Management Of Complex Patients Research Articles

Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence.

Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.

A global analysis of nutrition support practices in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy

Perioperative nutritional care has been identified as an important factor in the management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, there is no published consensus on best practice for nutritional management specific to this patient group. The purpose of this study was to identify the current nutrition care practices among international centres performing CRS and HIPEC for patients with peritoneal malignancy. An online survey was developed and sent to experienced CRS and HIPEC centres. The survey questions covered clinician and institution demographics, formal nutrition care pathways, pre-operative nutrition care, post-operative nutrition support and post-discharge nutritional follow-up. Eighty-two centres were contacted, and 42 responses were received. Respondents were from 20 different countries and were mostly dietitians (71%). Nutrition assessments were frequently completed (52% pre-operatively and 86% post-operatively) and most centres used a validated nutrition screening or assessment tool (79%). Perioperative nutrition support with respect to the use of enteral nutrition, parenteral nutrition and enhanced recovery after surgery varied widely between centres. The use of routine parenteral and enteral nutrition was significantly higher in Europe compared with other locations (p=0.028). Nutrition care is pivotal and has been positively integrated into the complex management of patients undergoing CRS and HIPEC globally, however variation in practice is evident. The findings highlight a unique opportunity to collaboratively investigate the role nutrition plays in determining outcomes and to identify the most appropriate nutrition support methods to achieve improved clinical outcomes for these high-risk patients.

Interdisciplinary management of mpox-related local complications: report on a series of cases.

Monkeypox (mpox) is a viral zoonosis, and human-to-human transmission can result from close contact with the respiratory secretions and mucocutaneous lesions of an infected person. The prodromal phase is followed by an eruptive phase, with skin and/or mucosal lesions that progress through several stages at different sites. In this study, we describe the importance of interdisciplinary care management and follow-up of patients with complicated mpox. A cross-sectional study was conducted from May 2022 until August 2022 at a secondary hospital in Madrid (Spain). Out of 100 patients with mpox seen at this institution, we selected and analyzed 11 with local complications. All the patients were male at birth, and the mean age was 32 (30-42) years. The clinical manifestations included skin rash or mucosal lesions, fever, myalgia and lymphadenopathies. The most frequent local complications were pharyngitis associated with dysphagia, penile edema, infection of the mucocutaneous lesions, and ulceration of the genital lesions. A multidisciplinary team was created for the care of patients with complications secondary to mpox. The team comprised dermatologists and specialists in infectious diseases, preventive medicine, and emergency medicine. This approach improved the ability to diagnose and treat early with supportive, topical, and systemic treatment. In our center most of the cases were self-limiting, and none were life-threatening. An interdisciplinary response to a public health alert enhances the management of complex patients and should be implemented in successive outbreaks of mpox.

P280 TEAMWORK IS SUCCESSFUL (1): FAVOUREABLE RE–CHALLENGE OF DOUBLE ANTI–HER2 TREATMENT IN SEVERE MYOCARDIAL DYSFUNCTION IN PATIENT WITH ADVANCED BREAST CANCER AND OCCULT TYPE II DIABETES

Abstract Introduction Cardiovascular diseases (CVD) and Cancer (C), the most important causes of mortality worldwide. share many risk factors and common pathophysiological processes such as chronic inflammation and unfavorable cardio–metabolic profile. Progress in oncological treatments improved the survival of oncological patients (Pt) but have increased the likelihood of short– and long–term CV cardiovascular complications. The multidisciplinary collaboration between cardiologist and onco–hematologists is the task of Cardioncology, an emerging new sub–specialization of clinical cardiology that often make available personalized treatment with a favorable outcome also in clinically complex patients. Here we present a case of severe acute heart failure in a woman with advanced breast C (BC). Clinical Case 2021 April: 55–year–old woman with G3 BC, (ER 0%PgR 0%,Ki6770%HER2+) (T4N3M1), (chest wall and liver) on well tolerated treatment with Docetaxel X 6 and continuous double antiHER2 block (Trastuzumab + Pertuzumab) X 4 and steroids as ancillary therapy. After about 6 months of therapy a lower airways infection occurred and acute congestive heart failure (HF) with severe left ventricular systolic dysfunction (LVEF 25%) ensued requiring hospitalization in the ICU, where newly detected type II diabetes was diagnosed. Appropriate HF therapy with insulin and anticoagulant was established and congestive clinical state resolved. On outpatient basis B–Blocker and anti–RAAS therapy was titrated switching to empagliflozin. About 7 months after discharge, we registered the full recovery up to a normalization of systolic function (LVEF 55%) and the disappearance of the intraventricular thrombus. For progression of C, pt underwent chemotherapy with Capecitabine at metronomic and in October 2022 after cardio–oncological collegial discussion, anti–HER2 therapy resumed. Paz started Trastuzumab–Emtansine, well tolerated with substantial stability of the clinical picture (NYHA I–II) and instrumental and echocardiographic evaluation (LVEF 65%). Conclusions This clinical case reaffirms that close collaboration between cardiologist and oncologist is fundamental for the successful management of complex patients and surveillance must also extend during (and after) treatment. It also demonstrates that an early diagnosis and an "evidence–based" cardiological therapy can allow the recovery of the cardio–toxic effect of anti–HER2 drugs and may allow to resume the therapy successfully.

Modern aspects of managing patients with inflammatory diseases of the external and middle ear

Introduction. The article considers approaches to the management of patients with inflammatory diseases of the middle ear at the outpatient and hospital stages.Aim. To substantiate the guidelines for endaural treatment of inflammatory ear diseases with Anauran® ear drops from the perspective of the best clinical efficiency.Materials and methods. A total of 53 patients (106 ears) were examined, of which 21 patients were diagnosed with otitis externa diffusa (24 ears), 23 patients (25 ears) with acute catarrhal otitis media and 9 patients (9 ears) with epitympanitis in remission, who underwent type 1 tympanoplasty. The efficacy of Anauran® as part of combination treatment was compared in the following age groups: in patients over 18 years old (mean age 39.2 ± 11.1 years) and in children (mean age 9.8 ± 6.5 years).Results and discussion. Absolute scores determined in assessing ear pain in the group of patients with acute otitis externa diffusa ranged from 3 to 9 scores; in the group with acute catarrhal otitis media – from 3 to 8 scores, in patients after tympanoplasty – from 2 to 8 scores. There was some difference in the assessment of the ear pain severity between children and patients over 18 years of age. The most short-term changes in ear pain occurred in children with acute otitis externa diffusa and acute catarrhal otitis media. As a result, the vast majority of patients showed a clinical effect on Day 7, which consisted in the recovery of the otoscopic status, a decrease in complaints by up to 96.3% in adults and up to 96.1% in children. The use of Anauran® ear drops in the complex management of patients with inflammatory diseases of the middle ear reduces the duration of treatment and eliminates problems with secondary bacterial infections in the postoperative period.Conclusions. The findings support the high efficiency of Anauran® in the combination therapeutic treatment of inflammatory processes of the outer and middle ear.

Using graph rewriting to operationalize medical knowledge for the revision of concurrently applied clinical practice guidelines

Clinical practice guidelines (CPGs) are patient management tools that synthesize medical knowledge into an actionable format. CPGs are disease specific with limited applicability to the management of complex patients suffering from multimorbidity. For the management of these patients, CPGs need to be augmented with secondary medical knowledge coming from a variety of knowledge repositories. The operationalization of this knowledge is key to increasing CPGs’ uptake in clinical practice. In this work, we propose an approach to operationalizing secondary medical knowledge inspired by graph rewriting. We assume that the CPGs can be represented as task network models, and provide an approach for representing and applying codified medical knowledge to a specific patient encounter. We formally define revisions that model and mitigate adverse interactions between CPGs and we use a vocabulary of terms to instantiate these revisions. We demonstrate the application of our approach using synthetic and clinical examples. We conclude by identifying areas for future work with the vision of developing a theory of mitigation that will facilitate the development of comprehensive decision support for the management of multimorbid patients.

Conventional versus Reduced-Frequency Follow-Up in Early-Stage Melanoma Survivors: A Systematic Review with Meta-Analysis

To date, there have been multiple studies and clinical guidelines or recommendations for complex management of melanoma patients. The most controversial subjects included the frequency of follow-up. This study provides a coherent and comprehensive comparison of conventional vs. reduced-frequency follow-up strategies for early-stage melanoma patients. The value of our study consists in the precise analysis of a large collection of articles and the selection of the most valuable works in relation to the topic according to rigorous criteria, which allowed for a thorough study of the topic. The search strategy was implemented using multiple databases. The inclusion criteria were randomized clinical trial or cohort studies that compared the outcomes of a conventional follow-up schedule versus a reduced-frequency follow-up schedule for patients diagnosed with melanoma. In this study, authors analyzed recurrence and 3-year survival. Meta-analysis of outcomes presented by Deckers et al. and Moncrieff et. al. did not reveal a significant difference favoring one of the groups (OR 1.14; 95%CI: 0.65-2.00; p = 0.64). The meta-analysis of 3-year overall survival included two studies. The statistical analysis showed no significant difference in favor of the conventional follow-up group. (OR 1.10; 95%CI: 0.57-2.11; p = 0.79). Our meta-analysis shows that there is no advantage in a conventional follow-up regimen over a reduced-frequency regimen in early-stage melanoma patients.

Abstract P5-08-18: A novel free-to-use software for upper limb volume quantification in breast cancer related lymphedema: implementing cutting-edge technology in the individualized therapeutic approaches of breast cancer survivors

Abstract BACKGROUND: Breast cancer related lymphedema (BCRL) is a detrimental condition affecting a growing number of breast cancer (BC) survivors worldwide [1]. Effective screening programs and early diagnosis are mandatory in the clinical management of this disabling condition and limb volume assessment plays a crucial role [1]. However, a reproducible volumetric assessment is still challenging in clinical practice. In this scenario, augmented reality tools have been recently proposed for volumetric quantification of BCRL [2]. Despite the advantages in safety and time effectiveness, the integration of these devices in clinical practice is affected by several barriers, and free-to-use software for volume quantification are still lacking [3]. Therefore, the aim of this study was to develop and validate a free-to-use software for volume quantification of BCRL in order to overcome barriers to technology implementation in the complex management of BC patients. METHODS: A cohort of mixed-gender young adults was assessed by tridimensional laser scanning, centimetric method, and water displacement method. The upper limb volume measures were saved and processed using a software package composed of three programs (Edit 3D, Slice 3D, Cut 3D). The novel software package was specifically developed and freely released on the online site https://mn-visions.gitbook.455io/software-kit-for-3dls-limb-volume-quantification/. In addition, hand volume has been assessed two groups (experimental group and optimization group). Digital volume quantification algorithms have been specifically designed using the gift wrapping (GW) or cubic tessellation (TE) method. The novel software package was subsequently used to assess a small pilot sample of BCRL patients. The upper limb volumes were analyzed to assess linear regression and correlation, level of agreement, and consistency between the different methods. RESULTS: Fourty upper limb volumes of 20 participants were assessed in the present study. The linear regression analysis showed a statistically significant correlation between laser scanning method and centimetric method (R2= 0.99, p&amp;lt; 0.0001). A high level of agreement was reported (R2 interval from 0.93 to 0.97, r ranged from 0.965 to 0.984) between the centimetric method and the novel software package. Hand volume has been assessed in 5 subjects (experimental group). The optimization group (n: 4) demonstrated that the hand volumes calculated from digital method (tessellation method) show a high correlation with the values obtained with water displacement (ρ = 0.83; p &amp;lt; 0.05). Preliminary data from BCRL women were recently assessed (n:3) and suggested a high correlation between LS3D and centimetric method (R2= 0.96). CONCLUSION: Our data underlined promising results for the implementation in clinical setting of the three programs Edit 3D, Slice 3D, Cut 3D for the upper limb volume quantification. In addition, significant correlations between water displacement method (gold standard) and hand digital volume method were highlighted, suggesting intriguing implications in a precise quantification of hand volume in clinical setting. These findings might provide advantages in reproducibility between different operators enhancing data sharing between different centers. Future data on BCRL patients are needed to confirm the role of this novel free-to-use software in the rehabilitation management of breast cancer survivors. REFERENCES: 1. Heller DR et al. Prevention Is Key: Importance of Early Recognition and Referral in Combating Breast Cancer–Related Lymphedema. Journal of Oncology Practice 2019;15:263–4. 2. Invernizzi M et al. Integrating Augmented Reality Tools in Breast Cancer Related Lymphedema Prognostication and Diagnosis. J Vis Exp. 2020 6;(156). 3. Kassamani YW et al. Diagnostic Criteria for Breast Cancer-Related Lymphedema of the Upper Extremity: The Need for Universal Agreement. Ann Surg Oncol. 2022;29(2):989-1002 Citation Format: Lorenzo Lippi, Mauro Nascimben, Alessandro de Sire, Arianna Folli, Nicola Fusco, Lia Rimondini, Marco Invernizzi. A novel free-to-use software for upper limb volume quantification in breast cancer related lymphedema: implementing cutting-edge technology in the individualized therapeutic approaches of breast cancer survivors [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-18.

NCCN Guidelines® Insights: Central Nervous System Cancers, Version 2.2022

The NCCN Guidelines for Central Nervous System (CNS) Cancers focus on management of the following adult CNS cancers: glioma (WHO grade 1, WHO grade 2-3 oligodendroglioma [1p19q codeleted, IDH-mutant], WHO grade 2-4 IDH-mutant astrocytoma, WHO grade 4 glioblastoma), intracranial and spinal ependymomas, medulloblastoma, limited and extensive brain metastases, leptomeningeal metastases, non-AIDS-related primary CNS lymphomas, metastatic spine tumors, meningiomas, and primary spinal cord tumors. The information contained in the algorithms and principles of management sections in the NCCN Guidelines for CNS Cancers are designed to help clinicians navigate through the complex management of patients with CNS tumors. Several important principles guide surgical management and treatment with radiotherapy and systemic therapy for adults with brain tumors. The NCCN CNS Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's most recent recommendations regarding molecular profiling of gliomas.

Effectiveness of Differentiated Hepatotrophic Therapy in Complex Management of Patients with Comorbidity of Chronic Pancreatitis and Chronic Viral Hepatitis С

An important problem of the combined course of chronic pancreatitis (CP) and chronic hepatitis C virus (HCV) is the study of the effects of chronic HCV, even after the treatment, in particular for the condition of the pancreas and liver in patients with CP. Often hepatotrophic therapy is used for this purpose, which should be differentiated depending on the needs of patients with comorbidity of CP and chronic HCV. The objective: to analyze the functional and structural condition of the pancreas and liver in patients with CP after the chronic HCV treatment by the proposed complex treatment with additional inclusion of hepatotrophic drugs. Materials and methods. 80 patients with a combined course of CP and chronic HCV were examined. According to the methods of treatment the patients were divided into three groups. The 1st group included 20 patients with CP and chronic HCV, who received a common complex for treatment (CCT) by protocol for 3 months. In the 2d group 25 patients with CP and chronic HCV received CCT with additional inclusion of hepatotrophic agent for 3 months. The 3d group included 35 patients with CP and chronic HCV with CAGE≥2.0, who took CTC with additional inclusion of hepatotrophic agent for 3 months and metadoxine for 3 months. Results. The more significant level of efficiency of therapeutic complex with the additional inclusion of hepatotrophic agent was determined when metadoxine was prescribed. It was found that the content of fecal α-elastase increased by 19.6 %, 37.5 % and 66.9 %, glucose level decreased by 13.4 %, 11.0 % and 28.4 %, glyconized hemoglobin – by 12.3 %, 22.1 % and 25.8 %, HOMA index – by 16.3 %, 21.9 % and 56.0 %, coprogram score – by 12.8 %, 18.3 % and 88.7 %, the total index of the pancreas structure – by 7.2 %, 15.1 % and 85.7 %, and the total indicator of liver structure – by 11.7 %, 17.5 % and 44.7 %, respectively in groups (p&lt;0.05). It was established that the inclusion of the hepatotrophic medicine in the standard therapy of CP with chronic HCV improved the results of treatment for the restoration of the functional and structural condition of the pancreas. Conclusions. The additional prescription of the hepatotrophic agents combination significantly increased the effectiveness of treatment according to the dynamics of the functional capacity of pancreas and restoration of its structure (p&lt;0.05). It was confirmed that a complex medical program with additional use of polysubstrate hepatoprotector exceeded the efficiency of the protocol treatment for the structural condition of the liver by 36.0 %, and with a combination of hepatotrophic agents – by 51.9 %; regarding the pancreas condition – by 22.3 % and 38.3 %, respectively (p&lt;0.05). The combined use of hepatotrophic agents was also more effective than monotherapy with one drug.

Pediatric Central Nervous System Cancers, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology.

Central nervous system (CNS) cancers account for approximately one quarter of all pediatric tumors and are the leading cause of cancer-related death in children. More than 4,000 brain and CNS tumors are diagnosed each year in children and teens, and the incidence rate has remained stagnant in recent years. The most common malignant pediatric CNS tumors are gliomas, embryonal tumors consisting of predominately medulloblastomas, and germ cell tumors. The inaugural version of the NCCN Guidelines for Pediatric Central Nervous System Cancers focuses on the diagnosis and management of patients with pediatric diffuse high-grade gliomas. The information contained in the NCCN Guidelines is designed to help clinicians navigate the complex management of pediatric patients with diffuse high-grade gliomas. The prognosis for these highly aggressive tumors is generally poor, with 5-year survival rates of <20% despite the use of combined modality therapies of surgery, radiation therapy and systemic therapy. Recent advances in molecular profiling has expanded the use of targeted therapies in patients whose tumors harbor certain alterations. However, enrollment in a clinical trial is the preferred treatment for eligible patients.

SUPeRO: A Multidimensional Approach to Prevent and Manage Oncological Frailty in a Radiation Oncology Unit.

Currently, the management of older cancer patients is directed by a personalized approach and, where possible, a tailor-made treatment. Based on our previous experiences and considering the opportunity of combining a geriatric department and a radiation-oncology department, we have developed a path that follows the patient from the beginning of the treatment, taking into account the complications/late toxicities and the survivors. This study aimed to evaluate the impact of remodeling and restructuring some oncology, radiotherapy, and geriatrics services based on the primary evidence for managing older cancer patients. In 2020, Gemelli ART underwent 60,319 radiation-oncology treatments, admitted 943 patients in the radiation-oncology and supportive care ward, and treated and followed 15,268 patients in clinics. The average length of stay of the admitted patients was reduced from 20.6 days to 13.2 days. In 2021, 1196 patients were assessed for frailty, 847 were admitted for toxicity, and 349 patients were evaluated within the geriatric oncology and supportive care outpatient clinic, and it was found that 59.2% were fit, 31.6% were vulnerable, and 9.2% were frail. This experience has shown a reduction in hospitalizations and the average hospital stay of patients in the case of side effects, a high toxicity to treatments, and the possibility of treating patients with a high level of complexity. This approach should represent the future target of geriatric oncology with the global management of older or complex patients with cancer.

Photodynamic therapy in the palliative treatment of a stage IV Klatskin tumor

Klatskin tumor is a perihilar cholangiocarcinoma of the lobar and common hepatic ducts (liver port cancer) which is localized proximally to the confluence of common hepatic and cystic ducts (before segmental hepatic ducts of the second order). Currently, photodynamic therapy (PDT) is recommended for the complex management of patients with inoperable extrahepatic cholangiocarcinoma because the discussed PDT technique significantly increases the life expectancy in comparison to the isolated palliative therapy. A clinical case presented in the article demonstrates the effectiveness of PDT technique in case of cholangiocarcinoma of bifurcation of the common hepatic duct T4N1M1, Bismuth-IV in combination with external drainage of bile ducts in order to resolve the mechanical jaundice. Conclusion . A significant effect of PDT application in a patient with inoperable Klatskin tumor is demonstrated. PDT included into the treatment of such patients increases their life expectancy versus the average survival rate in those having palliative therapy.

Immunosenescence is a therapeutic target for frailty in older adults: a narrative review.

Aging refers to a progressive decrease in functional performance, leading to increased mortality risk. At present, life expectancy is increasing worldwide and is expected to exceed 80 years by 2040. However, this increase in life expectancy also indicates a rise in the incidence and prevalence of diseases, such as cardiovascular, neurological, musculoskeletal, and oncological diseases, which are associated with aging. The exact underlying mechanisms of aging remain unknown, and whether it is a programmed process or the consequence of an accumulation of stress events remains unclear. Thus, more scientific research is needed to improve the management of complex and frail patients. Several databases were searched with the following key words: immunosenescence, inflamm-aging, frailty, sarcopenia and skeletal muscle, etc. Skeletal muscle is the core phenotype of frailty and sarcopenia. Immune aging and skeletal muscle decline interplay with each other and form a vicious circle. Maintaining muscle health is beneficial for immune function and delays the onset of frailty. Particularly, in the context of the ongoing corona virus disease (COVID)-19 pandemic, studies have shown that the elderly are more prone to the consequences of the SARS-CoV-2 virus. It has been reported that the rates of hospitalization in the 65-74, 75-84, and ≥85 years old group were 5×, 8×, and 10× greater than the 18-29 years old group, with corresponding COVID-19-related deaths being 60×, 140×, and 330× that of the younger reference group, respectively. Considering the above, this review aims to discuss the relationship between immunosenescence, skeletal muscle, and frailty, and to explore immunosenescence as a potential therapeutic target to prevent frailty and extend healthspan, with some emphasis on the effects of the COVID-19 pandemic on the elderly. Immunosenescence is a promising potential therapeutic target for frailty and is worthy of further investigation.

Effectiveness of Project ECHO Programs in Improving Clinician Knowledge and Confidence in Managing Complex Psychiatric Patients: a Waitlist-Controlled Study

ObjectiveThe authors aimed to determine if Project Extension for Community Healthcare Outcomes (ECHO), a health-education model utilising teleconferencing technology, improves the capacity of clinicians in assessing and managing complex psychiatric patients.MethodsThree pilot Project ECHO programs were evaluated as a prospective waitlist-controlled trial, focusing on Adult Eating Disorders, Adult Intellectual Disability Mental Health, and General Mental Health. Each program comprised 9–10 weekly teleconferencing group sessions. Participants and waitlist-controls completed pre- and post-program surveys. The primary outcomes were self-reported knowledge and confidence in assessing and managing complex patients relevant to each group. Linear mixed models were used to assess the group-by-time interaction, or change over time, as appropriate.ResultsBetween July 2020 and June 2021, three series of the Adult Intellectual Disability Mental Health program, two series of the Adult Eating Disorders program, and two series of the General Mental Health program were delivered. Compared to waitlist-controls (n = 21), there were statistically significant improvements in self-reported knowledge and confidence for all topics amongst participants of the Adult Eating Disorders program (n = 44). In the Adult Intellectual Disability Mental Health program, there were significant improvements in self-reported knowledge and confidence amongst participants (n = 67) for most topics compared to controls (n = 21). There were no waitlist-controls for the General Mental Health program, but within-group analysis (n = 28) showed significant improvements in participants’ knowledge and confidence following program completion, compared to baseline.ConclusionProject ECHO is a feasible and effective model to develop workforce capacity in managing complex psychiatric conditions.

Respiratory Intensive Care Unit management and efficacy during the COVID-19 outbreak in Naples, Italy.

The World Health Organization declared the Coronavirus Diseases 2019 (COVID-19) outbreak a global pandemic on March 11, 2020. COVID-19 had an impact on over 500 million people worldwide. According to the American Thoracic Society criteria, the respiratory spectrum of this disease ranges from mild illness to severe pneumonia, with the latter occurring in a not insignificant 15% of patients. A rapid increase in the incidence of COVID-19 pneumonia cases has been observed all over the world, resulting in a saturation of the Intensive Care Unit's capacity (ICUs). Because of this impressive outbreak, the ICU beds and invasive mechanical ventilators reached their capacity. Non-invasive supportive care has become an important option for keeping respiratory conditions under control. As a result, proper healthcare resource management was required to ensure adequate patient care. Respiratory Intensive Care Units (RICUs) have become a useful resource for managing complex patients due to a shortage of ICU capacity. This highlighted the importance of RICUs, where patients with moderate to severe respiratory failure can be treated with non-invasive respiratory support rather than being admitted to the ICU. The clinical outcomes and baseline characteristics of patients admitted to the RICU of Cotugno Hospital, a tertiary referral center in Naples (Italy), from January 2021 to October 2021 are described in this report.

Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis.

Hemiplegic shoulder pain (HSP) is a disabling complication affecting stroke survivors. In this context, rehabilitation might play a key role in its clinical management. Recent systematic reviews of the impact of rehabilitative approaches on pain reduction in patients with HSP are lacking. This systematic review of randomized controlled trials (RCTs) with meta-analysis aimed to investigate the efficacy of rehabilitative techniques in reducing HSP in stroke survivors. PubMed, Scopus, and Web of Science were searched from inception to March 8, 2021 to identify RCTs of stroke survivors with HSP undergoing specific rehabilitative techniques combined with conventional therapy to reduce pain intensity. A network meta-analysis and meta-analysis of the Bayesian network of random effects were performed. The risk of bias of studies was assessed with Version 2 of the Cochrane Risk of Bias tool for randomized trials. Of 1139 articles identified, 12 were included in the final synthesis. We analyzed data for 723 stroke survivors, reporting a significant overall decrease in pain intensity after a rehabilitative approach by the Bayesian meta-analysis (standardized mean difference 2.78, 95% confidence interval 0.89;-4.59; p=0.003). We report a significant reduction in HSP with botulinum toxin type A injection (p=0.001), suprascapular nerve pulsed radiofrequency (p=0.030), suprascapular nerve block (p=0.020), and trigger-point dry needling (p=0.005) as compared with conventional rehabilitation. Concerning the effect size, we identified a Bayesian factor10 of 97.2, with very strong evidence of superiority of rehabilitative techniques. The present systematic review and meta-analysis showed that adding other rehabilitative techniques to conventional rehabilitation was significantly more effective than conventional rehabilitation alone in the complex management of patients affected by HSP.

Можливості впливу засобів фізичної терапії на перебіг цукрового діабету та розвиток діабетичних ускладнень

According to the latest data from the World Health Organization experts, the incidence of diabetes mellitus in economically developed countries of the world is up to 6% of the population. Throughout the world and in Ukraine in particular, diabetes mellitus is one of the most common chronic non-infectious diseases. Complications of diabetes mellitus occupy the third place among various causes of death. The use of modern pharmacological agents in the treatment of diabetes mellitus does not solve all the problems of this difficult and multifaceted pathology, therefore the search for non-pharmacological methods of physical therapy and rehabilitation of such patients remains relevant and has been studied insufficiently. In addition, an effective combination of drug and physical treatment methods can accelerate the achievement of diabetes compensation, prevent or cause regression of the development of neurovascular complications. The purpose of the study was to discuss the possibilities of the influence of physical therapy on the course of diabetes mellitus and the development of diabetic complications at the current stage. Results. In accordance with modern requirements, rehabilitation of patients with diabetes mellitus and diabetic complications is carried out in acute, subacute and long-term rehabilitation periods at the inpatient and outpatient stages of treatment. Properly dosed physical activity has a positive effect on all types of metabolism; this may allow to reduce the level of glycemia, increase the number of insulin receptors and their sensitivity, as well as reduce the doses of hypoglycemic drugs. Physical therapy has a positive effect on the condition of the central and peripheral nervous system, the disorders of which are important in the development of diabetic complications. The level of physical exertions should correspond to the patient's state of health, his/her physical capabilities, taking into account the stage and state of compensation of the disease, the presence of diabetic complications. The probability of success in physical therapy for such patients depends on the complex of physical therapy tools in combination with physiotherapeutic methods and massage. The effectiveness and safety of the physical therapy should be monitored by the dynamics of glycemia, glycosuria, and body weight. Conclusion. Therefore, the modern strategy of complex management of diabetic patients from the standpoint of physical and rehabilitation medicine involves a multidisciplinary approach with the inclusion of effective means of physical therapy, rehabilitation technologies, physiotherapeutic methods, as well as ergotherapeutic measures aimed at increasing functional reserves, compensation of impaired vascular and innervation mechanisms, regeneration capabilities, secondary prevention of diabetic complications, social adaptation and restoration of working capacity of patients

746 A Novel Method of Remotely Managing Complex HHT Patients via Telephone Clinic to Reduce Severity and Frequency of Nosebleeds

Abstract Introduction Hereditary haemorrhagic telangiectasia (HHT) is a complex, multisystemic vascular dysplasia affecting approximately 85,000 European Citizens. Patients who have hereditary haemorrhagic telangiectasia can have severe debilitating manifestation of symptoms which can severely affect their quality of life. One of the severe manifestations is epistaxis, this can often lead to being anaemic, needing blood transfusion and hospital admission. Method Patient data was analysed to record number of hospital visits, A&amp;E attendances, and hospital admissions. Multidisciplinary approach to involve various teams including but not limited to specialist nurses and clinicians. Results Virtual clinics facilitate management of HHT patients with complex needs. Provision of (nurse led) specialist virtual clinic in the form of telephone consults giving advice regarding maintenance and emergency care in case of a nosebleeds. This facilitates safe pathway for emergent care and avoids hospital visit with every episode. The patients are provided with an emergency pack and a prevention pack. The emergency pack contains nasal packs, tranexamic acid mouthwash 5%, nasopore, kaltostat whereas the prevention pack contains triple therapy. Analysis of patient data suggests reduced number of hospital visits, A&amp;E attendances, and hospital admissions to seek specialist treatment. Conclusions Virtual clinics are an upcoming novel method of managing complex patients. They are beneficial for patients allowing them specialist access to medical advice to manage their symptoms at home. Improved patient care pathway allowing easy access of specialist medical advice. Safer management of complex HHT patients reducing frequent hospital visits for reasons like consultations, blood tests, admissions, and blood transfusion.