National Treatment Research Articles

MP19-04 NATIONAL TREATMENT UTILIZATION PATTERNS FOR PATIENTS WITH METASTATIC CASTRATE SENSITIVE PROSTATE CANCER

You have accessJournal of UrologyCME1 Apr 2023MP19-04 NATIONAL TREATMENT UTILIZATION PATTERNS FOR PATIENTS WITH METASTATIC CASTRATE SENSITIVE PROSTATE CANCER Fahad Sheckley, Jennifer Nguyen, Teona Iarajuli, Michael Stifelman, and Nitin Yerram Fahad SheckleyFahad Sheckley More articles by this author , Jennifer NguyenJennifer Nguyen More articles by this author , Teona IarajuliTeona Iarajuli More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , and Nitin YerramNitin Yerram More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003244.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The rapid evolution of treatments for metastatic castrate-sensitive prostate cancer (mCSPC) creates a challenge for providers to choose the best therapeutic strategy. Thus, most tend to rely on local practice patterns for guidance. We aim to report, by American Urological Association (AUA) sections, a retrospective analysis of treatment patterns and utilization in patients starting new therapy for mCSPC. METHODS: We conducted a retrospective analysis of fully adjudicated pharmacy and medical claims data from February 2015-2022, which included HIPAA-compliant information on diagnostic codes, tests, treatments, and procedures covering about 18 million U.S. cancer patients. Inclusion criteria for our study were males ≥18 years of age with at least one ICD 9/10 for prostate cancer and claim for treatment. Finally, a cohort identification process was performed to select for patients newly diagnosed with mCSPC. RESULTS: In total, 113,127 patients met our inclusion criteria and were analyzed. Results, summarized in Figure 1 (A&B), demonstrate trends in treatment for mCSPC for three select years. In 2015, LHRH-monotherapy was the most used treatment nationally at 56%, followed by first-generation anti-androgen (1st Gen AA; bicalutamide, etc) therapy at 33%. A reduction in usage of 1st Gen AA was noted (33% in 2015, 19% in 2018, 12% in 2021) with the introduction of novel hormone therapy (NHT; i.e. abiraterone, apalutamide, etc) in 2018. NHT usage rose from 27% in 2018 to 38% in 2021, with a concurrent drop in chemotherapy administration (12% in 2018, 9% in 2021). The AUA New England section reported the highest use of NHT in 2021 with 46%, while the North Central section reported the lowest at 36%. Urologists prescribed NHT to 9% of their patients with mCSPC in 2018 and 21% in 2021. CONCLUSIONS: As LHRH-monotherapy, first-generation anti-androgen and chemotherapy usage decline, NHT utilization has been rising, with more urologists prescribing novel treatments for mCSPC. As the trend continues, urologists may benefit from developing an internal workflow to prescribe NHT and monitor patients with mCSPC. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e265 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Fahad Sheckley More articles by this author Jennifer Nguyen More articles by this author Teona Iarajuli More articles by this author Michael Stifelman More articles by this author Nitin Yerram More articles by this author Expand All Advertisement PDF downloadLoading ...

자유무역협정상 물품무역의 수입국 조치와 관련된 투자협정중재에 관한 고찰

Purpose: This study analyzes issues over the national treatment clause, the most favored nation clause, and jurisdiction in international commercial arbitration under free trade agreements. Based on these clauses, implications after analyzing Vento v. Mexico are presented.
 Research design, data, and methodology: Adopting the literature research method, this study utilizes major related papers and Internet data.
 Results: For discriminatory application of an import restriction, an investor would need to identify other investors using the same trade agreement on which it is based, and must demonstrate that the import restriction does not likewise apply to these other investors. However, in this case, there is also a limitation in that it is more difficult for an investor who uses a unique business model that other investors do not use, to make a claim based on discriminatory treatment.
 Conclusions: The claimant in this case filed for ① discriminatory treatment by the Mexican government (breach of NT/MFN) and ② MST breach (lack of due process, etc.) by the Mexican government, but all of them were rejected.

Moving orthopaedic procedures out of the operating theatre:Outpatient needle arthroscopy can reduce cost & waste, and increase inpatient capacity compared to conventional knee arthroscopy

BackgroundNeedle arthroscopy (NA) is an emerging technique that could streamline pathways, facilitate timely care, and reduce service burden. The primary aim was to assess the practical and economic viability of an outpatient NA service. Secondary aims were to assess the relative costs and benefits compared to a conventional arthroscopy (CA) service. MethodsThis service feasibility study was conducted between 2021–2022 in a high-volume national treatment centre. A NA pathway was established for patients with chronic soft tissue pathology or early degenerative knee disease. The pathway was evaluated in terms of: i) cost; ii) efficiency, and iii) waste production, and an assessment was conducted of the patient-related and service-related effects. ResultsThe cost of the NA pathway was £1555.20 per patient, compared to £2,351.53 for CA. Time to management was 45 days for NA versus 180 days for CA. The NA pathway involved two hospital attendances, whereas CA required a minimum of three. NA cases produced 1.4 kg of non-recyclable waste compared to 5.0 kg produced by CA. For every two cases managed by NA instead of CA, capacity for one additional obligate-inpatient procedure was created. ConclusionsThe NA pathway offers a technically and economically viable approach for the management of refractory knee symptoms in the context of chronic soft tissue or early degenerative disease. NA placed less demand on hospital resources, produced two-thirds less non-recyclable waste, and is amenable to a one-stop clinic approach. Clinical studies focused on objective and patient-reported outcome measures are required to assess clinical efficacy.

Economic, social, and clinic influences on opioid treatment program retention in Dar es Salaam, Tanzania: a qualitative study

BackgroundMedications for opioid use disorder (MOUD) are associated with positive health outcomes. People remaining on MOUD have a reduced likelihood of drug overdose and mortality. Tanzania supports a national opioid treatment program (OTP) offering MOUD, but retention is a continual challenge. To date, most research on MOUD retention in Tanzania and other Sub-Saharan Africa settings has been focused on the individual-level, with little attention to economic, social, and clinic-level factors.MethodsWe qualitatively examined economic, social, and clinic factors that affect retention on MOUD, specifically methadone maintenance therapy, among former and current clients attending an OTP clinic Dar es Salaam, Tanzania. We conducted in-depth interviews with a total of 40 current and former clients receiving MOUD and four focus groups with an additional 35 current clients on MOUD between January and April 2020. We utilized a thematic analysis approach.ResultsDaily OTP clinic attendance posed a financial burden to current and former clients and was a barrier to remaining on MOUD. Though treatment is free, clients described struggles to attend clinic, including being able to afford transportation. Female clients were differentially impacted, as sex work was the most common income-generating activity that they participated in, which presented its own set of unique challenges, including barriers to attending during set clinic hours. Drug use stigma acted as a barrier to MOUD and prevented clients from securing a job, rebuilding trust within the community, and accessing transportation to attend the clinic. Being able to rebuild trust with family facilitated remaining on MOUD, as family provided social and financial support. Caretaking responsibilities and familial expectations among female clients conflicted with MOUD adherence. Finally, clinic level factors, such as clinic dispensing hours and punitive consequences for breaking rules, posed barriers to clients on MOUD.ConclusionSocial and structural factors, both within (e.g., clinic policies) and outside of (e.g., transportation) the clinic impact MOUD retention. Our findings can inform interventions and policies to address economic and social barriers to MOUD, that can contribute to sustained recovery.

Burden of Mycobacterium tuberculosis and Associated Factors among Presumptive Extra pulmonary Tuberculosis Patients from Selected Health Facilities, Addis Ababa, Ethiopia

BackgroundExtra pulmonary tuberculosis (EPTB) accounts for a significant proportion of tuberculosis (TB), a devastating disease of public health concern. The complexity of the cases, the involvement of many organs, resource constraints, and concerns regarding drug resistance make disease diagnosis and treatment difficult. This study aimed to determine the burden of tuberculosis and associated factors among presumptive EPTB patients in selected hospitals in Addis Ababa. Material and methodsA cross-sectional study was conducted from February to August 2022 in selected public hospitals in Addis Ababa. Those who attended the hospitals and were presumptively diagnosed as EPTB patient were included in the study. Sociodemographic and clinical data were collected using a semistructured questionnaire. The GeneXpert MTB/RIF assay, Mycobacterium Growth Indicator Tube (MGIT) culture, and solid culture using Löwenstein–Jensen (LJ) medium were used. The data were entered and analyzed using SPSS version 23, and a p-value ≤ 0.05 was considered as statistically significant. ResultsFrom a total of 308 participants enrolled in this study, the measured burdens of extrapulmonary tuberculosis using the Xpert MTB/RIF assay, liquid culture, and solid culture were 54 (17.5%), 45 (14.6%), and 39 (12.7%), respectively. In this study, sex, contact history with known TB cases, having a purulent type of aspirate, and being HIV positive had statistically significant associations with EPTB. ConclusionsThe burden of extrapulmonary tuberculosis among presumptive extrapulmonary tuberculosis cases was found to be significant. Sex, contact history with a known TB case, having apurulent type of aspirate, and being HIV positive were found to be associated with extrapulmonary tuberculosis infection. Strict adherence to the national tuberculosis diagnosis and treatment guidelines is important, while the true burden of the disease should be ascertained using standard diagnostic tests for better prevention and control interventions.

Anti-malarial drug use, appropriateness and associated factors among children under-five with febrile illnesses presenting to a tertiary health facility: a cross sectional study

BackgroundMalaria is endemic in 95% of Uganda and constitutes the country’s most significant public health problem—being the leading cause of morbidity and mortality, especially among children under five years of age. The current national malaria treatment policy is to use artemisinin-based combination therapy (ACT) as first-line treatment, and recommends parasitological confirmation of malaria before therapy. Adherence to this policy, however, remains suboptimal, with the self-initiated home-based therapy being common—posing undue exposures to, and pressure on the current artemisinin-based combinations, with the danger of emergence of drug resistance. The study evaluated the anti-malarial use and its appropriateness among febrile children under five presenting to a tertiary health facility in northern Uganda in light of the current malaria treatment policy.MethodsThis was a cross-sectional study in a tertiary health facility in northern Uganda between March and September 2021. Children aged 6–59 months with fever were selected using systematic random sampling. A pretested interviewer-administered questionnaire was used to collect clinical data from the caregivers. Data were analysed using SPSS version 23. Descriptive statistics and multiple logistic regression models were applied. P-value < 0.05 was considered for statistical significance.ResultsSeventy-two (34.3%) of the 210 children with fever in this study used anti-malarials prior to the hospital visit, 29.2% (21/72) of which were on a self-medication basis, 22.2% (16/72) were empiric prescriptions—all of which inappropriate, and only 48.6% (35/72) were prescribed based on a parasitological diagnosis of malaria. The most commonly used anti-malarials were artemether-lumefantrine 60/72 (88.3%), while a lesser proportion of quinine 7/72 (9.7%), artesunate 3/72 (4.2%) and dihydroartemisinin-piperaquine 2/72 (2.8%) were used. The factors independently associated with anti-malarial use among the children with febrile illnesses were duration of fever (p = 0.001); level of the nearest facility (p = 0.027), distance from the nearest health facility (p = 0.025), and caregivers’ age (p = 0.038).ConclusionsInappropriate use of anti-malarials for childhood febrile illnesses is prevalent in the study setting, facilitated by the ease of over-the-counter access, empiric prescription and use of leftover anti-malarials. This calls for a need to address communities’ health-seeking behaviour and the health providers’ practice alike.

When Major Depression Goes Untreated: National Treatment Guidelines Provide no Guidance when Patients Refuse Treatment.

When Major Depression Goes Untreated: National Treatment Guidelines Provide no Guidance when Patients Refuse Treatment.

Psychiatric Morbidity, Utilization and Quality of Mental Health Care in Long-Term Unemployed People.

Research has shown complex interactions between unemployment and mental health. However, the prevalence of specific mental disorders, utilization of mental health care services and influences on help-seeking behavior have been investigated surprisingly little in the past. In this study, we investigated a sample of long-term unemployed people in a cooperation program of the local unemployment agency and a psychiatric university hospital in a larger city in Germany. Mental disorders, treatment history, accordance of treatment to national treatment guidelines and factors influencing previous treatment were assessed. Participants (n = 879; male 56%, female 44%, mean age 43.9 years) showed a high psychiatric morbidity, mostly with diagnoses from the ICD-10 categories F1 (22%), F3 (61%) and F4 (68%). Currently, 18% were in psychiatric treatment, 6% were in psychotherapeutic treatment, and 28% received psychopharmacological treatment. Mostly young men underutilized the psychiatric-psychotherapeutic system, with middle-aged men and women being most frequently in psychopharmacological treatment. Of those treated, only about 10% of the subjects currently received a treatment according to national guidelines. The utilization of psychotherapeutic treatment was strikingly poor. This study identified high psychiatric morbidity and severe treatment gaps in unemployed people. These results can help to target subjects with specific needs for interventions and to modify counseling programs.

The impact of heterotopic ossification prophylaxis after surgical fixation of acetabular fractures: national treatment patterns and related outcomes

BackgroundHeterotopic ossification (HO) is a common complication after surgical fixation of acetabular fractures. Numerous strategies have been employed to prevent HO formation, but results are mixed and optimal treatment strategy remains controversial. The purpose of the study was to describe current national heterotopic ossification (HO) prophylaxis patterns among academic trauma centers, determine the association between prophylaxis type and radiographic HO, and identify if heterogeneity in treatment effects exist based on outcome risk strata. MethodsWe used data from a subset of participants enrolled in the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. We included only patients with closed AO-type 62 acetabular fractures that were surgically treated via a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. PREPARE Clinical Trial Registration Number: NCT03523962 Patient population This cohort study was nested within the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. The PREPARE trial is a multicenter cluster-randomized crossover trial evaluating the effectiveness of two alcohol-based pre-operative antiseptic skin solutions. All PREPARE trial clinical centers that enrolled at least one patient with a closed AO-type 62 acetabular fracture were invited to participate in the nested study. Results277 patients from 20 level 1 and level 2 trauma centers in the U.S. and Canada were included in this study. 32 patients (12%) received indomethacin prophylaxis, 100 patients (36%) received XRT prophylaxis, and 145 patients (52%) received no prophylaxis. Administration of XRT was associated with a 68% reduction in the adjusted odds of overall HO (OR 0.32, 95% CI, 0.14 – 0.69, p = 0.005). The overall severe HO (Brooker classes III or IV) rate was 8% for the entire cohort; XRT reduced the rate of severe HO in high-risk patients only (p=0.03). ConclusionHO prophylaxis patterns after surgical fixation of acetabular fractures have changed dramatically over the last two decades. Most centers included in this study did not administer HO prophylaxis. XRT was associated with a marked reduction in the rate of overall HO and the rate of severe HO in high-risk patients. Randomized trials are needed to fully elucidate the potential benefit of XRT. PREPARE Clinical Trial Registration Number: NCT03523962.

Medulloblastoma in adults: evaluation of the Dutch society for neuro-oncology treatment protocol

PurposeMedulloblastoma is a rare tumor in adults. The objective of this nationwide, multicenter study was to evaluate the toxicity and efficacy of the Dutch treatment protocol for adult medulloblastoma patients.MethodsAdult medulloblastoma patients diagnosed between 2010 and 2018 were identified in the Dutch rare tumors registry or nationwide pathology database. Patients with intention to treat according to the national treatment protocol were included. Risk stratification was performed based on residual disease, histological subtype and extent of disease. All patients received postoperative radiotherapy [craniospinal axis 36 Gy/fossa posterior boost 19.8 Gy (14.4 Gy in case of metastases)]. High-risk patients received additional neoadjuvant (carboplatin-etoposide), concomitant (vincristine) and adjuvant chemotherapy (carboplatin-vincristine-cyclophosphamide) as far as feasible by toxicity. Methylation profiling, and additional next-generation sequencing in case of SHH-activated medulloblastomas, were performed.ResultsForty-seven medulloblastoma patients were identified, of whom 32 were treated according to the protocol. Clinical information and tumor material was available for 28 and 20 patients, respectively. The histological variants were mainly classic (43%) and desmoplastic medulloblastoma (36%). Sixteen patients (57%) were considered standard-risk and 60% were SHH-activated medulloblastomas. Considerable treatment reductions and delays in treatment occurred due to especially hematological and neurotoxicity. Only one high-risk patient could complete all chemotherapy courses. 5-years progression-free survival (PFS) and overall survival (OS) for standard-risk patients appeared worse than for high-risk patients (PFS 69% vs. 90%, OS 81% vs. 90% respectively), although this wasn’t statistically significant.ConclusionCombined chemo-radiotherapy is a toxic regimen for adult medulloblastoma patients that may result in improved survival.

Circulation of Human Immunodeficiency Virus 1 A6 Variant in the Eastern Border of the European Union-Dynamics of the Virus Transmissions Between Poland and Ukraine.

The human immunodeficiency virus (HIV) type 1 A6 variant is dominating in high-prevalence Eastern European countries, with increasing prevalence over the remaining regions of Europe. The recent war in Ukraine may contribute to further introductions of this A6 lineage. Our aim was to model the transmission dynamics of the HIV-1 A6 variant between Poland and Ukraine. HIV-1 A6 partial pol sequences originating from Poland (n = 1185) and Ukraine (n = 653) were combined with publicly available sequences (n = 7675) from 37 other countries. We used maximum likelihood-based tree estimation followed by a bayesian inference strategy to characterize the putative transmission clades. Asymmetric discrete phylogeographic analysis was used to identify the best-supported virus migration events across administrative regions of Poland and Ukraine. We identified 206 clades (n = 1362 sequences) circulating in Poland or Ukraine (63 binational clades, 79 exclusively Polish, and 64 exclusively Ukrainian). Cross-border migrations were almost exclusively unidirectional (from Ukraine to Poland, 99.4%), mainly from Eastern and Southern Ukraine (Donetsk, 49.7%; Odesa, 17.6% regions) to the Central (Masovian, 67.3%; Lodz, 18.2%) and West Pomeranian (10.1%) districts of Poland. The primary sources of viral dispersal were the Eastern regions of Ukraine, long affected by armed conflict, and large population centers in Poland. The Polish outbreak of the A6 epidemic was fueled by complex viral migration patterns across the country, together with cross-border transmissions from Ukraine. There is an urgent need to include war-displaced people in the national HIV prevention and treatment programs to reduce the further spread of transmission networks.

Patient characteristics, treatment patterns and outcomes for patients with renal cell carcinoma in England: A retrospective cohort study using data from the National Cancer Registry and treatment and hospital data.

639 Background: Renal cell carcinoma (RCC) is the seventh most common cancer in the UK. It is necessary to examine recent treatment trends and outcomes in England to understand the evolving landscape. The primary aim was to describe the demographic and clinical characteristics of patients with RCC, and assess their overall survival (OS) and treatment duration, overall and by subgroups of interest. Secondly, we aimed to understand use of systemic therapies over time. Methods: This was a retrospective cohort study of patients diagnosed with RCC during 2014-2018 using national registry, treatment and hospital data in England. Descriptive statistics were explored with Chi-squared, Fishers exact and Wilcoxon rank sum tests. OS and treatment duration were analysed using Cox regression models to provide hazard ratios (HR) with 95% CI. Kaplan Meier curves were used to compare the proportion of patients alive or on treatment. Results: The cohort included 32,577 individuals; median age at diagnosis 67 years; 36.6% of patients were female; 81.4% exhibited clear cell histology. RCC diagnosed at stage I-III appeared to increase from 61% in 2015 to 68% in 2018. A total of 5,657 patients received at least 1 line of systemic treatment, decreasing to 2,606 and 989 patients for 2 and 3 treatment lines; at 3 months, treatment persisted for 59.9%, 19.0% and 20.5% respectively. In the cohort, 25,566 (78.5%, 95% CI: 78.0–78.9) were alive 1 year from the date of diagnosis and 21,856, (67%, 95% CI: 66.6–67.6) were alive at 3 years. In the subgroup with metastatic disease, 6,786 (37.1%, 95% CI: 35.9–38.2) were alive at 1 year which decreased to 18.0% (95% CI: 17.06–18.92) at 3 years. Among patients with metastatic disease at initial diagnosis, OS was reduced in those with non-clear cell compared to clear cell RCC (HR: 1.19 [95% CI 1.07-1.33]), and those without nephrectomy had a lower probability of survival compared with those who did have a nephrectomy (HR: 2.54, 95% CI: 2.34–2.75). Conclusions: This study presents the most recent and extensive RCC data from England, examining treatment duration, overall survival and patient demographics at presentation, by histology, metastatic status and line of therapy subgroups. These findings could facilitate exploration of potential unmet needs, inequities of treatment or risk factors for patients.

Ophthalmological results in the Hungarian comprehensive health care screening program, 2011-2022

The World Health Organisation's VISION 2020 and World report on vision programs prioritize blindness prevention and vision rehabilitation development. The ophthalmology program, which is part of Hungary's comprehensive health care screening program, plays an important role in the national implementation of these. Summary of the results of Hungary's comprehensive health care screening program's ophthalmology program, which has been going on for 12 years. The ophthalmological data of 168522 people aged between 12 and 99 years who participated in the national screening program were analyzed in nine categories: the presence of eye disease, the use of glasses, the refractive power of the glasses, refractive errors (myopia, anisometropia), the functional vision questionnaire, dry eye, colour vision, educational and communication activities. 18.1% of the participants reported having an eye disease, which was much more common in women and the elderly. The proportion of people who wore glasses reached 66%, with roughly one-third of them lacking appropriate glass strength. Myopia was the most common (58.7%) in people aged 18 to 35. Anisometropia was found in 6.5% of people. Women were more likely than men to have dry eyes (26.1%). Men had a higher rate of colour vision deficiency (5.7%) than women (0.7%). As blindness is 80% preventable, national screening tests and comprehensive educational activities that contribute to the early detection and treatment of eye diseases are important. It is critical to call attention to the significant growth in the prevalence of myopia in young people as well as the urgent need for the effective implementation of preventive measures. The importance of proper glasses must also be brought to the attention of the general population because incorrect glasses cause visual problems. The national ophthalmology screening and educational activity should be continued in the future, with the goal of reducing the incidence of eye diseases associated with visual impairment and increasing the proportion of people who wear appropriate glasses. To stop the spread of myopia, a national preventive and treatment program should be launched. Orv Hetil. 2023; 164(7): 253-259.

Clinical Profile of COVID-19 Patients Admitted at a Private Hospital During Three Surges in Mandalay, Myanmar.

Introduction During the coronavirus disease 2019 (COVID-19) pandemic, private hospitals in Mandalay started to manage COVID-19 infections according to national treatment guidelines since February 2021. Variations of clinical characteristics and their outcomes in different surges could be evaluated in the private hospital. This study aimed to assess the clinical profile and outcomes of COVID-19 patients admitted at a private hospital during three surgesin Mandalay. Methods This study is a retrospective record review of the case series of COVID-19 patients admitted at City Hospital, Mandalay. The study was conducted from January to December 2022. All of the hospital records of COVID-19 patients admitted during the second wave from February 2020 to 26 May 2021, the third wave from 27 May 2021 to 27 January 2022, and the fourth wave from 28 January to April 2022were included in the study. Results A total of 1606 admitted cases were included in the study. The mean with standard deviation (SD) of age was 55.7±18.5, and males were 778 (48.4%). The mean duration of hospital stay in days was 10.8±5.94, 10.6±6.11, and 7.3±2.88 in second, third, and fourth waves, respectively. The mean duration of hospital stay was shortened in the fourth wave. Comorbid conditions with hypertension and/or diabetes diseases were mostly observed in three waves of COVID-19 infection. Fever was the most presented symptom in three waves. Cough, sore throat, and rhinorrhea were observed more in the fourth wave compared with previous waves. Complication with pneumonia (71.3%), liver dysfunction (21.0%), acute respiratory distress syndrome (10.0%), thrombocytopenia (6.2%), acute kidney injury (5.5%), bleeding (3.9%), and pulmonary embolism (2.9%) were investigated. Antiviral treatment such as remdesivir or molnupiravir was used more in the patients of third and fourth waves than those of the second wave. Oxygen therapy (59.9%), prone position (35.5%), non-invasive ventilation (9.5%), invasive ventilation (0.5%), inotropes (4.6%), and renal replacement therapy (1.1%) were recorded in serious cases. Only 7.9% and 9.4% died in the hospital in second and third waves. No mortality was observed in the fourth wave. Conclusions The study recommended that COVID-19 patients with comorbid conditions of hypertension or diabetes and ages 65 and older should be taken with intensive care support at the hospital. This study also concluded that a private hospital in Mandalay could tackle with COVID-19 severe cases in line with national treatment guidelines since the second wave and could provide better management in the fourth wave. Antiviral treatment should be used in severe COVID-19 cases for further emergency management. In conclusion, private hospital involvement in the COVID-19 pandemic is supportive of the healthcare provision in Myanmar in an emergency situation.

Clinical significance of novel 8-factor model of DSM-5 PTSD in national VA PTSD residential treatment data: Internally- v. externally-cued intrusions

BackgroundIntrusion symptoms are a core defining feature of posttraumatic stress disorder (PTSD). It was recently proposed that intrusions may be comprised of two distinct underlying processes: internally-cued intrusions (e.g., trauma-related memories), and externally-cued intrusions (e.g., reactivity to trauma-related cues in one's environment). This is the first study to examine the functional correlates of these two intrusion clusters. MethodsParticipants included 7460 veterans discharged from 40 Veterans Affairs PTSD residential programs across the United States in fiscal years 2018 through 2020. Latent network modeling and structural equation modeling were used to assess the fit of an 8-factor model of PTSD symptoms, which were assessed using the PTSD Checklist for DSM-5 (PCL-5) PTSD symptoms at admission, and its association with symptoms of depression and generalized anxiety, and emotional and physical functioning. ResultsThe 8-factor model, with separate intrusion factors, showed superior model fit to the DSM-5 4-factor, 5-factor dysphoric arousal, 6-factor anhedonia, and 7-factor hybrid models of PTSD. Internally-cued intrusions were uniquely associated with dysphoric arousal, decreased avoidance, and worse physical health functioning; whereas, externally-cued intrusions were uniquely associated with greater avoidance, anxious arousal, negative affect, increased generalized anxiety symptoms, and worse emotional functioning. LimitationsLimitations include the cross-sectional design and use of self-report measures. ConclusionsFindings provide initial support for the clinical utility of a novel 8-factor model of PCL-5 PTSD symptoms, which distinguishes internally- and externally-cued intrusions. These separate intrusion symptom clusters may offer greater specificity and utility in informing the prognosis of and tailored interventions for PTSD.

Features of mixed medullary thyroid tumors: An NCDB analysis of clinicopathologic characteristics and survival

BackgroundMixed medullary-papillary thyroid carcinoma (MMPTC) and mixed medullary-follicular thyroid carcinoma (MMFTC) are rare variants with little known regarding behavior and prognosis. MethodsUsing the National Cancer Database (NCDB), demographics, clinicopathologic features, treatment, and overall survival (OS) from patients with MMPTC and MMFTC were compared to more prevalent subtypes. ResultsThere were 296,101 patients: 421 MMPTC (0.14%), 133 MMFTC (0.04%), 263,140 PTC (88.87%), 24,208 FTC (8.18%) and 8,199 MTC (2.77%). Compared to PTC, MMPTC and MMFTC patients were older (p < 0.001) with a higher Charlson-Deyo comorbidity index (p < 0.001). Mixed tumors exhibited lower rates of nodal disease but more distant metastases compared to PTC (p < 0.001). MMPTC demonstrated lower estimated 10-year OS than PTC and FTC (76.04%vs 89.04% and 81.95%,p < 0.001), yet higher than MTC (70.29%,p < 0.001). MMFTC had a worse OS compared to all groups (63.32%,p < 0.001). ConclusionPatients with MMFTC had significantly worse OS compared to DTC, portending a worse prognosis.

Government Procurement Defence Under GATT 1994 Article III:8(a): A Critical Review of the Turkey-Pharmaceutical Products Dispute

This article critically reviews the Turkey-Pharmaceutical Products Dispute, focusing on the question of whether Turkey’s drug insurance reimbursement scheme can be regarded as government procurement, which would allow Turkey’s drug production localization policy to be exempt from national treatment obligation. Both the panel (on the account that there was no ownership by the government) and the arbitrators (on the account that there was insufficient control of pharmaceutical products subject to the dispute), ruled against Turkey’s government procurement defence. In contrast, this article argues that given rising health costs and repeated global pandemics which compel governments to build up sufficient national production capability of health products to facilitate timely supply of medical products, it would be desirable to take a broad approach towards interpreting the scope of Article III:8(a) with respect to the pharmaceutical sector, granting greater policy space for member governments. pharmaceuticals, government procurement, national treatment, Article III:8(a) derogation, drug insurance reimbursement, domestic localization policy, health policy, Turkey

Abstract WP77: Cost-effectiveness Analysis Of Increasing Dual Antiplatelet Therapy Treatment After High-risk Transient Ischemic Attack Or Minor Ischemic Stroke

Background: Use of guideline recommended dual antiplatelet therapy (DAPT) after high-risk TIA or minor ischemic stroke is suboptimal. We performed a cost-effectiveness analysis of current DAPT treatment patterns and modeled optimal parameters for future healthcare delivery quality improvement (QI) interventions designed to increase DAPT use. Methods: We constructed two decision tree models. Our first model compared DAPT (90 days of aspirin and clopidogrel) to aspirin alone at current national treatment rates (45% of eligible patients receive DAPT). Our second model compared current DAPT treatment patterns to a theoretical QI intervention that increases DAPT use at an initial cost of $20,000 per institution, in keeping with costs of published stroke QI interventions, with variable annual maintenance costs. Healthcare costs and outcomes (stroke, MI, major bleed, death) were modeled using 90-day and lifetime horizons. We calculated incremental cost-effectiveness ratios (ICER) and considered an ICER&lt;$100,000 per quality-adjusted life year (QALY) to be cost-effective. Sensitivity analyses varying key inputs, including QI costs, were performed using Monte Carlo simulations. Results: Compared to aspirin alone, DAPT use was not cost-effective at 90 days (ICER $173,003/QALY) but was cost saving ($3,030) and more effective (0.31 more QALYs) over a lifetime at current treatment rates. Increasing the use of DAPT by 20% with a QI intervention was not cost-effective at 90 days (ICER $474,467/QALY) but was cost-effective over a lifetime (ICER $29,217/QALY). Increasing DAPT use with a QI intervention was the preferred strategy in 89% of Monte Carlo runs (lifetime horizon). QI interventions to increase DAPT use were cost-effective over a range of annual costs (Figure). Conclusion: In a modeling study, current rates of DAPT use after TIA/minor stroke are cost-effective over a lifetime, but a QI intervention to increase DAPT use is preferred in nearly all simulations.

An overview of the Swiss Neonatal Network &amp; Follow-up Group (SwissNeoNet)

: The Swiss Neonatal Network & Follow-up Group (SwissNeoNet) started as a paper based standardized data collection for very preterm born infants in 1995 for the purpose of research. It has since evolved into a sophisticated online medical registry with the chief aim of improving the quality of medical care for high-risk newborn infants through research, education and collaborative audit. In support of its aim, it collects primary hospitalization and neurodevelopmental follow-up data of various cohorts of newborns from all level III neonatal intensive care units (NICUs) and all peripheral intermediate care level IIB neonatal units (NUs) in Switzerland. It coordinates clinical, epidemiological and health-services research that provide orientation for Swiss neonatologists on how their performance compares with that of other networks, how different approaches in practices without clear evidence base associate with outcome, or how processes and outcomes evolve longitudinally. Its research also allowed former very preterm born children to express their own perception of their quality of life. SwissNeoNet closely monitors and compares NICUs and NUs and provides the infrastructure for quality improvement collaboratives. All units jointly and openly compare their performance and identify potential for changing clinical practices which has led to several local improvement projects as well as revisions of national treatment recommendations. To collaborate in research, to acquire benchmarks, and to serve as a benchmark, SwissNeoNet is actively engaged in several national and international collaborations. Receiving no governmental support, SwissNeoNet struggles with a limited budget to continuously operate a multifaceted, complex network with an electronically advanced, security sensitive infrastructure. Nevertheless, it plans expanding by connecting closer to the families and ultimately the former very preterm born children in the near future: building a patient reported outcome measure (PROM) repository and thus learning more about the parental/patient perspective will benefit clinical research, qualitative research, quality assessment, long-term follow-up recruitment and may even pave the way to later expand into citizen science and personalized health care.

A multicenter survey of asymptomatic cryptococcal antigenemia among patients with advanced HIV disease in Nigeria.

As of 2018, cryptococcal antigen (CrAg) screening in patients with advanced human immunodeficiency virus (HIV) disease (AHD) was not routinely implemented in Nigeria despite being recommended in the national HIV treatment guidelines. Our aim was to determine the prevalence and risk factors for asymptomatic cryptococcal antigenemia in adult people living with HIV (PLHIV) in Nigeria to advocate for the implementation of routine CrAg screening. A descriptive cross-sectional study and CrAg screening of consecutive adult PLHIV with CD4 counts ≤200 cells/μL was conducted from April 2018 to April 2019 at HIV clinics in eleven tertiary hospitals spread across Nigeria's six geopolitical regions. Prevalence of asymptomatic cryptococcal antigenemia was estimated by facility and geopolitical zone. Logistic regression was conducted to identify risk factors for cryptococcal antigenemia. In total, 1,114 patients with AHD were screened. The overall prevalence of asymptomatic cryptococcal antigenemia was 3.9% with wide variation across facilities (range: 0/75 [0%]- 15/122 [12.3%]) and geopolitical zones (range: 0/75 [0%]-19/279 [6.8%]). Prevalence of antigenemia was highest in the South-West (19/279 [6.8%]) and lowest in the North-East (0/75 [0%]). Prevalence was 5.2% (26/512) and 3.2% (18/561) in patients with CD4<100 and CD4 of 101-200, respectively. Of all patients with antigenemia, 50% were on antiretroviral therapy (ART) at the time of having a positive CrAg test. In adjusted analysis, cryptococcal antigenemia was significantly less in patients on ART and patients who had completed any formal education. The survey showed a high overall burden of cryptococcal antigenemia in Nigeria, with variable prevalence across geopolitical regions. We provided valuable evidence for implementing routine CrAg screening of AHD patients in Nigeria which has commenced in selected centres.