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Quality Improvement Methodologies: An Application in Cardiac Anesthesiology
No full textQuality improvement (QI) in medicine serves as the cornerstone of best practices. It enhances medical care by maximizing safety and efficiency while minimizing errors and waste. For a QI initiative to succeed it requires careful strategizing and effective change management plans, including the application of established QI methodologies to ensure sustainable success. Today, QI processes are integral to foundational learning for students and trainees, as well as for maintaining board certification for anesthesiologists. However, many anesthesiologists, including those actively pursuing QI efforts, are often unaware of these methodologies and their associated tools. A successful QI program that leads to sustainable improvement in outcomes relies on methodologies that assess the true current state, define value-added measures, evaluate defects and opportunities for enhancement, implement solutions through a robust change management plan, and ensure the sustainability of the process. This document provides a concise summary of methodologies that can be effectively led and executed by process improvement teams. We examine these methods within the context of cardiac anesthesiology, highlighting one institution\u27s experience in reducing surgical site infections following coronary artery bypass graft surgery. However, these principles are applicable to various healthcare situations and beyond
Broadening the definition of patient-safety events: lessons from a multicentre learning health system collaborative
No full textBACKGROUND: Improving safety in healthcare has been paramount for decades, yet despite major attention and investment, improvement has remained incremental. Patient safety is a major concern in US healthcare, leading to significant harm and economic losses annually. Accurately identifying safety events remains difficult due to methodological discrepancies and lack of standardisation. This study evaluated the feasibility of implementing a standardised case-review methodology and safety-event taxonomy across diverse hospital settings to assess opportunities for improvement (OFIs) and compare findings with traditional definitions.
METHODS: This multicentre retrospective cohort study reports data from 103 hospitals across the USA and Canada between 2016 and 2023. A multivariable logistic regression was performed to test case reviews for differences in the presence of one or more OFIs across several hospital types (bed size, academic status, urban setting, trauma level and Centres for Medicare and Medicaid Services overall star rating) and patient characteristics (age, gender, length of stay, admission and discharge code status and mortality).
RESULTS: 19 181 cases were reviewed across the Learning Health System Collaborative, with a median of 107 reviews per hospital. Mortality was the most common cohort selection, studied by 91 hospitals (88%). At least one OFI was identified in 12 714 cases (66.3%). The logistic regression analysis found that all hospital characteristics and patient age, length of stay, code status and discharge disposition were significantly associated with at least one OFI. Of the 46 444 OFIs identified, 41 439 (89%) were from categories focused on omissions of care. The categories of end-of-life, documentation and treatment/care alone accounted for 25 980 OFIs (56%).
CONCLUSION: The highest volumes of safety-related OFIs were associated with omissions of care, as opposed to the traditional definition of patient safety, which primarily includes outcomes from acts of commission
Changing trends in clinical presentation of primary hyperparathyroidism across countries over time
No full textPrimary hyperparathyroidism (PHPT), the third most common endocrine disorder, was so eloquently described first by Fuller Albright as a polymorphic condition in his classic paper and monograph as early as 1934. Over the decades, the clinical presentation of PHPT in developed countries has shifted significantly from a disease primarily affecting the bones and kidneys to an asymptomatic condition often discovered incidentally. In developing countries, the high prevalence of vitamin D deficiency is one of the main factors influencing the clinical presentation of PHPT. In Europe and North America, PHPT is predominantly asymptomatic. In South America, China, and Eastern parts of Europe, such as Turkey, Bulgaria, and Russia, there is an ongoing transition from symptomatic to asymptomatic cases. Asia shows variability: symptomatic cases dominate in the Indian subcontinent, Middle East, and Southeast Asia, while transitional patterns with predominant asymptomatic cases have now been reported in China, and Japan reports mostly asymptomatic cases. Factors influencing these changes include advancements in diagnostic technologies, detection of incidental parathyroid adenomas during thyroid ultrasonography, regional differences in vitamin D deficiency, dietary habits, and genetic polymorphisms in vitamin D and calcium-sensing receptors. A higher prevalence of nephrolithiasis in certain climates contributes to regional variations. This review examines the dynamic nature of PHPT\u27s clinical presentation, shaped by geographic, genetic, and environmental influences. Also, this review highlights the importance of addressing global disparities in an attempt to optimize patient outcomes
Conversion from Minimally Invasive Surgical Approaches to Open Surgery Among Patients with Endometrial Cancer in the SGO Clinical Outcomes Registry
No full textBACKGROUND: Endometrial cancer (EC) ranks as the most common gynecologic malignancy in the USA. While minimally invasive surgical (MIS) techniques have revolutionized EC management, conversion to laparotomy remains a concern due to the loss of laparoscopic benefits such as fewer surgical site infections and shorter hospital stays with reported rates varying widely. Factors influencing this conversion, including patient characteristics and tumor attributes, have not been fully understood. Our study aims to provide a framework for identifying patients at higher risk of conversion, thereby helping to inform surgical decision-making and patient counseling Addressing this gap, our study employs a national registry to analyze patient- and tumor-related factors associated with the transition from MIS to open surgery in EC.
PATIENTS AND METHODS: We queried the SGO Clinical Outcomes Registry (COR) to identify all patients with EC who underwent surgical management. The COR indeed validated clinical data from 29 sites collected between 2014 and 2018. The primary outcome was to assess the conversion rate from MIS to open surgery. Descriptive statistics using means with standard deviations or frequency with percentages were used. Chi-squared analysis was used to examine the bivariate relationship between group status and the subjects\u27 demographic and clinical variables.
RESULTS: A total of 3.4% (135/4028) of patients underwent conversion from MIS to open surgery. Demographic characteristics were balanced between the groups. Conversion was more prevalent in patients with obesity (29%) and morbid obesity (37%) than in patients who are underweight (2%), normal weight (16%), and overweight (16%). Similarly, conversion was more prevalent in patients with prior abdominal surgery (63% versus 52%; P = 0.001). Endometrioid (EC) predominated (59%) in the converted group, with higher-than-expected non-endometrioid rates (serous carcinoma 16%, clear cell carcinoma 4%, carcinosarcoma 5%, mixed histology 12%; all P \u3c 0.01). Advanced International Federation of Gynecology and Obstetrics (FIGO) stages were more common in patients who converted to open surgery (stage II: 5%, stage III: 25%, stage IV: 9%; all P \u3c 0.001). Type II (24%) and type III (5%) hysterectomies were more frequent in patients who converted to open (P \u3c 0.001). Logistic regression indicated body mass index (BMI), prior surgery, FIGO stage, histology, and hysterectomy type affected conversion (P \u3c 0.001), explaining 12.3% of the variance in the conversion outcome. Indications for conversion included uterine size, adhesions, and disease extent.
CONCLUSIONS: The adoption of MIS has become increasingly common standard of care for managing EC, attributed to enhanced perioperative outcomes. Factors associated with conversion such as uterine size, prior abdominal surgeries, surgical complexity, disease extent, and histologic types can affect the surgeon\u27s choice. Ultimately, a personalized surgical approach, tailored to individual patient attributes, remains pivotal for optimizing outcomes in EC management
Healthcare workers\u27 perspectives on trauma and mental health access for Rohingya refugees in Cox\u27s Bazar
No full textBACKGROUND: In August 2017, the Rohingya population of northern Rakhine State in Myanmar fled to Bangladesh following clearance operations by the Myanmar security forces that were characterized by widespread and systematic violence, constituting severe human rights violations. The clearance operations were preceded by years of consistent denial of the human rights of the Rohingya people in Myanmar. This study examines the impact of these human rights violations on the trauma experiences of Rohingya survivors, their resulting mental health, and the availability and access to post-migration mental health services.
METHODS: Qualitative one-on-one interviews were conducted with 26 health care professionals who cared for Rohingya refugees after their arrival in Bangladesh.
RESULTS: Trauma experienced by the Rohingya spanned the period before, during, and following migration and was ongoing at the time of data collection. The impact of Rohingya survivors\u27 concurrent grief and trauma in relation to the violence they experienced in Myanmar as well as during and after their journey to Bangladesh that, at times, exacerbated survivors\u27 trauma presentation. There were limited mental health services available in Bangladesh and additional structural and procedural barriers to care that limited responsiveness to Rohingya survivors\u27 mental health needs.
CONCLUSION: The Rohingya experienced traumatic human rights violations in Myanmar that led to their forced migration to Bangladesh. The Rohingya continued to experience trauma during their forced migration to Bangladesh and were exposed to additional stressors in the post-migration settings in refugee camps, including lack of access to adequate mental health services. These experiences have resulted in a spectrum of stress-and trauma-related symptoms. These findings show the mental health impact of protracted human rights violations on the Rohingya, revealing how trauma is not a singular event but a continuous experience. Detailing the limited mental health infrastructure and structural barriers facing Rohingya refugees in Bangladesh, the findings underscore the urgent need for trauma-informed interventions that address the complex psychological consequences of systemic violence and displacement. The findings emphasize the critical importance of holistic mental health support in refugee settings, providing evidence-based recommendations for the public health and humanitarian sector to consider when designing programs to address the mental health and psychosocial support needs of sexual violence survivors living in conditions of displacement
Comparative performance of tuberculin and defined-antigen cocktails for detecting bovine tuberculosis in BCG-vaccinated cattle in natural settings
No full textBovine tuberculosis (bTB) is a threat to cattle health and public safety. The current control programs are hampered by wildlife reservoirs and socioeconomic barriers. Vaccinating cattle with Bacillus Calmette-Guérin (BCG) effectively reduces transmission, offering a potential solution for controlling bTB. A key requirement for vaccination strategies using BCG is the validation of defined antigens to differentiate infections among vaccinated animals (DIVA). We compared tuberculin with DIVA peptide cocktails (ESAT-6, CFP-10, and Rv3615c) in 67 unvaccinated and 67 BCG-vaccinated cattle exposed to M. bovis in a natural setting. The cattle were tested every 4 months with a skin test and every 2 months with interferon-gamma (IFN-γ) release assays (IGRA) over a year of exposure. Before exposure, the DIVA skin, DIVA IGRA, and tuberculin tests showed 100% specificity in unvaccinated control calves. After exposure, the DIVA skin, DIVA IGRA, and comparative cervical tuberculin (CCT) tests had comparable sensitivities of 46% (95% CI 36, 56), 45% (95% CI 35, 55), and 47 (95% CI 37, 57), respectively, when assessed against animals positive by M. bovis culture PCR. The results suggest that test-and-slaughter control strategies using tests with low sensitivity are not expected to be effective in controlling bTB in high-prevalence herds, and highlight an urgent need to improve the sensitivity of diagnostic tests for bTB in these settings
US Geriatric Assessment Practices for Older Adults Undergoing Hematopoietic Cell Transplantation or Chimeric Antigen Receptor T Cell Therapy: An American Society for Transplantation and Cellular Therapy Physician Survey from the Aging Special Interest Group and Committee on Practice Guidelines.
No full textGeriatric assessment (GA) may identify vulnerabilities and promote risk-stratification in older adults predisposed to toxicities after autologous (auto), allogeneic (allo) hematopoietic cell transplantation (HCT) and chimeric antigen T-cell therapies (CAR T). With increased utilization cellular therapies for older adults the American Society for Transplantation and Cellular Therapy (ASTCT) Committee on Practice Guidelines and its Special Interest Group for Aging (SIG) conducted an online cross-sectional survey between April 2023 and August 2023 to determine transplantation and cellular therapy physicians\u27 practice patterns regarding GA in older patients receiving HCT and CAR T-cell therapies. E-mail surveys were sent to 1168 ASTCT physician members and only 96 (8.2%) respondents completed the survey. Most (86%) were affiliated with university/teaching centers and 70% had a combined HCT and cellular therapy practice. More than 50% of respondents were interested in pursuing GA but 68% described barriers. The top two recognized barriers to GA were lack of time (96%) and clinical support staff (90%). Despite interest, only 15% respondents reported to know the domains of GA \u27well\u27. Among those using GA, the minimum age used for routine GA was 65 years for allo-HCT and CAR T in over 91% respondents. Taken together, we recommend the HCT community leadership and GA experts combine efforts to address the gap in GA uptake and implementation
The Impact of Novel Lipid-Lowering Agents on Cardiovascular Risk Reduction: A Systematic Review and Meta-Analysis
No full textINTRODUCTION: Reducing the risk of atherosclerotic cardiovascular disease is the aim of lipid-lowering therapy (ASCVD). It is commonly acknowledged that low-density lipoprotein (LDL) is a major cause of ASCVD. Several online databases and search engines, such as Pub- Med and the Cochrane Library, were used to conduct a thorough search.
METHOD: This study included RCTs assessing the effect of PCSK9 inhibitors on cardiovascular events. The RevMan 5.4 software was used to conduct the meta-analysis. This analysis included nine RCTs in total.
RESULTS: Meta-analysis of the included studies showed that the levels of total cholesterol, LDL, and triglycerides were reduced after the use of PCSK9 inhibitors, and HDL levels were increased, which is good cholesterol. Most adverse cardiac events (MACE) were reduced after the use of PCSK9 inhibitors.
CONCLUSION: In conclusion, ezetimibe, a PCSK9 inhibitor added to statin therapy, further reduces MACE risk without affecting all-cause mortality, even though statins already significantly reduce major adverse cardiovascular events (MACE) and mortality
Generation and Characterization of Human iPSC-Derived Astrocytes with Potential for Modeling X-Linked Adrenoleukodystrophy Phenotypes
No full textX-adrenoleukodystrophy (X-ALD) is a peroxisomal metabolic disorder caused by mutations in the ABCD1 gene encoding the peroxisomal ABC transporter adrenoleukodystrophy protein (ALDP). Similar mutations in ABCD1 may result in a spectrum of phenotypes in males with slow progressing adrenomyeloneuropathy (AMN) and fatal cerebral adrenoleukodystrophy (cALD) dominating most cases. Mouse models of X-ALD do not capture the phenotype differences and an appropriate model to investigate the mechanism of disease onset and progress remains a critical need. Here, we generated induced pluripotent stem cell (iPSC) lines from skin fibroblasts of two each of apparently healthy control, AMN, and cALD patients with non-integrating mRNA-based reprogramming. iPSC lines expanded normally and expressed pluripotency markers Oct4, SOX2, NANOG, SSEA, and TRA-1-60. Expression of markers SOX17, Brachyury, Desmin, OXT2, and beta tubulin III demonstrated the ability of the iPSCs to differentiate into all three germ layers. iPSC-derived lines from CTL, AMN, and cALD male patients were differentiated into astrocytes. Differentiated AMN and cALD astrocytes lacked ABCD1 expression and accumulated saturated very long chain fatty acids (VLCFAs), a hallmark of X-ALD, and demonstrated differential mitochondrial bioenergetics, cytokine gene expression, and differences in STAT3 and AMPK signaling between AMN and cALD astrocytes. These patient astrocytes provide disease-relevant tools to investigate the mechanism of differential neuroinflammatory response in X-ALD and will be valuable cell models for testing new therapeutics