Choice For Patients Research Articles

Evolution of Medical and Surgical Management of Carotid Disease from Carotid Endarterectomy to Transfemoral Carotid Stenting to TCAR

Patients with carotid stenosis can be broadly classified into two categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past five decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high grade carotid stenosis. With the advancements in endovascular techniques, the technique of Trans Femoral Carotid Artery Stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past five years, the introduction of the newer technique of Trans Carotid Artery Revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS, however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.

Nutritional Guidelines for Patients with Type 1 Diabetes Mellitus and its Adherence- A Narrative Review

Abstract Nutritional guidelines are of importance in directing food choices of T1D patients. The objective is to summarise existing nutritional recommendations and examine its adherence by T1D patients. Literature was searched on dietary guidelines in T1D using electronic databases PubMed, Science Direct, Scopus, Google Scholar, in English and 29 papers were selected. As per ADA, EASD, ISPAD, and ICMR guidelines, energy recommendations for T1D are based on ideal body weight to prevent overweight and obesity. The safe amounts of carbohydrates, protein and fat includes 50–55%, 15–20% and 25–30% of total energy respectively with fiber intake recommended at 20–30 g/day. Vitamin and mineral supplementation are beneficial in the presence of deficiency. Adherence to nutritional recommendations was suboptimal but better in those who were frequently consulting a dietician. As suboptimal dietary adherence leads to poor glycaemic control, nutritional guidelines must be followed to manage T1D and prevent or delay diabetic complications.

Palbociclib: Randomized Studies and Real-world Evidence as the Basis for Therapeutic Planning in Metastatic Breast Cancer.

Endocrine-based combination therapy with an inhibitor of the cyclin-dependent kinases 4 and 6 (CDK4/6 inhibitors) is currently the first-line therapy of choice for patients with hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-), locally advanced or metastatic breast cancer (mBC). The efficacy and safety of the treatment with palbociclib, the first CDK4/6 inhibitor approved for this indication, have been confirmed in large randomized controlled clinical trials (RCTs) with strictly defined patient cohorts. Since then, many relevant questions about CDK4/6 inhibition with palbociclib for mBC have been investigated in RCTs and real-world studies. Based on this evidence, palbociclib is widely used in clinical practice since many years because of its efficacy and good tolerability. The aim of this review is to summarize findings from RCTs and RWE considering clinically relevant aspects such as safety, tolerability, quality of life and efficacy with a focus on specific questions and patient characteristics. A critical discussion and review of the overall evidence for endocrine-based therapy with the CDK4/6 inhibitor palbociclib can contribute to support therapy decisions in daily clinical practice.

Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists: Exploring Their Impact on Diabetes, Obesity, and Cardiovascular Health Through a Comprehensive Literature Review.

Glucagon-like peptide-1 receptor agonists (GLP-1-RAs) are a novel class of medications promising for treating type 2 diabetes mellitus (T2DM) and obesity-related conditions such as cardiovascular disease (CVD) and non-alcoholic fatty liver disease (NAFLD). This comprehensive literature review examines available research on these medications, focusing on their mechanisms of action, clinical effectiveness, safety profiles, and socioeconomic implications. A comprehensive search was performed using the PubMed, EMBASE, and Cochrane Library databases. Although initially developed for glucose management, these drugs have also demonstrated efficacy in promoting weight loss and reducing the risk of CVD. GLP-1-RAs function similarly to naturally occurring incretins. They stimulate insulin secretion in response to glucose levels, inhibit glucagon release, delay stomach emptying, and generate a sense of fullness via brain pathways. Head-to-head clinical studies have indicated that GLP-1-RAs outperform conventional antidiabetic medicines in terms of glycemic management and weight reduction. According to cardiovascular outcome studies, various drugs in this category have been found to reduce the frequency of severe adverse cardiovascular events. A common side effect is gastrointestinal toxicity, which can be mitigated by gradually increasing the dose. Personalized treatment is likely because the effectiveness, safety, and dose regimens of currently available GLP-1-RAs differ. GLP-1-RAs are a superior choice for patients with T2DM, especially those who already have CVD or require weight-control support. The high cost of these drugs creates hurdles to access and fair healthcare. Current research mainly focuses on increasing therapeutic uses and producing orally delivered medicines with greater potency and bioavailability. Integrating GLP-1-RAs into clinical practice can enhance patient outcomes and reduce the community burden of cardiometabolic disease.

Assessing Medical Students' Understanding of Do-Not-Resuscitate (DNR) Orders.

The evolution of medical directives surrounding cardiopulmonary resuscitation (CPR) has led to the prominence of do-not-resuscitate (DNR) orders. These orders aim to respect patient autonomy and ensure dignified end-of-life care. While regulations in the United States emphasize patient choice and comprehensive discussions, Saudi Arabia's approach to DNR orders integrates Islamic principles alongside expert medical judgment. This study aimed to assess the awareness and comprehension of DNR orders among medical students at Umm Al-Qura University, Makkah, Saudi Arabia. This study employed a cross-sectional design at Umm Al-Qura University in 2023. Convenience sampling yielded a sample of 145 participants, encompassing medical students from all years (first-sixth) and medical interns. A self-administered online questionnaire assessed participants' knowledge, beliefs, and attitudes regarding DNR orders. The questionnaire specifically addressed their familiarity with DNR orders, their understanding of the Islamic perspective on DNR, and the factors influencing their attitudes toward DNR. Results: The majority of respondents (62%) were familiar with the term "DNR," but only 52% correctly defined it. Social media was the primary source of information about DNR for most respondents (56%). A significant portion of respondents (60.7%) agreed with the concept of DNR, and 54% had personal experience with the term. Patient dignity (54%), religious concerns (66.7%), and legal concerns (60.7%) were identified as important factors in DNR decisions. A majority of respondents (67%) agreed that it is acceptable to discontinue life support for DNR patients, and 49.3% believed that organ donation should be encouraged among patient families. The study found that as medical students progressed through their training (from pre-clinical to clinical years and internship), their acceptance and understanding of DNR orders generally increased. The study found that medical students possess some basic familiarity with DNR orders, but there is considerable room for advancement in their comprehension and acceptance of the topic. Addressing these knowledge gaps may lead to improved patient outcomes. The findings also underscore the need to equip future physicians with a comprehensive understanding of DNR orders, their ethical ramifications, and effective communication strategies for engaging with patients and their families.

49158 Examination of Medicaid Insurance as a barrier to patient choice in scalp psoriasis treatment modalities in the African American population

49158 Examination of Medicaid Insurance as a barrier to patient choice in scalp psoriasis treatment modalities in the African American population

Perception of fecal microbiota transplantation in patients with ulcerative colitis in Korea: a KASID multicenter study.

Fecal microbiota transplantation (FMT) is a promising therapy for inducing and maintaining remission in patients with ulcerative colitis (UC). However, FMT has not been approved for UC treatment in Korea. Our study aimed to investigate patient perceptions of FMT under the national medical policy. This was a prospective, multicenter study. Patients with UC ≥ 19 years of age were included. Patients were surveyed using 22 questions on FMT. Changes in perceptions of FMT before and after education were also compared. A total of 210 patients with UC were enrolled. We found that 51.4% of the patients were unaware that FMT was an alternative treatment option for UC. After reading the educational materials on FMT, more patients were willing to undergo this procedure (27.1% vs. 46.7%; p < 0.001). The preferred fecal donor was the one recommended by a physician (41.0%), and the preferred transplantation method was the oral capsule (30.4%). A large proportion of patients (50.0%) reported that the national medical policy influenced their choice of FMT treatment. When patients felt severe disease activity, their willingness to undergo FMT increased (92.3% vs. 43.1%; p = 0.001). Education can increase preference for FMT in patients with UC. When patients have severe disease symptoms or their quality of life decreases their willingness to undergo FMT increases. Moreover, national medical policies may influence patient choices regarding FMT.

Long-term outcomes of percutaneous coronary intervention in patients with prior coronary artery bypass graft - A retrospective experience

ObjectiveTo evaluate the long-term clinical outcomes of percutaneous coronary intervention (PCI) in patients who had previously undergone coronary artery bypass grafting (CABG). MethodA total of 219 patients who had a history of CABG and underwent PCI at tertiary care centre were retrospectively enrolled in this study. Clinical endpoints such as major adverse cardiac events (MACE; cardiac death, non-fatal myocardial infarction [MI], and target vessel revascularization), any death, cardiac death, MI, target vessel revascularization (TVR), and target lesion revascularisation (TLR) were reported at long-term follow-up. ResultsAbout 66.6 % patients were treated on the native vessel, and 24.2 % on grafts vessel. In all, 360 stents [83.3 % drug-eluting stent (DES) and 16.6 % bare metal stent (BMS)] were implanted. Diabetes mellitus (p = 0.03), LVEF<55 % for PCI (p = 0.04), stent type [BMS (p < 0.001) and DES (p < 0.001)] and chronic kidney disease [(CKD) p < 0.01] were appeared to be the significant predictors of mortality. Age at CABG>50 years (p = 0.04), stent type [BMS (p = 0.03) and DES (p < 0.01)] and CKD (p < 0.01) as independent predictors for MACE. Higher event rate was reported in graft-vessel PCI group as compared to native-vessel PCI group: ISR (p < 0.01), TLR (p = 0.01), mortality (p = 0.04), MACE (p < 0.01) and MI (p = 0.05). Mortality (p < 0.001), MACE (p < 0.001) and MI (p < 0.001) were significantly lower in DES vs. BMS groups. ConclusionNative-vessel PCI was associated with better clinical outcomes than graft-vessel PCI that also with the use of DES as the first choice in patients with a history of CABG.

Review of Influencing Factors of Patients' Medical Choice Behavior in Online Health Community

The development of information technology has made online medical communities a new avenue for addressing medical resource shortages. However, the complexity of information and the asymmetry between physicians and patients makes patients confused when they consult in online health community (OHC). This study systematically analyzed and summarized relevant theories and factors influencing patients' medical choice behavior through literature review. The objective is to offer guidance for patients' decisions in selecting physicians and to support the sustainable development of online medical community platforms, as well as to provide practical insights for further exploration in this field. Objective: This review examines recent theories and factors influencing patients' medical choice behavior in online health community (OHC), aiming to offer insights for patient choice regarding physician selection and the sustainable development of online medical platforms. Methods: A literature analysis was conducted to summarize studies on patients' medical choice behavior in OHC, identifying relevant theories and influencing factors. Results: The analysis identified seven key theories in the study of patients' medical choice behavior: signal theory, trust theory, social capital theory, social exchange theory, the stimulus-organism-response (SOR) model, the elaboration likelihood model (ELM), and the opportunity-motivation-ability (OMA) framework. Factors such as physicians' professional capital, online effort, service quality, online reputation, patient preferences and disease heterogeneity significantly influence patients' medical choice behavior. Conclusion: There is a trend toward integrating multiple theories in understanding patients' medical choice behavior in OHC; however, interdisciplinary research remains limited. Most studies focus on patients’ medical choice behavior from the physicians' perspective, while research from the patients' viewpoint is lacking. This study suggests two future research directions: enhancing the integration of multidisciplinary theories and expanding the scope of research subjects.

Coronary protective effect of the J-Valve during transcatheter aortic valve implantation for patients with aortic stenosis and low coronary artery openings

BackgroundIn recent years, transcatheter aortic valve implantation (TAVI) has become a widely used treatment for low-risk elderly patients. As an alternative to TAVI via the femoral artery, transapical TAVI (TA-TAVI) is a better surgical choice for patients with severe vascular diseases. The J-Valve assists doctors in completing valve implantation easily using its positioning locator device, which prevents the self-leaflet from approaching the sinus wall. This function acts as coronary artery protection to avoid coronary occlusion. However, the clinical prognosis of J-Valve implantation for patients with aortic valve stenosis and low coronary openings is unclear.MethodsA retrospective analysis was performed on 30 patients with aortic stenosis (AS) and coronary openings measuring ≤ 10 mm in height. All patients underwent TA-TAVI with J-Valve implantation. Patients were screened using preoperative computed tomography three-dimensional imaging of the aortic root, and the safety and efficacy of the procedure were evaluated. The collected indexes included patients’ general data, cardiac function, preoperative imaging parameters, intraoperative data and postoperative short-term prognosis.ResultsOf the 30 patients in the study successfully underwent TA-TAVI and J-Valve implantation. Two patients required temporary cardiopulmonary bypass assistance during the operation due to heart failure. The implant success rate was 100%, and there were no deaths within 30 days postoperatively. No patients experienced intraoperative or postoperative coronary artery occlusion. Postoperative echocardiography, physiological state and laboratory test results indicated that all patients recovered well. The electrocardiograms remained normal after TA-TAVI, and heart function improved within 30 days.ConclusionTransapical TAVI with J-Valve implantation is a safe and effective treatment option for patients with AS and a low coronary artery opening. Preoperative coronary artery evaluation and the locators of the J-Valve are crucial in preventing coronary artery occlusion. This treatment regimen provides beneficial outcomes and warrants further multi-centre clinical research in the future.

TRPM2-AS promotes ovarian cancer cell proliferation and inhibits cell apoptosis by upregulating the nearby gene TRPM2 via miR-6764-5p

Ovarian cancer (OC) becomes a fatal gynecologic malignant cancer in females worldwide. Target therapy is a promising therapeutical choice for patients with OC, and identifying biomarkers and exploring molecular mechanisms are necessary. In this study, the functions and mechanism of long noncoding RNA transient receptor potential cation channel subfamily M member 2 antisense RNA (TRPM2-AS) in OC were explored. TRPM2-AS expression in OC cells was analyzed utilizing reverse transcription quantitative polymerase chain reaction (RT-qPCR). Cell counting kit-8 (CCK-8) and colony forming assays were carried out to explore the influence of TRPM2-AS on OC cell viability and proliferation. Cell apoptosis was detected using TdT-mediated dUTP Nick-End labeling (TUNEL) and flow cytometry analysis. Protein expression of apoptotic markers was subjected to western blotting. RNA pulldown or luciferase reporter assays were applied to explore the interaction between TRPM2-AS and miR-6764-5p or the binding of miR-6764-5p and TRPM2. The results showed that TRPM2-AS is highly expressed in OC cells and was mainly localized in cytoplasm. TRPM2-AS depletion suppressed OC cell viability and proliferation while increasing cell apoptotic rate. TRPM2 displayed a high level in OC cells and was positively regulated by TRPM2-AS. TRPM2-AS interacted with miR-6764-5p and thereby upregulated TRPM2 expression. In addition, TRPM2 overexpression reversed the repressive impact of TRPM2-AS depletion on malignant OC cellular process. In conclusion, TRPM2-AS promotes OC cell viability and proliferation while enhancing cell apoptosis through interaction with miR-6764-5p to regulate TRPM2 level.

Steering them softly with a quality label? A case study analysis of a patient channelling strategy without financial incentives.

Steering patients to lower priced and/or higher quality providers can increase the value of a healthcare system. In a managed care setting, health insurers may use financial incentives for this purpose. However, introducing cost-sharing differences among providers may cause enrolee discontent, which may result in disenrollment. Simply informing and guiding enrolees to preferred providers without financial incentives may therefore be an attractive alternative for insurers. But the effectiveness of such a soft channelling strategy is unclear. This paper investigates whether a Dutch health insurer's strategy of designating preferred hospitals for breast cancer surgery and for inguinal hernia repair affected its enrolees' hospital choices. In October 2008, preferred hospitals received a quality label ('TopCare') because of their high-quality performances in previous years. The insurer recommended these hospitals to enrolees without a financial incentive. Individual patient-level claims data from the insurer over a 5-year period (2006-2010) and a conditional logit choice model was used. Our study samples for breast cancer surgery and inguinal hernia repair included 7985 and 17,292 patients, respectively. It is found that for both procedures, patients ex ante already had a certain preference for the hospitals designated by the insurer as top-quality providers, even when considering possible additional travel time. Also, for both procedures, patient choice did not differ significantly before and after the launch of the TopCare label. The quality label did not increase patient demand for preferred hospitals. Thus, the insurer's strategy to steer patients to preferred hospital alternatives without a financial incentive was not effective.

Evaluating the impact of the 2010 Swedish choice reform in primary health care on avoidable hospitalization and socioeconomic inequities: an interrupted time series analysis using register data

BackgroundThe Swedish Primary Health Care (PHC) system has, like in other European countries, undergone a gradual transition towards marketization and privatization, most distinctly through a 2010 choice reform. The reform led to an overall but regionally heterogenous expansion of private PHC providers in Sweden, and with evidence also pointing to possible inequities in various aspects of PHC provision. Evidence on the reform’s impact on population-level primary health care performance and equity in performance remains scarce. The present study therefore aimed to examine whether the increase in private provision after the reform impacted on population-average rates of avoidable hospitalizations, as well as on corresponding socioeconomic inequities.MethodsThis register-based study used a multiple-group interrupted time-series design for the study period 2001–2017, with the study population (N = 51 million observations) randomly drawn from the total Swedish population aged 18–85 years. High, medium, and low implementing comparison groups were classified by tertiles of increase in private PHC providers after the reform. PHC performance was measured by avoidable hospitalizations, and socioeconomic position by education and income. Interrupted time series analysis based on individual-level data was used to estimate the reform impact on avoidable hospitalization risk, and on inequities through the Relative Index of Inequality (RII).ResultsAll three comparisons groups displayed decreasing risk of avoidable hospitalizations but increasing socioeconomic inequities across the study period. Compared to regions with little change in provision after the reform, regions with large increase in private provision saw a steeper decrease in avoidable hospitalizations after the reform (relative risk (95%): 1.6% (1.1; 2.1)), but at the same time steeper increase in inequities (by education: 2.0% (0.1%; 4.0); by income: 2.2% (-0.1; 4.3)).ConclusionsThe study suggests that the increase in private health care centers, enabled by the choice reform, contributed to a small improvement when it comes to overall PHC performance, but simultaneously to increased socioeconomic inequities in PHC performance. This duality in the impact of the Swedish reform also reflects the arguments in the European health policy debate on patient choice PHC models, with hopes of improved performance but fears of increased inequities.

Analysing the intra and interregional components of spatial accessibility gravity model to capture the level of equity in the distribution of hospital services in Italy: do they influence patient mobility?

BackgroundAn equal distribution of hospital structures represents an important factor to achieve Universal Health Coverage. Generally, the most diffused approach to measure the potential availability to healthcare is the provider-to-population ratio based on the number of beds or professionals. However, this approach considers only the availability of resources provided at regional or local level ignoring the spatial accessibility of interregional facilities that are particularly accessed by patients living at the borders. Aim of this study is to outline the distribution of the intra and interregional services in Italy to capture the level of equity across the country. Moreover, it explores the impact of the accessibility to these resources on interregional patient’s mobility to receive care.MethodsTo compute spatial accessibility, we propose an alternative approach that applies the enhanced two-step floating catchment area (ESFCA) to capture the level of attraction of intra and interregional hospitals to a given population. Moreover, the adoption of process and outcome indices captured to what extent the quality of structures influenced patients in choosing services located inside or outside their region of residence.ResultsThe study confirms that there is an unequal distribution of high-quality resources at regional and national level with a high level of inequality in the availability and accessibility of quality resources between the north and south part of Italy. This is particularly true considering the accessibility of intraregional resources in the southern part of the country that clearly influences patient choice and contribute to a significant cross border passive mobility to northern regions. This is confirmed by an econometric model that showed a significant effect of spatial accessibility with the propensity of patients of travel from the region of residence to receive care.ConclusionsThe analysis of intra and interregional components of spatial accessibility may contribute to identify to what extent patients are willing to travel outside their region of residence to access to care services. Moreover, it can contribute to gain a deeper understanding of the allocation of health resources providing input for policy makers on the basis of the principles of service accessibility in order to contain patient mobility.

BRAF + EGFR +/- MEK inhibitors after immune checkpoint inhibitors in BRAF V600E mutated and deficient mismatch repair or microsatellite instability high metastatic colorectal cancer

BackgroundImmune checkpoint inhibitors (ICIs) are the guideline endorsed first choice for patients with deficient mismatch repair or microsatellite instability high (dMMR/MSI-H) mCRC, however a significant proportion experience primary or secondary resistance. BRAF V600E mutated (BRAFm) and dMMR/MSI-H mCRC can be treated with BRAF + EGFR inhibitors but specific data on the efficacy after progression to ICIs are missing. MethodsWe collected consecutive patients with BRAFm dMMR/MSI-H mCRC treated from 2017 to 2024 with a combination of BRAFi+EGFRi+/-MEKi, after disease progression on ICIs. A control cohort of BRAFm pMMR/MSS mCRC patients treated with encorafenib+cetuximab+/-binimetinib from 2nd line was used. ResultsdMMR/MSI-H (n = 50) BRAFm mCRC patients were more often > 70-year-old, with right-sided primary tumors, without liver but more lymphnode metastases than pMMR/MSS (n = 170). They were treated more frequently beyond 2nd line and 45 % were primary progressors to ICIs. Lower ORR (18 % versus 32 %, p = 0.09) and DCR (60 % versus 73 %, p = 0.11) was seen without reaching significance in dMMR/MSI-H as compared to pMMR/MSS patients. After a median follow-up of 14.04 months, no differences in PFS (median 5.13 versus 4.50 months, HR 0.83, 95 %CI: 0.57–1.20, p = 0.31) and OS (median 10.75 versus 9.11 months, HR 0.89, 95 %CI: 0.59–1.32, p = 0.55) were observed. ConclusionsOur results show that BRAFm dMMR/MSI-H mCRC patients benefit from BRAFi+EGFRi+/-MEKi after progression under ICIs. Despite lower ORR and DCR, the outcome is not different from that observed in pMMR/MSS BRAFm CRC and is in line with the results of the BEACON registration trial.

Evaluating the implementation of weekly rifapentine-isoniazid (3HP) for tuberculosis prevention among people living with HIV in Uganda: A qualitative evaluation of the 3HP Options Trial.

Three months of isoniazid-rifapentine (3HP) is being scaled up for tuberculosis (TB) preventive treatment (TPT) among people living with HIV (PLHIV) in high-burden settings. More evidence is needed to identify factors influencing successful 3HP delivery. We conducted a qualitative assessment of 3HP delivery nested within the 3HP Options Trial, which compared three optimized strategies for delivering 3HP: facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), and patient choice between facilitated DOT and facilitated SAT at the Mulago HIV/AIDS clinic in Kampala, Uganda. We conducted 72 in-depth interviews among PLHIV purposively selected to investigate factors influencing 3HP acceptance and completion. We conducted ten key informant interviews with healthcare providers (HCPs) involved in 3HP delivery to identify facilitators and barriers at the clinic level. We used post-trial 3HP delivery data to assess sustainability. We conducted an inductive thematic analysis and aligned the emergent themes with the RE-AIM framework dimensions to report implementation outcomes. Understanding the need for TPT, once-weekly dosing, shorter duration, and perceived 3HP safety enhanced acceptance overall. Treatment monitoring by HCPs and reduced risk of HIV status disclosure enabled DOT acceptance. Dosing autonomy enabled SAT acceptance. Switching between DOT and SAT as required enabled acceptance for patient choice. Dosing reminders, reimbursement for clinical visits, and social support enabled 3HP completion; pill burden, side effects, and COVID-19-related treatment restrictions hindered completion. All HCPs were trained and participated in 3HP delivery with high fidelity. Training, care integration, and collaboration among HCPs enabled, whereas initial concerns about 3HP safety among HCPs delayed 3HP adoption and implementation. SAT was maintained post-trial; DOT was discontinued due to inadequate ongoing financial support beyond the study period. Facilitated delivery strategies made 3HP treatment convenient for PLHIV and were feasible and implemented with high fidelity by HCPs. However, the costs of 3HP facilitation may limit wider scale-up.

Combined Extracorporeal Shock Wave Lithotripsy and Endoscopic Retrograde Pancreatography for Painful Chronic Pancreatitis: Is It Effective?

AbstractManagement of pain in chronic pancreatitis (CP) is challenging, and surgery used to be the intervention of choice in patients having pain refractory to medical therapy. Advancement in minimally invasive interventions resulted in a paradigm shift in the management of pain in CP. Pancreatic endotherapy is currently considered the intervention of choice for the management of ductal hypertension in CP. However, multiple mechanisms including ductal hypertension and neurogenic as well as psychological factors contribute to the causation of pain in CP and therefore no single intervention is effective in all patients. The precise role of interventional procedure in a complex disease like CP with multiple pathogenic mechanisms requires a prospective comparative study with a sham group and there are no such comparative studies in the literature. In this news and views, we discuss a recently published sham-controlled randomized trial (Combined extracorporeal shock wave lithotripsy and endoscopic treatment for pain in chronic pancreatitis (SCHOKE) trial) that examined the efficacy of extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with the sham procedure.

Risk of Major Bleeding, Stroke/Systemic Embolism, and Death Associated With Different Oral Anticoagulants in Patients With Atrial Fibrillation and Severe Chronic Kidney Disease.

Patients with atrial fibrillation and severe chronic kidney disease have higher risks of bleeding, thromboembolism, and mortality. However, optimal anticoagulant choice in these high-risk patients remains unclear. Using deidentified electronic health records from the Optum Labs Data Warehouse, adults with atrial fibrillation and severe chronic kidney disease (estimated glomerular filtration rate <30 mL/min per 1.73 m2) initiating warfarin, apixaban, or rivaroxaban between 2011 and 2021 were included. Using inverse probability of treatment weighting, adjusted risks of major bleeding, stroke/systemic embolism, and death were compared among agents. A total of 6794 patients were included (mean age, 78.5 years; mean estimated glomerular filtration rate, 24.7 mL/min per 1.73 m2; 51% women). Apixaban versus warfarin was associated with a lower risk of major bleeding (incidence rate, 1.5 versus 2.9 per 100 person-years; subdistribution hazard ratio [sub-HR], 0.53 [95% CI, 0.39-0.70]), and similar risks for stroke/systemic embolism (incidence rate, 1.9 versus 2.4 per 100 person-years; sub-HR, 0.80 [95% CI, 0.59-1.09]) and death (incidence rate, 4.6 versus 4.5 per 100 person-years; HR, 1.03 [95% CI, 0.82-1.29]). Rivaroxaban versus warfarin was associated with a higher risk of major bleeding (incidence rate, 4.9 versus 2.9 per 100 person-years; sub-HR, 1.65 [95% CI, 1.10-2.48]), with no difference in risks for stroke/systemic embolism and death. Apixaban versus rivaroxaban was associated with a lower risk of major bleeding (sub-HR, 0.53 [95% CI, 0.36-0.78]). These real-world findings are consistent with potential safety advantages of apixaban over warfarin and rivaroxaban for patients with atrial fibrillation and severe chronic kidney disease. Further randomized trials comparing individual oral anticoagulants are warranted.

Implantable cardioverter defibrillator explantation upon patient request: Clinical and ethical considerations.

Implantable Cardioverter Defibrillator (ICD) implantation has significantly modified the natural history of patients at high risk of sudden cardiac death (SCD) in various types of heart diseases. However there is a high rate of psychological distress and reduced quality of life in patients with an ICD, more evident in younger individuals. The ICD removal upon patient request is a very rare event and causes many clinical and ethical issues. The article discusses the case of a young patient affected by hypertrophic obstructive cardiomyopathy, who underwent implantable cardioverter defibrillator (ICD) implantation as a primary prevention of sudden cardiac death (SCD). Two years after the implantation, the patient repeatedly requested removal of the ICD due to of a significant and untreatable psychological device intolerance. Intervention became possible only after extensive psychological evaluation, which excluded specific pathology, and the ratification of Italian law 219/2017 on informed consent and advance directives, which guarantees the patient's independent decisions on current and future medical treatment. The explantation was performed 7 years after the implant. The patient is alive and in good health. The paper debates the issues related to establishing a patient-physician relationship based on respect for the patient's autonomy and experience of illness, in reference to principles such as beneficence and non-maleficence, and the conflicts that sometimes arise between them. If a paternalistic approach in the patient-physician relationship evolves into a patient-centered model, it is more certain that the patient's choice is realistically known and shared, and that it is consistent with the patient's values and life goals. The shared decision making (SDM) process and the use of pathology-specific decision aids are able to transform the informed consent tool, usually related to medical-legal issues, into an aid for true partnership between the patient and the medical care team.

Utilizing technology for diet and exercise change in complex chronic conditions across diverse environments (U-DECIDE): feasibility randomised controlled trial

BackgroundDiet and exercise are important components of treatment for complex chronic conditions, however access to allied health support is limited. When available, support is often siloed and fragmented. Digital health incorporating patient choice may help to align health care services with preferences and goals. This study evaluated the implementation of a ubiquitously accessible patient-centred digital health diet and exercise service.MethodsU-DECIDE was a single-centre, 26-week randomised controlled trial set in kidney and liver disease clinics in a tertiary hospital in Brisbane, Australia. Participants were adults with a complex chronic condition referred for dietetic consultation with at least one feature of the metabolic syndrome. All participants received a dietary consultation, an activity monitor and usual care. Intervention participants were offered one text message per week and access to additional digital health options (increased text message frequency, nutrition app, exercise app, group-based diet and/or exercise video consultations). The primary outcome of feasibility was determined by safety (study-related serious adverse events: SRSAEs), recruitment (≥ 50% eligible patients), retention (≥ 70%), exposure uptake (≥ 75% of intervention group had greater access to health professional contact than comparator) and video consultation adherence (≥ 80% attendance). Secondary outcomes included process evaluation metrics and clinical outcomes.ResultsOf 67 participants (intervention n = 33, comparator n = 34), 37 (55%) were men, median (IQR) age was 51 (41–58) years. The most chosen digital health options were the nutrition app (n = 29, 88%) and exercise video consultations (n = 26, 79%). Only one participant chose no additional digital health options. The intervention group had no SRSAEs. The study exceeded targets for recruitment (52%), retention (81%) and exposure uptake (94%). Video consultation adherence was 42%. Engagement across digital health options was inconsistent.ConclusionsDigital health options incorporating patient choice were feasible and can be offered to people with complex chronic disease as a service model option.Trial registrationAustralia and New Zealand Trials Register: Trial Registration Number: ACTRN12620001282976. Registered 27th November 2020.