Mayo Clinic proceedings. Innovations, quality & outcomes最新文献

Objective

To evaluate the heterogeneity in treatment effect in posttraumatic stress disorder (PTSD) trials.

Patients and Methods

We downloaded data from a publicly available repository that captured PTSD trials published from January 1988 through February 2023. We applied restricted maximum-likelihood random-effect meta-analyses and meta-regression to explore potential moderators of treatment effect including methodologic study features (risk of bias domains and control group response rate), characteristics of the population, and intervention features following the theme, intensity, and platform framework.

Results

We included 199 PTSD trials that reported the outcomes of diagnosis resolution (122 trials, 8437 patients) and clinically meaningful improvement (133 trials, 9895 patients). Multiple treatments demonstrated effectiveness but with significant heterogeneity. Statistically significant moderators included risk of bias domains of randomization sequence and outcome measurement, control group response rate reflecting severity of PTSD in the enrolled population, and whether the psychotherapeutic approach was trauma focused (P values <0.05). There was no statistically significant effect for the frequency of treatments per week, format of the intervention (eg, individual vs group), duration of the intervention, or delivery method (in person vs not), (P values <0.05). Characteristics of the population such as sex, age, and military status did not appear to significantly affect the treatment effect (P values <0.05).

Conclusion

Trauma focused psychotherapies should be considered the first-line intervention to induce remission. Several patient characteristics or treatment context did not modify the treatment effect, which allows tailoring care based on patient values, preferences and logistics.

Objective

To reduce the frequency of insufficient overlap of intravenous (IV) and subcutaneous (SC) insulin during the treatment of diabetic ketoacidosis (DKA) as a quality improvement project.

Patients and Methods

Rates of insufficient IV and SC insulin overlap (< 2-hour overlap, SC insulin given after IV insulin discontinuation, or no SC insulin given after IV insulin discontinuation) were assessed in adults with DKA treated with IV insulin at a large tertiary care referral center in Rochester, Minnesota, from July 1, 2021, to March 15, 2023. After a preintervention analysis period, an electronic medical record–based best practice advisory was introduced to notify hospital providers discontinuing IV insulin if SC long-acting insulin had not been given in the previous 2-6 hours. Demographic characteristics and clinical outcomes before and after intervention were compared.

Results

A total of 352 patient encounters were included (251 in the preintervention phase and 101 in the postintervention phase). The rate of insufficient IV to SC insulin overlap decreased from (88 of 251) 35.1% before intervention to (20 of 101) 19.8% after intervention (P=.005). The rate of posttransition hypoglycemia (<70 mg/dL; to convert to mmol/L, multiply by 0.0259) decreased from (27 of 251) 10.7% to (4 of 101) 4% after intervention (P=.04). Rates of posttransition hyperglycemia (>250 mg/dL), rebound DKA, length of hospital stay, and duration of IV insulin therapy were similar before and after intervention.

Conclusion

Using quality improvement methodology, the rates of insufficient IV to SC insulin overlap during treatment of DKA in a large tertiary care referral center were measured and reduced through an electronic medical record–based best practice advisory targeting hospital providers.

Chronic diseases are the leading cause of death and disability in the United States, and much of this burden can be attributed to lifestyle and behavioral risk factors. Lifestyle medicine is an approach to preventing and treating lifestyle-related chronic disease using evidence-based lifestyle modification as a primary modality. NYC Health + Hospitals, the largest municipal public health care system in the United States, is a national pioneer in incorporating lifestyle medicine systemwide. In 2019, a pilot lifestyle medicine program was launched at NYC Health + Hospitals/Bellevue to improve cardiometabolic health in high-risk patients through intensive support for evidence-based lifestyle changes. Analyses of program data collected from January 29, 2019 to February 26, 2020 demonstrated feasibility, high demand for services, high patient satisfaction, and clinically and statistically significant improvements in cardiometabolic risk factors. This pilot is being expanded to 6 new NYC Health + Hospitals sites spanning all 5 NYC boroughs. As part of the expansion, many changes have been implemented to enhance the original pilot model, scale services effectively, and generate more interest and incentives in lifestyle medicine for staff and patients across the health care system, including a plant-based default meal program for inpatients. This narrative review describes the pilot model and outcomes, the expansion process, and lessons learned to serve as a guide for other health systems.

Coronary artery disease is the most common cause of heart failure, which is the leading cause of cardiovascular-related death worldwide. There are insufficient data to make strong recommendations for percutaneous coronary intervention (PCI) in patients with severe ischemic left ventricular systolic dysfunction (LVSD). In that context, we performed a meta-analysis to compare the outcomes of PCI with those of optimal medical therapy alone in patients with severe ischemic LVSD. A systematic search was conducted in PubMed, EMBASE, and ClinicalTrials.gov from inception to December 2023. Our outcome of interest was all-cause mortality in patients undergoing PCI vs medical therapy. We used random effects models to aggregate data and to calculate pooled incidence and relative risk with 95% CIs. Four studies including 2 randomized controlled trials with 2080 patients (PCI, 1082; optimal medical therapy, 998) were included. All-cause mortality did not differ significantly between the groups: 168 patients (15.5%) in the PCI group vs 200 patients (20.0%) in the optimal medical therapy group (relative risk, 0.88; 95% CI, 0.75-1.09; P=.25). In conclusion, the available evidence indicates that PCI does not improve all-cause mortality in patients with severe LVSD without lifestyle-limiting anginal symptoms. Further data are needed to identify subgroups of patients better served by each modality.

Behavior change is the foundation for effective lifestyle prescriptions, yet such change is individualized, nonlinear and typically requires ongoing support. Health and wellness coaching (HWC) is a behavior change intervention with rapidly accruing evidence of positive impact on health behaviors such as exercise, nutrition and stress management. Furthermore, HWC enhances prevention and mitigates exacerbation of chronic lifestyle diseases, at least in the short-term (up to 6 months post intervention). Although the impact on long-term stability of behavior change remains unclear, it is evident that effective partnering with patients using key communication strategies, autonomy promotion, and flexible permissiveness can empower patients to develop healthy lifestyles. This partnership can be cultivated by clinicians as well as clinical team members including nationally board-certified coaches. Although much research is needed regarding the ongoing maintenance of lifestyle changes beyond 6 months, this article seeks to equip clinicians with current evidence, theoretical insights and practical strategies from a “coach approach” to foster more intrinsic forms of motivation which, in turn, empowers patients to adopt and maintain health-promoting behaviors.

Objective

To perform a retrospective clinical study in order to investigate phenotypic penetrance within a large registry of patients with hypermobile Ehlers-Danlos syndrome (hEDS) to enhance diagnostic and treatment guidelines by understanding associated comorbidities and improving accuracy in diagnosis.

Patients and Methods

From May 1, 2021 to July 31, 2023, 2149 clinically diagnosed patients with hEDS completed a self-reported survey focusing on diagnostic and comorbid conditions prevalence. K-means clustering was applied to analyze survey responses, which were then compared across gender groups to identify variations and gain clinical insights.

Results

Analysis of clinical manifestations in this cross-sectional cohort revealed insights into multimorbidity patterns across organ systems, identifying 3 distinct patient groups. Differences among these phenotypic clusters provided insights into diversity within the population with hEDS and indicated that Beighton scores are unreliable for multimorbidity phenotyping.

Conclusion

Clinical data on the phenotypic presentation and prevalence of comorbidities in patients with hEDS have historically been limited. This study provides comprehensive data sets on phenotypic presentation and comorbidity prevalence in patients with hEDS, highlighting factors often overlooked in diagnosis. The identification of distinct patient groups emphasizes variations in hEDS manifestations beyond current guidelines and emphasizes the necessity of comprehensive multidisciplinary care for those with hEDS.

Cardiac hemangiomas are extremely rare tumors accounting for only 1.5%-2.5% of all cardiac tumors. According to most recent literature, only 13 mitral valve hemangiomas have been reported. A 78-year-old man was undergoing routine transthoracic echocardiography monitoring for an ascending aortic dilation when a vegetation on the mitral leaflet was incidentally detected. This lesion presented as a 0.5- × 0.6-cm mobile mass arising from the medial aspect of the A2 cusp. Despite the asymptomatic nature of the aforementioned lesion, resection was pursued given presumed diagnosis of papillary fibroelastoma and concern for risk of stroke. The mass was resected using minimally invasive robotic approach, and final pathology was consistent with hemangioma.

Objective

To assess the effect of coronavirus disease 2019 (COVID-19) infection on heart transplant recipients requiring immunotherapy. To investigate the effectiveness of vaccination in immunosuppressed heart transplant recipients during the initial years of the COVID-19 pandemic, and to examine the timing of COVID-19 infections in heart transplant recipients’ posttransplantation.

Patients and Methods

International data on COVID-19 infection in immunosuppressed populations is limited. Heart transplant recipients requiring immunotherapy are at risk for increased complications with COVID-19 infection. The availability of vaccination and temporal trends in this population has not been well described. We report outcomes in immunosuppressed patients during the initial years of the COVID-19 pandemic from March 1, 2019, to October 31, 2021, at Mayo Clinic in Florida.

Results

A total of 98 patients were reviewed, of which 49 were COVID-19–positive (CP), and 49 were negative (CN). The cohort was well matched, with a median age of 58 years (49–65 years) in both groups. Females consisted of 41% in the CP group and 18.4% in the CN group. Immunosuppression was not significantly different for CP or CN patients. The median time from transplant to CP was 384 days (237–677 days). The CN group’s median follow-up after transplant was 947 days (737–1191 days). The CP hospitalization rate was 24% with only 1 death. More CP patients were vaccinated than the CN group (92% vs 78%, P=.025).

Conclusion

Our study sheds light on COVID-19’s effect on heart transplant recipients and vaccination in this population. Our findings suggest a potentially heightened infection risk within the first 1.5 years posttransplant, highlighting the need to optimize management strategies and vaccine efficacy in this vulnerable group.

Objective

To investigate the experience of medical and graduate learners with second victim experience (SVE) after medical errors or adverse patient outcomes, including impact on training and identification of factors that shape their postevent recovery.

Patients and Methods

The validated Second Victim Experience and Support Tool-Revised (SVEST-R), Physician Well-Being Index, and supplemental open-ended questions were administered to multidisciplinary health care learners between April 8, 2022, and May 30, 2022, across a large academic health institution. Open-ended responses were qualitatively analyzed for iterative themes related to impact of SVE on the training experience.

Results

Of the 206 survey respondents, 144 answered at least 1 open-ended question, with 62.1% (n=91) reporting at least 1 SVE. Participants discussed a wide range of SVEs and indicated that their postevent response was influenced by their training environment. Lack of support from supervisors and staff exacerbated high stress situations. Some trainees felt blamed and unsupported after a traumatic experience. Others emphasized that positive training experiences and supportive supervisors helped them grow and regain confidence. Learners described postevent processing strategies helpful to their recovery. Some, however, felt disincentivized from seeking support.

Conclusion

This multidisciplinary study of learners found that the training environment was influential in postevent recovery. Our findings support the need for the inclusion of education on SVEs and adaptive coping mechanisms as part of health care professional educational curriculums. Educators and health care staff may benefit from enhanced education on best practices to support trainees after stressful or traumatic patient events.

Objective

To evaluate the completeness and reliability of recurrence data from an institutional cancer registry for patients with head and neck cancer.

Patients and Methods

Recurrence information was collected by radiation oncology and otolaryngology researchers. This was compared with the institutional cancer registry for continuous patients treated with radiation therapy for head and neck cancer at a tertiary cancer center. The sensitivity and specificity of institutional cancer registry data was calculated using manual review as the gold standard. False negative recurrences were compared to true positive recurrences to assess for differences in patient characteristics.

Results

A total of 1338 patients who were treated from January 1, 2010, through December 31, 2017, were included in a cancer registry and underwent review. Of them, 375 (30%) had confirmed cancer recurrences, 45 (3%) had concern for recurrence without radiologic or pathologic confirmation, and 31 (2%) had persistent disease. Most confirmed recurrences were distant (37%) or distant plus locoregional (29%), whereas few were local (11%), regional (9%), or locoregional (14%) alone. The cancer registry accuracy was 89.4%, sensitivity 61%, and specificity 99%. Time to recurrence was associated with registry accuracy. True positives had recurrences at a median of 414 days vs 1007 days for false negatives.

Conclusion

Currently, institutional cancer registry recurrence data lacks the required accuracy for implementation into studies without manual confirmation. Longer follow-up of cancer status will likely improve sensitivity. No identified differences in patients accounted for differences in sensitivity. New, ideally automated, data abstraction tools are needed to improve detection of cancer recurrences and minimize manual chart review.