Paradigm shift towards emergency cholecystectomy: one site experience of the Chole-QuiC process

INTRODUCTION

Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

METHODS

This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes.

RESULTS

Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p=0.042) and for operation times within 7 days (OR 0.32; p=0.037), with worse outcomes in BMI ≥35 (OR 3.32; p=0.005) and operation time >7 days (OR 3.11; p=0.037).

CONCLUSION

A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

The imperative of professional dementia care

Despite negative effects on their health and social lives, many informal carers of people living with dementia claim to be acting in accordance with a moral obligation. Indeed, feelings of failure and shame are commonly reported by those who later give up their caring responsibilities, suggesting a widespread belief that professional dementia care, whether delivered in the person's own home or in an institutional setting, ought always to be a last resort. In this paper, however, I suggest that this common intuition gets things the wrong way around. Adopting a relational egalitarian framework, I argue that the most serious injustices engendered by present-day dementia care services are contingent on broader societal structures-they can thus be ameliorated relatively easily (if resource intensively) by changing those structures. Informal dementia care, on the other hand, carries similar risks of injustice and is much more resistant to structural reform. While there may be moral obligations to provide informal dementia care in present-day societies, then, they arise because of the deficiencies of professional care, not the virtues of its informal counterpart. Though we may be far from achieving just care arrangements in most of our societies, we must never lose sight of the fact that, when we engage in morally permitted informal dementia care, we are exercising our last resort.

Advance Directives: The Principle of Determining Authenticity

In medical ethics, there is a well-established debate about the authority of advance directives over people living with dementia, a dispute often cast as a clash between two principles: respecting autonomy and beneficence toward patients. In this article, I argue that there need be only one principle in substitute decision-making: determining authenticity. This principle favors a substituted judgment standard in all cases and instructs decision-makers to determine what the patient would authentically prefer to happen-based not merely on the patient's decisions but also on their present settled dispositions. Adhering to this principle entails that, in a significant range of cases, an advance directive can (and indeed ought to) be overruled.

Grief, trauma and mistaken identity: Ethically deceiving people living with dementia in complex cases

Across care settings, the practice of lying to or withholding the truth from people living with dementia is common, yet it is objected to by many. Contrary to this common discomfort, I have argued in previous work that respecting members of this group as moral equals sometimes requires deceiving them. In this paper, I test my proposed practice against complex, controversial cases, demonstrating both its theoretical strength and its practical value for those working in social care.

A Framework for Developing Pharmacotherapy for Agitation in Alzheimer's Disease: Recommendations of the ISCTM* Working Group

Dementia is characterized by a significant decline in one of several cognitive domains such as memory, language and executive function, affecting independence and representing a significant deterioration from a previous level of functioning (1). Alzheimer’s Disease (AD) represents the most common form of dementia and contributes up to 70% of the almost 50 million dementia cases worldwide, a number that is projected to double in 20 years (2).

A systematic review of pharmacist-led audit and feedback interventions to influence prescribing behaviour in general practice settings

Introduction

Audit and Feedback (A&F) involves measuring data about practice, comparing it with clinical guidelines, professional standards or peer performance, and then feeding back the data to individuals/groups of health professionals to encourage change in practice (if required). A 2012 Cochrane review (1) found A&F was effective in changing health professionals’ behaviour and suggested that the person who delivers the A&F intervention influences its effect. Increasingly, pharmacists work in general practice and often have responsibility for medication review and repeat prescriptions. The effectiveness of pharmacist-led A&F in influencing prescribing behaviour is uncertain.

Aim

This secondary analysis from an ongoing update of the original Cochrane review aims to identify and describe pharmacist-led A&F interventions and evaluate their impact on prescribing behaviour in general practice compared with no intervention.

Methods

This sub-review is registered with PROSPERO: CRD42020194355 and complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (2). For the updated Cochrane review, the Cochrane Effective Practice and Organization of Care Group searched MEDLINE (1946 to present), EMBASE, CINAHL and Cochrane Library (March 2019) to identify randomised trials featuring A&F interventions. For this sub-review, authors screened titles and abstracts (May 2020) to identify trials involving pharmacist-led A&F interventions in primary care, extracted data, and assessed risk of bias (RoB) in eligible studies. Review results are summarised descriptively. Heterogeneity will be assessed and a random-effects meta-analysis is planned. Publication bias for selected outcomes and the certainty of the body of evidence will be evaluated and presented. Sub-group analyses will be conducted.

Results

Titles and abstracts of 295 studies identified for inclusion in the Cochrane A&F review update were screened. Eleven studies (all cluster-randomised trials) conducted in 9 countries (Denmark, Italy, Netherlands, Norway, Republic of Ireland, UK, Australia, Malaysia, USA) were identified for inclusion (Figure 1). Six studies had low RoB, two had high risk due to dissimilarities between trial arms at baseline and/or insufficient detail about randomisation, and three studies had unclear RoB. Studies examined the effect of A&F on prescribing for specific conditions (e.g. hypertension), medications (e.g. antibiotics), populations (e.g. patients &gt;70), and prescribing errors (e.g. inappropriate dose). The pharmacist delivering A&F was a colleague of intervention participants in five studies. Pharmacists’ levels of skill and experience varied; seven studies reported details of pharmacist training undertaken for trial purposes. A&F interventions in nine studies demonstrated changes in prescribing, including reductions in errors or inappropriate prescribing according to the study aims and smaller increases in unwanted prescribing compared with the control group. Data analyses are ongoing (results will be available for the conference).

Conclusion

The preliminary results demonstrate the effectiveness of pharmacist-led A&F interventions in different countries and health systems with influencing prescribing practice to align more closely with guidance. Studies measured different prescribing behaviours; meta-analysis is unlikely to include all 11 studies. Further detailed analysis including feedback format/content/frequency and pharmacist skill level/experience, work-base (external/internal to recipients), will examine the impact of specific features on intervention effectiveness.

References

1. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012(6):CD000259.

2. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

False Negative Rate (2%) of Lynch Syndrome Screening Utilizing A Two-Antibody (PMS2/MSH6) Immunohistochemistry Panel: Failure To Detect a Subset of MSH2-Deficient Endometrial Carcinomas

Introduction/Objective

Lynch syndrome (LS) is an inherited condition caused by defective DNA mismatch repair (MMR), leading to a higher incidence of cancers of multiple sites. Screening for LS is now recommended for new diagnoses of endometrial cancer (EC) using either two- (PMS2, MSH6) or four-antibody (2/4Ab) (PMS2, MSH6, MSH2, MLH1) immunohistochemical (IHC) panels. The 2Ab panel assumes consistent loss of expression of the minor dimer component, PMS2 or MSH6, when the major component, MLH1 or MSH2, respectively, is lost due to mutation. Recent studies have indicated that 2Ab testing may lead to underdiagnosis of MSH2-deficient tumors in cases where MSH6 staining is weak or focal, potentially leading to underdiagnosis of LS.

Methods

We conducted a retrospective study using archived slides for 293 cases of EC (identified via LIS search from 2016-2019) that were screened using the 2Ab panel (expanded to 4Ab when PMS2 or MSH6 were negative). MSH6 expression was reviewed; if weak, focal (less than 10% staining), or both, MSH2 IHC was performed. When a previously undetected loss of MSH2 expression was found, the attending clinician was informed such that referral to medical genetics could be arranged.

Results

Results Overall, 68 (23.2%) tumors were MMR deficient, with 54 (18.4%) showing MLH1/PMS2 loss, 7 (2.4%) with MSH2/MSH6 loss, 2 (0.7%) with isolated PMS2 loss, 4 (1.4%) with isolated MSH6 loss, and 6 (2.0%) with isolated MSH2 loss (i.e. intact but weak/focal MSH6, seen in biopsy and hysterectomy specimens). Interestingly, 1 tumor (1.5%) demonstrated loss of MSH6, MLH1 and PMS2. Two tumors (0.7%) with isolated MSH2 loss were previously unrecognized as MMR-deficient and hence at high risk for LS. Both cases were evaluated by PCR for microsatellite instability (MSI) and confirmed to have high-degree MSI.

Conclusion

This study identifies the frequency of mismatch repair deficient endometrial cancers in Atlantic Canada, highlights a potential pitfall of using two-stain IHC screening for Lynch syndrome, and supports emerging recommendations for universal Lynch syndrome screening in EC.

Ethical Deception? Responding to Parallel Subjectivities in People Living with Dementia

Many caregivers feel that they need to lie or withhold the truth from people living with dementia, but worry that, in doing so, they are violating a duty to tell the truth. In this article, I argue that withholding the truth from and, in limited circumstances, lying to people living with dementia is not only morally permissible, but morally required by a more general requirement that we treat each other as persons worthy of respect. I do so through an analysis of the groundings of the duty to tell the truth, and a critical reflection on its cognitively ableist construction.

Comparison of the Petrifilm Dry Rehydratable Film and Conventional Culture Methods for Enumeration of Yeasts and Molds in Foods: Collaborative Study

A collaborative study was performed involving 18 laboratories and 6 food types to compare 3M Petrifilm yeast and mold count plates with the method described in the U.S. Food and Drug Administration’s Bacteriological Analytical Manual. Four species of mold and 2 species of yeast were used to inoculate the following foods: hot dogs, corn meal, ketchup, orange juice, yogurt, and cake mix. Each collaborator received 15 samples of each food type: 5 low-level inoculations, 5 high- level inoculations, and 5 uninoculated samples. There was no significant difference between the means of the 2 methods for any product or inoculation level. The Petrifilm yeast and mold count plate method for enumeration of yeasts and molds in foods has been adopted first action by AOAC INTERNATIONAL.

Functional DNA methylation signatures for autism spectrum disorder genomic risk loci: 16p11.2 deletions and CHD8 variants

Background

Autism spectrum disorder (ASD) is a common and etiologically heterogeneous neurodevelopmental disorder. Although many genetic causes have been identified (> 200 ASD-risk genes), no single gene variant accounts for > 1% of all ASD cases. A role for epigenetic mechanisms in ASD etiology is supported by the fact that many ASD-risk genes function as epigenetic regulators and evidence that epigenetic dysregulation can interrupt normal brain development. Gene-specific DNAm profiles have been shown to assist in the interpretation of variants of unknown significance. Therefore, we investigated the epigenome in patients with ASD or two of the most common genomic variants conferring increased risk for ASD. Genome-wide DNA methylation (DNAm) was assessed using the Illumina Infinium HumanMethylation450 and MethylationEPIC arrays in blood from individuals with ASD of heterogeneous, undefined etiology (n = 52), and individuals with 16p11.2 deletions (16p11.2del, n = 9) or pathogenic variants in the chromatin modifier CHD8 (CHD8^+/−, n = 7).

Results

DNAm patterns did not clearly distinguish heterogeneous ASD cases from controls. However, the homogeneous genetically-defined 16p11.2del and CHD8^+/− subgroups each exhibited unique DNAm signatures that distinguished 16p11.2del or CHD8^+/− individuals from each other and from heterogeneous ASD and control groups with high sensitivity and specificity. These signatures also classified additional 16p11.2del (n = 9) and CHD8 (n = 13) variants as pathogenic or benign. Our findings that DNAm alterations in each signature target unique genes in relevant biological pathways including neural development support their functional relevance. Furthermore, genes identified in our CHD8^+/− DNAm signature in blood overlapped differentially expressed genes in CHD8^+/− human-induced pluripotent cell-derived neurons and cerebral organoids from independent studies.

Conclusions

DNAm signatures can provide clinical utility complementary to next-generation sequencing in the interpretation of variants of unknown significance. Our study constitutes a novel approach for ASD risk-associated molecular classification that elucidates the vital cross-talk between genetics and epigenetics in the etiology of ASD.

Electronic supplementary material

The online version of this article (10.1186/s13148-019-0684-3) contains supplementary material, which is available to authorized users.

Violence and aggression in the intensive care unit: What is the impact of Australian National Emergency Access Target?

INTRODUCTION

Violence in healthcare settings is a concern for healthcare professionals and patients. Media reports, and debate within the healthcare profession, and the academic literature infer that workplaces such as intensive care units are becoming exposed to increasing violence. Increases in the incidence of violent behaviour are sometimes attributed to the increased pressure on emergency departments to accelerate the throughput of patients to meet targets. To ensure the wellbeing of patients and staff, there is a need to evaluate the impact of such targets. The aim in this study was to evaluate the incidence and to describe the context in which patients' aggressive and violent behaviours occurred since the introduction of the National Emergency Access Target in a local tertiary Australian intensive care unit.

METHODS

A retrospective examination of events triggering violence-related emergency codes from 12 months before the introduction of the National Emergency Access Target up until 12 months after its implementation (2011-2013).

RESULTS

A small increase in the number of Code Grey/Code Black activation was identified after the introduction of the target (before = 18, after = 29). Admissions following drug overdoses, isolated head trauma, and cardiac arrest were the presentations most likely to have been associated with a violence-related emergency call. Female registered nurses, male critical care registered nurses, and clinical nurse specialists were the most at risk of occupational violence. Male nursing staff members were found to be more likely to be involved in incidences of verbal violence (p < 0.003).

CONCLUSION

Although there was a minimal increase in the overall number of emergencies triggered by violent behaviour, valuable information on the type of occupational violence occurring towards healthcare professionals and patients in this setting was found. We suggest that these findings add further important detail to the existing understanding of the problem of occupational violence. These detailed insights can further inform policy development, professional education, and practice.

Scaling-up NLP Pipelines to Process Large Corpora of Clinical Notes

Introduction: This article is part of the Focus Theme of Methods of Information in Medicine on “Big Data and Analytics in Healthcare”.

Objectives: This paper describes the scale-up efforts at the VA Salt Lake City Health Care System to address processing large corpora of clinical notes through a natural language processing (NLP) pipeline. The use case described is a current project focused on detecting the presence of an indwelling uri-nary catheter in hospitalized patients and subsequent catheter-associated urinary tract infections.

Methods: An NLP algorithm using v3NLP was developed to detect the presence of an indwelling urinary catheter in hospitalized patients. The algorithm was tested on a small corpus of notes on patients for whom the presence or absence of a catheter was already known (reference standard). In planning for a scale-up, we estimated that the original algorithm would have taken 2.4 days to run on a larger corpus of notes for this project (550,000 notes), and 27 days for a corpus of 6 million records representative of a national sample of notes. We approached scaling-up NLP pipelines through three techniques: pipeline replication via multi-threading, intra-annotator threading for tasks that can be further decomposed, and remote annotator services which enable annotator scale-out.

Results: The scale-up resulted in reducing the average time to process a record from 206 milliseconds to 17 milliseconds or a 12-fold increase in performance when applied to a corpus of 550,000 notes.

Conclusions: Purposely simplistic in nature, these scale-up efforts are the straight forward evolution from small scale NLP processing to larger scale extraction without incurring associated complexities that are inherited by the use of the underlying UIMA framework. These efforts represent generalizable and widely applicable techniques that will aid other computationally complex NLP pipelines that are of need to be scaled out for processing and analyzing big data.

The effect of purse-string approximation versus linear approximation of ileostomy reversal wounds on morbidity rates and patient satisfaction: the 'STOMA' trial

BACKGROUND

Ileostomy reversal is associated with surgical site infection (SSI) rates as high as 37%. Recent literature suggests that employing a purse-string approximation (PSA) of the reversal wound reduces this rate of SSI. Thus we wished to perform a randomised controlled trial to compare SSI rates in purse-string versus linear closure (PLC) wounds following ileostomy reversal.

METHODS

A randomised, controlled trial was conducted at University Hospital Limerick. Sixty-one patients undergoing ileostomy reversal were included. Thirty-four patients were randomised to PSA and 27 patients to linear closure. The primary endpoint was incidence of SSI and secondary endpoints measured were quality of life and satisfaction with cosmesis. Statistical analysis was performed on a per protocol basis using SPSS version 22.0.

RESULTS

Three patients in the PSA group developed an SSI compared to 8 in the PLC group at 30 days (8 vs 30%, p = 0.03). The mean time to SSI diagnosis was faster in the PSA group (3 vs 12.3 days, p = 0.08). Patients who developed SSI experienced a longer mean length of stay (6.8 vs 11.4 days, p = 0.012). On multivariate analysis, PLC was the only predictive factor of SSI formation (p < 0.001). There was no difference in patient satisfaction between the two study groups (p = 0.14).

CONCLUSIONS

PSA of wounds following ileostomy reversal significantly reduces SSI formation compared to linear approximation without any effect on patient satisfaction.

The Picture Talk Project: Starting a Conversation with Community Leaders on Research with Remote Aboriginal Communities of Australia

BACKGROUND

Researchers are required to seek consent from Indigenous communities prior to conducting research but there is inadequate information about how Indigenous people understand and become fully engaged with this consent process. Few studies evaluate the preference or understanding of the consent process for research with Indigenous populations. Lack of informed consent can impact on research findings.

METHODS

The Picture Talk Project was initiated with senior Aboriginal leaders of the Fitzroy Valley community situated in the far north of Western Australia. Aboriginal people were interviewed about their understanding and experiences of research and consent processes. Transcripts were analysed using NVivo10 software with an integrated method of inductive and deductive coding and based in grounded theory. Local Aboriginal interpreters validated coding. Major themes were defined and supporting quotes sourced.

RESULTS

Interviews with Aboriginal leaders (n = 20) were facilitated by a local Aboriginal Community Navigator who could interpret if necessary and provide cultural guidance. Participants were from all four major local language groups of the Fitzroy Valley; aged 31 years and above; and half were male. Themes emerging from these discussions included Research-finding knowledge; Being respectful of Aboriginal people, Working on country, and Being flexible with time; Working together with good communication; Reciprocity-two-way learning; and Reaching consent.

CONCLUSION

The project revealed how much more there is to be learned about how research with remote Aboriginal communities should be conducted such that it is both culturally respectful and, importantly, meaningful for participants. We identify important elements in community consultation about research and seeking consent.

Characterizing the inpatient care of young adults experiencing early psychosis

Introduction/objectives

The available literature suggests that treatments and health services for psychosis are considered to be poorly organized and highly variable. Little is known, however, about how inpatient care is provided to individuals experiencing early psychosis. To facilitate quality improvement activities, we characterized the care this patient group receives in an inner city hospital.

Methods

We performed chart reviews of individuals admitted to psychiatric inpatient units at St. Paul's Hospital, Vancouver, British Columbia between 01/04/2014 and 31/03/2016. Those who were 17–25 years of age and hospitalized for psychotic symptoms at the time of admission were included. Demographic and health service use were summarized using descriptive characteristics.

Results

We identified 73 inpatients (mean age = 22; males = 78%; Caucasian = 41%) that met study inclusion criteria, having a combined total of 102 care episodes and an average length of stay of 30.7 days (median = 18; min = 3; max = 268). Half of the care episodes were repeat admissions, with up to 30% of the patients readmitted within 28 days of discharge. Physical and mental status examinations (MSE) were performed in virtually all care episodes, although frequency is low (31.4% had daily physical examinations and 18.6% had MSE every nursing shift). In 49% and 50% of care episodes, patients were given oral antipsychotics and discharged on depot medications. Even when indicated, not all care episodes had follow-up appointments (60%) or referrals to income assistance (35%), community mental health teams (61%), and housing support (38%).

Conclusions

Specific programs are needed to address current gaps in inpatient care for patients with early psychosis.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A PROFESSIONAL PORTFOLIO OF LEARNING FOR UNDERGRADUATE NURSING STUDENTS

Traditionally, the assessment of clinical competence has been completed using 'paper based' systems which is still the predominant approach in Undergraduate Nursing Programs.

A PROFESSIONAL PORTFOLIO OF LEARNING FOR UNDERGRADUATE NURSING STUDENTS

Traditionally, the assessment of clinical competence has been completed using 'paper based' systems which is still the predominant approach in Undergraduate Nursing Programs.

From security to trust

The use of information technology for information management in healthcare is fundamentally about facilitating the holding of much more comprehensive data on people throughout the health system. More comprehensive health information obviously creates the potential for greatly improved health-care. At the same time, however, it raises concerns about the amount of information about individuals flowing through the system. This information has the potential not only to benefit the community but also to be used in ways which are discriminatory or otherwise harmful. This paper argues that if the potential of information technology to benefit information management in health-care is to be realized, there must be a shift in the culture of the health sector, to one which has a far greater emphasis on consumer privacy than is presently evident.

Prevalence of pancreatic, hepatic and renal microscopic lesions in post-mortem samples from Cavalier King Charles spaniels

OBJECTIVES

The objective of this study was to describe the prevalence of microscopic pancreatic, hepatic and renal lesions in post-mortem samples from Cavalier King Charles spaniels.

METHODS

The prevalence of microscopic lesions was determined by routine histopathology and compared to ante-mortem clinical signs.

RESULTS

There was evidence of chronic pancreatitis in 51·9% of the cases, and age correlated with severity. Renal lesions were diagnosed in 52·2% of cases, most of which were inflammatory. Ante-mortem diagnosis of pancreatic and renal disease was 25 and 16·7%, respectively. Primary hepatic lesions were diagnosed in 11·1% of cases; secondary hepatic lesions were diagnosed in 64·8%.

CLINICAL SIGNIFICANCE

Pancreatic and renal lesions are common in Cavalier King Charles spaniels, but they have similar rates of hepatic disease as the general population. The increasing prevalence of pancreatic lesions with age suggests that it might be a progressive condition.