Ambulatory Setting Research Articles

Use and De-implementation of Fecal Occult Blood Tests in the Acute Care Setting: A Systematic Review and Meta-Analysis

Abstract Background To determine methods of FOBT de-implementation in acute care practice while summarizing the reasons and contraindications for inappropriate FOBT in acute care settings. Fecal occult blood testing is valuable for colorectal cancer screening in ambulatory settings but is not valuable for diagnostics in acute care with consistent indications for discontinuation as a tradition-based practice. Methods We included all English language prospective and retrospective evaluation studies of FOBT use in acute care settings with or without de-implementation interventions and published as original research articles in peer-reviewed journals. A meta-analysis of FOBT positivity was conducted using a random effects model. Quality was assessed using Critical Appraisals Skills Programme criteria. Results Of 2,471 abstract/titles screened, 157 full-text articles were reviewed, and 22 articles met inclusion criteria of measuring prevalence or de-implementation of FOBT use in acute care settings. All 22 studies evaluated either FOBT use or de-implementation. Twenty articles reported FOBT positivity, with some illustrating that FOBT results were inconsequential to subsequent endoscopy decisions (n=7, 32%). The included studies represent a publication date range spanning 32 years, with limited documentation of de-implementation strategies. Four published studies described system-level disinvestment to administratively eliminate access to inpatient FOBT orders. Conclusion Overall, all studies endorsed that the use of FOBTs in acute care settings results in increased workload and/or cost without diagnostic benefit. Critical appraisal of low-value tradition-based practices such as FOBT use in acute care settings are essential for deploying deliberate and effective de-implementation strategies.

A narrative review on the performance and outcomes of penile and scrotal surgery in the ambulatory setting.

Following the COVID-19 pandemic, surgical wait times have surged, creating a backlog in elective urological procedures. This review aims to address the need to explore ambulatory care for penile and scrotal surgeries, which can offer benefits by shifting these procedures away from traditional inpatient settings. Recent studies confirm the safety and efficacy of performing penile and scrotal procedures in an ambulatory setting using local anesthesia (LA) or loco-sedative techniques. Of 616 reviewed cases, over 90% of patients expressed high satisfaction with LA and reported minimal postoperative complications. Pain management advancements, particularly the use of liposomal bupivacaine, reduced the need for opioids postoperatively. Importantly, no intraoperative complications or hospital admissions were reported, and adverse events were managed conservatively. The data highlighted in this review supports a move towards outpatient surgeries as a safe alternative to inpatient care for select cases. This review highlights the strong potential for ambulatory urological surgeries to alleviate surgical backlogs significantly, while reducing strain on hospital resources, and maintaining high levels of patient satisfaction. As evidence continues to grow on the safety, feasibility, and effectiveness of LA in office-based procedures, expanding ambulatory urological will be quintessential in modernizing patient care and reducing healthcare burdens.

Odontogenic Infections: Management in Ambulatory Care Settings for Nurse Practitioners

Dental insurance and access to care need substantial improvement in the United States, given their current inadequacies that contribute to suboptimal oral and physical health outcomes and escalate national health care expenditures. The disparities in access to dental care exacerbate oral health disparities across socioeconomic lines. With their broad reach and comprehensive approach to health care, nurse practitioners are uniquely positioned to play a pivotal role in enhancing oral health outcomes. They can effectively integrate preventive measures and early intervention strategies for conditions such as odontogenic infections, thereby reducing emergency department visits and improving overall patient health. This clinical feature critically examines evidence-based practices for the presentation, diagnosis, and management of odontogenic infections within primary care settings. Disseminating this knowledge aims to empower nurse practitioners to deliver timely and effective care, ultimately fostering more significant equity and accessibility in dental health services nationwide.

Evaluating the Impact of a Clinical Pharmacist in Patients Receiving New Chemotherapy for Breast Cancer: Analysis of a Pilot Study

Purpose: Breast cancer treatment may include chemotherapy, which is associated with significant toxicities. At the Sidney Kimmel Cancer Center at Jefferson Health, a pilot program was developed to add an oncology clinical pharmacist to the breast cancer clinic. The purpose of this study is to identify the impact of the clinical pharmacist in supportive care management, add to existing literature discussing the impact of the clinical pharmacist in ambulatory oncology settings, and justify future, permanent ambulatory oncology pharmacist positions within the institution. Methods: This single-center retrospective chart review assesses interventions made by the clinical pharmacist in patients with any stage of breast cancer who presented to the breast clinic for new chemotherapy treatment between September 1, 2020, and February 28, 2021. The primary outcome was to describe clinical pharmacist interventions at the first follow-up encounter after chemotherapy initiation. Secondary outcomes included classifying and quantifying total interventions and comparing intervention details between total and included patients within the 6-month timeframe. Results: Of 44 included patients, 29 had a follow-up encounter. The clinical pharmacist directly managed 33% of the 58 patient-reported adverse drug effects. In 6 months, the clinical pharmacist made 1,068 interventions spanning 189.6 documented hours. The most common interventions were coordination of care, education, and supportive care pharmacotherapy interventions. Conclusion: This study identified the pharmacist’s role in supportive care management and reports the successful integration of a clinical pharmacist into a breast cancer clinic. Future directions include conducting prospective studies to further explore the impact of the clinical pharmacist on treatment outcomes.

Impact of Antibiotic Stewardship on Treatment of Hospitalized Children with Skin and Soft-Tissue Infections

Background: Skin and soft-tissue infections (SSTIs) are common infectious syndromes in children. Overusing broad-spectrum antibiotics has contributed to rising antibiotic resistance, complicating treatment outcomes. To address this issue, antimicrobial stewardship programs (ASPs) have been implemented to optimize antibiotic use. This study evaluated the impact of a multifaceted ASP on antibiotic prescribing practices for SSTIs in a pediatric acute care setting over eight years. Methods: We conducted a quasi-experimental study at the Pediatric Acute Care Unit of the Padua University Hospital, including children admitted with SSTIs from October 2014 to September 2022, to evaluate the impact of a multifaceted ASP implemented in October 2015. The study was divided into three periods: pre-implementation (October 2014–September 2015), post-implementation (October 2015–March 2020), and COVID-19 (April 2020–August 2022). Data on antibiotic prescriptions and microbiological results were collected and analyzed. Results: The implementation of the ASP led to a significant reduction in the use of broad-spectrum antibiotics, particularly third-generation cephalosporins (from 40.4% to 9.8%) and glycopeptides (from 21.1% to 1.6%). There was a notable increase in the prescription of Access antibiotics, from 30% in the pre-implementation to over 60% in the post-implementation and 80% during COVID-19. No increase in the hospital length of stay was observed. Microbiological results showed no significant changes in bacterial profiles over time. Conclusions: The use of the ASP effectively improved antibiotic prescribing practices, reducing reliance on broad-spectrum antibiotics even during the COVID-19 pandemic. These findings highlight the value of ongoing stewardship efforts and suggest the need for similar programs in ambulatory settings to further address antibiotic resistance.

Diagnostic accuracy of point-of-care lung ultrasound for community-acquired pneumonia in children in ambulatory settings: A systematic review and meta-analysis

Introduction: To perform a systematic review of the diagnostic accuracy of point-of-care lung ultrasound, compared to chest radiography, in children and young people (0–21 years) who present to ambulatory settings with suspected community-acquired pneumonia. Methods: Registration: Prospero June 2021 CRD42021260552. Electronic searching performed on Medline, Embase, CINAHL and Science Citation Index from inception to 20 June 2023. Two researchers independently screened titles, abstracts, and full texts for study selection. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis of included studies. Results: The six studies included in this systematic review described point-of-care lung ultrasound performed primarily by paediatric emergency medicine clinicians on a total of 1099 paediatric patients, with a reference standard of chest radiography or chest radiography with clinical findings. The majority of included studies lacked clarity on training for the index test with potential bias around flow and timing of testing. Meta-analysis of the combined results of the included six studies calculated a pooled sensitivity of 90.9% (95% CI [85.5%, 94.4%]) and pooled specificity of 80.7% (95% CI [63.6%, 91.0%]). Conclusions: Point-of-care lung ultrasound has high sensitivity but lower specificity to diagnose acute pneumonia in children. Further research is needed which overcomes issues around training in point-of-care lung ultrasound, study design and reliability of the reference test (chest radiography) to better evidence the role of point-of-care lung ultrasound in diagnosing pneumonia in children in ambulatory and resource-limited settings.

Outpatient Antibiotic Use and Treatment Failure Among Children With Pneumonia

Although a viral etiology can be detected in most cases of pediatric pneumonia, antibiotic treatment is common. The effectiveness of antibiotics in the outpatient setting for children diagnosed with pneumonia is not known. To compare outcomes among children diagnosed with pneumonia who were and were not treated with oral antibiotics. This retrospective cohort study identified Medicaid-insured children and adolescents 17 years or younger diagnosed with pneumonia and discharged from ambulatory settings in a multistate claims database from January 1, 2017, to December 31, 2019. Propensity score matching was used to mitigate confounding. Data were analyzed from August 31, 2023, to August 16, 2024. Antibiotic receipt, defined as an oral antibiotic dispensed from a pharmacy on the day of the index visit or on the subsequent day. Children who did not receive antibiotics included those who were not prescribed antibiotics and those who were prescribed antibiotics but did not fill the prescription. Treatment failure and severe outcomes within 2 to 14 days after the index visit. Treatment failure included hospitalization or ambulatory revisits for pneumonia, new antibiotic dispensation with a same-day ambulatory visit, or complicated pneumonia. Severe outcomes included hospitalization for pneumonia or complicated pneumonia. Among the 103 854 children with pneumonia included in the analysis, the median age was 5 (IQR, 2-9) years, and 54 665 (52.6%) were male. Overall, 20 435 children (19.7%) did not receive an antibiotic within 1 day. The propensity score-matched analysis included 40 454 children (20 227 per group). Treatment failure occurred in 2167 children (10.7%) who did not receive antibiotics and 1766 (8.7%) who received antibiotics (risk difference, 1.98 [95% CI, 1.41-2.56] percentage points). Severe outcomes occurred in 234 of 20 435 children (1.1%) who did not receive antibiotics and in 133 of 83 419 (0.7%) who did (risk difference, 0.46 [95% CI, 0.28-0.64] percentage points). In this cohort study of children diagnosed with pneumonia in ambulatory settings, almost 20% did not receive antibiotics within a day of diagnosis. Although not receiving antibiotics was associated with a small increase in the risk of treatment failure, severe outcomes were uncommon regardless of whether antibiotics were received. These results suggest that some children diagnosed with pneumonia can likely be managed without antibiotics and highlight the need for prospective studies to identify these children.

The mortality implications of increasing and decreasing sST2 levels during acute decompensated heart failure

Abstract Introduction Soluble Suppressor of Tumorigenicity (sST2), a marker of cardiac remodelling and fibrosis, has demonstrated promises in prognostication of heart failure (HF) and therefore recommended as an additional test for risk stratification of HF in the 2017 ACC/AHA/HFSA guidance. It is well investigated as single measurements in acute and ambulatory settings. Data regarding sST2 level changes during acute decompensated heart failure (ADHF) and its potential in providing additional prognostic information is however sparse. We therefore sought to evaluate changes in sST2 and its prognostic implications in hospitalized patients during ADHF. Methods Between December 2019 and February 2022, consecutive patients with ADHF and reduced ejection fraction (EF<50%) presenting to our University Hospital were recruited as part of the Investigating the soluble ST2 biomarker in addition to Natriuretic peptides in managing patients with Heart Failure and a Reduced Ejection Fraction (INST2ANT-HF) study (REC Reference: 19/EE/0269). Serum samples were taken at clinician determined decompensation and recompensation in all participants, who were then followed up for one year post discharge. The study primary end point was all-cause mortality at one year. A 2x2 contingency table was constructed to display the relationship between the frequency of unchanged/increased or decreased sST2 levels at recompensation and the frequency of mortality at one year (Table 1). A Kaplan-Meier curve was plotted to display the survival probability of the two groups during one-year follow up (Figure 1), and log-rank test applied to evaluate for significant difference in the survival distributions. Results In 169 patients with paired sST2 samples, median age (IQR) was 72 (62-80.8), 39 (23.2%) were female and 160 (95.2%) were ethnically white. 158 (94.1%) presented with NYHA class II-IV and the median (IQR) EF was 26% (17.5-32.5). Median (IQR) length of stay in hospital was 8 days (5-13). Median (IQR) sST2 level at decompensation and recompensation were 60ng/ml (40-93.3) and 39.5ng/ml (24-64.8) respectively. At clinician determined recompensation, sST2 level decreased in 136 (81%) patients while 32 (19%) had unchanged/increased sST2 levels. One-year mortality was 37.5% in patients with unchanged or increasing sST2 levels during ADHF, compared to 16.2% in those with decreased sST2 levels. The mean (SE) survival time was 332 (7) days for patients with unchanged/increasing sST2, and 274 (22.5) days for patients with decreasing sST2 at HF recompensation (p=0.003). Conclusion Our data demonstrates that there was a downward trend in sST2 in most patients during recovery from an ADHF episode. Importantly, a static or increasing sST2 level from HF decompensation to recompensation was associated with a significantly higher risk of mortality at one year. Further research may ascertain if the mortality risk is also dependent on the percentage changes in sST2 concentrations.Table 1:2x2 contingency tableFigure 1:Kaplan-Meier curve

Caring for Patients With Diabetes in the Ambulatory Setting

Caring for Patients With Diabetes in the Ambulatory Setting

Clinical Practice Patterns and Evidence-Based Medicine in Blepharoplasty: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

The American Board of Plastic Surgery (ABPS) Continuous Certification tracer data on blepharoplasty offers valuable information on national trends in clinical practice. The present study was performed to analyze evolving trends in blepharoplasty and compare practice patterns to Evidence-Based Medicine (EBM) publications within the same timeframe. Tracer data for blepharoplasty procedures performed by ABPS-certified surgeons between 2005 and 2020 was analyzed. Data between two timeframes, 2005-2014 (early cohort, EC) and 2015-2020 (recent cohort, RC), were compared to identify evolving trends in blepharoplasty over time. Results were then compared to EBM-based publications. Of 3,050 blepharoplasties (1,510 EC; 1,540 RC), 82% were performed in female patients and the average age was 56 years. Blepharoplasty was most frequently performed in an ambulatory setting (56%) compared to in hospital (25%); significantly more cases are being performed in the office (p< 0.001) in the RC compared to the EC. Mean surgical duration has decreased by 13 minutes (p< 0.001), and fewer surgeries are being performed with concomitant procedures (p< 0.001). Fewer surgeons use antibiotics (p< 0.001), and fewer surgeons use DVT prophylaxis in the form of sequential compression devices after anesthesia (p< 0.001). More skin resections were performed for upper blepharoplasties (p=0.016), while fewer cases of lower lid blepharoplasty involved either skin-muscle flaps (p=0.038) or transcutaneous fat removal (p=0.004). Most surgeons did not perform canthal tightening during their blepharoplasty (82%). A review of over 15-years of ABPS blepharoplasty tracer data allows surgeons to compare their practice with national trends and EBM. The tracer data illustrates a shift in technique towards shorter and simpler procedures in the office setting.

External validation of a machine learning based classification algorithm for ambulatory heart rhythm diagnostics using smartphone-photoplethysmography - the SMARTBEATS algorithm study

Abstract Introduction Smartphone-photoplethysmography (PPG) can be used for heart rhythm monitoring. According to current guidelines, ECG verification is required for a new diagnosis of atrial fibrillation (AF). Accurate machine learning (ML) based automatic algorithms have the potential to facilitate clinical applications generating large numbers of PPG recordings, by offloading the need for manual over-read. Purpose The aim of this study was to evaluate the diagnostic performance of an automatic ML-based algorithm for heart rhythm diagnostics using smartphone-PPG recorded by patients with AF in an unsupervised ambulatory setting. Methods Patients undergoing direct current cardioversion (DCCV) at a university hospital for treatment of AF or atrial flutter (AFL) were asked to perform one-minute heart rhythm recordings post-cardioversion at least twice daily for 30 days. All participants were provided with an iPhone 7 smartphone running the CORAI Heart Monitor PPG application simultaneously with a single-lead ECG recording (KardiaMobile). The automatic algorithm uses support vector machines (SVM) to classify heart rhythm from smartphone-PPG recordings. The SVM classifier evaluated here was trained on ambulatory PPG recordings made by patients in a separate cardioversion cohort, ensuring complete independence between training and validation sets. PPG recordings in the validation cohort were analyzed by the automatic algorithm and diagnostic performance was calculated by comparing heart rhythm classification output from the SVM classifier to the heart rhythm diagnosis from the simultaneous ECG recordings. ECG recordings were interpreted independently by two cardiologists and were set as gold standard. Results The SVM classifier was trained on data from 153 patients with 11,749 PPG recordings, of which 5,873 (50.0%) were labelled as AF and 5,876 (50.0%) as sinus rhythm (SR), as assessed by manual reading. In the validation cohort, 280 patients, with a median age of 69.0 years (31% women), registered 18,005 simultaneous PPG and ECG recordings. Recordings interpreted as AFL on ECG (2.0%), as having insufficient quality on ECG (4.9%) or PPG (2.8%), and low certainty algorithmic classifications (1.2%) were excluded, leaving 16,057 PPG recordings. Included ECG recordings consisted of 71.2% interpreted as (SR) and 28.8% as AF. Algorithm classification of the PPG recordings in the validation cohort diagnosed AF (sensitivity) in 99.7% and SR (specificity) in 99.7% of the recordings, with an overall accuracy of 99.7%. F1-score was 99.4% and area under the ROC curve (AUC) was 0.999. Conclusion A machine learning based algorithm for automatic heart rhythm diagnostics showed excellent diagnostic performance for smartphone-PPG recordings in an unsupervised ambulatory setting, minimizing the need for ECG verification in cardioversion populations.

Evaluating an integrated clinical pharmacy service model in an ambulatory cardiac clinic- a single centre study

Abstract Background Evidence suggests that multidisciplinary cardiology clinics improve patient outcomes. Currently, there is limited data on the type of pharmacist-led interventions occurring in cardiac ambulatory clinics in the Australian setting. Purpose The primary aim of this pilot audit is to examine the frequency and type of pharmacist-led interventions in the ambulatory clinics of this specialist hospital. The secondary aim is to assess factors associated with hospital readmissions within 30 days of Pharmacists' reviews. Methods A retrospective pilot audit was conducted for patients who attended an integrated multidisciplinary Heart Failure (HF) and Hypertension (HTN) clinic from April 2023 to February 2024. Patients’ demographics, Charlson comorbidity index (CCI), and the number and types of pharmacist interventions and readmission data 30 days post clinic review were recorded. Descriptive statistics were used to evaluate patient characteristics and logistic regression for hospital readmissions. Results A total of 398 patients were reviewed by pharmacists, with 300 (75%) from the HF clinics and 98 (25%) from the HTN clinics. Patients’ median age was 63± 14.8 years and median CCI was 4± 3.7. Pharmacists documented medication histories for all patients (100%) and provided 355 recommendations, of which 213 (60%) were actioned by the cardiologist. Pharmacists had a face-to-face consultation and provided education and counselling to 175 (44%) patients. The most common types of interventions were related to guideline-directed prescribing and deprescribing (68, 39%), followed by up-titration of current therapies (61, 35%). Pharmacists also provided education on medication adherence and lifestyle modifications (28, 16%) as well as optimizing medications related to other comorbidities (18, 10%). A total of 8 patients (2%) were re-admitted l within 30 days of clinic review from either heart failure exacerbation or hypertensive crisis. Patients who had a face-to-face consultation and education with a pharmacist were less likely to be readmitted within 30 days (P=0.048). However, none of the other predictors tested for readmission such as age (P= 0.572), gender (0.296), history of non-compliance (0.834), CCI (0.984) or a diagnosis of HF or HTN (0.473) were predictors for readmission within 30 days of clinic review. Conclusion Pharmacists play an integral role in the cardiac ambulatory setting by providing expert medication advice and patient education to optimize patients’ outcomes. This study demonstrates that the activities performed by pharmacists working in Australian cardiac clinics are consistent with other international ambulatory clinics. The study also identified opportunities to develop a similar service for other ambulatory clinics at this hospital such as lipid and atrial fibrillation clinics. Additionally, further research is required to assess long term benefit of pharmacist led interventions on cardiac patients.

A nurse-led multidisciplinary service for Nipple-Areola complex tattooing after breast cancer: reporting on a complex intervention with TIDieR analysis

BackgroundThe Nipple-Areola Complex (NAC) tattooing can restore physical and mental integrity after breast cancer, but it is not always easily accessible for women. This paper aims to report on the development of a multidisciplinary nurse-led service for NAC tattooing for women who underwent breast cancer surgery with NAC removal to allow its thorough review and replication.MethodsThe Medical Research Council’s framework for developing complex healthcare interventions was followed. According to the results of a literature review, and the context analysis, an initial intervention was planned. The Template for Intervention Description and Replication checklist was chosen to ensure the quality and completeness of the intervention description.ResultsThe Breast Unit and the Research departments were engaged; three nurse-tattooists were selected; the informative material was created and shared with patients, families and local associations, involving them actively. Finally, the setting and the materials were defined. A monthly schedule of activities was set: patients with the indication for NAC tattooing were contacted by the nurse case manager. Each treatment involves 3–4 sessions, 30–40 days apart, in an ambulatory setting. It consists of NAC shaping and tattooing with a dermographer and sterile needles.ConclusionImplementing freely and equally multidisciplinary nurse-led clinics might provide this treatment ensuring the patient’s quality of life and nurse competence. The NAC tattooing is a complex intervention that represents the final part of the breast cancer surgical care pathway.

Consensus Considerations and Good Practice Points for Use of Continuous Glucose Monitoring Systems in Hospital Settings.

Continuous glucose monitoring (CGM) systems provide frequent glucose measurements in interstitial fluid and have been used widely in ambulatory settings for diabetes management. During the coronavirus disease 2019 (COVID-19) pandemic, regulators in the U.S. and Canada temporarily allowed for CGM systems to be used in hospitals with the aim of reducing health care professional COVID-19 exposure and limiting use of personal protective equipment. As such, studies on hospital CGM system use have been possible. With improved sensor accuracy, there is increased interest in CGM usage for diabetes management in hospitals. Laboratorians and health care professionals must determine how to integrate CGM usage into practice. The aim of this consensus guidance document is to provide an update on the application of CGM systems in hospital, with insights and opinions from laboratory medicine, endocrinology, and nursing.

Individualized and Controlled Exercise Training Improves Fatigue and Exercise Capacity in Patients with Long-COVID

(1) Background: Long-term health effects after SARS-CoV-2 infections can manifest in a plethora of symptoms, significantly impacting the quality of life of affected individuals. (2) Aim: The present paper aimed to assess the effects of an individualized and controlled exercise intervention on fatigue and exercise capacity among Long-COVID (LC) patients in an ambulatory setting. (3) Methods: Forty-one (n = 41) LC patients performed an exercise protocol with an individualized control of the patients’ training intensity during the study period based on the individual’s ability to achieve the target criteria. The program was carried out two to three times a week, each session lasted 30 min, and the study parameters were recorded at the beginning of the program, as well as after 6 and 12 weeks, respectively. These included both patient-reported (PCFS questionnaire, FACIT–Fatigue questionnaire) and objective (one-minute sit-to-stand test (1MSTST), workload) outcomes. (4) Results: The exercise training intervention resulted in significant improvements in the FACIT–Fatigue (F(2, 80) = 18.08, p &lt; 0.001), 1MSTST (χ2(2) = 19.35, p &lt; 0.001) and workload scores (χ2(2) = 62.27, p &lt; 0.001), while the PCFS scores remained unchanged. Changes in the workload scores were dependent on the frequency of the completed exercise sessions and were higher in the LC patients with a moderate Post COVID Syndrome Score (PCS) compared to a severe PCS. (5) Conclusions: The individualized and controlled training approach demonstrated efficacy in reducing fatigue and enhancing exercise capacity among outpatient LC patients. However, for complete regeneration, a longer, possibly indefinite, treatment is required, which in practice would be feasible within the framework of legislation.

Naloxone Distribution Models in the United States: A Scoping Review.

Increasing naloxone distribution is a high priority means to mitigating opioid overdose rates in the United States. Since a variety of naloxone distribution models exist, with differences in infrastructure and funding between states and health-systems, it is important to review their differences and understand the strengths and barriers to widespread implementation of each model. The following 4 databases were searched for articles reporting on naloxone distribution models: (1) PubMed/Medline (National Library of Medicine), (2) Embase (Elsevier), (3) Scopus (Elsevier), and (4) the Cochrane library. Reports from all years written in English that discussed naloxone distribution models in the United States were included, as were all study designs. Of 5825 articles initially identified, 173 were selected for full text review. Of these, 49 met full criteria and were included for data extraction and analysis. Most distribution models occurred in community-based opioid education and naloxone distribution programs and in community pharmacies via a standing order/statewide protocol. Most programs reported strengths related to feasibility, but frequently reported cost as a limitation. Fewer studies described distribution models in ambulatory care or hospital settings, though these studies also highlighted strengths related to feasibility, particularly with support from working partners, and when utilizing an interprofessional care approach. Few studies reported health/economic outcomes data associated with naloxone distribution, such as changes in the number of patient/layperson access, the number of opioid overdose reversals, or cost-savings. This review outlines the many ways in which naloxone is distributed in the United States and emphasizes a need for improved outcomes data collecting/reporting in the various settings where naloxone is distributed. This would allow for future studies to evaluate which distribution model factors are associated with improvements in health outcomes, such as increased layperson access, and lower opioid overdose/mortality rates.

Use of long-acting triple therapy for chronic obstructive pulmonary disease (COPD) in practice: The ELETHON physicians' survey

Gaps in optimal COPD management have been identified in clinical practice, with discrepancies between guideline recommendations and routine care. The reasons for such discrepancies are incompletely understood. The ELETHON survey aimed to identify physicians' attitudes towards general concepts of COPD management and, in particular, initiation of inhaled triple therapies. ELETHON was a nationwide cross-sectional survey with general practitioners (GP) and pulmonary specialists (PS) working in the ambulatory outpatient setting in Germany, using a structured 17-item questionnaire (single or multiple choice questions) addressing the topics of secondary prevention, exacerbation detection, strategies for therapy escalation, choice of inhaled triple therapies and evaluation of treatment benefits. Questionnaires filled by n=2028 GPs and n=371 PS were analyzed. In both groups, secondary prevention was deemed important in COPD care (GP/PS 76.4%/90.6%), with inhalation technique, vaccination status, and appropriate inhaled pharmacotherapy as key components. Activity/rehabilitation was rarely mentioned by GPs (48.3% vs. 84.5%). Exacerbations and symptomatic worsening were the main triggers for therapy escalation, but were not recorded in a structured way. "Hospitalization" and "≥2 ambulatory exacerbations" were mentioned most frequently as thresholds. Neither GPs nor PS measured eosinophils in the majority of patients. Fixed triple combinations were preferred, with availability of different treatment steps in the same device as important decision aid. Treatment success was evaluated by exacerbations, quality of life, symptoms, lung function and rescue medication use, while COPD Assessment Test (CAT) score was rarely used by GPs and PS. The ELETHON survey identified gaps in COPD management in Germany. While secondary prevention is deemed important, escalation of inhaled therapy is undertaken rather late, the reported importance of vaccinations does not match current quota in German COPD patients, and non-pharmacological measures are often unused. Exacerbation and symptom documentation is rather subjective, validated questionnaires and blood eosinophils are of minor relevance. These results provide evidence of barriers and hidden potentials towards optimization of routine ambulatory care for COPD patients in Germany.

Malnutrition risk screening in adult oncology outpatients: An ASPEN systematic review and clinical recommendations.

Malnutrition screening is not widely practiced in outpatient cancer centers. This review aims to determine the validity of malnutrition screening tools and provide recommendations for clinical use. Studies identified by a systematic review assessed the general validity of screening tools in adult oncology outpatients from five databases through 2022. The American Society for Parenteral and Enteral Nutrition (ASPEN) convened a working group of members from the Academy of Nutrition and Dietetics, Academy of Oncology Nurse and Patient Navigators, American Cancer Society, American Society for Clinical Oncology, American Society for Nutrition, American Society for Radiation Oncology, Association of Cancer Care Centers, and Oncology Nursing Society to answer the following questions: (1) should clinicians screen for malnutrition, (2) which malnutrition screening tools are recommended, and (3) what are the clinical applications for malnutrition risk screening in adult oncology outpatients? Twenty of 738 studies met the criteria and were reviewed. Six screening tools with specific cut-points demonstrated validity and are recommended, including the Mini Nutritional Assessment (≤23.5), Malnutrition Screening Tool (MST; MST ≥ 2 and patient-led MST ≥ 2), Malnutrition Universal Screening Tool (MUST; MUST ≥ 1 and MUST ≥ 2), Nutrition Risk Screening-2002 (NRS-2002; NRS-2002 ≥ 2 and NRS-2002 ≥ 3), NUTRISCORE ≥ 5, and Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF; PG-SGA SF ≥ 7 and PG-SGA SF ≥ 8). Six screening tools are valid for malnutrition risk identification in oncology ambulatory settings and recommended before treatment initiation and regularly thereafter, depending on treatment course. Research is needed to understand to what extent early diagnosis and management of malnutrition improves the clinical care of oncology patients.

In-hospital initiation of sodium-glucose co-transporter-2 inhibitors in patients with acute heart failure.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors provide cardiovascular and kidney benefits to patients with heart failure (HF) and/or chronic kidney disease (CKD), regardless of diabetes status and left ventricular ejection fraction (LVEF). Despite robust data demonstrating the efficacy of SGLT-2 inhibitors in both ambulatory and hospital settings, real-world evidence suggests slow and varied adoption of SGLT2 inhibitors among patients hospitalized for HF. Barriers to implementation of SGLT2i may include clinicians' concerns regarding potential adverse events such as diabetic ketoacidosis (DKA), volume depletion, and symptomatic hypoglycemia; or concerns regarding physiologically expected reductions in eGFR. Guidelines lack specific, practical safety data and definitive recommendations regarding in-hospital initiation and continuation of SGLT2i in patients hospitalized with HF. In this review, we discuss the safety of in-hospital SGLT2 inhibitor initiation based on recent trials and highlight the clinical implications of their early use in patients hospitalized for HF.

Longitudinal frailty assessment in the prediction of survival among patients with advanced chronic kidney disease: a prospective observational single-centre cohort study

ObjectivesThis study aims to describe the prevalence, characteristics and longitudinal changes in frailty among outpatient chronic kidney disease (CKD) and haemodialysis (HD) populations and their impact on survival.DesignProspective observational cohort...