1
|
Bahl A, Mielke N, Gibson SM, George J. The use of procedural kits may reduce unscheduled central line dressing changes: A matched pre-post intervention study. J Infect Prev 2024; 25:73-81. [PMID: 38584709 PMCID: PMC10998547 DOI: 10.1177/17571774241232063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 01/25/2024] [Indexed: 04/09/2024] Open
Abstract
Background Unscheduled dressing changes for central venous lines (CVLs) have been shown to increase the risk of bloodstream infections. Objective The objective of this study is to determine if the use of an innovative dressing change kit reduces the rate of unscheduled dressing changes. Methods This pre-post interventional study took place at a large, academic, tertiary care center in metro Detroit, Michigan, the United States. We assessed the impact of the interventional dressing change procedure kit on the rate of unscheduled dressing changes for adult patients who underwent placement of a CVL inclusive of a central catheter, peripherally inserted central catheter, or hemodialysis catheter. Data was collected for the pre-intervention cohort through electronic health records (EHRs), while data for the post-intervention cohort were collected by direct observation by trained research staff in combination with EHR data. The primary outcome was the rate of unscheduled dressing changes. Secondary outcomes included rate of unscheduled dressing changes based on admission floor type, etiology of unscheduled dressing changes, and central line-associated bloodstream infections (CLABSIs). Results The study included a convenience sample of 1548 CVLs placed between May 2018 and June 2022 with a matched analysis including 488 catheters in each of the pre- and post-intervention groups. The results showed that the unadjusted rate of unscheduled dressing evaluations was significantly reduced from the pre-intervention group (0.21 per day) to the post-intervention group (0.13 per day) (p < .001). The adjusted rate ratio demonstrated the same trend at 1.00 pre- and 0.60 post-intervention (p < .001). Stratifying the analysis based on the highest level of care showed that the intervention was effective in reducing the unadjusted rate of unscheduled dressing evaluations for both the advanced and regular medical floor subgroups pre- to post-intervention; the advanced subgroup had an reduction from 0.22 to 0.15 per day (p = .001), while the regular medical floor subgroup had a reduction from 0.21 to 0.09 per day (p < .001). CLABSIs were similar in both groups (0.6% vs 0.8%; p = 1.00) in pre- and post-intervention groups, respectively. Discussion Procedural kits for central line dressing changes are effective in reducing unscheduled dressing changes and may have a role in reducing CLABSI. Further studies assessing the impact of dressing change kits on cost, procedural compliance, and the precise impact on CLABSI are needed.
Collapse
Affiliation(s)
- Amit Bahl
- William Beaumont Hospitals Corp, Royal Oak, MI, USA
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | | | - Julie George
- William Beaumont Hospitals Corp, Royal Oak, MI, USA
| |
Collapse
|
2
|
Todd BR, Xing Y, Zhao L, Nguyen A, Swor R, Eberhardt L, Bahl A. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open 2024; 5:e13138. [PMID: 38559566 PMCID: PMC10981136 DOI: 10.1002/emp2.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/15/2024] [Accepted: 02/16/2024] [Indexed: 04/04/2024] Open
Abstract
Background Hypertension (HTN) is common in discharged emergency department (ED) patients, yet the short-term outcomes of treating HTN at ED discharge are unclear. This study aimed to investigate whether emergency physician (EP) prescription of oral antihypertensive therapy at ED discharge for hypertensive patients is associated with a decreased 30-day risk of the severe adverse events (AEs), death, and revisits to the ED. Methods We conducted an observational cohort study assessing the 30-day outcomes of discharged ED patients with HTN, comparing outcomes based on whether antihypertensive therapy was prescribed. All discharged adult ED patients from an eight-hospital system with a diagnosis of HTN from January 2016 to February 2020 were screened, and consisted of a mix of suburban and urban patients with broad ethnic and socioeconomic backgrounds. Patients were categorized into the treatment group if they received a prescription for antihypertensive medication at ED discharge. The primary outcome was severe composite AEs from HTN (aortic catastrophe, heart failure, myocardial infarction, hemorrhagic and ischemic stroke, or hypertensive encephalopathy) within 30 days of ED discharge. The secondary outcomes were death or ED revisit over the same period. Results The study sample consisted of 93,512 ED visits; 57.5% were female, and mean age was 59.3 years. 4.7% of patients were prescribed antihypertensive treatment at ED discharge. Within 30 days, 0.7% of patients experienced an AE, 0.1% died, and 15.2% had an ED revisit. The treatment group had significantly lower odds of AE (adjusted odds ratio [aOR]: 0.224, 95%CI 0.106-0.416, p < 0.001), and ED revisits (aOR: 0.610, 95%CI 0.547-0.678, p < 0.001), adjusting for age, race, degree of HTN, ED treatment for elevated HTN, Elixhauser comorbidity index, and heart failure history. There was no difference in odds of death 30 days after discharge. Conclusion and relevance Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.
Collapse
Affiliation(s)
- Brett R. Todd
- Oakland University William Beaumont School of MedicineRochester HillsMichiganUSA
- Department of Emergency MedicineCorewell William Beaumont University HospitalRoyal OakMichiganUSA
| | - Yuying Xing
- Beaumont Research Institute, Corewell HealthRoyal OakMichiganUSA
| | - Lili Zhao
- Beaumont Research Institute, Corewell HealthRoyal OakMichiganUSA
| | - An Nguyen
- Department of Emergency MedicineCorewell William Beaumont University HospitalRoyal OakMichiganUSA
| | - Robert Swor
- Oakland University William Beaumont School of MedicineRochester HillsMichiganUSA
- Department of Emergency MedicineCorewell William Beaumont University HospitalRoyal OakMichiganUSA
| | - Lauren Eberhardt
- Oakland University William Beaumont School of MedicineRochester HillsMichiganUSA
| | - Amit Bahl
- Oakland University William Beaumont School of MedicineRochester HillsMichiganUSA
- Department of Emergency MedicineCorewell William Beaumont University HospitalRoyal OakMichiganUSA
| |
Collapse
|
3
|
Bahl VJ, Bahl A. Adenoid Cystic Cancer of the Lacrimal Gland: Management Aspects and Treatment Outcomes. Indian J Otolaryngol Head Neck Surg 2024; 76:2158-2161. [PMID: 38566663 PMCID: PMC10982151 DOI: 10.1007/s12070-023-04426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/03/2023] [Indexed: 04/04/2024] Open
Abstract
Adenoid cystic carcinoma (ACC) of the lacrimal gland is the most common malignant epithelial tumor of the lacrimal gland. The biological behavior of these tumors is characterized by a slow growth with frequent nerve invasion but rare invasion of the neck nodes. Local extension intracranially with bone erosions is seen in locally advanced tumors. Distant metastasis to lungs bone and liver are commonly reported. Treatments using surgery and radiotherapy are generally preferred for adequate tumor control. However there is still no consensus on the best treatment approach. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-023-04426-5.
Collapse
Affiliation(s)
- Vishwa Jyoti Bahl
- Department of Ophthalmology, MM Medical College & Hospital, Solan, HP India
| | - Amit Bahl
- Department of Radiotherapy & Oncology, PGIMER, Chandigarh, India
| |
Collapse
|
4
|
Bahl A, Panda NK, Verma RK, Sharma V, John JJ, Kumar P, Oinam AS, Trivedi G, Bakshi J. Pilot Evaluation of Perioperative High Dose Rate Brachytherapy in Head Neck Cancers. Indian J Otolaryngol Head Neck Surg 2024; 76:2166-2170. [PMID: 38566724 PMCID: PMC10982244 DOI: 10.1007/s12070-023-04455-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/19/2023] [Indexed: 04/04/2024] Open
Abstract
Perioperative high dose rate brachytherapy involves insertion of brachytherapy catheter over the tumor bed during surgical removal of disease followed by radiation in the postoperative period. It has applications in radiotherapy dose escalation or reirradiation and for extending the surgical margins. We report here initial results of treatment in five cases of locally advanced head and neck cancers.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Radiation Oncology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Naresh K. Panda
- Department of Otolaryngology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Roshan K. Verma
- Department of Otolaryngology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Vikas Sharma
- Department of Otolaryngology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Jerry J. John
- Department of Plastic Surgery, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Pramod Kumar
- Department of Plastic Surgery, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Arun S. Oinam
- Department of Radiation Oncology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Gaurav Trivedi
- Department of Radiation Oncology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Jaimanti Bakshi
- Department of Otolaryngology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
5
|
Mielke N, Lee R, Bahl A. Pediatric hemolysis in emergency departments: Prevalence, risk factors, and clinical implications. PLoS One 2024; 19:e0299692. [PMID: 38512885 PMCID: PMC10956767 DOI: 10.1371/journal.pone.0299692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024] Open
Abstract
OBJECTIVE This study aimed to analyze the prevalence, risk factors, and clinical implications of hemolyzed laboratory samples in the pediatric emergency department (ED), a subject on which existing data remains scarce. METHODS We conducted a multi-site observational cohort analysis of pediatric ED encounters in Metro Detroit, Michigan, United States. The study included participants below 18 years of age who had undergone peripheral intravenous catheter (PIVC) placement and laboratory testing. The primary outcome was the presence of hemolysis, and secondary outcomes included identifying risk factors for hemolysis and assessing the impact of hemolysis on PIVC failure. RESULTS Between January 2021 and May 2022, 10,462 ED encounters met inclusion criteria, of which 14.0% showed laboratory evidence of hemolysis. The highest proportion of hemolysis occurred in the infant (age 0-1) population (20.1%). Multivariable regression analysis indicated higher odds of hemolysis for PIVCs placed in the hand/wrist in the toddler (age 2-5) and child (age 6-11) subgroups. PIVCs placed in the hand/wrist also demonstrated higher odds of failure in infants. CONCLUSIONS Hemolysis in the pediatric ED population is a frequent complication that occurs at similar rates as in adults. PIVCs placed in the hand/wrist were associated with higher odds of hemolysis compared to those placed in the antecubital fossa. Clinicians should consider alternative locations for PIVC placement if clinically appropriate. Further research is needed to better understand the clinical implications of pediatric hemolysis.
Collapse
Affiliation(s)
- Nicholas Mielke
- Creighton University School of Medicine, Omaha, Nebraska, United States of America
| | - Ray Lee
- Corewell Health Research Institute, Royal Oak, Michigan, United States of America
| | - Amit Bahl
- Corewell Health William Beaumont University Hospital, Royal Oak, Michigan, United States of America
| |
Collapse
|
6
|
Bahl A, Millard M, Hijazi M, Chen NW. Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data. J Vasc Access 2024; 25:519-525. [PMID: 36113061 DOI: 10.1177/11297298221122118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVES Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity. METHODS This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival. RESULTS Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02). CONCLUSIONS This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | | | - Mahmoud Hijazi
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nai-Wei Chen
- Beaumont Health Research Institute, Royal Oak, MI, USA
| |
Collapse
|
7
|
Growcott S, Renninson E, Rayner L, McKeon J, Ayre G, Comins C, Challapalli A, Owadally W, Beasley M, Hawley L, Hilman S, Strawson-Smith T, Bahl A. Commentary on the New National Institute for Health and Care Excellence Guideline for Metastatic Spinal Cord Compression. Clin Oncol (R Coll Radiol) 2024; 36:200-201. [PMID: 38216346 DOI: 10.1016/j.clon.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 01/14/2024]
Affiliation(s)
- S Growcott
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - E Renninson
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - L Rayner
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - J McKeon
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - G Ayre
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - C Comins
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - A Challapalli
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - W Owadally
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - M Beasley
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - L Hawley
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - S Hilman
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - T Strawson-Smith
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - A Bahl
- Department of Clinical Oncology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| |
Collapse
|
8
|
Bahl A, Alsbrooks K, Zazyczny KA, Johnson S, Hoerauf K. An Improved Definition and SAFE Rule for Predicting Difficult Intravascular Access (DIVA) in Hospitalized Adults. J Infus Nurs 2024; 47:96-107. [PMID: 38377305 PMCID: PMC10913859 DOI: 10.1097/nan.0000000000000535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Patients with difficult intravascular access (DIVA) are common, yet the condition is often ignored or poorly managed, leading to patient dissatisfaction and misuse of health care resources. This study sought to assess all published risk factors associated with DIVA in order to promote prospective identification and improved management of patients with DIVA. A systematic literature review on risk factors associated with DIVA was conducted. Risk factors published in ≥4 eligible studies underwent a multivariate meta-analysis of multiple factors (MVMA-MF) using the Bayesian framework. Of 2535 unique publications identified, 20 studies were eligible for review. In total, 82 unique DIVA risk factors were identified, with the 10 factors found in ≥4 studies undergoing MVMA-MF. Significant predictors of DIVA included vein visibility, vein palpability, history of DIVA, obesity (body mass index [BMI] >30), and history of intravenous (IV) drug abuse, which were combined to create the mnemonic guideline, SAFE: See, Ask (about a history of DIVA or IV drug abuse), Feel, and Evaluate BMI. By recognizing patients with DIVA before the first insertion attempt and treating them from the outset with advanced vein visualization techniques, patients with DIVA could be subject to less frequent painful venipunctures, fewer delays in treatment, and a reduction in other DIVA-associated burdens.
Collapse
Affiliation(s)
- Amit Bahl
- Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Bahl and Johnson), Becton Dickinson and Co, Franklin Lakes, New Jersey (Alsbrooks and Hoerauf), and Bryn Mawr Hospital, Bryn Mawr, Pennsylvania (Zazyczny)
- Amit Bahl, MD, is a physician scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Kim Alsbrooks has over 30 years of experience in the medical field. She started as a Radiologic Technologist then Registered Nurse, working on specialized hospital teams in Oncology and Vascular Access. She has worked at BARD/Becton, Dickinson, and Company, where she is now the Sr Director of Medical Affairs, for the past 20 years. Her work is mostly focused on vascular access evidence generation and research. Kim speaks across the US and internationally on vascular access topics
- Kelly Ann Zazyczny, BSN, RN, RT (R), VA-BC, is the director of nursing of the Psychiatric, Women, and Children's Division at Bryn Mawr Hospital, Vascular Access Nursing Services for the Main Line Health System. She has been a clinical leader for over 25 years, holding positions at Main Line Health, The Children's Hospital of Philadelphia, and Children's Healthcare of Atlanta. Her clinical focus has been on pediatrics, vascular access, radiology, and research. She has been named one of the Top Nurses in Nursing Management by Main Line Today for the last 3 years
- Steven Johnson, DO, is a board-certified emergency medicine physician and critical care fellow at the University of Southern California. He also conducts catheter-related research in his work as a research scientist at Beaumont Health. He developed a passion for improving peripheral venous access after witnessing firsthand how poor catheter performance affects patient outcomes and overall health
- Klaus Hoerauf, MD, PhD, currently serves as worldwide vice president of medical affairs, medication delivery solutions, at Becton, Dickinson, and Company. In this role, he leads Medical & Scientific Affairs and Health Economics and Outcomes Research departments. He has an MD and a Doctorate in Cardiology from the Medical University of Münster and has been appointed as associate professor of anesthesiology and intensive care medicine at the Medical University of Vienna, Austria. He is certified in anesthesiology and intensive care medicine, emergency medicine, and pain therapy
| | - Kimberly Alsbrooks
- Corresponding Author: Kimberly Alsbrooks, BSN, RN, RT (R), VA-BC, Becton Dickinson and Company, 18-03 NJ-208, Franklin Lakes, NJ, USA 07417 ()
| | - Kelly Ann Zazyczny
- Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Bahl and Johnson), Becton Dickinson and Co, Franklin Lakes, New Jersey (Alsbrooks and Hoerauf), and Bryn Mawr Hospital, Bryn Mawr, Pennsylvania (Zazyczny)
- Amit Bahl, MD, is a physician scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Kim Alsbrooks has over 30 years of experience in the medical field. She started as a Radiologic Technologist then Registered Nurse, working on specialized hospital teams in Oncology and Vascular Access. She has worked at BARD/Becton, Dickinson, and Company, where she is now the Sr Director of Medical Affairs, for the past 20 years. Her work is mostly focused on vascular access evidence generation and research. Kim speaks across the US and internationally on vascular access topics
- Kelly Ann Zazyczny, BSN, RN, RT (R), VA-BC, is the director of nursing of the Psychiatric, Women, and Children's Division at Bryn Mawr Hospital, Vascular Access Nursing Services for the Main Line Health System. She has been a clinical leader for over 25 years, holding positions at Main Line Health, The Children's Hospital of Philadelphia, and Children's Healthcare of Atlanta. Her clinical focus has been on pediatrics, vascular access, radiology, and research. She has been named one of the Top Nurses in Nursing Management by Main Line Today for the last 3 years
- Steven Johnson, DO, is a board-certified emergency medicine physician and critical care fellow at the University of Southern California. He also conducts catheter-related research in his work as a research scientist at Beaumont Health. He developed a passion for improving peripheral venous access after witnessing firsthand how poor catheter performance affects patient outcomes and overall health
- Klaus Hoerauf, MD, PhD, currently serves as worldwide vice president of medical affairs, medication delivery solutions, at Becton, Dickinson, and Company. In this role, he leads Medical & Scientific Affairs and Health Economics and Outcomes Research departments. He has an MD and a Doctorate in Cardiology from the Medical University of Münster and has been appointed as associate professor of anesthesiology and intensive care medicine at the Medical University of Vienna, Austria. He is certified in anesthesiology and intensive care medicine, emergency medicine, and pain therapy
| | - Steven Johnson
- Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Bahl and Johnson), Becton Dickinson and Co, Franklin Lakes, New Jersey (Alsbrooks and Hoerauf), and Bryn Mawr Hospital, Bryn Mawr, Pennsylvania (Zazyczny)
- Amit Bahl, MD, is a physician scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Kim Alsbrooks has over 30 years of experience in the medical field. She started as a Radiologic Technologist then Registered Nurse, working on specialized hospital teams in Oncology and Vascular Access. She has worked at BARD/Becton, Dickinson, and Company, where she is now the Sr Director of Medical Affairs, for the past 20 years. Her work is mostly focused on vascular access evidence generation and research. Kim speaks across the US and internationally on vascular access topics
- Kelly Ann Zazyczny, BSN, RN, RT (R), VA-BC, is the director of nursing of the Psychiatric, Women, and Children's Division at Bryn Mawr Hospital, Vascular Access Nursing Services for the Main Line Health System. She has been a clinical leader for over 25 years, holding positions at Main Line Health, The Children's Hospital of Philadelphia, and Children's Healthcare of Atlanta. Her clinical focus has been on pediatrics, vascular access, radiology, and research. She has been named one of the Top Nurses in Nursing Management by Main Line Today for the last 3 years
- Steven Johnson, DO, is a board-certified emergency medicine physician and critical care fellow at the University of Southern California. He also conducts catheter-related research in his work as a research scientist at Beaumont Health. He developed a passion for improving peripheral venous access after witnessing firsthand how poor catheter performance affects patient outcomes and overall health
- Klaus Hoerauf, MD, PhD, currently serves as worldwide vice president of medical affairs, medication delivery solutions, at Becton, Dickinson, and Company. In this role, he leads Medical & Scientific Affairs and Health Economics and Outcomes Research departments. He has an MD and a Doctorate in Cardiology from the Medical University of Münster and has been appointed as associate professor of anesthesiology and intensive care medicine at the Medical University of Vienna, Austria. He is certified in anesthesiology and intensive care medicine, emergency medicine, and pain therapy
| | - Klaus Hoerauf
- Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Bahl and Johnson), Becton Dickinson and Co, Franklin Lakes, New Jersey (Alsbrooks and Hoerauf), and Bryn Mawr Hospital, Bryn Mawr, Pennsylvania (Zazyczny)
- Amit Bahl, MD, is a physician scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Kim Alsbrooks has over 30 years of experience in the medical field. She started as a Radiologic Technologist then Registered Nurse, working on specialized hospital teams in Oncology and Vascular Access. She has worked at BARD/Becton, Dickinson, and Company, where she is now the Sr Director of Medical Affairs, for the past 20 years. Her work is mostly focused on vascular access evidence generation and research. Kim speaks across the US and internationally on vascular access topics
- Kelly Ann Zazyczny, BSN, RN, RT (R), VA-BC, is the director of nursing of the Psychiatric, Women, and Children's Division at Bryn Mawr Hospital, Vascular Access Nursing Services for the Main Line Health System. She has been a clinical leader for over 25 years, holding positions at Main Line Health, The Children's Hospital of Philadelphia, and Children's Healthcare of Atlanta. Her clinical focus has been on pediatrics, vascular access, radiology, and research. She has been named one of the Top Nurses in Nursing Management by Main Line Today for the last 3 years
- Steven Johnson, DO, is a board-certified emergency medicine physician and critical care fellow at the University of Southern California. He also conducts catheter-related research in his work as a research scientist at Beaumont Health. He developed a passion for improving peripheral venous access after witnessing firsthand how poor catheter performance affects patient outcomes and overall health
- Klaus Hoerauf, MD, PhD, currently serves as worldwide vice president of medical affairs, medication delivery solutions, at Becton, Dickinson, and Company. In this role, he leads Medical & Scientific Affairs and Health Economics and Outcomes Research departments. He has an MD and a Doctorate in Cardiology from the Medical University of Münster and has been appointed as associate professor of anesthesiology and intensive care medicine at the Medical University of Vienna, Austria. He is certified in anesthesiology and intensive care medicine, emergency medicine, and pain therapy
| |
Collapse
|
9
|
Mielke N, Gorz R, Bahl A, Zhao L, Berger DA. Association between ABO blood type and coronavirus disease 2019 severe outcomes across dominant variant strains. J Am Coll Emerg Physicians Open 2024; 5:e13115. [PMID: 38322377 PMCID: PMC10844762 DOI: 10.1002/emp2.13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/04/2023] [Accepted: 01/19/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives Existing evidence suggests a link between ABO blood type and severe outcomes in coronavirus disease 2019 (COVID-19). We aimed to assess the relationship between blood type and severe outcomes across variant strains throughout the pandemic. Methods This was a multicenter retrospective observational cohort analysis from a large health system in southeastern Michigan using electronic medical records to evaluate emergency encounters, hospitalization, and severe outcomes in COVID-19 based on ABO blood type. Consecutive adult patients presenting to the emergency department with a primary diagnosis of COVID-19 (U07.1) from March 1, 2020 through December 31, 2022 were assessed. Patients who presented during three distinct time intervals that coincided with Alpha, Delta, and Omicron variant predominance were included in the analysis. Exclusions included no record of ABO blood type, positive PCR COVID-19 test within the preceding 28 days, and if transferred from out of the health system. Severe outcomes were inclusive of intensive care unit admission, mechanical ventilation, or death, which, as a composite, represented our primary outcome. Secondary outcomes were hospital admission and length of stay. A logistic regression model was employed to test the association between ABO blood type and severe outcome, adjusting for age, sex, race, vaccination status, Elixhauser comorbidity indices, and the dominant variant time period in which the encounter occurred. Results Of the 33,796 COVID-19 encounters, 9416 met inclusion criteria; 4071 (43.2%) were type O, 3417 (36.3%) were type A, 459 (4.9%) were type AB, and 1469 (15.6%) were type B blood. Note that 66.4% of the cohort was female (p = 0.18). The proportion of composite severe disease among the four blood types was similar and ranged between 8.6% and 8.9% (p = 0.98). Note that 53.0% of type A blood patients required hospital admission, compared to 51.9%, 50.4%, and 48.1% of type AB, B, and O blood, respectively (p < 0.001). Compared to patients with O blood type (43.2%), non-O blood type (58.8%; composite of A, AB, and B) exhibited no statistically significant difference in the proportion of composite severe disease (8.8% vs. 8.7%; p = 0.81) Multivariable regression analyses exhibited no significant difference regarding the presence of severe outcomes among the four blood types or O versus non-O blood types during T1, T2, and T3. Conclusions ABO blood type was not associated with COVID-19 severe outcomes across the Delta, Alpha, and Omicron dominant COVID waves across a large health system in southeastern Michigan. Further research is needed to better understand if ABO blood type is a risk factor for severe disease among evolving COVID-19 variants and other viral upper respiratory infections.
Collapse
Affiliation(s)
- Nicholas Mielke
- Department of MedicineCreighton University School of MedicineOmahaNebraskaUSA
| | - Rebecca Gorz
- Department of Emergency MedicineCorewell Health William Beaumont University HospitalRoyal OakMichiganUSA
| | - Amit Bahl
- Department of Emergency MedicineCorewell Health William Beaumont University HospitalRoyal OakMichiganUSA
| | - Lili Zhao
- Department of Clinical ResearchCorewell Health Research InstituteRoyal OakMichiganUSA
| | - David A Berger
- Department of Emergency MedicineCorewell Health William Beaumont University HospitalRoyal OakMichiganUSA
| |
Collapse
|
10
|
Gala S, Alsbrooks K, Bahl A, Wimmer M. The economic burden of difficult intravenous access in the emergency department from a United States' provider perspective. J Res Nurs 2024; 29:6-18. [PMID: 38495321 PMCID: PMC10939017 DOI: 10.1177/17449871231213025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Background Peripheral intravenous catheter placement is one of the most common invasive procedures that nurses will perform, especially in emergency departments. Aims This early analysis aimed to quantify the economic burden associated with intravenous therapy in patients presenting in emergency departments with difficult intravenous access, receiving traditional peripheral intravenous catheters. This may inform the opportunity for improvement for investment in nursing tools and services regarding difficult venous access burden reduction. Methods Model parameter data were obtained from published literature where possible via a targeted literature review for the terms including relative variations of 'Difficult Venous Access', 'burden', and 'costs', or elicited from expert clinical opinion. A simple decision tree model was developed in Microsoft® Excel 2016. Results included number of insertion attempts, number of patients requiring escalation, catheter failures due to complications, healthcare professional (e.g. nurse) time, and total costs (including/excluding health care professional time). Sensitivity analyses were performed. Results The model considers 64,000 individuals presenting in the emergency department annually, of which 75% (48,000) require a peripheral intravenous catheter; of these 22% (10,560) are estimated to have difficult venous access. The total cost burden of difficult venous access is estimated to be $890,095 per year/$84.29 per patient with difficult venous access, including the cost of clinician time. Key total cost drivers include the population size treated in the emergency department annually, the proportion of midlines placed by a specialist IV (intravenous access) nurse and the percentage of patients with difficult venous access. Conclusion This is the first formal analysis estimating the significant economic burden of difficult venous access in emergency departments via peripheral intravenous catheter placement, a task frequently performed by nurses. Further studies are needed to evaluate nursing-centric strategies for reducing this burden. Additionally, adoption of a concise definition is needed, as is routine use of reliable assessment tools so that future cost analyses can be better contextualised.
Collapse
Affiliation(s)
- Smeet Gala
- Associate Director, HEOR, Becton Dickinson and Co, Franklin Lakes, NJ, USA
| | - Kim Alsbrooks
- Senior Director Medical Affairs, Becton Dickinson and Co, Franklin Lakes, NJ, USA
| | - Amit Bahl
- Emergency Medicine Physician, Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Megan Wimmer
- Director, HEOR, Becton Dickinson and Co, Franklin Lakes, NJ, USA
| |
Collapse
|
11
|
Vasudev NS, Ainsworth G, Brown S, Pickering L, Waddell T, Fife K, Griffiths R, Sharma A, Katona E, Howard H, Velikova G, Maraveyas A, Brown J, Pezaro C, Tuthill M, Boleti E, Bahl A, Szabados B, Banks RE, Brown J, Venugopal B, Patel P, Jain A, Symeonides SN, Nathan P, Collinson FJ, Powles T. Standard Versus Modified Ipilimumab, in Combination With Nivolumab, in Advanced Renal Cell Carcinoma: A Randomized Phase II Trial (PRISM). J Clin Oncol 2024; 42:312-323. [PMID: 37931206 PMCID: PMC10824383 DOI: 10.1200/jco.23.00236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/09/2023] [Accepted: 09/09/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE Ipilimumab (IPI), in combination with nivolumab (NIVO), is an approved frontline treatment option for patients with intermediate- or poor-risk advanced renal cell carcinoma (aRCC). We conducted a randomized phase II trial to evaluate whether administering IPI once every 12 weeks (modified), instead of once every 3 weeks (standard), in combination with NIVO, is associated with a favorable toxicity profile. METHODS Treatment-naïve patients with clear-cell aRCC were randomly assigned 2:1 to receive four doses of modified or standard IPI, 1 mg/kg, in combination with NIVO (3 mg/kg). The primary end point was the proportion of patients with a grade 3-5 treatment-related adverse event (trAE) among those who received at least one dose of therapy. The key secondary end point was 12-month progression-free survival (PFS) in the modified arm compared with historical sunitinib control. The study was not designed to formally compare arms for efficacy. RESULTS Between March 2018 and January 2020, 192 patients (69.8% intermediate/poor-risk) were randomly assigned and received at least one dose of study drug. The incidence of grade 3-5 trAEs was significantly lower among participants receiving modified versus standard IPI (32.8% v 53.1%; odds ratio, 0.43 [90% CI, 0.25 to 0.72]; P = .0075). The 12-month PFS (90% CI) using modified IPI was 46.1% (38.6 to 53.2). At a median follow-up of 21 months, the overall response rate was 45.3% versus 35.9% and the median PFS was 10.8 months versus 9.8 months in the modified and standard IPI groups, respectively. CONCLUSION Rates of grade 3-5 trAEs were significantly lower in patients receiving modified versus standard IPI. Although 12-month PFS did not meet the prespecified efficacy threshold compared with historical control, informal comparison of treatment groups did not suggest any reduction in efficacy with the modified schedule.
Collapse
Affiliation(s)
- Naveen S. Vasudev
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Gemma Ainsworth
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Sarah Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | | | - Tom Waddell
- Department of Medical Oncology, Christie Hospital, Manchester, United Kingdom
| | - Kate Fife
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | - Anand Sharma
- Mount Vernon Cancer Centre, Middlesex, United Kingdom
| | - Eszter Katona
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Helen Howard
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Galina Velikova
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | | | - Janet Brown
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Carmel Pezaro
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Mark Tuthill
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Bernadett Szabados
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Rosamonde E. Banks
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Joanne Brown
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Balaji Venugopal
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Poulam Patel
- Division of Cancer & Stem Cells, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Ankit Jain
- The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Stefan N. Symeonides
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Paul Nathan
- Mount Vernon Cancer Centre, Middlesex, United Kingdom
| | - Fiona J. Collinson
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Thomas Powles
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| |
Collapse
|
12
|
Bahl A, Mielke N, DiLoreto E, Gibson SM. Operation STICK: A vascular access specialty program for the generalist emergency medicine clinician. J Vasc Access 2024:11297298231222060. [PMID: 38214160 DOI: 10.1177/11297298231222060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVE Comprehensive education and training programs are urgently needed to improve vascular access outcomes in the emergency department (ED). This study aimed to demonstrate the success of a formalized vascular access program in developing competent ED clinicians in traditional and ultrasound-guided insertion methods. METHODS This was a retrospective observational study exploring the success of trainees in obtaining competency in peripheral vascular access at an academic suburban ED with 120,000 annual visits. Eligible participants included healthcare workers that enrolled in the Operation STICK vascular access program and perform vascular access procedures as an aspect of their clinical practice. Competency in vascular access included both traditional and ultrasound-guided (US) peripheral intravenous catheter (PIVC) insertions. Competency was defined as demonstration of successful insertion of one traditional and one US PIVC in compliance with checklist. The primary objective was competency. Secondary objectives included trainee time to competency, trainee number of line encounters, and changes in program competency achievements over time. RESULTS From October 15, 2021, to April 15, 2023, 141 clinicians participated in peripheral vascular access training via the Operation STICK model, which included 72 (51.1%) nurses, 52 (36.9%) ED technicians, and 17 (12.0%) healthcare personnel with other medical training. Clinicians overall reported an average of 5.6 years of experience inserting peripheral intravenous catheters (PIVCs) and 23 (16.3%) had experience with using ultrasound. About 122 (86.5%) clinicians successfully completed the program and demonstrated competency in traditional and ultrasound-guided techniques. Time to competency varied over time, with a median of 124 days in the early phase, 32.5 days middle phase, and 10.6 h over 9.5 days in the later phase of the program (p < 0.001). CONCLUSIONS Achieving competency in PIVC insertion necessitates a focused effort on refining and systematizing education and training approaches. Recognizing the inherent challenges present in ED settings, it is feasible to effectively and efficiently train emergency clinicians to be expert in both basic and advanced PIVC placement techniques through participation in a well-organized vascular access training program.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Emily DiLoreto
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | | |
Collapse
|
13
|
Bahl A, Mielke N, Xing Y, DiLoreto E, Zimmerman T, Gibson SM. A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial. J Vasc Access 2024:11297298231219776. [PMID: 38183178 DOI: 10.1177/11297298231219776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVE Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. The impact of education and training on vascular access outcomes in this vulnerable population is unclear. We aim to demonstrate the success of a program (Operation (O) STICK) on improving vascular access outcomes in DIVA patients. METHODS This was a quasi-experimental pre-post interventional study conducted at a tertiary care emergency department (ED) with 120,000 annual visits and 1100 hospital beds. Adult patients requiring an ultrasound-guided (US) peripheral intravenous catheter (PIVC) in the ED were eligible participants. Traditional (palpation method) insertions were excluded. Using multivariable linear regression and inverse probability weighted (IPW) linear regression, the standard group inclusive of PIVCs inserted by staff without formalized OSTICK training were compared to the interventional group inclusive of PIVCs inserted by staff with training and competency in the OSTICK training model. RESULTS Data were collected over two time intervals: 4/1/21-9/30/21 (pre; non-OSTICK) and 10/1/22-3/31/23 (post; OSTICK). 2375 DIVA patients included 1035 (43.6%) non-OSTICK and 1340 (56.4%) OSTICK PIVCs. Overall, OSTICK PIVCs had a higher proportion of upper arm or forearm placements (94.6% vs 57.4%; p < 0.001), 20 gauge catheters (97.1% vs 92.3%; p < 0.001), and left-sided placements (54.4% vs 43.5%; p < 0.001). 62.7% of OSTICK PIVCs were placed by ED technicians, compared to 25.5% in the non-OSTICK group (p < 0.001). OSTICK PIVCs were placed on the first attempt 86.2% of the time and by the second attempt 95.4% of the time. In a subanalysis of 1343 hospitalized patients (689 (51.3%) OSTICK vs 654 (48.7%) non-OSTICK), OSTICK PIVCs survived for a median of 92% of the patient's hospital length of stay, compared to non-OSTICK PIVCs at 74% (p < 0.001). CONCLUSIONS Formalized vascular access training in the ED leads to improved adherence to best practices for PIVC insertion, high success of cannulation with minimal attempts, and improved PIVC functionality during hospitalization for DIVA patients. Importantly, these outcomes are sustainable as they were captured 12 months after implementation of the program.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Yuying Xing
- Corewell Health Research Institute, Royal Oak, MI, USA
| | - Emily DiLoreto
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Todd Zimmerman
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | | |
Collapse
|
14
|
Bahl A, Clement V, DiLoreto E, Mielke N, Carr A, Panza G, Gibson SM. Evaluating the impact of external forces on peripheral intravenous catheter movement using ultrasound: A randomized pilot study. J Vasc Access 2024:11297298231222052. [PMID: 38183179 DOI: 10.1177/11297298231222052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND A major contributor to peripheral intravenous catheter (PIVC) failure may be related to PIVC movement within the vein which is associated with vein wall damage. The magnitude of PIVC movement against the vein wall has not previously been quantified. This study aimed to examine PIVC movement within the vein when minor forces were applied to the PIVC. METHODS This was a prospective, pilot trial including healthy volunteers in an outpatient research laboratory. The primary objective was to examine the in movement (millimeters) of the PIVC using ultrasound with external pull forces (4, 5, and 6 lbs; 1.8, 2.3, and 2.7 kg, respectively) applied to the PIVC in random order. RESULTS Participants (N = 11) were aged 40.36 ± 16.10 years with 54.55% being Male. Mean ± SD PIVC movement for 4, 5, and 6 lbs of force was 4.65 ± 1.88, 3.88 ± 2.28, and 5.25 ± 2.06 mm, respectively. There was substantial PIVC movement when a force was applied to the PIVC, but no statistically significant difference between 4, 5, and 6 lb forces (p > 0.05). CONCLUSION When external pull forces were applied to the PIVC, substantial PIVC movement within the vein occurred in a healthy population. Strategies that reduce PIVC movement and/or remove or limit external pull forces from the PIVC are needed. Future studies on hospitalized patients are warranted to quantify vein wall injury and PIVC failure due to PIVC movement from various pull forces.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | | | - Emily DiLoreto
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Nicholas Mielke
- Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | | | - Gregory Panza
- Department of Research, Hartford Healthcare, Hartford, CT, USA
| | | |
Collapse
|
15
|
Bahl A, Mielke N, Johnson S. Reliability and compliance of peripheral intravenous catheter documentation: A prospective observational study. J Vasc Access 2024; 25:89-93. [PMID: 35578560 DOI: 10.1177/11297298221097555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Proper documentation of the functionality and complications of peripheral intravenous catheters (PIVC) is the standard of care. This data can improve communication among team members about access concerns and highlight opportunities to improve PIVC care. Our objective is to determine if nursing personnel are compliant with institutional standards for documentation and documentation is reliable. METHODS This prospective observational analysis was conducted at a tertiary care academic center with 120,000 ED visits and 1100 hospital beds. Adults over 18 with a PIVC placed in the ED via palpation technique who were being admitted to regular medical/surgical wards were eligible. The primary outcome was compliance with PIVC documentation per institutional standards. Secondary outcomes included compliance subcategorized as insertion, daily assessment, and removal and reliability of assessments. RESULTS During July and August 2020, 77 patients were enrolled with a total of 1201 observations of PIVC compliance. PIVC documentation compliance was 86.0% (1033/1201). Compliance on insertion and removal was 93.3% (431/462) and 80.5% (186/231), respectively, with removal assessment being the least compliant at 49.4%. Daily catheter assessments were compliant 81.9% (416/508) of the time. PIVC documentation reliability was based on 693 total observations with 87.9% (609/693) reliability overall, and a reliability of 91.6% (423/462) and 74.9% (173/231) for insertion and removal, respectively. PIVC orientation had the highest reliability (98.7%) while post-removal assessment had the lowest reliability (45.5%). CONCLUSIONS We observed moderate documentation compliance and reliability for PIVC assessments for catheters placed in the ED. Documentation of removal-related variables was the most deficient aspect of the assessments. Given the high rate of PIVC failure and its vast array of consequences, improvement of PIVC documentation of removal reasons is essential to better identify type and incidence of complications and help develop targeted solutions. Further larger studies are needed to survey PIVC documentation practices.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Steven Johnson
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| |
Collapse
|
16
|
Challapalli A, Barwick TD, Dubash SR, Inglese M, Grech-Sollars M, Kozlowski K, Tam H, Patel NH, Winkler M, Flohr P, Saleem A, Bahl A, Falconer A, De Bono JS, Aboagye EO, Mangar S. Bench to Bedside Development of [ 18F]Fluoromethyl-(1,2- 2H 4)choline ([ 18F]D4-FCH). Molecules 2023; 28:8018. [PMID: 38138508 PMCID: PMC10745874 DOI: 10.3390/molecules28248018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Malignant transformation is characterised by aberrant phospholipid metabolism of cancers, associated with the upregulation of choline kinase alpha (CHKα). Due to the metabolic instability of choline radiotracers and the increasing use of late-imaging protocols, we developed a more stable choline radiotracer, [18F]fluoromethyl-[1,2-2H4]choline ([18F]D4-FCH). [18F]D4-FCH has improved protection against choline oxidase, the key choline catabolic enzyme, via a 1H/2D isotope effect, together with fluorine substitution. Due to the promising mechanistic and safety profiles of [18F]D4-FCH in vitro and preclinically, the radiotracer has transitioned to clinical development. [18F]D4-FCH is a safe positron emission tomography (PET) tracer, with a favourable radiation dosimetry profile for clinical imaging. [18F]D4-FCH PET/CT in lung and prostate cancers has shown highly heterogeneous intratumoral distribution and large lesion variability. Treatment with abiraterone or enzalutamide in metastatic castrate-resistant prostate cancer patients elicited mixed responses on PET at 12-16 weeks despite predominantly stable radiological appearances. The sum of the weighted tumour-to-background ratios (TBRs-wsum) was associated with the duration of survival.
Collapse
Affiliation(s)
- Amarnath Challapalli
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK; (A.C.); (T.D.B.); (S.R.D.); (M.I.); (M.G.-S.); (K.K.)
- Department of Clinical Oncology, Bristol Haematology and Oncology Center, Horfield Road, Bristol BS2 8ED, UK;
| | - Tara D. Barwick
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK; (A.C.); (T.D.B.); (S.R.D.); (M.I.); (M.G.-S.); (K.K.)
- Department of Radiology & Nuclear Medicine, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK; (H.T.); (N.H.P.)
| | - Suraiya R. Dubash
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK; (A.C.); (T.D.B.); (S.R.D.); (M.I.); (M.G.-S.); (K.K.)
| | - Marianna Inglese
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK; (A.C.); (T.D.B.); (S.R.D.); (M.I.); (M.G.-S.); (K.K.)
| | - Matthew Grech-Sollars
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK; (A.C.); (T.D.B.); (S.R.D.); (M.I.); (M.G.-S.); (K.K.)
| | - Kasia Kozlowski
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK; (A.C.); (T.D.B.); (S.R.D.); (M.I.); (M.G.-S.); (K.K.)
| | - Henry Tam
- Department of Radiology & Nuclear Medicine, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK; (H.T.); (N.H.P.)
| | - Neva H. Patel
- Department of Radiology & Nuclear Medicine, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK; (H.T.); (N.H.P.)
| | - Mathias Winkler
- Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK; (M.W.); (A.F.)
| | - Penny Flohr
- Division of Clinical Studies, The Institute of Cancer Research and Royal Marsden Hospital, Cotswold Road, Sutton SM2 5NG, UK; (P.F.); (J.S.D.B.)
| | - Azeem Saleem
- Invicro, A Konica Minolta Company, Burlington Danes Building, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK;
- Hull York Medical School, University of Hull, Cottingham Road, Hull HU6 7RX, UK
| | - Amit Bahl
- Department of Clinical Oncology, Bristol Haematology and Oncology Center, Horfield Road, Bristol BS2 8ED, UK;
| | - Alison Falconer
- Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK; (M.W.); (A.F.)
| | - Johann S. De Bono
- Division of Clinical Studies, The Institute of Cancer Research and Royal Marsden Hospital, Cotswold Road, Sutton SM2 5NG, UK; (P.F.); (J.S.D.B.)
| | - Eric O. Aboagye
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK; (A.C.); (T.D.B.); (S.R.D.); (M.I.); (M.G.-S.); (K.K.)
| | - Stephen Mangar
- Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK; (M.W.); (A.F.)
| |
Collapse
|
17
|
Gan R, Stokes S, Bahl A, Jose J. Modified transseptal approach in endoscopic transsphenoidal pituitary surgery. J Laryngol Otol 2023; 137:1409-1412. [PMID: 36799014 DOI: 10.1017/s0022215123000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE Transsphenoidal pituitary surgery is commonly performed via a direct transostial approach with a posterior septectomy. However, a technique via an endoscopic transseptal route has been described that avoids a posterior septectomy, but it comes with its own disadvantages. METHODS This paper describes a modification, and discusses its pros and cons. RESULTS The initial incision in the mucosa is placed level with the anterior middle turbinate. The mucoperichondrial flap is raised ipsilaterally until the sphenoid sinus ostium. An incision is made at the osseocartilaginous junction, and the contralateral mucoperichondrial flap is raised. The bony septum and posterior aspect of this flap is excised. The size and position of this window can be adapted. At the end of the operation, the lateralised intact mucoperichondrial flap is moved back to the midline. CONCLUSION Excision or deflection of the cartilaginous septum is not required. It maintains an intact septal mucosa on one side and avoids a septal perforation.
Collapse
Affiliation(s)
- R Gan
- Ear, Nose & Throat Department, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - S Stokes
- Neurosurgery Department, Hull Royal Infirmary, Hull University Teaching Hospitals NHS Trust, UK
| | - A Bahl
- Neurosurgery Department, Hull Royal Infirmary, Hull University Teaching Hospitals NHS Trust, UK
| | - J Jose
- Ear, Nose & Throat Department, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| |
Collapse
|
18
|
Mielke N, Xing Y, Gibson SM, DiLoreto E, Bahl A. Bridging the Gap in Traditional PIVC Placement: An Evaluation of Operation STICK Vascular Access Outcomes. Ther Clin Risk Manag 2023; 19:937-948. [PMID: 38023627 PMCID: PMC10676087 DOI: 10.2147/tcrm.s435628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Education and training is core to improving peripheral intravenous access outcomes. This study aimed to show that a vascular access training program (Operation STICK) in the emergency department (ED) improves the outcomes of traditionally placed peripheral intravenous catheters (PIVC). Methods This was a pre-post quasi-experimental study of traditionally placed PIVCs at a large ED in southeastern Michigan, United States. A control group (non-OSTICK) was compared to an experimental group (OSTICK) using a 3:1 propensity score matched analysis. Groups were comprised of ED patients with traditional PIVC placements in two separate six-month periods: non-OSTICK PIVCs from April to September 2021 and OSTICK PIVCs (placed by an OSTICK graduate) from October 2022 to March 2023. The primary outcome was PIVC functionality. The secondary outcome was adherence to best practices. Results A total of 6512 PIVCs were included in the study; 4884 (75.0%) were in the non-OSTICK group, while 1628 (25.0%) were in the OSTICK group. 68.1% of OSTICK PIVCs and 59.7% of non-OSTICK PIVCs were placed by ED technicians (p < 0.001). 91.3% of OSTICK PIVCs were placed on the first attempt, and 98.5% were placed within two attempts. A subgroup analysis of admitted patients (2540 PIVCs; 553 (21.8%) OSTICK-trained and 1987 (78.2%) non-OSTICK-trained) revealed 87.6% of OSTICK PIVCs and 80.3% of non-OSTICK PIVCs were 20 gauge (p < 0.001). The median proportion of dwell time to hospital length of stay was 94% for OSTICK PIVCs, compared to 88% for non-OSTICK PIVCs (p < 0.001). Conclusion This study underscores the value of education and training in enhancing vascular access outcomes. Implementing Operation STICK, a comprehensive vascular access training program, at a large ED has led to high first-stick success, adherence to best practice recommendations for site and device selection, and improved PIVC functionality for traditionally placed catheters.
Collapse
Affiliation(s)
- Nicholas Mielke
- Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Yuying Xing
- Corewell Health Research Institute, Royal Oak, MI, USA
| | | | - Emily DiLoreto
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Amit Bahl
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| |
Collapse
|
19
|
Freedman RL, Mielke N, Younes E, Kim C, Bahl A, Bahl RS. Carotid blood flow in abnormal head posture: a prospective observational study exploring facial asymmetry in strabismus. J AAPOS 2023; 27:281.e1-281.e4. [PMID: 37717618 DOI: 10.1016/j.jaapos.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE To investigate whether abnormal head posture (AHP) induces changes in common carotid artery blood flow (CCBF), thereby leading to the development of facial asymmetry in the setting of strabismus and ocular torticollis. METHODS This was a prospective observational study of pediatric subjects in an urban ophthalmology clinic who underwent bilateral carotid artery ultrasound examination with spectral Doppler in an upright, straight-head posture and with a head tilt of 30°-45° to the right and left. The primary outcome was change in carotid flow on the side of the head tilt. The secondary outcome was change in blood flow on the contralateral side of the head tilt. RESULTS Seventeen subjects were enrolled, and 34 carotid arteries were assessed. There was no significant difference between upright, straight-head position and head tilt in ipsilateral (7.8 ± 1.8 mL/s vs 7.5 ± 2.0 mL/s [P = 0.4312]) or contralateral (7.8 ± 1.8 mL/s vs 8.1 ± 2.4 mL/s [P = 0.3401]) CCBF. CONCLUSIONS CCBF does not fluctuate with AHP and thus does not appear to be the etiology for facial asymmetry in strabismus.
Collapse
Affiliation(s)
- Ryan L Freedman
- Department of Ophthalmology, Visual and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Edmond Younes
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Chaesik Kim
- Department of Ophthalmology, Visual and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Reecha S Bahl
- Department of Ophthalmology, Visual and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan.
| |
Collapse
|
20
|
Calleja R, Mielke N, Lee R, Johnson S, Bahl A. Hemolyzed Laboratory Specimens in the Emergency Department: An Underappreciated, but Frequent Problem. J Emerg Nurs 2023; 49:744-754. [PMID: 37389514 DOI: 10.1016/j.jen.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/29/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Hemolysis of blood samples from emergency department (ED) patients leads to delays in treatment and disposition. The aim of this study is to determine the frequency of hemolysis and variables predictive of hemolysis. METHODS This observational cohort study was conducted among three institutions: academic tertiary care center and two suburban community EDs, with an annual census of over 270,000 ED visits. Data were obtained from the electronic health record. Adults requiring laboratory analysis with at least one peripheral intravenous catheter (PIVC) inserted within the ED were eligible. Primary outcome was hemolysis of lab samples and secondary outcomes included variables related to PIVC failure. RESULTS Between January 8, 2021 and May 9, 2022, 141,609 patient encounters met inclusion criteria. The average age was 55.5 and 57.5% of patients were female. Hemolysis occurred in 24,359 (17.2%) samples. In a multivariate analysis, when compared to 20-gauge catheters, smaller 22-gauge catheters had an increased odds of hemolysis (OR 1.78, 95% confidence interval (CI) 1.65-1.91; P < .001), while larger 18-gauge catheters had a lower odds of hemolysis (OR 0.94; 95% CI 0.90-0.98; P = .0046). Additionally, when compared to antecubital placement, hand/wrist placement demonstrated increased odds of hemolysis (OR 2.06; 95% CI 1.97-2.15; P < .001). Finally, hemolysis was associated with a higher rate of PIVC failure (OR 1.06; 95%CI 1.00-1.13; P = 0.043). DISCUSSION This large observational analysis demonstrates that lab hemolysis of is a frequent occurrence among ED patients. Given the added risk of hemolysis with certain placement variables, clinicians should consider catheter gauge/placement location to avoid hemolysis that may result in patient care delays and prolonged hospital stays.
Collapse
|
21
|
Bahl A, Johnson S, Mielke N, Chen NW. Risk Factors for Coated Midline Catheter-Related Thrombosis: A Secondary Analysis of Existing Trial Data. J Infus Nurs 2023; 46:259-265. [PMID: 37611283 DOI: 10.1097/nan.0000000000000518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Midline catheter-related thrombosis (MCRT) is a high-stakes complication. The authors aimed to explore risk factors for the development of symptomatic MCRT, including patient, procedure, catheter, and vein characteristics. This study performed an analysis of existing trial data that compared MCRT in 2 MCs with differing antithrombotic properties. Cox regression was used for univariable and multivariable analyses to evaluate the primary outcome of MCRT. Among 191 patients in this analysis, the average age was 60.2 years (standard deviation = 16.7 years), and 59.7% were female (114/191). Clinical indications for MC placement included antibiotics (60.7%), difficult venous access (32.5%), or both (6.8%). Body temperature ≥38°C (adjusted hazard ratio [aHR] = 6.26; 95% CI, 1.24-20.29; P = .03), catheter-to-vein ratio >0.40 (aHR = 2.65; 95% CI, 0.99-6.74; P = .05), and MC distance from antecubital fossa >7.0 cm (aHR = 2.82; 95% CI, 1.10-7.90; P = .03), were each significantly associated with the higher risk of the occurrence of symptomatic MCRT. This study found that catheter-to-vein ratio >0.40, distance from the antecubital fossa >7 cm, and body temperature ≥38°C were each associated with higher risk of MCRT. Current practices should be modified to include a minimum vein size to avoid MC insertions that occupy >40% of a given vein. Further research is needed to explain the impact of the catheter tip position and fever in relation to MCRT.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Drs Bahl and Johnson); Oakland University William Beaumont School of Medicine, Rochester, Michigan (Mr Mielke); Beaumont Research Institute, Royal Oak, Michigan (Dr Chen)
- Amit Bahl, MD, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Steven Johnson, DO, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. Dr Johnson is well regarded for his expertise, clinical care, and research contributions in the fields of point-of-care ultrasound and vascular access
- Nicholas Mielke, BS, is a senior medical student pursuing a career in internal medicine. Mr Mielke has published several manuscripts in the field of vascular access and has supported the study team in multiple capacities, ranging from study design to manuscript preparation
- Nai-Wei Chen, PhD, is a senior biostatistician with extensive experience in design, creation, and management of datasets for primary and secondary analyses. Dr Chen has coauthored numerous publications with the study team within the discipline of vascular access
| | - Steven Johnson
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Drs Bahl and Johnson); Oakland University William Beaumont School of Medicine, Rochester, Michigan (Mr Mielke); Beaumont Research Institute, Royal Oak, Michigan (Dr Chen)
- Amit Bahl, MD, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Steven Johnson, DO, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. Dr Johnson is well regarded for his expertise, clinical care, and research contributions in the fields of point-of-care ultrasound and vascular access
- Nicholas Mielke, BS, is a senior medical student pursuing a career in internal medicine. Mr Mielke has published several manuscripts in the field of vascular access and has supported the study team in multiple capacities, ranging from study design to manuscript preparation
- Nai-Wei Chen, PhD, is a senior biostatistician with extensive experience in design, creation, and management of datasets for primary and secondary analyses. Dr Chen has coauthored numerous publications with the study team within the discipline of vascular access
| | - Nicholas Mielke
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Drs Bahl and Johnson); Oakland University William Beaumont School of Medicine, Rochester, Michigan (Mr Mielke); Beaumont Research Institute, Royal Oak, Michigan (Dr Chen)
- Amit Bahl, MD, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Steven Johnson, DO, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. Dr Johnson is well regarded for his expertise, clinical care, and research contributions in the fields of point-of-care ultrasound and vascular access
- Nicholas Mielke, BS, is a senior medical student pursuing a career in internal medicine. Mr Mielke has published several manuscripts in the field of vascular access and has supported the study team in multiple capacities, ranging from study design to manuscript preparation
- Nai-Wei Chen, PhD, is a senior biostatistician with extensive experience in design, creation, and management of datasets for primary and secondary analyses. Dr Chen has coauthored numerous publications with the study team within the discipline of vascular access
| | - Nai-Wei Chen
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan (Drs Bahl and Johnson); Oakland University William Beaumont School of Medicine, Rochester, Michigan (Mr Mielke); Beaumont Research Institute, Royal Oak, Michigan (Dr Chen)
- Amit Bahl, MD, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. He is the recipient of several foundation and industry grants for research and has authored numerous peer-reviewed manuscripts in high-impact medical journals. Dr Bahl is a passionate speaker who presents internationally on the complications of vascular access devices and strategies to improve patient outcomes
- Steven Johnson, DO, is a physician-scientist with board certification in emergency medicine and subspeciality expertise in point-of-care ultrasound. Dr Johnson is well regarded for his expertise, clinical care, and research contributions in the fields of point-of-care ultrasound and vascular access
- Nicholas Mielke, BS, is a senior medical student pursuing a career in internal medicine. Mr Mielke has published several manuscripts in the field of vascular access and has supported the study team in multiple capacities, ranging from study design to manuscript preparation
- Nai-Wei Chen, PhD, is a senior biostatistician with extensive experience in design, creation, and management of datasets for primary and secondary analyses. Dr Chen has coauthored numerous publications with the study team within the discipline of vascular access
| |
Collapse
|
22
|
Bahl A, Mielke N, Xing Y. Risk of midline catheter-related thrombosis due to catheter diameter: An observational cohort study. Thromb Res 2023; 228:172-180. [PMID: 37331120 DOI: 10.1016/j.thromres.2023.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Deep vein thrombosis is a common and serious complication associated with midline catheters (MC). The aim of this investigation was to determine if catheter diameter is related to development of thrombosis. METHODS This was an observational cohort study conducted at a tertiary care academic center in Southeastern Michigan. Hospitalized adults that required a MC were eligible participants. Primary outcome was symptomatic MC associated upper extremity deep vein thrombosis (DVT) comparing three catheter diameters. Secondary outcomes included complications based on size and DVT comparing catheter to vein ratio. RESULTS Between January 1, 2017, and December 31, 2021, 3088 MCs met inclusion criteria; the distribution of 3 French (Fr), 4 Fr, and 5 Fr MCs was 35.1 %, 57.0 %, and 7.9 %, respectively. The majority of the population was female (61.2 %) and the average age was 64.2 years old. DVT occurred in 4.4 %, 3.9 %, and 11.9 % of 3 Fr, 4 Fr, and 5 Fr MCs, respectively (p < 0.001). In multivariable regression analysis, there was no difference in the odds of developing DVT for the 4 Fr MC compared to the 3 Fr (aOR 0.88; 95 % CI 0.59-1.31; p = 0.5243), however, there was significantly higher odds for the 5 Fr (aOR 2.72; 95 % CI 1.62-4.51; p = 0.001). Additionally, for every additional day the MC was in place, the odds of DVT increased by 3 % (aOR 1.03; 95 % CI 1.01-1.05; p = 0.0039). When comparing accuracy of the size model versus catheter to vein ratio model for predicting DVT, receiver operating characteristic curve analysis demonstrated the area under the curve for size was 73.70 % (95 % CI 68.04 %-79.36 %) compared to 73.01 % (95 % CI: 66.88 %-79.10 %) for catheter-to-vein ratio. CONCLUSIONS Smaller diameter catheters should be preferentially chosen to mitigate the risk of thrombosis when therapy via midline catheters is required. Choosing a catheter based on reduced size or 1:3 catheter to vein ratio threshold has similar accuracy in predicting DVT.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, United States of America.
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States of America
| | - Yuying Xing
- Corewell Health Research Institute, Royal Oak, MI, United States of America
| |
Collapse
|
23
|
Biernacka KM, Barker R, Sewell A, Bahl A, Perks CM. A role for androgen receptor variant 7 in sensitivity to therapy: Involvement of IGFBP-2 and FOXA1. Transl Oncol 2023; 34:101698. [PMID: 37307644 PMCID: PMC10276180 DOI: 10.1016/j.tranon.2023.101698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/10/2023] [Accepted: 05/21/2023] [Indexed: 06/14/2023] Open
Abstract
Prostate cancer (PCa) is one of the leading causes of cancer-related deaths in men. Localised PCa can be treated effectively, but most patients relapse/progress to more aggressive disease. One possible mechanism underlying this progression is alternative splicing of the androgen receptor, with AR variant 7(ARV7) considered to play a major role. Using viability assays, we confirmed that ARV7-positive PCa cells were less sensitive to treatment with cabazitaxel and an anti-androgen-enzalutamide. Also, using live-holographic imaging, we showed that PCa cells with ARV7 exhibited an increased rate of cell division, proliferation, and motility, which could potentially contribute to a more aggressive phenotype. Furthermore, protein analysis demonstrated that ARV7 knock-down was associated with a decrease in insulin-like growth factor-2 (IGFBP-2) and forkhead box protein A1(FOXA1). This correlation was confirmed in-vivo using PCa tissue samples. Spearman rank correlation analysis showed significant positive associations between ARV7 and IGFBP-2 or FOXA1 in tissue from patients with PCa. This association was not present with the AR. These data suggest an interplay of FOXA1 and IGFBP-2 with ARV7-mediated acquisition of an aggressive prostate cancer phenotype.
Collapse
Affiliation(s)
- K M Biernacka
- Cancer Endocrinology Group, Translational Health Sciences, University of Bristol Southmead Hospital, BS10 5NB, Bristol, UK
| | - R Barker
- Cancer Endocrinology Group, Translational Health Sciences, University of Bristol Southmead Hospital, BS10 5NB, Bristol, UK
| | - A Sewell
- Department of Cellular Pathology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - A Bahl
- Bristol Haematology and Oncology Centre, Department of Clinical Oncology, University Hospitals Bristol, Bristol BS2 8ED, UK
| | - C M Perks
- Cancer Endocrinology Group, Translational Health Sciences, University of Bristol Southmead Hospital, BS10 5NB, Bristol, UK.
| |
Collapse
|
24
|
Bahl A, Qureshi B, Bravo C, Mahr C, Li S. Race and Incidence of Right Heart Failure after Left Ventricular Assist Device Implantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
|
25
|
Bahl A, Panda N, Bakshi J, Verma R, Oinam A, Mohindra S, Ghoshal S, Gupta R. 23P Treatment outcomes in nasal cavity and paranasal sinus tumors treated with postoperative volumetric modulated arc therapy. ESMO Open 2023. [DOI: 10.1016/j.esmoop.2023.101044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
|
26
|
McGrane J, Frazer R, Bahl A, Parslow DS, Alam SM, Nelms S, Shaheen A, Lydon A, Abhi D, Clements G, Keenan H, Wang Y, Ford V, Challapalli A, Ferrera A, Moorcraft SY, Mohamed W, Jones E, Liu JKH, Ratnayake G. Multi-centre review of systemic anti-cancer prescribing patterns and treatment drop off rates in the United Kingdom 2018-2021. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
689 Background: The treatment landscape of metastatic renal cell carcinoma (mRCC) has evolved over recent years with several systemic anti-cancer therapies (SACT) licensed across different lines of treatment. There is ongoing discussion amongst oncology professionals about how best to optimise treatments in terms of sequencing to maximise the potential number of lines or to give the best treatments first. A previous south-west UK audit was completed in 2021 reviewing the drop off rates across 5 UK sites identifying that 69% of patients were able to receive second line therapy and 34% were able to receive third line therapy. Methods: In this study we conducted retrospective analysis of all patients who commenced treatment with SACT for mRCC between 1st January 2018 and 30th June 2021 in 18 centres across the 4 nations of the United Kingdom. All NHS reimbursed treatment options including the COVID interim treatment guideline options were included. Patients who received SACT as part of a clinical trial were also included. Patients who continued on their respective lines of treatment were censored. We also identified patients who had been on a period of active surveillance before staring SACT in this cohort. Results: 1549 patients (71% male: 29% female) were included. IMDC subgroup patients included 21.6% favourable, 52.3% intermediate, 25.1% poor and 1% unavailable. 9.1% of patients had been on active surveillance before starting SACT – defined as a period of longer than 3 months from mRCC diagnosis to starting SACT. Of those patients that started SACT 60.5% of eligible patients had 2nd line therapy, 25.3% had 3rd line, 7.2% received 4th line therapy and only 1% had 5th line therapy. In the 1st line setting 58.9% received single agent VEGF TKI, 24.5% received combination ipilimumab and nivolumab (IO-IO) immunotherapy, 14 % received IO/ VEGF TKI combination and 2.6% received other/trial treatment. The single agent VEGF TKI ratio for 1st line SACT declined year by year with rising IO-IO and IO/VEGF TKI combination ratios seen. In the second- and third-line settings cabozantinib (33.2% 2nd line and 44.4% 3rd line) and nivolumab (32.8% 2nd line and 22.6% 3rd line) were the most common options. Disease progression or death was the most common cause of SACT discontinuation amounting to 57.4%, 62.5% and 79% of SACT cessation in the 1st, 2nd and 3rd lines respectively. Treatment toxicity SACT discontinuation rates were 22.8%, 21.4% and 10.9% for 1st, 2nd and 3rd lines respectively. Conclusions: These results suggest that with more treatment options available, including combination/immunotherapy therapies, more patients are able to receive second- and third-line therapies. That said there remains significant drop off rates mostly driven by disease progression that would support the use of our most effective therapies in the upfront setting.
Collapse
Affiliation(s)
- John McGrane
- Royal Cornwall Hospital NHS Trust, Cornwall, United Kingdom
| | - Ricky Frazer
- Velindre Cancer Centre, Cardiff, Wales, United Kingdom
| | - Amit Bahl
- University Hospitals Bristol, Bristol, United Kingdom
| | | | | | - Sarah Nelms
- University Hospital Dorset, Poole, United Kingdom
| | - Ahmed Shaheen
- Northern Centre for Cancer Care (NCCC), Newcastle upon Tyne, United Kingdom
| | - Anna Lydon
- South Devon Healthcare NHS Foundation Trust, Torquay, United Kingdom
| | - Dhruv Abhi
- Edinburgh Cancer Centre, Edinburgh, United Kingdom
| | - Gemma Clements
- The Northern Ireland Cancer Centre, Belfast, United Kingdom
| | | | - Yifei Wang
- The Oxford Cancer and Haematology Centre, Oxford, United Kingdom
| | - Victoria Ford
- Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Amarnath Challapalli
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | | | | | - Eleanor Jones
- University Hospital Southampton, Southampton, United Kingdom
| | - Justin KH Liu
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | | |
Collapse
|
27
|
Challapalli A, Renninson E, White P, Elumalai T, Parikh O, Vickers A, Birtle AJ, Brocklehurst A, Bhana R, Wickramasinghe K, Jayaprakash KT, Gray E, Sephton M, Bowzyk Al-Naeeb A, Foulstone E, Soundy A, Ashurst L, Bahl A. Real world prospective evaluation of clinical outcomes in patients with non-metastatic castrate resistant prostate cancer treated with darolutamide. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
335 Background: The RECORD Study is a real world data, prospective evaluation of clinical outcomes in patients with nmCRPC treated with Darolutamide. This study will increase the understanding of treatment response and management and in particular inform regarding use of next generation imaging in this setting. Methods: Patient data from 9 UK centres was collected based on the recommendation of NICE for Darolutamide as an option for the treatment of non-metastatic castrate resistant prostate cancer (nmCRPC) from November 2020. Data cut-off was 15 September 2022. The study is ongoing. Results: 87 patients were analysed with a median age of 78 (range 61-92). Median pre-treatment PSA and PSA doubling time (PSAdT) were 13 (range 1.99-110.6) mg/L and 5.05 (range 0.6 - 10) months. 42 patients (49.4%) had pre-treatment PSAdT of <6 months and 43 (50.6%) patients had PSAdT of ≥6 months (2 patients had no pre-treatment PSAdT data). 6 patients (6.90%) had next generation imaging prior to initiation of Darolutamide. Median duration of treatment on Darolutamide was 17 months for patients with pre-treatment PSAdT <6 months but median duration had not been reached for patients with pre-treatment PSAdT ≥6 months after 24 months of treatment, a significant difference p=0.018 (HR=0.385, 95% CI 0.17-0.88). 30 patients have come off treatment so far (34.5%); 21 (70%) for disease progression, 5 (16%) for a medical cause unrelated to the drug (e.g. COVID infection, reduced performance status secondary to pre-existing Parkinson's), 3 (10%) for unacceptable toxicity (rash, Grade3 fatigue, muscle aches, memory issues), and 1 patient died (unrelated). Conclusions: In the RECORD study, predominantly the diagnosis of nmCRPC is based on conventional imaging. The majority of patients respond and tolerate Darolutamide well, comparable with the ARAMIS trial. There is a significant difference between time on Darolutamide for those with pre-treatment PSAdT of <6 months compared with ≥6 months. Further long-term toxicity, MFS and OS data will continue to be collected prospectively within the study.
Collapse
Affiliation(s)
- Amarnath Challapalli
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Emily Renninson
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Paul White
- University of the West of England, Bristol, United Kingdom
| | - Thiraviyam Elumalai
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Omi Parikh
- Royal Blackburn Teaching Hospital, East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom
| | - Alexander Vickers
- Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Alison Jane Birtle
- Royal Preston Hospital, Lancashire teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | | | - Rajanee Bhana
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Kanchana Wickramasinghe
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | | | - Emma Gray
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, United Kingdom
| | - Matthew Sephton
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, United Kingdom
| | - Anna Bowzyk Al-Naeeb
- Bedford Hospital, Bedfordshire Hospitals NHS Foundation Trust, Bedford, United Kingdom
| | - Emily Foulstone
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Alexandra Soundy
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Lauren Ashurst
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| |
Collapse
|
28
|
Challapalli A, White P, Masson S, Foulstone E, Renninson E, Bravo A, Pearson S, Dailami N, Persad R, Koupparis A, Rowe E, Oxley J, Kabala J, Ash-Miles J, Bahl A. The Bristol Bladder Trial: Five year outcomes in patients treated with neoadjuvant cabazitaxel and cisplatin chemotherapy for muscle invasive transitional cell carcinoma of the urinary bladder. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
493 Background: Neoadjuvant cisplatin-based combination chemotherapy (NAC) improves survival in muscle invasive bladder cancer (MIBC). However, response rates and survival remain suboptimal. We sought to evaluate the efficacy of cabazitaxel with cisplatin in this patient group. These patients have now been followed for survival status for 5 years post NAC and radical cystectomy. Methods: This was a single arm (Simon 2 stage), phase 2 study. Patients with MIBC were included if fit to receive NAC and to undergo radical cystectomy. 26 evaluable patients were required to detect an objective response rate (ORR) of >35% with 80% power. ORR was defined as pathological complete response (pCR) plus partial response (pathological downstaging, ≥T2 at diagnosis to ≤T1 at cystectomy). Treatment was with cisplatin 70mg/m2 and cabazitaxel 15mg/m2 on day 1 of a 21-day cycle, for 4 cycles prior to surgery. Toxicity was recorded using CTCAE v.4.03. QoL data was assessed during and after chemotherapy using EQ-5D-5L and EORTC-QLQ-C30, BLM30 questionnaires. Patients were followed for 5 years post cystectomy for progression free survival (PFS) and overall survival (OS). Results: ORR was seen in 15 out of 26 evaluable patients, 57.7%, with 24.6% achieving pCR. 1 out of 15 patients who achieved ORR died due to disease progression in the 5 year follow up period. The median PFS and OS were not reached by the 5 year follow up time point with a 5 year survival rate of 65.4% being seen in this patient cohort. Median OS in non-responders (11 patients) was 20.5 months and 5 year survival rate for the non-responders was 36.4% compared to 93.3% for responders. Conclusions: Neoadjuvant cabazitaxel with cisplatin chemotherapy is an effective regimen with 65.4% patients alive and progression-free at 5 years. It also indicates that ORR (and not just pCR), is a good predictor of patient survival at 5 years post radical cystectomy with only 1 out of 15 patients who achieved ORR progressing and dying in this period. However, in current clinical practice, there are no validated predictive biomarkers regarding potential response to NAC. Taken together with our previously published data, cabazitaxel with cisplatin as neoadjuvant chemotherapy is a safe, well-tolerated and effective regimen and should be compared to the regimens e.g. cisplatin/gemcitabine considered as standard in this setting. Clinical trial information: NCT01616875 .
Collapse
Affiliation(s)
- Amarnath Challapalli
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Paul White
- University of the West of England, Bristol, United Kingdom
| | - Susan Masson
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Emily Foulstone
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Emily Renninson
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Alicia Bravo
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Sylvia Pearson
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Narges Dailami
- University of the West of England, Bristol, United Kingdom
| | - Raj Persad
- North Bristol NHS Trust, Bristol, United Kingdom
| | | | - Edward Rowe
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Jon Oxley
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Julian Kabala
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| |
Collapse
|
29
|
Bahl A, Johnson S, Hijazi M, Mielke N, Chen NW. Cost effectiveness of ultrasound-guided long peripheral catheters in difficult vascular access patients. J Vasc Access 2023:11297298231154297. [PMID: 36789955 DOI: 10.1177/11297298231154297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
OBJECTIVE Peripheral intravenous catheter (PIVC) placement is a routinely performed invasive procedure in hospital settings with an unacceptably high failure rate that can result in significant costs. This investigation aimed to determine the cost-effectiveness of using long peripheral catheters (LPC) versus standard short peripheral catheters (SPC) in the difficult vascular access (DVA) population. METHODS A secondary analysis was performed of a randomized control trial that compared a 20-gauge 4.78 cm SPC to a 20-gauge 6.35 cm SPC for the endpoint of survival. This study assessed cost-effectiveness of the comparative interventions. Costs associated with increased hospitalization length of stay due to PIVC failure, including labor, materials, equipment, and treatment delays were estimated by utilizing healthcare resource utilization data. Cost-effectiveness of the LPC was analyzed through the incremental cost-effectiveness ratio, the cost-effectiveness acceptability curve, and the incremental net benefit. A sensitivity analysis was conducted to evaluate the robustness of the results during the time interval of PIVC insertion. RESULTS Among the 257 patients, the average total cost for therapy was lower in the LPC group compared to the SPC group ($400 vs $521; mean difference -$121, 95% bootstrapped CI -$461 to $225). A marginally significant absolute difference of complication averted was found for LPC versus SPC (10.8%, p = 0.07). The estimated incremental cost-effectiveness ratio (ICER) for LPC as compared with SPC was -$1123 (95% bootstrapped CI -$8652 to $5964) per complication averted. In a willingness to pay (WTP) analysis, as WTP = $0, the incremental net benefit (INB) $121 was positive, indicating LPC was less costly. Analysis of PIVCs that survived ⩽48 h (n = 134) demonstrated a lower average total cost for therapy among the LPC group ($418 vs $531; mean difference -$113, 95% bootstrapped CI -$507 to $282). Forty-seven of 66 (71.2%) LPCs did not experience a complication, compared with 37 of 68 (54.4%) SPCs, resulting in a significant absolute difference of complication adverted of 16.8% (p = 0.04). In addition, with a positive slope, the INB $113 was positive as WTP = $0, indicating LPC was estimated to be cost-effective. CONCLUSIONS When using ultrasound guidance for vascular access, LPCs are potentially a cost-effective strategy for reducing PIVC complications in DVA patients compared to SPCs. Given this finding, ultrasound-guided LPCs should be routinely considered as first-line among the DVA population in order to improve their overall care and wellbeing.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Steven Johnson
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Mahmoud Hijazi
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nai-Wei Chen
- Research Institute, Beaumont Hospital, Royal Oak, MI, USA
| |
Collapse
|
30
|
Renninson E, Sonker P, Challapalli A, Hudson Z, Hilman S, Bahl A. Audit of Avelumab Maintenance Therapy for Advanced or Metastatic Urothelial Carcinoma Treated in the Early Access Scheme. Clin Oncol (R Coll Radiol) 2023. [DOI: 10.1016/j.clon.2022.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
31
|
Renninson E, Channell K, Ball J, Masson S, Challapalli A, Bahl A. Patient Experience and Impact of Rectal Spacers on Dosimetry and Acute Toxicity in Patients Undergoing Radical Radiotherapy for Prostate Cancer. Clin Oncol (R Coll Radiol) 2023. [DOI: 10.1016/j.clon.2022.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
32
|
Cook GJ, Wong WL, Sanghera B, Mangar S, Challapalli A, Bahl A, Bassett P, Leaning D, Schmidkonz C. Eligibility for 177Lu-PSMA Therapy Depends on the Choice of Companion Diagnostic Tracer: A Comparison of 68Ga-PSMA-11 and 99mTc-MIP-1404 in Metastatic Castration-Resistant Prostate Cancer. J Nucl Med 2023; 64:227-231. [PMID: 36302657 PMCID: PMC9902859 DOI: 10.2967/jnumed.122.264296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 02/04/2023] Open
Abstract
177Lu-prostate-specific membrane antigen-617 (177Lu-PSMA-617) is an effective therapy for metastatic castration-resistant prostate cancer (mCRPC), with evidence of improved survival over standard care. The VISION trial inclusion criteria required a metastatic lesion-to-liver ratio of greater than 1 on 68Ga-PSMA-11 PET scans. We aimed to determine whether an equivalent ratio is suitable for a SPECT tracer, 99mTc-MIP-1404, and to compare lesion and lesion-to-normal-organ ratios between the 2 radiotracers. Methods: Two cohorts of patients with mCRPC matched for age, prostate-specific antigen level, and total Gleason score, with either 99mTc-MIP-1404 SPECT/CT (n = 25) or 68Ga-PSMA-11 PET/CT (n = 25) scans, were included for analysis. Up to 3 lesions in each site (prostate/prostate bed, lymph nodes, bone and soft-tissue metastases) as well as normal liver, parotid gland, spleen, and mediastinal blood-pool SUVmax were measured. Results: 99mTc-MIP-1404 SPECT lesion SUVmax was not significantly different from 68Ga-PSMA-11 PET (median, 18.2 vs. 17.3; P = 0.93). However, 99mTc-MIP-1404 liver SUVmax was higher (median, 8.5 vs. 5.8; P = 0.002) and lesion-to-liver ratios were lower (median, 2.7 vs. 3.5; P = 0.009). There was no significant difference in parotid gland or splenic SUVmax or lesion-to-parotid gland ratios between the 2 tracers although there was a small difference in lesion-to-spleen ratios (P = 0.034). Conclusion: There are differences in biodistribution and, in particular, liver activity, between 68Ga-PSMA-11 and 99mTc-MIP-1404. Therefore, if 99mTc-MIP-1404 is used to assess eligibility for 177Lu-PSMA-617 therapy, a lower adjusted lesion-to-liver ratio should be used.
Collapse
Affiliation(s)
- Gary J.R. Cook
- Cancer Imaging Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Wai-Lup Wong
- Paul Strickland Scanner Centre, Mount Vernon Hospital, Northwood, Northwood, United Kingdom
| | - Bal Sanghera
- Paul Strickland Scanner Centre, Mount Vernon Hospital, Northwood, Northwood, United Kingdom
| | - Stephen Mangar
- Department of Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Amarnath Challapalli
- Department of Clinical Oncology, Bristol Cancer Institute, Bristol, United Kingdom
| | - Amit Bahl
- Department of Clinical Oncology, Bristol Cancer Institute, Bristol, United Kingdom
| | | | - Darren Leaning
- Department of Clinical Oncology, James Cook University Hospital, South Tees NHS Trust, Middlesbrough, United Kingdom
| | - Christian Schmidkonz
- Department of Nuclear Medicine, University Hospital Erlangen, Erlangen, Germany; and,Department of Industrial Engineering and Health, Technical University of Applied Sciences Amberg-Weiden, Weiden, Germany
| |
Collapse
|
33
|
Gravestock P, Clark E, Morton M, Sharma S, Fisher H, Walker J, Wood R, Hancock H, Waugh N, Cooper A, Maier R, Marshall J, Chandler R, Bahl A, Crabb S, Jain S, Pedley I, Jones R, Staffurth J, Heer R. Using the AR-V7 biomarker to determine treatment in metastatic castrate resistant prostate cancer, a feasibility randomised control trial, conclusions from the VARIANT trial. NIHR Open Res 2023; 2:49. [PMID: 37035713 PMCID: PMC7614403 DOI: 10.3310/nihropenres.13284.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 04/05/2023]
Abstract
Background Prostate cancer is the most commonly diagnosed malignancy in the UK. Castrate resistant prostate cancer (CRPC) can be difficult to manage with response to next generation hormonal treatment variable. AR-V7 is a protein biomarker that can be used to predict response to treatment and potentially better inform management in these patients. Our aim was to establish the feasibility of conducting a definitive randomised controlled trial comparing the clinical utility of AR-V7 biomarker assay in personalising treatments for patients with metastatic CRPC within the United Kingdom (UK) National Health Service (NHS). Due to a number of issues the trial was not completed successfully, we aim to discuss and share lessons learned herein. Methods We conducted a randomised, open, feasibility trial, which aimed to recruit 70 adult men with metastatic CRPC within three secondary care NHS trusts in the UK to be run over an 18-month period. Participants were randomised to personalised treatment based on AR-V7 status (intervention) or standard care (control). The primary outcome was feasibility, which included: recruitment rate, retention and compliance. Additionally, a baseline prevalence of AR-V7 expression was to be estimated. Results Fourteen participants were screened and 12 randomised with six into each arm over a nine-month period. Reliability issues with the AR-V7 assay meant prevalence was not estimated. Due to limited recruitment the study did not complete to target. Conclusions Whilst the trial did not complete to target, we have ascertained that men with advanced cancer are willing to take part in trials utilising biomarker guided treatment. A number of issues were identified that serve as important learning points in future clinical trials.
Collapse
Affiliation(s)
- Paul Gravestock
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, NE3 3HD, UK
| | - Emma Clark
- Translational and Clinical Research Institute, NU Cancer, Newcastle upon Tyne, Tyne and Wear, NE1 7RU, UK
| | - Miranda Morton
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE2 4AE, UK
| | - Shirya Sharma
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE2 4AE, UK
| | - Holly Fisher
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE1 7RU, UK
| | - Jenn Walker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE2 4AE, UK
| | - Ruth Wood
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE2 4AE, UK
| | - Helen Hancock
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE2 4AE, UK
| | - Nichola Waugh
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE2 4AE, UK
| | | | - Rebecca Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, NE2 4AE, UK
| | - John Marshall
- Trial Management Group, VARIANT Trial, Newcastle upon Tyne, Tyne and Wear, NE1 7RU, UK
| | - Robert Chandler
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, NE3 3HD, UK
| | - Amit Bahl
- University Hospitals Bristol NHS Foundation Trust, Bristol, BS1 3NU, UK
| | - Simon Crabb
- University of Southampton, Southampton, Hampshire, SO17 1BJ, UK
| | - Suneil Jain
- Queens University Belfast, Belfast, BT7 1NN, UK
| | - Ian Pedley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, NE3 3HD, UK
| | - Rob Jones
- Institute of Cancer Services, University of Glasgow, Glasgow, G12 0YN, UK
| | - John Staffurth
- Velindre University NHS Trust, Cardiff, CF15 7QZ, UK
- Division of Cancer and Genetics, Cardiff University, Cardiff, CF14 4XN, UK
| | - Rakesh Heer
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, NE3 3HD, UK
- Translational and Clinical Research Institute, NU Cancer, Newcastle upon Tyne, Tyne and Wear, NE1 7RU, UK
| |
Collapse
|
34
|
Robert N, Sehgal T, Singh R, Oinam A, Trivedi G, Singh B, Bahl A, Madan R, Rai B. Rotational Set Up Uncertainly in Non-6D Couch and its Effects in Clinical Target Volume- Planning Target Volume Margin Calculation for Different Sites. J Med Phys 2023; 48:43-49. [PMID: 37342596 PMCID: PMC10277305 DOI: 10.4103/jmp.jmp_78_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/06/2022] [Accepted: 12/05/2022] [Indexed: 06/23/2023] Open
Abstract
Purpose The purpose of this study was to estimate and incorporate rotational error to translational error for clinical target volume (CTV) to planning target volume (PTV) margin calculations for non-6D couch. Materials and Methods The study involved cone-beam computed tomography (CBCT) images of the patients who already had treatment in Varian Trilogy Clinac. The different sites studied were brain (70 patients, 406 CBCT images), head and neck (72 patients, 356 CBCT images), pelvis (83 patients, 606 CBCT images), and breast (45 patients, 163 CBCT images). Rotational and translational patient shifts were measured with the help of Varian eclipse offline review. The rotational shift introduces translational shift as it resolved along craniocaudal and mediolateral directions. Both rotational and translational error follow normal distribution and their respective errors were used to calculate CTV-PTV margin using van Herk model. Results Rotational effect on CTV-PTV margin contribution increases with increase in size of CTV. It also increases with increase in distance between center of mass of CTV and isocenter. These margins were more pronounce in single isocenter supraclavicular fossa-Tangential Breast plans. Conclusions There is always rotational error in all sites and it causes shift and rotation of the target. Rotational contribution to the CTV-PTV margin depends upon geometric center of CTV and isocenter distance and also on size of CTV. CTV-PTV margins should incorporate rotational error along with transitional error.
Collapse
Affiliation(s)
- Ngangom Robert
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tinish Sehgal
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjit Singh
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Oinam
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Trivedi
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Budhi Singh
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Bahl
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Madan
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
35
|
Bahl A, Gibson SM, Jankowski D, Chen NW. Short peripheral intravenous catheter securement with cyanoacrylate glue compared to conventional dressing: A randomized controlled trial. J Vasc Access 2023; 24:52-63. [PMID: 34112019 DOI: 10.1177/11297298211024037] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Short peripheral intravenous catheters (PIVCs) fail prior to completion of therapy in up to 63% of hospitalizations. This unacceptably high rate of failure has become the norm for the most common invasive procedure in all of medicine. Securement strategies may improve PIVC survival. METHODS We conducted a prospective, single-site, parallel, two-arm randomized controlled investigation with a primary outcome of catheter failure comparing securement with standard semi-permeable dressing and clear tape (SPD) to standard semipermeable dressing and clear tape with cyanoacrylate glue (SPD + CG). Adult emergency department patients with a short PIVC and anticipated hospital duration ⩾ 48 h were enrolled and followed until IV failure or completion of therapy for up to 7 days. Secondary outcomes included complications and cost comparisons between groups. Primary outcome was assessed by intention to treat and per protocol analyses. FINDINGS 350 patients were enrolled between November 2019 and October 2020. PIVC survival for SPD + CG was similar to SPD group with the absolute risk difference of IV failure in the intention-to-treat (-5.8%, p = 0.065) population and improved in the per protocol (-8.1%, p = 0.04) population, respectively. Kaplan-Meier survival analysis indicated there was a significant benefit of the SPD + CG at greater than 2 days of hospitalization (p = 0.04). Prior to 48 h, there was no survival enhancement to either group (p = 0.98) in the intention to treat population. In a multivariable analysis with piecewise Cox regression, when the IV was functional greater than 48 h, the risk of IV failure in the SPD + CG was 43% less than the SPD group (adjusted hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.34 to 0.97; p = 0.04). Cumulative cost related to IV during hospitalization was similar between groups with a lower incremental rescue cost in the SPD + CG group. INTERPRETATION SPD combined with cyanoacrylate glue provides similar benefit to patients compared to SPD alone and potentially improves short PIVC survival when the IV was inserted >48 h. As this strategy is cost neutral, it could be considered in admitted patients, particularly those with longer anticipated hospital durations.
Collapse
Affiliation(s)
- Amit Bahl
- Beaumont Hospital, Royal Oak, MI, USA
| | | | | | | |
Collapse
|
36
|
Bahl A, Alsbrooks K, Gala S, Hoerauf K. Symptomatic Deep Vein Thrombosis Associated With Peripherally Inserted Central Catheters of Different Diameters: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296221144041. [PMID: 37366542 PMCID: PMC10328005 DOI: 10.1177/10760296221144041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 06/28/2023] Open
Abstract
We assessed the relationship between peripherally inserted central catheter (PICC) diameters and symptomatic deep vein thrombosis (DVT) rates. We conducted a systematic search for articles published between 2010 and 2021 reporting DVT incidence by catheter diameter in patients who had a PICC, followed by meta-analyses for DVT risk in each diameter group. Pooled DVT rates were incorporated into an economic model. Of 1627 abstracts screened, 47 studies were included. The primary meta-analysis of 40 studies demonstrated the incidence of DVT was 0.89%, 3.26%, 5.46%, and 10.66% for 3, 4, 5, and 6 French (Fr) PICCs (P = .01 between 4 and 5 Fr). Rates of DVT were not significantly different between oncology and nononcology patients (P = .065 for 4 Fr and P = .99 for 5 Fr). The DVT rate was 5.08% for ICU patients and 4.58% for non-ICU patients (P = .65). The economic model demonstrated an annual, incremental cost savings of US$114 053 for every 5% absolute reduction in 6 Fr PICCs use. Using the smallest PICC that meets the patients' clinical needs may help to mitigate risks and confer savings.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine,
Beaumont Hospital, Royal Oak, MI, USA
| | | | - Smeet Gala
- Medical Affairs, Becton Dickinson and
Company, Franklin Lakes, NJ, USA
| | - Klaus Hoerauf
- Medical Affairs, Becton Dickinson and
Company, Franklin Lakes, NJ, USA
- Department of Anesthesiology and
Intensive Care, Medical University of
Vienna, Wien, Austria
| |
Collapse
|
37
|
Stoevelaar H, Bahl A, Helsen N, Michels NR, Smets L, Speakman MJ, Stranne J, Toelen J, Van der Aa F, Van Ruysevelt L, Yperman J, Zilli T, Tombal BF, Michel MC. Personalised versus non-individualised case-based CME: A randomised pilot study. J Eur CME 2022; 11:2153438. [DOI: 10.1080/21614083.2022.2153438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - Amit Bahl
- University Hospitals Bristol National Health Service Foundation Trust-Bristol Haematology and Oncology Centre, Bristol, UK
| | | | - Nele R.M. Michels
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Mark J. Speakman
- International Society for the Study and Exchange of Evidence from Clinical Research and Medical Experience (ISSECAM), Lier, Belgium
- Department of Urology, Musgrove Park Hospital, Somerset Foundation Trust, Taunton, UK
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Sahlgrenska University Hospital-Västra Götaland, Gothenburg, Sweden
| | - Jaan Toelen
- International Society for the Study and Exchange of Evidence from Clinical Research and Medical Experience (ISSECAM), Lier, Belgium
- Department of Development and Regeneration, Leuven, Belgium
- Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Frank Van der Aa
- Department of Development and Regeneration, Leuven, Belgium
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Luc Van Ruysevelt
- International Society for the Study and Exchange of Evidence from Clinical Research and Medical Experience (ISSECAM), Lier, Belgium
- e-HIMS, Lier, Belgium
| | | | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Bertrand F. Tombal
- International Society for the Study and Exchange of Evidence from Clinical Research and Medical Experience (ISSECAM), Lier, Belgium
- Urology, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Martin C. Michel
- International Society for the Study and Exchange of Evidence from Clinical Research and Medical Experience (ISSECAM), Lier, Belgium
- Department of Pharmacology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| |
Collapse
|
38
|
Bahl A, Mielke N, Johnson S, Desai A, Qu L. Severe COVID-19 outcomes in pediatrics: An observational cohort analysis comparing Alpha, Delta, and Omicron variants. Lancet Reg Health Am 2022; 18:100405. [PMID: 36474521 PMCID: PMC9714340 DOI: 10.1016/j.lana.2022.100405] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022]
Abstract
Objective COVID-19 can rarely lead to severe illness in pediatric patients. The aim of this study was to determine if severe outcomes in pediatric COVID-19 have changed over the course of the pandemic. Methods This was a multicenter, observational cohort analysis from a large regional healthcare system in metro Detroit using electronic health record data to evaluate emergency visits, hospitalization, and severe COVID-19 disease in pediatric patients. Consecutive pediatric patients presenting to the emergency department with a primary diagnosis of COVID-19 were included. Outcomes data was gathered from three distinct time intervals that coincided with Alpha, Delta, and Omicron variant predominance (Time interval 1 (T1) 1/1/2021-6/30/2021: Alpha, T2 7/1/2021-12/31/2021: Delta, T3 1/1/2022-6/16/2022): Omicron. The primary outcome was severe disease inclusive of composite intensive care unit admission, mechanical ventilation, multisystem inflammatory syndrome in children (MIS-C), myocarditis, or death. Secondary outcomes included severe outcomes considering viral coinfection and vaccination status. Results Between 1/1/2021 and 6/16/2022, there were 4517 emergency COVID-19 visits, of which 12.5% (566) of children were hospitalized. 24.4% (138), 31.6% (179), and 44.0% (249) of admissions occurred during T1, T2 and T3 respectively. Most patients were male (55.1%) and 59.9% identified as Caucasian. The median age was 5.0 (interquartile range 1.0, 13.0) with infants comprising 22.8% (129), toddlers 25.1% (142), children 23.0% (130), and teenagers 29.2% (165). Over the course of the pandemic, the proportion of infants in hospitalization increased from 16.7% in T1 to 19.6% in T2 to 28.5% in T3 (p < 0.01) while the proportion of teenagers in hospitalization decreased from 39.1% in T1 to 31.3% in T2 to 22.1% in T3 (p < 0.001). Oxygen therapy was required in a minority (29.9%) of cases with supplemental oxygen utilized the least in T3 (16.5%) and most in T2 (30.2%). Composite severe disease decreased throughout the pandemic occurring in 36.2% in T1, 27.4% in T2, and 18.9% in T3. A multivariable logistic regression analysis revealed the odds of composite severe disease was significantly lower in T3 compared to T1 (adjusted odds ratio [aOR] 0.35, 95% Confidence Interval 0.21-0.60, p < 0.001). Fully vaccinated or fully vaccinated and boosted admission rates remained low throughout all periods with 4.4% in T1, 4.5% in T2 and 8.4% in T3. Viral coinfection was most common during T2 (16.8%) followed by T3 (12.5%) and least common in T1 (5.1%) (p = 0.006). Coinfection occurred more commonly in younger children with a median age of 1.2 (0.0, 4.5) compared to those with mono-infection with a median age of 6 (1.0, 14.0) (p < 0.001). Severe outcomes occurred in 45.6% of coinfection cases compared to 22.1% without coinfection (p < 0.001). Conclusions While Omicron cases had the highest admission frequency, severe illness was lower than Delta and Alpha variants. Coinfection with respiratory viruses increased the risk of severe outcomes and impacted infants more than older children. Funding None.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA,Corresponding author. Attending Physician, Department of Emergency Medicine, Beaumont Hospital, Royal Oak, 3601 13 Mile Rd, Royal Oak, MI 48073.
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Steven Johnson
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Ankita Desai
- Department of Pediatric Infectious Diseases, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Lihua Qu
- Department of Outcomes Research, Beaumont Health Research Institute, Royal Oak, MI, USA
| |
Collapse
|
39
|
Ghoshal S, Dracham CB, Sundaram A, Kumar R, Bal A, Das A, Bahl A, Verma RK, Elangovan A. Prognostic Value of HPV Infection Assessed by p16 Immunohistochemistry and the Influence of Tobacco Usage in Oropharyngeal Cancers: Real World Scenario. Indian J Otolaryngol Head Neck Surg 2022; 74:5823-5831. [PMID: 36742604 PMCID: PMC9895501 DOI: 10.1007/s12070-021-02427-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
To find if an association could be established between Human Papilloma Virus (HPV) infection and oropharyngeal cancers (OPCs) in a group of patients known to be regular users of tobacco, and to determine the impact of HPV status on clinical outcomes.Case records of 212 patients with AJCC-7 (The American Joint Committee on Cancer 7th edition) stages II-IVB non metastatic squamous cell carcinoma of the oropharynx treated using radical radiotherapy with or without chemotherapy during the years 2015-2018 were retrieved. Formalin-fixed, paraffin-embedded blocks from oropharyngeal biopsies were available for 177 patients and were evaluated for p16 expression by immunohistochemical (IHC) staining. More than 50% nuclear staining with or without cytoplasmic staining was considered HPV+ . The association between tobacco use and HPV, as well as the influence of HPV status on survival outcomes were assessed. p16 expression was found to be positive in 23(13%) patients. Significant association was found between chewable tobacco usage and HPV positivity (p = 0.051). The median follow up was 20.5 months (range: 3-80). 5-year Overall Survival was 43.4% and 29.8% (p = 0.044) in HPV+ and HPV- patients, respectively. Local control was significantly better in HPV+ patients (38.6% vs. 25.3%, p = 0.049). There was also a trend towards improved Disease-free Survival in HPV+ patients (31 months vs. 15 months, p = 0.078). Though less in prevalence among the Indian population, improved outcomes in HPV+ OPC patients and widely available IHC HPV assays signifies the routine implementation of p16 testing in day-to-day clinical practice.
Collapse
Affiliation(s)
- Sushmita Ghoshal
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Chinna Babu Dracham
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Archana Sundaram
- Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Kumar
- Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amanjit Bal
- Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashim Das
- Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amit Bahl
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Roshan Kumar Verma
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Elangovan
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
40
|
Gentili C, McClean S, McGeagh L, Bahl A, Persad R, Harcourt D. The impact of hegemonic masculine ideals on self-esteem in prostate cancer patients undergoing androgen deprivation therapy (ADT) compared to ADT-naïve patients. Psychooncology 2022; 31:1958-1971. [PMID: 35833603 DOI: 10.1002/pon.6001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/08/2022] [Accepted: 07/10/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Androgen deprivation therapy (ADT) for Prostate Cancer (PCa) is associated with side effects that could lead to negative body image and low masculine self-esteem of survivors. We compared a group of PCa survivors following ADT with ADT-naïve patients, expecting the ADT group to show lower masculine self-esteem. We also expected patients with hegemonic masculinity ideals to show poorer masculine self-esteem and we hypothesized that ADT would moderate this relationship, expecting PCa patients on ADT with stronger hegemonic ideals to show the worst masculine self-esteem scores among study participants. METHODS We compared 57 PCa survivors on ADT (Mage = 64.16 (7.11)) to 59 ADT-naïve patients (Mage = 65.25 (5.50)), on the Masculine Self-Esteem Scale (MSES), Body Image Scale (BIS), and Hegemonic Masculinity Ideals Scale (HMIS). RESULTS While the two groups did not significantly differ on masculine self-esteem (F [1, 115] = 3.46, p = 0.065, ηp 2 = 0.029) and body image (F [1, 115] = 3.46, p = 0.065, ηp 2 = 0.029), younger age was significantly associated with higher body image issues (F [1, 115] = 8.63, p < 0.01, ηp 2 = 0.071, β = -0.30). Hegemonic masculinity significantly predicted more masculine self-esteem related issues (t (2, 114) = 2.31, β = 0.375, p < 0.05). ADT did not moderate this relationship. CONCLUSIONS The results suggest that endorsing hegemonic masculinity could represent a risk factor for low masculine self-esteem regardless of ADT status and that younger age is associated with negative body image among PCa survivors. IMPLICATIONS These results suggest the importance of inclusion of topics related to hegemonic masculinity when providing support to PCa survivors, both when discussing treatment side effects, as well as in the later phases of survivorship. This pilot also suggests that younger PCa survivors might benefit from body-image focused support regardless of treatment plan.
Collapse
Affiliation(s)
- Caterina Gentili
- Faculty of Health and Applied Sciences, Centre for Appearance Research, University of the West of England, Bristol, UK
| | - Stuart McClean
- Faculty of Health and Applied Sciences, Centre for Public Health & Wellbeing, University of the West of England, Bristol, UK
| | - Lucy McGeagh
- Supportive Cancer Care Research Group, Faculty of Health and Life Sciences, Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK
| | - Amit Bahl
- University Hospitals Bristol NHS Trust, Bristol, UK
| | | | - Diana Harcourt
- Faculty of Health and Applied Sciences, Centre for Appearance Research, University of the West of England, Bristol, UK
| |
Collapse
|
41
|
Bahl A, Johnson S, Mielke N, Chen NW. Risk Factors for Midline Catheter Failure: A Secondary Analysis of an Existing Trial. Ther Clin Risk Manag 2022; 18:999-1007. [PMID: 36238957 PMCID: PMC9553030 DOI: 10.2147/tcrm.s383502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/16/2022] [Indexed: 11/06/2022] Open
Abstract
Objective While midline catheters (MCs) are considered to be a reliable form of vascular access, up to 25% of the placements culminate in failure. We aimed to explore risk factors for MC failure. Methods We performed an analysis of existing randomized controlled trial data involving a comparison of two midline catheters. The study aimed to assess risk factors related to MC failure, including patient, procedure, catheter, and vein characteristics. Cox regression was used for univariable and multivariable analyses to evaluate the association between characteristics and MC failure. Results Among 191 patients that were included in this secondary analysis, more patients were female (114/191 [59.7%]) and average age was 60.2 (SD = 16.7) years. Clinical indications for MC placement included antibiotics (60.7%), difficult venous access (32.5%), or both (6.8%). In a univariable Cox regression analysis, the increase in pulse rate (HR 1.02; 95% CI, 1.00–1.04; P=0.02), temperature ≥38°C (HR 5.59; 95% CI, 1.96–15.94; P=0.001), oxygen saturation <93% (HR 2.91; 95% CI, 1.03–8.24; P=0.04), norepinephrine in dextrose infusion (HR 2.41; 95% CI, 1.17–4.97; P=0.02) and cephalic vein insertion (HR, 2.47; 95% CI, 1.09–5.57; P=0.03) were all associated with higher risk of MC failure. In a multivariable Cox model, difficult venous access (aHR 2.05; 95% CI, 1.04–4.05; P=0.04) and norepinephrine in dextrose (aHR 2.29; 95% CI, 1.09–4.82; P=0.03) was associated with catheter failure. Conclusion Elevated pulse rate, decreased oxygen saturation level, temperature ≥38°C, and norepinephrine use were each associated with an increased risk of MC failure. These factors should be considered when selecting the most appropriate vascular access device for individual patients. Additionally, the cephalic vein insertion has the highest risk for MC failure and other access points could be preferentially considered.
Collapse
Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA,Correspondence: Amit Bahl, Department of Emergency Medicine, Beaumont Hospital, Royal Oak, 3601 13 Mile Road, Royal Oak, MI, 48073, USA, Email
| | - Steven Johnson
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nai-Wei Chen
- Research Institute, Beaumont Hospital, Royal Oak, MI, USA
| |
Collapse
|
42
|
Murgić J, Fröbe A, Challapalli A, Bahl A. ROLE OF ANDROGEN RECEPTOR-TARGETED AGENTS IN LOCALIZED PROSTATE CANCER. Acta Clin Croat 2022; 61:51-56. [PMID: 36938555 PMCID: PMC10022413 DOI: 10.20471/acc.2022.61.s3.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023] Open
Abstract
Anti-androgen therapy continues to be a basic pilar of treatment for both localized and metastatic prostate cancer. The advent of new generation of androgen receptor targeted agents (ARTA) transformed the care of patients with advanced disease. After such a success, the steps were taken to incorporate a new generation of ARTAs into the treatment landscape of localized prostate cancer. High-risk prostate cancer represents the most aggressive form of localized disease with significant metastatic potential and poor outcome. Here, the impact of novel therapies will likely be profound and transforming. This clinical space has already been a showcase for multidisciplinary treatment where the combination of local therapies with systemic treatment gradually improved patient outcomes and the chances of cure. The most recent step in redefining the treatment of localized disease is the adoption of novel ARTAs moving forward the multidisciplinary platform. In this narrative review, we discuss current clinical evidence supporting the use of novel ARTAs in patients with localized high-risk prostate cancer and cover recent developments in biomarker-driven strategies for treatment individualization in this clinical context.
Collapse
Affiliation(s)
- Jure Murgić
- Department of Oncology and Nuclear Medicine, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ana Fröbe
- Department of Oncology and Nuclear Medicine, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia
| | - Amarnath Challapalli
- University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol BS13NU, UK
| | - Amit Bahl
- University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol BS13NU, UK
| |
Collapse
|
43
|
Johnson S, Pai E, Voroba A, Chen NW, Bahl A. 222 ED-ACT, Examining D-dimer and Empiric Anti-coagulation in COVID-19 Related Thrombosis. Ann Emerg Med 2022. [PMCID: PMC9519214 DOI: 10.1016/j.annemergmed.2022.08.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
44
|
Challapalli A, Ratnayake G, McGrane J, Frazer R, Gupta S, Parslow D, Kingdon S, Lydon A, Sharma A, Tuthill M, McCusker C, Ford V, Ferrera A, Malik J, Boh Z, Jones E, T.R. Geldart, Nelmes S, Brown J, Bahl A. 1463P Patterns of care and outcomes of metastatic renal cell carcinoma (mRCC) patients (pts) with bone metastases (BM): A UK multicenter review. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
45
|
Ratnayake G, Challapalli A, McGrane J, Frazer R, Gupta S, Parslow D, Kingdon S, Lydon A, Sharma A, Tuthill M, McCartney T, Jabbar R, Charnley N, Malik J, Abhi D, Chau C, Geldart T, Halstead A, Anuforom U, Bahl A. 1457P A UK multicentre retrospective review of metastatic renal cell carcinoma (mRCC) patients (pts) outcomes with brain metastases (BM) in the modern era. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
46
|
McGuire D, Mielke N, Bahl A. Atypical Presentation of Traumatic Pediatric Carotid Artery Dissection: A Case Report. Clin Pract Cases Emerg Med 2022; 6:229-231. [PMID: 36049190 PMCID: PMC9436487 DOI: 10.5811/cpcem.2022.4.56488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/15/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: Carotid artery dissection is a rare but serious condition manifesting with signs and symptoms that closely overlap with other more benign medical diagnoses. This vascular injury, however, can result in debilitating sequelae, including thromboembolic cerebrovascular accidents. Case Report: We describe the atypical presentation of a healthy eight-year-old male who presented to the emergency department (ED) with generalized abdominal pain and non-bloody, non-bilious emesis. These symptoms occurred nine days after he sustained blunt head trauma after a non-syncopal fall from standing while playing hockey. He was initially diagnosed with gastroesophageal reflux disease and constipation and was discharged home. The following day he developed an acute headache followed shortly by gait ataxia, prompting a return visit to the ED. Imaging of the head and neck revealed a left internal carotid artery dissection. The patient was started on intravenous unfractionated heparin and admitted to the hospital. He was later discharged symptom-free on therapeutic enoxaparin for eight weeks, followed by daily aspirin therapy. Conclusion: Pediatric trauma patients, especially those sustaining insult to the head and cervical spine, are at risk for craniocervical arterial injuries. This rare but dangerous pathology often manifests in a non-specific, delayed fashion making it a challenging diagnosis for physicians to make on the initial medical encounter.1,2 Maintaining a high clinical suspicion for carotid artery dissection is required to make this diagnosis and should guide a thorough history, physical examination, and appropriate imaging in order to improve patient morbidity and mortality. This case emphasizes key clinical features and risk factors of this disease that may help emergency clinicians promptly recognize and treat this entity.
Collapse
Affiliation(s)
- Duncan McGuire
- Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine, Department of Emergency Medicine, Royal Oak, Michigan
| | - Amit Bahl
- Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| |
Collapse
|
47
|
McGeagh L, Robles LA, Persad R, Rowe E, Bahl A, Aning J, Koupparis A, Abrams P, Perks C, Holly J, Johnson L, Shiridzinomwa C, Challapalli A, Shingler E, Taylor H, Oxley J, Sandu M, Martin RM, Lane JA. Prostate cancer-Exercise and Metformin Trial (Pre-EMpT): study protocol for a feasibility factorial randomized controlled trial in men with localised or locally advanced prostate cancer. Pilot Feasibility Stud 2022; 8:179. [PMID: 35962445 PMCID: PMC9372971 DOI: 10.1186/s40814-022-01136-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Evidence from observational studies have shown that moderate intensity physical activity can reduce risk of progression and cancer-specific mortality in participants with prostate cancer. Epidemiological studies have also shown participants taking metformin to have a reduced risk of prostate cancer. However, data from randomised controlled trials supporting the use of these interventions are limited. The Prostate cancer–Exercise and Metformin Trial examines that feasibility of randomising participants diagnosed with localised or locally advanced prostate cancer to interventions that modify physical activity and blood glucose levels. The primary outcomes are randomisation rates and adherence to the interventions over 6 months. The secondary outcomes include intervention tolerability and retention rates, measures of insulin-like growth factor I, prostate-specific antigen, physical activity, symptom-reporting, and quality of life. Methods Participants are randomised in a 2 × 2 factorial design to both a physical activity (brisk walking or control) and a pharmacological (metformin or control) intervention. Participants perform the interventions for 6 months with final measures collected at 12 months follow-up. Discussion Our trial will determine whether participants diagnosed with localised or locally advanced prostate cancer, who are scheduled for radical treatments or being monitored for signs of cancer progression, can be randomised to a 6 months physical activity and metformin intervention. The findings from our trial will inform a larger trial powered to examine the clinical benefits of these interventions. Trial registration Prostate Cancer Exercise and Metformin Trial (Pre-EMpT) is registered on the ISRCTN registry, reference number ISRCTN13543667. Date of registration 2nd August 2018–retrospectively registered. First participant was recruited on 11th September 2018.
Collapse
Affiliation(s)
- Lucy McGeagh
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.,Supportive Cancer Care Research Group, Faculty of Health and Life Sciences, Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK
| | - Luke A Robles
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Raj Persad
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Edward Rowe
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jonathan Aning
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | | | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Claire Perks
- Insulin-like Growth Factors and Metabolic Endocrinology Group, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jeffrey Holly
- Insulin-like Growth Factors and Metabolic Endocrinology Group, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lyndsey Johnson
- Clinical Research Centre, North Bristol NHS Trust, Bristol, UK
| | | | - Amarnath Challapalli
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ellie Shingler
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Hilary Taylor
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.,Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Meda Sandu
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Richard M Martin
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.,Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - J Athene Lane
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK. .,Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.
| |
Collapse
|
48
|
Johnson S, Mielke N, Mathew T, Maine GN, Chen N, Bahl A. Predictors of hospitalization and severe disease due to breakthrough SARS‐CoV‐2 infection in fully vaccinated individuals. J Am Coll Emerg Physicians Open 2022; 3:e12793. [PMID: 35919515 PMCID: PMC9337843 DOI: 10.1002/emp2.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/18/2022] [Accepted: 07/12/2022] [Indexed: 11/12/2022] Open
Abstract
Objective We aimed to identify risk factors for hospital admission and severe disease among fully vaccinated (FV) individuals with COVID‐19. Further, we investigated if risk factors for hospitalization and severe disease are similar between unvaccinated (UV) and vaccinated individuals. Methods This was a multicenter, observational cohort analysis from a large regional healthcare system in metro Detroit using electronic health record data to evaluate risk factors for hospitalization and severe COVID‐19 disease. Vaccination data were retrieved using electronic medical records linked to our statewide immunization database. Consecutive adult FV and UV patients with a primary admission diagnosis of COVID‐19 were included in the comparative analysis. Partially vaccinated patients and patients who had received a booster dose were excluded. The primary outcome of this study was hospital admission and severe disease inclusive of intensive care unit (ICU) admission, mechanical ventilation, or death. Results Between December 15, 2020 and December 19, 2021, 20,584 emergency department visits met our inclusion criteria. Among these, 2005 (9.7%) visits consisted of FV individuals, 18,579 (90.3%) were UV, and 40.3% of UV and 52.7% of FV required hospitalization with similar (12.7% and 12.6%, respectively) rates of severe disease. Hospitalized UV patients with severe disease were younger than their FV counterparts (49.5% <65 years vs. 13.5% p < 0.001). Risk factors for severe disease on UV and FV included age ≥65 years (UV: adjusted odds ratio [aOR] 1.49, 95% confidence interval [CI] 1.28–1.73, p < 0.001 and FV: aOR 2.50, 95% CI 1.44–4.36 p = 0.001) and weighted Elixhauser score >10 (UV: aOR 9.11, 95% CI 6.92–12.00, p < 0.001 and FV: aOR 6.04, 95% CI 2.68–13.26, p < 0.001). However, only on UV status, body mass index (BMI) ≥30 kg/m2 was associated with increased odds of severe disease (aOR 2.59, 95% CI 2.09–3.22, p < 0.001). Conclusions FV patients with breakthrough SARS‐CoV‐2 infection who require hospitalization and have severe disease are older and have more medical comorbidities compared to UV patients. When comparing risk factors for severe disease between UV and FV individuals, FV status is particularly associated with reduced risk among patients with a BMI ≥30 kg/m2 and a moderate number of medical comorbidities, regardless of age, highlighting the importance of vaccination in these particularly vulnerable groups.
Collapse
Affiliation(s)
- Steven Johnson
- Department of Emergency Medicine Beaumont Hospital Royal Oak USA
| | - Nicholas Mielke
- Oakland University, William Beaumont School of Medicine Royal Oak USA
| | - Trini Mathew
- Department of Infectious Disease Beaumont Hospital Royal Oak USA
| | - Gabriel N Maine
- Histocompatibility Laboratory Beaumont Hospital Royal Oak USA
| | | | - Amit Bahl
- Department of Emergency Medicine Beaumont Hospital Royal Oak USA
| |
Collapse
|
49
|
Payne HA, Jain S, Peedell C, Edwards A, Thomas JA, Das P, Hansson Hedblom A, Woodward E, Saunders R, Bahl A. Delphi study to identify consensus on patient selection for hydrogel rectal spacer use during radiation therapy for prostate cancer in the UK. BMJ Open 2022; 12:e060506. [PMID: 35858729 PMCID: PMC9305805 DOI: 10.1136/bmjopen-2021-060506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify consensus on patient prioritisation for rectal hydrogel spacer use during radiation therapy for the treatment of prostate cancer in the UK. DESIGN Delphi study consisting of two rounds of online questionnaires, two virtual advisory board meetings and a final online questionnaire. SETTING Radical radiation therapy for localised and locally advanced prostate cancer in the UK. PARTICIPANTS Six leading clinical oncologists and one urologist from across the UK. INTERVENTIONS Rectal hydrogel spacer. PRIMARY AND SECONDARY OUTCOME MEASURES None reported. RESULTS The panel reached consensus on the importance of minimising toxicity for treatments with curative intent and that even low-grade toxicity-related adverse events can significantly impact quality of life. There was agreement that despite meeting rectal dose constraints, too many patients experience rectal toxicity and that rectal hydrogel spacers in eligible patients significantly reduces toxicity-related adverse events. However, as a consequence of funding limitations, patients need to be prioritised for spacer use. A higher benefit of spacers can be expected in patients on anticoagulation and in patients with diabetes or inflammatory bowel disease, but consensus could not be reached regarding patient groups expected to benefit less. While radiation therapy regimen is not a main factor determining prioritisation, higher benefit is expected in ultrahypofractionated regimens. CONCLUSION There is a strong and general agreement that all patients with prostate cancer undergoing radical radiation therapy have the potential to benefit from hydrogel spacers. Currently, not all patients who could potentially benefit can access hydrogel spacers, and access is unequal. Implementation of the consensus recommendations would likely help prioritise and equalise access to rectal spacers for patients in the UK.
Collapse
Affiliation(s)
- Heather Ann Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Suneil Jain
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Clive Peedell
- Department of Radiotherapy and Oncology, James Cook University Hospital, Middlesbrough, UK
| | | | | | - Prantik Das
- Department of Oncology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Emily Woodward
- Health Economics, Boston Scientific AG, Solothurn, Switzerland
| | | | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| |
Collapse
|
50
|
Johnson SE, Pai E, Voroba A, Chen NW, Bahl A. Examining D-dimer and Empiric Anti-coagulation in COVID-19-Related Thrombosis. Cureus 2022; 14:e26883. [PMID: 35978762 PMCID: PMC9375952 DOI: 10.7759/cureus.26883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Thrombosis is thought to occur frequently in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to elucidate the relationship between macro/microvascular thrombosis, D-dimer levels, and empiric anticoagulation in coronavirus disease 2019 (COVID-19). Methods This was an exploratory prospective, single-site, observational study. Adult emergency department patients with COVID-19 requiring hospitalization received a point-of-care lower extremity venous duplex ultrasound. The primary endpoint was thromboembolism and associated D-dimer level. Secondary endpoints included rates of micro and macro thrombotic complications as well as empiric anticoagulant use. Results Between January 13th and April 12th 2021, 52 patients were enrolled. Median D-dimer at presentation was 650 ng/mL (range 250-10,000 ng/mL) among patients with negative duplex studies. During hospitalization, 18 patients underwent 20 additional studies assessing for venous thromboembolism (VTE). These studies yielded one deep vein thrombosis (DVT) diagnosis. Among patients with negative studies median D-dimer was 1,246 ng/mL (range 329-10,000 ng/mL). Two patients experienced microvascular complications. Seven patients were started on empiric full dose anticoagulation. Conclusion While VTE remains a major concern amongst patients with COVID-19, the normal D-dimer cut off of >500 ng/mL likely should not be used to initiate further VTE workup. Additionally, moderately elevated D-dimer did not correlate strongly with microvascular complications and may not be relevant in the decision to initiate empiric anticoagulation.
Collapse
|