RocScholar (Rochester Regional Health)
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A case report on missed case of lynch syndrome with PMS2 loss of expression at extreme age.
Get PDFLynch syndrome is an autosomal dominant disorder affecting one of the mismatch repair (MMR) genes. Amsterdam and revised Bethesda criteria are used to identify individuals at risk for Lynch syndrome, but they have limited sensitivity. The CRC Risk assessment tool is effective in identifying high-risk individuals and mutation carriers of Lynch syndrome. Here, in this case report, we present an 84-year-old female with a positive family history of colon cancer in her mother and grandmother, presented in the clinic for a 3-year colonoscopy follow-up, who was found to have a 3 cm sigmoid lesion with central ulceration at 28 cm. The pathology of the sigmoid lesion revealed moderately to poorly differentiated invasive adenocarcinoma of the sigmoid colon. Immunohistochemistry testing for MMR proteins revealed a loss of nuclear expression of PMS2. She underwent a robotic total abdominal colectomy, and a robot-assisted laparoscopic hysterectomy in the same setting. This case offers valuable insight into the reasons behind the delayed diagnosis of lynch syndrome and suggests solutions to prevent such cases from being missed
D-3 Comparative Mortality Trends in Atrial Fibrillation vs. Other Arrhythmias in Acute Myocardial Infarction: A CDC WONDER Database Analysis
No full textManagement of Complex Patients and Patient Dismissal Processes for the Department of Primary Care
No full textManagement of Complex Patients and Patient Dismissal Processes for the Department of Primary Care. Rebecca Dellefave, MS, BSN, RN, VP, CNO RRH Ambulatory Services; Elizabeth Carreira, MSBA, BSN, NEA-BC, CPPs, AMB-BC, Director of Nursing; Georgina Curtiss, Quality Specialist, Unity Hospital Quality Management.
Develpoment of an ambulatory care complex patient management process
Frailty Predicts Mortality and Procedural Performance in Patients With Non-Variceal Upper Gastrointestinal Bleeding
No full textIntroduction: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common cause of hospitalization in the United States, with approximately 400 000 admissions annually and a 5%-10% mortality rate. This study aimed to evaluate frailty\u27s impact on NVUGIB outcomes.
Methods: We utilized the 2019 National Readmission Database (NRD) to identify adult patients (≥ 18 years) admitted with a principal diagnosis of NVUGIB using ICD-10-CM codes. NVUGIB hospitalizations were stratified by frailty using the hospital frailty risk score (HFRS) of 5 or more as the cut-off for frailty. Multivariate regression analyses were conducted to analyze the outcomes. STATA 14.2 was used for statistical testing.
Results: Among 218 647 NVUGIB admissions, 99 892 (45.69%) were frail. Frail patients were older, more often female, and had higher comorbidity burdens. They showed significantly greater in-hospital mortality (adjusted odds ratio [aOR] 5.64, 95% CI 4.94-6.44; p \u3c 0.001), acute kidney injury (5.85), respiratory failure (6.93), septic shock (40.94), hemorrhagic shock (2.64), vasopressor use (4.36), mechanical ventilation (6.04), and ICU admission (5.41). Although frail patients had higher odds of esophagogastroduodenoscopy (EGD) with intervention (1.04; p \u3c 0.001), they were less likely to receive EGD within 24 h (0.75; p \u3c 0.001). They also had higher odds of rebleeding (1.18; p \u3c 0.001) and radioembolization (2.69; p \u3c 0.001). Length of stay increased by 2.30 days, total charges rose by $28 518, discharge to rehabilitation was more frequent (3.12; p \u3c 0.01), and 30-day readmission was higher (15.24% vs. 11.43%, HR 1.16; p \u3c 0.001).
Conclusion: Frailty independently predicts worse clinical outcomes and increased resource use in NVUGIB. Recognizing frailty may improve risk stratification and guide more tailored management strategies for this high-risk population
A phase 3 study of ravulizumab to protect patients with chronic kidney disease from cardiac surgery-associated acute kidney injury and major adverse kidney events (ARTEMIS)
No full textBACKGROUND: Cardiac procedures, particularly those requiring cardiopulmonary bypass (CPB), are associated with the development of cardiac surgery-associated acute kidney injury (CSA-AKI). Development of CSA-AKI occurs as a result of inflammation, uncontrolled complement activation, and kidney cell damage. In patients with preoperative renal impairment, such as those with chronic kidney disease (CKD), there is an increased risk of both CSA-AKI and poorer clinical outcomes. Currently, there are limited effective, targeted pharmacological interventions for the prevention or treatment of CSA-AKI, although emerging therapies are being investigated, particularly in patients with existing CKD. The ARTEMIS (RAvulizumab to PRotect PaTients with Chronic Kidney DisEase froM CSA-AKI and Subsequent Major Adverse Kidney Events) trial will assess the efficacy and safety of ravulizumab (a complement C5 inhibitor) in reducing the risk of major adverse kidney events (MAKE) in patients with preoperative CKD undergoing non-emergent cardiac surgery with CPB.
METHODS: This trial is currently recruiting patients with CKD who have planned cardiac surgery requiring CPB including coronary artery bypass grafting, valve replacement or repair, or combined procedures. This is a phase 3, randomized, double-blind, placebo-controlled, global study assessing the efficacy and safety of a single preoperative dose of ravulizumab. These outcomes will be assessed using the occurrence of MAKE and its components, as well as the occurrence and severity of CSA-AKI throughout the study period.
DISCUSSION: Complement activation is known to occur during and after cardiac procedures as a result of CPB and ischemia-reperfusion injury, leading to a cycle of cell damage and death. Therefore, it is hypothesized that preoperative administration of ravulizumab will provide immediate and complete complement inhibition, which will be sustained throughout the surgical period, preventing the uncontrolled complement activation associated with the development of CSA-AKI, thus minimizing poor outcomes for patients.
TRIAL REGISTRATION: ClinicalTrials.gov NCT05746559. Registered on February 27, 2023
HRS/ACC scientific statement: Guiding principles on same-day discharge for intracardiac catheter ablation procedures
No full textPercutaneous catheter ablation in interventional cardiac electrophysiology has evolved over the past several decades. Technologic advances and evolving procedural strategies have improved procedural efficiencies, increased success rates, and lowered complication rates. These advances have increased the ability to treat more patients successfully; however, limitations to access have grown. Access challenges (exacerbated during the COVID-19 public health emergency) and economic pressures have driven a shift in practice trends to reduce hospitalization duration and optimize resource utilization. A same-day discharge (SDD) strategy has increasingly been used to address these challenges. Incorporating a SDD strategy has recently been supported by global clinical studies (demonstrating proof of concept) and real-world evidence/United States Centers for Medicare & Medicaid Services claims data (characterizing a low incidence of complications and need for readmission/emergency department visits). This document analyzes available global clinical data and real-world evidence examining the impact of a cardiac ablation SDD strategy on patient safety, patient access, operational efficiencies, and health care expenditures. Recommended best practices will also be characterized built on the foundation of a shared decision-making strategy that optimizes patient safety, comfort, and procedural outcomes. As clinical flow paradigms evolve with alternate sites of care (ie, ambulatory surgery centers), real-world registries to track outcomes should inform future decision-making
Effect of group virtual exercise on people with Parkinson\u27s disease: A randomized controlled trial
No full textBackground: For people with Parkinson\u27s disease (PwPD), high-intensity exercise in individual or group format can improve function and quality of life (QoL). Individualized virtual exercise programs have been effective for people with PD, but the feasibility and impact of group exercise in the virtual format has not been investigated.
Purpose: To compare the effect of individual and group virtual exercise on functional mobility and QoL for PwPD.
Methods: Twenty PwPD were randomized to individualized (n = 10) or group (n = 10) virtual exercise 2 times per week for 8 weeks. Exercises were multi-dimensional, and intensity was monitored with a wrist-worn heart rate (HR) monitor. Outcomes were assessed before and after the program, including standing balance, gait speed, gait endurance, motor function, QoL, and self-efficacy. Within-and between-group changes were analyzed using a mixed model analysis of variance (ANOVA) and nonparametric tests were used for analysis.
Results: Participants attended over 75% of scheduled sessions. Within-group analysis showed statistically significant improvements in Five Times Sit-to-Stand (p \u3c .01), mini-BESTest (p = .03), comfortable (p \u3c .01) and fast gait speeds (p = .02), and gait endurance (p \u3c .01) with large effect sizes (partial eta squared \u3e 0.25). There were no statistically significant differences between groups on any outcomes (p \u3e .09). In more than 70% of sessions, participants reached an exercise intensity ≥ 65% HR maximum.
Conclusion: This high-intensity, virtual exercise program was safe and effective at improving balance and functional mobility for community-dwelling PwPD in individual and group format. Virtual exercise programs, either in an individual or group format, can increase access to high-quality programs for PwPD
Beyond the Badge: Bridging Leadership and Management in Healthcare
No full textBeyond the Badge: Bridging Leadership and Management in Healthcare. Dr. Saarwaani Vallabhajosyula, Internal Medicine Resident Program - Chief, Rochester General Hospital; Dr. Omofolarin Babayale, Internal Medicine Resident Program - Chief, Rochester General Hospital; Dr. Anas Hashem, Internal Medicine Resident Program - Chief, Rochester General Hospital
Objectives: Understand the roles and distinctions between managers and leaders Explore key strategies for advocating for underrepresented groups and fostering a non-toxic culture Apply ethical leadership principles to manage moral injury and distress in clinical practic