Compatibility of Standard Vagus Nerve Stimulation and Investigational Microburst Vagus Nerve Stimulation Therapy with fMRI

Vagus nerve stimulation devices are conditionally approved for MR imaging with stimulation turned off, and the requirement to modify the stimulation settings may be a barrier to scanning in some radiology practices. There is increasing interest in studying the effects of stimulation during MR imaging/fMRI. This study evaluated the safety of standard and investigational microburst vagus nerve stimulation therapies during MR imaging/fMRI. A prospective, multicenter study was conducted in patients with an investigational vagus nerve stimulation device that delivered either standard or investigational microburst vagus nerve stimulation. Thirty participants underwent sequential MR imaging and fMRI scans, encompassing 188 total hours of scan time (62.7 hours with standard vagus nerve stimulation and 125.3 hours with investigational microburst vagus nerve stimulation). No adverse events were reported with active stimulation during MR imaging or during 12 months of follow-up. Our results support the safety of standard and investigational microburst vagus nerve stimulation therapy during MR imaging and fMRI scans.

British Society for Immunology and United Kingdom Primary Immunodeficiency Network (UKPIN) consensus guideline for the management of immunoglobulin replacement therapy

Currently, there is no guideline to support the use of immunoglobulin replacement therapy (IgRT) in primary and secondary immunodeficiency disorders in UK. The UK Primary Immunodeficiency Network (UK-PIN) and the British Society of Immunology (BSI) joined forces to address this need. Given the paucity of evidence, a modified Delphi approach was used covering statements for the initiation, monitoring, discontinuation of IgRT as well as home therapy programme. A group of six consultant immunologists and three nurse specialists created the statements, reviewed responses and feedback and agreed on final recommendations. This guideline includes 22 statements for initiation, 22 statements for monitoring, 11 statement for home therapy, and 19 statements for discontinuation of IgRT. Further areas of research are proposed to improve future delivery of care.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Emergency readmissions to paediatric surgery and urology: The impact of inappropriate coding

Introduction In England, emergency readmissions within 30 days of hospital discharge after an elective admission are not reimbursed if they do not meet Payment by Results (PbR) exclusion criteria. However, coding errors could inappropriately penalise hospitals. We aimed to assess the accuracy of coding for emergency readmissions. Methods Emergency readmissions attributed to paediatric surgery and urology between September 2012 and August 2014 to our tertiary referral centre were retrospectively reviewed. Payment by Results (PbR) coding data were obtained from the hospital's Family Health Directorate. Clinical details were obtained from contemporaneous records. All readmissions were categorised as appropriately coded (postoperative or nonoperative) or inappropriately coded (planned surgical readmission, unrelated surgical admission, unrelated medical admission or coding error). Results Over the 24-month period, 241 patients were coded as 30-day readmissions, with 143 (59%) meeting the PbR exclusion criteria. Of the remaining 98 (41%) patients, 24 (25%) were inappropriately coded as emergency readmissions. These readmissions resulted in 352 extra bed days, of which 117 (33%) were attributable to inappropriately coded cases. Conclusions One-quarter of non-excluded emergency readmissions were inappropriately coded, accounting for one-third of additional bed days. As a stay on a paediatric ward costs up to £500 a day, the potential cost to our institution due to inappropriate readmission coding was over £50,000. Diagnoses and the reason for admission for each care episode should be accurately documented and coded, and readmission data should be reviewed at a senior clinician level.

The United Kingdom Primary Immune Deficiency (UKPID) Registry: report of the first 4 years' activity 2008-2012

This report summarizes the establishment of the first national online registry of primary immune deficency in the United Kingdom, the United Kingdom Primary Immunodeficiency (UKPID Registry). This UKPID Registry is based on the European Society for Immune Deficiency (ESID) registry platform, hosted on servers at the Royal Free site of University College, London. It is accessible to users through the website of the United Kingdom Primary Immunodeficiency Network (www.ukpin.org.uk). Twenty-seven centres in the United Kingdom are actively contributing data, with an additional nine centres completing their ethical and governance approvals to participate. This indicates that 36 of 38 (95%) of recognized centres in the United Kingdom have engaged with this project. To date, 2229 patients have been enrolled, with a notable increasing rate of recruitment in the past 12 months. Data are presented on the range of diagnoses recorded, estimated minimum disease prevalence, geographical distribution of patients across the United Kingdom, age at presentation, diagnostic delay, treatment modalities used and evidence of their monitoring and effectiveness.

A framework to aid adoption of automated rehabilitation devices into clinical practice: synthesising and Interpreting Language for Clinical Kinematics (SILCK)

The Synthesising and Interpreting Language for Clinical Kinematics (SILCK) is an informatic framework for developing software to control automated rehabilitation devices. It aids adoption of devices into rehabilitation practice, by bridging the gap between clinical practice and internal device operation. SILCK defines data entities and processes for capturing clinical observations of patients and their rehabilitation goals in formats which can be used to direct the tailoring of device parameters to the individual patient's needs.

Abstract PD08-02: Disparities in the Utilization of Reconstruction after Mastectomy: The California Teachers Study

Background: For breast cancer patients undergoing mastectomy, factors such as insurance status, race/ethnicity, age, and type of hospital influence whether post-mastectomy reconstruction (PMR) is performed. This study was undertaken to determine if additional patient variables and clinicopathologic features also influence the utilization of PMR using the California Teachers Study (CTS).

Methods: Patients were identified from the CTS, a cohort of approximately 133,000 female public school teachers and administrators, followed prospectively from 1995 forward to investigate exposures associated with incident cancer and other outcomes. All in situ and invasive breast cancers were identified through linkage with the California Cancer Registry, as well as with the California Office of Statewide Health Planning and Development (OSHPD) hospital discharge database to determine the rates of mastectomy with and without reconstruction. Patterns in PMR rates were examined by calendar year, age, race/ethnicity, type of insurance, type of hospital, tumor stage, body mass index (BMI), family history of breast cancer (FH), smoking history, physical activity, and prior breast implant status using a chi-square test. Univariable and multivariable-adjusted odds ratios (OR) with 95% confidence intervals (CI) were estimated for relative odds of immediate reconstruction vs. mastectomy only.

Results: During follow-up, 1,253 CTS participants with incident breast cancer underwent mastectomy with (N = 368) and without (N = 885) reconstruction. In multivariable stepwise logistic regression analyses, calendar year, age, type of insurance, tumor stage, and prior breast implant were statistically significantly associated with use of reconstruction. The proportion of patients undergoing immediate PMR increased from 21.8% during 1995–1999 to 26.4% during 2005–2009. A statistically significant dose-response was apparent between older age at surgery and decreased likelihood of post-mastectomy reconstruction (Ptrend&lt;0.001). Race/ethnicity was not significantly associated with the use of PMR because the majority of patients were non-Hispanic white (89.5%). Most participants either had private insurance (56.8%) or Medicare (42.4%); those with private insurance were twice as likely to undergo PMR compared to patients with Medicare (OR 2.23: 95%CI 1.25–4.00, p = 0.01). Compared to participants with in situ and stage I breast cancer combined, participants with stage II or stage III breast cancer had one-third to one-half lower odds of postmastectomy reconstruction relative to mastectomy only (ORstageII = 0.67, 95% CI = 0.49–0.90, p = 0.01; ORstageIII=0.47, 95% CI=0.29–0.77, p = 0.002). Participants with a prior history of a breast implant were 7 times more likely to undergo PMR than participants with no such history (OR 7.14: 95%CI 2.38–21.41, p &lt; 0.001).

Conclusions: In the CTS population, having a prior breast implant and lower tumor stage were additional variables associated with increased odds of PMR. This study validates previous studies which have shown that private insurance and younger age are associated with the use of reconstruction after mastectomy. Patient and health care provider education is warranted to ensure that all patients undergoing mastectomy are offered and have access to PMR.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-02.