Safety and Feasibility of a Protocolized Daily Assessment of Readiness for Liberation From Venovenous Extracorporeal Membrane Oxygenation

BACKGROUND

Decannulation from venovenous extracorporeal membrane oxygenation (ECMO) at the earliest and safest possible time may improve outcomes and reduce cost. Yet, no prospective studies have compared weaning strategies for liberation from ECMO.

RESEARCH QUESTION

Is a protocolized daily assessment of readiness to liberate from venovenous ECMO safe and feasible?

STUDY DESIGN AND METHODS

We conducted a prospective, single-arm safety and feasibility study of a protocol for daily assessment of readiness to liberate from venovenous ECMO among consecutive adult patients receiving venovenous ECMO across four ICUs at a single center between June 20, 2020, and November 24, 2020. The ECMO-free protocol included three phases: (1) the safety screening, (2) non-ECMO Fio2 titration, and (3) the ECMO-free trial. Enrollment, interventions, and data collection were performed prospectively by trained study staff.

RESULTS

Twenty-six patients received the ECMO-free protocol on 385 patient-days. The safety screening was passed during a total of 59 ECMO-free daily assessments (15.3%) among 20 patients. Every passed safety screening proceeded to an ECMO-free trial. Twenty-eight passed ECMO-free trials (47.5%) occurred among 16 patients (61.5%). No missed safety screenings, protocol deviations, or adverse events occurred. Of the 16 patients who passed an ECMO-free trial, 14 patients (87.5%) were decannulated. Among decannulated patients, 12 patients (85.7%) were decannulated on the same day as a passed ECMO-free trial, 6 patients (42.9%) were decannulated on the first day that they passed an ECMO-free trial, and 6 patients (42.9%) passed an ECMO-free trial at least twice consecutively before decannulation. The median time from first passed ECMO-free trial to decannulation was 2 days (interquartile range, 0-3 days).

INTERPRETATION

The ECMO-free protocol is feasible and may identify patients for decannulation earlier than gradual approaches to weaning.

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial

Importance

Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings.

Objective

To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics.

Design, Setting, and Participants

This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months.

Interventions

Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing.

Main Outcomes and Measures

Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects.

Results

Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, -1.7 to 5.7; P = .29).

Conclusions and Relevance

In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable.

Trial Registration

ClinicalTrials.gov Identifier: NCT02738944.

A Comparison of Two Widely Used Risk Stratification Systems for Thyroid Nodule Sonographic Evaluation

BACKGROUND

The 2015 American Thyroid Association (ATA2015) and the American College of Radiology Thyroid Imaging and Reporting Data System (ACR TI-RADS) are two widely used thyroid sonographic systems.

OBJECTIVES

To compare the two systems for accuracy of cancer risk prediction.

METHODS

Preoperative ultrasound images from 265 patients who underwent thyroidectomy at our hospital from January 2012 to March 2019 were retrospectively categorized by the ACR TI-RADS and ATA2015 systems. Diagnostic performances were compared.

RESULTS

Of 238 nodules assessed, 115 were malignant. Malignancy risks for the five ACR TI-RADS categories were 0%, 7.5%, 11.4%, 59.6%, and 90.0%. Malignancy risks for the five ATA2015 categories were 0%, 6.8%, 17.0%, 55.5%, and 92.1%. The proportion of total nodules biopsied was higher with the ATA2015 system than the ACR TI-RADS system: 88.7% vs. 66.3%. Proportions of malignant nodules and benign nodules biopsied were higher with ATA2015 than with ACR TI-RADS: 93.3% vs. 87.8% and 84.4% vs. 46.3%, respectively. Specificity and sensitivity rates were 53.6% and 84.3%, respectively, for ACR TI-RADS, and 15.5% and 93.3%, respectively, for ATA2015. The two systems showed similarly accurate diagnostic performance (AUC > 0.88). False negative rates for ACR TI-RADS and ATA2015 were 15.6% and 6.6%, respectively. Rates of missed aggressive cancer were similar for the two systems: 3.4% and 3.7%, respectively.

CONCLUSIONS

ACR TI-RADS was superior to ATA2015 in specificity and avoiding unnecessary biopsies. ATA2015 yielded better sensitivity and a lower false negative rate. Identification of aggressive cancers was identical in the two systems.

Enhanced Recovery after Surgery is Feasible and Beneficial and Should Be the Standard in Major Gynecological Surgeries

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are evidence-based protocols designed to standardize medical care, improve outcomes, and lower healthcare costs.

OBJECTIVES

To evaluate the implementation of the ERAS protocol and the effect on recovery during the hospitalization period after gynecological laparotomy surgeries.

METHODS

We compared demographic and clinical data of consecutive patients at a single institute who underwent open gynecological surgeries before (August 2017 to December 2018) and after (January 2019 to March 2020) the implementation of the ERAS protocol. Eighty women were included in each group.

RESULTS

The clinical and demographic characteristics were similar among the women operated before and after implementation of the ERAS protocol. Following implementation of the protocol, decreases were observed in post-surgical hospitalization (from 4.89 ± 2.56 to 4.09 ± 1.65 days, P = 0.01), in patients reporting nausea symptoms (from 18 (22.5%) to 7 (8.8%), P = 0.017), and in the use of postoperative opioids (from 77 (96.3%) to 47 (58.8%), P < 0.001). No significant changes were identified between the two periods regarding vomiting, 30-day re-hospitalization, and postoperative minor and major complications.

CONCLUSIONS

Implementation of the ERAS protocol is feasible and was found to result in less postoperative opioid use, a faster return to normal feeding, and a shorter postoperative hospital stay. Implementation of the protocol implementation was not associated with an increased rate of complications or with re-admissions.

COVID-19-related acute kidney injury; incidence, risk factors and outcomes in a large UK cohort

BACKGROUND

Acute kidney injury (AKI) is common among patients hospitalised with COVID-19 and associated with worse prognosis. The aim of this study was to investigate the epidemiology, risk factors and outcomes of AKI in patients with COVID-19 in a large UK tertiary centre.

METHODS

We analysed data of consecutive adults admitted with a laboratory-confirmed diagnosis of COVID-19 across two sites of a hospital in London, UK, from 1st January to 13th May 2020.

RESULTS

Of the 1248 inpatients included, 487 (39%) experienced AKI (51% stage 1, 13% stage 2, and 36% stage 3). The weekly AKI incidence rate gradually increased to peak at week 5 (3.12 cases/100 patient-days), before reducing to its nadir (0.83 cases/100 patient-days) at the end the study period (week 10). Among AKI survivors, 84.0% had recovered renal function to pre-admission levels before discharge and none required on-going renal replacement therapy (RRT). Pre-existing renal impairment [odds ratio (OR) 3.05, 95%CI 2.24-4,18; p <  0.0001], and inpatient diuretic use (OR 1.79, 95%CI 1.27-2.53; p <  0.005) were independently associated with a higher risk for AKI. AKI was a strong predictor of 30-day mortality with an increasing risk across AKI stages [adjusted hazard ratio (HR) 1.59 (95%CI 1.19-2.13) for stage 1; p < 0.005, 2.71(95%CI 1.82-4.05); p < 0.001for stage 2 and 2.99 (95%CI 2.17-4.11); p < 0.001for stage 3]. One third of AKI3 survivors (30.7%), had newly established renal impairment at 3 to 6 months.

CONCLUSIONS

This large UK cohort demonstrated a high AKI incidence and was associated with increased mortality even at stage 1. Inpatient diuretic use was linked to a higher AKI risk. One third of survivors with AKI3 exhibited newly established renal impairment already at 3-6 months.

Bleeding in Patients With Gastrointestinal Cancer Compared With Nongastrointestinal Cancer Treated With Apixaban, Rivaroxaban, or Enoxaparin for Acute Venous Thromboembolism

OBJECTIVE

To compare the bleeding risk in patients with gastrointestinal (GI) cancer with that in patients with non-GI cancer treated with anticoagulation for acute cancer-associated venous thromboembolism (Ca-VTE).

PATIENTS AND METHODS

Consecutive patients with Ca-VTE seen at the Mayo Thrombophilia Clinic between March 1, 2013, and April 20, 2020, were observed prospectively to assess major bleeding and clinically relevant nonmajor bleeding (CRNMB).

RESULTS

In the group of 1392 patients with Ca-VTE, 499 (35.8%) had GI cancer including 272 with luminal GI cancer (lower GI, 208; upper GI, 64), 176 with pancreatic cancer, and 51 with hepatobiliary cancer. The rate of major bleeding and CRNMB in patients with GI cancer was similar to that in 893 (64.2%) patients with non-GI cancer treated with apixaban, rivaroxaban, or enoxaparin. Apixaban had a higher rate of major bleeding in luminal GI cancer compared with the non-GI cancer group (15.59 vs 3.26 per 100 person-years; P=.004) and compared with enoxaparin in patients with luminal GI cancer (15.59 vs 3.17; P=.04). Apixaban had a lower rate of CRNMB compared with rivaroxaban in patients with GI cancer (3.83 vs 9.40 per 100 person-years; P=.03). Patients treated with rivaroxaban in the luminal GI cancer group had a major bleeding rate similar to that of patients with non-GI cancer (2.04 vs 4.91 per 100 person-years; P=.37).

CONCLUSION

Apixaban has a higher rate of major bleeding in patients with luminal GI cancer compared with patients with non-GI cancer and compared with enoxaparin in patients with luminal GI cancer. Rivaroxaban shows no increased risk of major bleeding in patients with GI cancer or luminal GI cancer compared with patients with non-GI cancer.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03504007.

Risks associated with colonoscopy in a population-based colon screening program: an observational cohort study

BACKGROUND

The risks associated with colonoscopy performed through the British Columbia Colon Screening Program (BCCSP) are not known. We aimed to determine the rate of colonoscopy-related serious adverse events within this program.

METHODS

For this prospective observational study, we used the BCCSP database to identify participants 50 to 74 years of age who had a positive result on fecal immunochemical testing (FIT) between Nov. 15, 2013, and Dec. 31, 2017, followed by colonoscopy. Unplanned medical events were recorded at the time of colonoscopy and 14 days later. We reviewed the unplanned events and defined them as serious adverse events if they resulted in death, hospital admission or intervention; we also classified them as probably, possibly or unlikely related to the colonoscopy. The primary outcome was the overall rate of serious adverse events; the secondary outcomes were 14-day post-colonoscopy rates of perforation, bleeding and death.

RESULTS

During the study period, a total of 96 192 colonoscopies were performed by 308 physicians at 50 sites. The median age of patients was 62 (10th-90th percentile 52-71) years, and 56% were male. Of these, 78 831 patients were contacted after the colonoscopy. Serious adverse events were deemed to have occurred in 350 colonoscopies (44 per 10 000, 95% confidence interval [CI] 39-50 per 10 000), with a number needed to harm of 225. Of the 332 (94.9%) serious adverse events that were probably or possibly related to colonoscopy, perforation occurred in 6 (95% CI 5-8) per 10 000 colonoscopies, bleeding in 26 (95% CI 22-30) per 10 000 colonoscopies and death in 3 (95% CI 1-10) per 100 000 colonoscopies.

INTERPRETATION

The rate of serious adverse events associated with colonoscopy in the BCCSP was in keeping with previous publications and met accepted benchmarks. The findings of this study inform stakeholders of the risks associated with colonoscopy in an FIT-based colon screening program.

Extra Peritoneal Packing for Exsanguinating Pelvic Hemorrhage: Should We Do It in the Emergency Department?

BACKGROUND

Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage.

OBJECTIVES

To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR).

METHODS

Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008-2018.

RESULTS

Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038).

CONCLUSIONS

EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT.

Robotic-assisted Heller Myotomy Is a Safe Operation

BACKGROUND

Surgical myotomy is the best therapeutic option for patients with achalasia. The minimally invasive technique is considered to be the preferred method for many surgeons. Robotic-assisted laparoscopic myotomy has several advantages over conventional laparoscopic surgery. These benefits include more accurate incisions that may result in a lower rate of intra-operative complications.

OBJECTIVES

To describe our technique of performing robotic-assisted Heller myotomy and to review the initial results of this procedure.

METHODS

All patients undergoing robotic-assisted Heller myotomy for achalasia between the years 2012-2018 at Rabin Medical Center were retrospectively reviewed from our institutional prospective database.

RESULTS

Thirty patients underwent robotic-assisted Heller myotomy for achalasia. Mean operative time was 77 minutes (range 47-109 minutes) including docking time of the robotic system. There were no cases of conversion to laparoscopic or open surgery. There were no cases of intra-operative perforation of the mucosa. None of the patients had postoperative morbidity or mortality. Good postoperative results were achieved in 25 patients. Four patients required additional intervention (3 had endoscopic dilatations and 1 with known preoperative endstage achalasia had undergone esophagectomy). One patient was lost to follow-up.

CONCLUSIONS

Robotic-assisted Heller myotomy is a safe technique with a low incidence of intra-operative esophageal perforation compared to the laparoscopic approach. We believe that robotic-assisted surgery should be the procedure of choice to treat achalasia.

Endoscopic Cyanoacrylate Injection Versus Balloon-Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

BACKGROUND AND AIMS

The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis.

APPROACH AND RESULTS

Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all-cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow-up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all-cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs.

CONCLUSIONS

BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.

Successful Implementation of Enhanced Recovery in Elective Colorectal Surgery is Variable and Dependent on the Local Environment

OBJECTIVE

To evaluate local hospital success with enhanced recovery implementation as measured by colorectal surgery process measure (PM) compliance and characterize local environment factors associated with success within a contemporary quality improvement collaborative.

SUMMARY BACKGROUND DATA

Enhanced recovery programs (ERP) have proven an effective perioperative quality improvement strategy, but local variation in implementation can hinder patient outcome improvement.

METHODS

Individual hospitals participating in a national colorectal ERP quality improvement program were evaluated with quantitative (patient-level process and outcome) and qualitative (survey and structured interviews with hospital teams) data between 2017 and 2020. Hospitals with implementation success were identified: high performers (80% of elective colorectal surgery patients compliant with >6/9 PMs) and high improvers (top quartile of PM adherence improvement over time). Hospital and implementation characteristics were compared with chi-square tests. Trends in average annual outcome change were estimated with logistic and linear regression.

RESULTS

Of 207 total hospitals, 62 were characterized as High Performance and 52 as High Improvement. High Performance hospitals were larger, with more annual colorectal surgeries (128 vs 101, P = 0.039). Qualitative assessment revealed fewer barriers of staff buy-in and competing priorities, and more experience with standardized perioperative care in High Performance hospitals. High Improvement hospitals had lower baseline PM adherence (54.1% vs 69.6%, P < 0.001) and less experience with standardized perioperative care (30.8% vs 58.1%, P < 0.001) but were noted to have a positive trend in annual patient outcomes: annual morbidity (Δ-1.14% vs -0.20%, P = 0.035), readmission (Δ-1.85% vs 0.002%, P = 0.037), and prolonged length of stay (Δ-3.94 vs -1.19, P = 0.037) compared to Low Improvement hospitals.

CONCLUSIONS

When evaluating a collection of hospitals implementing ERP, only half of hospitals reached consistent High Performance or high improvement. Characteristics of the local environment need further study to understand the barriers to effective implementation in a pragmatic setting.

TrueVue transillumination volume rendering for three-dimensional transoesophageal echocardiography in interventional imaging

AIMS

The aim of the present article is to address the advantages of real-time TrueVue transillumination rendering for three-dimensional transoesophageal echocardiography in the context of echocardiographic procedural guidance for structural interventions for several procedural concerns.

METHODS

Procedures in which transillumination imaging was used during at least one step of the whole intervention were retrospectively collected; the loops were reviewed by an experienced imaging specialist and the most important concerns imaged in the loops were listed. The apparent added value of transillumination for each of these concerns was scored independently by two imager specialists, and their agreement was derived.

RESULTS

Between January and June 2019, 50 procedures were performed in our centre. Transillumination imaging was used in 64% of these cases. Considering all the loops the added value of transillumination compared with the conventional rendering was scored greater than 3 in a Likert scale in 87% of analysed loops by both the operators with a good agreement (κ  = 0.47, P  = 0.001). A different level of perceived advantage and agreement was observed between three image features that improved: substantial agreement (κ  = 0.652, P  = 0.001) for enhancing the contrast between structures and cavities (n  = 24 loops); good agreement for the contrast between different structures (κ  = 0.588, P  = 0.002) (n  = 37 loops); moderate agreement for the perception of interaction between the device and structures (κ  = 0.3, P  = 0.027) (n  = 7 loops).

CONCLUSION

The use of new volume-rendering techniques in interventional imaging may be useful especially for solving the concerns regarding the cavity-structure contrast.

Clinical Outcomes of Robotic Assisted Partial Nephrectomy for Pathologic T3a Renal Masses with Venous Tumor Thrombus

OBJECTIVE

To evaluate the safety, efficacy, and early oncologic outcomes of pT3a renal cell carcinoma (RCC) with venous involvement treated with robotic partial nephrectomy (RPN), given that experience and outcomes in this group is limited.

METHODS

A retrospective chart review of patients undergoing RPN from 9/2009-7/2020 was performed. Outcomes were captured from patients with pathologic T3a disease with vein involvement. Clinical characteristics were analyzed using SPSS (IBM, Armonk, NY). Local recurrence-free survival (LRFS) and metastasis-free survival (MFS) at 2 years were calculated from Kaplan-Meier survival curves.

RESULTS

For 45 included patients, mean operative and warm ischemia times were 199.6 min ± 47.3 and 30.5 min ± 10.5, with mean estimated blood loss of 324.9 cc ±209.5. Rates of transfusion, embolization, re-admission, and re-operation at 30 days were 8.9% (4/45), 2.2% (1/45), 11.1% (5/45), and 6.7% (3/45; cystoscopic stent placement), respectively. All tumors were malignant on pathology, with clear cell RCC being the most common (91.0%, n=41). The positive margin rate was 6.7% (n=3). Local recurrence occurred in 4.4% (n=2) at a mean time of 5.2 months ± 2.3. Four patients (8.9%) progressed to metastatic disease at a mean of 22.2 months ± 23.0. At 2 years, LRFS was 95.4% and MFS was 95.3%.

CONCLUSIONS

We present the largest known series of patients RPN for pT3a renal masses with venous tumor involvement. We found it both feasible and safe in the appropriate hands. Short term oncologic outcomes for these patients appear more favorable than historic literature suggested. SOURCES OF FUNDING: none.

Publicly reported health performance measures 2010-2020

AIM

Performance measurement is central to healthcare management in many countries. The aim of this study was to determine whether performance measurement in a New Zealand healthcare organisation met a range of criteria supported by healthcare management literature.

METHOD

Performance expectations published in statements of intent and annual plans from an 11-year period were analysed for evidence of continuity, accuracy, effectiveness, patient centredness and clinical relevance.

RESULTS

731 distinct performance measurements were identified. 48% were measured only once. Of those where comparison was possible, 21.9% met at least one expected target or range. In published reports there was limited reference to data verification methods, tests of significance, prospective linkage to actions, counterbalancing measures, application of benchmarks or standards, or patient measure prioritisation.

CONCLUSIONS

These findings suggest that healthcare organisations do not find performance measurement easy. This may be due to the wrong choice of measures, inappropriate targets, incomplete analyses or difficulty in linking measurement results to actions.

Embedding Learning in a Learning Health Care System to Improve Clinical Practice

PROBLEM

In an ideal learning health care system (LHS), clinicians learn from what they do and do what they learn, closing the evidence-to-practice gap. In operationalizing an LHS, great strides have been made in knowledge generation. Yet, considerable challenges remain to the broad uptake of identified best practices. To bridge the gap from generating actionable knowledge to applying that knowledge in clinical practice, and ultimately to improving outcomes, new information must be disseminated to and implemented by frontline clinicians. To date, the dissemination of this knowledge through traditional avenues has not achieved meaningful practice change quickly.

APPROACH

Vanderbilt University Medical Center (VUMC) developed QuizTime, a smartphone application learning platform, to provide a mechanism for embedding workplace-based clinician learning in the LHS. QuizTime leverages spaced education and retrieval-based practice to facilitate practice change. Beginning in January 2020, clinician-researchers and educators at VUMC designed a randomized, controlled trial to test whether the QuizTime learning system influenced clinician behavior in the context of recent evidence supporting the use of balanced crystalloids rather than saline for intravenous fluid management and new regulations around opioid prescribing.

OUTCOMES

Whether spaced education and retrieval-based practice influence clinician behavior and patient outcomes at the VUMC system level will be tested using the data currently being collected.

NEXT STEPS

These findings will inform future directions for developing and deploying learning approaches at scale in an LHS, with the goal of closing the evidence-to-practice gap.

Telemedicine for adult congenital heart disease patients during the first wave of COVID-19 era: a single center experience

AIM

To summarize our experience on the implementation of a telemedicine service dedicated to adult congenital heart disease (ACHD) patients during the lockdown for the first wave of Coronavirus disease 2019 (COVID-19).

METHODS

This is a prospective study enrolling all ACHD patients who answered a questionnaire dedicated telematic cardiovascular examination.

RESULTS

A total of 289 patients were enrolled, 133 (47%) were male, 25 (9%) were affected by a genetic syndrome. The median age was 38 (29-51) years, whereas the median time interval between the last visit and the telematic follow-up was 9.5 (7.5-11.5) months. Overall, 35 patients (12%) reported a worsening of fatigue in daily life activity, 17 (6%) experienced chest pain, 42 (15%) had presyncope and 2 (1%) syncope; in addition, 28 patients (10%) presented peripheral edema and 14 (5%) were orthopneic. A total of 116 (40%) patients reported palpitations and 12 had at least one episode of atrial fibrillation and underwent successful electrical (8) or pharmacological (4) cardioversion. One patient was admitted to the emergency department for uncontrolled arterial hypertension, five for chest pain, and one for heart failure. Two patients presented fever but both had negative COVID-19 nasal swab.

CONCLUSION

During the COVID-19 pandemic, the use of telemedicine dramatically increased and here we report a positive experience in ACHD patients. The postpandemic role of telemedicine will depend on permanent regulatory solutions and this early study might encourage a more systematic telematic approach for ACHD patients.

Patients with More Severe IBD Get Clostridioides difficile Rather than Clostridioides difficile Increasing the Severity of IBD

BACKGROUND

Inflammatory bowel disease (IBD) patients who have Clostridioides difficile infection (CDI) have worse outcomes.

AIMS

We aimed to determine whether such outcomes are the result of CDI or whether CDI occurs in patients who have more severe IBD.

METHODS

This was a retrospective study of patients hospitalized for ≥ 2 IBD flares from 2010 to 2019. The primary outcome was time to IBD flare between hospitalizations. First, time to flare was compared between patients who were hospitalized for a flare complicated by CDI and subsequently for a CDI-negative flare (cohort A, denoted +/-) versus patients who were hospitalized for two CDI-negative flares (cohort B, -/-). Second, time between flares was compared within the subset of cohort A patients who had three flares (cohort C, -/+/-) before and after CDI.

RESULTS

Time between flares was a median of 4 months (IQR 1-9) among 51 cohort A patients versus 12 months (IQR 6-38) among 51 cohort B patients (log-rank P < 0.01). In contrast, the median time between flares was similar within cohort C before and after CDI (log-rank P = 0.54). At time of the second IBD flare, patients in cohort A (+/-) were more likely to have moderate or severe disease compared to patients in cohort B (-/-).

CONCLUSIONS

Patients with prior CDI had shorter time to subsequent IBD flare relative to their CDI-negative counterparts. This is not likely due to CDI itself because there was no difference in time between flares before versus after acquiring CDI. Rather, patients who acquire CDI may have more severe IBD.

Safety of Chronic Simvastatin Treatment in Patients with Decompensated Cirrhosis: Many Adverse Events but No Liver Injury

BACKGROUND

The high mortality rate of decompensated cirrhosis underlines the need for new treatments. Experimental models of cirrhosis and its reported relationship with atherosclerotic cardiovascular disease have provided data supporting the rational use of statins in these patients. However, little is known about the safety of statins in this setting.

AIM

We evaluate the safety of chronic simvastatin treatment in patients with decompensated cirrhosis.

METHODS

We conducted a prospective, open, uncontrolled, phase 2a trial in 30 patients with Child-Pugh class A (n = 6), B (n = 22), and C (n = 2) decompensated cirrhosis. The patients received standard treatment throughout the trial plus simvastatin 20 mg/day for 2 weeks and thereafter simvastatin 40 mg/day up to 1 year.

RESULTS

Sixteen out of 30 patients (53.3%) showed adverse events, including gastrointestinal toxicity (36.7%), muscle injury (MI) (36.7%), and headache (13.3%). No liver injury was registered. Due to MI alone, simvastatin dosage was reduced in 23.4% of cases and transiently interrupted in 13.3%. Once these adverse events were overcome, simvastatin was resumed until the end of the trial. MI was associated with baseline MELD score > 12 (p = 0.035) and with baseline Child-Pugh class C. No MI was associated with final Child-Pugh score ≤ 6 (p = 0.030) or final Child-Pugh class A (p = 0.020).

CONCLUSIONS

Chronic treatment with simvastatin 40 mg/day in patients with decompensated cirrhosis was associated with several adverse events, being MI the only clinically significant one, which appears to be related to the simvastatin dosage and the degree of cirrhosis severity. Noticeably, no liver injury was recorded.

J. J, Mathur S, Sudhir P, King M, Cuijpers P, Chorpita B, Fairburn CG, Patel V. Effectiveness and costs associated with a lay counselor-delivered, brief problem-solving mental health intervention for adolescents in urban, low-income schools in India: 12-month outcomes of a randomized controlled trial

BACKGROUND

Psychosocial interventions for adolescent mental health problems are effective, but evidence on their longer-term outcomes is scarce, especially in low-resource settings. We report on the 12-month sustained effectiveness and costs of scaling up a lay counselor-delivered, transdiagnostic problem-solving intervention for common adolescent mental health problems in low-income schools in New Delhi, India.

METHODS AND FINDINGS

Participants in the original trial were 250 school-going adolescents (mean [M] age = 15.61 years, standard deviation [SD] = 1.68), including 174 (69.6%) who identified as male. Participants were recruited from 6 government schools over a period of 4 months (August 20 to December 14, 2018) and were selected on the basis of elevated mental health symptoms and distress/functional impairment. A 2-arm, randomized controlled trial design was used to examine the effectiveness of a lay counselor-delivered, problem-solving intervention (4 to 5 sessions over 3 weeks) with supporting printed booklets (intervention arm) in comparison with problem solving delivered via printed booklets alone (control arm), at the original endpoints of 6 and 12 weeks. The protocol was modified, as per the recommendation of the Trial Steering Committee, to include a post hoc extension of the follow-up period to 12 months. Primary outcomes were adolescent-reported psychosocial problems (Youth Top Problems [YTP]) and mental health symptoms (Strengths and Difficulties Questionnaire [SDQ] Total Difficulties scale). Other self-reported outcomes included SDQ subscales, perceived stress, well-being, and remission. The sustained effects of the intervention were estimated at the 12-month endpoint and over 12 months (the latter assumed a constant effect across 3 follow-up points) using a linear mixed model for repeated measures and involving complete case analysis. Sensitivity analyses examined the effect of missing data using multiple imputations. Costs were estimated for delivering the intervention during the trial and from modeling a scale-up scenario, using a retrospective ingredients approach. Out of the 250 original trial participants, 176 (70.4%) adolescents participated in the 12-month follow-up assessment. One adverse event was identified during follow-up and deemed unrelated to the intervention. Evidence was found for intervention effects on both SDQ Total Difficulties and YTP at 12 months (YTP: adjusted mean difference [AMD] = -0.75, 95% confidence interval [CI] = -1.47, -0.03, p = 0.04; SDQ Total Difficulties: AMD = -1.73, 95% CI = -3.47, 0.02, p = 0.05), with stronger effects over 12 months (YTP: AMD = -0.98, 95% CI = -1.51, -0.45, p < 0.001; SDQ Total Difficulties: AMD = -1.23, 95% CI = -2.37, -0.09; p = 0.03). There was also evidence for intervention effects on internalizing symptoms, impairment, perceived stress, and well-being over 12 months. The intervention effect was stable for most outcomes on sensitivity analyses adjusting for missing data; however, for SDQ Total Difficulties and impairment, the effect was slightly attenuated. The per-student cost of delivering the intervention during the trial was $3 United States dollars (USD; or $158 USD per case) and for scaling up the intervention in the modeled scenario was $4 USD (or $23 USD per case). The scaling up cost accounted for 0.4% of the per-student school budget in New Delhi. The main limitations of the study's methodology were the lack of sample size calculations powered for 12-month follow-up and the absence of cost-effectiveness analyses using the primary outcomes.

CONCLUSIONS

In this study, we observed that a lay counselor-delivered, brief transdiagnostic problem-solving intervention had sustained effects on psychosocial problems and mental health symptoms over the 12-month follow-up period. Scaling up this resource-efficient intervention is an affordable policy goal for improving adolescents' access to mental health care in low-resource settings. The findings need to be interpreted with caution, as this study was a post hoc extension, and thus, the sample size calculations did not take into account the relatively high attrition rate observed during the long-term follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03630471.

Roles of preoperative anxiety and depression in the outcomes of microvascular decompression in hemifacial spasm for adolescent patients

Hemifacial spasm (HFS) has been recognized as the frequently occurring disease of cranial nerve. At the same time, several articles indicate that, dystonia results in certain psychological disorders. Consequently, this study aimed to examine the association of preoperative depression and anxiety with HFS severity; meanwhile, the role in microvascular decompression (MVD) outcomes after surgery among adolescent patients was also examined.All cases had been classified as two groups based on MVD outcomes among HFS cases; in addition, the preoperative Hamilton anxiety rating scale (HARS) and the Hamilton depression rating scale (HDRS) scores were compared between patients not and still suffering from spasm. Moreover, the multiple logistic regression model was employed in assessing the relationship between preoperative HARS as well as HDRS scores and outcomes of adolescent cases undergoing MVD.The preoperative HARS and HDRS scores showed positive correlation with Cohen spasm grades in HFS patients. Meanwhile, compared with spasm-free group, patients of persistent spams group had apparently higher preoperative HARS and HDRS scores.Our results suggest that, preoperative anxiety and depression status show close association with HFS severity, and they could also impact the MVD outcomes for adolescent cases.

Variation in resources and impact on performance: results of the emergency department benchmarking survey

AIM

The resources and capacity of New Zealand's emergency departments (EDs) to cope with surges in demand are unknown. The aims were to describe the current resources and capacity of New Zealand EDs and explore how these relate to ED performance.

METHODS

A survey of EDs in New Zealand was conducted to capture elements of governance, staffing and structure of the EDs in the calendar year 2018. These were linked to processes and outcomes of care.

RESULTS

Eighteen of 26 EDs responded. These were representative of the range of EDs nationally. There was wide variability between the EDs across all the surveyed elements. Although no single element was strongly related to performance measures, combinations of elements were. When there was a lack of doctors and available ED or hospital beds relative to the workload, then performance was worse. The correlations were: for time to assessment r=0.728, p=0.001, for ED length of stay r=0.759, p<0.001, for patients who did not wait r=0.619, p=0.006 and for deaths in the ED r=0.649, p=0.004.

CONCLUSION

There is marked variation among New Zealand hospitals with respect to structure, staffing and workload, which may be impacting negatively on ED performance and limit the ability of some hospitals to cope with surges in demand for acute care.

Outcomes of lumbar spinal fusion in super-elderly patients aged 80 years and over: Comparison with patients aged 65 years and over, and under 80 years

Despite the increasing prevalence of spinal surgery in super-elderly (SE) patients, the outcomes and complication rates have not been fully elucidated. The purpose of this study was to compare the outcomes and complications of lumbar spinal fusion for degenerative lumbar spinal stenosis (DLSS) in SE patients aged 80 years and over with those in patients aged 65 years and over, and under 80 years.This study analyzed 160 patients who underwent spinal fusion for DLSS between January 2011 and November 2019. Thirty patients in the SE group (group SE, ≥80 years) and 130 patients in the elderly group (group E, ≥65 years and <80 years) were enrolled. The performance status was evaluated by preoperative American society of anesthesiologists (ASA) score. Visual analog scales for back pain (VAS-BP) and leg pain (VAS-LP), and Korean Oswestry disability index (K-ODI) were used to assess clinical outcomes preoperatively and 1 year postoperatively. Percent changes of VAS-BP, VAS-LP and K-ODI were also analyzed. Fusion rates were evaluated by computed tomography 6 months and 1 year postoperatively. Furthermore, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and postoperative complications were compared.The average age of group SE was 82.0 years and that of group E was 71.6 years. There were no differences in preoperative ASA score, preoperative or postoperative VAS BP and VAS-LP, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and fusion rates between the groups. Preoperative and postoperative K-ODI were higher in group SE than group E (all P < .05). However, percent changes of VAS-BP, VAS-LP and K-ODI showed no significant differences. Overall early and late complications were not significantly different between the groups; however postoperative delirium was more common in group SE than group E (P = .027). SE status was the only risk factor for postoperative delirium with odds ratio of 3.4 (P = .018).Spinal fusion surgery is considerable treatment to improve the quality of life of SE patients with DLSS, however careful perioperative management is needed to prevent postoperative delirium.

An observational study substantiating the statistical significance of cardiopulmonary exercise with laboratory tests during the acute and subacute phases of center and home-based cardiac rehabilitation

Cardiac rehabilitation (CR) can improve clinical indicators in patients with cardiovascular diseases. The literature reports a 20% reduction in all-cause mortality and a 27% reduction in heart-disease mortality following CR. Although its clinical efficacy has been established, there is uncertainty whether center-based (CBCR) is more effective than home-based (HBCR) programs in acute and subacute phases. We aimed to verify significant differences in their effectiveness for the improvement of cardiopulmonary function by analyzing cardiopulmonary exercise (CPX) with laboratory tests following both CR programs.A single-center cohort study of 37 patients, recently diagnosed with underlying cardiovascular diseases, underwent CBCR(18) and HBCR(19). CBCR group performed a supervised exercise regimen at the CR center, for 1 hour, 2 to 3 days a week, for a total of 12 to18 weeks. HBCR group completed a self-monitored exercise program at home under the same guidelines as CBCR. Participants were evaluated by CPX with laboratory tests at 1- and 6-month, following the respective programs.There was no statistical significance in clinical characteristics and laboratory findings. Pre-post treatment comparison showed significant improvement in VO2/kg, minute ventilation/carbon dioxide production slope, breathing reserve, tidal volume (VT), heart rate recovery, oxygen consumption per heart rate, low-density lipoprotein (LDL), LDL/HDL ratio, total cholesterol, ejection fraction (EF) (P < .05). CBCR approach showed greater improvement with significance in VO2/kg, metabolic equivalents, and EF on between groups analysis (P < .05).The time effect of CPX test and laboratory data showed improvement in cardiopulmonary function and serum indicators for both groups. VO2/kg, metabolic equivalents, and EF were among the variables that showed significant differences between groups. In the acute and subacute phases of 1 to 6 months, the CBCR group showed a greater cardiac output improvement than the HBCR group.

The curative effect of androgen deprivation therapy alone is insufficient in high-risk prostate cancer

To compare the outcomes of patients with high-risk prostate cancer treated by primary radical prostatectomy (RP) and primary androgen deprivation therapy (ADT).The study included patients with high-risk or very high-risk prostate cancer. Patients treated with definitive radiation therapy and those with clinical N1 and M1 disease were excluded. The RP group was divided into sub-cohorts of patients treated with ADT and those who received ADT after biochemical recurrence post-RP. Cancer-specific survival (CSS) and overall survival (OS) were analyzed using the Kaplan-Meier method and the Cox proportional hazards model.The study analyzed 859 patients divided into the RP group (n = 654) and ADT group (n = 205). Castration-resistant prostate cancer was detected in 23 (3.5%) patients in the RP group and 43 (21.0%) patients in the ADT group. Mortality cases included 63 (9.6%) patients in the RP group and 91 (44.4%) patients in the ADT group. CSS (P = .0002) and OS (P < .0001) were significantly higher in the RP group than in the ADT group. In the sub-cohort, CSS did not differ significantly between the RP and ADT groups, whereas OS was significantly higher in the RP group than in the ADT group (P < .0001). In the multivariate analysis, primary ADT increased CSS (hazard ratio, 2.068; P = .0498) and OS (hazard ratio, 3.218; P < .0001) compared with RP.In clinically localized high-risk prostate cancer patients, primary RP was associated with better CSS and OS than primary ADT. Comprehensive counseling in this cohort of patients will help the selection of treatment.

Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

OBJECTIVE

To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon.

BACKGROUND

Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons.

METHODS

We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days.

RESULTS

We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01).

CONCLUSION

Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.