SPECT/CT versus planar imaging to determine treatment strategy for non-small-cell lung cancer: a cost–effectiveness analysis

Aim: SPECT/CT has been found to improve predicted postoperative forced expiratory volume in one second (ppoFEV1) assessments in patients with non-small-cell lung cancer (NSCLC). Methods: An economic simulation was developed comparing the cost–effectiveness of SPECT/CT versus planar scintigraphy for a US payer. Clinical outcomes and cost data were obtained through review of the published literature. Results: SPECT/CT increased the accuracy ppoFEV1 assessment, changing the therapeutic decision for 1.3% of nonsurgical patients to a surgical option, while 3.3% of surgical patients shifted to more aggressive procedures. SPECT/CT led to an expected cost of $4694 per life year gained, well below typical thresholds. Conclusion: SPECT/CT resulted in substantially improved health outcomes and was found to be highly cost-effective.

Medications Reconciled at Discharge Versus Admission Among Inpatients at a Children’s Hospital

BACKGROUND AND OBJECTIVES Discharge prescription practices may contribute to medication overuse and polypharmacy. We aimed to estimate changes in the number and types of medications reported at inpatient discharge (versus admission) at a tertiary care pediatric hospital. METHODS Electronic medication reconciliation data were extracted for inpatient admissions at The Hospital for Sick Children from January 1, 2016, to December 31, 2017 (n = 22 058). Relative changes in the number of medications and relative risks (RRs) of specific types and subclasses of medications at discharge (versus admission) were estimated overall and stratified by the following: sex, age group, diagnosis of a complex chronic condition, surgery, or ICU (PICU) admission. Micronutrient supplements, nonopioid analgesics, cathartics, laxatives, and antibiotics were excluded in primary analyses. RESULTS Medication counts at discharge were 1.27-fold (95% confidence interval [CI]: 1.25–1.29) greater than admission. The change in medications at discharge (versus admission) was increased by younger age, absence of a complex chronic condition, surgery, PICU admission, and discharge from a surgical service. The most common drug subclasses at discharge were opioids (22% of discharges), proton pump inhibitors (18%), bronchodilators (10%), antiemetics (9%), and corticosteroids (9%). Postsurgical patients had higher RRs of opioid prescriptions at discharge (versus admission; RR: 13.3 [95% CI: 11.5–15.3]) compared with nonsurgical patients (RR: 2.38 [95% CI: 2.22–2.56]). CONCLUSIONS Pediatric inpatients were discharged from the hospital with more medications than admission, frequently with drugs that may be discretionary rather than essential. The high frequency of opioid prescriptions in postsurgical patients is a priority target for educational and clinical decision support interventions.

Effect of Web-based Clinical Decision Support Systems on Adherence to Venous Thromboembolism Prophylaxis guideline among ICU Nonsurgical Patients: A Prospective Before and After Study

Background and objective: There is a gap between expert recommendations and clinical practice in (Venous Thromboembolism) VTE prophylaxis among nonsurgical patients worldwide. Rate of adherence to evidence-based practice is inadequate in the nonsurgical population. Therefore, this study aimed to determine The effect of Clinical Decision Support Systems(CDSS) on the use of the appropriate VTE Prophylaxis in Nonsurgical Patients in the Intensive Care Unit (ICU).Method: We conducted a cross-sectional study (pre and post-implementation CDSS for recommendation VTE prophylaxis order set) to analyze the effect of the CDSS within CPOE on the appropriate VTE prophylaxis in three ICUs of the Nemazee hospital (before intervention from 20 April 2020, to 21 November 2020 and post-intervention duration form 7 April 2021, to 9 July 2021). The pre-intervention and post-intervention phase samples comprised 175 and 27 patients, respectively. P-value is less than 0.05 was considered a significant level. All statistical analysis was performed by SPSS version 24.Results: Adherence to VTE prophylaxis guidelines after introduced CDSS for recommendation VTE prophylaxis within CPOE system in nonsurgical patients in ICUs increase from 48.6% to 77.8% (p-value<01). However, mortality rate (pre-intervention 13.80% vs post-intervention 14.80%(p-value=0.88)) and means of length of stay (pre-intervention 13.66 vs post intervention13.63(p-value=0.49)) in ICU have not significantly change after introduced CDSS for recommendation VTE prophylaxis order sets.Conclusion: The results indicate that the CDSS for recommendation VTE prophylaxis within CPOE improves adherence to VTE prophylaxis in nonsurgical patients at ICUs, which assist provider to select the most tailored VTE prophylaxis. Further study needs to evaluate implemented CDSS for recommendation VTE prophylaxis in nonsurgical patients at a province and national level.

Treatment and Survival Patterns of Primary Adenosquamous Carcinoma of the Liver: A Retrospective Analysis

Background and AimsPrimary adenosquamous carcinoma (ASC) is a rare liver malignancy with very little data published so far. We describe the clinical characteristics of this tumor and analyze its survival pattern to improve the diagnosis and treatment.Materials and MethodsThis study collected data of 15 patients with primary hepatic ASC in our hospital within 10 years (from 2009 to 2018). We analyzed the clinical characteristics, imaging data, treatment, and survival of ASC in the study. Two of these cases have been reported.ResultsThe common clinical symptoms of hepatic ASC are liver pain and jaundice. Laboratory examination showed that carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) increased, but Alpha-FetoProtein (AFP) did not. Primary hepatic ASC is a rare subtype of intrahepatic cholangiocarcinoma (ICC) and meets the requirements of pathological diagnosis: CK20 (-), CK7 (+), CK19 (+), and p63 (+). Of the 15 patients, 11 were treated surgically, of which 3 patients received adjuvant chemotherapy. The prognosis of ASC patients is poor with a median survival time (MST) of 6 months (range: 2 to 15). The duration of MST in surgically treated patients was longer than that of nonsurgical patients (7.0 months vs. 3.0 months). Patients that received adjuvant chemotherapy survived longer (MST: 15 months). Patients with lymph node metastasis had a worse prognosis.ConclusionPrimary hepatic ASC is a rare malignant tumor with a poor prognosis. Radical surgery may be an effective treatment for prolonging survival. Surgical treatment combined with adjuvant therapy may further improve survival.

Basal ganglia calcification is associated with local and systemic metabolic mechanisms in adult hypoparathyroidism

Context Hypoparathyroidism is characterized by low serum calcium, increased serum phosphorus, and inappropriately low or decreased serum parathyroid hormone, which may be associated with soft tissue calcification in the basal ganglia of the brain. Objective To assess the prevalence and factors involved in the pathophysiology of basal ganglia calcification (BGC) in the brain in chronic hypoparathyroidism, and to evaluate proposed pathophysiologic mechanisms. Design Case-control study with retrospective review of medical records over 20 years. Setting Single academic medical center. Patients 142 patients with chronic hypoparathyroidism and CT head scans followed between 1/1/2000 and 7/9/2020, and 426 age- and sex-matched controls with CT head scans over the same interval. Interventions None. Main Outcome Measures Demographic, biochemical, and CT head imaging findings, with semi-quantitative assessment of volumetric BGC. Results The study found that 25.4% of 142 patients followed for a median of 17 years after diagnosis of chronic hypoparathyroidism had BGC, which developed at a younger age than in controls. BGC was 5.1-fold more common in nonsurgical patients, and less common in postsurgical patients. Low serum calcium and low calcium/phosphate ratio correlated with BGC. Neither serum phosphorus nor calcium x phosphate product predicted BGC. Lower serum calcium was associated with greater volume of BGC. The extent of BGC varied widely, with nonsurgical patients generally having a greater volume and distribution of calcification. Conclusions BGC is associated with low serum calcium and low serum calcium/phosphate ratio, which may be related to severity of the disease, its etiology, or duration of treatment.

Hipopara-Red, Real Life Experience in 322 Patients With Hypoparathyroidism

Context Hypoparathyroidism is a rare disease and, as such, its natural history, long-term complications, and correct clinical management remain unclear. Objective To describe the natural history and clinical characteristics of the disease. Design and Setting To present a retrospective observational analysis from 7 specialized centers in Buenos Aires, Argentina. Patients Chronic hypoparathyroid patients followed-up between 1985 and December 2018. Main Outcome Measures Data on demographics, etiology, clinical complications, biochemical parameters, dual-energy x-ray absorptiometry (DXA) values, and treatment doses were collected. Results A total of 322 subjects with chronic hypoparathyroidism were included; 85.7% were female, the mean age was 55.2 ± 16.8 years, and the mean age at diagnosis was 43.8 ± 16.8 years. Prevalence of surgical hypoparathyroidism was 90.7%, with the most common causes being thyroid carcinoma and benign thyroid disease. A history of hypocalcemia requiring hospitalization was present in 25.7% of the whole group and in 4.3% of patients who had a history of seizures. Overall, 40.9% of our patients had reported at least 1 neuromuscular symptom. Renal insufficiency was present in 22.4% of our patients and was significantly associated with age (P &lt; 0.0001). Hyperphosphatemia was present in 42% of patients. A history of severe hypocalcemia, paresthesias, tetany, ganglia calcifications, seizures, and cataracts was significantly higher in nonsurgical patients. Conclusion Although these patients were followed-up by experienced physicians, clinical management was heterogeneous and probably insufficient to assess all the potential complications of this chronic disease. Almost 70% of the study’s group of patients met the experts’ indications for considering the use of rhPTH 1–84. Being aware of this fact is the 1st step in improving our medical management of this disease in the future.

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic

Background The role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established. Methods A retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared. Results Trauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% ( P = .99) for all critically ill patients; and 13.9% vs. 27.4% ( P = .12) for COVID-19 critically ill patients. Conclusion Acute care surgery is an “essential” service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services.

Approach to Palliative Care Consultation for Patients With Malignant Bowel Obstruction in Gynecologic Oncology: A Qualitative Analysis of Physician Perspectives

PURPOSE: Malignant bowel obstruction (MBO) from gynecologic cancer is associated with increased symptoms and short survival. A gynecologic oncologist’s approach to palliative care consultation in the setting of MBO has not been well studied—it could be an opportune time for collaboration with palliative care. MATERIALS AND METHODS: This qualitative analysis of interviews with gynecologic oncologists focuses on their perspectives on palliative care consultation at the time of MBO. Interviews were analyzed using a framework analysis, and key themes and quotations were extracted. RESULTS: We interviewed 15 gynecologic oncologists from 8 institutions in Chicago. They described a variety of expectations from palliative care consultation. Most frequently, they consulted palliative care for specific questions but managed the remainder of the care. Most participants frequently consulted palliative care, but they also worried about fragmentation of care, the timing of when to introduce a new team during MBO, and the selection of appropriate patients for a limited resource. Many participants preferred earlier palliative care consultation, and many described an emotional toll of caring for patients with MBO. Palliative care consultation was most readily discussed for nonsurgical patients. CONCLUSION: Participants’ expectations of palliative care consultations during MBO varied and were not always met. We recommend strengthening communication and protocols for palliative care involvement that meet the needs of specific patient populations and physician teams for surgical and nonsurgical patients. More research is needed to better understand how to integrate palliative care into oncologic and surgical care with gynecologic oncologists.

Hemodynamic Effects of Dexmedetomidine in Adults With Reduced Ejection Fraction Heart Failure

Background: Dexmedetomidine (DEX) can cause hypotension complicating its use in critically ill patients with labile hemodynamics secondary to an underlying disease state such as heart failure. The aim of this study was to determine the effect of DEX on mean arterial pressure (MAP) in nonsurgical patients with heart failure and reduced ejection fraction (HFrEF). Methods: This retrospective single-center cohort study evaluated patients who received DEX in the cardiac care and medical intensive care units at a large academic hospital. The primary end point was the change in MAP within 6 hours following DEX initiation. Results: Sixty-five patients with HFrEF diagnosis were compared 1:1 to a control group without HFrEF. Both groups experienced a decrease in MAP over the study period. Patients with HFrEF had a greater absolute percentage reduction in MAP 1 hour following DEX initiation compared to the control group (−9.6% vs −5.2%; P < .01). When accounting for the combined effect of DEX initiation and HFrEF diagnosis on the primary end point, patients with HFrEF did not have a significant difference in MAP compared to the control group over the study period. Conclusions: Within 6 hours following DEX initiation, both groups experienced a decrease in MAP. The effect of DEX on MAP over the composite time period was not found to be significantly different in the HFrEF group compared to the non-HFrEF group. However, patients with HFrEF experienced a greater reduction in MAP in the first hour following DEX initiation compared to the non-HFrEF group. Prospective studies are needed to evaluate the effect of DEX on patients with acute decompensated HFrEF compared to patients with compensated HFrEF.