bluuebunny/crossref_metadata_2025 huggingface dataset:
E009 An audit looking into bisphosphonate co-prescription and compliance in patients with giant cell arteritis
Authors: Bolger Alistair A , Hutton Lisa
Published: April 2024

Background/Aims

The treatment of giant cell arteritis includes glucocorticoid use to reduce inflammation. There are known drawbacks of long-term glucocorticoid use, including osteopenia and osteoporosis. The British Society for Rheumatology giant cell arteritis guidelines recommend that we should consider appropriate pharmacological bone protection at the time of presentation to counteract this. Glucocorticoid toxicity risks increases with both dosage and duration of steroid use. To reduce steroid burden, we consider introduction of the steroid sparing agents such as tocilizumab and methotrexate. This audit was to look into whether we were locally achieving bone protection consideration and to whether steroid sparing agents were helping in terms of compliance of bisphosphonates.

Methods

We retrospectively looked at the clinical letters of the patients locally diagnosed with giant cell arteritis in the previous 3 years to ascertain whether there was documentation of decisions around starting bisphosphonates at the time of diagnosis and whether the patients tolerated bisphosphonate therapy for the recommended duration. Patients were classified into 3 groups, as to whether their treatment was glucocorticoids with tocilizumab (TOC), glucocorticoids with methotrexate (MTX) or glucocorticoid monotherapy (MONO).

Results

49 Patients were identified. 3 of these patients were excluded for various reasons. 17 were in the TOC group, 11 in the MTX group, and 18 in the MONO group. Documentation of consideration of bisphosphonates at diagnosis was 94% in TOC, 91% in MTX and 100% in MONO. Overall this was 96%. Compliance of bisphosphonate therapy for the recommended duration was 88% in TOC, 90% in MTX and 86% in MONO. Overall compliance was 88%. There was no statistically significant difference between the steroid sparing groups and the monotherapy group both in terms of consideration of initiation of bisphosphonate treatment and compliance of bisphosphonate treatment, with p values of 0.52 and 0.8 respectively.

Conclusion

Overall, we found that locally there was good consideration of bisphosphonate therapy at diagnosis and that compliance remained good throughout treatment. This can help reduce the side effect profile of glucocorticoid toxicity. Although, there was no statistically significant difference in our study of concordance of bisphosphonates between the two groups, steroid sparing agents are useful in our arsenal at reducing the risks of glucocorticoid toxicity.

Disclosure

A.A. Bolger: None. L. Hutton: None.
E010 Impact of rheumatologist ultrasound clinic on the management of inflammatory arthritis at a tertiary centre rheumatology department
Authors: Murad Awin Mohammed , Jubber Ameen , Moorthy Arumugam
Published: April 2024

Background/Aims

Musculoskeletal ultrasound plays an important role in the assessment and management of inflammatory arthritis, enabling early diagnosis and prompt initiation of disease modifying therapy, as well as escalation of therapy as part of a treat-to-target strategy. It can help clinicians distinguish between true joint inflammation and non-inflammatory causes of increased pain scores. We reviewed our weekly rheumatology ultrasound clinic service where patients are referred to aid in clinical decision making. The study aimed to evaluate the cohort of patients attending the rheumatology ultrasound clinic at University Hospitals of Leicester, a busy tertiary centre, serving a multi-ethnic population, and to assess the impact of this clinic on the management of inflammatory arthritis in these patients.

Methods

Data was collected retrospectively from the ultrasound clinic at University Hospitals of Leicester between June 2022 and June 2023. Outcome measures included: date of scan request, date of scan, underlying disease, C - reactive protein (CRP), anti-CCP level, presence of radiographic erosions, presence of active synovitis or erosions on ultrasound, other rheumatologic disease and how the ultrasound findings changed the patient’s management.

Results

The total number of patients attending the clinic during the study period was 91. Of these, 70% were female and 30% male. Over the study period, 11.8% of patients did not attend their appointment. At the time of referral, 68% of patients had a CRP<5, 91% had a negative anti-CCP and 83% had no radiographic erosions. Following the scan, 13% of the patients had active synovitis, and 10% received at least one steroid injection. Interestingly, 86% had no active inflammation and no indication to escalate their disease modifying drug. In our patient cohort, 16% had pre-existing fibromyalgia. In all appointments, the clinician performing the scan showed the ultrasound images to the patient and explained the findings.

Conclusion

This ultrasound clinic is a key part of the treat-to-target strategy for inflammatory arthritis, enabling escalation of disease modifying therapy where indicated. It allows ultrasound guided and marked injections to be given when needed and identifies patients with non-inflammatory causes of increased pain scores, preventing patients from receiving unnecessary immunosuppression.

Disclosure

A. Mohammed Murad: None. A. Jubber: None. A. Moorthy: None.
E011 Magnetic resonance imaging in axial spondyloarthritis: usage, reporting times and scanning times - a service evaluation in a large tertiary centre
Authors: Weddell Jake , Shah Rahul , Robinson Philip , Barr Andrew , Vandevelde Claire , Freeston Jane , McGonagle Dennis , Marzo-Ortega Helena
Published: April 2024

Background/Aims

Rapid access to magnetic resonance imaging (MRI) of the spine and sacroiliac joints is essential for the timely diagnosis of axial spondyloarthritis (axSpA). A recent NASS/BRITSpA national FOI survey highlighted deteriorating waiting times to access MRI for the assessment of inflammatory back pain in the UK, with only 73% of Trusts reporting access within 8 weeks, compared to 90% in 2017. In addition, NHS England and the Royal College of Radiologists have recently published a target of 28 days for turn-around time (TAT) for a verified report to be provided after image acquisition in any circumstance. Aims: To evaluate the usage of MRI performed under the “inflammatory back pain protocol” at a large tertiary centre, including the time from MRI request to scan being performed, TAT for reporting and whether this has changed over time.

Methods

A service evaluation audit was conducted at Leeds Teaching Hospitals Trust (LTHT). MRIs of the spine and sacroiliac joints requested between December 2021 and May 2023 under the local “inflammatory back pain protocol” were identified by the radiology department. Data extracted from medical records included: indication for MRI request, time elapsed from request to scan, and from scan to verified report.

Results

A total of 668 MRI requests were identified. The commonest reason for MRI request was to aid the diagnosis of axSpA 75% (n = 501); followed by disease activity monitoring in established axSpA (16.7%, n = 111) and assessment of axial involvement in peripheral psoriatic arthritis, i.e. diagnosis of axPsA (8.5% n = 57 scans). The majority (92%) had a request to scan time of 8 weeks, with a TAT to report of 4 weeks (77%). However, a greater delay in TAT to verified report was seen from December 2022 to May 2023 with <45% of reports issued within 28 days, despite no change in scanning time. Causes identified were related to local workforce issues including delays in appointing new radiographers and radiology consultants.

Conclusion

The main reason for request of an MRI under the inflammatory back pain protocol at LTHT is to support making a diagnosis of axSpA. A significant number of patients were scanned for treatment monitoring and to diagnose axial psoriatic arthritis, although data on the utility of MRI for these indications are limited. Whilst nearly all patients were scanned within 2 months at all time periods, the TAT to report has significantly deteriorated since December 2022 in our region, due to workforce issues. Further understanding of the impact of workforce factors on service delivery in rheumatology is required.

Disclosure

J. Weddell: None. R. Shah: None. P. Robinson: None. A. Barr: None. C. Vandevelde: None. J. Freeston: None. D. McGonagle: None. H. Marzo-Ortega: None.
E021 Patient initiated follow-up long term condition pathway audit
Authors: Ellis Jessica , King Callum , Loganathan Aravinthan , Sengupta Raj
Published: April 2024

Background/Aims

In October 2022 we created a PIFU Long Term Condition (PIFU-LTC) pathway for our department in line with guidance issued by GIRFT for rheumatological patient initiated follow-up. Entry and exclusion criteria for the pathway were agreed by clinicians. Entry criteria included presence of a relevant diagnosis and established disease (≥ 12-month duration). Exclusion criteria included significant cognitive impairment and/or communication difficulties. Guidance regarding documentation standards, follow- intervals and responses to patient contacts were formalised in the standard operating procedure. We undertook an audit of the pathway to evaluate successes and identify areas for improvement.

Methods

Between 3/10/22 and 30/3/2023 520 patients had been added to the pathway. A random sample of 10% (n = 52) were audited. Data was extracted onto a bespoke data collection proforma. Data collected included: entry and exclusion criteria for the pathway, current medications, subsequent flares and time to review.

Results

33 female and 19 male patients were audited. 86% (n = 45) were of White ethnicity. Mean age was 61 (range 20-83). 81% (n = 42) of patient diagnoses met entry criteria for the pathway. Other diagnoses included osteoarthritis, gout and undifferentiated arthralgia. 92% (n = 48) joined ≥12 months since initial diagnosis. 1 patient had significant cognitive difficulties. Documentation regarding information provision was poor. 40% (n = 21) of patients had no record of being provided a PIFU-LTC information leaflet. 33% (n = 17) had no documentation regarding action to take in case of a flare. 15% (n = 8) of patients had contacted the department since entering the pathway (range 21 to 288 days after joining). 6 of these patients reported a disease flare. Duration between patient contact and telephone review by a clinician ranged between 1- 3 days. 4 patients were also offered a face-to-face clinic appointment, with a range of 2-22 days from first contact until this review. As of October 2023, only 3 patients had been taken off the PIFU pathway.

Conclusion

This audit had highlighted successes, included the numbers of patients moved onto the pathway and limited inclusion of patients meeting exclusion criteria. Key areas for improvement include improving documentation standards in clinic letters, ensuring adequate information provision to patients and reducing delays to face-face clinic follow up. Further development of the pathway may include expansion of the pathway to other diagnostic groups.

Disclosure

J. Ellis: None. C. King: None. A. Loganathan: None. R. Sengupta: None.
E027 A rare cause of shoulder pain: calcific tendonitis at the pectoralis major humeral insertion
Authors: Quinlan Eavan M , Kazmi Muhammad
Published: April 2024

Background/Aims

Shoulder pain in the elderly is very common and often caused by calcific tendonitis of the rotator cuff muscles. We report the case of a lady presenting with unilateral shoulder pain who had an X-Ray which showed calcification over the proximal humerus. This calcification turned out to be due to calcific tendonitis of the humeral insertion of the pectoralis major, which is very rare. Unfamiliarity with this unusual condition could lead to inappropriate investigation, such as invasive biopsy, and possible mismanagement.

Methods

A 61-year-old lady of Pakistani origin with dual antibody positive rheumatoid arthritis, well controlled on methotrexate, reported new and severe right shoulder pain during her outpatient appointment. Her past history included coeliac disease, osteoarthritis, hypertension, iron and vitamin D deficiency, and she was not currently taking any calcium supplements. The pain had rapidly progressed over weeks to months without any trauma history and was significantly limiting all shoulder movements, particularly shoulder abduction and rotation. Her rheumatoid arthritis was in remission. Concerningly, she reported nocturnal pain, which alongside the rapidly progressive nature of the pain raises suspicions of a more sinister cause like malignancy.

Results

Blood tests showed a normal CRP, calcium profile and ALP. An X-Ray of the right shoulder showed no calcification or osteoarthritis affecting the glenohumeral joint, but demonstrated the unusual finding of a prominent focus of calcification close to the lateral aspect of the proximal humerus. An MSK radiologist advised further imaging to confirm nature of lesion. Subsequent USS confirms a focus of calcification (14mm x 18mm) in the pectoralis major humeral insertion, adjacent to the long head of the biceps tendon. Features that are suggestive of benign calcification rather than neoplasm include the characteristic location of the calcification and absence of an overlying soft tissue mass. The patient was reassured regarding the benign nature of the calcification and was managed conservatively with simple analgesia and physiotherapy.

Conclusion

Calcific tendinopathy is a common disease, but calcification of the pectoralis major at its humeral insertion point is very rare. This case highlights the importance of familiarity with this condition to enable the clinician to make an accurate diagnosis, and reduce the likelihood of unnecessary investigations and stress for the patient. Conservative management, such as simple analgesia and physiotherapy, is very effective for the majority of patients and should be used as first-line treatment. Steroid injection can be considered with orthopaedic intervention advised for those who have not responded to conservative management.

Disclosure

E.M. Quinlan: None. M. Kazmi: None.
E053 The use of online platforms in the treatment of chronic musculoskeletal disease
Authors: Wall Amanda J W , Kelleher Eoin , Wanigasekera Vishvarani , Irani (nee Soni) Anushka
Published: April 2024

Background/Aims

Persistent pain is a common feature of rheumatic diseases, and has a significant impact on the emotional, physical and social wellbeing of individuals. Despite pharmacological treatment for inflammatory arthritis, such as rheumatoid arthritis (RA), 10-20% have features suggestive of co-existing centralised pain. These patients have worse pain, mood and sleep despite DMARD therapy. Similar to fibromyalgia (FM), non-pharmacological treatments are likely to be useful for this problem. Evidence supports cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT) for the management of chronic musculoskeletal pain. Unfortunately, access to services is poor for many people. This has driven the development of online treatment programmes and apps. The current study explores willingness of patients with rheumatic diseases to use online platforms in this context.

Methods

An observational cohort study of patients with a clinical diagnosis of either RA or FM were recruited from NHS outpatient clinics. Data collection was via the online platform Redcap. Analysis compared demographic and clinical features of those with past use of online platforms or apps for health purposes using Student’s t-test and chi squared tests. A similar comparison was conducted for future use of online platforms or apps.

Results

Of 343 patients 177(52%) FM, 166(48%) RA), 264 (77%) were female with mean (SD) age 48 (13.6). Past use of online platforms is summarised in Table 1. Significantly more patients with FM (70%) would be willing to try an online platform in future, compared to those with RA (30%). Those with future interest are more likely to be younger (mean age 46), have lower mood (mean PHQ-9 13), worse sleep (mean ISI 14.6) and less pain (mean VAS 6.6) compared to those who would not (mean age 60, PHQ-9 12, ISI 12.6 and VAS 7.0 respectively).

Conclusion

Those with FM are more likely to engage with online platforms or apps for health purposes than those with RA. In this analysis, users were more likely to be younger and experience more severe anxiety and depression but further work is needed to evaluate the contributing factors which will be essential when optimising the impact of online healthcare initiatives.

Disclosure

A.J.W. Wall: None. E. Kelleher: None. V. Wanigasekera: None. A. Irani (nee Soni): None.
E077 Evaluation of group education for patients with large vessel vasculitis prescribed subcutaneous methotrexate
Authors: Ducker Georgina , Mukhtyar Chetan B
Published: April 2024

Background/Aims

Patient education in rheumatology is of proven value to educate as well as to reduce demand on health care services. This can be delivered in a multitude of ways, in person and more recently with the use of multi-media modalities. There is limited evidence to specifically demonstrate the benefit of patient education for patients with vasculitis. Education needs to be adapted to meet patient needs. In addition to one-to-one appointments, we have been conducting in-person group education for this patient group. We present our experience.

Methods

Patients prescribed subcutaneous methotrexate for large vessel vasculitis were given the opportunity to attend a group education session run by the specialist nurse. The sessions were held over a 4-month period, in groups of 3-5 individuals. Patients were provided with written information including the links to online resources prior to attending the group education session which consisted of a verbal presentation and a short video. Patients also had the opportunity to ask questions during the group session. If patients were happy to proceed with the planned treatment, a prescription for the subcutaneous methotrexate was provided and initial blood monitoring commenced. After attending the group session, patients were given an evaluation form to complete

Results

The responses from the evaluation forms are shown in the following table:

Conclusion

Group education has proved to be a successful way of providing education to patients with large vessel vasculitis needing to learn about the indications for use, along with the safe handling and administration of subcutaneous methotrexate.

Disclosure

G. Ducker: None. C.B. Mukhtyar: None.
The Microbiome and Gynecologic Cancer: Cellular Mechanisms and Clinical Applications
Authors: Chalif Julia , Wang Heather , Spakowicz Daniel , Quick Allison , Arthur Elizabeth K. , O'Malley David , Chambers Laura M.
Published: April 2024

(Abstracted from Int J Gynecol Cancer 2023:ijgc-2023-004894

The microbiome, the collective microbiota and their associated genetic material colonizing mucosal surfaces, produces compounds that impact immunologic response, cell proliferation and signaling, gene expression, and metabolism of nutrients and hormones. Alterations to the microbiota-host relationship are linked to diseases, including cancer.
What Do LGBTQ+ Medical Students Experience and Need in Medical School? A Multicenter Qualitative Study in Thailand
Authors: Srifuengfung Maytinee , Wiwattarangkul Teeravut , Vadhanavikkit Papan , Wiwattanaworaset Pakawat , Chiddaycha Mayteewat , Oon-arom Awirut , Wainipitapong Sorawit
Published: April 2024

Purpose

This study evaluated the experiences and needs of lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities (LGBTQ+) attending medical schools in Thailand.

Method

Medical students from 4 medical schools in Thailand were recruited in 2022. LGBTQ+ participants were selected via purposive sampling and invited for semistructured interviews. Verbatim transcripts were analyzed using reflexive thematic analysis.

Results

Interviews were conducted with 39 students identifying as lesbian, gay, bisexual, transgender, queer, questioning, nonbinary, asexual, or androgynous, with a mean age of 21. The experiences of these LGBTQ+ individuals in medical school had 4 themes: (1) normalization of LGBTQ+ identity among friends, or not openly identifying as LGBTQ+ (because it was viewed as unnecessary), facilitated everyday life; (2) fear of negative judgments from being LGBTQ+ by attending physicians and patients; (3) authenticity to sexual or gender identity provided relief; and (4) personal histories of discrimination affected self-disclosure and social dynamics. Overall, approximately 17% of reported stressors were directly associated with participants’ LGBTQ+ identity. The identified needs within medical schools comprised 2 themes: (1) treat each other with equal respect (with 3 subthemes: nonjudgmental attitudes supported by effective discrimination reporting systems, more LGBTQ+-related education and extracurricular activities, and activities driven by voluntariness without gender-based selection); and (2) abolishment or amendment of regulations that strictly enforce gender binaries. These amendments could include implementing flexible dress codes, establishing gender-neutral restrooms and dormitories, and introducing gender-neutral titles. Transgendered participants reported experiencing the most significant disparities due to binary regulations and infrastructures.

Conclusions

LGBTQ+ medical students in Thailand reported fear of negative perceptions by attending physicians and patients. Exposing everyone, particularly attending physicians, to examples of unintentional discrimination is recommended. There is also a need to promote LGBTQ+-related education and extracurricular activities and to ensure activities and regulations are not gender divided.
Increasing the Threshold to Perform Preperitoneal Pelvic Packing Decreases Morbidity Without Affecting Mortality
Authors: Pesante Benjamin D. , Moore Ernest E. , Pieracci Fredric M. , Kim Ye Joon , Mauffrey Cyril , Parry Joshua A.
Published: April 2024

OBJECTIVES:

To determine the effectiveness of an updated protocol that increased the transfusion threshold to perform preperitoneal pelvic packing in patients with pelvic ring injuries and hemodynamic instability (HDI).

METHODS:

Design:

Retrospective review.

Setting:

Urban level 1 trauma center.

Patients Selection Criteria:

Severely injured (injury severity score > 15) patients with pelvic ring injuries treated before and after increasing the threshold to perform preperitoneal pelvic packing from 2 to 4 units of red blood cells (RBCs). HDI was defined as a systolic blood pressure <90 mm Hg.

Outcome Measures and Comparisons:

Mortality from hemorrhage, anterior pelvic space infections, and venous thromboembolisms before and after increasing preperitoneal pelvic packing threshold.

RESULTS:

One hundred sixty-six patients were included: 93 treated under the historical protocol and 73 treated under the updated protocol. HDI was present in 46.2% (n = 43) of the historical protocol group and 49.3% (n = 36) of the updated protocol group (P = 0.69). The median age of patients with HDI was 35.0 years (interquartile range 26.0–52.0), 74.7% (n = 59) were men, and the median injury severity score was 41.0 (interquartile range 29.0–50.0). Patients with HDI in the updated protocol group had a lower heart rate on presentation (105.0 vs. 120.0; P = 0.004), required less units of RBCs over the first 24 hours (6.0 vs. 8.0, P = 0.03), and did not differ in age, injury severity score, systolic blood pressure on arrival, base deficit or lactate on arrival, resuscitative endovascular balloon occlusion of the aorta, resuscitative thoracotomy, angioembolization, or anterior pelvis open reduction internal fixation (P > 0.05). The number of PPPs performed decreased under the new protocol (8.3% vs. 65.1%, P < 0.0001), and there were fewer anterior pelvic infections (0.0% vs. 13.9%, P = 0.02), fewer VTEs (8.3% vs. 30.2%; P = 0.02), and no difference in deaths from acute hemorrhagic shock (5.6% vs. 7.0%, P = 1.00).

CONCLUSIONS:

Increasing the transfusion threshold from 2 to 4 units of red blood cells to perform pelvic packing in severely injured patients with pelvic ring injuries decreased anterior pelvic space infections and venous thromboembolisms without affecting deaths from acute hemorrhage.

LEVEL OF EVIDENCE:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials*
Authors: D’Amico Filippo , Pruna Alessandro , Putowski Zbigniew , Dormio Sara , Ajello Silvia , Scandroglio Anna Mara , Lee Todd C. , Zangrillo Alberto , Landoni Giovanni
Published: April 2024

OBJECTIVES:

Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality.

DATA SOURCES:

We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024.

STUDY SELECTION:

Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings.

DATA EXTRACTION:

The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928.

DATA SYNTHESIS:

Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87–0.99; p = 0.03; I
2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes.

CONCLUSIONS:

Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
Vonoprazan 10 mg or 20 mg vs. lansoprazole 15 mg as maintenance therapy in Asian patients with healed erosive esophagitis: A randomized controlled trial
Authors: Xiao Yinglian , Qian Jiaming , Zhang Shutian , Dai Ning , Chun Hoon Jai , Chiu Chengtang , Chong Chui Fung , Funao Nobuo , Sakurai Yuuichi , Eisner Jessica D. , Xie Li , Chen Minhu
Published: April 2024

Background:

Erosive esophagitis (EE) is a gastroesophageal reflux disease characterized by mucosal breaks in the esophagus. Proton pump inhibitors are widely used as maintenance therapy for EE, but many patients still relapse. In this trial, we evaluated the noninferiority of vonoprazan vs. lansoprazole as maintenance therapy in patients with healed EE.

Methods:

We performed a double-blind, double-dummy, multicenter, phase 3 clinical trial among non-Japanese Asian adults with endoscopically confirmed healed EE from April 2015 to February 2019. Patients from China, South Korea, and Malaysia were randomized to vonoprazan 10 mg or 20 mg once daily or lansoprazole 15 mg once daily for 24 weeks. The primary endpoint was endoscopically confirmed EE recurrence rate over 24 weeks with a noninferiority margin of 10% using a two-sided 95% confidence interval (CI). Treatment-emergent adverse events (TEAEs) were recorded.

Results:

Among 703 patients, EE recurrence was observed in 24/181 (13.3%) and 21/171 (12.3%) patients receiving vonoprazan 10 mg or 20 mg, respectively, and 47/184 (25.5%) patients receiving lansoprazole (differences: –12.3% [95% CI, –20.3% to –4.3%] and –13.3% [95% CI, –21.3% to –5.3%], respectively), meeting the primary endpoint of noninferiority to lansoprazole in preventing EE recurrence at 24 weeks. Evidence of superiority (upper bound of 95% CI <0%) was also observed. At 12 weeks, endoscopically confirmed EE recurrence was observed in 5/18, 2/20, and 7/20 of patients receiving vonoprazan 10 mg, vonoprazan 20 mg, and lansoprazole, respectively. TEAEs were experienced by 66.8% (157/235), 69.0% (156/226), and 65.3% (158/242) of patients receiving vonoprazan 10 mg, vonoprazan 20 mg, and lansoprazole, respectively. The most common TEAE was upper respiratory tract infection in 12.8% (30/235) and 12.8% (29/226) patients in vonoprazan 10 mg and 20 mg groups, respectively and 8.7% (21/242) patients in lansoprazole group.

Conclusion:

Vonoprazan maintenance therapy was well-tolerated and noninferior to lansoprazole for preventing EE recurrence in Asian patients with healed EE.

Trial Registration:

https://clinicaltrials.gov; NCT02388737.
Transitional Care In Patients With Hirschsprung Disease: Those Left Behind
Authors: Thompson David S. , Davidson Joseph R. , Ford Kathryne , Loukogeorgakis Stavros , Eaton Simon , Blackburn Simon , Curry Joseph
Published: April 2024

BACKGROUND:

The long term effects of Hirschsprung disease are clinically variable. Improved understanding of challenges patients may face as adults can help inform transitional care management.

OBJECTIVE:

To explore the outcomes and transitional care experiences in adult patients with Hirschsprung.

DESIGN:

Cohort study.

SETTING:

Single center.

PATIENTS:

All patients treated for Hirschsprung 1977-2001 (aged >18 at time of survey July 2018-2019). Eligible patients were sent validated multi-domain surveys as well as qualitative questions regarding their transitional care.

MAIN OUTCOME MEASURES:

Status of transitional care, bowel function and quality of life assessment. Qualitative analysis of transitional care experience.

RESULTS:

Of 139 patients, 20 had received transition care (10 had at least 1 visit but had been discharged and 10 were receiving ongoing follow-up). These patients had inferior bowel function and quality of life scores at follow-up. Twenty-three (17%) patients had issues with soiling at time of discharge, 7 received transitional care. Of these, 9/23 (39%) had a normal bowel function score (≥17), 5/23 (22%) had a poor score (<12) and one patient had since had a stoma formation. Eighteen (13%) patients had active moderate-severe issues related to bowel function, only 5 had been transitioned, and just 2 remained under ongoing care. Importantly, when these patients were discharged from our pediatric center, at a median age of 14 (IQR 12-16) years, 10/17 had no perceptible bowel issues, suggesting a worsening of function after discharge.

LIMITATIONS:

The retrospective design and reliance on clinical notes to gather information of discharge status as well as patient recall of events.

CONCLUSION:

There remains a small but significant proportion of Hirschsprung patients for whom bowel function either remains or becomes a major burden. These results support a need to better stratify patients requiring transitional care, and ensure a clear route to care if their status changes after discharge. See Video Abstract.
Long-Term Corneal Endothelial Parameters of COVID-19 Patients With Ocular Surface Symptoms
Authors: Kılıçarslan Oğuzhan , Yılmaz Çebi Aslıhan , Doğan Cezmi , Arslan Osman Şevki
Published: April 2024

Purpose:

This study aimed to investigate the long-term effects of COVID-19 on corneal endothelial cell morphology in patients with ocular symptoms to assess possible corneal involvement in patients who recovered.

Methods:

The COVID-19 group included patients diagnosed and treated at Istanbul University Cerrahpasa Medical Faculty with confirmed SARS-CoV-2 infection and ocular irritation symptoms. The control group was comprised of age- and sex-matched individuals. The controls had no ocular pathologies. Noncontact specular microscopy (Konan Cell Check SL, Hyogo, Japan) was performed using the center method after 156 ± 16 days of COVID-19 diagnosis. Parameters such as endothelial cell density (ECD), hexagonality (HEX), coefficient of variation, and central corneal thickness were analyzed.

Results:

Specular microscopy results of 54 COVID-19 patients with ocular irritation symptoms and 72 controls were evaluated. Ocular symptoms in COVID-19 patients included conjunctival hyperemia, foreign body sensation, tearing, ocular secretion, and chemosis. Mean (±SD) ECD was 2770 ± 31 (cells/mm2) in the COVID-19 group and 2897 ± 26 in the control group, and mean (±SD) HEX was 46.52 ± 6.38 in the COVID-19 group and 58.22 ± 13.94 in the control group. COVID-19 patients exhibited significantly lower endothelial ECD and HEX levels than controls (P = 0.003 and P < 0.001, respectively). Coefficient of variation and central corneal thickness analyses did not reach statistical significance.

Conclusions:

COVID-19 can cause long-term alterations in the corneal endothelial cells, leading to decreased ECD and HEX. Future research should focus on the long-term implications of COVID-19 on the corneal health and visual outcomes.
Hippocampal subfields in remitted schizophrenia
Authors: Liou Ying-Jay , Liu Mu-N. , Yang Kai-Chun , Hu Li-Yu , Hsieh Wen-Chi , Chou Yuan-Hwa
Published: April 2024

Background:

Current evidence of volume changes in hippocampal subdivisions in schizophrenia remains inconsistent, and few studies have investigated the relationship between regional hippocampal volumes and symptom remission.

Methods:

In this cross-sectional study, we recruited 31 patients with schizophrenia and 31 healthy controls (HCs). Symptomatic remission in schizophrenia was determined according to Remission in Schizophrenia Working Group criteria. The volumes of hippocampal longitudinal subregions and transverse subfields were measured using manual and automatic techniques, respectively. Between-group regional hippocampal volume differences were analyzed using multivariate analysis of covariance followed by univariate analysis of covariance.

Results:

Compared with the HCs, the patients with schizophrenia had smaller bilateral heads and tails along the longitudinal axis; they also had reduced volumes of the bilateral CA1, CA3, CA4, GC-ML-DG, molecular layer, tail, left subiculum, left HATA, and right parasubiculum along the transverse axis in the hippocampus (all corrected p < 0.05). Furthermore, compared with the HCs and patients with remitted schizophrenia, the patients with nonremitted schizophrenia had smaller bilateral hippocampal tail subfields (corrected p < 0.05).

Conclusion:

Our results indicated that the pathophysiology and symptomatic remission of schizophrenia are related to changes in the volumes of hippocampal subdivisions. These volume changes might be clinically relevant as biomarkers for schizophrenia identification and treatment.
Wallenberg syndrome associated with hysteria: A case report
Authors: Li Xue
Published: April 2024

Rationale:

Wallenberg syndrome, also referred to as posterior inferior cerebellar artery syndrome, represents the most prevalent form of bulbar syndrome and typically arises from occlusion of the posterior inferior cerebellar artery or its perforator artery. This vascular impairment can result in profound dysphagia, significantly compromising both survival time and quality of life for stroke survivors. Managing swallowing disorders associated with Wallenberg syndrome alone poses considerable challenges, while diagnosing and treating complex swallowing disorders stemming from other etiologies present formidable obstacles for clinicians and rehabilitation therapists alike. Naturally, such intricate swallowing disorders are infrequently encountered in clinical practice.

Patient concerns:

The dysphagia experienced by a 60-year-old Asian male with right medulla infarction was severe, rendering him unable to swallow any food or saliva. However, unlike typical bulbar palsy patients, these individuals exhibit functional dysphagia disorders in addition to neurodysphagia. Notably, there is no damage observed in the brain’s cognitive areas; however, evident cognitive impairment related to swallowing is present.

Diagnosis:

Swallowing disorders associated with Wallenberg syndrome, in conjunction with swallowing hysteria syndrome, were examined.

Interventions:

Cognitive training incorporating mirror swallowing techniques, high‐intensity electrical stimulation, and balloon expansion therapy.

Outcomes:

Following treatment, the patient swiftly regained normal swallowing function within a span of 21 days, and this functionality was sustained during the six-month follow-up period.

Lessons:

Wallenberg syndrome frequently presents with severe dysphagia, characterized by complex and debilitating symptoms, resulting in a poor prognosis. Due to the prolonged requirement of nasogastric feeding even after treatment, alternative etiologies for dysphagia are often overlooked. Isolated hysterical swallowing syndrome is relatively uncommon in clinical practice, particularly when coexisting with Wallenberg syndrome; however, fortunately, it exhibits a more favorable recovery outcome. The objective of this case report is to prompt clinicians and rehabilitation therapists to consider other potential causes of swallowing disorders in patients with Wallenberg syndrome when conventional treatments prove ineffective, thereby enhancing the rehabilitative outcomes for these individuals.
Over-the-counter access to hormonal contraception: a global perspective
Authors: Otto Alana K. , Klein David A. , Lau May , Dhar Cherie P. , Hwang Loris Y.
Published: April 2024

Purpose of review

Oral contraceptive pills are among the most popular contraceptives worldwide, including among adolescents, and are available over the counter in over 100 countries. However, when a prescription is required, oral contraceptives may be difficult to obtain, particularly for adolescents. Recent approvals of over-the-counter progestin-only pills in the United Kingdom and United States have brought widespread attention to this topic.

Recent findings

Progestin-only pills, including the norgestrel pill recently approved for over-the-counter use in the United States, are highly effective and may be used safely without a prescription or medical monitoring, including by adolescents. These pills are associated with relatively high user satisfaction. Although over-the-counter availability may improve contraceptive access overall, issues related to insurance coverage and out-of-pocket cost may continue to pose practical barriers to access for many individuals.

Over-the-counter oral contraceptives are an appropriate and important contraceptive option for many adolescents. Over-the-counter availability has the potential to increase access to safe and effective contraception in the United States, United Kingdom, and other countries where a prescription is currently required. Future research on use patterns among adolescents is needed, as are advocacy efforts and policies to ensure access and affordability.
Disordered eating in adolescents with type 1 diabetes: risk factors and screening recommendations
Authors: Chad-Friedman Emma , Clary Lauren , Jhe Grace
Published: April 2024

Purpose of review

Adolescents with Type 1 diabetes (T1D) are at significantly greater risk for disordered eating behaviors compared to their peers without T1D. Given that this is a dangerous and potentially lethal combination, this review aims to support pediatric medical providers in increasing competence in identification, assessment, and prevention of disordered eating behaviors in adolescents with T1D.

Recent findings

This review provides an up-to-date synthesis of unique risk factors for disordered eating behaviors in adolescents with T1D, including the daily diabetes management tasks, effects of insulin on weight and hunger, family conflict, and reinforcement from their environment for disordered behaviors. This review recommends two brief screening tools, the Diabetes Eating Problems Survey-Revised (DEPS-R) and Modified SCOFF (mSCOFF), to be used in busy practices; it also provides practical strategies for providers

to use with patients in the form of effective, nonjudgmental language.

A clear understanding of unique experiences impacting adolescents with T1D may increase use of evidence-based screening tools and identification of disordered eating behaviors among a high-risk population in clinic/practice. In addition, providers’ intentional use of nonjudgmental and de-stigmatizing language may lead to more positive interactions for adolescents and willingness to engage in further treatment.
Right anatomical hepatectomy using extrahepatic glissonean pedicle approach combined liver hanging for hepatocellular carcinoma: surgical approach in a developing country
Authors: Pham Anh T. , Truong Cuong M. , Trinh Phuong H. , Thi Nguyen Chinh , Pham My H. , Dang Quoc H.
Published: April 2024

Backgrounds/aims:

To evaluate the outcomes of hepatocellular carcinoma (HCC) patients who underwent right anatomical hepatectomy using the combination of the extrahepatic Glissonean pedicle approach (Takasaki’s technique) and liver hanging maneuver (LHM) (Belghiti’s technique).

Patients and methods:

A retrospective analysis of 30 cases of HCC treated with right hepatectomy using extrahepatic Glissonean pedicle approach and LHM by only one surgeon at our department from March 2020 to August 2023. Clinical characteristics, pathological results, postoperative outcomes, and survival rate were analyzed.

Results:

Among the 30 HCC patients analyzed, males accounted for 96.7% of patients. The mean age was 54.9±11 years. 96.7% had normal preoperative liver function (Child-Pugh A). LHM with an extrahepatic Glissonean approach was feasible in 100% of cases with minor blood loss, no blood transfusion, intraoperative complications, or perioperative mortality. The mean operative time was 123.8±29.0 min. The mean hospital stay was 9.37±4.02 days. Postoperative liver failure accounted for 6.7%. Pathological results: 63.3% moderately differentiated HCC; 36.7% poorly differentiated HCC. 1-year, 2-year, and 3-year survival rates were 86.1, 73.8, and 59.0%, respectively. Recurrence was witnessed in 13 (43.3%) cases, with 6 (20%) cases in remnant liver. 1-year, 2-year, and 3-year disease-free survival were 69.3, 42.0, and 28.0%, respectively.

Conclusion:

Right anatomical hepatectomy using extrahepatic Glissonean pedicle approach combined LHM for HCC was feasible and safe at our high-volume oncology center in a developing country.
Combining Critical Ethnography and Critical Discourse Analysis in Mental Health Nursing Research
Authors: Jager Fiona , Domingue Jean-Laurent , Perron Amélie , Jacob Jean Daniel
Published: April 2024

Background

It is uncommon to combine critical ethnography with critical discourse analysis (CDA) in health research, yet this combination has promise for managing challenges inherent in critical mental health nursing research.

Objectives

This article describes a methodologically innovative way to address issues that arise in the context of critical mental health nursing research

Methods

This article draws on two studies that each employed a combination of critical ethnography and CDA in the context of mental health nursing research, discussing the challenges and implications of this approach.

Results

Although the combination critical ethnography and CDA presents several challenges, it also provides a framework for researchers to sustain a critically reflective stance throughout the research process. This facilitates the process of reanalyzing and reflecting on how healthcare practices and knowledge both support and are constrained by hegemonic discourses.

Discussion

This combination has the potential to facilitate the production of new, emancipatory knowledge that will assist nurses in understanding issues of structural inequity within the healthcare system.
The Impact of Environmental and Occupational Noise on Maternal and Perinatal Pregnancy Outcomes
Authors: Ulin Mara , Edokobi Nneoma , Ganjineh Brandon , Magann Everett F. , Whitham Megan D.
Published: April 2024

Importance

Pregnant women are exposed to both occupational and environmental noise during their pregnancy. The association between noise and adverse health outcomes is well known. Less is known about the relationship between noise and its effects on the embryo/fetus and pregnancy.

Objectives

The purpose of the study is to review what is known about the effect(s) of environment and occupational noise during pregnancy on maternal and perinatal outcomes.

Evidence Acquisition

Electronic databases (PubMed, CINAHL, and Embase) were searched from 1995–2023 with the only limitation being that the articles were in English. Studies were selected that examined associations between environmental and occupational noise and pregnancy outcome, maternal outcome, or perinatal outcome.

Results

There were 233 articles identified. After reviewing all abstracts and selected full texts, 25 publications were used as the basis of this review. Multiple studies have been undertaken evaluating the effects of noise on embryonal/fetal growth, fetal development, maternal hypertension, gestational diabetes, and maternal anxiety and depression. The overall effects of occupational and environmental exposure on both fetal and maternal outcomes remain uncertain.

Conclusions

Further high-quality studies are needed to determine the association between noise and pregnancy outcomes.

Relevance

Even though this review suggests a relationship between noise and maternal/fetal outcomes, confirmation will require well designed future studies.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this learning activity, the participant should be able to explain how sound is measured, the thresholds of sound in children and adults, and exposure levels that result in hearing loss; describe the effects of exposure to noise during pregnancy and its effects on adverse pregnancy outcomes; and discuss the effects of environmental and occupational noise on the developing embryo/fetus.