Suboptimal Treatment Research Articles

Current treatment of acute coronary syndromes in cancer patients: the need for improvement

Abstract Background Cancer patients can develop acute coronary syndromes (ACS) due to their oncological therapy exposure or shared risk factors between cancer and cardiovascular disease. Cancer patients have been reported to receive suboptimal treatment in this setting, with lower rates of coronary angiography and or primary percutaneous intervention, despite the clear benefit of these therapies in ACS. This disparity in the care of cancer patients can lead to worse cardiovascular outcomes. Purpose To describe the contemporary therapeutic approach in patients with a history of cancer or current cancer presenting with an acute coronary syndrome to a tertiary care cardiology hospital. Methods We performed an electronic chart review of patients admitted to the cardiac intensive coronary unit of a tertiary care Cardiology hospital in our city, from May 2021 to February 2023. Patients with a current or historical diagnosis of cancer and acute coronary syndrome (with and without ST segment elevation) were identified. We collected the following information: demographic data, oncological diagnosis, cancer treatment history, ACS type, and ACS management. Results Seventy-five patients had diagnosis of current or historical cancer in the selected period. Of them, 40 patients were admitted with diagnosis of acute coronary syndrome. Mean age was 69.8 + 10.0 years. Twenty-one patients (52.5%) had a historical diagnosis of cancer and nineteen patients had diagnosis of current cancer. Of patients with historical cancer the most common type was hematological, followed by prostate and renal cancer. The most common types of active malignancies were prostate, colon, and renal cancer. ST-segment elevation myocardial infarction (STEMI) was the most common type of ACS (27 patients). Notably, only half of the patients presenting with STEMI underwent primary percutaneous coronary intervention, four patients received fibrinolytic treatment, and one third of patients with STEMI did not receive reperfusion therapy. Among patients with STEMI, mean time from symptom onset to reperfusion therapy was 495 minutes. Regarding the 13 patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI), eight underwent an invasive strategy (coronary angiography) in the first 48 hours, of whom six had percutaneous coronary intervention, and one underwent coronary artery bypass graft surgery. Five patients with NSTEMI (38.4%) did not undergo coronary angiography during their hospitalization. Conclusions Patients with active or historical cancer presenting with STEMI receive late reperfusion treatment and up to one out of three do not receive reperfusion therapy. An important proportion of cancer patients presenting with NSTEMI do not even undergo invasive strategy. It is imperative to provide optimal care of cancer patients presenting with ACS.

Abstract 18313: Sex Disparities in Optimal Medical Therapy for Ischemic Heart Disease

Background: Despite secondary prevention guidelines recommending optimal medical therapy (OMT) forischemic heart disease (IHD), which includes antiplatelets, statins, renal-angiotensin aldosterone inhibitors (RAASi), and β-blockers, significant sex disparities in OMT utilization have been observed. However, theimpact of national efforts on narrowing this gap in contemporary cohorts remains uncertain. Methods: Using data from the National Health and Nutrition Examination Survey cycles 2011-2020, we examined the distribution and trends of OMT medication classes and combinations used in the preceding 30 days (verified through containers in most cases) among adult men and women with self-reported IHD (myocardial infarction or coronary artery disease). Results: Among 1905 adults included (40.6% women, mean age 65.4years), women had significantlylower proportions of OMT use across all medication classes- antiplatelets (68% vs. 77.7%), statins (57.2% vs. 73.9%), RAASi (45.6% vs. 59.0%), and β-blockers (51.2% vs. 61.1%); as well as combinations such as aspirin+statins (47.4% vs. 64.1%) and all four medications (17.5% vs. 32.5%). After adjusting forsociodemographic and clinical factors, the odds of using antiplatelets (OR 0.71 95%CI 0.52-0.94), statins (OR 0.62, 0.40-0.96), and RAASi (OR 0.56, 0.38-0.84) were significantly lower among women than men,whereas β-blocker use was comparable. Moreover, between 2011 to 2020, fewer women consistentlyreported using statins, RAASi, β-blockers, antiplatelets+statins, and all four medications in each survey cycle. Conclusion: This nationally representative study reveals persistent sex disparities in OMT utilization forIHD, with women receiving suboptimal treatment compared to men. These findings emphasize the urgentneed for novel targeted interventions to address and mitigate the sex disparities in OMT utilization foreffective IHD prevention.

Atrial Fibrillation in Patients with Myelofibrosis

Background: Atrial fibrillation (AF) is the most common arrythmia (1-2% of the general population) and is associated with high risk of arterial thrombotic events. AF is not well characterized in the context of myeloproliferative neoplasms (MPN). Recent studies imply that thrombotic risk stratification among MPN AF patients may be suboptimal using the standard CHA2DS2VASC score, and true predictor of thrombotic risk may be presence of myelofibrosis instead. Clinical context in which AF occurs in myelofibrosis patients had not been investigated so far, but such analysis is needed to better understand why is the presence of myelofibrosis in particular the main predictor of thrombotic events among AF MPN patients. We aimed to evaluate prevalence and clinical associations of AF among patients with myelofibrosis. Methods: We retrospectively investigated a cohort of 154 patients with overt myelofibrosis treated in 6 Croatian hematology centers in period 2004-2022. Diagnoses were reassessed according to the 2016 WHO criteria for primary myelofibrosis (PMF) and the 2008 IWGMRT criteria for secondary myelofibrosis (SMF). Presence of AF documented in medical records and clinical correlations of AF status with main disease related characteristics were analyzed. Results: Among a total of 154 patients, 86 had PMF, 35 had post polycythemia vera (PV) and 33 had post essential thrombocythemia (ET) SMF. Median age was 69 years. There were 91 (59%) males, 111 (75%) patients were JAK2, 9 (7.3%) CALR and 4 (3.3%) MPL mutated. AF was present in 15 (9.7%) patients with myelofibrosis which was significantly more frequent than anticipated in the general population of similar age (P<0.001). There were no significant associations of AF with neither etiology of myelofibrosis, age, sex, mutational status, degree of bone marrow fibrosis, spleen size, history of thrombosis, estimated glomerular filtration rate, hemoglobin, WBC nor platelet count (P>0.05 for all analyses). DIPSS score did not differ between AF and non-AF PMF patients, but MYSEC-PM score was significantly higher among AF SMF patients (P=0.029). AF in comparison to non-AF patients more frequently had constitutional symptoms (87% vs 54%, P=0.015), positive bleeding history (27% vs 6%, P=0.004), heart failure (47% vs 12%, P<0.001), obesity (21% vs 4%, P=0.010), lower MCHC (313 vs 318 g/L, P=0.031), higher urea (median 8.5 vs 6.8 g/L, P=0.009) and higher CHA2DS2VASC score (4 vs 3 points, P=0.003). AF more frequently received anticoagulants and diuretics than non-AF patients (P<0.05), whereas similar rates of cytoreductive therapy and aspirin were utilized. Despite all myelofibrosis patients with AF patients having CHA2DS2VASC score ≥2 points, only 60% of them received anticoagulant therapy, 27% received aspirin and 73% received cytoreductive therapy. No significant difference in survival and thrombosis was observed between AF and non-AF myelofibrosis patients (P>0.05 for all analyses) although study may be underpowered for these analyses. Summary/Conclusion: AF is frequent in patients with myelofibrosis and might be associated with higher frequency of constitutional symptoms, particular cardiovascular comorbidities and consistently high predetermined CHAD2DS2VASC risk. Nevertheless, unexpectedly low proportion of patients receives anticoagulant therapy, possibly due to anticipated risk of bleeding and cytopenias common in myelofibrosis patients. It remains a question whether suboptimal treatment or presence myelofibrosis itself might be a risk factor for unfavorable outcomes among AF MPN patients.

Value of care by reducing treatment terminations during radiation therapy.

6 Background: Disruptions in cancer care adversely affect patient clinical outcomes, particularly when a patient does not complete the prescribed course of treatment. Adverse outcomes include decreased overall survival and earlier/increased disease relapse or progression requiring additional salvage, palliative, and/or supportive therapies. We have reported on the incidence of treatment terminations (TT) in a large multi-center academic radiation medicine department. This study addresses the healthcare expenditure toward sub-optimal treatment associated with TT. Methods: TT of patients undergoing radiation treatment between 1/2013 and 1/2023 were prospectively tracked as part of departmental quality and safety monitoring. A TT was defined as the discontinuation of therapy at any point following informed consent and treatment simulation. The rate of TT was calculated as a percentage of all new patients who start radiation treatments. Cost of care was estimated using mean values from the 2023 Medicare Part B Fee schedule for New York, accounting for consultation, simulation and planning, treatment delivery, and weekly physician and physics treatment checks prior to TT. Cuts to the Medicare Physician Fee Schedule, Medicare reimbursement, and stagnant Medicare Conversion Factor relative to inflation over the 10 years were not accounted for. Results: There were a total of 1,467 TTs out of 28,707 planned treatment courses (5.1%). The average expenditure prior to TT was $8,584 per patient. Aggregated over the past decade, $12.59 million represents an underestimate of healthcare spend toward these situations at one institution. The rate of TT decreased from 9.3% in 2013 to 3.3% in 2022. As discussed separately, this TT rate was reduced via prospective analysis as part of our ongoing department quality and safety program, with incremental changes to pre-treatment evaluation, on-treatment management, and scheduling processes. Assuming stagnant clinical volume, this translates into decreased spend of $1.48 million annually toward incomplete (sub-optimal) treatments. Conclusions: Radiation TTs reflect major deviations from the original care plan. By understanding reasons for TT, we have more effectively selected optimal treatment paradigms and supported patients proactively through their treatment course. Avoiding divergence from intended cancer care decreases adverse outcomes, thereby improving value of the treatment course.

Compared to what? An analysis of comparators in trials informing the National Institute of Clinical Excellence (NICE) low back pain guideline

BackgroundLow back pain (LBP) is the leading cause of disability globally. Clinical practice guidelines (CPGs) have been developed in hopes of encouraging evidence-based care for LBP. However, poor quality of trials that underpin CPGs can lead to misleading recommendations for LBP. ObjectivesTo categorize the comparator used in trials included in the National Institute of Clinical Excellence (NICE) LBP CPG and describe the proportion and association of suboptimal comparators with NICE recommendation. MethodsWe conducted a cross-sectional analysis to describe the proportion of trials included in the NICE LBP CPG that used a suboptimal comparator. If comparators used an ineffective treatment, a treatment of unknown effectiveness, or no or minimal treatment then they were considered suboptimal. ResultsWe included 408 trials and analyzed 580 comparators used in the trials. 30.9% of the comparators used in the trials were suboptimal. Trials testing invasive treatments (32.4%) had the highest proportion of suboptimal comparators followed by non-surgical (32.3%) and pharmacological (19.0%) treatments. Trials using suboptimal treatments were less likely to have their treatment recommended (odds ratio: 0.68; 95% CI: 0.47, 0.98) for use by NICE. ConclusionThere is a concerning proportion of suboptimal comparators used in LBP trials that may be misleading CPG recommendations, funding allocation decisions, and ultimately clinical practice. Efforts to increase the use of optimal comparators in LBP trials are urgently needed to better understand what treatments should be recommended.

Appraising the performance of ChatGPT in psychiatry using 100 clinical case vignettes.

ChatGPT has emerged as the most advanced and rapidly developing large language chatbot system. With its immense potential ranging from answering a simple query to cracking highly competitive medical exams, ChatGPT continues to impress the scientists and researchers worldwide giving room for more discussions regarding its utility in various fields. One such field of attention is Psychiatry. With suboptimal diagnosis and treatment, assuring mental health and well-being is a challenge in many countries, particularly developing nations. To this regard, we conducted an evaluation to assess the performance of ChatGPT 3.5 in Psychiatry using clinical cases to provide evidence-based information regarding the implication of ChatGPT 3.5 in enhancing mental health and well-being. ChatGPT 3.5 was used in this experimental study to initiate the conversations and collect responses to clinical vignettes in Psychiatry. Using 100 clinical case vignettes, the replies were assessed by expert faculties from the Department of Psychiatry. There were 100 different psychiatric illnesses represented in the cases. We recorded and assessed the initial ChatGPT 3.5 responses. The evaluation was conducted using the objective of questions that were put forth at the conclusion of the case, and the aim of the questions was divided into 10 categories. The grading was completed by taking the mean value of the scores provided by the evaluators. Graphs and tables were used to represent the grades. The evaluation report suggests that ChatGPT 3.5 fared extremely well in Psychiatry by receiving "Grade A" ratings in 61 out of 100 cases, "Grade B" ratings in 31, and "Grade C" ratings in 8. Majority of the queries were concerned with the management strategies, which were followed by diagnosis, differential diagnosis, assessment, investigation, counselling, clinical reasoning, ethical reasoning, prognosis, and request acceptance. ChatGPT 3.5 performed extremely well, especially in generating management strategies followed by diagnoses for different psychiatric conditions. There were no responses which were graded "D" indicating that there were no errors in the diagnosis or response for clinical care. Only a few discrepancies and additional details were missed in a few responses that received a "Grade C" CONCLUSION: It is evident from our study that ChatGPT 3.5 has appreciable knowledge and interpretation skills in Psychiatry. Thus, ChatGPT 3.5 undoubtedly has the potential to transform the field of Medicine and we emphasize its utility in Psychiatry through the finding of our study. However, for any AI model to be successful, assuring the reliability, validation of information, proper guidelines and implementation framework are necessary.

Cytogenetic risk explored within an electronic patient reported outcomes (ePROs) remote symptom monitoring platform among patients with acute myelogenous leukemia (AML).

349 Background: Patients with AML and poor-risk cytogenetic abnormalities often have suboptimal treatment response and poor long-term survival, Electronic Patient Reported Outcomes (ePROs) integration into routine oncology practice have been shown to improve patient time on therapy, survival, and resource utilization. This study explores the use of an ePRO platform to explore differences in treatment experience and ePRO compliance in patients with AML and poor and other-risk cytogenetics. Methods: Adult patients with AML undergoing treatment were enrolled in the Carevive remote symptom monitoring (RSM) platform between March 1, 2021 and April 20, 2023. Patients received baseline and weekly surveys to assess patient-reported symptom burden, physical function, overall health, and survey compliance throughout treatment. Baseline characteristics included age, sex, race, frailty status (modified Geriatric Assessment, CARE survey item, and/or self-reported activity level), comorbidities, and social determinants of health. Symptoms (derived from the PRO-CTCAE), physical function (PROMIS 4a), and quality of life (QoL) (EORTC QLQ-C30, items #29-30) were assessed weekly. Results were stratified by poor vs. other cytogenetic risk. As this was an exploratory study, statistical significance was not reported. Results: Of a total of 124 patients, 47 (38%) had poor-risk and 77 (62%) had other-risk disease by cytogenetics. Weekly survey compliance was comparable (68% vs 69%), and median age was 66 (range 35-88) and 69 (range 21-88), respectively. About 50% of all patients were male, 76% were White, and 69% had ≥1 comorbidity. Patients with other-risk were younger with 40% fewer comorbidities (mean 0.95, median 0, range 0-5) than patients with poor cytogenetic risk (mean 1.36, median 1, range 0-5). Overall symptoms were reported 12% more frequently among patients with other risk (1.49 symptoms per patient-week) compared to patients with poor risk (1.33 symptoms per patient-week). Fatigue was reported by 20% of patients across all patient-weeks for both risk groups; shortness of breath was reported 6% and 10% across all patient-weeks for poor and other risk groups, respectively. Although baseline treatment bother was 17% higher for poor risk patients, over time, QoL and treatment bother were comparable between both groups, and physical function was directionally higher. Conclusions: This study illustrates the feasibility of using remote symptom monitoring for evaluating patients with poor vs. other cytogenetic risk in routine care, with relatively high survey compliance in a real-world setting. Despite poor prognostic status, the experience of poor cytogenetic risk patients was comparable to other cytogenetic risk patients and reported directionally lower levels of symptom burden and higher levels of function over time.

59 Neuropsychiatric Clustering of Veterans with TBI: The Link Between Neuropsychological Test Validity and Somatic Post-Concussive Symptoms

Objective:There is a wide variability in the neuropsychiatric presentation of mild traumatic brain injury (mTBI), and accurate diagnosis and treatment is complicated by within-condition heterogeneity and overlapping symptoms of common comorbidities (e.g., PTSD). Such diagnostic complexities can obfuscate clinical decision-making and lead to suboptimal treatment response. In contrast to traditional diagnostic categories, person-centered analysis methods create data-derived groupings wherein individuals within a cluster are similar and individuals across clusters are different. The current study sought to apply clustering to dimensional emotional and neuropsychological features in treatment-seeking Veterans with mTBI, with the goal of identifying more precise, homogeneous clinical profiles.Participants and Methods:Study participants were 190 Veterans with mTBI history participating in a clinical neuropsychological assessment of cognitive complaints (Mean age: 34.38, 89.6% male, average years of education: 13.14). Participants completed a diagnostic interview, neuropsychological tests, and symptom questionnaires (NBSI, PCL, BDI, BAI, AUDIT, PSQI). To identify clusters of similar neuropsychiatric presentations, we first conducted dimension reduction on data from the cognitive tests and self-report measures using principal components analysis. Second, cluster analysis and cluster validation was performed on the resultant principal components (R: kmeans, clusterboot, clusterValid) to find homogeneous subgroups of participants.Results:The clinical data was best represented by principal components reflecting anxious arousal, depressive cognitions, somatic post-concussive symptoms, reexperiencing and avoidance symptoms, and objective cognitive deficits. Cluster analysis using bootstrapping and cluster validity indices (e.g., Silhouette width, Dunn index) indicated that a 6-subgroup solution was optimal (subgroups were labeled Group A-Group F). Group A was characterized by moderate levels across all dimension scores. Group B was characterized by elevated somatic post-concussive symptoms and cognitive deficits. Group C was characterized by intact cognitive performance and low somatic post concussive symptoms. Group D was characterized by elevated depressive cognitions. Group E was characterized by high anxious arousal but low depressive cognitions and reexperiencing and avoidance. Group F was characterized by elevated reexperiencing and avoidance. The subgroups did not differ statistically on any demographic items, such as years of education, age, or gender. However, there were statistically significant differences across groups in performance validity failure (x2(10) = 27.17, p=.002); Group B showed the highest rate of failure.Conclusions:Results demonstrate that phenotypically similar subgroups of individuals can be identified within treatment-seeking Veterans with mTBI. Data suggest that somatic post-concussive symptoms may be linked to cognitive deficits, however the rate of validity failure indicates that neuropsychological test scores may not reflect true cognitive ability. In contrast to prior studies that treat mTBI as a unitary construct that accounts for symptoms, our data suggest that a nuanced evaluation yields vastly diverse clinical presentations. Cluster analytic frameworks hold promise for better assessment and treatment planning for Veterans, as both patients and their treating clinicians would be greatly served by the ability to use common clinical assessment tools to better identify a given individual’s clinical needs. A critical next step is to validate subgroups using novel samples and data sources (e.g., neurobiology, genetics) and to determine if these subgroupings can be effectively utilized to personalize treatment assignment.

Suboptimal treatment of acromegaly potentially leading to onset and progression of B cell lymphoma

Suboptimal treatment of acromegaly potentially leading to onset and progression of B cell lymphoma

Prevalence and Predictors of Non-Compliance with Pharmacological Treatment in Diabetes

Although the incidence of failure to comply to prescribe drugs is very varied, it may be the most frequent cause of suboptimal treatment results in diabetic patients. In the research region, there are little data on the extent of non-adherence to medicines and related causes. Objective: To determine the prevalence of non-adherence to medications in patients with diabetes and the factors leading to such practices. Methods: A descriptive study designed was chosen to evaluate 191 patients with diabetes enrolled at the department of medicine, combined military hospital, Nowshera, during the period May 2022 to May 2023. Non-adherence was confirmed clinically by taking history and biochemically by poor glycemic profile. SPSS version 24 was used to analyze the data. Results: The age of the patients ranged from 18 to 60 years. The mean age of the patients was 36.17 years with standard deviation 7.53. Age group 18 to 40 years comprised of 113 (59.2%) participants. The male participants were 129 (67.5%) in number. Non-adherence was observed in 86(45.5%) patients. Factors leading to non-adherence included financial constraints 32(37.2%), medications related to complications 16(18.6%). Conclusions: Diabetes patients often fail to comply with their prescribed prescriptions in the study region. To reduce disengagement among diabetes patients, public health programs should be reinforced.

Use of IDegLira to Intensify, Simplify, and Increase Appropriateness of Type2 Diabetes Therapy: A Real-Life Experience.

Fixed ratio combination of insulin degludec and liraglutide (IDegLira) represents an option to revise inappropriate therapies in patients with poorly controlled type2 diabetes. This study aimed to assess the pattern of use and 1-year effectiveness of IDegLira. A retrospective chart review was performed to assess changes in glycated hemoglobin (HbA1c) (primary endpoint), fasting blood glucose (FBG), body weight, estimated glomerular filtration rate (eGFR), and lipid profile following IDegLira initiation. Previous versus concomitant diabetes treatments were also compared. Overall, 87 patients (mean age 73.9 ± 9.2years, diabetes duration 18.2 ± 6.7years, 62.1% men, HbA1c 8.3 ± 1.3%, BMI 30.4 ± 5.5kg/m2) initiated IDegLira. Previously, 21.8% of patients were treated with oral hypoglycemic agents (OHA group), 47.1% with basal insulin ± OHA (BOT group), 5.8% with GLP-1 RA ± basal insulin (GLP1-RA group), and 25.3% with basal-bolus schemes (BB group). At the first prescription of IDegLira, secretagogues and schemes including two or more OHA were substantially reduced, leaving metformin as the most prevalent OHA (81.6%) used in combination with IDegLira. Starting dose of IDegLira ranged from 18.7 ± 3.1U (OHA group) to 24.1 ± 4.4U (BB group). After 1year, HbA1c was significantly reduced by 1.25% (95%CI -1.48; -1.03), FBG by 52.9mg/dl, and body weight by 2.0kg. Also, eGFR levels and lipid profile significantly improved. No severe hypoglycemia occurred. It is possible to proactively review suboptimal or inappropriate diabetes treatment according to the most recent guidelines. Results suggest that initiation of IDegLira was associated with a reduction in drugs to be administered daily and relevant improvements in clinical outcomes.

Thromboprophylaxis in atrial fibrillation: correct interpretation and effective use of CHA2DS2-VASc and HAS-BLED scores

Thromboprophylaxis is one of the most important aspects of atrial fibrillation (AF) management as irregular atrial contractions foster formation of blood clots that may result in ischemic stroke. Strokes caused by AF are relatively large and often lead to death or sever disability, but they may be avoided with appropriate anticoagulation therapy. Unfortunately, the risk factors for stroke overlap with risk factors for bleeding, creating a genuine challenge for clinicians seeking to strike a balance in preventing these two types of complications. This is why risk assessment scores CHA2DS2-VASc and HAS-BLED have been developed. While their role to optimize the anticoagulation therapy was confirmed in multiple studies, the misinterpretation of the criteria within these scores and their inappropriate application can result in suboptimal treatment and needlessly expose patients to the risk of stroke, hemorrhage, or both. This review aims to present appropriate interpretation of CHA2DS2-VASc and HAS-BLED scores and discuss how anticoagulation therapy of AF patients should be guided by those two scores.

Combating Weight Stigma in Healthcare: A Cross-Country Analysis and Intervention Initiative

Abstract Background Rising global obesity rates coincide with increasing weight stigmatization, affecting various life aspects, including healthcare. Discrimination impacts patient well-being and care quality, leading to suboptimal treatment. This research compares weight stigma among healthcare professionals in Romania, UK, and Greece, addressing personal and second-hand weight bias. Methods The study used cross-sectional data from the Breaking Weight Bias survey, including 125 healthcare professionals from Romania, Greece, and the UK. Data collection occurred between June and August 2021 via an online survey. Measures included the Universal Measure of Bias-FAT (UMF-FAT) questionnaire, personal experience with weight bias, and experiences of weight bias in medical settings. Results More women participated in the study across all countries. The mean age was 37.12 years (SD = 10.92). Bachelor's degrees were most common (43.4%), with Greece having the highest percentage of Master's (41.7%). Romania had the highest Doctoral degrees (32.4%). Private healthcare settings were the most common (51.3%). UMB-FAT results showed varying bias between countries. Romania had the highest rates (M = 3.08, SD = 0.768). Statements indicating more bias included poor hygiene (M = 2.40, SD = 1.832) and lacking consideration for others (M = 1.74, SD = 1.459). Over half of the participants (53.3%) experienced personal weight-related teasing. Greece had the highest rate (62.9%). Regarding second-hand weight bias experiences in medical settings, a high level of agreement (30-50%) was observed. Conclusions This study confirms weight bias in healthcare professionals across multiple countries, revealing moderate bias levels. Despite limitations, the findings contribute to understanding weight bias across different regions and fields. There is a need for weight-bias education among healthcare professionals, as it can harm patient-provider relationships and care quality. Key messages • Research confirms moderate weight bias in healthcare professionals across Romania, UK, and Greece. • Study highlights the need for weight-bias education in medical training to improve patient-provider relationships.

Initiation of Disease-Modifying Antirheumatic Drugs in Older Medicare Beneficiaries With New Diagnosis of Late-Onset Rheumatoid Arthritis.

Older adults with rheumatoid arthritis (RA) account for up to one-third of the RA population and are less likely to receive optimal treatment. For the subgroup of older adults with late-onset RA (LORA), who experience more symptomatic and progressive disease, suboptimal treatment could be more consequential than the general population who age with RA. We evaluated use of disease-modifying antirheumatic drugs (DMARDs) in older adults with a new diagnosis of LORA. In this retrospective observational study, we identified adults 66 years of age or older with a new diagnosis of LORA using Medicare data from 2008 to 2017. Information on baseline patient characteristics and DMARD initiation during the first 12 months after LORA diagnosis were collected. We also assessed concomitant use of glucocorticoids (GCs). We identified 33,373 older adults with new diagnosis of LORA. Average age at LORA diagnosis was 76.7 (SD 7.6); 75.4% were female, 76.9% were White, and 35.6% had low-income subsidy (LIS). Less than one-third were initiated on a DMARD (28.9%). In multivariable analyses, DMARD initiation was associated with younger age, fewer comorbidities, and absence of LIS status. Concomitant long-term (>3 months) GC use was higher among those on any DMARD (44.3%) compared with those without (15.2%). DMARD initiation after new diagnosis of LORA is low despite current clinical practice guidelines recommending early aggressive initiation of treatment. Long-term GC use is common among those on any DMARDs, raising concern for suboptimal DMARD use. Further studies are needed to understand drivers of DMARD use in older adults.

Diagnosis of lung cancer following emergency admission: Examining care pathways, clinical outcomes, and advanced NSCLC treatment in an Italian cancer Center

BackgroundLung cancer patients diagnosed following emergency admission often present with advanced disease and poor performance status, leading to suboptimal treatment options and outcomes. This study aimed to investigate the clinical and molecular characteristics, treatment initiation, and survival outcomes of these patients. MethodsWe retrospectively analyzed data from 124 patients diagnosed with lung cancer following emergency admission at a single institution. Clinical characteristics, results of molecular analyses for therapeutic purpose, systemic treatment initiation, and survival outcomes were assessed. Correlations between patients’ characteristics and treatment initiation were analyzed. ResultsMedian age at admission was 73 years, and 79.0 % had at least one comorbidity. Most patients (87.1 %) were admitted due to cancer-related symptoms. Molecular analyses were performed in 89.5 % of advanced non-small cell lung cancer (NSCLC) cases. In this subgroup, two-thirds (66.2 %) received first-line therapy. Median overall survival (OS) was 3.9 months for the entire cohort, and 2.9 months for patients with metastatic lung cancer. Among patients with advanced NSCLC, OS was significantly longer for those with actionable oncogenic drivers and those who received first-line therapy. Improvement of performance status during hospitalization resulted in increased probability of receiving first-line systemic therapy. DiscussionPatients diagnosed with lung cancer following emergency admission demonstrated poor survival outcomes. Treatment initiation, particularly for patients with actionable oncogenic drivers, was associated with longer OS. These findings highlight the need for proactive medical approaches, including improving access to molecular diagnostics and targeted treatments, to optimize outcomes in this patient population.

Enhancing panic disorder treatment with mobile-aided case management: an exploratory study based on a 3-year cohort analysis.

Individuals with panic disorder frequently face ongoing symptoms, suboptimal treatment adherence, and increased relapse rates. Although mobile health interventions have shown promise in improving treatment outcomes for numerous mental health conditions, their effectiveness, specifically for panic disorder, has yet to be determined. This study investigates the effects of a mobile-aided case management program on symptom reduction and quality of care among individuals with panic disorder. This 3-year cohort study enrolled 138 participants diagnosed with panic disorder. One hundred and eight participants joined the mobile-aided case management group and 30 in the treatment-as-usual group. Data were collected at baseline, 3-month, 6-month, and 12-month treatment checkpoints using self-report questionnaires, in-depth interviews, direct observation, and medical record analysis. During the maintenance treatment phase, the mobile-assisted case management group decreased both panic severity (p = 0.008) and state anxiety (p = 0.016) more than the control group at 6 months. Participants who underwent case management experienced enhanced control over panic symptoms, heightened self-awareness, and elevated interpersonal support. The mobile-aided case management is beneficial in managing panic disorder, especially maintenance treatment.

Development and validation of an ultra-high performance liquid chromatography-tandem mass spectrometry method for quantifying lenacapavir plasma concentrations: Application to therapeutic monitoring

Although current antiretroviral therapy (ART) effectively suppresses HIV in the blood, regimens may fail due to suboptimal treatment history and non-adherence to ART. In these scenarios, accumulation of viral resistance mutations to ART drug classes may occur. For these treatment-experienced people living with HIV (PLWH), activity against resistant viral strains is required; lack of therapeutic efficacy will result in continued viral replication and progression to acquired immunodeficiency syndrome. New treatment options have emerged. Lenacapavir is a first-in-class long-acting HIV-1 capsid inhibitor approved for the treatment of HIV in treatment-experienced patients. Lenacapavir is approved with an initiation regimen of oral and subcutaneous injection dosing followed by subcutaneous self-injection every 6 months. With infrequent dosing, therapeutic drug monitoring may be necessary to ensure adequate concentrations are consistently achieved in the plasma to assure treatment adherence and prevent further HIV resistance formation. To this end, we developed and validated a highly selective ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to quantify lenacapavir concentrations in human plasma. A simple protein precipitation with acetonitrile followed by supernatant dilution was performed. Lenacapavir and its stable labeled internal standard were separated at 1.90 min using a multi-step UPLC gradient. The assay for lenacapavir quantification was extensively validated according to the United States Food and Drug Administration Bioanalytical Guidelines over a clinically relevant range of 0.1 to 500 ng/mL with excellent linearity (R2 ≥ 0.9960). This analytical method achieves acceptable performance of trueness (89.7–104.1 %), repeatability, and precision (CV < 15 %). We applied this method to quantify a clinical sample and to determine the percent protein-unbound. This method can be utilized for the therapeutic monitoring of lenacapavir in human plasma for monitoring HIV treatment efficacy.

A multicenter retrospective electronic health record database evaluation of subjects with Mycoplasma genitalium

BackgroundMycoplasma genitalium is a sexually transmitted infection (STI) increasing in prevalence. The recent availability of nucleic acid amplification tests (NAATs) has led to updated diagnostic and treatment guidelines. As medication therapy experts, pharmacists can facilitate appropriate antimicrobial selection and stewardship and optimize best patient-care practices in the setting of M. genitalium infection. ObjectiveThis study aimed to evaluate patient demographics, therapeutic approaches, and complications of patients with laboratory evidence of M. genitalium hypothesizing that younger adolescent females are affected by this organism, receive suboptimal treatment, and have more complications than adults. MethodsThis was a retrospective cohort study using TriNetX multicenter electronic health record data of subjects aged 12 years and older with evidence of M. genitalium DNA detected via NAATs. The cohort was divided into 2 age groups: adolescents (12-21 years) and adults (older than 21 years). We evaluated age, sex, race, ethnicity, diagnostic codes, and medication codes. ResultsOur study included 1126 subjects (192 adolescents [17.1%] and 934 adults [82.9%]) who tested positive for M. genitalium. Subjects in the adolescent group had higher odds of being women (2.52 [1.80, 3.54], P < 0.001), having inflammatory diseases of female pelvic organs diagnostic codes (1.51 [1.06, 2.16], P = 0.025), increased odds of azithromycin prescription (1.70 [1.17, 2.48], P = 0.005), and decreased odds of moxifloxacin prescription (0.41 [0.26, 0.64], P < 0.001). ConclusionsOur study revealed a higher prevalence of M. genitalium infection in adults and adolescents with increased odds of receiving azithromycin and decreased odds of receiving moxifloxacin. Both age groups had decreased odds of receiving doxycycline compared with azithromycin despite guidelines recommending initial empirical antibiotic treatment with doxycycline and growing macrolide resistance. Suboptimal treatment of this infection may lead to lifelong complications. Pharmacists may provide crucial guidance and education to both patients and health care providers regarding appropriate treatment for M. genitalium.

Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services

BackgroundItaly can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily).MethodsA set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions.RESULTS31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments.ConclusionsHealthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.

Intensify Standardized Anticoagulation for Cancer-associated Pulmonary Embolism: From Single-center Real-world Data

Pulmonary embolism (PE) is a significant contributor to mortality in patients with cancer. Although anticoagulation serves as the cornerstone of treatment for cancer-associated PE, it has not been emphasized in real-world settings. The aim of this study was to examine the impact of suboptimal anticoagulant treatment on the prognosis of cancer-associated PE. A cohort of 356 individuals newly diagnosed with acute PE were enrolled. The primary outcome of the study was recurrent venous thromboembolism (VTE), and the secondary outcomes were all-cause mortality and major bleeding (consisting of a reduction in the hemoglobin level by at least 20 g/L, transfusion of at least 2 units of blood, or symptomatic bleeding in a critical area or organ or fatal bleeding). Of the total participants, 156 (43.8%) were diagnosed with cancer. A comparison between the cancer and noncancer groups revealed that patients with cancer were more frequently asymptomatic (41.0% vs 4.5%; P < 0.001), less likely to have right ventricular dysfunction (4.5% vs 14.0%; P=0.001), received less anticoagulant treatment during hospitalization (85.3% vs 98.5%; P < 0.001), and had a shorter duration of anticoagulation (5.02 [7.40] months vs 14.19 [10.65] months; P < 0.001). In addition, patients with cancer were found to be at a higher risk of recurrent VTE (17.3% vs 4.0%; P < 0.001) and all-cause mortality (23.7% vs 10.5%; P=0.001). Multiple Cox regression analysis indicated that discontinuation of anticoagulation at 3 months was a significant risk factor for recurrent VTE in the cancer group (HR, 15.815; 95% CI, 3.047-82.079; P=0.001). The brief duration of anticoagulation therapy and elevated likelihood of recurrent VTE serve as cautionary indicators for the need to enhance awareness of standardized anticoagulant treatment for cancer-associated PE. The ultimate goal is to enhance patient prognosis and quality of life.