Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

INTRODUCTION

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

METHODS

We conducted 40 semi-structured interviews in the United States from May 2020-Feburary 2022 with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) Model. The audiences were recruited by multiple methods including fliers, a community advisory board, Facebook ads, phone calls or emails to schools and health systems, and snowball sampling. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. We used deductive coding approach using a structured codebook, two coders, analyses in MAXQDA, and matrices.

RESULTS

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level) and community outreach, providers' approach to the HPV vaccine recommendations and use of educational materials in addition to counseling parents or young adults (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and health education information around HPV vaccination (practice level). Related to socio-ecology, the lack of transportation and culture of limited discussion about vaccination in rural communities and the lack of policies facilitating the uptake of the HPV vaccine (e.g., school mandates) were described as challenges.

CONCLUSION

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Use of sugammadex in prevention of post-operative urinary retention in minimally invasive hernia surgery

PURPOSE

Post-operative urinary retention (POUR) is a known complication of hernia surgery. Minimally invasive inguinal hernia repair (IHR) is typically done under general anesthesia with neuromuscular blockade (NMB), which is commonly reversed with an anticholinesterase inhibitor paired with an anticholinergic agent. Sugammadex is a unique NMB reversal agent that does not have to be paired with an anticholinergic. We sought to explore the role of sugammadex in reducing the rate of POUR following these procedures.

METHODS

Data were collected retrospectively at a single institution between February 2016 and October 2019. We identified and studied patients who underwent minimally invasive IHR and received either sugammadex or neostigmine/glycopyrrolate for NMB reversal. The primary endpoint was POUR requiring bladder catheterization. Secondary endpoints included post-operative and 30-day readmissions.

RESULTS

274 patients were included in this study (143 received neostigmine and glycopyrrolate, 131 sugammadex). The sugammadex patients were on average 5 years older than the neostigmine/ glycopyrrolate patients (63.2 vs 58.2, p = 0.003), and received less median intravenous fluids (IVF) (900 ml vs 1000 ml; p = 0.015). There was a significant difference in the rate of POUR between the sugammadex and neostigmine/glycopyrrolate patients (0.0% vs 8.4%, p ≤ 0.001). The difference remained significant after controlling for age and IVF. The odds of POUR for those who received neostigmine/glycopyrrolate were 25 × higher than the odds of those who received sugammadex.

CONCLUSION

The results of this study reflect the protective role of sugammadex against POUR in minimally invasive IHR cases.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

Introduction

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

Methods

We conducted 40 semi-structured interviews with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) model and used deductive coding approach. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities.

Results

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level), providers' approach to the HPV vaccine recommendations (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and information (practice level).

Conclusions

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

[Breast restoration by the lipomodeling technique after breast sequelae following complications of reduction mammoplasty]

BACKGROUND

Complications of reduction mammoplasty can lead to aesthetic sequelae, which are known to be difficult and delicate to treat, and only a few articles deal with this subject.

PURPOSE

The objective of this article is to present and analyze our experience of lipomodeling for the secondary management of aesthetic sequelae occurring after a complication of reduction mammoplasty.

MATERIAL AND METHODS

An uniform and consecutive series of 22 female patients, operated with the lipomodeling technique from December 2003 to March 2019 by the last author, to correct aesthetic sequelae after secondary complications of reduction mammoplasty was studied analyzing the efficiency and the tolerance of this technique.

RESULTS

The results showed 86.4% of very good results and 13.6% of good results. Seventeen patients (77.3%) were highly satisfied with the postoperative outcome, and 5 patients were satisfied (22.7%). The number of procedures varied from 1 to 3: 15 patients (68.2%) underwent only one session of lipomodeling, 5 patients (22.7%) underwent two sessions, and 2 patients (9.1%) underwent three sessions. The mean time between two interventions was 4 months (3-12). No patient of this series initiates any medico-legal proceeding towards the first surgeon.

CONCLUSION

After this study, lipomodeling, in association with ancillary procedures, seems to be an effective and safe solution to correct aesthetic sequelae following secondary complications of reduction mammoplasty. It should have a key role for the correction of these sequelae. An effective and appropriate care of these patients leads to good results and patients' final satisfaction, and manages to avoid any medico-legal proceeding, always badly lived as much for the patient as for the first surgeon.

Tick bite risk factors and prevention measures in an area with emerging Powassan virus disease

Background

In the United States (U.S.), Powassan virus is primarily transmitted to humans by the black-legged tick (Ixodes scapularis). Rarely, infections can present as severe neuroinvasive disease. In 2019, four neuroinvasive disease cases were reported in Sussex County, New Jersey, U.S. We administered a survey to county residents to better understand tick bite risk factors and the performance of personal prevention measures.

Methods

A survey was administered in October 2019 to adult residents of randomly selected households. Questions focused on tick bite prevention and risk factors. Crude and adjusted odds ratios (ORs) and 95% confidence intervals were calculated for various outcomes.

Results

Of 274 participants, 25% were previously diagnosed with a tick-borne disease, and 42% reported finding an attached tick in 2019. Yardwork and gardening (OR = 7.38) and spending >50 hours outdoors per week (OR = 8.15) were associated with finding an attached tick. Finding an attached tick was inversely associated with the number of prevention measures used, indicating that a layered approach could reduce the risk of tick bites. Those who performed post-outdoor activity prevention measures (e.g., tick checks) were less likely to have a tick attached compared to finding a crawling tick.

Conclusion

Compliance with prevention recommendations was low, despite a high prevalence of reported tick bites and significant outdoor exposures. Older adults and persons who spend significant time outdoors or engage in yardwork or gardening were at the highest risk of tick bites. Additional research is needed to further understand the barriers to tick bite prevention.

Protocol in a Day: An Educational Institutional Workshop for Protocol Development

PURPOSE/OBJECTIVE(S)

The Protocol-in-a-Day (PIAD) workshop was developed to support junior faculty and residents with clinical trial protocol design, with the main goal of providing initial feedback during development to reduce time for review and approval from institutional oversight committees. Our objectives are to mentor and educate participants and to evaluate the time to institutional approval by oversight committees.

MATERIALS/METHODS

PIAD provided concurrent educational feedback on 6 key elements of trial design. These included: (1) regulatory aspects; (2) institutional scientific review committee (SRC) and institutional review board (IRB); (3) clinical research and data coordination (including nursing); (4) statistics; (5) correlatives including imaging, biospecimens, and health services research/patient-reported outcomes; and (6) operations. The average number of days from submission to IRB approval or study activation for PIAD protocols was compared to other protocols submitted between January 2018 - January 2022 within the Division of Radiation Oncology. Participants were also given a 15-question survey to assess their perspective of the impact of the workshop.

RESULTS

A total of 25 protocols went through the PIAD workshop between January 2018-January 2022. Of the 25 protocols, 7 (28%) were excluded from this study due to not being submitted possibly after participants benefited from education on the limitations of their design. Eighteen protocols were included in our final analyses. These protocols included phase II (n = 11), phase 1 (n = 5), and phase III (n = 2). At the time of this report, all protocols (n = 18) have received IRB approval and have been activated. Protocol elements that could impact study activation included protocols requiring investigational new drug (IND) approval (n = 8) and multicenter studies (n = 1). Analyzing the time of submission to request for activation showed a decrease in time for protocols that went through PIAD vs those that did not [PIAD protocols, 254 days vs All other protocols, 262 days]. Likewise, those who attended PIAD had a lower average time from submission to IRB Approval [ PIAD protocols, 40 days vs All other protocols, 59 days]. All participants (100%) of the PIAD workshop responded that the educational program "improved the overall quality of the study design." The most commonly cited changes were protocol language (n = 17), statistics (n = 15), consent language (n = 8), and study design (n = 8). Aspects participants identified as the most educational included mentorship from regulatory, clinical research finance, and IRB review.

CONCLUSION

PIAD from participant surveys provided high educational value in the areas of improving trial quality, language and statistical design. When analyzing the average time, from 'submission to IRB initial approval' and 'submission to activation', PIAD protocols had a shorter time for approval, and thus suggests PIAD is effective in improving the overall design of protocols.

A systematic review of interventions to promote HPV vaccination globally

BACKGROUND

Despite the human papillomavirus (HPV) vaccine being a safe, effective cancer prevention method, its uptake is suboptimal in the United States (U.S.). Previous research has found a variety of intervention strategies (environmental and behavioral) to increase its uptake. The purpose of the study is to systematically review the literature on interventions that promote HPV vaccination from 2015 to 2020.

METHODS

We updated a systematic review of interventions to promote HPV vaccine uptake globally. We ran keyword searches in six bibliographic databases. Target audience, design, level of intervention, components and outcomes were abstracted from the full-text articles in Excel databases.

RESULTS

Of the 79 articles, most were conducted in the U.S. (72.2%) and in clinical (40.5%) or school settings (32.9%), and were directed at a single level (76.3%) of the socio-ecological model. Related to the intervention type, most were informational (n = 25, 31.6%) or patient-targeted decision support (n = 23, 29.1%). About 24% were multi-level interventions, with 16 (88.9%) combining two levels. Twenty-seven (33.8%) reported using theory in intervention development. Of those reporting HPV vaccine outcomes, post-intervention vaccine initiation ranged from 5% to 99.2%, while series completion ranged from 6.8% to 93.0%. Facilitators to implementation were the use of patient navigators and user-friendly resources, while barriers included costs, time to implement and difficulties of integrating interventions into the organizational workflow.

CONCLUSIONS

There is a strong need to expand the implementation of HPV-vaccine promotion interventions beyond education alone and at a single level of intervention. Development and evaluation of effective strategies and multi-level interventions may increase the uptake of the HPV vaccine among adolescents and young adults.

US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study

BACKGROUND

Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians.

METHODS

Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed.

RESULTS

Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity.

CONCLUSIONS

Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.

[How to manage late periprosthetic fluid collections (seromas) in patients with breast implants?]

The widespread use of silicone implants in reconstructive and aesthetic breast surgery led to an increase in the incidence of breast implant associated anaplastic large cell lymphoma, BIA-ALCL, mainly associated with the use of macro-textured breast implants. BIA-ALCL is a serious complication presenting clinically as a late onset periprosthetic seroma. Thus, its occurrence became an alarming sign feared by most plastic surgeons. Therefore, a good knowledge with respect to early diagnosis, subsequent workup, and treatment is crucial in the management of periprosthetic seroma. The diagnosis of late onset seroma is clinically evident. Although idiopathic seroma is the most common cause, BIA-ALCL should be always eliminated. A complete workup is usually necessary. An ultrasound performed by a radiologist specialized in breast imaging followed by an ultrasound guided puncture is imperative. Consequently, the cytological and the bacteriological analysis will orient us toward the etiology (infectious, neoplastic or mechanical). A standardized management of late periprosthetic seroma does not exist, with various factors are to be taken into consideration. These include the surgeon's experience, the diagnosis, and the medical institution facilities. Although idiopathic seroma is managed by a simple puncture and drainage, other causes may require a surgical procedure with implant removal, capsulotomies, and/or total capsulectomies.

Persistence of N-oxides transformation products of tertiary amine drugs at lab and field studies

This work aimed at studying the formation and persistence of N-oxides transformation products (TPs) of tertiary amine drugs by combining laboratory and field studies relevant for surface water. A monitoring study using passive samplers was first achieved for assessing attenuation of selected pharmaceuticals and their related N-oxides and N-, O-dealkylated TPs (i.e., venlafaxine, tramadol, amisulpride and sulpiride) along a 1.7 km river stretch between two sampling sites. This study revealed the stability of tramadol-N-oxide, amisulpride-N-oxide and the fast dissipation of O-desmethylvenlafaxine-N-oxide, as well as the significance of N-oxidized TPs in comparison to N-dealkylated TPs and parent compounds in river. Lab-scale experiments were then implemented for a better understanding of their mechanisms of formation and degradation under aerobic water/sediment testing and under simulated solar photochemistry. N-oxidation reactions were always a minor transformation pathway under both degradation conditions with respect to N-and O-dealkylation reactions. The amount of generated N-oxides were similar for venlafaxine, tramadol and sulpiride and peaked in the 8.4-12.8% and <4% of their initial concentration (100 μg/L), during photodegradation and biodegradation experiments, respectively. Other transformation pathways such as hydroxylation and α-C-hydroxylation followed by oxidation to amide or dehydration were also identified. Investigated N-oxides TPs (except O-desmethylvenlafaxine-N-oxide) were found stable under solar photolysis and aerobic biodegradation with a very slight reverse reaction to parent compound observed for tramadol-N-oxide and amisulpride-N-oxide. Lab-scale degradation experiments were not able to anticipate the high occurrence levels of N-oxide compounds in the environment. This was most likely due to faster degradation kinetics and/or higher sorption to sediment of parent compounds and dealkylated TPs over N-oxide TPs, resulting in higher relative accumulation of the latter.

302 MONITORING FALLS RISK IN THE COMMUNITY USING AN IMPLANTABLE CARDIAC MONITOR WITH EMBEDDED ACCELEROMETER

Background

Falls are the most common cause of injury amongst older adults. Falls can lead to hospitalisation, functional decline and are associated with increased morbidity and mortality. The holy grail for clinicians would be to predict increased likelihood of falls occurring and intervene before the event. Understanding underlying dynamic biophysiological changes may therefore inform novel predictor models and falls prevention. This study examines activity and cardiac data acquired from an implanted Medtronic Reveal LINQ™ Insertable Cardiac Monitor (ICM) with an embedded tri-axial accelerometer.

Methods

Thirty participants with at least one unexplained fall in the previous two years were prospectively recruited. All met criteria for ICM insertion following comprehensive assessment. Participants were followed for one year and attended every three-months for cardiac and gait assessment. Information pertaining to activity levels, posture changes and cardiac parameters were collected daily from the device. Summary metrics and trends were collected for inclusion in a continual assessment of falls risk.

Results

Mean age of participants was 68.0 years (±9.3). 19/30 (63.3%) were female. 22/30 (73.3%) had at least one cardiovascular condition documented in their medical history. There was seasonal variation in activity levels. Twelve participants had falls and cardiovascular, gait and activity variables were examined at the time of a fall to determine any trends in biophysiological changes.

Conclusion

Causes of falls are usually multifactorial. A holistic approach is necessary to manage and minimise risk factors. The use of an ICM with an embedded tri-axial accelerometer allows clinicians to formulate an algorithm to determine if a person is at an increased risk of falling based on biophysiological changes. This may create an opportunity for falls to be predicted and prevented.

Advance Care Planning Experiences Among Sexual and Gender Minority People

IMPORTANCE

Advance care planning (ACP) can promote patient-centered end-of-life (EOL) care and is intended to ensure that medical treatments are aligned with patient's values. Sexual and gender minority (SGM) people face greater discrimination in health care settings compared with heterosexual, cisgender people, but it is unknown whether such discrimination occurs in ACP and how it might affect the ACP experiences of SGM people.

OBJECTIVES

To increase understanding of barriers and facilitators of ACP facing SGM individuals.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods national study of ACP included a telephone survey of self-identified SGM and non-SGM participants in a nationally representative sample drawn from a larger omnibus national panel by SSRS. Qualitative interviews were conducted with a subset of survey participants who identified as SGM. Data were collected from October 2020 to March 2021.

EXPOSURES

Self-identified SGM.

MAIN OUTCOMES AND MEASURES

The survey included 4 items from the validated ACP Engagement Survey, adapted to capture experiences of discrimination. Interviews asked about participants' experiences with ACP, including the appointment of medical decision-makers, sharing preferences, and experiences within the health care system more broadly.

RESULTS

A total of 603 adults participated in the survey, with 201 SGM individuals (mean [SD] age, 45.7 [18.7] years; 101 [50.2%] female; 22 [10.9%] Black, 37 [18.4%] Hispanic, and 140 [69.7%] White individuals) and 402 non-SGM individuals (mean [SD] age, 53.7 [19.2] years; 199 [49.5%] female; 35 [8.7%] Black, 41 [10.2%] Hispanic, and 324 [80.6%] White individuals). Regarding reasons for not completing ACP, SGM respondents, compared with non-SGM respondents, were more likely to say "I don't see the need" (72 [73.5%] vs 131 [57.2%], P = .006) and "I feel discriminated against by others" (12 [12.2%] vs 6 [2.6%], P < .001). Of 25 completed interviews among SGM participants, 3 main themes were identified: how fear and experiences of discrimination affect selection of clinicians and whether to disclose SGM identity; concerns about whether EOL preferences and medical decision-makers would be supported; and a preference to discuss EOL decisions and values outside of clinical settings.

CONCLUSIONS AND RELEVANCE

This study found that fear of disclosing sexual orientation or gender identity information and discrimination are important barriers to ACP for SGM in clinical settings, but discussions of preferences and values still occur between many SGM people and medical decision-makers. More SGM-specific patient-centered care might better support these discussions within the health care system. Furthermore, health systems can facilitate improved engagement by supporting clinician sensitivity training, including guidance on documentation and requirements.

Seroprevalence of Powassan Virus Infection in an Area Experiencing a Cluster of Disease Cases: Sussex County, New Jersey, 2019

In 2019, a geographically focal cluster of 3 Powassan virus neuroinvasive disease cases occurred in New Jersey. We conducted a serosurvey of 273 adult area residents and estimated that immunoglobulin M seroprevalence was 0.31% (95% confidence interval [CI], .04%-1.00%) and 23% (95% CI, 7%-100%) of infections result in neuroinvasive disease.

Educational Resources and Self-Management Support to Engage Patients in Advance Care Planning: An Interpretation of Current Practice in the US

BACKGROUND

Educational resources and decision aids help patients, their care partners and health care providers prepare for and confidently engage in Advance Care Planning (ACP). Incorporating ACP resources as part of a self-management approach may lead to fuller engagement with ACP beyond identifying a surrogate decision-maker, towards supporting a person to identify their values and goals and to communicate them with their care partners and health care providers.

OBJECTIVE

To examine the use of educational resources and decision aids to support self-management of ACP in 11 health systems across the US.

METHODS

This study was a qualitative interview study examining barriers and facilitators to ACP. Guided by interpretative description and the chronic care model, we sought to describe how health care stakeholders (clinicians and administrators) and patients use ACP resources to support engagement with ACP.

RESULTS

274 health care stakeholders were interviewed, and 7 patient focus groups were conducted across 11 health systems. The majority of participants reported using resources to support completion of preference documentation, with fewer participants using resources that promote more engagement in ACP. ACP resources were reported as valuable in preparing for and complementing a complex, interpersonal, and interprofessional process. Barriers to using resources included a lack of a defined workflow and time.

CONCLUSION

Our data suggest that ACP resources that promote engagement are valued but under-utilized in practice. The use of ACP resources with an inter-professional team and a self-management approach is a promising strategy to mitigate the barriers of ACP implementation while improving engagement in ACP.

Understanding The Use Of Medicare Procedure Codes For Advance Care Planning: A National Qualitative Study

In 2016 Medicare introduced advance care planning Current Procedural Terminology (CPT) codes to reimburse clinicians for time spent providing the service. Despite recent increases, use of these codes remains low for reasons incompletely captured by quantitative research. To further identify barriers and facilitators to code use for Medicare fee-for-service enrollees, we conducted case studies at eleven health systems, including 272 interviews with clinicians, administrators, and key leadership. Five themes related to use of the new codes emerged: code-based constraints to billing, burdening patients with unexpected charges, ethical concerns with billing for discussion of advance care plans, incentives to signal the importance of their use in billing, and increasing both workflow burden and the need for institutional supports and training. Respondents also observed that use was facilitated by health systems' investment in clinician training and in processes to audit the codes' use. Our findings suggest that increased reimbursement, strong institutional commitment and support, and streamlined workflow could improve the use of the new CPT codes to document receipt of and ensure access to Medicare advance care planning.

Treating strangeness: Medicine and human dignity at the time of COVID-19

The concomitance of a migratory wave and the hospital crisis once again raises the question of the care that the French healthcare system is able to provide to migrants. On the occasion of SFFEM's 19th annual day, we present a synthesis of the research work that has been communicated at that time. Firstly, we will discuss how doctors have been able to overcome strangeness to revive the notion of hospitality according to Levinas; secondly, we will discuss how the hospital is departing from its mission of institutional hospitality because of administrative injunctions; thirdly, we will discuss how ethnomedicine gives us keys to open up to other cultural norms; fourthly, we will see the inadequacy that exists between rights of access to medical care and their effectiveness; finally, the conclusion of Xavier Emmanuelli, founder of the social ambulance service, will remind us how much the values of the French Republic call us to the notion of care and openness to otherness.

Efficacy of the hypothermic compression bandage in the surgical wound of cardiac devices

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pocket hematoma is one of the most frequent complications (10%) of the cardiac devices implant. To reduce the risk of bleeding, once the wound is sutured and isolated with a sterile dressing, the nurse performs a compression bandage over the area of the generator pocket. The choice of the type of bandage on the wound of the generator pocket is the responsibility of the nurse and there are several methods that vary according to the center. The vasocontrictive property of ice is known but its applicability is not demonstrated in these types of wounds.

Objective

Evaluate the efficacy of the hypothermic compression bandage versus conventional compression bandage, for the prevention of surgical wound post cardiac device implant hematoma in chronic oral anticoagulant and / or platelet antiaggregant treatment.

Methodology

This is a randomized prospective study. The protocol was accepted by ethical committee. The team of nurses from the arrhythmia laboratory recruited 310 patients (sample size with statistical calculation) who were going to undergo an implant or replacement of a pacemaker or internal defibrillator. Those patients who were under treatment with oral anticoagulant and/or platelet antiaggregants were selected. Through a list of random numbers two therapeutic branches were created: the intervention group was applied a compressive bandage with ice and the usual group lacked the conventional compressive bandage. Both bandages placed just at the end of wound closure and for 6 hours post-implant. Skin status was stratified between healthy, ecchymosis, mild hematoma and severe hematoma. The assessment of the state of the skin was performed by a blinded nurse, in the control of the wound at 7 days post intervention.

The primary endpoint was the appearance of hematoma. The secundary endpoint was the appearance of severe hematoma, defined as bleeding with vital commitment that required drainage or rehospitalization.

Results

310 patients participated in the study. 156 patients were randomized to the intervention group and 153 to usual care. The mean age of the sample was 73.77 ± 10.68 years and 74.8% were men. There were no significant differences between the intervention and usual care groups on any baseline demographic or clinical characteristics. A total of 13 patients presented hematoma and 36 patients presented ecchymosis. In the intervention group, 5.88% (n = 18) of ecchymosis and 1.3% (n = 4) of mild hematoma were observed. In the usual care group, 5.88% (n = 18) of ecchymosis and 2.9% (n = 9) of mild hematoma were observed. No patient in neither groups had severe hematoma. No significant differences were observed between the two types of bandage in any of the 3 levels of hematomas. There were also no significant differences between hematoma and the type of platelet antiaggregants or oral anticoagulant.

Conclusion

After this study it is observed that there is no difference between applying a compression bandage with or without cold.

Factors Associated With Candida auris Colonization and Transmission in Skilled Nursing Facilities With Ventilator Units, New York, 2016-2018

BACKGROUND

Candida auris is an emerging, multidrug-resistant yeast that spreads in healthcare settings. People colonized with C. auris can transmit this pathogen and are at risk for invasive infections. New York State (NYS) has the largest US burden (>500 colonized and infected people); many colonized individuals are mechanically ventilated or have tracheostomy, and are residents of ventilator-capable skilled nursing facilities (vSNF). We evaluated the factors associated with C. auris colonization among vSNF residents to inform prevention interventions.

METHODS

During 2016-2018, the NYS Department of Health conducted point prevalence surveys (PPS) to detect C. auris colonization among residents of vSNFs. In a case-control investigation, we defined a case as C. auris colonization in a resident, and identified up to 4 residents with negative swabs during the same PPS as controls. We abstracted data from medical records on patient facility transfers, antimicrobial use, and medical history.

RESULTS

We included 60 cases and 218 controls identified from 6 vSNFs. After controlling for potential confounders, the following characteristics were associated with C. auris colonization: being on a ventilator (adjusted odds ratio [aOR], 5.9; 95% confidence interval [CI], 2.3-15.4), receiving carbapenem antibiotics in the prior 90 days (aOR, 3.5; 95% CI, 1.6-7.6), having ≥1 acute care hospital visit in the prior 6 months (aOR, 4.2; 95% CI, 1.9-9.6), and receiving systemic fluconazole in the prior 90 days (aOR, 6.0; 95% CI, 1.6-22.6).

CONCLUSIONS

Targeted screening of patients in vSNFs with the above risk factors for C. auris can help identify colonized patients and facilitate the implementation of infection control measures. Antimicrobial stewardship may be an important factor in the prevention of C. auris colonization.

The Patient in Your Alzheimer's Disease Study May be in Another: Duplication and Deception in Clinical Trials of Alzheimer's Disease

Duplicate and deceptive subjects, a significant issue in CNS studies, are not often considered in Alzheimer's Disease (AD) clinical trials. However, AD patients and their study partners may be motivated to take advantage of different mechanisms of action, increase odds of receiving active treatment, and/or obtain financial compensation, which may lead them to participate in multiple studies. CTSdatabase reviewed memory loss subjects (n=1087) from January 2017 through May 2019 to determine how many attempted to screen at multiple sites. 117 subjects (10.8%) visited more than one site within two years. When these potential AD subjects went to additional sites, it was predominantly for non-memory indications (often MDD or schizophrenia). For those that participated in studies, the rate of duplication approached 4% of screened AD subjects. This data indicates that significant numbers of AD subjects attempt to enroll at multiple sites, which confounds efficacy and safety signals in clinical trials.

"Don't Talk to Them About Goals of Care": Understanding Disparities in Advance Care Planning

BACKGROUND

Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions.

METHOD

In this national study, we conducted semi-structured interviews with purposively selected clinicians from 6 diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them.

RESULTS

Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (preconceived views of patients' preferences, narrow definitions of successful ACP, and lack of institutional resources), while the final theme illustrated facilitators to ACP (acknowledging bias and rejecting stereotypes, mission-driven focus on ACP, and acceptance of all preferences).

CONCLUSIONS

Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.

A195 A RARE CAUSE OF SEVERE REFRACTORY DIARRHEA IN A PATIENT WITH COMMON VARIABLE IMMUNE DEFICIENCY ASSOCIATED INTESTINAL ENTEROPATHY

Background

CVID is the most common type of severe antibody deficiency. Gastrointestinal manifestations affect approximately 20–50% of patients. Boland et al. described in a case series that 2/3 CVID patients were able to achieve clinical and endoscopic remission with Vedolizumab. This α4β7 integrin antagonist inhibits intestinal T cell translocation by blocking integrin interactions with mucosal vascular addressin cell adhesion molecule 1, reducing lymphocyte mediated inflammation. However, despite its novel use for this indication, limited data is available on the consequences of this therapy in patients with CVID.

Aims

To report on a case assessing the efficacy and outcomes of Vedolizumab for the treatment of CVID associated autoimmune enteropathy.

Methods

We present the case of a 50-year-old male presenting with severe refractory diarrhea and malnutrition. A colonoscopy demonstrated patchy ulceration and biopsies revealed ulcerated active colitis, negative for CMV. He was treated with Vedolizumab and Total Parental Nutrition (TPN). His diarrhea resolved, he gained 20 kg and he was weaned off TPN. In 2019, he re-presented with severe diarrhea. Subsequently endoscopic evaluation revealed patchy edematous colonic mucosa and biopsies demonstrated minimally active colitis, negative for CMV. He again responded to Vedolizumab re-induction, however shortly after, his diarrhea returned aggressively. CT enterography demonstrated active jejunal inflammation. Subsequently, an EGD revealed multiple duodenal ulcers and luminal narrowing. Biopsies of the small bowel were sent to histopathology.

Results

CMV superinfection was diagnosed on pathology (image 1). This patient’s diarrhea completely resolved with IV Gancyclovir and he was discharged on maintenance treatment with oral Valganciclovir.

Conclusions

This represents the first reported case of CMV enteritis secondary to Vedolizumab for the treatment of CVID associated autoimmune enteropathy. In this case, clinical and endoscopic remission was observed with Vedolizumab, however subsequently hampered by CMV reactivation. Hommel et al., published a positive correlation in a single centre retrospective cohort study of CMV reactivation in patients with ulcerative colitis treated with Vedolizumab. A large retrospective review of data from a multicenter consortium database of over 1000 Vedolizumab treated IBD patients reported CMV colitis in only 4 patients. CMV reactivation appears to be an exceptionally rare but important event in patients treated with Vedolizumab. Based on this report, patients with CVID associated enteropathy and refractory diarrhea should be carefully screened for CMV when treated with Vedolizumab. Further prospective data assessing the incidence of CMV reactivation in patients with Vedolizumab therapy is required to further define these findings.

Funding Agencies

None

Severe adverse events during medical and surgical treatment of hip and knee prosthetic joint infections

INTRODUCTION

The management of prosthetic joint infection requires a complex treatment procedure and can be associated with complications. However, the occurrence of severe adverse events during this intervention has been poorly evaluated.

PATIENTS AND METHODS

A 5-year multicentric retrospective study including patients from 3 hospitals in the South-Western France referral center for complex bone and joint infections (Crioac GSO) and treated for hip or knee prosthetic joint infection with 1 or 2-stage implant exchanges. The objective was to describe grade≥3 adverse events, according to the CTCAE classification, occurring within 6 weeks after surgery and to identify their associated factors.

RESULTS

One hundred and eighteen patients were identified. We observed 71 severe events in 50 patients (42.3%; 95% confidence interval [CI95%]: 33.8-51.4%). Sixteen severe events were an evolution of the infection. The remaining 55 others (47 grade 3 and 8 grade 4) occurred in 41 patients (34.7%; CI95%: 26.8-43.7%). They were distributed as follows: 27 (49.1%) medical complications, 21 (38.2%) surgical complications and 7 (12.7%) antibiotic-related complications. The main identified risk factor was a two-stage prosthetic exchange with OR=3.6 (CI95% [1.11-11.94], P=0.032). Obesity was limit of significance with OR=3.3 (CI95% [0.9-12.51], P=0.071). Infection with coagulase negative Staphylococcus was a protective factor with OR=0.3 (CI95% [0.12-0.99], P=0.047).

CONCLUSION

Severe adverse events are frequent following prosthetic exchange for PJI (34.7%) and are related to the high frequency of comorbidities in this population and to the complex surgical procedures required. The risk factor significantly associated with these events was a two-stage exchange.