Brave new world: expanding home care in stem cell transplantation and advanced therapies with new technologies.

Hematopoietic stem cell transplantation and cell therapies like CAR-T are costly, complex therapeutic procedures. Outpatient models, including at-home transplantation, have been developed, resulting in similar survival results, reduced costs, and increased patient satisfaction. The complexity and safety of the process can be addressed with various emerging technologies (artificial intelligence, wearable sensors, point-of-care analytical devices, drones, virtual assistants) that allow continuous patient monitoring and improved decision-making processes. Patients, caregivers, and staff can also benefit from improved training with simulation or virtual reality. However, many technical, operational, and above all, ethical concerns need to be addressed. Finally, outpatient or at-home hematopoietic transplantation or CAR-T therapy creates a different, integrated operative system that must be planned, designed, and carefully adapted to the patient's characteristics and distance from the hospital. Patients, clinicians, and their clinical environments can benefit from technically improved at-home transplantation.

Enhanced recovery and same-day discharge after brain tumor surgery under general anesthesia: initial experience with Hospital-at-Home-based postoperative follow-up.

OBJECTIVE: The objective of this study was to describe the outcomes of outpatient oncological neurosurgery (OON) in a European clinical setting and to compare them with the conventional inpatient protocol. METHODS: Patients who had undergone OON (either tumor removal or biopsy) at the authors' center since 2019 were analyzed. A matched cohort of patients was selected from patients undergoing tumor surgery in the same period. Collected data included patient demographics, postoperative progress, specific location of the target lesion, and the procedure performed. RESULTS: There were 18 patients in the case group and 59 patients in the control group. The outpatient surgeries had a same-day discharge rate of 89%, and all ambulatory patients successfully completed the Enhanced Recovery After Surgery program within 6.24 hours of the procedure. All ambulatory patients underwent Hospital-at-Home postoperative follow-up for an average of 4.12 days. Radiological complications were present in 11% of the case group and 8% of the control group. Postoperative neurological deficit occurred in 6% of the same-day discharge group and 3% of the control group. Among the patients in the control group, 3% suffered from postoperative seizures, whereas no seizures were observed in the case group. These differences were not statistically significant. General anesthesia-related complications were not observed in any of the patients. CONCLUSIONS: The authors' findings demonstrate that Enhanced Recovery After Surgery protocols and same-day discharge craniotomy for tumor resection and image-guided biopsy under general anesthesia, when patients are carefully selected, can be safely performed with excellent outcomes in a European clinical setting. The OON program proved to be a viable alternative to conventional hospitalization, showing comparable safety records and offering advantages in terms of patient recovery.

Barriers and facilitators in the implementation of a telemedicine-based outpatient brain tumor surgery program.

OBJECTIVE: Despite growing evidence on the benefits of outpatient oncological neurosurgery (OON), it is only performed in a few specialized centers and there are no previous descriptions of established OON programs in Europe. Moreover, increasing application of telemedicine strategies, especially after the start of the coronavirus disease 2019 (COVID-19) pandemic, is drastically changing neurosurgical management, particularly in the case of vulnerable populations such as neuro-oncological patients. In this context, the authors implemented an OON program in their hospital with telematic follow-up. Herein, they describe the protocol and qualitatively analyze the barriers and facilitators of the development process. METHODS: An OON program was developed through the following steps: assessment of hospital needs, specific OON training, multidisciplinary team organization, and OON protocol design. In addition, the implementation phase included training sessions, a pilot study, and continuous improvement sessions. Finally, barriers and facilitators of the protocol's implementation were identified from the feedback of all participants. RESULTS: An OON protocol was successfully designed and implemented for resection or biopsy of supratentorial lesions up to 3 cm in diameter. The protocol included the patient's admission to the day surgery unit, noninvasive anesthetic monitoring, same-day discharge, and admission to the hospital-at-home (HaH) unit for telematic and on-site postoperative care. After a pilot study including 10 procedures in 9 patients, the main barriers identified were healthcare provider resistance to change, lack of experience in outpatient neurosurgery, patient reluctance, and limitations in the recruitment of patients. Key facilitators of the process were the patient education program, the multidisciplinary team approach, and the HaH-based telematic postoperative care. CONCLUSIONS: Initiating an OON program with telematic follow-up in a European clinical setting is feasible. Nevertheless, it poses several barriers that can be overcome by identifying and maximizing key facilitators of the process. Among them, patient education, a multidisciplinary team approach, and HaH-based postoperative care were crucial to the success of the program. Future studies should investigate the cost-effectiveness of telemedicine to assess potential cost savings, from reduced travel and wait times, and the impact on patient satisfaction.

Effectiveness and safety of ertapenem used in hospital-at-home units: data from Spanish Outpatient Parenteral Antimicrobial Therapy Registry.

AIM: To evaluate the effectiveness and safety of ertapenem in patients hospitalized at home. PATIENTS & METHODS: Retrospective analysis of data from Spanish Outpatient Parenteral Antimicrobial Therapy (OPAT) registry. RESULTS: Data from 1428 patients (median age 70 years; 5.4% institutionalized) and 1547 infectious processes (24% self-administration) were analyzed. Clinical cure or improvement was achieved in 93.8% of cases. Rate of related readmissions was 4.2%, of clinically important complications -3.9%, and of adverse drug reactions -3.2%. High comorbidity burden, contagion in nursing home and certain types of infection were associated with worse prognosis. Self-administration was effective and safe, except in case of nursing home-acquired infections. CONCLUSION: Ertapenem OPAT was effective and safe. Caregivers in nursing homes should be better trained in OPAT-related procedures.

Effect of transdermal nitroglycerin on inflammatory mediators in patients with peripheral atherosclerotic vascular disease.

OBJECTIVE: To demonstrate that nitroglycerin improves biological markers of arterial inflammation in patients with peripheral vascular disease. BACKGROUND: Atherosclerosis is an inflammatory disease in which there is an increase in active inflammation markers such as C-reactive protein and other factors released by endothelial cells. Nitroglycerin acts by a chemical liberation of nitric oxide. We have previously published the results from several controlled clinical trials confirming an anti-inflammatory action of nitroglycerin. METHODS: Forty patients with peripheral vascular disease entered a randomized, double-blind, placebo-controlled pilot study for 6 weeks. Twenty-one patients were treated with continuous application of a transdermal nitroglycerin patch (15 mg/24 hours) on the anterior face of the thigh. Venous blood samples were obtained before treatment and 2 and 6 weeks after. We measured plasma levels of C-reactive protein, cGMP (also intraplatelet cGMP), E-selectin, ICAM, VCAM-1, IL-6, and nitrites/nitrates. RESULTS: No biological parameter was modified in the placebo group. On the contrary, nitroglycerin significantly reduced plasma levels of C-reactive protein and sE-selectin and increased the levels of intraplatelet cGMP. CONCLUSIONS: The results of this preliminary study show that nitroglycerin has an anti-inflammatory action in patients with peripheral vascular disease. This may provide a new therapeutic approach to understanding the efficacy of nitrovasodilators in the improvement of atherosclerotic syndromes.

Staphylococcus aureus resistente a la meticilina y hospitalización a domicilio / Methicillin-resistant Staphylococcus aureus and hospital at home

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[Reproducibility of C-reactive protein analyses]. / Reproducibilidad de los análisis de proteína C reactiva.

The aim of this study was to measure the reliability of different nephelometric techniques for measuring C-reactive protein (CRP). One hundred and twenty samples were obtained from 40 patients. All 120 samples were divided in three parts to measure CRP using three different methods. Reliability was determined by the kappa index and intraclass correlation coefficient. The intraclass correlation coefficient ranged from 0.78 to 0.94. When CRP values were categorized in four groups, the kappa index reached 75-86% and percentage of agreement varied from 95% to 97%. When CRP values were divided into two groups, the kappa index was 73% to 78% and the percentage of agreement was 86% to 89%. We found that CRP determinations with different nephelometric methods were highly reproducible, even when different analysts were involved. Ultrasensitive techniques are needed only if the clinical objective is to obtain a CRP measurement under 0.3 mg/dl.

Reproducibilidad de los análisis de proteína C reactiva / Reproducibility of c-reactive protein analyses

El objetivo de este estudio es medir la reproducibilidad de diferentes técnicas nefelométricas para la determinación de la proteína C reactiva (PCR). Se obtuvieron 120 muestras de 40 pacientes. Cada muestra fue dividida en tres alícuotas y se determinó la PCR por tres procedimientos diferentes. La reproducibilidad se midió mediante el índice kappa y el coeficiente de correlación intraclase. El coeficiente de correlación intraclase varió entre 0,78 y 0,94. El índice kappa ponderado obtuvo valores entre 75 y 86 por ciento y el porcentaje de acuerdo entre las técnicas varió entre 95 y 97 por ciento. Al dicotomizar la PCR, el índice kappa varió entre 73 y 78 por ciento y el porcentaje de acuerdo entre 86 y 89 por ciento. Se concluye que la determinación de la PCR es muy reproducible con diferentes técnicas nefelométricas. Sólo si el objetivo del clínico es medir la PCR por debajo del límite de 0,3 mg/dl, sería necesario emplear técnicas ultrasensibles (AU)