Management Of New Cases Research Articles

Venous thromboembolism in Cushing syndrome: results from an EuRRECa and Endo-ERN survey.

Patients with Cushing syndrome (CS) are at increased risk of venous thromboembolism (VTE). The aim was to evaluate the current management of new cases of CS with a focus on VTE and thromboprophylaxis. A survey was conducted within those that report in the electronic reporting tool (e-REC) of the European Registries for Rare Endocrine Conditions (EuRRECa) and the involved main thematic groups (MTG's) of the European Reference Networks for Rare Endocrine Disorders (Endo-ERN) on new patients with CS from January 2021 to July 2022. Of 222 patients (mean age 44 years, 165 females), 141 patients had Cushing disease (64%), 69 adrenal CS (31%), and 12 patients with ectopic CS (5.4%). The mean follow-up period post-CS diagnosis was 15 months (range 3-30). Cortisol-lowering medications were initiated in 38% of patients. One hundred fifty-four patients (69%) received thromboprophylaxis (including patients on chronic anticoagulant treatment), of which low-molecular-weight heparins were used in 96% of cases. VTE was reported in six patients (2.7%), of which one was fatal: two long before CS diagnosis, two between diagnosis and surgery, and two postoperatively. Three patients were using thromboprophylaxis at time of the VTE diagnosis. The incidence rate of VTE in patients after Cushing syndrome diagnosis in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Thirty percent of patients with CS did not receive preoperative thromboprophylaxis during their active disease stage, and half of the VTE cases even occurred during this stage despite thromboprophylaxis. Prospective trials to establish the optimal thromboprophylaxis strategy in CS patients are highly needed. The incidence rate of venous thromboembolism in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Notably, this survey showed that there is great heterogeneity regarding time of initiation and duration of thromboprophylaxis in expert centers throughout Europe.

The Effect of Add-on Memantine in New Onset Combat-Related Posttraumatic Stress Disorder Core Symptoms: A Pilot Study.

Objective: Studies using standard neuropsychological instrumentation have shown memory deficits in posttraumatic stress disorder (PTSD) patients. We examined the efficacy and safety of memantine in new cases of combat-related PTSD in the military by conducting a 16-week prospective double-blind randomized controlled trial. Method : Twenty-six new combat-related PTSD cases were recruited from among the military personnel based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Patients were assigned to memantine and Placebo groups. They were monitored at baseline, week eight, and week 16. Memantine was added to each patient's current medication with an initial dosage of 5 mg/day, raised by 5 mg/day every week until it reached the maintenance level of 20 mg/day. The concurrent drugs were essentially kept unchanged during the trial. The primary outcome was PTSD severity as assessed by the Clinician-administered PTSD Scale (CAPS). The CAPS is a valid and reliable tool for the diagnosis of PTSD and measurement of its severity according to the DSM-4. Results: CAPS mean score in baseline (P = 0.811) and weeks eight (P = 0.389) and 16 (P = 0.066) did not show any significant differences between the two groups. The mean CAPS score in the memantine group significantly (P = 0.006) decreased (Mean differences = -8.79) compared to the placebo group, showing that intervention with memantine was effective. The mean total CAPS in weeks eight (Mean differences = -14.21) and 16 (Mean differences = -27) were less than the baseline, which was significantly meaningful (P < 0.001). Conclusion: Findings of this study suggest that add-on memantine can be effective in veteran patients with PTSD. So our data provide useful insight into the management of new cases of combat-related PTSD.

The Transmogrification of Surgical Telehealth: a PRISMA Review

Telehealth has been used to care for patients at a distance in specific clinical and demographic situations, but the demand for physical isolation during the COVID-19 pandemic has expanded its application to the broader community. This systematic literature review, of very recent publications, elucidates the new ways telehealth has been implemented, confirms it’s acceptability, accessibility and safety by collating reviews, trial and cohort studies from peer reviewed journals meeting defined risk of bias criteria. Five literature reviews, three qualitative studies and 22 quantitative studies were included, which confirmed that telehealth is a safe medium for delivery of surgical health care, is accessible and efficient for the majority of patients and clinicians across the age and socioeconomic spectrum. It is time and resource efficient for providers and recipients and improves the delivery of patient-centred care. Many providers have published innovative solutions to the difficulties of telehealth, such as conducting a physical examination or technological limitations at the remote site. Health care can now be delivered directly to the home or the workplace. Routine in-person postoperative review of patients should be replaced by patient-led telehealth unless there is a specific reason for face-to-face review. Assessment and management of new cases could be managed more efficiently if a carefully planned digital referral process is developed and adopted.

Impact of the COVID-19 pandemic on clinical activity during the lockdown in North France: A single center experience.

e13594 Background: During the French COVID-19 pandemic, clinical activity for cancer care has declined and modified the management of patients in cancer institute. France has imposed two national lockdowns of the population (from March 17 to May 11 and from October 30 to December 15 2020). We evaluate the impact of the lockdown period in North France on clinical activity. Methods: We measured and compared key-indicators of clinical activity between different periods: 2019 versus 2020; before and during the first and second lockdown. Results are given as percentage of changes with 95% confidence interval (CI). Results: The comparative analysis between 2019 and 2020 showed that most clinical activities except hospitalizations (-0.0% [-0.2; +0.1%] has changed. There was a significant increase in overall treated patients (+0.4% [+0.3; +0.5], telemedicine +99.9% [+99.4; +99.7], MRI (+8.8% [+8.2; +9.5], ambulatory chemotherapy (+3.5% [+3.3; +3.8]), number of chemotherapies prepared (+2.0 [+.1.9; +2.2]) and admission in palliative care unit (+15.3%, [+10.8; +19.8]). On the contrary, a significant decrease in treated patients aged &gt; 65 years old (-6.4% [-6.9; -5.9]), incidence rate (-3.1% [-3.6; -2.7]), multidisciplinary team meeting on patient assessment (-3.1% [-3.5;-2.5]), pathology reports (-2.9% (-3.3;-2.6]), radiotherapy (-4.6% [-4.7;-4.4]) and surgery (-6.7% [-7.4;-5.6]) were observed. In 2020, before and during the first lockdown all key-indicators declined except telemedicine (+40,400%) and admission in palliative care unit (+35.5% [+31.0-+49.7]). During the first lockdown, key-indicators decreased from -63.0% [-70.3-59.2] for outpatient visits to -5.1% [-7.0-3.8] for chemotherapy. The impact caused by the second lockdown was non-significant compared to the first one since all key-indicators has increased during the second lockdown: from +23.8% [+22.2; +25.5] for radiotherapy to +76.6% [+72.5; +79.5] for the management of new cases. Conclusions: Dramatic changes occurred in 2020 during the COVID-19-related lockdown compared to 2019. An Increase in chemotherapy treatment and admission on palliative care unit and a decrease in surgery and radiotherapy strongly suggests that the clinical activity was changed in 2020 compared to 2019. This was in line with the reduction of cancer screening in 2020. The impact of the first lockdown on clinical activities was higher compared to the second one. These observations should be investigated further in order to better understand the effects of a pandemic-related lockdown on cancer care.

A bird's eye view: Sexual health adviser coordination of contact tracing for hepatitis B.

An National Health Service sexual health adviser led service to facilitate management of new cases of hepatitis B from all settings across a large Scottish health board was initiated in 2012. Sexual health advisers contacted testing clinicians to support referral into appropriate services and facilitate identification, testing and vaccination of sexual partners, family and household contacts. A retrospective audit of contact tracing outcomes was conducted between September 2012 and December 2019. From a total of 1344 people diagnosed with hepatitis B, 2248 household and sexual contacts were identified. A documented outcome was established for 1741 (78%) of contacts, equalling 1.3 per index case. 257 (11%) of traced contacts were hepatitis B surface antigen positive, 162 (7%) had natural immunity and 1222 (54%) were vaccinated, either before or after contact tracing. This suggests a multi-agency approach to contact tracing for hepatitis B can achieve good outcomes. Further work is required to reduce the disproportionate burden of hepatitis B among ethnic minority subpopulations in Scotland.

Educational strategy intervention and remote supervision on the post-discharge management of tuberculosis diagnosed in the hospital: Randomized clinical trial.

One of the most serious problems in TB control is non-adherence to treatment leading to the risk of drug resistance and subsequent treatment failure. To assess the impact of an educational strategy intervention and remote supervision on the post-discharge management of new cases of TB diagnosed in hospital on TB cure rate. Secondarily, to assess the impact of this intervention on default rate. Randomized control trial conducted at a general, tertiary care, university affiliated hospital. New cases of TB diagnosed in hospital were included. The primary outcome was cure rate and secondary outcome was default rate. Analysis was carried out by modified intention to treat. A total of 169 new tuberculosis patients were enrolled. Among them, 80 were assigned to intervention group and 89 to control group. The cure rate was 71.3% in the intervention group and 58.4% in the control group. In the multivariate binary logistic regression model to evaluate the effect of the intervention, controlled by age, sex, current smoking status and directly observed treatment short, intervention was independently associated with cure rate (OR=0.47; 95% CI: 0.24-0.94; P=0.033).There was a significant difference in the default rate between the control and intervention groups (18.0% vs 5.0%, respectively, P=0.039). An educational strategy intervention and remote supervision on the post-discharge management of new cases of TB with in-hospital diagnosis had a positive effect of small magnitude on cure rate. Secondarily, the treatment default rate has been significantly decreased with the intervention.

Population trends in the incidence and initial management of osteoarthritis: age-period-cohort analysis of the Clinical Practice Research Datalink, 1992-2013.

ObjectiveTo determine recent trends in the rate and management of new cases of OA presenting to primary healthcare using UK nationally representative data.MethodsUsing the Clinical Practice Research Datalink we identified new cases of diagnosed OA and clinical OA (including OA-relevant peripheral joint pain in those aged over 45 years) using established code lists. For both definitions we estimated annual incidence density using exact person-time, and undertook descriptive analysis and age-period-cohort modelling. Demographic characteristics and management were described for incident cases in each calendar year. Sensitivity analyses explored the robustness of the findings to key assumptions.ResultsBetween 1992 and 2013 the annual age-sex standardized incidence rate for clinical OA increased from 29.2 to 40.5/1000 person-years. After controlling for period effects, the consultation incidence of clinical OA was higher for successive cohorts born after the mid-1950s, particularly women. In contrast, with the exception of hand OA, we observed no increase in the incidence of diagnosed OA: 8.6/1000 person-years in 2004 down to 6.3 in 2013. In 2013, 16.4% of clinical OA cases had an X-ray referral. While NSAID prescriptions fell from 2004, the proportion prescribed opioid analgesia rose markedly (0.1% of diagnosed OA in 1992 to 1.9% in 2013).ConclusionRising rates of clinical OA, continued use of plain radiography and a shift towards opioid analgesic prescription are concerning. Our findings support the search for policies to tackle this common problem that promote joint pain prevention while avoiding excessive and inappropriate health care.

Insights into the epidemiology of incident Heart Failure (HF): outcomes of rapid HF access clinic applying the NICE guidelines

Purpose: The onset of heart failure (HF) is associated with early increase in the risk of hospitalisation and mortality. The National Institute for Clinical Excellence (NICE) HF guidelines mandate prompt diagnosis and management of new cases of HF. Thus patients with suspected HF must have an echocardiogram and assessment by a clinical specialist within 2 weeks, if they had a previous myocardial infarction or if their serum natriuretic peptide (NTproBNP) is >2000 pg/ml; or within 6 weeks if their serum NTproBNP is 400-2000 pg/ml. We report the activity and the findings of the first 9 months after establishing a rapid access one-stop HF clinic implementing the 2010 NICE guidelines for suspected incident HF cases, serving an English city with a population of 550,000 people. Methods: We established 3/week clinics with the capacity of 18 patients per week. We collected data on the patients attending the dedicated one-stop HF consultant-led clinic in the first 9 months to January 2013. The patients underwent electrocardiography and echocardiography on the same day of the clinic visit. We gathered data on NTproBNP, echocardiographic and clinical findings. We monitored the waiting time for the clinic to assess the adherence to the guidelines. Only incident cases of HF were accepted for review. Results: In the first nine months of the service, we accepted 605 referrals, of whom 539 patients (90%) attended the clinic. Following formal assessment by a consultant cardiologist with interest in heart failure, electrocardiography and detailed echocardiography: 183 patients (34%) were found to have HF with left ventricular systolic dysfunction (HF-LVSD), 196 patients (36%) with HF and preserved left ventricular ejection fraction (HFPEF), 44 patients (8%) with HF due to valve disease and/or pulmonary hypertension and there were 116 patients (22%) with no evidence of HF. Therefore, NTproBNP > 400 pg/ml in patients with symptoms and signs of potential HF accurately predicted the diagnosis of HF in 78% of the patients. 90% of the patients referred to the clinic were seen within the time-frame stipulated by NICE guidelines. Assuming that all the patients with new symptoms and signs of potential HF are being referred to the service, this suggests the rate in our city of 564 new incident HF cases per annum (PA), which corresponds to a rate of 103 new cases/100,000 people PA. Conclusions: The service proved the feasibility of implementing HF NICE guidelines in the real world. It gave us a real world insights into the incidence of HF in the community and a realistic picture of the incidence of HFPEF and HF-LVSD.

Evaluation of trypanocidal drugs used for human African trypanosomosis againstTrypanosoma lewisi

Trypanosomes from animals are potential pathogens for humans. Several human cases infected by Trypanosoma lewisi, a parasite of rats, have been reported. The number of these infections is possibly underestimated. Some infections were self-cured, others required treatment with drugs used in human African trypanosomosis. An in vitro evaluation of these drugs and fexinidazole, a new oral drug candidate, has been performed against T. lewisi in comparison with T. brucei gambiense. All have comparable activities against the two parasites. Suramin was not effective. In vivo, drugs were tested in rats immunosuppressed by cyclophosphamide. The best efficacy was obtained for fexinidazole, and pentamidine (15 mg/kg): rats were cured in 7 and 10 days respectively. Rats receiving nifurtimox-eflornithine combination therapy (NECT) or pentamidine (4 mg/kg) were cured after 28 days, while melarsoprol was weakly active. The identification of efficient drugs with reduced toxicity will help in the management of new cases of atypical trypanosomosis.

Clinical outcome of skin yaws lesions after treatment with benzathinebenzylpenicillin in a pygmy population in Lobaye, Central African Republic

BackgroundYaws is a bacterial skin and bone infectious disease caused by Treponema pallidum pertenue. It is endemic, particularly among pygmies in Central African Republic. To assess the clinical cure rate after treatment with benzathinepenicillin in this population, we conducted a cohort survey of 243 patients in the Lobaye region.Findings and conclusionThe rate of healing of lesions after 5 months was 95.9%. This relatively satisfactory level of therapeutic response implies that yaws could be controlled in the Central African Republic. Thus, reinforcement of the management of new cases and of contacts is suggested.

Two 8-month regimens of chemotherapy for treatment of newly diagnosed pulmonary tuberculosis: international multicentre randomised trial

A WHO-recommended 8-month regimen based on ethambutol and isoniazid was evaluated in a randomised clinical trial against a 6-month standard regimen. 1355 patients with newly diagnosed smear-positive pulmonary tuberculosis were randomly assigned one of three regimens: daily ethambutol, isoniazid, rifampicin, and pyrazinamide for 2 months, followed by ethambutol and isoniazid for 6 months (2EHRZ/6HE); the same drugs but given three times weekly in the initial intensive phase (2[EHRZ]3/6HE); or the same initial intensive phase as the first regimen, followed by 4 months of daily rifampicin and isoniazid (2EHRZ/4HR). Follow-up was to 30 months after the start of chemotherapy. Sputum was regularly examined by microscopy and culture. Unfavourable outcome was defined as failure during treatment or relapse afterwards. Analyses were by intention to treat. At 2 months, a significantly higher proportion of patients assigned the daily intensive phase than of those assigned the three-times-weekly regimen were culture negative (700/828 [85%] vs 333/433 [77%], p=0.001). 12 months after the end of chemotherapy, the proportions of unfavourable outcomes were 36 of 346 (10%) with 2EHRZ/6HE, 48 of 351 (14%) with 2(EHRZ)3/6HE, and 17 of 347 (5%) with 2EHRZ/4HR. Both 8-month regimens were significantly inferior to the control 6-month standard regimen (difference between control and 2EHRZ/6HE 5.5% [95% CI 1.6 to 9.4]; between control and 2(EHRZ)3/6HE 8.8% [4.5 to 13.0]). Adverse effects leading to interruption of treatment for 7 days or longer occurred in 28 patients (12 2EHRZ/6HE, five 2[EHRZ]3/6HE, 11 2EHRZ/4HR). The results of this study must be taken into account in recommendations on management of new cases of smear-positive tuberculosis.

Diagnosis and initial management of stroke and transient ischemic attack across UK health regions from 1992 to 1996: experience of a national primary care database.

The aim of this study was to establish the difference in burden of cerebrovascular disease across the different health regions of the United Kingdom and to determine whether the initial management of new cases of stroke and transient ischemic attack (TIA) was uniform across the United Kingdom: The General Practice Research Database (GPRD) is a national database used for epidemiological studies. This was a cohort study identifying incident cases of stroke and TIA over a 5-year study period between 1992 and 1996. The population studied was patients registered with general practitioners contributing to the GPRD across the different health regions of the United Kingdom: Outcome measures were new diagnoses of stroke and TIA, new prescriptions for antiplatelet and anticoagulant agents, and referrals made for specialist opinion. The age-adjusted annual incidence rate across all regions was 151 per 100 000 for stroke and 190 per 100 000 for TIA. There was almost a 2-fold difference in the incidence of cerebrovascular disease between the regions. The management of stroke and TIA in terms of antiplatelet prescription and of referral onward for further opinion to hospital specialists varied significantly between regions. Reported stroke and TIA incidence on the GPRD was comparable to that of other European studies. There were striking regional differences in the incidence of disease. The primary care management, both in prescription and referral rates, varied significantly between the different regions. There was a marked underuse of antiplatelet and anticoagulant agents, and referral rates for specialists' opinions were low.

Near patient tests for Helicobacter pylori in primary care

Objectives: To model cost-effectiveness of near patient tests (NPT) for H. pylori in screening proven cases of peptic ulcer disease (PUD) and in the management of new cases of dyspepsia, in order to establish minimum standards for the performance characteristics of NPTs. NPTs may allow more accurate diagnosis to guide appropriate management options and thus influence the costs of treating both new and existing cases of dyspepsia. However, there are confusing data over whether these tests perform adequately.Methods: Decision analysis using a Markov cost-effectiveness model to determine costs and likely PUD recurrence rates for the competing strategies.Results: For patients with previously proven PUD, giving H. pylori eradication therapy to all patients was more cost-effective than using a NPT. ‘Payback’ time was 14 months, dependent on the cure rate of eradication therapy and the rate of co-existing non-ulcer dyspepsia (NUD). For previously uninvestigated cases of dyspepsia, the use of NPT was more cost-effective than endoscopy in all cases. Payback time varied from 6 years 6 months to 1 year 5 months, depending on the cost of maintenance therapy. The NPT would require a minimum sensitivity of 70% to achieve this result; specificity was not important in this context.Conclusions: Based on reported evaluations, all current NPTs for H. pylori meet the performance standard required for selecting dyspeptic patients for endoscopy. On these data, all patients with proven PUD should receive eradication therapy without prior NPT. Eur J Gen Pract 1998;4:149-54.

Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa

Objective: To conduct an economic evaluation of directly observed treatment (DOT) and conventionally delivered treatment for the management of new cases of tuberculosis in adults.Design: Community based directly observed treatment,...

Invisible schizophrenia: A postal survey of the incidence and management of new cases of schizophrenia in primary care

Most new cases of schizophrenia are referred to hospital by general practitioners. It has been assumed that newly diagnosed schizophrenic patients pass through the filter between primary care and specialist psychiatric services with minimal delay. Little, however, is known of the incidence and initial management of schizophrenia in primary care. In this study questionnaires were sent to 175 general practitioners in Camberwell and Gloucester, enquiring after their experience of managing schizophrenia. Sixty per cent of respondents had seen an undiagnosed schizophrenic patient at some stage of their career. The general practice annual incidence rate of schizophrenia was estimated to be 12/100,000 in Gloucester and 26/100,000 in Camberwell. The large majority of patients were seen by a psychiatrist within a few weeks of general practitioner contact, but a significant minority of general practitioners sought to manage patients without making referral and prescribed psychotropic drugs before receiving an opinion. Eight per cent of patients did not see a psychiatrist.