Socioeconomic determinants of community knowledge and practice in relation to malaria in high- and low-transmission areas of central India.

This study was undertaken with an aim of exploring community knowledge and treatment practices related to malaria and their determinants in high- and low-transmission areas of central India. A community-based cross-sectional study was carried out between August 2015 and January 2016 in two high- and two low-malaria-endemic districts of central India. A total of 1470 respondents were interviewed using a pre-tested structured interview schedule. Respondents residing in high-transmission areas with higher literacy levels, and of higher socioeconomic status, were found to practise more modern preventive measures than those living in low-transmission areas with low literacy levels and who were economically poor. Level of literacy, socioeconomic status and area (district) of residence were found to be the main factors affecting people's knowledge of malaria aetiology and clinical features, and prevention and treatment practices, in this community in central India.

'God grant it may do good two all': the madhouse practice of Joseph Mason, 1738-79.

Private madhouses made a significant contribution to the development of psychiatric practices in eighteenth-century England. Joseph Mason of Bristol, proprietor of a madhouse at Stapleton and then at nearby Fishponds, was part of a dynasty of successful and respected mad-doctors. A deeply religious man, his Christian ethics constituted the guiding force in his work with patients and interactions with their relatives. He was also an astute man of business, who recognized that comfortable domestic surroundings and the achievement of recoveries would enhance his reputation and attract lucrative middle-class custom. His treatment approaches, illustrated in a 1763 diary, were eclectic and pragmatic, comprising various medicines, dietary regulation, graded social interactions, and the cultivation of individualized therapeutic relationships with his patients.

Trends in US Vascular Access Use, Patient Preferences, and Related Practices: An Update From the US DOPPS Practice Monitor With International Comparisons.

BACKGROUND: Since the bundled end-stage renal disease prospective payment system began in 2011 in the United States, some hemodialysis practices have changed substantially, raising the question of whether vascular access practice also has changed. We describe monthly US vascular access use from August 2010 to August 2013 with international comparisons, and other aspects of US vascular access practice. STUDY DESIGN: Prospective observational cohort study of vascular access. SETTING & PARTICIPANTS: Maintenance hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) in the United States (N=3,442; US patients) and 19 other nations (N=8,478). PREDICTORS: Country, patient demographics, time period. OUTCOMES: Vascular access use, pre-end-stage renal disease access timing of first nephrologist care and arteriovenous access placement, patient self-reported vascular access preferences (United States only), treatment practices as stated by medical directors. RESULTS: In the United States from August 2010 to August 2013, arteriovenous fistula (AVF) use increased from 63% to 68%, while catheter use declined from 19% to 15%. Although AVF use did not differ greatly across age groups, arteriovenous graft use was 2-fold higher among black (26%) versus nonblack US patients (13%) in 2013. Across 20 countries in 2013, AVF use ranged from 49% to 92%, whereas catheter use ranged from 1% to 45%. Patient-reported vascular access preferences differed by sex and race, with 16% to 20% of patients feeling uninformed regarding benefits/risks of different vascular access types. Among new (incident) US hemodialysis patients, AVF use remains low, with ∼70% initiating hemodialysis therapy with a catheter (60% starting with catheter when having ≥4 months of predialysis nephrology care). In the United States, longer typical times to first AVF cannulation were reported. LIMITATIONS: Noncompletion of surveys may affect the generalizability of findings to the wider hemodialysis population. CONCLUSIONS: AVF use has increased, with catheter use decreasing among prevalent US hemodialysis patients since the introduction of the prospective payment system. However, AVF use at dialysis therapy initiation remains low, suggesting that reforms affecting predialysis care may be necessary to incentivize improvements in fistula rates at dialysis therapy initiation as achieved for prevalent hemodialysis patients.

Treatment practices, outcomes, and costs of multidrug-resistant and extensively drug-resistant tuberculosis, United States, 2005-2007.

To describe factors associated with multidrug-resistant (MDR), including extensively-drug-resistant (XDR), tuberculosis (TB) in the United States, we abstracted inpatient, laboratory, and public health clinic records of a sample of MDR TB patients reported to the Centers for Disease Control and Prevention from California, New York City, and Texas during 2005-2007. At initial diagnosis, MDR TB was detected in 94% of 130 MDR TB patients and XDR TB in 80% of 5 XDR TB patients. Mutually exclusive resistance was 4% XDR, 17% pre-XDR, 24% total first-line resistance, 43% isoniazid/rifampin/rifabutin-plus-other resistance, and 13% isoniazid/rifampin/rifabutin-only resistance. Nearly three-quarters of patients were hospitalized, 78% completed treatment, and 9% died during treatment. Direct costs, mostly covered by the public sector, averaged $134,000 per MDR TB and $430,000 per XDR TB patient; in comparison, estimated cost per non-MDR TB patient is $17,000. Drug resistance was extensive, care was complex, treatment completion rates were high, and treatment was expensive.

High-volume facilities are significantly more likely to use guideline-adherent systemic immunotherapy for metastatic Merkel cell carcinoma: implications for cancer care regionalization.

Merkel cell carcinoma (MCC) is a neuroendocrine skin cancer with a high rate of mortality. While still relatively rare, the incidence of MCC has been rapidly rising in the US and around the world. Since 2017, two immunotherapeutic drugs, avelumab and pembrolizumab, have been FDA-approved for the treatment of metastatic MCC and have revolutionized outcomes for MCC. However, real-world outcomes can differ from clinical trial data, and the adoption of novel therapeutics can be gradual. We aimed to characterize the treatment practices and outcomes of patients with metastatic MCC across the US. A retrospective cohort study of adult cases of MCC in the National Cancer Database diagnosed from 2004 to 2019 was performed. Multivariable logistic regressions to determine the association of a variety of patient, tumor, and system factors with likelihood of receipt of systemic therapies were performed. Univariate Kaplan-Meier and multivariable Cox survival regressions were performed. We identified 1017 cases of metastatic MCC. From 2017 to 2019, 54.2% of patients received immunotherapy. This increased from 45.1% in 2017 to 63.0% in 2019. High-volume centers were significantly more likely to use immunotherapy (odds ratio 3.235, p = 0.002). On univariate analysis, patients receiving systemic immunotherapy had significantly improved overall survival (p < 0.001). One-, 3-, and 5-year survival was 47.2% (standard error [SE] 1.8%), 21.8% (SE 1.5%), and 16.5% (SE 1.4%), respectively, for patients who did not receive immunotherapy versus 62.7% (SE 3.5%), 34.4% (SE 3.9%), and 23.6% (SE 4.4%), respectively, for those who did (Fig. 1). In our multivariable survival regression, receipt of immunotherapy was associated with an approximately 35% reduction in hazard of death (hazard ratio 0.665, p < 0.001; 95% CI 0.548-0.808). Our results demonstrate that the real-world survival advantage of immunotherapy for metastatic MCC is similar to clinical trial data. However, many patients with metastatic disease did not receive this guideline-recommended therapy in our most recent study year, and use of immunotherapy is higher at high-volume centers. This suggests that regionalization of care to high-volume centers or dissemination of their practices, may ultimately improve patient survival.

Newborn Screening for Spinal Muscular Atrophy: Variations in Practice and Early Management of Infants with Spinal Muscular Atrophy in the United States.

In the United States (U.S.), newborn screening (NBS) for spinal muscular atrophy (SMA) is implemented by individual states. There is likely variation in the practice patterns of state NBS programs and among the providers caring for newborns with SMA. This is a prospective, descriptive, observational study that seeks to quantify and describe practice patterns and heterogeneities in state NBS programs and provider practices in the U.S. We surveyed U.S. state NBS programs and care providers of newborns with SMA. Thirty states and 41 practitioners responded. NBS program practices vary by state. Most (74%) state programs provide results to both primary care and specialist providers and also defer confirmatory SMA testing to those providers. Two states had relatively high rates of false-positive or inclusive results. The total birth prevalence of SMA was 1:13,862. Most providers were in tertiary care centers (90%) and were child neurologists (81%) and/or had fellowship training in Neuromuscular Medicine or Electromyography (76%). All providers see new referrals in less than a week, but many do not initiate treatment until >3 weeks of age (39%), with most commonly reported delays related to insurance processes. Most (81%) prefer onasemnogene abeparvovec-xioi (OA) as the treatment of choice, mainly due to perceived efficacy and the route/frequency of administration. NBS practice patterns in the U.S. vary by state but overall yielded the predicted birth prevalence of positive results. Providers evaluate these newborns urgently, but many do not initiate therapy until after 3 weeks of age. Treatment delays are mainly related to insurance processes.

Primary care providers' knowledge, beliefs and treatment practices for gout: results of a physician questionnaire.

OBJECTIVE: We sought to examine primary care providers' gout knowledge and reported treatment patterns in comparison with current treatment recommendations. METHODS: We conducted a national survey of a random sample of US primary care physicians to assess their treatment of acute, intercritical and tophaceous gout using published European and American gout treatment recommendations and guidelines as a gold standard. RESULTS: There were 838 respondents (response rate of 41%), most of whom worked in private practice (63%) with >16 years experience (52%). Inappropriate dosing of medications in the setting of renal disease and lack of prophylaxis when initiating urate-lowering therapy (ULT) accounted for much of the lack of compliance with treatment recommendations. Specifically for acute podagra, 53% reported avoidance of anti-inflammatory drugs in the setting of renal insufficiency, use of colchicine at a dose of ≤2.4 mg/day and no initiation of a ULT during an acute attack. For intercritical gout in the setting of renal disease, 3% would provide care consistent with the recommendations, including initiating a ULT at the appropriate dose with dosing titration to a serum urate level of ≤6 mg/dl and providing prophylaxis. For tophaceous gout, 17% reported care consistent with the recommendations, including ULT use with dosing titration to a serum urate level of ≤6 mg/dl and prophylaxis. CONCLUSION: Only half of primary care providers reported optimal treatment practices for the management of acute gout and <20% for intercritical or tophaceous gout, suggesting that care deficiencies are common.

Review of Potential Barriers to Effective Hemostatic Management of Acquired Hemophilia A by Non-Hemophilia Experts in the United States.

Acquired hemophilia A (AHA) is an ultra-rare autoimmune disorder caused by autoantibodies against factor VIII. It often presents with life-threatening bleeding to non-hemophilia experts, who have limited awareness of this condition. This review evaluated hemostatic management and identified barriers to optimal management of AHA by non-hemophilia experts in the United States through a literature review. AHA case reports published by non-hemophilia experts from January 2016 through November 2021 in non-hematology journals were critically reviewed for a chronology of clinical course and management, consultation with a hemophilia expert, referencing of available AHA recommendations, discussion of all hemostatic options, and bleed control outcomes; 24 case reports representing 24 patients were identified. Twelve patients had an apparent delay in diagnosis, 17 cases did not seek expert consultation, and 15 did not reference the 2009 International AHA Recommendations, including six in whom hemostatic treatment was not consistent with the recommendations. Of the 17 articles published after the 2017 AHA Guidance, eight did not reference them. Of the five articles published after the 2020 International Recommendations for AHA, three did not reference them. Overall, 14 articles did not discuss all available hemostatic treatment options. Four patients died. Our findings reveal variability in hemostatic management of AHA by non-hemophilia experts in the United States. Lack of AHA awareness remains a primary barrier for optimal management of AHA among non-hemophilia experts. Increasing education about existing AHA guidelines, including available therapies and access to expert care at hemophilia treatment centers, may help improve the outcomes of patients with AHA.

Community-based care for autistic youth: community providers' reported use of treatment practices in the United States.

Introduction: To illustrate the landscape of community-based care for autistic youth in the United States, we identified transdisciplinary psychosocial intervention practice sets that community providers report utilizing to care for this population, and examined characteristics associated with provider-reported utilization. Methods: The Usual Care for Autism Study (UCAS) Survey assessed provider demographics and provider-reported use of transdisciplinary practices for common ASD co-occurring problems: social difficulties, externalizing behaviors, and anxiety. Community practitioners (N = 701) from allied health, behavioral, education, medical, mental health and other disciplines who treat or work with autistic youth (7-22 years) participated. Results: Exploratory factor analysis yielded four factors: Consequence-Based Strategies (CBS), Cognitive-Behavioral and Therapy Strategies (CBTS), Antecedent-Based Strategies (ABS), and Teaching Strategies (TS). Providers across disciplines reported utilizing ABS more often than other sets. Providers from behavioral disciplines, with less than 4-year or Master degrees, or with more experience reported the most use of ABS, CBS and CBTS. Medical and behavioral providers reported the most use of TS. Setting and child characteristics were associated with practice set use, indicating variability by disability and client socioeconomic status. Discussion: Findings reflect the complexity and inconsistency of the service landscape for autistic youth across the U.S. Only by understanding the service landscape and predictors of practice utilization, can researchers, policymakers, provider groups, and the autistic community facilitate effective implementation strategy development and use to ultimately improve community-based care.

Navigating the Pandemic: An Exploration of Medical Practitioners' Preparedness, Concerns, Adaptations, and Practices During the COVID-19 Epidemic in India.

Introduction The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has had profound health and societal impacts, and healthcare providers from diverse backgrounds had to continuously adapt and update to manage patient care, prevent morbidity-mortality, and minimize transmission of the infection. Methodology A cross-sectional survey was conducted among 218 doctors in western India. A structured questionnaire was used to gather data on demographic characteristics, patient consultations, infection prevention practices, COVID-19 diagnosis, management, vaccination attitudes, and healthcare program disruptions. Multistage probability sampling was undertaken to select 161 (64%) private and 57 (26%) public sector doctors from the list of clinics and hospitals reporting COVID-19 cases in the urban municipal corporation area of South Gujarat. Private sector doctors were contacted through the network of public administrative staff and caregivers of their area. They were provided the choice of date, time, and mode (telephonically, face to face, or online) of interview. Descriptive measures of central tendency and variation were calculated. Inferential statistics was applied to test the significance of the difference between sub-groups. For ratio and interval variables, t-test (for two groups) and ANOVA (for more than two groups) were applied while for nominal and ordinal variables, chi-square and appropriate tests were applied. Results The mean age of the 218 doctors included in the study was 43.6 ± 11.1 years while the mean duration of practice was 16.9 ±10.8 years. During the pandemic, patients' consultation frequencies decreased at the clinics while telephonic and residential consultancies increased, which was statistically significant (P=0.000). Social distancing (n= 187; 85%), isolation (n=157; 72%), and consultation reduction (n=65; 30%) were adopted by doctors. Both public and private doctors preferred government-recognized COVID-19 centers for testing (n=167; 76.7%) and reverse transcriptase-polymerase chain reaction (RT-PCR) as the standard diagnostic test (n=196; 90%). A combination of antipyretics, favipiravir, and antibiotics was used to manage symptomatic cases. Concerns and emotional stress for personal and family safety were prominent among this group of frontline medical doctors (94%). Delivery of healthcare programs for chronic conditions like hypertension and tuberculosis was negatively affected (n=102; 47%). Despite these challenges, doctors managed cases and advised vaccination to control the pandemic. Conclusion This study among over 200 qualified medical practitioners during the pandemic attempts to fill gaps in COVID-19 management, prevention, and safety measures. To the best of our knowledge, this is one of the few studies providing genuine insights into the practice of private doctors with a large sample size. Findings show the established treatment, prophylaxis, and vaccination protocols among private and public practitioners. It highlights the need for adaptable healthcare strategies and collaboration between public and private sectors for managing future global health emergencies.

Household Water Treatment Practice and Associated Factors in Rural Households of Sodo Zuria District, Southern Ethiopia: Community-Based Cross-Sectional Study.

Introduction: In Ethiopia, access to safe drinking water is very low, and even safe water at the point of distribution is subjected to frequent and substantial contamination during collection, transport, and storage. The purpose of this study was to assess the level of household water treatment practices and associated factors in rural households of the Sodo Zuria district, southern Ethiopia. Methods: A community-based cross-sectional study was conducted in 836 households using a multistage sampling technique. A structured and pre-tested questionnaire was used. Binary and multivariate logistic regression analysis was used. Results: The household water treatment practice was 44.1%. Households having a higher estimated monthly income, AOR = 1.5 (1.23, 3.47), older age greater than 45 years, AOR = 1.69 (1.08, 2.64), fetching water twice a day, AOR = 2.8 (1.21, 9.17), weekly washing of the water storage container, AOR = 0.3 (0.11, 0.83), and using the dipping technique to draw water from the collection jar, AOR = 1.67 (1.14, 2.42) were significant factors in the practice of household water treatment in the study. Conclusions: The household water treatment practice was low. Higher estimated monthly income, older household heads, fetching water twice per day, washing the water storage container weekly, and dipping techniques to draw water from water storage containers were significant factors of household water treatment practices. Thus, proper hygiene of water storage, and engaging the community in income-generating activities were recommended.

TreatmentPatterns: An R package to facilitate the standardized development and analysis of treatment patterns across disease domains.

BACKGROUND AND OBJECTIVES: There is an increasing interest to use real-world data to illustrate how patients with specific medical conditions are treated in real life. Insight in the current treatment practices helps to improve and tailor patient care, but is often held back by a lack of data interoperability and a high-level of required resources. We aimed to provide an easy tool that overcomes these barriers to support the standardized development and analysis of treatment patterns for a wide variety of medical conditions. METHODS: We formally defined the process of constructing treatment pathways and implemented this in an open-source R package TreatmentPatterns (https://github.com/mi-erasmusmc/TreatmentPatterns) to enable a reproducible and timely analysis of treatment patterns. RESULTS: The developed package supports the analysis of treatment patterns of a study population of interest. We demonstrate the functionality of the package by analyzing the treatment patterns of three common chronic diseases (type II diabetes mellitus, hypertension, and depression) in the Dutch Integrated Primary Care Information (IPCI) database. CONCLUSION: TreatmentPatterns is a tool to make the analysis of treatment patterns more accessible, more standardized, and more interpretation friendly. We hope it thereby contributes to the accumulation of knowledge on real-world treatment patterns across disease domains. We encourage researchers to further adjust and add custom analysis to the R package based on their research needs.

Determinants of Household-Level Water Treatment Practices in Southern Ethiopia.

Background: Household water treatment and handling is an important component of a global strategy to provide safe water to millions of people who live without adequate water currently. Household water treatment at the point of use also helps to improve drinking water quality for millions who suffer due to contamination of their drinking water. This study aims to assess household-level water treatment practices and associated factors in Southern Ethiopia. Methods: A community-based cross-sectional study was conducted among selected households using a systematical random sampling technique in Bule town. Data was collected using a pretested, structured questionnaire and analyzed using STATA version 16. A variable with a P-value ⩽ .25 in bi-variable regression was entered into multivariable regression and then a variable with a P-value ⩽ .05 was taken as statistically significant. Results: The study found that only 29.9% (with a 95% CI: 25.3-34.6) of households have good water treatment practices for drinking purposes. Regarding predictors of household-level water treatment practices, respondents who had good knowledge were 5 times (AOR = 6.98, 95% CI = 4.01-11.9) more likely to practice household-level water treatment than their counterparts. In addition, respondents who earn more than 3000 ETB per month are twofold more likely to practice household water treatment than those with an average monthly income of less than 1000 ETB (AOR = 2.37, 95% CI = 1.22-4.60). Conclusions: Household-level water treatment was less common in Bule town. The household's monthly income and their knowledge status were found to be the determinants of household-level water treatment practices in the study area.

Usual care for youth with autism spectrum disorder: Community-based providers' reported familiarity with treatment practices.

Objective: To examine patterns and predictors of familiarity with transdisciplinary psychosocial (e.g., non-pharmacologic) practices for practitioners treating youths with autism spectrum disorder (ASD) in the United States. Method: Practitioners (n = 701) from behavioral, education, medical, and mental health backgrounds who worked with youth (ages 7-22) with ASD completed the Usual Care for Autism Survey, which assessed provider demographics and self-reported familiarity with transdisciplinary treatment practices for the most common referral problems of ASD. We examined relations between provider-, setting-, and client-level characteristics with familiarity of key groups of the treatment practices (practice sets). Practice sets were identified using exploratory factor analysis (EFA), and demographic predictors of practice subsets were examined using generalized estimating equations (GEE). Results: The EFA yielded a three-factor solution: (1) environmental modifications/antecedent strategies; (2) behavior analytic strategies; and (3) cognitive strategies, with overall familiarity ranked in this order. Medical providers indicated the least familiarity across disciplines. More experience with ASD and treating those with intellectual disabilities predicted greater familiarity with only environmental modifications/antecedent strategies and behavior analytic, but not cognitive strategies. Experience treating low SES clients predicted familiarity with environmental modification and behavior analytic strategies while experience treating high SES clients predicted familiarity with behavior analytic and cognitive strategies. Conclusion: This is the first study to identify transdisciplinary, interpretable sets of practices for treating youth with ASD based on community providers' reported familiarity. Results highlight factors associated with familiarity with practice sets, which is essential for mapping practice availability, and optimizing training and dissemination efforts for youth with ASD.

Real-world first-line treatment of patients with BRAFV600E-mutant metastatic colorectal cancer: the CAPSTAN CRC study.

BACKGROUND: BRAFV600E mutations occur in 8%-12% of metastatic colorectal cancer (mCRC) cases and are associated with poor survival. European guidelines recommend combination (doublet or triplet) chemotherapy plus bevacizumab in first line. However, an unmet need remains for more effective treatments for these patients. PATIENTS AND METHODS: CAPSTAN CRC is a European, retrospective, multicenter, observational study evaluating real-world treatment practices for patients with BRAFV600E-mutant mCRC treated between 1 January 2016 and 31 January 2020. The primary objective was to describe first-line treatment patterns. Secondary objectives included describing baseline demographics, mutational testing procedures, treatment effectiveness, and safety. RESULTS: In total, 255 patients (median age 66.0 years; 58.4% female) with BRAFV600E-mutant unresectable mCRC from seven countries were included. Most had right-sided tumors (52.5%) and presented with synchronous disease at diagnosis (66.4%). Chemotherapy plus targeted therapy (68.7%) was preferred at first line over chemotherapy alone (31.3%). The main first-line treatments were FOLFOX plus bevacizumab (27.1%) and FOLFOXIRI (folinic acid, 5-fluorouracil, oxaliplatin, irinotecan) with/without bevacizumab (27.1%/19.2%). Median duration of first-line treatment was 4.9 months. Overall, 52.5% received second-line treatment. Across all first-line regimens, progression-free survival (PFS) and overall survival were 6.0 [95% confidence interval (CI) 5.3-6.7] months and 12.9 (95% CI 11.6-14.1) months, respectively. Triplet plus targeted therapy was associated with more adverse events (75.0%) compared with triplet chemotherapy alone (50.0%) and doublet chemotherapy alone (36.1%). Multivariate analysis identified low body mass index and presence of three or more metastatic sites as significant prognostic factors for PFS. CONCLUSIONS: This study is, to date, the largest real-world analysis of patients with BRAFV600E-mutant mCRC, providing valuable insights into routine first-line treatment practices for these patients. The data highlight the intrinsic aggressiveness of this disease subgroup, confirming results from previous real-world studies and clinical trials, and stressing the urgent need for more effective treatment options in this setting.

An empirical modeling approach to predicting pollutant loads and developing cost-effective stormwater treatment strategies for a large urban watershed.

Stormwater treatment strategies were evaluated for the upper Ballona Creek Watershed in Los Angeles, CA using an empirical model of stormwater runoff quantity and quality with zeroth-order regularization and a limited memory Broyden-Fletcher-Goldfarb-Shanno Bound constrained optimization routine. The model used landuse based estimation on the runoff volume, event mean concentration (EMC) and pollutant load employing ten different landuses, including highways and local roads. The model was validated by showing that its predictions were in reasonable agreement (r2 ~0.6 to 0.8) with total zinc (Zn), Total Kjeldahl Nitrogen (TKN), and Total Suspended Solids (TSS) loadings measured at the monitoring site at the bottom of the watershed. The developed model was used to demonstrate and quantify the benefits of the stormwater treatment practices (STPs) prioritized at specific landuses with high pollutant mass emission rates. For this demonstration, total Zn was selected as it is one of the most concerning pollutants in an extremely urbanized area such as the Ballona Creek Watershed. Transportation landuse including local roads and highways was found to be the best candidate for the STP applications due to their high percent load contribution per percent area. By focusing STPs for transportation landuse, the water quality goal of total Zn in the study watershed was expected be achieved at approximately 75% less cost.

Projecting the long-term benefits of single pill combination therapy for patients with hypertension in five countries.

OBJECTIVE: To project the 10-year clinical outcomes associated with single pill combination (SPC) therapies compared with multi-pill regimens for the management of hypertension in five countries (Italy, Russia, China, South Korea and Mexico). METHODS: A microsimulation model was designed to project health outcomes between 2020 and 2030 for populations with hypertension managed according to four different treatment pathways: current treatment practices (CTP), single drug with dosage titration then sequential addition of other agents (start low and go slow, SLGS), free choice combination with multiple pills (FCC) and combination therapy in the form of a single pill (SPC). Model inputs were derived from the Global Burden of Disease 2017 dataset. Simulated outcomes of mortality, chronic kidney disease (CKD), stroke, ischemic heart disease (IHD), and disability-adjusted life years (DALYs) were estimated for 1,000,000 patients on each treatment pathway. RESULTS: SPC therapy was projected to improve clinical outcomes over SLGS, FCC and CTP in all countries. SPC reduced mortality by 5.4% in Italy, 4.9% in Russia, 4.5% in China, 2.3% in South Korea and 3.6% in Mexico versus CTP and showed greater reductions in mortality than SLGS and FCC. The projected incidence of clinical events was reduced by 11.5% in Italy, 9.2% in Russia, 8.4% in China, 4.9% in South Korea and 6.7% in Mexico for SPC versus CTP. CONCLUSIONS: Ten-year projections indicated that combination therapies (FCC and SPC) are likely to reduce the burden of hypertension compared with conventional management approaches, with SPC showing the greatest overall benefits due to improved adherence.

Practice Patterns for the Treatment of Uveal Melanoma with Iodine-125 Plaque Brachytherapy: Ocular Oncology Study Consortium Report 5.

BACKGROUND: Treatment planning for I-125 plaque therapy for uveal melanoma has advanced significantly since the Collaborative Ocular Melanoma Study trial, with more widely available image-guided planning and improved dosimetry. OBJECTIVE: We evaluated real-world practice patterns for I-125 plaque brachytherapy in the United States by studying practice patterns at centers that comprise the Ocular Oncology Study Consortium (OOSC). METHODS: The OOSC database and responses to a treatment practice survey were evaluated. The database contains treatment information from 9 institutions. Patients included in the database were treated between 2010 and 2014. The survey was conducted in 2018 and current treatment planning methods and prescriptions were queried. RESULTS: Examination of the OOSC database revealed that average doses to critical structures were highly consistent, with the exception of one institution. Survey responses indicated that most centers followed published guidelines regarding dose and prescription point. Dose rate ranged from 51 to 118 cGy/h. As of 2018, most institutions use pre-loaded plaques and fundus photographs and/or computed tomography or magnetic resonance imaging in planning. CONCLUSIONS: While there were differences in dosimetric practices, overall agreement in plaque brachytherapy practices was high among OOSC institutions. Clinical margins and planning systems were similar among institutions, while prescription dose, dose rates, and dosimetry varied.

Adherence to Treat-to-target Management in Rheumatoid Arthritis and Associated Factors: Data from the International RA BIODAM Cohort.

OBJECTIVE: Compelling evidence supports a treat-to-target (T2T) strategy for optimal outcomes in rheumatoid arthritis (RA). There is limited knowledge regarding the factors that impede implementation of T2T, particularly in a setting where adherence to T2T is protocol-specified. We aimed to assess clinical factors that associate with failure to adhere to T2T. METHODS: Patients with RA from 10 countries who were starting or changing conventional synthetic disease-modifying antirheumatic drugs and/or starting tumor necrosis factor inhibitors were followed for 2 years. Participating physicians were required per protocol to adhere to the T2T strategy. Factors influencing adherence to T2T low disease activity (T2T-LDA; 44-joint count Disease Activity Score ≤ 2.4) were analyzed in 2 types of binomial generalized estimating equations models: (1) including only baseline features (baseline model); and (2) modeling variables that inherently vary over time as such (longitudinal model). RESULTS: A total of 571 patients were recruited and 439 (76.9%) completed 2-year followup. Failure of adherence to T2T-LDA was noted in 1765 visits (40.5%). In the baseline multivariable model, a high number of comorbidities (OR 1.10, 95% CI 1.02-1.19), smoking (OR 1.32, 95% CI 1.08-1.63) and high number of tender joints (OR 1.03, 95% CI 1.02-1.04) were independently associated with failure to implement T2T, while anticitrullinated protein antibody/rheumatoid factor positivity (OR 0.63, 95% CI 0.50-0.80) was a significant facilitator of T2T. Results were similar in the longitudinal model. CONCLUSION: Lack of adherence to T2T in the RA BIODAM cohort was evident in a substantial proportion despite being a protocol requirement, and this could be predicted by clinical features. [Rheumatoid Arthritis (RA) BIODAM cohort; ClinicalTrials.gov: NCT01476956].

The effect of legislation on the treatment practices and role of naturopaths in South Africa.

BACKGROUND: In South Africa naturopaths have been practising for over half a century. Over this period, changes in legislation have resulted in different levels of training and registration processes - which has impacted on the profession in various ways. This paper explores the effect of legislation on the treatment practices and role of naturopaths in South Africa. METHODS: This was a qualitative study which used an exploratory approach. Participants were sampled from the list of naturopaths registered with the Allied Health Professions Council of South Africa (AHPCSA). A set of 15 open-ended survey questions were emailed to 59 naturopaths. Twenty one naturopaths participated: 13 responded via email and eight were interviewed. Responses were coded and thematically analysed. RESULTS: It was found that despite differences in training and years of practice experience, four core treatment practices of diet therapy, lifestyle medicine, supplementation and physical therapies were common to all participants with the older, more experienced naturopaths using a wider range of treatment practices. There is a shared common vision of wanting the profession to have greater participation in the public healthcare system. This research has found that legislation influences the treatment practices and role played by naturopaths in South Africa. The findings of this paper acknowledges the limiting impact of state legislation on naturopathic and other complementary medicine professions. CONCLUSION: Naturopathy has to operate within the legislative framework and this appears to be one of the key factors which has contributed to the lack of growth of naturopathy in South Africa. Findings thus highlight the need for new legislation to reflect the changes in society to ensure that the emergent healthcare needs of the population are met.