Premature Termination Of Treatment Research Articles

Dynamics of prescribing and accessing medications for opioid use disorder: a community-based systems analysis

Background Although medications for opioid use disorder (MOUD) are effective for treating opioid use disorder (OUD), persistent barriers still prevent patients from accessing this life-saving care. Policies to increase MOUD access have produced suboptimal results. This study presents a qualitative system dynamics model that elucidates the complexities of accessing and staying in MOUD treatment. Methods We utilized a community-based system dynamics approach to modeling the MOUD treatment system. We engaged a cohort of system experts/stakeholders, including individuals who had received MOUD, treatment providers, and policymakers, in interviews and group model building to develop and refine a simulation model. We then created a qualitative causal loop diagram based on insights gained while developing the simulation model and a review of interview transcripts. Results The causal loop diagram captures four key factors affecting treatment initiation, retention, and leaving: (1) fraught interactions between patients and healthcare providers; (2) stigma-driven regulation of MOUD creating a culture of fear and defensive medicine; (3) a punitive culture in clinics and opioid treatment programs offering MOUD; and (4) the internalization of the abstinence narrative contributing to premature termination of treatment. Conclusions Our analysis highlights how interdependent and non-linear feedback processes diminish or counteract the effectiveness and sustainability of MOUD policy interventions. Due to system memory and cultural resistance to change, even rolling back reactionary policies may do little to curb established behavioral patterns. In addition, conflicting and competing strategies among various actors within the system contribute to goal misalignment and a lack of standardization of care.

PCSK9 Inhibitors and Anthracyclines: The Future of Cardioprotection in Cardio-Oncology.

The field of cardio-oncology is an expanding frontier within cardiovascular medicine, and the need for evidence-based guidelines is apparent. One of the emerging focuses within cardio-oncology is the concomitant use of medications for cardioprotection in the setting of chemotherapy regimens that have known cardiovascular toxicity. While clinical trials focusing on cardioprotection during chemotherapy are sparse, an inaugural trial exploring the prophylactic potential of Sodium-Glucose Cotransporter-2 inhibitors (SGLT2is) for anthracycline (ANT)-induced cardiotoxicity has recently commenced. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, though less studied in this oncology demographic, have exhibited promise in preclinical studies for conferring cardiac protection during non-ischemic toxic insults. While primarily used to reduce low-density lipoprotein, PCSK9 inhibitors exhibit pleiotropic effects, including the attenuation of inflammation, reactive oxygen species, and endothelial dysfunction. In ANT-induced cardiotoxicity, these same processes are accelerated, resulting in premature termination of treatment, chronic cardiovascular sequelae, heart failure, and/or death. This review serves a dual purpose: firstly, to provide a concise overview of the mechanisms implicated in ANT-induced cardiotoxicity, and, finally, to summarize the existing preclinical data supporting the theoretical possibility of the cardioprotective effects of PCSK9 inhibition in ANT-induced cardiotoxicity.

The role of psychiatric symptoms, sociodemographic factors, and baseline sleep variables on pediatric insomnia treatment outcomes in a clinically referred population.

The current study aimed to examine clinically relevant psychiatric and sociodemographic predictors of insomnia treatment outcomes in pediatric patients clinically referred for insomnia. Pediatric patients (N = 1428; ages 1.5 - 18 years), presenting for insomnia evaluation in a medical/sleep center-based behavioral sleep clinic were followed for treatment as clinically indicated. According to patient age, parent/patients completed validated measures of insomnia severity, psychiatric symptoms, and sociodemographic measures. Patients were also categorized by treatment outcome status (i.e., not recommended to follow-up after initial evaluation and treatment session, successful treatment completion, lost to follow-up after initial evaluation and treatment session, and early termination) according to the clinically indicated treatment recommended and dose of treatment received. Youth had elevated scores on psychiatric screening indexes with affective problems being highest for all age groups. Other co-morbid sleep disorders were present in nearly 25% of insomnia patients and use of sleep aids (melatonin; hypnotics) was commonplace. Baseline insomnia severity significantly predicted sleep treatment trajectories and post-treatment insomnia severity with large effects for all age groups. Other clinically relevant predictors of insomnia treatment outcomes included medication use and externalizing mental health concerns in younger patients and internalizing mental health concerns and chronological age in older patients. Lack of treatment follow-up and premature treatment termination was observed for patients with the worst insomnia symptoms at time of initial evaluation. Pediatric health providers delivering insomnia treatment should take a developmentally sensitive approach that is proactive with regards to managing treatment barriers that are likely influenced by severity of insomnia and co-morbid mental health concerns.

Attention Deficit Hyperactivity Disorder: A Risk Factor for Premature Discontinuation of Inpatient Opioid Withdrawal Treatment.

Background: Substance use disorders present a tremendous challenge within contemporary healthcare systems. Specifically, in the domain of opioid use disorders (OUDs), several foundational elements are crucial for the efficacious management of afflicted individuals. Regrettably, the premature discontinuation of inpatient opioid withdrawal treatment is a prevalent phenomenon. This study aims to elucidate the prevalence of the premature termination of inpatient opioid withdrawal treatment among patients with comorbid ADHD. Methods: We conducted a comprehensive assessment of all participants currently undergoing inpatient opioid withdrawal treatment. Our assessment protocol included the administration of the ADHD Self-Report Scale (ADHD-SR) and the Wender Utah Rating Scale (WURS-k). Additionally, participants who met the thresholds on one or both questionnaires underwent further evaluation using the Diagnostic Interview for ADHD in Adults (DIVA-2.0). Results: The prevalence of individuals diagnosed with ADHD within the studied cohort was determined to be 29.3%. Among the subset of participants identified as ADHD-positive, a notable 54.5% prematurely ceased therapy. In contrast, among those identified as ADHD-negative, the premature discontinuation rate was substantially lower at 28.3%. Conclusions: In summary, the impact of ADHD as a comorbid condition on the efficacy of inpatient opioid withdrawal treatment has been underscored. By identifying comorbid ADHD early in the treatment process, tailored therapeutic approaches may help to maximize the effectiveness of interventions and may improve patient outcomes. This underscores the importance of proactive screening for ADHD as a psychiatric comorbidity in optimizing the management of individuals undergoing inpatient opioid withdrawal treatment.

Psychotherapist factors that patients perceive are associated with treatment failure.

Psychotherapy is a well-established and effective treatment for various psychiatric problems, but a substantial proportion of patients do not benefit from it, and many terminate treatment prematurely. Previous studies suggest that therapist dissatisfaction may play a pivotal role in premature treatment termination. This study, therefore, aimed to investigate therapist factors that may contribute to less-than-optimal results and dropout. Data were collected through a survey of patients (n = 736) with the experience of previous unsuccessful psychotherapy treatments. Based on prior research, the survey covered 13 therapist behaviors and traits, such as being unstructured or unengaged. The most common therapist factor that patients associated with treatment failure was poor assessment/understanding (86.7%), followed by inflexibility (71.7%) and poor knowledge (70.1%). Furthermore, this study identified four novel therapist-related factors: breaking the treatment contract, inappropriate sexual behaviors or comments, using non-conventional methods, and dominating behaviors. Overall, this study highlights the significance of therapist-related factors in premature treatment termination and treatment failure, shedding light on the crucial role therapists play in the therapeutic process. Understanding these factors is essential for improving psychotherapy outcomes and reducing dropout rates. Further investigations are needed to explore the impact of these therapist behaviors on treatment outcomes and to develop strategies for enhancing therapist competencies and skills to foster a more effective therapeutic alliance. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

트라우마의 관점에서 본 프리엘의 『제게 답을 주세요, 제발!』 읽기

This paper examines Friel's Give Me Your Answer, Do! from the standpoint of trauma. In the play, Tom, a writer, has been traumatized since his daughter Bridget was committed to a mental institution ten years ago. Tom's response to the pain of Bridget's confinement and his inability to express the depth of his suffering is manifested in the act of writing hardcore pornographies. In this sense, Tom's pornographies are a form of self-expression, both as a physical writing of his pain and anger at the trauma he is suffering and as a creative act to preserve his life. Not only are Tom's self-destructive behaviors driven by the life drive, but his efforts to survive are constantly counteracted by the death drive. These aspects testify to the continuous struggle, compromise, and symbiosis between the dominant death drive and the opposing self-preservation and life drive of the traumatized individual. This study interprets David's role as a therapist treating traumatized patients in psychotherapy work and analyzes his hasty final assessment as premature termination of trauma treatment. However, since trauma cannot be cured once and for all, the treatment can be postponed indefinitely, and recovery is explored as an endless process.

Variables associated with antibiotic treatment tolerance in patients with Mycobacterium avium complex pulmonary disease

BackgroundTreatment of Mycobacterium avium complex pulmonary disease (MAC-PD) involves prolonged courses of multiple antibiotics that are variably tolerated and commonly cause adverse drug reactions (ADR). The purpose of this retrospective, single-center study was to identify demographic and disease-related variables associated with significant ADRs among patients treated with antibiotics against MAC-PD.MethodsWe reviewed all patients treated with antibiotic therapy for MAC-PD at a single center from 2000 to 2021. Patients were included if they met diagnostic criteria for MAC-PD, were prescribed targeted antibiotic therapy for any length of time and had their treatment course documented in their health record. We compared patients who completed antibiotics as originally prescribed (tolerant) with those whose antibiotic treatment course was modified or terminated secondary to an ADR (intolerant).ResultsOver the study period, 235 patients were prescribed antibiotic treatment with their clinical course documented in our center’s electronic health record, and 246 treatment courses were analyzed. One hundred forty-three (57%) tolerated therapy versus 108 (43%) experienced ADRs. Among the 108 intolerant courses, 67 (63%) required treatment modification and 49 (46%) required premature treatment termination. Treatment intolerance was associated more frequently with smear positive sputum cultures (34% vs. 20%, p = 0.009), a higher Charlson Comorbidity Index (CCI) (4 vs. 6, p = 0.007), and existing liver disease (7% vs. 1%, p = 0.03). There was no between-group difference in BMI (21 vs. 22), fibrocavitary disease (24 vs. 19%), or macrolide sensitivity (94 vs. 80%). The use of daily therapy was not associated with intolerance (77 vs. 79%). Intolerant patients were more likely to be culture positive after 6 months of treatment (44 vs. 25%).ConclusionsPatients prescribed antibiotic therapy for MAC-PD are more likely to experience ADRs if they have smear positive sputum cultures at diagnosis, a higher CCI, or existing liver disease. Our study’s rate of early treatment cessation due to ADR’s was similar to that of other studies (20%) but is the first of its kind to evaluate patient and disease factors associated with ADR’s. A systematic approach to classifying and addressing ADRs for patients undergoing treatment for MAC-PD is an area for further investigation.

Safety and Feasibility of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy With Calcium-Containing Solutions: A Randomized Controlled Trial.

Calcium-free (Ca-free) solutions are theoretically the most ideal for regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT). However, the majority of medical centers in China had to make a compromise of using commercially available calcium-containing (Ca-containing) solutions instead of Ca-free ones due to their scarcity. This study was designed to probe into the potential of Ca-containing solution as a secure and efficient substitution for Ca-free solutions. In this prospective, randomized single-center trial, 99 patients scheduled for CRRT were randomly assigned in a 1:1:1 ratio to one of three treatment groups: continuous veno-venous hemodialysis Ca-free dialysate (CVVHD Ca-free) group, continuous veno-venous hemodiafiltration calcium-free dialysate (CVVHDF Ca-free) group, and continuous veno-venous hemodiafiltration Ca-containing dialysate (CVVHDF Ca-containing) group at cardiac intensive care unit (CICU). The primary endpoint was the incidence of metabolic complications. The secondary endpoints included premature termination of treatment, thrombus of filter, and bubble trap after the process. The incidence of citrate accumulation (18.2% vs. 12.1% vs. 21.2%) and metabolic alkalosis (12.1% vs. 0% vs. 9.1%) did not significantly differ among three groups (p > 0.05 for both). The incidence of premature termination was comparable among the groups (18.2% vs. 9.1% vs. 9.1%, p = 0.582). The thrombus level of the filter and bubble trap was similar in the three groups (p > 0.05 for all). In RCA-CRRT for CICU population, RCA-CVVHDF with Ca-containing solutions and traditional RCA with Ca-free solutions had a comparable safety and feasibility. ChiCTR2100048238 in the Chinese Clinical Trial Registry.

Failed Fertilization in ART: What are the Causes and Methods to Improve Fertilization

Introduction of clinical ICSI made a revolution in achieving higher fertilization in ART programs. However, ICSI does not completely eliminate the risk of fertilization failure as total fertilization failure (TFF) occurs in 1-3% of ICSI cycles. TFF leads to unexpected premature termination of the ART treatment, inflicting a substantial psychological and financial burden on patients. The potential reasons for TFF include inability of the oocyte to activate the cascade of fertilization events, suboptimal oocytes or sperm quality, and technical issues in performing ICSI. Specifically, oocyte-related factors include oocyte cytoplasmic immaturity caused by insufficient protein synthesis or aberrant signalling pathways, spindle abnormalities, and defective proteins involved in fertilization. Sperm-related factors are primarily associated with abnormalities in the structure, expression, and localization pattern of PLC[Formula: see text]. Several laboratory approaches involving pharmacological agents help in activation of the oocytes thereby prevent the fertilization failure. However, as of now, there is no conclusive evidence to demonstrate the benefit of artificial oocyte activation hence, TFF following ICSI remains an ongoing and significant challenge in ART laboratory.

Premature termination of inpatient eating disorder treatment: Does timing matter?

BackgroundPremature termination of treatment is a serious problem in the treatment of eating disorders. Prior research attempting to differentiate patients who are able to complete treatment from those who terminate early has yielded mixed results. One proposed explanation for this is a failure to examine the time course of treatment termination. This study was designed to explore associations between baseline patient characteristics and timing of treatment termination.MethodsParticipants were 124 eating disorder patients admitted voluntarily to the inpatient program at Toronto General Hospital between 2009 and 2015. At admission, all patients completed measures of eating disorder symptoms, eating disorder cognitions, depressive symptoms and emotional dysregulation. Body weight was measured weekly. Data analyses were completed using one-way ANOVAs and Chi Square tests.ResultsResults showed significant associations between timing of treatment termination and eating disorder diagnosis, severity of eating disorder cognitions and severity of depressive symptoms. Post-hoc analyses revealed that patients who left treatment early had more severe depressive symptoms, eating disorder cognitions related to eating and difficulties engaging in goal directed behaviors when emotionally dysregulated.ConclusionsPatients who terminated inpatient treatment early in their admissions differ from patients who terminated later and those who completed treatment. These differences have potential clinical implications for the clinical management of patients with severe eating disorders requiring inpatient admission.Trial registration This paper is not associated with a clinical trial.

Second Line Treatment with Bruton Tyrosine Kinase Inhibitor (BTKi) or Bcl-2 Inhibitor (Bcl-2i) in Patients with Chronic Lymphocytic Leukemia (CLL): Primary Analysis of the Czech Study Group for CLL (CSCLL)

Introduction: Venetoclax in combination with rituximab (VenR) along with either ibrutinib or acalabrutinib monotherapy represent the most common regimens currently used for the treatment of relapsed/refractory (RR) chronic lymphocytic leukemia (CLL) in the Czech Republic. As all of these regimens are approved for identical indications in RR CLL, the selection of the most appropriate treatment depends on the drug toxicity profile and patient´s comorbidities. Methods: We conducted a retrospective analysis of data from the Czech National Registry of CLL patients (CLLEAR). Patients were treated in one of eight Czech hematological centres between December 2015 and June 2023. Only those who received chemoimmunotherapy in the first-line and Bruton tyrosine kinase inhibitor (BTKi) or Bcl-2 inhibitor (Bcl-2i) in the second-line treatment were included in the study. All patients fulfilled iwCLL diagnostic criteria and had provided informed consent before their data were captured in the CLLEAR. Key CLL-related clinical and laboratory parameters were obtained from the database (Table 1). Ibrutinib and acalabrutinib monotherapy were given at standard doses until disease progression (PD) or unacceptable toxicity. The combination of venetoclax and rituximab (VenR) was administered in the regular dosing schedule for 24 months. Results: Out of 291 patients included in the study, 70.1% (204/291) were treated with ibrutinib, 8.9% (26/291) received acalabrutinib and 20.9% (61/291) VenR. The median age at the start of the second-line treatment was 72.1 and 70.6 years, respectively (BTKi and Bcl-2i). There were no significant differences in sex, clinical stage, CIRS, creatinine clearance and time since diagnosis until the beginning of the second-line treatment. Bendamustine and rituximab followed by fludarabine, cyclophosphamide and rituximab were the most common regimens used in the firs-line treatment. Deletion (del) 17p and/or TP53 mutation, and del 11q were more frequent in the BTKi cohort, while unmutated IGVH gene was detected similarly in both groups (Table 1). Median follow-up was longer in BTKi than in Bcl-2i group (19.2 vs. 11.5 months). The overall response rate (ORR) was evaluated in 191 patients treated with BTKi and in 42 patients treated with Bcl-2i for at least six months. The ORR was comparable between the BTKi and Bcl-2i cohort, 90.6% (173/191) vs. 92.9% (39/42) (p = 0.774). More complete remissions (CR) were seen in Bcl-2i group, 12.0% (23/191) vs. 42.9% (18/42) (p<0.001). Median progression-free survival (mPFS) was 37.4 (31.4 - 43.35) months vs. not reached (BTKi vs Bcl-2i), HR 1.07 (95% CI, 0.59 - 1.94) (p = 0.833, Figure 1). Median overall survival (mOS) was 64.3 (37.2 - 91.5) months vs. not reached (BTKi vs Bcl-2i), HR 1.35 (95% CI 0.70 - 2.63) (p=0.371, Figure 1). Similar results were observed in the subgroup with del17p and/or TP53 mutation (mPFS: 35.6 months vs. not reached, HR 1.80, 95% CI, 0.69 - 4.69), as well as in the subgroup with unmutated IGVH gene (mPFS: 35.6 months vs. not reached, HR 1.36, 95% CI, 0.72 - 2.55). At the time of data analysis, hematological toxicity and infectious complications were premature for comparison (data were assessed in 31.3% of BTKi and 57.4% of Bcl-2i patients). Grade III-IV hypertension and other non-hematological toxicity (excluding infections) prevailed in BTKi cohort (19.2% BTKi, 9.6% Bcl-2i). The median treatment duration of BTKi and Bcl-2i was 14.7 (0.7 - 53.4) and 9.7 (0.3 - 25.8) months, respectively. Early discontinuation was observed more frequently post BTKi compared to post Bcl-2i administration, 43.9% (101/230) vs. 26.2% (16/61) (p<0.001). Except for the progression (24.8% BTKi, 18.8% Bcl-2i), the most common causes leading to premature discontinuation were death (23.8% BTKi, 12.5% Bcl-2i), infection (9.99% BTKi, 37.5% Bcl-2i), and non-hematological toxicity (24.8% BTKi, 6.3% Bcl-2i). Conclusion: In terms of high-risk prognostic markers, a higher prevalence of del 17p and/or TP53 mutation, and del 11q were observed in the BTKi cohort. In contrast, frequency of the unmutated IGVH gene was comparable in both groups. Difference in median PFS and OS was not statistically significant within the current follow-up period. However, premature termination of treatment was more commonly seen in BTKi group. To confirm our primary outcomes, longer follow-up is warranted.

OA11 Osteoporosis, denosumab, and hypocalcaemia in multimorbid renal impairment

Abstract Introduction Osteoporosis affects approximately 30% of patients with chronic kidney disease (CKD) at stages 3-5, with 10% of women and 5% of men experiencing a fragility fracture within a given three-year follow up period. First-line management of osteoporosis with bisphosphonates is often precluded in CKD, with alendronate and zoledronate being contraindicated in creatinine clearances of < 35mL/min, and risedronate if < 30mL/min. Denosumab, a RANK-ligand inhibiting monoclonal antibody, can be used in cases of poorer renal function, however causes hypocalcaemia more commonly than bisphosphonates. Concomitant CKD compounds this risk if creatinine clearance falls below 30mL/min, presenting additional challenges for management. Case description A 75-year old woman with known osteoporosis and chronic kidney disease secondary to hypertension and a pauci-immune necrotising glomerulonephritis was found to have a serum calcium of 2.08mmol/L approximately three months after commencing six-monthly denosumab. Her lumbar spine T-score on dual x-ray absorptiometry showed severe osteoporosis at −2.9, with a fragility fracture of the humerus sustained four years prior. Her baseline eGFR was 23mL/min/1.73m2, and creatinine clearance was 22mL/min. Her past medical history was extensive and included secondary hyperparathyroidism due to CKD and resulting vitamin D deficiency, with a PTH of 23.0pmol/L, serum calcium of 2.26mmol/L, and a serum 25-OH vitamin D3 level of 33.5nmol/L four months prior to denosumab therapy. The history also included Sjögren’s syndrome on long-term daily prednisolone 7.5mg, alternate-day hydroxychloroquine 200mg, and daily leflunomide 10mg for accompanying synovitis of the hands, hypothyroidism controlled with daily levothyroxine 50mcg, hypertension controlled with daily 2.5mg bisoprolol, peripheral neuropathy secondary to vitamin B12 deficiency on three-monthly hydroxocobalamin, myocardial infarction with percutaneous coronary intervention to three arteries, diverticular disease with abscess perforation requiring laparotomy and intensive care admission, and a previous deep vein thrombosis on long-term anticoagulation with apixaban. The patient had received risedronate in the past while her creatinine clearance still permitted this. Her vitamin D deficiency had been managed orally with Adcal-D3 and colecalciferol 800IU once daily, which was uptitrated to 1600IU once daily prior to commencing denosumab. However, despite the patient’s serum vitamin D levels rising from 33.5 to 37.2nmol/L in the months preceding her first denosumab infusion, serum calcium had fallen below normal range on post-infusion blood tests. Serum phosphate returned at 0.91mmol/L, and vitamin D had fallen to 23.1nmol/L in the three months following denosumab treatment. Consequently, the patient was commenced on longer term intensive vitamin D supplementation. Discussion This case raises the issue of multifactorial hypocalcaemia against a backdrop of osteoporosis, persistent vitamin D deficiency, and medical comorbidity limiting management options. The significance of CKD in this case highlights the importance of monitoring and replacing vitamin D. While the hypocalcaemia detected at three months post-infusion may have occurred in part due to the direct effect of denosumab, the patient’s vitamin D deficiency no doubt also played a role in this, and failing to detect the deficiency may have resulted in premature termination of denosumab treatment. This case also highlights the extended timeframe in which such hypocalcaemia may present. Case-series literature describes hypocalcaemia manifesting at, on average, eight days post-infusion in patients with CKD-associated hyperparathyroidism. However we demonstrate here that extended lag times up to twelve weeks are possible; the patient was symptomatic with leg cramping at the time of clinic follow up. Future practice may benefit from establishing monitoring regimes for those with CKD and osteoporosis receiving denosumab, or bisphosphonates toward the lower end of permitted renal function. Key learning points Chronic kidney disease both limits available management options in osteoporosis, and increases the likelihood of complications from the remaining available agents – illustrated here with hypocalcaemia. Hypocalcaemia in a patient with chronic kidney disease and osteoporosis may be driven by several factors: hyperphosphataemia, vitamin D deficiency, and the effect of denosumab to prevent mobilisation of calcium from bone to serum can all be culprits. Calcium, phosphate, and vitamin D all need to be tightly monitored in medically complex patients on treatment for osteoporosis.

Chemotherapy compliance in elderly patients with solid tumors: a real-world clinical practice data

Introduction. Malignant tumors in elderly people are more than ten times more prevalent than in the younger population. The data on the compliance with chemotherapy in older cancer patients managed outside of clinical trials is scarce. Material and methods. We retrospectively assessed 181 consecutive cancer patients aged 65 years or more who received systemic chemotherapy. The study aimed to examine chemotherapy compliance in a large series of elderly patients managed in routine clinical practice. We also investigated the ability to complete chemotherapy in relation to selected factors, such as tumor type, treatment setting and line, type of chemotherapy, presence of comorbidities, body mass index (BMI), an expected glomerular filtration rate, hemoglobin level (Hb), a neutrophil- to-lymphocyte ratio, and Eastern Cooperative Oncology Group performance status (PS). Results. Thirty-three percent of patients did not complete an initially pre-defined chemotherapy plan. The main reasons were disease progression (20%) and unacceptable toxicity (10%). Independent factors related to premature treatment termination included a lower BMI, a lower Hb level, lower PS, and palliative (compared to currative) setting. Conclusions. In conclusion, premature chemotherapy termination not related to disease progression is relatively rare in elderly patients and may be predicted with routinely used clinical parameters.

Thromboelastography and Traditional Coagulation Testing in Non-ICU-Admitted Patients with Acute Kidney Injury: An Observational Cohort Study

Introduction: This study aimed to elucidate the coagulation disorders in non-ICU patients with acute kidney injury (AKI) and their contribution to clotting-related outcomes of intermittent kidney replacement therapy (KRT). Methods: We included non-ICU-admitted patients with AKI requiring intermittent KRT, clinically having a risk of bleeding and against systemic anticoagulant use during KRT between April and December 2018. The premature termination of treatment due to circuit clotting was considered a poor outcome. We analyzed the characteristics of thromboelastography (TEG)-derived and traditional coagulation parameters and explored the potential-affecting factors. Results: In total, 64 patients were enrolled. Hypocoagulability was detected in 4.7%–15.6% of patients by a combination of the traditional parameters, i.e., prothrombin time (PT)/international normalized ratio, activated partial PT, and fibrinogen. No patient had hypocoagulability observed on TEG-derived reaction time; only 2.1%, 3.1%, and 10.9% of patients had hypocoagulability on TEG-derived kinetic time (K-time), α-angle, and maximum amplitude (MA), respectively, which were also platelet-related coagulation parameters, despite 37.5% of the cohort having thrombocytopenia. In contrast, hypercoagulability was more prevalent, involving 12.5%, 43.8%, 21.9%, and 48.4% of patients on TEG K-time, α-angle, MA, and coagulation index (CI), respectively, although thrombocytosis was only in 1.5% of the cohort. Patients with thrombocytopenia showed lower fibrinogen level (2.6 vs. 4.0 g/L, p = 0.00), α-angle (63.5° vs. 73.3°, p = 0.00), MA (53.5 vs. 66.1 mm, p = 0.00), and CI (1.8 vs. 3.6, p = 0.00) but higher thrombin time (17.8 vs. 16.2 s, p = 0.00) and K-time (2.0 vs. 1.2 min, p = 0.00) than those with a platelet count over 100 × 10⁹/L. 41 patients were treated with heparin-free protocol, and 23 were treated with regional citrate anticoagulation (RCA). The premature termination rate was 41.5% on heparin-free patients, while 8.7% of patients underwent an RCA protocol (p = 0.006). Heparin-free protocol was the strongest adverse factor to poor outcomes. A heparin-free subgroup analysis found that the circuit clotting risk was increased by 61.7% with a 10 × 10⁹/L elevation in platelet count (odds ratio [OR] = 1.617, p = 0.049) and decreased by 67.5% following a second increase of PT (OR = 0.325, p = 0.041). No significant correlation was found between TEG parameters and premature circuit clotting. Conclusions: Most non-ICU-admitted patients with AKI had normal-to-enhanced hemostasis and activated platelet function based on TEG results, as well as a high rate of premature circuit clotting when receiving heparin-free protocol despite thrombocytopenia. Further studies are needed to better determine the use of TEG in respect to management of anticoagulation and bleeding complications in AKI patients with KRT.

Pressurized intraperitoneal aerosol chemotherapy, reasons for interrupting treatment: a systematic review of the literature.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) gives encouraging results in the treatment of peritoneal metastasis (PM). The current recommendations require at least 3 sessions of PIPAC. However, some patients do not complete the full treatment course and stop after only 1 or 2 procedures, hence the limited benefit. A literature review was performed, with search terms including "PIPAC" and "pressurised intraperitoneal aerosol chemotherapy." Only articles describing the causes for premature termination of the PIPAC treatment were analysed. The systematic search identified 26 published clinical articles related to PIPAC and reporting causes for stopping PIPAC. The series range from 11 to 144 patients, with a total of 1352 patients treated with PIPAC for various tumours. A total of 3088 PIPAC treatments were performed. The median number of PIPAC treatments per patient was 2.1, the median PCI score at the time of the first PIPAC was 19 and the number of patients who did not complete the recommended 3 sessions of PIPAC was 714 (52.8%). Disease progression was the main reason for early termination of the PIPAC treatment (49.1%). The other causes were death, patients' wishes, adverse events, conversion to curative cytoreductive surgery and other medical reasons (embolism, pulmonary infection, etc…). Further investigations are necessary to better understand the causes for interrupting PIPAC treatment and also improving the selection of patients who are most likely to benefit from PIPAC.

Individual factors predict substance use treatment course patterns among patients in community-based substance use disorder treatment.

Substance use disorders (SUDs) usually involve a complex natural trajectory of recovery alternating with symptom reoccurrence. This study examined treatment course patterns over time in a community SUD clinic. We examined depressive symptoms level, primary SUD assigned at each admission, and lifetime misuse of multiple substances as potential risk factors for premature treatment termination and subsequent treatment readmission. De-identified longitudinal data were extracted from charts of 542 patients from an SUD treatment center. Survival analysis methods were applied to predict two time-to-event outcomes: premature treatment termination and treatment readmission. Primary opioid (vs alcohol) use disorder diagnosis at admission was associated with higher hazard of premature termination (HR = 1.91, p<0.001). The interaction between depressive symptoms level and substance use status (multiple vs single use) on treatment readmission was significant (p = 0.024), such that higher depressive symptoms level was predictive of readmission only among those with a history of single substance use (marginally significant effect). Lifetime use of multiple (vs single) substances (HR = 1.55, p = 0.002) and age (HR = 1.01, p = 0.019) predicted increased hazard of readmission. Findings did not support a universal role for depressive symptoms level in treatment course patterns. Primary SUD diagnosis, age, and history of substance misuse can be easily assessed and incorporated into treatment planning to support SUD patients and families. This study is the first to our knowledge that afforded a stringent test of these relationships and their interactions in a time-dependent, recurrent event, competing risks survival analysis examining both termination and readmission patterns utilizing a real-world clinic-based sample.

Premature termination, satisfaction with care, and shared decision-making during home treatment compared to inpatient treatment: A quasi-experimental trial.

Inpatient equivalent home treatment (IEHT), implemented in Germany since 2018, is a specific form of home treatment. Between 2021 and 2022, IEHT was compared to inpatient psychiatric treatment in a 12-months follow-up quasi-experimental study with two propensity score matched cohorts in 10 psychiatric centers in Germany. This article reports results on the treatment during the acute episode and focuses on involvement in decision-making, patient satisfaction, and drop-out rates. A total of 200 service users receiving IEHT were compared with 200 matched statistical "twins" in standard inpatient treatment. Premature termination of treatment as well as reasons for this was assessed using routine data and a questionnaire. In addition, we measured patient satisfaction with care with a specific scale. For the evaluation of patient involvement in treatment decisions, we used the 9-item Shared Decision Making Questionnaire (SDM-Q-9). Patients were comparable in both groups with regard to sociodemographic and clinical characteristics. Mean length-of-stay was 37days for IEHT and 28days for inpatient treatment. In both groups, a similar proportion of participants stopped treatment prematurely. At the end of the acute episode, patient involvement in decision-making (SDM-Q-9) as well as treatment satisfaction scores were significantly higher for IEHT patients compared to inpatients. Compared to inpatient care, IEHT treatment for acute psychiatric episodes was associated with higher treatment satisfaction and more involvement in clinical decisions.

Patients’ Reasons for “No Shows” and Premature Termination of Treatment at an Outpatient Mental Health Program

One in five Canadians currently experience mental health problems, and although effective psychotherapy treatment is currently available, patients’ decision to end therapy before completing treatment impacts limited resources. This qualitative study explored the experiences of 15 patients who either did not attend a scheduled intake appointment or had dropped out of service prematurely from an outpatient mental health clinic. Overall, the overarching themes identified were overall experience with service and access, multiple factors and external circumstances, experience with group structure, group processes and interactions, and age-related differences. Younger participants shared a need for flexible and spontaneous service.

Effect of infection with hepatitis B virus on the survival outcome of diffuse large B-cell lymphoma in the prophylactic antiviral era.

Patients with lymphoma who are also infected with Hepatitis B virus (HBV) have a poor prognosis. This could be partly explained by the delay or premature termination of anti-tumor treatment because of HBV reactivation. However, there is limited data on the survival outcome of patients HBV-related lymphoma in the era of prophylactic antivirals. Data for 128 patients with HBV surface antigen-positive diffuse large B-cell lymphoma was collected. The median age was 54 years and the ratio of men to women was 1.2:1. All patients received immune-chemotherapy and prophylactic antiviral therapy. The median number of cycles of immune-chemotherapy was six. The overall response rate was 82%, with a complete remission rate of 75%. With a median follow-up of 58.4 months, the 5-year progression-free survival and overall survival rates were 75.7% and 74.7%, respectively. Nine patients experienced HBV reactivation but none experienced HBV-associated hepatitis. Patients with low and high HBV DNA loads had comparable survival outcomes. In conclusion, HBV infection had no negative effect on the prognosis of DLBCL in the era of prophylactic antiviral therapy.

Identifying peaks in attrition after clients initiate mental health treatment in a university training clinic.

Mental health treatment noncompliance (preintake attrition, premature termination) has serious consequences both for mental health providers, as well as for individuals suffering from mental illness. However, prior work has examined preintake attrition and premature treatment termination separately, which limits our ability to determine when attrition is highest (before or after intake), and whether different factors predict attrition throughout the treatment process. Moreover, preintake attrition has been conceptualized as failing to attend a scheduled intake, thereby overlooking potential attrition that may occur earlier. The current investigation sought to fill these gaps using data from a university training mental health clinic. Of the 264 individuals who initiated contact with the clinic between 2012 and 2017, only about a quarter of individuals successfully completed therapy. Nearly 60% of prospective clients who contacted the clinic did not schedule intake. Although 10% of attrition occurred before the clinic could even recontact prospective clients, being placed on a waitlist accounted for the most attrition. Indeed, nearly two thirds of individuals placed on the waitlist did not schedule an intake, accounting for 30% of the overall sample. Client factors (age, previous psychotherapy engagement) did not predict preintake attrition, but wait times did. Having just one "no show" for an appointment predicted premature termination, decreasing the likelihood of completion to one in four. Together, these findings suggest that attrition was the highest prior to scheduling intake, and different factors predicted preintake attrition and premature termination. (PsycInfo Database Record (c) 2022 APA, all rights reserved).