Clinical Review Research Articles

Development of a novel cancer diagnostic center to facilitate care coordination for patients with new or suspected diagnoses of cancer.

81 Background: Navigating a cancer diagnosis is a multifaceted challenge, characterized by intricate care coordination that creates potential for workup and treatment delays, lapses in care, and potentially negatively affecting clinical outcomes. We have developed a novel physician and advanced practitioner-led cancer diagnostic program (CDP) to help navigate patients with a suspected cancer through the diagnostic and staging workup, discussion of results, and linkage to oncologic care. Patients are referred to the CDP, an administrative intake coordinator creates a medical chart, verifies insurance, gathers records, and schedules appointments. An intake nurse reaches out within 24 hours to obtain clinical information and review of systems. Patients are offered an in-person or video visit with the advanced practitioner for history and physical, labs, and further coordination of testing. Here, we aim to describe the demographic and clinical patterns of referral and clinical outcomes of patients who were referred to a CDP over one calendar year. Methods: We retrospectively analyzed 154 patients with a new cancer diagnosis to have at least 1 encounter at the Johns Hopkins CDP between January 1, 2022, and December 31, 2022. Data were retrospectively collected from medical records and stored within Johns Hopkins REDCap. Descriptive analyses were used to describe the data. Results: Among the 154 total patients included in this analysis, 65.6% were White, 24.7% were Black, 3.2% were Asian, and 1.9% were of Hispanic, Latino, or Spanish origin. Insurance coverage was most frequently (46.8%), Medicare (40.3%), and Medicaid (8.4%). Referral distribution shows 50 inpatient and 104 outpatient referrals. Primary cancer diagnoses were most often gastrointestinal (39.6%), upper airway and lung (26.6%), and genitourinary (9.1%). Conclusions: The Johns Hopkins CDP exemplifies the potential for dedicated diagnostic and treatment initiation programs to improve oncologic care, particularly for vulnerable populations. The center facilitates expedited diagnostic resolution, to increased ease of workup for patients and providers, and potentially improve clinical outcomes such as linkage to care and time to treatment. Accepting referrals from inpatient and outpatient settings captures a broad patient pool, including those who may otherwise experience lapses in care owing to complex care navigation needs. In conclusion, we describe a novel care delivery model to potentially optimize healthcare delivery in oncologic care. Inpatient Referral Outpatient Referral Percent minority populations 34% 23.1% Stage 4 at diagnosis 74% 52.9% Patients initiating treatment with curative intent 42.3% 30% Median length of hospitalization 7 days N/A Median time from pathology results to discharge -2.5 days N/A Median time from pathology results to treatment initiation 20 days 16.5 days

Summary of the best evidence for the safe use of pneumatic tourniquet in limb surgery

PurposeTo retrieve, evaluate, and summarize the best available evidence regarding the safe use of pneumatic tourniquet in patients undergoing Limb surgery, providing guidance for preoperative assessment, operation methods and precautions, complication prevention and treatment in clinical practice.MethodsUsing the PIPOST tool, we formulated an evidence-based question, conducted searches in relevant Chinese and international databases and websites for clinical decisions, guidelines, evidence summaries, systematic reviews, and expert consensus on the use of limb surgical tourniquets. The search was limited to literature published until September 30, 2023. Quality assessment and evidence extraction were performed on eligible documents.ResultsThis study included a total of 13 articles, including 2 clinical decision-making articles, 3 guidelines, 5 expert consensus articles, 1 standard and 2 systematic reviews. A total of 34 best pieces of evidence recommendations were summarized across 10 aspects, including indications and contraindications for the use of pneumatic tourniquets, preoperative evaluation of operators, selection and placement of tourniquet cuffs, tourniquet inflation, monitoring during inflation, tourniquet deflation, common complications and prevention, equipment safety, documentation, and training and education.ConclusionThe best evidence summarized in this study can provide reference for clinical medical staff to safely use pneumatic tourniquets, but in clinical practice, targeted selection and application of evidence should be combined with specific situations to improve the safety and hemostatic effect of pneumatic tourniquet use.

Rapidly growing knowledge of Mycobacterium smegmatis: A case series and review of antimicrobial susceptibility patterns

Mycobacterium smegmatis is a rapidly growing nontuberculous mycobacterium that is rarely isolated from clinical specimens and is frequently considered to be a contaminant. We conducted a retrospective review of mycobacterial cultures positive for M. smegmatis from 1998 to 2023 at our institution to evaluate the clinical significance of recovering this mycobacterium. Antimicrobial susceptibility patterns were also determined. Twenty-two M. smegmatis isolates were identified from 17 patients, 12 of whom met criteria for clinical chart review. M. smegmatis was deemed a cause of infection in 5/5 isolates from skin or soft tissue, 3/3 from bone, 1/1 from blood, and 0/3 from respiratory specimens. All cases thought to be significant were treated with at least 2 active agents for periods varying from 2 weeks up to 8 months. 18 isolates had antimicrobial susceptibility testing performed and all were susceptible to doxycycline, imipenem, linezolid, moxifloxacin, trimethoprim/sulfamethoxazole, and tobramycin while all isolates were resistant to clarithromycin. When recovered in culture, the presence of M. smegmatis should be correlated with clinical presentation as it may represent a true infection.

Caring for children with cerebral palsy: A commentary on cerebral palsy in children: a clinical practice review

Caring for children with cerebral palsy: A commentary on cerebral palsy in children: a clinical practice review

Optimizing triple therapy in patients with metastatic hormone-sensitive prostate cancer

Triple therapy with docetaxel, androgen deprivation therapy (ADT) and androgen receptor pathway inhibitors (ARPIs) has demonstrated survival benefits in patients with metastatic hormone-sensitive prostate cancer (mHSPC), especially in those with high-risk disease. However, once the use of ADT and docetaxel is established, guidelines do not clearly specify which ARPI is most appropriate. In this work, a literature review to identify phase III clinical trials, systematic reviews, meta-analyses, and clinical practice guidelines on triple therapy in mHSPC was carried out. Evidence and recommendations were qualitatively reviewed to provide guidelines on the most suitable ARPI based on patient risk, disease volume, and nature of metastases (synchronous or metachronous). This review aims to update the previously published consensus on the optimal pharmacological treatment for mHSPC and to expose the opinions of hospital pharmacy, urology and medical and radiation oncology experts.

Genedrive kit for detecting single nucleotide polymorphism m.1555A>G in neonates and their mothers: a systematic review and cost-effectiveness analysis.

Neonates with suspected sepsis are commonly treated with gentamicin, an aminoglycoside. These antibiotics are associated with high risk of ototoxicity, including profound bilateral deafness, in people with the m.1555A>G mitochondrial genetic variant. This early value assessment summarised and critically assessed the clinical effectiveness and cost-effectiveness of the Genedrive MT-RNR1 ID Kit for identifying the gene m.1555A>G variant in neonates and mothers of neonates needing antibiotics or anticipated to need antibiotics. Following feedback from the scoping workshop and specialist assessment subgroup meeting, we also considered the Genedrive MT-RNR1 ID Kit for identifying the m.1555A>G variant in mothers prior to giving birth. For clinical effectiveness, we searched three major databases in October 2022: MEDLINE, EMBASE and CINAHL (Cumulative Index to Nursing and Allied Health Literature). For cost-effectiveness, in addition to the three mentioned databases we searched Cochrane and RePEc-IDEAS. Study selection and risk-of-bias assessment were conducted by two independent reviewers (Ryan PW Kenny and Akvile Stoniute for clinical effectiveness and Hosein Shabaninejad and Tomos Robinson for cost-effectiveness). Any differences were resolved through discussion, or by a third reviewer (Nick Meader). Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. One study (n = 751 neonates recruited) was included in the clinical effectiveness review and no studies were included in the cost-effectiveness review. All except one outcome (test failure rate: low risk of bias) were rated as being at moderate risk of bias. The study reported accuracy of the test (sensitivity 100%, 95% confidence interval 29.2% to 100%; specificity 99.2%, 95% confidence interval 98% to 99.7%), number of neonates successfully tested (n = 424/526 admissions), test failure rate (17.1%, although this was reduced to 5.7%), impact on antibiotic use (all those with a m.1555A>G genotype avoided aminoglycosides), time taken to obtain a sample (6 minutes), time to genotyping (26 minutes), time to antibiotic treatment (55.18 minutes) and the number of neonates with m.1555A>G (n = 3). The economic component of this work identified key evidence gaps for which further data are required before a robust economic evaluation can be conducted. These include the sensitivity of the Genedrive MT-RNR1 ID Kit for identifying the gene m.1555A>G variant in neonates, the magnitude of risk for aminoglycoside-induced hearing loss in neonates with m.1555A>G, and the prevalence of the m.1555A>G variant. Other potentially important gaps include how data regarding maternal inheritance may potentially be used in the clinical pathway. This early value assessment suggests that the Genedrive MT-RNR1 ID Kit has the potential to identify the m.1555A>G variant and to be cost-effective. The Genedrive MT-RNR1 ID Kit dominates the current standard of care over the lifetime, as it is less costly and more effective. For a 50-year time horizon, the Genedrive MT-RNR1 ID Kit was also the dominant strategy. For a 10-year time horizon, the incremental cost-effectiveness ratio was estimated to be £103 per quality-adjusted life-year gained. Nevertheless, as anticipated, there is insufficient evidence to conduct a full diagnostic assessment of the clinical effectiveness and cost-effectiveness of the Genedrive MT-RNR1 ID Kit in neonates directly or in their mothers. This report includes a list of research priorities to reduce the uncertainty around this early value assessment and to provide the additional data needed to inform a full diagnostic assessment, including cost-effectiveness modelling. This study is registered as PROSPERO (CRD42022364770). This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135636) and is published in full in Health Technology Assessment; Vol. 28, No. 75. See the NIHR Funding and Awards website for further award information.

Development of air therapy as a novel therapeutic branch in the field of rehabilitation.

Developing technology in the field of rehabilitation is vital to accelerate recovery and decrease the side effects of current modalities. Rehabilitation is a challenging science in which the main challenge is not just treating the patient but also to shorten the rehabilitation time and avoid harmful effects. Thus, this review demonstrates the possible design and effects of air therapy as a novel treatment branch besides hydrotherapy, electrotherapy, and manual therapy in the field of rehabilitation. The search was conducted over clinical trials, literature reviews, and systematic reviews on the possible effects of treatments that may have similar effects to the newly developed air therapy. This search was conducted in the Web of Science, Scopus, EBSCO, and Medline databases. Air therapy could be used to improve the function of mechanoreceptors, improve circulation and microcirculation, decrease pain, the release of trigger points, regain the elasticity of soft tissues, treat acute and chronic inflammations, decrease muscle cramps and spasticity, strengthen muscle, and decrease muscle fatigue and Decreasing muscle fatigue and delayed muscle soreness. Air therapy is a novel treatment modality that can be used effectively in the field of rehabilitation. Air therapy could be a valuable and safe treatment in rehabilitation.

OTUD7B promotes cell migration and invasion, predicting poor prognosis of gastric cancer

BackgroundOTUD7B, a member of the ovarian tumor (OTU) protein superfamily, functions as a deubiquitinating enzyme and is associated with various biological processes and disease conditions, including tumors. In this study, we aimed to explore the expression patterns, prognostic significance, and the functional roles and underlying mechanisms of OTUD7B in gastric cancer (GC). Materials and MethodsUsing a blend of bioinformatics, clinical case reviews, and molecular experiments, we evaluated the expression of OTUD7B in GC at both mRNA and protein levels. We examined the relationship between OTUD7B expression and clinicopathological characteristics of GC patients. Additionally, in vitro assays were utilized to assess the effects of OTUD7B on the migratory and invasive capabilities of GC cells. RNA sequencing analysis was conducted to identify critical genes and pathways linked to OTUD7B in GC. ResultsOTUD7B was found to be significantly overexpressed in GC, both at mRNA and protein levels. Higher levels of OTUD7B were positively associated with advanced tumor TNM stage, higher histological grade, and presence of lymph/vein invasion. These correlations were indicative of poorer overall survival (OS) and disease-free survival (DFS) in GC patients. In vitro assays revealed that genetic knockout of OTUD7B markedly reduced the migration and invasion of GC cells, while overexpression of OTUD7B led to enhanced cellular migration and invasion. Furthermore, RNA sequencing and bioinformatic analyses indicated that the absence of OTUD7B suppressed signaling pathways related to cancer progression, metastasis, and metabolism. Mechanistically, OTUD7B likely promotes GC metastasis through the WNT signaling pathway, specifically targeting β-catenin. ConclusionsOTUD7B serves as a novel marker for poor prognosis in GC and actively promotes tumor metastasis. Our results shed light on the signaling pathways regulated by OTUD7B and highlight potential targets for therapeutic intervention.

Early ward discharge clinic: facilitating discharges and prompt follow-up for medical inpatients in a district general hospital

Early discharge and follow-up for medical admissions could facilitate reduced length of stay and improve patient satisfaction. However, evidence to confirm this is lacking. Peterborough City Hospital (PCH) designed an...

Microwave ablation: a technical and clinical comparison to other thermal ablation modalities to treat benign and malignant thyroid nodules.

Microwave ablation (MWA) is a novel modality for thermal ablation (TA) to treat benign and malignant thyroid nodules, mostly papillary thyroid cancer (PTC). Compared to surgery, TA is less invasive and less painful, has faster recovery, better cosmetic outcomes, and fewer complications. TA techniques have been evolving over the past decade to be more energy efficient, precise, and produce long-lasting results. The general approach is similar between various TA techniques. However, each technique has uniqueness in its energy delivery and, thus, risk profile and outcomes. MWA has a few critical technical differences that make it safer for patients with surgical implants and cardiac comorbidities. It has proven effective in treating benign thyroid nodules (BTNs) in adults and pediatric populations with benign and malignant lesions. The clinical and theoretical outcomes of MWA compared to other thermal ablative techniques, such as radiofrequency ablation (RFA) and laser ablation (LA), have been investigated in some studies and meta-analyses. Minimally invasive procedures such as MWA are an important tool for the management of thyroid lesions. Thus, it is crucial for clinicians to be equipped with the knowledge to use these tools. In this review, we provide a clinical review detailing the technical differences and clinical outcomes for the three major TA techniques-MWA, RFA, and LA.

Lower gastrointestinal signs and symptoms: assessment, investigations, diagnosis and management strategies

This clinical review focuses on the most common presentations of lower gastrointestinal (GI) signs and symptoms, exploring their prevalence, aetiology, clinical presentation, and the importance of thorough history-taking and examination. In addition, it discusses the investigations and management plans. This paper builds upon existing studies that focused on the presentations of upper GI signs, symptoms and management plans.

What are the mechanisms of effect of group antenatal care? A systematic realist review and synthesis of the literature

BackgroundThere is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model.MethodsWe conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention-Mechanism-Outcome (CIMO) configurations.ResultsA wide range of sources were identified, yielding 100 relevant sources in total (89 written and 11 audiovisual). Overall, there was no clear pattern of ‘what works for whom, in what circumstances’ although some studies have identified clinical benefits for those with more vulnerability or who are typically underserved by standard care. Findings revealed six interlinking mechanisms, including: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further, relatively under-developed theory related to impact on professional practice. An overarching mechanism of empowerment featured across most studies but there was variation in how this was collectively or individually conceptualised and applied.ConclusionsMechanisms of effect are amplified in contexts where inequalities in access and delivery of care exist, but poor reporting of populations and contexts limited fuller exploration. We recommend future studies provide detailed descriptions of the population groups involved and that they give full consideration to theoretical underpinnings and contextual factors.RegistrationThe protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768).

Lumen-apposing metal stents and their emerging role in therapeutic endoscopic ultrasound

The field of therapeutic endoscopic ultrasound (EUS) has expanded significantly in the past 2 decades, thanks in part to the invention and wide use of lumen-apposing metal stents (LAMS). LAMS are used as alternatives to surgical or interventional radiological procedures, and yield excellent outcomes. Initially, their use was limited to management of various types of pancreatic fluid collections, including walled-off necrosis or pseudocysts. In recent years, the indications have expanded to biliary drainage, particularly in cases of malignant bile duct obstruction. LAMS are also used in gastric outlet obstruction and to access bile duct in patients with surgically altered anatomy. This clinical review aims to briefly expand on these indications and discuss the supporting literature for use of LAMS.

Evaluating the Efficacy of Bacteriophage Therapy against Multidrug-Resistant Klebsiella pneumoniae Infections

Multidrug-resistant (MDR) Klebsiella pneumoniae poses a significant challenge to conventional antibiotic treatments. This study aims to assess the efficacy of bacteriophage therapy against MDR Klebsiella pneumoniae through a combination of in vitro assays, animal model experiments, and clinical case reviews. Phages isolated from environmental samples demonstrated potent lytic activity against MDR strains. In vitro assays showed that phages significantly reduced bacterial counts at a multiplicity of infection (MOI) of 1 or higher. Animal model experiments revealed that phage therapy, particularly using a cocktail of multiple phages, markedly improved survival rates and reduced bacterial loads in infected tissues compared to saline controls and standard antibiotics. Clinical case reviews indicated that patients receiving phage therapy experienced high rates of bacterial clearance and clinical improvement. These findings support the potential of bacteriophage therapy as an effective alternative or adjunct to traditional antibiotics in managing MDR Klebsiella pneumoniae infections.

Measuring Self-Care: A Description of the Family of Disease-Specific and Generic Instruments Based on the Theory of Self-Care of Chronic Illness.

In recent years, there has been an exponential increase in attention paid to the patient-reported outcome of self-care. Many investigators have used one of the families of self-care instruments freely available on the website www.self-care-measures.com. These self-care measures have been translated into many languages, which are also available on the website. The measures include both disease-specific and generic instruments, which are based on a common theoretical framework, the Middle Range Theory of Self-Care of Chronic Illness. The purpose of this article is to illustrate similarities among the instruments and to standardize their scoring, analysis, and use. We describe the Self-Care of Heart Failure Index, the Self-Care of Coronary Heart Disease Inventory, the Self-Care of Hypertension Inventory, the Self-Care of Diabetes Inventory, the Self-Care of Chronic Obstructive Pulmonary Disease Inventory, the Self-Care of Chronic Illness Inventory, and the Self-Care Inventory. Detailed guidance on scoring, translation, and analysis is provided. Complementary measures of self-care self-efficacy and those used to measure caregiver contributions to patient self-care are briefly described. Many of the common questions of instrument users are answered in this article. Following this guidance will facilitate consistent use of the instruments, which will enable users to compare their results to those of others worldwide and facilitate future reviews and meta-analyses.Clinical ImplicationsThis review, emphasizing standard scoring and interpretation, is useful for clinicians and researchers across various populations and settings.

Evidence for the Use of Opioid Medication for Pediatric Acute Pain in the Outpatient Setting: Technical Report.

This technical report summarizes the results of a systematic review designed to support the American Academy of Pediatrics' "Clinical Practice Guideline: Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings." PubMed and Excerpta Medica Database were searched from 2010 to 2023 to identify randomized clinical trials and systematic reviews related to outpatient opioid prescribing to children. Overall, 11 randomized controlled trials were included. Although data were limited, no evidence was found that pain control by opioids is superior to nonopioid alternatives. Further, opioids are often associated with adverse events. The review also suggests that family and patient education and providing disposal methods may decrease risks associated with opioid prescription. Future studies can build on this foundation of evidence to support the appropriate use of opioids for acute pain in children treated in the outpatient setting.

Talking about diseases; developing a model of patient and public-prioritised disease phenotypes.

Deep phenotyping describes the use of standardised terminologies to create comprehensive phenotypic descriptions of biomedical phenomena. These characterisations facilitate secondary analysis, evidence synthesis, and practitioner awareness, thereby guiding patient care. The vast majority of this knowledge is derived from sources that describe an academic understanding of disease, including academic literature and experimental databases. Previous work indicates a gulf between the priorities, perspectives, and perceptions held by different healthcare stakeholders. Using social media data, we develop a phenotype model that represents a public perspective on disease and compare this with a model derived from a combination of existing academic phenotype databases. We identified 52,198 positive disease-phenotype associations from social media across 311 diseases. We further identified 24,618 novel phenotype associations not shared by the biomedical and literature-derived phenotype model across 304 diseases, of which we considered 14,531 significant. Manifestations of disease affecting quality of life, and concerning endocrine, digestive, and reproductive diseases were over-represented in the social media phenotype model. An expert clinical review found that social media-derived associations were considered similarly well-established to those derived from literature, and were seen significantly more in patient clinical encounters. The phenotype model recovered from social media presents a significantly different perspective than existing resources derived from biomedical databases and literature, providing a large number of associations novel to the latter dataset. We propose that the integration and interrogation of these public perspectives on the disease can inform clinical awareness, improve secondary analysis, and bridge understanding and priorities across healthcare stakeholders.

Role of Ultrasound and Magnetic Resonance Elastography in Evaluation of Hepatic Fibrosis in Patients with Viral Hepatitis B And C : A Clinical Review

Role of Ultrasound and Magnetic Resonance Elastography in Evaluation of Hepatic Fibrosis in Patients with Viral Hepatitis B And C : A Clinical Review

Optimising Emergency Care for Older Adults: A Case Study of the EDITH Service Following a Proximal Humerus Fracture

Abstract Background The Emergency Department in the Home (EDITH) service offers emergency Occupational Therapy and medical assessments to older adults at home, thus negating the need for hospital attendances. Mr X, an 86-year-old with vascular dementia and hypertension, sustained a left proximal humerus fracture from a fall. Following assessment in the ED, Mr X was deemed fit for discharge and was referred to EDITH for an acute functional assessment and clinical review. Methods Within 72 hours of discharge, Mr X was visited at home by an Occupational Therapist (OT) and an Advanced Nurse Practitioner (ANP). The OT conducted a home environment assessment, falls-risk screening, delirium screening, reviewed social supports, and performed a functional assessment. Education on one-handed dressing techniques and falls prevention was provided. The ANP conducted a clinical review, and reviewed Mr X’s medication and analgesia. Mr X had the support of his wife to assist with Activities of Daily Living (ADLs), functional mobility and medication management. Mr X’s son purchased assistive equipment recommended by the OT, to enhance home safety. Referrals were made to the local memory support service, a Physiotherapist, and his Public Health Nurse to organise formal care supports. Results Mr X remained at home with support from his wife, primary care services, and virtual EDITH follow-up. Mr X had a scheduled review at the fracture clinic following his ED attendance. Conclusion Emergency care practitioners play a crucial role in addressing acute functional and clinical changes in older adults attending the ED. Supported ED discharges and service integration during the acute phase can prevent hospital admissions. Collaboration between emergency medicine and primary care is essential for addressing acute medical needs and long-term functional outcomes. With adequate social support and timely services, older adults can recover successfully at home.

The Use Of Simulation To Develop, Test And Implement A Multidisciplinary Team Care Pathway Bundle For Inpatients With Parkinson’s Disease

Abstract Background Hospitalised PD patients experience poorer outcomes. Model-2 hospitals lack onsite subspecialty neurology services whilst frequently managing PD inpatients. Aiming to enhance care of PD inpatients our multidisciplinary team (MDT) utilise simulation to design and deliver a new PD care pathway bundle. Methods The developed care bundle aims to facilitate i) screening for causes of PD deterioration, ii) identification of time sensitive and contraindicated medications and iii) prioritisation of timely MDT referral within the first 24 hours of admission. Using simulation of the NPO PD patient, usability of the bundle was tested through correct medication conversion (via Parkinsons calculator) and MDT clinical review for NG tube insertion with patient inclusion. Results Simulation delivery and structured debrief thereafter, further enhanced development and improvement of the simulation. It reinforced how the care bundle initiated early MDT referral and highlighted the pros/cons of MDT discussion with and without the patient. Once deemed satisfactory by all team members, ward-based simulation facilitated staff education and awareness of the new tool. Conclusion Simulation in the test and clinical environment facilitated implementation of a new MDT care pathway bundle at hospital level. Evaluation of effectiveness of the new care pathway require future audits and additional simulation campaigns.