Patient Comorbidities Research Articles

Docetaxel Versus Androgen-Receptor Signaling Inhibitors (ARSI) as Second-Line Therapy After Failure of First-Line Alternative ARSI for the Elderly ≥ 75 Years Old With Metastatic Castration-Resistant Prostate Cancer (mCRPC): A SPARTACUSS—Meet-URO 26 Real-World Study

BackgroundAndrogen receptor signalling inhibitors (ARSIs) abiraterone acetate (AA) enzalutamide (Enza), are currently the standard first-line (L1) treatments for metastatic castration-resistant prostate cancer (mCRPC), and docetaxel (D) is reserved as second-line (L2) after ARSI failure. Nonetheless, D use in men ≥ 75 years old is restricted owing to treatment toxicities and patient comorbidities, and a L2 alternative ARSI is frequently used. We aimed to evaluate real-life survival and toxicity outcomes of these elderly patients after failure of L1 ARSI treatment. Material and MethodsWe retrospectively evaluated efficacy and safety in a real-world international cohort of consecutive patients ≥ 75 years old when starting L1 ARSI for mCRPC according to the choice of L2 treatment (D versus alternative ARSI). ResultsOf the 122 identified patients, 57 (46.7%) had received L2 ARSI and 65 (53.3%) L2 D. No difference was found in the L1 overall survival (OS) for the ARSI and D groups (32.8 vs. 30.0 months, respectively; Hazard ratio [HR] = 1.22; 95% CI, 0.77-1.95; P = .40) or in the L2 OS (18.5 vs. 17.8 months, respectively; HR = 1.09; 95% CI, 0.69-1.74; P = .71). No difference was observed for rPFS from L2 (P = .12), although a trend was observed for a numerically improved rPFS on D. ConclusionWithin the limitations of a retrospective design and small population, our study suggests that D or ARSI after failure of L1 alternative ARSI are clinically comparable L2 options for elderly patients with mCRPC.

Which treatment in acetabular fractures of the elderly: Osteosynthesis, osteosynthesis-THA or orthopedic treatment? 2-years retrospective outcomes of a therapeutic algorithm

IntroductionAcetabular fractures account for 7% of osteoporotic fractures, with an epidemiological peak between 75 and 80 years of age. The aim of this study is to evaluate the results of treatment of these fractures in a population aged over 65. HypothesisSurgical treatment would lead to better survival and functional outcomes in the management of acetabular fractures in subjects aged over 65. Material and methodsPatients over 65 years of age treated for acetabular fracture between January 2017 and May 2020 were included in this retrospective single-center study and divided into three treatment groups: osteosynthesis, osteosynthesis-THA (Osteosynthesis-THA) and orthopedic treatment. The choice of treatment was made according to an algorithm that considered the patient's co-morbidities, autonomy and bone lesions. The primary endpoint was patient survival at 12 and 24 months' follow-up. Results94 patients (mean age 78.5 +/-8.4 years) were included: 29 patients treated with orthopedic therapy, 46 patients with osteosynthesis and 19 patients with osteosynthesis-THA. Mean follow-up was 32.7+/-14.9 months.Mortality rates were higher in the orthopedic and osteosynthesis-THA groups (20.7% and 21.1% respectively). Patients in the orthopedic and osteosynthesis-THA groups showed excess mortality, with hazard ratios (HR) of 3.4 ([1.02; 11.3], p < 0.05) and 3.3 ([0.9; 12.3], p = 0.08) respectively, compared with those treated with osteosynthesis.Mean PMA at 2 years, mean Harris score at 2 years and Parker score were significantly higher in the operated groups.The rate of conversion to THA (THA) was higher in the orthopedic treatment group (27.6%). The complication rate was 24% (11/46) for the osteosynthesis group, 42% (8/19) for the osteosynthesis-THA group. DiscussionApplying our decision algorithm, orthopedic treatment is inferior to surgical treatment in terms of survival and functional results, with a higher re-intervention rate for THA than treatment with osteosynthesis. This study confirms the place of osteosynthesis, with higher functional scores, lower complication and revision rates, and a positive effect on mortality. Level of evidenceIV; Retrospective cohort study

Exploration of drug therapy related problems in a general medicine ward of a tertiary care hospital of Eastern Nepal

BackgroundInpatients are at higher risk of Drug Therapy Related Problems (DTRPs), and early identification and management of these DTRPs is crucial for optimal treatment outcomes and ensuring rational drug therapy. ObjectiveThis study aims to assess DTRPs in a general medicine ward of a tertiary care hospital in eastern Nepal. MethodsA three-month prospective observational study was conducted on inpatients admitted to the general medicine ward of the hospital. Pharmacists routinely performed patient drug therapy reviews, by which suspected DTRPs were identified and recorded as per the Pharmaceutical Care Network Europe Association (PCNE) v.9.1 guidelines. Binary logistic regression analysis was used to determine the influence of predictor variables on the occurrence of DTRPs. ResultsA total of 301 inpatients were enrolled, out of which 233 (77.4%) had one or more DTRPs. Altogether, 528 DTRPs with an average of 2.27 ± 0.92 DTRPs per patient were identified. The primary causes of the DTRPs were drug selection (40.47%), treatment duration (16.71%), dispensing (15.75%), and dose selection (13.12%). Antimicrobials were involved in 55.18% of the DTRPs. DTRPs were more prevalent in elderly, comorbid patients, patients with longer hospital stay days, and polypharmacy, which was statistically significant (p<0.05). Furthermore, multivariate binary logistic regression analysis showed that geriatric patients had a higher risk of experiencing DTRPs, with an adjusted odds ratio of 1.832 (1.021-3.286) at p-value < 0.05. ConclusionDTRPs are frequently prevalent in hospital wards, emphasizing the crucial role of clinical pharmacists in identifying, resolving, and preventing DTRPs in inpatient settings for optimal treatment outcomes.

Factores predictivos del ingreso hospitalario y sociosanitario en la fijación de fracturas de tobillo por trauma de baja energía

Ankle fractures are increasingly common in frail patients, with hospitalization being the principal cost driver, particularly for the elderly who often need referral to nursing facilities. This study aims to identify factors affecting resource utilization per admission (hospital and nursing) in the fixation of low-energy ankle fractures. This retrospective cohort study examined patients undergoing fixation for low-energy ankle fractures. The primary outcome was the length of hospitalization. Secondary outcomes included delays in fixation and the need for referral to a nursing institution. Multiple linear and logistic regression models were used to determine predictors related to patient demographics, injury characteristics, and treatment. We analyzed 651 patients with a median age of 58 years. The median hospitalization duration was 9 days, primarily before surgery. Extended hospitalization was associated with antithrombotic treatment (b=4.08), fracture-dislocation (2.26), skin compromise (7.56), complications (9.90), and discharge to a nursing center (5.56). Referral to a nursing facility occurred in 17.2%, associated with older age (OR=1.10) and an ASA score ≥III (6.96). Prolonged hospitalization was mainly due to surgical delays and was related to fracture-dislocations, skin compromise, and complications. Older and comorbid patients were more likely to need nursing facilities, and delays in these facilities' availability contributed to extended hospital stays.

Periprosthetic acetabular fractures: classifications, treatment and challenges

Periprosthetic acetabular fractures (PPAF) are fractures of the acetabulum with ahip endoprosthesis in place. They are arare complication, although they are occurring more frequently due to the increase in patients being fitted with total hip arthroplasty (THA) and the long service life of the implants. At present, only asmall amount of scientific literature exists, particularly regarding the surgical treatment of these fracture types.The aim of this paper is to provide an overview of the topic of PPAF with acritical review of the current literature and to present the necessary surgical treatment.An evaluation of the current literature on the topic of PPAF with afocus on the surgical treatment of fractures is carried out.Surgical treatment is technically demanding due to the pelvic ring instability with removal of the bone tension for secure acetabular cup fixation and should lead to the recovery of the biomechanical stability of the pelvis and thus the secure anchoring of the acetabular cup. An interdisciplinary approach requiring both trauma surgery and orthopaedic expertise is certainly recommended, as older and comorbid patients with poor bone quality are particularly frequently affected.The treatment of periprosthetic acetabular fractures, especially in older patients, requires not only the individual expertise of surgeon involved in the operation but also agoal-oriented and consistent interdisciplinary approach by the surgeons involved from the fields of orthopaedics and trauma surgery in view of the patients' frequent comorbidities. By working together, the optimal and individualized operation can be performed for the patient.

The age-adjusted Charlson comorbidity index in acetabular fracture in geriatric acetabular fractures

ObjectiveThis study aimed to analyze factors of comorbidity in older patients with acetabular fracture to know the role of disease in the treatment of this population. MethodsDesign: retrospective cohort study. SettingSingle Level 2 Trauma Center. Patient selection criteriaA prospective database of acetabular fractures in patients over 55 years between January 2011 and January 2021 was studied. The exclusion criteria were age, pathological fracture, associated pelvic or hip fracture, follow-up of less than one year, and not having a computed tomography. Outcome measures and comparisonsPatients were categorised as low (0–2), intermediate (3–4) or high (≥5) risk according to the age-adjusted Charlson comorbidity index (ACCI). The primary outcomes were risk of complications, number of complications and mortality at one year according to the ACCI scale. The difference between the pre-fracture Clinical Frailty Scale (CFS) and the one-year follow-up was also analysed. Descriptive and multivariable regression analyses were performed and ROC curves were constructed. ResultsA total of 119 patients with acetabular fracture were collected. Ninety-eight out of those met inclusion criteria for our study. In regard to ACCI groups, 22% were low-risk, 26% were intermediate-risk, and 52% were high-risk. Statistically significant differences were found according to age, sex, mechanism of injury, treatment type, surgical treatment type, Clinical Frailty Scale (CFS) score, readmissions, complications, and mortality. ROC curves showed an association between ACCI and CFS in terms of complications and mortality, with the exception of unadjusted Charlson comorbidity index. On the multivariable regression analysis, associations were found between ACCI and presence of complications (OR 1.37, 95% CI 1.06–1.77, p=0.015) and mortality (OR 1.32, 95% CI 1.04–1.67, p=0.025) and between CFS and complications (OR 2.01, 95% CI 1.30–3.11, p=0.001) and mortality (OR 1.59, 95% CI 1.08–2.35, p=0.019). No statistical correlation was established between ASA and complications or mortality. ConclusionPresurgical ACCI and CFS scales may serve as a risk assessment method in treatment decision-making for patients with acetabular fracture. An association is observed between patients with a pre-fracture ACCI score ≥5 (high-risk) and a pre-fracture CFS score >4 (mild frailty) and mortality and complications at one year.

Exploring diseases burden in HIV population: Results from the CHAO (Comorbidities in HIV/AIDS outpatients) cross-sectional study in Kenya

BackgroundAfrica is the epicenter of the HIV epidemic, with over two-thirds of the global population living with HIV. It is also facing a dramatic increase in non-communicable diseases (NCDs) amidst its aging population. This necessitates a healthcare approach that addresses both infectious diseases and NCDs in HIV-positive individuals. In Kenya, with 1.4 million HIV-positive people, efforts include widespread ART access and integrating HIV services into the health system. Challenges remain in healthcare infrastructure, particularly in rural areas. The Comorbidities in HIV/AIDS Outpatients (CHAO) Project, funded by the Italian Cooperation Agency, aims to improve understanding and management of comorbidities in HIV patients, highlighting the need for cost-effective healthcare strategies to address this dual burden. MethodsThe CHAO (Comorbidities in HIV/AIDS Outpatients) project conducted a cross-sectional epidemiological study across 25 clinics in Meru County, Kenya. The study included comprehensive surveys and screenings for various comorbidities among HIV-positive patients receiving treatment, utilizing both clinical evaluations and laboratory tests to assess the prevalence of infectious diseases and NCDs. ResultsA total of 1051 HIV-positive individuals were included in the study: 75 % females, 25 % males, median age 47 years, the majority (96 %) on long-term ART, mostly Dolutegravir-based (95 %). 55.4 % had at least one comorbidity, with NCDs such as dyslipidemia (21.22 %) and hypertension (20.17 %) being the most prevalent. The study also noted significant occurrences of communicable diseases, including syphilis (5.23 %), hepatitis B (2.19 %), and hepatitis C (0.29 %). The prevalence of comorbidities varied with age, highlighting the impact of aging on disease burden. DiscussionThe high prevalence of comorbidities among HIV-positive patients in Meru County underscores the need for integrated healthcare strategies that address both infectious diseases and NCDs. The findings advocate for systematic screening and management of comorbidities within HIV care programs, emphasizing the need for holistic health approaches to improve outcomes for this population.

Dengue fever in hyperglycemic patients: an emerging public health concern demanding eyes on the effective management strategies.

Hyperglycemia, also known as diabetes, is a metabolic disorder characterized by elevated levels of glucose in the bloodstream. It can lead to the prolonged dysfunction, injury, and deterioration of several organs. In addition, dengue is a viral illness transmitted by mosquitoes that has reached epidemic proportions worldwide. In this article, we focused on the severity of comorbidities, difficulties in managing them, and preventive measures meant to lessen the risks associated with comorbidities in diabetic patients with dengue infection. We explored a number of databases, including PubMed, Scopus, Embase, Web of Science, Google Scholar, and the Cochrane Library, for this review article using various related keywords. The findings of this review article indicate that elderly dengue patients with diabetes should be admitted to the hospital for close observation and early management using fluid therapy. An observed association exists between dengue hemorrhagic fever (DHF) and diabetes, indicating a possible consequence in this specific group. Additionally, patients with diabetes who contract dengue show elevated levels of inflammatory markers. Diabetes mellitus deteriorates the immune system, which exacerbates the progression of dengue fever. Cutting-edge technology and scientific research may assist in addressing the challenges that diabetes and dengue viruses pose in low- and middle-income countries. Implementing innovative diabetic care management is essential to ensuring consistency of care, improving a healthy lifestyle, and lowering patient risk factors and comorbidities. Dengue fever has spread to epidemic levels throughout the world. Inflammatory markers increase and the prevalence of DHF is greater in diabetes individuals with dengue infection. Given the continued growth of dengue in Asian nations, it is imperative that we concentrate our efforts and resources on providing more precise and effective treatment for this emerging issue.

A Comparative Analysis of Patient-Reported Outcomes Following Free Tissue Transfer, Partial Foot Amputation, and Below-Knee Amputation in High-Risk Limb Salvage Patients.

The surgical decision for limb-salvage with free tissue transfer (FTT), partial foot amputation (PFA), or below-knee amputation (BKA) for complex lower extremity (LE) wounds hinges on several factors, including patient choice and baseline function. However, patient-reported outcome measures (PROMs) on LE function, pain, and QoL for chronic LE wound interventions are limited. Thus, the study aim was to compare PROMs in patients who underwent FTT, PFA, or BKA for chronic LE wounds. PROMs were collected via QR code for all adult chronic LE wound patients who presented to a tertiary wound center between June 2022 and June 2023. A cross-sectional analysis of patients who underwent FTT, PFA, or BKA was conducted. The 12-Item Short Survey (SF-12), PROM Information System Pain Intensity (PROMIS-3a), and Lower Extremity Functional Scale (LEFS) were completed at 1, 3, and 6 months and 1, 3, and 5 years postoperatively. Patient demographics, comorbidities, preoperative characteristics, and amputation details were collected. Of 200 survey sets, 71 (35.5%) underwent FTT, 51 (25.5%) underwent PFA, and 78 (39.0%) underwent BKA. Median postoperative time points of survey completion between FTT (6.2 months, IQR: 23.1), PFA (6.8 months, IQR: 15.5), and BKA (11.1 months, IQR: 21.3) patients were comparable (P = 0.8672). Most patients were male (n = 92, 76.0%) with an average age and body mass index (BMI) of 61.8 ± 12.6 years and 30.3 ± 7.0 kg/m2, respectively. Comorbidities for FTT, PFA, and BKA patients included diabetes mellitus (DM; 60.6% vs 84.2% vs 69.2%; P = 0.165), peripheral vascular disease (PVD; 48.5% vs 47.4% vs 42.3%; P = 0.790), and chronic kidney disease (CKD; 12.1% vs 42.1% vs 30.8%; P = 0.084). No significant differences were observed between FTT, PFA, and BKA patients in mean overall PROMIS-3a T-scores (49.6 ± 14.8 vs 54.2 ± 11.8 vs 49.6 ± 13.7; P = 0.098), LEFS scores (37.5 ± 18.0 vs 34.6 ± 18.3 vs 38.5 ± 19.4; P = 0.457), or SF-12 scores (29.6 ± 4.1 vs 29.5 ± 2.9 vs 29.0 ± 4.0; P = 0.298). Patients receiving FTT, PFA, or BKA for chronic LE wounds achieve comparable levels of LE function, pain, and QoL postoperatively. Patient-centered functionally based surgical management for chronic LE wounds using interdisciplinary care, preoperative medical optimization, and proper patient selection optimizes postoperative PROMs.

Sterile Draping of Operative Microscopes in Breast Free Flaps and Surgical Site Infections.

Operative microscopes are traditionally draped in single-use plastic to prevent infection theoretically. The necessity of this routine in breast free flap surgery is unclear. Alternatively, sterile wrapping of microscope handles would reduce operating room waste and provide a more cost-effective and environmentally sustainable approach to sterility. This study aimed to determine whether the draping technique used during abdominally based free flaps (Ab-FF) influenced the rate of surgical site infections. We conducted a retrospective review of Ab-FF performed consecutively between March 2017 and August 2022. Patient demographics, comorbidities, perioperative data, and postoperative complications were collected. The primary outcomes included postoperative surgical site infections and environmental impact. Of the 281 identified breasts reconstructed with Ab-FF, operating microscopes were sterilely covered with microscope drapes (n = 215) or handle covers (n = 66) composed of polyethylene-based plastic. Overall, postoperative infections occurred in 9.3% of cases (n = 26) in either the recipient breast (n = 11, 3.9%) or abdominal donor site (n = 15, 5.3%), primarily due to S. aureus and Streptococcus species . The handle (n = 6, 9.1%) and drape (n = 20, 9.3%) cohorts had similar infection rates with no sequelae of operative complications. In multivariate analysis, radiation was the only independent predictor of postoperative infection, while bilateral reconstructions were independently protective. Replacing a microscope drape with a handle reduces carbon emissions by 1276 grams of CO 2 and direct costs by $7.84 per item. The principles of "Lean and Green" surgery prioritize reducing operating room generated waste to achieve financial and environmental sustainability. This cohort study of 281 breast free flaps demonstrates that switching from whole microscope draping to handle wrapping was not associated with an increased rate or odds of infection. Adopting a microscope handle wrapping protocol decreased the carbon footprint and operative costs. The results of this study offer evidence to support adoption and further exploration of pragmatic, cost-effective, and sustainable approaches to microsurgical breast reconstruction.

Unintended readmissions and reoperations within 30 and 90 days following adult spinal deformity surgery.

This study investigated the rates and etiologies of unintended readmissions and reoperations within 30 and 90 days after adult spinal deformity (ASD) surgery. The authors aimed to identify the risk factors for readmission and reoperation by analyzing patient demographic and surgical characteristics. This retrospective cohort study included 307 consecutive patients who underwent surgery for ASD from 2012 to 2022 at a single academic institution. Data were collected on patient demographic characteristics, comorbidities, operative details, and postoperative complications. Chi-square and multivariable logistic regression models were used to identify the risk factors associated with 30- and 90-day readmissions and reoperations. The mean ± SD age at surgery was 66.6 ± 10.5 years, and the majority (80.8%) of patients were female. The 30-day and 90-day readmission rates were 11.7% and 15.3%, respectively. Multivariable regression for 30-day readmissions revealed that length of hospital stay (LOS) after index surgery of > 20 days (OR 2.48) and surgical factors such as vertebral column resection (VCR) (OR 4.26) and pelvic fixation (OR 4.38) were risk factors. Other factors such as the American Society of Anesthesiologists Physical Status Classification System (ASA) class, prior spine surgery, and age were not associated with 30-day readmissions. Ninety-day readmission was associated with high ASA class (OR 2.37) and LOS > 20 days (OR 2.82). The 30- and 90-day reoperation rates were 7.8% and 10.1%, respectively. The variables associated with 30-day reoperations were intraoperative VCR (OR 3.34) and LOS > 20 days (OR 9.38). Ninety-day reoperations were associated with dural tears (OR 3.33) and LOS > 20 days (OR 3.68). This study provides valuable insights into the incidence of unintended readmission and reoperation within 30 and 90 days after ASD surgery in an Asian population. By identifying the associated risk factors, healthcare providers can customize surgical strategies and optimize perioperative care to effectively mitigate these events.

A comparative analysis of free fibula flap donor leg and recipient vessel selection in composite oromandibular defect reconstructions

BackgroundThe fibula free flap (FFF) is acknowledged as the primary choice for reconstructing composite oromandibular defects (COMD), yet the impact of donor leg selection remains inadequately explored. This study aims to investigate the correlation between flap failure and the choice of donor leg and recipient vessel side. Materials & MethodsIn a retrospective analysis spanning 2011 to 2020, FFFs for COMD were examined using electronic records. Patient data, comorbidities, radiation history, FFF details, and intraoperative variables were considered. Laterality was categorized into "Cis" and "Trans" groups, further subclassified based on blood supply. Analyses involved logistic regression, bivariate analysis, and propensity score matching. ResultsA total of 155 subjects with intraoral mucosal defects repaired only by the skin paddle of FFF were included. Cases were categorized into "Cis" (n=65; 42%) and "Trans" (n=90; 58%) groups based on COMD side and donor leg selection. No significant baseline differences emerged. Logistic regression found no laterality impact on total FFF failure. Initially, gender correlated with flap failure, but adjustment diminished the association. Partial skin paddle necrosis correlated with diabetes, not laterality. Propensity score matching revealed no significant differences between right and left legs in laterality or total flap failure risk. Subgroup analysis found no differences in parameters or flap failure rates within "Cis" and "Trans" groups. ConclusionDonor leg selection in COMD reconstruction with FFFs does not exhibit specificity. Furthermore, despite potential limitations in vessel anastomosis due to pedicle length or trauma history, recipient vessel side selection does not evidently affect flap failure.

Lost dwell time and cycler alarms in inpatient automated peritoneal dialysis at a tertiary care hospital

Background and aims Dwell time is a critical component of automated peritoneal dialysis (APD) prescription, the stage at which transmembrane mass and fluid transfer occur. Loss of prescribed dwell time (LDT) can negatively influence the efficiency of APD. We investigated the incidence of LDT and related causes using APD in the acute care setting at a tertiary care center. Methods Retrospective analysis was conducted of all inpatients receiving APD treatments from 1 December 2021 to 1 June 2023. Patient demographics, comorbidities, laboratory, and treatment data were extracted from electronic medical records and a propriety database. Results N = 235 cycler treatments completed by 32 patients were included for analysis. The total LDT per treatment exceeding 30 minutes and 60 minutes occurred in 27% and 20% of all treatments. LDT of more than 10 minutes per each cycle exchange occurred in 26%. Session disruptions were caused by slow out-flow (55%), inadequate drain volumes (32%), patient line occlusions (20%), and priming errors (23%). The slow flow alarm requiring user intervention was reported to occur in about one-third of all treatments (31%). Conclusion There was significant LDT and inadequate drain volume seen in about one-quarter and one-third of all inpatient APD treatments respectively. This can impact solute clearance and ultrafiltration. Slow flow alarms were the most prevalent and the leading cause of LDT followed by inadequate drain volume. Future studies are required to investigate measures to reduce slow drain and improve drain volume in the hospital setting.

Real-world safety and effectiveness of pirfenidone and nintedanib in the treatment of idiopathic pulmonary fibrosis: a systematic review and meta-analysis.

Multiple randomized controlled studies have shown that pirfenidone and nintedanib are effective and safe for treating idiopathic pulmonary fibrosis. This study aimed to evaluate their efficacy, safety, and tolerability in a real-world setting. We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases for real-world studies published up to March 3, 2023, on pirfenidone and nintedanib for idiopathic pulmonary fibrosis. A total of 74 studies with 23,119 participants were included. After 12months of treatment, the change from baseline in percent predicted FVC (%FVC) was - 0.75% for pirfenidone and - 1.43% for nintedanib. The change from baseline in percent predicted DLCO (%DCLO) was - 2.32% for pirfenidone and - 3.95% for nintedanib. The incidence of acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) was 12.5% for pirfenidone and 14.4% for nintedanib. The IPF-related mortality rates of pirfenidone and nintedanib were 13.4% and 7.2%, respectively. The all-cause mortality was 20.1% for pirfenidone and 16.6% for nintedanib. In the pirfenidone group, 16.6% of patients discontinued treatment because of adverse events, and in the nintedanib group, 16.2% of patients discontinued treatment because of adverse events. The incidence of adverse events was 56.4% and 69.7% for pirfenidone and nintedanib, respectively. The results of this study indicate that pirfenidone and nintedanib are both effective in slowing down the decline of lung function in IPF patients in real-world settings. The incidence of adverse events with pirfenidone is lower than that with nintedanib, but both are below the clinical trial data, and no new major adverse events have been observed. The discontinuation rates due to adverse reactions of the two drugs are consistent with clinical trial data, indicating good tolerability. However, the mortality rates and AE-IPF incidence rates of these two drugs in real-world settings are higher than those in previous clinical trials, with pirfenidone patients showing a higher mortality rate. Further large-sample studies are needed to investigate the risks of these drugs in these aspects. Additionally, we recommend that future real-world studies pay more attention to patients' subjective symptoms and conduct stratified analyses of the efficacy and safety of pirfenidone and nintedanib based on factors such as patients' baseline lung function, comorbidities, and age, in order to provide more personalized medication advice for IPF patients in clinical practice.

A Retrospective Analysis of Disease Epidemiology, Comorbidity Burden, Treatment Patterns, and Healthcare Resource Utilization of Migraine in the United Arab Emirates.

Migraine is a recurrent, disabling neurological disorder with a substantial global disease burden. However, limited real-world data are available on the patient characteristics, treatment patterns, comorbidities, and economic burden of migraine in the United Arab Emirates (UAE). In this study, we evaluated the disease burden, comorbidities, treatment patterns, specialties involved in migraine diagnosis, and healthcare resource utilization (HCRU) and associated costs in patients with migraine in Dubai, UAE. A retrospective, secondary database cohort study was conducted from 01 January 2014 to 31 March 2022 using the Dubai Real-World Database. Patients aged ≥ 18years with at least one diagnosis claim for migraine with continuous enrollment during the study period were included. Patients were stratified into treatment sub-cohorts. Outcomes were evaluated in terms of clinical characteristics, comorbidities, specialists visited, treatment patterns, and HCRU. The study included 203,222 patients (mean age: 40years), with male predominance (55.4%). About 13.4% of patients had specific cardiovascular comorbidities. Frequently prescribed drug classes were nonsteroidal anti-inflammatory drugs (84.4%), triptans (29.8%), and beta-blockers (12.8%), while only 1.0% of patients with migraine were prescribed newer medications like calcitonin gene-related peptide antagonists. General medicine was the most frequently visited specialty on the index date (51.5%). The all-cause and migraine-specific median gross costs during the 12-month post-index period were US $1252.6 (2.4-564,740.7) and US $198.1 (0-168,903.3) respectively, with maximum contribution from inpatients. The contribution of migraine-specific median costs to all-cause median costs was highest for the diagnosis-related group (64.9%), followed by consumables (35.2%), medications (32.0%), procedures (24.5%), and services (24.5%). Migraine significantly impacts healthcare costs in the UAE. The role of newer therapies in migraine management should be explored to reduce the associated socioeconomic burden and improve patients' quality of life.

Patterns and predictors of opioid dispensing among older cancer patients from 2008 to 2015.

Understanding factors associated with opioid dispensing in cancer patients is important for developing tailored guidelines and ensuring equitable access to pain management. We examined patterns and predictors of opioid dispensing among older cancer patients from 2008 to 2015. We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database linked to Medicare claims. We included the most common cancer types among patients aged 66-95 years. Opioids dispensed within 30 days before and 120 days after cancer diagnosis were assessed. We used logistic regression models to examine trends, adjusted odds ratios (aORs), and 95% confidence intervals (CIs) for opioid dispensing, considering patient demographics, geography, cancer stage, comorbidities, and treatment options. Models were stratified by sex. A total of 211,759 cancer patients aged 66-95 years were included in the study. For cancers combined, non-Hispanic Black men had a significantly lower odds of receiving opioids during the 120 days post-diagnosis (aOR = 0.89, 95% CI = 0.84-0.94) compared to non-Hispanic White men. Factors such as pre-diagnosis opioid dispensing, age, geography, cancer stage, comorbidities, and type of cancer treatment were associated with opioid dispensing during the 120 days post-diagnosis. Surgery had the strongest association, with men undergoing surgery being 4.4 times more likely to receive opioids within 120 days post-diagnosis (aOR = 4.41, 95% CI = 4.23-4.60), while women had an odds ratio of 2.72 (95% CI = 2.62-2.83). Chemotherapy and radiotherapy were also positively associated with opioid dispensing, with less pronounced estimates. We observed significant variations in opioid dispensing among cancer patients aged 66-95 years across cancer types and demographic and clinical factors.

The Therapeutic Potential of Transdermal Gabapentin in the Symptomatic Management of Chronic Neuropathy

Standard pharmacotherapeutic options in the management of neuropathic pain are often poorly tolerated due to various contraindications, drug interactions, and troublesome adverse events. The investigation and pharmaceutical development of localized anti-neuropathic options is increasing among researchers and manufacturers, but results have not yet determined the role in therapy of transdermal/locally acting analgesics, anti-neuropathics, and anti-inflammatories. Compounding Pharmacies and FDA 503b Outsourcing Facilities aid in this critical endeavor through endogenous compounding and manufacturing (respectively) of transdermal analgesic formulations. This review summarizes the currently available clinical data supporting the implementation of transdermal gabapentin preparations in the management of chronic neuropathic symptoms. Transdermally applied analgesic, anti-inflammatory, and anti-neuropathic preparations are crucial in the development of pain management modalities which reduce the risk of numerous well-known complications, including drug-drug interactions, conflicting patient comorbidities, and CNS depressant effects. The adjunctive treatment of neuropathy with a transdermal analgesic/antispasmodic preparation remains under-investigated, and the role of these preparations in the management of chronic neuropathic pain remains unclear.

Impact of early palliative care referral in patients with locally advanced and metastatic GI/lung cancer.

201 Background: Early palliative care improves quality of life and survival in patients with metastatic NSCLC. As a result, ASCO recommends early palliative care integration in patients with metastatic cancer. However, generalizing the benefits outside of a clinical trial may be difficult due to selection bias of patients that opt into palliative care due to advanced symptom burden and real-world resource constraints. Therefore, the benefits of this in real-world practice may not be realized. We aimed to evaluate early vs late palliative care referral impact on unplanned hospital visits and survival among GI and lung cancer patients at a large health system cancer center. Methods: The study design was a retrospective, single health system, review of patients treated at Orlando Health from 2021-2022.156 patients of all stage GI and Lung cancers were included. For these patients, early referral was defined as receiving a palliative referral within 8 weeks of cancer diagnosis. Any referral later than this was considered late and it was possible for patients to opt out of referral. Our main outcomes were unplanned hospital visits and survival. To compare the rates of these between palliative care referral groups, a multivariable negative binomial regression model was fitted. To assess any differences in survival, a multivariable cox hazard regression model was fitted. These were adjusted for age, sex, diagnosis, stage, ECOG, race, and insurance. Results: Patients with any palliative care referral had increased unplanned hospital visits and shorter survival than patients who did not have referrals. Specifically, patients with no palliative care referrals had a 62% lower relative rate of unplanned hospital visits compared to patients with early referral (RR = 0.38 [0.22-0.66], p&lt;0.001). And patients with any time referral had approximately 8 months lower restricted mean survival times (RMST) when followed for 2 years for stage 1-3 cancers than patients receiving no palliative care (14 vs 22 month RMST; stage x palliative care interaction, p &lt;0.05). In contrast, stage 4 patients had similar survival of ~14-month RMST when followed for 2 years regardless of referral. Conclusions: In real world practice palliative care referral was associated with increased unplanned hospital visits. Additionally, in this retrospective review, palliative care referral was not found to confer a survival advantage in gastrointestinal and Lung cancer patients. We postulate that this is related to selection bias in the opt in approach to palliative care referral biasing towards a sicker population with higher symptom burden and comorbidities. Our future prospective study will build upon this work through expansion of palliative care services and to better evaluate patient co-morbidities. Our goal is to increase utilization of palliative care for patients with GI and lung malignancies as part of a multidisciplinary integrative approach.

Recurrent Urinary Tract Infection- Etiology, Risk Factors and Outcome in a Tertiary Care Hospital of Bangladesh

Background: Urinary tract infections (UTIs) are one of the major causes of morbidity and comorbidities in patients with underlying conditions, and it accounts for the majority of the reasons for hospital visit globally. The high prevalence of recurrent UTIs represents a modifiable determinant for both societal and personal burdens, hence the importance of disease prophylaxis. Consultations for UTIs represent between 1% and 6% of all medical visits (~7 million visits and ~US$1.6 billion annually). They are associated with a significant burden of morbidity and mortality in the elderly, among whom UTIs are most prevalent. Methods: This cross-sectional descriptive type of observational study was conducted in the Department of Nephrology in Anwer Khan Modern Medical College Hospital, Dhaka, Bangladesh from January 2023, to December 2023. A total no of 93 patients were included in the study. Inpatients, age range 21-85 years, presenting or highly suspicious of having UTIs and the occurrence of ≥2 symptomatic episodes within 6 months or ≥3symptomatic episodes within 12 months were recruited in the study. Any patient who was terminally ill, who fails to give urine samples, with a history of antibiotic administration in the last two weeks and any female who was in their menstruation period were excluded from the study. Results: Among them 79 were female and 14 were male. Female to male ratio was 5.64:1. Mean age of the patients was 58.61±17.51 (Mean±SD). Most of the patients were of 61-70 years age group 23/93 (24.73%) and after that41-50 years 19/93 (20.43%). 92.47% (86/93) were married and 7.53% (7/93) were unmarried. Most of the patients were of Diabetes mellitus (DM) 57/93 (61.29%). After that Hypertension, Chronic Kidney Disease (CKD) and CKD + DM about 51/93 (54.84%), 39/93 (41.94%) and 36/93 (38.71%) respectively. 54/79 (68.35%) were of menopause and 24/79 (30.38%) women had regular menstrual cycle. 1/79 (1.27%) was pregnant.Escherichia coli(E coli) was the most prevalent uropathogens with 47/93 (50.54%) followed by Klebsiella pneumoniae 12/93 (12.90%), Pseudomonas aeruginosa 10/93 (10.75%), Streptococcus pyogenes 8/93 (8.60%), Staphylococcus aureus 6/43 (6.45%), Enterococcus faecalis 5/93 (5.38%) and others 5/93 (5.38%). 77.42% were of relapse and 22.52% were of reinfection. The Mean±SD of HbA1c was 7.83±2.15% and that of Serum creatinine and Hemoglobin were 2.17±1.18 mg/dl and 9.82±2.60gm%. On routine examination of urine, 39/93 (41.94%) patient had trace albumin present in urine and 57/93 (61.29%) had reducing sugar. 71/93 (76.34%) had1-2 pus cell in urine and 22/93 (23.66%) presented with plenty of pus cell with 19/93 (20.43%) had 0-4 RBC’s (Red blood cell). Factors associated with recurrent UTI were Age &gt;50 years (56.99%), Female gender (84.95%), Married (92.47%), Menopause (58.06%), Diabetes mellitus (61.29%), Indwelling catheter &gt;6 days (25.81%) and Genitourinary abnormalities (15.05%). Conclusion: This study has demonstrated that hospitalization, married individuals, duration of catheter, diabetes mellitus, genitourinary tract abnormalities, female gender and menopause are the most important factors associated with UTIs. Appropriate measures may help to reduce UTIs due to these associated factors. We recommend routine UTIs screening of patients of the following category: hospitalized, genitourinary tract abnormalities, indwelling catheter, diabetic, female gender, menopause and married individuals. If these routine checks are put in place, prevention of UTI can be realized at lower cost. Bangladesh J Medicine 2024; 35: 173-179

Allergocomponent diagnostics in the management of comorbid patients

Polyvalent sensitization (simultaneous formation of antibodies to allergens from several sources, for example, to cat allergens, birch pollen, strawberry allergens), which can occur at any age, concerns a significant number of patients with allergic diseases. The diagnostic search for a causal allergen is difficult in patients with polyvalent sensitization and/or cross-reactions to allergens of unrelated groups of allergens. We have carried out work on the detection of polysensitization in patients by the ALEX2 molecular diagnostic method, which detects specific antibodies to 300 allergens (120 allergens and 180 allergenic molecules + total IgE) in one study. The presented clinical examples clearly show the possibility of identifying the spectrum of causal allergens to clarify the diagnosis, which subsequently makes it possible to prescribe the right treatment to prevent the development of complications, which is especially important for comorbid patients