Practice Patterns in Hepatitis B Virus Screening Before Cancer Chemotherapy in a Major US Hospital Network

Background

Cancer patients receiving chemotherapy face an increased risk of reactivation of chronic hepatitis B virus infection.

Aim

To determine the HBV screening rate in patients receiving cancer chemotherapy in various clinical settings.

Method

We identified 11,959 adult cancer patients (age ≥ 18 years) receiving parenteral chemotherapy between 2012 and 2015 within a major US hospital network, including a large university hospital, community teaching hospitals, and community oncology clinics.

Result

Two thousand and forty-five patients (17.1%) were screened for either HBV surface antigen (HBsAg) or HBV core antibody (HBcAb) before chemotherapy, and 1850 patients (15.5%) had both HBsAg and HBcAb tested before chemotherapy. 8.4% were exposed to HBV, and 0.9% had chronic HBV infection (both HBsAg/HBcAb positive). Patients with hematologic tumor were more often screened than with solid tumor (55.6 vs. 8.3%, p < 0.001). Patients receiving chemotherapy with higher HBV reactivation risk had higher yet suboptimal HBV screening rate (41.1% B-depleting agents, 21.5% anthracycline, 14.9% steroid, 64.7% anti-TNF alpha and 18.6% other chemotherapy, p < 0.001). Patients with age ≥ 50 years (old 16.2% vs. young 23.9%, p < 0.001) and Asian ethnicity (Asian 13.6 vs. Caucasian 16.6%, p < 0.001) were screened less for HBV despite higher prevalence of HBV exposure (old 9.3% vs. young 4.3%, p < 0.001 and Asian 27.8% vs. Caucasian 6.4%, p < 0.001). Patients receiving chemotherapy in community oncology clinics were less screened versus community teaching hospitals or university hospital (12.7 vs. 19.1 vs. 19.7%, p < 0.001), despite similar prevalence of HBV infection. On multivariate analysis, receiving chemotherapy at a community oncology clinic [odds ratio (OR) 0.57, 95% confidence interval (CI) 0.45–0.72, p < 0.001] was independently associated with less HBV screening compared to receiving chemotherapy at a university or community teaching hospital.

Conclusion

HBV screening among patients undergoing cancer chemotherapy was suboptimal and less commonly performed in community oncology clinics compared to teaching hospitals.

     

Skin and Soft Tissue Infections Due to Nontuberculous Mycobacteria

Purpose of Review

This review describes recent trends in the epidemiology of nontuberculous mycobacteria (NTM), emerging pathogens, new insights into NTM pathogenesis, and advances in diagnosis and treatment.

Recent Findings

Emerging pathogens include Mycobacterium chimaera and drug-resistant subspecies of Mycobacterium abscessus. Important virulence mechanisms of pathogenic NTM include the ability to alter the macrophage’s permissiveness to intracellular bacterial growth. New diagnostic tools consist of DNA probes, gene sequencing, and matrix-assisted laser desorption ionization-time of flight. These methods allow rapid speciation of NTM species, in some cases directly from patient samples. There are few novel agents available to treat NTM, although some repurposed drugs show excellent activity.

Summary

The incidence of NTM infections appears to be increasing in a number of regions around the world. Molecular methods are now the diagnostic tools of choice. Discovery of novel effective agents and/or drug combinations with greater likelihood of cure, shorter treatment duration, and fewer side effects are research priorities.

     

Rapid access clinic for unexplained lymphadenopathy and suspected malignancy: prospective analysis of 1000 patients

Background

In patients presenting with peripheral lymphadenopathy, it is critical to effectively identify those with underlying cancer who require urgent specialist care.

Methods

We analyzed a large dataset of 1000 consecutive patients with unexplained lymphadenopathy referred between 2001 and 2009 to the Royal Marsden Hospital (RMH) rapid access lymph node diagnostic clinic (LNDC).

Results

Cancer was diagnosed in 14% of patients. Factors predictive for malignant disease were male sex, age, supraclavicular and multiple site involvement. Cancer-associated symptoms were present for a median of 8 weeks. The median time from referral to start of cancer therapy was 53 days. Fine needle aspiration (FNA) was performed in 83% of patients with malignancies. Sensitivity and specificity of FNA were limited (50 and 87%, respectively for any malignancy; 30 and 79%, respectively for lymphoma). The vast majority of cancer patients received diagnostic biopsies on the basis of suspicious clinical and ultrasound findings; the FNA result contributed to establishing the diagnosis in only 4 cases.

Conclusions

In conclusion, we demonstrate that Oncologist-led rapid access clinics are successful concepts to assess patients with unexplained lymphadenopathy. Our data suggest that a routine use of FNA should be reconsidered in this setting.

     

Diagnostic Discordance,Health Information Exchange,and Inter-Hospital Transfer Outcomes: a Population Study

Background

Studying diagnostic error at the population level requires an understanding of how diagnoses change over time.

Objective

To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy.

Design

Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality.

Participants

Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013.

Main Measures

We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality.

Key Results

Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10–1.11, p?<?0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p?<?0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89–0.99, p?<?0.001).

Conclusions

Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.

     

Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural–Urban Variations

BACKGROUND

Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings.

OBJECTIVE

To examine rural–urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program.

DESIGN

This was an observational study using patient registry.

SUBJECTS

The study included adult enrollees (n?=?15,843) with a mental disorder from 133 participating community health clinics.

MAIN OUTCOMES

We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits.

KEY RESULTS

While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems.

CONCLUSIONS

Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural–urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

     

Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals: a Cross-Sectional Study

Background

Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized.

Objective

To identify the association between insurance coverage and mortality of patients transferred between hospitals.

Design

We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers.

Setting

Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers.

Patients

The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals.

Measurements

Adjusted inpatient mortality and 24-h mortality, stratified by insurance status.

Results

Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p?=?0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p?=?0.026), and earlier in their hospital course (3.9 vs 2.0 days, p?=?0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13–1.36, p?<?0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11–1.60, p?<?0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses.

Limitations

This is an observational study where transfer appropriateness cannot be directly assessed.

Conclusions

Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.

     

Manual Intrapleural Saline Flushing Plus Urokinase: A Potentially Useful Therapy for Complicated Parapneumonic Effusions and Empyemas

Purpose

We sought to evaluate the safety profile and effectiveness of manual pleural saline flushing, in addition to urokinase, for managing complicated parapneumonic effusions and empyemas.

Methods

Retrospective comparative review of 23 consecutive patients with complicated parapneumonic effusions or empyemas who received saline flushing plus urokinase through small-bore chest catheters, and 39 who were only treated with fibrinolytics. Both groups had similar baseline characteristics and treatments were mostly protocol-driven.

Results

As compared with patients only receiving urokinase, those additionally treated with saline flushing needed less fibrinolytic doses (a single dose being sufficient in 15 vs 44%, p = 0.019), chest tube duration (5 vs 2 days, p < 0.01), and length of hospital stay (8 vs 6 days, p = 0.011). There were no adverse events attributed to saline therapy.

Conclusions

Manual pleural saline flushing via chest tube, in addition to urokinase, is a safe and potentially beneficial therapy in patients with pleural infection.

     

Endoscopic ultrasound-guided transesophageal thoracentesis for minimal pleural effusion

Background

Pleural effusion is a common finding both in patients with benign and malignant diseases of pleura and lung with diagnostic thoracentesis establishing the diagnosis in the majority of cases. The diagnostic thoracentesis can be done either blindly or under the guidance of ultrasound or computed tomography. However, minimal pleural effusion is difficult to sample even under image guidance. Endoscopic ultrasound (EUS) is known to detect smaller volume of pleural effusion and, thus, can help in guiding thoracentesis.

Aim

To analyze the safety and efficacy of EUS-guided diagnostic thoracentesis in patients with undiagnosed minimal pleural effusion retrospectively.

Methods

Retrospective analysis of the data of patients with minimal pleural effusion, who underwent EUS-guided transesophageal diagnostic thoracentesis over last 2 years, was performed.

Results

Thirteen patients (11 male; mean age 46.7?±?16.2 years) with undiagnosed minimal pleural effusion underwent successful EUS-guided transesophageal diagnostic thoracentesis using a 22-G needle. Seven (53%) patients had fever on presentation whereas two presented with cough and loss of appetite. Eight to 54 mL fluid was aspirated with an attempt to completely empty the pleural cavity. There were no complications of the procedure.

Conclusions

EUS-guided diagnostic thoracentesis is a safe and effective alternative for evaluating patients with minimal pleural effusion.

     

Evaluation of the International Consensus Guidelines for the Surgical Resection of Intraductal Papillary Mucinous Neoplasms

Background

International consensus guidelines for intraductal papillary mucinous neoplasms (IPMNs) were revised in 2012.

Aims

We aimed to evaluate the clinical utility of each predictor in the 2006 and 2012 guidelines and validate the diagnostic value and surgical indications.

Methods

Forty-two patients with surgically resected IPMNs were included. Each predictor was applied to evaluate its diagnostic value.

Results

The 2012 guidelines had greater accuracy for invasive carcinoma than the 2006 guidelines (64.3 vs. 31.0%). Moreover, the accuracy for high-grade dysplasia was also increased (48.6 vs. 77.1%). When the main pancreatic duct (MPD) size ≥8 mm was substituted for MPD size ≥10 mm in the 2012 guidelines, the accuracy for high-grade dysplasia was 80.0%.

Conclusions

The 2012 guidelines exhibited increased diagnostic accuracy for invasive IPMN. It is important to consider surgical resection prior to invasive carcinoma, and high-risk stigmata might be a useful diagnostic criterion. Furthermore, MPD size ≥8 mm may be predictive of high-grade dysplasia.

     

Centre characteristics determine ambulatory care and referrals in patients with spondyloarthritis

Objective

To describe the variability in rheumatology visits and referrals to other medical specialties of patients with spondyloarthritis (SpA) and to explore factors that may influence such variability.

Methods

Nation-wide cross-sectional study performed in 2009–2010. Randomly selected records of patients with a diagnosis of SpA and at least one visit to a rheumatology unit within the previous 2 years were audited. The rates of rheumatology visits and of referrals to other medical specialties were estimated—total and between centres—in the study period. Multilevel regression was used to analyse factors associated with variability and to adjust for clinical and patient characteristics.

Results

1168 patients’ records (45 centres) were reviewed, mainly ankylosing spondylitis (55.2 %) and psoriatic arthritis (22.2 %). The patients had incurred in 5908 visits to rheumatology clinics (rate 254 per 100 patient-years), 4307 visits to other medical specialties (19.6 % were referrals from rheumatology), and 775 visits to specialised nurse clinics. An adjusted variability in frequenting rheumatology clinics of 15.7 % between centres was observed. This was partially explained by the number of faculties and trainees. The adjusted intercentre variability for referrals to other specialties was 12.3 %, and it was associated with urban settings, number of procedures, and existence of SpA dedicated clinics; the probability of a patient with SpA of being referred to other specialist may increase up to 25 % depending on the treating centre.

Conclusion

Frequenting rheumatology clinics and referrals to other specialists significantly varies between centres, after adjustment by patient characteristics.

     

The Effect of Azathioprine on Anastomotic Healing: An Experimental Study in Rats

Purpose

The cytotoxic and immunosuppressive effects of azathioprine, which mitigate the disease activity in inflammatory bowel disease, may compromise the healing of intestinal anastomoses leading to an increased risk of anastomotic leakage. The effect of azathioprine treatment on intestinal healing was tested.

Methods

In an experimental study, rats were randomly given one oral dose of azathioprine (5 mg or 20 mg/kg body weight per day) or placebo. After 28 days of treatment, a left colonic anastomosis was performed. After three days of healing, the breaking strengths of the anastomoses were tested, along with measurements of azathioprine major metabolite concentrations: 6-thioguanine and 6-methyl-mercaptopurine.

Results

There were no significant differences in the anastomotic breaking strength between the three groups.

Conclusions

Daily treatment for four weeks with high or low azathioprine doses has no inhibitory effect on colonic healing in rats.

     

Results of the Gore Bio-A fistula plug implantation in the treatment of anal fistula: a multicentre study

Background

The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas.

Methods

A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin.

Results

The healing rate after 1 year of follow-up was 52 % (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10 % (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32 ± 10.2 min, and the average length of hospital stay was 3.3 ± 1.8 days.

Conclusions

Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.

     

Alterations in hematologic indices during long-duration spaceflight

Background

Although a state of anemia is perceived to be associated with spaceflight, to date a peripheral blood hematologic assessment of red blood cell (RBC) indices has not been performed during long-duration space missions.

Methods

This investigation collected whole blood samples from astronauts participating in up to 6-months orbital spaceflight, and returned those samples (ambient storage) to Earth for analysis. As samples were always collected near undock of a returning vehicle, the delay from collection to analysis never exceeded 48 h. As a subset of a larger immunologic investigation, a complete blood count was performed. A parallel stability study of the effect of a 48 h delay on these parameters assisted interpretation of the in-flight data.

Results

We report that the RBC and hemoglobin were significantly elevated during flight, both parameters deemed stable through the delay of sample return. Although the stability data showed hematocrit to be mildly elevated at +48 h, there was an in-flight increase in hematocrit that was ~3-fold higher in magnitude than the anticipated increase due to the delay in processing.

Conclusions

While susceptible to the possible influence of dehydration or plasma volume alterations, these results suggest astronauts do not develop persistent anemia during spaceflight.

     

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services

Background

Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. “Virtual visits” are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit.

Objective

To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care.

Design

Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences.

Participants

Primary care patients with hypertension.

Exposure

Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension.

Main measures

Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit.

Key results

Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140–160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, ??2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, ??0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]).

Conclusions

Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

     

Metachronous colorectal cancer

Aim

In this study, we present our patients with metachronous colorectal cancer.

Patients and methods

In the period between 1990 and 2009, 670 patients with colorectal cancer were treated.

Results

Metachronous cancer was developed in 4 (0.6%) patients. The time interval between index and metachronous cancer was 28 months to 22 years (mean 146 months).

Conclusion

Metachronous colorectal cancer is a potential risk that proves the necessity of postoperative colonoscopic control of all patients with colorectal cancer.

     

Laparoscopic colectomy for colonic carcinoma

Aim

The aim of this study is to present our experience with the laparoscopic treatment approach for colonic carcinoma.

Patients and methods

Between 2005 and 2010, laparoscopic colectomy was performed in 13 patients; 9 patients underwent laparoscopic right hemicolectomy, 3 sigmoidectomy and 1 patient underwent laparoscopic caecectomy.

Results

With regards to the right hemicolectomies, the average operative time was 168 min and the average hospital stay 5.3 days. In patients who underwent laparoscopic sigmoidectomy, the average operative time was 176 min, while the average hospital stay was 10.2 days. Finally, the laparoscopic caecectomy was performed in 85 min. There was one conversion (7.7%) to an open procedure, as well as one case (7.7%) of anastomotic leakage, which was treated with re-laparotomy and a Hartmann’s procedure. Up to today, all patients remain healthy with no signs of tumor recurrence.

Conclusion

Laparoscopic colectomy for cancer, in the hands of an experienced laparoscopic surgeon, is a safe and efficient procedure.

     

Long-term efficacy of comprehensive multidisciplinary antibiotic stewardship programs centered on weekly prospective audit and feedback

Objective

To evaluate the long-term effects of comprehensive antibiotic stewardship programs (ASPs) on antibiotic use, antimicrobial-resistant bacteria, and clinical outcomes.

Design

Before–after study.

Setting

National university hospital with 934 beds.

Intervention

Implementation in March 2010 of a comprehensive ASPs including, among other strategies, weekly prospective audit and feedback with multidisciplinary collaboration.

Methods

The primary outcome was the use of antipseudomonal antibiotics as measured by the monthly mean days of therapy per 1000 patient days each year. Secondary outcomes included overall antibiotic use and that of each antibiotic class, susceptibility of Pseudomonas aeruginosa, the proportion of patients isolated methicillin-resistant Staphylococcus aureus (MRSA) among all patients isolated S. aureus, the incidence of MRSA, and the 30-day mortality attributable to bacteremia.

Results

The mean monthly use of antipseudomonal antibiotics significantly decreased in 2011 and after as compared with 2009. Susceptibility to levofloxacin was significantly increased from 2009 to 2016 (P = 0.01 for trend). Its susceptibility to other antibiotics remained over 84% and did not change significantly during the study period. The proportion of patients isolated MRSA and the incidence of MRSA decreased significantly from 2009 to 2016 (P < 0.001 and = 0.02 for trend, respectively). There were no significant changes in the 30-day mortality attributable to bacteremia during the study period (P = 0.57 for trend).

Conclusion

The comprehensive ASPs had long-term efficacy for reducing the use of the targeted broad-spectrum antibiotics, maintaining the antibiotic susceptibility of P. aeruginosa, and decreasing the prevalence of MRSA, without adversely affecting clinical outcome.

     

A comparison of the diagnostic value of MRI and <Superscript>18</Superscript>F-FDG-PET/CT in suspected spondylodiscitis

Purpose

The purpose of this study was to evaluate the diagnostic value of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT scan) and magnetic resonance imaging (MRI) in diagnosing spondylodiscitis and its complications, such as epidural and paraspinal abscesses.

Methods

From January 2006 to August 2013 patients with a clinical suspicion of spondylodiscitis, with an infection, or with fever of unknown origin were retrospectively included if ¹⁸F-FDG-PET/CT and MRI of the spine were performed within a 2-week time span. Imaging results were compared to the final clinical diagnosis and follow-up data were collected.

Results

Sixty-eight patients were included of whom 49 patients were diagnosed with spondylodiscitis. MRI showed an overall sensitivity of 67 % and specificity of 84 %. Diagnostic accuracy was 58 %, when MRI was performed within 2 weeks after the start of symptoms and improved to 82 %, when performed more than 2 weeks after onset of symptoms. ¹⁸F-FDG-PET/CT showed a sensitivity of 96 % and a specificity of 95 %, with no relation to the interval between the scan and the start of symptoms.

Conclusions

As compared to MRI, ¹⁸F-FDG-PET/CT has superior diagnostic value for detecting early spondylodiscitis. After 2 weeks both techniques perform similarly.