Reducing patients' rate of frequent attendance through a training intervention for physicians.

BACKGROUND: Frequent attendance is a common issue for primary care health centres. The phenomenon affects the quality of care, increases doctors' workloads and can lead to burnout.This study presents the results of an educational intervention for primary care physicians, aimed at helping them to decrease the prevalence rate of excessive attendance by patients at their centres. METHODS: A training programme was carried out for 11 primary care doctors in Barcelona who had patient lists totalling 20,064 patients. The goal of the training was to provide the participating physicians with techniques to curb frequent attendance. Additionally, the programme sought to offer them strategies to prevent professional burnout and tools to better organize their everyday medical practice. The study used a quasi-experimental design for an evaluation of an educational intervention, featuring a pre-test assessment (before the training programme) and a post-test assessment (after the training programme), as well as comparison with a control group that did not undergo the training. The study assessed the effects of the programme on the rates of frequent attendance of patients served by the participating physicians. These rates were compared with those registered by the patients seen by the control group physicians over the same period. RESULTS: Among the group of physicians who received the training, the mean prevalence of patients who qualified as frequent attenders decreased from 22% prior to the training programme to 8% after completion of the programme. In other words, 14% of patients (2,809) limited the frequency of their visits to primary care physicians after their physicians had completed the training programme. Meanwhile, the study recorded an average decrease of 3.1 visits per year by the patients of the physicians who had undergone the training. Statistically significant differences between this group and the control group were observed. CONCLUSIONS: The educational intervention proved effective at helping primary care physicians to decrease their patients' rates of frequent attendance. It also contributes to the impact research of continuing education on doctors and their patients. We need to increase primary care spending from the current 14% to the 25%, to address this problem, among others.

Out-Patient versus In-Patient Arteriovenous Fistula Creation for Dialysis: Assessing Cost-Effectiveness Alongside Clinical Implications.

(1) Background: The surgical procedure to create an arteriovenous fistula (AVF) can be performed in either an ambulatory or in-patient hospital setting, depending on the case's complexity, the anesthesia type used, and the patient's comorbidities. The main scope of this study is to assess the cost-effectiveness and clinical implications of surgically creating an AVF in both ambulatory and in-hospital settings. (2) Methods: We conducted a retrospective observational study, in which we initially enrolled all patients with end-stage kidney disease (ESKD) admitted to the Vascular Surgery Department, Emergency County Hospital of Targu Mures, Romania, to surgically create an AVF for dialysis, between January 2020 and December 2022. The primary endpoint of this study is to assess the cost-effectiveness of surgically creating an AVF in an ambulatory vs. in-hospital setting by comparing the costs required for the two types of admissions. Further, the 116 patients enrolled in this study were divided into two groups based on their preference for hospitalization: out-patients and in-patients. (3) Results: Regarding in-patient comorbidities, there was a higher prevalence of peripheral artery disease (PAD) (p = 0.006), malignancy (p = 0.020), and previous myocardial infarction (p = 0.012). In addition, active smoking (p = 0.006) and obesity (p = 0.018) were more frequent among these patients. Regarding the laboratory data, the in-patients had lower levels of white blood cells (WBC) (p = 0.004), neutrophils count (p = 0.025), lymphocytes (p = 0.034), and monocytes (p = 0.032), but there were no differences between the two groups regarding the systemic inflammatory biomarkers or the AVF type. Additionally, we did not register any difference regarding the outcomes: local complications (p = 0.588), maturation failure (p = 0.267), and primary patency (p = 0.834). In our subsequent analysis, we discovered no significant difference between the hospitalization type chosen by patients regarding AVF primary patency failure (p = 0.195). We found no significant association between the hospitalization type and the recorded outcomes (all ps > 0.05) in both multivariate linear regression and Cox proportional hazard analysis. (4) Conclusions: In conclusion, there are no significant differences in the clinical implications, short-term and long-term complications of AVF for out-patient and in-patient admissions. Additionally, we found no variation in the costs associated with laboratory tests and surgical supplies for an AVF creation. Therefore, it is safe to perform ambulatory AVFs, which can reduce the risk of hospital-acquired infections and provide greater comfort to the patient.

[Main clinical characteristics of pain in patients with lumbosacral transitional vertebrae]. / Osnovnye klinicheskie kharakteristiki boli u patsientov s perekhodnymi poyasnichno-kresttsovymi pozvonkami.

OBJECTIVE: Based on an analysis of modern medical literature, to study the main clinical characteristics of pain in patients with transitional lumbosacral vertebrae. MATERIAL AND METHODS: A search was made for articles in the scientific electronic libraries CYBERLENINKA, eLIBRARY, Google Scholar, and the electronic database of biomedical publications PubMed. Sixty-eight scientific publications corresponded to the stated goal. RESULTS: The review of literature shows that the localization of pain in patients with transitional vertebrae corresponds to the zone of pseudarthrosis between the enlarged transverse process of the LV vertebra and the wing of the sacrum. In most patients, the pain is deep, not superficial. Pain intensity ranges from 3.0 to 8.4, reaching an average of 6.0 on the visual analog scale. Pain can radiate to one of the buttocks and the lower limb. The intensity of pain in the leg at the same time, on average, reaches 5.4 points. The pain syndrome can last for months, the course of the disease acquires a sluggish, undulating character with periodic exacerbations. The causes of exacerbations of pain may be excessive loads on the spine, concomitant vertebrogenic diseases and spinal injuries, excess weight, and in women, a history of pregnancy. Pain management can be either conservative or surgical. The scope of conservative treatment consists of using acupuncture and taking non-steroidal anti-inflammatory drugs. The greatest therapeutic effect is achieved with local injection therapy of analgesics and glucocorticoids at the neoarticulation point. The effectiveness of the course of therapeutic blockades reaches a period from several months to a year. The arsenal of surgical techniques includes pseudoartrectomy, radiofrequency denervation, minimally invasive endoscopic surgery, and transpedicular fusion. In most patients, after surgical treatment, complete relief of pain is noted. CONCLUSION: The review provides information on the predominant localization of pain in patients with transitional vertebrae, its nature, intensity, irradiation, duration, causes of exacerbation, as well as the effectiveness of the methods of conservative and surgical treatment.

Clinical and sociodemographic characteristics of patients with epilepsy attended at a regional reference psychiatric emergency unit.

OBJECTIVE: Epilepsy is one of the most prevalent chronic neurological diseases, presenting a high frequency of psychiatric disorders (PD). This study sought to evaluate the clinical and sociodemographic profile of patients with epilepsy (PWE) attended at a regional reference psychiatric emergency unit. METHODS: A retrospective, cross-sectional, and descriptive observational study was conducted utilizing a patient record database of individuals with epilepsy who were attended in a regional reference psychiatric emergency unit between January 2018 and August 2022. RESULTS: Out of the 31,800 psychiatric emergency visits, 260 (0.8 %) were of patients with epilepsy (ICD-10: G40). The majority were males (63.5 %) with a mean age of 42.11±15.39 years, single marital status (154; 59.25 %) and elementary education (75; 28.9 %). Most of them (203; 78.1 %) presented at least one psychiatric comorbidity at the emergency visit, but 109 (41.9 %) were not receiving any psychiatric follow-up. A total of 106 patients (40.8 %) had experienced at least one past psychiatric hospitalization. CONCLUSIONS: The occurrence of PD is highly prevalent in PWE, and probably with a high frequency of psychiatric emergencies occurring among them. Further studies are needed to assess such patient profile, particularly involving data from psychiatric emergency units.

Cardiorespiratory fitness, perceived fitness and autonomic function in in-patients with different depression severity compared with healthy controls.

Over 300 million individuals worldwide suffer from major depressive disorder (MDD). Individuals with MDD are less physically active than healthy people which results in lower cardiorespiratory fitness (CRF) and less favorable perceived fitness compared with healthy controls. Additionally, individuals with MDD may show autonomic system dysfunction. The purpose of the present study was to evaluate the CRF, perceived fitness and autonomic function in in-patients with MDD of different severity compared with healthy controls. We used data from 212 in-patients (age: 40.7 ± 12.6 y, 53% female) with MDD and from 141 healthy controls (age: 36.7 ± 12.7 y, 58% female). We assessed CRF with the Åstrand-Rhyming test, self-reported perceived fitness and autonomic function by heart rate variability (HRV). In specific, we used resting heart rate, time- and frequency-based parameters for HRV. In-patients completed the Beck Depression Inventory-II (BDI-II) to self-assess the subjectively rated severity of depression. Based on these scores, participants were grouped into mild, moderate and severe MDD. The main finding was an inverse association between depression severity and CRF as well as perceived fitness compared with healthy controls. Resting heart rate was elevated with increasing depression severity. The time-based but not the frequency-based autonomic function parameters showed an inverse association with depression severity. The pattern of results suggests that among in-patients with major depressive disorder, those with particularly high self-assessed severity scores show a lower CRF, less favorable perceived fitness and partial autonomic dysfunction compared to healthy controls. To counteract these conditions, physical activity interventions may be effective.

Schneiderian First Rank Symptoms Significantly Predict a Dissociative Disorder Diagnosis in Psychiatric In-Patients.

Previous empirical studies on the relationship between psychotic symptoms and dissociative disorders focused on auditory hallucinations only or employed limited statistical analyses. We investigated whether the frequency of Schneiderian first rank symptoms (FRS) predicts the presence or absence of a dissociative disorder (DD). Psychiatric in-patients (n = 116) completed measures of dissociation, FRS and general psychological distress (GPD). DD diagnoses were confirmed by multidisciplinary teams or administering the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R). The FRS were recorded in the Multidimensional Inventory of Dissociation (MID) and a mean score obtained for 35 relevant items: Voices arguing, voices commenting, made feelings, made impulses, made actions, influences on body, thought withdrawal, and thought insertion. A global severity index (GSI) of GPD was obtained from the Symptom Checklist-90-Revised (SCL-90-R). Logistic regression models examined whether FRS predict diagnostic classification of patients under a DD (n = 16) or not (n = 100), controlling for GSI. The overall fit of the model was significant (p = .0002). DD was correctly classified using frequency of FRS, controlling for GSI. The latter was moderately associated with FRS (r = 0.56). FRS more than doubled the odds of a DD diagnosis (odds = 2.089; 95% CI = 1.409-3.098; correct classification rate 87.1%). The study provides convincing evidence that FRS are closely related to DDs. FRS should alert clinicians to consider DDs in differential diagnosis of psychiatric in-patients. Future research should analyze whether FRS also predict a diagnosis of schizophrenia or other psychiatric disorders.

Pan-Indian Clinical Registry of Invasive Fungal Infections Among Patients in the Intensive Care Unit: Protocol for a Multicentric Prospective Study.

BACKGROUND: Fungal infections are now a great public health threat, especially in those with underlying risk factors such as neutropenia, diabetes, high-dose steroid treatment, cancer chemotherapy, prolonged intensive care unit stay, and so on, which can lead to mycoses with higher mortality rates. The rates of these infections have been steadily increasing over the past 2 decades due to the increasing population of patients who are immunocompromised. However, the data regarding the exact burden of such infection are still not available from India. Therefore, this registry was initiated to collate systematic data on invasive fungal infections (IFIs) across the country. OBJECTIVE: The primary aim of this study is to create a multicenter digital clinical registry and monitor trends of IFIs and emerging fungal diseases, as well as early signals of any potential fungal outbreak in any region. The registry will also capture information on the antifungal resistance patterns and the contribution of fungal infections on overall morbidity and inpatient mortality across various conditions. METHODS: This multicenter, prospective, noninterventional observational study will be conducted by the Indian Council of Medical Research through a web-based data collection method from 8 Advanced Mycology Diagnostic and Research Centers across the country. Data on age, gender, clinical signs and symptoms, date of admission, date of discharge or death, diagnostic tests performed, identified pathogen details, antifungal susceptibility testing, outcome, and so on will be obtained from hospital records. Descriptive and multivariate statistical methods will be applied to investigate clinical manifestations, risk variables, and treatment outcomes. RESULTS: These Advanced Mycology Diagnostic and Research Centers are expected to find the hidden cases of fungal infections in the intensive care unit setting. The study will facilitate the enhancement of the precision of fungal infection diagnosis and prompt treatment modalities in response to antifungal drug sensitivity tests. This registry will improve our understanding of IFIs, support evidence-based clinical decision-making ability, and encourage public health policies and actions. CONCLUSIONS: Fungal diseases are a neglected public health problem. Fewer diagnostic facilities, scanty published data, and increased vulnerable patient groups make the situation worse. This is the first systematic clinical registry of IFIs in India. Data generated from this registry will increase our understanding related to the diagnosis, treatment, and prevention of fungal diseases in India by addressing pertinent gaps in mycology. This initiative will ensure a visible impact on public health in the country. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54672.

Psychiatric in-patient care in England: as safe as it can be? An examination of in-patient suicide between 2009 and 2020.

BACKGROUND: Psychiatric in-patients have a greatly elevated risk of suicide. We aimed to examine trends in in-patient suicide rates and determine if characteristics of in-patients who died by suicide have changed over time. METHODS: We identified all in-patients in England who died by suicide between 2009 and 2020 from the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates were calculated using data from Hospital Episodes Statistics. RESULTS: The rate of in-patient suicide per 100 000 bed days fell by 41.9% between 2009-2011 and 2018-2020. However, since 2016 the rate has remained static with no significant fall. Rates fell in men, those aged 30-59, and those with schizophrenia and other delusional disorders or personality disorder. Rates also fell for suicide by hanging (including hanging on the ward) and jumping. No falls were seen in suicide rates among women, younger and older age groups, and those with affective disorder. There was no indication of a transfer of risk to the post-discharge period or to home treatment/crisis care. More in-patients in the latter part of the study were aged under 25, were on authorised leave, and had psychiatric comorbidity. CONCLUSIONS: In-patient suicide has significantly fallen since 2009, suggesting patient safety may have improved. The recent slowdown in the fall in rates, however, highlights that renewed preventative efforts are needed. These should include a greater focus on women, younger and older patients, and those with affective disorder. Careful reviews prior to granting leave are important to ensure a safe transition into the community.

Integrated protocol for the prevention and treatment of skin ulcers in patients with end-stage renal disease.

Chronic Kidney Disease (CKD) is an escalating global health concern, affecting more than 10 % of the general population worldwide, amounting to over 800 million individuals. One of its major complications for patients is the high prevalence of skin ulcers . This study aims to develop a protocol for ulcer management within the context of a hospital-based dialysis center. The success of this strategy is deeply rooted in the collaboration of a multidisciplinary team, continually enriched by specialist training. The clinical nurse specialist (CNS) in wound care plays a pivotal role in this approach. By employing a systematic methodology, the protocol is tailored to emphasize holistic care for patients diagnosed with end-stage renal disease undergoing hemodialysis. It accentuates the significance of proactive prevention, in-depth patient education, and the immediate identification of early wound signs. The research underscores the necessity to further weave in specialized training for ulcer care, ensuring each hospital visit is maximized for efficiency and effectiveness. Central to this protocol is the understanding that CKD is a growing concern, that the optimal management of ulcers relies heavily on multidisciplinary collaboration, and that an emphasis on prevention, patient education, and timely wound recognition is crucial to enhance patient care and experience.

Elevated glycosylated hemoglobin levels are associated with severe acute kidney injury following coronary artery bypass surgery.

BACKGROUND: Diabetic patients are at increased risk of acute kidney injury (AKI) following surgery. The significance of uncontrolled diabetes on kidney function after coronary artery bypass grafting (CABG) remains controversial. Our aim was to study the association between pre-operative hemoglobin A1c (HbA1c) and severe cardiac surgery-associated AKI (CSA-AKI) following CABG. METHODS: A single-center, retrospective cohort study including patients who underwent isolated CABG from 2010 to 2018 was performed. Patients were grouped into pre-operative HbA1c of <6.5 %, 6.5-8.5 %, and ≥8.5 %. Postoperative serum creatinine levels were queried for up to 30 days, and the 30-day risk of severe AKI was compared among groups. Multivariable logistic regression was used to study factors associated with severe CSA-AKI and the association of severe CSA-AKI with postoperative outcomes. Cox regression was used to study the association between severe CSA-AKI and all-cause mortality from the time of surgery to the last follow-up or death. RESULTS: A total of 2424 patients met the inclusion criteria. Patients were primarily male (70.5 %), with a median age of 64 years (IQR 57-71). Median bypass and cross-clamp times were 95 (IQR 78-116) and 78 min (IQR 63-95). Severe CSA-AKI occurred within 30 days in 5.7 %, 6.7 %, and 9.1 % of patients with pre-op HbA1c of <6.5 %, 6.5-8.5 %, and ≥8.5 %, respectively. After adjusting for covariates, HbA1c >8.5 %, was independently associated with severe CSA-AKI 30 days after CABG (aOR 1.59, 95%CI 1.06-2.40). In addition, severe CSA-AKI was associated with increased 30- (aOR 15.83,95%CI 7.94-31.56) and 90- day mortality (aOR 9.54, 95%CI 5.46-16.67), prolonged length of stay (aOR 3.46,95%CI 2.41-4.96) and unplanned 30-day readmission (aOR 2.64, 95%CI 1.77-3.94). Lastly, severe CSA-AKI was associated with increased all-cause mortality (aHR 3.19, 95%CI 2.43-4.17). CONCLUSION: Elevated preoperative HbA1c (≥8.5 %) was independently associated with an increased 30-day risk of severe CSA-AKI, which is a consistent predictor of adverse outcomes after CABG. Delaying surgery to achieve optimal glycemic control in an elective setting may be reasonable.

Clinical characteristics and outcomes of patients with COVID-19 and tuberculosis coinfection.

BACKGROUND: Data on the coincidence of Tuberculosis (TB) and Coronavirus disease 2019 (COVID-19) are limited. We sought to investigate the clinical characteristics and outcomes of coinfected patients in Henan and identify whether TB disease is associated with an increased risk of intensive care unit (ICU) admission and mortality. METHOD: We conducted a retrospective matched cohort study of COVID-19 inpatients involving 41 TB-positive patients with 82 patients without TB. Leveraging data was collected from electronic medical records. RESULTS: There were no significant differences in clinical manifestations, the need for mechanical ventilation and vasopressors, ICU admission, or in-hospital mortality between 2 groups. TB-positive patients had a lower lymphocyte counts (1.24 ± 0.54 vs. 1.59 ± 0.58, p = 0.01), B cells (99/µl vs. 201/µl, p < 0.01), CD4+ T cells (382/µl vs. 667/µl, p < 0.01), CD8+ T cells (243/µl vs. 423/µl, p < 0.01), NK cells (145/µl vs. 216/µl, p = 0.01), IL-2 (14.18 ± 11.23 vs. 31.86 ± 34.55, p < 0.01) and TNF-α (3.42 ± 2.93 vs. 5.62 ± 3.69, p < 0.01). Notably, the TB-positive group had a longer duration of SARS-CoV-2 shedding (67 days vs. 22 days, p < 0.01). CONCLUSIONS: Concomitant TB does not significantly impact clinical outcomes of hospitalised patients with acute COVID-19. However, TB-positive patients had longer duration of SARS-COV-2-RNA positivity.

Bleeding risk and P2Y12 inhibitors in all-comer patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: a single-centre cohort study.

AIMS: To characterize and follow patients with ST-segment elevation myocardial infarction (STEMI) at high bleeding risk (HBR) according to the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score, and to examine the use of P2Y12 inhibitors and the subsequent risk of major adverse cardiovascular events (MACE) and bleeding. METHODS AND RESULTS: This single-centre cohort study included 6179 consecutive STEMI patients who underwent percutaneous coronary intervention (PCI) at Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Individual linkage to nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Of the 5532 (89.5%) patients with available PRECISE-DAPT scores, 33.0% were at HBR and more often elderly and female with more comorbidities than non-HBR patients. One-year cumulative incidence rates per 100 person-years were 8.7 and 2.1 for major bleeding and 36.8 and 8.3 for MACE in HBR and non-HBR patients, respectively. Among the 4749 (85.8%) patients who survived and collected a P2Y12 inhibitor ≤7 days from discharge, 68.2% of HBR patients were treated with ticagrelor or prasugrel and 31.8% with clopidogrel, while 18.2% non-HBR patients were treated with clopidogrel. Adherence was high for all (>75% days coverage). The risk of MACE was lower in ticagrelor- and prasugrel-treated patients than in clopidogrel-treated patients without differences in major bleeding. CONCLUSION: One-third of PCI-treated all-comer patients with STEMI were at HBR according to the PRECISE-DAPT score and were more often treated with potent P2Y12 inhibitors instead of clopidogrel. Thus, ischaemic risk may be weighted over bleeding risk in STEMI patients at HBR.

Washout appearance of hepatocellular carcinomas using standardized contrast-enhanced ultrasound (CEUS) including an extended late phase observation - Real-world data from the prospective multicentre DEGUM study.

BACKGROUND: Non-invasive diagnosis of hepatocellular carcinoma (HCC) in contrast-enhanced ultrasound (CEUS) is based on the combination of arterial phase hyperenhancement (APHE) and subsequent late (>60 seconds) and mild contrast washout (WO). Whereas APHE is seen in the majority of HCC, wash-out pattern may vary in onset and intensity. In some HCC lesions, even no washout is seen at all. OBJECTIVE: Our prospective multicentre DEGUM HCC CEUS study aimed at identifying typical and atypical washout appearance of HCC in a real-life setting. METHODS: High-risked patients for HCC with focal liver lesions upon B-mode ultrasound were recruited prospectively. In a multicentre real-life setting, a standardised CEUS examination including an extended late phase up to 6 minutes was performed. CEUS patterns of HCC were recorded, and onset and intensity of washout appearance were assessed with respect to patient and tumour characteristics. Histological findings served as reference standard. RESULTS: In 230/316 HCC (72.8%), a CEUS pattern of APHE followed by WO was observed. In 158 cases (68.7%), WO was typical (onset > 60 seconds, mild intensity). 72 cases (31.3%) showed marked and / or early WO, whereas in 41 HCCs (13%), APHE was followed by sustained isoenhancement.Atypical WO upon CEUS was associated with macroinvasion of the liver vessels, portal vein thrombosis and diffuse growth pattern, but not tumour size and histological grading. CONCLUSIONS: In a prospective multicentre real-life setting, APHE is followed by atypical washout appearance or no washout at all in almost half of the HCCs with APHE. The examiner has to bear in mind that in spite of a characteristic APHE in HCCs, washout appearance can be atypical in CEUS, especially in HCCs with macrovascular invasion or diffuse growth pattern.

Adverse drug reactions to chloroquine/hydroxychloroquine in combination with azithromycin in COVID-19 in-patients: data from intensive pharmacovigilance in Morocco, 2020.

In Morocco, chloroquine/hydroxychloroquine + azithromycin have been used off-label for COVID-19 treatment. This study aimed to describe the distribution, nature and seriousness of the adverse drug reactions (ADRs) associated with the two drug combinations in COVID-19 in-patients. We conducted a prospective observational study based on intensive pharmacovigilance in national COVID-19 patients' management facilities from April 1 to June 12, 2020. Hospitalized patients treated with chloroquine/hydroxychloroquine + azithromycin and who experienced ADRs during their hospital stay were included in the study. The causality and seriousness of the ADRs were assessed using the World Health Organization-Uppsala Monitoring Centre method and the agreed criteria in the ICH guideline (E2A) respectively. A total of 237 (51.7%) and 221 (48.3%) COVID-19 in-patients treated respectively with chloroquine + azithromycin and hydroxychloroquine + azithromycin experienced 946 ADRs. Serious ADRs occurred in 54 patients (11.8%). Gastrointestinal system was most affected both in patients taking chloroquine + azithromycin (49.8%) or hydroxychloroquine + azithromycin (54.2%), followed by nervous system and psychiatric. Eye disorders were more frequent in patients receiving chloroquine + azithromycin (10.3%) than those receiving hydroxychloroquine + azithromycin (1.2%). Cardiac ADRs accounted for 6.4% and 5.1% respectively. Chloroquine + azithromycin caused more ADRs by patients than hydroxychloroquine + azithromycin (2.6 versus 1.5 ADRs/patient). Causality assessment was possible for 75.7% of the ADRs. Diabetes was identified as a risk factor for serious ADRs (ORa 3.56; IC: 95% 1.5-8.6). The off-label use of the two drug combinations in COVID-19 in-patients according to the national therapeutic protocol seems to be safe and tolerable. ADRs were mainly expected. However, precaution should be taken in using the drugs in diabetic patients to prevent the risk of serious ADRs.

Reverse cardiac remodeling in patients undergoing combination therapy of transcatheter mitral valve repair.

Aims: For patients with severe mitral valve regurgitation (MR), different kinds of transcatheter mitral valve repair (TMVr) exist, targeting the leaflets, annulus, and chordae. The concomitant combination (COMBO) therapy of TMVrs is rarely used as treatment, and there are very few publications about this therapeutic strategy. We evaluated the effect of COMBO-TMVr on the cardiac left chambers and clinical data, including survival. Methods: We included 35 patients at high risk who underwent concomitant sequential transcatheter mitral valve edge-to-edge repair (M-TEER) and another TMVr for severe MR in our hospital between March 2015 and April 2018. Of these, 13 had adequate follow-up transthoracic echocardiography (TTE) up to around 1 year after the procedure. Results: Survival for all patients was 83% at 1 year, 71% at 2 years, and 63% at 3 years, respectively. In the 13 patients with adequate TTE follow-up, M-TEER plus either Cardioband (n = 4), Carillon Mitral Contour System (n = 7), or Neochord (n = 2) were used, respectively. Ten patients had secondary, and three patients primary MR. After 1 year, changes [median (Q1, Q3)] of left ventricular (LV) end-systolic diameter of -9.9 cm (-11.1, 0.4), LV end-diastolic diameter of -3.3 cm (-8.5, 0.0), LV end-systolic volume (LVESV) of -17.4 mL (-32.6, -0.4), LV end-diastolic volume (LVEDV) of -13.5 mL (-15.9, -3.2), LV mass of -19.5 g (-24.2, -7.6), and left atrial volume (LAV) index (LAVi) of -16.4 mL (-23.3, -11.3) were observed. A significant reduction was also seen in the change ratios of LVESV, LVEDV, LV mass, and LAVi, respectively. Conclusion: We found that COMBO therapy of TMVr seems feasible and may support reverse remodeling of left cardiac chambers during 1 year after the procedure in a cohort of patients at high risk.

Honeycomb lung is a major risk factor for preoperative radiological tumor size underestimation in patients with primary lung cancer.

Background: Lung cancer frequently occurs in lungs with background idiopathic interstitial pneumonias (IIPs). Limited resection is often selected to treat lung cancer in patients with IIPs in whom respiratory function is already compromised. However, accurate surgical margins are essential for curative resection; underestimating these margins is a risk for residual lung cancer after surgery. We aimed to investigate the findings of lung fields adjacent to cancer segments affect the estimation of tumor size on computed tomography compared with the pathological specimen. Methods: This analytical observational study retrospectively investigated 896 patients with lung cancer operated on at Fujita Health University from January 2015 to June 2020. The definition of underestimation was a ≥10 mm difference between the radiological and pathological maximum sizes of the tumor. Results: The lung tumors were in 15 honeycomb, 30 reticulated, 207 emphysematous, and 628 normal lungs. The ratio of underestimation in honeycomb lungs was 33.3% compared to 7.4% without honeycombing (P=0.004). Multivariate analysis showed that honeycombing was a significant risk factor for tumor size underestimation. A Bland-Altman plot represented wide 95% limits of agreement, -40.8 to 70.2 mm, between the pathological and radiological maximum tumor sizes in honeycomb lungs.