Outpatient Clinic Research Articles

Clinical utility of nurses’ telephone follow-up program (Tsukiji Call) for resectable locally advanced esophageal squamous cell carcinoma patients received neoadjuvant DCF therapy.

384 Background: The standard neoadjuvant treatment in Japan for resectable locally advanced esophageal squamous cell carcinoma (ESCC) is docetaxel (DTX) + cisplatin (CDDP) + 5-fluorouracil (5-FU) (DCF) based on the results of the JCOG1109 study. Neoadjuvant DCF therapy is administrated triweekly; in the first week in a hospital, and the remaining two weeks at hom. After the administration of neoadjuvant DCF therapy, patients might suffer from febrile neutropenia or gastrointestinal symptoms such as nausea, vomiting, constipation, diarrhea, and stomatitis even during remaining two weeks at home. Therefore, nurses in our hospital teach self-care at home for these patients who received neoadjuvant DCF therapy. However, some patients experienced emergency admission due to worsening adverse events. To prevent these events, nurses in our hospital conducted a telephone follow-up program (Tsukiji Call) for patients at home. Methods: This retrospective analysis included locally advanced ESCC patients who received neoadjuvant DCF therapy in our hospital between Feb 2023 and Jul 2024. Three courses of DCF (DTX [day 1]: 70 mg/m2, CDDP [day 1]: 70 mg/m2, 5-FU [continuous infusion on days 1-5]: 750 mg/m2, every three weeks) were planned as neoadjuvant treatment. On days 8-14 of the first course of neoadjuvant DCF therapy, Tsukiji Call was conducted by nurses in our hospital to check fever and nausea, vomiting, constipation, diarrhea, and stomatitis based on the CTCAE ver. 5.0 for patients at home before the first outpatient clinic. Eligible patients were divided into the Tsukiji Call and non-Tsukiji Call groups. We used Fisher's exact test to evaluate the frequency of grade 2 (Gr.2) or more adverse events (AEs) between two groups at the first outpatient clinic. Results: This study identified 90 patients (Tsukiji Call: 20, non-Tsukiji Call: 70). The median age (range) and gender male/female, PS 0/1/2, cStage I/II/III/IVA/IVB were 66.5 years (45-76 years) and 15 (75%)/5(25%), 19(95%)/1(5%)/0, 1(5%)/4(20%)/11(55%)/1(5%)/3(15%) in Tsukiji Call group, and were 64 years (46-79 years) and 49(70%)/21(30%), 67(95%)/2(2%)/1(1%), 1(1%)/13(18%)/50(71%)/0/6(8%) in non-Tsukiji Call group, respectively. In the first outpatient clinic, the frequency of Gr.2 or more AEs on fever, nausea, vomiting, constipation, diarrhea, stomatitis and any events between in Tsukiji Call and non-Tsukiji Call groups were 0/0(p = 1), 2(10%)/1(1%) (p = 0.123), 0/0 (p = 1), 0/0 (p = 1), 0/4(5%) (p = 0.572), and 0/10(14%) (p = 0.109), 2(10%)/15(21%) (p = 0.342), respectively. One patient in each group was emergently admitted within 7 days after discharge. Conclusions: Non-hematologic toxicities during DCF therapy may be reduced by Tsukiji Call by nurses in the hospital, which seemed to be in preventing the worsening of adverse events.

Evaluation of medication appropriateness index in cardiovascular outpatient clinic: A cross-sectional study.

Older adults often have polypharmacy and multimorbidity. Cardiovascular diseases (CVDs) are the most common multimorbidities in older adults and are linked to wide range of adverse drug effects and drug-related problems. The medication appropriateness index (MAI) has been widely used in several patient settings to assess Potentially Inappropriate Medication (PIM) prescribing in older adults. The purpose of this study was to evaluate PIM prescribing in cardiovascular disease outpatient clinic. It also aimed at assessing the validity of the MAI to detect and quantify PIMs specifically in CVD outpatient clinics. This was a cross-sectional, single-center study in cardiovascular outpatient setting. Demographic, clinical, and medication information from older adults (≥ 65years old) were collected and reviewed. Two clinical pharmacists randomly selected 70 patients, evaluated 539 medications, and assessed their appropriateness using the MAI. The Statistical Package for the Social Sciences (SPSS) descriptive and logistic regression analyses was to calculate the number of PIMs, the MAI scores, and factors associated with PIM prescribing. Our data showed that 87.1% of patients had at least one PIM and the number of PIMs per patient was 2.10. Approximately 60% of the patients had an MAI weighted score of zero (no prescription error). The mean MAI score per patient was 17.61 and the mean MAI score per medication was 2.72. The overall agreement between the two raters was 87.3% with moderate chance-adjusted agreement as indicated by the kappa static of 0.43. The factors that were associated with increased PIM prescribing were the total number of medications and being ≥85years old. A relatively high prevalence of PIMs was found in the studied population. The MAI is a reliable and valid tool to detect PIM prescribing in CVD outpatient clinics. It mandates implementing specific measures to reduce PIMs.

Abstract TP144: Telemedicine Appointments early after Acute Ischemic Stroke may Reduce 30-day Emergency Department Visits

Introduction: Limiting the rate of unplanned emergency department (ED) revisits for patients with acute ischemic stroke is an important aspect of secondary stroke prevention. This is influenced by patients’ demographics, comorbidities, stroke severity, disposition destination, and may be impacted by early outpatient follow-up where stroke risk factors and etiology continue to be evaluated. Methods: We retrospectively identified all acute ischemic stroke patients discharged from an 11-hospital network, the largest healthcare system in the state of Georgia, from October 1, 2022 to March 31, 2024; we excluded patients who were discharged to a long-term acute care or hospice facility. Baseline characteristics, inpatient metrics and post-discharge outpatient follow-up were assessed to identify factors associated with ED visits within 30- and 90-days after discharge. Results: Of 2,191 patients, 143 (6.5%) had ED visits within 30 days and 296 (13.5%) within 90 days. The median age was 68 [IQR 57, 77]. History of heart failure (HF), atrial fibrillation (AF), chronic kidney disease and end stage renal disease each increased the likelihood of an ED re-visit within 30 and 90 days whereas diabetes mellitus increased the likelihood of an ED re-visit at 90 days only. In multiple logistic regression analyses, factors independently associated with 30-day ED visit was a history of HF (OR 1.57, 95% CI 1.07-2.28; p=0.02) and AF (OR 1.49, 95% CI 1.00-2.19; p=0.04); at 90 days, only an increased Charlson Comorbidity Index score was associated with ED visit (OR 1.09, 95% CI 1.02-1.16; p=0.01). There were 501 (23%) patients who completed an outpatient neurology clinic follow-up within 30 days of discharge, including 81 patients (4%) who completed a telemedicine outpatient visit; patients completing a telemedicine visit were less likely to have a 30-day ED visit than those who had an in-person visit (OR= 0.13, 95% CI 0.01-0.62; p=0.05). Conclusion: ED revisits after hospitalization for acute ischemic stroke are relatively common and associated with patients who have comorbid conditions including HF and AF. Our study suggests that telemedicine-based follow-ups were associated with lower rates of unplanned ED revisits within 30 days. Efforts to increase outpatient neurology clinic access through telemedicine may reduce ED visits after discharge for acute ischemic stroke patients.

A phase Ib study of immunotherapy with ex-vivo pre-activated and expanded CBNK cells in combination with cetuximab, in patients with colorectal cancer (CRC) with minimal residual disease (MRD): Final report.

176 Background: Colorectal cancer (CRC) is the second most common type of cancer. Even following successful curative treatment, patients often relapse, likely because of undetected micro-metastatic foci. Tumor-informed ctDNA testing has helped to identify those patients before they developed radiographic evidence of disease, introducing the concept of minimal residual disease (MRD) in solid tumors. No standard-of-care treatment options are available for MRD patients. Therefore, we have designed a phase IB trial of the combination of in vitro pre-activated and pre-expanded cord blood natural killer (pre-A+E CBNK) cells with cetuximab. We hypothesized that we could achieve CAR-like efficacy without genetic engineering, by pre-activating NK cells with inflammatory cytokines and by using antibodies to redirect NK cell specificity and antibody-dependent cellular cytotoxicity. The highly immunosuppressive CRC tumor microenvironment is understudied, and novel NK-cell therapy could be highly effective in MRD clearance. Methods: 15 patients with CRC-MRD were enrolled in this trial and completed treatment. All the patients received immunodepleting treatment prior to an infusion of pre-A+E CBNK cells, up to a dose of 1x10^8/kg. Patients were monitored inpatient for 24 hours after treatment for infusion-related reaction, and were then seen for toxicity follow-up in the outpatient clinic twice/week for 4 weeks (DLT window). Samples for correlative analysis were collected at different times. Results: 8/15 patients enrolled were female and 7 were male, age range 26-69. They all had no measurable radiographic evidence of disease and a positive ctDNA Signatera test at baseline. 11/15 were previously treated for metastatic disease; 13 patients had a history of metastases (including 7 liver, 2 lymph nodal, 2 peritoneal). All of them received 5-FU-based chemotherapy. 7/15 were RAS/RAF WT, 4/10 were KRAS mut, 1/10 had BRAF mutation, 1/10 had HER2 amplification. They were all pMMR. No DLT was observed, only 1 patient had G2 CRS requiring tocilizumab. 9/15 patients treated so far had ctDNA clearance at some point. One patient had negative ctDNA at 3 and 6 months, 4/15 were negative at d28 and 7/15 at d14. 4/15 patients have not met the 90-day time point yet. 10/12 patients analyzed up to the primary endpoint had decreased ctDNA over baseline CBNK cells in blood peaked 3 hours post-infusion and persisted at 3 days. Phenotype analysis of CBNK pre-post, donor NK and other immune cells is ongoing. Conclusions: Cetuximab in combination with pre-A+E CBNK is safe and showed promising results for the treatment of MRD-CRC. Clinical trial information: NCT050468 .

The usefulness of Charlson Comorbidity Index (CCI) scoring in predicting all-cause mortality in Outpatients with Clinical Diagnoses of COPD.

Since comorbid conditions are frequently present in chronic obstructive pulmonary disease (COPD) and affect outcome, a composite scoring system to quantify comorbidity might be helpful in assessing mortality risk. We tested the hypothesis that the Charlson Comorbidity Index (CCI) score at the time of an outpatient medical clinic encounter for COPD predicts all-cause mortality. Cox Proportional Hazards analyses were used in 200 randomly selected patients to relate CCI scores to all-cause mortality out to 5 years. Mean age was 62 ± 10 years, 56% were female, FEV1 was 62%, CCI was 3.08 ± 2.30, and 30% had a CCI ≥ 4, indicating 3 or more comorbid conditions. All-cause mortality was 8.5% and 20% at 3 and 5 years, respectively. In univariate testing, the CCI score and hospitalizations predicted mortality, but FEV1 did not. In multivariable testing, which included covariates of age, sex, socioeconomic status, race, FEV1 percent-predicted, and all-cause hospitalizations in the preceding year, CCI expressed as a continuous variable strongly predicted mortality: hazard ratio (HR) 1.38 for each unit increase in the score (p < 0.0001). While 1 or 2 comorbid conditions were not significantly related to mortality, 3 or more comorbid conditions (compared to none) strongly predicted mortality: HR 9.80, 95% CI 3.80 to 25.00. Comorbidity, assessed with the CCI, is strongly predictive of mortality in outpatients with a clinical diagnosis of COPD, and this relationship appears to be non-linear. This instrument may be useful in determining prognosis in this population.

Increasing Screening for Sexually Transmitted Infections Among Adolescents and Young Adults Diagnosed With Sickle Cell Disease: A Quality Improvement Project

BackgroundSexually transmitted infections affect 20 million adolescents and young adults in the United States annually. Local ProblemIn a pediatric outpatient sickle cell disease clinic, in southeastern, US, 16% (43/272) of patients aged 16-24 had a documented sexual health history and 12% (4/77) completed STI screenings. The clinic's aim was to increase sexual health assessment, STI screenings, diagnosis, and treatment. Methods/InterventionUsing process redesign, a standardized sexual health and STI screening process at routine visits was implemented to increase completion of sexual health histories and STI screening. ResultsSexual health history collection rates increased from 16% (43/272) pre- to 92% (107/116) post-intervention. The rate of STI testing offered increased from 12% (5/43) pre- to 100% (116/116) post-intervention. The STI testing rates increased 22.5 % from 40% (2/5) pre- to 49% (20/41) post-intervention. ConclusionsEvidence-based standardized interventions can successfully be used to assist in sexual health documentation and STI screening.

Development of Machine Learning Algorithms for Identifying Patients With Limited Health Literacy.

Limited health literacy (HL) leads to poor health outcomes, psychological stress, and misutilization of medical resources. Although interventions aimed at improving HL may be effective, identifying patients at risk of limited HL in the clinical workflow is challenging. With machine learning (ML) algorithms based on readily available data, healthcare professionals would be enabled to incorporate HL screening without the need for administering in-person HL screening tools. Develop ML algorithms to identify patients at risk for limited HL in spine patients. Between December 2021 and February 2023, consecutive English-speaking patients over the age of 18 and new to an urban academic outpatient spine clinic were approached for participation in a cross-sectional survey study. HL was assessed using the Newest Vital Sign and the scores were divided into limited (0-3) and adequate (4-6) HL. Additional patient characteristics were extracted through a sociodemographic survey and electronic health records. Subsequently, feature selection was performed by random forest algorithms with recursive feature selection and five ML models (stochastic gradient boosting, random forest, Bayes point machine, elastic-net penalized logistic regression, support vector machine) were developed to predict limited HL. Seven hundred and fifty-three patients were included for model development, of whom 259 (34.4%) had limited HL. Variables identified for predicting limited HL were age, Area Deprivation Index-national, Social Vulnerability Index, insurance category, Body Mass Index, race, college education, and employment status. The Elastic-Net Penalized Logistic Regression algorithm achieved the best performance with a c-statistic of 0.766, calibration slope/intercept of 1.044/-0.037, and Brier score of 0.179. Elastic-Net Penalized Logistic Regression had the best performance when compared with other ML algorithms with a c-statistic of 0.766, calibration slope/intercept of 1.044/-0.037, and a Brier score of 0.179. Over one-third of patients presenting to an outpatient spine center were found to have limited HL. While this algorithm is far from being used in clinical practice, ML algorithms offer a potential opportunity for identifying patients at risk for limited HL without administering in-person HL assessments. This could possibly enable screening and early intervention to mitigate the potential negative consequences of limited HL without taxing the existing clinical workflow.

Association between behavioral problems and parental stress in children and adolescents with epilepsy.

The current study evaluated the association between behavioral problems in children and adolescents with epilepsy and parental stress. A prospective observational study of 314 consecutive parents of children and adolescents with epilepsy who attended the out-patient epilepsy clinic of a tertiary care hospital was done between June 2022 and September 2023. Self-reported Child Behaviour Check List (CBCL) was reported by parents; who also reported the parental stress scale (PSS). The data as per CBCL guidelines was evaluated in three groups of children and adolescents with epilepsy aged 1.5 to 5years; 6 to 10years and 11 to 18years. The associations between score on CBCL with reported score on PSS was evaluated. Among the 314 children and adolescents with epilepsy, 37(11.8%) were aged between 1.5 to 5years; while 108(34.4%) aged between six to 10years, the remaining 169(53.8%) aged between 11 to 18years. In children below 5years of age, internalizing factors like anxiety/depression, somatic symptoms were significantly higher. Importantly, the reported scores on PSS were lower in parents of adolescents than children with epilepsy. When evaluated for correlation of CBCL with PSS, internalizing characteristics like withdrawal were strongly associated with parental stress in children below the age of 5years. On the contrary, in children aged above five years, and in adolescents externalizing characteristics showed strong correlations with parental stress. Child's higher school performance had a negative correlation with PSS(R-Square: -0.499; p<0.001) and requirement for special school or child not attending school had positive correlation with PSS(R-square: 0.433;p<0.001). Behavioral problems in children and adolescents with epilepsy differ with age. Parental stress is associated with internalizing behavior in pre-school children whereas externalizing behavior dominated in children and adolescents. Poor performance of children at school and requirement for special school is associated with high parental stress.

Increasing RAS mutation result availability in newly diagnosed patients with metastatic colorectal cancer by their first outpatient medical oncology clinic visit at a large safety net hospital.

110 Background: Rat sarcoma virus mutation testing (RASmt) is critical in guiding systemic therapy selection for patients with metastatic colorectal cancer (mCRC) in the first-line setting. Missing results at the initial medical oncology visit can negatively impact patient outcomes by delaying treatment or leading to inappropriate treatment selection. This quality improvement (QI) project aims to increase the percentage of patients with newly diagnosed mCRC with RASmt results available by their first outpatient medical oncology appointment at a large safety net hospital to 20% over an 8-month period. Methods: A multidisciplinary team of key stakeholders including clinicians, a pathologist, and administrators was assembled to determine factors associated with failure to obtain RASmt. A baseline analysis of all patients referred to the gastrointestinal (GI) oncology clinic from June 2022 to April 2023, with manual review of electronic medical records by investigators, showed that only 6% (3/46) of newly diagnosed patients with mCRC had RASmt results available by their first GI oncology appointment. Two Plan-Do-Study-Act (PDSA) cycles were conducted to assess interventions that were implemented based on process mapping and reasons for unavailable test results. To increase the percentage of patients with RASmt results available, starting December 2023, patients initially diagnosed with mCRC as inpatients who were being followed by the oncology consult service had RASmt ordered on the tissue biopsy prior to discharge (PDSA1). Starting April 2024, the medical directorfor outpatient GI oncology clinics ordered RASmt for all patients with mCRC referred to the clinic at the point of referral (PDSA2) . New patient referrals were reviewed through July 3, 2024. Results: At baseline, the most common reason for unavailable RASmt results was the lack of test orders, with 70% (32/46) of new patients with mCRC not having RASmt ordered prior to their first appointment. Once RASmt was ordered, the average time for results was 13 days. After the first intervention, 4% (1/23) of patients with mCRC had RASmt results available at their first appointment. After the second intervention, 42% (5/12) of patients had RASmt results available. Additionally, median time from diagnosis of mCRC to first appointment decreased from 23 days at baseline to 17 days during PDSA1 to 12 days during PDSA2. Conclusions: By ordering RASmt at the point of referral, the percentage of patients who had RASmt available at their first appointment markedly increased from 6% to 42%. This QI initiative additionally demonstrates the importance of multidisciplinary teams to enhance patient care efficiency at a large safety net hospital. Further efforts are ongoing to increase RASmt availability beyond 42% with a focus on reducing the turnaround time of the test.

Higher plasma total tau concentrations among patients reporting CNS-related side effects from antiseizure medication.

Side effects from antiseizure medication (ASM) are common in epilepsy but biomarkers for detection and monitoring are missing. This study investigated associations between CNS-related side effects from ASM and blood concentrations of the brain injury markers neurofilament-light (NFL), total tau, glial acidic fibrillary protein (GFAP), S100 calcium-binding protein B (S100B) and neuron-specific enolase (NSE). This is a population-based cohort study of adults with epilepsy recruited from five Swedish outpatient neurology clinics from December 2020 to April 2023. Side effects classified as CNS-related: tiredness, dizziness, headache, concentration, memory, mood, motor/tremor, or sleep. Marker concentrations in the groups CNS side effects/no side effects were analyzed with Mann-Whitney U-test and significant differences were included in multivariable logistic regression models adjusting for age, epilepsy duration, seizure status, acquired structural lesion, and mono-/polytherapy. The cohort consisted of 367 patients, 187 (51 %) were females, the median age was 43 years (IQR 30-61), and 123 (34 %) reported CNS side effects. Total tau was higher among participants reporting CNS side effects (median 4.44 (95 %CI 4.12-4.88) pg/ml) compared with participants without side effects (3.84 (95 %CI 3.52-4.07) pg/ml, p < 0.01). The difference remained significant in multivariable regression models. NSE was higher among participants without side effects but did not remain significant in the multivariable regression model. No differences were observed for NFL, GFAP or S100B. Higher total tau plasma concentration could be associated with increased risk of CNS side effects from ASM. Longitudinal studies could determine if this reflects vulnerability or detrimental effects of ASM. PREDICT, clinicaltrials.gov identifier NCT04559919.

Spontaneous recovery in the majority of stable dysplastic hips treated with active surveillance.

Worldwide controversy exists on the optimal treatment of stable dysplastic hips. The most common treatment options are abduction brace treatment and active surveillance. The primary aim of this study was to assess the effect of active surveillance in stable hip dysplasia, by investigating the percentage of Graf IIb stable dysplastic hips that recover spontaneously without abduction brace treatment. The second aim was to identify prognostic factors for spontaneous recovery of stable dysplastic hips. A single-centre, prospective cohort study was conducted at the Máxima Medical Center between 1 March 2019 and 1 March 2023. Infants aged three to 4.5 months at the first outpatient clinic visit, diagnosed with Graf IIb hip dysplasia, and treated with active surveillance were included. Spontaneous recovery was defined as infants who had a normalized hip on ultrasound (α-angle ≥ 60°) after six weeks of active surveillance without receiving abduction brace treatment. Baseline infant characteristics and ultrasound measurements were used as potential predictor variables for spontaneous recovery in logistic regression analyses. A total of 508 infants with Graf IIb stable dysplastic hips were included. Overall, 473 infants (93.1%) recovered spontaneously with active surveillance. Of the remaining 35 infants, 25 infants (4.9%) received six weeks and ten infants (2.0%) received 12 weeks of additional Pavlik harness treatment until hip normalization. In univariate and multivariate analyses, an impaired hip abduction was negatively associated (OR 0.43 (95% CI 0.20 to 0.93); p = 0.033) and being a firstborn child positively associated (OR 2.20 (95% CI 1.04 to 4.63); p = 0.042) with spontaneous recovery. The majority of Graf IIb stable dysplastic hips recover spontaneously in infants aged three to 4.5 months after six weeks of active surveillance. We recommend active surveillance with ultrasound as primary treatment for these infants. However, care must be taken with active surveillance in infants with a limited hip abduction.

Investigating the frequency of neural autoantibodies in refractory focal epilepsy.

There have been conflicting reports about the frequency of neural autoantibodies in epilepsy cohorts, which is confounded by the lack of clear distinction of epilepsy from acute symptomatic seizures due to encephalitis. The aim of this study was to determine the frequency of neural autoantibodies in a well characterised population of refractory focal epilepsy of known and unknown cause. Cases were recruited from epilepsy outpatient clinics at the Princess Alexandra, Mater, Royal Brisbane and Women's and Cairns Base Hospitals from 2021 - 2023. Included cases were refractory to medical therapy, met the ILAE definition of focal epilepsy and were characterised using anatomo-electro-clinical correlation. Cases with prior encephalitis, inflammatory neurological disease or prior parenchymal brain insults were excluded. A total of 100 patients were recruited. No cases with clinically significant neural autoantibodies were discovered. One was positive for serum anti-NMDAR antibodies, however autoantibodies were absent from CSF. Cases were also screened using a predictive score (McGinty et al.). From this, 2 cases were identified as seronegative autoimmune associated epilepsy and demonstrated significant reduction in seizure frequency with administration of immunotherapy. These cases had common features including temporo-perisylvian semiology especially ictal piloerection and high seizure frequency. Clinically relevant neural autoantibodies are uncommon in well characterised chronic focal epilepsy populations. Despite this there are isolated cases that still demonstrate improved seizure control with the use of immunotherapy. Such cases highlight the need for further studies to understand the role of immunity in novel pathophysiological mechanisms in epilepsy.

The association of polytherapy and psychiatric comorbidity in epilepsy.

Managing epilepsy may require using more than one anti-seizure medication (ASM). While combination therapy may help, risks, including psychiatric problems, are not fully explored in Africa. We examined the relationship between polytherapy and psychiatric comorbidities among attendees of an epilepsy community clinic. We prospectively assessed individuals attending an outpatient clinic in Kilifi, Kenya, for patterns of ASM prescribing (mono- or polytherapy) and reviewed psychiatric diagnoses. We used the Psychosis Screening Questionnaire and the Patient Health Questionnaire Version 9 to assess for psychosis and depression, and the Child Behavior Checklist to assess for emotional and behavioural problems. We conducted a cross-sectional logistic regression analysis to determine factors associated with polytherapy and examine the impact of polytherapy and specific medication on psychiatric comorbidities. Of 3,016 attendees, most were on older ASM (99.7%), with about a third (32.9%) on polytherapy. The most commonly co-administered drugs were phenobarbital and carbamazepine (13.0%). Children were less likely to be on multiple medications than adults, and there was no difference between the sexes. Polytherapy was associated with focal to bilateralised seizures (aOR 1.2 [95% confidence interval:1.0-1.4]) and frequent seizures (aOR=2.1 [1.5-2.9]). Combining drugs increased the likelihood of any psychiatric problems (aOR=1.3 [1.0-1.8]), with polytherapy associated with depression (aOR=2.9 [1.0-8.4]) and psychosis (aOR=1.9 (1.0-3.6)). Polytherapy, especially with older drugs, is associated with psychiatric comorbidities in this population. Resorting to polytherapy needs to be carefully considered. Prioritizing research into the long-term effects of ASM on psychiatric comorbidities is crucial for improving mental health outcomes in epilepsy, particularly in low-income settings.

Experiencing Complications After Metabolic and Bariatric Surgeries is a Risk Factor for Postoperative Emergency Department Admissions: a Retrospective Cohort Study.

Emergency department admissions significantly burden hospital staff and countries' health system. Studies are encouraged for effective and correct utilization of emergency departments. Rational management of obesity-related medical problems and postoperative complications may reduce emergency department visits. This study aimed to determine the rates, characteristics, and antecedents of emergency room admissions after metabolic and bariatric surgeries (MBSs) performed in our hospital. According to our hypothesis, experiencing postoperative complications is the most common reason for emergency department admissions. The study was designed as a single-center, retrospective, cohort study. Metabolic and bariatric surgeries performed in our hospital between June 2021 and June 2023 were evaluated. Clavien Dindo Classification was used to classify complications. The reasons for emergency department admissions, re-hospitalization and surgical requirements, time relationships, and possible antecedents were examined in stages. A total of 153 patients were evaluated in the study. The average follow-up period was found to be 609.63 ± 222.89. The emergency department admission rate following MBSs was found to be 31%, and the admission rate within the first month was 7.8%. The major complication rate following MBSs was 4.6%. Experiencing complications was the most important antecedent for admissions 1month postoperatively. In patients with complications after MBS, the discharge decision should be provided with stricter controls, and outpatient clinic controls should be planned more frequently. Providing training to patients on managing complications should be considered as a strategy that may reduce the number of emergency department visits. ACTRN12624000810516.

Yield of family screening for dilated cardiomyopathy: 10-year experience at amultidisciplinary cardiogenetic outpatient clinic.

Current family screening approaches in dilated cardiomyopathy (DCM) depend on the presence or absence of afamilial genetic variant, in which variant pathogenicity (i.e. benign or pathogenic) classification drives screening recommendations. However, this approach has never been systematically evaluated. To describe the yield of DCM family screening stratified by variant classification in the Netherlands, we included 358 relatives (mean age ± standard deviation: 44.4 ± 15.9 years at baseline; 52% female; 41% (likely) pathogenic (LP/P)variant carriers from 210 families). Demographics, symptoms and genetic/cardiac test results were obtained. Endpoints were the development of DCM (left ventricular ejection fraction < 50% of non-ischaemic aetiology) or occurrence of major adverse cardiovascular events (MACE) (i.e. heart failure hospitalisation, ventricular arrhythmia or death). Probability of DCM or MACE was assessed with the Kaplan-Meier method. DCM was present in 32relatives (9%) (25/32 (78%) with LP/Pvariant) at baseline and in an additional 10/97 relatives (10%) (9/10 (90%) with LP/Pvariant) who were re-evaluated during amedian follow-up time of 5.0years (interquartile range: 3.2-7.4). Of the 128 relatives without the familial LP/Pvariant, none developed DCM. MACE was experienced by5 relatives (1%) (4/5 (80%) with LP/Pvariant), all of whom had DCM at the time of the event. The yield of DCM family screening was ~10% at baseline and another ~10% during 5‑year follow-up. Relatives without the familial LP/Pvariant could be safely discharged. These results reinforce the use of agenetics-first screening approach in relatives from families with an LP/P variant. This will lower the burden on resources in Dutch hospitals and help allocate resources to those who are most likely to benefit.

Quality of Life and Adaptation of People With a Colostomy Plug: A Before-After Interventional Study.

The purpose of this study was to examine health-related quality of life and adaptation of persons with a colostomy before and after use of a colostomy plug. Single group before-and-after study. The study sample comprised 19 people with a colostomy who attended an outpatient clinic João Pessoa, in Paraiba, Brazil. Inclusion criteria were: over 18years, protruding colostomy, diameter 20 to 45 mm, elimination pattern of up to 3 solid or pasty fecal stools per day, and medical prescription for the use of the colostomy plug. Data were collected between November 2018 and February 2019. Three outpatient visits per participant were completed; informed consent and baseline data were collected during clinic visit one. Data collected at baseline included demographic and pertinent clinic data. Stoma specific quality of life was measured using the City of Hope Quality of Life - Ostomy Questionnaire; adaptation to an ostomy was measured using the Scale for the Level of Adaptation of Ostomy Patients (SLAOP). Participants were also taught to use a colostomy plug during this visit. A second visit occurred between the 8th and 10th day of use; participants' ability to use the device was assessed during this visit. A third visit occurred 30 to 35days after plug use; instruments used to measure adaptation and health-related quality of life were readministered. Participants who had significantly higher scores for quality of life and adaptation were identified in people who used the plug in all dimensions of the Scale for Level of Adaptation of people with stomas and City of Hope Quality of Life - Ostomy Questionnaire, except for the interdependence mode. Significant, positive and strong correlations were identified between adaptation and quality of life before (r =0.823; P =.000015) and after (r =0.808; P =.000028) use of the colostomy plug. Findings suggest that use of a colostomy plug improved adaptation and quality of life in some patients living with a colostomy.

Prevalence and determinants of lower urinary tract symptoms in pregnant women.

The management of lower urinary tract symptoms (LUTS) is crucial for providing quality pregnancy care. This study aims to determine the prevalence and predictors of LUTS in pregnant women. This cross-sectional study was conducted between November 2023 and February 2024 with a total of 1703 pregnant women who attended routine pregnancy care at four state hospital obstetrics outpatient clinics. Data were collected using a pregnant woman information form and the "Bristol Female Lower Urinary Tract Symptoms-Short Form (BFLUTS-SF)". Descriptive statistics, the independent sample t-test, analysis of variance (ANOVA) test, Tukey or Tamhane's T2 post-hoc tests, and multiple linear regression (Stepwise) analysis were carried out. All analyses were conducted with a 95% confidence interval and a significance level of p<0.05. The prevalence of LUTS among pregnant women was found to be 99.2%. High prevalence rates were obtained for storage symptoms, voiding symptoms, and urinary incontinence symptoms (respectively, 99.2%, 48.8%, and 61.2%). Multiple linear regression analysis indicated that previous pregnancy stress urinary incontinence (SUI), history of curettage and urinary tract infection (UTI), absence of episiotomy, presence of SUI in the mother and/or sister, smoking, being employed, and being in the third trimester are significant predictors of LUTS during pregnancy (p<0.05). The findings of this study indicate that LUTS is commonly in pregnant women. For quality pregnancy care, it is recommended to organize community-based, repeated educational programs and counseling services aimed at preventing and reducing LUTS in women.

Two Different NF1 Pathogenic Variants in a Family With Neurofibromatosis Type 1.

Neurofibromatosis type 1 (NF1) is a genetic disorder with an incidence of approximately one in 3,000. More than half of the patients have new de novo pathogenic variants of the NF1 gene. In most family cases, all family members share an identical NF1-variant. The aim of the study was to investigate the very rare phenomenon of de novo variants in cases of familial neurofibromatosis type 1 and highlight its implications for genetic testing and counseling. Patients underwent clinical examination in our NF outpatient clinic and genetic testing for the NF1-gene was performed by targeted sequencing. All family members were profiled by short-tandem repeat marker analysis. Additionally, a probability calculation was performed for this extremely rare event. In one NF1 family consisting of mother, father, and two sons, two different pathogenic variants of the NF1 gene were found. The father and one son share one NF1-variant and the other son carries a different de novo NF1-variant. Neither of these two NF1-variants was found in the unaffected mother. Short-tandem repeat analysis confirmed the paternity and revealed that the two sons inherited two different NF1-alleles from their father. The probability of two different NF1-variants occurring in one family is calculated as 1:9,000,000. Two different NF1-variants in one family is an extremely rare phenomenon: yet its occurrence is not impossible and therefore should be considered in genetic diagnosis and counselling. For an offspring with the indication for neurofibromatosis type 1, but lacking the familial pathogenic variant, a screening of the whole NF1-gene is necessary to detect potential new pathogenic variants and for exact diagnosis.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative outpatient clinic data.

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders (OUD), from large samples in the community. To determine sex disparities in non-medical opioid use (NMOU) at the end of treatment with medications for opioid use disorder (MOUD), using national data. Observational study of outpatient MOUD programs in the "Treatment episode data set-discharges" (TEDS-D) for 2019. Persons aged ≥ 18 in their first treatment episode, in outpatient MOUD-based therapy for heroin or other opioids (N = 10,065). The binary outcome was presence/absence of NMOU in the month prior to discharge. In univariate analyses, males had higher odds of NMOU compared to females (odds ratio=1.22; p = 6.84 ×10-5 after Bonferroni correction). A multivariable logistic regression detected a relatively small male>female odds ratio of 1.14 (p = 0.0039), surviving adjustment for demographic variables and social determinants of health. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., if they were in the white racial category, and were not of hispanic ethnicity). Also, using by smoking, inhalation or injection routes (versus oral) was associated with greater odds of NMOU, irrespective of sex. This national community sample shows that males overall have greater odds of NMOU in their first treatment episode with MOUD, a potential indicator of more unfavorable outcomes. Further analyses should examine the underpinnings of this disparity, including clinical severity features.

Intranasal oxytocin for apathy in people with frontotemporal dementia (FOXY): a multicentre, randomised, double-blind, placebo-controlled, adaptive, crossover, phase 2a/2b superiority trial.

No treatments exist for apathy in people with frontotemporal dementia. Previously, in a randomised double-blind, placebo-controlled, dose-finding study, intranasal oxytocin administration in people with frontotemporal dementia improved apathy ratings on the Neuropsychiatric Inventory over 1 week and, in a randomised, double-blind, placebo-controlled, crossover study, a single dose of 72 IU oxytocin increased blood-oxygen-level-dependent signal in limbic brain regions. We aimed to determine whether longer treatment with oxytocin improves apathy in people with frontotemporal dementia. We conducted a multicentre, randomised, double-blind, placebo-controlled, adaptive, crossover, phase 2a/2b trial, enrolling participants from 11 expert frontotemporal dementia outpatient clinics across Canada and the USA. People aged 30-80 years with a diagnosis of probable frontotemporal dementia, a Neuropsychiatric Inventory apathy score of 2 or higher, a study partner who interacted with them for at least 3 h per day, and stable cognitive and behavioural medications for 30 days were eligible for inclusion. In stage 1, participants were randomly assigned (1:1:1:1:1:1) to one of three dose schedules (every day, every other day, and every third day) of 72 IU intranasal oxytocin or placebo and to the order they would received the intervention in the crossover; intranasal oxytocin or placebo were administered twice daily for 6 weeks, with a 6-week washout and then crossover to the other intervention. In stage 2, new participants were randomised (1:1) to the dose that had been determined as optimal in stage 1 or to placebo, with crossover as in stage 1. Randomisation used variable block sizes and was stratified by participant sex and Clinical Dementia Rating severity score. All kits of investigational product were identical and produced centrally, and all local teams, study staff, and participants were masked to treatment allocation and order. The primary outcome was difference in the change in Neuropsychiatric Inventory apathy scores for oxytocin versus placebo periods in the per-protocol population after 6 weeks of treatment. Safety was assessed at each visit via electrocardiogram, blood work, and collection of data on adverse events. This trial is registered at ClinicalTrials.gov (NCT03260920). Between Jan 31, 2018, and Dec 11, 2020, 70 patients were screened for stage 1 and 60 (86%) were enrolled. 45 (75%) completed both treatment periods of stage 1. 72 IU oxytocin every third day was the optimal dose schedule from stage 1 based on its Bayesian posterior probability (Pr(Best)=0·478). Between June 28, 2021, and Jan 31, 2023, 42 patients were screened for stage 2, and 34 (81%) were enrolled. 28 (82%) completed both treatment periods in stage 2. 38 (40%) of 94 participants were female and 56 (60%) were male (mean age 65·9 years, SD 8·2) Treatment with oxytocin every third day resulted in an improved Neuropsychiatric Inventory apathy score, with an estimated -1·32 points (95% CI -2·43 to -0·21) relative to placebo (one sided p=0·010). Two adverse events were reported in at least 5% of participants: upper respiratory tract infection (five [6%] of 78 participants on placebo and three [5%] on every third day at all doses of oxytocin) and headache (two [3%] participants on placebo, one [7%] of 15 participants on oxytocin every day, and two [4%] of 55 participants on oxytocin every third day). No adverse events were attributed to oxytocin treatment. Intranasal oxytocin given every third day was well tolerated and was associated with a small reduction in apathy in patients with frontotemporal dementia. Future trials might investigate intermittent dosing of more potent formulations than in this study, to establish whether larger effects are possible. Canadian Institutes of Health Research and Weston Foundation.