Patient exposure dose in interventional cardiology per clinical and technical complexity levels. Part 1: results of the VERIDIC project

Background Patients can be exposed to high skin doses during complex interventional cardiology (IC) procedures. Purpose To identify which clinical and technical parameters affect patient exposure and peak skin dose (PSD) and to establish dose reference levels (DRL) per clinical complexity level in IC procedures. Material and Methods Validation and Estimation of Radiation skin Dose in Interventional Cardiology (VERIDIC) project analyzed prospectively collected patient data from eight European countries and 12 hospitals where percutaneous coronary intervention (PCI), chronic total occlusion PCI (CTO), and transcatheter aortic valve implantation (TAVI) procedures were performed. A total of 62 clinical complexity parameters and 31 technical parameters were collected, univariate regressions were performed to identify those parameters affecting patient exposure and define DRL accordingly. Results Patient exposure as well as clinical and technical parameters were collected for a total of 534 PCI, 219 CTO, and 209 TAVI. For PCI procedures, body mass index (BMI), number of stents ≥2, and total stent length >28 mm were the most prominent clinical parameters, which increased the PSD value. For CTO, these were total stent length >57 mm, BMI, and previous anterograde or retrograde technique that failed in the same session. For TAVI, these were male sex, BMI, and number of diseased vessels. DRL values for Kerma-area product ( PKA), air kerma at patient entrance reference point ( Ka,r), fluoroscopy time (FT), and PSD were stratified, respectively, for 14 clinical parameters in PCI, 10 in CTO, and four in TAVI. Conclusion Prior knowledge of the key factors influencing the PSD will help optimize patient radiation protection in IC.

Medicine-Based Evidence in Congenital Heart Disease: How Artificial Intelligence Can Guide Treatment Decisions for Individual Patients

Built on the foundation of the randomized controlled trial (RCT), Evidence Based Medicine (EBM) is at its best when optimizing outcomes for homogeneous cohorts of patients like those participating in an RCT. Its weakness is a failure to resolve a clinical quandary: patients appear for care individually, each may differ in important ways from an RCT cohort, and the physician will wonder each time if following EBM will provide best guidance for this unique patient. In an effort to overcome this weakness, and promote higher quality care through a more personalized approach, a new framework has been proposed: Medicine-Based Evidence (MBE). In this approach, big data and deep learning techniques are embraced to interrogate treatment responses among patients in real-world clinical practice. Such statistical models are then integrated with mechanistic disease models to construct a “digital twin,” which serves as the real-time digital counterpart of a patient. MBE is thereby capable of dynamically modeling the effects of various treatment decisions in the context of an individual's specific characteristics. In this article, we discuss how MBE could benefit patients with congenital heart disease, a field where RCTs are difficult to conduct and often fail to provide definitive solutions because of a small number of subjects, their clinical complexity, and heterogeneity. We will also highlight the challenges that must be addressed before MBE can be embraced in clinical practice and its full potential can be realized.

Global Unbiased Determination Of Comorbidity (GUDC) In U.S. Older Adults

With age, many adults develop multiple comorbid conditions; and resulting clinical complexity increases markedly so that identifying how specific conditions effect others remains important. Here, our primary objective was rapid unbiased appraisal of pair-wise condition-specific comorbidity; our second objective was identification of common conditions with highest and lowest rates of such comorbidity. In 2016, utilization of ICD-10 codes became mandatory for providers rendering care to Medicare beneficiaries. Universal adoption of ICD-10 coding ensued and concomitantly, all patients had ICD-9 codes replaced with new codes, so that 2017 data represent an opportunity to examine massive amounts of ‘freshly’ coded patient claims data. Evaluating ICD-10 coding data at individual and population levels, we appraised how often two codes were utilized together, i.e. estimated pair-specific comorbidity. Expanding this computationally, we determined the extent to which any given condition was co-coded with all other utilized diagnostic codes, i.e., estimated global, unbiased pair-wise comorbidity. We term this metric the global unbiased dyadic comorbidity (GUDC) value. Based on 40 million claims for a representative sample of 1.5 million older adults across the U.S., GUDC values varied with age and gender but were highly stable across varying comorbid condition prevalence, e.g., common (>1%) vs. less common (1/1000-1/100) prevalence. GUDC values for HIV in older adults were modest, compared to high values for ARDS, we infer substantive progress in HIV management among older adults. We discuss the interpretation and potential applications of GUDC and conclude that access to comorbidity appraisals may advance geriatric care, more study is needed.

Eating Disorders and Type 1 Diabetes: a perspective

: Patients with type 1 diabetes (T1D) are at risk of clinical eating disorders (EDs) and disordered eating behaviors (DEBs) than the general population. This burden is related mainly to diabetes-related physical and psychosocial issues especially beginning during childhood. DEBs must be investigated carefully and promptly managed in case of suspicion, as they can evolve into severe clinical EDs over time and are strictly related to poor outcomes. The significant number of scientific articles dealing with the relationship between T1D and DEBs or EDs confirms the complexity of these problems and the difficulties in diagnosis and treatment. This paper examined current scientific literature related to this topic, emphasizing the epidemiological and clinical complexity of the phenomenon and briefly summarizing EDBs management strategy in T1D patients.

Management of Patients with Nonmetastatic Castration-Resistant Prostate Cancer: Recommendations of a Multidisciplinary Panel of Experts from South America

Most prostate cancer patients who undergo androgen-deprivation therapy or orchiectomy will eventually develop castration-resistant prostate cancer (CRPC), often preceded by a nonmetastatic CRPC state known as M0CRPC. The recent development of second-generation antiandrogens provides clinicians with efficacious and safe treatments for M0CRPC. However, the complexity of these patients, who typically have to deal with underlying comorbidities and polypharmacy, often challenges therapeutic decisions in this setting. The recent development of novel imaging techniques also provides clinicians with tools for detecting metastases with high sensitivity and specificity. However, the lack of evidence on the early detection of metastases and the corresponding impact on therapeutic decisions makes these techniques a double-edged sword that must be managed appropriately. Here, we present the expert view of the rapidly evolving concept of M0CRPC and provide recommendations for the identification of these patients, the appropriate use of the emerging imaging modalities, and patients’ management, particularly considering their clinical complexity and the recent development of next-generation antiandrogens.

Single sitting multimodality management of hemorrhoid

Background: It is usual to face clinical complexity in piles patients. They usually present with variable number of pile masses and in different grades of progression. This led to the idea of offering concomitant single stage management in our hemorrhoid patients matching to our criteria. We conducted hospital based descriptive study among the patients coming to my clinical practice falling in grade-1-3.Methods: All the patients falling in grade-1-3 and matching to our criteria were included. The study was conducted from January 2012 to December 2020. Place of study was basically at two centres: Karamdeep medical centre, Kanpur and Mayo health care, Mohali. Total number of patients were 581. Patients having grade-4 piles and with local co-morbidities were excluded from the study. Modalities of treatment used were sclerotherapy, band ligation and hemorrhoidectomy.Results: Patients managed were divided into four groups – group 1 included patients with piles in grade-1; group-2 included patients having piles in grade-1 and 2; group-3 included patients having piles in grade-1 and 3; and group-4 included patients having piles in grade-1, 2 and 3. Total 952 pile masses were treated in 581 patients. Sclerotherapy was required in 732 (77%) masses, banding in 99 (10.3%) masses and surgery in 122 (12.7%) masses.Conclusions: Concomitant treatment policy proved to be comprehensive way to tackle pile patients of grade-1-3. Mixed and matched method using surgical and non-surgical modalities in a single sitting proved to be beneficial. 86.4% cases were cured this way. Cost of the treatment was economical with lesser complications including local mutilation and better quality of life.

Clinical Characteristics of Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like Episodes

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes(MELAS)syndrome, a maternally inherited mitochondrial disorder, is characterized by its genetic, biochemical and clinical complexity. The most common mutation associated with MELAS syndrome is the mtDNA A3243G mutation in the MT-TL1 gene encoding the mitochondrial tRNA-leu(UUR), which results in impaired mitochondrial translation and protein synthesis involving the mitochondrial electron transport chain complex subunits, leading to impaired mitochondrial energy production. Angiopathy, either alone or in combination with nitric oxide (NO) deficiency, further contributes to multi-organ involvement in MELAS syndrome. Management for MELAS syndrome is amostly symptomatic multidisciplinary approach. In this article, we review the clinical presentations, pathogenic mechanisms and options for management of MELAS syndrome.

Rehabilitation in post-COVID patients. A single center experience

The COVID 19 disease is frequently associated with significant disability related to intensive care unit-acquired weakness, decontitioning, myopathies and neuropathies. However there are no data on the results of a specific rehabilitative treatment in this group of patients. The aim of our work was to evaluate the effectiveness f a personalized rehabilitative therapy in group of post-COVID patients (A, 47 patients, average age 65.3±11.6 y, 27 M,) comparing the results with a group of post-cardiosurgical patients COVID 19 negative (B, 47 patients, average age 63.5±10.3 y, 29 M) evaluating the degree of clinical complexity (Rehabilitation Complexity Scale, RCS-E V13) and the degree of autonomy recovery (Six-minute walking test SMWT, Barthel Index, BI) pre and post-treatment. In Group A patients the Rehabilitation program is associated with a significant improvement in autonomy recovery (BI admission 29.7±20 vs discharge 72.7±28.6 p<0.005, SMWT admission 146±25 vs 318±18 m, p<0.005) and in clinical complexity (RCS admission 10.9±1.1 vs discharge 5.3, p<0.05). At admission the comparison between Group A vs B has show: 1. a reduced pre-rehabilitation hospital stay (days) in Group Vs A (B 8.2±2 vs 31±5 0.005) 2. a similar degrre of clinical complexity (RCS scale A 10.9±1.1 vs 1.6±11.2 p ns) 3. a greater loss autonomy in post-COVID patients (BI scale A 29.7±20 vs B 47.7±19, p 0.05; SMWT A 145±25 m vs B 255±18 m, p 0.05) After a similar period of rehabilitation (A 29.7±12.8 days vs B 29.6±10 days, p ns) we observed in both Groups: 1. a reduction of clinical complexity ((RCS scale A 5.3±2 vs 6.6±2 p ns 2. an improvement of degree of autonomy recovery ((BI scale A 72.7±28 vs B 47.7±19, p ns; SMWT A 385±18 m vs B 410±25m, p ns) Conclusions Post-COVID patients show a greater loss of autonomy than post-cardiosurgery patients. Rehabilitative treatment has proven effective in ensuring adequate functional recovery with similar results to those obtained in the population of cardiological subjects COVID 19 negative. FUNDunding Acknowledgement Type of funding sources: None.

‘Capable of being in uncertainties’: applied medical humanities in undergraduate medical education

Numerous medical schools have been updating and modernising their undergraduate curricula in response to the changing health needs of today’s society and the updated General Medical Council competencies required for qualification. The humanities are sometimes seen as a way of addressing both of these requirements. Medical humanities advocates would argue that the humanities have a vital role to play in undergraduate medical education, allowing students to develop the critical tools required by the 21st-century clinician to deliver the best person-centred care. While we endorse this view, we contend that such training must be taught authentically to have maximal impact. This article arises from a collaboration between Imperial College London and Birkbeck, University of London, which aimed to embed the humanities into Imperial’s undergraduate medical curriculum. Here, we use a teaching session on graphic medicine and narrative as a case study to illustrate how the humanities can be a powerful tool for students to explore professional clinical complexity and uncertainty when taught in a transdisciplinary way. In this session, uncertainty operated on several different levels: the introduction of unfamiliar concepts, materials, and methods to students, transdisciplinary approaches to teaching, and the complexities of real-life clinical practice. Further, we argue that to manage uncertainty, medical students must cross from a scientific training based on positivist understandings of evidence and knowledge, to one which foregrounds multiplicity, nuance, interpretive critical thinking, and which understands knowledge as contingent and contextually produced. In facilitating such learning, it is crucial that the teaching team includes experts from both medical and humanities fields to scaffold student learning in an intellectually dynamic way, drawing on their disciplinary knowledge and wide range of personal professional experiences.

1390Utilisation of hospital Services during COVID 19 Pandemic in New Zealand

Background Many factors have impacted the use of hospital services during the COVID-19 pandemic. This work described the volume and pattern changes of emergency department (ED) and inpatient admissions during earlier pandemic period in New Zealand in 2020. Methods ED and inpatient admissions during the pandemic period were compared with the figures and characteristics in the same time period in the previous years Results Over the period, ED and inpatient admissions decreased by 25 and 20 percent respectively. Remarkable declines of 41% in ED and 40% in inpatient were observed during the alert level 4 lockdown period. In the ED admissions, the degree of the decline was higher in less urgent presentations (triage levels 4 and 5), young patients (aged 0-24 years) and the patients without long term conditions. In the inpatient admissions, the degree of the decline was higher in the patients with lower level of inpatient clinical complexity, young patients and the admissions of respiratory diseases (especially influenza), viral infections, and injuries due to traffic and sport accident. In contrast, some hospitalisations increased during the period, including alcohol-related ED presentations, bacterial infections and injuries related to falls and assault occurred in home. Conclusions The changes in hospitalisation utilisation are likely associated with the changes in people’s behaviour in seeking health services, in behaviours of health risk or protective factors, and the changes in healthcare provided to the population during the period. Key messages The results provide insights for further assessment of health needs and health services.