Long-term Management Of Patients Research Articles

Challenges in the Long-term Management of Patients With Coccidioidal Meningitis: A Retrospective Analysis of Treatment and Outcomes.

Coccidioidal meningitis (CM) is the most severe form of disseminated coccidioidomycosis. Despite years of clinical experience, it remains a difficult condition to treat, often requiring surgical procedures, such as placement of a ventriculoperitoneal shunt, in addition to lifelong antifungal therapy. We performed a retrospective analysis of patients with CM seen in a large referral center in Central Valley, California, from 2010 to 2020. Data pertinent to CM were collected and analyzed. Among 133 patients with CM identified in the 10-year period, nonadherence to antifungal therapy was noted in 43% of patients. Of the 80 patients who underwent ventriculoperitoneal shunt placement for management of intracranial pressure, shunt failure requiring revision surgery occurred in 42 (52.5%). Rehospitalizations due to CM-related reasons occurred in 78 of 133 patients (59%). Twenty-three percent of patients (n = 29) died due to complications from CM, on an average 22 months after the diagnosis of CM. Encephalopathy at presentation was associated with a significantly higher risk of death. Patients with CM in central California are predominantly rural agricultural workers with elevated levels of poverty and low health literacy and many barriers to care, leading to high rates of medication nonadherence and loss to follow-up outpatient care. Management challenges are frequent, such as failure of antifungal therapy, high rates of rehospitalization, and the need for repeated shunt revision surgeries. In addition to the development of curative new antifungal agents, understanding the barriers to patient adherence to care and antifungal therapy and identifying means to overcome such barriers are of paramount importance.

Current status of patient-reported outcome measures and other subjective assessment grading tools in bladder pain syndrome.

Bladder pain syndrome (BPS) is characterised by chronic pain in the bladder area accompanied by urgency and/or frequency without the presence of other confusable diseases. Owing to a lack of gold standard diagnostic tests and definitive cure it is paramount to define treatment goals and validated measurements of outcomes. Patient-reported outcome measures (PROMs) are validated questionnaires completed by patients that can help to reduce ambiguity in the BPS patient treatment pathway, but they are currently underutilised. We present to our knowledge the first summary and analysis of all available PROMs in BPS patients. Review and critical evaluation of all relevant BPS guidelines presented in English language and a systematic search for PubMed database articles relating to PROMs and subjective assessment grading tools in BPS, interstitial cystitis and chronic pelvic pain syndrome. The ideal PROMs for BPS should assess urinary symptoms, pain, quality of life and sexual health. There are five PROMs designed specifically for BPS patients. The most universally used and quoted is the O'Leary-Sant questionnaire followed by the Pelvic Pain and Urgency Score and the Wisconsin Interstitial Cystitis scale. However, there is no single PROM for BPS that is ideal, and for comprehensive assessment several questionnaires are often used simultaneously. Patient-reported outcome measures are a valuable tool for use in the long-term management of patients burdened with BPS. There are now several disease-specific PROMs in use that have their respective advantages and disadvantages. Their use should be encouraged in future research as well as continued efforts to develop new PROMs that can address current shortcomings.

PO-05-201 ONE-YEAR LONG-TERM FOLLOW UP FOR POST-ACUTE SEQUELAE OF COVID-19 POTS PATIENTS

Persistence of orthostatic tachycardia, palpitations, and fatigue beyond 4 weeks of an acute COVID-19 infection has been termed Post-Acute Sequelae of COVID-19 (PASC) POTS. We have previously reported 6-month outcomes of PASC POTS. Long-term management and outcomes of these patients is unknown. To examine the long-term management and outcomes of PASC POTS patients. We conducted a retrospective study of all patients who were diagnosed with POTS at Cardiology, Neurology, and Rehabilitation Post-COVID clinic after a COVID-19 infection between March 1, 2020, and November 1, 2022, at the University of Texas Health San Antonio. We examined COVID history, POTS diagnosis, management, and one-year outcomes of post-COVID POTS patients. In 42 patients that were diagnosed with PASC POTS, 33 had a one-year follow-up. 100% were female, 60.6% were Caucasian. Average age was 40.6 + 11 years while the average BMI was 31.9 + 10.4 kg/m2. The most common symptoms were fatigue (87.9%), palpitations (75.7%), brain fog (72.7%), orthostatic tachycardia, exercise intolerance, and dyspnea (70%). The mean heart rate change with 10-minute standing test was 42.68 + 26.73 beats per minute. At 12-months follow-up, the most common symptom was still fatigue (66.7%), palpitations (45.5%), orthostatic tachycardia, and orthostatic intolerance (42.4%). All patients were managed with increased salt and fluid intake, lower compression stockings and rehabilitation. Fifty five percent of patients were treated with Enhanced External Counter Pulsation (EECP), 42% were treated with beta blockers, 18% with fludrocortisone, 15% with midodrine, and 15% with Pyridostigmine. At 1 year follow-up, 33% of patients reported improvement in their symptoms, 33% reported worsening of symptoms, 24% reported stable symptoms, and 9% had resolution. PASC POTS patients continue to experience adverse symptoms even at one year. Physical therapy and rehabilitation and pharmacological therapy appear improve symptoms in a minority of patients.

Exit strategies in inflammatory bowel disease: Looking beyond anti-tumor necrosis factors.

The long-term management of patients with inflammatory bowel disease (IBD) is still a matter of debate, and no clear guidelines have been issued. In clinical practice, gastroenterologists often have to deal with patients in prolonged remission after immunomodulatory or immunosuppressive therapies. When planning an exit strategy for drug withdrawal, the risk of disease relapse must be balanced against the risk of drug-related adverse events and healthcare costs. Furthermore, there is still a dearth of data on the withdrawal of novel biologics, such as the anti-α4β7 integrin antibody (vedolizumab) and anti-IL12/23 antibody (ustekinumab), as well as the small molecule tofacitinib. Models for estimating the risk of disease relapse and the efficacy of retreatment should be evaluated according to the patient's age and IBD phenotype. These models should guide clinicians in programming a temporary drug withdrawal after discussing realistic outcomes with the patient. This would shift the paradigm from an exit strategy to a holiday strategy.

Reducing Gadolinium Exposure in Patients Undergoing Monitoring for Meningiomas.

Background Due to the non-malignant and slow-growing nature of many meningiomas, surveillance with serial magnetic resonance imaging (MRI) serves as an acceptable management plan. However, repeated imaging with gold-standard contrast-based studies may lead to contrast-associated adverse effects. Non-gadolinium T2 sequences may serve as a suitable alternative without the risk of adverse effects of contrast. Thus, this study sought to investigate the agreement between post-contrast T1 and non-gadolinium T2 MRI sequences in the measurement of meningioma growth. Methodology The Virginia Commonwealth University School of Medicine (VCU SOM) brain tumor database was used to create a cohort of meningioma patients and determine the number of patients who had T1 post-contrast imaging accompanied by readily measurable imaging from either T2 fast spin echo (FSE) or T2 fluid-attenuated inversion recovery (FLAIR) sequences. Measurements of the largest axial and perpendicular diameters of each tumor were conducted by two independent observers using T1 post-contrast, T2 FSE, and T2 FLAIR imaging series.Lin's concordance correlation coefficient (CCC) was calculated to assess inter-rater reliability between observers and agreement between measurements of tumor diameter among the different imaging sequences. Results In total, 33 patients (average age = 72.1 ± 12.9 years, 90% female) with meningiomas were extracted from our database, with 22 (66.7%) undergoing T1 post-contrast imaging accompanied with readily measurable imaging from T2 FSE and/or T2 FLAIR sequences. The inter-rater reliability between the measurements of T1 axial and perpendicular diameters was 0.96 (95% confidence interval (CI) = 0.92-0.98) and 0.92 (95% CI = 0.83-0.97), respectively. The inter-rater reliability between the measurements of T2 axial perpendicular diameters was 0.93 (95% = CI 0.92-0.97) and 0.89 (95% CI = 0.74-0.95), respectively. The agreements between the measurement of T1 and T2 FSE axial diameter by each observer were 0.97 (95% CI = 0.93-0.98) and 0.92 (95% CI = 0.81-0.97). The agreements between the measurements of T1 and T2 FSE perpendicular diameter measurements by each observer were 0.98 (95% CI = 0.95-0.99) and 0.88 (95% CI = 0.73-0.95). Conclusions Two-thirds of our patients had meningiomas that were readily measurable on either T2 FSE or T2 FLAIR sequences. Additionally, there was excellent inter-rater reliability between the observers in our study as well as an agreement between individual measurements of T1 post-contrast and T2 FSE tumor diameters. These findings suggest that T2 FSE may serve as a safe and similarly effective surveillance method for the long-term management of meningioma patients.

Dormancy in Breast Cancer.

The pattern of delayed recurrence in a subset of breast cancer patients has long been explained by a model that incorporates a variable period of cellular or tumor mass dormancy prior to disease relapse. In this review, we critically evaluate existing data to develop a framework for inferring the existence of dormancy in clinical contexts of breast cancer. We integrate these clinical data with rapidly evolving mechanistic insights into breast cancer dormancy derived from a broad array of genetically engineered mouse models as well as experimental models of metastasis. Finally, we propose actionable interventions and discuss ongoing clinical trials that translate the wealth of knowledge gained in the laboratory to the long-term clinical management of patients at a high risk of developing recurrence.

Abstract 5906: Gut microbiota signatures are associated with immunotherapy induced cognitive decline and neurotoxicity

Abstract Studies have demonstrated promising outcomes of combined immune checkpoint blockade (CICB) modulating tumor cytotoxicity via targeting cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death 1 (PD-1). The emergence of long-term patient management has been transformed among health care professionals as patient survival rates are increasing significantly. Despite promising advances, patient outcomes are heterogenic and are correlative to host intrinsic and extrinsic factors. Multiple reports have highlighted the negative effects of cancer treatments towards inducing cognitive impairment and neurotoxicity often referred to as “chemofog”. More recently, the gut microbiome has been increasingly recognized to regulate antitumor immunity and further distinct microbiome signatures can confer favorable outcomes in the context of CICB. Interestingly, specific microbes within the gut microbiome have been shown to regulate social behavior and cognition via the bidirectional communication along the gut-brain axis though changes in microbiota-derived metabolites and vagal afferent fibers. Insights into mechanisms of immunotherapy induced cognitive decline are warranted. Thus, we hypothesize CICB exacerbates cognitive impairment and neurotoxicity via the detrimental alterations to the gut microbiome. To address this, we profiled the gut microbiome, through 16S rRNA gene and metagenomic sequencing of fecal samples from patients (n=146) with advanced melanoma treated with CICB stratified based on severity of cognitive dissonance. Beta-diversity, incorporating weighted UniFrac distances by principal coordinate analysis (PCoA), revealed a cluster of samples from patients with cognitive impairment as compared to samples from those with minimal to absent cognitive decline. Further, taxonomical analysis showed significant alterations in relative abundances of microbial candidates (e.g., L. intestinalis, A. muciniphila, F. prausnitizii, and R. hominis). These results suggests that CICB patients with cognitive impairments and neurotoxicity have altered microbiome signatures which may potentially exacerbate downstream neuroinflammatory signaling. Further studies investigating specific host-microbe pathways and profiling microbiota-derived metabolites which are implicated in these detrimental effects are essential for biomarker discovery and mechanistic insight. Citation Format: Anik Banerjee, Christina Roland, Sarah Johnson, Nadim Ajami, Jennifer Wargo. Gut microbiota signatures are associated with immunotherapy induced cognitive decline and neurotoxicity. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5906.

220 Sex Differences in Cardiac Damage in Aortic Stenosis

OBJECTIVES/GOALS: Sex differences in aortic stenosis (AS) are vastly underestimated, contribute to disparities in treatment and worse outcomes for women including disproportionately higher mortality rates. This study aims to investigate sex differences in extent of cardiac damage (CD) from pressure overload in AS that may help account for the observed disparities. METHODS/STUDY POPULATION: CD in AS refers to a series of pathologic changes in the myocardium that occur due to chronic pressure overload imposed on the left ventricle by a progressively stenotic aortic valve (AV). These changes are associated with poor outcomes and lower survival in patients with AS. To acquire a deeper understanding of the factors and mechanisms affecting differences in the long-term survival and management of patients with AS, we are proposing to assess baseline stage of CD on echocardiography, and changes in transvalvular hemodynamics and CD stage (Δ CD) over time, in patients with moderate and severe AS at one of 2 large tertiary-care hospitals in MA. We also plan to assess time to and performance of aortic valve replacement (AVR), stratified by hemodynamic severity of stenosis and CD stage, and their interaction with sex. RESULTS/ANTICIPATED RESULTS: We hypothesize that women will have a higher stage of CD on their initial echocardiogram (TTE), demonstrating moderate or greater severity of AS, than men with the same hemodynamic severity of valvular stenosis. We additionally hypothesize that those with more advanced cardiac damage stage will likely have masking of transvalvular progression on echocardiogram. Finally, we anticipate that women will have AVR performed less frequently than men and will have minimal improvement in their Kansas City Cardiomyopathy Questionnaire (KCCQ) scores post-AVR indicative of more heart failure symptoms and a lower quality of life. DISCUSSION/SIGNIFICANCE: This study will seek to better understand sex-based differences in extent of cardiac damage to pressure overload in aortic stenosis (AS) to minimize treatment and outcome disparities for women and allow for more individualized and patient-centered care.

SICI-GISE/SICOA Consensus document: Clinical follow-up of patients after acute coronary syndrome or percutaneous coronary intervention

In the last decades, advances in percutaneous coronary intervention (PCI) strategies have significantly reduced the risk of procedural complications and in-hospital mortality of patients with acute coronary syndromes (ACS), thus increasing the population of stable post-ACS patients. This novel epidemiological scenario emphasizes the importance of implementing secondary preventive and follow-up strategies. The follow-up of patients after ACS or elective PCI should be based on common pathways and on the close collaboration between hospital cardiologists and primary care physicians. However, the follow-up strategies of these patients are still poorly standardized. This SICI-GISE/SICOA consensus document was conceived as a proposal for the long-term management of post-ACS or post-PCI patients based on their individual residual risk of cardiovascular adverse events. We defined five patient risk classes and five follow-up strategies including medical visits and examinations according to a specific time schedule. We also provided a short guidance for the selection of the appropriate imaging technique for the assessment of left ventricular ejection fraction and of non-invasive anatomical or functional tests for the detection of obstructive coronary artery disease. Physical and pharmacological stress echocardiography was identified as the first-line imaging technique in most of cases, while cardiovascular magnetic resonance should be preferred when an accurate evaluation of left ventricular ejection fraction is needed. The standardization of the follow-up pathways of patients with a history of ACS or elective PCI, shared between hospital doctors and primary care physicians, could result in a more cost-effective use of resources and potentially improve patient's long-term outcome.

Long-term results of coronary bypass grafting supplemented with surgical stimulation of extracardiac myocardial vascularization in patients with diffuse coronary artery disease

Highlights. In recent decades, the number of patients with diffuse, multivessel coronary artery disease has increased due to widespread use of endovascular methods of treatment, long-term conservative management of patients, and the expansion of indications for surgical revascularization. In order to improve the results of treatment, in 2007 academician Yu. L. Shevchenko developed and began using the method of stimulation of extracardiac angiogenesis – «YurLeon». The present article demonstrates the long-term results of supplementing coronary bypass surgery with this method in patients with diffuse coronary artery disease.Aim. To evaluate long-term results of coronary bypass surgery supplemented by extracardiac myocardial revascularization.Methods. The prospective, randomized study included 205 patients with diffuse, multivessel coronary artery disease who were treated at the St. George Thoracic and Cardiovascular Surgery Clinic, National Medical and Surgical Center named after N.I. Pirogov. The majority of patients were men – 75% (n = 153), whereas women accounted for 25% (n = 52), all patients were 60 to 78 years old (67.3±5.74 years). The group I consisted of patients with coronary bypass surgery supplemented with the «YurLeon» technique, the group II consisted of patients with coronary bypass grafting only. All patients provided consent to participate in the study. The clinical condition of patients, echocardiography, myocardial scintigraphy and coronary angiography data, quality of life indicators (the 36-Item Short Form Health Survey) were assessed.Results. In the long-term postoperative period (36 months), the group I, compared with the group II, presented with a statistically significant decrease in the functional class of angina pectoris (1[1–2] vs. 2[1–2], p = 0.02); fewer adverse events: myocardial infarction (4.5% vs. 11.6%, p = 0.011), recurrent angina pectoris (10% vs. 17.9%, p = 0.038); an increase in the left ventricular ejection fraction (59.0±5.15% vs. 53.2±6.13%, p = 0.001); a decrease in the Summed Rest Score (SRS) (4.5±3.5 vs. 8.4±5.7, p = 0.012) according to myocardial scintigraphy with technetril; a decrease in the Summed Thickening Score (STS) (6.1±3.3 vs. 10.7±2.9, p = 0.012); a decrease in the hibernating myocardium (3.5±2.2% vs. 7.4±5.1%, p = 0.03); additional extracardiac sources were found in the group I according to coronary graft angiography, there were no statistically significant differences between the groups by occluded autogenous venous bypass grafts (in the group I – 23 out of 46 venous conduits (49%), in the group II – 30 out of 49 venous conduits (51%), p = 0.089); The groups differed in terms of quality of life (the 36-Item Short Form Health Survey): physical functioning (87.3±10.32 vs. 75.3±14.15 points, p = 0.001); role-based functioning due to physical condition (90.1±10.50 vs. 79.7±7.01 points, p = 0.012); pain (93.10±6.37 vs. 80.5±5.21 points, p = 0.03); the total physical component of health (57.9±5.4 vs. 45.8±6.1 points, p = 0.012).Conclusion. We have accumulated 15 years of experience in conducting complex myocardial revascularization in patients with coronary artery disease and diffuse coronary atherosclerosis, which allowed us to prove the effectiveness and safety of the YurLeon technique.

Technological advances and digital solutions to improve quality of life in older adults with chronic obstructive pulmonary disease: a systematic review

Several technological advances and digital solutions have been proposed in the recent years to face the emerging need for tele-monitoring older adults with Chronic Obstructive Pulmonary Disease (COPD). However, several challenges have negatively influenced an evidence-based approach to improve Health-Related Quality of Life (HR-QoL) in these patients. To assess the effects of tele-monitoring devices on HR-QoL in older adults with COPD. On November 11, 2022, PubMed, Scopus, Web of Science, and Cochrane were systematically searched for randomized controlled trials (RCTs) consistent with the following PICO model: older people with COPD as participants, tele-monitoring devices as intervention, any comparator, and HR-QoL as the primary outcome. Functional outcomes, sanitary costs, safety, and feasibility were considered secondary outcomes. The quality assessment was performed in accordance with the Jadad scale. A total of 1845 records were identified and screened for eligibility. As a result, 5 RCTs assessing 584 patients (423 males and 161 females) were included in the systematic review. Tele-monitoring devices were ASTRI telecare system, WeChat social media, Pedometer, SweetAge monitoring system, and CHROMED monitoring platform. No significant improvements in terms of HR-QoL were reported in the included studies. However, positive effects were shown in terms of the number of respiratory events and hospitalization in patients telemonitored by SweetAge system and CHROMED platform. Although a little evidence supports the role of tele-monitoring devices in improving HR-QoL in older patients, positive effects were reported in COPD exacerbation consequences and functional outcomes. Tele-monitoring solutions might be considered as sustainable strategies to implement HR-QoL in the long-term management of older patients with COPD.

Influence of morphology and hemodynamics on thrombosis in kawasaki disease patients

Kawasaki Disease (KD) patients with co-occurrent coronary artery aneurysms (CAAs) are prone to thrombosis. This study explores the thrombotic influence of morphology and hemodynamics in KD patients with CAAs. Patient-specific computed tomography angiogram images of 9 patients were used to rebuild coronary models (including 23 aneurysms; 10 in thrombosed group, and 13 in non-thrombosed group) and perform computational simulations to obtain the hemodynamic parameters. The thrombosed and non-thrombosed groups were compared in terms of six parameters, namely, the maximum diameter (Dmax), aspect ratio (Rl/d), shape, time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), and relative residence time (RRT). The results showed that: (1) In thrombosed aneurysms, there were several vortex structures (eddy zone), of which the position changed continuously in a cardiac cycle. In non-thrombosed aneurysms, the streamlines showed a large streaming zone. (2) Abnormal hemodynamic areas of aneurysms with thrombosis tended to appear in the same region (especially the proximal and near myocardial side of aneurysms). (3) In the non-thrombosed group, there was a correlation between the morphological and hemodynamic parameters. In thrombosed aneurysms, the flow pulsatility has a significant impact on the flow pattern. The thrombosed coronary aneurysms exhibited more risk factors and the co-location of hemodynamic abnormalities was consistent with the position of thrombosis. A score of risk factors could provide the thrombotic information of coronary aneurysms, which might be helpful for long-term clinical management of KD patients.

Long-Term Spasticity Management in Post-Stroke Patients: Issues and Possible Actions-A Systematic Review with an Italian Expert Opinion.

Spasticity is a well-known motor dysfunction occurring after a stroke. A group of Italian physicians' experts in treating post-stroke spasticity (PSS) reviewed the current scientific evidence concerning the state-of-the-art clinical management of PSS management and the appropriate use of botulinum toxin, aiming to identify issues, possible actions, and effective management of the patient affected by spasticity. The participants were clinicians specifically selected to cover the range of multidisciplinary clinical and research expertise needed to diagnose and manage PSS. When evidence was not available, the panel discussed and agreed on the best way to manage and treat PSS. To address the barriers identified, the panel provides a series of consensus recommendations. This systematic review provides a focused guide in the evaluation and management of patients with PSS and its complications. The recommendations reached by this panel of experts should be used by less-experienced doctors in real life and should be used as a guide on how to best use botulinum toxin injection in treating spasticity after a stroke.

Long-term efficacy of spinal cord stimulation for chronic primary neuropathic pain in the contemporary era: a systematic review and meta-analysis.

Spinal cord stimulation (SCS) is a modern neuromodulation technique extensively proven to be an effective modality for treatment of chronic neuropathic pain. It has been mainly studied for complex regional pain syndrome (CRPS) and failed back surgery syndrome (FBSS) and recent data almost uniformly establishes its statistically significant positive therapeutic results. It has also been compared with other available treatment modalities across various studies. However, long term data on maintenance of its efficacious potential remains less explored. Few studies have reported data on long follow-up times (>= 12 months) and have compared its efficacy with other treatment options for chronic pain, respectively. Our study pools and analyzes the available data and compares SCS with other treatment options. It also analyzes the efficacy of SCS in long term management of patients with chronic pain. We reviewed all the data available on MEDLINE, Embase and Cochrane CENTRAL using a search strategy designed to fit our pre-set inclusion and exclusion criteria. Both single-arm and double-arm studies were included. The primary outcome was defined as decrease of visual analogue scale (VAS) by >50% at 6, 12 and/or 24 months after SCS. According to the pooled data of double-arm studies, SCS has unanimously proven its superiority over other treatment options at 6 months follow-up; however it fails to prove statistically significant difference in results at longer treatment intervals. Dorsal root ganglion stimulation, a relatively recent technique with the same underlying physiologic mechanisms as SCS, showed far more promising results than SCS. Single-arm studies show around 70% patients experiencing greater than 50% reduction in their VAS scores at 6 and 12 months. SCS is a viable option for management of chronic neuropathic pain secondary to FBSS and CRPS. However, data available for its long term efficacy remains scarce and show no further statistically significant results.

Liver Transplantation: A Right or a Privilege? Sustainable Liver Transplant Financing With an Innovative Model for the Developing World

Living donor liver transplant in addition to its lifesaving therapy is a cost-effective alternate to long-term disease management in patients with chronic liver disease. Financial constraint is the biggest hurdle faced by patients in developing countries in availing the liver transplantation. So, we conducted this study to report a government-funded financial support system for liver transplant services. A total of 198 patients who underwent living donor liver transplant with at least 90 days follow-up were included in the study. According to proxy means test score, 52.2% patients were from low and middle socioeconomic groups and 64.6% of patients underwent liver transplantation through government support. Out of 198 patients who underwent liver transplantation 29.6% had monthly income below 25,000 Pakistani rupees ($114). In recipients, 90-day mortality was 7.1% and morbidity was 67.1%. Donor morbidity was 23.2% without any mortality. This financial model can serve as a valuable source for middle and low income group countries to overcome the financial challenge and make liver transplant an accessible, affordable, and economically viable option.

Biological equivalent dose is associated with radiological toxicity after lung stereotactic ablative radiation therapy

IntroductionStereotactic ablative radiation therapy (SABR) is the standard of care for inoperable early-stage non-small-cell lung cancer. Although the probability of grade ≥ II toxicities is low, many patients present radiological subclinical toxicities usually associated with long-term patient management challenges. We evaluated radiological changes and correlated them with the received Biological Equivalent Dose (BED). MethodsWe retrospectively analyzed chest CT scans of 102 patients treated with SABR. An experienced radiologist evaluated the radiation-related changes 6 months and 2 years after SABR. The presence of consolidation, ground-glass opacities, organizing pneumonia pattern, atelectasis and the extent of affected lung were recorded. Dose-volume histograms of the lung healthy tissue were transformed to BED. Clinical parameters such as age, smoking habits, and previous pathologies were registered and correlations between BED and radiological toxicities were drawn. ResultsWe observed a positive and statistically significant correlation between lung BED over 300 Gy and the presence of organizing pneumonia pattern, the degree of lung affectation and the 2-year prevalence and/or increase of these radiological changes. Radiological changes in patients receiving BED > 300 Gy to a healthy lung volume ≥ 30 cc increased or remained in the 2 years follow-up scan. We found no correlation between radiological changes and the analyzed clinical parameters. ConclusionsThere seems to be a clear correlation between BEDs higher than 300 Gy and radiological changes both short and long term. If confirmed in an independent patient cohort, these findings could lead to the first radiotherapy dose constraints for grade I pulmonary toxicity.

Behavioral Interpretation of Willingness to Use Wearable Health Devices in Community Residents: A Cross-Sectional Study

Wearable health devices (WHDs) have become increasingly advantageous in long-term health monitoring and patient management. However, most people have not yet benefited from such innovative technologies, and the willingness to accept WHDs and their influencing factors are still unclear. Based on two behavioral theories: the theory of planned behavior (TPB) and the diffusion of innovation (DOI), this study aims to explore the influencing factors of willingness to use WHDs in community residents from the perspective of both internal and external factors. A convenience sample of 407 community residents were recruited from three randomly selected Community Health Service Centers (CHSCs) in Nanjing, China, and were investigated with a self-developed questionnaires. The mean score of willingness to use WHDs was 17.00 (range 5-25). In the dimensions of TPB, perceived behavioral control (β = 1.979, p < 0.001) was the strongest influencing factor. Subjective norms (β = 1.457, p < 0.001) and attitudes (β = 0.651, p = 0.016) were also positively associated with willingness. In innovation characteristics of DOI, compatibility (β = 0.889, p < 0.001) and observability (β = 0.576, p = 0.003) had positive association with the willingness to wear a WHD. This study supports the applicability of the two behavioral theories to interpret the willingness to use WHDs in Chinese community residents. Compared with the innovative features of WHDs, individual cognitive factors were more critical predictors of willingness to use.

Inhaled corticosteroids administration/withdrawal as a therapeutic continuum for patients with chronic obstructive pulmonary disease in real clinical practice

Chronic obstructive pulmonary disease (COPD) is a progressing disease. Each exacerbation impairs the patient’s prognosis and increases burden for the healthcare system. The most common maintenance treatment options for COPD include long-acting bronchodilators – β2-agonists (LABA) and long-acting antimuscarinic agents (LAMA), and inhaled glucocorticosteroids (ICS), in fixed/opened double and triple combinations. Triple therapy in subjects with exacerbation history is the most effective way to prevent negative outcomes of the disease. It can reduce the frequency of exacerbations, slow down the disease progression, improve quality of life, and reduce mortality in the long run. On the other hand, the response to triple therapy may change over the time depending on airways inflammation level, infection activity, and exacerbation frequency. Current COPD guidelines propose different indications for therapy escalation and de-escalation (ICS addition/withdrawal) for more personalized and safe treatment. At the same time, many practical issues of this process are still unclear, e.g. how often treatment regimens should be reviewed and what escalation/de-escalation criteria should be prioritized. The authors strongly believe that COPD therapy should adapt a holistic treatment approach (continuum) with quick responses to any changes in the patient’s condition.The aim of our work was to create an algorithm for ICS administration/ withdrawal for COPD patients on long-acting dual bronchodilators maintenance therapy and to establish a therapeutic continuum that takes into account exacerbation history, symptoms severity, blood eosinophilia level, and concomitant asthma.Conclusion. This instrument can be a useful and convenient tool for long-term patient management when access to specialized medical care might be restricted. It takes into account the main current recommendations for COPD management and is easy to apply in real clinical practice.

Long-term risk, clinical management, and healthcare resource utilization of stable patients with coronary artery disease and post-myocardial infarction in Greece - TIGREECE study

BackgroundIn light of the scarcity of evidence, TIGREECE evaluated the clinical management and long-term outcomes of patients at high risk for an atherothrombotic event who have suffered a myocardial infarction (MI), managed by cardiologists/internists in routine hospital and private office settings in Greece. MethodsTIGREECE, a multicenter, 3-year prospective cohort study, enrolled patients ≥50 years old, with a history of MI 1–3 years before enrollment and with at least one of the following risk factors: age ≥65 years, diabetes mellitus requiring medication, second prior MI, multivessel coronary artery disease, and creatinine clearance 15–60 mL/min. The primary outcome was a composite of MI, unstable angina with urgent revascularization, stroke, or all-cause death. ResultsBetween 5 June 2014 and 25 July 2015, 305 eligible consented patients (median age: 67.3 years; 81.3% males; 14.8% active smokers; 80.7% overweight/obese) were enrolled; 52.5% had ≥2 qualifying risk factors. The median time from the index MI [ST-segment elevation myocardial infarction (STEMI) in 51.1%, non-STEMI in 33.1%] to enrollment was 1.7 years. Of the patients, 65.9% had been discharged on dual antiplatelet therapy. At enrollment, 94.4% were receiving antiplatelets: 60.0% single [acetylsalicylic acid (ASA): 43.3%; clopidogrel: 15.7%] and 34.4% dual (ASA + clopidogrel: 31.8%) therapy. The Kaplan–Meier estimated 3-year primary composite event rate was 9.3% [95% confidence interval (CI): 6.4–13.0), and the ischemic composite event rate was 6.7% (95% CI: 4.2–9.9). ConclusionsStudy results indicate that in the routine care of Greece one in ten patients experience a recurring cardiovascular event or death, mainly of ischemic origin, 1–3 years post-MI.

P441 Long-term CD treatment failure and dose modification rates with vedolizumab and other biologics: Results from a large prospective observational study

Abstract Background Durable treatment effectiveness is an important consideration in the long-term management of patients with Crohn’s disease (CD) receiving biologic therapy. The aim of this analysis was to evaluate rates of failure and dose modification for biologic treatment over time in patients with CD using data from a large long-term observational study evaluating secondary outcomes in patients initiating treatment on vedolizumab (VDZ) and other biologics. Methods We analysed data from a multicentre, prospective, observational, post-authorisation safety study (PASS; NCT02674308, EUPAS6469) following VDZ or other biologic treatment cohorts under routine standard of care. Longitudinal data on treatment failure (including biologic discontinuation†, IBD non-surgical hospitalization, primary IBD surgery and corticosteroid initiation) up to 36 months and dose modification at any time during the study were analysed in biologic-naïve and biologic-experienced patients with CD in the treatment cohorts. Results The cohort comprised 1338 biologic-naïve patients (pts) (VDZ, n=312; other biologics, n=1026) and 1543 biologic-experienced pts (VDZ, n=829; other biologics, n=714). Baseline pt characteristics (Table 1) were broadly similar across different treatment cohorts, although there were some notable differences with respect to fistulising disease and age at CD diagnosis. Treatment failure rates for biologic-naïve and biologic-experienced pts cumulatively over time at specific time points are shown in Table 2. The proportion of pts continuing biologic treatment with dose modification at any time during the study period for biologic-naïve pts was 13/312 (4.2%) in VDZ-treated pts vs 502/1026 (48.9%) in the group treated with other biologics and 34/829 (4.1%) vs 433/714 (60.6%), respectively for biologic-experienced pts. Conclusion This large observational study reported rates of treatment failure, hospitalization, and IBD-related surgeries during long-term follow-up of biologic-naïve and biologic-experienced pts with CD. Dose modification occurred less frequently in biologic-naïve and biologic-experienced pts treated with VDZ compared with pts receiving other biologic treatments during the study.