Hyperkalemia Following Parathyroidectomy in Patients with Renal Hyperparathyroidism—New Thresholds for Urgent Perioperative Dialysis

Parathyroidectomy (PTX) is a mainstay of treating secondary hyperparathyroidism (SHPT) in patients with kidney failure in order to reduce the incidence of cardiovascular events (CVE), increase overall survival and improve quality of life. Perioperative hyperkalemia may lead to devastating cardiac complications. Distinct preoperative thresholds for serum potassium levels (SPL) were defined, but neither their usefulness nor consecutive risks are understood. This study compared the results and efficacy of different clinical procedures in preventing or treating perioperative hyperkalemia, including postoperative urgent hemodialysis (UHD). Methods: Patients from Charité-Universitätsmedizin Berlin and Rheinland Klinikum Lukaskrankenhaus, Neuss, undergoing PTX due to SHPT between 2008 and 2018 were analyzed retrospectively with regard to demographic parameters, surgery specific conditions and perioperative laboratory results. Comparisons of patient values from both centers with focus on perioperative hyperkalemia and the need for UHD were performed. Results: A total of 251 patients undergoing PTX for SHPT were included (Neuss: n = 121 (48%); Berlin: n = 130 (52%)). Perioperative hyperkalemia (SPL ≥ 5.5 mmol/L) was noted in 134 patients (53%). UHD on the day of surgery was performed especially in patients with intraoperative hyperkalemia, in females (n = 40 (16%) vs. n = 27 (11%); p = 0.023), in obese patients (n = 27 (40%) vs. n = 50 (28%), p = 0.040) and more often in patients treated in Neuss (n = 42 (35%) vs. 25 (19%); p = 0.006). For patients treated in Neuss, the intraoperative hyperkalemia cut-off level above 5.75 mmol/L was the most predictive factor for UHD (n = 30 (71%) vs. n = 8 (10%); p < 0.001). Concerning secondary effects of hyperkalemia or UHD, no patient died within the postoperative period, and only three patients suffered from acute CVE, with SPL > 5.5 mmol/L measured in only one patient. Conclusion: Perioperative values could not predict postoperative hyperkalemia with the need for UHD. Previously defined cut-off levels for SPL should be reconsidered, especially for patients undergoing PTX. Early postoperative dialysis in patients with postoperative hyperkalemia can be performed with a low risk for complications and may be indicated for all patients with increased perioperative SPL.

Discussing patient preferences for levels of life-sustaining treatment: development and pilot testing of a Danish POLST form

Background Medically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients’ preferences for levels of life-sustaining treatment are known and documented. Methods The study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners’ clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient’s values and preferences. Family members and/or nursing staff could participate. Participants’ assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation. Results In total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future. Conclusion The Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients’ preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study.

Development of a model of medication review for use in clinical practice: Bristol medication review model

Background Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model. Methods A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. (BMC Fam Pract. 18:5, 2017), using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group (patients, doctors and pharmacists) developed the model through an iterative consensus process (appraisal of documents plus group discussions), working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material. Results We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice. Conclusions The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.

P.180 What do patients expect of a competent neurosurgeon?

Background: To improve accountability and reflect patient and societal needs, the Royal College of Physicians and Surgeons of Canada proposed Competence by Design (CBD) for all residency programs. This study compares neurosurgical patient values and expectations of their neurosurgeon to resident competences proposed by CBD curriculum. Methods: Semi-structured interviews of 30 neurosurgical patients and family members were recorded, transcribed and analyzed for themes. Results: Of the first 13 interviews (8 males, 5 females; median age 54), 10 had English as a first language, all completed post-secondary education, and 8 had a brain tumor. In addition to expecting excellent surgical skills and comprehensive medical knowledge, participants expected “good” neurosurgeons to be human (compassionate, empathetic, no ego), transparent communicators, accountable, passionate, collaborative, emotionally composed and highly intuitive. However, there were marked differences in minimum set of competencies required and the expectations of the thresholds to determine competence for neurosurgeons. Conclusions: Patient perspectives show commonalities and marked differences of the expected competencies compared to CBD and significant variability of the thresholds of competence. Further investigations should explore these themes in other specialties. The existing CBD curriculum will need to expand its framework to include humanistic values to improve public perceptions of competence.

Van patiëntenrechten naar patiëntenwaarden

From patients' rights to patients' values In 2022, the Patient’s Rights Act will be 20 years old. This Act has created a permanent recognition of the central position of the patient and his autonomy within the Belgian healthcare system. The Act did undergo some limited changes, but generally remained the same. Nevertheless, the evolution of the healthcare reveals new points of interest and demands attention to so-called patient values, namely quality, care innovation and patient participation. These patient values also reflect the critics formulated on the Patient’s Rights Act. The Belgian patient’s rights framework today consists of a number of other regulations besides the Patient’s Rights Act itself. All these regulations currently form a diffuse patient’s rights framework. In order to guarantee the central position of patient’s rights in our health care system for the next 20 years, a new approach of patient’s rights protection through the patient values is suggested in this article, focusing on quality, care innovation and patient participation and based on the existing legal patient’s rights framework.

Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

Clinical question What is the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes? Current practice Chronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries. Recommendation The guideline expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain. How this guideline was created An international guideline development panel including patients, clinicians with content expertise, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel applied an individual patient perspective. The evidence This recommendation is informed by a linked series of four systematic reviews summarising the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain. Understanding the recommendation The recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small to modest risk of mostly self limited and transient harms. Shared decision making is required to ensure patients make choices that reflect their values and personal context. Further research is warranted and may alter this recommendation.

Review of the 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation—What Has Changed and How Does This Affect Daily Practice

The high prevalence of atrial fibrillation (AF) in the overall population and its association with substantial morbidity, increased mortality and health care cost has instigated significant basic and clinical research efforts over recent years. The publication of multiple new high-quality randomized multi-center trials in the area of AF management and the rapidly evolving technological progress in terms of diagnostic possibilities and catheter ablation in recent years demanded a revision of the previous ESC AF Guidelines from 2016. The 2020 guidelines provide up-to-date, evidence-based guidance for the management of AF. One of the most important innovations is the presentation of a new concept for structural characterization of AF (the “4S AF scheme”) replacing the traditional classification based on its temporal pattern alone (paroxysmal-persistent-permanent). The 4S-AF-scheme highlights the importance of systematic assessment of stroke risk, severity of symptoms, total AF burden and underlying substrate as the foundation for effective and individualized AF treatment for each and every patient. Further novelties relate to the presentation of an easy and intuitive management pathway (“ABC pathway”) and strengthening the recommendations for early rhythm control, in particular the role of first line catheter ablation in heart failure. Another core component of the guidelines is the focus on patient involvement to achieve optimal outcomes. Patient education, shared decision making and incorporation of patient values and patient reported outcome of treatment interventions as well as integrated care by a multidisciplinary team all have a central role in the proposed management pathway for AF.

Patient values: A foundation for eHealth design and evaluation in BENEFIT for all (Preprint)

BACKGROUND eHealth interventions are developed to support and facilitate patients with lifestyle changes and (self) care tasks after being diagnosed with a chronic heart disease. Creating long lasting effects in lifestyle change and health outcomes with eHealth interventions is challenging and requires good understanding of patient values. OBJECTIVE This study aims to identify which values of cardiac patients should be considered when designing a technological lifestyle platform. METHODS A mixed-method design was applied, combining data from usability testing with an additional online survey study, to validate the outcomes of the usability tests. RESULTS Eleven relevant patient values were identified, including the need for security, support, not wanting to feel anxious, tailoring of treatment, and personalized, accessible care. The validation survey shows that all values but one (Value 9: To have extrinsic motivation to accomplish goals or activities (related to health/lifestyle)) were regarded as important/very important. A rating of very unimportant or unimportant was given by less than 2% of the respondents (0.5%¬¬–1.6%) to all values except but one (Value 9). CONCLUSIONS There is a remarkably high consensus among patients regarding the identified values reflecting goals and themes central to patients in their lives, while living with or managing their cardiovascular disease. The identified values can serve as a starting point for future research to translate and integrate these values into the design of the eHealth technology. This may call for prioritization of values, as not all values can be met equally.