Scholarly Commons @ Baystate Health
Not a member yet
8474 research outputs found
Sort by
Perioperative Outcomes of Colpocleisis at a Single Institution: A Retrospective Cohort Study
No full textImportance: There is limited literature reporting perioperative outcomes among colpocleisis types.
Objectives: This study aimed to describe perioperative outcomes after colpocleisis at a single institution.
Study design: Patients who underwent colpocleisis at our academic medical center between August 2009 and January 2019 were included. A retrospective chart review was performed. Descriptive and comparative statistics were generated.
Results: A total of 367 of 409 eligible cases were included. Median follow-up was 44 weeks. There were no major complications or mortalities. Le Fort and posthysterectomy colpocleises were faster than transvaginal hysterectomy (TVH) with colpocleisis (95 and 98 minutes, respectively, vs 123 minutes; P = 0.00) with decreased estimated blood loss (100 and 100 mL, respectively, vs 200 mL; P = 0.000). Urinary tract infection and postoperative incomplete bladder emptying occurred in 22.6% and 13.4% of all patients, respectively, with no difference among the colpocleisis groups (P = 0.83 and P = 0.90). Patients who underwent concomitant sling were not at increased risk of postoperative incomplete bladder emptying (14.7% for Le Fort and 17.2% for total colpocleisis). Prolapse recurred after 0 Le Fort (0%), 6 posthysterectomy (3.7%), and 0 TVH with colpocleisis procedures (0%) (P = 0.02).
Conclusions: Colpocleisis is a safe procedure with a relatively low complication rate. Le Fort, posthysterectomy, and TVH with colpocleisis have similarly favorable safety profiles and very low overall recurrence rates. Concomitant TVH at the time of colpocleisis is associated with increased operative time and increased blood loss. Concomitant sling procedure at the time of colpocleisis does not increase the risk of short-term incomplete bladder emptying
The changing landscape of interventional cardiology: A survival guide in the era of health system consolidation
No full textPractice environments for interventional cardiologists have evolved dramatically and now include small independent practices, large cardiology groups, multispecialty groups, and large integrated health systems. Increasingly, cardiologists are employed by hospitals or health systems. Data from MedAxiom and the American College of Cardiology (ACC) demonstrate an exponential increase in the percentage of cardiologists in employed positions from 10% in 2009 to 87% in 2020. This white paper explores these profound changes, considers their impact on interventional cardiologists, and offers guidance on how interventional cardiologists can best navigate this challenging environment. Finally, the paper offers a potential model to improve the employed physician experience through greater physician involvement in decision making, which may increase jobs satisfaction
Standardized reporting of pulmonary transfusion complications: Development of a model reporting form and flowchart
No full textBackground: Pulmonary complications of blood transfusion, including transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and transfusion-associated dyspnea, are generally underdiagnosed and under-reported. The international TRALI and TACO definitions have recently been updated. Currently, no standardized pulmonary transfusion reaction reporting form exists and most of the hemovigilance forms have not yet incorporated the updated definitions. We developed a harmonized reporting form, aimed at improved data collection on pulmonary transfusion reactions for hemovigilance and research purposes by developing a standardized model reporting form and flowchart.
Materials and methods: Using a modified Delphi method among an international, multidisciplinary panel of 24 hemovigilance experts, detailed recommendations were developed for a standardized model reporting form for pulmonary complications of blood transfusion. Two Delphi rounds, including scoring systems, took place and several subsequent meetings were held to discuss issues and obtain consensus. Additionally, a flowchart was developed incorporating recently published redefinitions of pulmonary transfusion reactions.
Results: In total, 17 participants completed the first questionnaire (70.8% response rate) and 14 participants completed the second questionnaire (58.3% response rate). According to the results from the questionnaires, the standardized model reporting form was divided into various subcategories: general information, patient history and transfusion characteristics, reaction details, investigations, treatment and supportive care, narrative, and transfused product.
Conclusion: In this article, we present the recommendations from a global group of experts in the hemovigilance field. The standardized model reporting form and flowchart provide an initiative that may improve data collected to address pulmonary transfusion reactions.
Keywords: anaphylaxis; flowchart; hemovigilance; reporting; transfusion-associated circulatory overload; transfusion-associated dyspnea; transfusion-related acute lung injury
Barriers and Facilitators to the Outpatient Management of Low-risk Pulmonary Embolism from the Emergency Department
No full textStudy objective: Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism (PE) from emergency departments (EDs) in the US remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of PE from the ED using implementation science methodology. Methods: We conducted semistructured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk PE. We developed an interview guide using the implementation science frameworks—the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Results: We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of PE. Although outer setting determinants, such as medicolegal climate, follow-up, and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities, and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes. Conclusion: In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute PE should be informed by these barriers and facilitators, which are aligned with the deimplementation theory
Stepped care versus center-based cardiopulmonary rehabilitation for older frail adults living in rural MA: Design of a feasibility randomized controlled trial
No full textBackground: Cardiac and pulmonary rehabilitation programs are grossly underutilized, and participation is particularly low in rural regions.
Methods: We are conducting a 2-arm, randomized controlled feasibility trial. Eligible participants include older frail adults with cardiac or pulmonary disease living in a predominantly rural county in western Massachusetts. Participants are randomized 1:1 to treatment as usual or stepped care. Patients randomized to treatment as usual participate in twice weekly center-based rehabilitation sessions over eight weeks and are encouraged to exercise at home in between sessions. Patients randomized to the stepped-care arm are offered/enrolled in the center-based rehabilitation program followed by possible step up to three interventions based on prespecified non-response criteria: 1) Transportation-assisted center-based rehabilitation, 2) Home-based telerehabilitation, and 3) Community health worker-supported home-based telerehabilitation. The primary feasibility outcomes are average number of eligible patients randomized per month, baseline measure completion, proportion attending at least 70% of the prescribed sessions, average number of sessions attended in the stepped-care arm, and proportion in the stepped-care arm completing patient reported outcome measures. Each of these process indicators is evaluated by preset Stop and Go thresholds.
Conclusion: The proposed stepped-care model is an efficient, patient-centered, approach to expanding access to cardiac and pulmonary rehabilitation. Meeting the Go thresholds for the prespecified process indicators will justify conducting a definitive full-scale randomized controlled trial to compare the effectiveness and value (cost-effectiveness) of stepped-care versus center-based rehabilitation in older frail adults living rural counties
Outcomes of a Multidisciplinary Team in the Management of Patients with Early-Stage Breast Cancer Undergoing Neoadjuvant Chemotherapy at a Community Cancer Center
No full textBackground: The utilization of neoadjuvant chemotherapy (NAC) remains highly variable in clinical practice. The implementation of NAC requires coordination of handoffs between a multidisciplinary team (MDT). This study aims to assess the outcomes of an MDT in the management of early-stage breast cancer patients undergoing neoadjuvant chemotherapy at a community cancer center. Methods: We conducted a retrospective case series on patients receiving NAC for early-stage operable or locally advanced breast cancer coordinated by an MDT. Outcomes of interest included the rate of downstaging of cancer in the breast and axilla, time from biopsy to NAC, time from completion of NAC to surgery, and time from surgery to radiation therapy (RT). Results: Ninety-four patients underwent NAC; 84% were White and mean age was 56.5 yrs. Of them, 87 (92.5%) had clinical stage II or III cancer, and 43 (45.8%) had positive lymph nodes. Thirty-nine patients (42.9%) were triple negative, 28 (30.8%) were human epidermal growth factor receptor (HER-2)+, and 24 (26.2%) were estrogen receptor (ER) +HER-2-. Of 91 patients, 23 (25.3%) achieved pCR; 84 patients (91.4%) had downstaging of the breast tumor, and 30 (33%) had axillary downstaging. The median time from diagnosis to NAC was 37.5 days, the time from completion of NAC to surgery was 29 days, and the time from surgery to RT was 49.5 days. Conclusions: Our MDT provided timely, coordinated, and consistent care for patients with early-stage breast cancer undergoing NAC as evidenced by time to treatment outcomes consistent with recommended national trends.
Keywords: breast cancer; breast cancer therapy; breast radiation therapy; breast surgery; care pathway; multidisciplinary team; neoadjuvant chemotherapy
Children with Attention Deficit Hyperactivity Disorder Are More Likely to Fail Growth Hormone Stimulation Testing than Children without Attention Deficit Hyperactivity Disorder: A Retrospective Chart Review
No full textIntroduction: Children with ADHD often present to pediatric endocrinologists due to growth concerns. Growth hormone stimulation testing (GHST) may be utilized as part of the workup. We evaluate whether children with ADHD and short stature or growth failure are more likely to fail GHST compared to children without ADHD.
Methods: We retrospectively studied children who underwent GHST as part of evaluation for short stature and/or growth failure and had an intact pituitary over a 16-year period (2002-2018). We performed univariate and logistic regression analyses with stratification by age.
Results: We included 260 children; 78 children had ADHD and were older, mean age (±SD) 12.2 (±2.6) years versus children without ADHD, mean age (±SD) 10.4 (±3.8) years. The population was largely Caucasian, and boys outnumbered the girls. Of the children with ADHD, only 9 were not medically treated. There was no difference in z-scores for height, weight, and BMI, or mid-parental height between the two groups. We found that children with ADHD were more likely to fail GHST than children without ADHD across the peak GH cut-offs of 10, 7, and 5 ng/mL (p = 0.003, p = 0.023, and p = 0.046 accordingly). The same trend persisted after regression analysis with adjustment for sex and stratification by age, and effect was more robust in the older group.
Discussion: The result shows higher likelihood of lower GH peaks in response to GHST in children with ADHD and short stature or impaired linear growth. Future work should evaluate possible mechanistic explanation and the role of psycho-stimulant medications.
Keywords: Attention deficit hyperactivity disorder; Children and adolescents; Growth hormone peak; Growth hormone stimulation testing; Short stature
Spontaneous Rupture of the Extensor Pollicis Longus Tendon: A Systematic Review
No full textBackground: Extensor pollicis longus (EPL) rupture and tenosynovitis of the third dorsal compartment is often described in association with a history of rheumatoid arthritis or in the setting of a distal radius fracture. However, the literature suggests multiple other potential factors that may lead to a seemingly spontaneous rupture.
Methods: We performed a systematic review following guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search consisted of headings and keywords related to tendon injuries, tendinopathy, hand surgery, tendon transfer, and injections, as published in reports and studies. Citations were screened by title and abstract against predetermined inclusion and exclusion criteria by 2 independent reviewers, with a third reviewer resolving discrepancies. To be eligible, articles had to meet the following inclusion criterion: describe cases of spontaneous EPL rupture or tenosynovitis of the third dorsal compartment. The exclusion criterion was any history of distal radius fracture or rheumatoid arthritis.
Results: We identified 29 articles that met the inclusion criterion.
Conclusions: A myriad of prodromal events or predisposing factors ultimately led to EPL rupture or tenosynovitis of the third compartment. Methods of reconstruction described included primary repair, tendon grafting, and tendon transfer techniques; all with generally good outcomes. These results highlight the inherent fragility of this tendon and support the historical recommendation for early release of the EPL tendon in the setting of tenosynovitis of the third dorsal compartment.
Keywords: distal radius; hand; research & health outcomes; rheumatoid arthritis; tendon
Methadone Induction for a Patient With Precipitated Withdrawal in the Emergency Department: A Case Report
No full textIn the era of illicit fentanyl, reports on difficulties with buprenorphine inductions for patients with opioid use disorder are emerging. Methadone is the only other approved medication treatment with efficacy similar to buprenorphine but without risks of precipitated withdrawal. Unfortunately, outpatient methadone inductions can take days to weeks to complete, due in part to regulations that limit administration to opioid treatment programs. We describe a patient with opioid use disorder who presented to the emergency department in precipitated withdrawal who completed a same-day methadone induction with next-day dosing at an opioid treatment program as part of an emergency department methadone protocol. As opioid-related deaths rise, emergency department-initiated methadone is feasible for patients with opioid use disorder