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Success of different closure modalities of gastrogastric or jejunal-gastric fistulas after EUS-directed transgastric intervention
No full textBACKGROUND AND AIMS: EUS-directed transgastric intervention (EDGI) involves the creation of a temporary tract between the gastric pouch or proximal jejunum and excluded stomach by deploying a lumen-apposing metal stent (LAMS) between the adjacent lumens. Once the intended intervention is completed, the LAMS is removed. Practices for closure of the resulting gastrogastric or jejunal-gastric fistula vary widely. The purpose of this study was to investigate the efficacy of different closure modalities.
METHODS: This was a retrospective study across 6 different medical centers of patients who had undergone EDGI with subsequent LAMS removal. Patients without a follow-up study with either an upper GI series or repeat endoscopy to assess fistula closure were excluded.
RESULTS: Of 106 included patients, 22 patients (21%) had persistent fistulas on follow-up study. Argon plasma coagulation (APC) combined with OverStitch (Boston Scientific, Marlborough, MA) was the most common modality used for fistula closure, with a persistent fistula found in 8 of 45 patients (17.8%). By comparison, a persistent fistula was found in 4 of 15 patients (26.7%) whose fistulas were not closed. APC combined with through-the-scope (TTS) clips had a high success rate in closing fistulas with a persistent fistula in 1 of 18 patients (5.6%). Patients with persistent fistulas had longer LAMS dwell times than those without fistulas (median, 100.5 days [IQR, 40-182.5] vs 30.5 days [IQR, 22-41.75], respectively; P \u3c .001). When adjusting for LAMS dwell times, closures with APC + OverStitch, APC + TTS clips, or OverStitch were not associated with a decreased fistula rate compared with no closure.
CONCLUSIONS: A long LAMS dwell time, independent of closure technique, is associated with a high rate of persistent fistula. Based on the available data, minimizing LAMS dwell times should be recommended after EDGI. Whether primary closure helps decrease the risk of persistent fistula needs further investigation
Venous Thromboembolism Prevention in the Hospitalized Medical Patient
No full textAcutely ill hospitalized medical patients are at a higher risk of venous thromboembolism (VTE) compared to the general population. A universal thromboprophylaxis strategy upon admission is inadequate as it fails to consider individual patient VTE and bleeding risk factors. Validated risk assessment models help identify patients at elevated risk for VTE or bleeding, facilitating appropriate thromboprophylaxis. Extended VTE thromboprophylaxis should be considered in high VTE risk patients at low bleed risk upon discharge as VTE risk can remain increased for up to 45 days postdischarge
Photoacoustic Imaging for Image-Guided Gastric Tube Placement: Ex Vivo Characterization
No full textOver 250,000 gastrostomy tubes (G-tubes) are placed annually in the United States. Percutaneous endoscopic gastrostomy (PEG) is the most widely used clinical method for placing G-tubes within the stomach. However, endoscope detectability is limited due to the scattering of light by tissues. Poor organ visibility and low sensitivity of the palpation techniques cause blind needle insertions, which cause colon/liver perforations, abdominal bleeding, and gastric resections. Additionally, imaging artifacts and the poor distinguishability between water-filled tissues make ultrasound (US) imaging-based techniques incompatible with G-tube placement. The risk of ionizing radiation exposure and the confinement of fluoroscopy to radiology suites limits its bedside utility in patients. Considering these limitations, we propose to design a safe, point-of-care integrated US and photoacoustic (PA) imaging system for accurate G-tube placement procedures, for a broad spectrum of patients, and to characterize the system\u27s effectiveness. Our proposed technology utilizes a clinically safe contrast agent and a dual-wavelength approach for precise procedures. Our ex vivo tissue studies indicated that PA imaging accurately differentiates the different organs at specific wavelengths. Our characterization studies revealed that PA imaging could detect lower concentrations of Indocyanine Green (ICG) dye coating the colon wall, minimizing the risk of ICG dye-related toxicity and providing safer G-tube placements
The economic value of a transplant nephrologist: The case for improving compensation models
No full textThis article examined the economic value of transplant nephrologists and the need for adequate compensation. Kidney transplantation is a health and lifespan-extending procedure that relies on the expertise of transplant nephrologists. However, current compensation models, primarily based on relative value units (RVUs), often fail to capture the full scope of their work, particularly nonbillable activities essential to patient care. Additionally, regulatory compliance issues, particularly those related to the physician self-referral law (also known as the Stark law), complicate compensation structures. The Stark law mandates that physician compensation must align with fair market value to avoid conflicts of interest, adding complexity to designing compensation packages that accurately reflect the value of transplant nephrologists\u27 contributions. This article critiques the RVU-based system, highlighting its limitations in adequately compensating these specialists and proposing solutions such as integrating customized RVUs and outcome value units to better account for nonbillable work and incentivize high-quality care. The use of Medicare organ acquisition cost reports is also suggested to align compensation more closely with the actual economic value generated. A comprehensive approach that addresses both the quantitative and qualitative aspects of transplant nephrologists\u27 work, while navigating regulatory requirements, is essential for adequate and equitable compensation
Chronic Total Occlusion Percutaneous Coronary Intervention: Present and Future
No full textChronic total occlusion percutaneous coronary intervention has evolved into a subspecialty of interventional cardiology. Using a variety of antegrade and retrograde techniques, experienced operators currently achieve success rates of 85% to 90%, with an incidence of major periprocedural complications of ≈ 2% to 3%. Several developments in equipment (new microcatheters and guidewires, novel reentry devices), imaging (computed tomography angiography guidance, intravascular imaging for reentry), techniques (intraocclusion contrast injection, advanced subintimal tracking and reentry), and artificial intelligence (automated computed tomography image analysis and prediction of the likelihood of crossing success with various techniques) could further improve outcomes. Global collaboration and rapid dissemination of new developments accelerate the pace of progress. While innovation is exciting and necessary, adhering to the basic principles of chronic total occlusion percutaneous coronary intervention (such as continual assessment of risks and benefits, meticulous angiographic review, and use of dual injection) remains critical for achieving optimal patient outcomes
Study protocol for a stepped-wedge, randomized controlled trial to evaluate implementation of a suicide risk identification model among behavioral health patients in three large health systems
No full textBACKGROUND: Age-adjusted suicide rates have increased in the U.S. over the past 25 years. Algorithm-based methods for identifying individuals at risk for suicide based on electronic health record and claims data have been validated but few studies have evaluated implementation or effects on population-level suicide attempt rates.
METHODS: This hybrid type I effectiveness-implementation pragmatic clinical trial will test a suicide risk identification model in behavioral health clinics at three large health systems. Local decision-makers will determine implementation specifics at each site. Clinics within each health system will be randomized to determine order of implementation. A stepped-wedge design using repeated measures pre/post-implementation maximizes statistical efficiency and power with fewer participants compared to a parallel design while allowing all clinics to participate. A pre-implementation period will serve as the baseline. The primary outcome will be the rate of suicide attempt per 1000 visits at 90- and 180-days following a behavioral health visit in which an individual was identified by the suicide risk model compared with the baseline period (no use of suicide risk model). Secondary outcomes include identification of suicide risk and recognition of individuals at risk for suicide (e.g., completed risk assessment), both compared to the baseline period. Generalized linear mixed models will be used to account for clustering within clinics and repeated measures over time, adjusting for relevant covariates to estimate the effect of the suicide risk model on outcomes. Implementation outcomes, including system-level determinants and clinician acceptance and use of the suicide risk model, will also be measured.
CONCLUSIONS: Few suicide risk models derived from administrative and clinical data have been tested in real world care settings. This trial will determine whether the use of such a risk model reduces suicide attempts compared to usual care. By describing important implementation factors, use of such risk models, if effective, may be accelerated for other health care systems.
TRIAL REGISTRATION: ClinicalTrials.gov NCT06060535
Let’s Talk About it: Utilizing a Code Blue Debrief for Inpatient Resuscitation Events
Get PDFBackground: There is evidence to support the use of implementing clinical debriefing programs in the hospital setting. Implementing a standard debriefing program for teams that care for patients in cardiac arrest is shown to improve outcomes, yet in practice most events are not debriefed. Many hospitals currently use a debriefing tool for traumatic clinical events. However, many of these debriefing programs are focused on the Emergency Departments and pediatric events. Hypothesis: Utilizing a standard debrief tool for inpatient clinical resuscitation (Code Blue) events can identify areas for quality improvement. Methods: A literature review was performed including articles that related to a debriefing process following inpatient Code Blues or other critical clinical incidents. Based on the literature, a formal debriefing tool that utilized a gather, analyze, summarize (GAS) model of Code Blue debriefing was created (American Heart Association, 2023). The tool requested staff to identify potential areas of improvement related to teamwork, medical management, and environment. This tool was presented to the critical care leadership team and was approved for initiation in the critical care setting. The form could be used either immediately after an event took place or at the earliest available time for the resuscitation group to meet. The Code Blue debrief form would then be gathered, findings input into a tracking document, and analyzed. The results were summarized and presented to the hospital Code Blue Committee to enact process changes and discuss areas of opportunity. After receiving positive feedback from nursing, providers, clinical unit leaders, nurse managers, and directors the Code Blue debrief process and tool was implemented throughout the inpatient departments in the hospital. Results: Upon analysis of the 66 Code Blue debriefs (from November 2023 through June 2024), largest opportunities for improvement included crowd control (20%), equipment availability (14%), and a lack of clear roles (12%). Based on this data, new processes were outlined to improve quality and efficiency of resuscitation events. To address crowd control a recommendation was presented to nursing Unit Based Council that outlined necessary team members and roles. The task of removing excess personnel from the event was designated to the code team. Mock codes continue to be performed on the unit and emphasized the importance of crowd control and clearly communicated roles. Conclusions: Based on the positive feedback from the interdisciplinary team, the Code Blue debrief tool will continue to be utilized to help improve our resuscitation event response.https://scholarlycommons.henryford.com/hfjhrs2025/1002/thumbnail.jp
Scrub Club: No Dues, Just News
Get PDFBackground: At one midwestern teaching hospital, nurse engagement was not optimal and professional development opportunities focused on research and evidence-based practice (EBP) were lacking. The clinical nurse specialist (CNS) team identified journal clubs as an opportunity to increase engagement after reviewing the literature. This journal club was named, Scrub Club. Aims or research questions: The aim of this quality improvement (QI) project was to foster inquiry, disseminate EBP, build professional relationships, and utilize Scrub Club as a platform for professional development and advancement. Design: The QI project design was centered around the Plan, Do, Study, Act (PDSA) framework. Previously, the CNS team offered a quarterly continuing education event based off the organization’s annual needs assessment. The team wanted an active learning format offered more frequently to meet nursing requests. To increase attendance, a hybrid format was developed and offered. The CNS team reviewed the previous nursing needs assessment and identified topics of interest. This event occurred monthly on the same day as shared governance and was offered multiple times. To extend this opportunity, a call-in line was developed and utilized. Sample/Setting: At one midwestern teaching hospital, Scrub Club focused on optimizing professional development for both inpatient and outpatient nursing staff, as well as for advanced practice nursing providers. Data collection Procedures: To assess the effectiveness of Scrub Club, the CNS team recorded participant attendance and reviewed professional development portfolio submissions. Continuing education (CE) hours were disseminated to active Scrub Club participants. Professional development portfolio submissions were analyzed for the use of Scrub Club as an activity. For this activity to be counted the participant would need to attend at least six sessions annually. These two methods allowed data to be viewed from a nursing engagement and professional development perspective. Analysis: The analysis of this QI project showed an increase in the amount of participation in this professional development activity. Findings: In calendar year 2022, 112 nurses attended Scrub Club. In calendar year 2023, the number of nurses who attended Scrub Club rose to 195. Additionally, 34 nurses identified Scrub Club attendance as an activity within their submitted professional advancement portfolios for the 2022-2023 application period. This journal club QI project showed to be an effective and innovative way to cultivate professional development and advancement.https://scholarlycommons.henryford.com/hfjhrs2025/1003/thumbnail.jp
Carotid and Vertebral Anteriography
No full textWith rapid advancements in noninvasive vascular imaging, the use of conventional catheter angiography for the diagnostic evaluation of diseases of the carotid and vertebral arterial vasculature has shown a steady decline over time. Cross-sectional imaging modalities and other noninvasive techniques for vascular diagnosis are less prone to some of the risks associated with the invasive nature of catheter angiography and less prone to operator techniques and experience. Certain patients with severe allergic reaction to iodinated contrast may be imaged with unenhanced MRI techniques and Doppler ultrasound. However, there remain unique situations where invasive catheter angiography can be invaluable in the evaluation of extracranial carotid and vertebral disease and can be a useful problem-solving tool. Some common indications for arteriography of the extracranial carotid and vertebral arteries include conditions such as steno-occlusive disorders commonly due to atherosclerotic vascular disease; evaluation of aneurysms and vascular malformations of the head and neck, including upper cervical spinal vascular lesions; pre-therapeutic evaluation of vascular tumors; and balloon test occlusion prior to vessel sacrifice or surgical exploration
Comparison of Race-Neutral versus Race-Specific Spirometry Equations for Evaluation of Child Asthma
No full textRATIONALE: Race-based estimates of pulmonary function in children could influence the evaluation of asthma in children from racial and ethnic minoritized backgrounds. OBJECTIVES: To determine if race-neutral (GLI-Global) versus race-specific (GLI-Race-Specific) reference equations differentially impact spirometry evaluation of childhood asthma. METHODS: The analysis included 8,719 children aged 5 to \u3c12 years from 27 cohorts across the United States grouped by parent-reported race and ethnicity. We analyzed how the equations affected forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), and FEV(1)/FVC z-scores. We used multivariable logistic models to evaluate associations between z-scores calculated with different equations and asthma diagnosis, emergency department (ED) visits, and hospitalization. MEASUREMENTS AND MAIN RESULTS: For Black children, the GLI-Global vs. Race-Specific equations estimated significantly lower z-scores for FEV(1) and FVC but similar values for FEV(1)/FVC, thus increasing the proportion of children classified with low FEV(1) by 14%. While both equations yielded strong inverse relationships between FEV(1) and FEV(1)/FVC z-scores and asthma outcomes, these relationships varied across racial and ethnic groups (p\u3c0.05). For any given FEV(1) or FEV(1)/FVC z-score, asthma diagnosis and ED visits were higher among Black and Hispanic versus White children (p\u3c0.05). For FEV(1), GLI-Global equations estimated asthma outcomes that were more uniform across racial and ethnic groups. CONCLUSIONS: Parent-reported race and ethnicity influenced relationships between lung function and asthma outcomes. Our data show no advantage to race-specific equations for evaluating childhood asthma, and the potential for race-specific equations to obscure lung impairment in disadvantaged children strongly supports using race-neutral equations