Non-drug Management Research Articles

Health and Economic Outcomes of Pembrolizumab in the Treatment of Metastatic Non-small Cell Lung Cancer (mNSCLC) and Melanoma in Italy.

In Italy, the management of metastatic non-small cell lung cancer and melanoma leads to significant healthcare challenges, necessitating cost-effective treatment strategies and offering valuable insights for healthcare policymakers and stakeholders. This study was designed to assess the costs, quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs) associated with the health and economic outcomes of (1) pembrolizumab-combined chemotherapy administered as a first-line treatment for metastatic non-squamous and squamous non-small cell lung cancer (NSCLC) where the tumour presents with a programmed death-ligand 1 expression level <50% and of (2) adjuvant pembrolizumab treatment for stage III melanoma. Three cost-effectiveness models developed by MSD were investigated for each treatment indication. A unique model was built to assess the overall effect of pembrolizumab versus chemotherapy or watchful waiting in patients with lung cancer or melanoma, respectively. Theoretical cohorts of patients with metastatic squamous and non-squamous NSCLC were followed over time using a partitioned survival model with weekly cycles. A weekly cycle Markov model was employed for melanoma. The analysis was conducted from the Italian National Health Service perspective, considering a time horizon of 40 years (lifetime). A single closed cohort of treatable patients was followed over time for each indication (4000, 7000 and 900 for NSCLC squamous, non-squamous and melanoma, respectively). The costs evaluated included those for adverse drug events, non-drug disease management, subsequent treatment and terminal care. Drug acquisition and administration costs were excluded. For each treatment indication assessed, pembrolizumab produced downstream direct cost offsets (- €122,498,568, -€133,369,076 and -€32,993,242 for NSCLC squamous, non-squamous and melanoma indications, respectively), increased quality of life (+2088, +5317 and +2307 QALYs for NSCLC squamous, non-squamous and melanoma indications, respectively) and reduced disability (-2658, -7202 and -3029 DALYs for NSCLC squamous, non-squamous and melanoma indications, respectively). Across indications, the total cost offsets of pembrolizumab were -€288,860,885, with 9712 QALYs gained and 12,889 DALYs avoided. The analysis demonstrated that, compared with chemotherapy, pembrolizumab is more cost effective in Italy as a first-line treatment in patients with metastatic squamous or non-squamous NSCLC and, if compared with watchful waiting, as adjuvant treatment in patients with stage III melanoma. The present analysis suggested that pembrolizumab use could lead to important health benefits for patients while offsetting a portion of cancer care costs.

Bibliometric Analysis of the Research Status and Global Trends in Behavioral and Psychological Symptoms of Dementia in Alzheimer's Disease from 2002 to 2022.

Several reviews on behavioral and psychological symptoms (BPSDs) in patients with Alzheimer's disease (AD) have summarized the current state of this field, but global trends are unclear. This study utilized CiteSpace to provide a global overview of the current state of research on AD and its BPSDs and to predict future research trends in the field. Data were retrieved from the Web of Science Core Collection. Bibliometric and cooccurrence analyses were performed using CiteSpace software. In total, 787 valid publications were included in the analysis. Publications on AD and BPSD have shown an increasing trend since 2002. The United States and the University of Toronto were the countries and institutions with the highest total number of publications, respectively. Japan and China were the second and third most influential in the field. Clive Ballard was the top author in terms of the number of publications. Journal of Alzheimer's Disease had the highest number of publications on this topic. Co-occurrence analysis showed that AD, behavioral symptoms, cognitive impairment, and early markers are hot topics in this area. Non-drug management of BPSDs, pharmacological treatment, and physiotherapy will be a hot topic in this field in the future. Our study visualized the relevant articles over the past 21 years to detect global hotspots and trends. Our findings may help researchers to identify research hotspots in this field and will help in the selection of appropriate research topics, while possibly leading to cross-regional cooperation.

Dietary and lifestyle factors associated with troublesome gastroesophageal reflux symptoms in Vietnamese adults.

Dietary and lifestyle habits related to troublesome gastroesophageal reflux symptoms (tGERS) differ significantly across populations. There have yet to be studies on the Vietnamese population. To identify dietary and lifestyle habits associated with tGERS in Vietnamese adults. A cross-sectional survey was conducted among Vietnamese adults aged 18 years and older from March 2023 to May 2023. Participants were recruited online through a widely read national newspaper and Facebook, one of Vietnam's most popular social media platforms. The survey questionnaire comprised 27 questions covering participants' basic demographic information, dietary and lifestyle habits, the presence and characteristics of tGERS, and inquiries about specific dietary and lifestyle patterns, foods, and beverages associated with tGERS. A total of 4,400 valid responses were collected, including 2050 participants without tGERS and 2,350 participants with tGERS. Multivariate analysis showed several factors associated with tGERS, including eating beyond fullness (OR 1.383, CI95% 1.127-1.698), tight clothing (OR 1.627, CI95% 1.256-2.107), stress (OR 1.566, CI95% 1.363-1.800), and insomnia (OR 1.321, CI95% 1.129-1.546). Among habits associated with tGERS, eating beyond fullness was the most frequently reported (64.6%). Interestingly, although a short meal-to-bed time and staying up late after midnight were not risk factors for tGERS, they were two common factors associated with tGERS in symptomatic participants, particularly those with nocturnal reflux symptoms. For food triggers, the three most common ones were greasy foods (71.9%), sour/spicy soups (64.7%), and citrus fruits (36.0%). In terms of beverages, carbonated soft drinks were at the top of triggering tGERS (40.3%), and beer and orange juice were the second and third most common triggers, accounting for 35.7 and 30.6%, respectively. We reported the dietary and lifestyle habits associated with tGERS in Vietnamese adults for the first time. These findings will serve as a basis for future studies on the primary prevention and nondrug management of tGERS in Vietnam.

Veteran Perspectives on Phantom Limb Pain and Non-Drug Interventions.

Phantom limb pain (PLP) commonly occurs post-amputation and can negatively affect the daily functioning of persons with amputation. Best practices for medication and non-drug management remain unclear. To better understand the PLP experience and patients' familiarity with treatments, phone interviews were conducted at the Minneapolis Veterans Affairs Regional Amputation Center in Veterans with amputations. Fifty Veteran participants (average age 66, 96% male) with lower limb amputation were recruited for phone-based data collection of patient-reported outcomes (ie, demographics using the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) and pain experience using the Phantom Phenomena Questionnaire) to characterize the population and a semi-structured interview. Notes taken during interviews were analyzed using the Krueger and Casey constant comparison analysis method. Participants had an average of 15 years since amputation, and 80% reported PLP as identified with the Phantom Phenomena Questionnaire. Investigators identified several core themes from the qualitative interviews including 1) high variability in the experience of PLP, 2) acceptance and resilience, and 3) PLP treatment perceptions. The majority of participants reported trying common non-drug treatments with none endorsed consistently as highly effective. More research is needed to inform identification and implementation of clinical best practices for non-drug interventions for PLP and understand the factors that influence engagement in non-drug interventions. The participants in this study were largely male, so these results may not be generalizable to females.

Summary of the Best Evidence for the Evaluation and Management of Chemotherapy-Related Nausea and Vomiting in Cancer Patients

Objective: To summarize the best evidence for the evaluation and management of chemotherapy-related nausea and vomiting in cancer patients, so as to promote the standardized management of chemotherapy-related nausea and vomiting in cancer patients. Methods: A computer search was conducted for all evidence on chemotherapy-associated nausea and vomiting interventions, including guidelines, expert consensus, best clinical practice information booklet, recommended practice, evidence summary, and systematic review. The search period is from April 30, 2022. After the literature quality evaluation, the evidence extraction and summary of the literature meeting the quality standards. Results: A total of 16 literatures were included, including 9 guidelines, 5 systematic reviews and 2 expert consensus papers. 46 pieces of best evidence on the assessment and management of chemotherapy related nausea and vomiting in cancer patients were summarized, including 6 aspects including risk assessment and management, non-drug management, drug management, multidisciplinary cooperation, education and training, and health education. Conclusion: This study summarized the current best evidence on the assessment and management of chemotherapy-related nausea and vomiting in cancer patients. Clinical staff should apply evidence according to specific clinical scenarios, professional skills and patients’ wishes in order to reduce the degree and incidence of chemotherapy-related nausea and vomiting in cancer patients and improve the quality of care.

Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis.

Pain, a complex subjective experience, is common in care home residents. Despite advances in pain management, optimal pain control remains a challenge. In this updated systematic review, we examined effectiveness of interventions for treating chronic pain in care home residents. A Cochrane-style systematic review and meta-analysis using PRISMA guidelines. Randomized and nonrandomized controlled trials and intervention studies included care home residents aged ≥60years receiving interventions to reduce chronic pain. Six databases were searched to identify relevant studies. After duplicate removal, articles were screened by title and abstract. Full-text articles were reviewed and included if they implemented a pain management intervention and measured pain with a standardized quantitative pain scale. Meta-analyses calculated standardized mean differences (SMDs) using random-effect models. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2.0. We included 42 trials in the meta-analysis and described 13 more studies narratively. Studies included 26 nondrug alternative treatments, 8 education interventions, 7 system modifications, 3 nonanalgesic drug treatments, 2 analgesic treatments, and 9 combined interventions. Pooled results at trial completion revealed that, except for nonanalgesic drugs and health system modification interventions, all interventions were at least moderately effective in reducing pain. Analgesic treatments (SMD-0.80; 95% CI-1.47 to-0.12; P= .02) showed the greatest treatment effect, followed by nondrug alternative treatments (SMD-0.70; 95% CI-0.95 to-0.45; P < .001), combined interventions (SMD-0.37; 95% CI-0.60 to-0.13; P= .002), and education interventions (SMD-0.31; 95% CI-0.48 to-0.15; P < .001). Our findings suggest that analgesic drugs and nondrug alternative pain management strategies are the most effective in reducing pain among care home residents. Clinicians should also consider implementing nondrug alternative therapies in care homes, rather than relying solely on analgesic drug options.

Prise en charge de l’hypersialorrhée iatrogène : revue de la littérature et recommandations pratiques

ObjectivesDrug-induced hypersalivation is a frequent drug adverse event of psychotropic drugs. This excess salivary pooling in the mouth can cause an impairment of a patient's quality of life leading to low rates of medication adherence. The optimal management of hypersalivation is thus crucial to improve patient care. To date, no recommendations for limiting drug-induced hypersalivation have been published. In this study, we conducted a systematic review to investigate the effectiveness of interventions aimed at reducing drug-induced hypersalivation. MethodsTreatment of drug-induced sialorrhea based on case reports and clinical studies were sought in May 2021 from PubMed, Google Scholar and Science Direct (keywords : « treatment », « hypersalivation », « induced », « drug », « clozapine »). Articles published between 1966 to May 2021 on the treatment of drug-induced hypersalivation were included in this study. ResultsSixty-seven articles were selected in this narrative review. First, patient education associated with non-drug related management are essential to improve the compliance to drugs inducing hypersalivation. The non-drug related management should be initiated with an increase in the frequency of swallowing with chewing gum. In the case of ineffectiveness, the dosage of drug responsive of sialorrhea can be adjusted according to the patient's response and his/her medical history (i.e. reducing the dose or splitting the daily dose). Finally, if the problem persists, a symptomatic treatment can be added according to the type of sialorrhea (diurnal or nocturnal), preferred galenic by patient, tolerance and availability of drugs. Several drugs have been tested to reduce hypersalivation induced by clozapine (61/67), risperidone (3/67), quetiapine (2/67) and aripiprazole (2/67). Among the 63 articles targeting a specific corrective treatment, anticholinergic agents were most described in the literature (41 cases out of 63) with atropine, glycopyrrolate and scopolamine (6/41 each). Other agents were described as clinically effective on hypersalivation: dopamine antagonists (9/63) with amisulpride (5/9), alpha-2-adrenergic agonists (5/63) with clonidine (3/5), botulinic toxin (4/63), and terazosine, moclobemide, bupropion and N-acetylcysteine (for each 1/63). ConclusionsIn the case of drug-induced hypersalivation, after failure of non-drug therapies and dosage optimization of the causative treatment, an anticholinergic drug can be initiated. In case of insufficient response, the different treatments presented can be used depending on the galenic form, tolerance and access to those medications. The assessment of the risk-benefit balance should be systematic. The heterogeneity of the studies, the little knowledge about the pharmacological mechanism of saliva flow modulation and the unavailability of corrective drugs are different factors contributing to the complexity of therapeutic optimization.

Practice of non-drug pain management in nursing care of critically ill orthopedic patients

Practice of non-drug pain management in nursing care of critically ill orthopedic patients

Causes and Treatment of Tension Headache: A Review

Tension-type headache (TTH) is the most prevalent primary headache problem, affecting 46 percent to 78 percent of people at some point in their lives. However, the majority have episodic infrequent TTH (1 day per month or fewer) with no specific need for medical treatment. The diagnosis is made based on the patient's medical history and physical examination. The exact etiology of tension-type headache is unknown. The most likely cause of rare tension-type headaches is activation of hyperexcitable peripheral afferent neurons from head and neck muscles. Nondrug management is commonly utilized and should be considered for all patients with TTH. The scientific evidence for the efficacy of most treatment approaches, on the other hand, is limited. Pharmacological treatment depends on whether the headache is acute or chronic. In this review we will cover the disease epidemiology, etiology, diagnosis, and management.&#x0D; The aim is to study the Causes and Treatment of Tension Headache method a population-based study in Denmark, About 24% to 37% of the population experienced TTH several times a month, 10% had it weekly, and 2% to 3% of the population had chronic TTH,&#x0D; In contrast to migraine, women are only slightly more affected than males (the female-to-male ratio of TTH is 5:4), and onset is delayed (25 to 30 years). Between the ages of 30 and 39.

Non-drug Stress Management for Patients with Cancer: A Systematic Review

Background: Patients with cancer suffer from the physical impacts of the disease, including pain in organs where cancer has spread to and treatment side effects. Many factors affect the mental state of cancer patients, especially stress which can cause muscle tension around the affected area and create a higher degree of pain. Stress impacts physical conditions and results in a worse quality of life. Thus, an appropriate approach to cope with, evaluate, and manage stress in cancer patients is considered crucial. Objective: The purpose of this systematic review was to determine and evaluate non-drug stress management guidelines for cancer patients. Methods: A systematic review was undertaken to synthesize knowledge concerning stress and non-drug stress management for cancer patients. Information was sourced from documents and articles published by related institutions in relevant electronic databases, including PubMed, PsycINFO, Dynamed, and ScienceDirect between 2013 and 2019. No limitations were imposed regarding the type of study design previously used. Conference abstracts were not accepted. The quality of all included studies was independently appraised by two review writers. Results: The search generated 129 studies, of which only 20 met the inclusion criteria. The 20 studies cover 11 studies of music for cancer prevention and 6 studies of mindfulness-based stress reduction in cancer patients. The studies utilized both quantitative and qualitative approaches, while three studies of biofeedback in cancer patients only collected quantitative data. For the outcome from the reviews, 6 studies found that music therapy, biofeedback, and mindfulness greatly impact physical alterations such as insomnia, nausea or vomiting, and pain. Furthermore, 17 studies found that non-drug management techniques had a positive impact on psychological adjustments such as stress and anxiety reduction and relaxation promotion. Non-drug stress management such as music, biofeedback, and mindfulness was found to reduce stress among patients. Conclusion: This review confirms that non-drug stress management approaches can reduce suffering, lead to a better quality of life, reduce mortality rates, minimize treatment costs, and prevent and mitigate unwanted symptoms in cancer patients. This approach can be adapted and applied to patients with other diseases in the future. However, because several of the reviewed studies did not have a follow-up period, the present study was unable to collect evidence suggesting how long the observed benefits will remain.

Cost-Effectiveness of Tumor Genomic Profiling to Guide First-Line Targeted Therapy Selection in Patients With Metastatic Lung Adenocarcinoma

ObjectivesA cost-effectiveness analysis comparing comprehensive genomic profiling (CGP) of 10 oncogenes, targeted gene panel testing (TGPT) of 4 oncogenes, and no tumor profiling over the lifetime for patients with metastatic lung adenocarcinoma from the Centers for Medicare and Medicaid Services’ perspective was conducted. MethodsA decision analytic model used 10 000 hypothetical Medicare beneficiaries with metastatic lung adenocarcinoma to simulate outcomes associated with CGP (ALK, BRAF, EGFR, ERBB2, MET, NTRK1, NTRK2, NTRK3, RET, ROS1), TGPT (ALK, BRAF, EGFR, ROS1), and no tumor profiling (no genes tested). First-line targeted cancer-directed therapies were assigned if actionable gene variants were detected; otherwise, nontargeted cancer-directed therapies were assigned. Model inputs were derived from randomized trials (progression-free survival, adverse events), the Veterans Health Administration and Medicare (drug costs), published studies (nondrug cancer-related management costs, health state utilities), and published databases (actionable variant prevalences). Costs (2019 US$) and quality-adjusted life-years (QALYs) were discounted at 3% per year. Probabilistic sensitivity analyses used 1000 Monte Carlo simulations. ResultsNo tumor profiling was the least costly/person ($122 613 vs $184 063 for TGPT and $188 425 for CGP) and yielded the least QALYs/person (0.53 vs 0.73 for TGPT and 0.74 for CGP). The costs per QALY gained and corresponding 95% confidence interval were $310 735 ($278 323-$347 952) for TGPT vs no tumor profiling and $445 545 ($322 297-$572 084) for CGP vs TGPT. All probabilistic sensitivity analysis simulations for both comparisons surpassed the willingness-to-pay threshold ($150 000 per QALY gained). ConclusionCompared with no tumor profiling in patients with metastatic lung adenocarcinoma, tumor profiling (TGPT, CGP) improves quality-adjusted survival but is not cost-effective.

Application of virtual reality on non-drug behavioral management of short-term dental procedure in children

BackgroundDue to the inherent characteristics of immersion, imagination, and interactivity in virtual reality (VR), it might be suitable for non-drug behavior management of children in dental clinics. The purpose of this trial was to measure the role of VR distraction on behavior management in short-term dental procedures in children.MethodsA randomized clinical trial design was carried out on 120 children aged between 4 and 8 years to identify the comparative efficacy of VR and tell-show-do (TSD) to improve behavioral management during dental procedures. The primary outcomes were evaluated anxiety, pain, and compliance scores in perioperative children. The levels of operative anxiety and pain were assessed using the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) and Wong Baker FACES Pain Rating Scale (WBFS), respectively. The Frankl Behavior Rating Scale (FBRS) was tested before and during dental procedures. The length of the dental procedure was compared between both groups after treatment.ResultsThe average anxiety and behavioral scores of the VR group significantly reduced compared with the control. The decreased anxiety score for the VR group and control group were 8 (7, 11) and 5 (5, 7), p < 0.05. The compliance scores of the control group during treatment were 3 (2, 3), and the same in the VR intervention were 3 (3, 4), p = 0.02. A significant reduction in pain was observed when using VR distraction (p < 0.05). Comparing the length of the dental procedure, the VR group (19.0 2 ± 5.32 min) had a shorter treatment time than the control group (27.80 ± 10.40 min).ConclusionThe use of VR significantly reduced the anxiety and pain of children and the length of the dental procedure and improved the compliance of children that underwent short-term dental procedures without an adverse reaction.Trial registrationChinese Clinical Trial Registry, ChiCTR2000029802. Registered on February 14, 2020

Perceptions of nonopioid treatment for pain in a homeless population.

Opioid abuse has developed into a public health emergency within the last decade because opioid medications, while addictive, are effective and commonly used for pain management. In 2016, over 42,000 deaths were attributed to opioids. Chronic pain affects about 50% of people experiencing homelessness in the US, and they have a higher overall rate of chronic pain than the general population; opioids are among the methods they might use to manage that pain. Complementary and alternative therapies for pain management have largely gone unexplored in the homeless population. To determine, among people experiencing homelessness, the willingness to use and current use of complementary and alternative treatments (physical and massage therapy, chiropractic treatments). A secondary objective was to investigate awareness and perception of osteopathic manipulative treatment (OMT) as a complementary treatment for chronic pain among the homeless population. A 32 question survey was administered verbally to guests of True Worth Place Homeless Shelter in Fort Worth, Texas in three 4hour sessions from February 2019 to April 2019. If participants gave verbal consent, a researcher read the questionnaire, one question at a time, and recorded the participant's responses. The survey included queries for opioid and nonopioid treatment modalities (physical and massage therapy, chiropractic, and OMT) to assess the perception of and current use of each among the population. Appropriate nonparametric statistical analysis was conducted to assess significance and correlations among the treatment groups. Of the 200 survey participants, 126 (91.3%) reported a history of opiate use for pain, but 136 (68.0%) believed that a nondrug pain intervention could better treat their pain. Additionally, 150 participants (75.0%) believed that regular manipulation, including OMT, would decrease their need for pain medications. Participants with a history of opioid use for pain were more likely to believe that the availability of regular manipulation, including OMT, at True Worth Place could decrease their need for pain medication (odds ratio=3.7143; 95% confidence interval=1.6122-8.5572; p=0.0009). Moreover, some participants (141; 70.5%) were already pursuing nondrug pain management modalities such as PT, massage therapy, and chiropractic care. The greatest barriers to receiving OMT were transportation and cost. This survey study was conducted to determine whether a homeless population would be willing to use nonopioid treatment, particularly OMT, for chronic pain management. Results revealed both a willingness to use and a previous use of nonopioid treatments for pain, along with a high prevalence of opiate use. Despite limited exposure to OMT, this population reported being potentially willing to pursue manipulation, including OMT, as a complementary treatment for pain relief alongside opioids if readily available.

Cost-effectiveness of pembrolizumab + chemotherapy versus chemotherapy and pembrolizumab monotherapy in first line treatment of NSCLC in the US – updated analyses with additional trial follow-up

Objective Pembrolizumab + chemotherapy substantially extends life expectancy for metastatic non-small cell lung cancer (NSCLC) patients. Its cost-effectiveness (CE) was previously evaluated based on interim trial analyses (follow-up ∼1 year). The present analysis describes CE incorporating additional follow-up based on protocol-specified final trial analyses (1–1.5 years additional follow-up), from a US healthcare payer perspective. Methods A partitioned survival model is used to compare pembrolizumab + chemotherapy vs chemotherapy using data from the KN189 (non-squamous patients) and KN407 (squamous patients) clinical trials. An indirect treatment comparison vs pembrolizumab monotherapy is made for patient subgroups with PD-L1 TPS ≥50% and 1–49% based on data from the KN024 and KN042 trials. Efficacy, treatment utilization, health utility, and safety data are derived from trials and projected over 20 years. Costs for drugs, non-drug disease management, and adverse events are also incorporated. Results Overall, versus chemotherapy alone, pembrolizumab + chemotherapy is projected to increase life expectancy by 1.12 years (3.35 vs 2.23) and 0.67 years (3.17 vs 2.50) in non-squamous and squamous patients, respectively. Resultant ICERs ($158,030/QALY and $178,387/QALY) are below a US 3-times GDP per capita threshold ($195,000/QALY). ICERs vs chemotherapy also generally fall below the threshold within PD-L1 sub-groups (except in squamous PD-L1 < 1%, which may have differed due to small sample size) while ICERs vs pembrolizumab monotherapy in PD-L1 ≥ 50% and 1–49% sub-groups generally exceed it (except in squamous PD-L1 1–49%); largely a result of the higher drug acquisition cost of pembrolizumab + chemotherapy relative to differences in life expectancy. Conclusions Taken together, with longer-term trial follow-up and in the context of prior literature, in the US, one of the two options for pembrolizumab use (either pembrolizumab + chemotherapy or pembrolizumab monotherapy), represents a cost-effective treatment in virtually all non-squamous and squamous metastatic NSCLC patient populations and PD-L1 sub-groups evaluated.

Blood Pressure Modulation With Low-Intensity Focused Ultrasound Stimulation to the Vagus Nerve: A Pilot Animal Study.

ObjectiveFor hypertensive individuals, their blood pressure (BP) is often managed by taking medications. However, antihypertensive drugs might cause adverse effects such as congestive heart failure and are ineffective in significant numbers of the hypertensive population. As an alternative method for hypertension management, non-drug devices-based neuromodulation approaches such as functional electrical stimulation (FES) have been proposed. The FES approach requires the implantation of a stimulator into the body. One recently emerging technique, called low-intensity focused ultrasound stimulation (FUS), has been proposed to non-invasively modulate neural activities. In this pilot study, the feasibility of adopting low-intensity FUS neuromodulation for BP regulation was investigated using animal models.MethodsA FUS system was developed for BP modulation in rabbits. For each rabbit, the low-intensity FUS with different acoustic intensities was used to stimulate its exposed left vagus nerve, and the BP waveform was synchronously recorded in its right common carotid artery. The effects of the different FUS intensities on systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MAP), and heart rate (HR) were extensively examined from the BP recordings.ResultsThe results demonstrated that the proposed FUS method could successfully induce changes in SBP, DBP, MAP, and HR values. When increasing acoustic intensities, the values of SBP, DBP, and MAP would tend to decrease more substantially.ConclusionThe findings of this study suggested that BP could be modulated through the FUS, which might provide a new way for non-invasive and non-drug management of hypertension.

Pediatric pain management competencies taught to nursing students in Rwanda: Perspectives of nurse educators, preceptors and nursing students

Competency for pediatric pain management is fundamental for nurses’ responsibility in caring for pediatric patients with pain. However, effective nursing management of pain in hospitalized children continues to be a challenge more often linked to competency deficit as a consequence of unpreparedness in the pre-licensing education. Previous studies have established that nursing students exhibited lack of knowledge and poor attitudes regarding pediatric pain management, but none of the studies were done in the Rwandan context. The current study explores the pediatric pain management competencies taught to nursing students in Rwanda. An exploratory descriptive qualitative design based on face-to-face individual interviews and focus group discussions was utilized. Fourteen nurse educators and preceptors and nineteen nursing students were recruited from five study settings to explore their perspectives about pediatric pain management competencies taught to nursing students. Participants’ narratives were analysed using thematic analysis from which six main themes emerged. Participants narrated that competencies related to children pain assessment, pain medication and non-drug pain management interventions were taught to students. However, findings also revealed the challenges that impacted the teaching and learning of paediatric pain management, which need to be addressed for the improvement of pre-service training about pain management in children. The findings from the study suggested further research for a better understanding of the nature of those challenges to inform tailored strategies aimed at improving quality health care provision to children through an improved pediatric pain management education at the undergraduate level.

Randomized Controlled Study Evaluating Efficiency of Low Intensity Transcranial Direct Current Stimulation (tDCS) for Dyspnea Relief in Mechanically Ventilated COVID-19 Patients in ICU: The tDCS-DYSP-COVID Protocol.

The severe respiratory distress syndrome linked to the new coronavirus disease (COVID-19) includes unbearable dyspneic suffering which contributes to the deterioration of the prognosis of patients in intensive care unit (ICU). Patients are put on mechanical ventilation to reduce respiratory suffering and preserve life. Despite this mechanical ventilation, most patients continue to suffer from dyspnea. Dyspnea is a major source of suffering in intensive care and one of the main factors that affect the prognosis of patients. The development of innovative methods for its management, especially non-drug management is more than necessary. In recent years, numerous studies have shown that transcranial direct current stimulation (tDCS) could modulate the perception of acute or chronic pain. In the other hand, it has been shown that the brain zones activated during pain and dyspnea are close and/or superimposed, suggesting that brain structures involved in the integration of aversive emotional component are shared by these two complex sensory experiences. Therefore, it can be hypothesized that stimulation by tDCS with regard to the areas which, in the case of pain have activated one or more of these brain structures, may also have an effect on dyspnea. In addition, our team recently demonstrated that the application of tDCS on the primary cortical motor area can modulate the excitability of the respiratory neurological pathways. Indeed, tDCS in anodal or cathodal modality reduced the excitability of the diaphragmatic cortico-spinal pathways in healthy subjects. We therefore hypothesized that tDCS could relieve dyspnea in COVID-19 patients under mechanical ventilation in ICU. This study was designed to evaluate effects of two modalities of tDCS (anodal and cathodal) vs. placebo, on the relief of dyspnea in COVID-19 patients requiring mechanical ventilation in ICU.Trial Registration: This protocol is derived from the tDCS-DYSP-REA project registered on ClinicalTrials.gov NCT03640455. It will however be registered under its own NCT number.

Cost-effectiveness of genomic profiling in veterans with metastatic lung adenocarcinoma.

7075 Background: Tumor profiling identifies patients who are eligible for targeted anticancer therapies. Common tumor profiling approaches include targeted gene panel testing (TGPT), which tests for common mutations in select genes, and multigene panel sequencing (MGPS), which tests for a broad range of mutations in a comprehensive set of genes. Our objective was to determine the lifetime cost-effectiveness of MGPS and TGPT compared to no tumor profiling for Veterans with metastatic lung adenocarcinoma from the Veterans Health Administration’s (VHA) perspective. Methods: A decision analytic model was developed to simulate outcomes for a closed cohort of hypothetical Veterans with metastatic lung adenocarcinoma considering anticancer therapy. OncoKB genes with levels of evidence 1 and 2 for guiding therapy were included. Three profiling strategies were studied: TGPT ( ALK, EGFR, ROS1), MGPS ( ALK, BRAF, EGFR, HER2, MET, NTRK1, NTRK2, NTRK3, RET, ROS1), and no tumor profiling. We assumed 95% of patients with actionable mutations received targeted therapies. Non-targeted therapy options included chemotherapy and/or immunotherapy, and no anticancer therapy. Model inputs were derived from randomized trials (progression-free survival), VHA and Medicare (drug costs), published studies (non-drug cancer-related management costs, health care utilities), and VHA National Precision Oncology Program and cBioPortal for Cancer Genomics databases (mutation prevalence). Costs (2019 US$) and quality-adjusted life years (QALYs) were discounted at 3%/year. Base-case scenario, one-way sensitivity analyses, and probabilistic sensitivity analyses (PSA) using 1,000 Monte Carlo simulations were completed. Results: Base-case results and corresponding 95% credible intervals from the PSA indicated the cost/QALY gained was $309,399 ($280,371-$343,161) for TGPT and $324,707 ($296,086-$359,778) for MGPS compared to no tumor profiling. Of the 3 strategies, MGPS resulted in the highest number of QALYs. One-way sensitivity analyses revealed the cost/QALY estimates were most impacted by changes in health state utility on a targeted therapy (quality of life), costs of alectinib, and non-drug cancer-related costs in patients receiving targeted therapy. Compared to no tumor profiling, cost-effectiveness ratios for both profiling approaches surpassed the $150,000/QALY threshold in 100% of PSA simulations. Conclusions: Tumor profiling (TGPT or MGPS) can optimize anticancer therapy selection in patients with metastatic lung adenocarcinoma and improve quality-adjusted survival, but compared to no tumor profiling, is not cost-effective.

Drug and Non-drug Treatment of Tourette Syndrome

Background:Tourette Syndrome (TS) is a neurodevelopmental disorder characterized by multiple repetitive motor and vocal tics. In most patients, its clinical course has a waxing and waning nature and most patients, usually children, will benefit from tolerant environmental and psychoeducation. Patients with more complicated tics, in particular, those with significant comorbidities will require drug therapy.Objective:The present paper is a mini-review of the current therapeutic arsenal for TS with reference to drug and non-drug management approach.Methods:A systematic survey of medical literature regarding the treatment decision making and the reported clinical trials or accumulating experience with different medications or other therapeutic modalities which were proven beneficial over the years.Results:Reviewing the literature indicates that dopamine antagonists, such as haloperidol and pimozoide, are the most reliable agents in terms of treatment response. Due to numerous adverse effects, newer atypical anti-psychotic drugs have been shown effective. Other widely accepted medications include alpha-2 adrenergic agonists, benzamides, dopamine depleting agents, benzodiazepines and dopamine depleting agents. In more selective and intractable cases botulinum toxin, dopamine agonists and cannabinoids should be also considered. Non-pharmacologic therapies reported beneficial effects, which include on the one hand, non-invasive behavioral techniques, such as comprehensive behavior therapy for tics. While on the other hand, in cases with particular protracted pharmaco-resistant tics electric stimulation techniques, such as deep brain stimulation, have been shown to be successful.Conclusion:Currently, there are numerous multifarious options for treatment of tics and other comorbid symptoms of TS. Nevertheless, treatment options and decision-making algorithms are still a clinical challenge.Area Covered:A step by step decision-making and various drugs and non-pharmacologic modalities appropriate for the management of TS.

Easy come, easy go? Current strategies for maintaining the effects of pulmonary rehabilitation in COPD patients

Easy come, easy go? Current strategies for maintaining the effects of pulmonary rehabilitation in COPD patients Abstract. Pulmonary rehabilitation (PR) is a comprehensive treatment method in the non-drug management of chronic respiratory diseases. Most evident data exists for COPD patients. However, the effect of PR is no longer detectable after 6 to 12 months, unless the patient participates in a kind of maintenance program following PR. But the contents of such a maintenance program are still unclear in terms of duration, location, methods and intensity. They are still subject of current research. Therefore concrete recommendations are still missing and further studies are necessary. This review aims to give an overview of the existing results in this field.