Current research priorities in perioperative intensive care medicine

INTRODUCTION

Surgical treatments are offered to more patients than ever before, and increasingly to older patients with chronic disease. High-risk patients frequently require critical care either in the immediate postoperative period or after developing complications. The purpose of this review was to identify and prioritise themes for future research in perioperative intensive care medicine.

METHODS

We undertook a priority setting process (PSP). A panel was convened, drawn from experts representing a wide geographical area, plus a patient representative. The panel was asked to suggest and prioritise key uncertainties and future research questions in the field of perioperative intensive care through a modified Delphi process. Clinical trial registries were searched for on-going research. A proposed "Population, Intervention, Comparator, Outcome" (PICO) structure for each question was provided.

RESULTS

Ten key uncertainties and future areas of research were identified as priorities and ranked. Appropriate intravenous fluid and blood component therapy, use of critical care resources, prevention of delirium and respiratory management featured prominently.

CONCLUSION

Admissions following surgery contribute a substantial proportion of critical care workload. Studies aimed at improving care in this group could have a large impact on patient-centred outcomes and optimum use of healthcare resources. In particular, the optimum use of critical care resources in this group is an area that requires urgent research.

A bioequivalence study of proposed bevacizumab biosimilar, MYL-1402O (A) vs EU-Avastin (B) and US-Avastin (C)

e14034

Background: MYL-1402O is a proposed bevacizumab biosimilar. The similarity of MYL-1402O to Avastin has been demonstrated in physicochemical analyses, and nonclinical studies. Methods: This single-center, randomized, double blind, three-arm, parallel-group, study was conducted in healthy adult male volunteers. The primary objective of this study was to establish PK similarity of A to B and C, and B to C. Subjects were randomized to receive either A, B or C 1 mg/kg over 90 minutes as an intravenous infusion. Dose was selected based on the lower dose in the linear range of PK and acceptable safety in healthy volunteers. Bioequivalence was to be concluded if the 90% CIs of the ratios (A/B, A/C and B/C) of LS means of the natural log transformed AUC0-inf were within 80% to 125%. AUC0-t, Cmax, tmax, kel and t½ were assessed as secondary PK parameters. Results: A total of 111 subjects (37/treatment) were enrolled and 110 [37 (A), 36 (B), 37(C)] were included in the analysis. Bioequivalence was demonstrated between A and B, A and C and between B and C. LS mean ratios were close to 1, and 90% CIs were within 0.80 to 1.25 for all of the comparisons. The secondary PK parameters were also comparable with the 90% CIs for ratios of AUC0-t and Cmax within 80%-125%. A total of 313 TEAEs were reported, 116 by 33 (89%) subjects who received A, 99 by 29 (78%) subjects who received B and 98 by 28 (76%) subjects who received C. Most TEAEs were consistent with the clinical data of bevacizumab (Avastin). No serious or unexpected TEAEs were reported. TEAEs were grade 1 or grade 2 in severity. The anti-drug antibodies are being evaluated (pending results). Conclusions: These results confirm bioequivalence of Myl-1402O vs. EU-Avastin and US-Avastin. All treatments were well tolerated and no significant safety issues emerged. Clinical trial information: NCT02469987 Clinical trial information: NCT02469987.

Improving patient care through implementation of a QOPI-focused interactive patient note template

197

Background: Participation in the ASCO Quality Oncology Practice Initiative (QOPI) has been shown to improve the quality and value of care provided by oncology practices. Our fellows’ oncology practice participates in QOPI. We sought to utilize QOPI metrics in conjunction with the documentation capabilities of our electronic medical record (EMR) to create a quality-focused standardized new patient note template to be used by all practitioners in our oncology clinic, in an effort to improve patient care through improved communication and efficiency. Methods: We examined the results from our most recent QOPI assessment cycle in spring of 2016 and identified areas where our practice met the metric less than 50% of the time. Oral chemotherapy, tobacco cessation, and fertility preservation counseling were identified as target areas. We surveyed the practitioners in the group to establish baseline knowledge of QOPI metrics and desire for a standardized note template. We then developed and implemented a note template incorporating QOPI metrics, pulling data directly from other areas within the medical record, and excluding extraneous information. Results: Only 58% of the fellows in our fellowship program responded that they had a general idea of the QOPI metrics, and only 37% believed their notes were QOPI-compliant; 84% were interested in a standardized note template that incorporates QOPI metrics. Through the assistance of EMR specialists, we created a standardized note that auto-populates information recorded elsewhere in the patient’s chart and allows physicians to select appropriate options from pre-populated lists based on the patient’s treatment. The physician cannot close the encounter until these selections are made Conclusions: QOPI metrics provide guideposts for oncology practitioners to provide quality care and communicate effectively. We created a note that encourages practitioners to complete recommended QOPI tasks in an effort to improve communication and patient care. Data collection regarding practitioner use and satisfaction with the new template and compliance with QOPI metrics is ongoing.

A novel role for endothelial tetrahydrobiopterin in mitochondrial redox balance

The redox co-factor tetrahydrobiopterin (BH4) regulates nitric oxide (NO) and reactive oxygen species (ROS) production by endothelial NOS (eNOS) and is an important redox-dependent signalling molecule in the endothelium. Loss of endothelial BH4 is observed in cardiovascular disease (CVD) states and results in decreased NO and increased superoxide (O2-) generation via eNOS uncoupling. Genetic mouse models of augmented endothelial BH4 synthesis have shown proof of concept that endothelial BH4 can alter CVD pathogenesis. However, clinical trials of BH4 therapy in vascular disease have been limited by systemic oxidation, highlighting the need to explore the wider roles of BH4 to find novel therapeutic targets. In this study, we aimed to elucidate the effects of BH4 deficiency on mitochondrial function and bioenergetics using targeted knockdown of the BH4 synthetic enzyme, GTP Cyclohydrolase I (GTPCH). Knockdown of GTPCH by >90% led to marked loss of cellular BH4 and a striking induction of O2- generation in the mitochondria of murine endothelial cells. This effect was likewise observed in BH4-depleted fibroblasts devoid of NOS, indicating a novel NOS-independent role for BH4 in mitochondrial redox signalling. Moreover, this BH4-dependent, mitochondria-derived ROS further oxidised mitochondrial BH4, concomitant with changes in the thioredoxin and glutathione antioxidant pathways. These changes were accompanied by a modest increase in mitochondrial size, mildly attenuated basal respiratory function, and marked changes in the mitochondrial proteome and cellular metabolome, including the accumulation of the TCA intermediate succinate. Taken together, these data reveal a novel NOS-independent role for BH4 in the regulation of mitochondrial redox signalling and bioenergetic metabolism.

Creating a Healthy Ship

In 2015 HMS DUNCAN was chosen as the intervention ship for an Institute of Naval Medicine (INM)-led project entitled Second Sea Lord (2SL)’s Feeding the Fleet Initiative. During her nine-month maiden deployment on Operation KIPION, a healthy lifestyle intervention was initiated, encompassing executive health, catering services, medical services and physical training. The key enabler of the success of the intervention was the formation of an effective Unit Health Committee. This article presents the lessons identified and provides useful examples from the intervention, which aimed to create a healthy lifestyle culture on board a deployed ship.

Implementing innovative, learner-centered methods to teach oncology fellows how to face difficult conversations

27

Background: Oncologists engage in emotionally charged conversations with patients and families about prognosis, goals of care, and end of life transitions. Many oncologists lack key skills for guiding patients through such conversations. Key skills include posing open ended questions to elicit the patient’s perspective, using silence effectively, and responding to emotion with empathy. We previously described a communication skills curriculum for first year medical oncology fellows consisting of a series of one hour monthly seminars (Epner and Baile, Academic Medicine, 2014). We now describe improvements in the curriculum based on extensive feedback from learners and teaching assistants. Methods: Anonymous feedback from first year fellows indicated longer sessions would allow for sufficient warm up and more in depth reflection and opportunity to practice. We therefore consolidated the sessions into quarterly 4 hour workshops. Several fellows also expressed discomfort with participating in role play of clinical scenarios in front of colleagues, so we implemented small group learning in which 3-4 fellows practiced communication skills in facilitated role play scenarios. We also replaced large group role play with narrative medicine techniques, such as reading and discussing medically-themed short stories and reflective writing exercises to allow the greatest amount of participation among learners. Results: Fellows completed anonymous surveys on which they rated items on a 4 point scale, with 1 being best and 4 worst. The average score of the two survey items pertaining to large group role play was 2.6. After changes in the curriculum, items pertaining to narrative medicine averaged 1.3, which was very favorable. Items pertaining to relevance and value of the curriculum also averaged less than 1.5 for all years. Attendance was 100% with the exception of fellows who were on vacation. Conclusions: Learner-centered, interactive innovations to our previous communication skills curriculum were highly rated by fellows and addressed issues of enhanced participation in a learning environment in which fellows felt safe to actively participate, reflect, and interact extensively with their peers.