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INTRODUCTION: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to constraints of the COVID-19 pandemic. This study aims to identify the patient cost, institutional charges, net margin revenue, and contribution margins associated with SDD, and analyze financial benefits when compared with admission. METHOD(S): Retrospective review of colectomy performed at a single institution over a 2-year period assessed for clinical outcomes, cost, charges, and revenue. The data was divided between 2 populations, SDD and postoperative day 1 (POD1) discharge. In addition to financial data, other outcomes included readmission, complication, and operative time. RESULT(S): There was a statistically significant difference favoring SDD over POD1 discharge in average: operating time (p = 0.00036), direct cost (p = 0.00000001), and charges (p = 0.00007711). SDD average patient cost were $9,186 USD compared with $11,698 USD for POD 1, and average hospital charges for SDD were $84,038 vs $97,566 for POD 1. Average net revenue was expectedly lower in SDD, $21,471, when compared with POD1, $26,719, however when comparing contribution margins (SDD $12,285 v POD1 $15,021), there was no statistically significant difference, p = 0.212. There were no statistically significant differences in readmission or operative complication between populations. CONCLUSION(S): Amidst pandemic-related resource constraints, we found that SDD was associated with lower patient cost and comparable contribution margin, without a significant difference in readmission and operative complication when compared with POD1 discharge.
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Introduction Delivery of the World Health Organisation elimination agenda for Hepatitis C Virus (HCV) requires active case finding, to engage hard to reach risk groups. Surrey is a relatively affluent part of the country, but contains pockets of significant unmet need, which are a barrier to the HCV care cascade. In 2020 the Surrey HCV Operational Delivery Network (ODN) piloted 'pop up clinics' for housed homeless populations during the COVID 19 pandemic. Based on this experience the ODN lead successfully bid for NHS England funding for a Mobile Outreach Van (MOV). Methods Detailed mapping of the ODN was undertaken jointly with the Hepatitis C Trust to identify potential locations to screen e.g., Opiate Substation Therapy dispensing pharmacies, and areas with high numbers of homeless people. MOV procurement and governance obtained in accordance with Trust policy. Individuals complete a brief liver health questionnaire including Blood Bourne Virus (BBV) risk factors. HCV screening is undertaken using Oraquick point of care testing. Those screening HCV Antibody positive (Ab +ve) receive a Clinical Nurse Specialist (CNS) assessment for therapy including a BBV screen HCV PCR and Fibro Scan. Hepatitis C Trust peer support is available to all individuals. Other significant findings prompt onward referral e.g., cirrhosis surveillance. Results First six months of operation the team have undertaken 50 testing days in 16 venues. 761 individuals have accepted HCV Ab screening. 40 (5.2%) tested HCV Ab +ve. 10 individuals confirmed viraemic and eligible for treatment. Another 7 individuals were re-engaged to undertake end of treatment or Sustained Virologic Response 12/48 PCR. In addition, 1 HCV Ab +ve (PCR negative), patient was diagnosed with Human Immunodeficiency Virus and referred to the local sexual health team. 16 individuals identified with advanced fibrosis or cirrhosis were referred to hospital for Hepatocellular Carcinoma surveillance. Patients engaged through the MOV service have received their treatment in the community via this service delivered by a CNS. Conclusions Nurse led MOV screen test treat model has proven to be safe and effective in engaging difficult to reach populations. Hepatitis C Trust peers accessibility help to address the anxiety/stigma surrounding HCV. MOV wider benefits include engagement with drug and alcohol services, and harm reduction. The next phase of implementation, the team plan to deliver needle exchange and naloxone in a partnership agreement with Surrey County Council.
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Introduction Home self-testing has been validated for HIV with evidence for increased uptake, comparable linkage to care and an absence of harm in those at risk. However, there are limited data on this strategy for people at risk of HCV infection (WHO 2021). Surrey HCV ODN Drug and Alcohol services (iAccess & Inclusion) provide a range of interventions including structured treatment for people with a history of alcohol or substance misuse. During COVID most clinics moved to telephone consultations, reducing BBV screening opportunities. This project targeted service users with > 12 months follow up for reengagement with HCV testing through supported home self-testing for HCV with rapid linkage to care through the ODN. Methods Interrogation of the EPR at the DTS (iAccess and Inclusion) identified a target population of older clients (>45years) who had not previously engaged with the offer of HCV testing. Exclusion criteria: previous positive HCVAb result, prior HCV treatment, negative DBS test within 6 months. Initial telephone contact from the hepatology CNS, Hep C Trust peer or Drug service recovery worker to was used to explain the project in detail and gain consent for participation. Participants received a postal testing pack including bespoke patient information leaflet and Oraquick® point of care test. The team used a dedicated phone number to discuss results and deliver support. Positive HCV Ab tests triggered an urgent assessment by the hepatology CNS supported by Hep C Trust peers. Results Preliminary results are available for the first six months (completion planned May 2022). Across the network 210 people agreed to participate and received home HCV self-test kits. 92 reported test results (44% of postal tests dispatched). Six HCVAb+ 80 HCVAb-, six test failures. 6.5% of completed tests detected HCV Ab. Of the six HCVAb+ identified to date five have attended for confirmatory PCR in the ODN. Two of five were PCR negative (spontaneous clearance), two PCR positive patients have commenced treatment and one awaits additional diagnostics. The strength of the ODN linkage to care processes is reflected in the client pathway, including two patients who were subsequently incarcerated and followed up by the ODN prison in reach team. Conclusions Postal testing for HCV using a rapid point of care test is feasible and provides an opportunity to engage at risk individuals for HCV testing. Once engaged linkage to care was effective utilizing the ODN network. This approach has also provided a useful avenue for HCV diagnosis and the care cascade during the pandemic when many clinic assessments have been managed remotely.
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Background and aims: Hyperglycaemia in acute ischaemic stroke (AIS) is common, reduces the efficacy of stroke thrombolysis and thrombectomy, with worse clinical outcomes. Insulin therapies are difficult to implement and maintain, and may cause symptomatic hypoglycaemia. An alternative treatment is Exenatide, a GLP-1 agonist that lowers blood glucose with a very low risk of hypoglycaemia. Methods: The Trial of Exenatide in Acute Ischaemic Stroke (TEXAIS) enrolled adult patients with AIS ≤9 hours of stroke onset to receive treatment with short-acting Exenatide (5μg bid subcutaneous injection) or Standard care for 5 days, or until hospital discharge (whichever sooner).Primary outcome: proportion of patients with ≥8 point improvement in NIHSS score (or NIHSS 0-1) at 7 days. Results: 350 patients randomised, median age 71 years (IQR 62, 79), and median NIHSS 4 (IQR 2, 8). Planned recruitment (n=528) stopped early due to Covid and time constraints. On Admission the median blood glucose was 6.7 (IQR 5.70, 8.50), and 42% patients had hyperglycaemia (>7.0 mmol/L). Primary outcome occurred in 97/171 (56.7%) in Standard care group vs 104/170 (61.2%) in Exenatide group [aOR: 1.22 (CI 0.79, 1.88) p=0.38]. Mean daily per-patient frequency of hyperglycaemia was significantly less in the Exenatide group (p=0.002). No episodes of hypoglycaemia reported over the treatment period. Nausea/vomiting occurred in 7/174 (4.0%) patients on Exenatide. Conclusions: In this Phase 2 trial Exenatide did not significantly reduce neurological disability at 7 days. Exenatide significantly reduced frequency of hyperglycaemic events, and was safe to use. These results warrant further investigation with larger Phase 3 trials.
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BackgroundVitamin D plays a vital part in modulating the immune system, with Vitamin D deficiency leading to increased susceptibility to infection.1 There is some evidence to suggest Vitamin D may play a protective role in the prevention of COVID-19 infection in hospitalised patients,2 but the topic remains controversial. Our study aims to investigate if low Vitamin D levels correlate with increased risk of COVID-19 infection, thereby representing a modifiable risk factor for COVID-19 infection.MethodA retrospective observational study was conducted on 3198 health care workers of a Greater London District General Hospital, who had undergone testing for 25-OH Vitamin D levels and COVID-19 antibody in June 2020. In accordance with NICE guidelines, Vitamin D deficiency was defined as less than 25 nmol/L, insufficiency as 25–50 nmol/L, and those with levels over 50 nmol/L were used as control comparisons. Evidence of previous SARS-CoV-2 infection was assessed by detection of SARS-CoV-2 IgG antibodies. Regression analysis was performed to determine independent significance, accounting for age and gender.Results3191 participants were included in this study, with age ranging from 19–78 years (mean 42.9) of which 78.2% were female. Both age and gender were not independently associated with positive SARS-CoV-2 IgG antibodies. 1997 (62.6%) participants had Vitamin D levels within the normal range, 899 (28.2%) participants had insufficient levels and 302 (9.4%) had Vitamin D deficiency. Both Vitamin D deficiency (OR 1.61, p=0.002) and insufficiency (OR 1.33, p=0.006) independently correlated with significantly increased incidence of positive COVID-19 antibodies than personnel with normal Vitamin D levels.ConclusionsWe report the largest single-centre study investigating the impact of low Vitamin D levels within healthcare workers to date. Significant correlation between low levels of Vitamin D and previous COVID-19 infection was identified. Oral Vitamin D supplementation to maintain levels >50 nmol/L may play a protective role against COVID-19. Larger studies are needed to investigate the role of Vitamin D supplementation in healthcare workers for further COVID-19 waves.ReferencesAranow C, et al. Journal of Investigative Medicine 2011;59:881–886.Nogues X, et al. J Clin Endocrinol Metab. 2021 Jun 7:dgab405.
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Rats contaminate foods and spread pathogens. Thus, changes in rat populations have consequences for society, especially in densely-populated cities. Following widespread social distancing and lockdown measures to curtail SARS-CoV-2, worldwide media outlets reported increased sightings of rats. To document possible changes in rat populations, we: (i) examined public service requests in the 6 years before, and during, ‘lockdown’ in New York City;(ii) used spatial analyses to identify calls in proximity to food service establishments (FSE);and (iii) surveyed pest-management companies. Over 6 years prior to the pandemic, we found a consistent moderate spatial association (r ¼ 0.35) between FSE and rat-related calls. During the early stages of the pandemic, the association between rat reports and food services did not decrease as would be expected by restaurant closures, but instead modestly increased (r ¼ 0.45). There was a 29.5% decrease in rat reports, overall. However, hotspot analysis showed that new reports were highly localized, yet absent in several industrial areas they were previously observed in, potentially masking a higher proportion of calls in neighborhoods near closed restaurants. Additionally, 37% of pest management companies surveyed reported that, unlike previous years, 50–100% of requests were from new clients and addresses. The finding that hotspots remained nearby dense clusters of restaurants does not support the common narrative that rats moved long distances. Rather, our results are consistent with rats finding nearby alternative food resources. Tracking these dynamics as the COVID-19 pandemic abates will be an important step to identifying how rats respond to society returning to normal activity patterns. © The Author(s) 2021.
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Intro/Background: In 2019, our department created an Assistant Chair for Faculty Development position with the purpose of working with the Chair to establish a culture fully engaging all faculty and their tremendous, diverse talents and to maintain a rewarding and engaging workplace. From this collaboration, a departmental faculty development (FDC) committee was established. Purpose/Objective: The FDC mission is to foster faculty morale and promote professional growth at all career levels through: (1) amplification and recognition of faculty accomplishments by seeking and responding to award opportunities;(2) facilitation of skill building for teaching, mentorship, and leadership development in various niches and divisions;and (3) equipping faculty to publish and disseminate their innovations and scholarly work. Methods: An 8-member committee representing assignments in operations, research and education, at all ranks, and all clinical sites was formed (4 women, 4 men;1 professor, 4 associate professors, 3 assistant professors). The FDC meets monthly to discuss faculty needs previously identified through survey and issues raised ad hoc. The committee serves as a nomination letter-writing bureau for local and national award opportunities. It also identifies diverse candidates for appointments to hospital and university committees. Outcomes (if available): In the first year, we held 10 monthly meetings and produced a departmental website with faculty development resources. Micro-lectures on university-assigned mentorship, promotion and tenure, resident evaluations, and faculty ultrasound skills training were delivered in faculty meetings. We introduced a new annual faculty retreat model. Faculty received twelve international, national and university awards in 2020. The FDC managed submissions for university and hospital-wide committee appointments. A planned 2-day mentoring skills workshop was postponed for COVID-19. Summary: While many institutions focus on faculty development from a global perspective, our program is novel in that it is structured at the department, level addressing the unique challenges and opportunities encountered by Emergency Medicine faculty. A website with resources under the following headings was produced: “Annual evaluation, CV, Promotion,” “Mentorship and Coaching,” “Scholarly Productivity and Publications,” “Required CME,” “Faculty Awards,” and “Time Management Resources.” We coordinate faculty mentorship and coaching with assigned mentors, annual reviews and planned workshops to improve mentor/mentee relationships and skills. We coordinate with departmental research committees to identify and respond to faculty research needs. Utilizing a new faculty retreat model, we transitioned from a traditional business-meeting format to a new FDC-moderated small-group working agenda focusing on important topics in scholarly productivity, onboarding of new faculty, education, clinical practice and operations. Faculty reviewed prompts and met with departmental leadership to brainstorm solutions to departmental challenges. Working points were summarized and action items reviewed with all faculty in the next departmental meeting. These action items outline a departmental faculty development agenda for the year ahead. Informal faculty feedback responses are positive about the new format for faculty retreats, the delivered micro-lectures on faculty development and annual evaluation and mentorship meetings. Future evaluation of the committee could focus on faculty engagement with FDC initiatives and metrics related to scholarly outputs.
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Background: To understand the factors associated with timing of adjuvant therapy in the management of intrahepatic and extrahepatic cholangiocarcinoma and the impact of delays on overall survival (OS). Methods: Data from the NCDB for patients with pathologically proven non-metastatic adenocarcinoma of the bile ducts from 2004 to 2014 were pooled and screened. Patients were included only if they underwent surgery and adjuvant chemotherapy (CMT) and/or radiotherapy (RT). Patients who underwent neoadjuvant therapy or received CMT or RT with palliative intent were excluded. Pearson's chisquared test and multivariate logistic regression analyses were used to assess the distribution of demographic, clinical, and treatment factors. After propensity-score matching with inverse probability of treatment weighting, OS was compared between patients who had initiation of adjuvant therapy past various time points using Kaplan Meier analyses and doubly-robust estimation with multivariate Cox proportional hazards modeling. Results: In total, 7,422 patients in our analysis underwent adjuvant treatment. This represented 43% of the study cohort of 17,123 patients. Of the patients who underwent adjuvant treatment, 3,956 (53%) initiated adjuvant therapy by two months, 6,234 (84%) by 3 months and 6,987 (94%) by four months. High-grade disease, macroscopically positive margins, tumors larger than five centimeters, and unknown LVSI status, were associated with earlier initiation of adjuvant treatment at two months or earlier. Patients who received early adjuvant therapy were also more likely to be treated with a combination of CMT and RT. Factors associated with delay of adjuvant therapy beyond three months postsurgery included Charlson scores of one or greater and Hispanic race. After propensity score weighting, there was no survival difference between groups when comparing initiation of adjuvant therapy before or after two, three or four month time pointsConclusions: We identified a number of patient characteristics related to the timing of initiating adjuvant therapy in patients with biliary cancers. There were no significant difference in OS associated with delaying adjuvant therapy beyond two, three or four month time-points. Our findings are relevant in the era of COVID-19 when minimizing patient exposure to healthcare settings during a pandemic may need to be considered when deciding on the timing of adjuvant therapy. If a delay is necessary, our results suggest that there is no survival detriment to initiating adjuvant therapy beyond three or four months after surgery for biliary cancers.