Outpatient Period Research Articles

Palliative radiotherapy to maintain outpatient status in elderly patients with esophageal carcinoma.

Radiation monotherapy effectively relieves symptoms of esophageal cancer. Many studies have reported relief from dysphagia with this treatment; however, the degree of the dysphagia is subjective. On the other hand, the length of outpatient management is objective. In this study, we investigated how radiation monotherapy can contribute to helping elderly patients with esophageal cancer remain as outpatients. Between January 2010 and December 2017, we followed 42 patients aged >75 years who underwent radiation monotherapy for esophageal carcinoma. Of these patients, 36 were included in the study. We retrospectively collected data on the patients' characteristics, tumor extension around the circumference of the esophagus, medical procedures, prognosis, cause of death, and outpatient management period. We also analyzed the relationships between the outpatient management period, the clinical stage, and the circumferential extension of the tumor. Of the 36 patients (26 males, 10 females), 27 were treated using doses of 60 or 66 Gy, and 9 received 40 or 50 Gy. The median survival period of the patients who died during the study was 14 months, and their median period of outpatient management was 9 months. Eight of the 12 patients with tumors extending across four-fifths or the entire circumference of the esophagus required medical intervention to administer nutrition. There were no significant differences in the period of outpatient management among the patients who died during the study in terms of clinical stage and horizontal location. Radiation monotherapy may facilitate outpatient management; however, patients with tumors extending all or most of the circumference of the esophagus required an additional medical procedure.

CLINICAL FEATURES OF THE COURSE AND ASSESSMENT OF TREATMENT STRATEGY IN CHILDREN WITH BRONCHITIS

Respiratory diseases always account for a significant proportion of visits to the pediatrician or family doctor, and bronchitis is usually a frequent clinical manifestation of acute respiratory diseases. The doctor often faces the question of how to objectively assess the clinical picture of bronchitis, and now the assessment of respiratory symptoms is often based on criteria such as cough, shortness of breath or wheezing on auscultation. However, today there are practically no data on the severity of bronchitis in children depending on the above criteria. A cohort of 158 children with bronchitis was created at the pulmonology and allergology Department of the Municipal Medical Institution "Regional Children's Clinical Hospital" in Chernivtsi. The severity of bronchitis was assessed at the beginning and on the 3rd and 7th day of inpatient using the Bronchitis Severity Score (BSS). According to this scale, mild bronchitis was verified in 30 patients which formed the I clinical group, and 128 children had moderate bronchitis (II clinical comparison group). Aggressive inflammation of the bronchi in children with moderate inflammation of the bronchial tree compared with patients with mild bronchitis was accompanied 1.6 times more often by recurrence, a history of episodes of community-acquired pneumonia in 9.4% of patients, long-term inpatient treatment (odds ratio 2.6) and halving the duration of the outpatient treatment period. The study of clinical severity of bronchitis in children of the comparison groups made it possible to establish an increase in the chances of a more severe course of the disease on the 7th day of hospitalization in children with moderate bronchitis (odds ratio 4.8) with persistence of cough in 68.7% of children in this group (odds ratio 3.8). Evaluation of inpatient treatment tactics indicated the need to increase the volume of complex therapy in patients with moderate bronchitis relative to children with mild disease (odds ratio 12.0, relative risk 8.8), as well as increasing the risk of the need for antibacterial therapy (odds ratio 3.7, relative risk 2.8) and the appointment of intravenous antibiotics for more than 3 days (odds ratio 5.0, relative risk 1.1).

RehabHand: Oriented-tasks serious games for upper limb rehabilitation by using Leap Motion Controller and target population in spinal cord injury

There is a growing interest in the use of technology in the field of neurorehabilitation in order to quantify and generate knowledge about sensorimotor disorders after neurological diseases, understanding that the technology has a high potential for its use as therapeutic tools. Taking into account that the rehabilitative process of motor disorders should extend beyond the inpatient condition, it's necessary to involve low-cost technology, in order to have technological solutions that can approach the outpatient period at home. to present the virtual applications-based RehabHand prototype for the rehabilitation of manipulative skills of the upper limbs in patients with neurological conditions and to determine the target population with respect to spinal cord injured patients. Seven virtual reality applications have been designed and developed with a therapeutic sense, manipulated by means of Leap Motion Controller. The target population was determined from a sample of 40 people, healthy and patients, analyzing hand movements and gestures. The hand movements and gestures were estimated with a fitting rate between the range 0.607-0.953, determining the target population by cervical levels and upper extremity motor score. Leap Motion is suitable for a determined sample of cervical patients with a rehabilitation purpose.

Re-amputation in patients with diabetes-related minor amputations who underwent physical therapy during their hospitalization

BackgroundDiabetes-related foot lesions are a major cause of non-traumatic lower limb amputations and are associated with a high re-amputation rate. Lesions can cause hindrance in activities of daily living, reduce physical function, and lower a patient’s quality of life. Physical therapy is necessary to prevent these limitations. Thus far, there has been limited investigation into the re-amputation rate in patients who have undergone physical therapy. This study aimed to elucidate modifiable risk factors for re-amputation in patients with minor amputations who were treated with physical therapy during their hospitalization.MethodsThis was a retrospective cohort study of 245 consecutive hospitalized patients who presented to our Wound Care Center between January 2015 and February 2018 and received physical therapy after a minor amputation. Participants were identified from admission records to surgical and physical therapy units stored in the electronic medical records. We examined re-amputations that occurred in the ipsilateral lower extremity during the 1-year post-discharge outpatient period. The maximum follow-up period was set at 1 year. We used Cox proportional hazards analysis to examine factors affecting the risk of re-amputation.ResultsOf the 129 patients enrolled, 42 patients (32.5%) underwent re-amputations during an average observation period of 6.2 months (range, 2.1 to 10.9 months). The factors associated with re-amputation were a requirement for hemodialysis, ankle dorsiflexion angle, and the Functional Independence Measure (FIM) ambulation score.ConclusionsIn diabetes patients with minor amputations, a requirement for hemodialysis, ankle dorsiflexion angle, and the FIM ambulation score were shown to be modifiable risk factors for re-amputation. This emphasizes that maintaining vascular endothelial function through lower limb muscle exercises for hemodialysis, improving ankle mobility, and relieving plantar pressure during walking are necessary to reduce the risk of re-amputation. Patients with these risk factors should be encouraged to participate in physical therapy.

Opioid-Free Anesthesia in the Perioperative Setting-A Preliminary Retrospective Matched Cohort Study.

Anesthesiologists have long used multimodal analgesia for effective pain control. Opioid-sparing anesthetics are gaining popularity among practitioners in light of increasing concerns for both immediate opioid side effects and the long-term opioid misuse among susceptible patients. Currently, there is a critical gap in knowledge regarding outcomes after an opioid-free anesthetic (OFA) during general anesthesia. We hypothesized that an opioid-free general anesthetic will not be inferior to a traditional opioid anesthetic (OA) as measured by the perioperative outcomes of postanesthesia care unit (PACU) duration, 12-hour postoperative summed pain intensity (SPI12) scores, total morphine equivalent doses (MEDs) utilized in the 12-hour postoperative inpatient (MED12) and total MEDs utilized in the 90-day outpatient periods (MED90). Patients were included if they were ≥18 years old, met criteria for American Society of Anesthesiologists classification I-IV, received general endotracheal anesthesia from a single anesthesia provider for a surgical operation in 2016, did not receive intraoperative administration of opioids, and were recovered in the PACU. A total of 25 patients were included in the OFA group and 29 control patients in the OA group (n = 54). A retrospective chart review of intraoperative records, perioperative pain scores, and medication utilization (inpatient and outpatient) was performed to obtain the data for the analysis of the primary outcomes. In both OFA and OA groups, the continuous outcomes were not normally distributed. Subsequent bivariate tests of the indicated OA versus OFA age (d = 0.58), surgery duration (d = 0.24), and preoperative pain score (d = 0.51) warranted inclusion in the multinomial regression. Surgical duration was not significantly associated with the primary outcomes. However, the continuous variables of age and preoperative Defense and Veterans Pain Rating Scale score were associated with differences in primary outcomes. Every 1-year increase in the age was associated with a 5.06 increase in SPI12 and 5.73 mg increase in MED12. Every 1-point increase in the preoperative Defense and Veterans Pain Rating Scale score was associated with an 8.45 minutes increase in PACU duration, 11.25 increase in SPI12, 17.85 mg increase in MED12, and 20.83 mg increase in MED90. In regard to the primary outcomes, there was a lack of significant differences between the OFA and OA groups in all outcomes (PACU duration, mean SPI12, MED12, and MED90). To our knowledge, this is the first matched cohort study directly comparing an OFA with a traditional anesthetic for general anesthesia in a wide range of surgical and clinical scenarios. There was no significant difference in SPI12 between the OFA group and OA group, suggesting that patients' subjective pain was similar immediately after surgery whether or not they received intraoperative opioids. Concurrently, no "catch-up" effect was observed as the PACU duration; MED12 and MED90 were not different between the OFA and OA groups. However, there were many covariates identified in this study because of the small sample size or each group. Additional research is needed to explore if these findings can be extrapolated to a larger more heterogeneous population. Our preliminary work suggests that eliminating patient exposure to opioids in the intraoperative period does not have a deleterious effect on perioperative patient outcomes.

Nutritional Support for Critically Ill Patients (Review)

Hospital mortality in critical illness has decreased over the last decade. At the same time, there has been an increase in the number of patients diagnosed with post-intensive care syndrome (PIT-syndrome) which reduces the life quality after discharge. One of the most important components preventing the development of PIT syndrome is nutritional support. The aim of the review is to highlight the need for a differentiated approach to nutritional support of critically ill patients during their treatment and rehabilitation. Among more than 200 primary sources of literature from various databases (Scopus, Web of science, RINC, etc.), 82 sources mainly published in the last 5 years were selected for review. Earlier publications maintaining clinical relevance were also included into the analysis. The review presents data on real practice of nutritional support in critically ill patients. In most cases, the risk of nutritional deficiencies is not assessed before treatment, and protein and energy requirements are not fully met. The algorithm of nutritional support is provided based on the phases of critical illness. Conclusion . Contemporary approaches to the nutrient and energy provision to critically ill patients suggest the differentiated nutritive support prescription depending on the disease stage. The emphasis is made on gradual achievement of target values of protein and energy provision, priority of enteral administration of nutrients, continuity in nutritional support between departments, as well as hospital and outpatient treatment periods. This approach allows both optimization of medical care for this extremely challenging category of patients and a reduction in the severity and duration of the PIT syndrome.

Padsevonil randomized Phase IIa trial in treatment-resistant focal epilepsy: a translational approach.

Therapeutic options for patients with treatment-resistant epilepsy represent an important unmet need. Addressing this unmet need was the main factor driving the drug discovery program that led to the synthesis of padsevonil, a first-in-class antiepileptic drug candidate that interacts with two therapeutic targets: synaptic vesicle protein 2 and GABAA receptors. Two PET imaging studies were conducted in healthy volunteers to identify optimal padsevonil target occupancy corresponding to levels associated with effective antiseizure activity in rodent models. Optimal padsevonil occupancy associated with non-clinical efficacy was translatable to humans for both molecular targets: high (>90%), sustained synaptic vesicle protein 2A occupancy and 10–15% transient GABAA receptor occupancy. Rational dose selection enabled clinical evaluation of padsevonil in a Phase IIa proof-of-concept trial (NCT02495844), with a single-dose arm (400 mg bid). Adults with highly treatment-resistant epilepsy, who were experiencing ≥4 focal seizures/week, and had failed to respond to ≥4 antiepileptic drugs, were randomized to receive placebo or padsevonil as add-on to their stable regimen. After a 3-week inpatient double-blind period, all patients received padsevonil during an 8-week outpatient open-label period. The primary endpoint was ≥75% reduction in seizure frequency. Of 55 patients randomized, 50 completed the trial (placebo n = 26; padsevonil n = 24). Their median age was 36 years (range 18–60), and they had been living with epilepsy for an average of 25 years. They were experiencing a median of 10 seizures/week and 75% had failed ≥8 antiepileptic drugs. At the end of the inpatient period, 30.8% of patients on padsevonil and 11.1% on placebo were ≥75% responders (odds ratio 4.14; P = 0.067). Reduction in median weekly seizure frequency was 53.7% and 12.5% with padsevonil and placebo, respectively (unadjusted P = 0.026). At the end of the outpatient period, 31.4% were ≥75% responders and reduction in median seizure frequency was 55.2% (all patients). During the inpatient period, 63.0% of patients on placebo and 85.7% on padsevonil reported treatment-emergent adverse events. Overall, 50 (90.9%) patients who received padsevonil reported treatment-emergent adverse events, most frequently somnolence (45.5%), dizziness (43.6%) and headache (25.5%); only one patient discontinued due to a treatment-emergent adverse event. Padsevonil was associated with a favourable safety profile and displayed clinically meaningful efficacy in patients with treatment-resistant epilepsy. The novel translational approach and the innovative proof-of-concept trial design maximized signal detection in a small patient population in a short duration, expediting antiepileptic drug development for the population with the greatest unmet need in epilepsy.

Effectiveness of treatment of patients with superficial vein thrombosis associated with varicose veins in real clinical practice

Introduction. Approaches to the treatment of superficial vein thrombosis associated with varicose veins (V-SVT) has undergone significant changes in the last decade as a result of randomized clinical studies on the effectiveness of anticoagulant therapy in V-SVT. At the same time, there is still not enough specific clinical data covering the results of treatment of patients with V-SVT and reflecting the willingness of doctors to abandon active surgical tactics in this variant of thrombophlebitis.Aim – study the effectiveness of treatment of patients with superficial vein thrombosis associated with varicose veins (V-SVT) in real clinical practice.Materials and methods. A retrospective non-comparative study of the results of treatment of 82 patients with V-SVT (w/m – 49/33, mean age – 55.5 years) who underwent of treatment in two departments of vascular surgery in 2019. A retrospective analysis of outpatient records of 81 patients with V-SVT discharged from the hospital was performed. Clinical and ultrasound parameters were highlighted to summarize the results. The methods of standard statistics applied using the program MS Excel 2016.Results. The localization of thrombus in the system of the great saphenous vein (GSV) in 68 cases (82.9%), in system of the small saphenous vein (SSV) in 8 cases (9.8%), in both systems – 6 cases (7.3%). Localization of the top of the thrombus 20–80 mm from the sapheno-femoral (SFJ)/sapheno-popliteal junctions (SPJ) – 60 (67.5%), passage into deep veins – 12 (13.4%), localization of the top of the thrombus to the level of the middle third of the thigh – 8 (9.0%), in the tributaries and trunk of the GSV/SSV on the leg below knee – 9 (10.1%). The type of the thrombus proximal part: occlusal – 61 (68.5%), non-occlusal – 6 (6.7%), floating – 22 (24.7%). Surgical interventions: high ligation of SFJ – 49 (55.1%), dissection of the SPJ – 8 (9.0%), high ligation + thrombectomy – 12 (13.4%). Conservative treatment at vascular surgery department – 20 (22.5%). Recovery – 81 (98.7%). Death – 1 (massive pulmonary embolism upon admission). After 1 month in the outpatient period, a complete relief of the inflammatory process was registered in 76 patients (93.8%), partial in 5 patients (6.2%). Regression of the thrombotic process: complete in 7 patients (8.7%), partial in 74 patients (91.3%). A case of successful treatment of a patient with V-SVT using parnaparin sodium given in this article.Conclusion. It is necessary to revise the drug therapy of V-SVT with increasing dose of anticoagulants and prolongation of anticoagulant therapy to achieve effective results in regression of thrombotic process in superficial veins of the lower extremities.

112-LB: ADO09, a Coformulation of Pramlintide (PRAM) and Insulin A21G, Improves Postprandial Glucose vs. Novolog in Type 1 Diabetes (T1D)

ADO09 is a co-formulation of PRAM and insulin A21G developed to leverage the beneficial effects of PRAM on post-prandial glucose without additional injections. This double-blind randomized cross-over trial studied pre-meal ADO09 vs. Novolog® over 24 days with degludec as basal insulin. Mixed meal tolerance test data (MMTTs) and CGM metrics of 21 T1D subjects were analyzed. Incremental plasma glucose MMTT-AUCs with ADO09 on day 24 were reduced by >100% after 1h and 2h (both p<0.001) and by 39% after 4h (not significant) vs. Novolog. Similarly, ∆PGmax was reduced by 19 mg/dL (p=0.01) and ∆PG_1h by 70 mg/dL (p<0.001)(Fig. 1). ADO09 showed improved CGM-metrics with higher 24h-time in range (TIR 70-180 mg/dL, + 51 min, p=0.01), time in tight range (80-140mg/dL, +70 min, p=0.002). Time <70 mg/dL was slightly higher (+9.6 min, p=0.046) as were hypoglycemic events (142 vs. 115) in the outpatient period. ADO09 significantly reduced body weight (-0.7kg vs. baseline, p=0.01). On the last outpatient day, mean daily bolus doses were 4 U lower with ADO09 (-21%, p=0.05). Both treatments were well tolerated with more gastrointestinal adverse events (24 vs. 6) observed with ADO09, consistent with typical effect of PRAM. In conclusion, ADO09 significantly improved CGM metrics including TIR, weight control and bolus insulin needs vs. Novolog over 24 days of use. Disclosure G. Meiffren: Employee; Self; ADOCIA. Stock/Shareholder; Self; ADOCIA. G. Andersen: Employee; Self; Profil Institute for Clinical Research. R. Eloy: Employee; Self; ADOCIA. C. Seroussi: Employee; Self; ADOCIA. Stock/Shareholder; Self; ADOCIA. C. Mégret: None. S. Famulla: None. Y. Chan: Employee; Self; ADOCIA. M. Gaudier: Employee; Self; ADOCIA. Stock/Shareholder; Self; ADOCIA. O. Soula: Board Member; Self; ADOCIA. Employee; Self; ADOCIA. Employee; Spouse/Partner; ADOCIA. Stock/Shareholder; Spouse/Partner; ADOCIA. Stock/Shareholder; Self; ADOCIA. J. DeVries: Advisory Panel; Self; Novo Nordisk A/S, Zealand Pharma A/S. Consultant; Self; Metronom Health. Employee; Self; Profil Institute for Clinical Research. T. Heise: Advisory Panel; Self; Mylan, Novo Nordisk A/S. Research Support; Self; ADOCIA, Aerami, Becton, Dickinson and Company, Biocon, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Gan & Lee Pharmaceuticals, MedImmune, Merck KGaA, Mylan, Nordic Bioscience, Novo Nordisk A/S, Poxel SA, Sanofi, Xeris Pharmaceuticals, Inc., Zealand Pharma A/S. Speaker’s Bureau; Self; Eli Lilly and Company, Novo Nordisk A/S.

MON-593 Single-Dose Effects of Anti-Obesity Drugs on Human Basal Metabolic Rate

Design and rationale: Obesity results from energy intake exceeding energy expenditure (EE) over a prolonged period. Many anti-obesity drugs are designed to decrease energy intake. However, their potential impact on EE is not well documented. We designed a placebo-controlled, double-blind, randomized cross-over study to determine the acute effects of several FDA-approved anti-obesity drugs on basal metabolic rate (BMR) under well-controlled conditions. Protocol and inclusion criteria: This ongoing study is limited to healthy males of all ethnicities aged 18–35 years with a BMI of 18.5 to 25.0 kg/m2. Following an overnight stay in the Metabolic Clinical Research Unit, fasting subjects were measured from 8:00am to 12:00pm in a whole-room indirect calorimeter, which was maintained at a thermoneutral temperature (26.7±0.9°C) to prevent non-shivering thermogenesis. The six treatments include placebo, caffeine as the positive control (300 mg), phentermine (37.5 mg), topiramate (200 mg), Qsymia (phentermine 15 mg / topiramate 92 mg), and naltrexone (100 mg), with a 1-week outpatient washout period after each treatment. Drug-naïve subjects received a single dose of each drug to minimize potential metabolic adaptations that may occur with weight-loss or chronic use. The prespecified primary outcome was a ≥5% increase in BMR vs. placebo for each drug. This difference can be detected for 16 subjects with 0.83 power at α=0.05 allowing for ≤25% dropout. Secondary outcomes include respiratory quotient (RQ), heart rate (HR), mean arterial pressure (MAP), and self-reported hunger. Preliminary data: To date, 7 subjects were recruited and 6 have completed the study (26.1±4.3 years, BMI 23.1±1.4 kg/m2, body fat percentage 18.4±4.1%). Interim analysis using paired t-tests shows, compared to placebo, caffeine trended towards increasing EE (1.17±0.07 vs. 1.27±0.12 kcal/min; p=0.07) and increased MAP by 5.5±4.2% (88±2 vs. 93±4; p<0.05), but did not change heart rate (59±10 vs. 61±13 bpm). Naltrexone increased EE by 5.9±4.3% (p<0.05). No treatments altered resting RQ compared to placebo (0.83±0.05). Phentermine increased resting HR, both alone (15.7±7.9%, p<0.01) and in Qsymia (9.2±3.6%, p<0.05), compared to placebo. Of the five drug-treatments, only Qsymia reduced self-reported hunger scores compared to placebo. Summary and future directions: Anti-obesity drugs may increase energy expenditure by upregulating sympathetic nervous system activity. Combined with appetite suppression, the impact on energy balance can lead to weight loss. We aim to complete our study to determine whether these drugs can acutely increase EE with minimal cardiovascular side-effects and compare our findings with long-term interventions.

Physical Activity and Factors Affecting Its Maintenance Among Patients With Coronary Heart Disease Not Undergoing Cardiac Rehabilitation in China.

BackgroundThe level of physical activity (PA) among patients with coronary heart disease (CHD) living in Chinese communities who do not participate in cardiac rehabilitation programs and the factors contributing to patient maintenance of PA are unclear.ObjectiveThis cross-sectional study, guided by the Transtheoretical Model, evaluated (1) the maintenance of PA in Chinese patients with CHD 12 months after hospital discharge and (2) the demographic, clinical, and psychological characteristics associated with maintenance of PA.MethodsA total of 1162 patients completed 6 questionnaires at 12 months posthospitalization to assess their maintenance of PA, stage of change, symptoms of depression and anxiety, and health-related quality of life and sleep.ResultsOnly 40% of patients with CHD maintained regular PA 12 months after hospital discharge. Walking was their primary PA. Thirty-seven percent of patients reported no intention of having regular PA. Male sex (odds ratio [OR], 1.69), awareness of PA's cardiac benefit (OR, 4.12), a history of regular PA before the cardiac event (OR, 6.08), history of chronic disease (OR, 1.43), mild depressive symptoms (OR, 1.40), moderate and severe depressive symptoms (OR, 0.41), smoking (OR, 0.54), and years of CHD (OR, 0.96) were related to maintenance of regular PA. Patients with CHD who maintained regular PA had better quality of life and sleep (P < .001) and fewer unplanned clinic visits (P = .001) and cardiac cause readmissions (P = .012) and reported fewer declines in PA capacity (P < .001).ConclusionsWalking is the most common form of PA 12 months posthospitalization among patients with CHD in China. Patient education and counseling about the cardiac benefits of PA, taking into account stage of change, are important considerations to improve maintenance of PA.

Does upper limb strength play a prominent role in health-related quality of life in stroke patients discharged from inpatient rehabilitation?

ABSTRACT Background: Impairments in arm function are a common problem in stroke survivors and have a large impact on health-related quality of life (HRQoL). Little is known about the longitudinal relationship between recovery of upper limb strength and changes in HRQoL. Objectives: This study aimed to determine to what extent changes in HRQoL are related to changes in upper limb strength after discharge from inpatient rehabilitation. Methods: 250 patients from an RCT were assessed at discharge from inpatient rehabilitation (baseline) and at 12 weeks post-discharge (follow-up). The Stroke Impact Scale was used to measure HRQoL, and the Motricity Index Arm was used to measure upper limb strength. Hierarchical regression analysis was performed to determine the predictive value of upper limb strength on HRQoL, relative to demographic and clinical characteristics. Regression analysis was used to determine the relation between upper limb strength improvement and HRQoL improvement. Results: Upper limb strength at baseline was a major predictor of HRQoL at follow-up, after accounting for demographic and clinical characteristics (p < .05). Improvement in HRQoL was positively related to improvement in upper limb strength (F(1, 240) = 18.351, p <.0005). Conclusions: These findings highlight the importance of upper limb strength in HRQoL, as HRQoL is associated with improvement in upper limb strength recovery. Better monitoring of recovery and treatment of upper limb strength during the outpatient rehabilitation period and beyond, i.e. outside the typical time-window of recovery in the first 3 months post-stroke, might contribute to higher quality of life for stroke survivors.

Investigating Lower Limb Hemodynamics during Flap Training Regimens and Patient-led Isometric Contraction Protocols.

The evidence for lower limb flap (LLF) training regimens is equivocal. The commonest cause of LLF failure is venous congestion. The aim of this study was to investigate whether venous congestion could be reduced by patient-led isometric calf contractions during flap training. A prospective clinical study was conducted using photospectroscopy and laser Doppler (Oxygen to See) to assess healthy limbs and LLF characteristics during flap training and isometric calf contractions. Tissue oxygen saturation, venous congestion, and blood flow were measured at rest, as well as during and after limb dangling and calf contraction exercises. In the acute postoperative period following LLF surgery, dependency markedly reduced superficial flow (-55.20% ± 19.17%), with a concurrent increase in venous congestion (33.80% ± 28.80%); supine isometric contractions improved superficial flow and reduced venous congestion from postoperative day 5. Contractions cause a significant increase in blood flow in the outpatient cohort (+84.40% ± 7.86%, P = 0.009), with a mean time since discharge of 14 weeks. Our data suggest patient-led isometric calf exercises are well tolerated and may reduce venous congestion in the acute phase. Progressive changes toward normal physiological function were demonstrated in the outpatient rehabilitation period. Incorporating calf exercises into LLF rehabilitation may allow longer periods of leg dependency, quicker recovery from surgery, and ultimately improve outcomes.

A Novel Dual-Hormone Insulin-and-Pramlintide Artificial Pancreas for Type 1 Diabetes: A Randomized Controlled Crossover Trial.

The rapid insulin-alone artificial pancreas improves glycemia in type 1 diabetes but daytime control remains suboptimal. We propose two novel dual-hormone artificial pancreas systems. We conducted a randomized crossover trial comparing a rapid insulin-alone artificial pancreas with rapid insulin-and-pramlintide and with regular insulin-and-pramlintide artificial pancreas systems in adults with type 1 diabetes. Participants were assigned to the interventions in random order during three 24-h inpatient visits. Each visit was preceded by an outpatient hormonal open-loop run-in period of 10-14 days. The dual-hormone artificial pancreas delivered pramlintide in a basal-bolus manner, using a novel dosing algorithm, with a fixed ratio relative to insulin. The primary outcome was time in the range 3.9-10.0 mmol/L. Compared with the rapid insulin-alone artificial pancreas system, the rapid insulin-and-pramlintide system increased the time in range from 74% (SD 18%) to 84% (13%) (P = 0.0014), whereas the regular insulin-and-pramlintide system did not change the time in range (69% [19%]; P = 0.22). The increased time in range with the rapid insulin-and-pramlintide system was due to improved daytime control (daytime time in range increased from 63% [23%] to 78% [16%], P = 0.0004). There were 11 (1 per 2.5 days) hypoglycemic events (<3.3 mmol/L with symptoms or <3.0 mmol/L irrespective of symptoms) with the rapid insulin-alone system, compared with 12 (1 per 2.3 days) and 18 (1 per 1.4 days) with the rapid and regular insulin-and-pramlintide systems, respectively. Gastrointestinal symptoms were reported after 0% (0 of 112) of meals with the rapid insulin-alone system, compared with 6% (6 of 108) and 11% (11 of 104) with the rapid and regular insulin-and-pramlintide systems, respectively; none of the symptoms were severe. A novel rapid insulin-and-pramlintide artificial pancreas improves glucose control compared with a rapid insulin-alone artificial pancreas (ClinicalTrials.gov number NCT02814123).

Dynamic monitoring of patients with chronic rhinosinusitis with nasal polyps

In connection with the prevalence and tendency to relapse, chronic rhinosinusitis with nasal polyps is an urgent problem not only for otorhinolaryngologists, but also for specialists whose therapeutic activity is somehow related to the respiratory system. Based on clinical observations, 5 phenotypes of this pathology were identified, each of which requires an individual approach to treatment and prevention. As a rule, the first stage is functional endoscopic rhinosinus surgery, the volume of which is determined depending on the phenotype. But even with a carefully performed operation, the result of surgical treatment may be unsatisfactory if there was no adequate care in the early inpatient and outpatient periods. This paper highlights the features of dynamic monitoring of patients with different phenotypes of chronic rhinosinusitis with nasal polyps.

Underutilization of Hospital-based Cardiac Rehabilitation after Acute Myocardial Infarction in Korea.

BackgroundCardiac rehabilitation (CR) after acute myocardial infarction (AMI) is recommended as a mandatory intervention in several national clinical practice guidelines published in America, Europe, and Korea to reduce recurrence and mortality. However, underutilization of CR is an established worldwide issue. In Korea, the promotion of CR is expected due to coverage by National Health Insurance. Nevertheless, the national status of CR use has not been reported. This retrospective cohort study aimed to investigate the current status of CR use in patients with AMI using nationwide data from the National Health Insurance Service of Korea.MethodsPatients with AMI admitted with the diagnosis of ‘I21’ code (from International Classification of Diseases, 10th revision, Clinical Modification) from July 1st, 2017 to June 30th, 2018 were included. CR use was defined as CR treatment or evaluation being performed during an outpatient follow-up period within 6 months after discharge. Participation rate and density were calculated nationally and by administrative division. Logistic regression analysis was performed to identify the influencing factors of CR participation.ResultsNationally, 1.5% of AMI patients (960/64,982) underwent CR during outpatient treatment after discharge. CR density was approximately 10. Logistic regression analysis revealed that influencing factors included old age, female sex, rural residence, and low Charlson comorbidity index.ConclusionHospital-based CR after AMI is underutilized despite its coverage by the National Health Insurance. More CR facilities have to be installed according to the needs of CR in various regions.

Employment-Related Factors of Forensic Psychiatric Outpatients with Psychotic Disorders.

PurposeEmployment is important for forensic psychiatric patients with psychotic disorders, in terms of reduction in symptoms, improving the quality of life, and preventing re-offenses. However, few detailed studies on employment status in such patients exist. We aimed to determine the employment rate among forensic psychiatric outpatients with psychotic disorders and identify the factors associated with employment.Patients and methodsThe study population comprised 406 patients with psychotic disorders who completed a forensic outpatient treatment order, were aged <65 years at discharge from a forensic psychiatric ward and provided written informed consent. Psychotic disorders were defined as psychiatric disorders classified into F2 in the International Statistical Classification of Diseases and Related Health Problems, 10th edition. Demographic data were collected from the medical records of the inpatient treatment period. Prognostic data during the outpatient treatment order period was provided by the reintegration coordinators responsible for coordinating the patients’ social environment during this period. Exploratory univariate and multivariable logistic regression analyses identified the factors associated with employment.ResultsThe mean age at discharge was 44.4±10.8 years. The mean follow-up period was 2.69±1.01 years. There were 4.6 times more men (n=334) than women (n=72). During the outpatient treatment order period, 56 of 406 participants achieved employment (13.8%). Participants who committed serious crime, including homicide, arson, robbery, and sexual assault, had a lower employment rate compared to participants who committed bodily injury crimes (multivariable odds ratio, 0.421; 95% confidence interval, 0.220–0.807). History of substance use and living with family after discharge from a forensic psychiatric ward positively contributed to employment.ConclusionThe employment rate among forensic psychiatric outpatients with psychotic disorders was low and was similar to that reported in previous studies on general psychiatric patients with schizophrenia. Furthermore, serious criminal behavior negatively impacted employment.

Experience Using Oncology Nurse Navigation to Help the Psychological Adjustment of an Outpatient With Rare Tumor Recurrence

Oncology Nurse Navigation is a professional service that integrates complex medical care procedures and promotes patient awareness of the major nursing problems. Using pre-assessment strategies and the integration of medical care information, Nurse Navigators help patients and their families gain comprehensive medical information and nursing care guidance from their initial post-diagnosis visit to their follow-up visits after remission. This article describes the author's experience with a 53-year-old married overseas Chinese woman who had been diagnosed with a rare tumor, PEComa, and who had traveled to Taiwan for treatment. During the outpatient care period with tumor progression, in addition to disease-related psychological and physical discomfort and pain, the prolonged uncertainty regarding treatment had induced adjustment difficulties and psychological symptoms in the patient. The patient's husband continued to work at his job in order to support the family's finances and was not able to maintain a close understanding of his wife's situation. He developed emotional stress when he saw his wife's disease relapse. The authors used Oncology Nurse Navigation approaches to actively assess the needs of the patient and her spouse, to explore their psychological state using emotional assessment scales, to understand the impact of recurrence on the family, to provide available resources and information, to help the couple learn to cope with psychological adjustment symptoms, to enhance their cognitive understanding of the disease, and to learn useful measures that helped them regain physical control, control over the treatment process, and effectively adapt to the disease and its effects. The authors' experience using Oncology Nurse Navigation with this patient may serve as a reference for healthcare professionals to facilitate the proactive assessment of patient needs at different stages of outpatient care, to remove barriers to seeking medical care through early interventions, and to implement a comprehensive and patient-centered approach to cancer treatment that may improve cancer treatment efficacy and quality of care.

Association of cyclophilin A level and pulse pressure in predicting recurrence of cerebral infarction.

Cyclophilin A (CypA), secreted from vascular smooth muscle cells and inflammatory cells in response to oxidative stress, promotes vascular atherosclerosis and development of carotid stenosis. Increased concentration of plasma CypA in acute cerebral infarction was demonstrated clinically. The primary aim of this study was to investigate the prognostic impact between CypA level and outcome in patients with acute ischemic stroke. Admission serum CypA concentrations were detected in 66 acute cerebral infarction patients and in 52 healthy individuals. Inflammatory biomarkers, including high-sensitivity C-reactive protein, adhesion molecules, interleukins, and matrix-metalloproteases, were also assessed. We also examined the relationship between plasma biomarkers, blood pressure (BP), pulse pressure, the carotid artery velocity, the prognostic assessment with modified Rankin scale, and stroke recurrence. Plasma CypA concentration was higher on the first day of hospitalization in the high BP stroke group than in normal BP stroke group, which was statistically significant, which was observed even in the third month and sixth month follow-up outpatient periods. For stroke recurrence prediction, there was an important association between the higher (>60) pulse pressure on the seventh day of hospitalization and CypA level on the third month and sixth month follow-up outpatient periods. Our study revealed higher circulating serum levels of CypA in the hypertensive stroke group than in the non-hypertensive stroke group. We expect that elevated plasma CypA level and raised pulse pressure during hospitalization to become valuable biomarkers in predicting stroke recurrence in the sixth month assessment of acute cerebral infarction.

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan

Japanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan. Participants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants' prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model. The participants included 3.3 times as many men (n=739) compared to women (n=227), and their combined mean age was 47.3 (SD=12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD=369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio=3.599, 95% CI [1.041, 12.445]). The all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.