A systematic review comparing the safety, cost and carbon footprint of disposable and reusable laparoscopic devices

INTRODUCTION

The objective of this systematic review of the literature is to compare a selection of currently utilized disposable and reusable laparoscopic medical devices in terms of safety (1st criteria), cost and carbon footprint.

MATERIAL AND METHODS

A search was carried out on electronic databases for articles published up until 6 May 2022. The eligible works were prospective (randomized or not) or retrospective clinical or medical-economic comparative studies having compared disposable scissors, trocars, and mechanical endoscopic staplers to the same instruments in reusable. Two different independent examiners extracted the relevant data.

RESULTS

Among the 2882 articles found, 156 abstracts were retained for examination. After comprehensive analysis concerning the safety and effectiveness of the instruments, we included four articles. A study on trocars highlighted increased vascular complications with disposable instruments, and another study found more perioperative incidents with a hybrid stapler as opposed to a disposable stapler. As regards cost analysis, we included 11 studies, all of which showed significantly higher costs with disposable instruments. The results of the one study on carbon footprints showed that hybrid instruments leave four times less of a carbon footprint than disposable instruments.

CONCLUSION

The literature on the theme remains extremely limited. Our review demonstrated that from a medical and economic standpoint, reusable medical instruments, particularly trocars, presented appreciable advantages. While there exist few data on the ecological impact, those that do exist are unmistakably favorable to reusable instruments.

Developing an integrated clinical decision support system for the early identification and management of kidney disease-building cross-sectoral partnerships

BACKGROUND

The burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care.

AIM

This paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care.

METHODS

Building on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system's design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation.

RESULTS

We established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events.

CONCLUSION

Disconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.

Clinical safety and tolerability evaluation of Withania somnifera (L.) Dunal (Ashwagandha) root extract in healthy human volunteers

BACKGROUND

Withania somnifera (L.) Dunal, known as Ashwagandha, is an adaptogen with significant importance in Ayurveda for its potential health benefits in strength ('balavardhan') and muscle growth ('mamsavardhan'). Despite numerous studies on its efficacy, limited research is reported on its clinical safety and tolerability in healthy individuals.

OBJECTIVE

This research evaluated the tolerability and safety of standardized Withania somnifera root extract (WSE) capsules (AgeVel®/Witholytin®) at 1000 mg/day dose upon oral administration in healthy male participants.

METHOD

A non-randomized, open-label, single-treatment clinical study included eighteen healthy male participants aged 18 to 60. The participants were administered a dose of 500 mg of the WSE capsules twice daily for four weeks. Each capsule contained not less than 7.50 mg of total withanolides. The study evaluated various indicators in a cohort of healthy participants throughout the trial, including vital signs, organ function tests, urine analysis, X-ray and ECG, cardiorespiratory endurance, body fat percentage, lean body weight, adverse events profile, and tolerability of the WSE capsules.

RESULTS

The participant's physical, hematological, and biochemical characteristics were normal, and no significant alterations or irregularities were observed in safety metrics like liver, kidney, and thyroid functions after administering AgeVel®/Witholytin®.

CONCLUSION

This study found that healthy male participants could consume a standardized WSE at a daily dosage of 1000 mg for four weeks without any adverse effects. Future research should focus on long-term safety assessments in male and female participants.

[Evaluation of clinical safety and diagnostic efficacy of domestic liver-specific magnetic resonance contrast agent (gadoxetate disodium)]

Objective: To evaluate the clinical safety and diagnostic efficacy of domestic gadoxetate disodium (GdEOBDTPA). Methods: The imaging data from patients with space-occupying liver lesions who underwent GdEOBDTPA enhanced magnetic resonance examination at West China Hospital of Sichuan University between January 2020 and September 2020 were analyzed retrospectively. Clinical indicators were evaluated by the incidental condition of transient severe respiratory motion artifacts (TSM) in the arterial phase to assess the safety profile.The differences in quantitative and qualitative indicators for the risk factors of TSM in the arterial phase between the TSM group and the non-TSM group were compared by t-test and χ2 test. Observational indicators of the accuracy of diagnostic procedures: The 2018 version of the Liver Imaging Reporting and Data System (LI-RADS) was used to evaluate the main signs, auxiliary signs, and LR grades of lesions. Postoperative pathological findings were used as the gold standard for evaluating and diagnosing hepatocellular carcinoma (HCC). Simultaneously, the relative enhancement degree of the liver, the contrast between the lesion and the liver, and the cholangiography in the hepatobiliary phase were evaluated. The McNemar test was used to compare the differences in the diagnostic efficiency of physician 1 and physician 2 in the diagnosis of hepatocellular carcinoma according to the 2018 version of LI-RADS. Results: A total of 114 cases were included in this study. The incidence rate of TSM was 9.6% (11/114). Age [(53.8 ± 11.3) years vs. (55.4 ± 15.4) years, t = 0.465, P = 0.497], body weight [(65.8 ± 11.1) kg vs. (60.8 ± 7.6) kg, t = 1.468, P = 0.228], body mass index [(23.9 ± 3.1) kg/m(2) vs. (23.4 ± 3.0) kg/m(2), t = 0.171, P = 0.680], liver cirrhosis ratio (39 cases vs. 4 cases, χ (2) =1.776, P = 0.183), proportion of mild to moderate pleural effusion (32 cases vs. 4 cases, χ (2) = 0.000, P = 0.986), and proportion of mild to moderate ascites (47 cases vs. 5 cases χ (2) = 0.000, P = 0.991) had no statistically significant difference between the groups of non-TSM and TSM patients. According to the 2018 version of LI-RADS for the LR5 category, there was no statistically significant difference between the two physicians' HCC diagnoses in terms of sensitivity (91.4% vs.86.4%, χ (2) = 1.500, P = 0.219), specificity (72.7 % vs. 69.7%, χ (2) = 0.000, P = 1.000), positive predictive value (89.2% vs. 87.5%, χ (2) = 2.250, P = 0.125), negative predictive value (77.4% vs. 67.6%, χ (2) = 2.250, P = 0.125), and accuracy (86.0% vs. 81.6%, χ (2) = 0.131, P = 0.125). According to physicians 1 and 2 film review results, 91.2% (104/114) and 89.5% (102/114) of the contrast agent were discharged into the common bile duct or duodenum, respectively. In addition, 86.0% (98/114) of the patients had good liver enhancement, and 91.2% (104/114) of the lesions showed low signals relative to the liver background. Conclusion: Domestic gadoxetate disodium has a good clinical safety profile and diagnostic efficacy.

Clinical safety study of photobiomodulation in acute spinal cord injury by scattering fiber

The study aimed to design a reliable and straightforward PBM method by implanting a medical scattering fiber above surgically exposed spinal cord in SCI patients. Moreover, the safety of this method was examined. Twelve patients with acute SCI (ASIA B) requiring posterior decompression were recruited. The medical scattering fiber was implanted above the spinal cord, and was continuously irradiated at 810 nm, 300 mW, 30 min/day, once per day for 7 days. The vital signs (temperature, blood pressure, respiratory rate, heart rate, and oxygen saturation), infection indicators (WBC, NEUT, hs-CRP, and PCT), photo-allergic reaction indicators (Eosinophil and Basophil), coagulation function indicators (PT, APTT, TT) and neurological stability indicators (ASIA sensory and motor scores) were recorded to evaluate the safety of PBM. Three months after surgery, 12 patients completed follow-up. In our study, direct PBM on SCI site did not cause clinically pathologic changes in vital signs of the patients. All patients had higher WBC, NEUT, and hs-CRP at day 3 during irradiation than those before surgery, and returned to normal at day 7. The changes in Eosinophil and Basophil that were closely associated with allergic reactions were within normal limits throughout the course of irradiation. The coagulation function (PT, APTT, and TT) of patients were also in the normal range. The ASIA sensory and motor scores of all patients had no changes throughout the irradiation process. However, in the follow-up, both ASIA sensory and motor scores of all patients had minor improvement than those in pre-irradiation, and 7 patients had adverse events, but they were not considered to be related to PBM. Our study might firstly employ direct PBM in the SCI by using scattered optical fibers. In a limited sample size, our study concluded that direct PBM at the site of SCI would not produce adverse effects within the appropriate irradiation parameters. The method is safe, feasible, and does not add additional trauma to the patient. Our preliminary study might provide a new methodology for the clinical PBM treatment of acute SCI.

Ruxolitinib reduces severe CRS response by suspending CAR-T cell function instead of damaging CAR-T cells

The therapeutic effect of CAR-T is often accompanied by sCRS, which is the main obstacle to the promotion of CAR-T therapy. The JAK1/2 inhibitor ruxolitinib has recently been confirmed as clinically effective in maintaining control over sCRS, however, its mechanism remains unclear. In this study, we firstly revealed that ruxolitinib significantly inhibited the proliferation of CAR-T cells without damaging viability, and induced an efficacy-favored differentiation phenotype. Second, ruxolitinib reduced the level of cytokine release not only from CAR-T cells, but also from other cells in the immune system. Third, the cytolytic activity of CAR-T cells was restored once the ruxolitinib was removed; however, the cytokines released from the CAR-T cells maintained an inhibited state to some degree. Finally, ruxolitinib significantly reduced the proliferation rate of CAR-T cells in vivo without affecting the therapeutic efficacy after withdrawal at the appropriate dose. We demonstrated pre-clinically that ruxolitinib interferes with both CAR-T cells and the other immune cells that play an important role in triggering sCRS reactions. This work provides useful and important scientific data for clinicians on the question of whether ruxolitinib has an effect on CAR-T cell function loss causing CAR-T treatment failure when applied in the treatment of sCRS, the answer to which is of great clinical significance.

Safer prescription of drugs: impact of the PREFASEG system to aid clinical decision-making in primary care in Catalonia

BACKGROUND

In 2008, the Institut Català de la Salut (ICS, Catalan Health Institute) implemented a prescription decision support system in its electronic clinical workstation (ECW), which automatically generates online alerts for general practitioners when a possible medication-related problem (MRP) is detected. This tool is known as PREFASEG, and at the time of beginning a new treatment, it automatically assesses the suitability of the treatment for the individual patient. This analysis is based on ongoing treatments, demographic characteristics, existing pathologies, and patient biochemical variables. As a result of the assessment, therapeutic recommendations are provided. The objective of this study is to present the PREFASEG tool, analyse the main alerts that it generates, and determine the degree of alert acceptance.

METHODS

A cross-sectional descriptive study was carried out to analyse the generation of MRP-related alerts detected by PREFASEG during 2016, 2017, and 2018 in primary care (PC) in Catalonia. The number of MRP alerts generated, the drugs involved, and the acceptance/rejection of the alerts were analysed. An alert was considered "accepted" when the medication that generated the alert was not prescribed, thereby following the recommendation given by the tool. The MRP alerts studied were therapeutic duplications, safety alerts issued by the Spanish Medicines Agency, and drugs not recommended for use in geriatrics. The prescriptions issued by 6411 ICS PC physicians who use the ECW and provide their services to 5.8 million Catalans through 288 PC teams were analysed.

RESULTS

During the 3 years examined, 67.2 million new prescriptions were analysed, for which PREFASEG generated 4,379,866 alerts (1 for every 15 new treatments). A total of 1,222,159 alerts (28%) were accepted. Pharmacological interactions and therapeutic duplications were the most detected alerts, representing 40 and 30% of the total alerts, respectively. The main pharmacological groups involved in the safety alerts were nonsteroidal anti-inflammatory drugs and renin-angiotensin system inhibitors.

CONCLUSIONS

During the period analysed, 28% of the prescriptions wherein a toxicity-related PREFASEG alert was generated led to treatment modification, thereby helping to prevent the generation of potential safety MRPs. However, the tool should be further improved to increase alert acceptance and thereby improve patient safety.

The safety and tolerability of alkaloids from Alstonia scholaris leaves in healthy Chinese volunteers: a single-centre, randomized, double-blind, placebo-controlled phase I clinical trial

CONTEXT

Capsule of alkaloids from the leaf of Alstonia scholaris (L.) R.Br. (Apocynaceae) (CALAS) is a new investigational botanical drug (No. 2011L01436) for bronchitis, post-infectious cough and asthma.

OBJECTIVE

To observe the clinical safety and tolerability of CALAS.

MATERIALS AND METHODS

Subjects were assigned to eight cohorts, and each received randomly CALAS or placebo in one of single ascending dose (SAD) of 8, 40, 120, 240, 360, 480, or in one of multiple ascending dose (MAD) of 40 or 120 mg, three times daily for 7 days. Each cohort contained two placebo subjects.

RESULTS

Sixty-two enrolled volunteers completed the study and no serious adverse events and clinically significant changes in vital signs, electrocardiography, and upper abdominal Doppler ultrasonography were observed. The ratios of treatment-emergent adverse events (TEAEs) were reported in 11/46 (23.91%) of CALAS groups and 3/16 (18.75%) of the placebo group (p > 0.05), respectively, based on the results of SAD and MAD. All TEAEs were mild, transient, and disappeared without any intervention. The TEAEs possibly related to CALAS treatment were as followings: hiccups (4/46: 8%), dry mouth and nausea (3/46: 6%), increased sleep (2/46: 4%), abdominal distension (1/46: 2%), bilirubin elevated (1/46: 2%).

DISCUSSION AND CONCLUSIONS

CALAS is safe and well-tolerated with no unexpected or clinically relevant safety concerns up to a single dose of 360 mg and three times daily for 7 days up to 120 mg in healthy Chinese volunteers, supporting further Phase II studies.

Clinical efficacy and safety of using calcipotriol-betamethasone compounding agent for psoriasis treatment: a systematic review and meta-analysis

The main objective is to evaluate clinical efficacy and safety of using calcipotriol-betamethasone compounding agent for psoriasis treatment through a systematic review and meta-analysis. We searched MEDLINE, Embase, The Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), and WanFang Data from inception till July 31, 2020. Efficacy was evaluated based on primary outcome indicators including skin lesion improvement and overall adverse reaction rate. Secondary outcome indicators included degree of life quality improvement, clinical effectiveness rate, and specific adverse reaction rates. RevMan5.3 was used to perform the meta-analysis. 22 studies finally met our inclusion criteria for the meta-analysis. The results indicated that for short-term treatment, a sequential therapy that uses calcipotriol betamethasone compounding agent and calcipotriol improves PASI score (MD = -0.94, 95% CI - 1.38 ~ - 0.49, P < 0.0001, I² = 49%), comparing with using only calcipotriol. From a drug safety perspective, the difference in overall adverse reaction rate is not significant between the calcipotriol group and the sequential treatment group (RR = 0.50, 95% CI 0.22 ~ 1.14, P = 0.10, I² = 33%). Calcipotriol betamethasone compounding agent may be more effective in plaque psoriasis treatment compared to use only calcipotriol, with no significant difference in adverse reaction rate between the two groups. Although the data were collected from 13 comparison groups, each group may not have sufficient data for a thorough and comprehensive analysis. Further research may be necessary for a more detailed evaluation of effectiveness of using calcipotriol betamethasone compounding agent for plaque psoriasis treatment.

Safety and efficacy of citric acid-upconverting nanoparticles for multimodal biological imaging in BALB/c mice

There has been significant progress with rare-earth coated upconversion nanoparticles (UCNPs) representing a promising new generation of contrast agents for biomedical applications. However, in vivo biological safety remains poorly investigated. This work examined citric acid-UCNP (NaYF4:Yb³⁺/Gd³⁺, ∼ 5 nm, Cit-UCNP) generated as contrast agents for multimodal imaging with concurrent magnetic resonance (MRI) and X-ray computed tomography (CT). We first examined the in vitro cytotoxicity and efficacy of Cit-UCNPs as a contrast agent. We then performed a systematic investigation of their in vivo biodistribution and biocompatibility. Our results noted that Cit-UCNPs have minimal toxicity and demonstrated significant potential as contrast agents for multimodal biomedical imaging. This study indicates Cit-UCNPs could be a valuable addition to enhance long-term targeted diagnostic and prognostic multimodal clinical imaging approaches.

Clinical safety of total glucosides of paeony adjuvant therapy for rheumatoid arthritis treatment: a systematic review and meta-analysis

BACKGROUND

Total glucosides of paeony (TGP), an active compound extracted from the roots of Paeonia lactiflora Pallas, has been increasingly used as the adjunctive therapy for rheumatoid arthritis (RA) patients. Though TGP could mitigate the unanticipated adverse effects during the conventional treatment of RA, high-quality evidence-based meta-analysis data on this subject are still insufficient. The objective of this study is to evaluate the clinical safety of TGP adjuvant therapy in the RA treatment.

METHODS

PubMed, EMBASE, Web of Science, China Network Knowledge Infrastructure (CNKI), SinoMed and WanFang Data were retrieved for randomized controlled trials (RCTs) and cohort study about TGP adjuvant therapy in patients with RA up to 28 January 2021. Literatures with eligibility criteria and information were screened and extracted by two researchers independently. The RevMan5.3 software was used for data analysis with effect estimates as risk ratio (RR) with 95% confidence interval (CI).

RESULTS

A total of 39 studies involving 3680 RA participants were included. There were 8 comparisons: TGP plus methotrexate (MTX) therapy versus MTX therapy, TGP plus leflunomide (LEF) therapy versus LEF therapy, TGP plus MTX and LEF therapy versus MTX plus LEF therapy, TGP plus tripterygium glycosides (TG) therapy versus TG therapy, TGP plus meloxicam (MLX) therapy versus MLX therapy and TGP plus sulfasalazine (SSZ) therapy versus SSZ therapy, TGP plus iguratimod (IGU) therapy versus IGU therapy, TGP plus prednisone acetate tablets (PAT) therapy versus PAT therapy. The meta-analysis results showed that the occurrence of hepatic adverse effect (RR = 0.31, 95% CI = 0.23-0.41, P < 0.00001) and leukopenia (RR = 0.41, 95% CI = 0.26-0.66, P = 0.0002) in TGP adjuvant therapy was significant decreased compared with non-TGP therapy. However, only TGP plus LEF therapy (RR = 0.22, 95% CI = 0.08-0.60, P = 0.003) and TGP plus MTX and LEF therapy (RR = 0.31, 95% CI = 0.22-0.42, P < 0.00001) had statistical difference in the subgroups of hepatic adverse effect. In leukopenia, TGP plus MTX and LEF therapy (RR = 0.47, 95% CI = 0.25-0.87, P = 0.02) had statistical difference.

CONCLUSIONS

This meta-analysis indicated that TGP adjuvant therapy might alleviate the incidence of hepatic adverse effect and leukopenia for the RA treatment compared to non-TGP therapy. The clinical safety of TGP adjuvant therapy warrant further investigation in experimental studies.

Clinical safety of intracranial EEG electrodes in MRI at 1.5 T and 3 T: a single-center experience and literature review

PURPOSE

Intracranial electroencephalography (EEG) can be a critical part of presurgical evaluation for drug resistant epilepsy. With the increasing use of intracranial EEG, the safety of these electrodes in the magnetic resonance imaging (MRI) environment remains a concern, particularly at higher field strengths. However, no studies have reported the MRI safety experience of intracranial electrodes at 3 T. We report an MRI safety review of patients with intracranial electrodes at 1.5 and 3 T.

METHODS

One hundred and sixty-five consecutive admissions for intracranial EEG monitoring were reviewed. A total of 184 MRI scans were performed on 135 patients over 140 admissions. These included 118 structural MRI studies at 1.5 T and 66 functional MRI studies at 3 T. The magnetic resonance (MR) protocols avoided the use of high specific energy absorption rate sequences that could result in electrode heating. The intracranial implantations included 114 depth, 15 subdural, and 11 combined subdural and depth electrodes. Medical records were reviewed for patient-reported complications and radiologic complications related to these studies. Pre-implantation, post-implantation, and post-explantation imaging studies were reviewed for potential complications.

RESULTS

No adverse events or complications were seen during or after MRI scanning at 1.5 or 3 T apart from those attributed to electrode implantation. There was also no clinical or imaging evidence of worsening of pre-existing implantation-related complications after MR imaging.

CONCLUSION

No clinical or radiographic complications are seen when performing MRI scans at 1.5 or 3 T on patients with implanted intracranial EEG electrodes while avoiding high specific energy absorption rate sequences.

Medicolegal Aspects of Teledermatology

Teledermatology has facilitated specialist care during the crisis caused by the coronavirus disease 2019 pandemic, eliminating unnecessary office visits and the possible exposure of patients or dermatologists. However, teledermatology brings forward certain ethical and medicolegal questions. A medical consultation in which the patient is not physically present is still a medical act, to which all the usual ethical and medicolegal considerations and consequences apply. The patient's right to autonomy and privacy, confidentiality, and data protection must be guaranteed. The patient must agree to remote consultation by giving informed consent, for which a safeguard clause should be included. Well-defined practice guidelines and uniform legislation are required to preserve the highest level of safety for transferred data. Adequate training is also needed to prevent circumstances involving what might be termed «telemalpractice».

Medicolegal aspects of teledermatology

Teledermatology has facilitated specialist care during the crisis caused by the coronavirus disease 2019 pandemic, eliminating unnecessary office visits and the possible exposure of patients or dermatologists. However, teledermatology brings forward certain ethical and medicolegal questions. A medical consultation in which the patient is not physically present is still a medical act, to which all the usual ethical and medicolegal considerations and consequences apply. The patient's right to autonomy and privacy, confidentiality, and data protection must be guaranteed. The patient must agree to remote consultation by giving informed consent, for which a safeguard clause should be included. Well-defined practice guidelines and uniform legislation are required to preserve the highest level of safety for transferred data. Adequate training is also needed to prevent circumstances involving what might be termed "telemalpractice."

[Health policy strategies for Patient Blood Management implementation throughout the Spanish health systems]

Los programas de Patient Blood Management (PBM) permiten reducir intervenciones sanitarias innecesarias e incorporar prácticas clínicas de alto valor que mejoran los resultados en salud y la eficiencia. Su adopción en España es todavía limitada y con una alta variabilidad entre hospitales. Las recientes guías de la Unión Europea sobre cómo implementar el PBM, así como las recomendaciones de expertos, indican que para conseguir un avance en este campo se requiere, no solo de la implicación de los profesionales, sino también de las autoridades sanitarias y direcciones hospitalarias. Este artículo proporciona algunas propuestas en materia de gestión y política sanitaria para promover el desarrollo del PBM en los sistemas de salud en España.

Self-administration of medication during hospitalization-a randomized pilot study

Background

Self-administration of medication (SAM) during hospitalization is a complex intervention where patients are involved in their course of treatment. The study aim was to pilot test the SAM intervention. The objectives were to assess the feasibility of conducting a randomized controlled trial on the safety and cost-consequences of SAM during hospitalization.

Methods

The study was performed in a Danish cardiology unit.

Patients ≥ 18 years capable of self-administering medication during hospitalization were eligible. Patients were excluded if they did not self-administer medication at home, were incapable of self-administering medication, were not prescribed medication suitable for self-administration, did not bring their medication, or were unable to speak Danish.

Feasibility was assessed as part of the pilot study. A future randomized controlled trial was considered feasible if it was possible to recruit 60 patients within 3 months, if outcome measurement method was capable of detecting dispensing errors in both groups, and if patients in the intervention group were more satisfied with the medication management during hospitalization compared to the control group.

Forty patients were recruited to gain experience about the intervention (self-administration). Additionally, 20 patients were randomized to the intervention or control group (nurse-led dispensing) to gain experience about the randomization procedure.

Dispensing error proportions were based on data collected through disguised observation of patients and nurses during dispensing. The error proportion in the control group was used for the sample size calculation. Patient acceptability was assessed through telephone calls.

Results

Of the 60 patients recruited, one withdrew and 11 were discharged before observation resulting in analysis of 39 patients in the intervention group and nine in the control group. A dispensing error proportion of 3.4% was found in the intervention group and 16.1% in the control group. A total of 91.7% of patients in the intervention group and 66.7% in the control group were highly satisfied with the medication management during hospitalization. The overall protocol worked as planned. Minor changes in exclusion criteria, intervention, and outcome measures were considered.

Conclusions

It may be feasible to perform a pragmatic randomized controlled trial of the safety and cost-consequences of self-administration of medication during hospitalization.

Trial registration

ClinicalTrials.gov, NCT03541421, retrospectively registered on 30 May 2018.

A clinical pathway for pre-operative screening of COVID-19 and its influence on clinical outcome in patients with traumatic fractures

PURPOSE

Coronavirus disease 2019 (COVID-19) has become a worldwide pandemic. The toughest issue traumatic orthopaedic surgeons are faced with is how to maintain a balance between adequate COVID-19 screening and timely surgery. In this study, we described our experience with pre-operative COVID-19 screening in patients with traumatic fractures. Furthermore, we analysed the clinical results of fracture patients undergoing confined or emergency surgery during the COVID-19 outbreak.

METHODS

This was a case series study. Patients with traumatic fractures who were admitted to our hospital for surgery were enrolled in this study during the COVID-19 outbreak from March to April 2020. All patients were enrolled and managed using the standardized clinical pathway we designed for preoperative COVID-19 screening. Clinical, laboratory and outcome data were analysed.

RESULTS

The average surgery waiting time from injury to surgery was 8.7 ± 3.4 days. The average waiting time from admission to surgery was 5.3 ± 2.8 days. These average waiting times were increased by 4.1 days and 2.0 days, respectively, compared with 2019 data. Cardiovascular complications, venous thromboembolism and pneumonia occurred in one, two and one patient, respectively. Three and two patients developed pre-operative and postoperative fevers, respectively.

CONCLUSIONS

We introduced a novel clinical pathway for pre-operatively screening of COVID-19 in traumatic orthopaedic patients. The delay in surgery caused by COVID-19 screening was minimized to a point at which reasonable and acceptable clinical outcomes were achieved. Doctors should pay more attention to perioperative complications, such as cardiovascular complications, venous thromboembolism, pneumonia and fever.

The biocompatibility of silver and nanohydroxyapatite coatings on titanium dental implants with human primary osteoblast cells

Silver nanoparticles (Ag NPs) are antimicrobial, with potential uses in medical implants, but Ag NPs alone can also be toxic to mammalian cells. This study aimed to enhance the biocompatibility of Ag NP-coated titanium dental implants with hydroxyapatite (HA) applied to the surface. Ti6Al4V discs were coated with Ag NPs, Ag NPs plus HA nanoparticles (Ag + nHA), or Ag NPs plus HA microparticles (Ag + mHA). The stability of coatings was explored and the biocompatibility with primary human osteoblasts over 7 days. Results showed that Ti6Al4V discs were successfully coated with silver and HA. The primary particle size of nHA and mHA were 23.90 ± 1.49 nm and 4.72 ± 0.38 μm respectively. Metal analysis showed that underlying silver coatings remain stable in DMEM culture media, but the presence of FBS in the media caused some initial (clinically beneficial) release of dissolved silver. With additions of HA, osteoblasts were adherent, had normal morphology, negligible lactate dehydrogenase (LDH) leak, and showed alkaline phosphatase (ALP) activity. Cell viability was around 70% throughout the Ag + nHA treatment. Overall, the implants coated with Ag + nHA maintained a higher degree of biocompatibility compared to those coated with Ag + mHA, or Ag NPs alone, suggesting the former has a benefit for clinical use.

[Modal analysis of failures and effects in intra-hospital transfers]

OBJECTIVES

To identify gaps in patient safety during intra-hospital transfers.

MATERIAL AND METHODS

A working group was set up and patient transfers carried out in the different healthcare areas of a hospital were identified. Using the Modal Failure and Effects Analysis (FMEA), the risks of each failure mode identified were quantified using the Risk Prioritisation Index (RPI) and establishing improvement measures for all RPIs with scores greater than 100.

RESULTS

There were 31 critical points that could lead to failures / deficiencies in 20 types of transfers. A total of 35 safety improvement measures were proposed for the transfers in the different areas analysed.

CONCLUSIONS

The use of FMEA has made it possible to objectify the risks for patient safety during internal hospital transfers by providing information to prioritise improvement strategies.

A randomized, controlled, single-blinded, multicenter evaluation of the efficacy and safety of a once weekly two dose otic gel containing florfenicol, terbinafine and betamethasone administered for the treatment of canine otitis externa

Background

Otitis externa is a common problem in small animal practice. Compliance with daily treatment is a major cause of treatment failure. The hypothesis tested is that a novel otic gel applied to the ear canal twice with a one-week interval is as efficacious as a daily otic suspension in the treatment of canine otitis externa. The study included 286 privately owned dogs with otitis externa.

In this single blinded randomized study, enrolled dogs received either an otic gel containing 1% florfenicol, 1% terbinafine and 0.1% betamethasone acetate twice with a one-week interval or a suspension containing hydrocortisone aceponate, miconazole and gentamicin daily for 5 days. Ears were cleaned with saline prior to administration of the first dose of medication. Dogs were evaluated at day (D) 0, 7, 28 and 56 with an otitis index score (OTIS-3), otic culture and cytology, pain and pruritus, and overall response to treatment (owner and investigator evaluation). Outcome measures were improvement of the OTIS-3 and number of dogs in clinical remission at each time point.

Results

OTIS-3 decreased significantly (p < 0.0001) by 63 and 64% for the otic gel and by 63 and 61% for the suspension on D28 and D56 respectively. There was no significant difference between groups at any time point with regard to clinical success, pain, pruritus, overall assessments or otic cytology and culture. The treatment response was considered excellent or good by approximately three quarters of both the clinicians and Owners. Otitis recurrence at D56 was seen in 11% of both groups. Adverse events attributable to the ear medications were not noted.

Conclusions

Administering an otic gel twice at a one-week interval is an effective, safe and convenient way to treat canine otitis externa.

The impact of workload on the ability to localize audible alarms

Very little is known about people's ability to localize sound under varying workload conditions, though it would be expected that increasing workload should degrade performance. A set of eight auditory clinical alarms already known to have relatively high localizability (the ease with which their location is identified) when tested alone were tested in six conditions where workload was varied. Participants were required to indicate the location of a series of alarms emanating at random from one of eight speaker locations. Additionally, they were asked to read, carry out mental arithmetic tasks, be exposed to typical ICU noise, or carry out either the reading task or the mental arithmetic task in ICU noise. Performance in the localizability task was best in the control condition (no secondary task) and worst in those tasks which involved both a secondary task and noise. The data does therefore demonstrate the typical pattern of increasing workload affecting a primary task in an area where there is little data. In addition, the data demonstrates that performance in the control condition results in a missed alarm on one in ten occurrences, whereas performance in the heaviest workload conditions results in a missed alarm on every fourth occurrence. This finding has implications for the understanding of both 'inattentional deafness' and 'alarm fatigue' in clinical environments.

A randomized placebo-controlled trial of the efficacy and safety of a terbinafine, florfenicol and betamethasone topical ear formulation in dogs for the treatment of bacterial and/or fungal otitis externa

BACKGROUND

Treatment of infected otitis externa (OE) relies on the topical application of specific formulations that most often contain an antibiotic, an antifungal and a glucocorticoid. This study is to report the results of a randomized, placebo-controlled field trial evaluating the efficacy and safety of OSURNIA™ (Elanco Animal Health, a division of Eli Lilly and Company, Greenfield, IN), a novel topical ear medication containing florfenicol, terbinafine and betamethasone acetate in an adaptable gel. The study includes 284 dogs with bacterial and/or fungal OE who were randomly assigned to receive two doses of Osurnia or its vehicle, one week apart. Dogs were evaluated at various time points through Day 45, and a total clinical score (TCS) was calculated based on pain, erythema, exudate, swelling, odor and ulceration. The primary outcome measure was the rate of treatment success (RTS), defined as a TCS of 0, 1 or 2 on Day 45. Before and after treatment, a "clap test" was performed to subjectively assess hearing, and blood and urine were collected for routine clinical pathology.

RESULTS

The RTS was significantly higher in ears treated with Osurnia (64.78%) than with placebo (43.42%). There was no significant interaction between efficacy and duration of history, recurrence of otitis or body weight. Adverse events were similar between groups. All dogs treated with Osurnia maintained their hearing, and there were no relevant clinical pathology changes.

CONCLUSIONS

The application of two doses of Osurnia, one week apart, is effective and safe to treat microbial otitis externa in dogs.

Medical Malpractice Issues in Dermatology: Clinical Safety and the Dermatologist

Clinical safety and medical liability are first-order concerns in today's medical practice. It is important to understand the circumstances under which medical acts fail to live up to the accepted standard of care and to recognize the impact that malpractice claims have on physicians. Practitioners must also grasp the concept of medical error, studying malpractice claims in order to identify the areas where improvement is needed. The risk of accusations of malpractice in dermatology is comparatively low, both in Spain and worldwide. However, a great variety of clinical scenarios in dermatology can potentially give rise to a claim, and malignant melanoma is most susceptible to risk. Dermatologists should know which actions during clinical consultation merit particular attention and care. Clinical practice carries inherent risk of malpractice claims, but taking certain recommended precautions can prevent them.

Handover in Intensive Care

Handover is a frequent and complex task that also implies the transfer of the responsibility of the care. The deficiencies in this process are associated with important gaps in clinical safety and also in patient and professional dissatisfaction, as well as increasing health cost. Efforts to standardize this process have increased in recent years, appearing numerous mnemonic tools. Despite this, local are heterogeneous and the level of training in this area is low. The purpose of this review is to highlight the importance of IT while providing a methodological structure that favors effective IT in ICU, reducing the risk associated with this process. Specifically, this document refers to the handover that is established during shift changes or nursing shifts, during the transfer of patients to other diagnostic and therapeutic areas, and to discharge from the ICU. Emergency situations and the potential participation of patients and relatives are also considered. Formulas for measuring quality are finally proposed and potential improvements are mentioned especially in the field of training.

Clinical safety and professional liability claims in Ophthalmology

INTRODUCTION

Patient safety is an international public health priority. Ophthalmology scientific societies and organisations have intensified their efforts in this field. As a tool to learn from errors, these efforts have been linked to the management of medical professional liability insurance through the analysis of claims.

MATERIAL AND METHODS

A review is performed on the improvements in patient safety, as well as professional liability issues in Ophthalmology.

RESULTS

There is a high frequency of claims and risk of economic reparation of damage in the event of a claim in Ophthalmology. Special complaints, such as wrong surgery or lack of information, have a high risk of financial compensation and need strong efforts to prevent these potentially avoidable events. Studies focused on pathologies or specific procedures provide information of special interest to sub-specialists. The specialist in Ophthalmology, like any other doctor, is subject to the current legal provisions and appropriate mandatory training in the medical-legal aspects of health care is essential.

CONCLUSIONS

Professionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical-legal aspects in the routine clinical practice can help to pave the way towards a satisfactory and safe professional career, and help in increasing patient safety. The aim of this review is to contribute to this training, for the benefit of professionals and patients.

Diagnostic validity of the STRATIFY and Downton instruments for evaluating the risk of falls by hospitalised acute-care patients: a multicentre longitudinal study

Background

Falls are major adverse events in hospitals. The appropriateness of using risk assessment instruments for falls in hospitals has recently been questioned, although the research performed in this respect presents some methodological shortcomings. The purpose of the present study is to evaluate the accuracy of the Downton and STRATIFY instruments to determine the risk of falls and to predict their incidence in acute care hospitals in the public health system in Andalusia (Spain).

Methods

A longitudinal, multicentre prospective study was made of a cohort of patients recruited between May 2014 and March 2016. The risk of falls was assessed using each of the above instruments during the first 24 h after hospital admittance, with later re-evaluations every 72 h until discharge. Descriptive statistics were obtained, bivariate and multivariate analysis were performed. The diagnostic validity of the process was assessed by calculations of sensitivity, specificity, positive and negative predictive values and ratios of positive and negative likelihood. ROC curve analysis was performed for both instruments.

Results

For this study, 1247 patients were recruited, of whom 977 completed all the follow-up assessments. Twenty-three of these patients (2.35%) suffered 24 falls. ROC curve analysis showed that the optimal cut-off point for each assessment instrument was below that described by the authors: AUC STRATIFY = 0.69 (95% CI: 0.57–0.8); AUC Downton = 0.6 (95% CI: 0.48–0.72). With a cut-off point of 1, the sensitivity of STRATIFY was 47.6% and its specificity, 85%. With a cut-off point of 2, Downton presented a sensitivity of 66.7% and a specificity of 55.3%.

Conclusions

The Downton and STRATIFY falls risk assessment instruments presented little utility as means of detecting the risk of falls among a sample of adult patients admitted to acute care hospitals. Fall prevention in hospitals should be based on the study of individual risk factors.

[Clinical safety and professional liability claims in Orthopaedic Surgery and Traumatology]

The specialist in orthopaedic and traumatological surgery, like any other doctor, is subject to the current legal provisions while exercising their profession. Mandatory training in the medical-legal aspects of health care is essential. Claims against doctors are a reality, and orthopaedic and traumatological surgery holds first place in terms of frequency of claims according to the data from the General Council of Official Colleges of Doctors of Catalonia. Professionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical-legal aspects in the routine clinical practice can help to pave the way towards a satisfactory and safe professional career. The aim of this review is to contribute to this training, for the benefit of professionals and patients.

Techniques to aid the implementation of novel clinical information systems: a systematic review

BACKGROUND

This systematic review identifies and evaluates techniques that aid the implementation of novel clinical information systems (CIS) within healthcare.

METHODS

We searched electronic databases (MEDLINE, EMBASE, PsycINFO and HMIC Health Management Information Consortium). Desktop reviews for all potentially eligible studies were also conducted via reference lists and forward citation searches. 14,198 abstracts were identified through the initial electronic search. 63 articles were retained following title and abstract reviews, and submitted for full text evaluation. Of these, 18 papers met eligibility criteria.

RESULTS

The 5 techniques that emerged from the review and that can assist CIS implementation were: system piloting, eliciting acceptance, use of simulation, training and education, and provision of incentives. These techniques were evaluated with a range of study endpoints (including system utilisation, clinical effectiveness, user satisfaction, attitudes towards system training, and attitudes towards implementation). Consideration of the clinical context in which the CIS was implemented was a consistent theme in the evidence-base.

CONCLUSIONS

Although some evidence is available for the effectiveness of the 5 implementation techniques found in this review, the variable endpoints and the non-comparable study designs mean that the evidence-base needs further developing. We discuss the potential role of simulation and clinical leadership, particularly in relation to surgeons, in CIS implementation and we propose practical advice for CIS implementation and evaluation within hospital settings.

Clinical development of Modified Vaccinia virus Ankara vaccines. Vaccine. 2013;31:4241-4246. [PMID: 23523410 DOI: 10.1016/j.vaccine.2013.03.020]

The smallpox vaccine Vaccinia was successfully used to eradicate smallpox, but although very effective, it was a very reactogenic vaccine and responsible for the deaths of one or two people per million vaccinated. Modified Vaccinia virus Ankara (MVA) is a replication-deficient and attenuated derivative, also used in the smallpox eradication campaign and now being developed as a recombinant viral vector to produce vaccines against infectious diseases and cancer. Many clinical trials of these new vaccines have been conducted, and the findings of these trials are reviewed here. The safety of MVA is now well documented, immunogenicity is influenced by the dose and vaccination regimen, and information on the efficacy of MVA-vectored vaccines is now beginning to accumulate.