Real-world Management Research Articles

Real-world Experience of Imatinib in Pediatric Chronic Phase Chronic Myeloid Leukemia: A Single-center Experience From India

IntroductionChronic myeloid leukemia (CML) is an uncommon malignancy in children in which tyrosine kinase inhibitors (TKIs) have significantly improved outcome in recent years. Patients and MethodsWe performed a retrospective analysis of CML patients (≤ 18 years old) presenting to our center between January 2005 and December 2018 with respect to baseline demographics, response to imatinib, and real-world management of those with a suboptimal response. ResultsA total of 124 patients were diagnosed with CML with 99 (80%) in the chronic phase. There was a male preponderance (males:females = 3.1:1) with a median age of 13 years. The common presenting clinical features were splenomegaly (90.9%) and fever (51.5%) with a median leukocyte count of 165 × 103/μL. The proportion of patients attaining a complete hematologic response (CHR) at 3 months, a complete cytogenetic response (CCyR) at 12 months, and a major molecular response at 12 months were 79.7%, 54.1%, and 50.9%, respectively. At a median follow-up of 67.4 months, the 5-year overall survival rate and the event-free survival (EFS) rate were 92% ± 3% and 64% ± 6%, respectively. Failure to achieve CCyR at 12 months was associated with poor EFS beyond 1 year (hazard ratio = 2.865, P = .044). Among 15 patients not achieving CHR at 3 months, dose escalation of imatinib resulted in the attainment of CHR in 13 (87%) patients. Seven patients in the cohort had a loss of the established response to imatinib because of documented poor compliance. ConclusionImatinib remains the frontline treatment of choice in CML with a reasonable outcome in children, especially when financial affordability, availability of second-generation TKIs, and poor compliance still remain major challenges in management. Dose escalation of imatinib remains an option in patients with a suboptimal response.

Management of patients with acute lymphoblastic leukemia in routine clinical practice: Minimal residual disease testing, treatment patterns and clinical outcomes in Belgium, Greece and Switzerland

ObjectivesTo describe real-world management and clinical and economic outcomes of patients with B-cell precursor acute lymphoblastic leukemia (ALL) in Belgium, Greece and Switzerland. MethodsThis descriptive, retrospective medical chart review collected patient-level data in 2018 from adults with ≥1 minimal residual disease (MRD) test during front-line ALL treatment. Data were stratified by MRD status. ResultsEighty-two patients were included (median age 44 years, 23 % Philadelphia chromosome-positive; MRD-positive: n = 17, MRD-negative: n = 50, MRD result unknown: n = 15). HyperCVAD (32 %) and HOVON (26 %) were the most frequently used front-line treatment protocols; 22 % of patients received stem cell transplantation. Overall, 76 % of ALL patients were hospitalized (mean 1.1 hospitalization/month). Complete hematological response (CRh) occurred in 66/82 patients (80 %). Median relapse-free survival from CRh was 32.7 months (MRD-positive: 11.7 months; MRD-negative: 33.3 months). Median overall survival from diagnosis was 28.9 months (MRD-positive: 15.3 months; MRD-negative: not reached). Most patients (88 %) were MRD tested during induction; testing rates considerably decreased thereafter (39 % during consolidation). ConclusionsB-cell precursor ALL represents a clinical burden and impacts healthcare resources; MRD-positive patients have worse prognosis than MRD-negative patients. Efforts should be made to adhere to recommendations for MRD testing in clinical guidelines.

Real-world management of advanced prostate cancer: A Canadian comparison of academic specialists and community-based prostate cancer physicians.

29 Background: The Canadian GU Research Consortium recently conducted a consensus development conference with 27 academic prostate cancer (PC) specialists leading to 31 consensus recommendations. We conducted a survey to compare community-based practice with the consensus recommendations on the management of metastatic castration sensitive prostate cancer (mCSPC), metastatic castration resistant prostate cancer (mCRPC) and non-metastatic castration resistant prostate cancer (nmCRPC). Methods: An 87-item online questionnaire was sent to 600 Canadian community urologists, medical oncologists, radiation oncologists, and general practitioner oncologists involved in the treatment of PC. Results: Seventy-two physicians responded to the questionnaire (12% response). A discordance of >25% was observed in 15 of 31 recommendations (48%). Among the areas of discordance were treatment approach for patients with nmCRPC and PSADT < 10 months who are negative for metastases on conventional imaging but metastatic on PET-based imaging. Of the academic physicians, 89% indicated treating with agents approved for nmCRPC compared to 50% of community physicians (p=0.0005). Important discrepancies were also observed across academic and community physicians for radiation to the prostate for low-volume mCSPC which was 74% vs 27%, (p<0.0001) respectively; criteria for stopping therapy in mCRPC in which 78% of academic physicians favored continuation of therapy in the event of PSA progression only, compared to 24% of community physicians. Sequencing of therapy after prior apalutamide for nmCRPC using subsequent docetaxel treatment was observed in 81% of academic physicians vs 35% of community physicians, (p<0.0001), and use of genetic testing was favored by 74% of academics vs 36% of community physicians, (p<0.0001) for newly diagnosed metastatic prostate cancer. Conclusions: The areas of discordance between a national sample of community-based PC physicians and academic consensus recommendations represent potential areas for education, practice tools and future research.

An SGBM-XVA demonstrator: a scalable Python tool for pricing XVA

In this work, we developed a Python demonstrator for pricing total valuation adjustment (XVA) based on the stochastic grid bundling method (SGBM). XVA is an advanced risk management concept which became relevant after the recent financial crisis. This work is a follow-up work on Chau and Oosterlee in (Int J Comput Math 96(11):2272–2301, 2019), in which we extended SGBM to numerically solving backward stochastic differential equations (BSDEs). The motivation for this work is basically two-fold. On the application side, by focusing on a particular financial application of BSDEs, we can show the potential of using SGBM on a real-world risk management problem. On the implementation side, we explore the potential of developing a simple yet highly efficient code with SGBM by incorporating CUDA Python into our program.

Management of epileptic seizures in school-age children: Educational project dedicated to school staff

ObjectiveThe objective of this study was to educate the school staff for a correct management of epileptic seizures in order to increase the safety of young people at school and promoting the administration of rescue drugs and in order to improve care and reduce improper calls to the health emergency number. MethodsThis project started in January 2016, and it is still ongoing at the Department of Neuroscience of Bambino Gesù Children's Hospital in Rome, Italy. There has been a data cut-off evaluation in November 2018. Two-hour training meetings with the school staff have been organized. The major topics of the training activities were as follows: report what epilepsy is, how to manage students with epileptic seizures, and how to administer rescue medications. During the meetings, the following two questionnaires were administered: one pretest in order to collect personal information and information on awareness of epilepsy, willingness to administer rescue medications, and anxiety in facing a seizure; and one posttest in order to check the knowledge acquired after the training sessions. Statistical analysis was performed using R version 3.2.3 (R Foundation for Statistical Computing, http://www.R-project.org/). Demographics (sex and age) and teaching experience were summarized with descriptive statistics for each variable. Demographics, teaching experience, awareness of disability, and knowledge of epilepsy were correlated to the management of seizures occurring in the classroom before the course; results are reported as odds ratios [OR] and 95% confidence interval (95 CI). ResultsNine hundred school staff members (95% school staff and 5% social workers) entered in the project between January 2016 and November 2018. Seven hundred and forty (82%) returned the questionnaires fulfilled, and not all of them were completely filled. Ninety-eight percent of school staff (676/691) were aware about epilepsy; however, only in 16% (110) the awareness of epilepsy came from medical staff, scientific brochures, or participation in conventions. Thirty-five percent of school staff (248/707) believed that epilepsy reduces learning abilities, and 58% (409/703) believed that children with epilepsy need school support. After the training, 68% of school staff (496/734) correctly filled in the questionnaire related to the management of acute seizures versus 8% of them (57/718) in the prequestionnaire. After the training, 89% of school staff (601/675) were ready to administer rescue medications versus 54% (384/712) before the training. The majority of participants reported that the level of anxiety related to the management of seizures after the training significantly reduced. ConclusionsResults of this project documented an increase in knowledge of epilepsy, a better knowledge on management of acute seizures in the school settings, a reduction in anxiety, and an increase in willingness to administer rescue medications. Further studies should be planned in order to document the changes in the real-world management of seizures, to evaluate if a reduction in hospital admittances might be reached, and to extend the project by assessing, through a questionnaire, the stigma and prejudices against the children affected by epilepsy by their classmates.

An interval joint-probabilistic stochastic flexible programming method for planning municipal-scale energy-water nexus system under uncertainty

In this study, an interval joint-probabilistic stochastic flexible programming method is proposed by integrating interval joint-probabilistic stochastic programming and flexible programming into one framework. It can not only be effective for handling interval-fuzzy information associated with flexible constraints, but also be efficient for reflecting interactions among correlated random variables as well as the resulting joint risk. It is applied to the real-world energy-water nexus system management problem in Zhengzhou City, China. A series of management schemes are investigated through the proposed approaches, including (i) five satisfaction degrees linked to the flexible constraints of water resources availability and electricity demand-supply balance, (ii) five satisfaction degrees related to the flexible constraint of power output limit, and (iii) ten scenarios for different combinations of joint and individual constraint-violation levels between water resources availability and electricity demand. Results reveal that capacity expansion of renewable energy can increase with time, and the installed capacity of renewable energy at the end planning period can increase by 29.94%. Under consideration of energy and water resources availability, maximum power output limit, electricity demand-supply balance, pollutant and CO2 emissions control, and capacity expansion, decision makers in Zhengzhou can achieve a minimum system cost under the scenario of low water resources availability and high electricity demand (i.e. S10 (p=0.2, p1=0.19, p2=0.01)). These results can effectively support the 13th Five-Year Plan of Henan Province for Energy Development, which is required to choose more renewable energies with low water consumption.

Venetoclax: the first anti-myeloma agent with a reliable biomarker.

Venetoclax: the first anti-myeloma agent with a reliable biomarker.

Real-World Management and Outcomes of Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma Treated in the United States

Real-World Management and Outcomes of Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma Treated in the United States

P169 DEFINITION OF REMISSION IN INFLAMMATORY BOWEL DISEASE: ASSESSMENT OF PATIENT AND PHYSICIAN PERSPECTIVES

A primary goal in IBD management is achieving disease remission; however, patient (pt)-physician alignment on this goal is unclear. International online surveys were conducted to gain insights into pts’ and physicians’ perspectives on real-world management of IBD. Herein, we report survey findings pertaining to their understanding and perceptions of disease remission in IBD.

P169 DEFINITION OF REMISSION IN INFLAMMATORY BOWEL DISEASE: ASSESSMENT OF PATIENT AND PHYSICIAN PERSPECTIVES

Abstract Background A primary goal in IBD management is achieving disease remission; however, patient (pt)-physician alignment on this goal is unclear. International online surveys were conducted to gain insights into pts’ and physicians’ perspectives on real-world management of IBD. Herein, we report survey findings pertaining to their understanding and perceptions of disease remission in IBD. Methods Surveys were completed online by pts and physicians in Canada, France, Germany, Italy, Spain, UK, and US. Using a mixed-recruitment method, pts were identified by physicians, pt advocacy groups, and panels, while physicians were identified by recruitment agencies and panels. Eligible pts were aged ≥18 y who were diagnosed with and received treatment for Crohn’s disease (CD) or ulcerative colitis (UC) and had not undergone surgery for UC. Eligible physicians were gastroenterologists who had treated pts with CD or UC (≥12 each) in the last month, were responsible for treatment decisions of their IBD pts, and for whom ≥30% of their IBD pts had moderate or severe disease per prespecified clinical criteria. A 1:1 CD:UC ratio was targeted for the pt survey. Alignment between pts and physicians on remission definitions and pt-physician communication about remission was assessed. Physicians’ estimates of remission rates in their moderate/severe IBD pts receiving biologic therapy and their satisfaction (1=very dissatisfied to 7=very satisfied) with remission rates with current IBD treatments also were reported. Results A total of 2398 IBD pts (1368 CD [40% male], 1030 UC [45% male]) and 654 physicians completed the surveys. Mean pt age was 42 y (CD) and 44 y (UC). Physicians had mean monthly caseloads of 42.9 (CD) and 43.3 (UC). The most common primary care settings were university/teaching hospitals (41%), private practices (31%), and regional/community hospitals (20%). Nearly one quarter of pts reported never having discussed remission with their physician; only 7% of physicians reported that they typically did not discuss remission with their pts. Pts most commonly defined remission as symptom resolution (45%), whereas most physicians defined remission through test results (64% CD, 70% UC), including colonoscopies (56% CD, 58% UC), biopsies (36%, 37%), and biochemical tests (8%, 6%). Most pts (62% CD, 64% UC) had never heard of the term “mucosal healing.” Despite low physician-reported remission rates (CD: 37%–54%; UC: 37%–55%), 25% and 36% of physicians reported high satisfaction (score ≥6) with CD and UC remission rates, respectively. Conclusions This international survey demonstrated differences in pts’ and physicians’ definitions of IBD remission and in their understanding of the role of histologic remission in IBD. The findings highlight the need for improved pt-physician communication and education regarding remission, which may improve adherence and outcomes.

Real-world management of hyperkalemia with patiromer among United States Veterans

ABSTRACT Objective: Patiromer is a sodium-free, non-absorbed, potassium (K+) binder approved for the treatment of hyperkalemia (HK). Among US Veterans with HK, this retrospective, observational cohort study evaluated patiromer utilization, RAASi continuation, and K+ concentration change following patiromer initiation. Methods: Using data from the Veterans Affairs Corporate Data Warehouse, Veterans with HK (K+ ≥5.1 mmol/L) were included upon patiromer initiation (index date) during the study period (1/2016–8/2018). All patients had heart failure (HF), diabetes, or chronic kidney disease (CKD). Patients with end-stage renal disease were excluded. The following outcomes were assessed within 6-months post-patiromer initiation: patiromer utilization (using proportion of days covered); K+ concentration change (pre- vs post-initiation); and RAASi continuation. Results: 288 Veterans with HK were included. Baseline characteristics were: median age 70 years, African-American race 24%, diabetes 83%, HF 32%, CKD 95%, and median K+ concentration 5.7 mmol/L. At 1, 3, and 6 months post-index, the median patiromer PDC was 100%, 66%, and 44%, respectively. K+ concentration reductions post-patiromer initiation were, on average, – 1.0 mmol/L (P < 0.001). At 3–6 months, 71% of patiromer initiators had K+ <5.1 mmol/L and 95% had K+ <5.5 mmol/L. RAASi therapy was continued in >80%–90% of patiromer-treated patients. Conclusions: The real-world utilization results suggest patiromer is used for the chronic management of HK. Clinically relevant K+ concentration reductions were observed at all study time points. The successful management of HK may have contributed to the observed high rate of RAASi therapy continuation. Further research is warranted to corroborate and extend these findings.

P393 Patient and physician perspectives on the management of inflammatory bowel disease: Role of steroids in the context of biologic therapy

Abstract Background Corticosteroids are a mainstay of inflammatory bowel disease (IBD) treatment but are not as effective as maintenance therapy and prolonged exposure is associated with significant morbidities. We assessed real-world management of IBD using an international online survey of patients (patients) and physicians and present results related to steroid use for IBD. Methods The online survey was conducted in Canada, France, Germany, Italy, Spain, UK, and the USA. The mixed-recruitment methodology was used: patients were recruited by physicians, pt advocacy groups, and panels; physicians were recruited by recruitment agencies and panels. Eligible patients were adults with Crohn’s disease (CD) or ulcerative colitis (UC) (targeted 1:1 ratio CD:UC) who had received IBD treatment but had not had surgery for UC. Eligible physicians were gastroenterologists who had treated ≥12 CD patients and ≥12 UC patients (≤70% with a disease of mild severity) in the prior month and were responsible for treatment decisions. Results Surveys were completed by 2398 IBD patients (1368 CD, 1030 UC) and 654 physicians. Mean ages were 43 y and 45 y for patients with CD and UC, respectively; 60% and 55% were female. Most patients (93% CD, 78% UC) had moderate/severe IBD per clinical criteria; 71% and 47%, respectively, had ever required hospitalisation. Physicians had a mean monthly caseload of 42.9 CD patients and 43.3 UC patients, and 62.4%–67.2% of their IBD patients had moderate/severe disease. Biologic therapy was currently used by 50% of CD patients and 32% of UC patients, consistent with results for physicians (54% CD, 43% UC). Most patients (69% CD, 58% UC) reported a loss of response (LOR) to prior treatments, and most physicians reported that their patients experienced a LOR to biologic therapy fairly/very frequently (66% CD, 56% UC). Approximately 75% of IBD patients had ever used steroids for their IBD; steroid use of ≥4 or ≥6 months in the past year was reported by 35% and 18% of CD patients, respectively, and by 40% and 19% of UC patients. Physicians reported that 40% and 14% of their IBD patients used steroids for ≥4 or ≥6 months in the past year. Among patients currently receiving steroid therapy, many (48% CD, 42% UC) were concerned about any steroid use, and two-thirds reported wanting to stop steroid treatment as soon as the disease was under control. Only 27% of physicians reported a concern about any steroid use; approximately half reported a concern about ≥4 months of steroid use per year. Conclusion This international survey demonstrated that steroid use is prevalent and LOR to biologics is common among moderate/severe IBD patients. There were differences in pt and physician perception of steroid use; many physicians believed ≥4 months of steroid use per year was not a concern. A significant unmet need remains for treatments that provide sustained control of IBD.

P482 Patient and physician perspectives on the management of inflammatory bowel disease: Disease remission and durability of treatment

Abstract Background Achieving disease remission and selecting durable maintenance therapy are essential treatment goals in IBD. To gain insight into real-world management of IBD from both the patient (pt) and physician perspective, we conducted international online surveys. Here we report results related to patients’ and physicians’ beliefs, experience, and expectations regarding IBD remission and durability of IBD treatments. Methods Surveys were fielded in Canada, France, Germany, Italy, Spain, UK, and the USA. The mixed-recruitment methodology was used; patients were recruited by physicians, patient advocacy groups, and panels; physicians were recruited by recruitment agencies and panels. Patients aged ≥18 years with a diagnosis of Crohn’s disease (CD) or ulcerative colitis (UC) who had received treatment for IBD and had not undergone surgery for UC were eligible. Physicians were eligible to participate if they were gastroenterologists who had treated ≥12 patients with CD and ≥12 patients with UC in the last month, were responsible for treatment decisions for their IBD patients, and for whom ≤70% of their IBD patients had a mild disease (based on prespecified clinical criteria). A 1:1 ratio of CD:UC patients was targeted for the patient survey. Results Surveys were completed by 2398 IBD patients (1368 CD, 1030 UC) and 654 physicians. Mean age was 43 years and 45 years for patients with CD and UC, respectively; 60% and 55% were female. Physicians had a mean monthly caseload of 42.9 CD patients and 43.3 UC patients; most physicians were in a university/teaching hospital (41%), private practice (31%), or regional/community hospital (20%). Most patients (78%) reported discussing remission with their physician, whereas nearly all physicians (93%) reported they typically discussed remission. Remission was most frequently defined by resolution of symptoms for patients (45%) and by test results for physicians (64% for CD, 70% for UC). Most patients felt that their IBD was only partially controlled (61%) with their current treatment; &amp;gt;80% expected to be on treatment in 5 y, and only 33% of patients were satisfied with this expectation. Although ~30% of patients expected their current treatment to control their IBD for ≥5 y, only 7% of physicians had this expectation; most physicians estimated a response duration of just 1–2 y with current treatments. Most physicians reported moderate satisfaction with response duration (60% for CD patients, 71% for UC) and remission rate (72% for CD, 81% for UC) with current treatments. Conclusion This international survey demonstrated both patients and physicians discuss remission but more patients expect sustained control of their disease. This lack of concordance in expectations may hinder communication and treatment optimisation. Better alignment between patients and physicians on treatment goals and measures of success may improve IBD management.

East meets West for the treatment of glioma: A discussion of real-world cases

Background and Aim: The standard of care for patients with gliomas should follow established guidelines. In real-world management, however, the management sometimes deviates from these guidelines. We organized a discussion of real-world clinical cases and summarized different considerations from Chinese and European specialists.Case Presentation: A multidisciplinary team comprising experts from Europe and China discussed two patients with glioma treated at Sun Yat-sen University Cancer Center and Liaoning Cancer Hospital and Institute, China. Patient 1 was a 43-year-old man with a recurrent oligodendroglioma in the left frontal lobe diagnosed based on histology alone. He had undergone a biopsy and was diagnosed with an oligodendroglioma 3 years previously. He underwent chemoradiotherapy followed by 12 cycles of chemotherapy with temozolomide (TMZ), and complete remission was achieved. However, the tumor recurred within a short period of time and was resected by a second surgery. The pathologic diagnosis of the recurrent tumor was a glioblastoma because 1p/19q was intact when detected by sequencing. Pathologic consultation from another hospital still considered an anaplastic oligodendroglioma based on the positive result of 1p19q loss of heterozygosity (LOH) determined by fluorescence in situ hybridization. Patient 2 was a 50-year-old man with a left temporal glioblastoma. He underwent tumor resection but no radiotherapy. After seven cycles of TMZ (5/28-day regimen), his symptoms deteriorated, and his treatment was changed to a TMZ dose-dense regimen (7 days on/7 days off) and bevacizumab (7.5 mg/kg every 2 weeks), plus tumor-treating field therapy. Consultation Results: The pathological diagnosis based on biopsy for Patient 1 was an oligodendroglioma (World Health Organization Grade II), whereas the result of the second surgical sample was glioblastoma or anaplastic oligodendroglioma (questionable). Although the accuracy of fluorescence in situ hybridization for the detection of 1p/19q LOH requires improvement, 1p/19q LOH is typically not reconstituted in oligodendroglioma. More likely, it was due to sampling; a positive observation field may be missed with consequent negative results, and both oligodendroglioma (with 1p/19q co-deletion and isocitrate dehydrogenase mutation) and astrocytoma (without 1p/19q co-deletion) may exist. With respect to further treatment for cases such as Patient 1, both Chinese and European experts agree that procarbazine + lomustine chemotherapy is appropriate, while re-irradiation is suggested only if the tumor recurs outside the original radiotherapy field or within the radiotherapy field in the future. Considering the medical history, the rapid tumor regrowth without postoperative radiotherapy in Patient 2 was not surprising. After application of a rescue treatment regimen, the general condition of the patient improved, which may have resulted from the bevacizumab. A consensus was reached between the Chinese and European experts regarding subsequent treatment of Patient 2. Continuation of TMZ and bevacizumab was suggested until further deterioration. Whether tumor-treating field therapy should play a role in this patient could not be evaluated. However, some other molecular targeted agents (e.g. vascular endothelial growth factor receptor tyrosine kinase inhibitors such as regorafenib or apatinib) after bevacizumab failure, the effectiveness of these drugs remains unclear. Conclusion: In clinical practice, although we should follow established guidelines, the final treatment regimen requires informed consent from the patient. Thus, some real-world cases may deviate from the established guidelines. When patients reach end-stage disease with a marked decrease in their performance status and no standard treatment options, active antitumor treatment might be more likely to be attempted in China, while symptomatic treatment is more frequently performed in Europe. Although treatment philosophies for patients with glioma are slightly different between Eastern and Western medical experts, any treatment strategies should satisfy these patients.

822 Drip or Ship? Real-world STEMI Management and Concordance With Guidelines for Patients From Outer-Metropolitan and Semi-Rural Centres

Deciding between intravascular thrombolytic therapy (TL) and percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is influenced by location. Australian guidelines recommend metropolitan patients receive PCI within 90 minutes of first medical contact while rural and remote patients receive TL before transfer and angiography within 24 hours. For outer-metropolitan patients with perceived transfer times to PCI-capable centres of 30-60 minutes, the decision becomes complex despite clear guideline criteria. Patients presenting to South Australian outer-metropolitan locations 30-80 kilometres from a PCI-capable centre between 2013 and 2019 with STEMI or cardiac arrest with ST-elevation were included. The initial location, transfer time, door to balloon time and first-medical-contact to balloon time were recorded. Incidence of MACE (combined incidence of mortality, re-infarction and revascularisation) at 12 months was recorded. 46 Patients were included (mean age 63, 60.9% male). Median time from first-medical-contact to balloon was 116 minutes (IQR 95,148). When seen initially and directly transferred for PCI by ambulance (n=20), the median time to balloon was 96 minutes (IQR 92,114). When seen initially at peripheral hospitals (n=26), median was 137 minutes (IQR 113,171). Only 7(15.2%) patients achieved revascularisation within 90 minutes. MACE at 12 months occurred in 15.2% of patients. The vast majority of patients transferred for primary-PCI in locations with perceived transfer times of 30-60 minutes failed to have revascularisation within guideline recommended timeframes. The auditing of transport times is important to calibrate perceived transfer times and inform this infrequent but vital clinical decision.

Suboptimal glycemic control among subjects with diabetes mellitus in India: a subset analysis of cross-sectional wave-7 (2016) data from the International Diabetes Management Practices Study (IDMPS).

Objective:To assess the real-world management practices of subjects with type 2 diabetes mellitus (T2DM) and type 1 diabetes mellitus (T1DM) in India.Methods:This cross-sectional study was conducted between 7 March 2016 and 15 May 2016 in India as part of the seventh wave (2016) of the International Diabetes Management Practices Study (IDMPS). Adult subjects with T1DM or T2DM visiting physicians during a 2-week recruitment period were included.Results:A total of 55 physicians included 539 subjects who met eligibility criteria. Of 495 subjects with T2DM, 303 were treated with oral glucose lowering drugs (OGLDs) only, 158 were treated with OGLD + insulin, and 27 received insulin only. Among 44 subjects with T1DM receiving insulin, 13 (29.5%) were also treated with OGLD therapy. The most commonly used insulin regimens were basal alone (69/184; 37.5%) and premixed alone (63/184; 34.2%) in subjects with T2DM, and basal + prandial insulin (24/44; 54.5%) in subjects with T1DM. Proportions of subjects achieving glycemic targets were low [glycated haemoglobin (HbA1c) <7%: T1DM = 7.3% (3/44), T2DM = 25.2% (106/495); as targeted by the treating physician: T1DM = 31.8% (14/44), T2DM = 32.1% (59/185); global target: T1DM = 4.8% (2/42) and T2DM = 1.7% (8/482)]. In subjects with T2DM, HbA1c <7% was noted in 11/22 subjects receiving insulin only and 76/260 receiving only OGLDs. Lack of experience in self-managing insulin dosing, poor diabetes education and failure to titrate insulin dosages were the main reasons for non-achievement of glycemic targets.Conclusion:Timely insulinization, education and empowerment of people with diabetes may help improve glycemic control in India.

428 Utility of Echocardiography in the Real-World Management of Pulmonary Embolism. A Single Centre Experience of Pulmonary Embolism

428 Utility of Echocardiography in the Real-World Management of Pulmonary Embolism. A Single Centre Experience of Pulmonary Embolism

Machine learning facilitated business intelligence (Part I)

PurposeThe purpose of this paper is to conduct a comprehensive review of the noteworthy contributions made in the area of the Feedforward neural network (FNN) to improve its generalization performance and convergence rate (learning speed); to identify new research directions that will help researchers to design new, simple and efficient algorithms and users to implement optimal designed FNNs for solving complex problems; and to explore the wide applications of the reviewed FNN algorithms in solving real-world management, engineering and health sciences problems and demonstrate the advantages of these algorithms in enhancing decision making for practical operations.Design/methodology/approachThe FNN has gained much popularity during the last three decades. Therefore, the authors have focused on algorithms proposed during the last three decades. The selected databases were searched with popular keywords: “generalization performance,” “learning rate,” “overfitting” and “fixed and cascade architecture.” Combinations of the keywords were also used to get more relevant results. Duplicated articles in the databases, non-English language, and matched keywords but out of scope, were discarded.FindingsThe authors studied a total of 80 articles and classified them into six categories according to the nature of the algorithms proposed in these articles which aimed at improving the generalization performance and convergence rate of FNNs. To review and discuss all the six categories would result in the paper being too long. Therefore, the authors further divided the six categories into two parts (i.e. Part I and Part II). The current paper, Part I, investigates two categories that focus on learning algorithms (i.e. gradient learning algorithms for network training and gradient-free learning algorithms). Furthermore, the remaining four categories which mainly explore optimization techniques are reviewed in Part II (i.e. optimization algorithms for learning rate, bias and variance (underfitting and overfitting) minimization algorithms, constructive topology neural networks and metaheuristic search algorithms). For the sake of simplicity, the paper entitled “Machine learning facilitated business intelligence (Part II): Neural networks optimization techniques and applications” is referred to as Part II. This results in a division of 80 articles into 38 and 42 for Part I and Part II, respectively. After discussing the FNN algorithms with their technical merits and limitations, along with real-world management, engineering and health sciences applications for each individual category, the authors suggest seven (three in Part I and other four in Part II) new future directions which can contribute to strengthening the literature.Research limitations/implicationsThe FNN contributions are numerous and cannot be covered in a single study. The authors remain focused on learning algorithms and optimization techniques, along with their application to real-world problems, proposing to improve the generalization performance and convergence rate of FNNs with the characteristics of computing optimal hyperparameters, connection weights, hidden units, selecting an appropriate network architecture rather than trial and error approaches and avoiding overfitting.Practical implicationsThis study will help researchers and practitioners to deeply understand the existing algorithms merits of FNNs with limitations, research gaps, application areas and changes in research studies in the last three decades. Moreover, the user, after having in-depth knowledge by understanding the applications of algorithms in the real world, may apply appropriate FNN algorithms to get optimal results in the shortest possible time, with less effort, for their specific application area problems.Originality/valueThe existing literature surveys are limited in scope due to comparative study of the algorithms, studying algorithms application areas and focusing on specific techniques. This implies that the existing surveys are focused on studying some specific algorithms or their applications (e.g. pruning algorithms, constructive algorithms, etc.). In this work, the authors propose a comprehensive review of different categories, along with their real-world applications, that may affect FNN generalization performance and convergence rate. This makes the classification scheme novel and significant.

Do-It-Yourself Artificial Pancreas Systems: A Review of the Emerging Evidence and Insights for Healthcare Professionals.

Application of artificial pancreas systems in type 1 diabetes (T1D) represents a change in approach to managing complex glucose and insulin dynamics using automated features with higher levels of safety, precision, and reliability than those afforded by manual adjustments. To date, limited commercial systems and more widely used open-source, hybrid closed loop, Do-It-Yourself Artificial Pancreas Systems (DIY APS) have been used in nontrial real-world management of T1D. The aims of this article are twofold. First, itsynthesizes the emerging literature on DIY APS and identifies a range of evidence including research, reviews, commentaries, and opinion pieces written by DIY APS users, healthcare professionals (HCPs), and researchers. It summarizes the emerging clinical evidence for DIY APS and provide insight into how the DIY APS movement began, has been disseminated throughout diabetes online communities, and is reshaping self-management of T1D in real-world settings. Second, the article provides commentaries that explore implications of DIY APS to healthcare practice. DIY APS are radically changing T1D management. Automating the process of frequently analyzing glucose readings and appropriately titrating insulin delivery is liberating people with T1D (PWD) from some of the demands of intensive management. Within this super-specialized area of T1D management, the expertise of DIY APS users has outstripped that of many HCPs. While educational, ethical, and legal constraints need to be resolved, HCPs still need to stay abreast of this rapidly developing area. Further research is needed to inform policy and practice relating to DIY APS. Meanwhile, HCPs continue to learn from PWD's real-world experiences of building and using DIY APS to improve metabolic and psychological outcomes.

Real-world management of male idiopathic infertility in indication for FSH treatment: a multicenter, longitudinal, observational cohort study (open registry)

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)