| : A series of nine cases from a regional cancer center in Northeast India | p. 69 |
| Srigopal Mohanty, Yumkhaibam Sobita Devi, Daffilyne Lyngdoh Nongrum, Laishram Jaichand Singh, Vimal Sekar, Deep Sikha Das DOI:10.4103/oji.oji_39_18 Background: Metaplastic carcinoma of the breast (MCB) is a rare histological subtype of breast carcinoma containing glandular and nonglandular components with mixed epithelial and mesenchymal differentiations. Aim of the Study: The study aimed to report clinical, radiological and pathological profiles, treatment and outcome of patients diagnosed with MCB from a tertiary care institute along with literature review. Materials and Methods:Diagnosed cases of MCB were obtained from the record over a period of January 2010 to December 2017, and data were recorded in a structured pro forma. Results: A total of 9 (0.9%) cases of MCB were identified out of 1031 breast cancer patients with the median age of presentation of 53 years. The palpable lump was the most common presentation (77.78%). The mean tumor size was 4.9 cm in greatest dimension. Sonographically, most of the lesions were solid (44.44%) followed by cystic (33.33%). Mammographically, microcalcifications were absent in eight cases. Histologically, 55.56% of cases were purely epithelial subtype (3: pure squamous and 2: adenosquamous) and 4 (44.44%) cases were mixed epithelial and mesenchymal subtypes (3: carcinosarcoma and 1: invasive lobular carcinoma with sarcomatous component and osseous metaplasia). All the cases were having triple-negative receptor status. Modified radical mastectomy (MRM) was performed in all cases and 33.33% of cases had axillary node positive. About 77.88% and 88.89% of cases received adjuvant chemotherapy and adjuvant radiotherapy, respectively. At median follow-up of 27 months, local recurrence and distant metastases were seen in 1 and 3 cases, respectively. At present, 33.33%, 22.22%, and 44.45% of patients were died, alive, and lost for follow-up, respectively. Conclusion: MCB is a rare histologic subtype of breast cancer with larger tumor size at presentation and MRM is the preferred surgical procedure over breast conservation surgery. Long-term and regular follow-up is necessary to know the outcome. |
Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Τετάρτη 26 Δεκεμβρίου 2018
Metaplastic carcinoma of breast
Anti-cancer and anti-inflammatory activities of aronia (Aronia melanocarpa) leaves
p. 586
Nhuan Do Thi, Eun-Sun Hwang
DOI:10.4103/2221-1691.248095
Objective: To determine the anti-cancer effect of aronia leaf extract on SK-Hep1 cells using migration, metallo metrix proteinase-2/-9 (MMP-2/-9) and MT-1 MMP expression and to evaluate the anti-inflammatory activities of the leaf extract. Methods: The effect of aronia leaf extract on cancer prevention was investigated. SK-Hep1 human liver cancer cell line was treated with aronia leaf extract at various concentractions. MTT assay was used to measure cancer cell growth inhibition, and wound migration assay was used for metastasis determination. The expression of MMP-2/-9 was measured at the protein level using zymography and the expression of MMP-2/-9 and MT-1 MMP was examined at the gene level by RT-PCR. Raw 264.7 macrophage cells were stimulated with lipopolysaccharides to induce inflammation, and then the inhibition of inflammation was evaluated by treatment of aronia leaf extract. Expressions of interleukin-6, tumor factor-α, and nitric oxide (NO) were also determined. Results: SK-Hep1 cell growth was inhibited in proportion to the concentration of aronia leaf extract. In migration assay, aronia leaf extract showed 61.3%-96.3% wound size inhibtion after treating 50-200 μg/mL of aronia leaf extract for 24 h. At the protein level, the expression of MMP-2 and MMP-9 decreased as the concentration of aronia leaf extract treated with SK-Hep1 cells increased. In addition, the same pattern as in the protein was also observed in the mRNA levels. The expressions of MMP-2 and MMP-9 protein were inhibited by 92.2% and 53.8%, respectively after treatment with 200 μg/mL aronia leaf extract. In addition, Raw 264.7 cells treated with aronia leaf extract did not affect cell survival. There was dose dependent inhibition of interleukine-6, tumor necrosis factor-α and nitric oxide after treating aronia leaf extract in lipopolysaccharides-treated Raw 264.7 cell. Conclusions: The results show that aronia leaf has anticancer and and antimetastatic properties in SK-Hep1 and Raw 264.7 cells.
Effects of phototherapy on outer hair cell function in infants with hyperbilirubinemia
p. 52
Vikas Mysore Dwarakanath, Pavana Mohan, Sapthami Patel
DOI:10.4103/jisha.JISHA_8_17
Introduction: Hyperbilirubinemia in newborns has been hypothesized to cause damage to inner ear, thus leading to sensorineural hearing loss. Phototherapy is treatment protocol in most of the hospitals for newborns with high bilirubin levels. The present study aimed to determine the effects of phototherapy on outer hair cell (OHC) function of cochlea. Methods: Twenty-two neonates with hyperbilirubinemia undergoing phototherapy and 22 neonates without any high-risk registers were included in the study. Distortion product otoacoustic emission (DPOAE) was administered before and after phototherapy. Auditory brainstem response (ABR) evaluation was done during the postphototherapy recording. Results: Results showed that DP amplitude and signal-to-noise ratio improved significantly after phototherapy. ABR evaluation revealed; 19 neonates had significantly prolonged wave V latency compared to normal, whereas no peaks were identified among three neonates. Most of the infantile hyperbilirubinemia are found to be harmless until and unless treatment is not initiated at the earliest, but still it is found that short-term increase in bilirubin level can induce temporary changes in OAEs and ABR measures. ABR needs to be repeated over a period of time for these three neonates to rule out auditory dyssynchrony (AD). Conclusion: The results indicate that phototherapy has temporary effects on OHC function and can improve as the bilirubin levels reduce. Follow-up testing over a period of time helps in discriminating the sensory pathology and AD.
http://www.jisha.org/currentissue.asp?sabs=y
Vikas Mysore Dwarakanath, Pavana Mohan, Sapthami Patel
DOI:10.4103/jisha.JISHA_8_17
Introduction: Hyperbilirubinemia in newborns has been hypothesized to cause damage to inner ear, thus leading to sensorineural hearing loss. Phototherapy is treatment protocol in most of the hospitals for newborns with high bilirubin levels. The present study aimed to determine the effects of phototherapy on outer hair cell (OHC) function of cochlea. Methods: Twenty-two neonates with hyperbilirubinemia undergoing phototherapy and 22 neonates without any high-risk registers were included in the study. Distortion product otoacoustic emission (DPOAE) was administered before and after phototherapy. Auditory brainstem response (ABR) evaluation was done during the postphototherapy recording. Results: Results showed that DP amplitude and signal-to-noise ratio improved significantly after phototherapy. ABR evaluation revealed; 19 neonates had significantly prolonged wave V latency compared to normal, whereas no peaks were identified among three neonates. Most of the infantile hyperbilirubinemia are found to be harmless until and unless treatment is not initiated at the earliest, but still it is found that short-term increase in bilirubin level can induce temporary changes in OAEs and ABR measures. ABR needs to be repeated over a period of time for these three neonates to rule out auditory dyssynchrony (AD). Conclusion: The results indicate that phototherapy has temporary effects on OHC function and can improve as the bilirubin levels reduce. Follow-up testing over a period of time helps in discriminating the sensory pathology and AD.
http://www.jisha.org/currentissue.asp?sabs=y
Long-term exposure to traffic noise
Effect of long-term exposure to traffic noise on acceptable noise level measures in traffic police officers p. 47
PG Vipin Ghosh, D Nagashreeya, V Hemavathi
DOI:10.4103/jisha.JISHA_24_18
Introduction: The acceptable noise level (ANL) measure is a subjective way of identifying how much of noise a person is able to put up with while listening to speech. Individuals with low ANL were observed to be satisfied hearing users than the individuals with high ANL. However, the reason for large individual variations of the measure is still not well understood. Exposure to noise may be one such factor that would affect the ANL which was never explored. Among the individuals who are exposed to noise, majority are exposed to occupational noise. Traffic police is such a working population who is exposed continuously to traffic noise during their duty hours. Hence, the present study was planned to investigate ANL measures in traffic police officers that might further provide insight toward the heterogeneity of the measure. Methods: A total of 38 participants were divided into two groups. Group 1 consisted of 19 traffic police officers with minimum of 5 years of job experience and Group 2 consisted of normal hearing individuals without any noise exposure. All the participants underwent routine audiological evaluations followed by ANL testing. Results: The mean ANL obtained in both the groups was statistically compared. The results revealed that the traffic police officers yielded better ANLs than participants in Group 2. Conclusion: This ability of traffic police officers to put up with more noise while listening to speech may be attributed to their long-standing experience in listening to wanted signals in noise.
http://www.jisha.org/currentissue.asp?sabs=y
PG Vipin Ghosh, D Nagashreeya, V Hemavathi
DOI:10.4103/jisha.JISHA_24_18
Introduction: The acceptable noise level (ANL) measure is a subjective way of identifying how much of noise a person is able to put up with while listening to speech. Individuals with low ANL were observed to be satisfied hearing users than the individuals with high ANL. However, the reason for large individual variations of the measure is still not well understood. Exposure to noise may be one such factor that would affect the ANL which was never explored. Among the individuals who are exposed to noise, majority are exposed to occupational noise. Traffic police is such a working population who is exposed continuously to traffic noise during their duty hours. Hence, the present study was planned to investigate ANL measures in traffic police officers that might further provide insight toward the heterogeneity of the measure. Methods: A total of 38 participants were divided into two groups. Group 1 consisted of 19 traffic police officers with minimum of 5 years of job experience and Group 2 consisted of normal hearing individuals without any noise exposure. All the participants underwent routine audiological evaluations followed by ANL testing. Results: The mean ANL obtained in both the groups was statistically compared. The results revealed that the traffic police officers yielded better ANLs than participants in Group 2. Conclusion: This ability of traffic police officers to put up with more noise while listening to speech may be attributed to their long-standing experience in listening to wanted signals in noise.
http://www.jisha.org/currentissue.asp?sabs=y
“Slime” dermatitis, a fad‐associated chronic hand dermatitis - Kondratuk - - Pediatric Dermatology - Wiley Online Library
"Slime" is the colloquial name for a non‐Newtonian viscoelastic putty‐like substance that is currently a popular plaything among pre‐teens and adolescents. Several ingredients in homemade slime recipes may cause irritant or allergic contact dermatitis. We report two children who developed slime‐associated chronic hand dermatitis, more prominently on their dominant hand. We review the potential for irritant and allergic contact dermatoses as the causes of dermatitis associated with homemade slime.
https://onlinelibrary.wiley.com/doi/10.1111/pde.13729
https://onlinelibrary.wiley.com/doi/10.1111/pde.13729
The impact of pediatric atopic dermatitis on families: A review - Yang - - Pediatric Dermatology - Wiley Online Library
Atopic dermatitis (AD) is an extremely common childhood disease, with considerable impact on the quality of life of affected children and their families. While pruritus is the hallmark symptom of this disease, AD has been well‐documented to impact patients beyond physical symptoms, resulting in behavior problems, mood disorders, and sleep disturbance.
Objective
This literature review outlines how atopic dermatitis impacts the quality of life of families of children affected by AD.
Methods
A total of 3436 articles were identified via an online search of the MEDLINE health literature database and were screened for relevance to quality of life impacts on families with children affected by AD.
Results
Caring for children affected by AD can be an extremely time‐consuming task that can impair personal relationships, decrease psychosocial functioning, and cause sleep loss among family members of affected patients. Additionally, AD may result in work absence or decreased work productivity for caregivers. Special diets, irritant and allergen avoidance strategies, and alternative therapies are commonly used by patients to manage their disease and require large amounts of family involvement.
Conclusions
Atopic dermatitis can greatly decrease quality of life of families of affected children in various domains, including sleep, finances, and relationships. Early intervention and psychotherapy may be needed in some patients to address these quality of life impairments.
https://onlinelibrary.wiley.com/doi/10.1111/pde.13727
Objective
This literature review outlines how atopic dermatitis impacts the quality of life of families of children affected by AD.
Methods
A total of 3436 articles were identified via an online search of the MEDLINE health literature database and were screened for relevance to quality of life impacts on families with children affected by AD.
Results
Caring for children affected by AD can be an extremely time‐consuming task that can impair personal relationships, decrease psychosocial functioning, and cause sleep loss among family members of affected patients. Additionally, AD may result in work absence or decreased work productivity for caregivers. Special diets, irritant and allergen avoidance strategies, and alternative therapies are commonly used by patients to manage their disease and require large amounts of family involvement.
Conclusions
Atopic dermatitis can greatly decrease quality of life of families of affected children in various domains, including sleep, finances, and relationships. Early intervention and psychotherapy may be needed in some patients to address these quality of life impairments.
https://onlinelibrary.wiley.com/doi/10.1111/pde.13727
Successful treatment of hemorrhagic bullous Henoch‐Schonlein purpura with intravenous immunoglobulins - Mauro - - Pediatric Dermatology - Wiley Online Library
Henoch‐Schonlein purpura (HSP) is the most common systemic vasculitis in childhood. There is no consensus about the management for isolated cutaneous manifestations in HSP. We describe a case of HSP presenting with severe skin lesions that did not respond to standard therapy with corticosteroids. The 11‐year‐old child was treated with intravenous immunoglobulins, which induced rapid and persistent resolution of symptomatology.
https://onlinelibrary.wiley.com/doi/10.1111/pde.13715
https://onlinelibrary.wiley.com/doi/10.1111/pde.13715
Biology of human melanocyte development, Piebaldism, and Waardenburg syndrome - Saleem - - Pediatric Dermatology - Wiley Online Library
Melanocyte development is orchestrated by a complex interconnecting regulatory network of genes and synergistic interactions. Piebaldism and Waardenburg syndrome are neurocristopathies that arise from mutations in genes involved in this complex network. Our understanding of melanocyte development, Piebaldism, and Waardenburg syndrome has improved dramatically over the past decade. The diagnosis and classification of Waardenburg syndrome, first proposed in 1992 and based on phenotype, have expanded over the past three decades to include genotype. This review focuses on the current understanding of human melanocyte development and the evaluation and management of Piebaldism and Waardenburg syndrome. Management is often challenging and requires a multidisciplinary approach.
https://onlinelibrary.wiley.com/doi/10.1111/pde.13713
https://onlinelibrary.wiley.com/doi/10.1111/pde.13713
Focal facial dermal dysplasia type 4.Bilateral preauricular scarlike defects surrounded by a hair collar, resembling membranous aplasia cutis congenita.
We present a rare case of focal facial dermal dysplasia type 4 (FFDD4) in an otherwise healthy boy infant, presenting as bilateral preauricular scarlike defects surrounded by a hair collar, resembling membranous aplasia cutis congenita. The presence of a hair collar supports the hypothesis that FFDD is caused by abnormal closure at facial embryonic fusion lines, but unlike midline scalp defects is not associated with neurological compromise. Other types of FFDD occur at different sites and can be associated with cranial dysgraphism. Awareness of this rare condition by dermatologists is imperative to enable prompt recognition and minimize diagnostic delay.
https://onlinelibrary.wiley.com/doi/10.1111/pde.13730
https://onlinelibrary.wiley.com/doi/10.1111/pde.13730
Bullous pemphigoid in adolescence - Patsatsi - - Pediatric Dermatology - Wiley Online Library
Bullous pemphigoid (BP) is the most common autoimmune blistering disease affecting the elderly but is quite rare in childhood. The majority of pediatric cases have been reported during early childhood. Adolescence is divided into three phases: early (10‐13 years), middle (14‐17), and late (18‐21). This review aimed to identify BP cases in adolescence and demonstrate their clinical features and course. Our literature search was performed in Medline with the terms "bullous pemphigoid in childhood and adolescence," "childhood bullous pemphigoid," "juvenile bullous pemphigoid," and "autoimmune blistering and autoimmune bullous diseases in childhood." The data extraction for late adolescence was limited by the fact that this age group is included in adult BP registries. We identified nine cases in early adolescence. Mucosa were affected in 5 of 9 cases. Treatment consisted of systemic prednisone (8/9), in combination with dapsone (2/9), azathioprine (2/9), or erythromycin/nicotinamide (1/9). Relapses were reported in 3 of 9 cases. We identified five cases occuring in middle adolescence. Mucosa were not affected. Treatment consisted of systemic prednisone (5/5), in combination with dapsone (3/5), azathioprine (2/5), doxycycline/nicotinamide (1/5), or mycophenolate mofetil (1/5). Relapses were reported in two of five cases. No case of BP in the late adolescence was included in the results, as only one case met the search criteria, and overlapped with pemphigus vulgaris. With only 14 cases found in our review, BP in adolescence appears even rarer than in earlier childhood. Despite its low prevalence, BP should be included in the differential diagnosis of autoimmune blistering diseases in adolescents.
https://onlinelibrary.wiley.com/doi/10.1111/pde.13717
https://onlinelibrary.wiley.com/doi/10.1111/pde.13717
Gastric duplication cyst in an adult with autoimmune hemolytic anemia: a case report and review of the literature
Gastric duplication cysts are uncommon congenital anomalies found primarily in children and rarely seen in the adult population. Accurate diagnosis of cysts before resection is difficult even using the most ad...
http://bit.ly/2BF9jhQ
Chronic Atypical Antipsychotic Use Is Associated With Reduced Need for Postoperative Nausea and Vomiting Rescue in the Postanesthesia Care Unit: A Propensity-Matched Retrospective Observational Study
BACKGROUND: Atypical antipsychotics are efficacious for chemoprophylaxis against chemotherapy-induced nausea and vomiting, but perioperative investigations have been scant. We sought to examine the association between chronic atypical antipsychotic therapy and the likelihood of postoperative nausea and vomiting. METHODS: In this single-center, propensity-matched, retrospective, observational study, elective noncardiac surgical cases from January 2014 to December 2017 were examined with regard to the primary outcome of rescue antiemetic administration in the postanesthesia care unit as a measure of postoperative nausea and vomiting. Chronic administration of olanzapine, aripiprazole, and risperidone was the exposure of interest. Other independent variables included outpatient antiemetics, modified Apfel score, age, American Society of Anesthesiologists physical status score, case length, and exposures to emetogenic and chemoprophylactic agents. Logistic regression was performed using case-level data. Conditional logistic regression was performed after 1:2 propensity matching, sampling without replacement. Monte Carlo simulation was performed to compute the mean patient-level treatment effect on the treated. RESULTS: Of 13,660 cases, 154 cases with patients receiving atypical antipsychotics were matched against 308 cases without, representing 115 and 273 unique patients, respectively. In a well-balanced cohort, the mean patient-level odds of being administered rescue antiemetic was lower for patients chronically taking the 3 atypical antipsychotics under consideration as compared to those not on atypical antipsychotics, with an odds ratio of 0.29 (95% CI, 0.11–0.75; P = .015). CONCLUSIONS: Chronic atypical antipsychotic therapy is associated with reduced risk of postanesthesia care unit antiemetic administration. These findings support the need for prospective studies to establish the safety and efficacy of postoperative nausea and vomiting chemoprophylaxis with these agents. Accepted for publication November 15, 2018. Funding: V.N.O'.-S. is partially supported by a Synergy Grant from the Woodruff Health Sciences Center. Otherwise, this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The Emory University Department of Anesthesiology generously supported the time of the authors in producing this work. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to Vikas N. O'Reilly-Shah, MD, PhD, Department of Anesthesiology, Emory University and Children's Healthcare of Atlanta, 3B S, 1364 Clifton Rd, NE, Atlanta, GA 30322. Address e-mail to voreill@emory.edu. © 2018 International Anesthesia Research Society
http://bit.ly/2QPGf1f
http://bit.ly/2QPGf1f
Daily Caffeine Consumption Does Not Influence Acupuncture Analgesia in Healthy Individuals: A Preliminary Study
Animal studies suggest that caffeine may interfere with acupuncture analgesia. This study investigated the modulation effect of daily caffeine intake on acupuncture analgesia in 27 healthy subjects using a crossover design. We found that real acupuncture increased pain thresholds compared to sham acupuncture. Further, there was no association between caffeine intake measurements of daily caffeine use, duration of caffeine consumption, or their interaction and preacupuncture and postacupuncture pain threshold changes. Our findings suggest that daily caffeine intake may not influence acupuncture analgesia in the cohort of healthy subjects who participated in study. Accepted for publication November 12, 2018. Funding: J.K. is supported by R01 AT008563, R21 AT008707, and R61/R33 AT009310 from the National Institutes of Health/National Center for Complementary and Integrative Health. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to Jian Kong, MD, MS, MPH, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Bldg 120, Room 101 C, Charlestown, MA 02129. Address e-mail to jkong2@mgh.harvard.edu. © 2018 International Anesthesia Research Society
http://bit.ly/2BF2j4z
http://bit.ly/2BF2j4z
Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change
BACKGROUND: Frailty is a geriatric syndrome thought to identify the most vulnerable older adults, and morbidity and mortality has been reported to be higher for frail patients after cardiac surgery compared to nonfrail patients. However, the cognitive consequences of frailty after cardiac surgery have not been well described. In this study, we examined the hypothesis that baseline frailty would be associated with postoperative delirium and cognitive change at 1 and 12 months after cardiac surgery. METHODS: This study was nested in 2 trials, each of which was conducted by the same research team with identical measurement of exposures and outcomes. Before surgery, patients were assessed with the validated "Fried" frailty scale, which evaluates 5 domains (shrinking, weakness, exhaustion, low physical activity, and slowed walking speed) and classifies patients as nonfrail, prefrail, and frail. The primary outcome was postoperative delirium during hospitalization, which was assessed using the Confusion Assessment Method, Confusion Assessment Method for the Intensive Care Unit, and validated chart review. Neuropsychological testing was a secondary outcome and was generally performed within 2 weeks of surgery and then 4–6 weeks and 1 year after surgery, and the outcome of interest was change in composite Z-score of the test battery. Associations were analyzed using logistic and linear regression models, with adjustment for variables considered a priori (age, gender, race, education, and logistic European System for Cardiac Operative Risk Evaluation). Multiple imputation was used to account for missing data at the 12-month follow-up. RESULTS: Data were available from 133 patients with baseline frailty assessments. Compared to nonfrail patients (13% delirium incidence), the incidence of delirium was higher in prefrail (48% delirium incidence; risk difference, 35%; 95% CI, 10%–51%) and frail patients (48% delirium incidence; risk difference, 35%; 95% CI, 7%–53%). In both univariable and multivariable models, the odds of delirium were significantly higher for prefrail (adjusted odds ratio, 6.43; 95% CI, 1.31–31.64; P = .02) and frail patients (adjusted odds ratio, 6.31; 95% CI, 1.18–33.74; P = .03) compared to nonfrail patients. The adjusted decline in composite cognitive Z-score was greater from baseline to 1 month only in frail patients compared to nonfrail patients. By 1 year after surgery, there were no differences in the association of baseline frailty with change in cognition. CONCLUSIONS: Compared to nonfrail patients, both prefrail and frail patients were at higher risk for the primary outcome of delirium after cardiac surgery. Frail patients were also at higher risk for the secondary outcome of greater decline in cognition from baseline to 1 month, but not baseline to 1 year, after surgery. Accepted for publication October 29, 2018. Funding: This work was supported by Older Americans Independence Center Research Career Development Core Award (P30 AG021334). C.H.B. was supported by National Institutes of Health (NIH) K76 AG057020, International Anesthesia Research Society, Johns Hopkins Clinician Scientist Award, and Magic That Matters Grant. C.W.H. was supported by NIH RO1 HL092259. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://bit.ly/KegmMq). Clinical trial registration numbers: NCT00981474 and NCT02587039. Reprints will not be available from the authors. Address correspondence to Charles H. Brown IV, MD, MHS, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287. Address e-mail to cbrownv@jhmi.edu. © 2018 International Anesthesia Research Society
http://bit.ly/2QRz6Ob
http://bit.ly/2QRz6Ob
Digital Quality Improvement Approach Reduces the Need for Rescue Antiemetics in High-Risk Patients: A Comparative Effectiveness Study Using Interrupted Time Series and Propensity Score Matching Analysis
BACKGROUND: Affecting nearly 30% of all surgical patients, postoperative nausea and vomiting (PONV) can lead to patient dissatisfaction, prolonged recovery times, and unanticipated hospital admissions. There are well-established, evidence-based guidelines for the prevention of PONV; yet physicians inconsistently adhere to them. We hypothesized that an electronic medical record–based clinical decision support (CDS) approach that incorporates a new PONV pathway, education initiative, and personalized feedback reporting system can decrease the incidence of PONV. METHODS: Two years of data, from February 17, 2015 to February 16, 2016, was acquired from our customized University of California Los Angeles Anesthesiology perioperative data warehouse. We queried the entire subpopulation of surgical cases that received general anesthesia with volatile anesthetics, were ≥12 years of age, and spent time recovering in any of the postanesthesia care units (PACUs). We then defined PONV as the administration of an antiemetic medication during the aforementioned PACU recovery. Our CDS system incorporated additional PONV-specific questions to the preoperative evaluation form, creation of a real-time intraoperative pathway compliance indicator, initiation of preoperative PONV risk alerts, and individualized emailed reports sent weekly to clinical providers. The association between the intervention and PONV was assessed by comparing the slopes from the incidence of PONV pre/postintervention as well as comparing observed incidences in the postintervention period to what we expected if the preintervention slope would have continued using interrupted time series analysis regression models after matching the groups on PONV-specific risk factors. RESULTS: After executing the PONV risk-balancing algorithm, the final cohort contained 36,796 cases, down from the 40,831 that met inclusion criteria. The incidence of PONV before the intervention was estimated to be 19.1% (95% confidence interval [CI], 17.9%–20.2%) the week before the intervention. Directly after implementation of the CDS, the total incidence decreased to 16.9% (95% CI, 15.2%–18.5%; P = .007). Within the high-risk population, the decrease in the incidence of PONV went from 29.3% (95% CI, 27.6%–31.1%) to 23.5% (95% CI, 20.5%–26.5%; P
http://bit.ly/2QQA11s
http://bit.ly/2QQA11s
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