Patient-specific Goals Research Articles

LO23: Identifying patient values and expectations for pulmonary embolism CT scanning in the emergency department

Introduction: There is an evidence-practice gap between guidelines for diagnosing pulmonary embolism (PE) and emergency physician practice. Computed tomography (CT) scanning is being overused to exclude PE in Canadian emergency departments (EDs) and current guidelines do not fit well with the ED model of patient care. There is a lack of research on patient opinions on PE testing, and a poor physician understanding of patient-specific goals in the ED. We are addressing this by conducting patient interviews to identify patient-specific values and opinions on PE testing in the ED. These will be used to develop patient-centered educational tools which physicians and patients can use to discuss the decision to order a CT PE scan. The aim of this study is to identify patient expectations and priorities on PE testing in the ED. Methods: This qualitative study uses constructivist grounded theory to analyze patient values and opinions on PE testing in ED patients from two hospitals. Participants are screened by monitoring the ED patient tracker. If a patient is being tested for PE, they are approached and consented by a researcher to take part in a 30-minute semi-structured interview. Each interview is transcribed verbatim and independently analyzed by four researchers using constant comparative coding. The researchers meet weekly to compare codes and agree on common coding terms. The codes are grouped into themes, and the interview script is modified to maximize information on emerging themes. From this, major themes with associated subthemes will be derived, each representing an opportunity, barrier or value which must be addressed in our new patient education tools. We have performed 23 interviews and expect to reach theme saturation at 30 interviews. Full results will be available by the 2019 CAEP conference. Results: From the patient interviews conducted so far, we have mapped four major themes: patient satisfaction comes from addressing their primary concern (for example, their pain); patients expect individualized care; patients prefer imaging over clinical examination when testing for PE; and patients expect 100% confidence from their ED physician when given a diagnosis. Conclusion: These four domains will be used to create a new patient-centered approach to PE testing in the ED which will include physician education, patient information and organizational changes to patient processing. This study incorporates evidence-based medicine with ethical and social implications to improve patient outcomes.

Diagnostic Yield of Customized Exercise Provocation Following Routine Testing

Clinical guidelines advocate for customization of exercise testing to address patient-specific diagnostic goals, including reproduction of presenting exertional symptoms. However, the diagnostic yield of adding customized exercise testing to graded exercise in patients presenting with exertional complaints has not been rigorously examined and is the focus of this study. Using prospectively collected data, we analyzed the diagnostic yield of customized additional exercise provocation following inconclusive graded exercise test with measurement of gas exchange. Additional testing was defined as "positive" if it revealed a clinically-actionable diagnosis related to the chief complaint or reproduced symptoms in the absence of an explanatory diagnosis or pathology. Of 1,110 patients who completed a graded test, 122 (11%) symptomatic patients underwent additional customized exercise testing (e.g., sprint intervals and race simulations). Compared with those who did not undergo additional testing, this group was younger (29 [interquartile range 19 to 45] vs 46 [25 to 58] year old) and disproportionately female (43% vs 27%). Presenting symptoms included palpitations (46%), lightheadedness/syncope (25%), chest pain (14%), dyspnea (11%), and exertional intolerance (3%). Additional testing was "positive" in 48 of 122 (39%) of patients by revealing a clinically actionable diagnosis in 26 of 48 (54%) or reproducing symptoms without an explanatory diagnosis in 22 of 48 (46%). In conclusion, while patient-centered customization of exercise testing is suggested by clinical guidelines, these data are the first to demonstrate that the selective addition of customized exercise provocation following inconclusive graded exercise testing improves the diagnostic yield of exercise assessment.

Spasticity-reducing hand surgery: Improved function, activity and patients’ satisfaction at one year follow-up

We evaluated if spasticity-reducing surgery in the upper extremity could improve motor function, fulfill patient's specific goals and influence performance of daily activities in patients with muscle overactivity. Thirty consecutive patients with spasticity due to various CNS injuries were evaluated pre- and post-surgery and followed one year by the team consisting of physician, physiotherapist and occupational therapist. Prior to surgery the patients’ clinical problem related to spasticity was defined and motor function and activity was assessed. Each patient's potential to comply with the post-surgical rehabilitation procedure was estimated and the intensity level chosen (low, moderate or high). The surgical intervention comprised lengthening of tendons, release of muscles and occasionally deformity corrections. Physiotherapy, occupational therapy, wrapping and application of orthoses started the first postoperative day. Patients were taught how to perform a home-training program. One week of intensive in-hospital rehabilitation followed 2–3 weeks after surgery and a new home-training program was designed. Subsequent follow-up visits were scheduled at 3, 6 and 12 months. General hand function (usefulness) and pain were evaluated using the VAS scale (0–10), spasticity using the Modified Ashworth Scale (0–5) and activity by COPM (mean values of performance and satisfaction). Wilcoxon signed rank test was used. At one year follow-up patients’ assessment of general hand function increased, 2.1 vs. 4.2 ( P < 0.001), pain decreased, 3.0 vs. 1.7 ( P < 0.05), and spasticity decreased, 3.5 vs. 2.1 ( P < 0.001). Both activity measures improved: performance 2.0 vs. 5.5 ( P < 0.01) and satisfaction 1.9 vs. 5.5 ( P < 0.01). In patients with disabling spasticity, hand surgery combined with comprehensive rehabilitation reduced muscle overactivity, improved hand function, reduced pain, and promoted patient ability for arm-hand activities and satisfaction in daily life at one year follow-up.

Statistical analysis of Goal Attainment Scaling endpoints in randomised trials.

Goal Attainment Scaling is an assessment instrument to evaluate interventions on the basis of individual, patient-specific goals. The attainment of these goals is mapped in a pre-specified way to attainment levels on an ordinal scale, which is common to all goals. This approach is patient-centred and allows one to integrate the outcomes of patients with very heterogeneous symptoms. The latter is of particular importance in clinical trials in rare diseases because it enables larger sample sizes by including a broader patient population. In this paper, we focus on the statistical analysis of Goal Attainment Scaling outcomes for the comparison of two treatments in randomised clinical trials. Building on a general statistical model, we investigate the properties of different hypothesis testing approaches. Additionally, we propose a latent variable approach to generate Goal Attainment Scaling data in a simulation study, to assess the impact of model parameters such as the number of goals per patient and their correlation, the choice of discretisation thresholds and the type of design (parallel group or cross-over). Based on our findings, we give recommendations for the design of clinical trials with a Goal Attainment Scaling endpoint. Furthermore, we discuss an application of Goal Attainment Scaling in a clinical trial in mastocytosis.

Cystic fibrosis-related education: Are we meeting patient and caregiver expectations?

ObjectiveThe purpose of this study was to improve patient education in clinic by evaluating patient perceptions of education provided, as well as patient self-confidence related to topics within cystic fibrosis (CF). The study assessed whether self-confidence matched knowledge and defined patient-specific goals for education timing and information sources. MethodsAge specific questionnaires were distributed over four months to patients 11 years of age and older and caregivers of patients of all ages at a single CF Foundation accredited care center. ResultsParticipants reported frequent education on all topics except for reproductive effects of CF and mental health. A positive correlation was seen between overall confidence in CF-related knowledge and performance on a validated knowledge scale in adolescent caregivers only. Participants expected all educational milestones to be met by 13–14 years of age. ConclusionsGaps in CF education remain and educational models should deliver information by the early teens without overlooking reproductive effects and mental health. Practice ImplicationsThe educational model for CF clinics should become more comprehensive by including education on topics such as mental health and reproductive effects. Providers are an important pathway for information and should not disregard the value of education provided during clinic visits.

Functional-guided radiotherapy using knowledge-based planning

Background and purposeThere are two significant challenges when implementing functional-guided radiotherapy using 4DCT-ventilation imaging: (1) lack of knowledge of realistic patient specific dosimetric goals for functional lung and (2) ensuring consistent plan quality across multiple planners. Knowledge-based planning (KBP) is positioned to address both concerns. Material and methodsA KBP model was created from 30 previously planned functional-guided lung patients. Standard organs at risk (OAR) in lung radiotherapy and a ventilation contour delineating areas of high ventilation were included. Model validation compared dose-metrics to standard OARs and functional dose-metrics from 20 independent cases that were planned with and without KBP. ResultsA significant improvement was observed for KBP optimized plans in V20Gy and mean dose to functional lung (p = 0.005 and 0.001, respectively), V20Gy and mean dose to total lung minus GTV (p = 0.002 and 0.01, respectively), and mean doses to esophagus (p = 0.005). ConclusionThe current work developed a KBP model for functional-guided radiotherapy. Modest, but statistically significant, improvements were observed in functional lung and total lung doses.

Medication management in older adults.

Managing medications is a major part of providing care to older adults. Polypharmacy is common in the elderly and is fraught with risks. A careful and systematic approach is needed for managing drug therapy in these patients, recognizing the patient's specific goals.

Complications in Patients Undergoing Spinal Fusion After THA.

Patients with lumbar spine and hip disorders may, during the course of their treatment, undergo spinal fusion and THA. There is disagreement among prior studies regarding whether patients who undergo THA and spinal fusion are at increased risk of THA dislocation and other hip-related complications. Is short or long spinal fusion associated with an increased rate of postoperative complications in patients who underwent a prior THA? A retrospective study of New York State's Department of Health database (SPARCS) was performed. SPARCS has a unique identification code for each patient, allowing investigators to track the patient across multiple admissions. The SPARCS dataset spans visit data of patients of all ages and races across urban and rural locations. The SPARCs dataset encompasses all facilities covered under New York State Article 28 and uses measures to further representative reporting of data concerning all races. Owing to the nature of the SPARCS dataset, we are unable to comment on data leakage, as there is no way to discern between a patient who does not subsequently seek care and a patient who seeks care outside New York State. ICD-9-Clinical Modification codes identified adult patients who underwent elective THA from 2009 to 2011. Patients who had subsequent spinal fusion (short: 2-3 levels, or long: ≥ 4 levels) with a diagnosis of adult idiopathic scoliosis or degenerative disc disease were identified. Forty-nine thousand nine hundred twenty patients met the inclusion criteria of the study. In our inclusion and exclusion criteria, there was no variation with respect to the distribution of sex and race across the three groups of interest. Patients who underwent a spinal procedure (short versus long fusion) had comparable age. However, patients who did not undergo a spinal procedure were older than patients who had short fusion (65 ± 12.4 years versus 63 ± 10.7 years; p < 0.001). Multivariate binary logistic regression models that controlled for age, sex, and Deyo/Charlson scores were used to investigate the association between spinal fusion and THA revisions, postoperative dislocation, contralateral THAs, and total surgical complications to the end of 2013. A total of 49,920 patients who had THAs were included in one of three groups (no subsequent spinal fusion: n = 49,209; short fusion: n = 478; long fusion: n = 233). Regression models revealed that short and long spinal fusions were associated with increased odds for hip dislocation, with associated odds ratios (ORs) of 2.2 (95% CI, 1.4-3.6; p = 0.002), and 4.4 (95% CI, 2.7-7.3; p < 0.001), respectively. Patients who underwent THA and spinal surgery also had an increased odds for THA revision, with ORs of 2.0 (95% CI, 1.4-2.8; p < 0.001) and 3.2 (95% CI, 2.1-4.8; p < 0.001) for short and long fusion, respectively. However, spinal fusions were not associated with contralateral THAs. Further, short and long spinal fusions were associated with increased surgical complication rates (OR = 2.8, 95% CI, 2.1-3.8, p < 0.001; OR = 5.3, 95% CI, 3.8-7.4, p < 0.001, respectively). We showed that spinal fusion in adults is associated with an increased frequency of complications and revisions in patients who have had a prior THA. Specifically, patients who had a long spinal fusion after THA had 340% higher odds of experiencing a hip dislocation and 220% higher odds of having to undergo a revision THA. Further research is necessary to determine whether this relationship is associated with the surgical order, or whether more patient-specific surgical goals of revision THA should be developed for patients with a spinal deformity. Level III, therapeutic study.

Postural stability and simulator sickness after walking on a treadmill in a virtual environment with a curved display

Virtual environments are a valuable rehabilitation tool that can be used to address unique patient-specific goals; however simulator sickness can cause feelings of discomfort and unwanted side effects that limit the effectiveness of treatment. The purpose of this research was to assess simulator-induced sickness (SIS) symptoms and postural stability before and after 45 min of immersion in a virtual environment with a treadmill-motion base and curved display.Thirty able-bodied Canadian Armed Forces members participated in this study. Symptoms of SIS were evaluated using the Simulator Sickness Questionnaire and postural stability was quantified using centre of pressure data during quiet stance. SIS symptoms and postural stability were evaluated three times throughout the session – at the start of the session, after 15 min, and after 45 min. Participants reported mild simulator sickness symptoms, including eyestrain, headache, difficulty focusing, and dizziness after immersion in the virtual environment, which was below the acceptable level. Postural instability was greater after 45 min in the virtual environment, but did not affect participant’s ability to successfully complete the session. The data reported in this paper provide useful baseline information of a healthy military population for clinical assessments and future studies using a virtual environment with a treadmill-motion base and large curved display.

Implementation of a Goal-Directed Mechanical Ventilation Order Set Driven by Respiratory Therapists Improves Compliance With Best Practices for Mechanical Ventilation.

Data regarding best practices for ventilator management strategies that improve outcomes in acute respiratory distress syndrome (ARDS) are readily available. However, little is known regarding processes to ensure compliance with these strategies. We developed a goal-directed mechanical ventilation order set that included physician-specified lung-protective ventilation and oxygenation goals to be implemented by respiratory therapists (RTs). We sought as a primary outcome to determine whether an RT-driven order set with predefined oxygenation and ventilation goals could be implemented and associated with improved adherence with best practice. We evaluated 1302 patients undergoing invasive mechanical ventilation (1693 separate episodes of invasive mechanical ventilation) prior to and after institution of a standardized, goal-directed mechanical ventilation order set using a controlled before-and-after study design. Patient-specific goals for oxygenation partial pressure of oxygen in arterial blood (Pao 2), ARDS Network [Net] positive end-expiratory pressure [PEEP]/fraction of inspired oxygen [Fio 2] table use) and ventilation (pH, partial pressure of carbon dioxide) were selected by prescribers and implemented by RTs. Compliance with the new mechanical ventilation order set was high: 88.2% compliance versus 3.8% before implementation of the order set ( P < .001). Adherence to the PEEP/Fio 2 table after implementation of the order set was significantly greater (86.0% after vs 82.9% before, P = .02). There was no difference in duration of mechanical ventilation, intensive care unit (ICU) length of stay, and in-hospital or ICU mortality. A standardized best practice mechanical ventilation order set can be implemented by a multidisciplinary team and is associated with improved compliance to written orders and adherence to the ARDSNet PEEP/Fio 2 table.

Description of Discordance Between LDL Cholesterol, Non-HDL Cholesterol, and LDL Particle Number Among Patients of a Lipid Clinic

Background: While LDL cholesterol measures the cholesterol content within an LDL particle (LDL-P), it may not reflect LDL-P concentrations. If discordance exists, LDL-P may better predict cardiovascular events compared to LDL-C and non-HDL cholesterol (non-HDL-C). In primary prevention patients, discordance has been associated with diabetes, ethnicity, gender, metabolic syndrome, and smoking history. &#x0D; Objective: To describe discordance in patients of a lipid clinic by exploring associations between patient characteristics and discordance among LDL-C, non-HDL-C, or LDL-P. Secondarily to compare proportion of patients with baseline concordance versus discordance who have ASCVD events, diagnoses of new onset diabetes or death.&#x0D; Methods: A retrospective, single-center cohort study at a large academic medical center was conducted. Patients establishing care from January 2009 through December 2012 with complete initial labs were included. Logistic regression models were used to explore associations between discordance and patient characteristics.&#x0D; Results: Of 603 patients screened, the final cohort included 166 patients with 104 (62.7%) discordant. LDL-P was the most common discordant value. Discordance was associated with gender, smoking status, use of lipid lowering medications, and achieving patient specific LDL-C goals. In terms of any event observed after initial measurements, no significant differences were detected between discordant and concordant groups.&#x0D; Conclusion: Within a lipid clinic population, discordance was associated with male gender, smoking status, lipid-lowering therapy, and being at patient specific LDL-C goal. While associations were found in our population, clinicians should consider measuring LDL-P to fully assess presence or extent of discordance.&#x0D; Conflict of Interest&#x0D; We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties. &#x0D; &#x0D; Type: Original Research

A method for a priori estimation of best feasible DVH for organs-at-risk: Validation for head and neck VMAT planning.

Despite improvements in optimization and automation algorithms, the quality of radiation treatment plans still varies dramatically. A tool that allows a priori estimation of the best possible sparing (Feasibility DVH, or FDVH) of an organ at risk (OAR) in high-energy photon planning may help reduce plan quality variability by deriving patient-specific OAR goals prior to optimization. Such a tool may be useful for (a) meaningfully evaluating patient-specific plan quality and (b) supplying best theoretically achievable DVH goals, thus pushing the solution toward automatic Pareto optimality. This work introduces such a tool and validates it for clinical Head and Neck (HN) datasets. To compute FDVH, first the targets are assigned uniform prescription doses, with no reference to any particular beam arrangement. A benchmark 3D dose built outside the targets is estimated using a series of energy-specific dose spread calculations reflecting observed properties of radiation distribution in media. For the patient, the calculation is performed on the heterogeneous dataset, taking into account the high- (penumbra driven) and low- (PDD and scatter-driven) gradient dose spreading. The former is driven mostly by target dose and surface shape, while the latter adds the dependence on target volume. This benchmark dose is used to produce the "best possible sparing" FDVH for an OAR, and based on it, progressively more easily achievable FDVH curves can be estimated. Validation was performed using test cylindrical geometries as well as 10 clinical HN datasets. For HN, VMAT plans were prepared with objectives of covering the primary and the secondary (bilateral elective neck) PTVs while addressing only one OAR at a time, with the goal of maximum sparing. The OARs were each parotid, the larynx, and the inferior pharyngeal constrictor. The difference in mean OAR doses was computed for the achieved vs. FDVHs, and the shapes of those DVHs were compared by means of the Dice similarity coefficient (DSC). For all individually optimized HN OARs (N = 38), the average DSC between the planned DVHs and the FDVHs was 0.961 ± 0.018 (95% CI 0.955-0.967), with the corresponding average of mean OAR dose differences of 1.8 ± 5.8% (CI -0.1-3.6%). For realistic plans the achieved DVHs run no lower than the FDVHs, except when target coverage is compromised at the target/OAR interface. For the validation of VMAT plans, the OAR DVHs optimized one-at-a-time were similar in shape to and bound on the low side by the FDVHs, within the confines of planner's ability to precisely cover the target(s) with the prescription dose(s). The method is best suited for the OARs close to the target. This approach is fundamentally different from "knowledge-based planning" because it is (a) independent of the treatment plan and prior experience, and (b) it approximates, from nearly first principles, the lowest possible boundary of the OAR DVH, but not necessarily its actual shape in the presence of competing OAR sparing and target dose homogeneity objectives.

Nutraceutical/Alternative Remedies in the Management of OA

Treating patients with osteoarthritis requires careful individualization in order to achieve patient-specific goals, which may vary from obtaining short-term pain relief to achieving long-term maintenance of function or even preservation of cartilage. In response to specific patient goals, the provider makes use of a toolbox of physical, adjunctive, alternative, pharmacologic, and operative interventions. Among the alternative category are the nutraceuticals, which will be reviewed here with particular attention given to those agents with randomized control trial (RCT) data showing statistically significant benefits. Some of these can be used to minimize patient symptoms with very low risks. The safety of these agents is particularly important in treating patients with osteoarthritis as many of the patients are older with significant comorbidities. Further, it is very likely that it will be necessary for the patients to continue treatment for many years.

Improving Balance through Virtual Reality and Physical Therapy Integration

Background and Purpose: Virtual reality (VR) is an innovative technology that shows promise in the assistance of physical therapy (PT). This case report explores the use of virtual reality with a patient suffering from unilateral vestibular hypofunction (UVH). Case Description: The patient is a 50-year-old male who was referred to physical therapy following a motor vehicle accident. The patient was diagnosed with having an acute left UVH, accompanied by reports of dizziness, imbalance and gait disturbances which impaired him from his work in construction. Intervention: The patient was seen two to three times a week for 40-minute sessions along with an individualized home exercise program. Interventions included vestibular rehabilitation exercises, balance training, gait training, and VR. The goals of VR were to provide task-specific simulations to improve postural balance, decrease anxiety through exposure therapy, and improve smooth eye pursuits to improve static balance. Outcomes: Outcomes used included subjective questionnaires such as the Activities-Specific Balance Confidence survey and the Dizziness Handicap Inventory (DHI) as well as functional tests like the Sensory Organization Test, Motor Control Test, and the Functional Gait Assessment (FGA). Outcome measures were performed at initial evaluation, at the 10th visit, and again at discharge. Notable improvements were seen on DHI and FGA scores. Conclusion: Dizziness, confidence, balance, and gait improved following vestibular rehabilitation combined with VR. Outcomes of this case suggest that virtual reality in conjunction with vestibular rehabilitation therapy is effective in improving deficits of unilateral vestibular hypofunction. Additionally, the use of VR in this case report suggests this can be an effective tool for intervention to facilitate patient-specific goals.

Dutch Dataset Pain Rehabilitation in daily practice: Content, patient characteristics and reference data.

No core set of measurement tools exists to collect data within clinical practice. Such data could be useful as reference data to guide treatment decisions and to compare patient characteristics or treatment results within specific treatment settings. The Dutch Dataset Pain Rehabilitation was developed which included the six domains of the IMMPACT core set and three new domains relevant in the field of rehabilitation (medical consumption, patient-specific goals and activities/participation). Between 2010 and 2013 the core set was implemented in 32 rehabilitation facilities throughout the Netherlands. A total of 8200 adult patients with chronic pain completed the core set at first consultation with the rehabilitation physician. Adult patients (18-90years) suffering from a long history of pain (38% >5years) were referred. Patients had high medical consumption and less than half were working. Although patients were referred with diagnosis of low back pain or neck or shoulder pain, a large group (85%) had multisite pain (39% 2-5 painful body regions; 46% >5 painful body regions). Scores on psychosocial questionnaires were high, indicating high case complexity of referred patients. Reference data for subgroups based on gender, pain severity, pain locations and on pain duration are presented. The data from this clinical core set can be used to compare patient characteristics of patients of other treatment setting and/or scientific publications. As treatment success might depend on case complexity, which is high in the referred patients, the advantages of earlier referral to comprehensive multidisciplinary treatment were discussed. A detailed description of case complexity of patients with chronic pain referred for pain rehabilitation. Insight in case complexity of patients within subgroups on the basis of gender, pain duration, pain severity and pain location. These descriptions can be used as reference data for daily practice in the field of pain rehabilitation and can be used to evaluate, monitor and improve rehabilitation care in care settings nationwide as well as internationally.

Maintenance of Clinical Endpoints After Discharge from a Pharmacist-Managed Risk Reduction Clinic at a Veterans Affairs Medical Center.

Diabetes, dyslipidemia, and hypertension are complex chronic disease states that often require close monitoring and frequent follow-up to achieve and maintain therapeutic control as determined by hemoglobin A1c (A1c), low-density lipoprotein (LDL), and blood pressure (BP). At the Charles George Veterans Affairs Medical Center (CGVAMC), physicians may refer their patients to the on-site pharmacist-managed Risk Reduction Clinic (RRC). Patients are discharged from the RRC once patient-specific therapeutic goals have been met for diabetes, dyslipidemia, and/or hypertension. This study investigated the change in A1c, LDL, and systolic blood pressure (SBP) after discharge from the CGVAMC RRC. To investigate (a) how clinical endpoints for diabetes, dyslipidemia, and hypertension change after discharge from the pharmacist-managed RRC at the CGVAMC; (b) the factors associated with worsening of monitoring parameters; and (c) the frequency of reconsultation to the RRC. In this single-center retrospective quality management study, patients were included if they had a completed consultation to the CGVAMC RRC between August 11, 2008, and January 1, 2011, for the management of type 2 diabetes, dyslipidemia, and/or hypertension. Patients were included if they were discharged from the RRC prior to October 1, 2011, due to goal attainment. Furthermore, it was required that patients have A1c, LDL, and SBP measurements, as applicable based on diagnoses, at least yearly during the first 2 years following discharge. Patients were excluded if they were discharged for any reason other than goal attainment or if they were followed by a specialty clinic related to the RRC, including the Diabetes PharmD, Diabetes MD, MIDAS (group diabetes), or MAGIC (group dyslipidemia) clinics. Data collection included patient demographics; date of and indication for consultation to the RRC; date of first RRC visit; date of discharge from the RRC; number of visits to the RRC; A1c, LDL, SBP, and weight at consultation to the RRC, at discharge, and during the 2 years following discharge from the RRC; and date of and indication for reconsultation to the RRC, as applicable. Two-tailed paired t-tests were used to compare A1c, LDL, and SBP at discharge from the RRC to A1c, LDL, and SBP during the follow-up period. Two-tailed unpaired t-tests were performed to determine which variables were associated with changes in the monitoring parameters after discharge from the RRC. One hundred forty-nine patients were included in this study. For all patients with a diagnosis of diabetes (N = 82), A1c rose from 6.49% to 6.79% (P < 0.001) during the first year and to 7.04% (P < 0.001) during the second year following discharge. For patients diagnosed with dyslipidemia (N = 137), LDL rose after discharge from 81.5 mg/dL to 90.8 mg/dL (P < 0.001) and to 90.9 mg/dL (P < 0.001), respectively. For patients diagnosed with hypertension (N = 132), SBP rose from 126.2 mm Hg to 131.5 mm Hg (P < 0.001) and to 133.9 mm Hg (P < 0.001), respectively. An increase in A1c after discharge was associated with lower discharge A1c (P = 0.014), higher consultation weight (P = 0.009), and higher discharge weight (P = 0.042). A rise in LDL was correlated to higher consultation LDL (P = 0.006), while higher SBP was associated with lower discharge SBP (P < 0.001). Twelve percent of patients were reconsulted to the RRC. A1c, LDL, and SBP rose after discharge from the pharmacist-managed risk reduction clinic, but these changes may not have been clinically significant based on the low reconsultation rate and values remaining close to generally accepted therapeutic goals. Patients likely to benefit from extending RRC services past goal attainment include those with higher A1c and LDL at the time of consultation and those with higher weight. As a result of this study, recommendations have been made to consider following up every 3-4 months for 2-3 additional visits for patients with baseline A1c > 8% and LDL > 115 mg/dL and those with weight > 220 pounds prior to discharging them from the CGVAMC RRC. Furthermore, we believe that all patients could benefit from extending follow-up to 6 months for 1-2 additional visits or as needed after their therapeutic goals have been reached.

Enteral Nutrition Support Reduces the Necessity of Total Parenteral Nutrition to Reach Patient-Specific Caloric Goals Postpancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) is associated with significant rates of postoperative complications. Although there is evidence that enteral nutrition support (ENS) may reduce postoperative sepsis, the true value of ENS in the abrogation of septic complications remains controversial. The aim of our study is to investigate the postoperative outcome of patients post-PD with and without ENS. Using our prospective institutional database, we identified 202 patients from 2001 through 2009 who underwent PD. Of the 202 patients, 121 matched our inclusion criteria. In total, 67 of 121 (55.4%) patients received ENS, whereas 54 (44.6%) patients had no ENS and served as controls. Postoperative morbidity and mortality were recorded and analyzed. No significant differences were found in the postoperative morbidity of the patients. The anastomotic leak rate was 13% in both the ENS and control groups (P = 0.846). There was no difference in mortality within the two groups (4% vs 5%, P = 0.881). Significantly more patients in the control group received total parenteral nutrition (P = 0.033). ENS is not associated with lower rates of postoperative morbidity and mortality. It does, however, reduce the necessity of additional total parenteral nutrition to reach patient-specific caloric goals.

Patient-specific dosimetric endpoints based treatment plan quality control in radiotherapy

In intensity modulated radiotherapy (IMRT), the optimal plan for each patient is specific due to unique patient anatomy. To achieve such a plan, patient-specific dosimetric goals reflecting each patient’s unique anatomy should be defined and adopted in the treatment planning procedure for plan quality control. This study is to develop such a personalized treatment plan quality control tool by predicting patient-specific dosimetric endpoints (DEs). The incorporation of patient specific DEs is realized by a multi-OAR geometry-dosimetry model, capable of predicting optimal DEs based on the individual patient’s geometry. The overall quality of a treatment plan is then judged with a numerical treatment plan quality indicator and characterized as optimal or suboptimal. Taking advantage of clinically available prostate volumetric modulated arc therapy (VMAT) treatment plans, we built and evaluated our proposed plan quality control tool. Using our developed tool, six of twenty evaluated plans were identified as sub-optimal plans. After plan re-optimization, these suboptimal plans achieved better OAR dose sparing without sacrificing the PTV coverage, and the dosimetric endpoints of the re-optimized plans agreed well with the model predicted values, which validate the predictability of the proposed tool. In conclusion, the developed tool is able to accurately predict optimally achievable DEs of multiple OARs, identify suboptimal plans, and guide plan optimization. It is a useful tool for achieving patient-specific treatment plan quality control.

Pathophysiology, assessment, and management of pain in critically ill adults.

The pathophysiology of pain in critically ill patients, the role of pain assessment in optimal pain management, and pharmacologic and nonpharmacologic strategies for pain prevention and treatment are reviewed. There are many short- and long-term consequences of inadequately treated pain, including hyperglycemia, insulin resistance, an increased risk of infection, decreased patient comfort and satisfaction, and the development of chronic pain. Clinicians should have an understanding of the basic physiology of pain and the patient populations that are affected. Pain should be assessed using validated pain scales that are appropriate for the patient's communication status. Opioids are the cornerstone of pain treatment. The use of opioids, administered via bolus dosing or continuous infusion, should be guided by patient-specific goals of care in order to avoid adverse events. A multimodal approach to pain management, including the use of regional analgesia, may improve patient outcomes and decrease opioid-related adverse events, though there are limited relevant data in adult critically ill patient populations. Nonpharmacologic strategies have been shown to be effective adjuncts to pharmacologic regimens that can improve patient-reported pain intensity and reduce analgesic requirements. Analgesic regimens need to take into account patient-specific factors and be closely monitored for safety and efficacy. Acute pain management in the critically ill is a largely underassessed and undertreated area of critical care. Opioids are the cornerstone of treatment, though a multimodal approach may improve patient outcomes and decrease opioid-related adverse events.

Relationship of Age on Enjoyment of Physical Activity in Upper Extremity Illness

Orthopaedic surgeons often work under the assumption that patients over 60 are low-demand individuals. This study addressed the primary null hypothesis that older age does not correlate with the enjoyment of physical activities in patients with upper extremity illness. Secondary analyses sought factors associated with enjoyment of physical activity, activity level and magnitude of disability. A cohort of 98 new and follow-up outpatients with upper extremity illnesses completed a measure of enjoyment of physical activity (Physical Activity Enjoyment Scale (PACES)), were categorized into one of three levels of activity after interview, and completed measures of general disability (Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function CAT), upper extremity-specific disability (Quick Disability of the Arm, Shoulder and Hand (QuickDASH) score), coping responses to pain (PROMIS Pain Interference CAT), and symptoms of depression (PROMIS Depression CAT). Greater enjoyment of physical activity correlated with older age (r = 0.29, p = 0.0039) but not with other explanatory variables. The final multivariable model of factors associated with greater physical activity included older age and male sex. The final multivariable model of factors associated with diminished PROMIS Physical Function included greater PROMIS Pain Interference, male sex, other pain conditions, and separated/divorced and single marital status and accounted for 34% of the variance. Enjoyment of physical activity does not decrease with age. Patient-specific expectations, goals and preferences for physical activity should be assessed prior to decision-making on treatment. Level IV, Prognostic Study case series.