The retrospective chart review: important methodological considerations

Estimation of the number of patient deaths recognized by a medical practitioner as caused by adverse events in hospitals in Japan: A cross-sectional study

Chart reviews have been used to assess the incidence and impact of adverse events, but most of them are not a nationally representative sample. In addition, the definition of adverse events is generally broad and covers unintended events; the relationship to outcome is often unclear, and official estimates have not matched those of medical practitioner's recognition. The number of patient deaths from adverse events remains unknown.This study aimed to investigate the number of adverse event related patient deaths and mortality rate as recognized by medical practitioners in Japan, and to reveal the applicability of our method for estimating the number of adverse event related patient death as an alternative to a chart review.In 2015, a mail survey of 3270 hospitals asked how many patient deaths had been caused by adverse events at the hospital in the last 3 years. The hospitals were selected by stratified random sampling according to the number of beds. The number of patient deaths caused by adverse events and the mortality rate were estimated, with adjustments for the hospital type and the number of beds.The mail survey response rate was 22.4% (731/3270). The number of patient deaths caused by adverse events in a year was estimated to be between 1326 and 1433. The mortality rate was estimated at 8.81 to 9.52 cases per 100,000 discharged patients, and 2.65 to 2.87 cases per 1,000,000 person-days. The mortality rate was high at acute care hospitals with ≥500 beds and at psychiatric hospitals.The nationwide number of patient deaths recognized by medical practitioners as caused by adverse events and its mortality rate were estimated. In comparison with a chart review, a mail survey was a faster and a cheaper way, and was able to cover a wide range of hospitals for estimating mortality rate of adverse events.

Reasons for missed appointments linked to a public-sector intervention targeting patients with stable chronic conditions in South Africa: results from in-depth interviews and a retrospective review of medical records

Background

Missed appointments serve as a key indicator for adherence to therapy and as such, identifying patient reasons for this inconsistency could assist in developing programmes to improve health outcomes. In this article, we explore the reasons for missed appointments linked to a centralised dispensing system in South Africa. This system dispenses pre-packed, patient-specific medication parcels for clinically stable patients to health facilities. However, at least 8%–12% of about 300,000 parcels are not collected each month. This article aims to establish whether missed appointments for collection of medicine parcels are indicative of loss-to-follow-up and also to characterise the patient and health system factors linked to missed appointments.

Methods

We applied an exploratory mixed-methods design in two overlapping research phases. This involved in-depth interviews to yield healthcare practitioners’ and patients’ experiences and medical record reviews. Data collection was conducted during the period 2014–2015. Qualitative data were analysed through a hybrid process of inductive and deductive thematic analysis which integrated data-driven and theory-driven codes. Data from medical records (N = 89) were analysed in MS excel using both descriptive statistics and textual descriptions.

Results

Review of medical records suggests that the majority of patients (67%) who missed original appointments later presented voluntarily to obtain medicines. This could indicate a temporal effect of some barriers. The remaining 33% revealed a range of CDU implementation issues resulting from, among others, erroneous classification of patients as defaulters. Interviews with patients revealed the following reasons for missed appointments: temporary migration, forgetting appointments, work commitments and temporary switch to private care. Most healthcare practitioners confirmed these barriers to collection but perceived that some were beyond the scope of health services. In addition, healthcare practitioners also identified a lack of patient responsibility, under-utilisation of medicines and use of plural healthcare sources (e.g. traditional healers) as contributing to missed appointments.

Conclusion

We suggest developing a patient care model reflecting the  local context, attention to improving CDU’s implementation processes and strengthening information systems in order to improve patient monitoring. This model presents lessons for other low-and-middle income countries with increasing need for dispensing of medicines for chronic illnesses.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0655-8) contains supplementary material, which is available to authorized users.

Regionalization and Outcomes of Lung Cancer Surgery in Ontario, Canada

Purpose

Regionalization of complex surgery to high-volume hospitals has been advocated based on cross-sectional volume-outcome studies. In April 2007, the agency overseeing cancer care in Ontario, Canada, implemented a policy to regionalize lung cancer surgery at 14 designated hospitals, enforced by economic incentives and penalties. We studied the effects of implementation of this policy.

Methods

Using administrative health data, we used interrupted time series models to analyze the immediate and delayed effects of implementation of the policy on the distribution of lung cancer surgery among hospitals, surgical outcomes, and health services use.

Results

From 2004 to 2012, 16,641 patients underwent surgery for lung cancer. The proportion of operations performed in designated hospitals increased from 71% to 89% after the policy was implemented. Although operative mortality decreased from 4.1% to 2.9% (adjusted odds ratio, 0.68; 95% CI, 0.58 to 0.81; P < .001), the reduction was due to a preexisting declining trend in mortality. In contrast, in the years after implementation of the policy, length of hospital stay decreased more than expected from the baseline trend by 7% per year (95% CI, 5% to 9%; P < .001), and the distance traveled by all patients to the hospital for surgery increased by 4% per year (95% CI, 0% to 8%; P = .03), neither of which were explained by preexisting trends. Analyses limited to patients ≥ 70 years of age demonstrated a reduction in operative mortality (odds ratio, 0.80 per year after regionalization; 95% CI, 0.67 to 0.95; P = .01).

Conclusion

A policy to regionalize lung cancer surgery in Ontario led to increased centralization of surgery services but was not independently associated with improvements in operative mortality. Improvements in length of stay and in operative mortality among elderly patients suggest areas where regionalization may be beneficial.

Following Suit: Using Conversation Cards for Priority Setting in Pediatric Weight Management

OBJECTIVE

To describe families' selections of Conversation Cards (CCs), a priority-setting tool in pediatric weight management, and examine CC-related differences based on families' anthropometric and sociodemographic characteristics.

METHODS

A retrospective medical record review was conducted of 2- to 17-year-olds with obesity and their families who enrolled in a pediatric weight management clinic between January, 2012 and September, 2016.

RESULTS

Medical records of 146 children were included. On average, families selected 10 ± 6 CCs (range, 3-32 CCs); only 50% of families (n = 73) indicated perceived readiness to make healthy changes. Adolescents (vs children) revealed less healthy eating behaviors (P = .001) and physical activity habits (P = .002). Goal setting was perceived to be a motivator across several sociodemographic characteristics (all P < .05).

CONCLUSIONS AND IMPLICATIONS

The CCs were useful in describing families' priorities. The diversity of issues identified by families highlighted the importance of multidisciplinary expertise in pediatric weight management.

An Ethical Justification for Termination of Resuscitation Protocols for Pediatric Patients

OBJECTIVE

The aim of this article was to compare specific characteristics and outcomes among adult and pediatric out-of-hospital cardiac arrest (OHCA) patients to show that the existing literature warrants the design and implementation of pediatric studies that would specifically evaluate termination of resuscitation protocols. We also address the emotional and practical concerns associated with ceasing resuscitation efforts on scene when treating pediatric patients.

METHODS

Relevant prospective and retrospective studies were used to compare characteristics and outcomes between adult and pediatric OHCA patients. Characteristics analyzed were nonwitnessed arrests, absence of shockable rhythm, no return of spontaneous circulation, and survival to hospital discharge.

RESULTS

Cases of unwitnessed arrests by emergency medical services providers are substantially the same in pediatric patients (41.0%-96.3%) compared with their adult counterparts (47.4%-97.7%). The adult studies revealed 57.6% to 92.2% of patients without an initial shockable rhythm. The pediatric studies showed a range of 64.0% to 98.0%. The range of adult patients without return of spontaneous circulation was 54.8% to 95.4%, and the range in pediatric patients was 68.2% to 95.6%. Survival rates among the adult studies ranged from 0.8% to 9.3% (mean, 5.0%; median, 5.2%), and in the pediatric studies they were 2.0% to 26.2% (mean, 9.2%; median, 7.7%).

CONCLUSIONS

The data compared demonstrate that characteristics and outcomes are virtually identical between adult and pediatric OHCA patients. We also found the 3 chief barriers hindering further research to be invalid impediments to moving forward. This review warrants designing pediatric studies that would specifically correlate termination of resuscitation protocols with patient survival and include predictive values.

Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: An observational study

Background:

Contemporary transcatheter aortic valve implantation (TAVI) devices and approach present opportunities to review historical practices initially informed by early treatment development and cardiac surgery. The avoidance of urinary catheterization in the older TAVI population is a strategy to minimize in-hospital complications. The purpose of the study was to explore elimination-related complications following the phased implementation of a default strategy of avoiding urinary catheterization in patients undergoing transfemoral (TF) TAVI.

Methods:

We conducted an observational study using a retrospective chart review of patients treated between 2011 and 2013 to identify patient characteristics, peri-procedure details, in-hospital outcomes and elimination-related complications in patients who did or did not receive a peri-procedure indwelling catheter. Descriptive analyses were used to report differences between the groups; we conducted a regression analysis to explore the relationship between the practice of urinary catheterization and total procedure time.

Results:

Of the 408 patients who underwent TF TAVR, 188 (46.1%) received a peri-procedure indwelling urinary catheter and 220 (53.9%) did not. There was no difference in in-hospital mortality (2.2%), disabling stroke (0.5%), or other major cardiac adverse events. The avoidance of a urinary catheter resulted in significantly lower rates of urinary tract infection requiring a new antibiotic regimen (1.4% versus 6.1%, p = 0.014), haematuria documented by medicine or nursing (3.7% versus 17.6%, p = 0.001), and the need for continuous bladder irrigation (2.7% versus 0%, p = 0.027).

Conclusion:

The avoidance of a urinary catheter may contribute to improved outcomes in patients undergoing TAVI. The intervention should be further evaluated within the broader study of minimalist TAVI.

Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis

BACKGROUND

Concussion is typically defined as a mild brain injury, and yet the brain is unlikely to be the only source of persistent post-concussion symptoms. Concurrent injury to the cervical spine in particular is acknowledged as a potential source of common persistent symptoms such as headache, dizziness and neck pain.

OBJECTIVES

To describe the cervical spine findings and outcomes of treatment in a series of patients with persistent post-concussion symptoms, and describe the clinical characteristics of a cervicogenic component when it is present.

DESIGN

Retrospective chart review of a consecutive series of patients with concussion referred to a physiotherapist for cervical spine assessment.

METHOD

Patient charts for all patients over a calendar year referred by a concussion service provider to a physiotherapist for cervical spine assessment were de-identified and transferred to the research team. Clinical data were independently extracted by two research assistants and analysed using descriptive statistics.

RESULTS/FINDINGS

Data were analysed from 46 patient charts. Those with a cervicogenic component (n = 32) were distinguished from those without a cervicogenic component (n = 14) by physical examination findings, particularly pain on manual segmental examination. Physiotherapy treatment of the cervicogenic component (n = 21) achieved improvements in function (mean increase of 3.8 in the patient-specific functional scale), and pain (mean decrease of 4.6 in the numeric pain-rating scale).

CONCLUSIONS

The clinical characteristics described give preliminary support to the idea that the cervical spine may contribute to persistent post-concussion symptoms, and highlight the value of physiotherapy assessment and treatment of the cervical spine following a concussive injury.

Association of a history of childhood-onset obesity and dieting with eating disorders

This was a retrospective, observational chart review conducted on a convenience sample of 537 outpatients, aged 16-60 years, referred to an Italian Dietetic and Nutrition University Center. The study aimed to look at the association between a history of childhood obesity and dieting behaviors with development of eating disorders (EDs) at a later age. Subjects with a history of EDs (n = 118), assessed using both self-report and health records, were compared with those with no EDs (n = 419), who were attending the clinic mainly for primary prevention of metabolic and cardiovascular risk. Logistic regression analysis was performed to assess the association of childhood-onset obesity with development of an ED at a later age. Childhood-onset obesity, gender, maternal history of eating disorders, and dieting were associated with a positive history of EDs at a later age (p < .05). It is important to raise professional awareness of early symptoms of EDs in children with a history of obesity and treat them accordingly.

Cine-CMR partial voxel segmentation demonstrates increased aortic stiffness among patients with Marfan syndrome

BACKGROUND

Standard cine-cardiac magnetic resonance (CMR) imaging is commonly used to evaluate cardiac structure, geometry and function. Prior studies have shown that automated segmentation via partial voxel interpolation (PVI) accurately quantifies phantom-based cardiac chamber volumes and necropsy left ventricular myocardial mass. Despite this, the applicability and usefulness of PVI in the determination of physiologic parameters of the aorta such as aortic stiffness has yet to be investigated.

METHODS

Routine CMR was conducted with a 1.5T (GE) scanner with pulse sequences similar to that of standard CMR (parameters: TR 3.4 msec, TE 1.14 msec, flip angle 60°, temporal resolution ~30-40 msec). Views were obtained in standard cardiac-oriented longitudinal or axial views (2, 3 and 4 chambers). Within non-dilated regions of the descending thoracic aorta, aortic area was quantified via a novel PVI automated process (LV-METRIC), which discerns relative amounts of blood pool in each voxel. Aortic stiffness, as calculated from brachial artery pulse pressure and aortic area at maximal and minimal dimensions, was evaluated in 60 total segments (one segment per patient). All segments were in the descending aorta and were not aneurysmal.

RESULTS

Sixty patients in total were studied, including 50 that had genetically-related aortic disorder [35 bicuspid aortic valve (BAV), 15 Marfan syndrome (MFS)]. Ten normal controls without aortic disease were included for comparison purposes. All patients (n=60) had evaluable CMR images for assessment of the descending aorta with use of automated segmentation. Patients with BAV and MFS were similar to controls in age, systolic blood pressure, brachial artery pulse pressure, smoking status or hypercholesterolemia (all P=NS). There were more women (P<0.001), lower body mass index (P=0.008), and greater height (P<0.001) in the MFS cohort compared to BAV and controls. Descending aortic area in either systole (maximal) or diastole (minimal) was similar among all three cohorts. However, change in aortic area (ΔArea) throughout the cardiac cycle was substantially lower in MFS than control subjects (P<0.001). In contrast, change in aortic area throughout the cardiac cycle was not significantly different between BAV vs. controls (P=0.62). Aortic stiffness was increased among MFS patients versus control subjects (P=0.014). When comparing MFS to BAV subjects, a comparable trend was observed (P=0.09). No statistical difference was evident in aortic stiffness in patients with BAV versus control subjects (P=0.29).

CONCLUSIONS

The application of PVI to standard CMR imaging can assess abnormal descending aorta functional indices in normal caliber segments in MFS subjects. Future prospective studies with larger subject populations are warranted to further determine the overall utility of automated aortic segmentation as a possible early biomarker of aortic dysfunction before overt dilatation.

Accelerating Chart Review Using Automated Methods on Electronic Health Record Data for Postoperative Complications

Manual Chart Review (MCR) is an important but labor-intensive task for clinical research and quality improvement. In this study, aiming to accelerate the process of extracting postoperative outcomes from medical charts, we developed an automated postoperative complications detection application by using structured electronic health record (EHR) data. We applied several machine learning methods to the detection of commonly occurring complications, including three subtypes of surgical site infection, pneumonia, urinary tract infection, sepsis, and septic shock. Particularly, we applied one single-task and five multi-task learning methods and compared their detection performance. The models demonstrated high detection performance, which ensures the feasibility of accelerating MCR. Specifically, one of the multi-task learning methods, propensity weighted observations (PWO) demonstrated the highest detection performance, with single-task learning being a close second.

Evaluation of fixed and variable hospital costs due to Clostridium difficile infection: institutional incentives and directions for future research

BACKGROUND

Economic analysis of Clostridium difficile infection (CDI) should consider the incentives facing institutional decision-makers. To avoid overstating the financial benefits of infection prevention, fixed and variable costs should be distinguished.

AIM

To quantify CDI fixed and variable costs in a tertiary referral hospital during August 2015.

METHODS

A micro-costing analysis estimated CDI costs per patient, including the additional costs of a CDI outbreak. Resource use was quantified after review of patient charts, pharmacy data, administrative resource input, and records of salary and cleaning/decontamination expenditure.

FINDINGS

The incremental cost of CDI was €75,680 (mean: €5,820 per patient) with key cost drivers being cleaning, pharmaceuticals, and length of stay (LOS). Additional LOS ranged from 1.75 to 22.55 days. For seven patients involved in a CDI outbreak, excluding the value of the 58 lost bed-days (€34,585); costs were 30% higher (€7,589 per patient). Therefore, total spending on CDI was €88,062 (mean: €6,773 across all patients). Potential savings from variable costs were €1,026 (17%) or €1,768 (26%) if outbreak costs were included. Investment in an antimicrobial pharmacist would require 47 CDI cases to be prevented annually. Prevention of 5%, 10% and 20% CDI would reduce attributable costs by €4,403, €8,806 and €17,612. Increasing the incremental LOS attributable to CDI to seven days per patient would have increased costs to €7,478 or €8,431 (if outbreak costs were included).

CONCLUSION

As much CDI costs are fixed, potential savings from infection prevention are limited. Future analysis must consider more effectively this distinction and its impact on institutional decision-making.

Prior History of Feeding-Swallowing Difficulties in Children With Language Impairment

PURPOSE

This study updated and extended our previous investigation (Malas et al., 2015) of feeding-swallowing difficulties and concerns (FSCs) in children with language impairments (LI) by using more stringent inclusion criteria and targeting children earlier in the care delivery pathway.

METHOD

Retrospective analyses were performed on the clinical files of 29 children (average age: 60 months, SD = 9.0) diagnosed as having LI using standardized testing, nonstandardized testing and final speech-language pathologist judgment. The files of children born prematurely or with a history of anatomical, structural, neurodevelopmental, cognitive, sensory, motor, or speech disorders were excluded. Literature-based indicators were used to determine the prevalence of difficulties in sucking, food transition, food selectivity, and salivary control. Values were compared with the general population estimate of Lindberg et al. (1992).

RESULTS

A significantly higher percentage of histories of FSCs (48%) were found in the files of children with LI when compared with the population estimate (χ2 = 13.741, df = 1, p < .001). Difficulties in food transition (31%) and food selectivity (14%) were the most frequent. Data confirm and extend our previous findings and suggest that a previous history of FSCs may characterize children with LI early in their care delivery pathway.

Secondary Use of EHR: Interpreting Clinician Inter-Rater Reliability Through Qualitative Assessment

In a retrospective secondary-use EHR study identifying a cohort of Non-Valvular Atrial Fibrillation (NVAF) patients, chart abstraction was done by two sets of clinicians to create a gold standard for risk measures CHA2DS2-VASc and HAS-BLED. Inter-rater reliability between each set of clinicians for NVAF and the outcomes of interest were variable, ranging from extremely low agreement to high agreement. To assess the chart abstraction process, a focus group and a survey was conducted. Survey findings revealed patterns of difficulty in assessing certain items dealing with temporality and social data. The focus group raised issues on the quality and completeness of EHR data, including missing encounters, truncated notes, and low granularity. It also raised the issue of the usability of the data system, the Clinical Data Viewer, which did not mirror a live EHR and made it difficult to record outcomes. Finally, the focus group found it was difficult to infer certain outcomes, like severity, from the provided data. These factors produced differences in clinician rated outcomes.

Predictors of Neonatal Tetanus Mortality in Katsina State, Northwestern Nigeria

Background

The mortality rate of neonatal tetanus (NNT) remains high in Nigeria. The study was guided by Mosley and Chen's model for the elements of child survival in developing countries. The goal of the study was to assess the associations between selected NNT risk factors, number of maternal tetanus toxoid injections, frequency of antenatal visits, place of delivery, and cord care with neonatal mortality as the outcome variable.

Methods

The study is a retrospective record review using data from 332 NNT records and analyzed using a logistic regression model.

Findings

Neonates whose mothers had 1 dose of tetanus toxoid vaccine were found to be 4% less prone to NNT mortality compared to neonates whose mothers did not have any dose of tetanus toxoid vaccine during pregnancy (P < .05, odds ratio = 4.12, 95% confidence interval = 1.04-16.29. Frequency of antenatal visits, place of delivery, and cord care were all not significant predictors of NNT mortality.

Conclusion

The study shows that there is association between NNT risk factors and neonatal mortality, hence the need to further strengthen the NNT surveillance system for early detection of potential risk factors. This would help develop specific public health interventions aimed at improving the outcome of NNT.

Implications

The identification and analysis of NNT mortality risk factors and promoting tetanus toxoid vaccination among pregnant women are effective strategies toward attaining NNT elimination goals in Nigeria.

Web-based Real-Time Case Finding for the Population Health Management of Patients With Diabetes Mellitus: A Prospective Validation of the Natural Language Processing-Based Algorithm With Statewide Electronic Medical Records

Background

Diabetes case finding based on structured medical records does not fully identify diabetic patients whose medical histories related to diabetes are available in the form of free text. Manual chart reviews have been used but involve high labor costs and long latency.

Objective

This study developed and tested a Web-based diabetes case finding algorithm using both structured and unstructured electronic medical records (EMRs).

Methods

This study was based on the health information exchange (HIE) EMR database that covers almost all health facilities in the state of Maine, United States. Using narrative clinical notes, a Web-based natural language processing (NLP) case finding algorithm was retrospectively (July 1, 2012, to June 30, 2013) developed with a random subset of HIE-associated facilities, which was then blind tested with the remaining facilities. The NLP-based algorithm was subsequently integrated into the HIE database and validated prospectively (July 1, 2013, to June 30, 2014).

Results

Of the 935,891 patients in the prospective cohort, 64,168 diabetes cases were identified using diagnosis codes alone. Our NLP-based case finding algorithm prospectively found an additional 5756 uncodified cases (5756/64,168, 8.97% increase) with a positive predictive value of .90. Of the 21,720 diabetic patients identified by both methods, 6616 patients (6616/21,720, 30.46%) were identified by the NLP-based algorithm before a diabetes diagnosis was noted in the structured EMR (mean time difference = 48 days).

Conclusions

The online NLP algorithm was effective in identifying uncodified diabetes cases in real time, leading to a significant improvement in diabetes case finding. The successful integration of the NLP-based case finding algorithm into the Maine HIE database indicates a strong potential for application of this novel method to achieve a more complete ascertainment of diagnoses of diabetes mellitus.

Referral Patterns as a Contextual Variable in Pediatric Brain Injury: A Retrospective Analysis

PURPOSE

Access to speech-language pathology (SLP) services is a critical variable in the rehabilitation of pediatric brain injury. In this study, we examined patterns of SLP referral and factors affecting referral during the acute period following brain injury in 2 large pediatric specialty hospitals.

METHOD

In a retrospective, cohort chart review study, data collection focused on referrals made during the acute period using International Classification of Diseases, Ninth Revision, Clinical Modification codes for primary diagnoses of brain injury between 2007 and 2014 (Centers for Disease Control and Prevention [CDC], 2014). A total of 200 charts were reviewed. Data extraction included demographic and injury-related variables, referral for rehabilitation across disciplines, and plans of care following assessment.

RESULTS

Samples for both facilities were similar except for primary mechanism of traumatic brain injuries and severity. SLP referral rate at Hospital 1 was 36% and only 2% at Hospital 2. Regression revealed that individuals were less likely to receive an SLP referral if injury severity was classified as unknown or mild or if they were younger in age.

CONCLUSION

SLP referral rates in the early acute period for children with brain injury were poor, creating a barrier to rehabilitation. This not only limits access to SLP services, but also may have broader and long-term impact.

Long-term treatment with low dose naltrexone maintains stable health in patients with multiple sclerosis

Introduction

A retrospective study was conducted on patients at Penn State Hershey Medical Center diagnosed with relapsing–remitting multiple sclerosis between 2006 and 2015.

Methodology

Laboratory and clinical data collected over this 10-year period were reviewed. Two cohorts of patients were established based on their relapsing–remitting multiple sclerosis therapy at the time of their first visit to Penn State. One group of patients (n = 23) was initially prescribed low dose naltrexone at the time first seen at Hershey. This group was offered low dose naltrexone because of symptoms of fatigue or refusal to take an available disease-modifying therapy. The second group of patients (n = 31) was treated with the glatiramer acetate (Copaxone) and offered low dose naltrexone as an adjunct therapy to their disease-modifying therapy.

Results

Patient data from visits after 1–50 months post-diagnosis were evaluated in a retrospective manner. Data obtained from patient charts included clinical laboratory values from standard blood tests, timed 25-foot walking trials, and changes in magnetic resonance imaging reports. Statistical analyses between the groups and for each patient over time indicated no significant differences in clinical laboratory values, timed walking, or changes in magnetic resonance imaging.

Conclusion

These data suggest that the apparently non-toxic, inexpensive, biotherapeutic is safe and if taken alone did not result in an exacerbation of disease symptoms.

Aripiprazole and Acute Extrapyramidal Symptoms in Children and Adolescents: A Meta-Analysis

BACKGROUND

Both the US FDA and the European Medicines Agency (EMA) have approved aripiprazole for use in adolescents for specific indications. Given the assumed favorable side-effect profile of aripiprazole, its use in children and adolescents has increased for both official and off-label indications (anxiety disorders, eating disorders, personality disorders). However, several cases of children and adolescents with new-onset extrapyramidal symptoms (EPS) after commencing treatment with aripiprazole have been reported, and a more systematic appraisal of this possible risk is lacking.

OBJECTIVE

We conducted a systematic review and a meta-analysis to assess the evidence for acute EPS (acute dystonia, akathisia, Parkinsonism) associated with the use of aripiprazole in children and adolescents.

METHOD

We searched the MEDLINE and Embase databases (2003-10 April 2016) for clinical trials in pediatric patients (aged 0-18 years) using the keywords 'aripiprazole' (regardless of the formulation) and 'extrapyramidal symptoms'. We evaluated the abstracts of papers using the following exclusion criteria: (1) study design: case report, letter to the editor, editorial, or poster presentation data; (2) unrelated PICOS (population, intervention, comparators, outcomes, study) structure. We performed a meta-analysis, in which we used effect sizes with 95 % confidence intervals (CIs). To examine the homogeneity of the effect size distribution, we used a Q-statistic. When we observed heterogeneity in effect sizes, we assessed the possible influence of moderator variables (age and sex, mean dose, study duration, and method of measuring EPS incidence) and evaluated the suitability of either a fixed or a random model. Finally, we assessed the incidence of EPS in children and adolescents treated with aripiprazole compared with placebo.

RESULTS

An initial search via PubMed and Embase yielded 328 hits. A manual search of the reference lists of review papers revealed seven additional relevant articles. We included 41 studies, with 2114 pediatric patients, in the meta-analysis. For the analysis of the mean incidence of EPS, data were provided by 24 studies, with a total of 1446 pediatric patients. Meta-analysis revealed a mean EPS incidence of 17.1 % (95 % CI 0.128-0.223). In terms of the incidence of various extrapyramidal side effects, overall, no significant effects of age, sex, mean dose, study duration, or measuring method could be demonstrated. The side effects 'EPS', 'parkinsonism', and 'tremor' were significantly more common in children and adolescents treated with aripiprazole than in those treated with placebo.

CONCLUSION

Our meta-analysis provides evidence for a non-negligible incidence of acute EPS in children and adolescents treated with aripiprazole. Although the study has several limitations and further investigation is needed, these findings may help clinicians make more balanced treatment choices and more closely monitor the use of this drug in youth.

Accuracy of working diagnosis by paramedics for patients presenting with dyspnoea

OBJECTIVE

The present study aims to determine the agreement between paramedic and ED or hospital working diagnosis in dyspnoeic patients.

METHODS

Non-consecutive written patient report forms were retrospectively audited for patients suffering from dyspnoea, who were transported to a tertiary hospital ED by ambulance paramedics. Accuracy of the paramedic working diagnosis was assessed by comparing agreement with either the primary or secondary ED diagnoses or hospital discharge diagnosis.

RESULTS

The study cohort was 293 patients. Exact agreement between paramedic versus ED or hospital diagnosis was 64%, 95% CI 58-69, k = 0.58, 95% CI 0.52-0.64. Only 226 (77%) had a 'clearly documented' paramedic diagnosis. Among these, agreement with either ED or hospital diagnosis was 79%, and there was a trend towards more agreement as paramedic level of practice increased (74%, 78% and 87% for Basic, Intermediate and ALS paramedics, respectively, P = 0.07). Conversely, ALS paramedics were less likely to document a working diagnosis (30/98, 31%) compared with Intermediate (22/102, 23%) and BLS paramedics (15/93, 16%), P = 0.008. Diagnostic agreement varied according to medical condition, from anaphylaxis (100%) and asthma (86%) to acute pulmonary oedema (46%).

CONCLUSIONS

There was moderate agreement between paramedic and ED or hospital diagnosis. The number of cases with no clearly documented working diagnosis suggested that a singular working diagnosis may not always serve the complexity of presentation of some dyspnoea patients: more open descriptors such as 'mixed disease' or 'atypical features' should be encouraged.

Twelve-month discontinuation of etonogestrel implant in an outpatient pediatric setting

OBJECTIVE

The etonogestrel (ENG) contraceptive implant is the most effective reversible contraceptive method. Uptake remains limited in adolescents, a population at high risk for unintended pregnancy. The objectives of this study were to determine the 12-month discontinuation rate of the ENG implant among adolescents in an outpatient setting and to characterize risk factors for discontinuation.

STUDY DESIGN

A retrospective chart review identified adolescent females aged 12 to 22years who received the ENG implant in one pediatric institution between January 1, 2011, and April 15, 2014. Patients were categorized into ENG discontinuers (removed prior to 12months) and ENG continuers (continued for ≥12months). Associations between demographic, clinical and postplacement characteristics with ENG discontinuation category were assessed with t tests, χ(2)/Fisher's Exact Tests and backwards stepwise logistic regression.

RESULTS

Of the 750 patients who had an ENG implant inserted, 77 (10.3%) had the device removed prior to 12months of use. The mean length of implant use for those who discontinued was 7.5months. Problematic bleeding was the most commonly cited reason for discontinuation. Older age at time of insertion, history of pregnancy and ≥1 medical visit for implant concerns (not including removal) were independently predictive (p<.01) of method discontinuation.

CONCLUSION

The vast majority of adolescents continued the ENG implant at 12months, making it an excellent contraceptive choice for adolescents within the outpatient pediatric setting. Greater efforts should be made to increase its use by pediatric providers.

IMPLICATIONS

The ENG implant is an excellent contraceptive option for adolescents in the outpatient pediatric setting.

Types, risk profiles, and outcomes of stroke patients in a tertiary teaching hospital in northern Ethiopia

Background

Stroke is becoming an increasingly serious public health issue in Ethiopia and the paucity of data specific to the Ethiopian setting is limiting the formulation of an appropriate response.

Objective

This study aimed to describe types, risk factors, management patterns, and outcomes among stroke patients treated at a tertiary teaching hospital in northern Ethiopia from 2012 to 2014.

Design

Medical record review with a standardized abstraction tool was used to obtain all data for this retrospective case study. Data was entered in EpiInfo Version 7 and analyzed using STATA12. Descriptive statistics were used to explore differences among stroke subtypes and compare with other sub-Saharan African countries.

Results

Among 142 stroke patients (mean age 62.8 ± 15.6 years, 54.2% male), ischemic stroke was the most frequent subtype (55.6%) followed by intracerebral hemorrhage (32.4%) and subarachnoid hemorrhage (5.6%). 38.0% of patients had pre-existing hypertension and 4.9% had pre-existing diabetes, and most were not on any treatment. 66.2% of patients were hypertensive at hospital arrival and nearly all presented with focal neurological deficit. Less than 10% arrived at the hospital within 3 h of stroke; nearly half (47.9%) were delayed over 24 h. 76.1% received CT Scan. We observed 12.0% in-hospital mortality.

Conclusions

Ischemic stroke was the predominant form of stroke, although to a lesser degree than in studies from developed countries. Under-diagnosing of hypertension and other risk factors and delayed presentation at the hospital are the major challenges to address.

•

Low ischemic to hemorrhagic stroke ratio compared with developed countries

•

Hypertension and other stroke risk factors were under-identified and under-treated.

•

Less than 10% of patients reached the hospital within 3 h of stroke symptoms.

•

Financial and social barriers to accessing CT Scan affected quality of stroke care.

The burden of osteoporotic hip fractures in Portugal: costs, health related quality of life and mortality

The study rationale was to provide a detailed overview of the costs, quality of life and mortality of hip fractures in Portugal. Mean individual fracture-related costs were estimated at €13,434 [12,290; 14,576] for the first year and €5985 [4982; 7045] for the second year following the fracture.

INTRODUCTION

Osteoporotic fractures represent a remarkable burden to health care systems and societies worldwide, which will tend to increase as life expectancy expands and lifestyle changes favour osteoporosis. The cost-effectiveness evaluation of intervention strategies demands accurate data on the epidemiological and economical reality to be addressed.

METHODS

Information was collected retrospectively on consumption of resources and changes in quality of life attributable to fracture as well as mortality, regarding 186 patients randomly selected to represent the distribution of hip fractures in the Portuguese population, in terms of gender, age and geographical provenience. Data were cross-tabulated with socio-demographic variables and individual resource consumption to estimate the burden of disease. A societal perspective was adopted, including direct and indirect costs. Multivariate analyses were carried out to assess the main determinants of health-related quality of life (HrQoL).

RESULTS

Mean individual fracture-related costs were estimated at €13,434 [12,290; 14,576] for the first year and €5985 [4982; 7045] for the second year following the fracture. In 2011 the economic burden attributable to osteoporotic hip fractures in Portugal could be estimated at €216 million. Mean reduction in HrQoL 12 months after fracture was estimated at 0.34. Regression analysis showed that age was associated with a higher loss of HrQoL, whereas education had the opposing effect. We observed 12 % excess mortality in the first year after hip fracture, when compared to the gender and age-matched general population.

CONCLUSIONS

Results of this study indicate that osteoporotic hip fractures are, also in Portugal, despite its low incidence of fractures and cost per event, associated with a high societal burden, in terms of costs, loss in HrQoL and mortality. These data provide valuable input to the design and selection of fracture prevention strategies.

Feeding-swallowing difficulties in children later diagnosed with language impairment

AIM

The aim of this retrospective study was to assess the relationship between feeding-swallowing difficulties (FSDs) and later language impairments in children.

METHOD

Retrospective analyses were carried out using the clinical files of 82 children with language impairments from a large urban rehabilitation center. Two subgroups of these children were established: children with motor impairments, referred to as the language impairment with motor impairment ('LI+MI') subgroup (n=23, mean age 4y 6mo, SD 8.7mo), and children without motor impairments, referred to as the language impairment without motor impairment ('LI-MI') subgroup (n=59, mean age 5y, SD 8mo). The prevalence of food selectivity, difficulties in sucking, salivary control issues, and food transition difficulties was extracted. Data were compared with a general population estimate of FSDs.

RESULTS

FSDs were documented in 62% of the clinical files; 87% of these files were from the LI+MI subgroup and 53% were from the LI-MI subgroup. Among each subgroup of children with language impairments, the prevalence of FSDs was significantly higher than the general population estimate of 20% (LI+MI:χ(2) =55.965, df=1, p<0.001; LI-MI: χ(2) =32.807, df=1, p<0.001). Furthermore, the prevalence of FSDs was significantly higher in children with language impairments and motor impairments than in those with language impairments but without motor impairments (χ(2) =6.936, df=1, p<0.01). Both food transition difficulties (χ(2) =14.99, df=1, p<0.001) and salivary control issues (χ(2) =5.02, df=1, p=0.02) were more frequent in the LI+MI subgroup than in the LI-MI subgroup. Combinations of two or more FSDs were also more frequent in the LI+MI subgroup than in the LI-MI subgroup (χ(2) =4.19, df=1, p=0.04).

INTERPRETATIONS

These findings suggest that early FSDs may be used as a potential marker for language impairment. However, larger prospective studies are needed to confirm this.

Outcome of treatment in patients with methamphetamine poisoning in an Iranian tertiary care referral center

Objective:

Methamphetamine is the second most widely abused drug worldwide. We performed a study on the treatment outcome of acute methamphetamine intoxication in a referral tertiary care University hospital in Iran.

Methods:

In this hospital-based, retrospective study which was carried out from 2012 to 2013, medical records of all patients aged 18 to 65 years who were admitted with a reliable history and clinical diagnosis of acute methamphetamine intoxication were abstracted and analyzed. Patients’ data included gender, age, type and route of poisoning, clinical manifestations, duration of hospitalization, and the treatment outcome. ANOVA, Chi-square, and binary logistic regression statistical tests were used for data analysis.

Findings:

A total of 129 patients with a mean age of 30.70 ± 0.93 (mean ± standard error), including 111 (86%) males, had been fully evaluated. Most of the patients had intentional poisoning (93.7%). In 42.6% of patients, inhalation was the main route of exposure. Most of the patients had complete improvement without any complication (89.1%). Age (odds ratio [OR], 1.05; 95% confidence interval [95% CI] 1.006–1.099), suicide history (OR, 30.33; 95% CI 3.11–295.24), route of poisoning ([ingestion: OR, 0.21; 95% CI 0.05–0.87], [inhalation: OR, 0.19; 95% CI 0.04–0.78]), and pulmonary system manifestations (OR 1.84; 95% CI 1.15–2.93) were predictive in patients outcome (P < 0.05).

Conclusion:

Methamphetamine poisoning was more common in males with intentional poisoning. Age, past history of suicide, route of poisoning, and pulmonary manifestations on admission could be considered as important predictive factors in patients’ outcome.

Effectiveness of a Medifast meal replacement program on weight, body composition and cardiometabolic risk factors in overweight and obese adults: a multicenter systematic retrospective chart review study

BACKGROUND

Recent medical guidelines emphasize the importance of actively treating overweight and obesity with diet and lifestyle intervention to achieve ≥ 5% weight loss in a 6-month period. Commercial programs offer one approach provided there is evidence of their efficacy and safety. This study was conducted to evaluate the effectiveness of the Medifast® 4 & 2 & 1 Plan™ on weight loss, body composition and cardiometabolic risk factors in overweight and obese adults.

METHODS

A systematic retrospective chart review of 310 overweight and obese clients following the Medifast 4 & 2 & 1 Plan at one of 21 Medifast Weight Control Centers® was conducted. Data were recorded electronically and key data points were independently verified. The primary endpoint was change from baseline body weight at 12 weeks. Within group paired t-tests were used to examine changes from baseline in a completers population. Differences between gender and age subgroups were examined using bivariate t-tests and mixed model regression analyses.

RESULTS

For the primary endpoint at 12 weeks, body weight among completers (n = 185) was reduced by a mean of 10.9 ± 5.6 kg (-10.1%, p < 0.0001), and at 24 weeks (n = 81) mean weight was reduced by 16.0 ± 7.9 kg (-14.3%). At 12 and 24 weeks, 85% and 96% of those remaining on the plan, respectively, had lost ≥ 5% of their baseline body weight. Lean mass was preserved to within 5% of baseline throughout the 24 weeks, and fat mass represented ≥ 80% of the body weight lost from 12 weeks onward. Men, women, seniors (≥ 65 years), and non-seniors (<65 years) all had significant weight reductions with preservation of lean mass. Significant improvements in blood pressure, pulse and waist-to-hip ratio were observed. Mean weight regain among the subset who entered a formal maintenance phase was <2% during an average follow-up of 34 weeks. The meal plan was well tolerated, and program adherence was >85%.

CONCLUSIONS

The 4 & 2 & 1 Plan used at Medifast Weight Control Centers was effective for weight loss, preservation of lean mass and improvement in cardiometabolic risk factors. The plan was generally well tolerated in a broad population of overweight and obese adults. #NCT02150837.

Everolimus use and associated factors among post-menopausal women with hormonal receptor positive/human epidermal growth factor receptor 2 negative metastatic breast cancer

BACKGROUND

Everolimus has been shown to be an effective HR+/HER2- mBC treatment in both clinical trials and real-world practice. The current study aims at understanding factors associated with everolimus use and how it is used in the real world.

METHODS

A retrospective chart review was conducted among postmenopausal HR+/HER2- mBC women who received everolimus, endocrine therapy (ET), or chemotherapy (CT) for mBC between 1 July 2012 and 15 April 2013 after an NSAI failure. Factors associated with everolimus use versus ET or CT were identified using multivariable logistic regressions. Reasons for prescribing everolimus and everolimus treatment patterns were described.

RESULTS

Liver metastasis and high tumor volume were associated with a higher likelihood of everolimus use versus ET (OR = 1.67, OR = 1.62) but a lower likelihood of everolimus use versus CT (OR = 0.43, OR = 0.30). Medicare-only insurance (OR = 0.30) as well as ECOG ≥2 (OR = 3.72) and prior CT in mBC (OR = 2.76) were associated with a lower and higher likelihood of everolimus use versus CT, respectively. The top reason for prescribing everolimus was efficacy (69-85%). About 15% and 29% of everolimus users in second line and third line or above received prior CT for mBC. Exemestane was the most common concomitant therapy with everolimus (56-87%). The majority of patients initiated everolimus at the labeled dose of 10 mg daily (>80%) and maintained this dose (>80%).

CONCLUSIONS

In the real world, everolimus was used in more severe patients than ET but less severe patients than CT based on visceral metastasis, tumor volume, and performance status. The top reason for prescribing everolimus was efficacy. A large proportion of patients received first or second line CT before everolimus initiation. The majority of patients used everolimus according to the labeled combination and dose. Future studies are needed to determine optimal sequencing of everolimus, ET, and CT for HR+/HER2- mBC.

Young patients with suspected uncomplicated renal colic are unlikely to have dangerous alternative diagnoses or need emergent intervention

Introduction

In the United States there is debate regarding the appropriate first test for new-onset renal colic, with non-contrast helical computed tomography (CT) receiving the highest ratings from both Agency for Healthcare Research and Quality and the American Urological Association. This is based not only on its accuracy for the diagnosis of renal colic, but also its ability to diagnose other surgical emergencies, which have been thought to occur in 10–15% of patients with suspected renal colic, based on previous studies. In younger patients, it may be reasonable to attempt to avoid immediate CT if concern for dangerous alternative diagnosis is low, based on the risks of radiation from CTs, and particularly in light of evidence that patients with renal colic have a very high likelihood of having multiple CTs in their lifetimes. The objective is to determine the proportion of patients with a dangerous alternative diagnosis in adult patients age 50 and under presenting with uncomplicated (non-infected) suspected renal colic, and also to determine what proportion of these patients undergo emergent urologic intervention.

Methods

Retrospective chart review of 12 months of patients age 18–50 presenting with “flank pain,” excluding patients with end stage renal disease, urinary tract infection, pregnancy and trauma. Dangerous alternative diagnosis was determined by CT.

Results

Two hundred and ninety-one patients met inclusion criteria. One hundred and fifteen patients had renal protocol CTs, and zero alternative emergent or urgent diagnoses were identified (one-sided 95% CI [0–2.7%]). Of the 291 encounters, there were 7 urologic procedures performed upon first admission (2.4%, 95% CI [1.0–4.9%]). The prevalence of kidney stone by final diagnosis was 58.8%.

Conclusion

This small sample suggests that in younger patients with uncomplicated renal colic, the benefit of immediate CT for suspected renal colic should be questioned. Further studies are needed to determine which patients benefit from immediate CT for suspected renal colic, and which patients could undergo alternate imaging such as ultrasound.