Seton Healthcare Family

AHORA (Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas) is a Spanish language tool to identify stroke symptoms. A survey of 300 primarily Spanish-speaking, non-medical professionals was conducted to assess the acceptance of the tool, specifically about ease of understanding and ability to implement it. The overwhelming majority of respondents reacted very positively to the tool, finding it quite easy to learn, teach, and understand. Respondent feedback, pitfalls, and questions for further research are presented.

Testosterone therapy (TT) is a type of gender-affirming hormone therapy (GAHT) in lesbian, gay, bisexual, transgender, and genderqueer (LGBTQ) populations for gender dysphoria (GD), body uneasiness, and sexual dysfunction. The physical and physiological effects of TT vary widely depending on the dosing regimen and duration of treatment. An individualized approach prioritizing patient-specific desired effects in the context of pre-existing characteristics and health history is strongly recommended. Although TT is an effective treatment for many patients, there has been an increase in the illegitimate acquisition of TT in recent years. Non-judicious prescribing and lack of physician surveillance increases the risk of unintended side effects and potential serious health consequences.

Daley, Mitchell1; Cardenas, Tatiana2; Hill, Charles3; Brown, Carlos4 Author Information

Wet wraps can be an effective means of improving atopic dermatitis (AD). Little research has been done regarding the comparative efficacy of topical steroid vehicles and patient preference. This study aimed to compare the efficacy of 0.1% triamcinolone acetonide ointment vs cream used with wet wraps in pediatric patients with AD and to explore patient preference/opinion. We performed a small, randomized, investigator-blind prospective study of 39 pediatric patients experiencing symmetric, bilateral AD flares. Patients were instructed to apply a topical steroid cream to one extremity and apply the same topical steroid in an ointment vehicle to the other extremity using the wet-wrap technique once or twice daily for 3 to 5 consecutive days. Patients were evaluated at a follow-up visit. Comparison of the change in Investigator's Global Assessment scores disclosed no significant difference between efficacy ratings of cream (mean difference=0.72) and ointment (mean difference=0.59) when used with wet wraps (P=0.22). Although patients found the ointment more difficult to apply, they were more likely to prefer ointments for future prescriptions (P<0.01). Patient preference of corticosteroid vehicle is what should ultimately drive treatment. In this small study, we found no difference in efficacy between triamcinolone acetonide wet wraps with cream vs ointment. Dermatologists should select the vehicle of the patient's choice as it may increase satisfaction with treatment.

Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs. We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05. After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05). The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes. Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery.

Objective: To review evidence behind anticoagulants in cancer-associated venous thromboembolism (VTE) with a focus on low-molecular-weight heparins (LMWH) and the role of direct oral anticoagulants (DOACs). Data Sources: PubMed was searched using terms “venous thromboembolism,” “cancer,” and “anticoagulation.” This search was restricted to clinical trials, meta-analyses, and subgroup analyses. Additional references were identified from reviewing literature citations. Study Selection: English-language prospective and retrospective studies assessing the efficacy and safety of LMWH and DOACs in patients with cancer. Data Analysis: Several trials were analyzed that compared anticoagulation therapies for prevention of recurrent VTE in patients with cancer. Many studies comparing LMWH and vitamin K antagonists (VKAs) found nonsignificant differences between therapies. A single study demonstrated that LMWHs are superior to VKAs. This evidence supporting LMWH for long-term VTE treatment in patients with cancer is based on comparison to VKA, but results are limited by methodological issues, and the benefit of LMWH may be driven by poor control. Subanalyses of DOAC trials suggest these are equally or more effective as VKA in cancer, but this conclusion is underpowered. Conclusion: DOACs have the potential to bypass many challenges with traditional therapy. After analyzing the evidence available, we conclude that after careful consideration of risks and benefits, use of DOACs for VTE treatment are a reasonable option in patients with cancer.

Non-pharmacological interventions can positively impact the aging process. These interventions include community involvement through age-friendly cities, disaster preparedness, as well as addressing the impact aging can have on the caregiver. Caregiving can expose family members to a unique set of stressors that are often not anticipated or addressed appropriately. This chapter discusses these interventions as well as the effects caregiving can have on family members and the benefit of providing resources for family members to better cope and provide care.

Children have decreased levels of antithrombin III (AT III) compared to adults. These levels may be further decreased during acute illness. Administration of exogenous AT III can increase anticoagulant efficacy. The objective of this study was to evaluate AT III doses rounded to available vial sizes compared to partial vial doses in critically ill pediatric patients, including patients receiving extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). This retrospective review evaluated pediatric patients 0-18 years of age admitted to a 24-bed medical/surgical pediatric intensive care unit between June 1, 2012, and December 31, 2014, who received plasma-derived AT III. Patients received unfractionated heparin, low-molecular-weight heparin, or no anticoagulation. This review included patients who received ECMO and CRRT. Eighty doses of AT III were administered to 24 patients (38 full vial size doses and 42 partial vial size doses). The AT III level following dose administration was ≥80% for 26 full vial doses (70%) and 16 partial vial doses (41%; p = 0.010). For patients who received multiple doses of AT III, the median time between doses was 45 hours following full vial doses, and 23 hours following partial vial doses (p = 0.011). Seven patients (29%) had documentation of new or increased bleeding. The median waste prevented from rounding doses to full vial sizes was 363 units. After receiving AT III doses rounded to full vial sizes, patients were more likely to have a therapeutic AT III level and a longer interval between administrations. Rounding AT III doses to full vial sizes reduces waste and can result in cost savings.

Background: Wearable technologies offer potential telestroke applications that are more mobile and potentially less expensive than traditional telemedicine carts. In an earlier, pilot phase of this research program the best performing software and hardware combination for transmission of encrypted video and audio streaming was selected for further testing. Method: We tested Vuzix M100 smart glasses device and Pristine EyeSight HIPAA-compliant video streaming services. The device wearers, emergency physicians, performed the NIHSS, and a remote vascular neurologist or neurology resident viewed the exam. Providers recorded their score and evaluated the functionality of the device with a standardized list of questions. Results: The device was assessed in 52 subjects. The providers wearing the device reported the device useful (Agree or Strongly Agree) in making an assessment in 79% of cases and that they could assess the patient well 90% of the time. However, the wearers also reported both distraction from and interference with patient interaction due to the device in 98% of cases evaluated. The viewers also reported finding the device useful in making an assessment of stroke symptoms in 79% of cases (a different set of 79% than the wearers), but in only 65% of cases did they Agree or Strongly Agree that they could assess the patient well. Viewers reported an inadequate field of view for visual field testing in 63% of cases. The inter-rater agreement between the wearer and viewer on the total NIHSS showed moderate agreement (κ = 0.45). Although the technology was easy to use in 92% of the assessments, technical problems (mainly connectivity lags) were reported by the wearer 46% of the time and by the viewer 31% of the time. The technology was rated inadequate for assessing patients in 1 case by the wearers and 3 cases by the viewers. Conclusion: Wearable smart glass technology is feasible in assessing stroke patients and shows promise as a telestroke solution, however interference with physician-patient interaction, limited field of view for visual field testing and connectivity glitches are perceived limitations.