Atrium Medical (Australia)

PurposeTo evaluate the Achieving Clinical Audits with Electronic Records (ACAER) program in supporting primary care providers in quality improvement initiatives across asthma and COPD.Patients and methodsThis observational cohort study included individuals aged ≥12 years with documented diagnosis of asthma or COPD, receiving asthma or COPD therapy, at high risk of exacerbation and hospitalization. Data were derived from the intervention, linked patient questionnaires completed as part of practice evaluation and quality improvement, and routine primary care electronic medical records (EMR) within the Optimum Patient Care Research Database Australia (OPCRDA). Changes in exacerbation rates and maintenance treatment were evaluated.Results7512 asthma and 6526 COPD patients were evaluated with EMR collection. A subset of 1327 asthma patients and 629 COPD patients were classified as active and high-risk. Patient questionnaires and evaluation reports were sent out between 29 October 2019 and 21 September 2021, the intervention period. For those at risk during the entire study period (2018–2023; N=1276), 48.4% and 59.3% of patients in the high-risk asthma and COPD populations, respectively, had maintenance therapy change in the first year post-intervention. Exacerbation rates fell after the intervention period in the high-risk asthma (74.8 to 32.4 per 1000 per month) and COPD (122.9 to 91.2 per 1000 per month) populations. High-risk asthma patients had increasing rates of exacerbations in the 2 years prior to the intervention period (linear trend: 2.79 exacerbations per 1000 per month [1.34, 4.24]; p=0.001), which declined and remained stable after the intervention (p=0.87; up to 2023). Exacerbation rates for high-risk COPD patients were stable pre-intervention (p=0.29). Post-intervention rates initially declined and then showed a marginal non-statistically significant increase (p=0.28).ConclusionOur findings support the potential for the ACAER asthma and COPD program to drive treatment change and improve long-term outcomes in high-risk patients in primary care settings.

Enhanced Recovery After Surgery (ERAS) protocols aim to improve perioperative outcomes and expedite recovery across various surgical specialties. While ERAS protocols have shown significant benefits in gastrointestinal and cardiovascular surgeries, their impact and effectiveness require further synthesis. This systematic review and meta-analysis evaluated the efficacy of ERAS protocols in enhancing recovery and reducing complications in gastrointestinal and cardiovascular surgeries. High-quality studies were selected based on adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and quality assessment using the Newcastle-Ottawa Scale (NOS). A systematic review and meta-analysis of six high-quality studies involving 45,678 patients were conducted using databases such as PubMed, MEDLINE, EMBASE, and Cochrane Central. Data on length of hospital stay (LOS), complications, 30-day readmissions, and mortality were extracted. Statistical analysis employed random-effects models to calculate pooled effect sizes, odds ratios (ORs), and hazard ratios. Subgroup analyses were performed based on surgery type, patient age, comorbidities, and follow-up duration. ORs for postoperative complications varied across subgroups (e.g., urgent vs. elective surgeries), with some ranges (e.g., 0.65-1.02) reflecting mixed effects; sensitivity analyses confirmed the robustness of pooled outcomes. Recovery times ranged from 1 to 3 days for gastrointestinal surgeries and 4 to 9 days for cardiovascular surgeries, demonstrating clinically meaningful variability. ERAS protocols showed greater recovery benefits in urgent surgeries (HR = 1.42, 95% CI: 1.15-1.75) and in patients with comorbidities (HR = 1.62, 95% CI: 1.33-1.96), likely due to their emphasis on rapid stabilization of perioperative care, including early mobilization and nutritional support. Heterogeneity, assessed through sensitivity analyses, ranged from moderate to substantial across subgroup analyses. ERAS protocols consistently enhance recovery outcomes, minimize complications, and reduce hospital stays in gastrointestinal and cardiovascular surgeries, demonstrating their utility in optimizing perioperative care. Future research should explore long-term outcomes and tailored implementation strategies to address patient-specific needs.

Patient: Male, 65-year-oldFinal Diagnosis: GoutSymptoms: Back pain • weaknes of lower limbsClinical Procedure: —Specialty: General and Internal MedicineObjective:Unusual clinical courseBackground:Spinal gout is not so uncommon. The numbers of case reports are low because of underdiagnosis. Nevertheless, the presentation of spinal gout in a patient who was never diagnosed with gout or hyperuricemia is rare. In addition, the probability of occurrence of spinal gout at the thoracic spine is low, making this case unique. Late or missed diagnosis causes treatment delays with grave outcomes.Case Report:A 65-year-old man with a past medical history of chronic lymphocytic leukemia presented with rapid and progressive weakness of the lower extremities that led to complete paraplegia over 2 weeks. Magnetic resonance imaging showed severe central canal stenosis with disc protrusion and a T4-5 ventral mass with abnormal marrow signaling. The margins at the erosion were sclerotic, and malignancy was top on the differential diagnosis. Open minimally invasive laminectomy with discectomy at T4-5 was done. Sections on the biopsy specimen demonstrated fragments of benign cartilage and bone and multiple granulomas palisading around areas of crystalline material, consistent with tophaceous gout. He was started on a urate-lowering treatment per the American College of Rheumatology guideline. Unfortunately, due to the late patient presentation, neurologic recovery was not possible.Conclusions:This case report illustrates an unusual presentation of gout with a catastrophic complication that could have been prevented with early diagnosis and treatment. Some reports have described patients with tophaceous deposits in the absence of gout flare among patients with urate overproduction due to myeloproliferative disorders. Further studies are needed to explore such relationships.

Visit-to-visit variability (VVV) is a relatively new concept in the hypertensive arena. Data regarding VVV are lacking in our region, and factors associated with VVV are rarely examined in previous studies. This study was conducted among 406 patients attended to the cardiology outpatient department of Teaching Hospital, Jaffna, Sri Lanka, in 2018 to assess the long-term variability of blood pressure (BP) by reviewing last six consecutive BP readings from the records retrospectively. Data regarding sociodemographic variables and behavioural factors such as medication adherence, physical activity, smoking, alcohol consumption, and relevant comorbidities were taken through an interviewer-administered questionnaire. Data were analysed by using SPSS version 25 and VVV of systolic blood pressure (SBP) matrix expressed as mean of SD and association were examined with various factors and VVV of SBP. SBP showed high VVV among the participants as expressed by mean of SD which was 13.06 ± 5.64. When comparing mean SD among the categories of different variables, female sex (P=0.023) and comorbidities such as diabetes mellitus (DM) (P=0.013), chronic kidney disease (CKD) (P=0.007), and risk of developing obstructive sleep apnoea (OSA) (P=0.04) showed significant variation. Medication adherence to prescribed hypertensive medication was a major issue even though significant association was not found with high VVV (P=0.536). The SD of SBP was then classified into high and low VVV groups by means of a cutoff point at the 50th percentile. Bivariate analysis by using Chi-squared test revealed comorbidities such as DM, CKD, and physical activity (P=0.044) were significantly associated with high VVV. Further multivariate regression analysis revealed that comorbidities such as DM and CKD have 1.561 times and 5.999 times more risk to show high variability, respectively. In conclusion, we recommend simple practical measures to achieve sustainable BP control among hypertensive patients with DM and CKD to minimize the VVV and improve their cardiovascular outcome.

There has been increasing interest in accelerated programs for knee arthroplasty. We examined the efficacy and safety of an outpatient surgery (OS) pathway in patients undergoing unicompartmental knee arthroplasty (UKA). This case-controlled study evaluates patients operated for UKA in an OS pathway (n=20) compared to rapid recovery (RR), the current standard (n=20). We investigated whether patients could be discharged on the day of surgery, resulting in comparable or better outcome by means of adverse events (AEs) in terms of pain (numerical rating scale, NRS), incidences of postoperative nausea and vomiting (PONV) and opiate use (<48h postoperatively), complication and readmission rates (<3months postoperatively). Patient-reported outcome measures (PROMS) were obtained preoperatively and 3months postoperatively. Postoperative pain (NRS>5) was the most common reason for prolonged hospital stay in the OS pathway. Eighty-five per cent of the patients were discharged on the day of surgery, whereas 95% of the patients were discharged on postoperative day 3 in the RR pathway. Overall, median pain scores in both pathways did not exceed a NRS score of 5, without significant differences (RR vs. OS) in the number of patients with PONV (4 vs. 2) and opiate use (11 vs. 9) <48h postoperatively. At 3months postoperatively, no significant differences were found for AEs and PROMS between both pathways. The results of this study illustrates that an OS pathway for UKA is effective and safe with acceptable clinical outcome. Well-established and adequate standardized protocols, inclusion and exclusion criteria and a change in mindset for both the patient and the multidisciplinary team are the key factors for the implementation of an OS pathway. Case-control study, Level III.

IntroductionPatient-specific medication reviews might be useful for correcting prescribing omissions. The Dutch Healthcare Inspectorate (IGZ) demands that a medication review is performed by a pharmacist in cooperation with a physician for all residents of nursing homes (twice a year) and residential homes (once a year).ObjectiveThis study aims to show the clinical practice of medication reviews for older people in residential and nursing homes by pharmacists. We asked the following research questions. (i) To what extent are medication reviews performed as required by the IGZ? (ii) How much time is needed to perform the required medication reviews? (iii) In the opinion of the pharmacist, is the medication review economically efficient and medically relevant?MethodsA web-based survey was sent to 87 hospital pharmacists and 270 community pharmacists.ResultsIn a ‘best case vs worst case’ scenario, 76% vs 42% of the IGZ-required medication reviews are performed. Considering a mean of 730.7 medication reviews required per year and the mean time spent on one medication review (29.3 min), a pharmacist would need to spend 2.5 months a year to meet the IGZ requirements. Almost every pharmacist considers medication reviews to be medically relevant, but only 47% consider them to be economically efficient.ConclusionsThis survey shows that medication reviews performed in institutional care settings do not meet the IGZ requirements, which is not surprising considering the time needed for one medication review. Automation of medication review processes should be initiated to increase efficiency.

Previous investigations suggested that the geometry of the proximal femur may be related to osteoarthritis of the tibiofemoral joint and various patellofemoral joint conditions. This study aims to investigate the correlation between proximal and distal femoral geometry. Such a correlation could aid our understanding of patient complications after total knee arthroplasty (TKA) and be of benefit for further development of kinematic approaches in TKA. CT scans of 60 subjects (30 males, 30 females) were used to identify anatomical landmarks to calculate anatomical parameters of the femur, including the femoral neck anteversion angle, neck-shaft angle (NSA), mediolateral offset (ML-offset), condylar twist angle (CTA), trochlear sulcus angle (TSA) and medial/lateral trochlear inclination angles (MTIA/LTIA). Correlation analyses were carried out to assess the relationship between these parameters, and the effect of gender was investigated. The CTA, TSA and LTIA showed no correlation with any proximal parameter. The MTIA was correlated with all three proximal parameters, mostly with the NSA and ML-offset. Per 5° increase in NSA, the MTIA was 2.1° lower (p<0.01), and for every 5mm increase in ML-offset, there was a 2.6° increase in MTIA (p<0.01). These results were strongest and statistically significant in females and not in males and were independent of length and weight. Proximal femoral geometry is distinctively linked with trochlear morphology. In order to improve knowledge on the physiological kinematics of the knee joint and to improve the concept of kinematic knee replacement, the proximal femur seems to be a factor of clinical importance. III.