Steroid Prescription Research Articles

P013 Driving improvement through audit: impact of 2017 regional audit and survey upon giant cell arteritis services in 2020

Background/Aims In 2017 an audit and survey of giant-cell arteritis (GCA) services were conducted across northwest England (reported previously). This re-survey in 2020, following publication of revised BSR guidance, sought to identify what changes were made in the intervening period, and provided the opportunity to assess the impact of COVID-19. Methods Rheumatologists from 16 hospitals in northwest England were invited to complete a survey in July 2020. Questions focused on service provision for GCA, including pathways, diagnostics and steroid prescription. Results Responses were received from 14/16 sites in 2017, and 15/16 in 2020. 9/15 (60%) sites reported that the 2017 audit and survey prompted changes to GCA services, with two (13%) stating that it clarified the need for implementation of existing plans. Two sites had a GCA pathway in 2017. Four of the seven sites who committed to introducing one have now done so, bringing the total in 2020 to six. Eight of the nine remaining sites plan to implement one, six with a specific date within six months. Six (40%) have completed additional local audit/QI since 2017. Temporal artery (TA) ultrasound (US) is now available in an additional four sites, bringing the total to 6/15 (40%) in 2020. Two sites reported improvement in both time between first rheumatology consultation and TA biopsy, and time to receive results (now <7 days for each task in 6/15 (40%)). Six additional sites reported providing leaflets on steroids routinely, bringing the total in 2020 to 12/15 (80%), versus 6/14 (43%) previously. Four sites (27%) now have a database of GCA patients (one in 2017). There was no major change in sites having a standard protocol for steroid taper (n = 8 2017; n = 7 2020, 89% and 100% of whom respectively use BSR guidance), nor in the number of patients routinely provided steroid cards (six in 2017; five in 2020). The three sites who do not report giving leaflets on steroids routinely, all had a pathway. 8/15 (53%) reported COVID-19 having an adverse effect upon services, including: reduced access to diagnostics (n = 7: TA US, biopsy, and PET-CT); delayed appointments (n = 4); delayed referrals (n = 3). The tertiary referral centre reported an improvement because access to tocilizumab was facilitated by a relaxation of rules by NHS England. Conclusion The original audit and survey of current GCA practice in 2017 highlighted areas for improvement for each site, and regionally. Sites contributing to this re-survey report that the exercise stimulated them to improve their current care. The 2017 exercise showed a strong correlation between reported practice (survey) and actual practice (audit), leading us to have confidence that responses provided a true picture of care. This work demonstrates the power of audit to drive improvement, at a regional level. Disclosure C.A. Sharp: None. J. Little: None. A. Shahbaz: None. E.F. Wood: None. S. Wig: None. P. Watson: None. S. Varughese: None. L. Teh: None. P. Shah: None. C. Saleh: None. L. Ottewell: None. L. Newton: None. S.R. Moore: None. E. McCarthy: Consultancies; E.M. has received consultancy fees from Chugai. E. MacPhie: None. K. Lazarewicz: None. J. Brockbank: None. J. Bluett: None. L. Mercer: None.

676 Variation in Medicare topical steroid prescription costs

676 Variation in Medicare topical steroid prescription costs

Prevalence of inflammatory bowel disease in young Greek Army male recruits from 2006 to 2018: a 13-year retrospective study from a tertiary center.

The prevalence and incidence of inflammatory bowel diseases (IBDs) vary among countries. Data regarding prevalence of IBD in Greece are limited or outdated. We reviewed the medical records of IBD patients from a population of 551,808 Greek Army recruits in a 13-year period (2006-2018). Study population consisted of males 18-37 of age from Northwest, Central Greece (including Attica), Peloponnese, and Aegean Sea Islands. Age, disease distribution, pharmaceutical treatment and IBD-related surgery at the time of patients' admission were recorded. The prevalence of IBD among male recruits during the studied period was 0.15% (839/551 808, 95% confidence interval 0.14-0.16%). Of these, 448 (53.4%) had Crohn's disease (CD) and 391 (46.6%) ulcerative colitis (UC). Although 32.1% of CD patients had been treated with biologics, most often infliximab (60% of them), azathioprine was the most common as monotherapy (27% of patients). Among UC patients, mesalamine was the most often prescribed treatment (64.2%), whereas treatment with biologics as monotherapy or in combination with azathioprine was used in a ratio 1:2 compared to CD patients. A gradual reduction in steroid use was noted from 2006 to 2018, coinciding with the advent and increasing use of biologics. IBD-related surgery had been performed in 8% and 2.8% of CD and UC patients, respectively. The prevalence of IBD in Greek male recruits was 0.15% with a slight CD predominance. Remarkable changes in therapeutic trends were noted with an increasing use of biologics and reduced prescription of steroids, especially for CD.

Steroids for delayed cerebral edema after traumatic brain injury.

Background: Brain edema is a common phenomenon after traumatic brain injury (TBI) resulting in increased intracranial pressure and subsequent neurological deterioration. Experimental studies have proven that brain edema is biphasic (cytotoxic followed by vasogenic). Till date, all studies, including the corticosteroid randomization after significant head injury (HI) trial, have used high-dose steroids in the acute period during which the edema is essentially cytotoxic in nature. No clinical data exist pertaining to delayed cerebral edema (vasogenic) and steroids.Methods: Patients who had received steroids for delayed cerebral edema after TBI were retrospectively analyzed over a 2-year period. Steroid dose, timing of steroid prescription, time to improvement of symptoms, and complications were noted.Results: There were six males and three females. Mean age was 41.1 years. There were no severe HI cases. All subjects had cerebral contusions on imaging. Dexamethasone was the preferred steroid starting with 12 mg/day and tapered in 5–7 days. The mean interval to steroid administration after trauma was 7 days. The mean duration of steroid prescription was 6.3 days. All patients had complete symptomatic improvement. The mean time to symptom resolution was 3.8 days. No patients experienced any complications pertinent to steroid usage.Conclusion: This is the first study to document efficacy of steroids for delayed cerebral edema after TBI, at least in mild/moderate head injuries. The timing of steroid usage and dose of steroids is key aspects that might determine its efficacy in TBI which was the drawbacks of the previous studies. Future prospective trials with the above factors in consideration may confirm/refute above findings.

Iatrogenic Cushing's Syndrome in Patients with Superficial Dermatophytosis.

Background:The epidemic-like scenario of superficial fungal infections in India has been complicated by the prescription of systemic and topical potent steroids. As a result, alarming number of patients are presenting with exogenous Cushing's syndrome.Methods:This cross-sectional study involved 23 patients of superficial dermatophytosis on steroids who presented with clinical features like that of Cushing's syndrome. Their clinical details and laboratory investigations including fungal culture and serum cortisol, were recorded on a pre-designed proforma.Results:There were 23 patients (14 males and 9 females) with mean age of 29.47 ± 15.5 years, majority with extensive tinea cruris and corporis. All of them received oral (Betamethasone) or parenteral corticosteroids along with potent topical steroids (clobetasol propionate and betamethasone valerate) for at least two months. In majority (56.5%), treatment was prescribed by unqualified medical practitioners and in the rest by alternative medical practitioners. Striae, buffalo hump, hirsutism were observed in 16 (69.5%), 15 (65.2%), 13 (56.5%) patients, respectively. Serum cortisol estimation revealed low levels and ranged from 0.66 to 6 μg/ml with a mean of 1.53 ± 1.27 μg/ml (normal 7-25 μg/ml).Conclusions:Corticosteroids are life saving for many dermatological diseases; their injudicious use (topical, oral, and parenteral) for prolonged periods in the treatment of superficial dermatophytosis can lead to Cushing's syndrome.

Community-acquired pneumonia: similarities and differences between European and American guidelines - A narrative review.

ABSTRACTCommunity-acquired pneumonia (CAP) is severe disease. Early prescription of an adequate treatment has a positive impact in the CAP outcome. Despite the evidence of existing relevant differences between CAP across geographical areas, general guidelines can be designed to be applied everywhere. Eight years have passed between the publication of the European (EG) and American (AG) CAP guidelines, thus the aim of this narrative review is to compare both guidelines and summarize their recommendations. The main similarity between both guidelines is the antibiotics recommendation with the exception that AG mention new antimicrobials that were not available at the time of EG publication. Both guidelines recommend against routinely adding steroids as an adjuvant treatment. Finally, both guidelines acknowledge that the decision to hospitalize a patient is clinical and should be complemented with an objective tool for risk assessment. EG recommend the CRB-65 while AG recommend the Pneumonia Severity Index (PSI). EG and AG share a similar core of recommendations and only differ in minor issues such as new antibiotics. Likewise, both guidelines recommend against the routine prescription of steroids as an adjuvant therapy.

Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution.

As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. A total of 1729 patients undergoing spine surgery between June 25, 2017, and June 30, 2018, at a single institution by surgeons performing ≥20 surgeries per quarter, with medication data during hospitalization available, were assessed. Patients were evaluated for nonopioid pain medication prescription rates and morphine milligram equivalents (MME) of opioids used during hospitalization. Of the total cohort, 198 patients were evaluated for Press Ganey Satisfaction Survey responses. A χ2 test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters. The mean total MME per patient hospitalization was 574.46, with no difference between quarters. However, mean MME per day decreased over time (P = .048), with highest mean 91.84 in Quarter 2 and lowest 77.50 in Quarter 4. Among all procedures, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid prescription rates increased, whereas benzodiazepine and γ-aminobutyric acid-analog prescriptions decreased. There were no significant differences between quarters for mean hospital ratings (P = .521) nor for responses to questions from the Press Ganey Satisfaction Survey regarding how often staff talk about pain (P = .164), how often staff talk about pain treatment (P = .595), or whether patients recommended the hospital (P = .096). There were also no differences between quarters for responses in all other patient satisfaction questions (P value range, .359-.988). Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates. 4. The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.

PRO141 Treatment Patterns PRIOR to the Use of Thrombopoietin Receptor Agonists in Patients with Immune Thrombocytopenia in Germany

To describe real-world treatment patterns and steroid usage as well as the steroid prescription alignment to clinical guidelines, prior to the use of thrombopoietin receptor agonists (TPO-RAs) in patients with immune thrombocytopenia (ITP) in Germany. The IMS® LRx prescription database was used to identify patients with at least one TPO-RA (romiplostim or eltrombopag) prescription between 7/2016 and 6/2019 in Germany. ITP treatments received prior to TPO-RA therapy were assessed. In total 3,553 patients were included in the analysis (2,752 eltrombopag, 801 romiplostim). Overall, 48% of patients were male and 57% of patients were >60 years when initiating TPO-RA. Oral steroids were the most commonly used therapy before TPO-RAs, in 2,289 of patients (64%; 69% eltrombopag, 48% romiplostim), followed by intravenous immunoglobulins (IVIg) in 249 of patients (7%; 6% eltrombopag, 10% romiplostim). Rituximab or other ITP treatments (e.g. azathioprine, mycophenolate mofetil, cyclophosphamide, dapsone) were rarely used before TPO-RAs. Rituximab was used in 2% of patients (1% eltrombopag, 4% romiplostim), other prior treatments in 5% of patients (5% eltrombopag, 6% romiplostim). Mean total days of steroid use prior to TPO-RAs was 169 days (median 105 days, maximum 540 days) and mean cumulative steroid (prednisolone equivalent) dose before TPO-RA therapy was 3,328 mg (median 2,522 mg, maximum 39,702 mg). Oral steroids were the most commonly used medication before TPO-RA therapy, reflecting their continued importance in the management of newly diagnosed ITP. However, treatment duration and cumulative steroid dose exceeded current guideline recommendations (ie from the American Society of Hematology 2019) and international consensus on ITP treatment. This over-use of steroids has the potential to lead to serious side effects and negatively impact on mental health, mood, sleep or weight gain for patients.

Knowledge, attitude, and behavior in the prescription of topical steroid for dermatological disorders among medical practitioners

Knowledge, attitude, and behavior in the prescription of topical steroid for dermatological disorders among medical practitioners

Role of Topical Anesthetics Versus Topical Steroids in The Management of Traumatic Ulcer: A Case Control Study

Traumatic ulcers represent one of the most common types of ulcers occurring in the oral cavity. The etiology for the causation of the traumatic ulcers might be due to mechanical trauma-which is the commonest, thermal and electrical trauma. The ulcers due to trauma are well circumscribed, most often deep with sloping margins and an erythematous halo around the ulcers. The management of traumatic ulcers usually ranges from the prescription of topical anesthetics, steroids to nutritional supplements.The aim of this study was to assess the prevalence of traumatic ulcers and to analyse the frequency of prescription of topical anesthetics and topical steroids in the management of traumatic ulcers.The study sample consisted of 94 patients with traumatic ulcer.The patients with traumatic ulcers included 56 males with a predominance of cases in the 3rd to 4th decade of life. The number of patients who were treated with topical anesthetics is 68 and topical corticosteroids are only 9. A combination of topical steroids and local anesthetics were used in 17 patients. The results reveal that the single most common drug used in the management of traumatic ulcer is the prescription of topical anesthetics. The second most common agent used is corticosteroids. On analysing the results based on the age group to the type of therapy, there was no significance. (P&gt;0.05)The use of topical anesthetics is the commonest in the management of oral traumatic ulcers.

The Clinical Course of Asthma After Withdrawal of Inhaled Corticosteroids

Maintenance of inhaled corticosteroids (ICSs) is recommended in adults with asthma. However, adherence rates in patients with mild asthma and side effects of long-term ICS use can lead to withdrawal. To analyze the real-world outcomes of ICS withdrawal by analyzing data from the Korean National Health Insurance database. Based on claims data from the National Health Insurance of Korea between 2011 and 2014, we identified patients diagnosed with asthma without chronic obstructive pulmonary disease or long-term systemic steroid use who had an ICS medication possession rate of more than 50% in a year. We compared patients who received ICS consistently (maintenance group) with patients who had no ICS prescription for more than 6 months (withdrawal group). We evaluated exacerbation leading to prescription of systemic steroid and emergency department visit or hospitalization. Excluding patients with chronic obstructive pulmonary disease and long-term systemic steroid users, we identified 145,511 patients for the asthma cohort (mean age, 60.0 years; ever-smoker, 63.5%): 132,175 maintained ICS and 13,336 withdrew ICS for more than 6 months. Only 71 patients (0.5%) experienced exacerbation leading to an emergency department visit or hospitalization in the withdrawal group. ICS was restarted within 1 year for 33.6% of the withdrawal group, and 90% of these patients restarted ICS within 158 days. This nationwide study of patients with asthma, characterized by a high proportion of elderly and smokers, showed that ICS withdrawal in about 10% of patients appeared to confer relatively minimal harm and exacerbation leading to hospitalization was not common. Further prospective studies are warranted to carefully explore the safety of ICS withdrawal in younger, nonsmoking, and well-controlled patients with asthma.

Older age is a risk factor for inadequate energy intake during acute, severe IBD and is associated with shorter time to relapse

Background Effects of nutritional intake on inflammatory bowel disease (IBD) flare resolution are unknown. We hypothesised that nutritional factors during hospitalisation for acute severe IBD are associated with risk of subsequent relapse. We also studied risk factors for inadequate energy intake. Methods Patients admitted to the Karolinska Hospital Gastroenterology ward with IBD flare during 2015–2016 were retrospectively identified. In total, 91 patients were included. Data on nutrition, disease factors, inflammatory markers, and daily energy requirement were extracted. Requirement of new systemic steroid prescription, intensification of biological therapy, readmission, surgery, and calprotectin level were individually used as proxies for disease relapse. Follow-up was one year after discharge. Adjustments for age and sex were made where appropriate. Results Overall, 19%, 31%, and 45% of patients had days with energy intake <30, <50, and <70% of calculated requirement. Older age was associated with a higher number of days with energy intake <30, <50, and <70% of calculated requirement (regression coefficient 0.03, 0.04, 0.06 respectively, p = .012, .017, .008). The number of days with energy intake <30 and <70% of the calculated requirement and the length of the hospitalisation were associated with shorter time to new steroid prescription (hazard ratio 1.3, 1.1, 1.04 respectively, p = .016, .034, .011). CRP and calprotectin were not associated with relapse. Conclusion Older age is a predictor of inadequate energy intake during hospitalisation for acute severe IBD. Inadequate energy intake adjusted for age and sex during IBD flare was better predictor of time to the next steroid-requiring relapse than inflammatory markers.

Asthma Care Quality, Language, and Ethnicity in a Multi-State Network of Low-Income Children.

Prior research has documented disparities in asthma outcomes between Latino children and non-Hispanic whites, but little research directly examines the care provided to Latino children over time in clinical settings. We utilized an electronic health record-based dataset to study basic asthma care utilization (timely diagnosis documentation and medication prescription) between Latino (Spanish preferring and English preferring) and Non-Hispanic white children over a 13-year study period. In our study population (n = 37,614), Latino children were more likely to have Medicaid, be low income, and be obese than non-Hispanic white children. Latinos (Spanish preferring and English preferring) had lower odds than non-Hispanic whites of having their asthma recorded on their problem list on the first day the diagnosis was noted (odds ratio [OR] = 0.83; 95% CI, 0.77 to 0.89 Spanish preferring; OR = 0.93; 95% CI, 0.87 to 0.99 English preferring). Spanish-preferring Latinos had higher odds of ever receiving a prescription for albuterol (OR = 1.96; 95% CI, 1.52 to 2.52), inhaled corticosteroids (OR = 1.45; 95% CI, 1.01 to 2.09), or oral steroids (OR = 1.48; 95% CI, 1.07 to 2.04) than non-Hispanic whites. Among those with any prescription, Spanish-preferring Latinos had higher rates of albuterol prescriptions compared with non-Hispanic whites (adjusted rate ratio [aRR] = 1.0; 95% CI, 1.01 to 1.13). In a multi-state network of clinics, Latino children were less likely to have their asthma entered on their problem list the first day it was noted than non-Hispanic white children, but otherwise did not receive inferior care to non-Hispanic white children in other measures. Further research can examine other parts of the asthma care continuum to better understand asthma disparities.

Evaluation of inpatients Clostridium difficile prevalence and risk factors in Cameroon

BackgroundClostridium difficile, rarely found in hospitals, is a bacterium responsible for post-antibiotic diarrhea and Pseudomembranous Colitis (CPM). C. difficile selective pressure represents potential public health problem due to the production of toxins A and B serious pathologies effects/consequences. A transversal and analytic study was to assess the risk factors of C. difficile infection and to determine the prevalence of C. difficile in patients received in randomly selected five hospitals in Yaoundé, Cameroon.MethodsA total of 300 stool samples were collected from consented patients using a transversal and analytic study conducted from 10th July to 10th November 2018 in five hospitals in Cameroon. The detection or diagnostic kit was CerTest C. difficile Glutamate Dehydrogenase + Toxin A + Toxin B based on immuno-chromatographic assay. A univariate and multivariate analysis allowed us to highlight the associated factors.ResultsThe results showed a prevalence of C. difficile of 27.33% (82/300 stool patients’samples taken). Of these 27.33%, the production of Toxin A and Toxin B were 37.80 and 7.31% respectively. In univariate analysis, hospitalization was a significant (P = 0.01) risk factor favoring C. difficile infection. In multivariate analysis, corticosteroids and quinolones use/administration were significantly (adjusted Odd Ratio, aOR = 14.09, 95% CI: 1.62–122.54, P = 0.02 and aOR = 3.39, 95% CI: 1.00–11.34, P = 0.05 respectively) risk factor for this infection.ConclusionThe prevalence of C. difficile infections (CDI) remain high in these settings and may be related not only to permanent steroids and antibiotics. Promoting education to both medical staff and patients on the prevalence and public health impact of C. difficile can be core inimproving rationale prescription of steroids and antibiotics to patients and promote human health and exponential growth in Cameroon.

Pediatric Asthma Health Care Utilization, Viral Testing, and Air Pollution Changes During the COVID-19 Pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic caused dramatic changes in daily routines and health care utilization and delivery patterns in the United States. Understanding the influence of these changes and associated public health interventions on asthma care is important to determine effects on patient outcomes and identify measures that will ensure optimal future health care delivery.ObjectiveWe sought to identify changes in pediatric asthma-related health care utilization, respiratory viral testing, and air pollution during the COVID-19 pandemic.MethodsFor the time period January 17 to May 17, 2015 to 2020, asthma-related encounters and weekly summaries of respiratory viral testing data were extracted from Children's Hospital of Philadelphia electronic health records, and pollution data for 4 criteria air pollutants were extracted from AirNow. Changes in encounter characteristics, viral testing patterns, and air pollution before and after Mar 17, 2020, the date public health interventions to limit viral transmission were enacted in Philadelphia, were assessed and compared with data from 2015 to 2019 as a historical reference.ResultsAfter March 17, 2020, in-person asthma encounters decreased by 87% (outpatient) and 84% (emergency + inpatient). Video telemedicine, which was not previously available, became the most highly used asthma encounter modality (61% of all visits), and telephone encounters increased by 19%. Concurrently, asthma-related systemic steroid prescriptions and frequency of rhinovirus test positivity decreased, although air pollution levels did not substantially change, compared with historical trends.ConclusionsThe COVID-19 pandemic in Philadelphia was accompanied by changes in pediatric asthma health care delivery patterns, including reduced admissions and systemic steroid prescriptions. Reduced rhinovirus infections may have contributed to these patterns.

PPARGC1B Is Associated with Nontraumatic Osteonecrosis of the Femoral Head: A Genomewide Association Study on a Chart-Reviewed Cohort.

Previous studies have demonstrated the influence of heritable factors on the development of nontraumatic osteonecrosis of the femoral head (ONFH). We hypothesized that genetic variation is associated with an increased risk of ONFH, and that variants could be identified by a genomewide association study (GWAS). Using data collected from the MyCode Community Health Initiative, we identified 118 adult patients with radiographically confirmed nontraumatic ONFH. Study patients were statistically compared with a control population of 56,811 unrelated individuals without a diagnosis of ONFH. A case-control GWAS was performed to identify single nucleotide variants (SNVs) associated with ONFH. Sensitivity analyses were performed to evaluate the association of the top SNVs with (cortico)steroid-associated ONFH and ONFH with femoral head collapse. Gene-based analyses were performed to identify potential causal genes. Of the 118 patients, 114 (96.6%) had bilateral ONFH at a median of 5 years of follow-up; 90.7% had at least one 3-week steroid prescription compared with 68.3% in controls. A GWAS identified 4 SNVs reaching genomewide significance. rs116468452 near CACNA1E was significantly associated with ONFH (p = 3.26 × 10, odds ratio [OR] = 5.6, 95% confidence interval [CI] = 3.21 to 9.76). rs10953090 in SAMD9 was significantly associated with ONFH in the steroid-exposed subset (p = 2.96 × 10, OR = 2.57, 95% CI = 1.84 to 3.58). rs112467115 in PI4K1B showed enhanced association in the collapsed subset (p = 7.82 × 10, OR = 4.5, 95% CI = 2.60 to 7.79). Gene-based analyses identified PPARGC1B as the only gene significantly associated with ONFH after Bonferroni correction (p = 1 × 10), with the lead SNV being rs78814834 (OR = 2.86, 95% CI = 1.87 to 4.38). We identified 4 SNVs and 1 gene, PPARGC1B, associated with ONFH. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient and health service factors associated with delays in cancer treatment for children without social security in Mexico.

The objective was to investigate factors associated with patient-related timing (PRT) to seek healthcare and health service-related timing (HSRT) to diagnose cancer and provide treatment to children without social security in Mexico. A cross-sectional survey was conducted in 13 Ministry of Health hospitals in the states of Chihuahua, Jalisco, Mexico City, Morelos, Oaxaca, Puebla, Queretaro, State of Mexico, and Tlaxcala. Study participants were parents of recently diagnosed pediatric cancer patients (≤ 17 years of age). Three groups of factors were investigated: (1) patients (child and parent characteristics); (2) healthcare providers (HCPs) (first-contact HCP, institution, perceptions of barriers to healthcare, etc.); and (3) disease factors (cancer type/site, stage/risk at diagnosis). PRT and HSRT-associated factors were identified using multiple negative binomial regressions. The study included 265 children; 49% sought care when symptoms first appeared. The median PRT was seven days, and the median HSRT was 40 days. Parents' perceptions of long wait times for appointments were associated with longer PRT and HSRT. Residing in the lowest or highest socioeconomic regions and persistent or worsening symptoms increased the probability of longer PRT. Older patient age, HCP requests for imaging tests or prescription for steroids, a higher number of doctors consulted, having a urinary tract cancer, and having an advanced stage or high-risk cancer increased the probability of longer HSRT. Strategies to shorten lag time from symptom onset to diagnosis and treatment are urgently needed for childhood cancers in Mexico.

Systemic Corticosteroid Use after Central Serous Chorioretinopathy Diagnosis

To analyze the frequency of systemic corticosteroid prescriptions before and after central serous chorioretinopathy (CSC) diagnosis. Retrospective claims-based analysis. A nationally representative sample of commercial insurance beneficiaries who received care between 2007 and2015. We limited the study population to beneficiaries with incident CSC diagnosed by an eye care provider, excluding those with other major ophthalmologic comorbidities. We developed a non-CSC comparison cohort matched to CSC patients by age, sex, general health (Charlson Comorbidity Index), and geographic region. We compared systemic corticosteroid prescriptions before and after CSC diagnosis and by diagnosing provider (optometrist vs. ophthalmologist) and evaluated likelihood of steroids treatment among CSC versus matched control patients using logistic and Cox proportional hazard regression models. Systemic corticosteroid prescription frequency among CSC patients within 12 months pre-diagnosis and at 6, 12, and 24 months post-diagnosis, median time to steroid initiation and discontinuation, and odds of receiving steroids post-diagnosis among CSC and control patients. We identified 3418 CSC patients. Nearly 39% (n= 1326) were prescribed systemic steroids at some point during the analysis period, versus 23% of controls (4033 of 17 178 patients). Over 12% of CSC patients (n= 430) within 1 year pre-diagnosis, and nearly 12% (n=404) within 1 year post-diagnosis. Most patients who received steroids after diagnosis were steroid naive (n= 231). Among those receiving steroids, CSC patients demonstrated longer median time to first post-diagnosis steroid prescription (1.82 years vs. 0.50 years for non-CSC patients) and longer time to last steroid prescription (1.62 years vs. 0.35 years for non-CSC patients). Although CSC patients were significantly less likely to receive steroids within 6 months post-diagnosis compared with non-CSC patients (odds ratio, 0.72; 95% confidence interval, 0.59-0.89), they were significantly more likely to receive steroids by 2 years post-diagnosis. Prescribing patterns were similar for patients diagnosed by an ophthalmologist versus optometrist. Despite evidence showing that steroids contribute to CSC development, many patients continue to be prescribed systemic corticosteroids after CSC diagnosis. Our results suggest a need for greater communication and collaboration among providers to ensure that clinical practice reflects evidence-based recommendations.

The TOMATO Study (Tacrolimus Metabolization in Kidney Transplantation): Impact of the Concentration-Dose Ratio on Death-censored Graft Survival.

Tacrolimus trough concentrations (mean/variability), as well as concentration-to-dose ratio (C/D ratio), affect kidney allograft outcomes. We investigated the link between the C/D ratio and death-censored kidney graft survival (DCGS). We performed a retrospective study on 1029 kidney transplant patients (2004-2016) with the following criteria: tacrolimus-based immunosuppression, >1-year graft survival, no initial use of everolimus, and available anti-human leukocyte antigen antibody data. We analyzed the impact of the time-varying C/D ratio on DCGS. Fast metabolizers were defined by a C/D ratio < 1.05. We also investigated the effect of an early (mo 3 to mo 6 post transplantation) C/D ratio below 1.05. Cox survival analyses were performed, adjusting for potential confounders (tacrolimus trough, variability of tacrolimus trough, de novo donor-specific antibody development, cytochrome P450 3A5 genotype, pregraft sensitization, mo 3 glomerular filtration rate). Time-varying C/D ratio was significantly associated with DCGS (hazard ratio [HR], 2.35; P < 0.001) in a univariate model, on the full analysis set comprising 1029 patients. In the multivariate time-varying model, based on 666 patients with available cytochrome P450 3A5 genotypes, the effect of the C/D ratio remained significant (HR, 2.26; P = 0.015); even when glomerular filtration rate at month 3 < 30 mL/min/1.73 m (HR, 2.61; P = 0.011), de novo donor-specific antibody development (HR, 4.09; P < 0.001) and continued steroid prescription (HR=2.08, P = 0.014) were taken into account (other covariates, including tacrolimus trough concentrations, were nonsignificant). In the same multivariate model, the effect of early C/D ratio (median at mo 3 and mo 6) remained significantly associated with DCGS (HR, 2.25; P = 0.041). C/D ratio is an independent and early predictor of DCGS. Identification of fast metabolizers could be a strategy to improve graft survival, for example, by optimizing tacrolimus formulation. Mechanistic studies to understand the C/D ratio effect are required.

Obstetrician patterns of steroid administration for the prenatal management of congenital pulmonary airway malformations.

Congenital pulmonary airway malformation (CPAM) is the most common prenatally-diagnosed lung malformation. This lesion, classified as macrocystic or microcystic, can lead to significant fetal compromise. Management options include observation, maternal antenatal steroid administration, and fetal surgical intervention. Current evidence suggests that microcystic (but not macrocystic) lesions and those with a cyst volume ratio (CVR) >1.6 are responsive to steroid therapy. The objective of this study was to identify patterns of prenatal steroid administration for the management of CPAMs and to identify characteristics of CPAMs prompting steroid administration. An 18-question survey was distributed to obstetricians from the Pregnancy-Related Care Research Network (PRCRN) and the North American Fetal Therapy Network (NAFTNet), from January to April 2019, to capture antenatal steroid prescribing patterns. Response rates were 28.3% (138/487) for PRCRN and 63.3% (19/30) for NAFTNet. Among PRCRN members, 16.8% administered prenatal steroids, with most (77.2%) doing so for both microcystic and macrocystic CPAMs; corresponding percentages for NAFTNet members were 90.9% and 52.6%. Two thirds (65.6%) of obstetricians who administer steroids do so for a CVR > 1.6, without evidence of mediastinal shift or hydrops fetalis. There is a lack of consensus among obstetricians as to the CPAM characteristics that should prompt administration of prenatal steroids. Many surveyed obstetricians do not use cyst type or CVR to guide decision-making regarding steroid therapy.