Neurodevelopmental outcome in complicated twin pregnancy: prospective observational study

OBJECTIVE

Twin pregnancy is associated with increased perinatal mortality and morbidity, but long-term neurodevelopmental outcome remains underinvestigated. The primary objective of this study was to investigate the incidence of adverse neurodevelopment after 1 year of age in complicated monochorionic diamniotic (MCDA) twin pregnancies compared with uncomplicated twin pregnancies.

METHODS

This was a prospective cohort study conducted at St George's University Hospital NHS Foundation Trust, London, UK. Women with a twin pregnancy culminating in at least one surviving child, aged between 12 and 60 months (corrected for prematurity) at the time of assessment, were invited to complete the relevant Ages and Stages Questionnaire® version 3 (ASQ-3) test. The two study groups were: (1) complicated MCDA twin pregnancies, including those with twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective fetal growth restriction, twin reversed arterial perfusion sequence and/or single intrauterine demise; and (2) uncomplicated MCDA and dichorionic diamniotic twin pregnancies. The primary outcome measure was an abnormal ASQ-3 score, defined as a score of more than 2 SD below the mean in any one of the five domains. Mixed-effects multivariable logistic regression analysis was performed to determine whether a complicated MCDA twin pregnancy was associated independently with an abnormal ASQ-3 score.

RESULTS

The study included 174 parents who completed the questionnaire for one or both twins; therefore, 327 ASQ-3 questionnaires were available for analysis. Of those, 117 (35.8%) were complicated MCDA twin pregnancies and 210 (64.2%) were controls. The overall rate of an abnormal ASQ-3 score in children born of a complicated MCDA twin pregnancy was nearly double that of those from uncomplicated twin pregnancies (14.5% vs 7.6%; P = 0.056). Children born of a complicated MCDA twin pregnancy had a significantly higher rate of impairment in the gross-motor domain compared with the control group (8.5% vs 2.9%; P = 0.031). Complicated MCDA twin pregnancies that underwent prenatal intervention had a significantly higher rate of abnormal ASQ-3 score compared with those that did not undergo prenatal intervention (28.1% vs 1.7%; P < 0.001). On multilevel logistic regression analysis, complicated MCDA twin pregnancy was an independent predictor of abnormal ASQ-3 score (adjusted odds ratio, 3.28 (95% CI, 3.27-3.29); P < 0.001).

CONCLUSIONS

This study demonstrates that survivors of complicated MCDA twin pregnancies have a higher rate of adverse neurodevelopmental outcome, independently of prematurity. Long-term neurodevelopmental follow-up in these pregnancies can ensure timely and optimal management of those affected. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

POS1573-PARE Patient-Reported Outcome Measures of Pain Alleviation With Cannabinoid Usage in Rheumatoid and Psoriatic Arthritis: a Cross-Sectional Study

Background

Patient-Reported Outcome Measures (PROMs) give us direct, immediate evidence of patient experience. Pain is a chronic, debilitating, multifactorial, presenting symptom that remains a difficult target to treat in populations with Inflammatory Arthritides.1 Increasingly, cannabis products are being utilized and investigated for their potential analgesic and immune-modulatory effects.2 The legislation and form of cannabis products deployed as therapy varies around the world and across populations. More data on usage and patient reported outcomes is needed to guide better clinical practice and inform sound legislative policy.

Objectives

To describe PROMs of pain, stiffness with cannabis use in a population of patients with Rheumatoid Arthritis (RA) or Psoriatic Arthritis (PsA).

Methods

This investigation was a monocentric, cross-sectional study. Inclusion criteria were adults receiving care at a University Rheumatology practice in Central Florida, USA from December 2019 to March 2020 who provided informed, written consent. Those who consented were provided with a brief, voluntary, and anonymous Qualtrics survey which queried patient-reported prevalence and outcome measures of short and long-term pain relief. 236 RA and 43 PsA patients were enrolled in this study. All subjects met the criteria for Rheumatoid, Psoriatic, or Inflammatory Arthritis (seronegative RA). Subjects’ scores before and after cannabinoid use were compared with a paired T-test after the parametric nature of the data was established. Ethical approval was obtained from the University of Central Florida Institutional Review Board (Study00001041).

Results

Cannabis product usage was reported in 16.95% of RA subjects (40/236) and 11.63% of PsA subjects (5/43). Of this group, 71% (RA) and 40% (PsA) endorsed current usage. Inhalation was the most prevalent form used in RA (27.50%). In PsA, the most commonly reported forms were liquid (30%) and topical/skin (30%). On the 10-point pain scale, RA patients reported a significant reduction in average pain by 1.83±1.91 points in the long-term and 2.28±2.10 points in the short-term. Those with PsA reported a significant reduction in average pain by 1.60±0.89 points in the long-term and 1.80±0.84 points in the short term. Stiffness was also reduced in the RA group (7.3%). 17.5% of patients with RA using cannabinoids reported side effects not leading to cessation.

Conclusion

In an academic rheumatology practice population, a substantial number of RA and PsA patients are choosing to self-treat with cannabis therapy to manage their pain and other symptoms. Subjects reported significant reductions in both short- and long-term pain; some patients reported total pain resolution with ongoing cannabinoid therapy. Stiffness was also reduced in a subset of RA patients. Subjects that reported adverse effects did not find these severe enough to warrant cessation. These study results may allow for a more open discussion to improve safety and optimize outcomes. Additionally, the significant prevalence of usage and pain reduction reported provide a compelling rationale for further interventional studies in populations with Inflammatory Arthritides.

References

[1]Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010;376(9746): 1094-1108. doi: 10.1016/s0140-6736(10)60826-4.

[2]Fitzcharles, Mary-Ann et al. “Position Statement: A Pragmatic Approach for Medical Cannabis and Patients with Rheumatic Diseases.” The Journal of Rheumatology vol. 46,5 (2019): 532-538. doi:10.3899/jrheum.181120.

Disclosure of Interests

Tara Jehu: None declared, Neha Bhaskar: None declared, Shazia Beg: None declared, Kathlyn Camargo Macias: None declared, Sweta Chalise: None declared, Neha Bhanusali Consultant of: healthcare consultant (non-pharmaceutical)

Awareness on Hypertension and its Self-Management Practices Among Hypertensive Patients Attending Outreach Clinics of a Medical College in South India

Background Recent data suggest that hypertension is a significant public health problem in India. The success strategies for hypertension management depend upon clients' awareness on hypertension and its self-management practices. Objective To determine awareness, self-management practices and compliance with treatment among hypertensive patients. Method This cross-sectional study was done in January 2012 at four health centres in Mangalore. All confirmed cases of hypertension attending the outpatient department were interviewed using a semi-structured interview schedule. Result Majority (58.7%) of the 315 participants were of the age group 41 to 60 years and majority (53.6%) were males. Most patients (69.5%) were educated up to high school level. The awareness level about hypertension was average or good in majority (52.4%) of the participants. Self-management practices were found to be average or good among 60.6% cases. Good compliance with treatment was seen in 78.7% cases and blood pressure was in control in 72.4% cases. Quality of self-management practices was found to influence control of blood pressure (p=0.021). Awareness, self-management practices and compliance were found to be significantly poor among aged (above 50 years), males, less educated, unemployed, unskilled or retired patients. Conclusion Awareness on hypertension and self-management practices were average or above among majority of the studied population. However this study identified groups who need to be better educated and further monitored to achieve universal blood pressure control among hypertensive population during the routine health care services in this settings.

Formulation Design, Optimization and Pharmacodynamic Evaluation of Sustained Release Mucoadhesive Microcapsules of Venlafaxine HCl

The objective of present research work was to design and characterize the venlafaxine HCl-loaded sodium alginate-based mucoadhesive microcapsules by ionic gelation technique using HPMC K100M as mucoadhesive polymer. The Placket-Burman Design was applied for preliminary screening of the formulations and systematic optimization by using Box-Behnken Design. The prepared microcapsules were characterized for drug content, entrapment efficiency, micromeritic properties, particle size, swelling index, mucoadhesive strength, in vitro drug release and in vivo antidepressant activity. FTIR and differential scanning calorimetry studies showed no incompatibility. Surface morphology studies revealed spherical nature of the prepared microcapsules. In vitro drug release studies revealed sustained release by diffusion mechanism. Further, the microcapsules were effective in reducing the depression induced by forced swimming test in Sprague-Dawley rats compared to the pure drug. The microcapsules were found to be stable under accelerated stability conditions, which suggest them as better alternative delivery systems for enhanced therapeutic efficacy of antidepressant drug, venlafaxine HCl.

Improvement in Dissolution Rate of Cefuroxime Axetil by using Poloxamer 188 and Neusilin US2

A combination of fusion and surface adsorption techniques was used to enhance the dissolution rate of cefuroxime axetil. Solid dispersions of cefuroxime axetil were prepared by two methods, namely fusion method using poloxamer 188 alone and combination of poloxamer 188 and Neusilin US2 by fusion and surface adsorption method. Solid dispersions were evaluated for solubility, phase solubility, flowability, compressibility, Kawakita analysis, Fourier transform-infrared spectra, differential scanning calorimetry, powder X-ray diffraction study, in vitro drug release, and stability study. Solubility studies showed 12- and 14-fold increase in solubility for solid dispersions by fusion method, and fusion and surface adsorption method, respectively. Phase solubility studies showed negative ΔG⁰_tr values for poloxamer 188 at various concentrations (0, 0.25, 0.5, 0.75 and 1%) indicating spontaneous nature of solubilisation. Fourier transform-infrared spectra and differential scanning calorimetry spectra showed that drug and excipients are compatible with each other. Powder X-ray diffraction study studies indicated that presence of Neusilin US2 is less likely to promote the reversion of the amorphous cefuroxime axetil to crystalline state. in vitro dissolution studies, T50% and mean dissolution time have shown better dissolution rate for solid dispersions by fusion and surface adsorption method. Cefuroxime axetil release at 15 min (Q15) and DE15 exhibited 23- and 20-fold improvement in dissolution rate. The optimized solid dispersion formulation was stable for 6 months of stability study as per ICH guidelines. The stability was ascertained from drug content, in vitro dissolution, Fourier transform-infrared spectra and differential scanning calorimetry study. Hence, this combined approach of fusion and surface adsorption can be used successfully to improve the dissolution rate of poorly soluble biopharmaceutical classification system class II drug cefuroxime axetil.

Predictive factors for early aspiration in liver abscess

AIM: To determine the predictive factors for early aspiration in liver abscess.

METHODS: A retrospective analysis of all patients with liver abscess from 1995 to 2004 was performed. Abscess was diagnosed as amebic in 661 (68%) patients, pyogenic in 200 (21%), indeterminate in 73 (8%) and mixed in 32 (3%). Multiple logistic regression analysis was performed to determine predictive factors for aspiration of liver abscess.

RESULTS: A total of 966 patients, 738 (76%) male, mean age 43 ± 17 years, were evaluated: 540 patients responded to medical therapy while adjunctive percutaneous aspiration was performed in 426 patients. Predictive factors for aspiration of liver abscess were: age ≥ 55 years, size of abscess ≥ 5 cm, involvement of both lobes of the liver and duration of symptoms ≥ 7 d. Hospital stay in the aspiration group was relatively longer than in the non aspiration group. Twelve patients died in the aspiration group and this mortality was not statistically significant when compared to the non aspiration group.

CONCLUSION: Patients with advanced age, abscess size > 5 cm, both lobes of the liver involvement and duration of symptoms > 7 d were likely to undergo aspiration of the liver abscess, regardless of etiology.

Association of resident coverage with cost, length of stay, and profitability at a community hospital

OBJECTIVE

The effect of care by medical residents on hospital length of stay (LOS), indirect costs, and reimbursement was last examined across a range of illnesses in 1981; the issue has never been examined at a community hospital. We studied resource utilization and reimbursement at a community hospital in relation to the involvement of medical residents.

DESIGN

This nonrandomized observational study compared patients discharged from a general medicine teaching unit with those discharged from nonteaching general medical/surgical units.

SETTING

A 620-bed community teaching hospital with a general medicine teaching unit (resident care) and several general medicine nonteaching units (no resident care).

PATIENTS

All medical discharges between July 1998 and February 1999, excluding those from designated subspecialty and critical care units.

MEASUREMENTS AND MAIN RESULTS

Endpoints included mean LOS in excess of expected LOS, mean cost in excess of expected mean payments, and mean profitability (payments minus total costs). Observed values were obtained from the hospital's database and expected values from a proprietary risk-cost adjustment program. No significant difference in LOS between 917 teaching-unit patients and 697 nonteaching patients was demonstrated. Costs averaged $3,178 (95% confidence interval (CI) +/- $489) less than expected among teaching-unit patients and $4,153 (95% CI +/- $422) less than expected among nonteaching-unit patients. Payments were significantly higher per patient on the teaching unit than on the nonteaching units, and as a result mean, profitability was higher: $848 (95% CI +/- $307) per hospitalization for teaching-unit patients and $451 (95% CI +/- $327) for patients on the nonteaching units. Teaching-unit patients of attendings who rarely admitted to the teaching unit (nonteaching attendings) generated an average profit of $1,299 (95% CI +/- $613), while nonteaching patients of nonteaching attendings generated an average profit of $208 (95% CI +/- $437).

CONCLUSIONS

Resident care at our community teaching hospital was associated with significantly higher costs but also with higher payments and greater profitability.