Cutibacterium acnes is a low-virulence pathogen that can cause prosthetic valve endocarditis (PVE), presenting significant diagnostic challenges due to its slow growth and indolent clinical course. We report a case of a 57-year-old male with a history of tissue aortic valve replacement, who presented with 6 months of intermittent fever and a nonproductive cough. Initial tests showed elevated inflammatory markers and moderate aortic regurgitation, but no vegetations were identified on transthoracic or transoesophageal echocardiography. After 13 months of symptoms, a PET scan showed significant FDG uptake around the bioprosthetic valve, and a single blood culture grew C. acnes. Transoesophageal echocardiography revealed abnormal rocking motion of the valve and severe paravalvular regurgitation, suggesting near-complete valve dehiscence. The patient underwent redo surgery for aortic root and valve replacement, and intraoperative cultures confirmed C. acnes infection. This case highlights the importance of considering low-virulence pathogens like C. acnes in patients with prolonged, nonspecific symptoms and initially negative cultures. Advanced imaging, particularly PET/CT, is crucial for early diagnosis and intervention. Early recognition and appropriate treatment are vital for preventing severe complications such as valve dehiscence and tissue destruction.
INTRODUCTION:The Wells score, which is a 9-item clinical rule, is used to assess the diagnostic probability of deep vein thrombosis (DVT) in suspected patients. However, the accuracy of the Wells rule has not been investigated in Ghanaians. METHODS:In a cross-sectional design, 138 suspected DVT patients underwent pretest probability of DVT using the Wells rule. Thereafter, a compressive duplex ultrasound study (CDUS) was performed on both legs to confirm the presence of DVT. Using the CDUS as the gold standard, the accuracy and reliability of the Wells rule were assessed as sensitivity, specificity, predictive values and accuracy diagnostic odds. Youden's index was used to determine the optimal cutoff of Wells score to predict DVT. RESULTS:The prevalence of DVT was 38.8% and it was associated with localized tenderness [OR (95% CI) = 3.4 (1.49 - 7.76), p = 0.003], calf swelling [3.72 (1.7 - 8.12), p = 0.001] and previous DVT [4.69 (1.74 - 12.61), p = 0.001]. The sensitivity, specificity, and accuracy diagnostic odds ratio for the 2-level Wells score were 38.3%, 93.3%, 73.9% and 8.44 respectively. From the receiver operator characteristic analysis, the area under curve for the 2-level Wells score was 0.76 and the optimal Wells score cut-point for diagnosing DVT based on Youden's index was >1, with sensitivity, specificity, positive and negative predictive values of 69.4%, 72.1%, 58.6% and 80.5% respectively. CONCLUSION:The prevalence of DVT in suspected patients in our study population was 38.8% and associated with localized tenderness, calf swelling and previous DVT. Reducing the cut-point of the Wells score to 1 increased the sensitivity and accuracy of the Wells rule in our study population.
BACKGROUND:Posterior spinal fixation (PSF) of the lumbosacral region is a commonly performed procedure for managing various spinal pathologies. Deep vein thrombosis (DVT) is a potential complication that can lead to serious outcomes such as thromboembolism. This study aimed to determine the prevalence of DVT and identify associated risk factors in patients undergoing lumbosacral PSF at Firoozgar Hospital, Tehran. METHODS:This prospective cohort study included patients who underwent lumbosacral PSF for degenerative diseases or trauma. All participants underwent lower limb color Doppler ultrasonography before surgery to rule out preexisting DVT. Postoperatively, they were monitored for clinical signs of DVT for two weeks and underwent a follow-up Doppler ultrasound. Demographic and clinical data were collected and analyzed using univariate and multivariate statistical methods to identify risk factors associated with DVT. RESULTS:DVT occurred in 5 of 109 patients (4.6%), of which 3 (2.8%) were symptomatic and 2 (1.8%) asymptomatic on routine postoperative ultrasound. DVT occurrence was significantly associated with factors including motor impairment, neurological deficits, duration of preoperative hospitalization, intraoperative blood loss, and the need for transfusion. Additional factors such as level of consciousness, severity of pain, time to postoperative mobilization, duration of surgery, age, underlying medical conditions, surgical history and cause, number of spinal fusion levels, and BMI also showed significant associations with DVT. No significant correlation was found with gender or preoperative anticoagulant use. CONCLUSION:Identifying risk factors for DVT in patients undergoing lumbosacral PSF can help inform targeted preventive strategies and improve patient outcomes. These findings underscore the importance of early mobilization, careful perioperative management, and individualized risk assessment in spinal surgery patients.
BACKGROUND:While hospitalists play a central role in inpatient care, the association between years of hospitalist experience and patient outcomes remains unclear. This study examined whether hospitalist experience is linked to clinical outcomes, including readmission rates, inpatient mortality, and patient satisfaction scores within a single academic medical center. METHODS:We conducted a retrospective cohort study of 59 hospitalists and 22,098 patient discharges between May and December 2023. Hospitalist experience was grouped as <2 years, 2-5 years, and >5 years. Patient data were extracted from the EPIC Clarity database. Outcomes included length of stay (LOS), 72-hour and 30-day readmissions, inpatient mortality, and patient satisfaction. Unadjusted regression models with provider-level random effects evaluated associations between hospitalist experience and outcomes. RESULTS:Among 14,804 unique patients, the mean LOS was 5.16 ± 8.15 days, with a 30-day readmission rate of 13.7% and inpatient mortality of 10.8%. Patient satisfaction scores averaged 8.7/10. Hospitalists with >5 years of experience had significantly shorter LOS (-0.67 days; 95% CI: -1.24 to -0.10; p <0.05) compared to those with ≤5 years. No significant associations were observed between hospitalist experience and readmissions, mortality, or satisfaction scores. CONCLUSIONS:Greater hospitalist experience is associated with reduced length of stay, but is not associated with readmission rates, inpatient mortality, or patient satisfaction scores. Future longitudinal, multi-institutional studies are warranted to better understand the relationship between hospitalist experience and diverse performance metrics.
BACKGROUND:Preoperative anxiety is linked to various adverse effects on anesthesia, intraoperative vital signs, and postoperative outcomes. Despite its widespread impact, managing preoperative anxiety is not consistently implemented, partly due to concerns over the efficacy and side effects of anxiolytic drugs. Previous clinical trials on the anxiolytic effect of melatonin showed conflicting results regarding its effect. Furthermore, they involved placing the patients in settings that deviate of real-world clinical practice. OBJECTIVE:We sought to assess the efficacy of melatonin as a preoperative anxiolytic in real-world settings. METHODS:This is a triple-blinded, randomized, controlled clinical trial that enrolled 87 patients aged 18 to 65 planned for elective surgery under general anesthesia. They were divided into three groups to receive melatonin, diazepam, or a placebo and were placed in the same waiting rooms as other non-enrolled patients. Preoperative anxiety was assessed at baseline and one-hour post-treatment using the Visual Analog Scale (VAS) and Amsterdam Preoperative Anxiety and Information Scale (APAIS). Secondary outcomes included changes in orientation and sedation levels. RESULTS:Of the 87 enrolled participants, 76 completed the second assessment. The median age of the participants was 38 years (IQR = 18.5), and 50.6% were females. Our study showed no significant effect of melatonin on preoperative anxiety, sedation, or orientation compared to diazepam or placebo. CONCLUSION:Our study highlights the need for incorporating other factors in future clinical trials on preoperative anxiety to better translate the results into a real-world setting. CLINICAL TRIAL REGISTRATION NUMBER:NCT06103188.
OBJECTIVES:Influenza is a viral infection, and the inappropriate use of antibiotics in its management is a global challenge. This study focused on antibiotic prescription patterns in patients with influenza symptoms and the level of compliance with international guidelines. METHODS:This retrospective, one-year cross-sectional study included patients with influenza symptoms admitted to a tertiary teaching hospital in Iran. The antibiotic prescription patterns were compared with the recommendations of the Infectious Diseases Society of America and the American Thoracic Society. In addition, the effects of antibiotic use on ICU admission, the need for vasopressors and mechanical ventilation, and mortality rates were assessed. RESULTS:Data were obtained from the hospital records of 102 patients with influenza admitted during the study period. Of these, 92 (89.2%) received antibiotics, whereas only 66 (64.7%) were eligible according to the guidelines. The guideline adherence rate was only 17.6% after evaluating the type, dose, and duration of antibiotic treatment. Our findings showed that regardless of other treatment modalities, timely use of antibiotics in eligible patients was associated with reduced mortality (59.6% vs. 23.9%, p = 0.04). CONCLUSION:Our findings indicated a tendency toward antibiotic overuse in treating influenza, with clinical practice not adhering to guideline recommendations in most patients. Nevertheless, the timely use of antibiotics in eligible patients was associated with reduced mortality.
OBJECTIVES:We aim to determine the frequency and causes of hospitalizations prior to an admission with a diagnosis of pulmonary embolism (PE). METHODS:We conducted a retrospective cohort study using the United States National Readmission Database (NRD) from 2018 to 2020 to evaluate hospitalizations with a primary diagnosis of PE and in-hospital outcomes. We identified the number and causes of hospital admissions occurring within the 30 days preceding the PE hospitalization. Factors associated with prior hospitalization and in-hospital mortality during PE admission were examined. This analysis describes the characteristics of PE patients with prior hospitalization but does not assess risk. RESULTS:A total of 2,651,870 hospital admissions for PE were included in the analysis, of which 16.3% (n = 431,700) had a prior hospitalization within the preceding 30 days. The most common reason for prior admission was sepsis (10.9%). Other notable but less frequent causes included orthopedic conditions associated with reduced mobility, cancer, and cardiovascular diseases. The strongest predictor of prior hospitalization was elective admission (OR 2.89, 95% CI 2.82-2.95). Additional factors associated with increased odds of prior hospitalization included cancer (OR 1.60, 95% CI 1.57-1.63), prior myocardial infarction (OR 1.24, 95% CI 1.20-1.28), and diabetes mellitus (OR 1.19, 95% CI 1.17-1.21). Prior hospitalization was associated with increased odds of in-hospital mortality during the PE admission (OR 1.95, 95% CI 1.89-2.00). CONCLUSIONS:Approximately one in six patients admitted with PE had a hospitalization in the preceding 30 days, and these patients experienced higher in-hospital mortality. Common reasons for prior admissions included sepsis, orthopedic conditions related to immobility, cancer, and cardiovascular disease.
BACKGROUND:There is a growing need to provide care for people approaching their end-of-life phase. A fast-track pathway was developed in the UK to speed up funding of care for people expected to die within 3 months. However, the accuracy of doctors' prediction of death is variable. AIM:To investigate the accuracy of doctors' prediction of death for patients referred to the fast-track pathway and explore clinical criteria predicting early death. METHODS:A retrospective audit of hospitalized patients referred to the fast-track pathway was conducted. Patients were followed up from the date of referral to the date of death. The percentage of patients who died within 3 months was calculated. We compared clinical criteria for patients who died within the first 2 weeks to patients who died later. Multiple logistic regression analysis was performed to identify predictors of death ≤7 days and ≤14 days. RESULTS:A total of 185 patients were referred to the fast-track pathway. Mean (SD) age was 81.1 (10.2) years, and the majority were females (n = 101; 54.6%). Most patients (n = 169; 91.4%) died within 3 months. Almost half of the patients (n = 84; 46%) died within 2 weeks. For death ≤7 days, predictors were age >85 years, odds ratio (OR) 1.9, 95% confidence interval (CI) 1.1 to 3.6, p = 0.004, and admission with sepsis or acute organ failure, 2.8 (1.2 to 5.7), p = 0.03 and 2.6 (1.1 to 8.1), p = 0.03, respectively. For death ≤14 days, predictors were age >85 years, 2.4 (1.3 to 4.5), p = 0.006, living in care home, 2.7 (1.3 to 5.8), p = 0.01, diagnosis of dementia, 1.7 (1.1 to 3.9), p = 0.04, and admission with sepsis or acute organ failure, 2.1 (1.2 to 5.6), p = 0.03 and 2.1 (1.0 to 8.9), p = 0.01, respectively. CONCLUSION:Doctors' prediction of death was good. Significant number of patients died early, especially very old patients with dementia, care home residents, and those presenting with sepsis or acute organ failure.
OBJECTIVES:Nearly two-thirds of older adults experience sleeping difficulties in the hospital setting, which can lead to delirium, mood instability, and delayed healing. Many members of the interprofessional hospital team are positioned to promote restorative sleep, but knowledge about how to intervene is limited. The purpose of this review is to provide members of the hospital care team with specific interventions to promote restorative sleep in hospitalized older adults. METHODS:A narrative literature review was performed in PubMed and CINAHL to identify studies focusing on pharmacological and non-pharmacological sleep promoting interventions in hospitalized older adults. A review of basic sleep biology is also provided to create a common understanding of this phenomenon for a wide range of interprofessional hospital care team members. RESULTS:A three-pronged approach focused on interventions related to staff culture, specific patient care activities, and hospital policies provides an organizing framework of non-pharmacological sleep promoting interventions. A judicious and cautious approach to the use of pharmacological and nutraceutical interventions is provided. CONCLUSION:The hospital care team should implement patient-centered and customized interventions to promote sleep for hospitalized older adults. Sleep promotion should include, at a minimum, non-pharmacological interventions (e.g. increasing familiarity, reducing sensory stimulation as bedtime approaches, maintaining environmental and behavioral zeitgebers). Pharmacological (e.g. ramelteon, trazadone, doxepin, dual orexin receptor antagonists) and nutraceutical (e.g. melatonin, magnesium) interventions may be appropriate, Certain pharmacological options are considered potentially unsafe for older adults (e.g. benzodiazepines, Z-drugs, antihistamines) and should be avoided in this population.
INTRODUCTION:Decisions about whether to admit patients with pulmonary embolism (PE) are often guided by risk stratification tools, such as the simplified Pulmonary Embolism Severity Index (sPESI). Patients deemed low-risk are typically treated as outpatients; however, some still experience complications. This study compares characteristics of low-risk PE patients managed as outpatients versus inpatients and evaluates patient-level factors associated with admission decisions. METHODS:We conducted a retrospective cohort study of adults (≥18 years) with objectively confirmed acute PE diagnosed between 1 June 2014, and 31 May 2019. Patients classified as low-risk (sPESI = 0) and without right ventricular dysfunction (RVD) were included. Clinical data were abstracted from records, and patients were categorized by initial sites of care (inpatient versus outpatient). Data analysis included descriptive statistics as well as multivariate logistic regression to identify factors associated with hospitalization. RESULTS:Of 229 eligible patients, 140 (61.1%) were admitted, and 89 (38.9%) managed as outpatients. Baseline characteristics were similar between groups; however, hospitalized patients often had heart rates (HR) ≥90 beats per minute (bpm), lower oxygen saturation, and more medical conditions requiring inpatient care. Among low-risk patients, HR 90-109 bpm (OR 1.78, 95% CI: 1.10-3.04), oxygen saturation between 90% and 94% (OR 1.10, 95% CI: 1.01-1.27), and medical indications for hospitalization >24 hours (OR 33.97, 95% CI: 8.47-236.09) were significantly associated with admission. CONCLUSIONS:Although classified as low-risk, over half of patients with acute PE were hospitalized. Elevated HR, reduced oxygen saturation, and comorbid conditions significantly influenced site-of-care decisions in this population. Outpatient management was associated with comparable 90-day safety outcomes, reinforcing its viability when patients are appropriately selected.
OBJECTIVE:Hospital settings may influence outcomes and resource utilization in end-stage kidney disease (ESKD) patients receiving peritoneal dialysis (PD). However, data on PD outcomes across hospital settings remain limited. This study aims to evaluate characteristics, in-hospital treatments, complications, and healthcare costs for PD patients in urban teaching, urban non-teaching, and rural hospitals across the United States. METHODS:We conducted a cohort study using the National Inpatient Sample database in the United States from 2003 to 2018. Multivariable logistic and linear regression models were employed to compare in-hospital treatment outcomes, mortality, and healthcare costs across hospital settings, adjusting for demographics, comorbidities, and hospital characteristics. RESULTS:A total of 99,528 hospitalized ESKD patients receiving PD were included. Among these patients, 60,833 (61%) were in urban teaching hospitals, 32,714 (33%) in urban non-teaching hospitals, and 5,981 (6%) were in rural hospitals. In multivariable analysis, patients in urban non-teaching hospitals had lower risk of PD catheter adjustments (OR 0.81, 95% CI 0.68-0.97), hyperkalemia (OR 0.85, 95% CI 0.76-0.95), metabolic acidosis (OR 0.69, 95% CI 0.61-0.78), volume overload (OR 0.82, 95% CI 0.71-0.95), and mortality (OR 0.76, 95% CI 0.63-0.93) but higher risk of PD peritonitis (OR 1.25, 95% CI 1.15-1.36), and sepsis (OR 1.13, 95% CI 1.03-1.24), compared with urban teaching hospitals. Meanwhile, patients in rural hospitals had a lower risk of metabolic acidosis (OR 0.84, 95% CI 0.79-0.90) and volume overload (OR 0.82, 95% CI 0.76-0.89) but higher need for hemodialysis (OR 1.12, 95% CI 1.06-1.19), and risk of PD peritonitis (OR 1.18, 95% CI 1.13-1.24). Urban non-teaching and rural care were associated with lower hospitalization length of stays by 1.5 and 0.5 days and costs by $31632 and $10376, respectively. CONCLUSION:Rural and urban non-teaching hospitals experienced fewer metabolic complications and less volume overload but faced higher rates of PD-related peritonitis compared to urban teaching hospitals. These findings highlight clinical and economic differences in PD across hospital settings in the United States and crucial strategies for personalizing PD care and optimize resources. Future research should explore system-level interventions to enhance PD delivery in diverse healthcare settings.
OBJECTIVES:Clinical handover is a major part of everyday work in healthcare settings. Clinical handover plays a great role between emergency medical services (EMS) and emergency nurses in providing safe and quality EMS. This study aims to assess the communication and handover mechanism between EMS and the emergency departments (ED) in Palestinian hospitals, to identify opportunities for improvement, and to make recommendations to improve the handover. METHODS:A descriptive, quantitative cross-sectional approach was used in this study. A sample of 220 emergency nurses working in governmental hospital and 130 paramedics working in the Palestine Red Crescent Society were conveniently selected from the West Bank, including Jerusalem. RESULTS:Our study showed that effective EMS-ED communication was perceived to have a high-degree impact on patient outcomes and patient waiting time in EDs, and a medium-degree impact on the readiness of healthcare providers. One-sample t-tests confirmed that perceived patient outcomes, readiness of healthcare providers, and patient waiting time in EDs were all perceived to be significantly influenced by EMS-ED communication. CONCLUSION:Our findings demonstrate that effective EMS-ED communication, as perceived by healthcare providers, significantly influences patient outcomes, healthcare provider readiness, and patient waiting times. The availability of communication tools and the accuracy/adequacy of information are also perceived to significantly impact patient handover effectiveness and patient health/medical procedures, collectively enhancing the perceived quality and efficiency of emergency healthcare services.
OBJECTIVES:In acutely admitted patients, comorbidities, and other patient characteristics known at admission might be risk factors for physiological deterioration during hospitalization. Knowledge of specific risk factors could therefore help clinicians escalate or decrease monitoring practices for selected patient categories. We investigated the association between information obtained at admission and the risk of subsequent severe vital signs deviations in acutely admitted medical patients. METHODS:We analyzed data from three clinical trials using continuous monitoring of vital signs in adults during acute medical hospitalizations. The primary exposure variable was number of comorbidities and were obtained from the medical record along with other potential risk factors at the time of admission. The primary outcome was cumulated duration of severe vital sign deviations (SpO2 < 85%, respiratory rate ≤5 min-1 or > 24 min-1, heart rate < 30 min-1 or > 130 min-1, or systolic blood pressure < 91 mmHg or > 219 mmHg). RESULTS:We included data from 553 patients (51% female, median age 72 years), of whom 96% were admitted with respiratory symptoms. Patients with two or more comorbidities had severe vital sign deviations lasting 145 minutes/24 hours as compared with 90 minutes/24 hours in patients with none or one comorbidity, p = 0.07. Patients with severe tachypnea upon arrival ( > 30 brpm) had long duration of deviations (241 minutes per 24 hours [IQR 132;421]) as well as patients with increased CRP > 100 mg/L whose durations of deviations were 175 minutes per 24 hours [IQR 60;339]. CONCLUSION:Comorbidity burden, tachypnea, and increased level of CRP upon arrival were to some extent risk factors for subsequent vital sign deviations. Information obtained at acute admissions can be useful in establishing and escalating patient monitoring level.
OBJECTIVES:The aim of this study was to measure and compare the serum levels of cystatin C and ADA between stable and exacerbated COPD. METHODS:The study was designed as a cross-sectional comparative study. Cases were defined as subjects who presented in the outpatient and inpatient departments with COPD and were stratified to stable COPD and acute exacerbation of COPD. Controls were healthy age-matched subjects who are not on any drugs and were nonsmokers. Association between cystatin C and ADA between stable and exacerbated COPD was assessed using logistic regression. RESULTS:There were a total of 182 subjects included in the study, of which, 63 had acute exacerbated COPD, 60 had stable COPD, and 59 were heathy controls. Logistic regression analysis showed that cystatin C (OR, 1.33, 95% CI: 1.16-2.56) and CRP (OR, 2.26, 95% CI: 1.59-2.69) levels were significantly higher, while ADA (OR, 0.82, 95% CI: 0.59-0.91) levels were significantly lower among those with stable COPD, compared to healthy controls. Similarly, cystatin C (OR, 1.48, 95% CI: 1.12-2.12) and CRP (OR, 3.39, 95% CI: 2.34-3.89) levels were significantly higher, while ADA (OR, 0.62, 95% CI: 0.41-0.87) levels were significantly lower among those with acute exacerbated COPD, compared to healthy controls. CONCLUSION:Cystatin C and c-reactive protein (CRP) were significantly elevated, while ADA was significantly reduced in both stable and acute exacerbated COPD. Future large-scale studies should further explore the value of these markers in predicting the severity of COPD.
BACKGROUND:Seamless collaboration is key to effective healthcare, yet cross-sector partnerships often struggle due to structural and professional differences. This study aimed to explore the dynamics of cross-sector partnership through the experiences and perspectives of hospital physicians, general practitioners (GPs), and patients managing multiple chronic conditions. METHOD:Data were gathered from 41 semi-structured interviews (14 hospital physicians, 10 GPs, and 17 patients with type 2 diabetes and at least one comorbidity). The Interpretive Description methodological approach guided the study, with the concept of Boundary Work providing the theoretical framework for examining how professional roles, boundaries, and collaboration were shaped and navigated across sectors. RESULTS:Four main themes were identified: (1) Mapping Current Collaboration: Contexts, Patients, and Channels, (2) Perceiving Collaboration: Positive Views and Shortcomings, 3) Expectations and Roles: Imbalanced Responsibilities, and 4) Tackling Collaboration Challenges and Acknowledging Barriers. Informants shared mixed views on cross-sector partnerships. While some reported successful collaboration, hospital physicians anticipated fewer patient referrals from GPs, whereas GPs often felt unsupported and left to handle complex cases alone. Cross-sector collaboration was widely perceived as frustrating and, at times, disappointing, highlighting the need for improvement. CONCLUSION:Hospital physicians, GPs, and patients alike advocate for improved cross-sectoral collaboration. Despite strong interest in enhancing cooperation, there is a need for professional consensus on which complex cases require cross-sector involvement. Moreover, clarifying the distribution of responsibilities and addressing the practical dimensions of collaboration and patient engagement are crucial for improving outcomes.
INTRODUCTION:Interprofessional collaboration (IPC), involving multidisciplinary teams of physicians, nurses, pharmacists, and other allied healthcare professionals, has been recognized as a strategy to streamline patient management and reduce systemic inefficiencies. IPC may help reduce hospital wait times (HWT), patients' length of stay (LOS) while enhancing overall quality of care. OBJECTIVE:This study explores how IPC, patient demographics, and admission characteristics influence HWT and LOS. METHODS:Data were drawn from the 2022 National Hospital Ambulatory Medical Care Survey (NHAMCS), n = 2,121 admitted patients in the United States. Multiple linear regression models were used to analyze the associations between IPC, patient demographics, urgency of admission, admission characteristics, and hospital wait times and length of stay. RESULTS:Increased IPC was significantly associated with shorter HWT (p < 0.05) but a marginal increase in LOS (p < 0.05). High-urgency admission was associated with reduced HWT (p < 0.05). Older patients experienced modestly shorter waits (p < 0.001) but longer stays (p < 0.001). Admission to a stepdown unit correlated with longer wait times (p < 0.05). CONCLUSIONS:Strengthening IPC and effectively managing high-urgency admissions may help reduce HWT. Further research is needed to explore why IPC is linked to longer hospital stays and how to optimize resource allocation in stepdown units. These insights hold prospects to guide strategies for improving hospital efficiency and patient experiences.
OBJECTIVES:Ruxolitinib, a Janus kinase (JAK) inhibitor, can lead to severe ruxolitinib discontinuation syndrome (RDS) upon abrupt cessation in myelofibrosis (MF). Pacritinib, a selective JAK2/IRAK1 inhibitor with minimal JAK1 inhibition, offers an alternative, particularly for patients with thrombocytopenia. This case report presents our experience of successfully switching from ruxolitinib to pacritinib in patients with MF and severe RDS. CASE PRESENTATION:Three males in their early 20s, 60s, and 70s of Arab ethnicity presented with diverse clinical presentations, including post-polycythemia vera MF, primary MF, and primary triple-negative MF with multiple comorbidities. Ruxolitinib discontinuation was carefully managed through gradual tapering, concurrent corticosteroid administration, and pacritinib initiation, effectively preventing withdrawal syndrome. All patients demonstrated significant clinical improvements with pacritinib. Notable outcomes included reductions in spleen size (ranging from 7 to 8 cm within 1-6 months), stabilization or improvement in hematologic parameters, and resolution of transfusion dependency in previously transfusion-dependent cases. One patient achieved transfusion independence within six months of treatment, while another exhibited marked symptom relief and improved quality of life within one month. Adverse events, including gastrointestinal symptoms, weight loss, and transient voice changes, were manageable through dose adjustments and supportive care, enabling continued therapy. CONCLUSION:Our cases contribute to the growing body of evidence supporting pacritinib's role in the evolving treatment landscape of MF.
OBJECTIVES:Complex logistics, geographical distance, and waiting times compromise compliance and outcomes for patients with type 1 diabetes (T1D) in Greece. We evaluated guideline adherence of diabetologists and associated costs to outline the rationale for launching an integrated center with an interdisciplinary team, telemedicine, and continuous provider training. METHODS:An expert panel of diabetologists was invited to complete an anonymous survey on routine care of patients aged 18-50 with no major complications. The survey explored (1) guideline adherence and laboratory monitoring, (2) referrals and availability, and (3) perspectives on an integrated center. Annual laboratory costs per patient per provider were estimated and compared with guideline predictions. RESULTS:Seventeen experts completed the survey, representing over 60% of non-integrated diabetes centers. A high annual cost was estimated [median 183.22 euros vs. 94.8 indicated by guidelines, p = 0.033, 95% CI (77.06, 232.14)]. Most experts reported no telemedicine availability and viewed an integrated center as an effective healthcare improvement. CONCLUSION:Our study identified increased costs, limited availability, and lack of remote monitoring, suggesting a centralized approach could reduce costs, streamline referrals, and improve care quality. However, these preliminary findings should be interpreted cautiously due to the small sample size.
