Moving CAR-Ts to the outpatient clinic

As centres obtain more experience with commercial CARs, there has been increasing interest in trying to move as much as the procedure as possible to the outpatient clinic to reduce costs, maximize reimbursement and increase patient satisfaction. The report by Ly et al. details how their centre implemented outpatient CAR therapy and were able to reduce admission time without affecting outcomes. Commentary on: Ly et al. Outpatient CD19-directed CAR T-cell therapy is feasible in patients of all ages. Br J Haematol 2023;203:688-692.     

Reliability of drug histories in a specialized geriatric outpatient clinic

To examine the reliability of drug histories of elderly outpatients, records of 122 frail elderly patients in a geriatric outpatient evaluation clinic were reviewed. Drug histories were taken by an internist during an initial clinical evaluation and by a nurse practitioner during a home visit. Home and office drug lists disagreed in 39 cases (32%). Roughly equal numbers of “extra” drugs were listed in the two settings. Number of medications (especially two or more), number of active medical problems (especially four or more), and depression were significant, independent predictors of an unreliable drug history. Neither dementia nor living situation was a significant predictor of an unreliable drug history. The only drugs associated with an unreliable history were megavitamins, beta-blockers, and centrally-acting antihypertensive agents. Using the home list as the reference, there were equal numbers of omission errors and commission errors in the office drug histories. Strategies to optimize the reliability of office drug histories need further investigation. Presented in part at American Federation of Clinical Research, Western Section, Annual Meeting, Carmel, CA, February 7, 1985. Supported in part by National Institute on Aging Alzheimer’s Disease Research Grant AG-01531 (JEJ).     

Oncology workforce issues: the challenge of the outpatient clinic

It is well-recognized that cancer prevalence is increasing and will continue to do so over the coming years. Adaptation of cancer services to this reality, however, has been slow. The oncology workforce, already short-staffed, will be overburdened if change does not occur in a timely manner. The results of this study seek to highlight the current workings of oncology outpatient clinics at this hospital, and to identify areas of deficiencies that need to be addressed. By presenting a portrait of our outpatient clinics, it is hoped that a discussion surrounding workforce issues can be actively engaged, as this is crucial in order to succeed in providing quality care for our cancer patients, and simultaneously to support and mentor our invaluable medical and allied health staff.     

Outbreak of hepatitis C virus infection in an outpatient clinic

BACKGROUND: From January through September 2001, seven patients were admitted to Fukaya Red Cross Hospital with typical clinical manifestations of acute hepatitis. Six were outpatients of the clinic, which is located near the hospital. An extensive survey of clinic outpatients conducted by the local health department revealed six more new acute hepatitis cases during this period. METHODS: A case control study was carried out to identify potential risk factors for infection. In total, 1946 outpatients with clinic records were scheduled to undergo hepatitis C virus (HCV)-antibody testing. For the HCV-Ab positive patients, HCV-RNA was subtyped and quantified, and sequences of HCV hypervariable region 1 were determined. RESULTS: Ultimately, 12 patients with acute hepatitis and two asymptomatic subjects were found to be a part of this outbreak. HCV isolates were divided into three major groups using phylogenetic tree analysis. Only a past history of visiting the clinic was significantly associated with acute hepatitis. The timing of the parenteral medical procedure at the clinic and the onset of acute hepatitis strongly suggested association of the two events. CONCLUSIONS: Our findings suggest that nosocomial HCV infection can occur in an outpatient clinic, even in countries where post-transfusion hepatitis has been almost entirely eliminated.     

Managing hepatitis B virus carriers with systemic chemotherapy or biologic therapy in the outpatient clinic

Aim: The number of outpatients receiving systemic chemotherapy in Japan has recently increased. We retrospectively examined whether hepatitis B virus (HBV) carriers were safely treated and managed with systemic chemotherapy or biologic agents as outpatients at our oncology center. Methods: A total of 40 115 consecutive infusion chemotherapy or biologic therapies were administrated to 2754 outpatients in the Chemotherapy and Oncology Center at Osaka University Hospital from December 2003 to March 2011. We first studied the prevalence of outpatients with hepatitis B surface antigen (HBsAg), and then retrospectively evaluated a database to determine the frequencies of testing for other HBV‐related markers and the incidence of developing hepatitis or HBV reactivation in patients positive for HBsAg. As a control for comparison, we also examined these same factors in patients with hepatitis C virus antibody (anti‐HCV). Results: The majority of physicians at our hospital screened for HBsAg (95%) and anti‐HCV (94%) prior to administrating chemotherapy. Of the 2754 outpatients, 46 (1.7%) were positive for HBsAg and 90 (3.3%) were positive for anti‐HCV. Fifteen patients that were HBsAg positive were treated with lamivudine or entecavir prior to chemotherapy. None of the patients with HBsAg taking a prophylactic antiviral developed hepatitis, and only one breast cancer patient without prophylactic antiviral treatment (1/31 [3.2%]) developed hepatitis due to HBV reactivation. Conclusion: HBV reactivation occurred in outpatients without prophylactic antiviral treatment, but the incidence was relatively low.     

Biologicals in rheumatology: Austrian experiences from a rheumatic outpatient clinic

The efficacy of biological agents has been shown in several randomized clinical trials. However, little is known regarding the performance of these drugs in daily rheumatological care. Totally, 173 patients treated with biological agents (infliximab, etanercept, adalimumab, anakinra) were retrospectively analyzed between November 2001 and December 2005 at an Austrian rheumatic outpatient clinic. In total, 224 courses of treatment with biological agents were followed up. Among the 93 drug discontinuations observed, the most frequent causes were inefficacy (56.5%) and side effects (31.9%). In 74 patients (51%), the first biological agent was withdrawn after a median treatment period of 10.7 (range 0–80) months. A second biological agent was given to 36 patients, a third to 11 and a fourth to 3 patients. Our data underline the necessity of large observational studies to assess the full spectrum of patients treated with biological agents in clinical routine. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Validation of computer simulation training for esophagogastroduodenoscopy: Pilot study

BACKGROUND: Little is known regarding the value of esophagogastroduodenoscopy (EGD) simulators in education. The purpose of the present paper was to validate the use of computer simulation in novice EGD training. METHODS: In phase 1, expert endoscopists evaluated various aspects of simulation fidelity as compared to live endoscopy. Additionally, computer-recorded performance metrics were assessed by comparing the recorded scores from users of three different experience levels. In phase 2, the transfer of simulation-acquired skills to the clinical setting was assessed in a two-group, randomized pilot study. The setting was a large gastroenterology (GI) Fellowship training program; in phase 1, 21 subjects (seven expert, intermediate and novice endoscopist), made up the three experience groups. In phase 2, eight novice GI fellows were involved in the two-group, randomized portion of the study examining the transfer of simulation skills to the clinical setting. During the initial validation phase, each of the 21 subjects completed two standardized EDG scenarios on a computer simulator and their performance scores were recorded for seven parameters. Following this, staff participants completed a questionnaire evaluating various aspects of the simulator's fidelity. Finally, four novice GI fellows were randomly assigned to receive 6 h of simulator-augmented training (SAT group) in EGD prior to beginning 1 month of patient-based EGD training. The remaining fellows experienced 1 month of patient-based training alone (PBT group). Results of the seven measured performance parameters were compared between three groups of varying experience using a Wilcoxon ranked sum test. The staffs' simulator fidelity survey used a 7-point Likert scale (1, very unrealistic; 4, neutral; 7, very realistic) for each of the parameters examined. During the second phase of this study, supervising staff rated both SAT and PBT fellows' patient-based performance daily. Scoring in each skill was completed using a 7-point Likert scale (1, strongly disagree; 4, neutral; 7, strongly agree). Median scores were compared between groups using the Wilcoxon ranked sum test. RESULTS: Staff evaluations of fidelity found that only two of the parameters examined (anatomy and scope maneuverability) had a significant degree of realism. The remaining areas were felt to be limited in their fidelity. Of the computer-recorded performance scores, only the novice group could be reliably identified from the other two experience groups. In the clinical application phase, the median Patient Discomfort ratings were superior in the PBT group (6; interquartile range [IQR], 5-6) as compared to the SAT group (5; IQR, 4-6; P = 0.015). PBT fellows' ratings were also superior in Sedation, Patient Discomfort, Independence and Competence during various phases of the evaluation. At no point were SAT fellows rated higher than the PBT group in any of the parameters examined. CONCLUSION: This EGD simulator has limitations to the degree of fidelity and can differentiate only novice endoscopists from other levels of experience. Finally, skills learned during EGD simulation training do not appear to translate well into patient-based endoscopy skills. These findings suggest against a key element of validity for the use of this computer simulator in novice EGD training.     

综合医院消化门诊以躯体症状为首发的抑郁症调查5754例

目的:了解综合医院消化门诊以躯体症状为首发的抑郁症患者就诊状况和误诊分析.方法:采用心理健康症状自评量表(SCL-901与中国精神疾病(心理障碍)分类方案与诊断标准(CCMD-3)调查我院消化门诊5 754例以躯体症状为首发的抑郁症患者.结果:只有少部分(5.3%)患者直接就诊于心理精神科,大部分就诊于其他临床科室,且表现的躯体症状多种多样,其中仅7.2%被临床科室医师识别,大部分被漏诊误治.结论:综合医院消化门诊就诊者以躯体症状为首发的抑郁症识别率很低.临床科室医师应提高对躯体疾病伴有抑郁症的识别和处理能力.     

Statement on outpatient percutaneous liver biopsy

This document represents a consensus statement dealing with optimum patient care in a significant clinical area. The statement has been prepared by the Patient Care Committee of the American Gastroenterological Association with the advice of other experts and with peer review. As with all such guidelines, this should be interpreted in a nondogmatic manner, so as not to exclude other therapies or opinions in any particular situation. Based on present knowledge, limited at times, future modifications or other changes in this statement may be necessary.     

Effects of a supervised,outpatient exercise and physiotherapy programme in children with cystic fibrosis

Previous work suggests benefit from outpatient exercise and physiotherapy in children with cystic fibrosis (CF), namely improved exercise capacity and lung function measures, as well reduced intravenous (IV) antibiotic needs. Our study aim was to investigate the effect of a year‐long supervised outpatient exercise and physiotherapy programme in children with CF. Subjects with CF aged ≥10 years who had received ≥4 courses of IV antibiotics in 2009 were enrolled and seen fortnightly for supervised exercise and physiotherapy throughout 2010. In addition, they were expected to exercise three times weekly, and if unwell complete additional physiotherapy sessions extra to usual chest physiotherapy. Assessments of exercise capacity using the Modified Shuttle Test (MST) and quality of life (QOL; CFQ‐UK) were recorded at baseline and after 1 year. Regular spirometry was performed before and throughout the study. Data were collected on IV antibiotic days. 12 subjects (6 female) were enrolled with mean (95% CI) age of 13.3 (11.8–14.6) years at study entry. A significant reduction in IV antibiotic days from 60 (56–64) days in 2009 to 50 (44–56) in 2010 (P = 0.02) was noted, along with improved MST distance (m) [735 (603–867) vs. 943 (725–1,161), P = 0.04] and level attained [9.4 (8.4–10.5) vs. 11.1 (9.6–12.6), P = 0.04]. Significant improvements in CFQ‐UK scores for physical [59 (47–72) vs. 83 (74–92), P = 0.001], emotional [63 (55–72) vs. 84 (74–93), P < 0.001], treatment [41 (30–51) vs. 61 (48–73), P = 0.002], and respiratory [54 (42–66) vs. 76 (70–82), P = 0.002] domains were noted. The mean (95% CI) rate of change of FEV₁ was ?4 (?18, +10)% in 2009, but was +6 (?2, +13)% in 2010, although this did not reach statistical significance. Supervised, outpatient exercise and physiotherapy are associated with improvements in QOL and exercise tolerance, a reduction in IV antibiotic days, and a trend towards reducing lung function decline in children with CF. The cost of IV antibiotics was reduced by £66,384 ($104,000) in 2010 when compared with 2009. Such cost‐benefit may have implications for workforce planning and service provision. Pediatr Pulmonol. 2012; 47:1235–1241. © 2012 Wiley Periodicals, Inc.     

High yield of chest radiography in walk-in clinic patients with chest symptoms

Purpose: To assess the yield of chest radiography among a group of symptomatic adults presenting to a walk-in clinic. Patients and methods: Outpatients presenting to a walk-in clinic for evaluation of cough, shortness of breath, or pleuritic chest pain were interviewed by nurses who recorded clinical data pertaining to the present illness and past medical history. Chest radiographs were then obtained prior to physician evaluation. Results: A total of 221 patients were enrolled in the study; 97% were men and the mean age was 62 (±10.3) years. New clinically important radiographic abnormalities, defined as those necessitating acute intervention and/or follow-up evaluation, were identified for 77 (34.8%) of the 221 patients studied. Abnormalities included 39 (17.6%) cases of infiltrates, 23 (10.4%) cases of nodules or mass lesions, and 19 (8.6%) cases of cardiomegaly or congestive heart failure. Evaluation of clinical data obtained during the triage interview revealed no statistically significant difference between those patients with and those without new radiographic abnormalities on their chest x-rays. Conclusion: Adult patients similar to those described in this study who present to a walk-in clinic with a chief complaint of cough, dyspnea, or pleuritic chest pain have a high likelihood of having new clinically important abnormalities found on their chest radiographs. Since patient characteristics did not predict which patients were more likely to have abnormal findings, the practice of obtaining chest radiographs for such individuals at the time of triage and prior to physician evaluation appears justified. Received from the Department of Medicine, Minneapolis Veterans Affairs Medical Center, University of Minnesota, Minneapolis, Minnesota. Presented in part at the Fifth Annual Midwest Regional Meeting of the Society of General Internal Medicine, Chicago, Illinois, November 12, 1988.     

Mobile cardiac catheterization: Comparison with outpatient and inpatient catheterization at tertiary facilities

The study group included 1,553 consecutive patients from areas serviced by our mobile catheterization laboratories: 719 procedures were performed in the mobile unit at their local hospitals, 277 were performed at a tertiary hospital with less than a 24 hr hospital stay, and 557 were performed at a tertiary hospital as inpatients. The indications for mobile catheterization were predominantly atypical chest pain, angina pectoris, or positive treadmill stress test, whereas patients with less than 24 hr hospitalization at the tertiary center had their catheterization performed for additional reasons. The majority of the inpatient indications were for recent myocardial infarction or unstable angina. Using the American College of Cardiology/American Heart Association (ACC/AHA) criteria for outpatient catheterization, the mobile catheterizations were performed safely with a complication rate of only 0.7% compared to a complication rate of 3.1% for inpatients demonstrating that a low risk group of patients can be prospectively identified and catheterized safely in the mobile setting. An extremely high risk group of patients with ongoing unstable angina and recent myocardial infarction was also identified which should undergo catheterization only at a tertiary center.     

Optimizing management and financial performance of the teaching ambulatory care clinic

OBJECTIVE: To examine how to optimize teaching ambulatory care clinics performance with regard to access to care, access to teaching, and financial viability. DESIGN: Optimization analysis using computer simulation. METHODS: A discrete-event simulation model of the teaching ambulatory clinic setting was developed. This method captures flow time, waiting time, competition for resources, and the interdependency of events, providing insight into system dynamics. Sensitivity analyses were performed on staffing levels, room availability, patient characteristics such as "new" versus "established" status, and clinical complexity and pertinent probabilities. MAIN RESULTS: In the base-case, 4 trainees:preceptor, patient flow time (registration to check out) was 148 minutes (SD 5), wait time was 20.6 minutes (SD 4.4), the wait for precepting was 6.2 minutes (SD 1.2), and average daily net clinic income was $1,413. Utilization rates were preceptors (59%), trainees (61%), medical assistants (64%), and room (68%). Flow time and the wait times remained relatively constant for strategies with trainee:preceptor ratios <4:1 but increased with number of trainees steadily thereafter. Maximum revenue occurred with 3 preceptors and 5 trainees per preceptor. The model was relatively insensitive to the proportion of patients presenting who were new, and relatively sensitive to average evaluation and management (E/M) level. Flow and wait times rose on average by 0.05 minutes and 0.01 minutes per percent new patient, respectively. For each increase in average E/M level, flow time increased 8.4 minutes, wait time 1.2 minutes, wait for precepting 0.8 minutes, and net income increased by $490. CONCLUSION: Teaching ambulatory care clinics appear to operate optimally, minimizing flow time and waiting time while maximizing revenue, with trainee-to-preceptor ratios between 3 and 7 to 1.     

Teicoplanin and oral ciprofloxacin as outpatient treatment of infective episodes in patients with indwelling central venous catheters and haematological malignancy

Summary Central venous catheters are often the focus of microbial colonization which may cause bacteraemia (or fungal septicaemia) in both neutropenic and non-neutropenic patients. Such episodes are associated with considerable morbidity and may require admission to hospital or replacement of the central line. We have used the combination of intravenous teicoplanin and oral ciprofloxacin to treat such episodes as outpatients, achieving a salvage rate of 74%. Seven of thirty-five episodes resulted in removal of the line. The treatment was well tolerated and well-suited to the day ward setting.     

Procedures for the outpatient management of patients with deep venous thrombosis1

Although deep venous thrombosis (DVT) is now widely managed on an outpatient basis, at a practical level there remains a potential for uncertainty as to which patient might prove suitable and in particular in regard to the lines of responsibility of each department involved in the delivery of clinical care. This guideline sets out recommendations for the standardization of the outpatient management of patients with DVT.     

老年门诊患者共病状况的临床研究

目的研究老年门诊患者共病及老年综合征的发病情况及各疾病的分布。方法在6月内对389例在我院老年医学科门诊就诊的老年患者进行常规诊疗与老年评估,采用门诊简易老年患者疾病与功能评估的流程,由老年专科医师记录目前疾病状况,包括：躯体疾病、功能状态、精神状态;详细记录用药清单,由专人进行老年综合征评估。结果 389例老年门诊患者中有376例合并有老年综合征,其中患2种疾病的老年人有32例（8.2%）,患〉2种疾病的有344例（88.4%）。老年慢性躯体疾病中发病率较高的分别为高血压、冠心病、高脂血症、糖尿病、脑卒中、肿瘤等。老年综合征中多重用药、视力障碍、睡眠障碍、听力障碍、跌倒高风险、慢性疼痛等发生率均〉40%。结论老年门诊患者中96.6%患者合并存在老年综合征,按筛查比例从高到低分别为多重用药、视力障碍、睡眠障碍、听力障碍、跌倒高风险、慢性疼痛、骨质疏松、尿便异常、营养风险或营养不良、半失能或完全失能、认知障碍、抑郁状态、衰弱综合征。     

Actual outpatient PTCA: results of the OUTCLAS pilot study.

This study tested the safety and feasibility of coronary angioplasty on an outpatient basis. The purpose of this approach includes cost-effectiveness and patient comfort. Included were 159 patients treated with balloon angioplasty or intracoronary stent placement, all performed via the radial artery with 6 French guiding catheters. Patients were selected for same-day discharge based on the absence of any adverse predictor for subacute occlusion or unfavorable clinical outcome during the first 24 hr after successful PTCA. One hundred and six (66%) patients were discharged 4-6 hr after PTCA. Stents were used in 40% of patients. There were no cardiac or vascular complications. We conclude that outpatient PTCA, performed via the radial artery, is both safe and feasible in a large part of a routine PTCA population.