Clinic Study Research Articles

The Impact of Single-Use Cystoscopes on Clinical Time Workflow in an Outpatient Setting

ObjectiveTo evaluate the change in overall clinical encounter time and clinical capacity after transitioning to single-use cystoscopes (Ambu A/S, Ballerup, Denmark) in an outpatient urology setting. MethodsA single-institution prospective study in an outpatient urology procedure clinic was performed. Discrete categories for each portion of nursing care responsibilities were defined, and time spent during each category was recorded. Two separate clinic days were observed and analyzed: one where the clinic exclusively used reusable cystoscopes and the other after the transition to single-use cystoscopes occurred. Additionally, clinic schedules were reviewed from all procedure clinics in the 3-month periods before and after the transition to single-use cystoscopes. Outcomes included overall clinical encounter time and the number of procedures per clinic day. ResultsThere were 12 flexible cystoscopies performed during each of the observed clinic days. Preliminary cystoscope cleaning and transportation tasks by nursing staff were eliminated when utilizing single-use cystoscopes. Average total encounter time decreased from 66 to 44 minutes, resulting in a 34% reduction in clinical encounter time. The median number of flexible cystoscopy procedures increased after the transition from 9 (IQR 7-12) to 16 (IQR 11-17), representing a 78% increase (p=0.003). ConclusionsTransition to a completely single-use cystoscopy outpatient procedure clinic improved clinical efficiency and facilitated an increased number of procedures per clinic day.

Home Medication Management and Practices among Post-stroke Patients: A Cross-sectional Study in a University-based Primary Care Clinic in Malaysia

Effective medication management practice (MMP) improves compliance of chronic conditions management and reduces medication error for better clinical outcomes. This is important for stroke survivors with multiple comorbidities and post-stroke complications. This study aimed to determine appropriateness of home MMP and its associated factors among post stroke patients. This was a cross-sectional, single-centre study involving 120 stroke patients of a primary care medical centre in Kuala Lumpur between January and March 2021. The assessment of MMP appropriateness relied on scores obtained through a set of questions administered via face-to-face, online or telephone interview. The mean age of participants was 65.1 (SD 11.7) years. 55.8% of participants had inappropriate home MMP; where the majority did not update their medication list (86.3%), did not memorise the medication’s name (75%), and did not return the leftover medication to the pharmacy (63.3%). Female gender (AOR: 2.74, 95% CI: 1.18-6.35, p-value: 0.019), household income (> RM4850) (AOR: 2.82, 95% CI: 1.03-7.69, p-value: 0.043), and number of clinic appointments (>2) (AOR: 5.27, 95% CI: 1.44-19.24, p-value: 0.012) were significantly correlated with better home MMP. The MMP among post-stroke patients was poor. Better home MMP were associated with female gender, higher socioeconomic status, and more frequent clinic appointments. Concerted health education should be provided, particularly focusing on medication management to improve home MMP in post-stroke patients and ultimately improving their overall health outcomes.

Abstract 2734: RC148, a novel bispecific antibody targeting PD-1 and VEGF for cancer immunotherapy

Abstract Vascular endothelial growth factor (VEGF) is one of the most important pro-angiogenic factors in modulating tumor microenvironment (TME), and the concentration of VEGF in TME is significantly higher than that of peripheral. Inhibiting VEGF can improve immunotherapy efficacy by modulating the TME, preventing angiogenesis and regulating immune cell populations. Combined anti-VEGF and anti-Programmed cell death protein 1 (PD-1)/Programmed cell death ligand (PD-L1) therapies have exerted potent antitumor effect in preclinic and clinic studies. Therefore, we developed a novel humanized IgG1 silenced bispecific antibody RC148 to target VEGF and PD-1. RC148 allows dimeric VEGF crosslinking and gradually enhances PD-1 binding activity, potentially reduces systemic toxicity of anti-VEGF therapy and enhances antitumor potency via VEGF trigged enrichment in tumor areas. In preclinical studies, RC148 blocks the binding of VEGF to VEGFR and PD-1 to PD-L1, prevents the growth and migration of human umbilical vein endothelial cells, enables efficient T cell activation, exhibited synergistic antitumor effects in rodent models and showed safety profiles in non-human primate studies. Citation Format: Jianmin Fang, Dong Li, Kaiyue Wu, Sisi Wang, Du Li, Guorui Zhao, Shenjun Li, Jing Jiang. RC148, a novel bispecific antibody targeting PD-1 and VEGF for cancer immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2734.

Antibiotic overuse, poor antimicrobial stewardship, and low specificity of syndromic case management in a cross section of men with urethral discharge syndrome in Kampala, Uganda.

High prevalence of sexually transmitted infections (STIs) combined with poor antimicrobial stewardship are drivers of STI antimicrobial resistance (AMR) especially in resource-limited settings where syndromic case management (SCM) is the norm. We characterized patterns of antibiotic use prior to clinic attendance and study enrollment in Ugandan men with urethral discharge syndrome (UDS), evaluated in-clinic prescribing, and the performance characteristics of SCM. Participants were recruited from government clinics participating in an existing gonococcal surveillance program in Kampala, Uganda. Questionnaires including antimicrobial use prior to attendance, prior episodes of UDS, penile swabs, and blood samples were collected. Bivariable and multivariable logistic regression models were used to estimate odds ratios (OR) for preselected factors likely to be associated with antibiotic use. In-clinic antibiotic treatment data were extracted from clinical notes, and the performance of SCM against laboratory-based STI diagnoses was evaluated. Between October 2019 and November 2020, 100(40%) of 250 men with UDS reported taking antibiotics in the 14days prior to attending the clinic. Of these 210(84%) had at least one curable STI and 20% had a reactive point-of-care HIV test. Multivariable analysis demonstrated significant associations between recent antimicrobial use and duration of UDS symptoms <6 days (OR 2.98(95%CI 1.07,8.36), p = 0.038), and sex with women only (OR 0.08(95%CI 0.01,0.82),p = 0.038). The sensitivity of SCM ranged from 80.0% to 94.4%; specificity was low between 5.6% and 33.1%. The positive predictive value of SCM ranged from 2.4(95%CI 0.7,6.0) for trichomoniasis to 63.4(95%CI 56.5,69.9) for gonorrhea. Pre-enrollment antibiotic use was common in this population at high risk of STI and HIV. Combined with the poor specificity of SCM for male UDS, extensive antibiotic use is a likely driver of STI-AMR in Ugandan men. Interventions to improve antimicrobial stewardship and deliver affordable diagnostics to augment SCM and decrease overtreatment of STI syndromes are required.

Antenatal corticosteroids reduce neonatal mortality in settings without assisted ventilatory support: a retrospective cohort study of early preterm births on the Thailand-Myanmar border.

Prematurity is the highest risk for under-five mortality globally. The aim of the study was to assess the effect of antenatal dexamethasone on neonatal mortality in early preterm in a resource-constrained setting without assisted ventilation. This retrospective (2008-2013) cohort study in clinics for refugees/migrants on the Thai-Myanmar border included infants born <34 weeks gestation at home, in, or on the way to the clinic. Dexamethasone, 24 mg (three 8 mg intramuscular doses, every 8 hours), was prescribed to women at risk of preterm birth (28 to <34 weeks). Appropriate newborn care was available: including oxygen but not assisted ventilation. Mortality and maternal fever were compared by the number of doses (complete: three, incomplete (one or two), or no dose). A sub-cohort participated in neurodevelopmental testing at one year. Of 15,285 singleton births, 240 were included: 96 did not receive dexamethasone and 144 received one, two or three doses (56, 13 and 75, respectively). Of live-born infants followed to day 28, (n=168), early neonatal and neonatal mortality/1,000 livebirths (95%CI) with complete dosing was 217 (121-358) and 304 (190-449); compared to 394 (289-511) and 521 (407-633) with no dose. Compared to complete dosing, both incomplete and no dexamethasone were associated with elevated adjusted ORs 4.09 (1.39 to 12.00) and 3.13 (1.14 to 8.63), for early neonatal death. By contrast, for neonatal death, while there was clear evidence that no dosing was associated with higher mortality, adjusted OR 3.82 (1.42 to 10.27), the benefit of incomplete dosing was uncertain adjusted OR 1.75 (0.63 to 4.81). No adverse impact of dexamethasone on infant neurodevelopmental scores (12 months) or maternal fever was observed. Neonatal mortality reduction is possible with complete dexamethasone dosing in pregnancies at risk of preterm birth in settings without capacity to provide assisted ventilation.

Adequate menstrual suppression in adolescents with inherited bleeding disorders often requires multiple treatment changes: Retrospective cohort study of a multidisciplinary clinic.

Heavy menstrual bleeding (HMB) is often the presenting symptom for females with inherited bleeding disorders (IBD). Multidisciplinary clinics leverage the expertise of hematologists and women's health specialists. This study characterizes the complexity of HMB management for adolescents with IBDs from a large multidisciplinary clinic. Adolescents often required multiple different menstrual suppression treatments, with only about 20% achieving acceptable suppression with their first treatment. Adolescents switched therapy most often for uncontrolled bleeding, followed by adverse effects, and patient preference. Given the difficulty in achieving adequate menstrual suppression, multidisciplinary clinics offer necessary expertise in accomplishing bleeding control with minimal adverse effects.

Treatment plan for maxillary third molars based on radiological findings varies among oral surgeons: a web-based “paper” clinic study

ObjectivesTo evaluate variation in treatment plans and pathological findings related to maxillary second and third molars based on PAN images and CBCT among Danish and Dutch oral and maxillofacial surgeons. Study designThis web-based “paper” clinic contained 10 cases of impacted maxillary third molars comprising clinical information, PAN, and CBCT. Treatment plan and pathological findings were established based on clinical information and PAN, thereafter, based on CBCT by 28 surgeons. Options for treatment plan for third molars were no treatment, or tooth removal. Options for treatment plan for second molars were no treatment, tooth removal, or endodontic and/or filling therapy. The surgeons assessed external root resorption, marginal bone loss, and follicular space. ResultsA change in treatment plan between PAN and CBCT was registered between 0% and 43% of the surgeons among the cases. The surgeons did not agree completely on the treatment plan in any of the cases. Variation was present among the surgeons evaluating pathological findings. In several cases, severity of root resorption was rated worse in CBCT than in PAN. ConclusionsVariation in treatment plan and pathological findings was observed among surgeons. No correlation between change in pathological findings and change in treatment plan was found. Statement of Clinical RelevanceVariation exists among oral surgeons regarding treatment planning and pathological findings related to maxillary second and third molars seen in panoramic images and CBCT. In several cases external root resorption was more severe seen in CBCT compared to panoramic imaging.

Investigation of maternal breastfeeding guarantee policy needs and influencing factors: a cross-sectional study in China.

The promotion of breastfeeding is an important strategy to prevent neonatal death and improve maternal and infant health. But Chinese efforts to improve breastfeeding practices have not been particularly effective. There is still a long way to go to achieve the national health development goals. We aimed to explore the maternal demand for breastfeeding guarantee policy in China and to determine the impact of a range of socio-demographic and neonatal-related variables on breastfeeding guarantee policy demand. The study was carried out in the Obstetrics and Gynecology hospital of Shanghai, one of China's earliest provincial and municipal maternal and child health care institutions. From June to November 2021, 1,292 women were recruited for the cross-sectional study in child health clinic. We collected relevant socio- demographic and neonatal-related data. Maternal breastfeeding needs were measured through a self-designed questionnaire on breastfeeding guarantee policy demands of mothers. The mean score of breastfeeding guarantee policy demand was 4.42 ± 0.51. There were statistically significant differences in the effects of maternal age, education level, family income per capita (Yuan), medical payment type, baby age, work status, and current feeding methods on the demand for breastfeeding guarantee policies (P < 0.05). Multiple linear regression analyses showed that higher education level (B = 4.437, P < 0.001), baby age (B = 2.150, P = 0.002), and current feeding methods (B = 2.754, P = 0.005) were significantly associated with a higher demand for a breastfeeding guarantee policy, the effect of medical payment type is the most influencing factor (B = -7.369, P < 0.001). The maternal needs for breastfeeding guarantee policy are multi-faceted and urgent. In the process of improving and implementing policies, the government and relevant departments should take into account the actual needs of women who have different education levels, baby ages, family economics, and feeding methods.

Prognostic impact of SF3B1 mutation and multilineage dysplasia in myelodysplastic syndromes with ring sideroblasts: a Mayo Clinic study of 170 informative cases.

The revised 4th edition of the World Health Organization (WHO4R) classification lists myelodysplastic syndromes with ring sideroblasts (MDS-RS) as a separate entity with single lineage (MDS-RS-SLD) or multilineage (MDS-RS-MLD) dysplasia. The more recent International Consensus Classification (ICC) distinguishes between MDS with SF3B1 mutation (MDS-SF3B1) and MDS-RS without SF3B1 mutation; the latter is instead included under the category of MDS not otherwise specified. The current study includes 170 Mayo Clinic patients with WHO4R-defined MDS-RS, including MDS-RS-SLD (N=83) and MDS-RSMLD (N=87); a subset of 145 patients were also evaluable for the presence of SF3B1 and other mutations, including 126 with (87%) and 19 (13%) without SF3B1 mutation. Median overall survival for all 170 patients was 6.6 years with 5- and 10-year survival rates of 59% and 25%, respectively. A significant difference in overall survival was apparent between MDS-RS-MLD and MDS-RS-SLD (P<0.01) but not between MDS-RS with and without SF3B1 mutation (P=0.36). Multivariable analysis confirmed the independent prognostic contribution of MLD (hazard ratio=1.8, 95% confidence interval: 1.1-2.8; P=0.01) and also identified age (P<0.01), transfusion need at diagnosis (P<0.01), and abnormal karyotype (P<0.01), as additional risk factors; the impact from SF3B1 or other mutations was not significant. Leukemia-free survival was independently affected by abnormal karyotype (P<0.01), RUNX1 (P=0.02) and IDH1 (P=0.01) mutations, but not by MLD or SF3B1 mutation. Exclusion of patients not meeting ICC-criteria for MDS-SF3B1 did not change the observations on overall survival. MLD-based, as opposed to SF3B1 mutation-based, disease classification for MDS-RS might be prognostically more relevant.

The effect of virtual reality glasses applied during intrauterine device insertion on pain, anxiety and satisfaction: Randomized controlled study.

This study was carried out to determine the effect of the use of "virtual reality glasses," on anxiety, pain, and satisfaction level in order to reduce anxiety and pain during intrauterine device (IUD) insertion, which is a painful and stressful procedure for women and to divert attention to increase satisfaction. This randomized controlled study in the gynecology clinic of a state hospital with 80 women who were accepted to participate in the study. Data were collected using structured patient information form, numerical pain rating scale, state-trait anxiety inventory, patient satisfaction evaluation form, and virtual reality glasses. Post-procedural pain scores in the control group after IUD application were higher than post-procedural pain in the virtual reality group. Measurements of post-procedure anxiety in the control group were higher than measurements of post-procedural in the virtual reality group. Satisfaction levels of women with virtual reality glasses during IUD insertion were also found to be high. It was determined that the use of virtual reality glasses, one of the methods of distraction during IUD insertion, was effective in reducing pain and anxiety and increasing patient satisfaction.

Heart failure clinic inclusion and exclusion criteria: cross-sectional study of clinic’s and referring provider’s perspectives

ObjectivesThere are substantial variations in entry criteria for heart failure (HF) clinics, leading to variations in whom providers refer for these life-saving services. This study investigated actual versus ideal HF...

Associations between vascular health, brain stiffness and global cognitive function.

Vascular brain injury results in loss of structural and functional connectivity and leads to cognitive impairment. Its various manifestations, including microinfarcts, microhaemorrhages and white matter hyperintensities, result in microstructural tissue integrity loss and secondary neurodegeneration. Among these, tissue microstructural alteration is a relatively early event compared with atrophy along the aging and neurodegeneration continuum. Understanding its association with cognition may provide the opportunity to further elucidate the relationship between vascular health and clinical outcomes. Magnetic resonance elastography offers a non-invasive approach to evaluate tissue mechanical properties, providing a window into the microstructural integrity of the brain. This retrospective study evaluated brain stiffness as a potential biomarker for vascular brain injury and its role in mediating the impact of vascular dysfunction on cognitive impairment. Seventy-five participants from the Mayo Clinic Study of Aging underwent brain imaging using a 3T MR imager with a spin-echo echo-planar imaging sequence for magnetic resonance elastography and T1- and T2-weighted pulse sequences. This study evaluated the effects of vascular biomarkers (white matter hyperintensities and cardiometabolic condition score) on brain stiffness using voxelwise analysis. Partial correlation analysis explored associations between brain stiffness, white matter hyperintensities, cardiometabolic condition and global cognition. Mediation analysis determined the role of stiffness in mediating the relationship between vascular biomarkers and cognitive performance. Statistical significance was set at P-values < 0.05. Diagnostic accuracy of magnetic resonance elastography stiffness for white matter hyperintensities and cardiometabolic condition was evaluated using receiver operator characteristic curves. Voxelwise linear regression analysis indicated white matter hyperintensities negatively correlate with brain stiffness, specifically in periventricular regions with high white matter hyperintensity levels. A negative association between cardiovascular risk factors and stiffness was also observed across the brain. No significant patterns of stiffness changes were associated with amyloid load. Global stiffness (µ) negatively correlated with both white matter hyperintensities and cardiometabolic condition when all other covariables including amyloid load were controlled. The positive correlation between white matter hyperintensities and cardiometabolic condition weakened and became statistically insignificant when controlling for other covariables. Brain stiffness and global cognition were positively correlated, maintaining statistical significance after adjusting for all covariables. These findings suggest mechanical alterations are associated with cognitive dysfunction and vascular brain injury. Brain stiffness significantly mediated the indirect effects of white matter hyperintensities and cardiometabolic condition on global cognition. Local cerebrovascular diseases (assessed by white matter hyperintensities) and systemic vascular risk factors (assessed by cardiometabolic condition) impact brain stiffness with spatially and statistically distinct effects. Global brain stiffness is a significant mediator between vascular disease measures and cognitive function, highlighting the value of magnetic resonance elastography-based mechanical assessments in understanding this relationship.

The Impact of Diabetes Education on Continuous Glucose Monitoring in SUS-Dependent Patients in a Northeastern Brazilian City.

Diabetes Mellitus (DM) is an important chronic disease that occurs worldwide. This study aims to investigate how the use of the FreeStyle® Libre system in Unified Health System (SUS) patients impacts diabetes parameters in patients who receive education on proper insulin administration and the use of the continuous monitoring device, as well as how this affects patients without any concomitant multidisciplinary support in Sergipe, Brazil. We conducted a prospective randomized study in a diabetes clinic in Sergipe, Brazil, using the flash method FreeStyle® Libre (Abbott). The participants were divided into two groups: one receiving diabetes education on CGM (continuous glucose monitoring), while the other did not. Before the intervention, the patient's treatment motivation and quality of life were assessed using a questionnaire, and baseline levels of glycated hemoglobin were measured using high-performance liquid chromatography (HPLC) and the point of care AlereTM Afinion with boronate fixation. We compared first- and second-phase data with respect to glycated hemoglobin, mean interstitial blood glucose, time on and above target for hypoglycemic and hyperglycemic events, and mean hypoglycemic duration. In group A, which received the diabetes education intervention, there was a significant reduction in average HbA1c levels from 8.6% to 7.9% after 3 months (p = 0.001). However, there was no significant difference in average glycemic values. Time above target decreased significantly from 50.62% to 29.43% (p = 0.0001), while time below target decreased from 22.90% to 20.21% (p = 0.002). There was no significant change in the number of hypoglycemic events, but the duration of hypoglycemia decreased significantly from 130.35 min to 121.18 min after 3 months (p = 0.0001). In Group B, there was no significant difference in mean HbA1c levels before (7.07%) and after (7.28%) sensor installation. This group maintained lower HbA1c levels compared to the other group. Average blood glucose levels also remained similar before (148.37 mg/dL) and after (154.65 mg/dL) the intervention. Although the time above the target glucose level increased significantly from 35.94% to 48.17%, the time at target decreased from 50.40% to 37.97%. No significant changes were observed in the time below target, the number of hypoglycemic events, or the duration of hypoglycemia. Our findings indicate that utilizing continuous glucose monitoring technology can enhance glycemic control, particularly in motivated, educated, low-income patients dependent on the SUS. To achieve positive results with FreeStyle Libre, it is imperative to allocate resources for multidisciplinary support.

"I don´t put people into boxes, but…" A free-listing exercise exploring social categorisation of asylum seekers by professionals in two German reception centres.

Newly arriving asylum seekers in Germany mostly live in large reception centres, depending on professionals in most aspects of their daily lives. The legal basis for the provision of goods and services allows for discretionary decisions. Given the potential impact of social categorisation on professionals' decisions, and ultimately access to health and social services, we explore the categories used by professionals. We ask of what nature these categorisations are, and weather they align with the public discourse on forced migration. Within an ethnographic study in outpatient clinics of two refugee accommodation centres in Germany, we conducted a modified free-listing with 40 professionals (physicians, nurses, security-personnel, social workers, translators) to explore their categorisation of asylum seekers. Data were qualitatively analysed, and categories were quantitatively mapped using Excel and the Macro "Flame" to show frequencies, ranks, and salience. The four most relevant social categorisations of asylum seekers referred to "demanding and expectant," "polite and friendly" behaviour, "economic refugees," and "integration efforts". In general, sociodemographic variables like gender, age, family status, including countries and regions of origin, were the most significant basis for categorisations (31%), those were often presented combined with other categories. Observations of behaviour and attitudes also influenced categorisations (24%). Professional considerations, e.g., on health, education, adaption or status ranked third (20%). Social categorisation was influenced by public discourses, with evaluations of flight motives, prospects of staying in Germany, and integration potential being thematised in 12% of the categorisations. Professionals therefore might be in danger of being instrumentalised for internal border work. Identifying social categories is important since they structure perception, along their lines deservingness is negotiated, so they potentially influence interaction and decision-making, can trigger empathy and support as well as rejection and discrimination. Larger studies should investigate this further. Free-listing provides a suitable tool for such investigations.

Hepatitis delta virus infection in Turkey: A meta-analysis of prevalence

ObjectivesHepatitis delta virus (HDV) infection has been granted orphan disease status by the US Food and Drug Administration and the European Medicines Agency owing to its rarity and relatively limited research and treatment options. Turkey is considered an endemic country for the virus. We aimed to provide a current and updated country- and region-specific HDV infection prevalence. MethodsIn this meta-analysis, we searched databases, including MEDLINE, PUBMED, EMBASE, and UlakBim (Turkish Medical Index) published between January 1, 2006, and December 31, 2022. We included blood donor studies, outpatient clinic studies that comprised patients without cirrhosis, and inpatient clinical studies that comprised patients with cirrhosis. Turkey was divided into three regions: West, Central, and East Turkey. ResultsAfter a systematic assessment, 41 studies were included. Using a random-effects model, the estimated HDV prevalence among hepatitis B surface antigen–positive blood donors, outpatient clinic, and inpatient clinic patients were 3.37% (confidence interval [CI] 1.99-6.11), 5.05% (CI 4.00-6.23), and 29.06% (CI 10.45-51.79), respectively. The HDV prevalence among outpatient clinic patients in Western, Central, and Eastern regions were 3.38% (CI 2.47-4.44), 2.15% (CI 1.37-3.09), and 9.81% (CI 6.61-13.55), respectively. ConclusionsEast Turkey continues to have a high burden of HDV. Public health efforts, such as screening, should be targeted accordingly.

A longitudinal mixed-methods study of pathology explanation clinics in patients with newly diagnosed localized prostate cancer.

To characterize the role of pathology explanation clinics (PECs) in prostate cancer care and determine their impact on patients, urologic oncologists, and quality of care. Semistructured interviews with 10 patients with newly diagnosed prostate cancer were conducted before and after a PEC pilot and at the 1- and 6-month follow-up visits. Information about participants' cancer knowledge and anxiety were collected quantitatively. Documented pathologist communications and proper review of outside biopsy slides were collected. Semistructured interviews were also completed with participating urologic oncologists following the pilot. Pathology explanation clinics improved participants' understanding of their diagnosis, cognitively and emotionally supporting them first in their urologic oncology visit and later in making an informed treatment decision. Mean knowledge scores were high, and a minority of participants had prostate cancer anxiety. Urologic oncologists noted improved understanding and reduced anxiety among participants, enabling nuanced conversations about prognosis and management during the visit. By ensuring review of outside biopsy slides and communication of clinically significant or unexpected diagnoses, PECs supported high-quality care and patient safety. In this small pilot, PECs positively affected patients with prostate cancer, their clinicians, and the overall care system. Additional studies in larger populations and diverse settings will be useful.

TAX PLANNING IN COST REDUCTION: A STUDY IN A MEDICAL SPECIALTY CLINIC IN THE CITY OF TIANGUÁ-CE

This research refers to a case study in a medical specialty clinic, which focuses on care in outpatient clinics and offices, located in the Municipality of Tianguá-CE. The objective is to demonstrate the best taxation option, in order to produce greater profitability for the company and reduce taxes paid. To this end, a comparison of the tax regimes was developed: Simples Nacional and Lucro Presumido in the year 2022, highlighting the analysis of the main taxes to be paid within these regimes. With correctly executed tax planning, it highlights the best tax regime for the company, providing greater organization and profitability.

A time-motion study and patient satisfaction in the fever clinic of a Government Medical College and Hospital in India

Background: During the recent pandemic, the number of patients with influenza-like symptoms had considerably increased in fever clinics of hospitals leading to queuing and increased patient dissatisfaction. Aims and Objectives: A time-motion study was therefore designed to evaluate the time taken at different service delivery points in the fever clinic and patient satisfaction regarding service delivery time. Materials and Methods: An institutional cross-sectional observational study was conducted at the fever clinic of Midnapore Medical College and Hospital for 1 month. A total of 200 patients were selected by systematic random sampling from the fever clinic outdoors and their movement was recorded and satisfaction assessed. Results: Most patients visited the clinic during the start of the week and in the first half of the day. The total mean time required from entry to exit was 9089 s±143.0. The maximum time was spent waiting time in the fever clinic entry queue followed by that at the pharmacy. The minimum time required was at the nursing table followed by a doctor’s consultation. The maximum meantime for movement between two stations was between station 5 (laboratory investigation station) and station 6 (pharmacy), that is, 1144 s±183.6. The majority of the study population was not satisfied with the time management in the fever clinic whereas only 18.0% of the participants were fully satisfied. Conclusion: Identifying the loopholes and formulating an effective time management strategy can help deliver better patient care as well as boost patient satisfaction.

Machine Learning Models of Polygenic Risk for Enhanced Prediction of Alzheimer Disease Endophenotypes.

Alzheimer disease (AD) has a polygenic architecture, for which genome-wide association studies (GWAS) have helped elucidate sequence variants (SVs) influencing susceptibility. Polygenic risk score (PRS) approaches show promise for generating summary measures of inherited risk for clinical AD based on the effects of APOE and other GWAS hits. However, existing PRS approaches, based on traditional regression models, explain only modest variation in AD dementia risk and AD-related endophenotypes. We hypothesized that machine learning (ML) models of polygenic risk (ML-PRS) could outperform standard regression-based PRS methods and therefore have the potential for greater clinical utility. We analyzed combined data from the Mayo Clinic Study of Aging (n = 1,791) and the Alzheimer's Disease Neuroimaging Initiative (n = 864). An AD PRS was computed for each participant using the top common SVs obtained from a large AD dementia GWAS. In parallel, ML models were trained using those SV genotypes, with amyloid PET burden as the primary outcome. Secondary outcomes included amyloid PET positivity and clinical diagnosis (cognitively unimpaired vs impaired). We compared performance between ML-PRS and standard PRS across 100 training sessions with different data splits. In each session, data were split into 80% training and 20% testing, and then five-fold cross-validation was used within the training set to ensure the best model was produced for testing. We also applied permutation importance techniques to assess which genetic factors contributed most to outcome prediction. ML-PRS models outperformed the AD PRS (r2 = 0.28 vs r2 = 0.24 in test set) in explaining variation in amyloid PET burden. Among ML approaches, methods accounting for nonlinear genetic influences were superior to linear methods. ML-PRS models were also more accurate when predicting amyloid PET positivity (area under the curve [AUC] = 0.80 vs AUC = 0.63) and the presence of cognitive impairment (AUC = 0.75 vs AUC = 0.54) compared with the standard PRS. We found that ML-PRS approaches improved upon standard PRS for prediction of AD endophenotypes, partly related to improved accounting for nonlinear effects of genetic susceptibility alleles. Further adaptations of the ML-PRS framework could help to close the gap of remaining unexplained heritability for AD and therefore facilitate more accurate presymptomatic and early-stage risk stratification for clinical decision-making.

Diagnostic challenges and disparities in young-onset dementia: insights from a Southeast London memory clinic study.

Diagnostic challenges and disparities in young-onset dementia: insights from a Southeast London memory clinic study.