Lack Of Comorbidities Research Articles

Medication adherence and associated factors among chronic heart failure patients on follow-up in north Shewa public hospitals, Oromia region, Ethiopia

BackgroundChronic heart failure affects approximately 26 million people globally. World Health Organization data show that only approximately half of chronically ill patients in developed countries adhere to recommended medication, with even lower rates in developing countries. Medication adherence is critical for managing chronic heart failure symptoms, delaying disease progression, and preventing hospitalizations. However, poor adherence increases rehospitalization, morbidity, mortality, and healthcare costs.ObjectiveTo assess medication adherence and associated factors among chronic heart failure patients on follow-up at North Shewa Public Hospitals, Oromia Region, Ethiopia, in 2023.MethodsThis institutional-based cross-sectional study was conducted from March 1 to April 30, 2023, G.C. A total of 603 individuals were selected consecutively among those who underwent chronic OPD after being proportionally allocated to five hospitals in the zone. The data were collected using an interviewer-administered questionnaire and a medical chart review. The data were entered into Epi-data version 3.1 and then exported to SPSS version 26 for analysis. The multivariable logistic regression model included variables with a P value < 0.25 in the bivariate analysis. The degree of association was expressed using an adjusted odds ratio (AOR) with a 95% confidence interval (CI) at a P value < 0.05.ResultsAmong the 603 patients, 56% had optimal medication adherence, with a 95% CI of 52.1 to 60. Being able to read and write (AOR: 2.20; 95% CI: 1.34, 3.61), having a secondary education (AOR: 1.97; 95% CI: 1.06, 3.67), having community-based health insurance (AOR: 1.82; 95% CI: 1.22, 2.71), not having comorbidities (AOR: 1.82; 95% CI: 1.18, 2.52), taking several drugs < 2 (AOR: 2.11; 95% CI: 1.20, 2.45), not adding salt when cooking (AOR: 1.72; 95% CI: 1.20, 2.45), and asking a doctor or nurse without fear (AOR: 1.87; 95% CI: 1.03, 3.40) were factors associated with medication adherence among CHF patients.ConclusionThis study revealed that 56% of chronic heart failure patients had optimal medication adherence. Factors associated with higher adherence included higher education, community health insurance, lack of comorbidities, fewer medications, avoiding added salt, and comfortable communication with providers. Health professionals should provide education to strengthen medication adherence.

Oncologist-Reported Barriers and Facilitators to Offering Cancer Clinical Trials to Their Patients.

NCCN guidelines indicate that cancer clinical trials (CCTs) are the best management for patients with cancer. However, only 5% of patients enroll in them. We examined oncologists' perceived barriers and facilitators to discussing CCTs. This qualitative study was part of the ASCO-ACCC Initiative to Increase Racial and Ethnic Diversity in Clinical Trials. Barriers and facilitators at the system, trial, provider, and patient levels were examined. To achieve triangulation, patient encounters were reviewed using chart-stimulated recall (CSR) methods, thereby obtaining a valid assessment of physician performance. Ten oncology providers participated in this study. Nine were oncologists, and one was a clinical research coordinator; five were female; four were White; three were Asian; and three were Black. Barriers to offering CCTs were a lack of trial availability; ineligibility; a lack of knowledge; assumptions about patient interest, benefits, or harms; patient's disease factors; and negative attitudes. Facilitators of offering CCTs were a physical space to discuss trials; greater trial availability; a systematic approach to offering trials; patient factors; patients seeking trials; a lack of comorbidities; patients being younger in age; patients being aware of, asking about, or hearing of trials from their surgeon; and higher levels of altruism. Many of the cited barriers are addressable with the cited facilitators. A larger study is needed to generalize and validate these findings.

Barriers to long-term follow-up in pediatric Hodgkin lymphoma survivors.

Pediatric Hodgkin lymphoma (HL) survivors have an increased risk of late effects following treatment. Barriers at the patient, provider, and payor level adversely affect adherence to long-term follow-up. We conducted a retrospective chart review of HL survivors diagnosed from 1999 to 2014 at Texas Children's Hospital. HL survivors were considered lost to follow-up if there were no documented visits to Texas Children's Cancer Center Long-Term Survivor (LTS) clinic for 2 or more years after their last LTS clinic visit. Univariate and multivariable logistic regression analyses were conducted to explore factors contributing to loss to follow-up. Reasons for not attending subsequent LTS visits were assessed by phone interviews in a subset of lost to follow-up patients. There were 120 HL survivors who had at least one LTS clinic visit in this timeframe; 64 (53%) were classified as lost to follow-up, and of these, 23 (36%) were interviewed. Eleven (47%) indicated that the reason for failure to follow-up was lack of or inadequate insurance, and seven (30%) stated they were unaware of the importance of continued follow-up. Loss to follow-up was associated with lack of insurance, earlier diagnosis, and lack of comorbidities in univariate analyses. Only earlier year of diagnosis (odds ratio [OR] 0.84, 95% confidence interval [CI]: 0.7-0.9, p=.01) and lack of insurance (OR 22.2, 95% CI: 4-123, p<.001) were associated with loss to follow-up in multivariable analyses. Insurance status and awareness of the need for long-term follow-up care are key factors associated with loss to follow-up in survivors of HL. Targeted education and low-cost options for survivorship care are potential strategies for improving adherence to long-term follow-up care in HL survivors.

National trends in neoadjuvant chemotherapy utilization in patients with early-stage node-negative triple-negative breast cancer: the impact of the CREATE-X trial.

Neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC) allows for assessment of tumor pathological response and has survival implications. In 2017, the CREATE-X trial demonstrated survival benefit with adjuvant capecitabine in patients TNBC and residual disease after NAC. We aimed to assess national rates of NAC for cT1-2N0M0 TNBC before and after CREATE-X and examine factors associated with receiving NAC vs adjuvant chemotherapy (AC). A retrospective cohort study of women with cT1-2N0M0 TNBC diagnosed from 2014 to 2019 in the National Cancer Database (NCDB) was performed. Variables were analyzed via ANOVA, Chi-squared, Fisher Exact tests, and a multivariate linear regression model was created. 55,633 women were included: 26.9% received NAC, 52.4% AC, and 20.7% received no chemotherapy (median ages 53, 59, and 71years, p < 0.01). NAC utilization significantly increased over time: 19.5% in 2014-15 (n = 3,465 of 17,777), 27.1% in 2016-17 (n = 5,140 of 18,985), and 33.6% in 2018-19 (n = 6,337 of 18,871, p < 0.001). On multivariate analysis, increased NAC was associated with younger age (< 50), non-Hispanic white race/ethnicity, lack of comorbidities, cT2 tumors, care at an academic or integrated-network cancer program, and diagnosis post-2017 (p < 0.05 for all). Patients with government-provided insurance were less likely to receive NAC (p < 0.01). Women who traveled > 60 miles for treatment were more likely to receive NAC (p < 0.01). From 2014 to 2019, NAC utilization increased for patients with cT1-2N0M0 TNBC. Racial, socioeconomic, and access disparities were observed in who received NAC vs AC and warrants interventions to ensure equitable care.

Reduction in eating disorder symptoms among adults in different weight loss interventions

Restriction of food intake and counting calories as part of weight loss programs are thought to trigger eating behaviors and attitudes which can lead to eating disorders. We have developed a treatment model, Regulation of Cues (ROC), that targets appetitive traits, including food responsiveness and satiety responsiveness, which could address overeating at an implicit level and reduce risk of detrimental behaviors and attitudes. This manuscript evaluates eating disorder symptoms, attitudes, and behaviors among adults with overweight or obesity randomized to ROC, behavioral weight loss (BWL), a combination of ROC + BWL (ROC+) and an active comparator (AC). Participants included 271 adults with a body mass index of 25 to 45, age 18 to 65 years, and a lack of comorbidities that could interfere with participation. Assessments occurred at baseline, mid-treatment (6 months), post-treatment (12-months) and 6- and 12-month follow-up. During treatment, participants in all four arms showed decreases in Eating, Weight, and Shape concerns on the Eating Disorder Examination-Questionnaire and binge eating symptoms on the Binge Eating Scale which were maintained at 6-month follow-up but increased at the 12-month follow-up. Both the ROC+ and BWL arms showed increases in Restraint during treatment which dissipated after treatment ended. This study contributes to a growing body of literature demonstrating that weight loss programs are not associated with increases in eating disorder symptoms. Future studies should evaluate interventions to maintain improvements in eating disorder symptoms following weight loss programs.

Physical activity and metabolic syndrome: A population base study (forest and tree model algorithms)

Lifestyle changes, prominently low mobility in recent years, have increased the prevalence of metabolic syndrome (MetS), and cardiovascular disease risk. This study aimed to determine the relationship between physical activity and MetS using modern statistical methods in a population-based study. The target population included 10,663 people aged 40-70 years in phase 1 of the Persian Kharameh cohort study conducted in 2017. The data used in this study had questions about physical activity, demographic, anthropometrics, blood pressure, and biochemical data. Participants who their activity was within the fourth quarter were 36% less likely to develop MetS than the participants in the first quarter. In the decision-Tree algorithm with all variables, physical activity was significant after gender and comorbidity. With a lack of comorbidities and physical activity less than 2338 Metabolic Equivalent of Task (MET) and age greater than 53 years, the probability was 26.7% for the male population. For the female population, if associated with comorbidities, a history of diabetes in first-degree relatives, or both, the chance of developing MetS was estimated to be 70.4%. In the decision-tree algorithm, 56.0% of the predictions for MetS were due to gender. After gender, the presence of comorbidities, age, occupation, family history of diabetes, place of residence, and physical activity was discovered as the essential variables in predicting and identifying factors associated with MetS, respectively. Modern statistical methods can be used in similar research due to better presentation of results in applied clinical laws. An essential approach for treating the syndrome and preventing its complications is a lifestyle change, including educating about physical activity and promoting it.

Early clinical features of new-onset refractory status epilepticus (NORSE) in adults

BackgroundThe aim of this study was to identify early clinical features of patients with new-onset refractory status epilepticus (NORSE) that could direct the treatment in the first days of hospitalisation.MethodsA retrospective cohort study of adult NORSE patients treated in the intensive care units of Helsinki University Hospital 2007-2018.ResultsWe found 19 adult NORSE patients who divided into three subgroups on the basis of their clinical features: viral encephalitis (n = 5, 26%), febrile infection-related epilepsy syndrome (FIRES) (n = 6, 32%) and afebrile NORSE (n = 8, 42%). FIRES and afebrile NORSE patients remained without confirmed etiology, but retrospectively two paraneoplastic and two neurodegenerative causes were suspected in the afebrile NORSE group.Viral encephalitis patients were median 64 years old (IQR 55-64), and four (80%) had prodromal fever and abnormal findings in the first brain imaging. FIRES patients were median 21 years old (IQR 19-24), all febrile and had normal brain imaging at onset. In the afebrile NORSE group, median age was 67 (IQR 59-71) and 50% had prodromal cognitive or psychiatric symptoms. FIRES patients differed from other NORSE patients by younger age (p = 0.001), respiratory prodromal symptoms (p = 0.004), normal brain MRI (p = 0.044) and lack of comorbidities (p = 0.011). They needed more antiseizure medications (p = 0.001) and anesthetics (p = 0.002), had a longer hospital stay (p = 0.017) and more complications (p < 0.001).ConclusionsAmong febrile NORSE patients, FIRES group was distinctive due to patients’ young age, prodromal respiratory symptoms and normal first brain imaging. These features should be confirmed by subsequent studies as basis for selecting patients for early intensive immunotherapy.

The Influence of Acitretin on Brain Lipidomics in Adolescent Mice-Implications for Pediatric and Adolescent Dermatological Therapy.

Administration of systemic retinoids such as acitretin has not been approved yet for pediatric patients. An adverse event of retinoid-therapy that occurs with lower prevalence in children than in adults is hyperlipidemia. This might be based on the lack of comorbidities in young patients, but must not be neglected. Especially for the development of the human brain up to young adulthood, dysbalance of lipids might be deleterious. Here, we provide for the first time an in-depth analysis of the influence of subchronic acitretin-administration on lipid composition of brain parenchyma of young wild type mice. For comparison and to evaluate the systemic effect of the treatment, liver lipids were analogously investigated. As expected, triglycerides increased in liver as well as in brain and a non-significant increase in cholesterol was observed. However, specifically brain showed an increase in lyso-phosphatidylcholine and carnitine as well as in sphingomyelin. Group analysis of lipid classes revealed no statistical effects, while single species were tissue-dependently changed: effects in brain were in general more subtly as compared to those in liver regarding the mere number of changed lipid species. Thus, while the overall impact of acitretin seems comparably small regarding brain, the change in individual species and their role in brain development and maturation has to be considered.

Evaluating the Association of Anesthesia Type with Postoperative Complications in Patients Undergoing Ankle Fracture Repair

Category: Ankle Introduction/Purpose: General and neuraxial anesthesia are both successful anesthesia techniques used in many orthopaedic procedures. Neuraxial anesthesia involves local anesthetics placed around the central nervous system (CNS) and spinal anesthesia is a subtype where the anesthetic is injected into intrathecal space. General anesthesia is usually recommended in ambulatory surgeries for its rapid onset of action. However, current literature shows contradicting complication profiles between these two anesthesia types. The purpose of this study was to compare the complications and length of hospital stay between patients who underwent general anesthesia versus neuraxial anesthesia during the repair of ankle fractures. Methods: Patients undergoing open reduction and internal fixation (ORIF) for ankle fracture from 2014 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: general anesthesia and neuraxial anesthesia. In this analysis, demographics data, comorbidities, and postoperative complications were collected and compared between the two cohorts. Bivariate analyses and multivariable logistical regression were performed. Results: Of 3,585 patients who underwent operative treatment for ankle fracture, 3,315 patients (92.5%) had general anesthesia and 270 (7.5%) had neuraxial anesthesia. Compared to patients who had general anesthesia, those who had neuraxial anesthesia were more likely to be older (58.0 vs 49.6 years old; p&lt;0.001), Caucasian (80.0% vs 71.9%; p=0.001), and have an ASA classification of III (38.1% vs 25.0%; p&lt;0.001). On bivariate analyses, patients who had neuraxial anesthesia were more likely to develop pulmonary complications (p=0.173) or extended length of stay more than 5 days (p=0.342) compared to the general anesthesia group. Following adjustment on multivariate analyses, the neuraxial anesthesia cohort no longer had increased likelihood of pulmonary complications or extended length of stay compared to the general anesthesia group. Conclusion: Prior studies have shown that neuraxial anesthesia methods are as effective as general anesthesia with fewer short- term outcomes. When compared to patients who underwent general anesthesia during ORIF for ankle fracture, neuraxial anesthesia patients experienced no significant increases in postoperative complications or extended length of hospital stay. In terms of the variables we explored in the NSQIP database, healthy ankle fracture patients could also benefit from neuraxial anesthetic methods, and they should be considered for this anesthetic type regardless of their lack of comorbidities that would make them high risk for general anesthesia.

Outcomes of stage IV melanoma in the era of immunotherapy: a National Cancer Database (NCDB) analysis from 2014 to 2016

BackgroundTo evaluate factors affecting the utilization of immunotherapy and to stratify results based on the approval of ipilimumab in 2011 and programmed death-1 inhibitors in 2014, an analysis of available...

Effect of a Novel Intervention Targeting Appetitive Traits on Body Mass Index Among Adults With Overweight or Obesity

Behavioral weight loss (BWL) programs result in weight loss for some, but most individuals regain the weight. The behavioral susceptibility theory proposes that genetically determined appetitive traits, such as food responsiveness (FR) and satiety responsiveness (SR), interact with the environment and lead to overeating and weight gain; the regulation of cues (ROC) intervention was developed specifically to target FR and SR. To evaluate the efficacy of ROC, ROC combined with BWL (ROC+), BWL, and an active comparator (AC) over 12 months of treatment and 12 months of follow-up. This randomized clinical trial was conducted from December 2015 to December 2019 in a university clinic. A total of 1488 volunteers from the community inquired about the study; 1217 were excluded or declined to participate. Eligibility criteria included body mass index (BMI) of 25 to 45, age 18 to 65 years, and lack of comorbidities or other exclusionary criteria that would interfere with participation. Data were analyzed from September 2021 to January 2022. ROC uniquely targeted FR and SR. BWL included energy restriction, increasing physical activity, and behavior therapy techniques. ROC+ combined ROC with BWL. AC included mindfulness, social support, and nutrition education. Change in body weight as measured by BMI. A total of 271 adults (mean [SD] age, 46.97 [11.80] years; 81.6% female [221 participants]; mean [SD] BMI, 34.59 [5.28]; 61.9% White [167 participants]) were assessed at baseline, midtreatment, posttreatment, and 6-month and 12-month follow-up. Sixty-six participants were randomized to AC, 69 to ROC, 67 to ROC+, and 69 to BWL. Results showed that ROC, ROC+, and BWL interventions resulted in significantly lower BMI at the end of treatment (BMI ROC, -1.18; 95% CI, -2.10 to -0.35; BMI ROC+, -1.56; 95% CI, -2.43 to -0.67; BMI BWL, -1.58; 95% CI, -2.45 to -0.71). Compared with BWL, BMI at the end of treatment was not significantly different from ROC or ROC+ (BMI ROC, 0.40; 95% CI, -0.55 to 1.36; BMI ROC+, 0.03; 95% CI, -0.88 to 0.93); however, the BMI of the AC group was substantially higher (BMI AC, 1.58; 95% CI, 0.72 to 2.45). BMI reductions at 24 months after randomization were similar for ROC, ROC+, and BWL. Importantly, FR was a moderator of treatment effects with more weight loss for participants who scored higher in FR in the ROC and ROC+ groups. These findings suggest that ROC and ROC+ provide alternative weight loss approaches for adults. These models could be particularly effective for individuals who struggle with FR and could be used as a precision approach for weight loss. ClinicalTrials.gov Identifier: NCT02516839.

Evaluating the Association of Anesthesia Type With Postoperative Complications in Patients Undergoing Ankle Fracture Repair

General and neuraxial anesthesia are both successful anesthesia techniques used in many orthopedic procedures. The purpose of this study was to compare the complications and length of hospital stay between patients who underwent general anesthesia versus neuraxial anesthesia during the repair of ankle fractures. Patients undergoing open reduction and internal fixation for ankle fracture from 2014 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: general anesthesia and neuraxial anesthesia. In this analysis, demographics data, comorbidities, and postoperative complications were collected and compared between the two cohorts. Bivariate analyses and multivariable logistical regression were performed. Of 3585 patients who underwent operative treatment for ankle fracture, 3315 patients (92.5%) had general anesthesia and 270 (7.5%) had neuraxial anesthesia. On bivariate analyses, patients who had neuraxial anesthesia were more likely to develop pulmonary complications (p = .173) or extended length of stay more than 5 days (p = .342) compared to the general anesthesia group. Following adjustment on multivariate analyses, the neuraxial anesthesia cohort no longer had increased likelihood of pulmonary complications or extended length of stay compared to the general anesthesia group. Healthy ankle fracture patients could also benefit from neuraxial anesthetic methods, and they should be considered for this anesthetic type regardless of their lack of comorbidities.

The Clinical Spectrum of Young Onset Dementia Points to Its Stochastic Origins.

Background:Dementia is a major global health problem and the search for improved therapies is ongoing. The study of young onset dementia (YOD)—with onset prior to 65 years—represents a challenge owing to the variety of clinical presentations, pathology, and gene mutations. The advantage of the investigation of YOD is the lack of comorbidities that complicate the clinical picture in older adults. Here we explore the origins of YOD.Objective:To define the clinical diversity of YOD in terms of its demography, range of presentations, neurological examination findings, comorbidities, medical history, cognitive findings, imaging abnormalities both structural and functional, electroencephagraphic (EEG) data, neuropathology, and genetics.Methods:A prospective 20-year study of 240 community-based patients referred to specialty neurology clinics established to elucidate the nature of YOD.Results:Alzheimer’s disease (AD; n = 139) and behavioral variant frontotemporal (bvFTD; n = 58) were the most common causes with a mean age of onset of 56.5 years for AD (±1 SD 5.45) and 57.1 years for bvFTD (±1 SD 5.66). Neuropathology showed a variety of diagnoses from multiple sclerosis, Lewy body disease, FTD-MND, TDP-43 proteinopathy, adult-onset leukoencephalopathy with axonal steroids and pigmented glia, corticobasal degeneration, unexplained small vessel disease, and autoimmune T-cell encephalitis. Non-amnestic forms of AD and alternative forms of FTD were discovered. Mutations were only found in 11 subjects (11/240 = 4.6%). APOE genotyping was not divergent between the two populations.Conclusion:There are multiple kinds of YOD, and most are sporadic. These observations point to their stochastic origins.

Outcomes of stage IV melanoma in the era of immunotherapy (IO): A National Cancer Database (NCDB) analysis.

e21520 Background: The majority of data for IO in melanoma stems from trials that have specific inclusion criteria and often exclude important populations. In this analysis, we present the first real-world evidence of outcomes for stage IV patients (pts) with cutaneous melanoma receiving IO from 2015–2017 (addition of anti-PD-1 therapies) and factors associated with receipt of IO, and compare these outcomes with pts receiving IO (likely interferon and interleukin-2) from 2004–2010, and IO (addition of ipilimumab) from 2011–2014. Methods: The NCDB was analyzed to identify pts with stage IV melanoma from 2004–2017. Pts were categorized into receipt of IO or not during time periods 2004–2010, 2011–2014, and 2015–2017. Overall survival (OS) was analyzed by Kaplan-Meier, log-rank, and Cox proportional hazard models; IO status was analyzed using logistic regression. Results: 24,544 pts were analyzed from 2004–2017. Overall, 5,238 pts (21.3%) that received IO had improved median OS compared to those that did not (20.2 vs. 7.4 mos; p&lt;0.0001). 4.1% received IO from 2004-2010, 7.8% from 2011-2014, and 9.4% from 2015-2017. Three-year OS significantly improved in pts treated with IO across treatment years; p&lt;0.0001 (Table). Similarly, median time to IO initiation improved over time: 62 days in 2011-2014 vs. 49 days in 2015-2017 (p&lt;0.0001). In the overall cohort, age&lt;65 years, female gender, private insurance, no comorbidities, residence in metropolitan area, and treatment at academic centers were associated with better OS (p&lt;0.0001 for all). Race was not associated with differences in OS (p=0.07). Multivariate analysis for 2015-2017 demonstrated that lack of treatment with IO [HR 1.98, 95%CI 1.81-2.17], radiation therapy [HR 1.20, 95%CI 1.09-1.32], presence of liver metastases [HR 1.87, 95%CI 1.63-2.13], and lack of surgery [HR 1.68, 95%CI 1.45-1.93] were independently associated with worse OS (p&lt;0.0001 for all). In multivariate analysis, receipt of IO from 2015-2017, was associated with age&lt;65 years [OR 1.27, 95%CI 1.08-1.50], African American race [OR 5.88, 95%CI 1.60-28.58], lack of comorbidities [OR 1.43, 95%CI 1.23-1.66], and treatment at academic centers [OR 1.44, 95%CI 1.26-1.65] (p&lt;0.05 for all). Conclusions: OS was improved in stage IV melanoma pts receiving IO, with the highest OS rate in 2015-2017. Our findings that represent a real-world population are consistent with recent trials, like KEYNOTE 006 and CheckMate 067 where 3-year OS for anti-PD-1 therapy was 50% and 52%, respectively. In our study, African Americans demonstrate a 5-fold increase in likelihood of receiving IO, a population underrepresented in clinical trials. Significant socioeconomic factors may impact receipt of IO and survival.[Table: see text]

Recent Evolution in the Management of Lymph Node Metastases in Melanoma.

IntroductionBased upon two large randomized international clinical trials (German Dermatologic Cooperative Oncology Group (DeCOG-SLT) and Multicenter Selective Lymphadenectomy Trial II (MSLT-II)) published in 2016 and 2017, respectively, active surveillance has been demonstrated to have equivalent survival outcomes to completion lymphadenectomy (CLND) for a subset of patients who have microscopic lymph node disease. In this study, the changes in national practice patterns were examined regarding the utilization of CLND after positive sentinel lymph node biopsy (SLNB).MethodsUsing the National Cancer Database, CLND utilization was examined in SLN-positive patients diagnosed with melanoma between 2012 and 2016. A hierarchal logistical regression model with hospital-level random intercepts was constructed to examine the factors associated with SLNB followed by observation vs. SLNB with CLND.ResultsOf the 148,982 patients identified, 43% (n = 63,358) underwent SLNB and 10.3% (n = 6,551) had a SLNB with microscopic disease. CLND was performed for 57% (n = 2,817) of these patients. Patients were more likely to undergo CLND if they were ≤ 55 years of age (OR, 1.454; p ≤ 0.0001), ages 56 – 65 (OR, 1.127; p = 0.026), Charlson Deyo Score = 0 (OR, 2.088; p = 0.043), or were diagnosed with melanoma in 2012 (OR, 2.259, p ≤ 0.0001).ConclusionsThe utilization of CLND among patients with microscopic nodal melanoma was significantly lower in 2016 compared to 2012. Younger age, lack of comorbidities, and primary tumor location on the trunk or head/neck were associated with higher utilization of CLND.

The treatment of inflammatory bowel disease during the SARS-CoV-2 epidemic – practical advices: (A COVID–19-pandémia orvosszakmai kérdései)

Patients with inflammatory bowel disease are more susceptible to severe viral infections requiring hospitalization regardless of treatment. Immunosuppressives and biological treatments multiply the chances of opportunistic and lung infections, especially in combination therapy, so due to the new coronavirus (severe acute respiratory syndrome coronavirus-2) epidemic, which primarily causes respiratory disease, it is advisable to use different therapeutic considerations for effective and safe patient care. Contrary to the expectations, a study from Italy and China each, despite of the large number of infected cases, did not report any SARS-CoV-2 positivity in patients with inflammatory bowel disease, which can be due to a number of favorable factors, such as the lower average age of the patients, lack of comorbidities, etc. However, it should not be forgotten that the patients on immunosuppressive and/or biological therapy belong to the compromised group. Consequently, in some cases there is a need to modify the therapy, but we should keep in mind that the relapse alongside with the need of medical consultation and even hospitalization elevate the chance of being infected. Thus, flare-ups ought to be avoided as far as they can be, so continuing the already started maintenance therapy can be a reasonable solution, but, in the high-risk group, modifying it can be reasonable as well. Our aim with this article is to make the health care more effective, and to give a practical recommendation for physicians during the epidemic, based on international publications. Orv Hetil. 2020; 161(25): 1022-1027.

Reoperations for Long-Term Complications Following Laparoscopic Adjustable Gastric Banding: Analysis of Incidence and Causality.

Background: Laparoscopic adjustable gastric banding (LAGB) gained popularity in the early 2000s as a purely restrictive procedure with modest weight loss. The potential for complications requiring reoperation has since become evident. A retrospective review was performed to determine the incidence of long-term complications and predictive factors requiring surgical reintervention after LAGB.Methods: Institutional review board approval was obtained, and a retrospective review of 200 consecutive patients undergoing LAGB over a period of six years was conducted at a single institution with American Society of Metabolic and Bariatric Surgery Center of Excellence designation. Data were collected on patient characteristics, comorbid conditions and complications requiring reintervention. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY).Results: Of the 200 patients, 176 (90.7%) were female with an average age of 53.6 years and preoperative body mass index (BMI) of 44.2 kg/m2. The average follow-up was 46 months. Complications occurred in 55 (28.4%) patients with band slippage/prolapse as the most common need for reoperation. Younger age, lack of comorbidities and diet/exercise compliance were associated with reintervention.Conclusions: LAGB has a high rate of reoperation secondary to complications associated with younger age. Alternative bariatric procedures may be more appropriate in these patients who have fewer comorbid conditions and are motivated to improve his or her health.

An analysis of hot spots of ESRD in the United States: Potential presence of CKD of unknown origin in the USA?

We hypothesized that high incidence rates of end-stage renal disease (ESRD) in certain counties of the U.S. are partly due to patients with a type of ESRD resembling chronic kidney disease of uncertain etiology (CKDu), which has been observed in Central America and other countries. Using data on 338,126 incident ESRD patients from the United States Renal Data System (USRDS) (2011-2013) and the Behavior Risk Factor Surveillance System (BRFSS) Supplement on county-level variables (2006), we describe both patient-level and county-level characteristics in counties with the highest quartile of ESRD incidence rate standardized for age, sex, and race (> 420 cases/million population/year) compared to the rest of the U.S. and two specific "hotspots" of ESRD: the San Joaquin Valley and the Rio Grande Valley. Logistic regression was used to examine characteristics associated with patients who had either missing cause of ESRD or "unknown" listed as the primary cause of ESRD. High incidence rates of ESRD were observed in southern Texas, the Southeast and parts of California (including the San Joaquin valley area), while low rates were seen in the Northwest and the Mountain Regions. The median crude incidence rate of ESRD was 335 (range 0-2,341) new cases per million population per year among counties. Significant predictors of missing/unknown primary cause of ESRD included: older age, white or unknown race, non-Hispanic ethnicity, lack of comorbidities at ESRD onset, lower estimated glomerular filtration rate (eGFR) at initiation, and lack of pre-dialysis care. Large areas of the U.S. have very high rates of ESRD incidence. We cannot confirm that CKDu is present in the U.S. based on this preliminary work. This topic therefore requires further investigation, as many of these patients may well be undocumented aliens working as farm laborers and therefore not registered in the USRDS. .

Clinicians' Attitudes Towards Do-Not-Resuscitate Directives in a Teaching Hospital in Saudi Arabia.

The Do-Not-Resuscitate (DNR) directive has provided a major leap in end-of-life care. To demonstrate the factors influencing physicians’ DNR decisions in King Fahd University Hospital in the Eastern Province of Saudi Arabia, 42 physicians from the medical and surgical departments of the same center were requested to participate in a cross-sectional survey.Thirty-six questionnaires were completed and returned from a total of 42 distributed among physicians, making a response rate of 85.7%. Certain diagnostic categories increase the likelihood of issuing a DNR order for a patient. Neurological (58.3%) and cardiovascular (41.7%) diseases were the highest response among other diseases in influencing physicians’ decisions. In addition, other factors like lack of comorbidities (55.5%), age (52.7%), and previous intensive care unit (ICU) admissions and resuscitation (44.4%) showed an effect on the directive decisions of DNR among investigated physicians. However, weak palliative care in the hospital (11.1%), religious beliefs (5.5%), and gender (2.7%) were the least associated factors affecting physicians’ DNR decisions.This study addresses the influencing factors of DNR orders issuance among King Fahd Hospital of the University physicians. Physicians noted that cultural standards and religious beliefs do play a role in their decision-making but had less of an effect as compared to other clinical data such as comorbidities, age, and previous ICU admissions.

Expanding the Indications for Ibrutinib: Complete Remission Obtained By Induction with Ibrutinib Followed By Consolidative Ahsct in Refractory Primary CNS Lymphoma

Introduction Primary central nervous system lymphoma (PCNSL) is an exceedingly rare and aggressive sub-type of Non-Hodgkin's Lymphoma. Despite initial polychemotherapy that includes High-Dose Methotrexate (HD-MTX), over half of patients will develop recurrent or refractory disease that requires salvage therapy.1 Ibrutinib, a Bruton's tyrosine kinase inhibitor, has become an alternative for salvage treatment in relapsed or refractory PCNSL (RR-PCNSL) that is particularly useful in patients who are ineligible for re-induction with HD-chemo. In RR-PCNSL, Ibrutinib led to a progression free survival (PFS) of roughly 5 months when used as monotherapy2,3 and 15 months when used as add-on therapy.4 While its role as salvage treatment has been documented, its use to facilitate consolidative autologous hematopoietic stem cell transplant (AHSCT) in RR-PCNSL is not currently known. The following case describes the first known report of a patient with RR-PCNSL who achieved persistent complete remission following Ibrutinib salvage treatment and consolidative AHSCT. Case Description A 64-year-old male presented to the emergency department with a two-week history ptosis, visual abnormalities, confusion, and increasing fatigue. On physical exam, he was found to have bilateral mydriasis, left third nerve cranial palsy, severe left-sided ptosis, and restricted upwards and downward gaze of the right eye. A contrast-CT was performed which showed multiple areas of abnormal enhancement throughout the frontal lobes, corpus callosum, and midbrain associated with significant vasogenic edema. These findings were confirmed on MRI. He underwent a stereotactic guided burr hole biopsy which was consistent with diffuse large B-cell lymphoma (DLBCL). Immunohistochemistry performed on the tissue showed that the neoplastic cells were CD3(-), CD5(-), CD20(+), CD10(-), BCL2(subset +), BCL6(+), MUM1(+) and Cyclin D1(-). Staging CT and bone marrow biopsy showed no evidence of systemic disease. He was diagnosed with PCNSL and went on to receive induction therapy with Rituximab, Methotrexate, Procarbazine, and Vincristine (R-MPV) with curative intent and received a total of 7 cycles. Initially, he had a significant radiographic response with a repeat MRI post cycle 4 showing only a few small areas of residual enhancement. However, after completion of the 7 cycles of R-MPV, his MRI showed evidence of disease progression with both new and enlarging intra-axial lesions. Given his ECOG of 0 and lack of comorbidities, it was decided that he would proceed with salvage treatment with Cytarabine and Etoposide with curative intent for refractory PCNSL. Unfortunately, after only four weeks of receiving cycle one of Cytarabine and Etoposide, a repeat MRI showed evidence of disease progression. He was then transitioned to palliative therapy with prednisone up until December 2017, at which point he was able to obtain Ibrutinib on a compassionate basis. He was started on Ibrutinib salvage therapy and achieved radiographic evidence of complete remission after four months of treatment. There were minimal adverse effects of Ibrutinib therapy, most notably a severe neutropenia requiring a temporary discontinuation of therapy for two weeks. He underwent consolidative AHSCT with Thiotepa, Busulfan and Melphalan conditioning in August 2018. His post-transplant course was complicated by culture negative febrile neutropenia with a subsequent source determined to be Clostridium difficile for which he was treated. An MRI head performed 3 months after his AHSCT showed no evidence of recurrent or residual disease. He continues to be followed by the Hematology Service in Newfoundland and has remained in complete remission since. Conclusions This case demonstrates the feasibility of a salvage approach using Ibrutinib followed by AHSCT when standard salvage options have been exhausted in refractory PCNSL. OffLabel Disclosure: Ibrutinib's indications do not currently include use as a induction treatment prior to AHSCT in refractory/recurrent PCNSL.