Implementation Of Standardized Protocol Research Articles

The response of yield, number of clusters, and cluster weight to meteorological factors and irrigation practices in grapevines: A multi-experiment study

Knowledge of the yield components of wine grapevines is essential to achieve target production and effectively design vineyard management. Therefore, it is necessary to map and analyze the factors that control the yield components to optimize wine production and profitability. The objective of this study was to identify the ranked effects of environmental and agrotechnical factors (e.g., meteorological, physiological, vegetative, and irrigation) on grapevine yield, number of clusters, and cluster weight, and to quantify their patterns. To achieve this objective, a multi-experiment database was used, assembling data collected during four long-term irrigation experiments including different varieties and diverse climatic regions across Israel. First, a paired analysis of the yield components was conducted to define the relationships among them. Then, prediction models for the three variables (i.e., yield components) were designed using the support vector machine (SVM) algorithm to explore the ranked effects and patterns of the controlling factors. Validation was conducted using a test set, consisting of 20% of the dataset. The relationships between yield and cluster weight (0 < r < 0.73) and between yield and the number of clusters were always positive (0.67 < r < 0.77), while negative relationships were found between cluster weight and number of clusters (-0.61 < r < 0). The accuracy of the prediction models was high, with mean absolute errors (normalized to the range) ranging between 4.1%-8.11%. The most dominant factors affecting yield components were cumulative leaf area index, accumulated growing degree days (GDD), cumulative irrigation, and evapotranspiration. Leaf area showed an optimum point, below and above which the values of the yield components decrease; GDD negatively affected yield and cluster weight but had a positive effect on the number of clusters; irrigation was positively associated with yield components but leveled out above 348-395 mm per season. Reference evapotranspiration had a negative effect on yield and cluster weight, and a generally positive effect on the number of clusters. Utilizing data from multiple experiments and applying multivariate analysis, allow to define general patterns of relationships and interactions between controlling factors and yield components. Extracting this knowledge from the data and managing the growing amounts of information can be achieved through complex modeling and the implementation of standard protocols for data collection and monitoring.

Do Uro-Oncology Day Care Procedures Need to Be Differed during COVID-19 Pandemic?-An Experience from Tertiary Cancer Care Center.

Mahendra PalBackground The SARS-CoV-2 virus pandemic has affected millions all over the world in very short span and changed the way how health care system work across the globe. It is essential to continue cancer treatment in spite of such pandemics. Various recommendations were proposed for cancer management based on risk stratification, however, in urological malignancies, day care procedures (DCPs) are a part of complete spectrum of cancer care and standard operating procedures (SOPs) for day care procedures (DCPs)in oncology is lacking at present. Materials and Methods This is an institutional review board approved retrospective observational analytical study performed in tertiary cancer care center, with aim to assess the impact of COVID-19 on Uro-oncology day care procedures (U-DCPs)in terms of changes in appointments and actual U-DCPs performed, demographic changes such as sex ratio and age wise attendance in pre and post lockdown period and to provide a SOPs to accomplishU-DCPsefficiently in pandemics. Results There was 67.89% and 68.16% reduction in total numbers of appointment and performed U-DCPs. A statistically significant difference was found in cystoscopy, intravesicalinstallation and miscellaneous UDCPs. Overall, 4.45% reduction and 4.52% increase in male and female patients underwent UDCPs respectively, M:F ratio reduced from 3.58:1 to 2.79:1 and 30% to 50% reduction in overall patient statistics in post lockdown compare to pre lockdown procedures. For various age groups there was a statistically significant change in the number for males underwent cystoscopy in (p<0.001), Intravesical therapies (p<0.001) and miscellaneous procedures(p< 0.004). Conclusion We are now coming up to the fact that effective management of healthcare system during pandemics require establishment and effective implementation of standard protocols. Routine major urological surgical care is continued using a tiered standard of protocols (SOPs) and adequate precautions. This study may provide an insight into impact of COVID-19 on UDCPs and what precautions and strategies can be institutionalized so that the patients and the health care workers remain protected from contracting infection while in performing DCPs during pandemic or similar circumstances.

Practices of Physical Therapist Regarding Chest Physiotherapy for Patients Undergoing Open Heart Surgery in Karachi

Background: Despite the critical role of chest physiotherapy in the recovery process post open-heart surgery, there is a paucity of data on the practices of physical therapists in Karachi. With the high incidence of cardiovascular surgeries and the significant burden of postoperative complications, understanding current physiotherapy practices is essential for improving patient outcomes. Objective: The objective of this study was to evaluate the current practices of physical therapists regarding chest physiotherapy for patients undergoing open-heart surgery in Karachi and to identify potential areas for standardization and improvement. Methods: A cross-sectional study was conducted using a questionnaire survey among 40 physiotherapists working in cardiothoracic units across six major hospitals in Karachi. Participants were selected through non-probability convenient sampling, and data on preoperative and postoperative physiotherapy practices were collected. The survey included both open-ended and close-ended questions, with an emphasis on the types of treatments administered during the first five postoperative days. Statistical analysis was performed using SPSS version 25. Results: The mean age of the physiotherapists was 31.20 (SD = 6.8) years with an average working experience of 7.592 (SD = 6.7) years. On the day of surgery, physiotherapy was provided routinely by 7.5%, as needed by 62.5%, and was never provided by 30% of the respondents. From the first to the fifth postoperative day, routine physiotherapy was administered by an increasing majority, peaking at 100% on the second day. Written guidelines for the management of extubated and intubated patients were accessible to 35% and 10% of participants, respectively. Conclusion: There is a substantial engagement in chest physiotherapy post open-heart surgery among physiotherapists in Karachi. However, the variability in practice and the lack of standardized guidelines point towards a need for the development and implementation of standardized protocols to ensure consistent and evidence-based care.

Increasing access to quality care for pregnant and postpartum people with opioid use disorder: Coordination of services, provider awareness and training, extended postpartum coverage, and perinatal quality collaboratives

IntroductionFifteen states participating in the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community (OMNI LC) developed action plan goals and activities to address the rise in opioid use disorder (OUD) among birthing persons. In a separate initiative, Perinatal Quality Collaboratives (PQCs) from 12 states participating in Centers for Disease Control and Prevention (CDC)-supported activities hosted trainings to improve the provision of OUD services and implement protocols for screening and treatment in delivery facilities. MethodsThis descriptive study synthesizes qualitative data extracted from 15 OMNI LC state action plans, excerpts from qualitative interviews conducted with OMNI LC state teams, and quantitative data from quarterly project performance monitoring reports from 12 CDC-funded PQCs implementing quality improvement activities to address clinical service gaps for pregnant and postpartum people with OUD. Qualitative data were deidentified, coded as barriers or facilitators, then aggregated into emergent themes. Count data are presented for quantitative results. ResultsThe OMNI LC states identified a lack of coordinated care among providers, stigma toward people with OUD, discontinued insurance coverage, and inconsistencies in screening and treating birthing people with OUD as barriers to accessing quality care. State-identified facilitators for access to quality care included: 1) improving engagement and communication between providers and other partners to integrate medical and behavioral health services post-discharge, and facilitate improved patient care postpartum; 2) training providers to prescribe medications for OUD, and to address bias and reduce patient stigma; 3) extending Medicaid coverage up to one year postpartum to increase access to and continuity of services; and 4) implementing screening, brief intervention, and referral to treatment (SBIRT) in clinical practice. PQCs demonstrated that increased provider trainings to treat OUD, improvements in implementation of standardized protocols, and use of evidence-based tools can facilitate access to and coordination of services in delivery facilities. ConclusionState-identified facilitators for increasing access to care include coordinating integrated services, extending postpartum coverage, and provider trainings to improve screening and treatment. PQCs provide a platform for identifying emerging areas for quality improvement initiatives and implementing clinical best practices to provide comprehensive, quality perinatal care for birthing populations.

Exploring Perfusion Safety: A Review of Clinical and Non-Clinical Factors with Emphasis on Quality Improvement

This literature review examines perfusion safety in cardiothoracic surgery, with a primary focus on cardiopulmonary bypass (CPB) and circulatory devices. PRISMA guidelines were followed and various databases, including PubMed, MEDLINE, and Google Scholar, were searched using relevant keywords to identify pertinent studies and literature on the subject. The review traces the historical development of perfusion techniques and underscores the importance of equipment factors, personnel considerations, and perfusion management strategies in ensuring patient safety during CPB and circulatory device usage. Clinical aspects of perfusion safety, encompassing equipment safety features, temperature management, anticoagulation, and blood conservation, are discussed. Non-clinical aspects, including the implementation of standardized protocols, robust training structures, positive team dynamics, and the fostering of a safety-oriented culture, are also examined. Quality improvement initiatives for blood conservation, monitoring, and incident reporting are explored, along with an acknowledgment of the significant contributions of major perfusion societies and boards (AmSECT, SCPS, EBCP) in establishing standards and promoting excellence in the field. Challenges related to device design, patient selection, and perioperative management are addressed, highlighting the need for standardized practices and ongoing research to enhance perfusion safety. This comprehensive review underscores the enduring commitment to advancing perfusion safety and quality through systematic research, education, and collaborative efforts in cardiothoracic surgery.

Does a dedicated "Scoliosis Team" and surgical standardization improve outcomes in adolescent idiopathic scoliosis surgery and is it reproducible?

The objective of this study was to determine if standardization improves adolescent idiopathic scoliosis (AIS) surgery outcomes and whether it is transferrable between institutions. A retrospective review was conducted of AIS patients operated between 2009 and 2021 at two institutions (IA and IB). Each institution consisted of a non-standardized (NST) and standardized group (ST). In 2015, surgeons changed institutions (IA- > IB). Reproducibility was determined between institutions. Median and interquartile ranges (IQR), Kruskal-Wallis, and χ2 tests were used. 500 consecutive AIS patients were included. Age (p = 0.06), body mass index (p = 0.74), preoperative Cobb angle (p = 0.53), and levels fused (p = 0.94) were similar between institutions. IA-ST and IB-ST had lower blood loss (p < 0.001) and shorter surgical time (p < 0.001). IB-ST had significantly shorter hospital stay (p < 0.001) and transfusion rate (p = 0.007) than IB-NST. Standardized protocols in IB-ST reduced costs by 18.7%, significantly lowering hospital costs from $74,794.05 in IB-NST to $60,778.60 for IB-ST (p < 0.001). Annual analysis of surgical time revealed while implementation of standardized protocols decreased operative time within IA, when surgeons transitioned to IB, and upon standardization, IB operative time values decreased once again, and continued to decrease annually. Additions to standardized protocol in IB temporarily affected the operative time, before stabilizing. Surgeon-led standardized AIS approach and streamlined surgical steps improve outcomes and efficiency, is transferrable between institutions, and adjusts to additional protocol changes.

Help! Caring for People With Mental Health Problems in the Emergency Department: A Qualitative Study

IntroductionAfter coronavirus disease 2019, there has been an increase in patients in the emergency department with mental health conditions. They are usually received by professionals who are not specialized in mental health. This study aimed to describe nursing staff's experiences in the emergency department, in the care they provide to people with mental health problems who often feel stigmatized by society and also in health care settings. MethodsThis is a descriptive qualitative study with a phenomenological approach. The participants were nurses from the Spanish Health Service from the emergency department of the Community of Madrid hospitals. Recruitment was performed by convenience sampling snowball sampling until data satruation was met. Data were collected through semistructured interviews conducted during January and February 2022. ResultsThe exhaustive and detailed analysis of the nurses’ interviews made it possible to extract 3 main categories—health care, psychiatric patient, and work environment—with 10 subcategories. DiscussionThe main study findings were the need to train emergency nurses to be prepared to care for people who experience mental health concerns including bias education and the need for implementation of standardized protocols. Emergency nurses never doubted their ability to care for people experiencing mental health disorders. Still, they recognized that they needed specialized professionals’ support at certain critical moments.

Screening for VACTERL Anomalies in Children with Anorectal Malformations: Outcomes of a Standardized Approach

PurposeThe majority of patients with an anorectal malformation (ARM) have associated congenital anomalies. It is well established that all patients diagnosed with an ARM should undergo systematic screening, including renal, spinal, and cardiac imaging. This study aimed to evaluate the findings and completeness of screening, following local implementation of standardized protocols. MethodsA retrospective cohort study was performed assessing all patients with an ARM managed at our tertiary pediatric surgical center, following a standardized protocol implementation for VACTERL screening (January 2016–December 2021). Cohort demographics, medical characteristics, and screening investigations were analyzed. Findings were compared with our previously published data (2000–2015), conducted prior to protocol implementation. ResultsOne hundred twenty-seven (64 male, 50.4%) children were eligible for inclusion. Complete screening was performed in 107/127 (84.3%) children. Of these, one or more associated anomalies were diagnosed in 85/107 (79.4%), whilst the VACTERL association was demonstrated in 57/107 (53.3%). The proportion of children that underwent complete screening increased significantly in comparison with those assessed prior to protocol implementation (RR 0.43 [CI 0.27–0.66]; p < 0.001). Children with less complex ARM types were significantly less likely to receive complete screening (p = 0.028). Neither presence of an associated anomaly, nor prevalence of the VACTERL association, differed significantly by ARM type complexity. ConclusionScreening for associated VACTERL anomalies in children with ARM was significantly improved following standardized protocol implementation. The prevalence of associated anomalies in our cohort supports the value of routine VACTERL screening in all children with ARM, regardless of malformation type. Level of EvidenceII.

Abstract TP74: Reducing Complications From Gastrostomy Tube Insertion In Stroke Patients - Quality Improvement Project At An Academic Tertiary Hospital

Introduction: Percutaneous gastrostomy tubes are frequently required for patients with strokes due to dysphagia, malnutrition, and intestinal dysmotility. Though generally well tolerated, delayed detection of complications following percutaneous gastrostomy tube insertion (including dislodgement, infection and bleeding) can lead to increased morbidity and mortality. Methods: At a single academic tertiary hospital, a standardized protocol was instituted (September 2021) to enhance early detection and prevention of feeding tube complications on the neurology service, consisting predominantly of stroke patients. The protocol comprised of: 1) consistent documentation of feeding tube insertion by proceduralists, 2) universal abdominal binder application, 3) nursing driven delirium screening, 4) post procedural nursing assessment for high-risk feeding tube site changes, and 5) an escalation algorithm to address early complications. We compared rates of complications pre- (July 2020 - August 2021, 13 months) and post- (September 2021 - June 2022, 10 months) protocol implementation. Results: A total of 103 gastrostomy tube insertions were reviewed (64 pre and 39 post protocol implementation). Overall complication rates decreased from 12.5% (N = 8 of 64; 3 dislodgements, 3 infections, 2 insertion site bleeding) to 2.5% (N = 1 of 39; 1 dislodgment) following the intervention. Mortality from complications decreased from 1.6% to 0%. Conclusion: Complication rates of percutaneous gastrostomy tube placement may be reduced through implementation of standardized protocols on inpatient stroke patients. Further studies are warranted to assess its long-term effects and viability in other specialty services.

SARS-CoV-2: Challenges in Reconverting Diagnostic Laboratories to Combat the Pandemic.

Coronavirus disease 2019 (COVID-19) was first detected in Mexico in February 2020. Even though health authorities did not perceive then the value of viral detection tests, we anticipated the demand for them. We set up to develop an expeditious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) molecular diagnostic service through the implementation of standardized protocols for biospecimen sampling, transportation, biobanking, preanalytical validation, and nucleic acids (NA) testing (NAT). Nasopharyngeal and oropharyngeal swabs collected in a special transportation medium were the biospecimens from which NAs were purified either manually or automatically. Viral RNA genome presence was determined using commercial SARS-CoV-2 detection kits (based on reverse transcription coupled with real-time PCR [RT-PCR]). Improvements in laboratory processing speed and reliability resulted from semi-automatizing laboratory processes and adopting a quality control/quality assurance system (QC/QA), respectively. NAs that were purified, either manually or automatically, were validated by preanalytical spectrophotometric characterization. Automated purification was less prone to contamination and reduced the processing time. The following six RT-PCR kits were evaluated for their convenience, specificity, sensitivity, time consumption, and required materials (in order, starting with the kit with the best results): RIDA gene and Viasure (tied), Vircell, LightMix, 1copy, and Logix Smart. Redesigning the laboratories' working areas, equipment, fluxes of personnel and material, and personnel skills, and overemphasizing biosafety safeguards were major challenges encountered in the middle of the sanitary crisis. Adopting a QC/QA system, utilizing automatization processes, and working closely with health authorities were key factors in our success. IMPORTANCE Rearranging our diagnostic laboratories to improve the fight against a new unexpected, unpredictable, and sudden public health threat demanded that we move quickly to redesign not only the laboratory processes but also the distribution of space, personnel activities, and fluxes of material coming in and out. We also had to work closely with governmental health authorities to gain their trust in our technical competence. Gaining the confidence of the clients, i.e., mainly individuals, the human resource departments of factories and corporations sending employees for testing, and medical institutions, and implementing as much automatization as possible of processes, in which only officially approved reagents (for extraction and analysis of NA) were used to generate opportune trustable testing results, were key factors. Our laboratories have gathered a considerable amount of experience and significant number of solutions, considering our geographic contexts alongside this continuously morphing pandemic, validating many techniques that might help other laboratories find a better and more precise workflow.

Epidemiology of chronic inducible urticaria in Moscow

BACKGROUND: Chronic inducible urticaria is a group of diseases that is characterized by the development of wheals, angioedema, or both in response to specific triggers for 6 weeks. According to global scientific international literature, the occurrence of chronic inducible urticaria is 0.5% in the general population and approximately 20%30% in all chronic urticarias. The prevalence of chronic inducible urticaria has no statistical data in the Russian Federation.&#x0D; AIM: This study aimed to evaluate the region-specific epidemiology of different forms of chronic inducible urticaria.&#x0D; MATERIALS AND METHODS: The analysis is based on the number of unique cases extracted from the medical care records in the adults segment of the digital platform United medical information and analytical system (UMIAS) (outpatient forms) in Moscow from 2017 to 2021, including keyword search.&#x0D; RESULTS: This study indicated that the prevalence of chronic inducible urticaria in Moscow is correlated with published global epidemiological data. Among patients with chronic inducible urticarial, females predominate (74.2%), and the median age was 43.8 years (37 years in males and 46.4 in females). The most common form in all verified cases of chronic inducible urticaria is symptomatic dermographism (11.12%), followed by contact urticaria (5.36%), cholinergic urticaria (2.28%), cold urticaria (1.92%), delayed pressure urticaria (0.36%), vibratory urticaria (0.11%), aquagenic urticaria (0.1%), and heat urticaria (0.08%). Chronic inducible urticaria rates in Moscow are high, which increase as in global practice. This research has limitations, including the lack of ubiquitous implementation of standard protocols of provocation testing in outpatient units and the low percentage of using validated questionnaires in the routine management of patients with chronic inducible urticaria.&#x0D; CONCLUSIONS: Further studies dedicated to this topic are greatly necessary to answer a wide spectrum of questions, including the diagnosis process and evaluation of the severity of chronic inducible urticaria, comorbid conditions, and optimization of the treatment protocols adapted for the particular phenotype.

Implications of Three-Dimensional Cell Culture in Cancer Therapeutic Research.

Replicating the naturalistic biomechanical milieu of cells is a primary requisite to uncover the fundamental life processes. The native milieu is significantly not replicated in the two-dimensional (2D) cell cultures. Alternatively, the current three-dimensional (3D) culture techniques can replicate the properties of extracellular matrix (ECM), though the recreation of the original microenvironment is challenging. The organization of cells in a 3D manner contributes to better insight about the tumorigenesis mechanism of the in vitro cancer models. Gene expression studies are susceptible to alterations in their microenvironment. Physiological interactions among neighboring cells also contribute to gene expression, which is highly replicable with minor modifications in 3D cultures. 3D cell culture provides a useful platform for identifying the biological characteristics of tumor cells, particularly in the drug sensitivity area of translational medicine. It promises to be a bridge between traditional 2D culture and animal experiments and is of great importance for further research in tumor biology. The new imaging technology and the implementation of standard protocols can address the barriers interfering with the live cell observation in a natural 3D physiological environment.

Changes in Emergency Department Practice of Adolescent Abnormal Uterine Bleeding after Implementation of an Institutional Clinical Guideline: A Retrospective Review

Background: Abnormal uterine bleeding (AUB) is a common adolescent gynecologic complaint, yet there is limited research for best management practices. A evidence-based clinical guideline was published in 2015 for abnormal uterine bleeding at Dell Children's Emergency Department (ED) to assist in clinical decision-making, with a stepwise lab and exam assessment and treatment decision tree. Studies have shown improved provider confidence and management plans after implementation of standardized protocols.

758 Constant evolution: Early experiences treating COVID-19 in a burn center

IntroductionThe COVID-19 pandemic came as an unexpected challenge to many healthcare systems around the world. Many centers struggled to provide COVID-19 ICU-level care while also maintaining adequate care for non-COVID-19-related conditions, especially in critical care specialty units like trauma and burn. We present a case series of our early experiences treating COVID-19 in a burn center.MethodsWe present a case.ResultsSee Table 1. Though one case was admitted prior to initiation of universal testing, routine infection-control protocols limited exposure to personnel and prevented transmission to staff. In May 2020, we implemented the use of N95 mask and eye protection during all aerosolizing procedures, N95 mask use in all ORs, and universal surgical mask use in all rooms regardless of COVID-19 status. An in-house risk-stratification system was used to screen patients based on symptoms and exposure. Burn-center admissions were screened at a lower threshold than throughout the institution given the unique nature of burn injury. Eventually, because of increasing community spread, all admissions to the hospital were universally screened with RT-PCR prior to admission. To minimize exposure to non-COVID patients and Burn Center staff, COVID-19 positive burn admissions were assessed on a case-by-case basis. High acuity patients were admitted to the Burn Center and followed by the COVID consult team. Lower acuity patients were admitted to the Burn Center but were treated on the medical COVID unit and followed by the burn consult service.ConclusionsThe COVID 19 pandemic has strained healthcare systems worldwide. Development and implementation of universal screening, testing, infection-control precautions, and triage strategies are critical elements of burn care during the COVID-19 pandemic. As we prepare for future surges due to more transmissible variants, implementation of standard protocols enables continued provision of quality care, preservation of the healthcare workforce, and efficient use of resources.

Current Perspectives on the Diagnosis and Management of Healthcare-Associated Ventriculitis and Meningitis.

Ventriculitis or post-neurosurgical meningitis or healthcare-associated ventriculitis and meningitis (VM) is a severe infection that complicates central nervous system operations or is related to the use of neurosurgical devices or drainage catheters. It can further deteriorate patients who have already presented significant neurologic injury and is associated with high morbidity, mortality, and poor functional outcome. VM can be difficult to distinguish from aseptic meningitis, inflammation that follows hemorrhagic strokes and neurosurgical operations. The associated microorganisms can be either skin flora or nosocomial pathogens, most commonly, Gram-negative bacteria. Classical microbiology can fail to isolate the culprit pathogen. Novel cerebrospinal fluid (CSF) biomarkers and molecular microbiology can fill the diagnostic gap and expedite pathogen identification and treatment. The pathogens may demonstrate significant resistant patterns and their antibiotic treatment can be difficult, as many important drug classes, including the beta-lactams and the glycopeptides, hardly penetrate to the CSF, and do not achieve therapeutic levels at the site of the infection. Treatment modifications, such as higher daily dose and prolonged or continuous administration, might increase antibiotic levels in the site of infection and facilitate pathogens clearance. However, in the case of therapeutic failure or infection due to difficult-to-treat bacteria, the direct antibiotic instillation into the CSF, in addition to the intravenous antibiotic delivery, may help in the resolution of infection. However, intraventricular antibiotic therapy may result in aseptic meningitis and seizures, concerning the administration of aminoglycosides, polymyxins, and vancomycin. Meanwhile, bacteria form biofilms on the catheter or the device that should routinely be removed. Novel neurosurgical treatment modalities comprise endoscopic evacuation of debris and irrigation of the ventricles. VM prevention includes perioperative antibiotics, antimicrobial impregnated catheters, and the implementation of standardized protocols, regarding catheter insertion and manipulation.

Changes in postoperative inpatient and outpatient opioid utilization after pharmacist‐led order set standardization and education for total knee and hip replacement at an academic medical center

AbstractIntroductionOpioid analgesics are often overprescribed after orthopedic procedures. Several strategies have been implemented nationally to curb opioid overprescription with modest success. At an institutional level, one novel idea is to implement surgery‐specific guidelines limiting opioid quantities prescribed postoperatively.ObjectivesThe primary objective of this study was to evaluate the effect of our institution's new standardized postoperative multimodal pain regimen guidance on cumulative opioid prescribed postoperatively at discharge, as measured in morphine equivalent dose (MED).MethodsAdults (≥18 years old) who underwent total knee or total hip replacement from August 2019 through March 2020 were eligible. Patients not prescribed opioids at discharge, incarcerated, or had postoperative stays 7 or more days were excluded. A pharmacist‐led standardized protocol was implemented on 21 November 2020, and provider education was completed on 18 December 2021. Patients were assigned to historical (August 2019 to November2019) or standardized (December 2019 to March 2020) cohorts based on discharge date. Secondary outcomes are cumulative and per‐prescription opioid pills, morphine equivalent daily dose (MEDD) prescribed at discharge, inpatient opioid, diazepam, and gabapentin utilization, and outpatient post‐op opioid and pain outcomes.ResultsForty patients preintervention and 52 patients postintervention were included. For postoperative discharge opioids prescribed, median cumulative MED decreased 46% (560.0 vs 300.0, P &lt; .001), quantity of pills decreased 14.3% (70 vs 60, P = .03), and MEDD decreased 16.7% (60.0 vs 50.0, P &lt; .001). Inpatient opioid exposure decreased 49% (38.1 vs 19.4, P &lt; .001), concurrent diazepam (20.0% vs 1.9%, P = .009), and gabapentin (85.0% vs 13.5%, P &lt; .001) use with opioids also decreased. Postoperative pain scores did not significantly differ (4.0 vs 5.0, P = .63).ConclusionPharmacist‐led standardized protocol implementation resulted in reduced postoperative opioid prescription and exposure, and decreased concurrent use of high‐risk drugs without affecting pain control. Opportunities exist to further decrease opioid prescribing by matching inpatient requirements.

Postoperative delirium and neurocognitive disorders.

Postoperative neurocognitive disorders (NCD) are significant causes of morbidity and mortality. In this paper, we will review our understanding and potential management of postoperative NCD. Postoperative delirium, delayed neurocognitive recovery and postoperative cognitive dysfunction (POCD) are recognized as a part of the continuous spectrum of postoperative NCD. Although the pathophysiology is still poorly understood, there is renewed focus on improving neurocognitive outcomes of aging surgical population. Novel methods of neurocognitive screening are developed and research in the prevention and management of NCD has gained traction. A spectrum of NCD exists in surgical patients ranging from postoperative delirium, delayed neurocognitive recovery, and POCD. Identification of patients at-risk for developing NCD can help target appropriate perioperative intervention. Also, specialized care teams and the implementation of standardized protocols are crucial for the successful management perioperative NCD. Finally, large, randomized, multicenter studies are needed to confirm benefits of preventive and treatment strategies.

Assessing sensitivity and reproducibility of RT-ddPCR and RT-qPCR for the quantification of SARS-CoV-2 in wastewater

Throughout the COVID-19 global pandemic there has been significant interest and investment in using Wastewater-Based Epidemiology (WBE) for surveillance of viral pathogen presence and infections at the community level. There has been a push for widescale implementation of standardized protocols to quantify viral loads in a range of wastewater systems. To address concerns regarding sensitivity, limits of quantification, and large-scale reproducibility, a comparison of two similar workflows using RT-qPCR and RT-ddPCR was conducted. Sixty raw wastewater influent samples were acquired from nine distinct wastewater treatment plants (WWTP’s) served by the Hampton Roads Sanitation District (HRSD, Virginia Beach, Virginia) over a 6-month period beginning March 9th, 2020. Common reagents, controls, master mixes and nucleic acid extracts were shared between two individual processing groups based out of HRSD and the UNC Chapel Hill Institute of Marine Sciences (IMS, Morehead City, North Carolina). Samples were analyzed in parallel using One-Step RT-qPCR and One-Step RT-ddPCR with Nucleocapsid Protein 2 (N2) specific primers and probe. Influent SARS-CoV-2 N2 concentrations steadily increased over time spanning a range from non-detectable to 2.13E + 05 copies/L. Systematic dilution of the extracts indicated that inhibitory components in the wastewater matrices did not significantly impede the detection of a positive N2 signal for either workflow. The RT-ddPCR workflow had a greater analytical sensitivity with a lower Limit of Detection (LOD) at 0.066 copies/μl of template compared to RT-qPCR with a calculated LOD of 12.0 copies/μL of template. Interlaboratory comparisons using non-parametric correlation analysis demonstrated that there was a strong, significant, positive correlation between split extracts when employing RT-ddPCR for analysis with a ρ value of 0.86.

Safety of Endoscopic Transsphenoidal Pituitary Surgery during the COVID-19 Pandemic and Comparison to the Pre-Pandemic Era.

Objective The COVID-19 pandemic has caused significant disruption to the surgical care of patients with pituitary tumors. Guidance issued early during the pandemic suggested avoiding transnasal approaches to minimize risks of transmitting COVID-19 to health care professionals involved in these procedures. Methods This observational, single-center study compares results of endoscopic transsphenoidal approach (TSA) for pituitary tumors since the start of the pandemic to a pre-pandemic period. Anesthetic time, surgical time, and complication rates were compared. Newly acquired COVID-19 infections and transmission rates to patients and staff were reviewed. Data were analyzed by using the independent t -test, Mann-Whitney U test, and Pearson Chi-square test, significance set at p <0.05. Results Over a 12-month period, a total of 50 and 69 patients underwent endoscopic TSA for pituitary tumor during and before the pandemic, respectively. All patients tested negative for COVID-19 preoperatively. Median duration of anesthesia was 35 minutes (interquartile range [IQR]: 22) during the pandemic and 25 minutes (IQR: 8, p = 0.0002) pre-pandemic. Median duration of surgery was 70 minutes (IQR: 28) during the pandemic and 79 minutes (IQR: 33.75, p = 0.126) pre-pandemic. There were no statistically significant differences between intraoperative CSF leaks and complication rates. No staff members tested positive for COVID-19. Three patients tested positive for COVID-19 postdischarge, but the infections were community acquired. Conclusion In contrast to published guidelines, adequate preoperative testing, a multidisciplinary approach and the implementation of standardized protocols and vaccination against COVID-19 allow for endoscopic transsphenoidal surgery to be performed safely in patients with pituitary pathology during the pandemic.

Endocrine late-effects and bone mineral density after combined treatment of malignant brain tumors in childhood and adolescence

ОбоснованиеОбоснование. Внедрение в клиническую практику стандартизированных протоколов комбинированного лечения онкологических заболеваний неизбежно приводит к развитию отдаленных последствий. Поскольку у лиц, излеченных в детском и подростковом возрасте, ожидаемая продолжительность жизни велика, своевременная диагностика и коррекция отдаленных последствий противоопухолевого лечения имеют даже большее значение, чем острые осложнения химиолучевой терапии.ЦельЦель. Изучить распространенность эндокринных нарушений, оценить распространенность и степень снижения минеральной плотности костной ткани (МПК) у лиц, перенесших комбинированное лечение злокачественных опухолей головного мозга в детском и молодом возрасте.Материалы и методыМатериалы и методы. Проведено ретроспективное исследование с участием 59 пациентов (31 мужчина; 28 женщин), перенесших в детском и молодом возрасте оперативное лечение злокачественной опухоли головного мозга с последующей лучевой терапией в объеме краниоспинального облучения в сочетании с полихимиотерапией или без нее. I группу составили 37 пациентов, которым комбинированное лечение проводилось в возрасте от 3 до 16 лет. Во II группу были включены 22 пациента, получившие лечение в возрасте от 16 до 38 лет.РезультатыРезультаты. Недостаточность соматотропного гормона по результатам пробы с инсулиновой гипогликемией выявлена у 48 пациентов (81%), вторичная надпочечниковая недостаточность — у 22 (37%). Большая часть обследованных (33 пациента (56%)) не достигли целевого роста. Лечение рекомбинантным гормоном роста (рГР) получили только 5 человек из I группы. Проведенный корреляционный анализ показал, что возраст на момент лечения — основной фактор, влияющий на конечный рост (r=0,619; p<0,001). Выявлена высокая частота развития гипотиреоза (n=39 (66%)), гипогонадизма (19 женщин; 17 мужчин). По результатам DXA снижение МПК ≤-2,0 SD по Z-критерию в поясничном отделе позвоночника выявлено у 35 из 59 обследованных (59%). МПК у пациентов I группы была значимо ниже по сравнению с пациентами, получившими лечение в более старшем возрасте (p<0,001). Обнаружена умеренная корреляция между МПК в поясничном отделе позвоночника на момент обследования и уровнем эстрадиола в крови у женщин (r=0,596; p<0,05) и тестостерона у мужчин (r=0,472; p<0,05). Выявлена прямая зависимость МПК от возраста на момент заболевания (r=0,781; p<0,01).ЗаключениеЗаключение. Полученные результаты свидетельствуют о необходимости ежегодного и пожизненного наблюдения пациентов после комбинированного лечения злокачественных опухолей головного мозга на предмет выявления отдаленных последствий лечения. Высокая распространенность остеопенических состояний определяет актуальность и необходимость проведения ранней диагностики для предотвращения дальнейшей потери костной массы, снижения прочности кости и риска переломов.