Heart failure care pathways: the power of collaboration and marginal gains.

Heart failure (HF) is increasingly common and incurs a substantial cost, both in terms of quality and length of life, but also in terms of societal and economic impact. While significant gains are being made in the therapeutic management of HF, we continue to diagnose most patients when they are acutely unwell in hospital, often with advanced disease. This article presents our experience in working collaboratively with primary care colleagues to redesign our HF pathway with the aim of facilitating earlier, community, diagnosis of HF. In so doing, and, thus, starting prognostic therapy much earlier in the course of the disease, we seek to avoid both the cost of emergency hospitalisation and the cost of poorer outcomes.

Automated pneumothorax triaging in chest X-rays in the New Zealand population using deep-learning algorithms.

INTRODUCTION: The primary aim was to develop convolutional neural network (CNN)-based artificial intelligence (AI) models for pneumothorax classification and segmentation for automated chest X-ray (CXR) triaging. A secondary aim was to perform interpretability analysis on the best-performing candidate model to determine whether the model's predictions were susceptible to bias or confounding. METHOD: A CANDID-PTX dataset, that included 19,237 anonymized and manually labelled CXRs, was used for training and testing candidate models for pneumothorax classification and segmentation. Evaluation metrics for classification performance included Area under the receiver operating characteristic curve (AUC-ROC), sensitivity and specificity, whilst segmentation performance was measured using mean Dice and true-positive (TP)-Dice coefficients. Interpretability analysis was performed using Grad-CAM heatmaps. Finally, the best-performing model was implemented for a triage simulation. RESULTS: The best-performing model demonstrated a sensitivity of 0.93, specificity of 0.95 and AUC-ROC of 0.94 in identifying the presence of pneumothorax. A TP-Dice coefficient of 0.69 is given for segmentation performance. In triage simulation, mean reporting delay for pneumothorax-containing CXRs is reduced from 9.8 ± 2 days to 1.0 ± 0.5 days (P-value < 0.001 at 5% significance level), with sensitivity 0.95 and specificity of 0.95 given for the classification performance. Finally, interpretability analysis demonstrated models employed logic understandable to radiologists, with negligible bias or confounding in predictions. CONCLUSION: AI models can automate pneumothorax detection with clinically acceptable accuracy, and potentially reduce reporting delays for urgent findings when implemented as triaging tools.

Medication use in the last year of life: a cross-sectional hospice study.

OBJECTIVES: The issue of polypharmacy and medication use in people with life limiting illness raises important questions from a clinical and ethical viewpoint. The objectives of our study were to (1) explore medication use among people with life limiting illness receiving hospice care; (2) apply consensus criteria to assess medication appropriateness; and (3) determine the overall pill burden in this patient population. METHODS: Six hospices in the North East of England were included. All deceased adult patients who received hospice care in 2018 were eligible for study inclusion. Descriptive statistics were used to report medication details; while medication appropriateness was assessed according to consensus criteria developed by Morin and colleagues. RESULTS: Six hundred and ninety patients were included in the study. Patients were using a mean number of 8.8 medications per day, while polypharmacy was evident in 80% of patients. In terms of potentially questionable medication, patients were prescribed a mean number of 1.3 per day. Common potentially questionable medications included vitamin and mineral supplements, antihypertensives, antiplatelets, lipid regulating agents and anticoagulants. The pill burden in this population was also high with, on average, people using 13.7 oral doses per day. CONCLUSIONS: Polypharmacy is common in patients accessing hospice care, as is the use of potentially questionable medication. The pill burden in this patient population is also high, which may be an additional treatment burden to patients. Holistic deprescribing approaches for this population should be developed and implemented.

Curation of the CANDID-PTX Dataset with Free-Text Reports.

Supplemental material is available for this article. Keywords: Conventional Radiography, Thorax, Trauma, Ribs, Catheters, Segmentation, Diagnosis, Classification, Supervised Learning, Machine Learning © RSNA, 2021.

Lymphoedema management by independent hospices: a cohort study.

OBJECTIVES: To consider the type and cost of clinical services delivered for patients with lymphoedema. DESIGN: Clinical cohort. SETTING: Independent hospices in the North East of England. PARTICIPANTS: All those attending lymphoedema services delivered by the independent hospice sector 2017/2018. RESULTS: 13 914 lymphoedema appointments were recorded across four independent hospices. Twelve thousand nine hundred and sixty-five were attended, which equates to an approximate cost of £1.56 million. Those with lymphoedema were predominately aged over 65 (54.5%) years with females across all age groups being more predominant (3.3:1). Where the cause was recorded, 66% of activity related to lymphoedema was not secondary to cancer. CONCLUSION: Independent hospices are providing a specialist lymphoedema service, which is high in volume and largely invisible. This service is delivered at not insignificant cost. In contrast to previous work, in the North East of England, lymphoedema sufferers are more likely to be female and not have the condition in association with cancer. The availability of rigorous data collection will allow the independent hospices to understand better the delivery and associated costs of lymphoedema services.

The prevalence of reversible cardiovascular risk factors in Israelis aged 25-55 years.

BACKGROUND: Coronary heart disease is a major cause of morbidity and mortality worldwide. Early detection of cardiovascular risk factors and intervention may reduce consequential morbidity and mortality. OBJECTIVES: To assess the prevalence of reversible and treatable cardiovascular risk factors among 26,477 healthy Israeli adults: 23,339 men and 3138 women aged 25-55 years. METHODS: We collected data during routine examinations performed as part of a screening program for Israel Defense Force personnel. RESULTS: The three most prevalent cardiovascular risk factors were a sedentary lifestyle (64%), dyslipidemia (55.1%) and smoking (26.8%). Overall, 52.9% of the men and 48.4% of the women had two or more cardiovascular risk factors. Moreover, 52.4% of young adult men and 43.3% of young adult women, age 25-34 years, had two or more reversible cardiovascular risk factors. CONCLUSIONS: In this expectedly healthy population there was a high prevalence of reversible and treatable cardiovascular risk factors in both genders and in young ages. These observations stress the need for routine health examinations and lifestyle modification programs even in the young healthy Israeli population.

Intraperitoneal ropivacaine and a gas drain: effects on postoperative pain in laparoscopic surgery.

STUDY OBJECTIVE: To assess the benefits of the combination of a gas drain and the instillation of local anesthetic on the incidence of pain after operative gynecologic laparoscopy. DESIGN: Randomized control trial (Canadian Task Force classification I). SETTING: Tertiary referral center. PATIENTS: One hundred twenty-eight patients undergoing operative gynecologic laparoscopy procedures lasting less than 105 minutes. INTERVENTIONS: Postoperatively, one group received a blocked drain and saline placed intraperitoneally; a second group was given a blocked drain and ropivacaine; a third group received a patent drain and saline; and a fourth was given a patent drain and ropivacaine. MEASUREMENTS AND MAIN RESULTS: Visual analogue pain scores (VAS) were measured at 1, 2, 4, and 12 hours and day 1 to day 7. Also measured was opioid consumption at 4 hours, nausea, and activity scores. We found a statistically significant improvement in pain scores at 2 and 4 hours in the group allocated to receive a patent drain and ropivacaine. CONCLUSION: We recommend the use of a gas drain and ropivacaine to reduce postoperative pain.

The effect of intraperitoneal ropivacaine on pain after laparoscopic excision of endometriosis.

STUDY OBJECTIVE: To compare the effects of ropivacaine and saline on pain after laparoscopic excision of endometriosis. DESIGN: Randomized, double-blind, controlled trial (Canadian Task Force classification I). SETTING: Women's hospital. PATIENTS: Ninety-three women undergoing excision of endometriosis. INTERVENTION: Laparoscopic excision of endometriosis, after which saline 100 mg (46 women) or ropivacaine 200 mg dissolved in 100 ml saline (47) was instilled intraperitoneally for postoperative analgesia. MEASUREMENTS AND MAIN RESULTS: No differences were seen between groups during the first 7 hours after surgery with respect to pain scores, analgesic requirements, postoperative nausea and vomiting, or time to discharge. CONCLUSION: We found no difference between ropivacaine and saline, instilled intraperitoneally, in their effects on pain after extensive excision of endometriosis.