scholarly journals Hemodynamics After Fontan Procedure are Determined by Patient Characteristics and Anastomosis Placement Not Graft Selection: a Patient-Specific Multiscale Computational Study

2021 ◽  
Author(s):  
Ethan Kung ◽  
Catriona Baker ◽  
Chiara Corsini ◽  
Alessia Baretta ◽  
Giovanni Biglino ◽  
...  
Keyword(s):  
Computational Study ◽  
Fontan Procedure ◽  
Flow Distribution ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
Systemic Circulation ◽  
Patient Specific ◽  
Virtual Surgery ◽  
Operative Outcomes ◽  
Graft Selection

Objectives: Patient-specific multiscale modeling simulates virtual surgeries of the Fontan procedure using three different graft options. Predictive modeling details post-operative outcomes that can help inform clinical decision support. Methods: Six patients underwent preoperative cardiac magnetic resonance imaging and catheterization. Virtual surgery is carried out for each patient to test the resulting hemodynamics of three Fontan graft options: ECC, 9mm Y-graft, and 12mm Y-graft. Results: 1) one-way ANOVA p>0.998 in all systemic pressures and flows between graft options, 2) p=0.706 for hepatic flow distribution between graft options, 3) local power loss differences do not affect the systemic circulation, 4) anastomosis positioning modification of the same Y-graft in the same patient changed left PA hepatic distribution from 0.66 to 0.49 Conclusions: Systemic pressures and blood flow after the Fontan procedure are not affected by graft selection but are well influenced by patient pulmonary vascular impedance. The hepatic distribution can be affected by anastomosis placement.

Numerical Analysis of the VAD Outflow Cannula Positioning on the Blood Flow in the Patient–Specific Brain Supplying Arteries

2020 ◽  
Vol 22 (2) ◽  
pp. 619-636 ◽  
Author(s):  
Zbigniew Tyfa ◽  
Damian Obidowski ◽  
Krzysztof Jóźwik
Keyword(s):  
Blood Flow ◽  
Computer Aided Design ◽  
Volume Flow Rate ◽  
Flow Distribution ◽  
Primary Objective ◽  
Patient Specific ◽  
Blood Flow Distribution ◽  
Reconstruction Process ◽  
Outflow Cannula ◽  
The Brain

AbstractThe primary objective of this research can be divided into two separate aspects. The first one was to verify whether own software can be treated as a viable source of data for the Computer Aided Design (CAD) modelling and Computational Fluid Dynamics CFD analysis. The second aspect was to analyze the influence of the Ventricle Assist Device (VAD) outflow cannula positioning on the blood flow distribution in the brain-supplying arteries. Patient-specific model was reconstructed basing on the DICOM image sets obtained with the angiographic Computed Tomography. The reconstruction process was performed in the custom-created software, whereas the outflow cannulas were added in the SolidWorks software. Volumetric meshes were generated in the Ansys Mesher module. The transient boundary conditions enabled simulating several full cardiac cycles. Performed investigations focused mainly on volume flow rate, shear stress and velocity distribution. It was proven that custom-created software enhances the processes of the anatomical objects reconstruction. Developed geometrical files are compatible with CAD and CFD software – they can be easily manipulated and modified. Concerning the numerical simulations, several cases with varied positioning of the VAD outflow cannula were analyzed. Obtained results revealed that the location of the VAD outflow cannula has a slight impact on the blood flow distribution among the brain supplying arteries.

scholarly journals Elderly Patients in Primary Care are Still at Risks of Receiving Potentially Inappropriate Medications

2021 ◽  
Vol 12 ◽  
pp. 215013272110350
Author(s):  
Pasitpon Vatcharavongvan ◽  
Viwat Puttawanchai
Keyword(s):  
Primary Care ◽  
Primary Care Clinic ◽  
Clinical Decision ◽  
Cross Sectional Study ◽  
Study Data ◽  
Patient Specific ◽  
Potentially Inappropriate Medications ◽  
Cross Sectional ◽  
Care Clinic ◽  
Inappropriate Medications

Background Most older adults with comorbidities in primary care clinics use multiple medications and are at risk of potentially inappropriate medications (PIMs) prescription. Objective This study examined the prevalence of polypharmacy and PIMs using Thai criteria for PIMs. Methods This study was a retrospective cross-sectional study. Data were collected from electronic medical records in a primary care clinic in 2018. Samples were patients aged ≥65 years old with at least 1 prescription. Variables included age, gender, comorbidities, and medications. The list of risk drugs for Thai elderly version 2 was the criteria for PIMs. The prevalence of polypharmacy and PIMs were calculated, and multiple logistic regression was conducted to examine associations between variables and PIMs. Results Of 2806 patients, 27.5% and 43.7% used ≥5 medications and PIMs, respectively. Of 10 290 prescriptions, 47% had at least 1 PIM. The top 3 PIMs were anticholinergics, proton-pump inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs). Polypharmacy and dyspepsia were associated with PIM prescriptions (adjusted odds ratio 2.48 [95% confident interval or 95% CI 2.07-2.96] and 3.88 [95% CI 2.65-5.68], respectively). Conclusion Prescriptions with PIMs were high in the primary care clinic. Describing unnecessary medications is crucial to prevent negative health outcomes from PIMs. Computer-based clinical decision support, pharmacy-led interventions, and patient-specific drug recommendations are promising interventions to reduce PIMs in a primary care setting.

scholarly journals Implementation of pharmacogenomic testing in oncology care (PhOCus): study protocol of a pragmatic, randomized clinical trial

2020 ◽  
Vol 12 ◽  
pp. 175883592097411
Author(s):  
Natalie Reizine ◽  
Everett E. Vokes ◽  
Ping Liu ◽  
Tien M. Truong ◽  
Rita Nanda ◽  
...  
Keyword(s):  
Clinical Laboratory ◽  
Drug Effects ◽  
Dose Intensity ◽  
Progression Free Survival ◽  
Clinical Decision ◽  
Drug Dose ◽  
Patient Specific ◽  
Drug Dosing ◽  
Patient Reported ◽  
Dose Modifications

Background: Many cancer patients who receive chemotherapy experience adverse drug effects. Pharmacogenomics (PGx) has promise to personalize chemotherapy drug dosing to maximize efficacy and safety. Fluoropyrimidines and irinotecan have well-known germline PGx associations. At our institution, we have delivered PGx clinical decision support (CDS) based on preemptively obtained genotyping results for a large number of non-oncology medications since 2012, but have not previously evaluated the utility of this strategy for patients initiating anti-cancer regimens. We hypothesize that providing oncologists with preemptive germline PGx information along with CDS will enable individualized dosing decisions and result in improved patient outcomes. Methods: Patients with oncologic malignancies for whom fluoropyrimidine and/or irinotecan-inclusive therapy is being planned will be enrolled and randomly assigned to PGx and control arms. Patients will be genotyped in a clinical laboratory across panels that include actionable variants in UGT1A1 and DPYD. For PGx arm patients, treating providers will be given access to the patient-specific PGx results with CDS prior to treatment initiation. In the control arm, genotyping will be deferred, and dosing will occur as per usual care. Co-primary endpoints are dose intensity deviation rate (the proportion of patients receiving dose modifications during the first treatment cycle), and grade ⩾3 treatment-related toxicities throughout the treatment course. Additional study endpoints will include cumulative drug dose intensity, progression-free survival, dosing of additional PGx supportive medications, and patient-reported quality of life and understanding of PGx. Discussion: Providing a platform of integrated germline PGx information may promote personalized chemotherapy dosing decisions and establish a new model of care to optimize oncology treatment planning.

Evaluation and cost estimation of laboratory tests overuse through a CCDSS in a university hospital

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
D Vallone ◽  
A Tamburrano ◽  
C Carrozza ◽  
A Urbani ◽  
A Cambieri ◽  
...  
Keyword(s):  
Cost Estimation ◽  
Laboratory Tests ◽  
Quality Care ◽  
Clinical Decision Support Systems ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
University Hospital ◽  
Specific Patient ◽  
Global Rate ◽  
Common Laboratory

Abstract Computerized Clinical Decision Support Systems (CCDSS) are information technology-based systems that use specific patient characteristics and combine them with rule-based algorithms. The aim of this study is to conduct a survey to measure and assess the over-utilization rates of laboratory requests and to estimate the monthly cost of inappropriate requests in inpatients of the “Fondazione Policlinico Universitario A. Gemelli IRCCS” Care Units. This observational study is based on the count of rules violations for 43 different types of laboratory tests requested by the Hospital physicians, for a total of 5,716,370 requests, over a continuous period of 20 months (from 1 July 2016 to 28 February 2018). Requests from all the hospital internal departments (except for Emergency, Intensive Care Units and Urgent requests) were monitored. The software intercepted and counted, in silent mode for the operator, all requests and violations for each laboratory test among those identified. During the observation period a mean of 285,819 requests per month were analyzed and 40,462 violations were counted. The global rate of overuse was 15.2% ± 3.0%. The overall difference among sub-groups was significant (p < 0.001). The most inappropriate exams were Alpha Fetoprotein (85.8% ± 30.5%), Chlamydia trachomatis PCR (48.7% ± 8.8%) and Alkaline Phosphatase (20.3% ± 6.5%). All the exams, globally considered, generated an estimated avoidable cost of 1,719,337€ (85,967€ per month) for the hospital. This study reports rates (15.2%) similar to other works. The real impact of inappropriateness is difficult to assess, but the generated costs for patients, hospitals and health systems are certainly high and not negligible. Key messages It would be desirable for international medical communities to produce a complete panel of prescriptive rules for all the most common laboratory exam. That is useful not only to reduce costs, but also to ensure standardization and high-quality care.

scholarly journals Early outcomes and predictors of patient satisfaction after TKA: a prospective study of 200 cases with a contemporary cemented rotating platform implant design

2021 ◽  
Vol 8 (1) ◽  
Author(s):  
Corné van Loon ◽  
Niels Baas ◽  
Verdonna Huey ◽  
James Lesko ◽  
Geert Meermans ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Clinical Improvement ◽  
Patient Characteristics ◽  
Patient Reported Outcome ◽  
Implant Design ◽  
Rotating Platform ◽  
Radiographic Outcomes ◽  
Operative Outcomes ◽  
Patient Reported ◽  
Time Point

Abstract Purpose The purpose of the study was to identify the earliest time point where subjects realized the greatest clinical improvement after TKA, and the time when post-operative scores became superior to pre-operative scores. Post-hoc exploratory analyses were conducted to investigate predictors of early post-operative outcomes and patient satisfaction. Methods Six investigators across 4 sites in the Netherlands prospectively implanted 200 subjects with a contemporary cemented rotating platform device. Patient Reported Outcome Measurements (PROMs) KOOS-PS, PKIP, and EQ-5D were collected pre-operatively and post-operatively through 2-years. PROMs change from pre-operative baseline were summarized, along with radiographic outcomes and adverse events (AEs). Pre-operative patient characteristics were explored for correlation with patient outcomes, and patient satisfaction for correlation with KOOS-PS. Results Follow-up compliance was 99% at 6-months, and 95.5% at 2-years. The percentage with higher KOOS-PS compared to baseline was 81.3% at 6-months. KOOS-PS, PKIP, and PKIP subscore means were all better at 6-weeks versus baseline. Gender, BMI, hypertension, and pre-operative KOOS-PS were weakly correlated with 6-week KOOS-PS (multivariate R-squared = 14.1%), but only pre-operative KOOS-PS demonstrated correlation with post-operative KOOS-PS at 6-months or later (R-squared < 5% at 6-months and 2 years). Satisfaction was moderately correlated with concurrent KOOS-PS at each post-operative time point, with (R-squared = 35.3% at 6-months, and 37.5% at 2 years). Conclusion The greatest mean clinical improvement occurred within the first 6-weeks. Although some pre-operative factors were correlated with higher early post-operative KOOS-PS outcomes, these advantages disappeared by 6-months aside from weak correlation with pre-operative KOOS-PS. Post-operative KOOS-PS was moderately correlated with concurrent post-operative satisfaction. These results may be used for pre-operative counseling and management of patient’s postoperative expectations. Trial registration Clinicaltrials.gov, NCT02339610. Registered 15 January 2015.

Abstract 115: Improving Door-to-Needle Times in Acute Ischemic Stroke: Interim Findings From Target: Stroke Phase II

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Gregg C Fonarow ◽  
Margueritte Cox ◽  
Eric E Smith ◽  
Jeffrey L Saver ◽  
Mathew J Reeves ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Phase I ◽  
Acute Ischemic Stroke ◽  
Phase Ii ◽  
Best Practice ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
Absolute Difference ◽  
First Year ◽  
Rate Of Increase

Background: The benefits of intravenous tPA in acute ischemic stroke are time-dependent with guidelines recommending a door-to-needle (DTN) time of ≤60 minutes. The implementation of Target: Stroke Phase I in 2010 was associated with an increase in the proportion of patients with DTN times ≤60 minutes in the US from 28.9% in 2009 to 51.0% in 2013. This study aims to assess whether these improvements in DTN times could be maintained or further improved since the launch of Target: Stroke Phase II in Q2 2014. Methods: Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤60 minutes were compared during final 4 quarters of Phase I (Q4 2012-Q3 2013) vs. Phase II (Q2 2014-Q1 2015) and overall by linear weighted regression. Results: There were 99,176 intravenous tPA treated patients from 1228 GWTG-Stroke hospitals. Patient characteristics were similar during Phase I and II. Median DTN time significantly declined from the last 4 quarters of Phase I to the first 4 quarters of Phase II: 61 minutes (IQR 47-81) to 57 minutes (IQR 43-74) (P<0.0001). The % of patients with DTN times ≤60 minutes increased from last 4 quarters of Phase I to Phase II: 49.7% to 58.5%, absolute difference +8.8%, (P<0.0001). The % of patients with DTN times ≤45 minutes also increased from Phase I to Phase II: 22.0% to 29.2%, absolute difference +7.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤60 minutes was 0.6% per year pre-Target Stroke, 5.6% per year during Phase I, and 8.6% in the first year of Phase II (P<0.0001) (Figure). Conclusions: The timeliness of tPA administration is continuing to improve in GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, ongoing quality improvement efforts will be required to meet the goals of ≥75% of patients with DTN times ≤60 minutes and ≥50% of patients with DTN times ≤ 45 minutes.

scholarly journals Retrospective SPECT/CT Dosimetry Following Transarterial Radioembolization

2020 ◽  
Author(s):  
Briana C. Thompson ◽  
William A. Dezarn
Keyword(s):  
Background Subtraction ◽  
Liver Tumors ◽  
Dose Calculation ◽  
Patient Characteristics ◽  
Beta Particle ◽  
Patient Specific ◽  
Image Study ◽  
Dose Distributions ◽  
Transarterial Radioembolization ◽  
Spect Images

Abstract Background: Transarterial Radioembolization (TARE) effectively treats unresectable primary and metastatic liver tumors through local injection of Yttrium-90 (90Y) beta particle emitting microspheres. These microspheres implant around the tumor, damaging tumorous cells while sparing healthy liver tissue. Current dosimetry models are highly simplistic and based patient characteristics such as body surface area and fail to consider many important factors. There is a large need for an imaged based dosimetry post-TARE which would improve treatment safety and efficacy. Current post-TARE imaging is 90Y bremsstrahlung SPECT/CT and we study the use of these images for post-TARE dosimetry. Methods: Retrospective image review of 10 patients having a Philips HealthcareTM SPECT/CT following TARE SIR-Spheres® implantation. Emission series with attenuation correction were resampled to 3mm resolution and used to create image based dose distributions. Dose distributions and analysis were performed in MIM Software SurePlanTM utilizing SurePlanTM Local Deposition Method (LDM) and our own dose convolution method (WFBH). We sought to implement a patient specific background subtraction technique prior to dose calculation to make these noisy bremsstrahlung SPECT images suitable for post-TARE dosimetry calculations. Results: On average the percentage of mean background counts to maximum count in the image across all patients was 9.4 ± 4.9% with a maximum of 17.6% and minimum of 2.3%. Absolute dose increased and profile line width decreased as background subtraction value increased. The average value of the LDM and WFBH dose methods were statistically the same. As background subtraction value increased, we found the DVH curves to become unrealistic and distorted.Conclusion: Background subtraction on bremsstrahlung SPECT image had a large effect on post-TARE dosimetry. The background contour we defined provides a systematic estimate to the activity background that accounts for the scanner and patient conditions at the time of the image study and is easily implemented using commercially available software. We found using the mean count in the background contour as a constant subtraction across the entire image gave the most realistic dose distributions. Comparison of dosimetry from background subtracted SPECT images to image based dosimetry obtained via 90Y PET images will be the subject of our next analysis.

scholarly journals Necrotizing fasciitis: presentation, microbiology and outcomes in a community hospital

2020 ◽  
Vol 7 (8) ◽  
pp. 2471
Author(s):  
Mercy N. Jimenez ◽  
Emily S. Seltzer ◽  
Bhavana Devanabanda ◽  
Martine Louis ◽  
Nageswara Mandava
Keyword(s):  
New York ◽  
Necrotizing Fasciitis ◽  
Clinical Decision Making ◽  
Community Hospital ◽  
Average Length ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
Blood Cultures ◽  
Average Length Of Stay

Background: Necrotizing fasciitis (NF) is an aggressive and often fatal, soft tissue infection. Delayed surgical therapy leads to worsened outcomes. This study evaluates the mortality, outcomes, and characteristics of patients with NF in a diverse New York City Community Hospital Network.Methods: Retrospective chart review from 2012 to 2019 using ICD-9 and ICD-10 codes of gas gangrene, Fournier’s gangrene, and necrotizing fasciitis was done. Of the 297 patients reviewed 28 met inclusion criteria of imaging findings, operative reports, and clinical diagnosis of NF by an attending surgeon.Results: On average patients in ER were seen by the surgical team within less than 12 hours. Most patients were debrided within 10 hours of surgical consultation and on average received 2.2 procedures. Of the wound cultures obtained 65.38% were polymicrobial in nature. The average length of stay was 17.4 days and 32% of patients required ICU admission. The surgical mortality rate was 7.61%.Conclusions: Necrotizing fasciitis is a rare entity and increasing provider knowledge on patient characteristics as well as the complexity of these patients and the types and number of procedures they require may help guide clinical decision making. We identified that while most of our patients had negative blood cultures on admission, those that had positive blood cultures had multiple organisms growing. Knowing that these patients are complex and likely require multiple procedures, prompt operative intervention is key.

scholarly journals Impact of Adjustment for Quality on Results of Metaanalyses of Diagnostic Accuracy

2007 ◽  
Vol 53 (2) ◽  
pp. 164-172 ◽  
Author(s):  
Mariska Leeflang ◽  
Johannes Reitsma ◽  
Rob Scholten ◽  
Anne Rutjes ◽  
Marcello Di Nisio ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Quality Assessment ◽  
Confidence Intervals ◽  
Systematic Reviews ◽  
Methodological Quality ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
High Quality ◽  
Poor Reporting

Abstract Background: We examined whether and to what extent different strategies of defining and incorporating quality of included studies affect the results of metaanalyses of diagnostic accuracy. Methods: We evaluated the methodological quality of 487 diagnostic-accuracy studies in 30 systematic reviews with the QUADAS (Quality Assessment of Diagnostic-Accuracy Studies) checklist. We applied 3 strategies that varied both in the definition of quality and in the statistical approach to incorporate the quality-assessment results into metaanalyses. We compared magnitudes of diagnostic odds ratios, widths of their confidence intervals, and changes in a hypothetical clinical decision between strategies. Results: Following 2 definitions of quality, we concluded that only 70 or 72 of 487 studies were of “high quality”. This small number was partly due to poor reporting of quality items. None of the strategies for accounting for differences in quality led systematically to accuracy estimates that were less optimistic than ignoring quality in metaanalyses. Limiting the review to high-quality studies considerably reduced the number of studies in all reviews, with wider confidence intervals as a result. In 18 reviews, the quality adjustment would have resulted in a different decision about the usefulness of the test. Conclusions: Although reporting the results of quality assessment of individual studies is necessary in systematic reviews, reader wariness is warranted regarding claims that differences in methodological quality have been accounted for. Obstacles for adjusting for quality in metaanalyses are poor reporting of design features and patient characteristics and the relatively low number of studies in most diagnostic reviews.

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