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Podolsky E, Hudek N, McCudden C, Presseau J, Yanikomeroglu S, Brouwers M, Brehaut JC. Choosing which in-hospital laboratory tests to target for intervention: a scoping review. Clin Chem Lab Med 2023; 61:388-401. [PMID: 36410390 PMCID: PMC9876731 DOI: 10.1515/cclm-2022-0910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Some laboratory testing practices may be of low value, leading to wasted resources and potential patient harm. Our scoping review investigated factors and processes that developers report using to inform decisions about what tests to target for practice improvement. METHODS We searched Medline on May 30th, 2019 and June 28th, 2021 and included guidelines, recommendation statements, or empirical studies related to test ordering practices. Studies were included if they were conducted in a tertiary care setting, reported making a choice about a specific test requiring intervention, and reported at least one factor informing that choice. We extracted descriptive details, tests chosen, processes used to make the choice, and factors guiding test choice. RESULTS From 114 eligible studies, we identified 30 factors related to test choice including clinical value, cost, prevalence of test, quality of test, and actionability of test results. We identified nine different processes used to inform decisions regarding where to spend intervention resources. CONCLUSIONS Intervention developers face difficult choices when deciding where to put scarce resources intended to improve test utilization. Factors and processes identified here can be used to inform a framework to help intervention developers make choices relevant to improving testing practices.
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Affiliation(s)
- Eyal Podolsky
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Natasha Hudek
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christopher McCudden
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Biochemistry, Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Eastern Ontario Regional Laboratory Association, Ottawa, ON, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sezgi Yanikomeroglu
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Melissa Brouwers
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jamie C. Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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Angerame MR, Holst DC, Phocas A, Williams MA, Dennis DA, Jennings JM. Usefulness of Perioperative Laboratory Tests in Total Hip and Knee Arthroplasty: Are They Necessary for All Patients? Arthroplast Today 2021; 7:136-142. [PMID: 33553540 PMCID: PMC7850936 DOI: 10.1016/j.artd.2020.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 11/09/2020] [Accepted: 12/07/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Laboratory studies are routinely obtained preoperatively and postoperatively for total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study evaluates the necessity of routine, perioperative laboratory tests and identifies risk factors for laboratory-associated interventions. METHODS This retrospective review evaluated 967 consecutive patients scheduled for primary, unilateral TKAs (n = 593) or THAs (n = 374) over an 18-month period at a single institution. Preoperative prothrombin time (PT) and International Normalized Ratio (INR), complete blood count (CBC), complete metabolic panel (CMP), and postoperative CBC and basic metabolic panel (BMP) were recorded along with any laboratory-associated intervention. Patient demographics and comorbidities identified risk factors for abnormal or actionable laboratory studies. RESULTS Preoperatively, the actionable rates for PT/INR, CMP, and CBC were 0.3%, 1.4%, and 0.5%, respectively. Vascular, renal, and immunologic diseases were risk factors for an actionable CBC. Risk factors for an actionable CMP include cardiac arrhythmia and diabetes. There were no risk factors for an actionable PT/INR. Postoperatively, only 1.5% of BMPs and 1.5% of CBCs were actionable. Congestive heart failure, renal disease vascular disease, or history of cancer (P = .030) were risk factors for an actionable CBC. There were no risk factors for an actionable BMP. Patients with an abnormal preoperative lab were 2.4 times more likely to have an actionable postoperative lab. Patients with an actionable preoperative lab were 11.3 times more likely to have an actionable postoperative lab. CONCLUSION Routine preoperative and postoperative labs may not be necessary on all patients undergoing a TKA or THA. Comorbid risk factors and abnormal or actionable preoperative CMPs and CBCs can help determine the usefulness of postoperative laboratory assessments.
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Affiliation(s)
| | - David C. Holst
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Alexandria Phocas
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
| | | | - Douglas A. Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
- Department of Mechanical and Materials Engineering, Denver University, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
| | - Jason M. Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
- Department of Mechanical and Materials Engineering, Denver University, Denver, CO, USA
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Goudra BG, Singh PM. Anesthesia for ERCP. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Dam-Larsen S, Darkahi B, Glad A, Gleditsch D, Gustavsson L, Halttunen J, Johansson KE, Pischel A, Reiertsen O, Törnqvist B, Zebski H. Best practice in placement of percutaneous endoscopic gastrostomy with jejunal extension tube for continuous infusion of levodopa carbidopa intestinal gel in the treatment of selected patients with Parkinson's disease in the Nordic region. Scand J Gastroenterol 2016; 50:1500-7. [PMID: 26083798 DOI: 10.3109/00365521.2015.1055793] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Continuous infusion of levodopa carbidopa intestinal gel (LCIG) is associated with a significant improvement in the symptoms and quality of life of selected patients with advanced Parkinson's disease. Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the most common and standard technique for fixing the tubing in place for LCIG infusion. MATERIAL AND METHODS A workshop was held in Stockholm, Sweden, to discuss the PEG/J placement for the delivery of LCIG in Parkinson's disease patients with the primary goal of providing guidance on best practice for the Nordic countries. RESULTS Suggested procedures for preparation of patients for PEG/J placement, aftercare, troubleshooting and redo-procedures for use in the Nordic region are described and discussed. CONCLUSIONS LCIG treatment administered through PEG/J-tubes gives a significant increase in quality of life for selected patients with advanced Parkinson's disease. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Further development of delivery systems and evaluation of approaches designed to reduce the demand for redo endoscopy are required.
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Affiliation(s)
- Sanne Dam-Larsen
- Medical Gastroenterology and Hepatology, Medical Department, Koege Hospital , Koege , Denmark
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Krishna SG, Rao BB, Thirumurthi S, Lee JH, Ramireddy S, Guindani M, Ross WA. Safety of endoscopic interventions in patients with thrombocytopenia. Gastrointest Endosc 2014; 80:425-34. [PMID: 24721520 DOI: 10.1016/j.gie.2014.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 02/18/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The risk of endoscopic interventions in thrombocytopenia has received little attention in the medical literature. OBJECTIVE The aim of this study was to assess the safety of endoscopic interventions including evaluation of GI bleeding (GIB) in patients with thrombocytopenia. DESIGN AND SETTING Retrospective study, tertiary oncology center. PATIENTS AND INTERVENTION Review of consecutive endoscopies with preprocedure platelet counts (PCs) of 75 × 10(3)/μL or lower. MAIN OUTCOME MEASUREMENTS Risk of bleeding with routine endoscopic interventions and transfusion requirement after evaluation of GIB. RESULTS A total of 617 (351 upper, 266 lower [90 colonoscopies]) endoscopies were performed in 395 patients. Forceps-biopsy specimens were obtained in 398 endoscopies (mean ± standard deviation [SD] PC: 38.21 ± 11.7 × 10(3)/μL) and 45 polypectomies were performed in 17 endoscopies (mean ± SD PC: 39.65 ± 8.53 × 10(3)/μL). The risk of bleeding was 1.5% (6 of 398 endoscopies) at the biopsy site and 4% (2 of 45 polypectomies) at the polypectomy site. Active GIB (mean ± SD PC: 32.85 ± 4.0 × 10(3)/μL) was observed in 68 (11% of 617) endoscopies and intervention (mean ± SD PC: 33.68 ± 4.6 × 10(3)/μL) was performed in 41 procedures. Together, angiodysplasias and ulcers were the most common etiology (51.2% of 41). Hemostasis was achieved in 39 (95.1% of 41) procedures. Comparison of blood transfusions ± 3 days of successful therapy showed a 52% reduction (P < .001). By multivariate analysis, a higher aggregate blood transfusion 3 days preceding endoscopy (odds ratio 1.32; 95% confidence interval, 1.16-1.50; P < .001) predicted endoscopic findings of active GIB. LIMITATIONS Retrospective design, single center. CONCLUSIONS In the largest endoscopic experience reported in thrombocytopenic patients (Common Terminology Criteria for Adverse Events grade 3 or lower), bleeding caused by standard forceps biopsy and polypectomy (≤10 mm) was minor and easily controlled. Endoscopic therapy for GIB is safe and significantly reduces the packed red blood cell requirement and should be considered in patients with thrombocytopenia in the setting of an appropriate transfusion strategy.
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Affiliation(s)
- Somashekar G Krishna
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Bhavana B Rao
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Srinivas Ramireddy
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michele Guindani
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - William A Ross
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Abstract
Office endoscopy is an accepted safe alternative to in-hospital care. Attention to detail will help to ensure that the vast majority of procedures will be successfully completed without incident. Although there are regional differences, in many parts of North America office endoscopy has become mainstream, and is preferred for common procedures. However, quality endoscopy is more complex than clean scopes and clean rooms. This article highlights many issues that serve to make office endoscopy a safe alternative to in-hospital procedures.
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Williamson JB, Judah JR, Gaidos JKJ, Collins DP, Wagh MS, Chauhan SS, Zoeb S, Buscaglia JM, Yan H, Hou W, Draganov PV. Prospective evaluation of the long-term outcomes after deep small-bowel spiral enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2012; 76:771-8. [PMID: 22771101 DOI: 10.1016/j.gie.2012.05.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 05/16/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Spiral enteroscopy can be safe and effective in the short term for evaluation of obscure GI bleeding, but long-term data are lacking. OBJECTIVE To assess the long-term clinical outcomes after deep small-bowel spiral enteroscopy performed for obscure GI bleeding. DESIGN Prospective cohort study. SETTING Academic referral center. PATIENTS This study included 78 patients who underwent antegrade spiral enteroscopy for evaluation of obscure GI bleeding. INTERVENTION Diagnostic spiral enteroscopy with hemostatic therapeutic maneuvers applied as indicated. MAIN OUTCOME MEASUREMENTS Postprocedure evidence of recurrent overt GI bleeding, blood transfusion requirements, need for iron supplementation, serum hemoglobin values, and the need for additional therapeutic procedures. RESULTS Long-term follow-up data (mean [± standard deviation] 25.3 ± 7.5 months; range 12.9-38.8 months) were obtained in 61 patients (78%). Among those with long-term follow-up data, overt bleeding before spiral enteroscopy was present in 62%, compared with 26% in the follow-up period (P < .0001). The mean (± SD) hemoglobin value increased from 10.6 ± 1.8 to 12.6 ± 1.9 g/dL (P < .0001). Blood transfusion requirements decreased by a mean of 4.19 units per patient (P = .0002), and the need for iron supplementation (P = .0487) and additional procedures (P < .0001) decreased in the follow-up period. There were 8 adverse events (9%) (7 mild, 1 moderate). LIMITATIONS Single-center study, intervention bias. CONCLUSION In patients with obscure GI bleeding, deep small-bowel spiral enteroscopy is safe and effective in reducing the incidence of overt bleeding. An increase in hemoglobin values along with a decrease in blood transfusion requirement, need for iron supplementation, and need for additional therapeutic procedures were found over long-term follow-up. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00861263.).
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Affiliation(s)
- J Blair Williamson
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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[Is systematic blood testing useful before colonoscopy?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:678-9. [PMID: 22795826 DOI: 10.1016/j.gastrohep.2012.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 05/20/2012] [Accepted: 05/21/2012] [Indexed: 11/20/2022]
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Postpolypectomy bleeding: incidence, risk factors, prevention, and management. Surg Laparosc Endosc Percutan Tech 2012; 22:102-7. [PMID: 22487620 DOI: 10.1097/sle.0b013e318247c02e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.
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Nwokediuko SC, Obienu O. Sedation practices for routine diagnostic upper gastrointestinal endoscopy in Nigeria. World J Gastrointest Endosc 2012; 4:260-5. [PMID: 22720128 PMCID: PMC3377869 DOI: 10.4253/wjge.v4.i6.260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 11/14/2011] [Accepted: 05/27/2012] [Indexed: 02/05/2023] Open
Abstract
AIM To determine the sedation practices and preferences of Nigerian endoscopists for routine diagnostic upper gastrointestinal endoscopy. METHODS A structured questionnaire containing questions related to sedation practices and safety procedures was administered to Nigerian gastrointestinal endoscopists at the 2011 annual conference of the Society for Gastroenterology and Hepatology in Nigeria which was held at Ibadan, June 23-35, 2011. RESULTS Of 35 endoscopists who responded, 17 (48.6%) used sedation for less than 25% of procedures, while 14 (40.0%) used sedation for more than 75% of upper gastrointestinal endoscopies. The majority of respondents (22/35 or 62.9%) had less than 5 years experience in gastrointestinal endoscopy. The sedative of choice was benzodiazepine alone in the majority of respondents (85.7%). Opioid use (alone or in combination with benzodiazepines) was reported by only 5 respondents (14.3%). None of the respondents had had any experience with propofol. Non-anaesthesiologist-directed sedation was practiced by 91.4% of endoscopists. Monitoring of oxygen saturation during sedation was practiced by only 57.1% of respondents. Over half of the respondents (18/35 or 51.4%) never used supplemental oxygen for diagnostic upper gastrointestinal endoscopy. CONCLUSION Sedation for routine diagnostic upper gastrointestinal endoscopy in Nigeria is characterized by lack of guidelines, and differs markedly from that in developed countries.
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Affiliation(s)
- Sylvester Chuks Nwokediuko
- Sylvester Chuks Nwokediuko, Olive Obienu, Gastroenterology Unit, Department of Medicine, University of Nigeria Teaching Hospital Ituku/Ozalla, 01129 Enugu, Nigeria
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Jain R, Maple JT, Anderson MA, Appalaneni V, Ben-Menachem T, Decker GA, Fanelli RD, Fisher L, Fukami N, Ikenberry SO, Jue T, Khan K, Krinsky ML, Malpas P, Sharaf RN, Dominitz JA. The role of endoscopy in enteral feeding. Gastrointest Endosc 2011; 74:7-12. [PMID: 21704804 DOI: 10.1016/j.gie.2010.10.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 10/13/2010] [Indexed: 12/15/2022]
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The "importance of ensuring adequate coagulation function" prior to resection of large colon polyps. Am J Gastroenterol 2010; 105:2116. [PMID: 20818366 DOI: 10.1038/ajg.2009.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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