Chronic Disease Risk Prediction Models and their Impacts on Behavioural and Health Outcomes: A Systematic Review and Meta-analysis

Risk prediction models are tools that predict an individual’s risk of developing a health outcome. They were developed to influence patient management by guiding preventive interventions, with the goal of reducing the incidence of new diseases. Studies examining their impacts are uncommon, and no consensus regarding their effects has been reached. This systematic review sought to determine the impact of risk prediction models for chronic diseases on physician behaviour, patient behaviour, and patient health outcomes. Twenty-two studies were found to be eligible for review. The results demonstrated that: 1) physician behaviour may be positively influenced, though a statistically significant result was not found; 2) alterations in patient behaviour were inconclusive; and 3) some aspects of patient health outcomes were significantly improved, such as changes in blood pressure, but these results may be clinically insignificant. The evidence indicates some effects may exist, though future studies are required to confirm this effect

Speech-Language Pathology Graduate Student Clinicians’ Self-Perceived Competency in Dysphagia Management

Speech-language pathologists (SLPs) are the preferred healthcare providers for managing the direct clinical care of patients with dysphagia. By assessing self-perceived competency during academic training, SLP graduate student clinicians may increase their understanding of their skills in dysphagia management. We modified the Dysphagia Competency Verification Tool (DCVT) to use a 5-point ordinal scale to explore how SLP graduate student clinicians’ self-perception of competency in dysphagia management changes over time and to determine the impact of clinical practicum experiences. Seventy-two SLP graduate student clinicians rated their self-perceived competency for four DCVT domains. We used Generalized Estimating Equations (GEE) models to analyze the statistical significance of self-perception of competency ratings for each of the DCVT domains across semesters while accounting for clinical practicum experiences. Overall, the SLP graduate student clinicians indicated an increase in DCVT scores from the beginning of their graduate training program to the time of graduation, but did not perceive themselves as Adequate on most items of the DCVT until their last semester. These results suggest that both SLP graduate student clinicians and SLP graduate training programs would benefit from using a standardized metric to assess self-perceived competence in dysphagia management. DCVT self-perceived competency ratings could inform SLP graduate student clinicians about areas of dysphagia management practice and skills that need further development, allowing them to target these specific areas and gain actual competence

Chemoprevention for Primary Breast Cancer Risk Reduction for Women at High Risk of Breast Cancer: Implementing an Evidence-Based Recommendation

This capstone project was an evidence-based quality improvement project with three objectives: (a) to understand current practice of primary breast cancer chemoprevention in an integrated health system; (b) to evaluate the most current evidence available and the U.S. Preventive Services Task Force’s (2013) Breast Cancer: Medications for Risk Reduction recommendation; and (c) to plan for implementation of the recommendation as a clinical practice guideline and evaluate the guideline outcomes through a future pilot study. The pilot study was not part of the capstone but included for planning purposes. Evidence exists of the effectiveness of selective estrogen receptor modulators and aromatase inhibitors for risk reduction of primary breast cancer for women at high risk for the development of breast cancer. Recommendations have been published by national prevention and oncology organizations advocating use of these pharmacologic agents in the high-risk female population. Despite good evidence, the use of medications to prevent breast cancer among women at high risk has not been put into practice. Local data support that women at high risk of breast cancer have not been educated about nor offered medications to reduce their risk. A Delphi method was used to understand obstacles to recommendation of chemoprevention and strategies to facilitate discussions with high-risk women. The development and implementation of a clinical practice guideline for breast cancer risk reduction would increase use of current evidence consistent with national standards of care, inform women of options for breast cancer risk reduction, and engage healthcare providers in shared decision-making with women relevant to breast cancer risks

Catheter-directed therapy to treat intermediate- and high-risk pulmonary embolism: Personal experience and review of the literature

Pulmonary embolism (PE) is the third leading cause of cardiovascular death in the western world. Prompt recognition, risk stratification, and individualized treatment are crucial to improve outcomes in patients with PE. Anticoagulation alone is a sufficient therapeutic option in low-risk patients, whereas primary reperfusion with systemic thrombolysis (ST) is usually chosen in high-risk patients. The choice of treatment in intermediate-risk patients is complex and depends on the clinical presentation. Catheter-directed therapy (CDTh) includes all therapies delivered via a catheter placed in the branches of the pulmonary arteries directly into the thrombus. Because ST bears a high risk of major bleeding and numerous patients have contraindications to ST, CDTh is an alternative to ST in intermediate- and high-risk PE patients. CDTh includes local thrombolysis using low-dose alteplase, ultrasound-assisted thrombolysis, and mechanical fragmentation and aspiration of the thrombi, as well as their combinations. In this review article, we have summarized devices and technical details for CDTh, discussed the efficacy and safety of CDTh in comparison to ST in previous clinical trials, and outlined future research directions regarding CDTh, both based on the literature and our personal experience from the local PE Response Team of the Center for the Management of Pulmonary Embolism (CELZAT) in Warsaw

Інтелектуальна CBR система для автоматизації процесу пошуку ефективних методів очищення викидних газів

В наш час більшість прикладних комп'ютерних засобів впроваджує методи та засоби штучного інтелекту. Одним з таких методів є так званий висновок заснований на прецедентах – Case based reasoning (CBR). Головна ідея CBR полягає у виборі рішення на основі досвіду. Тобто, розглянувши подібні випадки в минулому, можна класифікувати новий випадок. Саме цей підхід запропоновано авторами для використання в інтелектуальній системі вибору методів очищення викидних газів від оксидів азоту та сірки.In this study, the objective is to develop an intelligent system for making decisions on the choice of methods for cleaning exhaust gases from sulfur and nitrogen oxides using the Case-Based Reasoning- (CBR). The task of automating the selection of effective methods for cleaning waste gases is urgent and meets the paradigm of sustainable development. A database on methods for cleaning exhaust gases from nitrogen and sulfur oxides was created. The potential use of intelligent inference on precedents from the database to select the most appropriate cleaning method for new emission stream data is considered. The work of the CBR method is represented as a life cycle, which has four main stages: Retrieving, Reusing, Revising and Retaining. The following characteristics of precedents were considered: degree of purification, initial concentration, temperature, presence of impurities, obtained product, material consumption, and energy consumption. All of these characteristics (in CBR attributes), except for the fourth and fifth, are given by numerical values with respective units of measurement and can be easily normalized. The presence of impurities and the product are categorical attributes with a certain set of values (classes). One of the main problems in CBR was solved: the problem of choosing the type of indexes. A set of all input characteristics of the precedent as indices is suggested to be used for the proposed decision support system (DSS) for methods of cleaning gas emissions. The first two phases of the CBR lifecycle use the k-nearest neighbor method to Retrieving and Reusing. The Euclidean metric is used to estimate the distances between precedents in the developed system. During the third and fourth phases of CBR, the intervention of the decision maker is provided. The process finishes with the adoption of the found solution and the possible storage of this solution in the base of use cases. An intelligent decision-making system has been developed for the selection of methods for cleaning exhaust gases from sulfur and nitrogen oxides based on the method of inference by precedents (CBR), which has been done for the first time for such tasks of chemical technology

Systemic Treatment for Advanced and Metastatic Non-Clear Cell Renal Cell Carcinoma: Examining Modern Therapeutic Strategies for a Notoriously Challenging Malignancy

Non-clear cell renal cell carcinoma (nccRCC) is a heterogeneous group of malignancies that represents 25% of renal cell carcinoma (RCC) cases. Treatment for non-clear cell histologies is mostly based on evidence from small phase II clinical trials or extrapolated from successful therapies in clear cell RCC because of the low incidence of non-clear cell pathology. Advances in genomic profiling have improved clinicians’ understanding of molecular targets for nccRCC, such as altered mesenchymal epithelial transition (MET) gene status and fumarate hydratase (FH) gene inactivation, but patient outcomes remain poor and optimal management of this disease remains unclear. This review assesses outcomes by histologic subtype from 27 prospective and 13 ongoing clinical trials to identify therapeutic strategies for advanced or metastatic nccRCC. Vascular endothelial growth factor tyrosine kinase inhibitors (TKI), such as sunitinib, and mammalian target of rapamycin (mTOR) inhibitors, such as everolimus, have demonstrated efficacy and remain viable treatment options, with a preference for sunitinib. However, everolimus is preferred in patients with chromophobe RCC because folliculin (FLCN) gene mutations upregulate the mTOR pathway. Novel TKIs, such as cabozantinib, show improved outcomes in patients with papillary RCC because of targeted MET inhibition. Platinum-based chemotherapy continues to be the recommended treatment strategy for collecting duct and medullary RCC. Clinically meaningful antitumor activity has been observed across all non-clear cell histologies for immune checkpoint inhibitors, such as nivolumab, pembrolizumab, and ipilimumab. Ongoing trials are evaluating novel tyrosine kinase inhibitor and immunotherapy combination regimens, with an emphasis on the promising MET-inhibitor cabozantinib and pembrolizumab plus lenvatinib

Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium

Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients

Treatment of high- and intermediate-high-risk pulmonary embolism by the Pulmonary Embolism Response Team: Focus on catheter-directed therapies

Background: Multidisciplinary Pulmonary Embolism Response Teams (PERTs) were established to individualize the treatment of high-risk (HR) and intermediate-high-risk (IHR) pulmonary embolism (PE) patients, which pose a challenge in clinical practice. Methods: We retrospectively collected the data of all HR and IHR acute PE patients consulted by PERT CELZAT between September 2017 and October 2022. The patient population was divided into four different treatment methods: anticoagulation alone (AC), systemic thrombolysis (ST), surgical embolectomy (SE), and catheter-directed therapies (CDTx). Baseline clinical characteristics, risk stratification, PE severity parameters, and treatment outcomes were compared between the four groups. Results: Of the 110 patients with HR and IHR PE, 67 (61%) patients were treated with AC only, 11 (10%) with ST, 15 (14%) underwent SE, and 17 (15%) were treated with CTDx. The most common treatment option in the HR group was reperfusion therapy, used in 20/24 (83%) cases, including ST in 7 (29%) patients, SE in 5 (21%) patients, and CTDx in 8 (33%) patients. In contrast, IHR patients were treated with AC alone in 63/86 (73%) cases. The in-hospital mortality rate was 9/24 (37.5%) in the HR group and 4/86 (4.7%) in the IHR group. Conclusions: The number of advanced procedures aimed at reperfusion was substantially higher in the HR group than in the IHR PE group. Despite the common use of advanced reperfusion techniques in the HR group, patient mortality remained high. There is a need further to optimize the treatment of patients with HR PE to improve outcomes

Randomized Controlled Trial of Mechanical Thrombectomy Versus Catheter-directed Thrombolysis for Acute Hemodynamically Stable Pulmonary Embolism: Rationale and Design of the PEERLESS Study.

BACKGROUND The identification of hemodynamically stable pulmonary embolism (PE) patients who may benefit from advanced treatment beyond anticoagulation is unclear. However, when intervention is deemed necessary by the PE patient's care team, data to select the most advantageous interventional treatment option are lacking. Limiting factors include major bleeding risks with systemic and locally delivered thrombolytics and the overall lack of randomized controlled trial (RCT) data for interventional treatment strategies. Considering the expansion of the Pulmonary Embolism Response Team (PERT) model, corresponding rise in interventional treatment, and number of thrombolytic and non-thrombolytic catheter-directed devices coming to market, robust evidence is needed to identify the safest and most effective interventional option for patients. METHODS The PEERLESS study (ClinicalTrials.gov identifier: NCT05111613) is a currently enrolling multinational RCT comparing large-bore mechanical thrombectomy (MT) with the FlowTriever System (Inari Medical, Irvine, CA) vs catheter-directed thrombolysis (CDT). A total of 550 hemodynamically stable PE patients with right ventricular (RV) dysfunction and additional clinical risk factors will undergo 1:1 randomization. Up to 150 additional patients with absolute thrombolytic contraindications may be enrolled into a non-randomized MT cohort for separate analysis. The primary endpoint will be assessed at hospital discharge or 7 days post procedure, whichever is sooner, and is a composite of the following clinical outcomes constructed as a hierarchal win ratio: 1) all-cause mortality, 2) intracranial hemorrhage, 3) major bleeding, 4) clinical deterioration and/or escalation to bailout, and 5) intensive care unit admission and length of stay. The first 4 components of the win ratio will be adjudicated by a Clinical Events Committee, and all components will be assessed individually as secondary endpoints. Other key secondary endpoints include all-cause mortality and readmission within 30 days of procedure and device- and drug-related serious adverse events through the 30-day visit. IMPLICATIONS PEERLESS is the first RCT to compare two different interventional treatment strategies for hemodynamically stable PE and results will inform strategy selection after the physician or PERT determines advanced therapy is warranted

Group autonomy enhancing treatment versus cognitive behavioral therapy for anxiety disorders:A cluster‐randomized clinical trial

Background Although cognitive behavioral therapy (CBT) is effective in the treatment of anxiety disorders, few evidence-based alternatives exist. Autonomy enhancing treatment (AET) aims to decrease the vulnerability for anxiety disorders by targeting underlying autonomy deficits and may therefore have similar effects on anxiety as CBT, but yield broader effects. Methods A multicenter cluster-randomized clinical trial was conducted including 129 patients with DSM-5 anxiety disorders, on average 33.66 years of age (SD = 12.57), 91 (70.5%) female, and most (92.2%) born in the Netherlands. Participants were randomized over 15-week groupwise AET or groupwise CBT and completed questionnaires on anxiety, general psychopathology, depression, quality of life, autonomy-connectedness and self-esteem, pre-, mid-, and posttreatment, and after 3, 6, and 12 months (six measurements). Results Contrary to the hypotheses, effects on the broader outcome measures did not differ between AET and CBT (d = .16 or smaller at post-test). Anxiety reduction was similar across conditions (d = .059 at post-test) and neither therapy was superior on long term. Conclusion This was the first clinical randomized trial comparing AET to CBT. The added value of AET does not seem to lie in enhanced effectiveness on broader outcome measures or on long term compared to CBT. However, the study supports the effectiveness of AET and thereby contributes to extended treatment options for anxiety disorders. The study was preregistered at the Netherlands Clinical Trial Registry (https://www.trialregister.nl/trial/6250