Management Of Patients Research Articles

Contributing Factors to the Challenges of Patient Health Monitoring in Rural Healthcare Units: Basis for a Proposed Integrated Patient Management Portal

In the current era of abundant information, technological advancements have greatly impacted various fields particularly the healthcare sector. This research explores the difficulties encountered by rural healthcare facilities in Barangay Poblacion, Bacuag, Surigao del Norte, in monitoring patient health and suggests implementing a remote patient management platform to enhance healthcare delivery. Using a mixed-method approach, the study involved 37 participants, predominantly young females. The research identified key challenges such as limited access to healthcare facilities, a shortage of medical staff, communication issues, and insufficient healthcare resources. Although patient registration and monitoring of vital signs were relatively effective, challenges remained in scheduling appointments, availability of medical tests, and patient education. The overall positive perception of the current system (average weighted mean of 3.59) indicates room for improvement through the proposed remote patient management platform. This platform aims to improve real-time monitoring, data accuracy, and communication between patients and healthcare providers, thereby enhancing healthcare outcomes in rural areas

Acute generalized exanthematous pustulosis: European expert consensus for diagnosis and management.

Acute generalized exanthematous pustulosis (AGEP) is a rare, usually drug-induced, acute pustular rash. Despite the lack of strong data supporting the effectiveness of topical or systemic corticosteroids in this drug reaction, they are widely used. More generally, there is no consensus on the diagnostic modalities and the management of patients with AGEP. We aimed to provide European expert recommendations for the diagnosis and management or patients with AGEP. Members of the ToxiTEN group of the European Reference Network (ERN)-skin, all dermatologists and/or allergologists with expertise in drug reactions, elaborated these recommendations based on their own experience and on a review of the literature. Recommendations were separated into the following categories: professionals involved, assessment of the diagnosis of AGEP, management of the patient and allergological work-up after the acute phase. Consensus was obtained among experts for the list of professionals involved for the diagnosis and management of AGEP, including the minimum diagnostic work-up, the setting of management, the treatments, the modalities and the timing of allergological work-up and follow-up. European experts in drug allergies propose herein consensus on the diagnosis and management of patients with AGEP. A multidisciplinary approach is warranted, including dermatologists, allergologists and pharmacovigilance services.

Suboptimal monitoring and management in patients with unrecorded stage 3 chronic kidney disease in real-world settings: Insights from REVEAL-CKD.

Clinical practice guidelines for patients with chronic kidney disease (CKD) recommend regular monitoring and management of kidney function and CKD risk factors. However, the majority of patients with stage 3 CKD lack a diagnosis code, and data on the implementation of these recommendations in the real world are limited. To assess the implementation of guideline-directed monitoring and management practices in the real world in patients with stage 3 CKD without a recorded diagnosis code. REVEAL-CKD (NCT04847531) is a multinational, observational study of patients with stage 3 CKD. Eligible patients had ≥2 consecutive estimated glomerular filtration rate (eGFR) measurements indicative of stage 3 CKD recorded >90 and ≤730 days apart, lacked an International Classification of Diseases 9/10 diagnosis code corresponding to CKD any time before and up to 6 months after the second eGFR measurement. Testing of key measures of care quality were assessed. The study included 435,971 patients from 9 countries. In all countries, the prevalence of urinary albumin-creatinine ratio and albuminuria testing was low. Angiotensin-converting enzyme inhibitor, angiotensin receptor blocker and statin prescriptions were highly variable, and sodium-glucose cotransporter-2 inhibitor prescriptions remained below 21%. Blood pressure measurements were recorded in 20.2%-89.9% of patients. Overall, a large proportion of patients with evidence of stage 3 CKD did not receive recommended, guideline-directed monitoring and management. The variability in standard of care among countries demonstrates a clear opportunity to improve monitoring and management of these patients, most likely improving long-term outcomes.

PRADOC: A Multicenter Randomized Controlled Trial to Assess the Efficiency of PRADO-IC, a Nationwide Pragmatic Transition Care Management Plan for Hospitalized Patients With Heart Failure in France.

The PRADO-IC (Programme de Retour à Domicile après une Insuffisance Cardiaque) is a transition care program designed to improve the coordination of care between hospital and home that was generalized in France in 2014. The PRADO-IC consists of an administrative assistant who visits patients during hospitalization to schedule follow-up visits. The aim of the present study was to evaluate the PRADO-IC program based on the hypotheses provided by health authorities. The PRADOC study is a multicenter, controlled, randomized, open-label, mixed-method trial of the transition program PRADO-IC versus usual management in patients hospitalized with heart failure (standard of care group; NCT03396081). A total of 404 patients were recruited between April 2018 and May 2021. The mean patient age was 75 years (±12 years) in both groups. The 2 groups were well balanced regarding severity indices. At discharge, patients homogeneously received the recommended drugs. There was no difference between groups regarding hospitalizations for acute heart failure at 1 year, with 24.60% in the standard of care group and 25.40% in the PRADO-IC group during the year following the index hospitalization (hazard ratio, 1.04 [95% CI, 0.69-1.56]; P=0.85) or cardiovascular mortality (hazard ratio, 0.67 [95% CI, 0.34-1.31]; P=0.24). The PRADO-IC has not significantly improved clinical outcomes, though a trend toward reduced cardiovascular mortality is evident. These results will help in understanding how transitional care programs remain to be integrated in pathways of current patients, including telemonitoring, and to better tailor individualized approaches. URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03396081.

Effectiveness of ultrasonography in the diagnosis of temporomandibular joint disorders: A systematic review and meta-analysis.

Temporomandibular disorders (TMDs) pose diagnostic challenges, and selecting appropriate imaging modalities is crucial for accurate assessment. This study aimed to compare the diagnostic accuracy and efficacy of ultrasonography (US) and magnetic resonance imaging (MRI) in identifying TMDs. A comprehensive meta-analysis was conducted, including studies that compared US and MRI for TMJ disorder assessments. Fixed-effects models were utilized to calculate pooled odds ratios (ORs) and relative risks (RRs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the chi-squared test and I2 statistic. Newcastle-Ottawa scale was used to assess the methodological quality of the studies included. Six studies were included, involving a total of 281 participants. The meta-analysis demonstrated that MRI was statistically somewhat better than US in identifying TMJ disorders. The summary OR was 0.64 (95% CI: 0.46-0.90), and the summary RR was 0.80 (95% CI: 0.68-0.95). Heterogeneity among the studies was low (χ2 = 2.73, df = 5, p = .74; I2 = 0%). Demographic variables revealed variations in sample size, gender ratio and mean age across the studies. This meta-analysis provides evidence that MRI may be more effective than US in diagnosing TMDs. However, the study is limited by the small number of included studies and variations in demographic variables and study designs. Future research with larger samples and standardised protocols is essential to confirm and strengthen these findings. Understanding the diagnostic accuracy of MRI and US for TMJ disorders will aid clinicians in making informed decisions for effective TMJ disorder assessments and patient management.

Practical considerations in the management of patients treated with bosutinib for chronic myeloid leukemia.

Bosutinib is a second-generation tyrosine kinase inhibitor indicated for the treatment of patients with newly diagnosed Philadelphia chromosome-positive chronic phase chronic myeloid leukemia (CML), and for patients with Ph + chronic phase, accelerated phase, or blast phase CML resistant or intolerant to prior therapy. As is the case for all TKIs approved for treatment of CML, bosutinib is associated with adverse events (AEs) that require appropriate management to ensure adherence to treatment and optimized outcomes. The aim of this review is to provide physicians with updated practical information for the prevention and management of AEs occurring during treatment with bosutinib, including dosing strategies, based on the latest published evidence and clinical experience. Clinical studies and real-world evidence have shown bosutinib has a generally favorable safety profile, which has remained consistent across lines of therapy and in long-term reports. Adjusting the starting dose and/or modifying the dose during treatment with bosutinib are important strategies to manage AEs and improve tolerability, which are recognized within the label and in treatment guidelines. Dosing adjustment strategies to manage AEs are a recognized management approach for other TKIs in the treatment of CML and are not exclusive to bosutinib. In summary, long-term results from clinical trials and emerging real-world evidence demonstrate bosutinib has a safety profile that can largely be managed with treatment modifications and/or supportive care. Increased experience in managing toxicities and by using a personalized dosing approach may further improve adherence and outcomes with bosutinib.

Meta-analysis of the value of dual-energy computed tomography in the diagnosis of anterior cruciate ligament injuries of the knee

BackgroundThis meta-analysis assessed the efficacy of dual-energy computed tomography (DECT) in the diagnosis of anterior cruciate ligament (ACL) injuries.MethodsThe literature search was performed up to December 8, 2023, and included a comprehensive examination of several databases: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP. Diagnostic metrics sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and a summary receiver operating characteristic (SROC) were determined using a bivariate model analysis. Heterogeneity within the data was explored through subgroup analyses, which considered variables including geographical region, use of magnetic resonance imaging (MRI), arthroscopy, and study design.ResultsThe analysis included ten studies encompassing 544 patients. DECT demonstrated substantial diagnostic utility for ACL injuries of the knee, with a sensitivity of 0.91 (95% confidence interval [CI]: 0.88–0.94), a specificity of 0.90 (95% CI: 0.81–0.95), a PLR of 9.20 (95% CI: 4.50–19.00), a NLR of 0.10 (95% CI: 0.06–0.14), a DOR of 97.00 (95% CI: 35.00–268.00), and an area under the curve (AUC) of 0.95 (95% CI: 0.93–0.97). The subgroup analyses consistently showed high diagnostic precision for ACL injuries across Asian population (sensitivity: 0.91, specificity: 0.91, PLR: 9.90, NLR: 0.09, DOR: 105.00, AUC: 0.96), in MRI subgroup (sensitivity: 0.85, specificity: 0.94, PLR: 9.57, NLR: 0.18, DOR: 56.00, AUC: 0.93), in arthroscopy subgroup (sensitivity: 0.92, specificity: 0.89, PLR: 8.40, NLR: 0.09, DOR: 94.00, AUC: 0.95), for prospective studies (sensitivity: 0.92, specificity: 0.88, PLR: 7.40, NLR: 0.09, DOR: 78.00, AUC: 0.95), and for retrospective studies (sensitivity: 0.91, specificity: 0.93, AUC: 0.93).ConclusionDECT exhibits a high value in diagnosing ACL injuries. The significant diagnostic value of DECT provides clinicians with a powerful tool that enhances the accuracy and efficiency of diagnosis and optimizes patient management and treatment outcomes.

Efficacy and safety of the serratus anterior plane block (SAP block) for pain management in patients with multiple rib fractures in the emergency department: a retrospective study.

Chest trauma is a severe and frequent cause of admission to the emergency department (ED). The serratus anterior plane (SAP) block seems to be an effective method of pain management; however, data on efficacy and safety of a single SAP block performed in the ED by emergency physicians (EP) are limited. This study aimed to compare SAP block performed by the EP in the ED plus standard therapy to standard therapy alone in terms of pain severity at 0-3-6-12-18 and 24h, total opioid consumption (milligrams of morphine equivalents, MME), respiratory function (SpO2/FiO2 ratio), and adverse events (i.e. pneumothorax, infections in the site of injection, or Local Anaesthetic Systemic Toxicity syndrome due to SAP block) in the first 24h. This retrospective, monocentric study included adult patients admitted to the Sub-intensive Care Unit (SICU) of the ED with multiple rib fractures between 01/2022 and 03/2023. 156 patients (65.4% male; median age 62 years; median injury severity score 16; median thoracic trauma severity score 8) were included. 75 (48.2%) underwent SAP block. Patients undergoing SAP block showed significantly less pain 3-6-18h after a single block, required less MME (0 [0-20] vs. 20 [0-40], p < 0.001), showed higher SpO2/FiO2 ratio, and no adverse events were reported. The SAP block, in combination with standard therapy, appeared to be more effective in providing pain relief than standard therapy alone in patients admitted to the SICU for traumatic rib fractures.

Chondroitin sulfate proteoglycan 4 (CSPG4) increases invasion of recessive dystrophic epidermolysis bullosa-associated cutaneous squamous cell carcinoma by modifying TGFβ signaling.

Recessive dystrophic epidermolysis bullosa (RDEB) is a rare genetic skin-blistering disorder often progressing to metastatic cutaneous squamous cell carcinoma (cSCC) at chronic wound sites. Chondroitin sulfate proteoglycan 4 (CSPG4) is a cell-surface proteoglycan that is an oncoantigen in multiple malignancies, where it modulates oncogenic signaling, drives epithelial-to-mesenchymal transition (EMT), and enables cell motility. To evaluate CSPG4 expression and function in RDEB-cSCC. RDEB-cSCC cell lines were used to assess CSPG4-dependent changes in invasive potential, TGFβ1-stimulated signal activation, and clinically relevant cytopathology metrics in an in vitro full-thickness tumor model. CSPG4 expression in RDEB-cSCC and non-RDEB cSCC tumors was analyzed via immunohistochemistry and single-cell RNA sequencing (scRNA-seq), respectively. Inhibiting CSPG4 expression reduced invasive potential in multiple RDEB-cSCC cell lines and altered membrane-proximal TGFβ signal activation through changes in SMAD3 phosphorylation. CSPG4 expression was uniformly localized to basal-layer keratinocytes in fibrotic RDEB skin and tumor cells at the tumor/stroma interface at the invasive front in RDEB-cSCC tumors in vivo. Analysis of published scRNA-seq data revealed that CSPG4 expression was correlated with an enhanced EMT transcriptomic signature in cells at the tumor/stroma interface of non-RDEB cSCC tumors. Cytopathological metrics, like nucleus:cell area ratio, were influenced by CSPG4 expression in in vitro tumor models. We determined that CSPG4 expression in RDEB-cSCC cell lines enhanced invasive potential. Mechanistically, CSPG4 was found to enhance membrane-proximal TGFβ-stimulated signaling through SMAD3, which is a key mediator of EMT in RDEB-cSCC. The implication of these studies is that CSPG4 may represent a therapeutic target that can be leveraged for clinical management in patients with RDEB-cSCC.

Barriers and facilitators to evidence-based perioperative hypothermia management for orthopaedic patients: Asystematic review.

To assess barriers and facilitators to the implementation of guidelines for the prevention of inadvertent perioperative hypothermia in orthopaedic patients. Systematic review. Nine databases: PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, ProQuest Dissertations and Theses, Scopus, Web of Science and Trip Clinical Evidence Database. Primary studies published in English between January 2008 to July 2022 were screened. Study selection, quality assessment, and data extraction were completed independently by researchers. Data were extracted using the Consolidated Framework for Implementation Research and mapped to the Expert Recommendations for Implementing Change strategies. Eighty-seven studies were included in the review. The most frequently reported barriers and facilitators related to evidence strength, relative advantage, and cost of implementing perioperative hypothermia prevention guidelines. The top four ERIC strategies were: Identify and prepare champions; Conduct educational meetings; Assess for readiness and identify barriers and facilitators; and Inform local opinion leaders. This review provides synthesized evidence regarding barriers and facilitators to perioperative hypothermia guidelines for patients undergoing orthopaedic surgery. Our work provides theory guided strategies to promote implementation of perioperative hypothermia prevention to assist nurses caring for patients undergoing orthopaedic surgery. Findings provide professionals caring for patients undergoing orthopaedic surgery with theory-informed strategies to improve perioperative hypothermia prevention. Reducing perioperative hypothermia will improve outcomes for patients undergoing orthopaedic surgery. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. Due to the study design, no patient or public consultation took place.

Do functionality, strength, vascularization, inflammatory and biopsychosocial status improve by biopsychosocial model-based exercise in SSc?

This study aimed to investigation of the effects of the Cognitive Exercise Therapy Approach (Bilişsel Egzersiz Terapi Yaklaşımı-BETY), a supervised biopsychosocial model-based exercise intervention, on functionality, muscle strength, vascularization, anti-inflammatory and biopsychosocial status in Systemic Sclerosis (SSc) patients. Thirty-seven SSc patients were included. Twenty of them were recruited into the study group (SG) undergoing BETY group exercise sessions three times a week for three months and 17 were in the control group (CG) following a home exercise program. Assessments tools were the Modified Rodnan Skin Score (mRSS), Scleroderma Health Assessment Questionnaire (SHAQ), Modified Hand Mobility in Scleroderma (mHAMIS), Duruoz Hand Index (DHI), Six Minute Walk Test (6MWT), skeletal muscle strength measurements using an isokinetic dynamometer (Biodex System 3 Pro), Shear Wave Elastography (SWE), ELISA kits (for tumor necrosis factor-alpha, Interleukin-6, IL-10, serum irisin level), BETY-Biopsychosocial Questionnaire (BETY-BQ), Hospital Anxiety and Depression Scale (HADS), and Short Form-36 (SF-36). The SG demonstrated improvements in SHAQ, mHAMIS, 6MWT, BETY-BQ, HADS, and SF-36 values, excluding the DHI scores (p < 0.05). In contrast, CG showed worsening in SHAQ-general scleroderma symptoms and HADS scores compared to SG (p < 0.05). IL-10 and TNF-alpha increased in both groups, also various vascular parameters were significantly different changed in SG than CG (p < 0.05). Muscle strength values improved in the SG but decreased in the CG however this was statistically not significant (p > 0.05). BETY can be recommended as a nonpharmacologic approach to the disease management of SSc patients.

Trends and epidemiology in robotic-assisted total knee arthroplasty: Reduced complications and shorter hospital stays.

This study provides an in-depth analysis of the immediate postoperative outcomes and implications or robotic-assisted total knee arthroplasty (RA-TKA) compared with conventional TKA (C-TKA), particularly with regard to mortality, complications, hospital stay and costs, drawing from a comprehensive nationwide data set. The Nationwide Inpatient Sample (NIS) database, the largest all-payer inpatient healthcare database in the United States, was used to identify all patients who underwent RA-TKA or C-TKA from 2016 to 2019. A total of 527,376 cases, representing 2,638,679 patients who underwent elective TKA were identified, of which 88,415 had RA-TKA. To mitigate potential variations and selection bias in baseline characteristics between the two groups, a propensity score-matched analysis was employed to further balance and refine our data set, resulting in 176,830 patients evenly distributed between the groups. Analysis was performed according to demographics, immediate post-operative complications, and economic data, including payor class, length of stay and total charges. There was a marked shift towards RA-TKA, from an initial 0.70% in 2016 to a notable 7.30% by 2019. Patients who underwent RA-TKA were slightly younger (66.2 ± SD years), compared to the C-TKA group (66.7 ± SD years). Hospital stay was 1.89 days and 2.29 days for RA-TKA and C-TKA, respectively. Charges metrics revealed slightly higher charges for RA-TKA. Less postoperative complications were found in the RA-TKA group, such as blood loss, anaemia, acute kidney injury, venous thromboembolism, pulmonary embolism, pneumonia and surgical wound complication. Even following the propensity score matching, these findings remained consistent and statistically significant. RA-TKA use in the United States has grown substantially in the last few years and has been associated with significantly reduced immediate post-operative complications and length of hospital stay compared to C-TKA, offering safer surgical management for TKA patients. Further studies on the short- and long-term outcomes of RA-TKA would improve the understanding of the full potential of this technology. Level III.

Phenotype and prognostic factors in geriatric and non-geriatric patients with transthyretin cardiomyopathy.

Transthyretin cardiac amyloidosis (ATTR-CM) may be an underestimated cause of heart failure among geriatric patients and represent a unique phenotype and prognostic profile. This retrospective, observational, cohort study characterizes cardiac and extracardiac disorders at diagnosis and assesses prognosis among ATTR-CM patients based on age (geriatric vs. non-geriatric) and amyloidosis subtype (wild type, ATTRwt and hereditary, ATTRv). In total, 943 patients with ATTR-CM were included, of which 306 had ATTRv and 637 had ATTRwt. Among these, 331 (35.1%) were non-geriatric (<75years), and 612 (64.9%) were geriatric (≥75years). The population exhibited conduction abnormalities, atrial fibrillation and ischaemic heart disease that progressively deteriorated with age. Among ATTRwt patients, peripheral neuropathy, neurovegetative symptoms, and hearing loss were present across all age groups, but reports of carpal tunnel symptoms or surgery decreased with age. Conversely, among ATTRv patients, reports of extracardiac symptoms increased with age and Val122ILe mutation was highly prevalent among geriatric patients. The 3-year survival was higher among non-geriatric ATTR-CM patients (76%) than geriatric patients (55%) and predictors of 3-year mortality differed. Notably, predictors identified among geriatric patients were alkaline phosphatase (ALP) (HR=1.004, 95% CI: [0.001-1.100)], troponin T hs (HR=1.005, 95% CI: [1.001-1.120)] and tricuspid insufficiency (HR=1.194, 95% CI: [1.02-1.230)]. Whereas, among non-geriatric patients, NT-proBNP (HR=1.002, 95% CI: [1.02-1.04], global longitudinal strain (HR=0.95, 95% CI: [0.922-0.989], and glomerular filtration rate (HR=0.984, 95% CI: [0.968-1.00) were identified. We propose a 3-stage prognostic staging system combining troponin T hs (≥44ng/L) and ALP levels (≥119 UI/L). In the geriatric population, this model discriminated survival more precisely than the National Amyloidosis Centre staging, particularly for classifying between stage 1 (82%), stage 2 (50%) and stage 3 (32%) for ATTRv and ATTRwt. These diagnostic and prognostic indicators, along with ATTR subtype, highlight the distinct characteristics of this important, geriatric ATTR-CM patient group. Recognizing these mortality markers can be valuable for geriatricians to improve the prognostic quality management of geriatric patients with ATTR-CM.

The role of vitamin D in amelioration of oral lichen planus and its effect on salivary and tissue IFN-γ level: a randomized clinical trial

Background and objectivesOral lichen planus (OLP) is a common, prevalent, immune-mediated, inflammatory disease affecting both the skin and oral mucosa and is considered one of the potentially malignant diseases. Since OLP is regarded as an immunologically mediated disease, some studies suggest the use of vitamin D (VD) for its management as it exhibits immune-modulatory, anti-inflammatory, and antimicrobial properties, as well as anti-proliferative, pro-differentiative, and anti-angiogenic effects. VD has demonstrated a suppressive effect on TH1 pro-inflammatory cytokines, including IFN-γ while augmenting the secretion of anti-inflammatory cytokines. At the same time, VD deficiency is a prevalent public issue. Therefore, the present study aimed to investigate the role of VD as an adjunct to steroids in the management of VD-deficient OLP patients as well as its inhibitory effect on IFN-γ through measurement of salivary and tissue IFN-γ levels in OLP patients.MethodsA total of 40 patients with ulcerative or erythematous OLP, diagnosed according to the World Health Organization’s (WHO) modified criteria for OLP, were randomly allocated into one of the two study groups to receive either systemic steroids in addition to VD supplements (Group A) or systemic steroids only (Group B). Blood samples were collected for the measurement of serum VD level (SVDL) using the enzyme-linked immunosorbent assay (ELISA) to involve only patients with VD deficiency or insufficiency (≤ 30 ng/ml). Clinical evaluation of the lesion involved objective signs and subjective symptoms. Also, changes in salivary and tissue INF-γ levels (in pg/mL and pg/mg, respectively) were determined using the ELISA technique. All parameters were measured at baseline and after 4 weeks of treatment. The clinical pharmacy team devised a checklist to record all team interventions. The interventions were categorized into six domains, including drug interactions and/or adverse reactions, medication dose issues, drug selection issues, support with medication history, patient-related concerns, and suggestions for dental medication.ResultsAfter one month of treatment, a significantly greater number of patients in group A showed complete pain relief and resolution of clinical lesions, as well as a greater number of patients showing a reduction in the clinical severity of lesions than in group B (P = 0.005). Also, there was a statistically significant reduction in average VAS pain scores and clinical scores in group A compared to group B after 1 month of treatment (P = 0.001 and 0.002, respectively). Furthermore, there was a statistically significant greater reduction in salivary and tissue IFN-γ levels in group A than in group B (P ≤ 0.001 and 0.029, respectively) after 1 month of treatment.ConclusionCurrent evidence suggests a significant preventive and therapeutic role for VD as an adjunct to standard therapies indicated for OLP lesions. These protective and therapeutic functions are achieved through the suppressive effect of VD on pro-inflammatory cytokines, particularly IFN-γ. Also, salivary IFN-γ appears to be a valuable prognostic marker for monitoring the progression of OLP. In addition, the inter-professional collaboration between dentists and clinical pharmacists helped to deliver complete, patient-centered primary care and ensured the quality of the medications included in patient kits, thus improving patient treatment and management. Nevertheless, further studies with larger sample sizes, longer follow-ups, and standardized designs may still be needed.

Frontline therapy of acute myeloid leukemia with lower intensity regimens: Where are we now and where can we go?

The advent of molecularly targeted therapeutics has transformed the management of patients with acute myeloid leukemia (AML). Particularly for individuals unfit for intensive chemotherapy, lower intensity therapies (LIT) incorporating small molecules have significantly improved patient outcomes. With BCL2, IDH1, IDH2, and FLT3 inhibitors widely used for relapsed AML, combination regimens are now utilized in the frontline. Expansion of these targeted LIT combinations, along with development of novel agents including menin inhibitors, exemplifies the promise of precision medicine. Further understanding of molecular drivers of leukemic transformation and mechanisms of relapse will continue to advance frontline treatment options for patients with AML.

Enhancing the capacity of community health workers in prevention and control of epidemics and pandemics in Wakiso district, Uganda: evaluation of a pilot project

BackgroundCommunity Health Workers (CHWs) play a crucial role in outbreak response, including health education, contact tracing, and referral of cases if adequately trained. A pilot project recently trained 766 CHWs in Wakiso district Uganda on epidemic and pandemic preparedness and response including COVID-19. This evaluation was carried out to generate evidence on the outcomes of the project that can inform preparations for future outbreaks in the country.MethodsThis was a qualitative evaluation carried out one year after the project. It used three data collection methods: 30 in-depth interviews among trained CHWs; 15 focus group discussions among community members served by CHWs; and 11 key informant interviews among community health stakeholders. The data was analysed using a thematic approach in NVivo (version 12).ResultsFindings from the study are presented under four themes. (1) Improved knowledge and skills on managing epidemics and pandemics. CHWs distinguished between the two terminologies and correctly identified the signs and symptoms of associated diseases. CHWs reported improved communication, treatment of illnesses, and report writing skills which were of great importance including for managing COVID-19 patients. (2) Enhanced attitudes towards managing epidemics and pandemics as CHWs showed dedication to their work and more confidence when performing tasks specifically health education on prevention measures for COVID-19. (3) Improved health practices such as hand washing, vaccination uptake, and wearing of masks in the community and amongst CHWs. (4) Enhanced performance in managing epidemics and pandemics which resulted in increased work efficiency of CHWs. CHWs were able to carry out community mobilization through door-to-door household visits and talks on community radios as part of the COVID-19 response. CHWs were also able to prioritize health services for the elderly, and support the management of patients with chronic diseases such as HIV, TB and diabetes by delivering their drugs.ConclusionsThese findings demonstrate that CHWs can support epidemic and pandemic response when their capacity is enhanced. There is need to invest in routine training of CHWs to contribute to outbreak preparedness and response.

Preoperative short-course radiotherapy followed by chemotherapy and PD-1 inhibitor administration for locally advanced rectal cancer: A study protocol of a randomized phase II/III trial (STELLAR II study).

For patients with locally advanced rectal cancer, previous STELLAR studies have shown that a new adjuvant treatment paradigm of short-course radiotherapy followed by neoadjuvant chemotherapy can achieve pathological complete response rates superior to those of standard care; however, the 3-year DFS is inferior to neoadjuvant concurrent radiotherapy. Recent studies have shown that immune checkpoint inhibitors may improve the prognosis of rectal cancer and have good synergy with radiotherapy. Therefore, neoadjuvant chemotherapy combined with immune checkpoint inhibitors after a short course of radiotherapy has the potential to further improve complete response rates and prognosis. The STELLAR II study is a multicentre, open label, two-arm randomized, phase II/III trial of short-course radiotherapy followed by neoadjuvant chemotherapy concurrent with immunotherapy for locally advanced rectal cancer. A total of 588 patients with locally advanced rectal cancer (LARC) will be randomly assigned to the experimental and control groups. The experimental group will receive short-course radiotherapy and neoadjuvant chemotherapy in combination with sindilizumab, while the control group will receive short-course radiotherapy and neoadjuvant chemotherapy. Both groups will subsequently receive either total rectal mesenteric resection or a watch & wait (W&W) strategy. The phase II primary endpoint is the complete remission rate, and the secondary endpoints include grade 3-4 adverse events, perioperative complications, R0 resection rate, overall survival, local recurrence rate, distant metastasis rate and quality of life score. A seamless phase II/III randomized controlled design will be used to investigate the effectiveness and safety of the TNT strategy with the addition of immunotherapy. The trial opened, and the first patient was recruited on 31 August 2022. Trial registration number and date of registration: ClinicalTrials.gov NCT05484024, 29 July 2022. The STELLAR II trial will prospectively evaluate the efficacy of TNT treatment strategies that incorporate immune checkpoint inhibitors. The trial will yield important information to guide routine management of patients with local advanced rectal cancer.

When should a liver disease patient be admitted to the intensive care unit?

Liver diseases are asignificant global cause of morbidity and mortality. Liver cirrhosis can result in severe complications such as bleeding, hepatic encephalopathy (HE), and infections. Implementing aclear strategy for intensive care unit (ICU) admission management improves patient outcomes. Hemodynamically significant esophageal/gastric variceal bleeding (E/GVB) and grade4 HE, when accompanied by the need for renal replacement therapy (RRT), are definitive indications for ICU admission. E/GVB, spontaneous bacterial peritonitis (SBP), and infections with multidrug-resistant organisms (MDRO) require close and stringent critical assessment. Patients with severe hepatorenal syndrome (HRS) or respiratory failure have increased baseline mortality and most likely benefit from early ICU treatment. Rapid identification of sepsis in patients with liver cirrhosis is acrucial criterion for ICU admission. Prioritizing cases based on mortality risk and clinical urgency enables efficient resource utilization and optimizes patient management. In addition, "Liver Units" provide an intermediate care (IMC) level for patients with liver diseases who require close monitoring but do not need immediate intensive care.

Ultrasound imaging of bowel obstruction in infants and children.

We review the etiologies of bowel obstruction in infants and children that can be identified on ultrasound (US) including perforated appendicitis, intussusception, foreign body ingestion, colonic volvulus, intra-abdominal mass lesions, internal hernia, and stricturing inflammatory bowel disease. US can potentially identify the cause of bowel obstruction in these age groups, without the need for additional cross-sectional imaging, and can aid in patient management including interventional and surgical planning. Hence, it is important to be familiar with the sonographic imaging findings of bowel obstruction in infants and children.

Effect of combined rapid access point-of-care intestinal ultrasound clinic on the management of inflammatory bowel disease

BackgroundIntestinal ultrasound (IUS), although less widely practiced in the UK, offers several advantages in inflammatory bowel disease (IBD), particularly with regard to the accessibility of the test and immediate availability...