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Introduction Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians' attitudes to deintensify or intensify treatment. Methods Data from older adults (>= 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of >= 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of >= 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s). Results the rate of overtreatment in the glycemia group (n = 1264) was 9.8% (n = 124) and that in the BP group (n = 1052) was 7.3% (n = 77), whereas the rate of undertreatment was 14.2% (n = 180) and 15.2% (n = 160), respectively. in the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2-3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0-3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14-3.04). There was no independent association of BP undertreatment to the study confounders. the deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP. Conclusions the results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM. Plain Language Summary Plain language summary is available for this article., Turkish Society of Endocrinology and Metabolism (TEMD) [04/10/2016-01], The TEMD study was funded by the Turkish Society of Endocrinology and Metabolism (TEMD) (Grant no. 04/10/2016-01). Automated blood pressure monitors were provided by Sanovel A/S. the funding agencies had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. No Rapid Service Fee was received by the journal for the publication of this article.

Background Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. Methods We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1‑year follow-up data were gathered. Results At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). Conclusions Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.

Various studies on oral anticoagulants (OAC) use among atrial fibrillation (AF) patients have shown high rates of undertreatment and the presence of sex disparity. This study used the ‘Geisinger Neuroscience Ischemic Stroke’ (GNSIS) database to examine sex differences in OAC treatment among ischemic stroke patients with the pre-event diagnosis of AF in rural Pennsylvania between 2004 and 2019. We examined sex disparities in OAC undertreatment and associated risks based on age group and ischemic stroke year. A total of 1062 patients were included in the study and 1015 patients (96%) had CHA2DS2-VASc score ≥ 2, of which 549 (54.1%) were women. Undertreatment rates were not statistically significant between men and women in the overall cohort (50.0% vs. 54.5%, p = 0.18), and male sex was not found to be a significant factor in undertreatment (OR 0.82, 95% CI 0.62–1.09, p = 0.17). The result persisted even when patients were divided into four age groups and two groups based on the study time period. The undertreatment rates in both sex groups remained consistent following the introduction of novel oral anticoagulants. In conclusion, there was no evidence of sex disparity with respect to OAC treatment, even after stratifying the cohort by age and ischemic stroke year.

This study aimed to explore the pattern of use of different treatment lines in psoriasis (PsO) and psoriatic arthritis (PsA) patients from Southern Italy. A retrospective cohort study was performed during the years 2010–2018 using data from the Caserta Local Health Unit (LHU) claims database. All of the PsO or PsA patients were identified. The proportion of PsO/PsA patients untreated or treated with ≥1 drug classes (i.e., non-disease-modifying antirheumatic drugs (non-DMARDs), conventional synthetic DMARDs (csDMARDs), biological drugs (bDMARDs) or targeted synthetic small molecules (tsDMARDs)) was calculated in the years 2016–2018. Among the bDMARD users, the median times from the first registered PsO/PsA diagnosis/from the first csDMARD to the first bDMARD were calculated. Overall, 10,296 (1.1%) and 1724 (0.2%) PsO and PsA patients were identified. More than half of the PsO patients (N = 5301, 51.6%) and 15% of the PsA patients (N = 251) were not treated with any drug. A very low proportion of PsO patients (N = 121, 1.2%) received csDMARDs/bDMARDs dispensing. Instead, 538 (32.2%) PsA patients were treated with bDMARDs. The median times from the first diagnosis to the first bDMARD dispensing were 54.0 (Q1–Q3: 30.5–72.2) and 13.3 (Q1–Q3: 3.1–43.9) months in the PsO and PsA patients, respectively. The median time from the first csDMARD to the first bDMARD dispensing was shorter in the PsO [9.2 months Q1–Q3: 5.5–30.0)] than in the PsA [14.5 months (Q1–Q3: 8.6–33.5)] patients. A potential undertreatment of PsO (much less for PsA) in an LHU from Southern Italy, with a particularly low use of more recently marketed drugs, such as biological ones, was shown.

Introduction An increase in the number of cancer cases is expected in the near future. Breast cancer (BC) mortality rates increase with age even when adjusted for other variables. Here we analyzed BC disease-free survival (BCDFS) and BC specific survival (BCSS) in the El Alamo III BC registry of GEICAM Spanish Breast Cancer Group. Materials and methods El Alamo III is a retrospective registry of BC patients diagnosed between 1998 and 2001. Patients with stage I-III invasive BC of age groups 55-64 years (y), 70-74 years and >= 75 years were included. Patients and tumors characteristics, treatments and recurrences and deaths were analyzed. Results 4343 patients were included within the following age intervals: 2288 (55-64 years), 960 (70-74 years), and 1095 (>= 75 years). Older patients (>= 70 years) were diagnosed with more advanced tumors (stage III) than younger patients (21.5% versus 13.4%, p < 0.0001). Mastectomies were performed more on older patients and they received less chemotherapy than younger patients (66.6% versus 43.1%, p < 0.00001 and 30.8% versus 71.6%, p < 0.0001, respectively). With a median follow-up of 5.9 years, 17.7% patients had BCDFS events in the younger group and 19.8% in the older group (p < 0.0001). A decrease in BCSS was also observed in older patients, either when analyzing patients >= 70y (p < 0.0001) and when differentiating by the two older groups (p < 0.0001). Conclusions Our study suggests that older BC patients have worse outcomes what can be a consequence of receiving inadequate adjuvant treatments. Specific trials for these patients are warranted to allow us to treat them with the same scientific rigor than younger patients.

Heart failure (HF) has emerged as a global epidemic and it affects about 6 million adults in the US. HF medical treatment, as recommended in guidelines, significantly improves survival and quality of life; however, the mortality burden of HF remains high. For decades, treatment has been guided, mainly by symptoms, leading to undertreatment in a range of settings. Current evidence emphasises the unfavourable outcomes of HF even in early stages or in patients who achieve reverse remodeling and remission or recovery under optimised treatment. This should stimulate efforts towards a more objective, rigorous management, covering the entire spectrum of mild, moderate and severe HF.

Acute myeloid leukemia (AML) is a life-threatening malignancy that is more prevalent in the elderly. Because the patient population is heterogenous and advanced in age, choosing the optimal therapy can be challenging. There is strong evidence supporting antileukemic therapy, including standard intensive induction chemotherapy (IC) and non-intensive chemotherapy (NIC), for older patients with AML, and guidelines recommend treatment selection based on a patient’s individual and disease characteristics as opposed to age alone. Nonetheless, historic evidence indicates that a high proportion of patients who may be candidates for NIC receive no active antileukemic treatment (NAAT), instead receiving only best supportive care (BSC). We conducted a focused literature review to assess current real-world patterns of undertreatment in AML. From a total of 25 identified studies reporting the proportion of patients with AML receiving NAAT, the proportion of patients treated with NAAT varied widely, ranging from 10 to 61.4% in the US and 24.1 to 35% in Europe. Characteristics associated with receipt of NAAT included clinical factors such as age, poor performance status, comorbidities, and uncontrolled concomitant conditions, as well as sociodemographic factors such as female sex, unmarried status, and lower income. Survival was diminished among patients receiving NAAT, with reported median overall survival values ranging from 1.2 to 4.8 months compared to 5 to 14.4 months with NIC. These findings suggest a proportion of patients who are candidates for NIC receive NAAT, potentially forfeiting the survival benefit of active antileukemic treatment.

Purpose: The management of older adults with breast cancer (BC) remains controversial. The challenging assessment of aging idiosyncrasies and the scarce evidence of therapeutic guidelines can lead to undertreatment. Our goal was to measure undertreatment and assess its impact on survival. Methods: Consecutive patients with BC aged 70 years or older were prospectively enrolled in 2014. Three frailty screening tools (G8, fTRST, and GFI) and two functional status scales (Karnofsky performance score and Eastern Cooperative Oncology Group Performance Status) were applied. Disease characteristics, treatment options, and causes of mortality were recorded during a 5-year follow-up. In addition, we defined undertreatment and correlated its survival impact with frailty. Results: A total of 92 patients were included in the study. The median age was 77 (range 70-94) years. The prevalence of frailty was discordant (G8, 41.9%; fTRST, 74.2%; GFI, 32.3%). Only 47.8% of the patients had a local disease, probably due to a late diagnosis (73.9% based on self-examination). Thirty-three patients (35.6%) died, of which 15 were from BC. We found a considerably high proportion (53.3%) of undertreatment, which had a frailty-independent negative impact on the 5-year survival (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.1-12.5). Additionally, omission of surgery had a frailty-independent negative impact on overall survival (HR, 3.9; 95% CI, 1.9-7.9). Conclusion: BC treatment in older adults should be individualized. More importantly, assessing frailty (not to treat) is essential to be aware of the risk-benefit profile and the patient's well-informed willingness to be treated. Undertreatment in daily practice is frequent and might have a negative impact on survival, as we report. This article publication was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia, I.P., within CINTESIS, R&D Unit (reference UIDB/4255/2020).

Objective: To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs). Measures: Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs. Results: Fifteen studies were included. Prevalence of potential overtreatment (5%–86%, n = 15 studies) and undertreatment (1.4%–35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%–74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c 8.5% and the prevalence 1.4%–14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment. Conclusions and Implications: The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs. Refereed/Peer-reviewed

ObjectivesPancreatic exocrine insufficiency (PEI) is a common complication of chronic pancreatitis. However, little is known about the natural course of PEI and the effect of pancreatic enzyme replacement therapy on symptoms. The aim of this study was to evaluate the natural course and treatment of PEI in a nationwide cohort of patients with chronic pancreatitis.MethodsPatients with chronic pancreatitis were selected from the multicenter Dutch Chronic Pancreatitis Registry. Patients were classified in 3 groups: definite PEI, potential PEI, and no PEI. Definite PEI and no PEI were compared regarding the course of disease, symptoms, treatment, and quality of life.ResultsNine hundred eighty-seven patients were included from 29 centers, of which 304 patients (31%) had definite PEI; 451 (46%), potentially PEI; and 232 (24%), no PEI. Patients with definite PEI had significantly more malabsorption symptoms, a lower body mass index, and aberrant defecation. Lowered quality of life was not independently associated with PEI. Of the PEI patients using pancreatic enzyme replacement therapy, 47% still reported steatorrhea.ConclusionsPancreatic exocrine insufficiency is associated with malabsorption symptoms and a lower body mass index. Some form of pancreatic enzyme replacement therapy is reasonably effective in alleviating malabsorption symptoms, but improvement of treatment is needed.

Purpose: To assess the gap between visual acuity (VA) outcomes with anti-vascular endothelial growth factor (anti-VEGF) therapies in clinical trials and real-world practice, and explore the reasons for this gap. Methods: The literature was searched from January 1, 2013, to June 30, 2018, for studies reporting VA gains and injection frequencies in clinical trials and real-world practice. Results: Clinical trials of anti-VEGF agents and their extension studies demonstrated initial VA gains maintained at 4 years and beyond (up to 7 years) with continuous proactive treatment. Visual outcomes correlated with injection frequency. In real-world practice, patients are usually undertreated, accounting for the VA decline over time. Reasons for undertreatment include the burden of injections and monitoring visits imposed on patients/caregivers. However, another primary reason is the general mindset in the ophthalmological community that sustained benefits with treatment are not possible, leading to poor compliance and creating a vicious circle. Conclusions: Initial VA gains can be maintained with more intensive/proactive approaches. Promising new treatments requiring less frequent injections/monitoring will help in the near future; meanwhile, better results could be achieved by changing the community mindset that contributes to undertreatment.

The prevalence of breast cancer increases with age. Older breast cancer patients often present with locally advanced disease at presentation because mammography, which diagnosed early stage disease, is not recommended after the age of 75. In addition, they are often undertreated even when they are physically fit and have non-metastatic disease. As a result, survival is often poor. Physicians bias may be a factor in their undertreatment and lack of representation in prospective clinical trials. Physicians should be educated that chronological age is not a contraindication to curative treatment for older breast cancer patients. As a research group devoted to older cancer patients, women, and minorities, the International Geriatric Radiotherapy Group (IGRG) plans to conduct prospective trials to assess biomarkers for frailty, the controversial issue of mammography for older breast cancer patients, and the incorporation of frailty index for curative breast cancer treatment. The data obtained may help to decrease physician bias and to establish future guidelines for older breast cancer patients treatment.

Objectives: Under-diagnosis and suboptimal asthma control in children persists. An innovative care pathway was developed by a hospital department of pediatrics with the aim to detect pulmonary problems in children and provide appropriate treatment possibilities through systematic feedback towards the referring primary care physician. Primary care physicians can use this pathway to refer children with asthma-like symptoms for a one-day assessment. Goals are to measure the usage of the pathway by primary care general practitioners (GPs), the outcomes in terms of new diagnoses of asthma, the reduction in regular referrals, generated recommendations/therapy and the adequacy of asthma follow-up. Methods: We collected all feedback letters sent to the GP concerning children who underwent the Pulmocheck in 2010, 2011 and 2012. Furthermore, all GPs, who had referred a child to the Pulmocheck in this period and that subsequently was diagnosed with asthma and was further managed in primary care, were sent a follow-up questionnaire in 2014. Results: There were 121 referrals from 51 GPs in 3years to this pathway. In 59.5% of these referrals a new diagnosis of asthma was established. In 90.9% one or more changes in clinical management were advised. The response rate to the follow-up questionnaires was 65.7% of which 4.8% of the children with new established asthma were reviewed four times or more in the follow-up period, 17.4% two times, 65.2% once, and in 8.7% were not followed. Conclusions: The specialty pediatric asthma care pathway revealed a high number of children with newly diagnosed asthma, but was also helpful to exclude this diagnosis. However, the referral rate of GPs to this pathway was low, but in the children, that were referred several changes in the clinical management were advised and the frequency of monitoring of the children with diagnosed asthma was not in accordance with the asthma guidelines.

Purpose of reviewCancer incidence increases worldwide and thus more patients will suffer from cancer pain. As cancer pain severely affects quality of life, the decrease of pain should be of high priority for every clinician. In the last decade, attention for cancer pain and for its treatment has increased, and new pharmacological based treatment options became available. This gave reason to hypothesize a decrease in pain prevalence in cancer patients over the last decade.Recent findingsDespite increased attention to cancer pain, pain prevalence in cancer patients has not significantly changed over the last decade as compared to the four decades before. This absence of change might be because of comorbidities cancer patients have, but also to undertreatment of pain, because of a lack of knowledge and pain measurement. Other factors underlying this absence of change are the use of incorrect coanalgesics in the case of treatment of neuropathic pain, as well as the present absence of potent analgesics with little side effects.SummaryConsistent screening of pain in cancer patients and consequent correct treatment of pain might result in an impressive decrease in cancer pain. For further reduction of pain, new pharmacological analgesics need to be developed.

Background Evidence is emerging that older women may tolerate breast cancer therapies equally well as the young ones, providing that they receive good supportive care. It has also been reported that these patients remain outside the current therapeutic standards. The aim of this observational study was to assess the access of breast cancer patients to medical procedures. Methods We retrospectively reviewed a database of breast cancer patients registered in the National Cancer Registry in Poland, searching for the numbers of new cases and deaths in the years 2010–2015. We obtained the numbers and costs of key medical procedures provided for these patients from the National Health Fund in Poland. Breast cancer survival in the years 2010–2015 was estimated based on the mortality/incidence ratio. The t-Student test and Spearman correlation coefficient were used for the analysis of data obtained from both databases. Results There was no increase in survival throughout the years 2010–2015 in both analysed subpopulations of all breast cancer patients below and over 65 years of age, despite an unprecedented rise in healthcare funding in Poland. We noted 37% lower probability of 5-year survival in patients older than 65 years. The average number of outpatient visits and surgical procedures per person per year were slightly, yet significantly (p

Contains fulltext : 208428.pdf (Publisher’s version ) (Open Access) Understanding the overuse and underuse of health-care services in the end-of-life (EoL) phase for patients with lung cancer (LC) and colorectal cancer (CRC) is important, but knowledge is limited. To help identify inappropriate care, we present the health-care utilization profiles for hospital care at the EoL of patients with LC (N = 25 553) and CRC (N = 14 911) in the Netherlands between 2013 and 2015. An administrative database containing all in-hospital health-care activities was analyzed to investigate the association between the number of days patients spent in the emergency department (ED) or intensive care unit (ICU) and their exposure to chemotherapy or radiotherapy. Fewer patients received hospital care as death neared, but their intensity of care increased. In the last month of life, the average numbers of hospital bed days, ICU days, and ER contacts were 9.0, 5.5, and 1.2 for patients with CRC, and 8.9, 6.2 and 1.2 for patients with LC in 2015. On the other hand, the occurrence of palliative consultations ranged from 1% to 4%. Patients receiving chemotherapy 6 months before death spent fewer days in ICU than those who did not receive this treatment (odds ratios: CRC = 0.6 [95% confidence interval: 0.4-0.8] and LC = 0.7 [0.5-0.9]), while those receiving chemotherapy 1 month before death had more ED visits (odds ratios: CRC = 17.2 [11.8-25.0] and LC = 15.8 [12.0-20.9]). Our results showed that patients who were still receiving hospital care when death was near had a high intensity of care, yet palliative consultations were low. Receiving chemotherapy or radiotherapy in the final month of life was significantly associated with more ED and ICU contacts in patients with LC.

Despite increased attention to cancer pain, pain prevalence in patients with cancer has not improved over the last decade and one third of cancer patients on anticancer therapy and half of patients with advanced disease still suffer from moderate to severe pain. In this review, we explore the possible reasons for the ongoing high prevalence of cancer pain and discuss possible future directions for improvement in personalised pain management. Among possible reasons for the lack of improvement are: Barriers for patients to discuss pain with clinicians spontaneously; pain measurement instruments are not routinely used in daily practice; limited knowledge concerning the assessment of undertreatment; changes in patients’ characteristics, including the ageing of the population; lack of significant improvement in the treatment of neuropathic pain; limitations of pharmacological treatment and lack of evidence-based nonpharmacological treatment strategies. In order to improve cancer pain treatment, we recommend: (1) Physicians proactively ask about pain and measure pain using assessment instruments; (2) the development of an optimal tool measuring undertreatment; (3) educational interventions to improve health care workers’ skills in pain management; (4) the development of more effective and personalised pharmacological and nonpharmacological pain treatment.

Chronic pain is a frequent characteristic of elderly people and represents an actual and still poorly debated topic.We investigated pain prevalence and intensity, and its pharmacological therapy in elderly patients hospitalized in 101 internal medicine wards.Taking advantage of the "REgistro POliterapie Società Italiana Medicina Interna" (REPOSI), we collected 2535 patients of whom almost a quarter was older than 85 years old. Among them, 582 patients were affected by pain (either chronic or acute) and 296 were diagnosed with chronic pain.Patients with pain showed worse cognitive status, higher depression and comorbidities, and a longer duration of hospital stay compared to those without pain (all p .0366). Patients with chronic pain revealed lower level of independency in their daily life, worse cognitive status and higher level of depression compared to acute pain patients (all p .0156). Moreover, most of them were not treated for pain at admission (73.4%) and half of them was not treated with any analgesic drug at discharge (50.5%). This difference affected also the reported levels of pain intensity. Patients who received analgesics at both admission and discharge remained stable (p = .172). Conversely, those not treated at admission who received an analgesic treatment during the hospital stay decreased their perceived pain (p .0001).Our results show the need to focus more attention on the pharmacological treatment of chronic pain, especially in hospitalized elderly patients, in order to support them and facilitate their daily life after hospital discharge.

Pain is highly prevalent among the adult Latin American population. However, many patients with moderate to severe pain do not have access to effective pain management with opioids due to limited access to healthcare, overuse of nonopioid analgesics, regulatory barriers and lack of appropriate information about opioids. There is scarce training on use of opioids among physicians and other healthcare providers, which leads to misconceptions, mainly related to a fear of prescribing opioids. Although opioids are safe and effective drugs for the treatment of moderate to severe chronic pain, the use of opioids in Latin American nations is clearly below standards compared with developed countries.

Neonatal tumors are rare with no standard treatment approaches to these diseases, and the patients experience poor outcomes. Our aim was to determine the distribution of cancers affecting neonates and compare survival between these cancers and older children. We analyzed SEER data (1973–2007) from patients who were younger than 2 years at diagnosis of malignancy. Special permission was granted to access the detailed (i.e., age in months) data of those patients. The Chi-square Log-rank test was used to compare survival between neonates (aged 1 month to

Since publication of DSM-IV in 1994, the prevalence of parent-reported diagnosed attention-deficit/hyperactivity disorder (ADHD) has tripled to more than 10% of children. Although it is hard to know for sure whether ADHD is overdiagnosed, underdiagnosed, or misdiagnosed, it is argued that ADHD is especially prone to diagnostic inflation and overdiagnosis. Therefore, we propose a model of stepped diagnosis for childhood ADHD, which may reduce overdiagnosis without risking undertreatment. Calling attention to stepped diagnosis and formalizing the steps may improve its application in clinical practice.

Purpose The WHO guidelines on cancer pain management recommend a sequential three-step analgesic ladder. However, conclusive data are lacking as to whether moderate pain should be treated with either step II weak opioids or low-dose step III strong opioids. Patients and Methods In a multicenter, 28-day, open-label randomized controlled study, adults with moderate cancer pain were assigned to receive either a weak opioid or low-dose morphine. The primary outcome was the number of responder patients, defined as patients with a 20% reduction in pain intensity on the numerical rating scale. Results A total of 240 patients with cancer (118 in the low-dose morphine and 122 in the weak-opioid group) were included in the study. The primary outcome occurred in 88.2% of the low-dose morphine and in 57.7% of the weak-opioid group (odds risk, 6.18; 95% CI, 3.12 to 12.24; P < .001). The percentage of responder patients was higher in the low-dose morphine group, as early as at 1 week. Clinically meaningful (≥ 30%) and highly meaningful (≥ 50%) pain reduction from baseline was significantly higher in the low-dose morphine group (P < .001). A change in the assigned treatment occurred more frequently in the weak-opioid group, because of inadequate analgesia. The general condition of patients, which was based on the Edmonton Symptom Assessment System overall symptom score, was better in the morphine group. Adverse effects were similar in both groups. Conclusion In patients with cancer and moderate pain, low-dose morphine reduced pain intensity significantly compared with weak opioids, with a similarly good tolerability and an earlier effect.

WOS: 000384041400052, PubMed ID: 27583892, This study aimed to investigate the potential misuse of novel oral anticoagulants (NOACs) and the physicians' adherence to current European guideline recommendations in real-world using a large dataset from Real-life Multicenter Survey Evaluating Stroke Prevention Strategies in Turkey (RAMSES Study).RAMSES study is a prospective, multicenter, nationwide registry (ClinicalTrials.gov identifier NCT02344901). In this subgroup analysis of RAMSES study, patients who were on NOACs were classified as appropriately treated (AT), undertreated (UT), and overtreated (OT) according to the European Society of Cardiology (ESC) guidelines. The independent predictors of UT and OT were determined by multivariate logistic regression.Of the 2086 eligible patients, 1247 (59.8%) received adequate treatment. However, off-label use was detected in 839 (40.2%) patients; 634 (30.4%) patients received UT and 205 (9.8%) received OT. Independent predictors of UT included >65 years of age, creatinine clearance 50mL/min, urban living, existing dabigatran treatment, and HAS-BLED score of

Aim Five multicentre, cross-sectional Centralized Pan-Regional Surveys on the Undertreatment of Hypercholesterolaemia (CEPHEUS) were conducted in 29 countries across Asia, Western Europe, Eastern Europe, the Middle East, and Africa. The surveys assessed the current use and efficacy of lipid-lowering drugs (LLDs) worldwide and identified possible patient and physician characteristics associated with failure to attain low-density lipoprotein cholesterol (LDL-C) goals. The aim of this analysis was to consolidate the global results from these surveys. Methods The surveys involved patients aged ≥18 years who had been prescribed LLDs for at least 3 months without dose changes for at least 6 weeks. A single visit was scheduled for data collection, including fasting plasma lipid and glucose levels. Cardiovascular risk profile and LDL-C goal attainment were assessed according to the 2004 updated US National Cholesterol Education Program Adult Treatment Panel III guidelines. Results In total, 35 121 patients (mean age: 60.4 years) were included, and 90.3% had been prescribed statin monotherapy. Overall, only 49.4% of patients reached their recommended LDL-C level. LDL-C goals were attained in 54.8% (5084/9273) and 22.8% (3287/14 429) of patients were at high and very high cardiovascular risk, respectively. Factors associated with an increased likelihood of LDL-C goal attainment were lower baseline cardiovascular risk; presence of diabetes mellitus, hypertension, or history of cardiovascular disease; and treatment with simvastatin, atorvastatin, or rosuvastatin (vs. all other LLDs). Conclusion LDL-C goal attainment in patients taking LLDs is suboptimal worldwide, particularly in patients at high and very high cardiovascular risk.

AIM: Previous studies and national assessments indicate an undertreatment of mineralocorticoid receptor antagonists (MRA) in heart failure with reduced ejection fraction (HFrEF). This study aimed to investigate why MRA is not used to full extent. METHODS: A complete community-based heart failure population was studied. Several variables were collected, and medical records were scrutinized to identify reasons for not prescribing MRA. RESULTS: Of 2029 patients, 812 had EF ≤40%. Five hundred and fifty-three patients (68%) tried MRA at some point but 184 of these (33%) discontinued therapy. There were 259 patients that never tried MRA with 177 with a listed explanation or contraindication. Eighty-two patients, 10% of the total HFrEF population, had no clear contraindications. They were older and had less HF hospitalizations compared to patients on MRA (P 30 mL/min. CONCLUSIONS: The reasons why MRA are underutilized were mainly because of contraindications. However, the data suggest that physicians are overly cautious about moderately reduced kidney function. There seems to be a 10%-18% avoidable undertreatment with MRA, especially for elderly patients that are admitted to the hospital for other reasons than heart failure. This suggests that patients with heart failure would benefit from routine follow-up at a cardiology clinic.

Summary The aim of this study was to determine the extent of unawareness and undertreatment of asthma and allergic rhinitis in an adolescent and adult population in Copenhagen, Denmark. Methods Patients with asthma and rhinitis were recruited by a standardised asthma and rhinitis screening questionnaire. Out of a random sample of 10,877 subjects aged 14–44 years, 1149 subjects were treated or reported symptoms of asthma or rhinitis and agreed to participate. Those subjects were assessed on history, lung function tests, and skin prick tests. Disease severity and optimal treatment were decided according to the GINA and ARIA guidelines. Results A total of 726 participants suffered from asthma and/or allergic rhinitis. Concomitant upper and lower airways disease was found in 47%. Seventy-five per cent were allergic and 44% with a known allergy had been tested previously. Asthma was undiagnosed and untreated in 50% of all the asthmatics. According to the guideline recommendation, 76% of asthmatics were undertreated. Rhinitis was undiagnosed in 32% of patients and 83% with moderate to severe rhinitis were undertreated. Patient knowledge about self-care and education was low. Conclusions In this population a large proportion of patients were unaware of having asthma or rhinitis. The pharmaceutical treatment and management practice were inadequate. Our study emphasises the need for additional intervention.

SummaryChronic obstructive pulmonary disease (COPD) exacerbations could represent an opportunity for pro-active COPD management rather than mere treatment if previously unknown disease is discovered; the extent of underdiagnosis and undertreatment of COPD in patients attending an emergency department (ED) with an exacerbation is not known.During 2002, we recalled 131 COPD patients in stable conditions, 4–8 weeks after they had attended the ED or been discharged from our University Hospital (North-West of Italy). Information on diagnosis and management prior to the ED attendance were collected; spirometry and arterial blood gas analyses were performed.One-third of patients had never been diagnosed and treated even though 83% of them had moderate-to-very-severe COPD and about 30% already had respiratory failure. Only 20% had received information on the nature of the disease and none had received a written action plan. Only 60% were receiving long-acting bronchodilators and 41% of patients with respiratory failure were receiving long-term oxygen. A substantial number of undiagnosed and untreated patients with moderate-to-very-severe COPD came to our attention through an exacerbation. This enforces the importance of exacerbations as the starting point of pro-active COPD management and of the ED as a valuable sentinel to identify this subset of patients.

Objective: To examine trends in prescribing of angiotensin II receptor blockers (ARBs) as initial and second-line treatment of hypertension.Methods: We performed a cohort study in the Integrated Primary Care Information database, a general practice research database in The Netherlands. We included hypertensive patients who were newly treated with antihypertensive drugs between 1996 and 1999. Initial treatment was defined as the first prescribed antihypertensive drug after diagnosis of hypertension. As second-line treatment, we considered prescriptions of a second antihypertensive drug class, either as switch or addition. We used logistic regression and Cox proportional hazard analysis to estimate time trends in use of ARBs as initial or second-line treatment.Results: In total, 8% of the 3,102 newly treated hypertensive patients received ARBs as initial treatment. Initial ARB use increased significantly from 4% to 10% during the period 1996-1999, whereas calcium channel blocker and angiotensin-converting enzyme inhibitor (ACE-1) use decreased. ARBs were used as second-line treatment in less than 4% of 2,544 patients who were initially treated with an antihypertensive drug other than an ARB: 2% switched to an ARB (mostly from ACE-1s) and 1% received ARBs as add-on treatment. Diuretics and beta-blockers were used five to ten times more often as add-on treatment than ARBs.Conclusion: ARBs achieved a position in the treatment of hypertension as initial rather than second-line therapy.

The number of children diagnosed with attention deficit hyperactivity disorder (ADHD) and treated with medication is steadily increasing. The aim of this paper was to critically discuss five debatable assumptions on ADHD that may explain these trends to some extent. These are that ADHD (i) causes deviant behaviour, (ii) is a disease, (iii) is chronic and (iv) is best treated by medication and (v) that classification should precede treatment. Conclusion We argue that ADHD is not a disease, not the cause of deviant behaviour and in most cases not chronic. Treatment for attention and hyperactivity problems could start with psychosocial interventions and without a diagnostic label. A stepped diagnosis approach may reduce overdiagnosis without risking undertreatment.

Purpose: This study aimed to examine under-recognition, under-treatment and severity of under-treated DSM-IV mood and anxiety disorders among disability claimants. Methods: In a representative sample of Dutch disability claimants (n = 346), registry codes certified according to the International Classification of Diseases 10th edition (ICD-10) by insurance physicians, were compared with classifications according to the Diagnostic Statistical Manual of Mental Disorders (DSM-IV) detected by the Composite International Diagnostic Interview (CIDI). Levels of ICD-10/DSM-IV agreement were assessed for mood and anxiety disorders in the total sample, and prevalence of recent DSM-IV mood and anxiety disorders in a pure ICD-10 somatic subgroup. Treatment and severity of under-treated DSM-IV mood and anxiety disorders were assessed in two subgroups of disability claimants with either an ICD-10 somatic or mental disorder as primary cause of disability, irrespective of any ICD-10 comorbidity. Results: Levels of ICD-10/DSM-IV agreement were poor (kappa : 0.237 for mood and 0.260 for anxiety disorders). In the pure ICD-10 somatic subgroup, the prevalence of DSM-IV mood and anxiety disorders was 3.8% and 11.4%, respectively. In the ICD-10 somatic subgroup irrespective of any ICD-10 comorbidity, 45.2% (major depressive disorder), 80.0% (social phobia) and 53.3% (general anxiety disorder) were under-treated. In the ICD-10 mental subgroup, these percentages were 44.7%, 80.9% and 33.4%, respectively. In both of these subgroups, under-treated DSM-IV mood and anxiety disorders were predominantly serious in terms of impairment and disability. Conclusions: Serious mental disorders were found to be substantially under-diagnosed and under-treated among disability claimants. To optimize diagnosis and treatment of disabling mental disorder, medical professionals in insurance, occupational and in the health care sector should closely collaborate. For claimants with under-treated mental disorders, tailor-made multidisciplinary interventions are needed to promote return to work and to prevent permanent disability.

International audience; Objectives: evaluate the impact of the Geriatric Oncology consultation on the final therapeutic management of cancer in elderly patients aged 70 and older. Design: retrospective study. Setting: the Pilot coordination unit in Geriatric Oncology of Cote d'Or, Burgundy, France. Participants: From January 2010 to December 2010, 191 patients with cancer aged 70 and older. Measurements: the concordance between the treatments proposed following the tumor Board, those proposed following the Geriatric evaluation (GE) and those actually given to the patients was evaluated using the kappa agreement test. Results: One hundred and ninety-one patients were included. Mean age was 81.5. the most frequent cancer locations were breast (31.9%), colon-rectum (14.1%) and lung (10.5%). concordance between the cancer treatments proposed by the tumor Board and those suggested after the GE was excellent except for chemotherapy and targeted therapy, which were recommended less frequently by the geriatrician (Kappa = 0.67), and support care, which was more often proposed after the GE (Kappa = 0.61). However, concordance between treatments proposed by the geriatrician and treatment actually given was not so good for chemotherapy (Kappa = 0.58), and surgery (Kappa = 0.61), since both were often replaced by a less aggressive treatment. Conclusion: concordance between the therapies proposed during the tumor Board or after the Geriatric Oncology consultation and the treatment actually given was satisfactory. However, the role of the oncologist remains determinant in the final choice, especially for chemotherapy.

Several authors have demonstrated a trend toward the under-treatment of elderly and very elderly women with breast cancer. This study was undertaken to determine the impact of under-treatment of breast cancer in women age 80 and older.A retrospective chart review of all patients 80 years and older with a newly diagnosed breast cancer at the MD Anderson Cancer Center, Houston, TX, between September 1, 1989 and September 1, 2004 was performed. Data extracted from charts included patient demographics, comorbidity, treatments recommended, treatments received, complications of therapy, disease recurrence and disease related death. Treatments undertaken were analyzed in the context of accepted therapy at the time of diagnosis.Two hundred twelve patients were identified. The median age was 83.5 years (range 80-97). Overall survival in the entire cohort was 7.28 years with a median follow up of 4 years for patients still alive at the end of the study period. Fifty seven percent of patients were under-treated according to institutional and national guidelines. Women who underwent hormonal therapy only demonstrated decreased disease specific survival (P0.001 respectively) compared with patients who received multi-modality therapy. Women who underwent partial mastectomy without radiation treatment experienced a significant increase in local regional recurrence (P=0.045). There was an association of increased disease specific survival in patients who had surgical lymph node evaluation compared to those who did not (P=0.04).Outcomes are compromised in very elderly women with breast cancer in whom less than complete combined modality treatment is undertaken. With the previously demonstrated safety of radiation therapy, hormonal therapy and surgery in the very elderly population, multi-modality therapy should not be routinely withheld in patients in this age category.

Pain is frequently reported by patients infected with Acquired Immunodeficiency Virus (HIV), and its causes and specific treatment should be appropriately investigated. We evaluated 197 hospitalized HIV-positive patients with serial interviews and analysis of prescriptions and clinical evolution charts. The main characteristics of pain reported by these patients were: high intensity (60.7%), high frequency (72.0%) and well-known causes (88.8%). Fifty-two per cent of the patients reported persistent or frequent pain during the two weeks before hospital admission. Parameters such as gender, educational level and Karnofsky Index showed no direct relation to the presence or absence of pain. The most commonly affected sites were the head (28.0%) and the abdomen (26.2%). The frequency of indications of pain in the clinical evolution charts (46.2%) was considerably lower than the frequency of complaints reported by patients during the interviews (76.3%). Pain was undertreated in 83.2% of patients, both due to poor efficacy of the prescribed medications and to the excessive and inefficient use of standing order ("if necessary") regimens. We observed that pain was better managed during the hospitalization period, although this cannot be explained by improvement of the analgesic treatment; it might be due to successful treatment of the underlying disease. We concluded that pain reported by hospitalized HIV-positive patients is often underestimated and inadequately treated by assisting doctors, in spite of its severity and frequency.

Objective To determine the prevalence of dementia diagnoses and the use of antidementia drugs in a cohort of Italian older nursing home (NH) residents. Design Cross-sectional study. Setting The NH residents participating in 2 studies: the U.L.I.S.S.E. study and the Umbria Region survey. Participants A total of 2215 nursing home residents. Measurement Each resident underwent a comprehensive geriatric assessment at baseline by means of the RAI MDS 2.0. Dementia diagnosis was based on ICD-9 codes. Results The prevalence of dementia diagnosis according to ICD-9 codes was 50.7% (n = 1123), whereas 312 subjects had cognitive impairment with a cognitive performance scale score ≥3 without a diagnosis of dementia. Only 56 NH residents were treated (5% of the sample) and the main drugs used were cholinesterase inhibitor, whereas only 1 subject was treated with memantine. Limiting our analysis to patients with mild to moderate Alzheimer's disease, who are those reimbursed by the public health care system for receiving antidementia drugs, the percentage rose to 11.3%. Conclusion These findings demonstrate a high rate of underdiagnosis and undertreatment of dementia in Italian NH residents. Potential explanations include the lack of systematic assessment of cognitive functions, the limitations to antidementia drug reimbursement, the complexity of the reimbursement procedure itself, and the high prevalence of patients with severe dementia. Older NH residents still lack proper access to state-of-the-art diagnosis and treatment for a devastating condition such as dementia.

There are approximately 23 million patients with heart failure (HF) worldwide. The prognosis of patients with HF is still poor and a prospective approach for preventing and treating HF is necessary. The number of HF patients in Japan has been increasing since 1950 mainly because of a rapidly aging population. Furthermore, westernized dietary pattern, reduced physical activity, and obesity have become prominent, particularly in younger Japanese men. There is an increasing trend of diabetes and dyslipidemia, and the prevalence of smoking and hypertension continues to remain high. One of the largest HF cohorts in Japan, the CHART Studies, showed that coronary artery disease (CAD) was the most frequent etiology of HF currently. Thus, prospective strategies including accurate risk stratification, effective prevention of disease progression through evidence-based treatments, optimally personalized treatment particularly in elderly individuals, and life-long control of CAD risk factors are required to manage HF in Japan.

The prevalence and fatality rate of asthma have increased worldwide. Underdiagnosis and undertreatment of asthma are central to the occurrence of fatal asthma. Atopy is the principal risk factor associated with asthma. However, consideration of the epidemiologic, physiologic, pharmacologic, pathologic and clinical parameters of asthma assessment may provide valuable insight into death due to asthma. Psychologic and socioeconomic factors may further aggravate the asthma status. Ethnic minorities are at increased risk of asthma. The perception of dyspnea may be blunted in asthma sufferers. Slow-onset fatal asthma may be associated with submucosal eosinophilic, whereas sudden-onset may be associated with submucosal neutrophilia. Fatal asthma occurs in patients abusing regular |3 2 -agonist therapy. Peak flow assessment often provides insight into asthma deterioration prior to signs of respiratory distress. Markers of risk of death due to asthma further identify the fatality-prone asthma patient.