Patient Preferences for the Management of High-Grade Dysplasia in Barrett’s Esophagus

Surgical esophagectomy, intensive endoscopic surveillance, and mucosal ablative techniques, particularly photodynamic therapy (PDT), have been proposed as possible management strategies for Barretts high-grade dysplasia (HGD). Each option has advantages and disadvantages, and no firm consensus exists for the preferred strategy at this time. The purpose of this pilot study was to gain insight into patient preferences in Barretts HGD management. Twenty patients with Barretts esophagus were enrolled in a questionnaire study. The three possible management options for Barretts HGD including each options potential benefits and harms were presented to the subject in a formalized presentation that was designed to be easily comprehendible by patients. The subjects rated each strategy using a health-related quality of life instrument and chose one of the management strategies assuming they were found to have HGD. The average feeling thermometer rating scale values for the management strategies were as follows: endoscopic surveillance, 79; esophagectomy, 46; and PDT, 60. When asked to choose a strategy, 14 (70%) chose endoscopic surveillance, 3 (15%) chose esophagectomy, and 3 (15%) chose PDT. These findings were statistically significant (P = 0.0024). The patients who chose endoscopic surveillance felt comfortable with endoscopy, while the most common concern about esophagectomy, and PDT was the risk of death and the unknown risk of recurrence, respectively. In summary, when patients with Barretts esophagus were presented with three options to manage HGD, the majority chose endoscopic surveillance. Familiarity with endoscopic surveillance was the predominant reason for the choice.     

Implementation of a Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients Presenting to a Community Emergency Department With Atrial Fibrillation

Objectives

Atrial fibrillation (AFib) is the most common dysrhythmia in the United States. Patients seen in the emergency department (ED) in rapid AFib are often started on intravenous rate‐controlling agents and admitted for several days. Although underlying and triggering illnesses must be addressed, AFib, intrinsically, is rarely life‐threatening and can often be safely managed in an outpatient setting. At our academic community hospital, we implemented an algorithm to decrease hospital admissions for individuals presenting with a primary diagnosis of AFib. We focused on lenient oral rate control and discharge home. Our study evaluates outcomes after implementation of this algorithm.

Methods

Study design is a retrospective cohort analysis pre‐ and postimplementation of the algorithm. The primary outcome was hospital admissions. Secondary outcomes were 3‐ and 30‐day ED visits and any associated hospital admissions. These outcomes were compared before (March 2013–February 2014) and after (March 2015–February 2016) implementation. Chi‐square tests and logistic regressions were run to test for significant changes in the three outcome variables.

Results

A total of 1,108 individuals met inclusion criteria with 586 patients in the preimplementation group and 522 in the postimplementation group. Cohorts were broadly comparable in terms of demographics and health histories. Admissions for persons presenting with AFib after implementation decreased significantly (80.4% pre vs. 67.4% post, adjusted odds ratio [OR] = 3.4, p < 0.001). Despite this difference there was no change in ED return rates within 3 or 30 days (adjusted ORs = 0.93 and 0.89, p = 0.91 and 0.73, respectively).

Conclusions

Implementation of a novel algorithm to identify and treat low‐risk patients with AFib can significantly decrease the rate of hospital admissions without increased ED returns. This simple algorithm could be adopted by other community hospitals and help lower costs.

     

Breast cancer screening use by African Americans and whites in an HMO

OBJECTIVE: To examine racial differences in breast cancer screening in an HMO that provides screening at no cost. DESIGN: Retrospective cohort study of breast cancer screening among African-American and white women. Breast cancer screening information was extracted from computerized medical records. SETTING: A large HMO in New England. PATIENTS/PARTICIPANTS: White and African-American women (N=2,072) enrolled for at least 10 years in the HMO. MAIN RESULTS: Primary care clinicians documented recommending a screening mammogram significantly more often for African Americans than whites (70% vs 64%; P<.001). During the 10-year period, on average, white women obtained more mammograms (4.49 vs 3.93; P<.0001) and clinical breast examinations (5.35 vs 4.92; P<.01) than African-American women. However, a woman’s race was no longer a statistically significant predictor of breast cancer screening after adjustment for differences in age, estimated household income, estrogen use, and body mass index (adjusted number of mammograms, 4.47 vs 4.25, P=.17; and adjusted number of clinical breast examinations, 5.35 vs 5.31, P=.87). CONCLUSIONS: In this HMO, African-American and white women obtained breast cancer screening at similar rates. Comparisons with national data showed much higher screening rates in this HMO for both white and African-American women. This project was supported by a grant from the American Cancer Society (JGE), by a Robert Wood Johnson Generalist Faculty Scholar Award (JGE), and by the Harvard Pilgrim Health Care Foundation (SF, MB)     

Following the Arterial Switch Operation,Obese Children have Risk Factors for Early Cardiovascular Disease

Background. Children who have undergone the arterial switch operation (ASO) are at risk for premature coronary artery disease due to coronary re-implantation. Obesity may also pose cardiovascular risk. The purpose of this study was to evaluate comorbidities and markers of early cardiovascular disease in obese ASO patients. Methods. Obese [body mass index (BMI) ≥ 95th %] and normal weight (NW, BMI < 85th %) ASO patients, and NW controls without heart disease were enrolled, and underwent prospective vascular, echocardiographic, laboratory, exercise, and ambulatory blood pressure (BP) testing. Results were compared between groups. BP load was defined as proportion of recordings ≥ 95th %. Results. Thirty patients [13.2 years (11.2–16.8), 57% male] were evaluated: 10 obese ASO, 10 NW ASO, and 10 NW controls. Obese ASO patients, in comparison to NW ASO and controls, had higher systolic BP% [96% (90–99) vs. 67% (30–91) P= 0.07 (trend) and 34% (21–43) P= 0.005], night-time diastolic BP load [18% (14–24) vs. 0% (0–0) P= 0.01 and 0% (0–0) P= 0.01], left ventricular mass index [51.7 g/m^2.7 (46.6–53.3) vs. 40.7 g/m^2.7 (29.2–41.6) P < 0.01 and 28.9 g/m^2.7 (27.3–33.7) P < 0.01], and lower brachial artery reactivity [8.7% (6.2–11.9) vs. 14.6% (10.8–23.0) P= 0.03, and 16.7% (12.8–17.8) P= 0.05]. There was a trend toward increased carotid intima-media thickness, and significantly higher triglyceride and lower high-density lipoprotein levels in obese ASO patients. Conclusions. Following the ASO, obese patients have associated comorbidities, and markers of early cardiovascular disease. These may pose additional risk for future cardiovascular events in this unique population who underwent coronary artery re–implantation in infancy.