Outcome and feasibility of radiotherapy bridging in large B-cell lymphoma patients receiving CD19 CAR T in the UK

Radiotherapy (RT) has potential synergistic effects with chimeric antigen receptor (CAR) T but is not widely used as bridging therapy due to logistical challenges and lack of standardised protocols. We analysed RT bridging in a multicentre national cohort of large B-cell lymphoma patients approved for 3L axicabtagene ciloleucel or tisagenlecleucel across 12 UK centres. Of 763 approved patients, 722 were leukapheresed, 717 had data available on bridging therapy. 169/717 (24%) received RT bridging, 129 as single modality and 40 as combined modality treatment (CMT). Of 169 patients, 65.7% had advanced stage, 36.9% bulky disease, 86.5% elevated LDH, 41.7% international prognostic index (IPI) ≥3 and 15.2% double/triple hit at the time of approval. Use of RT bridging varied from 11% to 32% between centres and increased over time. Vein-to-vein time and infusion rate did not differ between bridging modalities. RT-bridged patients had favourable outcomes with 1-year progression-free survival (PFS) of 56% for single modality and 47% for CMT (1-year PFS 43% for systemic bridging). This is the largest cohort of LBCL patients receiving RT bridging prior to CAR T reported to date. Our results show that RT bridging can be safely and effectively used even in advanced stage and high-risk disease, with low dropout rates and excellent outcomes.

C-STIM: Protocol for a randomized, single-blind, crossover study of cerebellar repetitive transcranial magnetic stimulation (rTMS) for postural instability in people with progressive supranuclear palsy (PSP)

Background

Methods for modulating the cerebellum with transcranial magnetic stimulation (TMS) are well established, and preliminary data from our group and others has shown evidence of transient improvements in balance after cerebellar repetitive transcranial magnetic stimulation (rTMS) in progressive suprancuclear palsy (PSP). This study examines extensive posturography measures before and after 10 sessions of cerebellar rTMS and sham TMS in PSP.

Methods

Thirty subjects with PSP and postural instability will undergo cerebellar active and sham rTMS in a single-blind, crossover design with a randomized order of a 10-day intervention. Primary outcomes will be changes in sway area and medio-lateral range of sway with eyes open while standing on a stationary force-plate, and safety, tolerability, and blindedness. Secondary outcomes will include posturography and gait analysis with body-worn, triaxial inertial sensors, clinical balance scales and questionnaires, and a bedside test of vestibular function. Exploratory outcomes are changes in functional near infrared spectroscopy (fNIRS) signal over the prefrontal, supplementary motor, and primary motor cortices while standing and walking, and speech samples for future analysis.

Discussion

The C-STIM crossover intervention study adds a longer duration of stimulation and extensive posturography measures to more finely measure the improvements in balance and exploratory functional near-infrared spectroscopy (fNIRS) over the prefronal, supplementary motor, and primary motor cortices during balance assessments before and after 10 sessions of cerebellar rTMS and 10 sessions of sham cerebellar TMS. This project will improve our understanding of the importance of the cerebellum for control of postural stability in PSP.

Fungal brain abscess in a severely burned patient

Burn patients are particularly susceptible to atypical and opportunistic infections. Here we report an unusual case of a 40-year-old previously healthy man with a 74% TBSA burn injury who developed a presumed Fusarium brain abscess. This patient had a complicated infectious course including ESBL E. coli and Elizabethkingia bacteremia and pneumonia, MRSA ventilator-associated pneumonia, Mycobacterium abscessus bacteremia, and Fusarium fungemia. After diagnosis with a fungal abscess on magnetic resonance imaging of the brain, the patient was treated with aspiration and appropriate antifungal therapies. The patient was eventually transitioned to comfort care and died on hospital day 167. This is the first published report of a Fusarium-related brain abscess since it was first reported in a case report of a burned child in 1974.

Reassessing surgical guidelines for papillary thyroid cancer impact on survival: Expanding indications for lobectomy

BACKGROUND

Comparisons of lobectomy versus total thyroidectomy for papillary thyroid cancer have not addressed significant threats to valid inference from observational data. The purpose of this study was to compare survival after lobectomy versus total thyroidectomy for papillary thyroid cancer while addressing bias from unmeasured confounding.

METHODS

This retrospective cohort study included 84,300 patients treated with lobectomy or total thyroidectomy for papillary thyroid cancer in the National Cancer Database from 2004 to 2017. The primary outcome was overall survival evaluated by flexible parametric survival models and inverse probability weighting on the propensity score. Bias from unobserved confounding was assessed using two-way deterministic sensitivity analysis and 2-stage least squares regression.

RESULTS

The median age of treated patients was 48 years (interquartile range, 37-59), 78% were women, and 76% were white. We found no statistically significant differences in overall survival or 5- and 10-year survival between patients treated with lobectomy or total thyroidectomy. Additionally, we found no statistically significant difference in survival by subgroups, including tumor size (<4 cm or ≥4 cm), age (<65 or ≥65), or estimated risk of mortality. Sensitivity analyses suggested that an unmeasured confounder would need to have an extremely large effect to change the primary finding.

CONCLUSION

This is the first study to compare lobectomy and total thyroidectomy outcomes while adjusting for and quantifying the potential effects of unmeasured confounding variables on observational data. The findings suggest that total thyroidectomy is unlikely to offer a survival advantage over lobectomy regardless of tumor size, patient age, or overall risk of death.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Detailed Sub-study Analysis of the SECRAB Trial: Quality of Life, Cosmesis and Chemotherapy Dose Intensity

AIMS

SECRAB was a prospective, open-label, multicentre, randomised phase III trial comparing synchronous to sequential chemoradiotherapy (CRT). Conducted in 48 UK centres, it recruited 2297 patients (1150 synchronous and 1146 sequential) between 2 July 1998 and 25 March 2004. SECRAB reported a positive therapeutic benefit of using adjuvant synchronous CRT in the management of breast cancer; 10-year local recurrence rates reduced from 7.1% to 4.6% (P = 0.012). The greatest benefit was seen in patients treated with anthracycline-cyclophosphamide, methotrexate, 5-fluorouracil (CMF) rather than CMF. The aim of its sub-studies reported here was to assess whether quality of life (QoL), cosmesis or chemotherapy dose intensity differed between the two CRT regimens.

MATERIALS AND METHODS

The QoL sub-study used EORTC QLQ-C30, EORTC QLQ-BR23 and the Women's Health Questionnaire. Cosmesis was assessed: (i) by the treating clinician, (ii) by a validated independent consensus scoring method and (iii) from the patients' perspective by analysing four cosmesis-related QoL questions within the QLQ-BR23. Chemotherapy doses were captured from pharmacy records. The sub-studies were not formally powered; rather, the aim was that at least 300 patients (150 in each arm) were recruited and differences in QoL, cosmesis and dose intensity of chemotherapy assessed. The analysis, therefore, is exploratory in nature.

RESULTS

No differences were observed in the change from baseline in QoL between the two arms assessed up to 2 years post-surgery (Global Health Status: -0.05; 95% confidence interval -2.16, 2.06; P = 0.963). No differences in cosmesis were observed (via independent and patient assessment) up to 5 years post-surgery. The percentage of patients receiving the optimal course-delivered dose intensity (≥85%) was not significantly different between the arms (synchronous 88% versus sequential 90%; P = 0.503).

CONCLUSIONS

Synchronous CRT is tolerable, deliverable and significantly more effective than sequential, with no serious disadvantages identified when assessing 2-year QoL or 5-year cosmetic differences.

Outcomes of Nonoperative vs Operative Management of Acute Appendicitis in Older Adults in the US

Importance

Although the incidence of acute appendicitis among adults 65 years and older is high, these patients are underrepresented in randomized clinical trials comparing nonoperative vs operative management of appendicitis; it is unclear whether current trial data can be used to guide treatment in older adults.

Objective

To compare outcomes following nonoperative vs operative management of appendicitis in older adults and assess whether they differ from results in younger patients.

Design, Setting, and Participants

This retrospective cohort study used US hospital admissions data from the Agency for Healthcare Research and Quality's National Inpatient Sample from 2004 to 2017. Of 723 889 adult patients with acute uncomplicated appendicitis, 474 845 with known procedure date who survived 24 hours postprocedure and did not have inflammatory bowel disease were included (43 846 who were treated nonoperatively and 430 999 with appendectomy) were included. Data were analyzed from October 2021 to April 2022.

Exposures

Nonoperative vs operative management.

Main Outcomes and Measures

The primary outcome was incidence of posttreatment complications. Secondary outcomes included mortality, length of stay, and inpatient costs. Differences were estimated using inverse probability weighting of the propensity score with sensitivity analysis to quantify effects of unmeasured confounding.

Results

The median (IQR) age in the overall cohort was 39 (27-54) years, and 29 948 participants (51.3%) were female. In patients 65 years and older, nonoperative management was associated with a 3.72% decrease in risk of complications (95% CI, 2.99-4.46) and a 1.82% increase in mortality (95% CI, 1.49-2.15) along with increased length of hospitalization and costs. Outcomes in patients younger than 65 years were significantly different than in older adults, with only minor differences between nonoperative and operative management with respect to morbidity and mortality, and smaller differences in length of hospitalization and costs. Morbidity and mortality results were somewhat sensitive to bias from unmeasured confounding.

Conclusions and Relevance

Nonoperative management was associated with reduced complications in older but not younger patients; however, operative management was associated with reduced mortality, hospital length of stay, and overall costs across all age groups. The different outcomes of nonoperative vs operative management of appendicitis in older and younger adults highlights the need for a randomized clinical trial to determine the best approach for managing appendicitis in older patients.

Virtual Mentoring: A Novel Approach to Facilitate Medical Student Applications to General Surgery Residency

OBJECTIVE

The COVID-19 pandemic rapidly altered the landscape of medical education, particularly disrupting the residency application process and highlighting the need for structured mentorship programs. This prompted our institution to develop a virtual mentoring program to provide tailored, one-on-one mentoring to medical students applying to general surgery residency. The aim of this study was to examine general surgery applicant perception of a pilot virtual mentoring curriculum.

DESIGN

The mentorship program included student-tailored mentoring and advising in 5 domains: resume editing, personal statement composition, requesting letters of recommendation, interview skills, and residency program ranking. Electronic surveys were administered following ERAS application submission to participating applicants. The surveys were distributed and collected via a REDCap database.

RESULTS

Eighteen out of 19 participants completed the survey. Confidence in a competitive resume (p = 0.006), interview skills (p < 0.001), obtaining letters of recommendation (p = 0.002), personal statement drafting (p < 0.001), and ranking residency programs (p < 0.001) were all significantly improved following completion of the program. Overall utility of the curriculum and likelihood to participate again and recommend the program to others was rated a median 5/5 on the Likert scale (5 [IQR 4-5]). Confidence in the matching carried a premedian 66.5 (50-65) and a postmedian 84 (75-91) (p = 0.004).

CONCLUSION

Following the completion of the virtual mentoring program, participants were found to be more confident in all 5 targeted domains. In addition, they were more confident in their overall ability to match. General Surgery applicants find tailored virtual mentoring programs to be a useful tool allowing for continued program development and expansion.

Hospital Performance on Failure to Rescue Correlates With Likelihood of Home Discharge

INTRODUCTION

Failure to rescue (FTR) (avoiding death after complications) has been proposed as a measure of hospital quality. Although surviving complications is important, not all rescues are created equal. Patients also place considerable values on being able to return home after surgery and resume their normal lives. From a systems standpoint, nonhome discharge to skilled nursing and other facilities is the biggest driver of Medicare costs. We wanted to determine whether hospitals' ability to keep patients alive after complications was associated with higher rates of home discharge. We hypothesized that hospitals with higher rescue rates would also be more likely to discharge patients home after surgery.

METHODS

We conducted a retrospective cohort study using the nationwide inpatient sample. We included 1,358,041 patients ≥18 y old who had elective major surgery (general, vascular, orthopedic) at 3818 hospitals from 2013 to 2017. We predicted the correlation between a hospital's performance (rank) on FTR and its rank in terms of home discharge rate.

RESULTS

The cohort had a median age of 66 y (interquartile range [IQR] 58-73), and 77.9% of patients were Caucasian. Most patients (63.6%) were treated at urban teaching institutions. The surgical case mix included patients having colorectal (146,993 patients; 10.8%), pulmonary (52,334; 3.9%), pancreatic (13,635; 1.0%), hepatic (14,821; 1.1%), gastric (9182; 0.7%), esophageal (4494; 0.3%), peripheral vascular bypass (29,196; 2.2%), abdominal aneurysm repair (14,327; 1.1%), coronary artery bypass (61,976; 4.6%), hip replacement (356,400; 26.2%), and knee replacement (654,857; 48.2%) operations. The overall mortality was 0.3%, the average hospital complication rate was 15.9%, the median hospital rescue rate was 99% (IQR 70%-100%), and the median hospital rate of home discharge was 80% (IQR 74%-85%).There was a small but positive correlation between hospitals' performance on the FTR metric and the likelihood of home discharge after surgery (r = 0.0453; P = 0.006). When considering hospital rates of discharge to home following a postoperative complication, there was a similar correlation between rescue rates and probability of home discharge (r = 0.0963; P < 0.001). However, on sensitivity analysis excluding orthopedic surgery, there was a stronger correlation between rescue rates and home discharge rate (r = 0.4047, P < 0.001).

CONCLUSIONS

We found a small correlation between a hospital's ability to rescue patients from complication and that hospital's likelihood of discharging patients home after surgery. When excluding orthopedic operations from the analysis, this correlation strengthened. Our findings suggest that efforts to reduce mortality after complications will likely also help patients return home more frequently after complex surgery. However, more work needs to be done to identify successful programs and other patient and hospital factors that affect both rescue and home discharge.

Comparison of Postoperative Outcomes of Laparoscopic vs Open Inguinal Hernia Repair

Importance

Advocates of laparoscopic surgery argue that all inguinal hernias, including initial and unilateral ones, should be repaired laparoscopically. Prior work suggests outcomes of open repair are improved by using local rather than general anesthesia, but no prior studies have compared laparoscopic surgery with open repair under local anesthesia.

Objective

To evaluate postoperative outcomes of open inguinal hernia repair under general or local anesthesia compared with laparoscopic repair.

Design, Setting, and Participants

This retrospective cohort study identified 107 073 patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent unilateral initial inguinal hernia repair from 1998 to 2019. Data were analyzed from October 2021 to March 2022.

Exposures

Patients were divided into 3 groups for comparison: (1) open repair with local anesthesia (n = 22 333), (2) open repair with general anesthesia (n = 75 104), and (3) laparoscopic repair with general anesthesia (n = 9636).

Main Outcomes and Measures

Operative time and postoperative morbidity were compared using quantile regression and inverse probability propensity weighting. A 2-stage least-squares regression and probabilistic sensitivity analysis was used to quantify and address bias from unmeasured confounding in this observational study.

Results

Of 107 073 included patients, 106 529 (99.5%) were men, and the median (IQR) age was 63 (55-71) years. Compared with open repair with general anesthesia, laparoscopic repair was associated with a nonsignificant 0.15% (95% CI, -0.39 to 0.09; P = .22) reduction in postoperative complications. There was no significant difference in complications between laparoscopic surgery and open repair with local anesthesia (-0.05%; 95% CI, -0.34 to 0.28; P = .70). Operative time was similar for the laparoscopic and open general anesthesia groups (4.31 minutes; 95% CI, 0.45-8.57; P = .048), but operative times were significantly longer for laparoscopic compared with open repair under local anesthesia (10.42 minutes; 95% CI, 5.80-15.05; P < .001). Sensitivity analysis and 2-stage least-squares regression demonstrated that these findings were robust to bias from unmeasured confounding.

Conclusions and Relevance

In this study, laparoscopic and open repair with local anesthesia were reasonable options for patients with initial unilateral inguinal hernias, and the decision should be made considering both patient and surgeon factors.

A systematic review and meta-analysis of global and social functioning among people at risk of bipolar disorder

BACKGROUND

Functional status could predict development of bipolar disorder (BD) or have clinical significance. The relationship between BD risk and functioning is poorly understood. We undertook a systematic review examining the global and social functioning of those at risk for BD.

METHODS

We examined observational studies comparing a risk sample with healthy controls or full-threshold BD participants, using measures of global or social functioning. Risk status included family history of BD, meeting risk criteria, or having prodromal symptomatology, or premorbid functioning of persons with BD. Medline, PsycINFO, and Embase were searched. The Newcastle-Ottawa Scale for Cross-Sectional Studies was used to assess quality. Meta-analyses were performed where possible.

RESULTS

7215 studies were screened and 40 studies were included (8474 participants). Risk samples had poorer functioning than controls, and superior functioning to participants with BD. Meta-analysis indicated poorer global functioning among persons with familial risk compared to healthy controls (mean global functional difference: 5.92; 95 % confidence interval: 7.90, 3.95; mean premorbid functioning difference: 2.31; 95 % confidence interval: 0.70, 3.92). Studies with higher proportions of female participants had slightly poorer global functioning. High heterogeneity was attributable functional measures and potentially functionally differential subgroups within the risk samples.

LIMITATIONS

Broader measures of functioning, such as neurocognition and behavioural measures, were excluded. Measures of global functioning are limited by conflating functioning and symptoms.

CONCLUSIONS

Functioning in the BD risk populations is intermediate to that of healthy controls and persons with BD, indicating their value in definitions of BD risk, in itself a likely heterogeneous state.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

The validity of clinicians’ diagnoses: Is it bread and butter?

Major depression has become one of the most frequent diagnoses in Germany. It is also quite prominent in cases referred for medicolegal assessment in insurance, compensation or disability claims. This report evaluates the validity of clinicians’ diagnoses of major depression in a sample of claimants. In 2015, n = 127 consecutive cases were examined for medicolegal assessment. All had been diagnosed with major depression by clinicians. All testees underwent a psychiatric interview, a physical examination, they answered questionnaires for depressive symptoms according to DSM-5, embitterment disorder, post-concussion syndrome (PCS) and unspecific somatic complaints. Performance and symptom validity tests were administered. Only 31% of the sample fulfilled the diagnostic criteria for DSM-5 major depression according to self-report, while none did so according to psychiatric assessment. Negative response bias was found in 64% of cases, feigned neurologic symptoms in 22%. Symptom exaggeration was indiscriminate rather than depression-specific. By self-report (i.e. symptom endorsement in questionnaires), 64% of the participants qualified for embitterment disorder and 93% for PCS. In conclusion, clinicians’ diagnoses of depression seem frequently erroneous. The reasons are improper assessment of the diagnostic criteria, confusion of depression with bereavement or embitterment and a failure to assess for response bias.

Disclosure

No significant relationships.

Developing an online positive psychology application for people with bipolar disorder; ‘How expectations of consumers and professionals turned into an intervention.’

Introduction

In Bipolar Disorder (BD), people report a lower quality of life and lower levels of well-being than the general population. Additionally, patients with bipolar disorder have unmet needs which are closely linked to elements of positive psychology.

Objectives

The current study aimed to gain insight from patients with BD and care professionals about their thoughts of online Positive Psychology Interventions (PPI) to develop an app containing PPI’s for people with BD.

Methods

The study is conducted in accordance with the CeHRes roadmap principles. Data were collected by focus groups, questionnaires, rapid prototyping and online feedback from the participants. Three focus groups meetings (FGM) were held with consumers (8) and professionals (5).

Results

The FGM reveals a need for positive psychology interventions to cover some of the unmet needs that can be applied in an app in addition to the guidelines-advised treatment. Patients and professionals expect that PPIs in the current treatment in BD can meet some of the needs that are currently still unmet, specifically offering hope, increasing self-esteem, expressing feelings, acceptation and preventing social isolation. The process of contextual inquiry and value specification is helpful to guide this process.

Conclusions

The consensus on the different topics about the use of positive psychology intervention shows that both consumers and professionals underline the importance of applying PPI’s in BD. The use during subsyndrome and mild depressive episodes seem the most beneficial periods for patients with BD. A more extended study has to be conducted to confirm if these findings are more generalizable

Disclosure

No significant relationships.

Age is associated with increased morbidity after laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy is one of the most common emergency general surgery procedures in the United States. Little is known about its postoperative outcomes for older adults because appendicitis typically occurs in younger patients. The purpose of this study was to examine the association between age and postoperative complications after appendectomy. We hypothesized that age would have a significant and nonlinear association with morbidity.

METHODS

We conducted a retrospective cohort study of individuals whose laparoscopic appendectomies were recorded in the Veterans Affairs (VA) Surgical Quality Improvement Program (from 2000-2018; n = 14,619) and National Surgical Quality Improvement Program (2005-2019; n = 349,909) databases. The primary outcome was 30-day morbidity. We used logistic regression with fractional polynomials to model nonlinear relationships between age and outcomes.

RESULTS

The median age (interquartile range) of the nonveteran cohort was 36 years (26-51; 8.4% of patients were 65 or older) versus 51 years among veterans (35-63; 21% were 65 or older). For veterans and nonveterans, there was a significant and nonlinear relationship between age and risk of complications. In the nonveteran cohort, the predicted probability (with 95% confidence interval) of postoperative complications was 9.8% (9.7-10.1) at age 65, 11.9% (11.7-12.3) at age 75, and 14.5% (14.1-14.9) at age 85. Among veterans, the risk was 7.5% (6.9-8.1) at age 65, 8.3% (7.6-9.1) at age 75, and 9.1% (8.1-10.1) at age 85.

CONCLUSION

For both veterans and nonveterans, older age was associated with a significantly increased risk of postoperative complications. Notably, morbidity within the VA was lower for older adults than in non-VA hospitals.

Resident Involvement in Inguinal Hernia Repair is Safe but Associated With Increased Operative Time

INTRODUCTION

Understanding how resident participation in surgery affects outcomes is critical for academic surgeons. The purpose of this study was to evaluate if resident participation was associated with adverse outcomes for inguinal hernia repair.

METHODS

We used the Veterans Affairs Surgical Quality Improvement Program to look at 61,737 patients aged ≥18 y who had open inguinal hernia repairs from 1998 to 2018. Propensity weighting was used to compare postoperative complications and operative time for patients having surgery performed by an attending alone versus attending with a postgraduate year (PGY) 1, 3, or 5 residents.

RESULTS

There were 29,806 hernias (48%) repaired by an attending, 12,024 (19%) by an intern, 9008 (15%) by a PGY-3 resident, and 10,898 (18%) by a PGY-5 resident. After propensity weighting, there was a 0.13% (95% CI -0.11% to 0.38%, P = 0.29) increase in complications with PGY-1 participation compared to cases performed by attendings alone, a 0.3% increase (95% CI 0.01% to 0.59%, P = 0.04) for PGY-3 residents, and a 0.4% increase (95% CI 0.11% to 0.69%, P = 0.007) for PGY-5 residents. There was also an increase in operative time of 26 min (95% CI 25 to 27, P < 0.001) with PGY-1 participation, 19 min (95% CI 18 to 20, P < 0.001) with PGY-3 participation, and 23 min (95% CI 22 to 24, P < 0.001) with PGY-5 participation.

CONCLUSIONS

Resident involvement in inguinal hernia surgery was associated with a significant increase in operative time but had a minimal impact on postoperative complications. Although resident participation in hernia surgery is safe, surgical programs should focus on enhancing operative efficiency for residents.

760 IMPROVING THE MANAGEMENT AND DURATION OF RESOLUTION OF ACUTE KIDNEY INJURY IN THE ELDERLY

Introduction

Acute Kidney Injury (AKI) is prevalent in elderly populations due to several factors: polypharmacy, anatomic/physiologic changes of the kidneys associated with aging. AKI can contribute to increased length of stay, morbidity and mortality. This audit sets out to establish if the guidance established by NICE is being followed and how it may be better implemented.

Method

This study audited patients ≥65 years, who were admitted with AKI/developed an AKI during admission. Patients were excluded if they were on renal replacement therapy or under palliative care. Data was collected from case notes and Clinical Work Station. Data collection points used included: senior review within 24 hours; assessment of fluid status; medication review; strict fluid balance; examine for retention +/− catheter; daily U&E and appropriate imaging. Our independent variable was an AKI sticker, this included a revised checklist for above data collection points that was applied to patients’ medical notes. In addition to this, we used posters on appropriate wards which explained the guidance and management of AKI. Awareness was continued by presenting at Care of The Elderly teaching and medical grand round. Then re-audited the following month.

Results

Both cycles involved 45 patients. After implementation, improvements in urine analysis (5%vs35%), assessments of retention (0%vs38%) and assessments of fluid balance (55%vs78%) were seen. In cycle 2, medication was reviewed more frequently, specifically a 30% increase in the review of nephrotoxics. While senior review within 24 hours remains high in both cycles. We measured the outcome by checking the resolution time of AKI. Mean Resolution time was reduced by 1.4 days.

Conclusion

This audit has demonstrated an increase in the optimisation of the management of AKI through ensuring all appropriate interventions and examinations are completed and reducing resolution time by using stickers and the posters.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Use of local anesthesia for inguinal hernia repair has decreased over time in the VA system

PURPOSE

In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials' level 1 evidence.

METHODS

We used the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time-series design to examine the trend and rate of change of the use of local anesthesia.

RESULTS

We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64-67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P < 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year.

CONCLUSION

The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20 + years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.

Racial and Ethnic Disparities in Access to Local Anesthesia for Inguinal Hernia Repair

BACKGROUND

Many studies have identified racial disparities in healthcare, but few have described disparities in the use of anesthesia modalities. We examined racial disparities in the use of local versus general anesthesia for inguinal hernia repair. We hypothesized that African American and Hispanic patients would be less likely than Caucasians to receive local anesthesia for inguinal hernia repair.

MATERIALS AND METHODS

We included 78,766 patients aged ≥ 18 years in the Veterans Affairs Surgical Quality Improvement Program database who underwent elective, unilateral, open inguinal hernia repair under general or local anesthesia from 1998-2018. We used multiple logistic regression to compare use of local versus general anesthesia and 30-day postoperative complications by race/ethnicity.

RESULTS

In total, 17,892 (23%) patients received local anesthesia. Caucasian patients more frequently received local anesthesia (15,009; 24%), compared to African Americans (2353; 17%) and Hispanics (530; 19%), P < 0.05. After adjusting for covariates, we found that African Americans (OR 0.82, 95% CI 0.77-0.86) and Hispanics (OR 0.77, 95% CI 0.69-0.87) were significantly less likely to have hernia surgery under local anesthesia compared to Caucasians. Additionally, local anesthesia was associated with fewer postoperative complications for African American patients (OR 0.46, 95% CI 0.27-0.77).

CONCLUSIONS

Although local anesthesia was associated with enhanced recovery for African American patients, they were less likely to have inguinal hernias repaired under local than Caucasians. Addressing this disparity requires a better understanding of how surgeons, anesthesiologists, and patient-related factors may affect the choice of anesthesia modality for hernia repair.

Definitive-intent intensity modulated radiotherapy for modified-Adams' stage 4 canine sinonasal cancer: A retrospective study of 29 cases (2011-2017)

Dogs with sinonasal tumors with cribriform plate lysis (modified Adams' stage 4) treated with non-conformal definitive radiotherapy (RT) have short median survivals of 6-7 months. Intensity-modulated radiotherapy with its greater conformality and tumor dose homogeneity may result in more favorable outcomes. Dogs with epithelial or mesenchymal sinonasal tumors and CT evidence of cribriform lysis that received 10 daily fractions of 4.2 Gray using IMRT by helical tomotherapy were included in this single-institution retrospective case series study. Dogs with distant metastasis, previous treatment, or concurrent chemotherapy were excluded. Based on CT, tumors were divided into two groups: cribriform plate lysis only (stage 4a) or intracranial extension (stage 4b). Twenty-nine dogs were included, 23 with carcinoma and six with sarcoma. Eight dogs had stage 4b tumors; two presented with neurologic signs. Two dogs had lymph node metastasis at diagnosis, one confirmed and one suspected. Radiation dose distributions were standardized and patient positioning for RT was verified daily using on-board megavoltage CT. All evaluable dogs had improvement of clinical signs. Median progression free survival was 177 days (95% CI, 128-294 days). Median overall survival was 319 days (95% CI, 188-499 days). Radiotherapy was well tolerated. The most common side effect was grade 1 or 2 oral mucositis. Two dogs that received additional treatment at progression (stereotactic RT [1]; surgery [1]) developed significant late effects. Image-guided definitive-intent IMRT may improve survival in dogs with modified Adams' stage 4 sinonasal tumors and is associated with low morbidity. Intracranial tumor extension was not prognostic in this cohort of uniformly treated dogs.

Electroconvulsive therapy: a review on indications, methods, risks and medication

This paper reviews and presents data of practical impact for those administering electroconvulsive therapy (ECT). In the first section, physical and physiological aspects of the stimulus as well as methods of stimulation are discussed. The second section deals with indications for ECT, efficacy and treatment modalities such as seizure duration, treatment frequency and total number of ECT applications. The last section is devoted to side effects, risks, comedication and comorbidity.

Excluding non-English publications from evidence-syntheses did not change conclusions: a meta-epidemiological study

OBJECTIVES

We aimed to assess whether limiting the inclusion criteria solely to English-language publications affected the overall conclusions of evidence syntheses.

STUDY DESIGN AND SETTING

Our analyses used a dataset of a previous methods study that included 59 randomly selected Cochrane intervention reviews with no language restrictions. First, we ascertained the publication language of all 2,026 included publications. Next, we excluded studies based on the following criteria: (1) publication solely in non-English language, or (2) main publication (in case of multiple publications of the same study) in non-English language. We then re-calculated meta-analyses for outcomes that were presented in the main summary of findings tables of the Cochrane reports. If the direction of the effect estimate or the statistical significance changed, authors of the respective Cochrane reviews were consulted to assess whether the new evidence base would have changed their conclusions. The primary outcome of our analyses examined the proportion of conclusions that would change with the exclusion of non-English publications. We set the threshold for the approach as noninferior if the upper limit of the 95% confidence interval of the proportion of changed conclusions did not cross a margin of 10%.

RESULTS

Across all 59 Cochrane reviews, 29 (49%) included 80 non-English publications. For 16 (27%) of these Cochrane reviews, the exclusion of non-English publications resulted in the exclusion of at least one study. In the remaining 13 Cochrane reviews, the non-English publications were not the only or main publication of the study or they did not contribute to the main summary of the findings table, so their exclusion did not result in an exclusion of the study. Overall, the exclusion of non-English publications led to the exclusion of 31 studies contributing to 40 outcomes. For 38 of the 40 outcomes, the exclusion of non-English studies did not markedly alter the size or direction of effect estimates or statistical significance. In two outcomes, the statistical significance changed, but authors would have still drawn the same conclusion, albeit with less certainty. Thus, the proportion of changed conclusions in our sample was 0.0% (95% CI 0.0-0.6), which indicated the noninferiority of the approach. However, the majority of excluded studies were small.

CONCLUSION

Exclusion of non-English publications from systematic reviews on clinical interventions had a minimal effect on overall conclusions and could be a viable methodological shortcut, especially for rapid reviews.

Systems based analysis of human embryos and gene networks involved in cell lineage allocation

BACKGROUND

Little is understood of the molecular mechanisms involved in the earliest cell fate decision in human development, leading to the establishment of the trophectoderm (TE) and inner cell mass (ICM) stem cell population. Notably, there is a lack of understanding of how transcriptional networks arise during reorganisation of the embryonic genome post-fertilisation.

RESULTS

We identified a hierarchical structure of preimplantation gene network modules around the time of embryonic genome activation (EGA). Using network models along with eukaryotic initiation factor (EIF) and epigenetic-associated gene expression we defined two sets of blastomeres that exhibited diverging tendencies towards ICM or TE. Analysis of the developmental networks demonstrated stage specific EIF expression and revealed that histone modifications may be an important epigenetic regulatory mechanism in preimplantation human embryos. Comparison to published RNAseq data confirmed that during EGA the individual 8-cell blastomeres are transcriptionally primed for the first lineage decision in development towards ICM or TE.

CONCLUSIONS

Using multiple systems biology approaches to compare developmental stages in the early human embryo with single cell transcript data from blastomeres, we have shown that blastomeres considered to be totipotent are not transcriptionally equivalent. Furthermore we have linked the developmental interactome to individual blastomeres and to later cell lineage. This has clinical implications for understanding the impact of fertility treatments and developmental programming of long term health.

Knowledge Synthesis in Evidence-Based Medicine

Systematic reviews are the most common form of knowledge synthesis and remain a cornerstone of the practice of evidence-based medicine. They offer enhanced rigor and validity relative to traditional narrative review articles by reducing bias and increasing objectivity. In answering focused research questions, systematic reviews are directly applicable to clinical practice as well as the development of clinical guidelines and the identification of knowledge gaps, which may drive future primary research directions. Typically, such a rigorous process necessarily requires substantive time to carefully and systematically identify, screen, and synthesize all relevant available primary research on a topic. Further, other knowledge synthesis methods have emerged to address the varying needs of decision makers with respect to condensed timelines and more diverse research questions, as well as to allow incorporation of already synthesized evidence into reviews. These alternative methods include rapid reviews, scoping reviews, and overviews of systematic reviews, which are being used with increasing frequency by clinicians, decision-makers, and researchers. We encourage clinicians and researchers in nuclear medicine and other imaging sciences to acquire a greater familiarity with these methods and to consider them in clinical decision making, the development of clinical guidelines, and the planning of future research activities.

Folate supplementation to prevent birth abnormalities: evaluating a community-based participatory action plan for refugees and migrant workers on the Thailand-Myanmar border

Objectives

Preconception folic acid (PFA) taken at least 3 months before conception can decrease the incidence of neural tube defects (NTDs) by approximately 46%. NTDs contribute significantly to neonatal morbidity and mortality in migrant and refugee populations on the Thailand-Myanmar border (incidence 1.57/1000 live births). This audit aimed to assess uptake of PFA among migrant and refugee women, evaluate knowledge about PFA among local healthcare workers and implement a participatory community intervention to increase PFA uptake and decrease NTD incidence in this population.

Study design

A mixed-methods baseline evaluation was followed by an intervention involving health worker education and a community outreach program. A follow-up audit was performed 18 months post-intervention.

Methods

Data were gathered via surveys, short interviews and focus group discussions. The intervention program included community-based workshops, production and distribution of printed flyers and posters, and outreach to various local organisations.

Results

Uptake of PFA was <2% both before and after the intervention. Despite a substantial increase in local healthcare worker knowledge of PFA, no significant improvement in PFA uptake after the intervention was detected. Most pregnancies in this local community sample were reported to be unplanned.

Conclusions

High rates of NTDs with low PFA uptake remains a major public health challenge in this transient population. Results indicate that improved health worker knowledge alone is not sufficient to enhance PFA uptake in this population. Integration of PFA education within expanded family planning programs and broad-based food fortification may be more effective.

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Audited preconception folic acid (PFA) campaign on Thai-Myanmar border.

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Low awareness of PFA among health workers and migrant/refugee pregnant women.

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Improved local health worker PFA knowledge after campaign and follow-up held after 18 months.

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Overall, campaign proved ineffective in increasing PFA uptake among pregnant women.

Identification of the functional pathways altered by placental cell exposure to high glucose: lessons from the transcript and metabolite interactome

The specific consequences of hyperglycaemia on placental metabolism and function are incompletely understood but likely contribute to poor pregnancy outcomes associated with diabetes mellitus (DM). This study aimed to identify the functional biochemical pathways perturbed by placental exposure to high glucose levels through integrative analysis of the trophoblast transcriptome and metabolome. The human trophoblast cell line, BeWo, was cultured in 5 or 25 mM glucose, as a model of the placenta in DM. Transcriptomic analysis using microarrays, demonstrated 5632 differentially expressed gene transcripts (≥± 1.3 fold change (FC)) following exposure to high glucose. These genes were used to generate interactome models of transcript response using BioGRID (non-inferred network: 2500 nodes (genes) and 10541 protein-protein interactions). Ultra performance-liquid chromatography-mass spectrometry (MS) and gas chromatography-MS analysis of intracellular extracts and culture medium were used to assess the response of metabolite profiles to high glucose concentration. The interactions of altered genes and metabolites were assessed using the MetScape interactome database, resulting in an integrated model of systemic transcriptome (2969 genes) and metabolome (41 metabolites) response within placental cells exposed to high glucose. The functional pathways which demonstrated significant change in response to high glucose included fatty acid β-oxidation, phospholipid metabolism and phosphatidylinositol phosphate signalling.

Global patterns of care in advanced stage mycosis fungoides/Sezary syndrome: a multicenter retrospective follow-up study from the Cutaneous Lymphoma International Consortium

BACKGROUND

Advanced-stage mycosis fungoides (MF)/Sézary syndrome (SS) patients are weighted by an unfavorable prognosis and share an unmet clinical need of effective treatments. International guidelines are available detailing treatment options for the different stages but without recommending treatments in any particular order due to lack of comparative trials. The aims of this second CLIC study were to retrospectively analyze the pattern of care worldwide for advanced-stage MF/SS patients, the distribution of treatments according to geographical areas (USA versus non-USA), and whether the heterogeneity of approaches has potential impact on survival.

PATIENTS AND METHODS

This study included 853 patients from 21 specialist centers (14 European, 4 USA, 1 each Australian, Brazilian, and Japanese).

RESULTS

Heterogeneity of treatment approaches was found, with up to 24 different modalities or combinations used as first-line and 36% of patients receiving four or more treatments. Stage IIB disease was most frequently treated by total-skin-electron-beam radiotherapy, bexarotene and gemcitabine; erythrodermic and SS patients by extracorporeal photochemotherapy, and stage IVA2 by polychemotherapy. Significant differences were found between USA and non-USA centers, with bexarotene, photopheresis and histone deacetylase inhibitors most frequently prescribed for first-line treatment in USA while phototherapy, interferon, chlorambucil and gemcitabine in non-USA centers. These differences did not significantly impact on survival. However, when considering death and therapy change as competing risk events and the impact of first treatment line on both events, both monochemotherapy (SHR = 2.07) and polychemotherapy (SHR = 1.69) showed elevated relative risks.

CONCLUSION

This large multicenter retrospective study shows that there exist a large treatment heterogeneity in advanced MF/SS and differences between USA and non-USA centers but these were not related to survival, while our data reveal that chemotherapy as first treatment is associated with a higher risk of death and/or change of therapy and thus other therapeutic options should be preferable as first treatment approach.

High-resolution magnetic resonance imaging reveals nuclei of the human amygdala: manual segmentation to automatic atlas

The amygdala is composed of multiple nuclei with unique functions and connections in the limbic system and to the rest of the brain. However, standard in vivo neuroimaging tools to automatically delineate the amygdala into its multiple nuclei are still rare. By scanning postmortem specimens at high resolution (100-150µm) at 7T field strength (n = 10), we were able to visualize and label nine amygdala nuclei (anterior amygdaloid, cortico-amygdaloid transition area; basal, lateral, accessory basal, central, cortical medial, paralaminar nuclei). We created an atlas from these labels using a recently developed atlas building algorithm based on Bayesian inference. This atlas, which will be released as part of FreeSurfer, can be used to automatically segment nine amygdala nuclei from a standard resolution structural MR image. We applied this atlas to two publicly available datasets (ADNI and ABIDE) with standard resolution T1 data, used individual volumetric data of the amygdala nuclei as the measure and found that our atlas i) discriminates between Alzheimer's disease participants and age-matched control participants with 84% accuracy (AUC=0.915), and ii) discriminates between individuals with autism and age-, sex- and IQ-matched neurotypically developed control participants with 59.5% accuracy (AUC=0.59). For both datasets, the new ex vivo atlas significantly outperformed (all p < .05) estimations of the whole amygdala derived from the segmentation in FreeSurfer 5.1 (ADNI: 75%, ABIDE: 54% accuracy), as well as classification based on whole amygdala volume (using the sum of all amygdala nuclei volumes; ADNI: 81%, ABIDE: 55% accuracy). This new atlas and the segmentation tools that utilize it will provide neuroimaging researchers with the ability to explore the function and connectivity of the human amygdala nuclei with unprecedented detail in healthy adults as well as those with neurodevelopmental and neurodegenerative disorders.

A pilot interventional study to evaluate the impact of cholecalciferol treatment on HbA1c in type 1 diabetes (T1D)

BACKGROUND

Higher 25(OH)D3 levels are associated with lower HbA1c, but there are limited UK interventional trials assessing the effect of cholecalciferol on HbA1c.

AIMS

(1) To assess the baseline 25(OH)D3 status in a Manchester cohort of children with type 1 diabetes (T1D). (2) To determine the effect of cholecalciferol administration on HbA1c.

METHODS

Children with T1D attending routine clinic appointments over three months in late winter/early spring had blood samples taken with consent. Participants with a 25(OH)D3 level <50 nmol/L were treated with a one-off cholecalciferol dose of 100,000 (2-10 years) or 160,000 (>10 years) units. HbA1c levels before and after treatment were recorded.

RESULTS

Vitamin D levels were obtained from 51 children. 35 were Caucasian, 11 South Asian and 5 from other ethnic groups. 42 were vitamin D deficient, but 2 were excluded from the analysis. All South Asian children were vitamin D deficient, with mean 25(OH)D3 of 28 nmol/L. In Caucasians, there was a negative relationship between baseline 25(OH)D3 level and HbA1c (r = -0.484, P < 0.01). In treated participants, there was no significant difference in mean HbA1c at 3 months (t = 1.010, P = 0.328) or at 1 year (t = -1.173, P = 0.248) before and after treatment. One-way ANCOVA, controlling for age, gender, ethnicity, BMI and diabetes duration showed no difference in Δ HbA1c level.

CONCLUSION

We report important findings at baseline, but in children treated with a stat dose of cholecalciferol, there was no effect on HbA1c. Further studies with larger sample sizes and using maintenance therapy are required.

Work Practices and Histopathological Changes in the Tenosynovium in Carpal Tunnel Syndrome in Men

The aim of this prospective study was to assess whether the fibrous thickening of the carpal tunnel tenosynovium is influenced by working practices. We did this by investigating 50 men (58 hands) with idiopathic carpal tunnel syndrome, who were undergoing carpal tunnel decompression.

Occupational history, including vibration tool exposure, and presence of callosities and/or ingrained dirt on hands was recorded at the time of surgery. The flexor tenosynovium was biopsied, and assessed histologically by an observer blinded to occupational history.

Occupational group, age, weight and smoking showed no significant association with fibrous tenosynovial thickening. There was also no significant association between fibrous tenosynovial thickening and the presence of hand callosities/in-grained dirt or regular use of vibration tools. Thus no association was found between heavy occupational hand usage and the development of fibrous tenosynovial thickening around tendons within the carpal tunnel.

The Development and Analysis of a Database to Record Critical Incidents Associated with Intravenous Drug Administration in Critically III Patients

Staff were asked to report critical incidents associated with intravenous medications across a critical care network. These were categorised using a database by drug and drug class, seriousness and level of harm, process stage and communication factors. 139 critical incidents were identified in 3848 patient days. Noradrenaline, omeprazole, gentamicin and insulin were most commonly involved (range 6 to 9 incidents). Twenty two incidents involved drug supply, 61 prescriptions, 10 preparation and 58 administration.

The use of a structured database allowed a clearer understanding of incidents to be established and we make some recommendations to improve safety. The classification database could be established across many intensive care units to improve understanding of incidents associated with intravenous medications.