Pharmacological Treatment Research Articles

Public health and broader economic benefit of treating autoimmune and respiratory diseases in Greece

Abstract Background The increasing prevalence and incidence of autoimmune and respiratory diseases is a leading public health concern. This study aims to quantify the public health and broader economic gains from treating autoimmune and respiratory diseases in Greece. Methods A decision-analytic model was constructed evaluating the socioeconomic and fiscal gains of established standard of care treatments against 4 autoimmune disorders namely, rheumatoid arthritis, psoriatic arthritis, psoriasis, ankylosing spondylitis and against the respiratory diseases of asthma, and COPD. Morbidity reductions from treatment were translated into averted loss of income and absenteeism and averted tax revenue loss and prevented disability pensions. Targeted literature reviews were conducted to obtain the effectiveness of treatments on productivity-related outcomes. Economic data were obtained from official sources. Results Treating 1,000 patients for the autoimmune and respiratory conditions is estimated to generate annual gains of 196.3 productive life years (PLYs), to avert 48,547 absenteeism days and to prevent 1.2 disabilities. The annual socioeconomic and fiscal gains of treatments against autoimmune disorders are estimated at €6.5 million and €1.3 million, respectively. Preventing asthma and COPD-related morbidity, among 1,000 patients, is estimated to yield annual socioeconomic gains of €1.2 million and fiscal gains of €0.4 million. Conclusions Effective treatment of autoimmune and respiratory diseases may generate substantial public health, socioeconomic and fiscal gains, simultaneously promoting population’s health and the sustainability of the healthcare system. Key messages • It is the first study carried out in Greece aimed to assess the positive impact on public health and the broader economic value of treating autoimmune and respiratory diseases. • Therapeutic value of pharmacological interventions transcends the potential benefits to patients and public health.

Differences in the optimization of pharmacological treatment in patients with heart failure and reduced ejection fraction and advanced chronic kidney disease

Abstract Introduction Chronic kidney disease is very prevalent in patients with HF, makes their treatment difficult and worsens their prognosis, especially when it is advanced CKD (glomerular filtration rate <30 mL/min/m2). Renal insufficiency increases the risk of drug intolerance and an increase in serious side effects, which can lead to underuse, with consequent negative effects on patient prognosis. Purpose To analyze in a contemporary registry of HF patients followed in specialized HF units in Spain the achievement of dose targets for the most used drugs in HF with reduced ejection fraction (HFrEF) and the impact of advanced CKD. Methods We analyzed 914 patients with HFrEF consecutively included between 2019 and 2021 in the registry of the SEC-Excelente-IC quality accreditation program of the Spanish Society of Cardiology in 45 centers. We evaluated the proportion of patients treated with ACEI, ARA, ARNI, MRA, beta-blockers and SGLT2 inhibitors at the registry inclusion visit, the causes of non-prescription, and the achievement of the maximum dose recommended in the ESC clinical practice guidelines or the maximum tolerated dose in these patients, comparing the GFR groups, greater or less than 30 ml/min/m2. Results Of the 914 patients, 8.9% had a GFR<30 mL/min/m2. Their age was 76.9±9.7 years, 39.7% women, mean LVEF 32.8±9-6%. Patients with GFR<30 received in a significantly lower proportion all HF drugs except diuretics, ARBs and potassium chelators: sacubitril-valsartan 30.5% vs 59.2%; MRAs 31.7 vs 77.8%; SGLT2 inhibitors 34.1 vs 52.9% (p<0.001; Figure 1). The main reason for non-use was intolerance/contraindication for beta-blockers and "other" for the rest of the drugs (Figure 1). The proportion of patients in whom the maximum recommended, or maximum tolerated dose was reached was low in both groups, less than 40-50% for all drugs except MRA. There were no significant differences between the two groups in relation to the degree of renal dysfunction, although there was a tendency for the recommended doses to be obtained more frequently in the group with lower GFR (Figure 2). Conclusions In our contemporary cohort of real-life patients with HFrEF and advanced CKD, the use of recommended drugs for HF was significantly lower than in those patients with better renal function. However, where they were used, maximum recommended or tolerated doses were achieved in a higher proportion of patients. This indicates that with adequate selection it is possible to achieve the objectives proposed by the clinical practice guidelines in this complex group of patients.

TRATAMENTO COM METILFENIDATO E LISDEXANFETAMINA EM ADULTOS COM TDAH: UMA REVISÃO DA LITERATURA

Introduction: Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that, although frequently diagnosed in childhood, can persist into adulthood. ADHD has negative impacts on the quality of life and functioning of daily activities of individuals with this pathology. Treatment aims to improve the clinical and social condition and pharmacological treatment associated with non-pharmacological measures is recommended. Among pharmacotherapy, psychostimulants are the most recommended, with the first and second drugs being methylphenidate (Ritalin, Concerta) or lisdexamfetamine (Venvanse), respectively. However, these medications can have different effects, especially when consumed in the long term. Methodology: Articles published in journals indexed in the Scientific Electronic Library Online (SCIELO), National Library of Medicine/NLM (MEDLINE), UpToDate and National Library of Medicine/NLM (PUBMED) databases and websites recognized worldwide in the period 2014 were evaluated. to 2024. Results: After completing the data collection phase, 47 relevant articles were identified to compose the analysis of the proposed topic. Discussion: Based on the articles cited, it was observed that psychostimulants have good efficacy in treating ADHD, however, few studies have evaluated their long-term effects and with a significant number of study participants. Conclusion: Adults with ADHD should receive adequate treatment, aiming for a better quality of life and both methylphenidate and lisdexamfetamine are good therapeutic options, proving to be relatively effective and safe.

Safety and effectiveness of pulsed field ablation for pulmonary vein isolation in atrial fibrillation patients: a single centre experience

Abstract Introduction Atrial Fibrillation (AF) is the most frequent arrhythmia in the world with an exponentially increasing prevalence. Pulmonary veins (PV) are the primary triggering sites for AF and pulmonary veins isolation (PVI) is currently the standard therapy alongside pharmacological treatment and should be considered as first-line treatment. Pulsed-fieldablation (PFA) is a novel ablation modality that involves the application of electrical pulses causing cellular death, with preferential tissue specificity. Aim In this study, we evaluated the safety and efficacy of single-shot PFA in AF patients. Methods Single-center registry of consecutive patients undergoing PVI using the pentaspline PFA catheter (all with CARTO3D system v.7 and high-density mapping), between June 2022 and November 2023. Data on demographics, procedural characteristics, and electrocardiographic recurrence (assessed after a 3-month blanking period) were analyzed. Results 152 consecutive patients were included (63 ± 10 years, 57% male), with a mean CHA2DS2-VASc score of 2±1 points, median LVEF of 60% (IQR 59-65%), and a median CT-scan derived left atrial volume index of 56 mL/m2(IQR 44-69 mL/m2). A total of 40% had non-paroxysmal AF and a redo procedure was performed in 17% of patients. The median procedure time was 78 min (IQR 58-111 min) and fluoroscopy time was 11.6 min (IQR 8.2-15.6 min). Additionally, posterior wall isolation (PWI) was performed in 63 patients (41%). There were no esophageal complications, phrenic nerve injuries, cerebrovascular events, or procedure-related deaths. Two patients (1.3%) experienced acute cardiac tamponade, immediately treated with pericardiocentesis. Other complications were primarily vascular, in 5% of cases (4 femoral hematomas, 3 femoral pseudoaneurysms, 1 arteriovenous fistula). Over 293 (IQR 170 - 394) days of follow-up, considering electrocardiographic recurrence, 12% of patients had AF recurrence (5 with paroxysmal AF and 10 with persistent AF). These patients were older (69 ± 7y vs. 62 ± 11y, p=0.016), were more likely to undergo a redo procedure (33 vs. 8%, p=0.004), and had a higher percentage of posterior wall isolation (21 vs. 8%, p=0.038). Conclusions PFA for PVI wall ablation is safe and effective, with 100% intraprocedural technical success, a low rate of complications, and a high percentage of patients free from AF in the short-term.

Effectiveness of Mindfulness Therapy as a Complement to Pharmacological Treatment in the Control of Blood Pressure in Hypertensive Adults: A Quasi-Experimental Study in Lima, Peru.

To evaluate the effectiveness of mindfulness therapy as an adjunct to pharmacological treatment for improving blood pressure (BP) control in hypertensive adult patients at a health center in Lima, Peru. This study employed a quasi-experimental design with a quantitative and longitudinal cohort approach. The participants included 50 adults who were diagnosed with hypertension and who regularly attended the health center in the Villa El Salvador district of Lima, Peru. The data were collected using three instruments: the Depression Anxiety Stress Scale (DASS 21), validated in Peru; a sociodemographic questionnaire; and a BP recording sheet. The Wilcoxon test was utilized to assess the effectiveness of mindfulness therapy on BP control, while the nonparametric Friedman test was used to evaluate the effectiveness of mindfulness therapy considering confounding factors. Therapy resulted in favorable outcomes for BP control. After eight sessions, the average systolic BP decreased from 122.8 to 115.0mm Hg (a reduction of 7%), and the average diastolic BP decreased from 78.1 to 69.9mm Hg (a reduction of 11%). Mindfulness is an effective complementary therapy for controlling BP in hypertensive adults. It also helps reduce confounding factors such as stress, anxiety, and depression.

Multidisciplinary management of gastroesophageal reflux disease: an italian retrospective study

Abstract Background Millions of individuals are affected by gastroesophageal reflux disease (GERD) that causes significant discomfort negatively affecting patients’ overall quality of life. For a collaborative approach of continuous improvement in public health we wanted to know the real-world perspectives in the multidisciplinary and multimodal management pathway. Methods We aimed to interview a sample of gastroenterologists (GE), primary care physicians (GP), and otolaryngologists (ENT) to investigate the management of the intake and treatment of patients reporting symptoms of GERD. Symptoms were divided into typical and extraesophageal, and their severity and impact on quality of life was explored with the GERD Impact Scale (GSI) and Reflux Symptom Index (RSI). Results A total of 6211 patients were analyzed of whom with typical symptoms were 53.5%, while those with extraesophageal symptoms were 46.5%. The latter were more frequently reported by ENT patients (53.6%, p < 0.0001). GSI was highest in patients followed by GE (9 points) and GP (9 points) than ENT specialists (8 points), while the RSI was higher in the ENT group (14.3 ± 6.93) than in the groups of GP and GE, respectively (10.36 ± 6.36 and 10.81 ± 7.30, p < 0.0001). Chest pain had the greatest negative impact on quality of life (p < 0.0001). Of the 3,025 patients who used (proton pump inhibitors) PPIs, non-responders had a lower GSI when treated with a combination of adjunctive drug treatments and bioadhesive compounds, compared with single-component drugs. Conclusions The multidisciplinary and multimodal approach to the management pathway of GERD patients reveals variations in patient profiles by physician specialty, directing toward more appropriate and targeted treatments. In addition, the combination of adjunctive drug treatments and bioadhesive compounds appears to be effective in the management of patients refractory to PPIs. Key messages • The presentation of GERD symptoms is different in accordance with the physician’s speciality: the patients with GERD referred to a gastroenterologist had more severe disease and poorer quality of life. • The combination of adjunctive pharmacological treatments and bioadhesive compounds seems to be effective in the management of PPI refractory patients.

Effect of stereotactic body radiation therapy on left ventricular diastole function in symptomatic patients with hypertrophic obstructive cardiomyopathy

Abstract Background We applied stereotactic body radiotherapy (SBRT) for the first time in the treatment of patients with hypertrophic obstructive cardiomyopathy (HOCM), and significant improvements in symptoms and diastolic function were observed after treatment. Objectives To evaluate the impact of SBRT on cardiac structure, function, and clinical indicators in patients with HOCM. Methods This study included 12 drug-refractory symptomatic HOCM patients (6 who underwent SBRT and 6 who received pharmacological treatment alone) and conducted a retrospective analysis of their clinical data. Transthoracic echocardiography was used to assess various ultrasound parameters, including interventricular septal thickness, left ventricular outflow tract diameter, peak pressure gradient and diastolic function before treatment and at 1, 3, and 6 months after treatment. Additionally, assessments were made for symptoms; laboratory test results (NT-proBNP, cTnT, CK-mb, and CRP); 6-minute walk test results; New York Heart Association (NYHA) functional classification; and Kansas score before and 6 months after treatment. Results HOCM patients showed significant improvement in mitral valve systolic anterior motion after SBRT. Compared to that at baseline, the interventricular septum thickness gradually decreased at 1, 3, and 6 months after treatment (-8.8%, -8.0%, -14.4%, respectively) (P<0.05). Compared to those in the drug group, the left ventricular diastolic function and structural parameters, including the interventricular septum thickness (mean change from baseline of -3 mm [95% CI: -5.2 to -0.8 mm] and 1.3 mm [95% CI: 0.5 to 2.2 mm]; P<0.05), and the LA GLS (change of 2.1% [-0.03% to 4.2%] and -0.9% [-3.1% to 1.3%]; P<0.05), were significantly improved in HOCM patients at 6 months posttreatment. Similarly, the clinical indicators, including KCCQ, increased from baseline (61 (range, 47.3-70) to 84 (range, 70-89.5) at 6 months posttreatment (P<0.05), and the 6-minute walk test score increased from 187 meters (range, 50-370) to 401 meters (range, 280-540) (P<0.05). Conclusion SBRT significantly improved left ventricular diastolic function and reduced interventricular septum thickness in HOCM patients. Symptoms, exercise capacity and clinical indicators improved after SBRT in HOCM patients.

Impact and determinants of depression in cardiac hospitalized patients

Abstract Depression increases cardiovascular risk and involves worse clinical outcomes. Little attention is paid to it in hospitalized patients. We studied prevalence and determinants of depression in this group, in order to select patients for further specific management. Methods Consecutive patients admitted to Cardiology wards were included. Cardiovascular risk factors, clinical and psychosocial data were collected. Self perceived mental and physical health quality were assesed by 12-item Short Form survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) questionnaires were administered. Statistical analysis was performed using Spearman´s correlation, Mann-Whitney and Fisher tests, and Mantel-Cox, linear and logistic regression analyses. Results 170 consecutive patients, median age 74.5 (67.2-81.1), 59.4% male, were included. Most common pathologies were heart failure (44.7%) and coronary syndroms (28.8%). According to HADS results, depression was probable (score >10) in 10%, and at least possible (score > 8) in 27.1%. Both increased duration of hospitalization (Median 14 vs 7 days;p=0.016 and 11 vs 7 days;p=0.005 respectively). Anxiety was present in 16.5 % for probable case and 34.1% for possible case, with no significant change in median duration of hospitalization. 22.9% of patients were under antidepressant treatment, and 24% under anxiolytics, but they were added to treatment only in 1% and 7% respectively. No other not pharmacological measure was initiated. Self perceived mental health was diminished in probable depression (mean difference 14.9%;95%IC 9.7-20.2;p<0.001). Self perceived physical health was also lower (mean difference 6.4%;95%CI:1.1-11.8;p=0.016). Patients with depression were a mean of 5.6 years older (95%CI 1.4-9.8;p=0.032). Less than primary education (OR 5.69 (p 0.021), and Previous hospital admission OR 3.2 (1.0-10.3;p=0.034) increased the risk of depression in univariate analysis. By multivariate analysis, determinants of depression were anxiety (OR 22.5;95%CI 5.9-85.6;p<0.0001), need for surgery (OR 12.3;95%IC 2.1-73.2;p=0.009), need for intensive care unit surveillance (OR 4.2;95%CI 1.1-15.8;p=0.039), and age (OR 1.1;95%IC 1.0-1.2;p=0.001. AUC was 0.89;95%CI 0.81-0.96;p<0.0001. There was no difference in civil status, gender, income level, living accompanied, number of comorbidities, cardiovascular risk factor or reason for hospital admission. Conclusions Depression was prevalent in our hospitalized cardiac patients,in spite of previous pharmacological treatment. It prolongs duration of stay and impacts negatively in self perceived mental and physical health. Risk is increased in older people requiring intensive care surveillance or surgery, and specially by anxiety. These patients could benefit from a preventive multifactorial approach. Attention should also be paid to patients with a previous hospitalization and low educational level.ROC curve for multivariate model

Diagnosis of heart failure with preserved ejection fraction based on exercise stress echocardiography in real-world practice

Abstract Aims The diagnostic difficulty of heart failure with preserved ejection fraction (HFpEF) is related to the fact that many patients develop abnormal hemodynamics only during exercise. Exercise stress echocardiography is a first-line test to unmask such abnormalities, but exercise protocols and diagnostic criteria have not been established. It remains unclear how cardiologists diagnose HFpEF by exercise echocardiography in real-world practice. Methods and Results An international web-based survey was performed on 87 cardiologists, 59% of whom had ≥ 6 years of experience with exercise echocardiography. A retrospective cohort of 652 dyspneic patients who underwent exercise echocardiography was used to determine the impact of different diagnostic criteria on the proportion of HFpEF diagnosis. The most commonly used exercise echocardiography criterion for the HFpEF diagnosis was the HFA-PEFF algorithm (48%), followed by the ASE/EACVI criteria (24%) and some combinations of multiple parameters (22%). A retrospective study found that the proportion of HFpEF diagnosis varied substantially between the criteria used: 20.1% for the ASE/EACVI criteria and 44.3% for the HFA-PEFF algorithm. A survey demonstrated that 54% of the participating cardiologists would initiate sodium-glucose co-transporter 2 inhibitors based on exercise echocardiography results. Conclusion In real-world practice, exercise echocardiography criteria for HFpEF diagnosis vary among cardiologists. While many cardiologists consider initiating pharmacological treatment on exercise echocardiography results, the frequency of HFpEF diagnosis varies substantially depending on the diagnostic criteria used. The lack of universal diagnostic criteria may limit the delivery of evidence-based treatment to patients with HFpEF.

Determinants of adherence among patients with hypertension

Abstract Background Poor adherence to pharmacological treatment among patients with hypertension (HTN) is common. Approximately half of HTN patients do not use their medications as prescribed. Multiple barriers can influence adherence to antihypertensive medications. HTN patients may be characterized by the presence of frailty syndrome (FS) and cognitive impairment (CI). FS and CI may adversely affect the course of the disease and adherence to therapeutic recommendations. Purpose To assess the adherence and its determinants among patients with hypertension. Methods The study included 129 patients diagnosed with hypertension (81 men, 48 women; mean age M±SD=69.98±11.67) hospitalized in the Department of Occupational Diseases and Hypertension. Medical record analysis, the author's sociodemographic questionnaire, the Tilburg Frailty Idicator (TFI) to determine the presence of frailty syndrome, the Montreal Cognitive Assesment (MoCa) questionnaire to assess cognitive function, and the Adherence to Medication Scale (ARMS) to assess adherence were used. Results The majority of respondents were male (62.79%), living in large cities (31.78%), in a relationship (61.24%), with a high school education (68.22%), and retired (67.44%). Analysis of medical records among comorbidities showed diabetes (59.69%) and other cardiovascular diseases (58.91%) to be the most common. Hospitalizations due to hypertension within the past year in the range of 1-2 were reported in 72.09% of the subjects, 3-5 hospitalizations in 17.05%, and more than 5 hospitalizations in 10.85% subjects. The surveyed patients mostly kept self-monitoring diaries (61.24%), measured their blood pressure values 2-3 times a day (58.15%) with an upper arm blood pressure monitor (64.34%). In terms of self-care behaviors, respondents most often indicated following a diet with a restriction of unhealthy fats (52.71%), following a low-sodium diet (44.19%) and being physically active (33.33%). The mean blood pressure values in the study group were M±SD=139.73±16.73 mmHg for SBP and M±SD=81.48±13.25 mmHg for DBP, respectively. On the basis of the TFI, 99.22% of patients showed the presence of FS (M±SD =10.66±2.82), the MoCa questionnaire indicated abnormal values in cognitive function in 79.07% (M±SD =18.16±8.3). The average adherence ARMS score was M±SD 17,6±6,72 pcts. (higher the ARMS score the worse adherence). Univariate analysis as determinants of adherence showed unemployment (b=9.391;p=0.001), smoking (b=6.701;p=0.001), duration of illness (b=-0.153;p=0.003), 3-5 hospitalizations in the past year (b=3.891;p=0.014). Multivariate analysis among determinants of adherence showed unemployment (b=7.556;p=0.022), duration of illness (b=-0.167;p=0.002) and 3-5 hospitalizations (b=5.011;p=0.001). Conclusion Hypertensive patients are characterized by optimal adherence. Despite expectations, cognitive impairment and frailty syndrome did not determine adherence to medications.

Delays in diagnosis and treatment initiation of ATTR cardiac amyloidosis: a real-world data analysis

Abstract Introduction Cardiac amyloidosis (CA) is a serious condition characterized by the accumulation of abnormal protein deposits in the heart muscle, leading to functional impairments and, ultimately, heart failure. Transthyretin amyloid cardiomyopathy (ATTR-CM) is the most common form encountered in CA diagnosis with previously underestimated prevalence. ATTR-CM poses a diagnostic challenge, with a substantial number of cases diagnosed late and at advanced stages. The availability of specific pharmacological treatment using the transthyretin-stabilizer tafamidis further emphasizes the need for timely diagnosis. Here, we aim to assess delays in diagnosis and initiation of therapy in a real-world collective of patients with ATTR-CM. Methods All individuals diagnosed from 01/2018 to 05/2023 with ATTR-CM at our university hospital, Germany, were systematically assessed for eligibility in this study. Specifically, we enrolled patients who were undergoing transthyretin stabilizer therapy. The investigation aimed to determine the duration, in days, from the initial suspicion of heart disease to the definitive diagnosis of ATTR-CM. It was also investigated whether the diagnosis of ATTR-CM was made more quickly over time as awareness increased. Additionally, the study assessed the time elapsed until patients received pharmacological therapy following the confirmed diagnosis. The study was approved by the local ethics committee (23-11500-BO). Results After screening of 194 consecutive patients, 154 were included in the analysis, while 40 patients were excluded due to insufficient records. The results of this study reveal that a median of 300 (113-962) days elapsed from the initial suspicion of amyloidosis to the final confirmation. Initial indications of CA often presented as nonspecific symptoms such as unclear dyspnea (16.2% n=25), abnormal echocardiography (75.3% n=116), or, in rare cases, incidental findings (8.4% n=13). Following the diagnosis, an additional median of 84 (46-163.5) days passed before the first prescription of a transthyretin stabilizer. To assess an improvement of ATTR-CM diagnosis over time, we stratified the data into tertiles by date of first diagnosis. The results showed a gradually decrease in medium time to diagnosis of 466 (181-1035) days in the earliest tertile (2018-2019) to 389 (141-1508) days in the most recent tertile (2022-2023) (p<0.001). Conclusion This study shows a major healthcare deficit and underscores the medical need for improved screening procedures and diagnostic modalities to expedite the timely diagnosis of CA, as early identification of the condition is crucial for enhancing the quality of life for patients and preventing life-threatening complications.

Guideline-directed medical therapy patterns in heart failure with reduced ejection fraction: the OPTIMA-HF registry

Abstract Background/Introduction European guidelines strongly recommend an optimized pharmacological treatment in patients with heart failure with reduced ejection fraction (HFrEF) with a fast introduction of the four-pillars. Purpose Aim of the Optimization of Therapy in the Italian Management of Heart Failure [OpTIMa-HF] Registry was to collect data on HF patients to describe the current Italian population of HF patients with a specific focus on HFrEF treatment adherence and prescription rates, according to the most recent European Guidelines. Methods OPTIMA-HF is an observational, cross-sectional, multicenter, real-life study conducted in two different clinical settings: HF outpatients’ clinics of Italian University Hospitals and territorial Italian Cardiology outpatients’ services, that enrolled patients with chronic HFrEF receiving at least 1 oral medication for management of HF. Patients were characterized by baseline use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium glucose co-transporter II inhibitor (SGLT2i). Patient-level factors associated with medication use were examined. Results Overall, 1390 patients from 29 ambulatory cardiology practices and university hospitals were included. Mean age was 69.5 ± 11.9 years, 24% were female, and median EF was 33 (28-37). Among enrolled patients, 72.2% were prescribed ARNI, 17.1% ACEI/ARB, 95% beta-blocker, 75.5% MRA and 63% SGLT2i therapy (Figure 1). Despite high prescription rates for each single class, a still not sufficient number of patients was on treatment with all four pillars, in particular 40.4% considering the presence ARNI and 6.2%. When medications were prescribed, few patients were receiving target doses of ACEI/ARB (31.7%), ARNI (16%), and beta-blocker (33.3%), whereas a higher proportion were receiving target doses of MRA therapy (38%), and all were receiving target dose for SGLT2i. Among patients eligible for all classes of medication, only 1.1% were simultaneously receiving target doses of ACE/ARB/ARNI, beta-blocker, MRA and SGLT2i. Prescription rates did not significantly differ between the type of center (University Hospital vs. territorial Cardiology outpatients’ services). As regards patients not on treatment with any of the four pillars, a small but still present amount of patients had no contraindications to these drugs (Figure 1). Conclusions In this contemporary outpatient HFrEF Italian registry, significant high prescription rates of the four-pillars were observed, however therapy combination rate is still not sufficient and drugs' titration need to be implemented to receive the greatest benefits from an optimized treatment. Strategies to improve guideline-directed use of HFrEF medications remain urgently needed, and these findings may inform targeted approaches to optimize outpatient medical therapy.

Pharmacological Pain Treatment in Older Persons.

Pharmacological pain treatment in older persons is presented by a multi-disciplinary group of European pain experts. Drugs recommended for acute or chronic nociceptive pain, also for neuropathic pain and the routes of administration of choice are the same as those prescribed for younger persons but comorbidities and polypharmacy in older persons increase the risk of adverse effects and drug interactions. Not all drugs are available or authorised in all European countries. For mild-to-moderate pain, non-opioids including paracetamol and non-steroidal anti-inflammatory drugs are first-line treatments, followed by nefopam and metamizole. Codeine, dihydrocodeine and tramadol are prescribed for moderate to severe pain and 'strong' opioids, including morphine, hydromorphone, oxycodone, fentanyl, buprenorphine, methadone and tapentadol, for severe pain. Chronic neuropathic pain treatment relies on coanalgesics, including anti-epileptics (gabapentinoids) and anti-depressants with additional option of topical lidocaine and capsaicine. The choice of analgesic(s) and the route of administration should be guided by the pain characteristics, as well as by the patient's comorbidities, organ function and medications. Several directions have been highlighted to optimise pharmacological pain management in older individuals: (1) before starting pain treatment adequately detect and assess pain and always perform a full geriatric assessment, (2) consider kidney function systematically to adjust the doses of analgesics and avoid the risks of overdose, (3) start with the lowest dose of an analgesic and increase it gradually under the control of the effect, (4) involve the older persons and family in their treatment, (5) reevaluate pain regularly during treatment and (6) combine pharmacological treatment with non-pharmacological approaches.

The Impact of Standardized Training Resident on Pain Management in Patients with Advanced Lung Cancer.

This study aimed to investigate the effects of Standardized Training Resident on pharmacological interventions for pain management in patients with advanced lung cancer. A total of 84 patients with advanced lung cancer and associated pain were enrolled in the study from December 2019 to August 2023 and were divided into two groups based on their attending physician: a group managed by physician-ST Training Physicians (joint group) (n = 42) and physician-only group (usual group) (n = 42). The Brief Pain Inventory (BPI), oral morphine equivalent, and length of hospital stay. Furthermore, the Pain Management Index (PMI) was calculated. Health-related quality of life (HRQoL) was assessed at the 4-week follow-up using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). At week 4, compared to the usual group, the four BPI pain intensity categories were significantly lower in the joint group [worst pain: 4 (3-5) vs 8 (7-9); least pain: 1 (0-2) vs 3 (1-4); average pain: 2 (1-2) vs 5 (4-6); pain right now: 1.2 (0.7-1.9) vs 4 (3-5)] (all P > 0.05). The hospital stay duration was significantly reduced; for the seven pain interference categories, there were no significant improvements in the joint group. Significantly more patients achieved adequate pain control in the joint group than the usual group (p = .002). A reduction in OMEDD scores was observed for both cohorts, and the joint group's reduction was statistically more significant (p = 0.016). There were no significant differences in HRQoL between the two groups. Standardized Training for Radiation Oncology Physicians may lead to improved pharmacological interventions and enhanced pain relief. Recognizing the importance of these trainees in the healthcare team is crucial for achieving optimal pain management outcomes.

Beyond Pain: Innovative Approaches to Tension-Type Headache Management and Treatment

Introduction: Tension-type headache (TTH) is a common neurological disorder characterized by bilateral head pain and muscle tension, affecting up to 78% of the population. Despite its prevalence, TTH has historically received less attention than migraines. However, recent years have seen increased interest in understanding its pathophysiology and treatment options. This review comprehensively analyzes TTH management, covering non-pharmacological and pharmacological approaches to guide clinical practice and future research effectively. State of Knowledge: TTHs manifest as bilateral, pressing, encircling head pain, profoundly affecting individuals' quality of life. Recent years have witnessed increased interest in TTH understanding and treatment. Non-pharmacological interventions, including behavioral modifications, exercise, dietary adjustments, sleep hygiene, physical therapy, psychotherapy, and pharmacological treatments like over-the-counter medications, prophylactic drugs, psychedelics, and botulinum toxin A, have shown promise in alleviating symptoms. Conclusion: This review highlights the multifaceted management of TTH. Non-pharmacological interventions, including behavioral modifications and psychotherapy, offer symptom relief. Body awareness therapy, exercise, and psychotherapy benefit TTH symptoms and quality of life. Paracetamol, ibuprofen, and amitriptyline are standard treatments, with emerging options like psychedelics and botulinum toxin A. Personalizing treatment and understanding TTH mechanisms pose challenges. A multidisciplinary approach is essential for enhancing management and outcomes. More research is required to identify optimal treatments and long-term efficacy. Despite challenges, progress in TTH management brings hope for better patient care.

Exploring photobiomodulation in the management of bowel diseases: a concise critical review.

The complexity of the gastrointestinal system plays a crucial role in coordinating essential processes such as digestion, nutrient absorption, and waste elimination. inflammatory bowel diseases (IBD) pose significant treatment challenges due to their complex aetiology and varied symptoms. Conventional therapeutic approaches often involve pharmacological interventions, which may have side effects and limited efficacy. Photobiomodulation (PBM), also known as low-level light therapy, has emerged as a promising therapeutic or adjunctive alternative in the treatment of intestinal diseases. The search was conducted in the MEDLINE database via PubMed, SCOPUS, covering the period from 1990 to 2024. A total of 72 studies were selected, of which 9 focused on inflammatory bowel diseases IBD, including ulcerative colitis (UC) and Crohn's disease (CD). Among these studies, 1 was clinical protocol while eight experimental. The results showed that PBM has a significant positive effect in IBD studies in rats, with reduction of intestinal inflammation, improvement of mucosal integrity, and modulation of the immune response. However, no clinical studies were found necessary to obtain results and establish effective and safe treatment protocols. Nevertheless, PBM holds potential as a non-invasive and complementary therapeutic approach for managing IBD, offering new perspectives for the treatment of chronic intestinal diseases. Therefore, this brief review emphasizes the need to transition from preclinical research to clinical research on this topic and highlights the scarcity of clinical studies.

Convergence insufficiency prevalence in attention deficit and hyperactivity disorder children depends on the diagnosis criteria.

Attention deficit and hyperactivity disorder (ADHD) is a neurodevelopmental condition commonly seen in children and adolescents, characterised by an increase in distractibility or inattention. Several studies have noted a higher rate of visual problems in this group, especially convergence insufficiency (CI), but when using different diagnostic criteria. The aim of this study was to evaluate visual function in ADHD children and non-ADHD controls to compare the different signs for diagnosis of CI. In this prospective case-control study, a group of children aged 7-17 years, diagnosed with ADHD before the start of pharmacological treatment and matched for age and gender with non-ADHD controls were examined. Visual acuity (VA), objective and subjective refraction, accommodative amplitude and facility, heterophoria, positive and negative fusional vergences (PFV and NFV) and stereopsis were assessed. Sixty participants (30 ADHD and 30 non-ADHD controls) were evaluated. There was no significant difference between the two groups for VA, refraction and accommodative abilities. There were significant differences in PFV and NFV: PFV break/recovery values for the ADHD and control groups were 18.9/16.2∆ and 26.9/22.1∆, respectively. Respective values for NFV were 15.7/13∆ and 19.3/15.9∆. Using the three signs of receded near point of convergence (NPC), decreased PFV and exophoria 4∆ greater at near than distance, the prevalence of CI was equivalent for the ADHD and controls (p = 0.34) If only two signs were considered for the CI diagnosis, (i.e., receded NPC and decreased PFV), then prevalence was significantly greater for the ADHD group (p < 0.01). These results show a higher prevalence of binocular vision problems in the ADHD group. This suggests a relationship between vergence problems and ADHD, but the direction of this link remains unclear. Further studies with specific samples may be needed to understand fully the association between binocular vision disorders and ADHD.

Role of glia in delirium: proposed mechanisms and translational implications.

Delirium is a common acute onset neurological syndrome characterised by transient fluctuations in cognition. It affects over 20% of medical inpatients and 50% of those critically ill. Delirium is associated with morbidity and mortality, causes distress to patients and carers, and has significant socioeconomic costs in ageing populations. Despite its clinical significance, the pathophysiology of delirium is understudied, and many underlying cellular mechanisms remain unknown. There are currently no effective pharmacological treatments which directly target underlying disease processes. Although many studies focus on neuronal dysfunction in delirium, glial cells, primarily astrocytes, microglia, and oligodendrocytes, and their associated systems, are increasingly implicated in delirium pathophysiology. In this review, we discuss current evidence which implicates glial cells in delirium, including biomarker studies, post-mortem tissue analyses and pre-clinical models. In particular, we focus on how astrocyte pathology, including aberrant brain energy metabolism and glymphatic dysfunction, reactive microglia, blood-brain barrier impairment, and white matter changes may contribute to the pathogenesis of delirium. We also outline limitations in this body of work and the unique challenges faced in identifying causative mechanisms in delirium. Finally, we discuss how established neuroimaging and single-cell techniques may provide further mechanistic insight at pre-clinical and clinical levels.

AUMENTO DO USO DE ANSIOLÍTICOS APÓS A PANDEMIA – REVISÃO DA LITERATURA

Introduction: Anxiety disorders are significant areas of research due to the high incidence of anxiety being diagnosed in the population, leading to temporary or permanent disability. Investigations conducted on the mental health of Brazilian residents during the COVID-19 outbreak indicate an increase in diagnoses of anxiety, depression, and stress. The deterioration of mental well-being was influenced by multiple factors, including the absence of proper funeral ceremonies, the escalation of unemployment, and the decline in financial capacity, which heightened tension and anguish among those needing a source of income to support their families. This scenario significantly contributed to the increase in the use of anxiolytics, as many individuals resorted to these medications as a form of immediate relief for the symptoms of anxiety and stress exacerbated by the pandemic, highlighting the need for a broader and more integrated approach to mental health treatment in the current context. Objectives: To analyze the increase in the use of anxiolytics after the COVID-19 pandemic and its implications for public health. Methodology: This study is structured as a literature review, aiming to compile and analyze existing information on the topic. Additionally, the research is exploratory and descriptive, with the objective of mapping existing knowledge on the subject and outlining its nuances. The platforms Scielo, Portal de Periódicos CAPES, and Medline were used. The period considered was from 2018 to 2023, with texts fully available online, in Portuguese. Results: The results indicate a significant increase in the use of anxiolytics during and after the COVID-19 pandemic, especially among more vulnerable groups, such as the elderly and people with pre-existing health conditions. The use of medications like Alprazolam increased by 35% in 2020, reflecting the intensification of anxiety in the population. Conclusion: The pandemic exposed the fragility of mental health systems, highlighting the need for public policies that combine pharmacological treatment with continuous support. Future research is essential to monitor the long-term effects of anxiolytic use in the post-pandemic period.

Changes of bone turnover markers and bone mineral density among postmenopausal Thai women with osteoporosis receiving generic risedronate

BackgroundOsteoporosis has been recognized as a significant health issue in Thailand. Pharmacological interventions are important way to prevent fracture. However, one of the main challenges in selecting a medication is high cost, particularly for brand-name drugs. Data on generic bisphosphonate use in Thai are still lacking. Therefore, our study aimed to assess the efficacy and safety of generic risedronate in postmenopausal Thai women with osteoporosis.MethodsThis prospective study was conducted at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from December 2022 to January 2024. Serum C-terminal cross-linking telopeptide of type I collagen (CTX) and procollagen type I N-propeptide (P1NP) were measured at baseline. All participants subsequently received 35 milligrams of oral risedronate once weekly for 52 weeks. Serum CTX and P1NP were remeasured at different time points. BMD was reevaluated at 52 weeks after risedronate treatment initiation.ResultsA total of 80 participants were included. The mean age was 65.2 ± 6.6 years. The mean body mass index (BMI) was 23.45 ± 3.49 kg/m2. The median (IQR) serum CTX level at 12 weeks was significantly lower than that at baseline (0.28 (0.16–0.46) ng/mL versus 0.44 (0.26–0.64) ng/mL, respectively; p value < 0.01). The suppression of serum CTX was confirmed at 52 weeks after treatment initiation. Compared with those at baseline, the serum P1NP levels were significantly lower at 24 weeks after treatment initiation (30.33 (19.19–39.58) ng/mL versus 41.90 (30.33–68.67) ng/mL, respectively; p value < 0.01). In terms of the BMD assessment at 52 weeks, significant improvements were observed in both areal BMD (g/cm2) and T scores at all measured sites compared with baseline. The lumbar spine, femoral neck, and total hip BMD increased from baseline by 4.76%, 3.84% and 4.54%, respectively.ConclusionPostmenopausal women with osteoporosis who were treated with generic risedronate demonstrated significant suppression of the bone remodelling process at 3, 6, and 12 months after treatment initiation. Additionally, significant improvements in the lumbar spine, femoral neck, and total hip BMD were observed at 12 months of therapy. These findings suggest that generic risedronate could be considered a reasonable and interesting option for treating postmenopausal women with osteoporosis in Thailand.