Time Of Patient Assessment Research Articles

HER2-Low Breast Cancer: a New Subtype?

Breast cancer (BC) guidelines subdivide the disease into three main groups, namely hormone receptor (HR)-positive HER2-negative, HER2-positive, and triple-negative BC (TNBC). The natural history of the HER2-positive subtype has changed since the introduction of HER-targeted therapies, which demonstrated benefit only in case of HER2 overexpression (IHC, score 3+) or gene amplification. Such observation may depend on direct drug inhibition of HER2 downstream signaling, which is needed for survival and proliferation in HER2-addicted BC. Clinically focused categories cannot comprehensively describe biology, as almost half of the currently defined HER2-negative BCs show some degree of IHC expression and have been recently renamed as HER2-low. Why? As technological breakthroughs enable the synthesis of antibody-drug conjugates (ADCs), target antigens may be viewed not only as a biological switch to be turned on-off by targeted drugs but also as an anchor for ADC docking and tethering. As trastuzumab deruxtecan (T-DXd) has already proven in the clinical trial DESTINY-Breast04, even fewer HER2 available receptors on cancer cells may be sufficient for a clinical benefit. So, for HR-negative HER2-low subtype (~40% of TNBCs), though only 58 patients had been enrolled in DESTINY-Breast04, the observed benefit, together with the dismal prognosis of TNBC, warrants the use of T-DXd. Notably, another topoisomerase-based ADC, sacituzumab govitecan, has already been granted approval for pretreated TNBC (ASCENT). As no head-to-head comparison has been performed, the choice relies on regulatory approvals at the time of patient assessment, critical appraisal of available evidence, and careful evaluation of possible cross-resistance with sequential use of ADCs. As for HR-positive HER2-low disease (~60% of HR-positive tumors), DESTINY-Breast04 provides solid evidence for T-DXd prioritization in either second or third treatment lines. Although the remarkable activity observed in this setting favorably compares with outcomes observed in treatment-naive patients, the ongoing DESTINY-Breast06 will clarify the role of T-DXd in this population.

Can an ECG performed during emergency department triage and interpreted as normal by computer analysis safely wait for clinician review until the time of patient assessment? A pilot study

IntroductionElectrocardiograms (ECGs) are frequently performed during patient triage in Emergency Departments (EDs). Emergency Physicians (EPs) are interrupted during other tasks to review ECGs. Critics believe this practice could lead to distraction with consequent medical error and decision fatigue.ECGs can be interpreted by computer software at the time of capture; some evidence exists to suggest that an ECG performed during ED triage with an immediate computer interpretation (ICI) of ‘normal’ will seldom contain information necessitating a change to triage management. Material and methodsAll ED triage ECGs performed in the Royal Derby Hospital between 13th July 2017 and 12th July 2018 in patients without chest pain and with an ICI of ‘normal’ were identified through a database search. Forty were randomly selected and reviewed by two EPs (blinded to patient details, ICI and outcome) who were asked to identify those that required a change to triage management. ResultsThe study processes were feasible. At least one of the two EP reviewers felt that a change to triage management was required in 48% of cases (e.g. “review patient”, “obtain blood gas”, “review old ECGs”); they agreed on the need for change of management in 13% of cases. An ICI of normal had a NPV of 53% (95% CI 37–67%) for the need for a change to triage management based upon ECG findings. Inter-observer agreement was poor (kappa = 0.17). ConclusionsBased on these results, ED triage ECGs should still be presented to EPs for immediate review regardless of the ICI. Inter-observer agreement between EPs was poor. Further research is required to link triage ECG interpretation, need for intervention and patient outcome.

Cultural formulation interview: Awareness and attitudes of South African psychiatrists and psychiatry registrars.

BackgroundThe Cultural Formulation Interview (CFI) includes a set of 16 questions formulated for clinicians to obtain information about cultural influences on an individual’s clinical presentation during a mental health assessment. The CFI is a newly formulated interview that has been evaluated in various localities, but not in South Africa.AimWe assessed the awareness and attitudes of South African psychiatrists and psychiatrists in training towards the CFI and its use in their patient care.SettingParticipants were recruited via the South African Society of Psychiatrists (SASOP) database and were invited to complete an online questionnaire.MethodsCertain demographic aspects of psychiatrists and psychiatrists in training were compared with regard to their awareness of and attitudes towards the CFI.ResultsOf the 75 participants who completed the questionnaire, only 46.7% (n = 35) were aware of the CFI, and of these, only 5.3% (n = 4) used the CFI. There was generally a positive attitude towards the CFI with the majority of the participants agreeing that the CFI is easy to understand and relevant in clinical practice; however, none of the results showed statistical significance. Most participants who were aware of the CFI (89%, n = 31) were of the opinion that the CFI would prolong their patient assessment time.ConclusionMost participants had a positive attitude towards the CFI. The negative response regarding the CFI prolonging patient assessment time could be a potential barrier in its clinical application. This study is an essential first step for further research into the CFI and its use in SA and contributed towards improving awareness of the CFI.

Early Experience with a Novel Strategy for Assessment of Sepsis Risk: The Shock Huddle.

Introduction:Severe sepsis/septic shock (SS), a leading cause of death in children, is a complex clinical syndrome that can be challenging to diagnose. To assist with the early and accurate diagnosis of this illness, we instituted an electronic scoring tool and developed a novel strategy for the assessment of currently hospitalized children at risk for SS.Methods:The Shock Tool was created to alert providers to children at risk for SS. Above a threshold score of 45, patients were evaluated by a team from the pediatric intensive care unit (PICU), led by the Shock Nurse (RN), a specially trained PICU nurse, to assess their need for further therapies. Data related to this evaluation, termed a Shock Huddle, were collected and reviewed with the intensivist fellow on service.Results:Over 1 year, 9,241 hospitalized patients were screened using the Shock Score. There were 206 Shock Huddles on 109 unique patients. Nearly 40% of Shock Huddles included a diagnostic or therapeutic intervention at the time of patient assessment, with the most frequent intervention being a fluid bolus. Shock Huddles resulted in a patient transfer to the PICU 10% of the time.Conclusion:Implementation of an electronic medical record-based sepsis recognition tool paired with a novel strategy for rapid assessment of at-risk patients by a Shock RN is feasible and offers an alternative strategy to a traditional medical emergency team for the delivery of sepsis-related care. Further study is needed to describe the impact of this process on patient outcomes.

Impact of scribing history and physical notes and procedure reports on endoscopist efficiency during routine procedures: a proof-of-concept study.

BackgroundEfficiency is an important aspect of endoscopic practice that has received limited study. We evaluated the impact of scribing electronic pre-procedure history and physical examinations, and electronic procedure reports on endoscopist efficiency.MethodsWe used a stopwatch to measure the time between the procedures (scope out to scope in), pre-procedure patient assessment time, and procedure report generation time for 180 consecutive procedures performed by a single endoscopist with or without a scribe for recording history and physical and procedure reports. Schedulers were unaware of whether a scribe would be present.ResultsMean times for recording the pre-procedure history and physical and procedure reports were reduced by 34% (p = 0.001) and 71% (p < 0.0001), respectively, when scribes were used. The mean time saved by the endoscopist from scribing the history and the physical and procedure reports was 2.12 and 1.59 min, respectively. When both processes were scribed, the endoscopist spent 42% (p = 0.033) longer in the recovery area (absolute mean increase 1.01 min) compared with when no scribes were utilized. The total time saved per 6.5-h procedure block with both scribes averaged to 41.7 min.ConclusionThe use of scribes to record history and physical examination notes and procedure reports saved enough endoscopist time to allow additional procedures or longer procedures, or to free the time for other tasks.

A clinical tool to risk stratify potential kidney transplant recipients and predict severe adverse events.

Preoperative risk assessment of potential kidney transplant recipients often fails to adequately balance risk related to underlying comorbidities with the beneficial impact of kidney transplantation. We sought to develop a simple scoring system based on factors known at the time of patient assessment for placement on the waitlist to predict likelihood of severe adverse events 1year post-transplant. The tool includes four components: age, cardiopulmonary factors, functional status, and metabolic factors. Pre-transplant factors strongly associated with severe adverse events include diabetic (OR: 3.76, P<.001), coronary artery disease (OR: 3.45, P<.001), history of CABG/PCI (OR 3.1, P=.001), and peripheral vascular disease (OR 2.74, P=.008).The score was evaluated by calculation of concordance index. The C statistic of 0.74 for the risk stratification group was considered good discrimination in the validation cohort (N=127) compared to the development cohort (N=368). The pre-transplant risk group was highly predictive of severe adverse events (OR 2.36, P<.001). Patients stratified into the above average-risk group were four times more likely to experience severe adverse events compared to average-risk patients, while patients in the high-risk group were nearly 11 times more likely to experience severe adverse events. The pre-transplant risk stratification tool is a simple scoring scheme using easily obtained preoperative characteristics that can meaningfully stratify patients in terms of post-transplant risk and may ultimately guide patient selection and inform the counseling of potential kidney transplant recipients.

Prepubertal presentation of varicocele does not affect outcomes

Varicoceles in prepubertal boys are uncommon and little is known of the natural history. Historically, a large percentage of these boys have undergone surgical repair with the belief that such early presentation carried a worse prognosis, making assessment of longitudinal outcomes difficult. While there may be concern that varicocele could represent a progressive disease and therefore prepubertal presentation would portend a worse prognosis, we hypothesized that there would be no difference between the prepubertal boys and other adolescents with varicocele. We retrospectively reviewed a database of boys at a single institution with a documented left-sided varicocele between 1995 and 2011. Inclusion criteria were one or more of the following: 1. Clinician-documented Tanner 1 status, 2. Right testis orchidometric or ultrasound calculated volume of ≤3 cc's. Patients were drawn from a prospectively maintained database of all boys presenting to the outpatient urology clinic receiving a diagnosis of varicocele. A cohort of adolescent boys was assembled by matching as closely as possible with respect to testis volume disparity and grade of varicocele. All matches were within 2% of volume difference. Volume was calculated using the length*width*height*0.71 formula. Testis size disparity was set to a threshold of ≥20% using the Lambert formula: (VolumeRight - VolumeLeft)/VolumeRight*100%. Our primary outcome was defined as hypotrophy or the need for surgery for hypotrophy at the termination of the study. We planned a single subgroup analysis of boys based on presentation with or without hypotrophy. The decision for surgery or observation was made by the individual clinician at the time of patient assessment. On presentation, the prepubertal cohort was younger (10.8 vs 14.1 years), and with smaller left (2.4 vs 11.6 cc) and right (2.4 vs 11.6 cc) testis volume. There were no significant differences with respect to varicocele grade and volume differentials at presentation. At the end of the study, 76% of the prepubertal cohort had neither hypotrophy nor the requirement for operation, compared with 83% of the matched cohort (P = 0.71, Fisher's exact test). Similarly, there were no significant differences in outcome when comparing prepubertal boys with initial symmetry or hypotrophy to their matched cohort of older adolescents. The prepubertal varicocele is a rare clinical problem for which little data exists to guide the clinician. In a review of Pubmed indexed English language manuscripts, we were only able to find five papers with information on Tanner stage; only 31 prepubertal boys have longitudinal data reported. This study approximately doubles the number of boys for whom such data is available in the literature. Our chief limitation was sample size. A power analysis indicated that a final-analysis cohort of 90 prepubertal boys would be required to detect a 20% difference in outcome between that group and a matched cohort of pubertal or post-pubertal boys. We propose that given the lack of evidence for worse outcomes in prepubertal boys with varicocele that prepubertal status, in and of itself, not be considered an additional indication for correction of varicocele. In our retrospective cohort of prepubertal boys with left testis varicocele and their matched cohort, we did not detect a difference in the rate of good outcomes, defined as the absence of hypotrophy and lack of need for surgical intervention. While we may have suspected, as have others, that prepubertal presentation would have conveyed a more pressing need to intervene, it is likely that these boys represent the very same patients that we see more commonly later in their adolescence, and should thus be managed in a similarly conservative fashion.

Echo-planar diffusion-weighted MRI in the diagnosis of acute ischemic stroke: characterisation of tissue abnormalities and limitations in the interpretation of imaging findings

An accurate diagnosis is frequently difficult in early stroke. Diffusion-weighted (DW) magnetic resonance imaging (MRI) allows visualization of ischemic parenchyma and quantitative assessment of tissue changes before unequivocal abnormalities appear on T(2)-weighted MRI. We analyzed 105 MRI examinations of patients with acute stroke (<24 h) with regard to patterns of abnormalities in T(2)-weighted and DW MRI. Furthermore we assessed the influence of artifacts related to DW echo-planar single-shot MRI on image interpretation. Depending on the time of patient assessment there were three partly overlapping T(2)/DW patterns: (1) in the very early phase (</=1.5 h after symptom onset) there was no T(2) abnormality and no definite abnormality of diffusion; (2) no T(2) abnormality and restricted diffusion (1.5-4 h); (3) T(2) hyperintensity and restricted diffusion (>/=3 h). Typical artifacts (susceptibility distortions, N/2 artifact, chemical shift artifact and eddy currents artifact) had to be considered when interpreting images. Provided typical artifacts are taken into consideration, echo-planar DW MRI allows a more precise diagnostic assessment in acute stroke.