Category: Nevin Manimala

BMJ Open Qual. 2021 Nov;10(4):e001603. doi: 10.1136/bmjoq-2021-001603.

ABSTRACT

BACKGROUND: Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%-73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes.

OBJECTIVE: Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case.

METHODS: An interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a teaching practice within a large academic medical centre. Results were used to conduct an engineering process analysis, assess variation within and between practices, and identify common failure modes and potential solutions.

RESULTS: Processes to complete diagnostic referrals involve many sub-standard design constructs, with significant workflow variation between and within practices, statistical instability and special cause variation in completion rates and timeliness, and only 21% of all process activities estimated as value-add. Failure modes were similar between the two practices, with most process activities relying on low-reliability concepts (eg, reminders, workarounds, education and verification/inspection). Several opportunities were identified to incorporate higher reliability process constructs (eg, simplification, consolidation, standardisation, forcing functions, automation and opt-outs).

CONCLUSION: From a systems science perspective, diagnostic referral processes perform poorly in part because their fundamental designs are fraught with low-reliability characteristics and mental models, including formalised workaround and rework activities, suggesting a need for different approaches versus incremental improvement of existing processes. SE perspectives and methods offer new ways of thinking about patient safety problems, failures and potential solutions.

PMID:34844935 | DOI:10.1136/bmjoq-2021-001603

Clin Lymphoma Myeloma Leuk. 2021 Oct 31:S2152-2650(21)02388-0. doi: 10.1016/j.clml.2021.10.007. Online ahead of print.

ABSTRACT

POEMS syndrome, a rare plasma cell disorder, is challenging both in the diagnostic and therapeutic management. We present real word retrospective analysis of 108 cases analyzing clinical features and therapeutic modes. We compare our results with the available literature. This is the first description with such wide use of proteasome inhibitors in first line treatment. POEMS (Polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes) syndrome is a rare and challenging plasma cell disorder, both in the diagnostic and therapeutic management of the disease. Currently, the literature on POEMS is sparse with most evidence being case reports and small case studies. We present a retrospective real world experience of 108 patients with POEMS. We analyzed the clinical features and therapeutic interventions. Regarding clinical features, our findings demonstrated that skin lesions, thrombocythemia and polycythemia were present less frequently than reported previously. Regarding clinical interventions, this is one of the largest analyses of front line treatment in POEMS and the first one to include frequent utilization of proteasome inhibitors (37%). Bortezomib monotherapy was the most effective therapy achieving complete remission/very good partial remissions (CR/VGPR) in 69% of patients. Thirty percent of patients proceeded to planned autologous stem cell transplant (ASCT) as part of the front-line treatment resulting in statistically superior progression-free (PFS) and overall survival (OS) compared to non-ASCT treated patients (P= .003). In multivariate analysis, anemia, thrombocytopenia, and as age over 60 were associated with a negative impact on patient outcomes.

PMID:34844892 | DOI:10.1016/j.clml.2021.10.007

J Optom. 2021 Nov 26:S1888-4296(21)00065-0. doi: 10.1016/j.optom.2021.10.001. Online ahead of print.

ABSTRACT

OBJECTIVE: The main objective of this study was to obtain percentile curves of stereoacuity in arc seconds for a Spanish population aged between three and twelve years of age.

MATERIALS AND METHODS: A descriptive, observational and transversal study was conducted, which included children aged between three and twelve years of age who did not present with any known ocular and/or systemic diseases. The convenience sampling method was used to select the sample from three schools and one hospital in the Community of Madrid. The Bueno-Matilla Vision Unit’s random dot test was used to measure stereoacuity. A descriptive statistic was performed with the stereoacuity values that were obtained for the 5th, 10th, 25th, 50th, 75th, 90th and 95th percentiles.

RESULTS: The stereoacuity values of 1300 children were analysed. In the 50th percentile curve, it was determined that stereoacuity values close to 40 sec/arc were present from four years of age, and at four years and nine months, stereoacuity values close to 28 sec/arc were already being observed within said percentile, with values that were similar to those expected in the adult population. A progressive increase was observed, reaching 19 sec/arc before six years of age, with this stereoacuity value becoming more established in children from seven years of age.

CONCLUSION: Although given the specific type of sampling that was performed it was not possible to generalise the results to the entire population, these percentile curves may aid paediatric professionals in their assessment of the development of this visual ability, which is indicative of the degree of development of binocular vision.

PMID:34844895 | DOI:10.1016/j.optom.2021.10.001

Surgeon. 2021 Nov 26:S1479-666X(21)00163-3. doi: 10.1016/j.surge.2021.09.006. Online ahead of print.

ABSTRACT

This retrospective study was performed to analyse if laterality of the retrieved living donor kidney had any effect on donor and recipient outcomes after hand assisted laparoscopic donor nephrectomy (HALDN). 739 donors who underwent HALDN between January 2006 and January 2018 at a large tertiary transplant centre in the United Kingdom were included. Donor outcomes in individuals undergoing right versus left HALDN were compared with respect to conversion rates, morbidity, warm and cold ischaemia times and recipient failure rates, vascular and ureteric complications. 604 (81.7%) underwent left HALDN and 135 (18.3%) underwent right HALDN, mean age was 47.1 years and 46.8 years respectively with comparable gender distribution. The operative time was shorter for the left side (p = 0.003) and improved during the study for the left but not the right side. In recipients who received left kidneys there were more early technical failures observed (8 versus 1) though not statistically significant. Most centres prefer performing a left nephrectomy and recipient surgeons prefer a left kidney for transplantation primarily because of having a longer vein. This large study provides reassurance that right HALDN nephrectomy is a safe procedure with similar outcomes to left HALDN.

PMID:34844890 | DOI:10.1016/j.surge.2021.09.006

J Am Pharm Assoc (2003). 2021 Nov 15:S1544-3191(21)00474-X. doi: 10.1016/j.japh.2021.11.013. Online ahead of print.

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has drastically disrupted primary health care and pharmacy services, posing a challenge in people with chronic diseases who receive routine care. Currently, there exists limited literature on the indirect impact of the pandemic on chronic disease management, particularly related to accessibility to medications and health care resources.

OBJECTIVES: To determine the prevalence of medical- and medication-related problems reported by people with chronic diseases during the pandemic. The secondary objective was to identify the barriers and contributing factors related to these medical- and medication-related problems.

METHODS: The anonymous and voluntary, Web-based survey was filled out by interested adult respondents with chronic disease(s) across Michigan between September 1, 2020, and January 1, 2021. The primary outcome included self-reported medical- and medication-related problems during the pandemic. Secondary outcomes included potential risk factors for medical- and medication-related problems. Descriptive statistics was used to describe respondents’ demographics, chronic disease characteristics, medication adherence, medical- and medication-related problems, and COVID-19-related factors. The multivariable Firth logistic regression was used to analyze correlations between potential risk factors associated with medical- and medication-related problems.

RESULTS: A total of 1103 respondents completed the survey and were included in the analysis. Approximately, 51% of respondents reported a medication-related problem with 19.6% reported problems obtaining medication(s) and 31.7% reported forgetting or not taking their medication(s). The top reason for problems obtaining medication(s) was doctor’s office being closed for in-person visit(s). In addition, of all responses, more than half reported worsening symptoms of their chronic disease(s) during the pandemic especially with psychiatric disorders (79.5%) and inflammatory bowel disease (60%). Respondents with a significantly higher risk of medication-related problems included those who were younger, were female, and had psychiatric disorder(s), diabetes, arthritis, or lupus, and respondents with a significantly higher risk of medical-related problems included those with multiple chronic diseases, psychiatric disorder(s), and heart failure.

CONCLUSION: Understanding the consequences of the pandemic, such as medical- and medication-related problems, in this population is critical to improving health care accessibility and resources through potential outpatient pharmacy services during this and future pandemics.

PMID:34844885 | DOI:10.1016/j.japh.2021.11.013

Oral Surg Oral Med Oral Pathol Oral Radiol. 2021 Oct 23:S2212-4403(21)00690-8. doi: 10.1016/j.oooo.2021.10.011. Online ahead of print.

ABSTRACT

OBJECTIVE: The aim of the present study was to compare radiomorphometric measurements on panoramic images of patients with hyperthyroidism (HT) to those of a control population.

STUDY DESIGN: In this retrospective study, the mental index (MI), inferior panoramic mandibular index (PMI), antegonial index (AI), gonial index (GI), and mandibular cortical index (MCI) were evaluated on dental panoramic radiographs (DPRs) of 40 patients with HT and 40 healthy age- and sex-matched individuals and compared between the groups. Quantitative data (MI, PMI, AI, and GI) were analyzed with the Student t and Mann-Whitney U tests. Categorical data (MCI) were analyzed with the chi-square test.

RESULTS: Statistically significant differences between the patient and control groups were found for inferior PMI (P = .001) and AI (P = .017) values, with smaller mean values among the patients. However, the measurements of MI (P = .59) and GI (P = .164) and the MCI distribution (P = .13) were similar in both groups.

CONCLUSIONS: Evaluating the radiomorphometric indices of inferior PMI and AI on the DPRs of patients with HT who are at high risk of secondary osteoporosis could be helpful in the early diagnosis of osteoporotic changes and in formulating surgical treatment plans.

PMID:34844888 | DOI:10.1016/j.oooo.2021.10.011

Cardiovasc Revasc Med. 2021 Nov 26:S1553-8389(21)00753-3. doi: 10.1016/j.carrev.2021.11.026. Online ahead of print.

ABSTRACT

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. The timing and role of early coronary angiography (CAG) in OHCA patients without ST elevation remains unclear.

OBJECTIVE: We performed a meta-analysis of randomized controlled trials (RCTs) that compared early CAG to delayed CAG in OHCA patients without ST elevation.

METHODS: We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to September 2021) for studies comparing early CAG to delayed CAG in OHCA patients without ST elevation. We used a random-effect model to calculate relative ratio (RR) with 95% confidence interval (CI). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included neurological status with cerebral performance category ≤2 (CPC) and the rate of percutaneous coronary intervention (PCI) following CAG.

RESULTS: A total of 6 RCTs including 1822 patients, of whom 895 underwent early CAG, and 927 underwent delayed CAG, were included in this meta-analysis. There was no statistically significant difference between the 2 groups in terms of 30-day all-cause mortality (Relative risk [RR] 1.06; 95%CI 0.94-1.20; P = 0.32; I² = 13%), neurological status (CPC ≤2) (RR 1.01; 95%CI 0.90-1.13; P = 0.85, I² = 37%), and rates of PCI following CAG (RR 1.08; 95%CI 0.84-1.39; P = 0.56; I² = 49%).

CONCLUSION: In patients suffering OHCA without ST-elevation, early CAG is not associated with reduced 30-day mortality when compared to patients who underwent delayed CAG. Given our meta-analysis results including multiple trials that have not shown a benefit, it is likely that updated guidelines will not support early angiography in patients suffering OHCA without ST-elevation.

PMID:34844869 | DOI:10.1016/j.carrev.2021.11.026

Int Immunopharmacol. 2021 Nov 22:108390. doi: 10.1016/j.intimp.2021.108390. Online ahead of print.

ABSTRACT

OBJECTIVE: The aim of this study was to investigate the impact of asthma on the risk for mortality among coronavirus disease 2019 (COVID-19) patients in the United States by a quantitative meta-analysis.

METHODS: A random-effects model was used to estimate the pooled odds ratio (OR) with corresponding 95% confidence interval (CI). I² statistic, sensitivity analysis, Begg’s test, meta-regression and subgroup analyses were also performed.

RESULTS: The data based on 56 studies with 426,261 COVID-19 patients showed that there was a statistically significant association between pre-existing asthma and the reduced risk for COVID-19 mortality in the United States (OR: 0.82, 95% CI: 0.74-0.91). Subgroup analyses by age, male proportion, sample size, study design and setting demonstrated that pre-existing asthma was associated with a significantly reduced risk for COVID-19 mortality among studies with age ≥ 60 years old (OR: 0.79, 95% CI: 0.72-0.87), male proportion ≥ 55% (OR: 0.79, 95% CI: 0.72-0.87), male proportion ＜ 55% (OR: 0.81, 95% CI: 0.69-0.95), sample sizes ≥ 700 cases (OR: 0.80, 95% CI: 0.71-0.91), retrospective study/case series (OR: 0.82, 95% CI: 0.75-0.89), prospective study (OR: 0.83, 95% CI: 0.70-0.98) and hospitalized patients (OR: 0.82, 95% CI: 0.74-0.91). Meta-regression did reveal none of factors mentioned above were possible reasons of heterogeneity. Sensitivity analysis indicated the robustness of our findings. No publication bias was detected in Begg’s test (P = 0.4538).

CONCLUSION: Our findings demonstrated pre-existing asthma was significantly associated with a reduced risk for COVID-19 mortality in the United States.

PMID:34844871 | DOI:10.1016/j.intimp.2021.108390

J Tissue Viability. 2021 Nov 24:S0965-206X(21)00129-7. doi: 10.1016/j.jtv.2021.11.004. Online ahead of print.

ABSTRACT

A diabetic foot ulcer is a preventable complication of diabetes, which could lead to lower extremity amputation and increased mortality and morbidity. Self-care behaviors play a key role in the prevention of diabetic foot ulcers. This study aimed to estimate the total score of diabetic foot self-care behaviors. We searched databases such as Web of Science, Medline (PubMed), and Scopus using various keywords, including diabetic foot, diabetic feet, diabetic problem, diabetic foot ulcer, and self-care, for relevant articles with no time limit. The heterogeneity of the studies was assessed using Cochran’s Q test and I² statistic. Data were analyzed using STATA software version 12 using the meta-analysis method and a random effects model. In total, eight studies were analyzed with a sample size of 2,493. The pooled score of diabetes foot self-care was 62.84% and this score was higher in the studies conducted on two groups of patients with type I and type II diabetes compared to those performed only on patients with type II diabetes. The results also indicated correlation between the self-care score and year of publication (P < 0.001), and the self-care scores significantly declined during 2015-2021 (P < 0.001). Overall, the diabetic foot self-care score was moderate, which highlights the need to provide self-care education to diabetic patients.

PMID:34844853 | DOI:10.1016/j.jtv.2021.11.004

J Foot Ankle Surg. 2021 Oct 29:S1067-2516(21)00410-5. doi: 10.1053/j.jfas.2021.10.027. Online ahead of print.

ABSTRACT

Concentrated bone marrow aspirate (CBMA) offers an alternative to sesamoid resection in end stage sesamoid pathology. CBMA potentiates the anti-inflammatory effect, stimulates local tissue regeneration and osteogenesis, when injected into bone. The purpose of this study is to evaluate the functional outcomes in a cohort of athletes following CBMA injection for the treatment of hallux sesamoid disorders. A retrospective case series of consecutive patients treated with CBMA injection for hallux sesamoid disorders were identified. Radiographs, Foot and Ankle Outcome Scores (FAOS), and Visual Analogue Scale (VAS) score were collected pre- and postinjections. Descriptive statistics were presented as the mean and standard deviation for continuous variables and frequency as percentages for categorical variables. Fifteen consecutive patients with were included with a mean follow-up time of 20.1 (range 12-34) months. Significant improvement in all scoring subscales of the FAOS and VAS score was noted preinjection compared to final follow-up postinjection (p < .001). Eight of 11 patients that were involved in sports prior to the CBMA injection returned to play, with 7 successfully returning to preinjury level status. Three patients required further treatment (20%). The case series suggests that CBMA injection is a safe and effective treatment option for hallux sesamoid disorders with a high rate of return to play.

PMID:34844856 | DOI:10.1053/j.jfas.2021.10.027