bluuebunny/crossref_metadata_2025_split huggingface dataset:
E091 Improving recognition and referrals for axial spondyloarthritis in primary care
Authors: Hamilton Daniel 
Published: April 2023

Abstract

Background/Aims
It is estimated there is an 8.5-year delay from onset of symptoms to diagnosis of axial spondyloarthritis. The condition is poorly recognised in the United Kingdom. An audit of a general practice with 7,500 patients revealed only 7 patients living with the diagnosis, of which only 2 were diagnosed before the age of 45. Estimates suggest this figure should be closer to 35 to 40. In the 12 months prior to the audit, only 2 referrals were sent to rheumatology suspecting axial spondyloarthritis. The short-term aim of this study was to improve the recognition and referrals for axial spondyloarthritis in primary care from 2 per year to 15. The long-term goal is to increase the number of patients living with the diagnosis from 7 to 37.

Methods
EMIS alerts and pop-ups were created for patients, aged 20-45, presenting with “low back pain” or a similar coding to increase clinicians' clinical suspicion index. The alerts and pops included a hyperlink to the SPADE tool to facilitate reasoning. This was consolidated with an education webinar to refresh General Practitioners and Advanced Nurse Practitioners on the diagnostic criteria for axial spondyloarthritis.

Results
Following implementation of alerts and hyperlinks to the SPADE tool, general practitioners' confidence and knowledge of knowing when to suspect, assess and refer axial spondyloarthritis increased from 1.9, 1.7 and 2 to 4.8, 4.4 and 4.2 on a 5 point self-rated Likert scale. In the 12 months following the intervention, number of referrals had increased from 2 per year to 11.

Conclusion
This study has highlighted various findings. It has highlighted an insufficient number of referrals to rheumatology suspecting axial spondyloarthritis in order to maintain the suspected population of a general practice. This is likely linked to poor awareness and screening of the condition. It has also highlighted that clinicians in primary care respond positively to training for knowing when to suspect, assess and refer on for axial spondyloarthritis. However, this only measured a short-term change in knowledge and further testing is required to assess long term change. Furthermore, combined with education and the use of pop up and alerts has increased the awareness and referrals for axial spondyloarthritis from primary to secondary care. Future audits are required in the long term to assess for success in the long term goal.
Disclosure
D. Hamilton: None.
E094 Challenges in the diagnosis and investigation of giant cell arteritis during COVID-19 pandemic restrictions: does the Southend pretest probability score help to guide clinical diagnosis?
Authors: Gew Jessie , Loughrey Sarah , Wray Maria 
Published: April 2023

Abstract

Background/Aims
During 2020-2021 many usual hospital services were affected as focus turned towards managing COVID-19. Elective outpatient surgery ceased and rheumatology staff were redeployed to covid wards. This reduced the availability of temporal artery biopsy (TAB) and temporal artery ultrasound (TAUS) to aid in diagnosing giant cell arteritis (GCA). The rheumatology team making diagnoses of GCA or not-GCA were doing so often based entirely on clinical and laboratory findings. We aimed to determine referral patterns and investigations for suspected GCA during the covid pandemic, compare diagnoses at 6 months after initial assessment and retrospectively apply the Southend Pretest Probability Score (PTPS) and correlate with the diagnosis of GCA or not-GCA.

Methods
We reviewed all electronic referrals for suspected GCA from July 2020 - June 2021. Clinical details and investigations reviewed. PTPS applied giving a result of low, intermediate or high probability of GCA.

Results
84 referrals for suspected GCA over 12 months. 20 diagnosed GCA/large vessel vasculitis (LVV), 64 not-GCA. Peak referral months Nov 2020 and April 2021 with 13 and 16 referrals. Lowest in October 2020 with 1 referral. 57 female, 27 male. Mean age 70.1 years. 19% male referrals diagnosed GCA, 26% female diagnosed GCA. All LVV and PMR diagnoses were female. 27 TAUS, 6 TAB, 7 PET, 13 CT, 3 MRI performed. 30 patients had no additional investigations. Of 20 GCA; 14 had supporting investigations, 6 were clinical diagnoses. All GCA diagnoses were consistent at 6 months. One not-GCA case was subsequently diagnosed with LVV on CTPET. All other not-GCA diagnoses were consistent at 6 months. The PTPS was retrospectively applied based on available clinical information in all except 2 cases, and compared to GCA/not-GCA diagnosis and investigations undertaken.

Conclusion
Referral numbers for suspected GCA were higher than previous years however the number of actual GCA diagnoses was similar. With limitations on diagnostic investigations due to covid, diagnoses of GCA with and without additional tests were accurate at 6 months, and correlated with a high probability score. The PTPS is a therefore valuable clinical tool in the assessment of GCA.
Disclosure
J. Gew: None. S. Loughrey: None. M. Wray: Honoraria; M.W. has received honoraria from Roche- Chugai, Novartis.
Duloxetine, Gabapentin, and the Risk for Acute Myocardial Infarction, Stroke, and Out-of-Hospital Death in Medicare Beneficiaries With Non-Cancer Pain
Authors: Corriere Meghan A. , Dickson Alyson L. , Daniel Laura L. , Nepal Puran , Hall Kathi , Plummer W. Dale , Dupont William D. , Murray Katherine T. , Stein C. Michael , Ray Wayne A. , Chung Cecilia P. 
Published: April 2023

Objective:Duloxetine is a serotonin-norepinephrine reuptake inhibitor prescribed for musculoskeletal and other forms of chronic pain. Its dual pharmacologic properties have the potential to either raise or lower cardiovascular risk: adrenergic activity may increase the risk for acute myocardial infarction (AMI) and stroke, but antiplatelet activity may decrease risk. Gabapentin is another nonopioid medication used to treat pain, which is not thought to have adrenergic/antiplatelet effects. With the current emphasis on the use of nonopioid medications to treat patients with chronic pain, assessing cardiovascular risks associated with these medications among high-risk patients is important.Materials and Methods:We conducted a retrospective cohort study among a 20% sample of Medicare enrollees, aged 65 to 89, with chronic pain who were new users between 2015 and 2018 of either duloxetine (n = 34,009) or gabapentin (n = 233,060). We excluded individuals with cancer or other life-threatening conditions at study drug initiation. The primary outcome was a composite of AMI, stroke, and out-of-hospital mortality. We adjusted for comorbidity differences with time-dependent inverse probability of treatment weighting.Results:During 115,668 person-years of follow-up, 2361 patients had the composite primary outcome; the rate among new users of duloxetine was 16.7/1000 person-years compared with new users of gabapentin (21.1/1000 person-years), adjusted hazard ratio = 0.98 (95% CI: 0.83, 1.16). Results were similar for the individual components of the composite outcome as well as in analyses stratified by demographic and clinical characteristics.Discussion:In summary, cohort Medicare patients with non-cancer pain beginning treatment with duloxetine had rates of AMI, stroke, and out-of-hospital mortality comparable to those who initiated gabapentin.
The Telehealth Tradeoff
Authors: Bento Samantha P. , Stewart Catherine , Conroy Caitlin , Smith Allison , Reece Leah , Jervis Kelsey , Cole-Lewis Yasmin , Logan Deirdre , Randall Edin T. 
Published: April 2023

Objectives:
The COVID-19 pandemic required intensive interdisciplinary pain treatment (IIPT) programs to shift to virtual models of care. This study used a multimethod approach to examine outcomes of a pediatric hybrid IIPT program (50% in-person treatment and 50% synchronous video-based telehealth) and assessed staff experiences while treating within this model.

Materials and Methods:
Patients (M=14.73, SD=2.04; 79% female) reported pain intensity, functional disability, and psychological factors (anxiety, depressive symptoms, fear of pain, pain catastrophizing, social functioning) at admission, discharge, and short-term follow-up. Differences in treatment outcomes at discharge and short-term follow-up between patients who participated in the hybrid IIPT model (n=42) during the pandemic and those who participated in the traditional in-person model before the pandemic (n=42) were examined. Quantitative assessments of staff burnout and perceived effort and qualitative assessments exploring staff perspectives about the challenges and advantages of the hybrid IIPT model were gathered.

Results:
Youth in both groups made significant improvements across the majority of treatment outcomes; however, the hybrid group reported higher levels of pain at discharge and anxiety at follow-up. The majority of IIPT staff reported moderate to high levels of overall burnout, and almost half reported high levels of emotional exhaustion. Staff highlighted various challenges and benefits associated with treating within the hybrid model.

Discussion:
When considering telehealth as a treatment tool for youth with complex chronic pain, it is crucial to leverage its benefits while addressing its challenges for patients and providers.
Implementing Pediatric Surviving Sepsis Campaign Guidelines: Improving Compliance With Lactate Measurement in the PICU
Authors: Mazloom Anisha , Sears Stacey M. , Carlton Erin F. , Bates Katherine E. , Flori Heidi R. 
Published: April 2023

OBJECTIVES:
The 2020 pediatric Surviving Sepsis Campaign (pSSC) recommends measuring lactate during the first hour of resuscitation for severe sepsis/shock. We aimed to improve compliance with this recommendation for patients who develop severe sepsis/shock while admitted to the PICU.

DESIGN:
Structured, quality improvement initiative.

SETTING:
Single-center, 26-bed, quaternary-care PICU.

PATIENTS:
All patients with PICU-onset severe sepsis/shock from December 2018 to December 2021.

INTERVENTIONS:
Creation of a multidisciplinary local sepsis improvement team, education program targeting frontline providers (nurse practitioners, resident physicians), and peer-to-peer nursing education program with feedback to key stakeholders.

MEASUREMENTS AND MAIN RESULTS:
The primary outcome measure was compliance with obtaining a lactate measurement within 60 minutes of the onset of severe sepsis/shock originating in our PICU using a local Improving Pediatric Sepsis Outcomes database and definitions. The process measure was time to first lactate measurement. Secondary outcomes included number of IV antibiotic days, number of vasoactive days, number of ICU days, and number of ventilator days. A total of 166 unique PICU-onset severe sepsis/shock events and 156 unique patients were included. One year after implementation of our first interventions with subsequent Plan-Do-Study-Act cycles, overall compliance increased from 38% to 47% (24% improvement) and time to first lactate decreased from 175 to 94 minutes (46% improvement). Using a statistical process control I chart, the preshift mean for time to first lactate measurement was noted to be 179 minutes and the postshift mean was noted to be 81 minutes demonstrating a 55% improvement.

CONCLUSIONS:
This multidisciplinary approach led to improvement in time to first lactate measurement, an important step toward attaining our target of lactate measurement within 60 minutes of septic shock identification. Improving compliance is necessary for understanding implications of the 2020 pSSC guidelines on sepsis morbidity and mortality.
The Role of Excision for Treatment of Chromoblastomycosis: A Cutaneous Fungal Infection Frequently Mistaken for Squamous Cell Carcinoma
Authors: Rolon Alyssa M. , Tolaymat Leila M. , Sokumbi Olayemi , Bodiford Katherine 
Published: April 2023

BACKGROUND
Chromoblastomycosis is an uncommon fungal infection of the skin caused by a variety of dematiaceous fungal species that is typically contracted through direct inoculation into the skin.

OBJECTIVE
To collect and examine data pertaining to the clinical presentation and management of patients with chromoblastomycosis.

METHODS
Through a retrospective study, a pathology medical record search was performed from January 2004 to December 2020 at a single institution.

RESULTS
A total of 9 patients were identified. Seven of 9 cases occurred in solid organ transplant recipients. All cases were located on the extremities. Six of 9 cases were clinically suspected to be squamous cell carcinoma. Seven of 9 cases were treated with surgical excision. Six of 9 patients were treated with oral antifungal medication. Four of 9 patients had received combination therapy. Eight of 9 patients had no recurrence of the disease after treatment.

CONCLUSION
Chromoblastomycosis presents as verrucous papules or nodules and may clinically and histopathologically mimic squamous cell carcinoma. Immunosuppression is likely a risk factor for the development of chromoblastomycosis. This study highlights the importance of clinical awareness of this disease's clinical presentation and prevalence in immunosuppressed patient populations.
Superficial Peroneal Nerve Schwannoma
Authors: Abebe Metasebia W. , Weldemicheal Hanna A. 
Published: April 2023

Summary:
Schwannomas are benign tumors of the nerve sheath that arise from the proliferation of active peripheral Schwann cells. Although schwannomas are the most common benign peripheral nerve sheath tumors, superficial peroneal nerve schwannomas are rare in published works of literature. We report a 45-year-old woman with a 4-year history of progressively worsening dull aching pain and paresthesia over the right lateral leg. Physical examination revealed a 4 × 3 cm firm palpable mass and a decreased touch and pain sensation over the lateral aspect of the right calf and dorsum of the foot. She also had an electric shock-like pain on palpation and percussion of the mass. Magnetic resonance imaging demonstrated a well-defined, oval, smooth-walled heterogeneous lesion beneath the peroneus muscle with avid postcontrast enhancement and a split fat sign. Fine needle aspiration cytology also suggested the diagnosis of schwannoma. Based on clinical findings of a mass, decreased sensation, and a positive Tinel sign on the dermatome of superficial peroneal nerve, surgical management was decided. Upon surgical exploration, a firm, glistening mass arising from the superficial peroneal nerve was identified, carefully dissected, and shelled out while maintaining continuity of the nerve. At the 5-month follow-up, the patient reported complete resolution of the pain and paresthesia. Physical examination revealed intact sensation in the lower lateral aspect of the right calf and dorsum of the foot. Therefore, surgical excision should be considered a reasonable option in the management of this rare condition, with most patients achieving good to excellent results.
Hallermann–Streiff Syndrome in Concordant Monozygotic Twins With Congenital Cataracts, Exudative Retinal Detachments, and One Case of Corneal Perforation Requiring Keratoplasty
Authors: Sims Deion T. , Mattson Nicole R. , Huang Laura C. , Lee Michele D. , Bly Randall A. , Gallagher Emily R. , Baran Francine M. , Cabrera Michelle T. 
Published: April 2023

Purpose:
We describe the management of Hallermann–Streiff syndrome in monozygotic female twins with congenital cataracts, exudative retinal detachments, and 1 case of corneal descemetocele with associated dellen and subsequent perforation.

Methods:
This study was a case report and review of the literature.

Results:
Twins 1 and 2 exhibited all 7 cardinal characteristics of Hallermann–Streiff syndrome, presenting with spontaneous lenticular resorption, anterior uveitis, and glaucoma. They underwent bilateral cataract extraction with near total capsulectomy. Both twins experienced recurrent glaucoma, for which twin 1 underwent successful endocyclophotocoagulation in both eyes and twin 2 in the left eye alone. The fellow eye developed 2 sites of perilimbal corneal descemetoceles with associated dellen at the inferotemporal limbal corneal junction leading to spontaneous perforation of 1 site, requiring a full-thickness corneal graft. Both twins developed recurrent bilateral exudative retinal detachments unresponsive to oral prednisolone. Twin 1's last best-corrected visual acuity with aphakic spectacles was 20/260 in the right eye and 20/130 in the left eye at age 4 years and 8 months. Twin 2's last best-corrected visual acuity was 20/130 in each eye at age 4 years and 11 months, over a year after right eye penetrating keratoplasty.

Conclusions:
We describe 2 rare cases of Hallermann–Streiff syndrome in monozygotic twins complicated by corneal perforation requiring penetrating keratoplasty in 1 eye of 1 twin. Although corneal opacities have been described in this condition, this is the first case of corneal descemetocele in Hallermann–Streiff syndrome. The cornea was stabilized with a relatively favorable visual outcome over 1 year later.
Corneal Guttae After Descemet Membrane Endothelial Keratoplasty
Authors: Vasanthananthan Keamela , Bourgonje Vincent J. A. , Lie Jessica T. , Mulders-Al-Saady Rana , Groeneveld-van Beek Esther A. , de Leeuw Jacky , Miron Alina , Wijdh Robert H. J. , Stoutenbeek Remco , Melles Gerrit R. J. , Oellerich Silke , Kocaba Viridiana 
Published: April 2023

Purpose:
The aim of this study was to report on the occurrence of corneal guttae after Descemet membrane endothelial keratoplasty (DMEK).

Methods:
In this retrospective case series, 13 eyes of 13 patients who underwent DMEK at 2 tertiary referral centers between 2007 and 2021 (average available follow-up 73 ± 52 months, range 18–174 months) and showed corneal guttae during postoperative examinations were included. Eye bank images were retrospectively reviewed.

Results:
Occurrence of guttae was observed by specular microscopy in 13 eyes. In 11 cases, presence of guttae was confirmed by confocal microscopy and in 1 case by histology. Five eyes showed an increase in guttae density during the postoperative course. Surgery indications were Fuchs endothelial corneal dystrophy (n = 11), pseudophakic bullous keratopathy (n = 1), and DMEK graft failure after allograft rejection (n = 1); the latter eye had shown no signs of guttae after primary DMEK. Two eyes with guttae required a repeat DMEK due to graft failure. At the last available follow-up, all 11 remaining eyes had clear corneas and 10 eyes had a best-corrected visual acuity of ≥0.9 (decimal). During donor cornea processing in the eye bank, no guttae were observed on the donor tissue.

Conclusions:
Corneal guttae can occur after DMEK including in eyes operated for indications other than Fuchs endothelial corneal dystrophy and most likely guttae were present on the donor graft but were not detectable by routine slit-lamp and light microscopy evaluation in the eye bank. Postoperative guttae density varies among patients and especially small isolated guttae do not seem to affect clinical outcomes.
The Feasibility and Effects of Smartphone-Based Application on Cardiac Rehabilitation for Patients After Percutaneous Coronary Intervention
Authors: Lao Sarah Sio Wa , Chair Sek Ying , Wang Qun , Leong Mirian Lap Tong 
Published: April 2023

Background
Cardiac rehabilitation (CR) referral and participation are generally found to be underused worldwide. The data in Asian regions suggest significant underutilization compared with western countries.

Objectives
To promote the continuity and effects of CR, this study aimed at supporting self-care and improving CR effects in phase II CR with mobile health application for Macao patients who have undergone percutaneous coronary intervention.

Methods
The study was a randomized controlled trial conducted between January 2018 and June 2020 in a nongovernmental Hospital. Social cognitive theory was applied in the intervention for an experimental group. Measurements including anxiety and depression level, medication adherence, exercise capacity, physical activity level, cardiovascular risk modification, self-efficacy, quality of life, use of healthcare resources, mHealth CR utility, and satisfaction were analyzed.

Results
One hundred forty eligible patients were recruited, and 110 patients completed the study. Significant interventional effects of the experimental group were found on the reduction of total cholesterol, low-density lipoprotein, sitting time, anxiety level, and total anxiety and depression level (P < .05). In addition, significant improvement on the 6-minute walk test, regular exercise performance, self-efficacy of cardiac exercise and diet, and quality of life were found as interventional effects in the experimental group (P < .05). The feasibility of intervention was achieved in a satisfactory level.

Conclusions
This theoretically grounded mobile health CR study was a unique program tailor-made to meet the care needs of patients post percutaneous coronary intervention. It was feasible and effective to support CR effects and adherence and would inform further design of clinical practice and public policies.
The Mediating Role of Sleep Quality in the Association Between Negative Affect and Cognitive Function Among Patients With Nasopharyngeal Carcinoma After Intensity-Modulated Radiotherapy
Authors: Chen Ximei , Fan Yuying , Yan Minghui , Zhang Jun-e 
Published: April 2023

Background
Cognitive function impairment is a severe yet largely unrecognized adverse reaction among patients with nasopharyngeal carcinoma (NPC) following radiotherapy.

Objectives
The aims of this study were to examine the level of cognitive function, explore the influencing factors of the cognitive function of NPC after intensity-modulated radiotherapy (IMRT), and identify the mediating role of sleep quality between negative affect and cognitive function.

Methods
In total, 200 patients with NPC after IMRT were recruited from a tertiary cancer center in Southern China between September 2020 and March 2021. Participants completed the demographic and disease-related questionnaire, Montreal Cognitive Assessment Scale, Profile of Mood States–Short Form, and Pittsburgh Sleep Quality Index.

Results
The mean Montreal Cognitive Assessment Scale scores were 24.42 after adjustment, with 54.5% of patients having cognitive function impairment. Education level, income, seeking rehabilitation knowledge, radiation dose, sleep quality, and negative affect entered the final regression model and explained 82.6% of cognitive function variance. The total and direct effects of negative affect and indirect effects via sleep quality on cognitive function were significant (P < .05).

Conclusions
Clinicians should pay close attention to patients with poor educational levels, low income, and having difficulties seeking rehabilitation knowledge and patients who accept higher radiation doses. Improving their sleep quality and positive affect may contribute to preventing or reducing cognitive function impairment.

Implications for Practice
Clinical nurses should pay more attention to cognitive function among NPC patients after IMRT and take effective measures or interventions to prevent and reduce their cognitive function impairment.