Recommendations For Therapy Research Articles

Abstract PD15-11: PD15-11 Axillary dissection to determine nodal burden to inform systemic therapy recommendations in patients with clinically node-positive breast cancer: Pre-planned substudy of TAXIS (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG-53, GBG 101)

Abstract Introduction: Chemotherapy is recommended for patients with luminal breast cancer and more than three positive nodes. In addition, recent landmark trials raised the question if the exact number of positive nodes is required to indicate genomic testing. In the neoadjuvant setting, response-driven therapy is increasingly used and may be influenced by surgical staging of the axilla. The present study addressed the role of axillary lymph node dissection (ALND) as decision aid for systemic therapy in a contemporary cohort of patients with clinically node-positive breast cancer in the adjuvant and neoadjuvant setting. Methods: The study was preplanned in the international multicenter phase-III OPBC-03/TAXIS trial (ClinicalTrials.gov Identifier: NCT03513614). The first 500 patients with clinically node-positive breast cancer who were randomized after tailored axillary surgery (TAS) to undergo ALND or axillary radiotherapy (ART) without ALND in the context of extended regional irradiation were included from August 2018 to June 2022. Clinically node-positive breast cancer was defined by confirmed nodal disease at the time of initial diagnosis; in case of neoadjuvant therapy, the finding of residual nodal disease was mandatory for randomization. TAS consisted of removal of palpably suspicious findings and the sentinel nodes with the option of image guidance. In the ART arm, the total number of positive nodes was not known. We analyzed the impact of ALND on rate and type of systemic therapy. Results: A total of 500 patients with a median age of 57 years (IQR: 48-69 years) were included at 44 breast centers from six European countries. Subtype was hormone receptor (HR) positive (+) and human epidermal growth factor receptor 2 (HER2) negative (-) in 393 (80.0%), HR+/HER2+ in 52 (10.6%), HR-/HER2+ in 5 (1.0%) and HR-/HER2- in 34 (6.9%) patients. Of 343 patients (68.6%) who were treated in the adjuvant setting, 297 had HR+/HER2- disease. Of these 297 patients, 145 (48.8%) underwent ART without ALND and 152 (51.2%) underwent ALND after TAS. In the ART arm, the median number of lymph nodes removed was five (IQR 4-8), three (IQR 1-4) of which were positive and in the ALND arm, the number was 19 (IQR 14-26), four (IQR 2-9) of which were positive (p < 0.001). The use of ALND had no significant impact on the rate of patients with HR+/HER2- disease undergoing adjuvant chemotherapy (51.0% in the ART and 57.9% in the ALND arm, p=0.2), and there were no significant differences in type of systemic therapy with the exception of tamoxifen, which was 18.4% with ALND versus 9.0% without (p=0.018). A total of 143 patients (28.6%) underwent neoadjuvant chemotherapy, 13 had neoadjuvant antihormonal treatment and one had neoadjuvant double HER2-blockade without chemotherapy. Of the 143 patients who received neoadjuvant chemotherapy, 71 (49.7%) underwent ART without ALND and 72 (50.3%) underwent ALND. In the ART arm, the median number of lymph nodes removed was four (IQR 3-6), one (IQR 1-3) of which was positive and in the ALND arm, the number was 16 (IQR 12-19), two (IQR 1-5) of which were positive (p < 0.001). The use of ALND in patients after neoadjuvant treatment had no significant impact on the rate of adjuvant systemic therapy (71.8% in the ART and 65.3% in the ALND arm, p=0.4), with no significant differences in type of chemotherapy (e.g., capecitabine: 11.3% vs 12.5%, p=0.8; T-DM1: 11.3% vs. 11.1%, p>0.9) or antihormonal therapy (e.g., aromatase inhibitors: 49.3% vs. 41.7%, p=0.4; tamoxifen: 11.3% vs. 5.6%, p=0.2). Discussion: This study showed that although ALND significantly increased the number of positive nodes removed in the adjuvant and neoadjuvant setting, it had no relevant impact on rate and type of adjuvant systemic therapy. Citation Format: Walter P. Weber, Zoltan Matrai, Stefanie Hayoz, Christoph Tausch, Guido Henke, Daniel R. Zwahlen, Günther Gruber, Frank Zimmermann, Thomas Ruhstaller, Simone Muenst, Markus Ackerknecht, Sherko Küemmel, Vesna Bjelic-Radisic, Viktor Smanykó, Conny Vrieling, Rok Satler, Inna Meyer, Charles Becciolini, Susanne Bucher, Colin Simonson, Peter M. Fehr, Natalie Gabriel, Robert Maráz, Dimitri Sarlos, Konstantin J. Dedes, Cornelia Leo, Gilles Berclaz, Hisham Fansa, Christopher Hager, Klaus Reisenberger, Ákos Sávolt, Christian F. Singer, Roland Reitsamer, Jelena Winkler, Giang Thanh Lam Lam, Mathias K. Fehr, Tatiana Naydina, Magdalena Kohlik, Karine Clerc, Valerijus Ostapenko, Florian Fitzal, Martin Heidinger, Nadia Maggi, Alexandra Schulz, Pagona Markellou, Loïc Lelièvre, Daniel Egle, Jörg Heil, Michael Knauer, Christian Kurzeder. PD15-11 Axillary dissection to determine nodal burden to inform systemic therapy recommendations in patients with clinically node-positive breast cancer: Pre-planned substudy of TAXIS (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG-53, GBG 101) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD15-11.

Therapeutic Approaches to Non-Motor Symptoms of Parkinson's Disease: A Current Update on Preclinical Evidence.

Despite being classified as a movement disorder, Parkinson's disease (PD) is characterized by a wide range of non-motor symptoms that significantly affect the patients' quality of life. However, clear evidence-based therapy recommendations for non-motor symptoms of PD are uncommon. Animal models of PD have previously been shown to be useful for advancing the knowledge and treatment of motor symptoms. However, these models may provide insight into and assess therapies for non-motor symptoms in PD. This paper highlights non-motor symptoms in preclinical models of PD and the current position regarding preclinical therapeutic approaches for these non-motor symptoms. This information may be relevant for designing future preclinical investigations of therapies for nonmotor symptoms in PD.

Assessment of Sex Disparities in Nonacceptance of Statin Therapy and Low-Density Lipoprotein Cholesterol Levels Among Patients at High Cardiovascular Risk

Many patients at high cardiovascular risk-women more commonly than men-are not receiving statins. Anecdotally, it is common for patients to not accept statin therapy recommendations by their clinicians. However, population-based data on nonacceptance of statin therapy by patients are lacking. To evaluate sex disparities in nonacceptance of statin therapy and assess their association with low-density lipoprotein (LDL) cholesterol control. A retrospective cohort study was conducted from January 1, 2019, to December 31, 2022, of statin-naive patients with atherosclerotic cardiovascular disease, diabetes, or LDL cholesterol levels of 190 mg/dL (to convert to millimoles per liter, multiply by 0.0259) or more who were treated at Mass General Brigham between January 1, 2000, and December 31, 2018. Recommendation of statin therapy by the patient's clinician, ascertained from the combination of electronic health record prescription data and natural language processing of electronic clinician notes. Time to achieve an LDL cholesterol level of less than 100 mg/dL. Of 24 212 study patients (mean [SD] age, 58.8 [13.0] years; 12 294 women [50.8%]), 5308 (21.9%) did not accept the initial recommendation of statin therapy. Nonacceptance of statin therapy was more common among women than men (24.1% [2957 of 12 294] vs 19.7% [2351 of 11 918]; P < .001) and was similarly higher in every subgroup in the analysis stratified by comorbidities. In multivariable analysis, female sex was associated with lower odds of statin therapy acceptance (0.82 [95% CI, 0.78-0.88]). Patients who did vs did not accept a statin therapy recommendation achieved an LDL cholesterol level of less than 100 mg/dL over a median of 1.5 years (IQR, 0.4-5.5 years) vs 4.4 years (IQR, 1.3-11.1 years) (P < .001). In a multivariable analysis adjusted for demographic characteristics and comorbidities, nonacceptance of statin therapy was associated with a longer time to achieve an LDL cholesterol level of less than 100 mg/dL (hazard ratio, 0.57 [95% CI, 0.55-0.60]). This cohort study suggests that nonacceptance of a statin therapy recommendation was common among patients at high cardiovascular risk and was particularly common among women. It was associated with significantly higher LDL cholesterol levels, potentially increasing the risk for cardiovascular events. Further research is needed to understand the reasons for nonacceptance of statin therapy by patients and to develop methods to ensure that all patients receive optimal therapy in accordance with their preferences and priorities.

Anesthetic implications in porphyrias

The porphyrias are a group of disorders related to deficient heme biosynthesis, caused by malfunction of certain enzymes in the synthesis pathway. Erythropoietic porphyrias present with cutaneous symptoms and do not affect the nervous system. Hepatic porphyrias develop acute attacks with mild to severe neurovisceral symptoms, dramatic course, and rare, but possibly lethal outcomes. Anesthetic management of patients suffering from hepatic porphyria is challenging regarding the possibility of triggering or worsening the acute attack with medications that induce or maintain anesthesia. The medications are labeled as safe or unsafe according to laboratory experiments, clinical studies, case reports and experience. In this paper, we discuss underlying pathophysiology, presentation, therapy recommendations and anesthetic implications related to porphyrias.

Mitigating disparities in breast cancer treatment at an academic safety-net hospital.

Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital. We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status. 520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years. Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.

Sensor-based telerehabilitation system increases patient adherence after knee surgery.

Implementing evidence-based recommendations with the option of patient-individualised and situation-specific adaptations in telerehabilitation may increase adherence with improved clinical outcome. As part of a registry-embedded hybrid design (part 1), digital medical device (DMD)-usage in a home-based setting was analysed in a multinational registry. The DMD combines an inertial motion-sensor system with instructions for exercises and functional tests on smartphones. A prospective, single-blinded, patient-controlled, multicentre intervention study (DRKS00023857) compared implementation capacity of the DMD to standard physiotherapy (part 2). Usage patterns by health care providers (HCP) were assessed (part 3). Registry raw data (10,311 measurements) were analysed from 604 DMD-users, demonstrating clinically expected rehabilitation progression post knee injuries. DMD-users performed tests for range-of-motion, coordination and strength/speed enabling insight to stage-specific rehabilitation (χ2 = 44.9, p<0.001). Intention-to-treat-analysis (part 2) revealed DMD-users to have significantly higher adherence to the rehabilitation intervention compared to the matched patient-control-group (86% [77-91] vs. 74% [68-82], p<0.05). DMD-users performed recommended exercises at home with higher intensity (p<0.05). HCP used DMD for clinical decision making. No adverse events related to the DMD were reported. Adherence to standard therapy recommendations can be increased using novel high quality DMD with high potential to improve clinical rehabilitation outcome, enabling evidence-based telerehabilitation.

The relevance of identifying the biomechanical and functional effects of abdominar obesity on activities of daily living in individuals with low back pain

The Global Burden of Disease Studies 2019 defines low back pain (LBP) as pain in the area of the posterior aspect of the body from the lower margin of the twelfth rib to the lower gluteal folds with or without pain referred into one or both lower limbs that lasts for at least one day. Disability due to LBP increased by more than 50% since 1990 and this disability holds the first place in years of healthy life lost due to disability (YLD) which is reflected by medical, insurance and pension statistics of the countries of the civilized world (GBD 2019 Diseases and Injuries Collaborators, 2019).&#x0D; It has been established that a high body mass index is one of the main risk factors for LBP (Shiri et al., 2010). A number of studies demonstrating a significant association between LBP development and abdominal obesity. Based on the findings of these studies, it is concluded that abdominal obesity is an independent risk factor for LBP (Uçar et al., 2021). However, there are only a few studies on the musculoskeletal characteristics developed as a result of this association. Existing knowledge on the identification and explanation of biomechanical role of abdominal obesity in the development of LBP, description and evaluation of the movement patterns of people with LBP and abdominal obesity and comparing their characteristics to the movement patterns of healthy adults needs to be supplemented by new data.&#x0D; A study is proposed that investigates postural control and (neuro-) biomechanical movement patterns during various daily basic and complex movements in adults with abdominal obesity and LBP will qualitatively extend existing recommendations for LBP therapy.&#x0D; The investigation of central obesity-related postural alterations and compensatory mechanisms/strategies during activities of daily living compared to individuals without central obesity and exploring possible associations between those biomechanical alterations and body composition are relevant. In the concept of a “personalized medicine” approach, these individualized recommendations are needed to be added to comprehensive current patient-oriented strategies of obesity management for people with LBP. Such data and additional recommendations are also needed for the development of current methods of obesity management in order to properly and effectively organize physical exercise for people with LBP.&#x0D; References&#x0D; GBD 2019 Diseases and Injuries Collaborators. (2019). Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: A systematic analysis for the Global Burden of Disease Study. Global Health Metrics. The Lancet, 396(10258), 1204-. 1222. https://doi.org/10.1016/S0140-6736(20)30925-9&#x0D; Shiri, R., Karppinen, J., Leino-Arjas, P., Solovieva, S., &amp; Viikari-Juntura, E. (2010). The association between obesity and low back pain: A meta-analysis. American Journal of Epidemiology, 171(2), 135-154. https://doi.org/10.1093/aje/kwp356&#x0D; Uçar, İ., Karartı, C., Cüce, İ., Veziroğlu, E., Özüdoğru, A., Koçak, F. A., &amp; Dadalı, Y. (2021). The relationship between muscle size, obesity, body fat ratio, pain and disability in individuals with and without nonspecific low back pain. Clinical Anatomy, 34(8), 1201-1207. https://doi.org/10.1002/ca.23776

Radiomics Applications in Head and Neck Tumor Imaging: A Narrative Review.

Recent advances in machine learning and artificial intelligence technology have ensured automated evaluation of medical images. As a result, quantifiable diagnostic and prognostic biomarkers have been created. We discuss radiomics applications for the head and neck region in this paper. Molecular characterization, categorization, prognosis and therapy recommendation are given special consideration. In a narrative manner, we outline the fundamental technological principles, the overall idea and usual workflow of radiomic analysis and what seem to be the present and potential challenges in normal clinical practice. Clinical oncology intends for all of this to ensure informed decision support for personalized and useful cancer treatment. Head and neck cancers present a unique set of diagnostic and therapeutic challenges. These challenges are brought on by the complicated anatomy and heterogeneity of the area under investigation. Radiomics has the potential to address these barriers. Future research must be interdisciplinary and focus on the study of certain oncologic functions and outcomes, with external validation and multi-institutional cooperation in order to achieve this.

MeTooOT: Sexual Harassment Experiences of Occupational Therapy Academics and Recommendations for Systemic Change.

Sexual harassment is pervasive in academic health fields. Although a predominantly female profession, early career academics and trainees in occupational therapy (OT) remain vulnerable to sexual harassment. We aimed to describe experiences of sexual harassment of female-identifying academic OT practitioners. We conducted surveys and interviews using Interpretive Phenomenological Analysis to examine participants' experiences. Ten participants completed the survey and/or interview. Experiences ranged from inappropriate comments to persistent sexual assault. Four themes (blurred lines, unbalanced consequences, "how did I get here?" and "we don't talk about it") were generated based on participant responses. Power dynamics and the cultures and values of the OT profession were underlying elements of all themes. The consequences of sexual harassment were severe and affected personal and professional growth. For OT research and education to thrive, stronger support for victims and consistent, appropriate consequences for perpetrators are necessary to minimize negative outcomes for victims.

Utility of public knowledge bases for the interpretation of comprehensive tumor molecular profiling results.

With the growing use of comprehensive tumor molecular profiling (CTMP), the therapeutic landscape of cancer is rapidly evolving. NGS produces large amounts of genomic data requiring complex analysis and subsequent interpretation. We sought to determine the utility of publicly available knowledge bases (KB) for the interpretation of the cancer mutational profile in clinical practice. Analysis was performed across patients who previously underwent CTMP. Independent interpretation of the CTMP was performed manually, and then, the recommendations were compared to ones present in KBs (OncoKB, CIViC, CGI, CGA, VICC, MolecularMatch). A total of 222 CTMP reports from 222 patients with 932 genomic alterations (GA) were identified. For 368 targetable GA identified in 171 (77%) of the patients, 1381 therapy recommendations were compiled. Except for CGA, therapy ESCAT LOE I, II, IIIA and IIIB therapy options were equally represented in the majority of KB. Personalized treatment options with ESCAT LOE I-II were provided for 35 patients (16%); MolecularMatch/CIViC allowed to collect ESCAT I-II treatment options for 34 of them (97%), OncoKB/CGI-for 33 of them (94%). Employing VICC and CGA 6 (17%) and 20 (57%) of patients were left without ESCAT I or II treatment options. For 88 patients with ESCAT level III-B therapy recommendations: only 2 (2%), 3 (3%), 4 (5%) and 6 (7%) of patients were left without options with CIViC, MolecularMatch, CGI and OncoKB, and with VICC-12 (14%). Highest overlap ratio was observed for IIIA (0.81) biomarkers, with the comparable results for LOE I-II. Meanwhile, overlap ratio for ESCAT LOE IV was 0.22. Public KBs provide substantial information on ESCAT-I/R1 biomarkers, but the information on ESCAT II-IV and resistance biomarkers is underrepresented. Manual curation should be considered the gold standard for the CTMP interpretation.

Relapses of pain syndrome in patients with polymyalgia rheumatica during reduction of glucocorticoid therapy

An analysis of causes leading to pain recurrence in patients with polymyalgia rheumatica (PR) after tapering down the dose of glucocorticosteroids (GCS) is presented. True exacerbations resulting from the main disease recurrence and pseudo-exacerbations when the resumption of pain syndrome is not due inflammation but because of other causes – steroid myopathy or chronic adrenal insufficiency (AI) are identified. The experience of using tocilizumab, an inhibitor of interleukin-6 receptors, as steroid-sparing agent in patients with PR is considered. The factors contributing to pain syndrome development, which can mimic exacerbations of PR (associated myofascial pain, vitamin D deficiency, etc.) are indicated. The methodology for AI diagnosis in patients receiving GCS therapy is discussed in detail. Recommendations for the rational AI therapy including acute cases are given.

Traumatische tracheobronchiale Verletzungen – Empfehlung der interdisziplinären Arbeitsgruppe der DGT und DGU zur Etablierung einer einheitlichen Klassifikation für Diagnostik und Therapie

Traumatic tracheobronchial injuries are extremely rare. In comparison, iatrogenic injuries are somewhat more common. A literature search revealed that there is a large number of case reports and small case series for this clinical entity. There are hardly any reviews and they usually have a low level of evidence. One reason for this is the lack of a classification to allow comparison of the individual cases with each other. There is only one classification for iatrogenic injuries of the posterior tracheal wall, which the authors modified and expanded with regard to traumatic tracheobronchial injuries. This classification was extended by the authors to also include traumatic injuries. A three-digit classification is presented here. The grading of the injury covers the entire spectrum of injury patterns, from peribronchial emphysema to wall injuries of different depths to subtotal and complete rupture of the bronchus. In addition, the anatomical location and the cause of the injury were added to the classification. The levels of injury in the tracheobronchial tree are distinguished anatomically. The third digit distinguishes traumatic, iatrogenic and spontaneous injuries. On the basis of the three-digit classification resulting from these parameters, it is possible to group individual cases together and to develop recommendations for diagnostics and therapy.

Aging a Decade in a Day: Age Cutoff Bias in Adjuvant Therapy Allocation for Early-Stage Breast Cancer

Physicians may expedite interpretation of data presented as a continuous variable by binning the data into "high" and "low" subgroups (cutoff heuristic). Use of this cognitive shortcut with age may lead to fewer nuanced or inappropriate decisions. We hypothesized an age cutoff heuristic may lead to non-evidence-based adjuvant treatment allocation among patients with early-stage breast cancer. Two cohorts with strong indications for adjuvant treatment regardless of age that underwent lumpectomy for early-stage breast cancer between 2004 and 2017 were identified in the National Cancer Database. Cohort 1 had higher-risk features (estrogen receptor negative, endocrine therapy not planned, final margins positive, or size >3 cm; n=160,990) and was appropriate for radiation. Cohort 2 had hormone receptor positivity with tumors >5 mm (n=394,946) and was appropriate for endocrine therapy. Multivariable logistic regressions with odds ratios (ORs) and 99.8% confidence intervals (CIs) were performed to determine whether any single year-over-year age difference was independently associated with a difference in likelihood of adjuvant therapy recommendation. In cohort 1, radiation recommendation decreased sharply at age 70, ranging from 90% to 92% between the ages of 50 and 69 years to 81% for those aged 70 years. Multivariable logistic regressions showed year-over-year age difference was an independent predictor for adjuvant radiation recommendation at only age 70 versus 69 (OR, 0.47; CI, 0.39-0.57; P < .001). For cohort 2, endocrine therapy recommendation showed a small decline at age 70, and year-over-year age difference was a predictor of endocrine therapy recommendation at only age 70 versus 69 (OR, 0.86; CI, 0.74-0.99; P=.001). We observed a unique decline in appropriate adjuvant therapy recommendation between ages 69 and 70. This suggests use of an age cutoff heuristic to process patient age in this population as a categorical, binary variable. This is a previously undescribed phenomenon in early-stage breast cancer.

Developing the Study Question: Relationship Between Cardiologist Age and Delivery of Aortic Valve Replacement

Introduction:Aortic stenosis (AS) is the most common valve disease worldwide, but intervention for symptomatic AS is variable and dependent on patient age, frailty, and co-morbidities. Recent studies have suggested that the greatest determinant of receipt of aortic valve replacement (AVR) is a supportive recommendation by the patient’s cardiologist. Given that recommendations for cardiovascular therapies sometimes vary by clinician age, it is unclear whether cardiologist age is associated with referral for AVR.&#x0D; Objective:To determine whether cardiologist age is associated with referral for AVR.&#x0D; Hypothesis:We hypothesized that receipt of AVR is more likely to be associated with younger aged cardiologists (&lt;/= 40 years) than older aged cardiologists (&gt;40 years).&#x0D; Methods:Using the Centers for Medicare and Medicaid services (CMS) national database, we will use hierarchical logistic regression models to assess odds of AVR delivery according to cardiologist age group among patients hospitalized with primary diagnosis of AS. Models will be adjusted for patient-level covariates (demographics, insurance, comorbidities, comorbidity index) and hospital-level covariates (location, number of cardiologists per hospital). Secondary analyses will include stratifying odds AVR by type (transcatheter and surgical).&#x0D; Discussion:We expect to find that physicians who have completed their training more recently may have higher rates of AVR referrals. This includes the use of transcatheter AVR, in patients with elevated surgical risk, which is an established non-inferior alternative to surgical AVR in many patients. While there are many factors which dictate intervention for AS, we hope that by performing this study, we will be able to promote a guideline directed approach to the management of symptomatic AS. we will be limited in the ability to classify severity of AS, selecting patients with primary admit diagnosis of AS will likely focus on patients with symptoms related to AS, which would support severe AS diagnosis.

327 Optimizing the management of atopic dermatitis with a new minimal disease activity concept and criteria and consensus-based recommendations for systemic therapy

Abstract Inconsistent criteria are used to identify patients with atopic dermatitis (AD) who are candidates for systemic therapy and assess their response to systemic therapy. This may lead to undertreatment and treatment dissatisfaction. A treat-to-target (T2T) framework was previously proposed to guide systemic treatment decisions in patients with moderate-to-severe AD.1 While patient representatives were included in the T2T consensus voting process, no patient or caregiver stakeholders were included in the development of the T2T recommendations. Additionally, a recent analysis of the cross-sectional, 28-country MEASURE-AD study suggests that the treatment targets in the T2T criteria may be insufficient to ensure optimal treatment outcomes.2 To develop optimized and practical criteria for identifying patients who should receive systemic therapy, including definitions of treatment goals, treatment failure and disease severity. An executive steering committee (ESC) of seven international experts was formed in January 2021 to provide insights and perspectives on how to optimize the identification of patients who would most benefit from systemic therapy for AD. After discussing the gaps and needs in current AD management, the ESC agreed that there was a lack of evidence on patients’ treatment goals, needs, and expectations. The ESC, therefore, initiated a global, ethically and culturally diverse patient research study (N = 88) to collect these insights. Subsequently, nine regional sub-committees (SCs) were created to gain clinical perspectives from different regions worldwide (covering the USA and Puerto Rico, Latin America, Western Europe and Canada, Eastern Europe and Russia, the Middle East, Asia, and Australia and New Zealand). Overall, 87 experts from 44 countries contributed to the initiative, and 46 virtual ESC and SC meetings took place to discuss how to improve the lives of patients with AD. A virtual secure platform allowed discussions and contributions to continue outside these meetings. In April 2022, all experts rated their agreement with a series of recommendations regarding the identification and monitoring of patients eligible for systemic therapy, using a 10-point Likert scale in a modified eDelphi voting process. The consensus was pre-defined as ≥70% of all respondents rating agreement as 7 (‘mildly agree’), 8 (‘moderately agree’), 9 (‘agree’) or 10 (‘strongly agree’) with a recommendation. A strong consensus was defined as ≥90% agreement. Expert perspectives and patient insights led to the development of 34 patient-focused clinical recommendations on disease severity assessments, treatment goals and targets for clinician- and patient-reported outcomes, long-term disease control and a novel minimal disease activity (MDA) concept. A consensus of ≥80% was reached for all recommendations in one round of voting, with 88% of the recommendations reaching a ‘strong’ consensus. The MDA concept combines T2T principles with shared patient/clinician treatment decision-making principles. Patients are asked to select 1–3 feature(s) of AD which are most important to them (from the itch, skin appearance/condition, sleep disturbance, mental health, skin pain and impact on daily life). The clinician is asked to choose an objective measure of disease (from the Eczema Area and Severity Index [EASI], SCORing AD and/or the Investigator’s Global Assessment and body surface area). Treatment targets are then chosen from a list of ‘moderate’ and ‘optimal’ targets based on discussions between the clinician and patient. Optimal treatment targets include ≥90% improvement in EASI and a numeric rating scale of ≤ 1 for peak pruritus, sleep, and pain. Achievement of ‘optimal’ targets is defined as MDA. This international group of AD experts developed a novel MDA concept and criteria, which builds upon existing T2T work by providing a patient-centric approach to the optimal treatment of AD. The criteria and patient-focused clinical recommendations will help to identify and monitor patients with AD who could benefit from systemic therapy.

The new guideline "Diagnosis and therapy of female urinary incontinence" AWMF register no.: 015-091-important to know

The new interdisciplinary S2k guideline "Female urinary incontinence" has been online since December31, 2021 under the AWMF register number: 015-091. The guideline combines the two previously separately published guidelines "Urinary stress incontinence in women" and "Overactive bladder in women" and integrates the previously independent guideline "Sonography in the context of urogynaecological diagnostics". The focus is on the identification of the three most common types of urinary incontinence in women "stress incontinence", "urge incontinence" and "mixed incontinence" through appropriate diagnostics and their conservative and surgical therapy. In addition, achapter on the management of extraurethral urinary incontinence in urogenital fistulas has been included. The guideline was created under the leadership of the "German Society for Gynecology and Obstetrics" (DGGG) and the Working Group for Urogynecology and Pelvic Floor Reconstruction e. V. (AGUB). In the interdisciplinary guideline group, six urologists from the working group "Urological functional diagnostics and female urology" were also involved as elected representatives of the German Society for Urology (DGU). For the validity in German-speaking areas, mandate holders from Austria and Switzerland were present. The clinically and practically relevant and new consensus recommendations for diagnostics and therapy were approved after systematic research, selection, evaluation and synthesis of the evidence base. Evidence grading was not intended as the S2k guideline. The individual statements and recommendations were differentiated linguistically-not symbolically. For acomplete overview, we recommend studying the long version "Diagnostics and Therapy of Female Urinary Incontinence" at www.AWMF.org or the short version in two parts by Naumann G. etal. in Obstetrics and Women's Health (in press), which will be published soon.

Management of Borderline ovarian tumors (BOT): results of a retrospective, single center study in Switzerland

BackgroundBorderline tumors are malignant epithelial ovarian tumors with a very low incidence. Thus experience in diagnostics and treatment is still rare. The aim of this study was to present and analyze data of women with borderline ovarian tumor (BOT) regarding clinical features, histological characteristics, diagnostics and treatment management.MethodsIn this single center retrospective study women with BOT treated at the Departement of Gynecology and Obstetrics at the Kantonsspital Luzern between 2011 and 2018 were analyzed according to their clinical and histological reports.ResultsA total of 42 women were enrolled. The median age was 58.5 with a range from 26 to 85, of which 31 (73.8%) were postmenopausal. Regarding the histological subtypes, 23 women (54.8%) had serous and 15 (35.7%) had mucinous BOT. Seromucinous histology was found in 3 patients (7.1%) and endometrioid in 1 woman (2.4%), respectively. All women underwent surgery. In a total of 39 women (92.9%) a complete surgical staging for BOT was performed. In 29 women (69.0%) staging was performed by laparoscopy, 13 (31.0%) underwent laparotomy. The mean follow up was 52 months (range = 16.3–101.4 months). During this period two patients, initially diagnosed in FIGO stage 1, recurred after 21.7 and 44 months, respectively, the second woman died after 53 months because of the BOT.ConclusionIn the present study women were treated according to the international therapy recommendations and the rate of recurrence was very low. The most common risk factors for relapse are known to be FIGO stage, incomplete staging and peritoneal implants but were not present in our group. Thus further studies are necessary to investigate additional recurrence risks.

Selecting appropriate compression for lymphedema patients: American Vein and Lymphatic Society position statement.

Lymphedema is a significant and disabling disorder affecting millions of people worldwide. Compression therapy is an important component of lifelong treatment but the specifics of appropriate compression garment selection and prescribing is not always well understood by practitioners and payers. An expert panel of the American Vein and Lymphatic Society was convened to write a Position Statement with explanations and recommendations for the appropriate compression therapy to be used in the treatment of lymphedema patients. A Position Statement was produced by the expert panel with recommendations for documentation and compression therapy treatment. Their recommendations were reviewed, edited, and approved by the Guidelines Committee of the society. This societal Position Statement provides a useful document for reference for medical care providers for the appropriate compression therapy selection and treatment of patients with lymphedema.

Compartment syndrome following a jellyfish sting: a case report

BackgroundWhile the majority of reported cases of jellyfish envenomation are self-limited with few lasting complications, a few can cause life-threatening and debilitating illnesses. We present the case of a 15-year-old male who had an unusual presentation of a jellyfish sting that led to acute compartment syndrome.Case presentationA 15-year-old Lebanese (Arab) boy was stung by a jellyfish, which led to acute compartment syndrome in the left arm. Decompression fasciotomy and local application of diluted nitroglycerin helped to relieve the ulnar and radial artery spasms. The patient was left with shoulder and elbow pain and elbow flexion weakness, which improved after physiotherapy over a period of 6 weeks.ConclusionsCurrent therapy recommendations for acute compartment syndrome following jellyfish stings are mainly based on case reports. Urgent fasciotomy and local application of nitroglycerin have been demonstrated to be helpful in severe jellyfish stings associated with acute compartment syndrome.

Community Pharmacist and Family Medicine Collaboration for Pre-Visit Planning for Shared Patients Receiving Chronic Care Management Services

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients’ medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the CP. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations. CCM billing provided a mechanism for CPs to receive revenue for their services.