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Goenka A, Mundkur S, Sujir Nayak S, Shetty A, Thomas J, Mymbilly Balakrishnan J, Chandra Sekaran V, Dsouza B. Improving the emergency services using quality improvement project and Donabedian model in a quaternary teaching hospital in South India. BMJ Open Qual 2024; 13:e002246. [PMID: 38395464 PMCID: PMC10895229 DOI: 10.1136/bmjoq-2022-002246] [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] [Received: 01/12/2023] [Accepted: 01/07/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION The primary goal of quality improvement is to enhance patient outcomes, particularly in the emergency department (ED). Timely and effective care is crucial in these situations. By comprehending the challenges, evaluating current performance and implementing quality improvement projects, areas in need of enhancement can be pinpointed and addressed, resulting in better outcomes. METHODOLOGY This interventional study explores the implementation of quality improvement in the ED of a quaternary care teaching hospital in South India. It follows the Plan-Do-Check-Act (PDCA) cycle guided by the Donabedian model. Descriptive statistics were employed to measure changes in outcomes before and after implementation. To improve processes, Donabedian principles were applied, and a performance audit was conducted based on patient feedback and stakeholder input. Various ED indicators were measured. To address identified issues, formal root cause analysis was performed, leading to the generation of PDCA rapid change cycles. These cycles were implemented over 6 months, with two cycles executed, followed by postimplementation evaluation. RESULTS Post implementation, improvements were observed in several aspects of ED operations. These included reduced ED average length of stay, decreased time to analgesia, shorter cross-consultation time, faster transfer time from ED and improved investigation turnaround time (TAT). Additionally, there was a reduction in revisits to ED within 72 hours and a decrease in patients who left without being seen. These positive changes demonstrate the effectiveness of the quality improvement intervention using the PDCA cycle. CONCLUSION A comprehensive understanding of patient profile in the ED and factors influencing care is essential for the hospital to ensure sufficient resources and skilled emergency medicine physicians are available 24/7. By enhancing services in the ED, reducing patient waiting times and improving TAT, the overall efficiency of services can be improved. This leads to provision of timely quality care to patients and ultimately improves their outcomes.
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Affiliation(s)
- Apoorva Goenka
- Social and Health Innovation, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Innovation Think Tank, Siemens Healthineers, Bengaluru, Karnataka, India
| | - Suneel Mundkur
- Kasturba Medical College Manipal, Manipal, Karnataka, India
| | - Sachin Sujir Nayak
- Emergency Department, Kasturba Medical College Manipal, Manipal, Karnataka, India
| | - Avinash Shetty
- Department of Community Medicine, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Jibu Thomas
- Kasturba Hospital Manipal, Manipal, Karnataka, India
| | | | - Varalakshmi Chandra Sekaran
- Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Brayal Dsouza
- Social and Health Innovation, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Opele JK, Adepoju KO. Validation of the Donabedian Model of Health Service Quality in Selected States in Nigeria. Niger J Clin Pract 2024; 27:167-173. [PMID: 38409143 DOI: 10.4103/njcp.njcp_220_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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 01/08/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Every citizen of a nation has the basic constitutional right to quality health care. However, there is a dearth of literature on the validity and reliability of the Donabedian conceptual model of health service quality in Nigeria. AIM The current paper focused on validating the Donabedian model of quality health service in selected states in Nigeria. METHODS This is a prospective study of 479 health workforce consisting of 204 physicians, 180 nurses, and 95 health information management officers in three geopolitical zones in Nigeria. A multistage sampling technique was used to select respondents. Data were collected through a semi-structured questionnaire with a response rate of 87%. The overall reliability test of the variables yielded α =0.938. Data gathered was analyzed descriptively for the socio-demographic characteristics and Relative Importance Index (RII) to rank the criteria according to their relative importance. RESULTS Findings from the study reveal that the (RII) of all the items in the study instrument exceeded the universally acceptable threshold of 0.5, indicating a high level of care in Federal Tertiary Hospitals in Nigeria with regards to structure, process, and outcomes. CONCLUSION The study underscored the need for the adoption of the Donabedian model in the three other geopolitical zones in Nigeria for a generalized conclusion on the validity and reliability of the Donabedian conceptual model of health service quality. We recommended that research studies on health service quality should be anchored on Donabedian conceptual model as a way to increase awareness of the relevance of the model in improving clinical care in Nigeria.
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Affiliation(s)
- J K Opele
- Department of Library and Information Science, Federal University, Oye-Ekiti, Nigeria
| | - K O Adepoju
- Department of Health Information, University of Medical Sciences, Ondo, Ondo-State, Nigeria
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Li C, Cui L, Zhou S, He A, Ni Z. The formation mechanism of primary health care team effectiveness : a qualitative comparative analysis research. BMC Prim Care 2024; 25:45. [PMID: 38287250 PMCID: PMC10823627 DOI: 10.1186/s12875-024-02278-8] [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] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/16/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Team-based care is an essential part of primary health care (PHC), and its team service delivery process is a systematic one involving multiple and complex influences. Research on the formation mechanism can help improve the effectiveness of primary health care teams (PHCTs). METHODS First, based on the Donabedian model, we explored the theoretical framework of a PHC team's effectiveness formation mechanism. Semi-structured interviews were conducted with 23primary health care team members in Hangzhou, Zhejiang Province, China. A total of seven factors were then included as conditional variables using the crisp set qualitative comparative analysis (csQCA) to explore the complex influences between them and the outcome variable through univariate necessity analysis and path configuration analysis. RESULTS Univariate necessity analysis showed that only "Clear Goals" in the structural dimension were necessary for team effectiveness perception. Six pathways to good primary health care team perception of effectiveness were identified. Two of these paths were more typical. CONCLUSION "Clear Goals" was the core variable that should be emphasized when exploring the mechanism of PHCT formation. The results suggest that human resources in the management team should be rationally allocated, goal-oriented, and given good attention. Future studies should explore complex combinations of PHCT factors to improve the effectiveness of PHCTs.
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Affiliation(s)
- Chanjiao Li
- Department of Health Management and Policy, School of Public Health, Hangzhou Normal University, No. 2318, Yuhangtang Rd, Hangzhou, 311121, China
| | - Lu Cui
- Department of Health Management and Policy, School of Public Health, Hangzhou Normal University, No. 2318, Yuhangtang Rd, Hangzhou, 311121, China
- Department of Quality Management, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, 310016, China
| | - Siyu Zhou
- Department of Health Management and Policy, School of Public Health, Hangzhou Normal University, No. 2318, Yuhangtang Rd, Hangzhou, 311121, China
| | - Anning He
- Department of Health Management and Policy, School of Public Health, Hangzhou Normal University, No. 2318, Yuhangtang Rd, Hangzhou, 311121, China
| | - Ziling Ni
- Department of Health Management and Policy, School of Public Health, Hangzhou Normal University, No. 2318, Yuhangtang Rd, Hangzhou, 311121, China.
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McQueen RB, Inotai A, Zemplenyi A, Mendola N, Németh B, Kalo Z. Multistakeholder Perceptions of Additional Value Elements for United States Value Assessment of Health Interventions. Value Health 2024; 27:15-25. [PMID: 37820753 DOI: 10.1016/j.jval.2023.09.2910] [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] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES Limitations in conventional cost-effectiveness methods have led to calls for incorporation of additional value elements in assessments of health technologies. However, gaps remain in how additional value elements may inform decision making. This study aimed to prioritize additional value elements from the perspective of healthy individuals without a specific condition or indicated for a specific treatment in the United States among a multistakeholder panel and compare the importance of perspective-specific value elements. METHODS Additional value elements were prioritized in 2 phases: (1) we identified and categorized additional value elements in a targeted literature review, and (2) we convened a multistakeholder group-based preference elicitation study (N = 28) to evaluate the description of each value element and rank and generate normalized weights of each value element for its significance in value assessment. The importance of additional value elements was also weighted relative to patient-centric value elements. RESULTS The rank and weight of contextual value elements among 28 stakeholders were "severity of the disease" (26.2%), "disadvantaged and vulnerable target populations highly represented" (21.8%), "broader economic impact" (17.3%), "risk protection" (13.8%), "rarity of the disease" (11.3%), and "novel mechanism of action" (9.7%). Relative weight of the additional value elements versus patient-centric value elements was 52% and 48%, respectively. CONCLUSIONS Study findings may inform priority setting for value frameworks and emerging US government assessments. The group-based elicitation method is repeatable and useful for structured deliberative processes in value assessment and may help improve the consistency and predictability of what is important to stakeholders.
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Affiliation(s)
- R Brett McQueen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Andras Inotai
- Syreon Research Institute, Budapest, Hungary; Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Antal Zemplenyi
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Syreon Research Institute, Budapest, Hungary
| | - Nick Mendola
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Zoltan Kalo
- Syreon Research Institute, Budapest, Hungary; Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
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Pogorzelska-Maziarz M, de Cordova PB, Manning ML, Johansen ML, Grafova I, Gerolamo A. Voices from frontline nurses on care quality and patient safety during COVID-19: An application of the Donabedian model. Am J Infect Control 2023; 51:1295-1301. [PMID: 37625547 DOI: 10.1016/j.ajic.2023.08.014] [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] [Received: 03/15/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND The COVID-19 pandemic has adversely impacted quality of care and patient safety. This study aimed to describe registered nurses' (RNs) perceptions on the impact of the COVID-19 pandemic on their ability to adhere to patient safety protocols using Donabedian's Health Care Quality model. METHODS In October 2020, a survey was conducted among all actively licensed RNs in New Jersey who provided direct patient care during the first peak of COVID-19. RESULTS Of 3,027 participants, 68% reported that the number of patients assigned impacted their ability to adhere to protocols. RNs identified a variety of organizational structures impacting adherence, including inadequate staffing, staff qualifications, and inadequate resources. Impacted processes included the inability to adhere to patient safety protocols and conduct comprehensive assessments and surveillance, the need for additional time spent on personal protective equipment and isolation policies, and difficulty maintaining isolation integrity; the need to prioritize and cluster care; and guidelines limiting personnel who could enter the room. Nurses attributed both adverse patient and staff outcomes to inadequate staffing and high patient acuity. CONCLUSIONS These findings highlight the need for health care organizations to support frontline nursing staff in adhering to patient safety and infection prevention and control protocols during times of crises. Infection preventionists have substantial contact with bedside nurses and should leverage their collegial relationships to promote patient safety.
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Affiliation(s)
| | | | - Mary Lou Manning
- Thomas Jefferson University College of Nursing, Philadelphia, PA
| | - Mary L Johansen
- Rutgers University, Biomedical and Health Sciences, Newark, NJ
| | - Irina Grafova
- Rutgers University, Edward J. Bloustein School of Planning & Public Policy, New Brunswick, NJ
| | - Angela Gerolamo
- Thomas Jefferson University College of Nursing, Philadelphia, PA
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Clibbens N, Booth A, Sharda L, Baker J, Thompson J, Ashman M, Berzins K, Weich S, Kendal S. Explaining context, mechanism and outcome in adult community mental health crisis care: A realist evidence synthesis. Int J Ment Health Nurs 2023; 32:1636-1653. [PMID: 37574714 DOI: 10.1111/inm.13204] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
Mental health crises cause significant distress and disruption to the lives of individuals and their families. Community crisis care systems are complex, often hard to navigate and poorly understood. This realist evidence synthesis aimed to explain how, for whom and in what circumstances community mental health crisis services for adults work to resolve crises and is reported according to RAMESES guidelines. Using realist methodology, initial programme theories were identified and then tested through iterative evidence searching across 10 electronic databases, four expert stakeholder consultations and n = 20 individual interviews. 45 relevant records informed the three initial programme theories, and 77 documents, were included in programme theory testing. 39 context, mechanism, outcome configurations were meta-synthesized into three themes: (1) The gateway to urgent support; (2) Values based crisis interventions and (3) Leadership and organizational values. Fragmented cross-agency responses exacerbated staff stress and created barriers to access. Services should focus on evaluating interagency working to improve staff role clarity and ensure boundaries between services are planned for. Organizations experienced as compassionate contributed positively to perceived accessibility but relied on compassionate leadership. Attending to the support needs of staff and the proximity of leaders to the front line of crisis care are key. Designing interventions that are easy to navigate, prioritize shared decision-making and reduce the risk of re-traumatizing people is a priority.
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Affiliation(s)
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Leila Sharda
- School of Healthcare, University of Leeds, Leeds, UK
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Jill Thompson
- Health Sciences School, University of Sheffield, Sheffield, UK
| | | | | | - Scott Weich
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sarah Kendal
- School of Healthcare, University of Leeds, Leeds, UK
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Shimizu T, Harada Y. The first diagnostic excellence conference in Japan. Diagnosis (Berl) 2023; 10:353-355. [PMID: 37014947 DOI: 10.1515/dx-2023-0027] [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] [Received: 03/06/2023] [Accepted: 03/22/2023] [Indexed: 04/06/2023]
Abstract
In February 2023, the first national conference on Diagnostic Excellence was held in Japan. As the conference covered a wide range of academic areas, we placed particular emphasis on topics related to excellence in physicians' clinical reasoning. This focus reflected the culture of Japanese medical professionals, especially of physicians, who have shown passion for clinical diagnosis for decades, having held non-profit voluntary multi-institutional conferences during off-duty hours. Of the over 1,400 participants who attended the two-day conference, 80% were generalist physicians and residents, 10% were medical students, and the remainder were healthcare professionals and participants from other academic areas. Given the background of Japanese physicians' passion for clinical diagnosis, the conference organizers believed that focusing on the diagnostic thinking of physicians as part of the Diagnostic Excellence concept would have strong appeal to participants. Simultaneously, the organizers believed that it was important to target participants in their 20s-40s, and made efforts to utilize social networking services and advertising strategies, including creating individual posters with the help of professional designers. On reflection after the conference, consideration of the local characteristics of the population, particularly their interest in the target population, and the expansion of the conference's focus to include younger participants may have served as drivers of the success of the conference. This outcome of the conference in Asia is an intriguing step in the world deployment strategy of Diagnostic Excellence, and is expected to promote cooperation among Asia and the United States, Europe, and Oceania.
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Affiliation(s)
- Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Japan
| | - Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, Japan
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Heltne A, Frans N, Hummelen B, Falkum E, Germans Selvik S, Paap MCS. A systematic review of measurement uncertainty visualizations in the context of standardized assessments. Scand J Psychol 2023; 64:595-608. [PMID: 37259691 DOI: 10.1111/sjop.12918] [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: 04/26/2022] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 06/02/2023]
Abstract
This systematic review summarized findings of 29 studies evaluating visual presentation formats appropriate for communicating measurement uncertainty associated with standardized clinical assessment instruments. Studies were identified through systematic searches of multiple databases (Medline, Embase, PsycInfo, ERIC, Scopus, and Web of Science). Strikingly, we found no studies which were conducted using samples of clinicians and included clinical decision-making scenarios. Included studies did however find that providing participants with information about measurement uncertainty may increase awareness of uncertainty and promote more optimal decision making. Formats which visualize the shape of the underlying probability distribution were found to promote more accurate probability estimation and appropriate interpretations of the underlying probability distribution shape. However, participants in the included studies did not seem to benefit from the additional information provided by such plots during decision-making tasks. Further explorations into how presentations of measurement uncertainty impact clinical decision making are needed to examine whether findings of the included studies generalize to clinician populations. This review provides an important overview of pitfalls associated with formats commonly used to communicate measurement uncertainty in clinical assessment instruments, and a potential starting point for further explorations into promising alternatives. Finally, our review offers specific recommendations on how remaining research questions might be addressed.
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Affiliation(s)
- Aleksander Heltne
- Department of Research and Innovation, Clinic for Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Niek Frans
- Department of Inclusive and Special Needs Education, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, the Netherlands
| | - Benjamin Hummelen
- Department of Research and Innovation, Clinic for Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Erik Falkum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sara Germans Selvik
- Department of Psychiatry, Helse Nord-Trønderlag, Namsos Hospital, Namsos, Norway
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Muirne C S Paap
- Department of Research and Innovation, Clinic for Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Department of Child and Family Welfare, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, the Netherlands
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Verbeeck J, De Backer M, Verwerft J, Salvaggio S, Valgimigli M, Vranckx P, Buyse M, Brunner E. Generalized Pairwise Comparisons to Assess Treatment Effects: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:1360-1372. [PMID: 37730293 DOI: 10.1016/j.jacc.2023.06.047] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 09/22/2023]
Abstract
A time-to-first-event composite endpoint analysis has well-known shortcomings in evaluating a treatment effect in cardiovascular clinical trials. It does not fully describe the clinical benefit of therapy because the severity of the events, events repeated over time, and clinically relevant nonsurvival outcomes cannot be considered. The generalized pairwise comparisons (GPC) method adds flexibility in defining the primary endpoint by including any number and type of outcomes that best capture the clinical benefit of a therapy as compared with standard of care. Clinically important outcomes, including bleeding severity, number of interventions, and quality of life, can easily be integrated in a single analysis. The treatment effect in GPC can be expressed by the net treatment benefit, the success odds, or the win ratio. This review provides guidance on the use of GPC and the choice of treatment effect measures for the analysis and reporting of cardiovascular trials.
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Affiliation(s)
- Johan Verbeeck
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-Biostat), University of Hasselt, Hasselt, Belgium.
| | | | - Jan Verwerft
- Department of Cardiology and Critical Care Medicine, Hasselt Heart Center, Jessa Hospital Hasselt, Hasselt, Belgium; Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Samuel Salvaggio
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (University of Lugano), Lugano, Switzerland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hasselt Heart Center, Jessa Hospital Hasselt, Hasselt, Belgium; Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Marc Buyse
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-Biostat), University of Hasselt, Hasselt, Belgium; International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Edgar Brunner
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
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Chaiken B, Restuccia J. Process Improvement and Information Technology: The Keys to Health Care Transformation. J Ambul Care Manage 2023; 46:106-113. [PMID: 36727744 DOI: 10.1097/jac.0000000000000446] [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: 02/03/2023]
Abstract
Human beings are inherently resistant to change. In our technologically driven world, change happens fast, thereby regularly challenging us inherently change-averse humans to adjust. Only through rapid, effective, outcomes-driven change can we address the numerous challenges facing health care today. And as health care leaders, it is our responsibility to learn how to become the most effective change leader so that we can deliver the changes in systems, processes, and thinking required to deliver ever-improving quality, safety, and access to care while managing its cost.
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Affiliation(s)
- Barry Chaiken
- DocsNetwork Ltd, Boston, Massachusetts (Dr Chaiken); and Operations and Technology Department, Questrom School of Business, Boston University, Boston, Massachusetts (Dr Restuccia)
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Abstract
This Viewpoint discusses the failure of the Centers for Medicare & Medicaid Services’ SEP-1 sepsis outcome improvement initiative to improve patients’ sepsis outcomes and suggests changing the focus of sepsis quality metrics from processes to outcomes.
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Affiliation(s)
- Michael Klompas
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chanu Rhee
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, England
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Burnett SJ, Innes JC, Varughese R, Frazer E, Clemency BM. A Qualitative Analysis of the Experiences of EMS Clinicians in Recognizing and Treating Witnessed Cardiac Arrests. PREHOSP EMERG CARE 2022; 27:758-766. [PMID: 36082980 DOI: 10.1080/10903127.2022.2122643] [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: 05/27/2022] [Revised: 09/05/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Survival from out of hospital cardiac arrest (OHCA) increases when effective cardiopulmonary resuscitation (CPR) and defibrillation are performed early. Patients who suffer OHCA in front of emergency medical services (EMS) clinicians have greater likelihood of survival, but little is known about how EMS clinicians think about and experience those events. We sought to understand how EMS clinicians assessed patients who devolved to cardiac arrest in their presence and uncover the perceived barriers and facilitators associated with recognizing and treating witnessed OHCAs. METHODS EMS clinicians who had attended an EMS-witnessed OHCA and consented to participate were interviewed within 72 hours of the index case. Transcripts of the interviews were coded through the consolidated framework for implementation research to understand enabling and constraining factors involved and the predictability and anticipation of OHCA and subsequent management of patient care. Utstein data points, interventions, and associated times were extracted from the medical records. RESULTS We interviewed 29 EMS clinicians who attended 27 EMS-witnessed OHCAs. Twenty-six (96.3%) of the EMS-witnessed OHCAs were preceded by prodromal symptoms and were classified as predictable. Of the predictable cases, clinicians anticipated 53.8% of them and attributed the prodromes of other cases to serious but not peri-arrest etiologies. Participants described various environmental, crew, and intrapersonal enabling and constraining factors associated with recognizing and treating EMS-witnessed OHCAs. Environmental elements included issues of safety and physical locations, crew elements included familiarity with their partners and working with them in the past, and intrapersonal elements included abilities to collect information and stress associated with responding to and managing the calls. CONCLUSION Recognition and treatment of EMS-witnessed OHCAs are influenced by numerous environmental, crew, and intrapersonal factors. Future training and education on OHCA should include diverse locations, situations, and crew make-up, along with nontraditional patient complaints to broaden experiences associated with cardiac arrest management.
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Affiliation(s)
- Susan J Burnett
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, The State University of New York, Buffalo, New York
| | - Johanna C Innes
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, The State University of New York, Buffalo, New York
- American Medical Response of Western New York, Buffalo, New York
| | - Renoj Varughese
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, The State University of New York, Buffalo, New York
- American Medical Response of Western New York, Buffalo, New York
| | - Eric Frazer
- American Medical Response of Western New York, Buffalo, New York
| | - Brian M Clemency
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, The State University of New York, Buffalo, New York
- American Medical Response of Western New York, Buffalo, New York
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Zimmerman TM, Neth MR, Tanski ME, Chess L, Thompson K, Jui J, Sahni R, Daya MR, Lupton JR. Utilization and Effect of Direct Medical Oversight during Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2022; 27:744-750. [PMID: 35977073 DOI: 10.1080/10903127.2022.2113189] [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: 04/29/2022] [Revised: 06/17/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
STUDY OBJECTIVE Direct medical oversight (DMO), where emergency medical services (EMS) clinicians contact a physician for real-time medical direction, is used by many EMS systems across the United States. Our objective was to characterize the recommendations made by DMO during out-of-hospital cardiac arrests (OHCA) and to determine their effect on EMS transport decisions and patient outcomes. METHODS This is a secondary analysis of DMO call recordings from OHCA cases in the Portland, Oregon metropolitan area from January 1, 2018 to February 28, 2021. Data extracted from the audio recordings were linked to OHCA cases in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry). The primary outcomes are recommendations made by DMO: transport, continued field resuscitation, or termination of resuscitation (TOR). Secondary outcomes include EMS transport decisions, survival to hospital admission, and survival to hospital discharge. We used descriptive statistics, unpaired t-tests, and chi-square tests as appropriate for data analysis. RESULTS There were 239 OHCA cases for which DMO was contacted by EMS. The median time from EMS arrival to DMO contact was 25.6 min, and EMS requested TOR for 72.0% of patients. Compared to patients where EMS requested further treatment advice, patients for whom EMS requested TOR had poor prognostic signs including older age, asystole as an initial rhythm, and lower rates of transient return of spontaneous circulation prior to DMO call compared with cases where EMS did not request TOR. DMO recommended transport, continued field resuscitation, or TOR in 21.8%, 18.0%, and 60.2% of patients, respectively. Of the 239 patients, 59 (24.7%) were ultimately transported by EMS to the hospital, 14 (5.9%) survived to admission, and only 1 patient (0.4%) survived to hospital discharge and had an acceptable neurologic outcome (Cerebral Performance Category score of 2). CONCLUSIONS Patients for whom EMS contacts DMO for further treatment advice or requesting field TOR after prolonged OHCA resuscitation have poor outcomes, even when DMO recommends transport or further resuscitation, and may represent opportunities to reduce unnecessary DMO contact or patient transports. More research is needed to determine which OHCA patients benefit from DMO contact.
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Affiliation(s)
- Tristen M Zimmerman
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Matthew R Neth
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Mary E Tanski
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Laura Chess
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kathryn Thompson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Ritu Sahni
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joshua R Lupton
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
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Alkorashy HA, Al-Hothaly WA. Quality of nursing care in Saudi's healthcare transformation era: A nursing perspective. Int J Health Plann Manage 2022; 37:1566-1582. [PMID: 35083782 DOI: 10.1002/hpm.3425] [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: 05/27/2020] [Revised: 11/30/2021] [Accepted: 01/15/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Kingdom of Saudi Arabia corporates performance improvement strategies in health sector to transform hospital operations and instituting a culture of quality through performance improvement initiatives. Quality of nursing care (QNC) is a concern for nursing professionals and administration. Donabedian's 'Quality-of-Care' framework plays a vital role in transforming nursing care and determining appropriate intervention development and implementation plans. AIM To explore the nurses' perception for the QNC and find their perspectives in achievements and gaps by adopting the Donabedian model. METHODS A cross-sectional study was conducted on a convenience sample of 639 nurses from a tertiary hospital in Saudi Arabia using Karen-personnel instrument for measuring QNC. The achievements and gaps in nursing care quality determined by redistributing Karen statements to the three dimensions of the Donabedian structure, process and outcome model. FINDINGS The nurses' overall perception of the QNC was positive. According to the Donabedian model, the nurses focussed on care procedures (i.e., process-oriented) and required resources (i.e., structure-oriented), although the transformation era requires nurses' performance to focus on the outcome dimension. CONCLUSION To activate the vital roles of nurses in accomplishing health transformation initiatives, there should be collaborative efforts among nursing managers, educators and policy-makers to sustain quality of structure, process and outcome-oriented nursing care and be more outcome-oriented.
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Affiliation(s)
- Hanan A Alkorashy
- Nursing Administration & Education Department, College of Nursing, King Saud University, Riyadh, Saudi Arabia
- Nursing Administration Department, Faculty of Nursing, Alexandria University, Alexandria, Egypt
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Halalau A, Sonmez M, Uddin A, Karabon P, Scherzer Z, Keeney S. Efficacy of a pharmacist-managed diabetes clinic in high-risk diabetes patients, a randomized controlled trial - "Pharm-MD" : Impact of clinical pharmacists in diabetes care. BMC Endocr Disord 2022; 22:69. [PMID: 35296307 PMCID: PMC8925057 DOI: 10.1186/s12902-022-00983-y] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetes mellitus affects 13% of American adults. To address the complex care requirements necessary to avoid diabetes-related morbidity, the American Diabetes Association recommends utilization of multidisciplinary teams. Research shows pharmacists have a positive impact on multiple clinical diabetic outcomes. METHODS Open-label randomized controlled trial with 1:1 assignment that took place in a single institution resident-run outpatient medicine clinic. Patients 18-75 years old with type 2 diabetes mellitus and most recent HbA1c ≥9% were randomized to standard of care (SOC) (continued with routine follow up with their primary provider) or to the SOC + pharmacist-managed diabetes clinic PMDC group (had an additional 6 visits with the pharmacist within 6 months from enrollment). Patients were followed for 12 months after enrollment. Data collected included HbA1c, lipid panel, statin use, blood pressure control, immunization status, and evidence of diabetic complications (retinopathy, nephropathy, neuropathy). Intention-to-treat and per-protocol analysis were performed. RESULTS Forty-four patients were enrolled in the SOC + PMDC group and 42 patients in the SOC group. Average decrease in HbA1c for the intervention compared to the control group at 6 months was - 2.85% vs. -1.32%, (p = 0.0051). Additionally, the odds of achieving a goal HbA1c of ≤8% at 6 months was 3.15 (95% CI = 1.18, 8.42, p = 0.0222) in the intervention versus control group. There was no statistically significant difference in the remaining secondary outcomes measured. CONCLUSIONS Addition of pharmacist managed care for patients with type 2 diabetes mellitus is associated with significant improvements in HbA1c compared with standard of care alone. Missing data during follow up limited the power of secondary outcomes analyses. TRIAL REGISTRATION ClinicalTrials.gov , ID: NCT03377127 ; first posted on 19/12/2017.
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Affiliation(s)
- Alexandra Halalau
- General Internal Medicine Division, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, USA.
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
| | - Melda Sonmez
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Ahsan Uddin
- Medicine- Pediatrics Department, Beaumont Health, Royal Oak, MI, USA
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Zachary Scherzer
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Segev L, Schtrechman G, Kalady MF, Liska D, Gorgun IE, Valente MA, Nissan A, Steele SR. Long-term Outcomes of Minimally Invasive Versus Open Abdominoperineal Resection for Rectal Cancer: A Single Specialized Center Experience. Dis Colon Rectum 2022; 65:361-372. [PMID: 34784318 DOI: 10.1097/dcr.0000000000002067] [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] [Indexed: 02/08/2023]
Abstract
BACKGROUND Randomized studies have validated laparoscopic proctectomy for the treatment of rectal cancer as noninferior to an open proctectomy, but most of those studies have included sphincter-preserving resections along with abdominoperineal resection. OBJECTIVE This study aimed to compare perioperative and long-term oncological outcomes between minimally invasive and open abdominoperineal resection. DESIGN This study is a retrospective analysis of a prospectively maintained database. SETTINGS The study was conducted in a single specialized colorectal surgery department. PATIENTS All patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2016 were included. MAIN OUTCOME MEASURES The primary outcomes measured were the perioperative and long-term oncological outcomes. RESULTS We included 452 patients, 372 in the open group and 80 in the minimally invasive group, with a median follow-up time of 74 months. There were significant differences between the groups in terms of neoadjuvant radiation treatment (67.5% of the open versus 81.3% of the minimally invasive group, p = 0.01), operative time (mean of 200 minutes versus 287 minutes, p < 0.0001), and mean length of stay (9.5 days versus 6.6 days, p < 0.0001). Overall complication rates were similar between the groups (34.5% versus 27.5%, p = 0.177). There were no significant differences in the mean number of lymph nodes harvested (21.7 versus 22.2 nodes, p = 0.7), circumferential radial margins (1.48 cm versus 1.37 cm, p = 0.4), or in the rate of involved radial margins (10.8% versus 6.3%, p = 0.37). Five-year overall survival was 70% in the open group versus 80% in the minimally invasive group (p = 0.344), whereas the 5-year disease-free survival rate in the open group was 63.2% versus 77.6% in the minimally invasive group (p = 0.09). LIMITATIONS This study was limited because it describes a single referral institution experience. CONCLUSIONS Although both approaches have similar perioperative outcomes, the minimally invasive approach benefits the patients with a shorter length of stay and a lower risk for surgical wound infections. Both approaches yield similar oncological technical quality in terms of the lymph nodes harvested and margins status, and they have comparable long-term oncological outcomes. See Video Abstract at http://links.lww.com/DCR/B754.RESULTADOS A LARGO PLAZO DE LA RESECCIÓN ABDOMINOPERINEAL MÍNIMAMENTE INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: EXPERIENCIA DE UN SOLO CENTRO ESPECIALIZADOANTECEDENTES:Estudios aleatorizados han validado la proctectomía laparoscópica para el tratamiento del cáncer de recto igual a la proctectomía abierta, pero la mayoría de esos estudios han incluido resecciones con preservación del esfínter junto con resección abdominoperineal.OBJETIVO:Comparar los resultados oncológicos perioperatorios y a largo plazo entre la resección abdominoperineal abierta y mínimamente invasiva.DISEÑO:Análisis retrospectivo de una base de datos mantenida de forma prospectiva.ENTORNO CLINICO:Servicio único especializado en cirugía colorrectal.PACIENTES:Todos los pacientes que se sometieron a resección abdominoperineal por cáncer de recto primario entre 2000 y 2016.PRINCIPALES MEDIDAS DE VALORACION:Resultados oncológicos perioperatorios y a largo plazo.RESULTADOS:Se incluyeron 452 pacientes, 372 en el grupo abierto y 80 en el grupo mínimamente invasivo, con una mediana de seguimiento de 74 meses. Hubo diferencias significativas entre los grupos en términos de tratamiento con radiación neoadyuvante (67,5% del grupo abierto versus 81,3% del grupo mínimamente invasivo, p = 0,01), tiempo operatorio (media de 200 minutos versus 287 minutos, p < 0,0001) y la duración media de la estancia (9,5 días frente a 6,6 días, p < 0,0001). Las tasas generales de complicaciones fueron similares entre los grupos (34,5% versus 27,5%, p = 0,177). No hubo diferencias significativas en el número medio de ganglios linfáticos extraídos (21,7 versus 22,2 ganglios, p = 0,7), márgenes radiales circunferenciales (1,48 cm y 1,37 cm, p = 0,4), ni en la tasa de márgenes radiales afectados (10,8 cm). % versus 6,3%, p = 0,37). La supervivencia general a 5 años fue del 70% en el grupo abierto frente al 80% en el grupo mínimamente invasivo (p = 0,344), mientras que la tasa de supervivencia libre de enfermedad a 5 años en el grupo abierto fue del 63,2% frente al 77,6% en el grupo mínimamente invasivo (p = 0,09).LIMITACIONES:Experiencia en una institución de referencia única.CONCLUSIONES:Si bien ambos tienen resultados perioperatorios similares, el enfoque mínimamente invasivo, beneficia a los pacientes con estadía más corta y menor riesgo de infecciones de la herida quirúrgica. Ambos enfoques, producen una calidad técnica oncológica similar en términos de ganglios linfáticos extraídos y estado de los márgenes, y tienen resultados oncológicos comparables a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B754. (Traducción - Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Lior Segev
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gal Schtrechman
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - I Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Aviram Nissan
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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17
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Bergman ZR, Usher M, Olson A, Chipman JG, Brunsvold ME, Beilman G, Tignanelli C, Lusczek ER. Comparison of Outcomes and Process of Care for Patients Treated at Hospitals Dedicated for COVID-19 Care vs Other Hospitals. JAMA Netw Open 2022; 5:e220873. [PMID: 35238935 PMCID: PMC8895262 DOI: 10.1001/jamanetworkopen.2022.0873] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Early in the SARS-CoV-2 pandemic, the M Health Fairview Hospital System established dedicated hospitals for establishing cohorts and caring for patients with COVID-19, yet the association between treatment at COVID-19-dedicated hospitals and mortality and complications is not known. OBJECTIVE To analyze the mortality rate and complications associated with treatment at the COVID-19-dedicated hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated data prospectively collected from March 1, 2020, through June 30, 2021, from 11 hospitals in Minnesota, including 2 hospitals created solely to care for patients with COVID-19. Data obtained included demographic characteristics, treatments, and outcomes of interest for all patients with a confirmed COVID-19 infection admitted to this hospital system during the study period. EXPOSURES Patients were grouped based on whether they received treatment from 1 of the 2 COVID-19-dedicated hospitals compared with the remainder of the hospitals within the hospital system. MAIN OUTCOMES AND MEASURES Multivariate analyses, including risk-adjusted logistic regression and propensity score matching, were performed to evaluate the primary outcome of in-hospital mortality and secondary outcomes, including complications and use of COVID-specific therapeutics. RESULTS There were 5504 patients with COVID-19 admitted during the study period (median age, 62.5 [IQR, 45.0-75.6] years; 2854 women [51.9%]). Of these, 2077 patients (37.7%) (median age, 63.4 [IQR, 50.7-76.1] years; 1080 men [52.0%]) were treated at 1 of the 2 COVID-19-dedicated hospitals compared with 3427 (62.3%; median age, 62.0 [40.0-75.1] years; 1857 women (54.2%) treated at other hospitals. The mortality rate was 11.6% (n = 241) at the dedicated hospitals compared with 8.0% (n = 274) at the other hospitals (P < .001). However, risk-adjusted in-hospital mortality was significantly lower for patients in the COVID-19-dedicated hospitals in both the unmatched group (n = 2077; odds ratio [OR], 0.75; 95% CI, 0.59-0.95) and the propensity score-matched group (n = 1317; OR, 0.78; 95% CI, 0.58-0.99). The rate of overall complications in the propensity score-matched group was significantly lower (OR, 0.81; 95% CI, 0.66-0.99) and the use of COVID-19-specific therapeutics including deep vein thrombosis prophylaxis (83.9% vs 56.9%; P < .001), high-dose corticosteroids (56.1% vs 22.2%; P < .001), remdesivir (61.5% vs 44.5%; P < .001), and tocilizumab (7.9% vs 2.0; P < .001) was significantly higher. CONCLUSIONS AND RELEVANCE In this cohort study, COVID-19-dedicated hospitals had multiple benefits, including providing high-volume repetitive treatment and isolating patients with the infection. This experience suggests improved in-hospital mortality for patients treated at dedicated hospitals owing to improved processes of care and supports the use of establishing cohorts for future pandemics.
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Affiliation(s)
| | - Michael Usher
- Department of Medicine, University of Minnesota, Minneapolis
| | - Andrew Olson
- Department of Medicine, University of Minnesota, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | | | | | - Greg Beilman
- Department of Surgery, University of Minnesota, Minneapolis
- M. Health Fairview Health System Management, Minneapolis, Minnesota
| | - Christopher Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis
- Department of Medicine, University of Minnesota, Minneapolis
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18
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Kopp S, Gillberg C. [Symptoms, diagnostic process and outcome in girls and women with ADHD]. Lakartidningen 2022; 119:21132. [PMID: 36794415] [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] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
ADHD in girls is usually an impairing disorder that persists into adulthood in most cases. The negative consequences include school failure, psychiatric problems, substance abuse, self-harm, suicide attempts, increased risk of being physically and sexually maltreated, and unplanned/unwanted pregnancies. Chronic pain, overweight and sleep problems/disorders are also common. The symptom presentation is one with fewer obvious hyperactive and impulsive behaviours as compared with boys. Attention deficits, emotional dysregulation and verbal aggression are more common. Many more girls are now being diagnosed with ADHD than 20 years ago, but ADHD symptoms in girls are still quite often overlooked, and underdiagnosis is more common than in boys. Girls with ADHD are less often receiving pharmacological treatment for equally impairing symptoms of inattention and/or hyperactivity/impulsivity. There is a need for more studies of ADHD in girls and women, awareness among professionals and the general public needs to be increased, focused support in schools needs to be implemented and better intervention methods need to be developed.
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Affiliation(s)
- Svenny Kopp
- med dr, specialist i barn- och ungdoms-psykiatri, Gillberg-cent-rum, Göteborgs universitet, Göteborg
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19
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Arcot R, Cher ML, Qi J, Linsell SM, Dunn RL, George AK, Montie JE, Ginsburg KB. Delayed radical prostatectomy after a period of active surveillance is not associated with the use of secondary treatments compared with immediate prostatectomy. Prostate 2022; 82:323-329. [PMID: 34855239 DOI: 10.1002/pros.24277] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/16/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND We evaluated the use of secondary treatments in men with grade group (GG) 1 PC following a period of active surveillance (AS) compared with men undergoing immediate radical prostatectomy (RP) to evaluate what is potentially lost in terms of cancer control, if a patient trials AS and transitions to treatment. METHODS We reviewed the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men with GG1 PC undergoing RP from April 2012 to July 2018. Men were classified into groups based on time from diagnosis to RP: immediate (surgery within 1 year of diagnosis) and delayed RP (surgery >1 year after initiation of AS). Time to secondary treatment was estimated using Kaplan-Meier curves and compared using the log-rank test. A multivariable Cox proportional hazards model was fit to assess the association between timing of RP and use of secondary treatments. A chi-squared test was used to assess the association between delayed RP and adverse pathology. RESULTS We identified 1878 men that underwent an RP during the study period, of which 1489 (79%) underwent immediate RP and 389 (21%) underwent delayed RP. The incidence of adverse pathology was higher in men with delayed versus immediate RP (49% vs. 36%, p < 0.0001, respectively). However, we noted only a small absolute difference in the estimated 24-month secondary treatment-free probability between men with delayed versus immediate RP (93% and 96%, respectively). On multivariable analysis, delayed RP was associated with increased use of secondary treatments (hazard ratio = 1.94, 95% confidence interval = 1.23-3.06, p = 0.004). CONCLUSIONS The use of secondary treatment after RP in men with GG1 PC undergoing immediate or delayed prostatectomy was rare. These data suggest that the burden of treatment is near equivalent in patients who progress to treatment on AS compared with those who underwent immediate RP.
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Affiliation(s)
- Rohith Arcot
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Ji Qi
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Susan M Linsell
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Rodney L Dunn
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Arvin K George
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University, Detroit, Michigan, USA
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Mittel A, Kim DH, Cooper Z, Argenziano M, Hua M. Use of 90-day mortality does not change assessment of hospital quality after coronary artery bypass grafting in New York State. J Thorac Cardiovasc Surg 2022; 163:676-682.e1. [PMID: 32414596 PMCID: PMC7554081 DOI: 10.1016/j.jtcvs.2020.03.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/13/2020] [Accepted: 03/28/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Publicly reported postoperative 30-day mortality rates are commonly used to compare hospital quality after coronary artery bypass grafting. We sought to determine whether 90-day mortality rates, which are not publicly reported but better capture postdischarge mortality, are a better determinant of hospital performance. METHODS We performed a retrospective cohort analysis of 30- versus 90-day risk-standardized mortality rates at adult cardiac surgical centers in New York State from 2008 to 2014. Hospitals were classified as good or poor performing outliers at each time point based on the bounds of the 95% confidence interval around each hospital's predicted risk-standardized mortality rates determined via hierarchical models. The primary outcome was change in institutional performance via outlier classification from 30 to 90 days. RESULTS During the study period, 72,398 adults underwent a coronary artery bypass grafting procedure at 1 of 42 institutions. The risk-standardized mortality rates increased from 30 to 90 days at all institutions, with a median 30-day risk-standardized mortality rate of 2.16% (interquartile range, 0.69%) and median 90-day risk-standardized mortality rate of 3.69% (interquartile range, 1.00%). In using a 90-day instead of a 30-day metric, 3 hospitals changed outlier status. One hospital improved to a good from as expected performer, and 2 worsened to as expected from good performers. CONCLUSIONS In a cohort of patients who underwent coronary artery bypass grafting surgery from 2008 to 2014 in New York State, use of a 90-day mortality metric resulted in a change in hospital quality assessment for a minority of hospitals. The use of 90-day mortality may not provide additional value when evaluating institutional performance for this population.
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Affiliation(s)
- Aaron Mittel
- Department of Anesthesiology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY.
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Mass
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Mass
| | - Michael Argenziano
- Department of Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY
| | - May Hua
- Department of Anesthesiology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
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Droghetti M, Porreca A, Bianchi L, Piazza P, Giampaoli M, Casablanca C, D'Agostino D, Cochetti G, Romagnoli D, Schiavina R, Brunocilla E. Long-term outcomes of Holmium laser enucleation of prostate and predictive model for symptom recurrence. Prostate 2022; 82:203-209. [PMID: 34694647 DOI: 10.1002/pros.24259] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/20/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION AND OBJECTIVES Holmium laser enucleation of prostate (HoLEP) represents one of the most studied surgical techniques for benign prostatic hyperplasia (BPH). Its efficacy in symptom relief has been widely depicted. However, few evidence is available regarding the possible predictors of symptom recurrence. We aimed to evaluate long-term outcomes, symptom recurrence rate, and predictors in patients that underwent HoLEP. MATERIALS AND METHODS We retrospectively analyzed data from patients that consecutively underwent HoLEP for BPH from 2012 to 2015 at two tertiary referral centers. Functional outcomes were evaluated by uroflowmetry parameters and International Prostate Symptom Score (IPSS) questionnaire administration at follow-up visits at 12, 24, and 60 months. The primary outcome was the symptomatic patients' rate presenting lower urinary tract symptoms (LUTS) after 60 months from surgery, defined as in case of one or more of the following: IPSS more than 7, post voidal residue (PVR) more than 20 ml, need for medical therapy for LUTS or redo surgery for bladder outlet obstruction. Multivariable logistic regression analyses evaluated predictors for being symptomatic at follow-up. Covariates consisted of: preoperative peak flow rate (PFR), PVR, and IPSS, prostate volume, age (all as continuous), and surgical technique. RESULTS A total of 567 patients were available for our analyses. Median prostate volume was 80cc, with a median PFR of 8 ml/s and median PVR of 100cc. One hundred and twenty-five (22%) patients were found to be symptomatic at follow-up. Redo surgery was needed for 25 (4.4%) patients. After adjusting for possible confounders, an increase in preoperative PVR (odds ratio [OR] 1.005) and IPSS (OR 1.12) resulted as independent predictors for symptom recurrence (all p < 0.001). CONCLUSIONS HoLEP can provide durable symptom relief regardless of the chosen technique. Patients with an important preoperative symptom burden or a high PVR should be carefully counseled on the risk of symptom recurrence.
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Affiliation(s)
- Matteo Droghetti
- Division of Urology, IRCCS Azienda ospedaliero universitaria di Bologna, Bologna, Italy
| | - Angelo Porreca
- Department of Urology, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Lorenzo Bianchi
- Division of Urology, IRCCS Azienda ospedaliero universitaria di Bologna, Bologna, Italy
| | - Pietro Piazza
- Division of Urology, IRCCS Azienda ospedaliero universitaria di Bologna, Bologna, Italy
| | - Marco Giampaoli
- Division of Urology, IRCCS Azienda ospedaliero universitaria di Bologna, Bologna, Italy
| | - Carlo Casablanca
- Division of Urology, IRCCS Azienda ospedaliero universitaria di Bologna, Bologna, Italy
| | | | | | | | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda ospedaliero universitaria di Bologna, Bologna, Italy
| | - Eugenio Brunocilla
- Division of Urology, IRCCS Azienda ospedaliero universitaria di Bologna, Bologna, Italy
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Hagaman A, Rodriguez HG, Barrington C, Singh K, Estifanos AS, Keraga DW, Alemayehu AK, Abate M, Bitewulign B, Barker P, Magge H. "Even though they insult us, the delivery they give us is the greatest thing": a qualitative study contextualizing women's experiences with facility-based maternal health care in Ethiopia. BMC Pregnancy Childbirth 2022; 22:31. [PMID: 35031022 PMCID: PMC8759250 DOI: 10.1186/s12884-022-04381-z] [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] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/22/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Globally, amidst increased utilization of facility-based maternal care services, there is continued need to better understand women's experience of care in places of birth. Quantitative surveys may not sufficiently characterize satisfaction with maternal healthcare (MHC) in local context, limiting their interpretation and applicability. The purpose of this study is to untangle how contextual and cultural expectations shape women's care experience and what women mean by satisfaction in two Ethiopian regions. METHODS Health center and hospital childbirth care registries were used to identify and interview 41 women who had delivered a live newborn within a six-month period. We used a semi-structured interview guide informed by the Donabedian framework to elicit women's experiences with MHC and delivery, any prior delivery experiences, and recommendations to improve MHC. We used an inductive analytical approach to compare and contrast MHC processes, experiences, and satisfaction. RESULTS Maternal and newborn survival and safety were central to women's descriptions of their MHC experiences. Women nearly exclusively described healthy and safe deliveries with healthy outcomes as 'satisfactory'. The texture behind this 'satisfaction', however, was shaped by what mothers bring to their delivery experiences, creating expectations from events including past births, experiences with antenatal care, and social and community influences. Secondary to the absence of adverse outcomes, health provider's interpersonal behaviors (e.g., supportive communication and behavioral demonstrations of commitment to their births) and the facility's amenities (e.g., bathing, cleaning, water, coffee, etc) enhanced women's experiences. Finally, at the social and community levels, we found that family support and material resources may significantly buffer against negative experiences and facilitate women's overall satisfaction, even in the context of poor-quality facilities and limited resources. CONCLUSION Our findings highlight the importance of understanding contextual factors including past experiences, expectations, and social support that influence perceived quality of MHC and the agency a woman has to negotiate her care experience. Our finding that newborn and maternal survival primarily drove women's satisfaction suggests that quantitative assessments conducted shortly following delivery may be overly influenced by these outcomes and not fully capture the complexity of women's care experience.
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Affiliation(s)
- Ashley Hagaman
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, 60 College St, New Haven, CT, 06510, USA.
- Center for Methods in Implementation and Prevention Sciences, Yale University, New Haven, CT, USA.
| | - Humberto Gonzalez Rodriguez
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, 123 W. Franklin St, Chapel Hill, NC, 27516, USA
| | - Kavita Singh
- Carolina Population Center, University of North Carolina at Chapel Hill, 123 W. Franklin St, Chapel Hill, NC, 27516, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Abiy Seifu Estifanos
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Zambia Street, Tikur Anbessa Hospital Building, Lideta Sub-city, Addis Ababa, Ethiopia
| | - Dorka Woldesenbet Keraga
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Zambia Street, Tikur Anbessa Hospital Building, Lideta Sub-city, Addis Ababa, Ethiopia
| | | | - Mehiret Abate
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
| | | | - Pierre Barker
- Institute for Healthcare Improvement, Boston, MA, USA
| | - Hema Magge
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Zambia Street, Tikur Anbessa Hospital Building, Lideta Sub-city, Addis Ababa, Ethiopia
- Bill & Melinda Gates Foundation, Seattle, USA
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23
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Yang Y, Lo DK, Beardsmore C, Roland D, Richardson M, Danvers L, Wilson A, Gaillard EA. Implementing spirometry and fractional exhaled nitric oxide testing in childhood asthma management in UK primary care: an observational study to examine training and implementation cost and impact on patient's health use and outcome. Arch Dis Child 2022; 107:21-25. [PMID: 34244168 PMCID: PMC8685621 DOI: 10.1136/archdischild-2020-319310] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 04/17/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Implementation of guidelines into clinical practice is challenging and complex. This study aims to (1) identify the training needs and capacity requirements, and (2) explore the impact on healthcare utilisation and asthma-related quality of life of implementing both spirometry and fraction of exhaled nitric oxide in diagnosis of asthma among children in the UK primary care. METHODS Ten UK general practitioner practices and a total of 612 children (5-16 years) with diagnosed or suspected asthma were invited to participate in this prospective observational study. The total times that the trainer and trainee clinical staff spent on developing the training package, providing and receiving, and performing and interpreting the two tests as part of routine child asthma review were collected, and costs were calculated. We compared healthcare utilisation and asthma-related and general health-related quality of life data between the 6 months before and after the asthma review guided by objective tests. RESULTS The average training cost for the 27 primary care clinical members was £1395. The average cost to implement and deliver the test-guided asthma review among the 612 included children was £22. In the 6 months following the tests-guided asthma review, both unplanned primary care attendance, and hospital admissions were reduced, and the asthma-related health status increased significantly. CONCLUSION This study provides robust cost estimates of the resources needed to implement the National Institute for Health and Care Excellence asthma guideline. It also demonstrates the potential to save healthcare costs and improve health status among asthmatic children by implementing this guideline.
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Affiliation(s)
- Yaling Yang
- Nuffield Department of Primary Care Health Sciences, Oxford NIHR Biomedical Research Centre, Oxford University, Oxford, UK
| | - David Kh Lo
- Deaprtment of Respiratory Sciences, Leicester NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
| | - Caroline Beardsmore
- Deaprtment of Respiratory Sciences, Leicester NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
- Department of Paediatric Respiratory Medicine, Leicester Children's Hospital, Lecester Royal Infirmary, Leicester, UK
| | - Damian Roland
- SAPPHIRE Group, College of Life Sciences, University of Leicester and Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester, UK
| | | | - Lesley Danvers
- Deaprtment of Respiratory Sciences, Leicester NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
| | - Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Erol A Gaillard
- Deaprtment of Respiratory Sciences, Leicester NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
- Department of Paediatric Respiratory Medicine, Leicester Royal Infirmary, Leicester Children's Hospital, Leicester, UK
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24
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Lewis RH, Perkins M, Fischer PE, Beebe MJ, Magnotti LJ. Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes. J Trauma Acute Care Surg 2022; 92:21-27. [PMID: 34670960 DOI: 10.1097/ta.0000000000003430] [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: 11/25/2022]
Abstract
BACKGROUND Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE Prognostic study, Level IV.
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Affiliation(s)
- Richard H Lewis
- From the Department of Surgery University of Tennessee Health Science Center, Memphis, Tennessee
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25
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Nanditha NGA, Dong X, Tafessu HM, Wang L, Lu M, Barrios R, Montaner JSG, Lima VD. A province-wide HIV initiative to accelerate initiation of treatment-as-prevention and virologic suppression in British Columbia, Canada: a population-based cohort study. CMAJ Open 2022; 10:E27-E34. [PMID: 35042692 PMCID: PMC8920539 DOI: 10.9778/cmajo.20210093] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In 2010, HIV treatment as prevention (TasP), encompassing widespread HIV testing and immediate initiation of free antiretroviral treatment (ART), was piloted under the Seek and Treat for Optimal Prevention of HIV/AIDS initiative (STOP) in British Columbia, Canada. We compared the time from HIV diagnosis to treatment initiation, and from treatment initiation to first virologic suppression, before (2005-2009) and after (2010-2016) the implementation of STOP. METHODS In this population-based cohort study, we used longitudinal data of all people living with an HIV diagnosis in BC from 1996 to 2017. We included those aged 18 years or older who had never received ART and had received an HIV diagnosis in the 2005-2016 period. We defined the virologic suppression date as the first date of at least 2 consecutive test results within 4 months with a viral load of less than 200 copies/mL. Negative binomial regression models assessed the effect of STOP on the time to ART initiation and suppression, adjusting for confounders. All p values were 2-sided, and we set the significance level at 0.05. RESULTS Participants who received an HIV diagnosis before STOP (n = 1601) were statistically different from those with a diagnosis after STOP (n = 1700); 81% versus 84% were men (p = 0.0187), 30% versus 15% had ever injected drugs (p < 0.0001), and 27% versus 49% had 350 CD4 cells/μL or more at diagnosis (p < 0.0001). The STOP initiative was associated with a 64% shorter time from diagnosis to treatment (adjusted mean ratio 0.36, 95% confidence interval [CI] 0.34-0.39) and a 21% shorter time from treatment to suppression (adjusted mean ratio 0.79, 95% CI 0.73-0.85). INTERPRETATION In a population with universal health coverage, a TasP intervention was associated with shorter times from HIV diagnosis to treatment initiation, and from treatment initiation to viral suppression. Our results show accelerating progress toward the United Nations' 90-90-90 target of people with HIV who have a diagnosis, those who are on antiretroviral therapy and those who are virologically suppressed, and support the global expansion of TasP to accelerate the control of HIV/AIDS.
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Affiliation(s)
- Ni Gusti Ayu Nanditha
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
| | - Xinzhe Dong
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
| | - Hiwot M Tafessu
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
| | - Lu Wang
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
| | - Michelle Lu
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
| | - Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS (Nanditha, Dong, Tafessu, Wang, Lu, Barrios, Montaner, Lima); Faculty of Medicine (Nanditha, Montaner, Lima), University of British Columbia, Vancouver, BC
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Hershkovitz Y, Zager Y, Segal B, Klein Y. Manual Closed Reduction of Incarcerated Hernia: Is It Safe in the Emergency Department? Isr Med Assoc J 2022; 24:11-14. [PMID: 35077039] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Emergency surgical repair is the standard approach to the management of an incarcerated abdominal wall hernia (IAWH). In cases of very high-risk patients, manual closed reduction (MCR) of IAWH may prevent the need for emergency surgery. OBJECTIVES To evaluate the safety, success rate, and complications of MCR in the management of IAWH conducted in an emergency department. METHODS The data of all patients who underwent MCR between 2012 and 2018 were retrospectively collected. Patient demographics, presenting symptoms, clinical parameters, and management during the hospitalization were retrieved from the medical charts. RESULTS Overall, 548 patients underwent MCR during the study period. The success rate was 25.4% (139 patients). One patient had a complication that required a laparotomy 2 days after his discharge. A recurrent incarceration occurred in 23%, 60% of them underwent successful repeated MCR and the others underwent emergency surgery. Six patients (1.4%) had a bowel perforation after a failed MCR. CONCLUSIONS MCR can be performed safely in the emergency department and should be consider as an option to treat IAWH, especially in high operative risk patients.
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Affiliation(s)
- Yehuda Hershkovitz
- Department of Surgery, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaniv Zager
- Department of Surgery and Transplantation B, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Batia Segal
- Department of Surgery and Transplantation B, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoram Klein
- Department of Surgery and Transplantation B, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Tzur T, Tzur Y, Baruch S, Smorgick N, Melcer Y. Clinical Presentation of Paraovarian Cysts. Isr Med Assoc J 2022; 24:15-19. [PMID: 35077040] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND A paraovarian cyst (POC) is located between the ovary and the fallopian tube. In many cases POCs are diagnosed and managed as ovarian cysts. But since POC are a distinct entity in their clinical presentation and surgical intervention, they should be better defined. OBJECTIVES To describe the clinical perioperative and operative characteristics of patients with POCs in order to improve pre-operative diagnosis and management. METHODS A retrospective cohort study of patients with an operative diagnosis of POC between 2007 and 2019 in a single university-affiliated tertiary care medical center was included. Demographic characteristics as well as symptoms, sonographic appearance, surgery findings, and histology results were retrieved from electronic medical records. RESULTS During the study period 114 patients were surgically diagnosed with POC, 57.9% were in their reproductive years and 24.6% were adolescents. Most presented with abdominal pain (77.2%). Preoperative sonographic exams accurately diagnosed POC in only 44.7% of cases, and 50.9% underwent surgery due to suspected torsion, which was surgically confirmed in 70.7% of cases. Among women with confirmed torsion, 28.9% involved the fallopian tube without involvement of the ipsilateral ovary. Histology results showed benign cysts in all cases, except two, with a pathological diagnosis of serous borderline tumor. CONCLUSIONS POC should always be part of the differential diagnosis of women presenting with lower abdominal pain and sonographic evidence of adnexal cysts. If POC is suspected there should be a high level of suspicion for adnexal torsion and low threshold for surgical intervention, especially in adolescent, population who are prone to torsion.
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Affiliation(s)
- Tamar Tzur
- Department of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Tzur
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Baruch
- Department of Obstetrics and Gynecology, Sanz Medical Center-Laniado Hospital
| | - Noam Smorgick
- Department of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Marincheva G, Levi T, Perelshtein Brezinov O, Valdman A, Rahkovich M, Kogan Y, Laish-Farkash A. Echocardiography-guided Cardiac Implantable Electronic Device Implantation to Reduce Device Related Tricuspid Regurgitation: A Prospective Controlled Study. Isr Med Assoc J 2022; 24:25-32. [PMID: 35077042] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Endocardial leads of permanent pacemakers (PPM) and implantable defibrillators (ICD) across the tricuspid valve (TV) can lead to tricuspid regurgitation (TR) or can worsen existing TR with subsequent severe morbidity and mortality. OBJECTIVES To evaluate prospectively the efficacy of intraprocedural 2-dimentional-transthoracic echocardiography (2DTTE) in reducing/preventing lead-associated TR. METHODS We conducted a prospective randomized controlled study comparing echocardiographic results in patients undergoing de-novo PPM/ICD implantation with intraprocedural echo-guided right ventricular (RV) lead placement (Group 1, n=56) versus non-echo guided implantation (Group 2, n=55). Lead position was changed if TR grade was more than baseline in Group 1. Cohort patients underwent 2DTTE at baseline and 3 and/or 6 months after implantation. Excluded were patients with baseline TR > moderate or baseline ≥ moderate RV dysfunction. RESULTS The study comprised 111 patients (74.14 ± 11 years of age, 58.6% male, 19% ICD, 42% active leads). In 98 patients there was at least one follow-up echo. Two patients from Group 1 (3.6%) needed intraprocedural RV electrode repositioning. Four patients (3.5%, 2 from each group, all dual chamber PPM, 3 atrial fibrillation, 2 RV pacing > 40%, none with intraprocedural reposition) had TR deterioration during 6 months follow-up. One patient from Group 2 with baseline mild-moderate aortic regurgitation (AR) had worsening TR and AR within 3 months and underwent aortic valve replacement and TV repair. CONCLUSIONS The rate of mechanically induced lead-associated TR is low; thus, a routine intraprocedural 2DTTE does not have a significant role in reducing/preventing it.
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Affiliation(s)
- Gergana Marincheva
- Electrophysiology and Pacing Unit, Department of Cardiology, Assuta Ashdod University Medical Center Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Tal Levi
- Electrophysiology and Pacing Unit, Department of Cardiology, Assuta Ashdod University Medical Center Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Olga Perelshtein Brezinov
- Electrophysiology and Pacing Unit, Department of Cardiology, Assuta Ashdod University Medical Center Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Andrei Valdman
- Electrophysiology and Pacing Unit, Department of Cardiology, Assuta Ashdod University Medical Center Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Michael Rahkovich
- Electrophysiology and Pacing Unit, Department of Cardiology, Assuta Ashdod University Medical Center Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Yonatan Kogan
- Electrophysiology and Pacing Unit, Department of Cardiology, Assuta Ashdod University Medical Center Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Avishag Laish-Farkash
- Electrophysiology and Pacing Unit, Department of Cardiology, Assuta Ashdod University Medical Center Ben Gurion University of the Negev, Beer Sheva, Israel
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Paiella S, Landoni L, Tebaldi S, Zuffante M, Salgarello M, Cingarlini S, D'Onofrio M, Parisi A, Deiro G, Manfrin E, Bianchi B, Montagnini G, Crinò SF, Bassi C, Salvia R. Dual-Tracer (68Ga-DOTATOC and 18F-FDG-)-PET/CT Scan and G1-G2 Nonfunctioning Pancreatic Neuroendocrine Tumors: A Single-Center Retrospective Evaluation of 124 Nonmetastatic Resected Cases. Neuroendocrinology 2022; 112:143-152. [PMID: 33508821 DOI: 10.1159/000514809] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/28/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The combined use of 68gallium (68Ga)-DOTA-peptides and 18fluorine-fluoro-2-deoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) scans in the workup of pancreatic neuroendocrine tumors (PanNETs) is controversial. This study aimed at assessing both tracers' capability to identify tumors and to assess its association with pathological predictors of recurrence. METHODS Prospectively collected, preoperative, dual-tracer PET/CT scan data of G1-G2, nonmetastatic, PanNETs that underwent surgery between January 2013 and October 2019 were retrospectively analyzed. RESULTS The final cohort consisted of 124 cases. There was an approximately equal distribution of males and females (50.8%/49.2%) and G1 and G2 tumors (49.2%/50.8%). The disease was detected in 122 (98.4%) and 64 (51.6%) cases by 68Ga-DOTATOC and by 18F-FDG PET/CT scans, respectively, with a combined sensitivity of 99.2%. 18F-FDG-positive examinations found G2 tumors more often than G1 (59.4 vs. 40.6%; p = 0.036), and 18F-FDG-positive PanNETs were larger than negative ones (median tumor size 32 mm, interquartile range [IQR] 21 vs. 26 mm, IQR 20; p = 0.019). The median Ki67 for 18F-FDG-positive and -negative examinations was 3 (IQR 4) and 2 (IQR 4), respectively (p = 0.029). At least 1 pathological predictor of recurrence was present in 74.6% of 18F-FDG-positive cases (vs. 56.7%; p = 0.039), whereas this was not found when dichotomizing the PanNETs by their dimensions (≤/>20 mm). None of the 2 tracers predicted nodal metastasis. The receiver operating characteristic curve analysis showed that 18F-FDG uptake higher than 4.2 had a sensitivity of 49.2% and specificity of 73.3% for differentiating G1 from G2 (AUC = 0.624, p = 0.009). CONCLUSION The complementary adoption of 68Ga-DOTATOC and 18F-FDG tracers may be valuable in the diagnostic workup of PanNETs despite not being a game-changer for the management of PanNETs ≤20 mm.
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Affiliation(s)
- Salvatore Paiella
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
| | - Sarah Tebaldi
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
| | - Michele Zuffante
- Nuclear Medicine Unit, Integrated University Hospital of Verona, Verona, Italy
| | - Matteo Salgarello
- Department of Nuclear Medicine, Ospedale Sacro Cuore Don Calabria, Negrar, Verona, Italy
| | - Sara Cingarlini
- Pancreas Institute, Oncology Unit, University of Verona Hospital Trust, Verona, Italy
| | - Mirko D'Onofrio
- Pancreas Institute, Radiology Unit, University of Verona Hospital Trust, Verona, Italy
| | - Alice Parisi
- Pancreas Institute, Department of Diagnostics and Public Health, Section of Pathology, University Verona Hospital Trust, Verona, Italy
| | - Giacomo Deiro
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
| | - Erminia Manfrin
- Pancreas Institute, Department of Diagnostics and Public Health, Section of Pathology, University Verona Hospital Trust, Verona, Italy
| | - Beatrice Bianchi
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
| | - Greta Montagnini
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Francesco Crinò
- Pancreas Institute, Gastroenterology and Digestive Endoscopy Unit, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Pancreas Institute, General and Pancreatic Surgery Unit, University of Verona Hospital Trust, Verona, Italy
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Nahmias J, Byerly S, Stein D, Haut ER, Smith JW, Gelbard R, Ziesmann M, Boltz M, Zarzaur B, Biffl WL, Brenner M, DuBose J, Fox C, Galante J, Martin M, Moore EE, Moore L, Morrison J, Norii T, Scalea T, Yeh DD. A core outcome set for resuscitative endovascular balloon occlusion of the aorta: A consensus based approach using a modified Delphi method. J Trauma Acute Care Surg 2022; 92:144-151. [PMID: 34554137 DOI: 10.1097/ta.0000000000003405] [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: 10/20/2022]
Abstract
BACKGROUND The utilization of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma has grown exponentially in recent years. However, inconsistency in reporting of outcome metrics related to this intervention has inhibited the development of evidence-based guidelines for REBOA application. This study sought to attain consensus on a core outcome set (COS) for REBOA. METHODS A review of "landmark" REBOA articles was performed, and panelists (first and senior authors) were contacted for participation in a modified Delphi study. In round 1, panelists provided a list of potential core outcomes. In round 2, using a Likert scale (1 [not important] to 9 [very important]), panelists scored the importance of each potential outcome. Consensus for core outcomes was defined a priori as greater than 70% of scores receiving 7 to 9 and less than 15% of scores receiving 1 to 3. Feedback was provided after round 2, and a third round was performed to reevaluate variables not achieving consensus and allow a final "write-in" round by the experts. RESULTS From 17 identified panelists, 12 participated. All panelists (12 of 12, 100%) participated in each subsequent round. Panelists initially identified 34 unique outcomes, with two outcomes later added upon write-in request after round 2. From 36 total potential outcomes, 20 achieved consensus as core outcomes, and this was endorsed by 100% of the participants. CONCLUSION Panelists successfully achieved consensus on a COS for REBOA-related research. This REBOA-COS is recommended for all clinical trials related to REBOA and should help enable higher-quality study designs, valid aggregation of published data, and development of evidence-based practice management guidelines. LEVEL OF EVIDENCE Diagnostic test or criteria, level V. TRIAL REGISTRATION Core Outcomes in Trauma Surgery: Development of a Core Outcome Set for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) http://www.comet-initiative.org/Studies/Details/1709.
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Affiliation(s)
- Jeffry Nahmias
- From the Department of Surgery (J.N.), University of California, Irvine, Orange, California; Department of Surgery (S.B.), University of Tennessee Health Science Campus, Memphis, Tennessee; Department of Surgery (D.S.), Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California; Division of Acute Care Surgery, Department of Surgery (E.R.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Hiram C. Polk Md Department of Surgery (J.W.S.), University of Louisville, Louisville, Kentucky; Division of Trauma and Acute Care Surgery, Department of Surgery (R.G.), University of Alabama at Birmingham, Boshell Building, Birmingham, Alabama; Department of Surgery (M.Z.), University of Manitoba, Winnipeg, Manitoba, Canada; Division of Trauma, Acute Care and Critical Care Surgery, Department of Surgery (Mel.B.), Penn State Hershey Medical Center, Hershey, Pennsylvania; Department of Surgery (B.Z.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Surgery (W.L.B.), Scripps Clinic Medical Group, La Jolla, California; Department of Surgery (Meg.B.), University of California Riverside School of Medicine, Riverside CA; R Adams Cowley Shock Trauma Center (J.D., C.F., J.M., T.S.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (J.G.), University of California, Davis, Sacramento; Department of Surgery (M.M.), Scripps Mercy Hospital, San Diego, California; Ernest E Moore Shock Trauma Center at Denver Health (E.E.M.), University of Colorado Denver, Denver Colorado; Department of Surgery (L.M.), The University of Texas Health McGovern Medical School, Houston, Houston, Texas; Department of Emergency Medicine (T.N.), University of New Mexico Health Sciences Center, Albuquerque, New Mexico; Department of Traumatology and Acute Critical Medicine (T.N.), Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Surgery (D.D.Y.), University of Miami Miller School of Medicine, Miami, Florida
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Moletta L, Pierobon ES, Capovilla G, Valotto G, Gavagna L, Provenzano L, Zanchettin G, Salvador R, Costantini M, Merigliano S, Valmasoni M. Could the Pittsburgh Severity Score guide the treatment of esophageal perforation? Experience of a single referral center. J Trauma Acute Care Surg 2022; 92:108-116. [PMID: 34561399 DOI: 10.1097/ta.0000000000003417] [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: 11/27/2022]
Abstract
BACKGROUND Esophageal perforation (EP) is characterized by high morbidity and mortality. The Pittsburgh Severity Score (PSS) is a scoring system based on clinical factors at the time of EP presentation, intended to guide treatment. The aim of the study is to verify PSS usefulness in stratifying EP severity and in guiding clinical decisions. METHODS All patients referred to our unit for EP between January 2005 and January 2020 were enrolled. Patients were stratified according to their PSS into three groups (PSS ≤ 2, 3-5, and >5): the postoperative outcomes were compared. The predictive value of the PSS was evaluated by simple linear and logistic regression for the following outcomes: need for surgery, complications, in-hospital mortality, intensive care unit (ICU) and hospital stay, time to refeeding, and need for reintervention. RESULTS Seventy-three patients were referred for EP (male/female, 46/27). Perforations were more frequently iatrogenic (41.1%) or spontaneous (38.3%). The median PSS was 4 (interquartile range, 2-6). Surgery was required in 60.3% of cases. Pittsburgh Severity Score was associated with ICU admission, hospital stay, need for surgery and reintervention, postperforation complications and mortality. After regression analysis, PSS was significantly predictive of postperforation complications (p < 0.01), in-hospital mortality (p = 0.01), ICU admission (p < 0.01), need for surgical treatment (p < 0.01), and need for reintervention (p = 0.02). CONCLUSION Pittsburgh Severity Score is useful in stratifying patients in risk groups with different morbidity and mortality. It is also useful in guiding the therapeutic conduct, selecting patients for nonoperative management. Prospective studies are needed to confirm the role of the PSS in the treatment of esophageal perforation. LEVEL OF EVIDENCE Management, Therapeutic/Care; level IV.
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Affiliation(s)
- Lucia Moletta
- From the Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
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Beattie G, Cohan CM, Tang A, Chen JY, Victorino GP. Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement. J Trauma Acute Care Surg 2022; 92:177-184. [PMID: 34538828 DOI: 10.1097/ta.0000000000003415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/25/2022]
Abstract
BACKGROUND Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. METHODS Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression. RESULTS Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). CONCLUSION The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients. LEVEL OF EVIDENCE Prognostic, level IV.
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Affiliation(s)
- Genna Beattie
- From the Department of Surgery (G.B., C.M.C., A.T., G.P.V.), University of California, San Francisco, East Bay, Oakland; Chemical Sciences Division (J.Y.C.), Lawrence Berkeley National Laboratory, Berkeley, California
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Mokashi SA, Rosinski BF, Desai MY, Griffin BP, Hammer DF, Kalahasti V, Johnston DR, Rajeswaran J, Roselli EE, Blackstone EH, Svensson LG. Aortic root replacement with bicuspid valve reimplantation: Are outcomes and valve durability comparable to those of tricuspid valve reimplantation? J Thorac Cardiovasc Surg 2022; 163:51-63.e5. [PMID: 32684389 DOI: 10.1016/j.jtcvs.2020.02.147] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess intermediate-term outcomes of aortic root replacement with valve-sparing reimplantation of bicuspid aortic valves (BAV), compared with tricuspid aortic valves (TAV). METHODS From January 2002 to July 2017, 92 adults underwent aortic root replacement with BAV reimplantation and 515 with TAV reimplantation at the Cleveland Clinic. Balancing-score matching based on 28 preoperative variables yielded 71 well-matched BAV and TAV pairs (77% of possible pairs) for comparison of postoperative mortality and morbidity, longitudinal echocardiogram data, aortic valve reoperation, and survival. RESULTS In the BAV group, 1 hospital death occurred (1.1%); mortality among all reimplantations was 0.2%. Among matched patients, procedural morbidity was low and similar between BAV and TAV groups (1 stroke in TAV group; renal failure requiring dialysis, 1 patient each; red cell transfusion, 25% each). Five-year results: Severe aortic regurgitation was present in 7.4% of the BAV group and 2.9% of the TAV group (P = .7); 39% of BAV and 65% of TAV patients had none. Higher mean gradients (10 vs 7.4 mm Hg; P = .001) and left ventricular mass index (111 vs 101 g/m2; P = .5) were present in BAV patients. Freedom from aortic valve reoperation was 94% in the BAV group and 98% in the TAV group (P = .10), and survival was 100% and 95%, respectively (P = .07). CONCLUSIONS Both BAV and TAV reimplantations can be performed with equal safety and good midterm outcomes; however, the constellation of higher gradients, less ventricular reverse remodeling, and more aortic valve reoperations with BAV reimplantations raises concerns requiring continued long-term surveillance.
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Affiliation(s)
- Suyog A Mokashi
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Donald F Hammer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Rosen JE, Bulger EM, Cuschieri J. Respiratory events after intensive care unit discharge in trauma patients: Epidemiology, outcomes, and risk factors. J Trauma Acute Care Surg 2022; 92:28-37. [PMID: 34284468 PMCID: PMC8692327 DOI: 10.1097/ta.0000000000003362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 01/03/2023]
Abstract
BACKGROUND Respiratory complications are associated with significant morbidity and mortality in trauma patients. The care transition from the intensive care unit (ICU) to the acute care ward is a vulnerable time for injured patients. There is a lack of knowledge about the epidemiology of respiratory events and their outcomes during this transition. METHODS Retrospective cohort study in a single Level I trauma center of injured patients 18 years and older initially admitted to the ICU from 2015 to 2019 who survived initial transfer to the acute care ward. The primary outcome was occurrence of a respiratory event, defined as escalation in oxygen therapy beyond nasal cannula or facemask for three or more consecutive hours. Secondary outcomes included unplanned intubation for a primary pulmonary cause, adjudicated via manual chart review, as well as in-hospital mortality and length of stay. Multivariable logistic regression was used to examine patient characteristics associated with posttransfer respiratory events. RESULTS There were 6,561 patients that met the inclusion criteria with a mean age of 52.3 years and median Injury Severity Score of 18 (interquartile range, 13-26). Two hundred and sixty-two patients (4.0%) experienced a respiratory event. Respiratory events occurred early after transfer (median, 2 days, interquartile range, 1-5 days), and were associated with high mortality (16% vs. 1.8%, p < 0.001), and ICU readmission rates (52.6% vs. 4.7%, p < 0.001). Increasing age, male sex, severe chest injury, and comorbidities, including preexisting alcohol use disorder, congestive heart failure, and chronic obstructive pulmonary disease, were associated with increased odds of a respiratory event. Fifty-eight patients experienced an unplanned intubation for a primary pulmonary cause, which was associated with an in-hospital mortality of 39.7%. CONCLUSION Respiratory events after transfer to the acute care ward occur close to the time of transfer and are associated with high mortality. Interventions targeted at this critical time are warranted to improve patient outcomes. LEVEL OF EVIDENCE Prognostic and Epidemiological study, level III.
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Affiliation(s)
- Joshua E Rosen
- From the Surgical Outcomes Research Center, Department of Surgery (J.E.R.), University of Washington; Department of Surgery (J.E.R., E.M.B.), Harborview Medical Center, Seattle, Washington; and Department of Surgery (J.C.), University of California San Francisco, San Francisco, California
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Eisenberg MD, McCourt A, Stuart EA, Rutkow L, Tormohlen KN, Fingerhood MI, Quintero L, White SA, McGinty EE. Studying how state health services delivery policies can mitigate the effects of disasters on drug addiction treatment and overdose: Protocol for a mixed-methods study. PLoS One 2021; 16:e0261115. [PMID: 34914779 PMCID: PMC8675685 DOI: 10.1371/journal.pone.0261115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The United States is experiencing a drug addiction and overdose crisis, made worse by the COVID-19 pandemic. Relative to other types of health services, addiction treatment and overdose prevention services are particularly vulnerable to disaster-related disruptions for multiple reasons including fragmentation from the general medical system and stigma, which may lead decisionmakers and providers to de-prioritize these services during disasters. In response to the COVID-19 pandemic, U.S. states implemented multiple policies designed to mitigate disruptions to addiction treatment and overdose prevention services, for example policies expanding access to addiction treatment delivered via telehealth and policies designed to support continuity of naloxone distribution programs. There is limited evidence on the effects of these policies on addiction treatment and overdose. This evidence is needed to inform state policy design in future disasters, as well as to inform decisions regarding whether to sustain these policies post-pandemic. METHODS The overall study uses a concurrent-embedded design. Aims 1-2 use difference-in-differences analyses of large-scale observational databases to examine how state policies designed to mitigate the effects of the COVID-19 pandemic on health services delivery influenced addiction treatment delivery and overdose during the pandemic. Aim 3 uses a qualitative embedded multiple case study approach, in which we characterize local implementation of the state policies of interest; most public health disaster policies are enacted at the state level but implemented at the local level by healthcare systems and local public health authorities. DISCUSSION Triangulation of results across methods will yield robust understanding of whether and how state disaster-response policies influenced drug addiction treatment and overdose during the COVID-19 pandemic. Results will inform policy enactment and implementation in future public health disasters. Results will also inform decisions about whether to sustain COVID-19 pandemic-related changes to policies governing delivery addiction and overdose prevention services long-term.
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Affiliation(s)
- Matthew D. Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Alexander McCourt
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lainie Rutkow
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kayla N. Tormohlen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael I. Fingerhood
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Luis Quintero
- Carey Business School, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sarah A. White
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Emma Elizabeth McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Choi J, Min JG, Jopling JK, Meshkin S, Bessoff KE, Forrester JD. Intercostal nerve cryoablation during surgical stabilization of rib fractures. J Trauma Acute Care Surg 2021; 91:976-980. [PMID: 34446656 DOI: 10.1097/ta.0000000000003391] [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: 11/25/2022]
Abstract
BACKGROUND Intercostal nerve cryoablation (IC) offers potential for targeted and durable analgesia for patients with traumatic rib fractures. Our pilot study aimed to investigate thoracoscopic IC's safety, feasibility, and preliminary efficacy for patients undergoing surgical stabilization of rib fractures (SSRF). We hypothesized that concurrent surgical stabilization of rib fractures and intercostal nerve cryoablation (SSRF-IC) is a safe and feasible procedure without immediate or long-term complications. METHODS We retrospectively evaluated patients 18 years or older who underwent SSRF (with or without IC) for acute rib fractures at our level I trauma center between September 1, 2019, and September 30, 2020. We performed IC under thoracoscopic visualization (-70°C for 2 minutes per intercostal nerve bundle). Among patients whose only operative procedure during hospitalization was SSRF, we evaluated post-SSRF length of stay, operative times, opioid requirements (oral morphine equivalents), and pain scores (Numerical Rating Scale). Generalized estimating equations compared SSRF and SSRF-IC group outcomes (population mean [robust standard error]). We assessed long-term outcomes of patients who underwent SSRF-IC. RESULTS Thirty-four patients (144 ribs) underwent SSRF; of these, 20 patients (135 ribs) underwent SSRF-IC. Patients who did and did not undergo concurrent IC had no significant difference demographic, injury, or hospitalization characteristics. Among 20 patients who did not undergo other operations, 12 underwent SSRF-IC. We did not find significant difference between SSRF and SSRF-IC groups' median operative times or post-SSRF length of stay. Compared with SSRF group, SSRF-IC group did not have statistically significant change in pain score (0.2 [1.5] lower) or opioid use (43.9 [86.1] mg/d greater) between 12 hours before SSRF and last 24 admission hours. Among 17 SSRF-IC patients who followed-up postdischarge (median [range], 160 [9-357] days), one reported mild chest wall paresthesia; no other complications were reported. CONCLUSION This pilot study performing 135 intercostal nerve cryoablations on 20 patients suggests that IC is safe and feasible for patients undergoing SSRF. Evaluating IC's analgesic efficacy for rib fractures requires further study. LEVEL OF EVIDENCE Therapeutic, Level V.
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Affiliation(s)
- Jeff Choi
- From the Division of General Surgery, Department of Surgery (J.C., J.K.J., S.M., K.E.B., J.D.F.), Surgeons Writing About Trauma (J.C., J.G.M., J.K.J., S.M., K.E.B., J.D.F.), and School of Medicine (J.G.M.), Stanford University, Stanford, California
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Thomas CN, Lindquist TJ, Paull TZ, Tatro JM, Schroder LK, Cole PA. Mapping of common rib fracture patterns and the subscapular flail chest associated with operative scapula fractures. J Trauma Acute Care Surg 2021; 91:940-946. [PMID: 34417408 DOI: 10.1097/ta.0000000000003382] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 11/25/2022]
Abstract
BACKGROUND Rib fractures occur in approximately 10% of trauma patients and are associated with more than 50% of patients with scapula fractures. This study investigates the location and patterns of rib fractures and flail chest occurring in patients with operatively treated scapula fractures. Novel frequency mapping techniques of rib fracture patterns in patients who also injure the closely associated scapula can yield insight into surgical approaches and fixation strategies for complex, multiple injuries patients. We hypothesize that rib fractures have locations of common occurrence when presenting with concomitant scapula fracture that requires operative treatment. METHODS Patients with one or more rib fractures and a chest computed tomography scan between 2004 and 2018 were identified from a registry of patients having operatively treated scapula fractures. Unfurled rib images were created using Syngo-CT Bone Reading software (Siemens Inc., Munich, Germany). Rib fracture and flail segment locations were marked and measured for standardized placement on a two-dimensional chest wall template. Location and frequency were then used to create a gradient heat map. RESULTS A total of 1,062 fractures on 686 ribs were identified in 86 operatively treated scapula fracture patients. The mean ± SD number of ribs fractured per patient was 8.0 ± 4.1 and included a mean ± SD of 12.3 ± 7.2 total fractures. Rib fractures ipsilateral to the scapula fracture occurred in 96.5% of patients. The most common fracture and flail segment location was ipsilateral and subscapular; 51.4% of rib fractures and 95.7% of flail segments involved ribs 3 to 6. CONCLUSION Patients indicated for operative treatment of scapula fractures have a substantial number of rib fractures that tend to most commonly occur posteriorly on the rib cage. There is a pattern of subscapular rib fractures and flail chest adjacent to the thick bony borders of the scapula. This study enables clinicians to better evaluate and diagnose scapular fracture patients with concomitant rib fractures. LEVEL OF EVIDENCE Diagnostic test, level IV.
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Affiliation(s)
- Claire N Thomas
- From the Department of Orthopaedic Surgery (C.N.T., T.Z.P., J.M.T., L.K.S., P.A.C.), University of Minnesota, Minneapolis; Department of Orthopaedic Surgery (C.N.T., J.M.T., L.K.S., P.A.C.), Regions Hospital, University of Minnesota, St. Paul, Minnesota; Department of Biology (T.J.L.), Wheaton College, Wheaton, Illinois; and HealthPartners Orthopaedics and Sports Medicine (P.A.C.), Bloomington, Minnesota
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Beni CE, Arbabi S, Robinson BRH, O'Keefe GE. Acute intensive care unit resuscitation of severely injured trauma patients: Do we need a new strategy? J Trauma Acute Care Surg 2021; 91:1010-1017. [PMID: 34347741 PMCID: PMC9009679 DOI: 10.1097/ta.0000000000003373] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unlike recent advances in blood product resuscitation, intravenous crystalloid (IVF) use after intensive care unit (ICU) admission in hemorrhagic shock has received less attention and current recommendations are based on limited evidence. To address this knowledge gap, we aimed to determine associations between IVF administration during acute ICU resuscitation and outcomes. We hypothesized that larger IVF volumes are associated with worse outcomes. METHODS We linked our trauma registry with electronic health record data (2012-2015) to identify adults with an initial lactate level of ≥4 mmol/L and documented lactate normalization (≤2 mmol/L), excluding those with isolated head Abbreviated Injury Scale score ≥3. We focused on the period from ICU admission to lactate normalization, analyzing duration, volume of IVF, and proportion of volume as 1-L boluses. We used linear regression to determine associations with ICU length of stay and duration of mechanical ventilation in survivors, and logistic regression to identify associations with acute kidney injury and home discharge while adjusting for important covariates. RESULTS We included 337 subjects. Median time to lactate normalization was 15 hours (interquartile range, 7-25 hours), and median IVF volume was 3.7 L (interquartile range, 1.5-6.4 L). The fourfold difference between the upper and lower quartiles of both duration and volume remained after stratifying by injury severity. Hourly volumes tapered over time but persistently aggregated at 0.5 and 1 L, with 167 subjects receiving at least one 0.5-L bolus for 6 hours after ICU admission. Administration of larger volumes was associated with longer ICU length of stay and duration of mechanical ventilation, as well as acute kidney injury. CONCLUSION There is substantial variation in volume administered during acute ICU resuscitation, both absolutely and temporally, despite accounting for injury severity. Administration of larger volumes during acute ICU resuscitation is associated with worse outcomes. There is an opportunity to improve outcomes by further investigating and standardizing this important phase of care. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Catherine E Beni
- From the Department of Surgery (C.E.B., S.A., B.R.H.R., G.E.O.) and Harborview Injury Prevention and Research Center (S.A., B.R.H.R., G.E.O.), Harborview Medical Center, University of Washington, Seattle, Washington
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Warner MA, Schulte PJ, Hanson AC, Madde NR, Burt JM, Higgins AA, Andrijasevic NM, Kreuter JD, Jacob EK, Stubbs JR, Kor DJ. Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center. Mayo Clin Proc 2021; 96:2980-2990. [PMID: 34736775 PMCID: PMC8649051 DOI: 10.1016/j.mayocp.2021.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/08/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess changes in inpatient transfusion utilization and patient outcomes with implementation of a comprehensive patient blood management (PBM) program at a large US medical center. PATIENTS AND METHODS This is an observational study of graduated PBM implementation for hospitalized adults (age ≥18 years) from January 1, 2010, through December 31, 2017, at two integrated hospital campuses at a major academic US medical center. Allogeneic transfusion utilization and clinical outcomes were assessed over time through segmented regression with multivariable adjustment comparing observed outcomes against projected outcomes in the absence of PBM activities. RESULTS In total, 400,998 admissions were included. Total allogeneic transfusions per 1000 admissions decreased from 607 to 405 over the study time frame, corresponding to an absolute risk reduction for transfusion of 6.0% (95% confidence interval [CI]: 3.6%, 8.3%; P<.001) and a 22% (95% CI: 6%, 37%; P=.006) decrease in the rate of transfusions over projected. The risk of transfusion decreased for all blood components except cryoprecipitate. Transfusion reductions were experienced for all major surgery types except liver transplantation, which remained stable over time. Hospital length of stay (multiplicative increase in geometric mean 0.85 [95% CI: 0.81, 0.89]; P<.001) and incident in-hospital adverse events (absolute risk reduction: 1.5% [95% CI: 0.1%, 3.0%]; P=.04) were lower than projected at the end of the study time frame. CONCLUSION Patient blood management implementation for hospitalized patients in a large academic center was associated with substantial reductions in transfusion utilization and improved clinical outcomes. Broad-scale implementation of PBM in US hospitals is feasible without signal for patient harm.
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Affiliation(s)
- Matthew A Warner
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Patient Blood Management Program, Mayo Clinic, Rochester, MN.
| | - Phillip J Schulte
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Jennifer M Burt
- Patient Blood Management Program, Mayo Clinic, Rochester, MN
| | | | - Nicole M Andrijasevic
- Anesthesia Clinical Research Unit, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Justin D Kreuter
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Eapen K Jacob
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - James R Stubbs
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Patient Blood Management Program, Mayo Clinic, Rochester, MN
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Polycarpou A, Kim BD. Pediatric surgical rib fixation: A collected case series of a rare entity. J Trauma Acute Care Surg 2021; 91:947-950. [PMID: 34407006 DOI: 10.1097/ta.0000000000003376] [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: 11/25/2022]
Abstract
BACKGROUND Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data. METHODS Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up. RESULTS Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months. CONCLUSION Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma. LEVEL OF EVIDENCE Collected case series, level V.
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Ahmad T, Van Looy A. Development and testing of an explorative BPM acceptance model: Insights from the COVID-19 pandemic. PLoS One 2021; 16:e0259226. [PMID: 34735499 PMCID: PMC8568138 DOI: 10.1371/journal.pone.0259226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/18/2021] [Indexed: 12/04/2022] Open
Abstract
When emerging technologies transform an organization’s way of working, explorative business process management (BPM) becomes a new challenge. Although digital innovations can boost process efficacy and business productivity, employees do not necessarily accept the implied work changes. We therefore looked at the increased digitalization efforts during the COVID-19 lockdowns, during which employees were forced to drastically rethink work by heavily depending on technology for communication and almost all business tasks. This global setting allowed us to scrutinize disruptive work changes and how employees can cope with disruptive work adaptations. We also looked into the explorative skillset needed to adapt to these changes. To theorize about an explorative BPM acceptance model, eleven hypotheses were supported based on a solid theoretical foundation. We followed a quantitative research design using partial least squares for structural equation modeling (PLS-SEM) at the university administration settings in two regions, including purposive sampling. Data analysis covered both a measurement model assessment and structural model assessment. Our findings reveal that employees’ perceived work modalities, feeling creative and feeling flexible are more promising features than perceived influence and attitude related to explorative work and skill development. We also offer novel insights into explorative business process management (BPM) skills, and which skills are more productive in uncertain or dynamic working conditions. This research is a learning path for managers struggling with flexible or competitive business environments, and more specifically to facilitate employee willingness.
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Affiliation(s)
- Tahir Ahmad
- Department of Business Informatics and Operations Management, Faculty of Economics and Business Administration, Ghent University, Ghent, Belgium
- * E-mail:
| | - Amy Van Looy
- Department of Business Informatics and Operations Management, Faculty of Economics and Business Administration, Ghent University, Ghent, Belgium
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Hayek A, Rioufol G, Bochaton T, Rossi R, Mewton N, Paccalet A, Bonnefoy-Cudraz E, Thibault H, Derimay F. Prognosis After Percutaneous Foramen Ovale Closure Among Patients With Platypnea-Orthodeoxia Syndrome. J Am Coll Cardiol 2021; 78:1844-1846. [PMID: 34711343 DOI: 10.1016/j.jacc.2021.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
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Liu C, Peng Z, Dong Y, Li Z, Song X, Liu X, Andrijasevic NM, Gajic O, Albright RC, Kashani KB. Continuous Renal Replacement Therapy Liberation and Outcomes of Critically Ill Patients With Acute Kidney Injury. Mayo Clin Proc 2021; 96:2757-2767. [PMID: 34686364 DOI: 10.1016/j.mayocp.2021.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/07/2020] [Revised: 04/08/2021] [Accepted: 05/27/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To examine the association between continuous renal replacement therapy (CRRT) liberation and clinical outcomes among patients with acute kidney injury (AKI) requiring CRRT. METHODS This single-center, retrospective cohort study included adult patients admitted to intensive care units with AKI and treated with CRRT from January 1, 2007, to May 4, 2018. Based on the survival and renal replacement therapy (RRT) status at 72 hours after the first CRRT liberation, we classified patients into liberated, reinstituted, and those who died. We observed patients for 90 days after CRRT initiation to compare the major adverse kidney events (MAKE90). RESULTS Of 1135 patients with AKI, 228 (20%), 437 (39%), and 470 (41%) were assigned to liberated, reinstituted, and nonsurvival groups, respectively. The MAKE90, mortality, and RRT independence rates of the cohort were 62% (707 cases), 59% (674 cases), and 40% (453 cases), respectively. Compared with reinstituted patients, the liberated group had a lower MAKE90 (29% vs 39%; P=.009) and higher RRT independence rate (73% vs 65%; P=.04) on day 90, but without significant difference in 90-day mortality (26% vs 33%; P=.05). After adjustments for confounders, successful CRRT liberation was not associated with lower MAKE90 (odds ratio, 0.71; 95% CI, 0.48 to 1.04; P=.08) but was independently associated with improved kidney recovery at 90-day follow-up (hazard ratio, 1.81; 95% CI, 1.41 to 2.32; P<.001). CONCLUSION Our study demonstrated a high occurrence of CRRT liberation failure and poor 90-day outcomes in a cohort of AKI patients treated with CRRT.
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Affiliation(s)
- Chang Liu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Xuan Song
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Xinyan Liu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN.
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Böhm F, Mogensen B, Östlund O, Engstrøm T, Fossum E, Stankovic G, Angerås O, Ērglis A, Menon M, Schultz C, Berry C, Liebetrau C, Laine M, Held C, Rück A, James SK. The Full Revasc (Ffr-gUidance for compLete non-cuLprit REVASCularization) Registry-based randomized clinical trial. Am Heart J 2021; 241:92-100. [PMID: 34310907 DOI: 10.1016/j.ahj.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Complete revascularization in ST elevation myocardial infarction (STEMI) patients with multivessel disease has resulted in reduction in composite clinical endpoints in medium sized trials. Only one trial showed an effect on hard clinical endpoints, but the revascularization procedure was guided by angiographic evaluation of stenosis severity. Consequently, it is not clear how Fractional Flow Reserve (FFR)-guided percutaneous coronary intervention (PCI) affects hard clinical endpoints in STEMI. METHODS AND RESULTS The Ffr-gUidance for compLete non-cuLprit REVASCularization (FULL REVASC) - is a pragmatic, multicenter, international, registry-based randomized clinical trial designed to evaluate whether a strategy of FFR-guided complete revascularization of non-culprit lesions, reduces the combined primary endpoint of total mortality, non-fatal MI and unplanned revascularization. 1,545 patients were randomized to receive FFR-guided PCI during the index hospitalization or initial conservative management of non-culprit lesions. We found that in angiographically severe non-culprit lesions of 90-99% severity, 1 in 5 of these lesions were re-classified as non-flow limiting by FFR. Considering lesions of intermediate severity (70%-89%), half were re-classified as non-flow limiting by FFR. The study is event driven for an estimated follow-up of at least 2.75 years to detect a 9.9%/year>7.425%/year difference (HR = 0.74 at 80% power (α = .05)) for the combined primary endpoint. CONCLUSION This large randomized clinical trial is designed and powered to evaluate the effect of complete revascularization with FFR-guided PCI during index hospitalization on total mortality, non-fatal MI and unplanned revascularization following primary PCI in STEMI patients with multivessel disease. Enrollment completed in September 2019 and follow-up is ongoing.
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Affiliation(s)
- Felix Böhm
- Department of Cardiology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden.
| | - Brynjölfur Mogensen
- Department of Cardiology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Ollie Östlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Eigil Fossum
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Goran Stankovic
- University Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Andrejs Ērglis
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, University of Latvia, Riga, Latvia
| | - Madhav Menon
- Department of Cardiology, Waikato Hospital, Hamilton, New Zealand
| | - Carl Schultz
- Medical School, University of Western Australia, Perth, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Colin Berry
- West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK; British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany; Department of Internal Medicine I, Division of Cardiology, University of Giessen, Giessen, Germany
| | - Mika Laine
- Department of Vascular Surgery, Abdominal Center, Helsinki University and Helsinki University Central Hospital, Helsinki, Finland
| | - Claes Held
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Andreas Rück
- Department of Cardiology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Stefan K James
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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Gilshtein H, Neymark M, Harbi A, Lutsyk M, Duek D. Initial Experience with Transition from Open to Robotic-assisted Proctectomy for Patients with Rectal Cancer. Isr Med Assoc J 2021; 23:731-734. [PMID: 34811990] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND The learning curve for transition from open to laparoscopic proctectomies is difficult. Most surgeons have considerable laparoscopic experience prior to performing robotic-assisted procedures. There are data regarding the transition from open to robotic proctectomies. Minimally invasive anterior resection for rectal cancer has gained widespread popularity in recent years, especially when using a robotic platform. OBJECTIVES To analyze the experience to the transition from open to robotic anterior resection for rectal cancer. METHODS We performed a retrospective analysis of a computerized database. All patients who had a robotic-assisted proctectomy between December 2016 and March 2019 were included and were compared to patients who underwent an open anterior resection in the same time period. A single experienced colorectal surgeon with no prior experience in colorectal laparoscopic surgery performed the procedures. RESULTS During the study period, 55 patients underwent robotic-assisted proctectomy and 55 had an open proctectomy. Patients had similar pre-operative demographic and clinical characteristics with the majority of patients receiving neoadjuvant chemoradiation. The surgical time was significantly lower in the open surgery group (168 minutes vs. 310 minutes, P = 0.005). Both the surgical and pathological outcomes did not differ significantly between the two groups, with good short-term oncologic outcomes and low complication rates. CONCLUSIONS The transition from open to robotic-assisted proctectomy is feasible and safe and provides a good alternative for undertaking a minimally invasive surgery for the experienced open colorectal surgeon.
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Affiliation(s)
- Hayim Gilshtein
- Department of General Surgery, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
- Colorectal Unit, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Mariya Neymark
- Department of General Surgery, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Asaf Harbi
- Department of General Surgery, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
- Colorectal Unit, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Myroslav Lutsyk
- Department of Oncology, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Daniel Duek
- Department of General Surgery, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
- Colorectal Unit, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
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Gannon WD, Stokes JW, Bloom S, Sherrill W, Bacchetta M, Rice TW, Semler MW, Casey JD. Safety and Feasibility of a Protocolized Daily Assessment of Readiness for Liberation From Venovenous Extracorporeal Membrane Oxygenation. Chest 2021; 160:1693-1703. [PMID: 34166644 PMCID: PMC8727855 DOI: 10.1016/j.chest.2021.05.066] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 02/19/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Decannulation from venovenous extracorporeal membrane oxygenation (ECMO) at the earliest and safest possible time may improve outcomes and reduce cost. Yet, no prospective studies have compared weaning strategies for liberation from ECMO. RESEARCH QUESTION Is a protocolized daily assessment of readiness to liberate from venovenous ECMO safe and feasible? STUDY DESIGN AND METHODS We conducted a prospective, single-arm safety and feasibility study of a protocol for daily assessment of readiness to liberate from venovenous ECMO among consecutive adult patients receiving venovenous ECMO across four ICUs at a single center between June 20, 2020, and November 24, 2020. The ECMO-free protocol included three phases: (1) the safety screening, (2) non-ECMO Fio2 titration, and (3) the ECMO-free trial. Enrollment, interventions, and data collection were performed prospectively by trained study staff. RESULTS Twenty-six patients received the ECMO-free protocol on 385 patient-days. The safety screening was passed during a total of 59 ECMO-free daily assessments (15.3%) among 20 patients. Every passed safety screening proceeded to an ECMO-free trial. Twenty-eight passed ECMO-free trials (47.5%) occurred among 16 patients (61.5%). No missed safety screenings, protocol deviations, or adverse events occurred. Of the 16 patients who passed an ECMO-free trial, 14 patients (87.5%) were decannulated. Among decannulated patients, 12 patients (85.7%) were decannulated on the same day as a passed ECMO-free trial, 6 patients (42.9%) were decannulated on the first day that they passed an ECMO-free trial, and 6 patients (42.9%) passed an ECMO-free trial at least twice consecutively before decannulation. The median time from first passed ECMO-free trial to decannulation was 2 days (interquartile range, 0-3 days). INTERPRETATION The ECMO-free protocol is feasible and may identify patients for decannulation earlier than gradual approaches to weaning.
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Affiliation(s)
- Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah Bloom
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wren Sherrill
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W Rice
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew W Semler
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan D Casey
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Fortney JC, Bauer AM, Cerimele JM, Pyne JM, Pfeiffer P, Heagerty PJ, Hawrilenko M, Zielinski MJ, Kaysen D, Bowen DJ, Moore DL, Ferro L, Metzger K, Shushan S, Hafer E, Nolan JP, Dalack GW, Unützer J. Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial. JAMA Psychiatry 2021; 78:1189-1199. [PMID: 34431972 PMCID: PMC8387948 DOI: 10.1001/jamapsychiatry.2021.2318] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 03/16/2021] [Accepted: 06/29/2021] [Indexed: 11/14/2022]
Abstract
Importance Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. Objective To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. Design, Setting, and Participants This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Interventions Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Main Outcomes and Measures Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Results Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, -1.7 to 5.7; P = .29). Conclusions and Relevance In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. Trial Registration ClinicalTrials.gov Identifier: NCT02738944.
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Affiliation(s)
- John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Joseph M. Cerimele
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Jeffrey M. Pyne
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock
- Department of Veterans Affairs, Health Services Research and Development, Center for Mental Healthcare and Outcomes Research, Little Rock, Arkansas
| | - Paul Pfeiffer
- University of Michigan Medical School, Ann Arbor
- Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Patrick J. Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Matt Hawrilenko
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Melissa J. Zielinski
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Deborah J. Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Danna L. Moore
- School of Economic Sciences, Washington State University, Pullman
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | | | | | - Erin Hafer
- Community Health Plan of Washington, Seattle
| | | | | | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
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Paker M, Goldman T, Masalha M, Shlizerman L, Mazzawi S, Ashkenazi D, Ghanayim R. A Comparison of Two Widely Used Risk Stratification Systems for Thyroid Nodule Sonographic Evaluation. Isr Med Assoc J 2021; 23:714-719. [PMID: 34811987] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND The 2015 American Thyroid Association (ATA2015) and the American College of Radiology Thyroid Imaging and Reporting Data System (ACR TI-RADS) are two widely used thyroid sonographic systems. OBJECTIVES To compare the two systems for accuracy of cancer risk prediction. METHODS Preoperative ultrasound images from 265 patients who underwent thyroidectomy at our hospital from January 2012 to March 2019 were retrospectively categorized by the ACR TI-RADS and ATA2015 systems. Diagnostic performances were compared. RESULTS Of 238 nodules assessed, 115 were malignant. Malignancy risks for the five ACR TI-RADS categories were 0%, 7.5%, 11.4%, 59.6%, and 90.0%. Malignancy risks for the five ATA2015 categories were 0%, 6.8%, 17.0%, 55.5%, and 92.1%. The proportion of total nodules biopsied was higher with the ATA2015 system than the ACR TI-RADS system: 88.7% vs. 66.3%. Proportions of malignant nodules and benign nodules biopsied were higher with ATA2015 than with ACR TI-RADS: 93.3% vs. 87.8% and 84.4% vs. 46.3%, respectively. Specificity and sensitivity rates were 53.6% and 84.3%, respectively, for ACR TI-RADS, and 15.5% and 93.3%, respectively, for ATA2015. The two systems showed similarly accurate diagnostic performance (AUC > 0.88). False negative rates for ACR TI-RADS and ATA2015 were 15.6% and 6.6%, respectively. Rates of missed aggressive cancer were similar for the two systems: 3.4% and 3.7%, respectively. CONCLUSIONS ACR TI-RADS was superior to ATA2015 in specificity and avoiding unnecessary biopsies. ATA2015 yielded better sensitivity and a lower false negative rate. Identification of aggressive cancers was identical in the two systems.
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Affiliation(s)
- Miki Paker
- Department of Ear, Nose, and Throat, Emek Medical Center, Afula, Israel
| | - Tal Goldman
- Institute of Tissue Diagnostics and Cancer Research, Emek Medical Center, Afula, Israel
| | - Muhamed Masalha
- Department of Ear, Nose, and Throat, Emek Medical Center, Afula, Israel
| | - Lev Shlizerman
- Department of Ear, Nose, and Throat, Emek Medical Center, Afula, Israel
| | - Salim Mazzawi
- Department of Ear, Nose, and Throat, Emek Medical Center, Afula, Israel
| | - Dror Ashkenazi
- Department of Ear, Nose, and Throat, Emek Medical Center, Afula, Israel
| | - Rami Ghanayim
- Department of Ear, Nose, and Throat, Emek Medical Center, Afula, Israel
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Kugelman N, Lavie O, Cohen N, Schmidt M, Reuveni A, Ostrovsky L, Dabah H, Segev Y. Enhanced Recovery after Surgery is Feasible and Beneficial and Should Be the Standard in Major Gynecological Surgeries. Isr Med Assoc J 2021; 23:725-730. [PMID: 34811989] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are evidence-based protocols designed to standardize medical care, improve outcomes, and lower healthcare costs. OBJECTIVES To evaluate the implementation of the ERAS protocol and the effect on recovery during the hospitalization period after gynecological laparotomy surgeries. METHODS We compared demographic and clinical data of consecutive patients at a single institute who underwent open gynecological surgeries before (August 2017 to December 2018) and after (January 2019 to March 2020) the implementation of the ERAS protocol. Eighty women were included in each group. RESULTS The clinical and demographic characteristics were similar among the women operated before and after implementation of the ERAS protocol. Following implementation of the protocol, decreases were observed in post-surgical hospitalization (from 4.89 ± 2.56 to 4.09 ± 1.65 days, P = 0.01), in patients reporting nausea symptoms (from 18 (22.5%) to 7 (8.8%), P = 0.017), and in the use of postoperative opioids (from 77 (96.3%) to 47 (58.8%), P < 0.001). No significant changes were identified between the two periods regarding vomiting, 30-day re-hospitalization, and postoperative minor and major complications. CONCLUSIONS Implementation of the ERAS protocol is feasible and was found to result in less postoperative opioid use, a faster return to normal feeding, and a shorter postoperative hospital stay. Implementation of the protocol implementation was not associated with an increased rate of complications or with re-admissions.
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Affiliation(s)
- Nir Kugelman
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Ofer Lavie
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Nadav Cohen
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Meirav Schmidt
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Amit Reuveni
- Department of Anesthesiology, Carmel Medical Center, Haifa, Israel
| | - Ludmila Ostrovsky
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
| | - Hawida Dabah
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
| | - Yakir Segev
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel
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50
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Jewell PD, Bramham K, Galloway J, Post F, Norton S, Teo J, Fisher R, Saha R, Hutchings S, Hopkins P, Smith P, Joslin J, Jayawardene S, Mackie S, Mudhaffer A, Holloway A, Kibble H, Akter M, Zuckerman B, Palmer K, Murphy C, Iatropoulou D, Sharpe CC, Lioudaki E. COVID-19-related acute kidney injury; incidence, risk factors and outcomes in a large UK cohort. BMC Nephrol 2021; 22:359. [PMID: 34719384 PMCID: PMC8557997 DOI: 10.1186/s12882-021-02557-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/27/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common among patients hospitalised with COVID-19 and associated with worse prognosis. The aim of this study was to investigate the epidemiology, risk factors and outcomes of AKI in patients with COVID-19 in a large UK tertiary centre. METHODS We analysed data of consecutive adults admitted with a laboratory-confirmed diagnosis of COVID-19 across two sites of a hospital in London, UK, from 1st January to 13th May 2020. RESULTS Of the 1248 inpatients included, 487 (39%) experienced AKI (51% stage 1, 13% stage 2, and 36% stage 3). The weekly AKI incidence rate gradually increased to peak at week 5 (3.12 cases/100 patient-days), before reducing to its nadir (0.83 cases/100 patient-days) at the end the study period (week 10). Among AKI survivors, 84.0% had recovered renal function to pre-admission levels before discharge and none required on-going renal replacement therapy (RRT). Pre-existing renal impairment [odds ratio (OR) 3.05, 95%CI 2.24-4,18; p < 0.0001], and inpatient diuretic use (OR 1.79, 95%CI 1.27-2.53; p < 0.005) were independently associated with a higher risk for AKI. AKI was a strong predictor of 30-day mortality with an increasing risk across AKI stages [adjusted hazard ratio (HR) 1.59 (95%CI 1.19-2.13) for stage 1; p < 0.005, 2.71(95%CI 1.82-4.05); p < 0.001for stage 2 and 2.99 (95%CI 2.17-4.11); p < 0.001for stage 3]. One third of AKI3 survivors (30.7%), had newly established renal impairment at 3 to 6 months. CONCLUSIONS This large UK cohort demonstrated a high AKI incidence and was associated with increased mortality even at stage 1. Inpatient diuretic use was linked to a higher AKI risk. One third of survivors with AKI3 exhibited newly established renal impairment already at 3-6 months.
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Affiliation(s)
- Paul D Jewell
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Kate Bramham
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - James Galloway
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Centre for Rheumatic Disease, King's College London, London, UK
| | - Frank Post
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, UK
| | - Sam Norton
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - James Teo
- Department of Neurosciences, King's College Hospital NHS Foundation Trust, London, UK
| | - Richard Fisher
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Rohit Saha
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Sam Hutchings
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Phil Hopkins
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Priscilla Smith
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Jennifer Joslin
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Satish Jayawardene
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Sarah Mackie
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Ali Mudhaffer
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Amelia Holloway
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Henry Kibble
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Mosammat Akter
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Benjamin Zuckerman
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Kieran Palmer
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Ciara Murphy
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Domniki Iatropoulou
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Claire C Sharpe
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eirini Lioudaki
- Renal Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
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