Changes In Management Of Patients Research Articles

Current issues with procollagen III N-terminal peptide assay performance relevant to 2016 British Association for Dermatologist methotrexate-monitoring guidance.

Procollagen III N-terminal peptide (P3NP) testing is routinely used to detect possible liver fibrosis according to the cutoffs in the British Association of Dermatologists (BAD) 2016 guidelines for the safe and effective prescribing of methotrexate in skin disease. We report significant changes to P3NP test performance that will potentially change patient management according to the BAD 2016 guidelines.

The Queen Square Encephalitis Multidisciplinary Team Meeting - experience over three years, pre and post the COVID-19 pandemic

BackgroundPatients with suspected encephalitis continue to represent a diagnostic and therapeutic challenge, even in highly resourced centres. In February 2018, we set up a monthly in-person multidisciplinary team meeting (MDT). We describe the experience and outcomes of the MDT over three years. MethodsA retrospective analysis was performed to summarise patient demographics, MDT outcomes and final diagnoses. ResultsOver the three-year period, 324 discussions of 238 patients took place. Cases were diverse; approximately 40% related to COVID-19 or brain infection, 40% autoimmune or other inflammatory disorders and 20% encephalitis mimics or uncertain aetiologies. Feedback from an online survey sent to referring teams and attendees highlighted the value of the MDT; 94% reported the discussion was useful and 69% reported resulting change in patient management. ConclusionsMultidisciplinary input is crucial in this challenging area, ensuring that all diagnostic avenues are explored and opening doors to novel diagnostics and therapeutics. It also supports clinicians dealing with unwell patients, including in centres where less specialist input is available, and when decisions have to be made where there is little or no evidence base.

SP10.12 Would You Like a Pus Swab Sent?

Abstract Aim The Association of Coloproctology of Great Britain and Ireland (ACPGBI) consensus guidelines in emergency colorectal surgery states that microbiology sampling is of limited value in the management of anorectal abscesses. Several centres continue to send intra-operative swabs routinely for microbiology. This study aims to identify (1) if sampling changed postoperative management and (2) quantify the financial cost of sending unnecessary swabs within a district general hospital setting. Methods Retrospective study investigating intraoperative clinician use of microbiology swabs. Study sample included patients who underwent an incision and drainage of an anorectal abscess from 1st October 2021 to 1st October 2022 in a district general hospital setting. Results A review of patient data obtained 59 patients who underwent an incision and drainage of an anorectal abscess. Swabs were taken in 54 (91.5%) cases. At 2 months, 40.7% of the swab results had not been reviewed by a clinician. 89% of swab results were reported after the patient was discharged. No documentation mentioned reviewing microbiology results in a follow-up clinic. There was no documented change of antibiotics nor correlation found between swab results and magnetic resonance imaging (MRI) requests/findings. Each microbiology swab costs £3 and labour costs are a minimum of £10 per swab analysed by a band 6 biomedical scientist. Total cost incurred per year was therefore estimated at £702. Conclusions Surgeons tend not to review microbiology results at follow-up appointments. Furthermore, there was no evidence that microbiology sampling resulted in change in patient management. Unnecessary use of swabs contributes to the NHS economic burden with no additional clinical benefit.

Ultrasound Rounds: Anesthesiologist-Performed Intraoperative Point-of-Care Focused Assessment With Sonography in Trauma Examination Changes Surgical Management.

Focused Assessment with Sonography in Trauma (FAST) examinations have been performed for decades by surgeons during initial patient presentation for emergency care and surgical planning, as well as for guiding resuscitation. This case highlights how use of intraoperative FAST examinations performed by anesthesiologists can dramatically change patient management. Use by anesthesiologists perioperatively is an important skill, although it is not widely practiced.

Temporal changes in the prehospital management of trauma patients: 2014–2021

IntroductionAggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS. MethodsRetrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression. ResultsBetween the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p ​= ​0.001), TXA administration (0.3% vs. 33%, p ​< ​0.001), and whole blood administration (0% vs. 20%, p ​< ​0.001) increased. Advanced airway procedures (21% vs. 12%, p ​< ​0.001) and IV fluid administration (57% vs. 36%, p ​< ​0.001) decreased. ED mortality decreased from 8% to 5% (p ​= ​0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality. ConclusionPHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality.

Histopathological Findings in Turkish Patients Undergoing Sleeve Gastrectomy: Is Histopathologic Examination of Sleeve Gastrectomy Specimens Clinically Important?

Sleeve gastrectomy (SG) is a widely used surgical method in the treatment of obesity. This study aimed to reveal the histopathological changes in SG materials and to investigate the prevalence of clinically important lesions requiring follow-up. Three hundred five patients' data who underwent SG were analyzed. Cases were divided into three groups as normal, chronic inactive gastritis (CIG), and chronic active gastritis (CAG). Age, gender, and body mass index (BMI) of the three groups and the differences in the gastritis parameters of CIG and CAG groups were compared. Thirty-three patients (10.8%) were in the normal group, 145 (47.5%) were in the CIG group, and 127 (41.6%) were in the CAG group. Preoperative endoscopic examination was performed in all cases, but Helicobacter pylori (HP) treatment was not applied. HP were detected in 39.3%, atrophy in 3.9%, intestinal metaplasia (IM) in 4.9%, and lymphoid follicle (LF) in 30% of the cases. Inflammation, atrophy, IM, LF, and HP were significantly higher in the CAG group. The proton pump inhibitor (PPI)-related changes were seen in 20 cases and it was more frequent in the CIG group. Intramucosal signet ring cell carcinoma was detected in 1 case. Endocrine cell hyperplasia and dysplasia were present in 7 cases with CAG. Multiple grade 1 neuroendocrine tumors were detected in just 1 case. In our SG specimens, HP and clinically important lesions were significantly higher in the CAG group. Pathological examination should be carefully done as the lesions detected in SG specimens can change patient management.

Validation and potential usefulness of the updated PROMISE Minimal Risk Tool in patients with suspected coronary artery disease undergoing coronary CT angiography

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The steady decline in test positivity among patients with suspected coronary artery disease (CAD) has raised interest in developing strategies to identify patients who may not require testing. The updated PROMISE minimal-risk tool (PMRT) was developed specifically for this purpose, but never tested in our population. The aim of this study was to assess the diagnostic performance of this new tool, and to compare it with the guideline-recommended pre-test probability (PTP) and with the risk factor-weighted clinical likelihood (RF-CL) model in a Portuguese cohort of symptomatic patients undergoing coronary computed tomography angiography (CCTA). Methods We conducted a two-centre cross-sectional study of symptomatic patients undergoing CCTA for suspected CAD. Key exclusion criteria were age &amp;lt;30 years, known CAD, suspected acute coronary syndrome or symptoms other than chest pain or dyspnoea. A simplified version of the updated PMRT (without HDL-C), the guideline PTP, and RF-CL score were calculated for each patient. Obstructive CAD was defined as any luminal stenosis ≥ 50% on CCTA. ‘Low risk’ was defined as absence of obstructive CAD and coronary artery calcium (CAC) score &amp;lt; 100 (both conditions present, where CCTA results are unlikely to change patient management). The cut-off value of the PMRT with 95% positive predictive value for identifying patients with ‘Low risk’ was identified in ROC curve analysis. Results A total of 2162 patients (mean age 60±11years, 59% female) were included. Overall, 14.9% (N=323) of patients had obstructive CAD, and 73.5% (N=1589) fulfilled the criteria for ‘Low risk’. Patients with ‘Low risk’ were more frequently female, had higher prevalence of non-anginal chest pain and had fewer cardiovascular risk factors. For obstructive CAD, the discriminative power of the updated PMRT was similar to the one provided by the guideline PTP and RF-CL models (Figure 1A). However, for identifying patients with ‘Low risk’, the updated PMRT showed greater discriminative power than the guideline PTP and RF-CL models (Figure1B). The PMRT cut-off value with 95% positive predictive value for detecting patients at "Low risk" was identified as &amp;gt;46%. A total of 458 patients (21.2%) had a PMRT &amp;gt;46%. Conclusion In this cohort of symptomatic patients undergoing CCTA, the updated PMRT showed similar discriminative power for obstructive CAD, but greater discriminative power to identify "Low risk" than the guideline-recommended PTP and the RF-CL models. The criterion that identified "Low Risk" with 95% positive predictive value was present in roughly one fifth of patients undergoing CCTA, who would be less likely to derive benefit from testing.

#3074 CHANGES IN THE CLINICAL CHARACTERISTICS AND MANAGEMENT OF PATIENTS WITH AHUS OVER 10 YEARS: TRENDS FROM THE GLOBAL AHUS REGISTRY

Abstract Background and Aims Atypical haemolytic uraemic syndrome (aHUS) is a rare disease predominantly caused by alternative complement pathway dysregulation. Prior to 2011, before the targeted complement inhibitor eculizumab became available, aHUS frequently led to end-stage kidney disease (ESKD) and early death. Treatment with eculizumab led to notable improvements in outcomes; whether patient characteristics and management has continued to change over time is unknown. Using data from the Global aHUS Registry, we assessed clinical characteristics and management of patients with aHUS over 10 years to identify any potential trends. Method All patients enrolled in the Global aHUS Registry from 2012–2022 were included. Patients were categorised according to age at aHUS onset (adult [≥18 years] vs paediatric [&amp;lt;18 years]); onset of aHUS was defined as the earliest of initial symptom presentation, aHUS diagnosis, or first recorded thrombotic microangiopathy (TMA). Patient characteristics were summarised using descriptive analysis. Results Of the 1994 patients enrolled in the registry between 2012 and 2022, 33 (1.7%) were missing data on age at aHUS onset. Of the remaining 1961 patients, 813 (41.5%) were paediatric and 1148 (58.5%) were adult. Changes in patient characteristics and management are presented in Fig. 1. Plasma exchange/plasma infusion (PE/PI) prior to and including the year of enrolment was less common in paediatric than adult patients (58.5% vs. 71.3%) between 2012–2013 and declined substantially in paediatric (19.6%) relative to adult (55.1%) patients by 2020–2022. Similar proportions of paediatric patients required dialysis at the time of enrolment between 2012–2013 (5.1%) and 2020–2022 (5.9%), while numerically lower proportions of adults required dialysis over time (2012–2013, 15.2%; 2020–2022, 6.5%). The rate of paediatric patients requiring a kidney transplant prior and up to enrolment dropped from 2012–2013 (28.4%) to 2020–2022 (5.9%); however, the rate among adult patients remained comparable (2012–2013, 29.2%; 2020–2022, 27.1%). A decrease in the proportion of patients with a reported identified pathogenic variant and/or anti-CFH antibodies was observed in paediatric and adult patients between 2012–2013 (paediatric, 59.1%; adult, 45.5%) and 2020–2022 (paediatric, 49.0%; adult, 30.8%). The proportion of patients with a reported triggering event increased from 2012–2013 (paediatric, 6.3%; adult, 12.4%) to 2020–2022 (paediatric, 9.8%; adult, 28.0%). In this cohort, a total of 1208 patients were treated with eculizumab/ravulizumab between 2012 and 2022 (paediatrics, 476; adults, 732). Between 2012–2013, the median time from aHUS onset to treatment initiation was 94.9 days for paediatric patients (blue) and 51.1 days for adult patients (orange); this fell to 13.1 days in paediatrics and 24.1 days in adults between 2020–2022 (Fig. 2). Conclusion Utilisation of PE/PI to treat aHUS has decreased more in paediatric than adult patients over time. A decreased requirement for transplant in paediatric patients was evident, suggesting more paediatrics are now being diagnosed and treated earlier, leading to better outcomes with fewer patients progressing to renal failure and requiring kidney transplant. The proportion of both paediatric and adult patients with reported pathogenic variants and/or anti-CFH antibodies decreased over time and may reflect the rate at which a clinical constellation consistent with aHUS is identified. Moreover, aHUS may be recognised more frequently in the presence of a triggering condition, or a lower barrier for clinicians to suspect aHUS in recent years. Patients were more rapidly treated with a complement inhibitor, likely due to better awareness in the clinical community around complement inhibitors and the importance of early treatment initiation. Although patients with aHUS are being treated more promptly in recent years than 10 years ago, more work is needed, especially in adults, to move towards optimal clinical practice.

Utility of Echocardiography Screening for Cancer Therapy-Related Cardiac Dysfunction

Availability of echocardiography resources in New Zealand is under pressure due to workforce shortages. This study examined real-world utility of echocardiogram (echo) as a screening tool for cancer therapy-related cardiac dysfunction (CTRCD), changes in patient treatment, and outcome because of CTRCD detected by echocardiography. A retrospective audit was undertaken of all patients dispensed with trastuzumab, pertuzumab, and/or doxorubicin chemotherapy, with serial echocardiography performed, at Lakes and Bay of Plenty District Health Boards between January 2018 and January 2021. Two-dimensional ejection fraction (EF), three-dimensional (3D) EF, and global longitudinal strain (GLS) were used to classify patients with CTRCD based on current guidelines. Changes in patient management were examined. A total of 407 echos were performed in 107 patients. Of 25 (23%) patients with CTRCD, 11 had a change in cancer treatment and seven started cardiac medications. Fifteen (60%) patients showed recovery in EF/GLS measurements over time and eight (32%) showed spontaneous recovery. Patients were more likely to have a change in cancer treatment based on a change in left ventricular ejection fraction than GLS (p<0.001). The use of 3D EF and GLS was limited by 43% of the population who were obese, which was performed in 14% and 62% of studies, respectively. Cancer therapy-related cardiac dysfunction was associated with mortality in univariate (p=0.02) but not multivariate (p=0.06) analysis. Detection of CTRCD remains a priority. However, echo screening requires many resources and did not result in consistent changes in management approach. It is worth examining whether the use of biomarkers would be effective and resource sparing.

Pathology testing in non-trauma patients presenting to the emergency department with recurrent seizures.

Excessive pathology testing is associated with ED congestion, increased healthcare costs and adverse patient health outcomes. This study aimed to determine the frequency, yield and influence of pathology tests among patients presenting to the ED with atraumatic recurrent seizures. This was a retrospective cohort study conducted at a level 4 adult ED in Australia and included atraumatic patients presenting to ED with recurrent seizures over a 4-year period (2017-2020). The primary outcome was the frequency of pathology tests. Additionally, the proportion of abnormal pathology test results and the association between pathology tests and change in management were assessed. Of the 398 eligible presentations, 346 (86.9%, 95% confidence interval [CI] 83.3-89.9%) underwent at least one pathology test. In total 18.3% (n = 517) of pathology tests had an abnormal result which led to 15 changes in ED management among 12 presentations. Patients who had an abnormal pathology test result were more likely to undergo a change in antiepileptic drug management (odds ratio 2.08, 95% CI 1.23-3.65; P = 0.008). Most patients presenting to the ED with atraumatic recurrent seizures underwent pathology tests. Abnormalities were frequently detected but were uncommonly associated with change in management. Abnormal pathology test results were associated with changes in antiepileptic drug management although rarely led to acute changes in patient management. This study suggests that pathology tests may be excessively requested in this population.

Role of hospital strain in determining outcomes for people hospitalised with COVID-19 in England

BackgroundIn England, reported COVID-19 mortality rates increased during winter 2020/21 relative to earlier summer and autumn months. This study aimed to examine the association between COVID-19-related hospital bed-strain during this...

Effect of Amyloid PET on Clinical Management of Alzheimer’s Disease Medication Therapy: The Khatib Study (P11-6.009)

<h3>Objective:</h3> Evaluate the role of amyloid-beta PET scans as a diagnostic tool in clinical settings and its influence on patient care management with respect to Alzheimer’s disease drug therapy. <h3>Background:</h3> The NIA-AA 2018 guidelines for clinical research define Alzheimer’s disease (AD) on a biological basis, requiring the presence of amyloid deposition in the brain. This framework helps to more precisely define the processes underlying cognitive impairment, and is particularly poignant given the advent of amyloid-beta PET scans which allow the visualization of amyloid-beta in vivo. It is unclear how this framework may lead to changes in management of patients, particularly in an ethnically and culturally diverse location such as in South Florida. <h3>Design/Methods:</h3> We included 102 cognitively impaired patients from the multi-site Khatib Study (mean age 77+/−7 years, 45% women, 15% Hispanic). Patients were evaluated for AD drug therapy (cholinesterase inhibitors and memantine) before and after amyloid-beta PET scan by neurologists. The probabilities of change in AD drug therapy by amyloid-beta PET scan results were estimated using Wilson intervals for binomial proportions and tested using the McNemar test. <h3>Results:</h3> For amyloid PET positive patients (n=68), the use of AD drug therapy increased significantly (<i>p</i>&lt;.05), from 78% (95%CI [67,86]) to 91% (95% CI [82,96]). A total of 15% (95%CI [8,25]) started AD drug therapy and 2% (95%CI [0.3,8]) stopped AD drug therapy. For amyloid PET negative patients (n=34), the use of AD drug therapy decreased significantly (<i>p</i>&lt;.05), from 76% (95%CI [60,88]) to 53% (95%CI [37,69]). A total of 29% (95%CI [17,46]) stopped AD drug therapy and 6% (95%CI [2,19]) started AD drug therapy. <h3>Conclusions:</h3> Clinical confirmation of patients’ amyloid PET status resulted in increases in prescribed AD drug therapy for amyloid positive patients and decreases in the amyloid negative patients. This study highlights the significant bidirectional influence of amyloid PET scans on patient care management. <b>Disclosure:</b> Ms. Ariko has nothing to disclose. Miss Modjeski has nothing to disclose. Dr. Chang has nothing to disclose. Ms. Merrifield has received personal compensation for serving as an employee of The Council on Aging of Martin County - The Kane Center. Ms. Ripper has received personal compensation for serving as an employee of the council on aging of Martin County Inc. Mrs. Clark Dowd has nothing to disclose. James Galvin has nothing to disclose. Dr. Camargo has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biogen. Dr. Camargo has received personal compensation in the range of $500-$4,999 for serving as a Consultant for GE Health. The institution of Dr. Camargo has received research support from American Academy of Neurology.

Scheduled Programming of VNS Therapy Reduces Time-To-Dose and Office Visits in the COVID-19 Pandemic (P5-1.006)

<h3>Objective:</h3> To describe natural changes in patient management that occurred during the COVID-19 pandemic, and the impact these changes had on patients. <h3>Background:</h3> Recently available models of VNS therapy offer a scheduled programming feature that permits programming events to occur on a predetermined schedule, outside of typical office visits. During the COVID-19 pandemic, patient access to office visits has been limited, and remote patient management techniques, such as scheduled programming, have gained popularity. <h3>Design/Methods:</h3> To examine changes in real-world feature use, a database of programming events at primarily North American centers and collected through standard post-market surveillance was examined. The full year of 2018 (the year following release of this feature) was compared to the year of 2020, from March 1st through December 31st, when COVID-19 restrictions started to become more widespread in the United States. <h3>Results:</h3> Scheduled programming increased from 23.5% of all patients in 2018 to 30.5% in 2020. While frequency of feature use increased during the pandemic, the typical method of feature use did not meaningfully change. Of patients who used scheduled programming to titrate at least 1 step, the mean number of total steps titrated with this feature increased from 3.5 to 3.8 during the pandemic. Use of scheduled programming decreases the frequency of office visits required to achieve a dose, but pre-pandemic and peri-pandemic reduction in office visits in patients that used scheduled programming were not meaningfully different (−2.1 visits in 2020 vs −1.9 visits in 2018). During both time ranges, patients who experienced 3 or more scheduled programming events were more likely to achieve a target dose of 1.5 mA in less than three months. <h3>Conclusions:</h3> These findings suggest that scheduled programming can support VNS dosing and titration in situations where remote patient management is encouraged. <b>Disclosure:</b> Maxine Dibue-Adjei has received personal compensation for serving as an employee of LivaNova PLC. Maxine Dibue-Adjei has stock in LivaNova PLC. Miss PATEL has nothing to disclose. Dr. Tzadok has nothing to disclose. Firas Fahoum has received personal compensation in the range of $500-$4,999 for serving as a Consultant for LivaNova. Firas Fahoum has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for LivaNova. Mr. Gordon has received personal compensation for serving as an employee of LivaNova. Mr. Gordon has stock in LivaNova. The institution of Prof. Tahry has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Livanova. The institution of Prof. Tahry has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Livanova. The institution of Prof. Tahry has received research support from Livanova.

Diagnostic Yield of Abdominal Radiographs in the Pediatric Emergency Department.

Abdominal radiographs (ARs) are commonly used in the pediatric emergency department (PED). Their low diagnostic accuracy leads to overuse, excess radiation exposure, and increased resource usage. This study aims to assess the diagnostic yield of ARs in the evaluation of intraabdominal pathology in the PED. Retrospective, cross-sectional study of patients aged 0 to 18 years with an AR who visited the PED between 2017 and 2019. Diagnostic yield was analyzed with sensitivity, specificity, positive predictive value, negative predictive value (NPV), and likelihood ratio. A total of 4288 ARs were identified, with a rate of 6%. The overall abnormal AR rate was 31%. The incidences of an abnormal AR in abdominal pain, vomiting, and constipation were 26%, 37%, and 50%, respectively. There was a 13% rate of clinically significant diagnoses. The AR diagnostic yield showed 44% sensitivity, 70% specificity, 17% positive predictive value, and 90% NPV ( P < 0.05). Unadjusted odds ratio analysis of positive AR and abdominal pain, vomiting, and constipation revealed an odds ratio of 0.68 (95% confidence interval [CI], 0.63-0.75), 1.22 (95% CI, 1.06-1.39), and 1.72 (95% CI, 1.54-1.91), respectively. There is a low rate of intraabdominal pathologic processes that an AR can identify. A normal AR does not change patient management, nor does it reduce the need for further radiologic imaging. Despite a good NPV, the AR is not a useful diagnostic tool in the PED because of its limited ability to rule in or rule out clinically significant diagnoses.

Digital adherence technologies to improve tuberculosis treatment outcomes in China: a cluster-randomised superiority trial

Drug-sensitive tuberculosis treatment requires 6 months of therapy, so adherence problems are common. Digital adherence technologies might improve tuberculosis treatment outcomes. We aimed to evaluate the effect of a daily reminder medication monitor, monthly review of adherence data by the health-care provider, and differentiated care for patients with adherence issues, on tuberculosis treatment adherence and outcomes. We did a cluster-randomised superiority trial across four prefectures in China. 24 counties or districts (clusters) were randomly assigned (1:1) to intervention or control groups. We enrolled patients aged 18 years or older with GeneXpert-positive, rifampicin-sensitive pulmonary tuberculosis, who were receiving daily fixed-dose combination treatment. Patients in the intervention group received a medication monitor for daily drug-dosing reminders, monthly review of adherence data by health-care provider, and management of poor adherence; and patients in the control group received routine care (silent-mode monitor-measured adherence). Only the independent endpoints review committee who assessed endpoint data for some participants were masked to study group assignment. Patients were followed up (with sputum solid culture) at 12 and 18 months. The primary outcome was a composite of death, loss to follow-up, treatment failure, switch to multidrug-resistant tuberculosis treatment, or tuberculosis recurrence by 18 months from treatment start, analysed in the intention-to-treat population. Analysis accounted for study design with multiple imputation for the primary outcome. This trial is now complete and is registered with ISRCTN, 35812455. Between Jan 26, 2017, and April 3, 2019, 15 257 patients were assessed for eligibility and 3074 were enrolled, 2686 (87%) of whom were included in the intention-to-treat population. 1909 (71%) of 2686 patients were male, 777 (29%) were female, and the median age was 44 years (IQR 29-58). By 18 months from treatment start, using multiple imputation for missing outcomes, 239 (16% [geometric mean of cluster-level proportion]) of 1388 patients in the control group and 224 (16%) of 1298 in the intervention group had a primary composite outcome event (289 [62%] of 463 events were loss to follow-up during treatment and 42 [9%] were tuberculosis recurrence). The intervention had no effect on risk of the primary composite outcome (adjusted risk ratio 1·01, 95% CI 0·73-1·40). Our digital medication monitor intervention had no effect on unfavourable outcomes, which included loss to follow-up during treatment, tuberculosis recurrence, death, and treatment failure. There was a failure to change patient management following identification of treatment non-adherence at monthly reviews. A better understanding of adherence patterns and how they relate to poor outcomes, coupled with a more timely review of adherence data and improved implementation of differentiated care, may be required. Bill & Melinda Gates Foundation.

Chest X-ray Overuse in Cardiothoracic Intensive Care Unit per American College of Radiology Criteria

BackgroundA routine chest radiograph (CXR) is frequently incorporated into postoperative clinical pathways. Whereas prior studies evaluated CXR use for specific indications, overall CXR "stewardship" within cardiothoracic surgery remains undescribed. We characterized CXR use within a cardiothoracic intensive care unit (ICU) and quantified X-ray–driven changes in patient management. MethodsAll CXRs performed during 3 months in the cardiothoracic ICU of an academic 900-bed tertiary care hospital were retrospectively reviewed. Attending radiologist CXR reports and clinical history from ordering providers were manually reviewed to classify CXRs as indicated or not indicated by American College of Radiology (ACR) Appropriateness Criteria. Multiple resident-level providers further reviewed CXRs to determine whether the image demonstrated any actionable or unexpected findings. ResultsBetween October 1, 2021, and January 3, 2022, 1273 CXRs were performed on adult cardiac and general thoracic surgery patients; the most common indication was routine daily (55.9%), followed by support device monitoring (12.4%) and new ICU transfer (10.4%). Only 34.3% of performed CXRs met ACR Appropriateness Criteria; 65.7% did not (P = .002). Only 3.8% of not indicated CXRs had actionable or significant findings vs 13.0% of indicated CXRs (P = .02). Of the 32 not indicated CXRs with actionable findings, 37.5% recommended endotracheal tube repositioning and 28.1% recommended other line or tube repositioning. ConclusionsCXRs are overused in the cardiothoracic ICU according to ACR Appropriateness Criteria. CXRs performed outside these guidelines have significantly fewer actionable or meaningful findings. Optimizing CXR use can improve resource utilization and efficiency in care of cardiothoracic surgical patients.

Exploring the EVolution in PrognOstic CapabiLity of MUltisequence Cardiac MagneTIc ResOnance in PatieNts Affected by Takotsubo Cardiomyopathy Based on Machine Learning Analysis: Design and Rationale of the EVOLUTION Study.

Takotsubo cardiomyopathy (TTC) is a transient but severe acute myocardial dysfunction with a wide range of outcomes from favorable to life-threatening. The current risk stratification scores of TTC patients do not include cardiac magnetic resonance (CMR) parameters. To date, it is still unknown whether and how clinical, trans-thoracic echocardiography (TTE), and CMR data can be integrated to improve risk stratification. EVOLUTION (Exploring the eVolution in prognOstic capabiLity of mUlti-sequence cardiac magneTIc resOnance in patieNts affected by Takotsubo cardiomyopathy) is a multicenter, international registry of TTC patients who will undergo a clinical, TTE, and CMR evaluation. Clinical data including demographics, risk factors, comorbidities, laboratory values, ECG, and results from TTE and CMR analysis will be collected, and each patient will be followed-up for in-hospital and long-term outcomes. Clinical outcome measures during hospitalization will include cardiovascular death, pulmonary edema, arrhythmias, stroke, or transient ischemic attack.Clinical long-term outcome measures will include cardiovascular death, pulmonary edema, heart failure, arrhythmias, sudden cardiac death, and major adverse cardiac and cerebrovascular events defined as a composite endpoint of death from any cause, myocardial infarction, recurrence of TTC, transient ischemic attack, and stroke. We will develop a comprehensive clinical and imaging score that predicts TTC outcomes and test the value of machine learning models, incorporating clinical and imaging parameters to predict prognosis. The main goal of the study is to develop a comprehensive clinical and imaging score, that includes TTE and CMR data, in a large cohort of TTC patients for risk stratification and outcome prediction as a basis for possible changes in patient management.

Telestroke value through the eyes of emergency medicine providers: A counterfactual analysis

ObjectivesEmergency Medicine (EM) provider experiences consulting telestroke (TS) are poorly studied. In this qualitative study, we aimed to determine how TS changes patient management and to measure TS effects on EM provider confidence with acute ischemic stroke (AIS) treatment. Materials and methodsWe designed a survey for EM providers querying perceptions of TS value, confidence with treating AIS, and counterfactuals regarding what EM providers would have done without TS. Eligible EM providers participated in an audio-visual TS consult within a 6-state TS network between 11/2016–11/2017. ResultsWe received 48 surveys (response rate 43%). The most common reason (71%) for using TS was tPA eligibility expert opinion. Most EM providers (94%) thought the patient/family were satisfied with TS and none felt their medical knowledge was doubted because of using TS. EM providers had high confidence in diagnosing AIS (95%) and tPA decision-making (86%), but not in determining thrombectomy eligibility (10%). Among EM providers who administered tPA, 85% said tPA would not have been given without TS consultation. TS consultation changed patient diagnosis in 60% of all patients and treatment plans in 56% of non-stroke patients. Most EM providers (86%) had increased confidence in their knowledge of future stroke patient management. Nearly all TS consults (93%) resulted in EM providers being more likely to use TS again. ConclusionsTS consult frequently results in both patient management change and increased EM knowledge of stroke management with increased likelihood of repeat usage. Discomfort in determining eligibility for thrombectomy points to educational opportunities.

Donor specific antibody surveillance among pediatric kidney transplant programs: A report from the improving renal outcome collaborative.

Kidney transplantation (KT) is the preferred treatment for children with end-stage kidney disease. Recent advances in immunosuppression and advances in donor specific antibody (DSA) testing have resulted in prolonged allograft survival; however, standardized approaches for surveillance DSA monitoring and management of de novo (dn) DSA are widely variable among pediatric KT programs. Pediatric transplant nephrologists in the multi-center Improving Renal Outcomes Collaborative (IROC) participated in a voluntary, web-based survey between 2019 and 2020. Centers provided information pertaining to frequency and timing of routine DSA surveillance and theoretical management of dnDSA development in the setting of stable graft function. 29/30 IROC centers responded to the survey. Among the participating centers, screening for DSA occurs, on average, every 3 months for the first 12months post-transplant. Antibody mean fluorescent intensity and trend most frequently directed changes in patient management. Increased creatinine above baseline was reported by all centers as an indication for DSA assessment outside of routine surveillance testing. 24/29 centers would continue to monitor DSA and/or intensify immunosuppression after detection of antibodies in the setting of stable graft function. In addition to enhanced monitoring, 10/29 centers reported performing an allograft biopsy upon detection of dnDSA, even in the setting of stable graft function. This descriptive report is the largest reported survey of pediatric transplant nephrologist practice patterns on this topic and provides a reference for monitoring dnDSA in the pediatric kidney transplant population.

Prevalence, Associated Factors, and Impact of Workplace Violence among Physicians.

There is a dearth of objective data and studies pertaining to the prevalence and consequences of workplace violence against physicians in Nepal. This study aims to assess the prevalence, associated factors, and implications of workplace violence on Nepalese physicians. We conducted a cross-sectional study from March 2021 to August 2021. Nepal Medical Council-certified physicians currently working in Nepal were included in the study. Baseline characteristics, types of violence experienced, patterns, psychosocial impacts, and changes in patient management were collected. Out of 318 responses received, 302 responses met the inclusion criteria and were included in the final analysis. One-hundred and ninety (62.9%) respondents had ever faced workplace violence. Madhesh Province had the highest prevalence (81.5%). Verbal abuse (93.2%) was the most common type of violence encountered. We found a significant association between workplace violence and hours worked each week. We also found an association between workplace violence and years of experience. Our study found a significant increase in stress/depression/anxiety/idea of persecution, sense of defeat, job turnover, and loss of productivity/income with the increase in severity of workplace violence. Workplace violence is largely prevalent among Nepalese physicians. In the aftermath of workplace violence, a physician can undergo a multitude of adverse psychosocial consequences leading to a further decrease in productivity. More insights through research, formal training, and policy implementation are necessary to overcome this largely ignored problem of the medical fraternity in Nepal.