Patient Refusal Research Articles

PENGETAHUAN PERAWAT TENTANG CARING BEHAVIOR DI PUSKESMAS TIGARUNGGU KABUPATEN SIMALUNGUN TAHUN 2021

Caring is a moral attitude in nursing practice, the caring nature of nurses when dealing with sick people. The nurse must show that the nurse cares about the patient's condition. Caring is a fundamental concept of nursing that will describe a caring behavior person. Caring behavior is a way or behavior of nurses to patients, do not be indifferent to patients, do not discriminate against patients, both in terms of age, economy, culture, and religion. In general, caring behavior is a habit that nurses do when providing nursing care to patients. The purpose of the study was to determine the knowledge of nurses about caring behavior at Tigarunggu Health Center, Simalungun Regency in 2021. This study used a qualitative method where data collection was carried out by interviewing as many as 5 questions to be able to dig deeper into a knowledge of caring behavior. The sampling technique used a total sampling of 8 respondents. The data analysis technique used is thematic analysis. The results obtained: caring is a sense of caring for the patient and the patient's family, providing good nursing care, approaching, and being able to feel the pain experienced by the patient. Caring behavior is a habit that nurses do when providing nursing care to patients. How to provide caring behavior in nursing practice by getting closer to the patient, touching the patient, asking what is sick, and applying the 3S, namely smile, greet, and touch. The benefit of caring behavior is that the patient will feel satisfied with the treatment so that the patient feels the pain has reduced. The obstacles faced when practicing caring behavior are when the nurse is friendly, caring, has tried her best to the patient, but the patient refuses or is indifferent to the nurse.

Reasons for refusal of repeated prosthetics on implants according to the results of a patient survey

The main purpose of this study was to analyze the reasons for refusal of repeated prosthetics on implants of patients with removed implants. The analysis of the causes of such failures was carried out in 118 patients with removed implants with a period of 5—20 years of previous use of prostheses on implants. For 46 patients with repeated prosthetics were shown covered dentures on implants, 14 — fixed dentures with complete absence of teeth, 58 — fixed dentures with partial absence of teeth. To analyze the reasons for refusal of prosthetics on implants, a questionnaire of 16 questions was developed and used.
 As a result of the study, it was found that the main rea sons for the refusal of patients from re-implantation are the insufficient period of functioning of prostheses on implants due to the development of chronic inflammation around the implants, the high cost of prosthetics on implants and insufficient good health, constraining the decision on surgical interventions and complex prosthetics are a problem.
 Significant factors for refusing implantation were also noted: the duration of the prosthetics process on implants, the reluctance of additional bone-plastic surgery, insufficient esthetics of fixed prostheses on implants.
 More than half of the refusals from implantation in the complete absence of teeth are due to the impossibility of non-removable prosthetics.

Assessing the incidence of complications and malignancies in the long-term management of benign biliary strictures with a percutaneous transhepatic drain.

Percutaneous drainage catheters (PDCs) are required for the management of benign biliary strictures refractory to first-line endoscopic treatment. While biliary patency after PDC placement exceeds 75%, long-term catheterization is occasionally necessary. In this article, we assess the outcomes of patients at our institution who required long-term PDC placement.A single-institution retrospective analysis was performed on patients who required a PDC for 10 years or longer for the management of a benign biliary stricture. The primary outcome was uncomplicated drain management without infection or complication. Drain replacement was performed every 4 to 12 weeks as an outpatient procedure.Nine patients (three males and six females; age range of 48–96 years) required a long-term PDC; eight patients required the long-term PDC for an anastomotic stricture and one for iatrogenic bile duct stenosis. A long-term PDC was required for residual stenosis or patient refusal. Drain placement ranged from 157 to 408 months. In seven patients, intrahepatic stones developed, while in one patient each, intrahepatic cholangiocarcinoma or hepatocellular carcinoma occurred.Long-term PDC has a high rate of complications; therefore, to avoid the need for using long-term placement, careful observation or early surgical interventions are required.

More than treatment refusal: a National Cancer Database analysis of adjuvant treatment refusal and racial survival disparities among women with endometrial cancer

Disparities in adjuvant treatment between Black and White women with endometrial cancer exist and contribute to worse outcomes among Black women. However, factors leading to disparate treatment receipt are understudied. We examined whether patient refusal of adjuvant treatment (chemotherapy or radiation) differed between Black and White women and whether treatment refusal mediated racial disparities in survival among women with endometrial cancer. We used the National Cancer Database, a hospital-based cancer registry, to identify non-Hispanic Black and non-Hispanic White women diagnosed with endometrial cancer from 2004 to 2016 who either received or refused recommended radiation or chemotherapy. We used logistic regression to estimate multivariable-adjusted odds ratios and 95% confidence intervals for associations between race and treatment refusal. We also examined predictors of treatment refusal in race-specific models. Accelerated failure time models were used to estimate absolute differences in overall survival by race. We used causal mediation analysis to estimate the proportion of racial differences in overall survival attributable to racial differences in adjuvant treatment refusal. We considered the overall study population and strata defined by histology, and adjusted for sociodemographic, tumor, and facility characteristics. Our analysis included 75,447 endometrial cancer patients recommended to receive radiation and 60,187 endometrial cancer patients recommended to receive chemotherapy, among which 6.4% and 11.4% refused treatment, respectively. Among Black women recommended for radiation or chemotherapy, 6.4% and 9.6% refused, respectively. Among White women recommended for radiation or chemotherapy, 6.4% and 11.8% refused, respectively. After adjusting for sociodemographic variables, facility characteristics, and tumor characteristics, Black women were more likely to refuse chemotherapy than White women (adjusted odds ratio, 1.26; 95% confidence interval, 1.15-1.37), but no difference in radiation refusal was observed (adjusted odds ratio, 1.00; 95% confidence interval, 0.91-1.11). Some predictors of radiation refusal varied by race, namely income, education, histology, stage, and chemotherapy receipt (P interactions<.05), whereas predictors of chemotherapy refusal were generally similar between Black and White women. Among women recommended for radiation, Black women survived an average of 4.3 years shorter than White women, which did not seem attributable to differences in radiation refusal. Among women recommended for chemotherapy, Black women survived an average of 3.2 years shorter than White women of which 1.9 months (4.9%) could potentially be attributed to differences in chemotherapy refusal. We observed differences in chemotherapy refusal by race, and those differences may be responsible for up to about 2 months of the overall 3.2-year survival disparity between White and Black women. Radiation refusal did not explain any of the 4.3-year disparity among women recommended for radiation. Treatment refusal accounts for, at most, a small fraction of the total racial disparity in endometrial cancer survival. Although a better understanding of the reasons for patient treatment refusal and subsequent intervention may help improve outcomes for some women, other causes of disparate outcomes, particularly those reflecting the social determinants of health, must be investigated.

Challenges Facing Undergraduate Medical Education in Ambulatory Care Clinics at Tertiary Care Hospitals.

Background: Medical education has been rapidly growing and transforming due to the enormous evolution of medicine. There have been many proficient ways to learn in medicine, but academic lectures, attending wards, and ambulatory care clinics (ACC) remain the three main ways of gaining clinical knowledge and experience for medical students. Over the past decade, there has been a dramatic shift in care by focusing on ambulatory care rather than inpatient settings, which provides a golden opportunity to reinforce medical education. Purpose: Most of the published studies that have focused on the teaching barriers in ACC were descriptive rather than analytic studies. Herein, we aim to detect and determine the barriers to teaching in ACC settings using qualitative analysis. Methods: This is a cross-sectional, observational study, involving medical students in their clerkship years (i.e., fourth and fifth) from two different medical colleges in Riyadh, Saudi Arabia. Faculty who are involved in undergraduate medical education in both colleges were also included. Main Results: A total of 387 medical students studying at the two universities were enrolled in the study. Most of the participants preferred attending outpatient clinics with consultants (44.2%) and the majority preferred attending internal medicine (IM) and IM subspecialties clinics (40.4%). Regarding the challenges, students believe the top three barriers are related to: faculty (39%), environment (34.8%), and patients (14.8%). Faculty on the other hand see that the top three barriers are related to environment (55.6%), patients (24.4%), and faculty (20%). Conclusion: Undergraduate medical education in outpatient settings has many challenges. In our study, the most significant challenges were COVID-19-related restrictions, patient refusal, and insufficient time for teaching. Future studies are needed to investigate these barriers and explore potential solutions that can decrease their burden on undergraduate medical education.

Prospective Study on Prophylactic Micafungin Sodium against Invasive Fungal Disease during Neutropenia in Pediatric & Adolescent Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation.

Background: Invasive fungal diseases (IFDs) increase the mortality rate of patients with neutropenia who receive chemotherapy or have previously undergone hematopoietic stem cell transplantation (HSCT). Micafungin is a broad-spectrum echinocandin with minimal toxicity and low drug interactions. We therefore investigated the efficacy and safety of prophylactic micafungin in pediatric and adolescent patients who underwent autologous HSCT. Methods: This was a phase II, prospective, single-center, open-label, and single-arm study. From November 2011 to February 2017, 125 patients were screened from Seoul National University Children’s Hospital, Korea, and 112 were enrolled. Micafungin was administered intravenously at a dose of 1 mg/kg/day (maximum 50 mg/day) from day 8 of autologous HSCT until neutrophil engraftment. Treatment success was defined as the absence of proven, probable, or possible IFD up to 4 weeks after therapy. Results: The study protocol was achieved without premature interruption in 110 patients (98.2%). The reasons interrupting micafungin treatment included early death (n = 1) and patient refusal (n = 1). Treatment success was achieved in 109 patients (99.1%). Only one patient was diagnosed with probable IFD. No patients were diagnosed with possible or proven IFD. In the full analysis set, 21 patients (18.8%) experienced 22 adverse events (AEs); however, all AEs were classified as “unlikely” related to micafungin. No patient experienced grade IV AEs nor discontinued treatment, and none of the deaths were related to micafungin. Conclusions: Our study demonstrated that micafungin is a safe and effective option for antifungal prophylaxis in pediatric patients who underwent autologous HSCT, with promising efficacy without significant AEs.

What Leads to a Patient Refusal for Ambulatory Surgery? A Logistic Regression Prediction Model Based on a 5-year Retrospective Analysis of Patients with Abdominal Wall Hernia.

Ambulatory surgery has proven benefits in patient wellbeing and cost reduction in healthcare systems. However, some patients referred for ambulatory surgery are refused and directed instead towards inpatient care, which generates several drawbacks. The reasons for this refusal have not been yet studied. The aim of this study is to identify, retrospectively, significant variables associated with patient refusal for ambulatory surgery and develop a mathematical tool able to predict with strong accuracy those who will be rejected. Over a 5-year period (2014 - 2018), all patients that underwent abdominal hernia repair in our hospital in an inpatient setting, and that had been previously refused for ambulatory surgery, were analysed for a total of 94 variables. A multivariate logistic regression model was developed to identify risk factors associated with refusal using data from 136 patients (65 refused vs 71 accepted). A prediction index for refusal in ambulatory surgery - IRAS - was derived and tested (n = 62 patients). The risk index included five significant risk factors: type 2 diabetes mellitus [OR 14.669 (2.982; 72.154)], physical status [OR 49.155 (15.532; 155.555)], prior malignancy [OR 14.518 (2.653; 79.441)], prior abdominal surgery [OR 3.455 (1.006; 11.866)] and usage of antiplatelet agents [OR 25.600 (4.309; 152.066)]. All risk factors were associated with a high risk of refusal (OR between 3.455 for history of prior abdominal surgery and 49.155 according to the American Society of Anaesthesiologists physical status classification). Defining five points as the maximum IRAS score that predicts suitability for ambulatory surgery resulted in a positive predictive value of 93.55% and negative predictive value of 87.10%. Significant patient variables for refusal of an ambulatory procedure were determined and an easy to use risk index - IRAS - was built that is able to predict with good accuracy which patients will be refused. IRAS is a useful tool that can contribute to reduce time to surgery and improve patients' quality of life.

EP507: Patients’ reasons for genetic testing refusal in cancer evaluations: An analysis of the literature and opportunities to educate

eP507: Patients’ reasons for genetic testing refusal in cancer evaluations: An analysis of the literature and opportunities to educate

Prevalence, Clinical Implication, and Cause of Spine Hip Discordance in Elderly Patients with Fragility Hip Fracture.

BackgroundSpine-hip discordance (SHD) increases fracture risk. However, its prevalence and clinical implications have not been investigated in patients with hip fractures. This study determined the prevalence and association of SHD with mortality and investigated the cause of SHD in patients with hip fractures.MethodsThis study included patients admitted for fragility hip fractures between 2011 and 2020. All patients underwent dual energy X-ray absorptiometry and anteroposterior and lateral views of the lumbosacral spine during admission. Data on demographics, diagnosis, American Society of Anesthesiologists score, and mortality were collected. A T-score difference of more than 1.5 between L1–4 and the femur neck was considered discordant, and 3 groups (lumbar low [LL] discordance, no discordance [ND], and femur neck low [FL] discordance) were compared. In the discordance group, lumbar radiographs were reviewed to determine the cause of discordance.ResultsAmong 1,220 eligible patients, 130 were excluded due to patient refusal or bilateral hip implantation; therefore, this study included 1,090 patients (271 male and 819 female). The prevalence of LL, ND, and FL was 4.4%, 66.4% and 29.2% in men and 3.9%, 76.1%, and 20.0% women. Mortality was not associated with discordance. The most common causes of discordance were physiological in the LL group and pathological in the FL group for both sexes.ConclusionsPatients with hip fractures showed lower rates of ND and higher rates of FL compared to the general population. True discordance should be carefully judged for pathological and artifact reasons. The clinical implications of SHD require further investigation.

Understanding “Patient refuses” among 90+ year old patients with cancer or presumed cancer

ObjectivesPatients who are 90+ years of age are a growing – but understudied – group at risk for cancer. Because many of these patients are undertreated (with no tissue/cytologic diagnosis), we sought to better understand how such decisions are arrived upon. MethodsThis study focused on patients between 2007 and 2017. None had received cancer therapy. Medical records were reviewed for quotations relevant to decision-making and analyzed qualitatively. ResultsNinety-four patients (median age 93 years) with a cancer diagnosis/presumed diagnosis were identified; most were women (82%) with an average of six co-morbidities (dementia occurred in approximately one-third). The primary qualitative theme was a keen appreciation on the part of all stakeholders of the gravity of the decision to forgo a cancer work-up/therapy, with four subthemes: 1) substantial, detailed medical information about the patient's medical condition (“600 mL of yellow, hazy fluid with an LDH [lactate dehydrogenase] level greater than 450 …”); 2) complex discussions about the risks and benefits of no biopsy and/or no cancer treatment (“[the patient] would not prefer to have the quality of any remaining time ruined with salvage chemo and radiation”); 3) the inclusion of multiple individuals in decision-making (“I had a lengthy discussion with the patient and her daughter;” “I spoke by phone with one of my pathology colleagues”); and 4) patient-voiced decision-making (“I want to die.”). ConclusionHealthcare providers appear to understand the seriousness of no cancer-directed therapy and no work-up in patients 90 years of age and older. Neither ageism nor nihilism was observed.

Comparison Between Analgesic Effect of Dexamethasone and Dexmedetomidine as an Adjuvant to Bupivacaine for Spinal Anaesthesia for Elective Caesarean Sections

Background Caesarean sections are usually performed under spinal anaesthesia. It provides effective postoperative pain control over a limited period of time. As a result, various intrathecal additives have been used. Recently, dexamethasone and dexmedetomidine have been used as adjuncts for different types of regional anaesthesia without increasing the risk of neurological complications. Objectives: We compared the analgesic effects of intrathecal dexamethasone and dexmedetomidine in elective caesarean sections. Design: A single-blind randomized trial. Setting: Benha University Hospital, between February 2021 and July 2021. Patients: We randomly enrolled 633 pregnant women in this study. Only 580 patients met all the inclusion and exclusion criteria. The inclusion criteria were age of 18 to 40 years old, an ASA class ІІ - III, gestational age &gt; 37 weeks, BMI less than 30 kg/m2 who were electively scheduled for. The exclusion criteria included patient refusal, age &lt; 18 or &gt; 40 years, known allergy to medications used in the study, BMI more than 30 kg/m2, coagulopathies or anticoagulant use, cerebrovascular insufficiency, neuromuscular diseases and diabetic neuropathy. Intervention: The dexmedetomidine group (A) received 10 μg of dexmedetomidine with 12.5 mg hyperbaric bupivacaine 0.5%intrathecally(n=290). The dexamethasone group (B) received 4 mg of dexamethasone with 12.5 mg hyperbaric bupivacaine 0.5%intrathecally(n=290). Main outcome: The time to initial analgesic rescue (pethidine 0.5 mg/kg) and the duration of motor blockage were assessed. Results: The time to the first rescue analgesia and motor blockade were significantly higher in the dexmedetomidine group. (418 min vs 190 min), P&lt;0.001, (324 min vs 144 min), P &lt;0.001 respectively. Conclusion: According to this study, both drugs could be safely added to bupivacaine intrathecally. Dexmedetomidine provides significantly longer postoperative analgesia and motor blockade times than dexamethasone. Further dose-response studies are needed to determine the optimum dosage of dexamethasone and dexmedetomidine and the safety of the intrathecal route.

Totally Excited about Moving Mobility and Exercise (TEAM Me): A Successful Multidisciplinary Exercise Quality Improvement Initiative for Pediatric and Young Adult Oncology and Stem Cell Transplant Inpatients.

Background: Pediatric, adolescent and young adult (PAYA) patients are less active than their healthy counterparts, particularly during inpatient stays. Methods: We conducted a quality improvement initiative to increase activity levels in patients admitted to our pediatric oncology and cellular therapy unit using a Plan-Do-Study-Act (PDSA) model. An interdisciplinary team was assembled to develop an incentive-based inpatient exercise and activity program titled Totally Excited About Moving Mobility and Exercise (TEAM Me). As part of the program, patients were encouraged by their care team to remain active during their inpatient stay. As an additional incentive, patients earned stickers to display on TEAM Me door boards along with tickets that could be exchanged for prizes. Activity was assessed by documentation of physical therapy participation, tests of physical function, and surveys of staff perceptions of patient activity levels, motivations, and barriers. Results: Compared to baseline, patient refusals to participate in physical therapy decreased significantly (24% vs. 2%) (p < 0.02), and staff perceptions of patient motivation to stay active increased from 40% to 70% in the post implementation period. There were no changes in physical function tests. Conclusions: An incentive-based exercise program for young oncology inpatients greatly improved patient activity levels, participation in physical therapy and influenced professional caregivers’ beliefs.

Abstract WP46: Patterns Of Emergency Medical Transport For Suspected Acute Stroke, Acute Myocardial Infarction, And Other Diagnoses During The Covid-19 Pandemic: A Retrospective Analysis Of A Large Hospital-based Emergency Medical Services (EMS) Agency

Introduction: During the initial peak of the COVID-19 pandemic, many centers globally reported a significant decrease in volumes of emergencies including acute stroke (AS) and acute myocardial infarction (AMI). While the reason for this remains unknown, pandemic-driven anxiety among patients may have resulted in unwarranted refusals to transport when deemed necessary by EMS (Emergency Medical Services) providers. We sought to study the impact of COVID-19 pandemic on the patterns of Emergency Medical transport (EMTr) and patient refusals to transport when serious medical conditions were suspected by EMS personnel. Methods: In this retrospective, observational study of Grady Health System’s EMS, we compared the rates of EMTr and refusals for adult patients with suspected diagnoses of AS, AMI, and other medical conditions in the first year of the pandemic (Y1, Mar 2020-Feb 2021) with the corresponding period in the year prior (Y0). We also compared the temporal trends for these variables across the different pandemic waves (1 st , Mar-May 2020; 2 nd , Jun-Aug 2020; 3 rd , Sep 2020-Feb 2021) with the corresponding periods in the year before. Results: Grady EMS responded to 207,888 calls in Y1 compared to 201,968 in Y0. The overall rate of refusals for all diagnoses was 15.5% in Y1 vs 14.1% in Y0, that for AS was 2.25% in Y1 vs 1.77% in Y0 and 7.5% in Y1 vs 5.67% in Y0 for AMI (Figure). Conclusion: There were more refusals in the first two waves of the pandemic. While refusals were higher for AS and AMI, this was not statistically significant. Our study provides valuable insight into the behavioral patterns of patients seeking emergency care during the pandemic and emphasizes a need for public education and more research.

Clinical feasibility of curative surgery after nab-paclitaxel plus gemcitabine-cisplatin chemotherapy in patients with locally advanced cholangiocarcinoma.

387 Background: In a recent phase II trial, nab-paclitaxel plus gemcitabine-cisplatin (Gem/Cis/nab-P) demonstrated prolonged survival and unprecedentedly high response rate in patients with advanced cholangiocarcinoma following treatment. We aimed to evaluate the clinical feasibility of this triplet chemotherapy as induction chemotherapy in patients with locally advanced cholangiocarcinoma. Methods: We retrospectively reviewed patients with locally advanced cholangiocarcinoma who were treated with Gem/Cis/nab-P between October 2019 to December 2020. Resectability after induction chemotherapy was evaluated by a multidisciplinary team. Treatment response and surgical pathology were reviewed. Results: Of the 85 patients were included in this study. 46 (54.1%) had measurable lesions. The objective response rate (ORR) and disease control rate in patients with measurable disease were 51.1% and 85.1%, respectively. Fifty-two (61.2%) patients were determined as resectable. Four patients that were judged to be resectable did not undergo surgery due to patient refusal or poor performance status after chemotherapy. Finally, 48 out of 85 patients (56.5%) underwent subsequent curative surgery after induction chemotherapy. There were six complete remission cases (12.5%) in the final pathology, which all reported patients with extrahepatic cholangiocarcinoma. R0 resection was achieved in 46 out of the 48 patients (95.8%). Despite the initial locally advanced cholangiocarcinoma, a pathologic T stage of less than T2 was reported in 44 (95.7%) patients. Lymph node metastasis was confirmed in 13 (27.1%) patients. The overall survival rates in patients who had chemotherapy followed by surgery was better than in those treated with chemotherapy alone ( P = 0.009). Conclusions: Gem/Cis/nab-P as induction chemotherapy showed promising efficacy and clinical feasibility before curative surgery in patients with locally advanced cholangiocarcinoma. This study showed that triplet chemotherapy using Gem/Cis/nab-P has a clear down-staging effect through a high response rate in patients with cholangiocarcinoma

Factors Associated With Patient's Refusal of Recommended Cancer Surgery: Based on Surveillance, Epidemiology, and End Results

ObjectivesMost non-metastatic cancer patients can harvest a preferable survival after surgical treatment, however, patients sometimes refuse the recommended cancer-directed surgery. It is necessary to uncover the factors associated with patent's decision in taking cancer surgery and explore racial/ethnic disparities in surgery refusal.MethodsBased on the Surveillance, Epidemiology and End Results (SEER)-18 program, we extracted data of non-metastatic cancer patients who didn't undergo surgery. Ten common solid cancers were selected. Four racial/ethnic categories were included: White, black, Hispanic, and Asian/Pacific Islander (API). Primary outcome was patient's refusal of surgery. Multivariable logistic regression models were used, with reported odds ratio (OR) and 95% confidence interval (CI).ResultsAmong 318,318 patients, the incidence of surgery refusal was 3.5%. Advanced age, female patients, earlier cancer stage, uninsured/Medicaid and unmarried patients were significantly associated with higher odds of surgery refusal. Black and API patients were more likely to refuse recommended surgery than white patients in overall cancer (black-white: adjusted OR, 1.18; 95% CI, 1.11–1.26; API-white: adjusted OR, 1.56; 95% CI, 1.41–1.72); those racial/ethnic disparities narrowed down after additionally adjusting for insurance type and marital status. In subgroup analysis, API-white disparities in surgery refusal widely existed in prostate, lung/bronchus, liver, and stomach cancers.ConclusionsPatient's socioeconomic conditions reflected by insurance type and marital status may play a key role in racial/ethnic disparities in surgery refusal. Oncological surgeons should fully consider the barriers behind patient's refusal of recommended surgery, thus promoting patient-doctor shared decision-making and guiding patients to the most appropriate therapy.

Development, Implementation, and Evaluation of an Early Mobility Protocol in a Regional Level II Trauma Center.

The purpose of this project was to develop and evaluate a collaborative nursing/therapist protocol for early mobility in a medical-surgical intensive care unit (MICU) in a regional level II trauma center. Data for patients in the MICU were compared for the periods August 3, 2015-August 2, 2016, and August 3, 2014-August 2, 2015. Semistructured interviews were conducted with 10 nurses and 1 therapist. Average MICU length of stay decreased from 3.81 to 3.50 days (P = .057). Mean time in mobility chairs did not change (0.12 days vs 0.11 days, P = .389). Mean number of days to first documented level 2-5 activity decreased significantly, from 1.81 to 1.51 days (P = .036). The percentage of hospitalizations with any documented level 3 or 4 activity increased significantly (from 3.8% to 7.4% and from 61.5% to 66.7%, P = .003 and P = .031, respectively). Barriers/challenges to implementation included having enough people to assist, space, documentation, having to coax the physician to place order for upright mobility, availability of therapists for later stages of protocol, patient variability, fear of patient falls, availability of therapy chairs, staff changes, time, and patient refusal. A multidisciplinary approach to protocol development for early mobility in an intensive care unit was successfully implemented at a regional level II trauma center.

Nirmatrelvir/Ritonavir Prescription Rate and Outcomes in Coronavirus Disease 2019: A Single Center Study.

Nirmatrelvir/ritonavir was Korea's first oral antiviral agent to treat coronavirus disease 2019 (COVID-19). We analyzed the nirmatrelvir/ritonavir prescription rate and treatment outcomes in treatment-eligible patients with COVID-19 receiving home-based care. We retrospectively collected data of patients with COVID-19-eligible for nirmatrelvir/ritonavir treatment from January 14, 2022, to February 15, 2022. We analyzed the prescription rate of nirmatrelvir/ritonavir, the reasons for non-prescription, and patient outcomes. A total of 414 patients were included, of whom 44.2% were male, and the mean age was 64.6 (standard deviation [SD] = 8.5). Approximately 73.2% (n = 303) of patients were not prescribed nirmatrelvir/ritonavir. More than fourth-fifths of the patients refused nirmatrelvir/ritonavir treatment (n = 262, 86.5%). The mean symptom duration was significantly shorter in the prescription group (5.2 days [SD = 2.3] vs. 4.4 days [SD = 1.9], P = 0.001). A total of 6 (1.4%) patients were hospitalized, and none of the patients who received nirmatrelvir/ritonavir required admission. Among the patients prescribed nirmatrelvir/ritonavir (n = 111), 17 (15.3%) patients experienced side effects, and 5 (4.5%) patients discontinued nirmatrelvir/ritonavir due to side effects. The nirmatrelvir/ritonavir prescription rate was low, with more than fourth-fifths of non-prescriptions being due to patient refusal. Symptom resolution was faster, and no life-threatening side effects were reported. Accurate information about drug safety must be provided to patients to make informed decisions regarding nirmatrelvir/ritonavir treatment.

Screening for participants in the ISCHEMIA trial: Implications for clinical research.

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) found that there was no statistical difference in cardiovascular events with an initial invasive strategy as compared with an initial conservative strategy of guideline-directed medical therapy for patients with moderate to severe ischemia on noninvasive testing. In this study, we describe the reasons that potentially eligible patients who were screened for participation in the ISCHEMIA trial did not advance to enrollment, the step prior to randomization. Of those who preliminarily met clinical inclusion criteria on screening logs submitted during the enrollment period, over half did not participate due to physician or patient refusal, a potentially modifiable barrier. This analysis highlights the importance of physician equipoise when advising patients about participation in randomized controlled trials.

Further Imaging for Suspected Isolated Greater Trochanteric Fractures: Multiplanar Reformation Computed Tomography or Magnetic Resonance Imaging.

BackgroundMost isolated greater trochanter (IGT) fractures are treated conservatively. However, some require surgical fixation although indications for surgery have not yet been established. Many surgeons perform surgical fixation when the intertrochanteric extension crosses the midline on magnetic resonance (MR) images. Nevertheless, for mechanical strength, cortical bone integrity is more important than that of intramedullary cancellous trabeculae. We retrospectively evaluated the clinical usefulness of multiplanar reformation computed tomography (MPR CT) in determining treatment strategies for IGT fractures.MethodsWe evaluated 99 cases of suspected IGT fractures between October 2004 and December 2019. They were 66 women and 33 men with a mean age of 77 years. The mean follow-up period was 34 months. Most patients were evaluated with plain radiographs, followed by additional imaging study via MPR CT in 65 cases, magnetic resonance imaging (MRI) in 5 cases, and both in 17 cases. Typically, fractures were fixed surgically when a cortical breakage was detected in the intertrochanteric area on MPR CT, while fractures without evidence of cortical breakage on MPR CT were treated conservatively.ResultsIn 13 out of 82 cases evaluated by MPR CT, incomplete cortical breakage in the intertrochanteric area was detected, of which 10 were treated surgically. The remaining 3 cases were treated conservatively due to patient’s refusal, poor medical condition, and failure to detect breakage. Of 69 cases without cortical breakage, 61 cases were successfully treated conservatively. Among the 17 cases evaluated by both MPR CT and MRI, cortical breakage was detected in 3, of which the intertrochanteric extension crossed the midline on the MR image only in 1 case. Of the remaining 14 cases without breakage, the intertrochanteric extension crossed the midline in 5. Among these 5 cases, 3 were treated conservatively.ConclusionsThe results suggest that MPR CT is a useful imaging modality for further evaluation of IGT fractures. It was especially valuable in evaluating cortical bone integrity, which may be more critical for fracture stability.

Traumatic cervical spine spondyloptosis: A systematic review.

Background:Spondyloptosis is a rare presentation of cervical spine traumatism where listhesis is more than 100%. Traumatic cervical spine spondyloptosis (TCS) is one of the least discussed forms of cervical spine traumatisms because of its rarity and the gravity of patient's condition, limiting good management, and the number of reported cases.Objectives:This study aimed to discuss clinical, radiological, and best management tools of the aforementioned pathology.Materials and Methods:Scopus, ScienceDirect, PubMed, and Google Scholar databases were searched for English articles about traumatic cervical spondyloptosis. Titles, abstracts, or author-specified keywords that contain the words “spondyloptosis” AND “cervical” AND “spine” were identified. There were no time limits. In sum, 542 records were identified, 63 records were screened, and 46 records were included in this review, describing 64 clinical cases of traumatic cervical spondyloptosis. The clinical cases of two patients managed at our department are also presented and included. In the end, 66 cases were included in this study. Demographics, clinics, radiology, management tools, and outcome of the reviewed cases were discussed. This study was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2009. The American Spinal Injury Association Impairment Scale (AIS) score was used to evaluate the clinical presentations.Results:This review included 66 patients consisting of 46 males (70%) and 20 females (30%), with a mean age of 41 years. The accident was indicated in 62 cases; it was a road traffic accident in 29 cases (46%), a fall in 24 cases (38%), and motor vehicle accident in 15 cases (24%). The lesion was iatrogenic in four patients. Twenty-one patients were received without motor or sensitive deficit and so scored Grade E on AIS, 10 with Grade D, 11 Grade C, four Grade B, and 20 with Grade A. On imaging, spondyloptosis involved the C1–C2 segment in two cases (3%), C2–C3 in three cases (5.5%), C3–C4 in one case (1.5%), C4–C5 in six cases (9%), C5–C6 in nine cases (13%), C6–C7 in 20 cases (30%), and C7–T1 in 26 cases (38%). In all cases, there was either fracture or dislocation in posterior elements. Bilateral pedicles or facet joint fractures were noted in 53% of the 56 patients where the associated lesions were described, but it jumps to 89% when a vertebra is projected in front of another. In two cases, there was no mention of closed reduction via transcranial traction; in 13 cases (20%), it was avoided for a reason (child, patient's refusal,…). In the 51 cases where the traction was clearly applied, 17 cases (33%) were reduced totally; in 13 cases (25%) the reduction was partial; it failed in 19 cases (37%); and in the remaining cases, the result was not clear. Traction weight varied from 4 kg to 27.2 kg, applied from 6 h to 20 days. Where total reduction was achieved, an average weight of 11.9 kg with proximal average time of 6 days was needed, whereas an average of 11.5 kg was needed for partial reduction with proximal average time of 10 days. 62 patients were operated rather in one or two times. Anterior approach was used in 20 patients (32%), a posterior approach in 14 patients (23%), and combined anterior/posterior approaches in 28 patients (45%). In four patients, the outcome was not available; in the remaining 62 cases, an improvement of an initial deficit was noted in 25 patients (40%), conservation of an initial motor force integrity was noted in 19 patients (30%), and nine patients (14.5%) kept the same initial deficit. Few complications were declared: dura tears with cerebrospinal fluid leaks, meningitis, esophageal laceration, and vocal cord paralysis. There was a mortality of 11% (seven cases).Conclusion:Traumatic cervical spine spondyloptosis predominates in the lowest levels of the cervical spine, allowed in all cases by a failure in posterior elements. It is a lesion with the worst clinical presentation. Traumatic cervical spine spondyloptosis is highly instable, imposing urgent reduction followed by surgical stabilization. At the limit of the reviewed cases, outcome is in general good, but mortality is still important.