Antibody-Suppressor CXCR5+CD8+ T Cells Are More Potent Regulators of Humoral Alloimmunity after Kidney Transplant in Mice Compared to CD4+ Regulatory T Cells

Adoptive cell therapy (ACT), especially with CD4+ regulatory T cells (CD4+ Tregs), is an emerging therapeutic strategy to minimize immunosuppression and promote long-term allograft acceptance, although much research remains to realize its potential. In this study, we investigated the potency of novel Ab-suppressor CXCR5+CD8+ T cells (CD8+ TAb-supp) in comparison with conventional CD25highFoxp3+CD4+ Tregs for suppression of humoral alloimmunity in a murine kidney transplant (KTx) model of Ab-mediated rejection (AMR). We examined quantity of peripheral blood, splenic and graft-infiltrating CD8+ TAb-supp, and CD4+ Tregs in KTx recipients and found that high alloantibody-producing CCR5 knockout KTx recipients have significantly fewer post-transplant peripheral blood and splenic CD8+ TAb-supp, as well as fewer splenic and graft-infiltrating CD4+ Tregs compared with wild-type KTx recipients. ACT with alloprimed CXCR5+CD8+ T cells reduced alloantibody titer, splenic alloprimed germinal center (GC) B cell quantity, and improved AMR histology in CCR5 knockout KTx recipients. ACT with alloprimed CD4+ Treg cells improved AMR histology without significantly inhibiting alloantibody production or the quantity of splenic alloprimed GC B cells. Studies with TCR transgenic mice confirmed Ag specificity of CD8+ TAb-supp-mediated effector function. In wild-type recipients, CD8 depletion significantly increased alloantibody titer, GC B cells, and severity of AMR pathology compared with isotype-treated controls. Anti-CD25 mAb treatment also resulted in increased but less pronounced effect on alloantibody titer, quantity of GC B cells, and AMR pathology than CD8 depletion. To our knowledge, this is the first report that CD8+ TAb-supp cells are more potent regulators of humoral alloimmunity than CD4+ Treg cells.

Patient-perceived understanding of home-going medication with transitions of care services at a pediatric institution

BACKGROUND

Transitions of care (TOC) is the coordination and continuity of healthcare as a patient transfers between different settings.1 This can include a wide range of services, such as medication reconciliation, patient counseling, bedside delivery of medications, and others that meet individual patient needs.2 In the pediatric population, patients are at increased risk of potential medication errors and subsequent harm due to reduced patient and/or caregiver health literacy, limited dosage form availability, and errors in medication administration.5 The use of TOC services at the time of hospital discharge in this population has the potential to make a positive impact on patient safety and the treatment of medical conditions.

OBJECTIVES

The primary objective of this study was to determine if patient-perceived understanding of home-going medications was greater in patients and/or caregivers that received medication bedside delivery and education from a pharmacy-led TOC service at a large, pediatric academic medical center. The secondary objective was to determine if the primary practice area of the pharmacist providing medication education led to changes in understanding of home-going medication(s).

METHODS

Using institution-wide, patient satisfaction surveys from January 1, 2021, through December 31, 2021, patient and/or caregiver responses were queried for two questions about home-going medications, relating to the understanding of administration and the potential side effects. Patients were divided into two groups depending on TOC services received, as documented in the electronic medical record (EMR). Survey responses for each of the two questions were categorized as top-box percentage by study group. Hypothesis testing between study groups for the primary and secondary outcomes were conducted using chi-squared tests at an alpha of 0.05. Statistical analyses were conducted using SAS version 9.4.

RESULTS

Of the 1,159 patients included in the study, 441 received TOC services, deemed the intervention group, and 718 did not receive TOC services, deemed the control group. When the intervention and control group were asked about understanding of medication administration, 96.37% versus 93.18% (p=0.007) of patients gave the most favorable response of "yes, definitely," respectively. Further, 78.51% versus 77.44% (p=0.053) of patients gave the most favorable response when asked about understanding potential medication side effects, respectively.

CONCLUSION

Patients receiving TOC services by a member of the pharmacy team had a greater score for understanding of both medication administration and side effects. Furthermore, this greater score was consistent among the education provided by the inpatient and outpatient pharmacist.

National learning curves among robotic thoracic surgeons in the United States: Quantifying the impact of procedural experience on efficiency and productivity gains

OBJECTIVE

This study aims to characterize the aggregate learning curves of US surgeons for robotic thoracic procedures and to quantify the impact on productivity.

METHODS

National average console times relative to cumulative case number were extracted from the My Intuitive application (Version 1.7.0). Intuitive da Vinci robotic system data for 56,668 lung resections performed by 870 individual surgeons between 2021 and 2022 were reviewed. Console time and hourly productivity (work relative value units/hour) were analyzed using linear regression models.

RESULTS

Average console times improved for all robotic procedures with cumulative case experience (P = .003). Segmentectomy and thymectomy had the steepest initial learning curves with a 33% and 34% reduction of the average console time for proficient (51-100 cases) relative to novice surgeons (1-10 cases), respectively. The hourly productivity increase for proficient surgeons ranged from 11.4 work relative value units/hour (+26%) for lobectomy to 17.0 work relative value units/hour (+50%) for segmentectomy. At the expert level (101+ cases), average console times continued to decrease significantly for esophagectomy (-18%) and lobectomy (-23%), but only minimally for wedge resections (-1%) (P = .003). The work relative value units/hour increase at the expert level reached 50% for lobectomy and 40% for esophagectomy. Surgeon experience level, dual console use, system model, and robotic stapler use were factors independently associated with console time for robotic lobectomy.

CONCLUSIONS

The aggregate learning curve for robotic thoracic surgeons in the United States varies significantly by procedure type and demonstrate continued improvements in efficiency beyond 100 cases for lobectomy and esophagectomy. Improvements in efficiency with growing experiences translate to substantial productivity gains.

Incidence of subsequent surgical decompression following minimally invasive approaches to treat lumbar spinal stenosis: A retrospective review

BACKGROUND CONTEXT

Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression.

PURPOSE

To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years.

OUTCOME MEASURES

The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery.

METHODS

Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors.

RESULTS

A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively.

CONCLUSIONS

Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

CXCR5 + CD8 + T Cell-mediated Suppression of Humoral Alloimmunity and AMR in Mice Is Optimized With mTOR and Impaired With Calcineurin Inhibition

BACKGROUND

Adoptive cellular therapy (ACT) with antibody-suppressor CXCR5 + CD8 + T cells (CD8 + T Ab-supp ) inhibits alloantibody production, antibody-mediated rejection (AMR), and prolongs graft survival in multiple transplant mouse models. However, it is not known how conventional immunosuppressive agents impact the efficacy of CD8 + T Ab-supp ACT.

METHODS

We investigated the efficacy of CD8 + T Ab-supp cell ACT when combined with calcineurin inhibitor (CNi) or mammalian target of rapamycin inhibitor (mTORi) in a murine model of kidney transplant.

RESULTS

ACT-mediated decrease in germinal center B cells, posttransplant alloantibody titer, and amelioration of AMR in high alloantibody-producing CCR5 knockout kidney transplant recipients were impaired when ACT was combined with CNi and enhanced when combined with mTORi. CNi (but not mTORi) reduced ACT-mediated in vivo cytotoxicity of IgG + B cells and was associated with increased quantity of germinal center B cells. Neither CNi nor mTORi treatment impacted the expression of cytotoxic effector molecules (FasL, Lamp1, perforin, granzyme B) by CD8 + T Ab-supp after ACT. Concurrent treatment with CNi (but not mTORi) reduced in vivo proliferation of CD8 + T Ab-supp after ACT. The increase in quantity of splenic CD44 + CXCR5 + CD8 + T cells that occurs after ACT was reduced by concurrent treatment with CNi but not by concurrent treatment with mTORi (dose-dependent).

CONCLUSIONS

Impaired efficacy of ACT by CNi is attributed to reduced persistence and/or expansion of CD8 + T Ab-supp cells after ACT. In contrast, concurrent immunosuppression with mTORi preserves CD8 + T Ab-supp cells quantity, in vivo proliferation, and in vivo cytotoxic effector function after ACT and enhances suppression of humoral alloimmunity and AMR.

Clinical outcomes and cost savings of a nonmedical switch to a biosimilar in children/young adults with inflammatory bowel disease

OBJECTIVES

The safety, efficacy, and cost savings associated with biosimilar medications are well established. However, a lack of pediatric data exists surrounding clinical outcomes when switching from an originator to a biosimilar. Our primary aim is to evaluate clinical outcomes following a nonmedical switch from the infliximab originator to a biosimilar in children and young adults with inflammatory bowel disease (IBD). Our secondary aim is to estimate cost savings associated with this switch.

METHODS

A quality improvement project was implemented to establish safe switching protocols, then those patients who underwent a nonmedical switch from the infliximab originator to the biosimilar were retrospectively reviewed. Demographic data, physician global assessments (PGAs), and laboratory values were recorded 1 year pre- and post-switch. Continuation rates on the biosimilar were reported at 6 and 12 months. Cost savings were estimated using two different pricing models.

RESULTS

Fifty-three patients underwent a nonmedical switch. Laboratory values including inflammatory markers, infliximab levels, and PGA scores remained similar when assessed pre- and post-switch. No infusion reactions or antidrug antibody development occurred. Two patients reported psoriasis-like rashes. Five patients switched back to the originator during the study period. There were 379 biosimilar infusions completed with an estimated total cost savings of $11,260 (average sales price) and $566,223 (wholesale acquisition cost).

CONCLUSIONS

Clinical remission rates, inflammatory laboratory markers, serious adverse events, infliximab levels, and antidrug antibodies remained similar after a one-time nonmedical switch to an infliximab biosimilar. Nonmedical switching to biosimilars resulted in significant cost savings.

Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.

Discrepancy Between Reported and Calculated Pain Reduction in Patients With Spinal Cord Stimulation Therapy and Lack of Agreement Between Patient Satisfaction and Degree of Pain Relief

OBJECTIVES

This study aimed to determine agreement between reported percentage pain reduction (RPPR) and calculated percentage pain reduction (CPPR) in patients with percutaneous spinal cord stimulation (SCS) implants, and to correlate RPPR and CPPR with patient satisfaction. We also sought to determine which patient-reported outcome measures are most improved in patients with SCS.

MATERIALS AND METHODS

Fifty patients with percutaneous spinal cord stimulator implants with a mean follow-up of 51.1 months were interviewed and surveyed to assess their pain level, impression of degree of pain relief, satisfaction with the therapy, and desire to have the device again. Baseline pain level was obtained from their preimplant records.

RESULTS

Overall, RPPR was found to be 53.3%, whereas CPPR was 44.4%. Of all patients, 21 reported <50% pain reduction; however, most of these (12/21, 57%) were satisfied with the outcome of therapy. In terms of individual improvement in outcomes, activities of daily life was the most improved measure at 82%, followed by mood, sleep, medication use, and health care utilization at 74%, 62%, 50%, and 48%, respectively.

CONCLUSIONS

RPPR appears to be a complex outcome measure that may not agree with CPPR. Overall RPPR is greater than the CPPR. On the basis of our data, these independently valid measures should not be used interchangeably. A 50% pain reduction threshold is not a requisite for patient satisfaction and desire to have the device again. Activities of daily living was the most improved measure in this cohort, followed by mood, sleep, medication usage, and decrease in health care utilization.

A self calibrating, magnetic sensor approach accurately positions an aortic damage control stent in a porcine model

Objectives

Non-compressible torso hemorrhage remains a high mortality injury, with difficulty mobilizing resources before exsanguination. Previous studies reported on a retrievable stent graft for damage control and morphometric algorithms for rapid placement, yet fluoroscopy is impractical for the austere environment. We hypothesized that magnetic sensors could be used to position stents relative to an external magnet placed on an anatomic landmark, whereas an electromagnet would allow self-calibration to account for environmental noise.

Methods

A magnetic sensor alone (MSA) and with integrated stent (MSIS) were examined in a porcine model under anesthesia. A target electromagnet was placed on the xiphoid process (position 0 cm). Sensors were placed in the aorta and measurements obtained at positions 0 cm, +4 cm, and +12 cm from the magnet and compared with fluoroscopy. Sensors were examined under conditions of tachycardia/hypertension, hypotension, vibration, and metal shrapnel to simulate environmental factors that might impact accuracy. General linear models compared mean differences between fluoroscopy and sensor readings.

Results

Both sensors were compatible with a 10 French catheter system and provided real-time assessment of the distance between the sensor and magnetic target in centimeters. Mean differences between fluoroscopy and both magnetic sensor readings demonstrated accuracy within ±0.5 cm for all but one condition at 0 cm and +4 cm, whereas accuracy decreased at +12 cm from the target. Using the control as a reference, there was no significant difference in mean differences between fluoroscopy and both MSA or MSIS readings at 0 cm and +4 cm for all conditions. The system retained effectiveness if the target was overshot.

Conclusion

Magnetic sensors achieved the highest accuracy as sensors approached the target. Oscillation of the electromagnet on and off effectively accounts for environmental noise.This approach is promising for rapid and accurate placement of damage control retrievable stent grafts when fluoroscopy is impractical.

Level of evidence

Not applicable.

Similar Growth Outcomes in Children with Inflammatory Bowel Disease Initiated on Infliximab Originator or Biosimilar

BACKGROUND

Growth is an important clinical outcome, especially in childhood-onset inflammatory bowel disease (IBD). Prior research has demonstrated growth improvements with infliximab therapy. There are limited studies evaluating whether clinical and growth outcomes in children initiated on the infliximab originator and infliximab biosimilar are similar.

METHODS

This was a single-center retrospective review of patients with IBD, younger than 17 years old, and initiated on the infliximab originator or biosimilar for at least 12 months between April 2016 and February 2021. Propensity score matching was utilized. Laboratory values, disease activity scores, and growth values were collected at baseline (prior to infliximab initiation), 6 months, and 12 months post initiation. Linear mixed models with random intercepts were used to test differences in measures over time and between study groups.

RESULTS

There were 113 patients on the originator and 39 patients on a biosimilar who met eligibility criteria. Propensity score methodology identified 37 dyads (1:1 match). Weight, height, and body mass index z scores increased over time (from baseline to 12 months) for both groups ( P < 0.05) and there was a similar rate of change between study groups. Clinical outcomes of lab values (albumin, C-reactive protein, and hemoglobin) and disease activity scoring were similar from baseline to 12 months between study groups.

CONCLUSIONS

There were similar improvements in growth and clinical outcomes in patients initiated on the infliximab originator compared to an infliximab biosimilar agent. This study adds to the limited research evaluating whether infliximab biosimilars have similar growth outcomes in children with IBD.

Bariatric Patient Engagement in a Pre-surgery Virtual Patient Navigation Platform (VPNP)

BACKGROUND

This study analyzed patient engagement with a virtual patient navigation platform (VPNP) designed to help guide bariatric surgery candidates through the complex pre-operative workup for surgery.

METHODS

Data on baseline sociodemographic and medical history was collected on patients enrolled in the bariatric program at a single academic institution between March and May 2021. The System Usability Scale (SUS) survey was administered to assess VPNP usability. Two groups emerged: "engaged" (ENG; n = 30) who activated their accounts and completed the SUS, and "not-engaged" (NEG; n = 35) who did not activate their accounts (n = 13) or did not use the app (n = 22) and were therefore ineligible for the SUS survey.

RESULTS

Analyses demonstrated that only insurance status differed between groups (private insurance: 60% versus 34.3% for ENG versus NEG, respectively; p = 0.038). SUS survey analysis demonstrated high perceived usability (median score = 86.3), corresponding to the 97th percentile of usability. The top three reasons for disengagement included being too busy (22.9%), not being interested (20%), and being unsure about the purpose of the app (20%).

CONCLUSIONS

The VPNP scored in the 97th percentile of usability. However, given a majority of patients did not engage with the app, and engagement was associated with completing pre-surgery requirements faster (unpublished), future work will focus on mitigating identified reasons for patients not engaging.

Impact of pharmacist alternative therapy interventions in a pediatric Medicaid population

BACKGROUND: Ambulatory clinical pharmacists are viewed as the medication experts on the health care team and frequently assist with medication access concerns. However, medication access and insurance navigation are difficult because of wide variations in insurance formularies. Accountable care organizations (ACOs) incorporate pharmacists as members of their population health teams to assist with these efforts. These ACO pharmacists are uniquely positioned to assist pediatric ambulatory care pharmacists with medication access concerns. This collaboration has the potential to not only improve patient care but also provide cost savings. OBJECTIVE: To estimate cost savings to an ACO derived from alternative therapy interventions made by pharmacists embedded in pediatric ambulatory clinics, using resources created by ACO pharmacists, within a pediatric Medicaid population. The secondary objectives were to quantify the frequency of alternative therapy interventions provided by these pharmacists, evaluate the impact on medication access through the avoidance of prior authorizations (PAs), and assess the frequency and cost savings of alternative therapy interventions per treatment category. METHODS: This was a retrospective review of alternative therapy interventions provided by pediatric ambulatory care pharmacists within a health-system in central Ohio. Interventions were collected within an electronic health record from January 1, 2020, to December 31, 2020. Cost savings were calculated using average wholesale pricing, and PA avoidance was quantified. RESULTS: A total of 278 alternative therapy interventions were made with an estimated cost savings of $133,191.43. Primary care clinics (n = 181, 65%) had the most documented interventions. A total of 174 (63%) interventions resulted in the avoidance of a PA. The antiallergen (28%) treatment category had the most documented interventions. CONCLUSIONS: Alternative therapy interventions were provided by pediatric ambulatory care pharmacists in collaboration with pharmacists working for an ACO. The use of ACO prescribing resources can result in cost savings to an ACO and PA avoidance within a pediatric Medicaid population. DISCLOSURES: The statistical analysis of this work was supported by the National Center for Advancing Translational Sciences (CTSA Grant UL1TR002733). Dr Sebastian discloses her role as a pharmacy consultant for Molina Healthcare Pharmacy and Therapeutics Committee. All other authors declare no relevant conflicts of interest or financial relationships.

Perceptually Discriminating the Highest Priority Alarms Reduces Response Time: A Retrospective Pre-Post Study at Four Hospitals

OBJECTIVE

Reduce nurse response time for emergency and high-priority alarms by increasing discriminability between emergency and all other alarms and suppressing redundant and likely false high-priority alarms in a secondary alarm notification system (SANS).

BACKGROUND

Emergency alarms are the most urgent, requiring immediate action to address a dangerous situation. They are clinician-triggered and have higher positive predictive value (PPV). High-priority alarms are automatically triggered and have lower PPV.

METHOD

We performed a retrospective pre-post study, analyzing data 15 months before and 25 months after a SANS redesign was implemented in four hospitals. For emergency alarms, we incorporated digitized human speech to distinguish them from automatically triggered alarms, leaving their onset and escalation pathways unchanged. For automatically triggered alarms, we suppressed some by delaying initial onset and escalation by 20 s. We used linear mixed models to assess the change in response time, Fisher's exact test for the proportion of response times longer than 120 s, and control charts for process stability.

RESULTS

Response time for emergency alarms decreased at all hospitals (main, from 26.91 s to 22.32 s, p < .001; cardiac, from 127.10 s to 52.43 s, p < .001; cancer, from 18.03 s to 15.39 s, p < .001). Improvements were sustained. Automatically triggered alarms decreased 25.0%. Response time for the three automatically triggered cardiac alarms increased at the four hospitals.

CONCLUSION

Auditory sound disambiguation was associated with a sustained reduced nurse response time for emergency alarms, but suppressing some high-priority automatically triggered alarms was not.

APPLICATION

Distinguishing and escalating urgent, actionable alarms with higher PPV improves response time.

Prevalence and Predictability of Occult Satellite Nodules in Clinical Stage Ia Non-small Cell Lung Cancer following Lobectomy

INTRODUCTION

We sought to assess the prevalence and clinical predictors of satellite nodules in patients undergoing lobectomy for clinical stage Ia disease.

PATIENTS AND METHODS

The National Cancer Database was queried for patients who underwent lobectomy for clinical stage cT1N0 NSCLC. Collaborative staging information was used to identify patients who were pathologically upstaged based on having separate tumor nodules in the same lobe as the primary tumor. Multivariable logistic regression was used to assess the association of clinical factors with the detection of separate nodules.

RESULTS

A separate tumor nodule was recorded in 2.8% (n = 1284) of 45,842 clinical stage Ia patients treated with lobectomy or bilobectomy. Female gender (3.1% vs. male 2.5%; P = .002) and non-squamous histology (adenocarcinoma 3.2% and large cell neuroendocrine 3.0% vs. squamous cell 1.9% tumors; P < .001) were associated with the presence of separate nodules. The frequency increased for tumors larger than 3 cm (≤ 3cm, 2.7% vs. > 3cm, 3.8%; P < .001). Other factors associated with separate nodules were upper lobe location, pleural and/or lymphovascular invasion and occult lymph node disease. The best predictive model for separate nodules based on the available clinical variables resulted in an area under the curve of 0.645 (95% CI 0.629-0.660).

CONCLUSION

Separate tumor nodules may be detected with a low but relatively consistent frequency across the spectrum of patients with clinical stage Ia NSCLC. The predictive ability using basic clinical factors in the database is limited.

The Impact of Medication Synchronization on Proportion of Days Covered within the Pediatric Setting

Introduction

Poor adherence to medication regimens accounts for the substantial worsening of disease, death, and increased healthcare costs of approximately $100 billion annually in the United States. Patients participating in medication synchronization had 3.4 to 6.1 times increased odds of adherence, depending on the drug class. Abundant literature supports medication synchronization within the adult population. This IRB-exempt, prospective quality improvement project is an example of implementing and assessing medication synchronization inclusive of the pediatric setting.

Methods

This study is a single-center, prospective, quality improvement project for patients seen at Nationwide Children's Hospital (NCH) Complex Care Clinic that also fill prescriptions at NCH Outpatient Pharmacies. The project assessed patient medication adherence using the Proportion of Days Covered and the number of trips to the pharmacy 90 days before and 90 days postimplementation. We also assessed patient and pharmacy staff satisfaction 3 months after project implementation.

Results

There was a statistically significant increase in the number of days covered for patients 90 days postimplementation compared to 90 days before implementation (Difference: 3.60; 95% confidence interval: 1.87, 5.33; P = 0.001). Additionally, there was a statistically significant decrease in pharmacy trips pre- and postimplementation (Difference: 2.17; 95% confidence interval: 1.26, 3.07; P < 0.001). Overall, pharmacy staff and patients reported satisfaction with the service.

Conclusions

Implementing a medication synchronization service improved medication adherence and decreased trips to the pharmacy within the pediatric population.

Mouse Model of Spinal Cord Hypoperfusion with Immediate Paralysis Caused by Endovascular Repair of Thoracic Aortic Aneurysm

BACKGROUND

A clinically relevant mouse model of thoracic endovascular aortic repair-induced ischemic spinal cord injury has been lacking since the procedure was first employed in 1991. The hypothesis was that ligation of mouse intercostal arteries would simulate thoracic endovascular aortic repair-induced ischemic spinal cord injury and behavioral deficit. The aim was to create a mouse model of thoracic endovascular aortic repair-induced spinal cord hypoperfusion by ligating five pairs of mouse intercostal vessels.

METHODS

Mice were divided into sham (n = 53) and ligation (n = 60) groups. The procedures called for double ligation of three pairs and single ligation of two pairs of thoracic intercostal arteries in adult C57BL/6 mice. A laser Doppler probe was used in vivo on the spinal cords and intercostal arteries to document the extent of arterial ligation and spinal cord hypoperfusion. The Basso Mouse Scale for Locomotion, histological studies, and electron microscopy demonstrated postligation locomotive and histopathological changes.

RESULTS

Ligation induced a significant and instantaneous drop in blood flow in the intercostal arteries (% change; mean = -63.81; 95% CI, -72.28 to -55.34) and the thoracic spinal cord (% change; mean = -68.55; 95% CI, -80.23 to -56.87). Paralysis onset was immediate and of varying degree, with behavioral deficit stratified into three groups: 9.4% exhibited severe paralysis, 37.5% moderate paralysis, and 53.1% mild paralysis at day 1 (n = 32; P < 0.001). Mild and moderate paralysis was transient, gradually improving over time. Severe paralysis showed no improvement and exhibited a higher mortality rate (83%; n = 15 of 18) compared to moderately (33%; n = 6 of 18) and mildly (24%; n = 6 of 25) paralyzed mice (P < 0.001). The overall ligation group survival rate (84%; n = 46 of 55) was significantly lower than the sham group (100%; n = 48 of 48) with P = 0.003.

CONCLUSIONS

The mouse model generates reproducible spinal cord hypoperfusion and accompanying histopathological ischemic spinal cord damage. The resulting anatomical changes and variable behavioral deficits mimic the variability in radiological and clinical findings in human patients.

EDITOR’S PERSPECTIVE

A dumbbell rescue stent graft facilitates clamp-free repair of aortic injury in a porcine model

Objective

Noncompressible torso hemorrhage is a high-mortality injury. We previously reported improved outcomes with a retrievable rescue stent graft to temporize aortic hemorrhage in a porcine model while maintaining distal perfusion. A limitation was that the original cylindrical stent graft design prohibited simultaneous vascular repair, given the concern for suture ensnarement of the temporary stent. We hypothesized that a modified, dumbbell-shaped design would preserve distal perfusion and also offer a bloodless plane in the midsection, facilitating repair with the stent graft in place and improve the postrepair hemodynamics.

Methods

In an Institutional Animal Care and Use Committee-approved terminal porcine model, a custom retrievable dumbbell-shaped rescue stent graft (dRS) was fashioned from laser-cut nitinol and polytetrafluoroethylene covering and compared with aortic cross-clamping. Under anesthesia, the descending thoracic aorta was injured and then repaired with cross-clamping (n = 6) or dRS (n = 6). Angiography was performed in both groups. Operations were divided into phases: (1) baseline, (2) thoracic injury with either cross-clamp or dRS deployed, and (3) recovery, after which the clamp or dRS were removed. Target blood loss was 22% to simulate class II or III hemorrhagic shock. Shed blood was recovered with a Cell Saver and reinfused for resuscitation. Renal artery flow rates were recorded at baseline and during the repair phase and reported as a percentage of cardiac output. Phenylephrine pressor requirements were recorded.

Results

In contrast with cross-clamped animals, dRS animals demonstrated both operative hemostasis and preserved flow beyond the dRS angiographically. Recovery phase mean arterial pressure, cardiac output, and right ventricular end-diastolic volume were significantly higher in dRS animals (P = .033, P = .015, and P = .012, respectively). Whereas distal femoral blood pressures were absent during cross-clamping, among the dRS animals, the carotid and femoral MAPs were not significantly different during the injury phase (P = .504). Cross-clamped animals demonstrated nearly absent renal artery flow, in contrast with dRS animals, which exhibited preserved perfusion (P<.0001). Femoral oxygen levels (partial pressure of oxygen) among a subset of animals further confirmed greater distal oxygenation during dRS deployment compared with cross-clamping (P = .006). After aortic repair and clamp or stent removal, cross-clamped animals demonstrated more significant hypotension, as demonstrated by increased pressor requirements over stented animals (P = .035).

Conclusions

Compared with aortic cross-clamping, the dRS model demonstrated superior distal perfusion, while also facilitating simultaneous hemorrhage control and aortic repair. This study demonstrates a promising alternative to aortic cross-clamping to decrease distal ischemia and avoid the unfavorable hemodynamics that accompany clamp reperfusion. Future studies will assess differences in ischemic injury and physiological outcomes.

Clinical Relevance

Noncompressible aortic hemorrhage remains a high-mortality injury, and current damage control options are limited by ischemic complications. We have previously reported a retrievable stent graft to allow rapid hemorrhage control, preserved distal perfusion, and removal at the primary repair. The prior cylindrical stent graft was limited by the inability to suture the aorta over the stent graft owing to risk of ensnarement. This large animal study explored a dumbbell retrievable stent with a bloodless plane to allow suture placement with the stent in place. This approach improved distal perfusion and hemodynamics over clamp repair and heralds the potential for aortic repair while avoiding complications.

Primary care Providers' approaches to cervical cancer screening in Muslim females

The utilization of the Papanicolaou (Pap) test and the human papillomavirus (HPV) vaccine has significantly decreased rates of cervical cancer and related mortality. Disparities in receiving these preventive screenings are scarcely studied in Muslim females. Our study explores primary care providers' (PCP) approaches to cervical cancer screening in Muslim females. We created a cross-sectional Qualtrics survey using convenience sampling of PCPs who perform Pap tests in central Ohio. Recruitment emails were disseminated via departmental email listservs. We had 200 analyzable responses and 78% of respondents reported having Muslim patients. Bivariate analysis was used to identify predictors of providers' approaches. Providers younger than 35 years obtained a sexual history from Muslim females less frequently, family medicine providers were more likely to obtain a sexual history from Muslim females, and gynecologists were more likely to offer the HPV vaccine to Muslim females. Providers who counseled patients about Pap tests (P<0.001) and HPV modes of transmission (P<0.004) were more likely to offer cervical cancer screening for Muslim females. Our findings suggested that providers' age and specialty may be predictors of proactive cervical cancer screening and prevention in Muslim females and that there is a gap between current guidelines and preventive clinical practices regarding the HPV vaccine and transmission counseling.

Lymph Node Upstaging for Robotic, Thoracoscopic, and Open Lobectomy for Stage T2-3N0 Lung Cancer

BACKGROUND

There may be equivalent efficacy of the lymph node evaluation for minimally invasive lobectomy compared with open lobectomy for stage I non-small cell lung cancer. We sought to compare the lymph node evaluation for lobectomy by approach for patients with larger tumors who are clinically node negative.

METHODS

This retrospective study analyzed 24 257 patients with clinical stage T2-3N0M0 non-small cell lung cancer from the National Cancer Database. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics. The rates of pathologic lymph node upstaging were compared. A Cox multivariable regression model was performed to test the association with overall survival.

RESULTS

After IPTW adjustment 20 834 patients were included in the analysis. Of these, 1996 patients underwent robotic lobectomy, 5122 patients underwent thoracoscopic lobectomy, and 13 725 patients underwent open lobectomy from 2010 to 2017. The IPTW-adjusted N1 upstaging rate was similar for robotic (11.79%), thoracoscopic (11.49%), and open (11.85%) lobectomy (P = .274). The adjusted N2 upstaging rates were 5.03%, 5.66%, and 6.15% for robotic, thoracoscopic, and open lobectomy, respectively (P = .274). On IPTW-adjusted multivariable analysis, robotic and thoracoscopic lobectomy were associated with improved survival compared with open lobectomy (P < .001).

CONCLUSIONS

There was no significant difference in N1 and N2 lymph node upstaging rates between surgical approaches for patients with clinical stage T2-3N0 non-small cell lung cancer, indicating similarly effective lymph node evaluation. Overall survival after robotic and thoracoscopic lobectomy was significantly better compared with open lobectomy in this patient population with a high propensity for occult nodal disease.

Impact of post-discharge phone calls on non-urgent hospital returns < 90 days following primary bariatric surgery

INTRODUCTION

Quality of care delivery may improve patient outcomes post-bariatric surgery. We examined the quality of post-discharge phone calls (Ph_DC) to determine the impact on early (< 90 day) non-urgent hospital returns (NUHR) following primary bariatric surgery.

METHODS

A retrospective review was performed on patients who underwent Roux-en-Y-gastric bypass (RYGB) or sleeve gastrectomy (SG) in 2019. Patients were compared between presence of care coaching (Jan-June 2019) versus no care coaching (July-Dec 2019). Baseline demographics, comorbidities, psychiatric history, and Ph_DC were collected. Index Ph_DCs were coded for completeness using a scoring system and rated by call quality. Patients were stratified into NUHR versus control group (Never returns [NR]). Primary analysis examined the impact of Ph_DC on NUHR. Sub-analysis examined the impact of call quality. Univariate analysis was performed using Chi-square or Fisher's exact tests. Multivariate analysis (MVA) was used to determine predictors of NUHR. A p-value of ≤ 0.05 was statistically significant.

RESULTS

A total of 359 patients were included. Compared to the NR group (n = 294), NUHRs (n = 65) were more likely to be younger (41.3 + 12.1 versus 45.0 + 10.8 years, p = 0.024), with baseline anxiety (41.5% versus 23.5%, p = 0.003), and undergo RYGB (73.3% versus 57.8%, p = 0.031). There was a significant difference in number of Ph_DC in the NUHR and NR groups (p = 0.0206). Care-coached patients had significantly higher rates of high-quality phone calls (p < 0.0001) compared to non-care-coached patients. MVA demonstrated younger age (OR = 0.97, CI: 0.95-1.00; p = 0.023), anxiety (OR = 2.09, CI: 1.17-3.73; p = 0.012), RYGB (OR = 1.88, CI: 1.02-3.45; p = 0.042), and > 50% call quality versus no Ph_DC (OR = 0.45, CI: 0.25-0.83; p = 0.010) were independently associated with NUHRs.

CONCLUSION

High-quality Ph_DCs may play a role in mitigating NUHRs. Care coaching represents a potential intervention to decrease high rates of NUHR in primary bariatric surgery patients.

Sugammadex versus neostigmine for neuromuscular blockade reversal in outpatient surgeries: A randomized controlled trial to evaluate efficacy and associated healthcare cost in an academic center

Introduction

Neuromuscular blockade is an essential component of the general anesthesia as it allows for a better airway management and optimal surgical conditions. Despite significant reductions in extubation and OR readiness-for-discharge times have been associated with the use of sugammadex, the cost-effectiveness of this drug remains controversial. We aimed to compare the time to reach a train-of-four (TOF) response of ≥0.9 and operating room readiness for discharge in patients who received sugammadex for moderate neuromuscular blockade reversal when compared to neostigmine during outpatient surgeries under general anesthesia. Potential reduction in time for OR discharge readiness as a result of sugammadex use may compensate for the existing cost-gap between sugammadex and neostigmine.

Methods

We conducted a single-center, randomized, double arm, open-label, prospective clinical trial involving adult patients undergoing outpatient surgeries under general anesthesia. Eligible subjects were randomized (1:1 ratio) into two groups to receive either sugammadex (Groups S), or neostigmine/glycopyrrolate (Group N) at the time of neuromuscular blockade reversal. The primary outcome was the time to reverse moderate rocuronium-induced neuromuscular blockade (TOF ratio ≥0.9) in both groups. In addition, post-anesthesia care unit (PACU)/hospital length of stay (LOS) and perioperative costs were compared among groups as secondary outcomes.

Results

Thirty-seven subjects were included in our statistical analysis (Group S= 18 subjects and Group N= 19 subjects). The median time to reach a TOF ratio ≥0.9 was significantly reduced in Group S when compared to Group N (180 versus 540 seconds; p = 0.0052). PACU and hospital LOS were comparable among groups. Postoperative nausea and vomiting was the main adverse effect reported in Group S (22.2% versus 5.3% in Group N; p = 0.18), while urinary retention (10.5%) and shortness of breath (5.3%) were only experienced by some patients in Group N. Moreover, no statistical differences were found between groups regarding OR/anesthesia, PACU, and total admission costs.

Discussion

Sugammadex use was associated with a significantly faster moderate neuromuscular blockade reversal. We found no evidence of increased perioperative costs associated with the use of sugammadex in patients undergoing outpatient surgeries in our academic institution.

Clinical trial registration

[https://clinicaltrials.gov/] identifier number [NCT03579589].

Effects of prophylactic indomethacin on intraventricular hemorrhage and adverse outcomes in neonatal intensive care unit

OBJECTIVE

To identify the relationship between prophylactic indomethacin (PI) administration and incidence of intraventricular hemorrhage.

STUDY DESIGN

A retrospective analysis of extremely premature infants <27 weeks gestational age born between January 2014 and September 2020.

RESULTS

A total of 421 infants were included from three of Nationwide Children's Hospital delivery centers. Of those 255 (61%) received PI. After adjustment by inverse proportionality treatment weighting (IPTW), no differences were found in incidence of intraventricular hemorrhage (IVH) at the time of the first ultrasound, 31% vs. 33% in PI and control groups respectively (p = 0.68). The rate of rise of serum creatinine from baseline to day of life four was significantly higher in the PI group (0.14 mg/dl PI and 0.03 mg/dl control, p < 0.001).

CONCLUSION

PI was not associated with any benefit in prevention of IVH, but is associated with adverse effects including acute rise in creatinine.

Preventable operating room delays in robotic-assisted thoracic surgery: Identifying opportunities for cost reduction

BACKGROUND

This study aimed to characterize the types of intraoperative delays during robotic-assisted thoracic surgery, operating room staff awareness/perceptions of delays, and cost impact of delays on overall operative costs.

METHODS

Robotic-assisted thoracic surgery cases from May to August 2019 were attended by 3 third-party observers to record intraoperative delays. The postoperative surveys were given to operating room staff to elicit perceived delays. Observed versus perceived delays were compared using the McNemar test. Direct costs and charges per delay were calculated.

RESULTS

Forty-four cases were observed, of which a majority were lobectomies (n = 38 [86%]). A total of 71 delays were recorded by observers, encompassing 75% of cases (n = 33), with an average delay length of 3.6 minutes (±5.3 minutes). The following delays were observed: equipment failure (n = 40, average delay length 5.0 minutes (±6.5 minutes), equipment missing (n = 15, 2.2 minutes [±1.4 minutes]), staff unfamiliarity with equipment (n = 4, 3.4 minutes [± 1.5 minutes]), and other (n = 12, 4.5 minutes [±5.3 minutes]). The detection rates for any intraoperative delay were consistently lower for all of the operating room team members compared with observers, including surgeons (34.3% vs 77.1%; P = .0003), first assistants (41.9% vs 74.2%; P = .0075), surgical technologists (39.4% vs 72.7%; P = .0045), and circulating nurses (41.18% vs 76.47% minutes; P = .0013). The average operating room variable direct cost of delays based on the average total delay length per case was $225.52 (±$350.18) and was 1.6% (range 0-10.6%) of the total case charges.

CONCLUSION

The lack of perception of intraoperative delays hinders operating teams from effectively closing the variable cost gaps. Future studies are needed to explore methods of increasing perception of delays and opportunities to improve operating room efficiency.

Wedge Resection Versus Lobectomy for Clinical Stage IA NSCLC with Occult Lymph Node Disease

BACKGROUND

Sublobar resection is increasingly performed for stage Ia non-small cell lung cancer (NSCLC), but pathologic lymph node upstaging remains a common clinical scenario. This study compares the long-term prognosis of patients with clinical stage Ia disease and occult lymph node disease undergoing wedge resection versus lobectomy.

METHODS

The National Cancer Database was queried for patients treated with wedge resection or lobectomy for clinical stage Ia (cT1N0) NSCLC and who were pathologically upstaged with either pN1/pN2 disease. Overall survival (OS) was compared by extent of resection using inverse probability of treatment weight (IPTW) adjusted Cox regression analyses.

RESULTS

A total of 5,437 clinical stage Ia patients with were included, who were found to have occult pN1 (n= 3,408, 62.7%) or pN2 (n= 2,029, 37.3%). The majority of patients were treated with lobectomy (n=5,082, 93.5%) and 6.5% of patients underwent wedge resection (n=355). Lobectomy was associated with improved OS compared to wedge resection for patients with occult pN1 disease (median OS, 70.0 (95% CI:66.6-77.4) months vs. 36.4 (95% CI:24.2-45.6) months, p<0.001), but not for pN2 disease (median OS, 48.2.1 (95% CI:43.8-52.9) months vs. 43.7 (95%CI:31.2-62.4) months, p=00.24). On IPTW adjusted multivariable analysis, adjusting for demographics, comorbidities, margin status and pathologic T and N-stage, lobectomy remained associated with improved survival (adjusted hazard ratio 0.73 (95% CI:0.60-0.89; p=0.0016).

CONCLUSIONS

Lobectomy is associated with improved survival in clinical stage Ia NSCLC patients with occult lymph node disease. These data may aid the decision for completion lobectomy for patients with unanticipated N1 lymph node upstaging.

Evaluating the incidence of spinal cord injury after spinal cord stimulator implant: an updated retrospective review

INTRODUCTION

While spinal cord stimulator implant is an increasingly safe procedure, one of the most feared complications is spinal cord injury. Still, literature regarding its incidence remains highly variable. This retrospective analysis aims to evaluate the incidence of spinal cord injury after spinal cord stimulator implant using a large-scale claims database.

METHODS

The PearlDiver-Mariner database of national all payer claims was used to identify patients who underwent spinal cord stimulator implant (percutaneous or paddle) and developed subsequent spinal cord injury within 45 days. The primary outcome was to determine the overall incidence of spinal cord injury after spinal cord stimulator implant. Secondary outcomes included an evaluation of potential factors associated with developing spinal cord injury using univariable and multivariable regression analysis.

RESULTS

A total of 71,172 patients who underwent a spinal cord stimulator implant were included in the analysis, of which 52,070 underwent percutaneous and 19,102 underwent paddle spinal cord stimulator lead implant. The overall incidence of spinal cord injury after spinal cord stimulator implant (any lead type) was found to be 0.42% (302 patients). The incidence of spinal cord injury after percutaneous and paddle lead implants did not differ at 0.45% (233 patients) and 0.36% (69 patients)(p=0.12), respectively. Overall, variables associated with a significantly increased OR (95% confidence interval) of developing spinal cord injury included male gender by 1.31 times (1.04 to 1.65)(p=0.02); having a claim for low molecular weight heparin within 30 days by 3.99 times (1.47 to 10.82)(p<0.01); a diagnosis for osteoporosis within 1 year by 1.75 times (1.15 to 2.66)(p<0.01); and a diagnosis of cervical or thoracic spinal canal stenosis within 1 year by 1.99 (1.37 to 2.90)(p<0.001) and 4.00 (2.63 to 6.09)(p<0.0001) times, respectively.

CONCLUSIONS

Overall, our results support the notion that spinal cord stimulator implant continues to be a safe procedure for chronic pain patients. However, risk factor mitigation strategies for the prevention of spinal cord injury after spinal cord stimulator implant should be undertaken prior to performing the procedure.

Analysis of trends in perioperative outcomes in over 1000 robotic-assisted anatomic lung resections

Robotic-assisted surgery is gaining popularity as a minimally invasive approach for anatomic lung resection. We investigated the temporal changes in case volume, costs, and postoperative outcomes for robotic-assisted anatomic lung resection in over 1000 cases. We reviewed our institutional STS database for patients who had undergone robotic-assisted lobectomy, bi-lobectomy, or segmentectomy as the primary procedure between years 2009-2021. The patients were divided into two groups: first 500 cases (n = 501) and second 500 cases (n = 500). Temporal trends of case volume, surgical indications, hospital length of stay, costs, and perioperative outcomes were analyzed. A total of 1001 patients were analyzed, of which 968 (96.7%) patients underwent robotic-assisted lobectomy, 21 (2.1%) patients underwent bi-lobectomy, 10 (1.0%) patients underwent segmentectomy, and 3 (0.3%) patients underwent sleeve lobectomy. Primary lung cancer was the most common indication (87.7%), followed by metastatic lung tumors (7.1%), and benign diagnosis (5.2%). The overall postoperative complication rate decreased from 46.1% for the first 500 cases compared to 29.6% for the second 500 cases (p < 0.0001). The median hospital length of stay was down trending, which was 4 days [IQR: 3-7] for the first 500 cases and 3 days [IQR: 3-5] (p = 0.0001) for the second. The inflation-adjusted direct and indirect hospital costs were significantly lower in the second 500 cases (p < 0.0001). The complications rates, hospital costs, and hospital length of stay for robotic-assisted anatomic pulmonary resection decreased significantly over time at a single institution. Continuous improvement in perioperative outcomes may be observed with increasing institutional experience.

Antibody-suppressor CXCR5+ CD8+ T cellular therapy ameliorates antibody-mediated rejection following kidney transplant in CCR5 KO mice

CCR5 KO kidney transplant (KTx) recipients are extraordinarily high alloantibody producers and develop pathology that mimics human antibody-mediated rejection (AMR). C57BL/6 and CCR5 KO mice (H-2^b ) were transplanted with A/J kidneys (H-2^a ); select cohorts received adoptive cell therapy (ACT) with alloprimed CXCR5⁺ CD8⁺ T cells (or control cells) on day 5 after KTx. ACT efficacy was evaluated by measuring posttransplant alloantibody, pathology, and allograft survival. Recipients were assessed for the quantity of CXCR5⁺ CD8⁺ T cells and CD8-mediated cytotoxicity to alloprimed IgG⁺ B cells. Alloantibody titer in CCR5 KO recipients was four-fold higher than in C57BL/6 recipients. The proportion of alloprimed CXCR5⁺ CD8⁺ T cells 7 days after KTx in peripheral blood, lymph node, and spleen was substantially lower in CCR5 KO compared to C57BL/6 recipients. In vivo cytotoxicity towards alloprimed IgG⁺ B cells was also reduced six-fold in CCR5 KO recipients. ACT with alloprimed CXCR5⁺ CD8⁺ T cells (but not alloprimed CXCR5^- CD8⁺ or third-party primed CXCR5⁺ CD8⁺ T cells) substantially reduced alloantibody titer, ameliorated AMR pathology, and prolonged allograft survival. These results indicate that a deficiency in quantity and function of alloprimed CXCR5⁺ CD8⁺ T cells contributes to high alloantibody and AMR in CCR5 KO recipient mice, which can be rescued with ACT.

National Trends and Outcomes of Segmentectomy in the Society of Thoracic Surgeons Database

BACKGROUND

Segmentectomy is gaining popularity as a parenchyma-sparing alternative for anatomic lung resection. This study sought to investigate temporal changes in patient selection, case volume, and outcomes for segmentectomy using the Society of Thoracic Surgeons (STS) National Database.

METHODS

The STS General Thoracic Database was queried for patients who had undergone segmentectomy as the primary procedure between 2002 and 2018. The American College of Surgeons Oncology Group definition of high-risk patients on the basis of pulmonary function and major cardiovascular comorbidities was applied. Annual trends of case volume, patient risk profile, surgical indication, approach, and outcomes were analyzed.

RESULTS

A total of 10 629 patients were analyzed from 310 contributing centers. The annual segmentectomy volume more than doubled from <4 per center in 2009 to 8.6 per center by 2017. Lung cancer was the most common indication (70.1%), followed by benign disease (15.6%) and metastatic tumors (14.3%). Although the operative indication remained constant, the subset of high-risk patients (24.5%) decreased gradually over time (slope, -0.6% per year; P = .001). After 2012, segmentectomies were most commonly performed minimally invasively (video-assisted thoracoscopic surgery, 58.3%; robotic surgery, 19.4%), with a steadily declining use of thoracotomy (overall, 22.3%; slope, -2.4%/y; P = .001). Overall complication rates decreased over the study period from 41.7% to 26.1% (slope, -0.57%/y; P = .001). The overall major complication rate was 4.6% (range, 2.0%-7.1%), 30-day mortality was 1.0% (range, 0.7%-5.0%), and both have been trending downward since 2009 (P = .01).

CONCLUSIONS

Segmentectomies are increasingly performed nationally, with a steady decline in the subset of high-risk patients over time. Complication rates have decreased significantly, parallel to the increasing use of minimally invasive techniques by video-assisted thoracoscopic surgery and robotic surgery.

[18F] Sodium Fluoride Dose Reduction Enabled by Digital Photon Counting PET/CT for Evaluation of Osteoblastic Activity

The aim of the study was to assess the quality and reproducibility of reducing the injected [¹⁸F] sodium fluoride ([¹⁸F]NaF) dose while maintaining diagnostic imaging quality in bone imaging in a preclinical skeletal model using digital photon counting PET (dPET) detector technology. Beagles (n = 9) were administered three different [¹⁸F]NaF doses: 111 MBq (n = 5), 20 MBq (n = 5), and 1.9 MBq (n = 9). Imaging started ≃45 min post-injection for ≃30 min total acquisition time. Images were reconstructed using Time-of-Flight, ultra-high definition (voxel size of 1 × 1 × 1 mm³), with 3 iterations and 3 subsets. Point spread function was modeled and Gaussian filtering was applied. Skeleton qualitative and quantitative molecular image assessment was performed. The overall diagnostic quality of all images scored excellent (61%) and acceptable (39%) by all the reviewers. [¹⁸F]NaF SUV_mean showed no statistically significant differences among the three doses in any of the region of interest assessed. This study demonstrated that a 60-fold [¹⁸F]NaF dose reduction was not significantly different from the highest dose, and it had not significant effect on overall image quality and quantitative accuracy. In the future, ultra-low dose [¹⁸F]NaF dPET/CT imaging may significantly decrease PET radiation exposure to preclinical subjects and personnel.

Evaluation of a remote hybrid staffing model for ambulatory clinical pharmacists in a pediatric health system during the COVID-19 pandemic

Purpose

To describe and quantify patient care activities performed by ambulatory clinical pharmacists supporting medical specialty clinics in a pediatric health system utilizing a hybrid staffing model during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Five ambulatory clinical pharmacists, integrated within a health-system specialty pharmacy (HSSP), utilized a web-based data collection tool to record time spent performing patient care activities over a 2-week period. Work location (onsite or offsite) of the pharmacist was reported for each activity. Activities were classified as direct or indirect patient care. Direct patient care activities were subcategorized as telemedicine appointments, in-person clinic appointments, HSSP call center work, medication access support, electronic medical record consults, and previsit planning/postvisit documentation. Administrative tasks and precepting were considered indirect patient care activities.

Results

A total of 1,190 activities were completed, with 77% of all activities performed offsite. Direct and indirect patient care activities accounted for 871 (73.2%) and 319 (26.8%) of total activities, respectively. No activity took longer for the pharmacists to complete offsite versus onsite.

Conclusion

Using a hybrid staffing model employed by a pediatric health system, ambulatory clinical pharmacists were able to efficiently provide a high volume of direct patient care activities even when working offsite. Rapid adaptation and implementation of telemedicine services was critical for pharmacists to continue to provide essential services within pediatric medical specialty clinics.

Segmentectomy for clinical stage I non-small cell lung cancer: National benchmarks for nodal staging and outcomes by operative approach

BACKGROUND

Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach.

METHODS

A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach.

RESULTS

A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028).

CONCLUSIONS

Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.

Invariant NKT Cells Promote the Development of Highly Cytotoxic Multipotent CXCR3+CCR4+CD8+ T Cells That Mediate Rapid Hepatocyte Allograft Rejection

Hepatocyte transplant represents a treatment for metabolic disorders but is limited by immunogenicity. Our prior work identified the critical role of CD8+ T cells, with or without CD4+ T cell help, in mediating hepatocyte rejection. In this study, we evaluated the influence of invariant NKT (iNKT) cells, uniquely abundant in the liver, upon CD8-mediated immune responses in the presence and absence of CD4+ T cells. To investigate this, C57BL/6 (wild-type) and iNKT-deficient Jα18 knockout mice (cohorts CD4 depleted) were transplanted with allogeneic hepatocytes. Recipients were evaluated for alloprimed CD8+ T cell subset composition, allocytotoxicity, and hepatocyte rejection. We found that CD8-mediated allocytotoxicity was significantly decreased in iNKT-deficient recipients and was restored by adoptive transfer of iNKT cells. In the absence of both iNKT cells and CD4+ T cells, CD8-mediated allocytotoxicity and hepatocyte rejection was abrogated. iNKT cells enhance the proportion of a novel subset of multipotent, alloprimed CXCR3+CCR4+CD8+ cytolytic T cells that develop after hepatocyte transplant and are abundant in the liver. Alloprimed CXCR3+CCR4+CD8+ T cells express cytotoxic effector molecules (perforin/granzyme and Fas ligand) and are distinguished from alloprimed CXCR3+CCR4-CD8+ T cells by a higher proportion of cells expressing TNF-α and IFN-γ. Furthermore, alloprimed CXCR3+CCR4+CD8+ T cells mediate higher allocytotoxicity and more rapid allograft rejection. Our data demonstrate the important role of iNKT cells in promoting the development of highly cytotoxic, multipotent CXCR3+CCR4+CD8+ T cells that mediate rapid rejection of allogeneic hepatocytes engrafted in the liver. Targeting iNKT cells may be an efficacious therapy to prevent rejection of intrahepatic cellular transplants.

Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study

Background: Recently formed ileostomies may produce an average of 1,200 ml of watery stool per day, while an established ileostomy output varies between 600-800 ml per day. The reported incidence of renal impartment in patients with ileostomy is 8-20%, which could be caused by dehydration (up to 50%) or high output stoma (up to 40%). There is a lack of evidence if an ileostomy could influence perioperative fluid management and/or surgical outcomes. Methods: Subjects aged ≥18 years old with an established ileostomy scheduled to undergo an elective non-ileostomy-related major abdominal surgery under general anesthesia lasting more than 2 h and requiring hospitalization were included in the study. The primary outcome was to assess the incidence of perioperative complications within 30 days after surgery. Results: A total of 552 potential subjects who underwent non-ileostomy-related abdominal surgery were screened, but only 12 were included in the statistical analysis. In our study cohort, 66.7% of the subjects were men and the median age was 56 years old (interquartile range [IQR] 48-59). The median time from the creation of ileostomy to the qualifying surgery was 17.7 months (IQR: 8.3, 32.6). The most prevalent comorbidities in the study group were psychiatric disorders (58.3%), hypertension (50%), and cardiovascular disease (41.7%). The most predominant surgical approach was open (8 [67%]). The median surgical and anesthesia length was 3.4 h (IQR: 2.5, 5.7) and 4 h (IQR: 3, 6.5), respectively. The median post-anesthesia care unit (PACU) stay was 2 h (IQR:0.9, 3.1), while the median length of hospital stay (LOS) was 5.6 days (IQR: 4.1, 10.6). The overall incidence of postoperative complications was 50% (n = 6). Two subjects (16.7%) had a moderate surgical wound infection, and two subjects (16.7%) experienced a mild surgical wound infection. In addition, one subject (7.6%) developed a major postoperative complication with atrial fibrillation in conjunction with moderate hemorrhage. Conclusions: Our findings suggest that the presence of a well-established ileostomy might not represent a relevant risk factor for significant perioperative complications related to fluid management or hospital readmission. However, the presence of peristomal skin complications could trigger a higher incidence of surgical wound infections.

Comparative analysis of long-term oncologic outcomes for minimally invasive and open Ivor Lewis esophagectomy after neoadjuvant chemoradiation: a propensity score matched observational study

BACKGROUND

Locally advanced esophageal carcinoma is typically treated with neoadjuvant chemoradiation and esophagectomy (trimodality therapy). We compared the long-term oncologic outcomes of minimally invasive Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases after trimodality therapy.

METHODS

This is a retrospective review of 223 patients diagnosed with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by M-ILE or O-ILE from April 2009 to February 2019. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Kaplan-Meier survival curves were calculated for overall survival and recurrence-free survival comparing the two groups. Multivariate Cox proportional hazards regression models were used to determine predictive variables for overall and recurrence-free survival.

RESULTS

The IPTW cohort included patients with esophageal carcinoma who underwent M-ILE (n = 142) or O-ILE (n = 68). The overall rate of postoperative adverse events was not significantly different after IPTW adjustment between the O-ILE and M-ILE trimodality groups (53.4% vs. 39.2%, p = 0.089). The 3-year overall survival (OS) for the M-ILE group was 59.4% (95% CI: 49.8-67.8) compared to 55.7% (95% CI: 39.2-69.4) for the O-ILE group (p = 0.670). The 3-year recurrence-free survival for the M-ILE group was 59.9% (95% CI: 50.2-68.2) compared to 61.6% (95% CI: 41.9-76.3) for the O-ILE group (p = 0.357). A complete response to neoadjuvant chemoradiation was significantly predictive of improved OS and RFS.

CONCLUSION

The overall and recurrence-free survival rates for M-ILE were not significantly different from O-ILE for esophageal carcinoma after trimodality therapy. Complete response to neoadjuvant chemoradiation was predictive of improved overall and recurrence- free survival.

Enoxaparin Dose Requirements to Achieve Therapeutic Low-molecular-weight Heparin Anti-factor Xa Levels in Infants and Young Children

INTRODUCTION

Enoxaparin is commonly used to treat pediatric thrombosis. Several small retrospective studies have suggested that infants and young children require higher enoxaparin doses to achieve therapeutic anti-factor Xa levels compared with adults.

MATERIALS AND METHODS

This is a retrospective study of hospitalized children who received enoxaparin for the treatment of thrombosis at a free-standing children's hospital. The primary objective was to ascertain the enoxaparin dose required to achieve an anti-factor Xa level of 0.5 to 1.0 U/mL among 4 age groups in a large cohort of infants and young children between 60 days and 5 years of age.

RESULTS

A total of 176 infants and children were evaluated. The majority of patients were less than 1 year of age (n=104). An inverse relationship between enoxaparin dose needed to achieve therapeutic anti-factor Xa levels and patient age was noted, particularly in the first year of life. Patients who were 60 days to less than 7 months at the time of enoxaparin initiation (n=73) required the highest mean dose among the age groups at 1.73 mg/kg subcutaneously every 12 hours (P<0.0001).

CONCLUSION

Infants and young children require higher doses of enoxaparin to achieve therapeutic anti-factor Xa levels compared with adults.

Efficacy of a mobile technology-based intervention for increasing parents' safety knowledge and actions: a randomized controlled trial

Background

Leading causes of unintentional child injury such as poisoning and falls are preventable, and the majority occur in the home. Numerous home safety interventions have been developed and tested to increase safety behaviors; however, no smart phone-based applications (apps) have been developed and evaluated for this purpose. The objective of this study was to evaluate whether a mobile technology-based health behavior change intervention, the Make Safe Happen® app, was an effective tool to increase safety knowledge and safety actions/behaviors for the prevention of child unintentional injuries in and around the home.

Methods

Data were collected in pretest and posttest online surveys from an existing nationwide population-based survey panel. Intervention subjects were randomized to organically (participant-driven) use the Make Safe Happen® app for 1 week, which provided home safety information and the ability to purchase safety products, while control participants were assigned to download and use an app about a topic other than home safety. The primary outcomes of safety knowledge and home safety actions were assessed by using linear mixed model regressions with intention-to-treat analyses.

Results

A total of 5032 participants were randomized to either the intervention (n = 4182) or control (n = 850) group, with 2055 intervention participants downloading and entering their participant IDs into the Make Safe Happen® app. The online posttest survey was completed by 770 intervention and 283 control subjects. Mean knowledge parent safety score increased at a greater rate for intervention than control subjects (p < 0.0001), and at posttest was significantly higher for intervention than control subjects (p < 0.0001). The percentage of intervention subjects who reported doing all one-time and repeated safety actions significantly increased from pretest to posttest (p < 0.0001 and p = 0.0001, respectively), but there was no change among the control subjects (p = 0.1041 and p = 0.9755, respectively). At posttest, this percentage was larger for intervention than control subjects only for repeated safety actions (p = 0.0340).

Conclusions

The mobile application significantly improved safety knowledge and safety actions for participants using the Make Safe Happen® app, although loss to follow-up was a limitation. The results of this study indicate the usefulness of widespread distribution and use of the Make Safe Happen® app.

Trial registration numberNCT02751203; Registered April 26, 2016.

The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma

BACKGROUND

Operable esophageal carcinoma is potentially curable with surgical resection. The short-term outcomes and overall survival rate for operable esophageal carcinoma may be impacted by the healthcare facility type where patients receive care.

METHODS

A total of 37, 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Data Base at over 12,721 facilities were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazard models were used to evaluate differences in overall survival between facility types, which accounted for facility esophageal cancer volume. Propensity score methodology with inverse probability of treatment weighting was used to adjust for patient related baseline differences between facility types.

RESULTS

Patients with clinical stage I-III esophageal carcinoma who underwent esophagectomy at academic healthcare facilities had a significantly better overall survival compared with patients who underwent esophagectomy at community healthcare facilities [HR = 0.89: CI [0.84-0.95] (p = 0.0005)]. The rate of esophagectomy was significantly higher at the academic facilities (49.0% versus 26.5%; p < 0.0001). The 30-day and 90-day mortality rates for esophagectomy were significantly better for patients who underwent esophagectomy for esophageal cancer at the academic facility types.

CONCLUSION

Patients with clinical stage I-III esophageal carcinoma who received care at academic facility types had significantly better overall survival compared with community facility types. The utilization of esophagectomy was significantly higher and the short-term surgical outcomes were better for patients treated at academic facility types.

Survey of provider perceptions of enhanced recovery after surgery and perioperative surgical home protocols at a tertiary care hospital

Enhanced recovery after surgery (ERAS) and perioperative surgical home (PSH) initiatives are widely utilized to improve quality of patient care. Despite their established benefits, implementation still has significant barriers. We developed a survey for perioperative clinicians to gather information on perception and knowledge of ERAS/PSH programs to guide future expansion of these programs at our institution. The survey included questions about familiarity with ERAS/PSH and perceived value, perceived barriers to protocol implementation, preferred learning methods and prioritization of various ERAS/PSH protocol elements into care delivery and provider education. Faculty surgeons and anesthesiologists, in addition to advanced practice nurses and postgraduate physician trainees in the Departments of Surgery and Anesthesiology were asked to complete the survey. Overall survey participation was 25% (223/888). About half of survey respondents had provided care to a patient on an ERAS/PSH protocol, and a majority felt at least somewhat knowledgeable about ERAS/PSH protocols. Perception of the value of ERAS/PSH was positive. Participants were enthusiastic about on-going learning, with multimodal pain management being the topic of most interest and learning by direct participation in care of protocol patients being the favored educational approach. A significant majority of participants felt that upcoming health providers should receive formal ERAS/PSH education as part of their training. Based on our survey results, we plan to explore teaching methods that successfully engage learners of all levels of clinical expertise and also overcome the major barriers to gaining knowledge about ERAS/PSH identified by study participants, most notably lack of time for busy clinicians.

Racial disparities in provider recommendation for esophagectomy for esophageal carcinoma

BACKGROUND

Racial disparities currently exist for the utilization rate of esophagectomy for Black patients with operable esophageal carcinoma.

METHODS

A total of 37 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Database were analyzed between 2004 and 2016. A multivariable-adjusted logistic regression model was used to evaluate differences in the odds ratio of esophagectomy not being recommended based on race. Kaplan-Meier curves and log-rank tests were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting (IPTW) was used to balance baseline differences in patient demographics.

RESULTS

After IPTW adjustment, we identified 30 552 White patients and 3529 Black patients with clinical stage I-III esophageal carcinoma. Black patients had three times greater odds of not being recommended for esophagectomy (odds ratio: 3.03, 95% confidence interval: 2.67-3.43, p < 0.0001) compared to White patients. Black patients demonstrated significantly worse 3- and 5-year overall survival rates compared to White patients (log-rank p < 0.0001).

CONCLUSION

Black patients with clinical stage I-III esophageal cancer were significantly less likely to be recommended for esophagectomy even after adjusting for baseline demographic covariates compared to White patients.

Invariant NKT cells promote expansion of novel CXCR3+CCR4+CD8+ T cells in the liver following allogeneic hepatocyte transplant

Hepatocyte transplant (HcTx) is a treatment for metabolic diseases and a bridge to liver transplant but is limited by immunogenicity. Our prior work identified the critical role of CD4-dependent and CD4-independent CD8+ T cells in HcTx rejection. Herein, we evaluated the influence of invariant natural killer T cells (iNKTs), abundant in the liver, upon CD8+ T cell responses in the presence and absence of CD4+ T cells. To investigate this, C57BL/6 (wild-type; WT) or iNKT deficient Jα18 KO (H-2b) received FVB/N (H-2q) HcTx. Cohorts were depleted of CD4+ T cells and/or reconstituted with iNKTs. Recipients were evaluated for cytotoxicity, CD8+ T cell phenotype, and HcTx rejection. By comparing CD4-sufficient WT and Jα18 KO recipients, we found that the presence of iNKTs significantly enhanced in vivo CD8-mediated cytotoxicity (83±3% vs 23±3%; p&lt;0.001) but did not affect survival (10 days vs 14 days; p=ns). However, in CD4-deficient recipients, iNKTs were critical, since without CD4+ T cells and iNKTs, CD8-mediated in vivo cytotoxicity was completely abrogated (31±3% vs 2±1%; p&lt;0.001) and HcTx survival was significantly prolonged (14 days vs 56 days; p&lt;0.001). iNKTs enhanced the quantity of a novel CD8+ T cell subset, CD44+IFN-γ+CXCR3+CCR4+CD8+ T cells, in the liver (2-fold) in all HcTx recipients (p&lt;0.03 for all comparisons). CXCR3+CCR4+CD8+ T cells, when compared to CXCR3+CCR4−CD8+ T cells, express higher IFN-γ (32±3% vs 9±1%; p&lt;0.001) and TNF-α (37±3% vs 6±1%; p&lt;0.001). They also exhibit greater in vivo cytotoxicity (13±1% vs 5±1%; p&lt;0.001) and mediate rapid HcTx rejection in RAG1 KO recipients (5 days vs 16 days; p=0.02). We show that iNKTs enhance the expansion of highly cytotoxic CXCR3+CCR4+CD8+ T cells that mediate rapid rejection of HcTx.

Family-centered communication: A pilot educational intervention using deliberate practice and patient feedback

OBJECTIVE

There are few opportunities in medical education dedicated to learning skills for effective communication in life altering patient scenarios. We therefore aimed to develop and assess a longitudinal advanced communication curriculum for pediatric residents using patient feedback and deliberate practice.

METHODS

Pediatric residents at a large academic center were randomized into 2 groups. The intervention group received 6 educational sessions from 2019 to 2020, parent feedback of performance via the Communication Assessment Tool (CAT), and monthly communication tips. Communication skills of both groups were assessed at the end of the intervention.

RESULTS

We collected 937 CAT assessments on 36 first-year residents. The intervention group demonstrated statistically significant improvement in communication skills from pre to post assessment (p = 0.0063, (odds ratio (OR) 1.76, 95 % confidence interval (CI) [1.17, 2.63]) compared to the control group (p = 0.080, OR 1.41, 95 % CI [0.96, 2.05]).

CONCLUSIONS

There are patient and self-identified performance gaps in communication skills for pediatric residents, underscoring the need for formalized curricula dedicated to these skills.

PRACTICE IMPLICATIONS

Our study highlights the value of deliberate practice and the integration of family feedback as an educational tool in communication skills development.

Evaluation of the Efficacy of Enoxaparin in the Neonatal Intensive Care Unit

OBJECTIVE

This article evaluates the efficacy of enoxaparin when targeting anti-factor Xa levels of 0.5 to 1 units per milliliter in the neonatal intensive care unit.

STUDY DESIGN

This is a retrospective chart review of 45 neonates receiving enoxaparin for the treatment of venous thromboembolism. Enoxaparin dosing and corresponding anti-factor Xa levels were collected. Time to resolution of clot was confirmed by imaging and compared between clots in various locations.

RESULTS

The median time to clot resolution was 76 days (interquartile range 40-91 days). Clot location, postnatal age, and sex at the clot onset were significantly associated with time to clot resolution in a multivariable Cox model (p-value: 0.03, 0.03, and < 0.01, respectively). Of the 54 patients analyzed for safety, 5 patients (9.3%) experienced bleeding events resulting in the discontinuation of enoxaparin.

CONCLUSION

Based on our findings, 50% of all patients evaluated, regardless of thrombus location, achieved resolution within the first 76 days of therapy. Clots located in the extremities tended to resolve sooner, hence earlier reimaging should be considered.

Implementation of a Pharmacist-Led Antimicrobial Time-Out for Medical-Surgery Services in an Academic Pediatric Hospital

OBJECTIVE

This report describes a quality improvement initiative to implement a pharmacist-led antimicrobial time-out (ATO) in a large, freestanding pediatric hospital. Our goal was to reach 90% ATO completion and documentation for eligible patients hospitalized on general pediatric medicine or surgery services.

METHODS

A multidisciplinary quality improvement team developed an ATO process and electronic documentation tool. Clinical pharmacists were responsible to initiate and document an ATO for pediatric medicine or surgery patients on or before the fifth calendar day of therapy. The quality improvement team educated pharmacists and physicians and provided ATO audit and feedback to the pharmacists. We used statistical process control methods to track monthly rates of ATO completion retrospectively from October 2017 through March 2018 and prospectively from April 2018 through April 2019. Additionally, we retrospectively evaluated the completion of 6 data elements in the ATO note over the final 12-month period of the study.

RESULTS

Among 647 eligible antimicrobial courses over the 19-month study period, the mean monthly documentation rate increased from 54.6% to 83.5% (p < 0.001). The mean ATO documentation rate increased from 32.8% to 74.2% (p < 0.001) for the pediatric medicine service and from 65.0% to 88.1% for the pediatric surgery service (p = 0.006). Among 302 notes assessed for completeness, 35.8% had all the required data fields completed. A tentative antimicrobial stop date was the data element completed least often (49.3%).

CONCLUSIONS

We implemented a pharmacist-led ATO, highlighting the role pharmacists play in antimicrobial stewardship. Additional efforts are needed to further increase ATO completion rates and to define treatment duration.