prematuros em parada cardiorrespiratória: protocolo de revisão sistemática

Introduction: Cardiorespiratory arrest is a clinical situation characterized by the interruption of blood circulation. It is estimated that 11.1% of all live births in the world are premature, generating short and long-term repercussions. One of the main challenges during cardiacarrest in premature infants is providing sufficient, but not excessive, oxygen during assisted ventilation. Objective: To compare the effectiveness and safety of using room air in relation to 100% oxygen in the resuscitation of premature infants in cardiorespiratory arrest. Methods: To this end, we will carry out a systematic review of randomized clinical trials (RCTs). The study protocol was registered on the Prospero Platform (CRD42024519724). We will include preterm infants with gestational age <37 weeks with CA. The searches were carried out in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via Pubmed, Excerpta Médica dataBASE (Embase) via Elsevier, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Library, Latin American Literature and the Caribbean Doctor in Health Sciences (LILACS) through the Virtual Health Library Portal, without restrictions on language or year of publication. The selection of studies, transmission of data, assessment of the bias of included studies and assessment of the certainty of the evidence will be carried out by two independent investigators. Expected results: Clarify the transit and safety of using room air compared to 100% oxygen, provide useful information for clinical decision-making, and support future high-quality randomized clinical trials on the topic. Conclusion: This study aims to compile existing research to analyze the effectiveness and safety of application of 100% oxygen in the resuscitation of premature infants. Keywords: Heart arrest; infant premature; systematic review.

Efficacy of pharmacological interventions for ADHD: protocol for an updated systematic review and dose–response network meta-analysis

BackgroundAttention-deficit/hyperactivity disorder (ADHD) affects approximately 5% of children globally, with symptoms often persisting into adulthood. While pharmacological interventions are commonly employed for management, understanding the optimal dosing for efficacy and tolerability remains crucial. This study aims to conduct a dose–response network meta-analysis to estimate the efficacy of pharmacological treatments across different doses, aiming to inform clinical decision-making and improve treatment outcomes.MethodsThis updated systematic review will include randomized controlled trials evaluating ADHD medication efficacy in children, adolescents, and adults. An updated search from a 2018 NMA will be conducted across multiple electronic databases with no language restrictions, using specific eligibility criteria focused on randomized controlled trials. The primary outcome will assess the severity of ADHD core symptoms, while secondary outcomes will consider treatment tolerability. A dose–response Bayesian hierarchical model will be used to estimate dose–response curves for each medication, identifying optimal dosing strategies.DiscussionWith this dose–response network meta-analysis, we aim to better understand the dose–response relationship of pharmacological treatment in ADHD, which could help clinician to the identification of optimal doses.Systematic review registrationOSF https://doi.org/10.17605/OSF.IO/3MY4A.

Predicting criminal offence in adolescents who exhibit antisocial behaviour: a machine learning study using data from a large randomised controlled trial of multisystemic therapy.

Accurate prediction of short-term offending in young people exhibiting antisocial behaviour could support targeted interventions. Here we develop a set of machine learning (ML) models that predict offending status with good accuracy; furthermore, we show interpretable ML analyses can complement models to inform clinical decision-making. This study included 679 individuals aged 11-17 years who displayed moderate-to-severe antisocial behaviour, from a controlled trial of Multisystemic-therapy in England. The outcome was any criminal offence in the 18 months after study baseline. Four types of ML algorithms were trained: logistic regression, elastic net regression, random forest, and gradient boosting machine (GBM). Prediction models were developed (1) using predictors readily available to clinicians (e.g. sociodemographics, previous convictions), and (2) with additional information (e.g. parenting). Model agnostic feature importance values were calculated and the most important predictors identified. Nested cross-validation with 100 iterations of random data splits and 10-fold cross-validation within each iteration was employed, and the average predictive performance was reported. Among the ML models using readily available predictors, the GBM is the strongest model (AUC 0.85, 95% CI 0.85-0.86); the other models have average AUCs of 0.82. This performance was better than using only the total number of previous offences as the predictor (0.67, 0.66-0.68), and the model simply assuming past offending status as the prediction (0.81, 0.80-0.81). Additional predictors slightly increased the performance of logistic regression and random forest models but decreased the performance of elastic net regression and gradient boosting machine-based models. The potential utility of ML approaches for accurately predicting criminal offences in high-risk youth is demonstrated. Interpretable ML-based predictive models could be utilised in youth services or research to help develop and deliver effective interventions.

Prevalence of thyroid dysfunction among pregnant women in the horn of Africa: A systematic review and Meta-analysis

BackgroundThyroid dysfunction ranks among the most prevalent endocrine disorders. This disorder during pregnancy has been linked to adverse effects on both the mother and the baby. However, there is a scarcity of data and inconsistent documentation regarding thyroid issues in pregnant women in low-income nations. ObjectiveThe aim of this systematic review and meta-analysis was to determine the general prevalence of thyroid disorders in pregnant women. MethodsTo identify relevant studies, a comprehensive search was conducted across Scopus, PubMed, Science Direct databases, and Google Scholar and repository registers from January 1, 2000 to December 31, 2023. Ten pertinent publications were chosen for the final meta-analysis. Relevant data was extracted using Microsoft Excel and analyzed using STATA software version 17, employing a random-effect model. Sensitivity analysis was conducted to evaluate each study's impact on the outcome, and Egger's test was utilized to detect publication bias. A trim-and-fill analysis was executed to adjust for bias in the effect estimate. Heterogeneity across studies was assessed using Cochran's Q statistic and I2 statistics. Subgroup analysis was carried by study design, country and publication year. ResultsIn this systematic review and meta-analysis, the prevalence of thyroid dysfunction among 2538 pregnant women was 12.0 % (95 % CI: 8.00 %–17.00 %). To account for the significant heterogeneity observed, a random effect model was utilized. Specifically, the prevalence of hypothyroidism in pregnant women was determined to be 10.00 % (95 % CI: 4.00–16.00 %) with a high level of heterogeneity (I2 = 94.27 %, p < 0.001). Notably, the sensitivity analysis conducted did not reveal any substantial impact on the overall pooled prevalence of thyroid dysfunction. ConclusionThe meta-analysis revealed a significantly higher rate of thyroid disorders among pregnant women compared to global estimates. To assess the effects of treating thyroid conditions on pregnancy outcomes and inform clinical decisions, it is recommended to implement cost-effective thyroid-stimulating hormone screening during pregnancy.

Repetitive transcranial magnetic stimulation as a therapy for post-stroke dysphagia: An overview of systematic reviews and meta-analysis

Objective Post-stroke dysphagia is a common swallowing disorder that occurs after a stroke, leading to an increased risk of aspiration pneumonia and malnutrition. There is a pressing need for effective and safe interventions for its rehabilitation. This review aims to answer two key scientific questions: (1) What is the efficacy of repetitive transcranial magnetic stimulation in the rehabilitation of post-stroke dysphagia? (2) Is repetitive transcranial magnetic stimulation a safe intervention for post-stroke dysphagia? Data Sources A comprehensive search was conducted across four electronic databases: PubMed, Cochrane Library, Web of Science, and Embase. The search aimed to identify relevant studies concerning our topic of interest and was completed on 28 May 2024. Review methods In accordance with the PRISMA checklist, a comprehensive search of four databases was conducted, which identified 13 relevant systematic reviews. The inclusion criteria were systematic reviews that evaluated the efficacy and safety of repetitive transcranial magnetic stimulation for post-stroke dysphagia. Exclusion criteria were reviews that did not focus on post-stroke dysphagia or did not evaluate repetitive transcranial magnetic stimulation as a therapeutic intervention. The quality, bias, reporting, and overall evidence quality of these reviews were assessed using validated tools, including the AMSTAR 2 tool for assessing the methodological quality of systematic reviews, the ROBIS tool for assessing the risk of bias, and the GRADE approach for evaluating the overall quality of evidence. This rigorous approach ensures that our review provides a comprehensive and reliable overview of the current state of knowledge on the use of repetitive transcranial magnetic stimulation for post-stroke dysphagia. Results The sample sizes for the individual studies included in the systematic reviews/meta-analyses ranged from 66 to 555. The total number of participants across all studies included in the overall analyses was 752. The evidence was limited by the methodological flaws and heterogeneity of the systematic reviews. The quality of the evidence varied from high to low, with most outcomes having moderate quality. Future research should adopt more rigorous, standardized, and comprehensive designs to confirm the efficacy and safety of repetitive transcranial magnetic stimulation for post-stroke dysphagia. The main reason for downgrading the evidence quality was the small sample size and high heterogeneity of the primary studies. Conclusion This overview synthesized research on repetitive transcranial magnetic stimulation for dysphagia, aiming to inform clinical and policy decisions. However, the current evidence does not conclusively establish the safety and efficacy of repetitive transcranial magnetic stimulation for post-stroke dysphagia rehabilitation. The studies reviewed varied in quality, and many were of poor quality. Therefore, while some studies suggest potential benefits of repetitive transcranial magnetic stimulation, these findings should be interpreted with caution. There is a pressing need for more rigorous, high-quality research to validate the use of repetitive transcranial magnetic stimulation for post-stroke dysphagia rehabilitation. The implications of these findings for clinical practice and policy will be clearer once we have more robust, evidence-based recommendations.

Flagging Frailty in the Emergency Department: A System to Identify and Visualise Frailty

Abstract Background Older adults with frailty who present to the Emergency Department (ED) are at increased risk of hospitalisation, prolonged length of stay, deconditioning and loss of independence.1 Early identification of frailty using a validated tool, such as the Clinical Frailty Scale (CFS), is widely recommended to inform clinical decisions, identify the best pathway of care for older adults with frailty, and for potential use as a predictor or an outcome.2 We aimed to develop and implement a system of frailty identification which is highly visible, digitised and integrated with routine ED processes. Methods In the ED of a large teaching hospital, an expanded interdisciplinary Acute Frailty Team (AFT) commenced work in the ED in February 2024. The AFT aimed to screen all over 70s presenting within working hours for frailty using CFS. ED consultants collaborated with software developers through iterative design stages to create a ‘Frailty Flag’ for the ED Whiteboard with the requirements that it is highly visible, easy to use and highlights patients with higher frailty scores. Results In April 2024, a ‘Frailty Flag’ was launched on the ED Whiteboard, prominently displaying the CFS and using traffic light colouring to highlight those with higher CFS scores. As part of standard work, the AFT populate the CFS on the ED Whiteboard, which is viewed by all staff in ED on large wall-mounted screens. Feedback from ED and inpatient staff indicate that a highly visible frailty score is a valuable addition to the ED Whiteboard which allows them to prioritise care and supports decision making regarding suitability for geriatric care pathways. Conclusion A Frailty Flag on the ED Whiteboard allows for easy, accessible communication of frailty scores to the ED multi-disciplinary team. Next steps involve integrating the Frailty Flag with in-patient systems and developing standard work for out of hours use of the system.

B - 118 Exploration of Supplemental Recognition Measures for the RBANS

Abstract Objective RBANS is a widely used cognitive screener that lacks memory recognition measures for 2 recall tasks. Performance on verbal and visual recognition measures, relative to recall, may help inform clinical decision-making and treatment planning. Our pilot project aims to understand how individuals with valid cognitive data and normal memory functioning perform on newly developed RBANS story and figure memory recognition tests. Method Of those referred for outpatient neuropsychological assessment at a veterans hospital between 2017–2024, 89 received the newly established recognition measures as part of their clinical evaluation. Our analysis included veterans that displayed valid profiles (TOMM trial 1 ≥ 45, n = 53). Assessment occurred 30% face-to-face and 70% telehealth. In addition to key demographic factors listed in table 1, race/ethnicity breakdown included: 92% White, 4% Black, 2% Asian, 2% Hispanic. These veterans were subdivided into 3 intact memory groups: list recall (≥ 25%ile, n = 31), story recall (≥ 25%ile, n = 37), figure recall (≥ 25%ile, n = 42) to determine average recognition performances across domains. Results The individuals with valid cognitive data and normal memory recall performed as listed in table 1. Although our novel story and figure recognition measures differ from those published in Duff et al. (2021), our pilot project data largely overlapped with their reported findings despite demographic differences. Conclusion(s) These novel recognition scores can help establish normal story and figure recognition performance to assist with clinical diagnosis and treatment planning. With greater and more diverse samples, we may be able to establish relative cut points for expected recognition memory performances across intact, amnestic/cortical, and vascular/subcortical.

Evaluating the atherosclerosis cardiovascular disease risk score in patients with brain metastases: Associations with overall survival and high-value care outcomes

ObjectiveBrain metastases (BM) constitute the most common intracranial tumor in adults. Prior literature indicates the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score is associated with increased risk of cancer, potentially attributable to shared risk factors. Understanding the role of ASCVD risk scores in BM may help optimize their care and inform clinical decision-making. Our aim was to explore associations between ASCVD risk score in BM patients and their overall survival, hospital charges, and non-routine discharge disposition. MethodsElectronic medical records were reviewed to collect clinical data for BM patients undergoing surgery at a single institution (2017–2021). Regression analyses were performed accordingly and maximally selected rank statistics were employed to identify an optimal cutoff for ASCVD risk scores. The random survival forest (RSF) machine learning technique identified the most important variable associated with survival outcomes in BM patients. ResultsA total of 139 patients were included with average age 62.93±9.29 years, 48.2 % male, 25.2 % with high hospital charges, and 23.7 % experiencing non-routine discharge. Among these patients, 32.3 % had prior history of an ASCVD event, while 67.7 % did not. Overall, this cohort had an average 10-year ASCVD risk score of 12.51±12.98, indicating intermediate risk of ASCVD among all BM patients. On multivariate logistic regression, prior history of ASCVD was associated with higher odds of high hospital charges (OR=3.670, p=0.018), and higher ASCVD risk scores were associated with greater odds of non-routine discharge (OR=1.059, p=0.012). On the multivariate Cox regression model, higher ASCVD risk scores correlated with worse overall survival (HR=1.031, p=0.014). A threshold of 25.1 was identified for high-risk ASCVD scores. Patients with ASCVD scores >25.1 exhibited reduced overall survival in Kaplan-Meier analysis (p=0.015) and multivariate Cox regression (HR: 2.811, p=0.016). Notably, ASCVD risk scores were found to be the most important variable in predicting worse survival outcomes in BM patients compared to other established frailty indices. ConclusionThis study indicates higher ASCVD risk scores in BM patients are associated with worse overall survival. Integrating ASCVD assessment into clinical workflow may facilitate more informed risk-based decision-making.

MOY 2 - ‘Cachexia Index’ for Prognostication in Surgical Patients with Locally Advanced Oesophageal or Gastric Cancer: A Multicentre Cohort Study

Abstract Background Features of cancer cachexia are known to adversely influence patient outcomes, yet few currently inform clinical decision-making. This study assessed the value of ‘cachexia index’ (CXI), a novel prognostic marker, in patients planned for curative multimodal therapy (neoadjuvant chemotherapy (NAC) and surgery) for oesophagogastric cancer. Methods Consecutive patients newly diagnosed with locally advanced (T3/4 or ≥N1) oesophagogastric cancer were identified through the West of Scotland and South-East Scotland Cancer Networks. CXI was calculated as (L3 skeletal muscle index) x (serum albumin) / (neutrophil-lymphocyte-ratio). Sex-stratified cut-off values were determined based on area under the curve (AUC), and patients were divided into low and normal CXI groups. Primary outcomes of interest were disease progression during NAC and overall survival (≥5-years follow-up). Results Overall, 385 patients (72% male, median 66 years) were treated with NAC for oesophageal (n=274) or gastric (n=111) cancer across the study period. While patients with a low CXI (males: &amp;lt;52 [AUC: 0.691] and females: &amp;lt;41 [AUC: 0.759]) were older and more comorbid, disease characteristics were comparable to those with a normal CXI. Rates of disease progression during neoadjuvant chemotherapy, leading to inoperability, were higher in patients with low CXI (28% vs. 12%, aOR: 3.07 (95% CI: 1.67-5.64), p&amp;lt;0.001). Moreover, low CXI was associated with worsened post-operative mortality (p=0.019) and decreased overall survival (median: 14.9 vs. 56.9 months, aHR: 1.85 (95% CI: 1.42-2.42), p&amp;lt;0.001). Conclusion CXI represents a valuable marker of ‘host stage’, and a potential adjunct to routine tumour staging. This could improve prognostication and decision-making in patients with locally advanced oesophagogastric cancer.

Paediatric very rare tumours registration and management in European countries with low health expenditure average rates.

Within the Paediatric Rare Tumours Network-European Registry (PARTNER) project, we aimed to evaluate the situation on the registration and management of paediatric patients affected by very rare tumours (VRT) in the European low health expenditure average rates (LHEAR) countries. A survey regarding infrastructure, organisation, and clinical decision-making information on VRT was designed. This survey was distributed to the representatives of LHEAR countries involved in the activities of the PARTNER Work Package 7. Eighteen answers from 17 countries were collected regarding the national organisation, methods of registration of VRT cases, the availability of medical experts in VRT, the access to updated diagnostic and therapeutic procedures (such as proton therapy, immunotherapy and, targeted therapies), and research on paediatric VRT. A high variability in the registration and management of patients with VRT has been observed with additional wide inequalities in pathology review, uniformity of clinical decisions, availability of selected procedures, and diagnostic and research tools. In the majority of LHEAR countries, no clinical or research structures have been implemented for children and adolescents with VRT. Therefore, VRT still have an orphan status in these countries. These significant differences on the technology access and use between European regions need to be addressed.

Characteristics and outcomes of heart failure in Japan: A hospital-based administrative database analysis.

Epidemiological and outcome studies on patients in Japan with heart failure (HF) categorized by left ventricular ejection fraction (LVEF) are currently limited. The aim of this non-interventional database study was to provide further information on these patients. Administrative claims data and electronic medical records from hospitals participating in the Voluntary Hospitals in Japan (VHJ) organization were used. Patients hospitalized with a primary diagnosis of HF between 1 April 2017 and 30 March 2020 were categorized by baseline LVEF on echocardiogram: HF with reduced EF (HFrEF, LVEF <40%); HF with preserved EF (HFpEF, LVEF ≥50%); and HF with mildly reduced EF (HFmrEF, 40% to <50% LVEF). Patients were evaluated for baseline characteristics, pre-admission diagnosis, prescription drugs, length of hospitalization, HF treatment cost, overall cost of hospitalization, and in-hospital prescription. An exploratory analysis compared post-hospitalization mortality and re-hospitalization rates. In total, 10646 hospitalized patients from 17 VHJ hospitals were enrolled. Of these, 7212 were included in the analysis set and categorized into HFpEF (3183, 44.1%), HFmrEF (1280, 17.7%), and HFrEF (2749, 38.1%) groups based on baseline LVEF. Beta-blocker use increased during hospitalization, with a mean (95% confidence interval [CI]) of 23.3% (22.3-24.3) of patients receiving these agents before admission versus 69.4% (68.3-70.5) at discharge. Administration of diuretics, angiotensin converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs) showed a similar trend. Differences in treatments were observed between HF categories at discharge, with a higher proportion (95% CI) of ACE inhibitor use in the HFrEF group (40.6% [38.7-42.4]) versus HFmrEF (27.5% [25.1-30.0]) and HFpEF (20.6% [19.2-22.1]) groups (P<0.0001), and more ARB use in the HFmrEF and HFpEF groups (32.5% [29.9-35.1] and 31.2% [29.6-32.9], respectively) versus HFrEF (25.1% [23.5-26.8]; P<0.0001). Mean (standard deviation [SD]) length of hospitalization was 22.2 (23.3) days, and the median (interquartile range) was 17 (11-25) days. Estimated average cost of HF treatment per patient during index hospitalization was 300090 yen with HFrEF treatment costing the most. Average total healthcare expenditure during hospitalization was 1225650 yen per index hospitalization per patient, with HFrEF also the most expensive. During a mean (SD) observation period of 324 (304) days, ~21% of patients in each group required re-hospitalization for HF, and 625 patients (8.7%) died. The proportion of patients in each HF category was largely consistent with existing data. Discharge medications indicated high prescription of guideline-directed therapy. This study provides real-world data on patients with HF in Japan that can help inform future clinical decision-making.

Learning from our patients: An exploratory study to inform the development of a case tracking dashboard for internal medicine subspecialty fellows

Background Case tracking (following-up prior patient encounters) can help inform future clinical decisions and supplement experiential learning. Internal medicine subspecialty fellows see a high volume of patients and need to become subject matter experts within a short time frame, yet little is known about their specific needs and motivations around case tracking. Objective The objective of this study was to explore internal medicine subspecialty fellows’ motivations, preferences, and practices around case tracking. Methods We conducted interviews with internal medicine subspecialty fellows at a single academic medical center during the 2022–2023 academic year. Interviews were analyzed using qualitative content analysis. Results 22 fellows were interviewed for our study. We found that most fellows engaged in case tracking with lists in the electronic health record (EHR). Fellows primarily tracked cases of clinical uncertainty and patients with specific diseases or conditions of interest. Fellows sought information on patients’ health outcomes, results, and clinical notes. Motivations for tracking were predominantly related to curiosity, professional growth, and development of practice patterns. Barriers to case tracking included time, challenges maintaining patient lists, losing track of patients, and lack of motivation to develop and maintain an organized system. Conclusions Internal medicine subspecialty fellows engaged in and valued case tracking as a way to supplement their experiential learning. Our study highlighted their current practices, motivations, preferences, and challenges related to case tracking. We plan to use these findings to help develop an EHR-embedded dashboard to facilitate case tracking among subspecialty fellows.

Bayesian interpretation of likelihood ratios in clinical diagnosis and public health

Purpose of review This study provides a Bayesian interpretation of likelihood ratios and their role in updating the pretest probability of disease, typically represented by the prevalence, to a posttest probability. Recent findings We highlight the importance of likelihood ratios in this process, particularly in low prevalence settings. For example, we demonstrate that a high LR+ can significantly increase the posttest probability of disease, providing crucial information for clinical decision-making. Furthermore, we emphasize the significance of the fold increase in the probability of disease given a positive test result, particularly in low prevalence settings. Summary This study underscores the importance of considering likelihood ratios on our posttest updated probability of disease and highlights their implications for public health and individual diagnosis. Understanding these factors can enhance the accuracy and effectiveness of diagnostic decision-making, ultimately leading to improved public health outcomes and patient care.