Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction?

BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flap is a common method of breast reconstruction. Enhanced recovery after surgery (ERAS) postoperative protocols have been used to optimize patient outcomes and facilitate shorter hospital stays. The effect of patient expectations on length of stay (LOS) after DIEP has not been evaluated. The purpose of this study was to investigate whether patient expectations affect LOS. METHODS: A retrospective chart review was performed for patients undergoing DIEP flaps for breast reconstruction from 2017 to 2020. All patients were managed with the same ERAS protocol. Patients were divided in Group I (early expectations) and Group II (standard expectations). Group I patients had expectations set for discharge postoperative day (POD) 2 for unilateral DIEP and POD 3 for bilateral DIEP. Group II patients were given expectations for POD 3 to 4 for unilateral DIEP and POD 4 to 5 for bilateral. The primary outcome variable was LOS. RESULTS: The study included 215 DIEP flaps (45 unilateral and 85 bilateral). The average age was 49.8 years old, and the average body mass index (BMI) was 31.4. Group I (early expectations) included 56 patients (24 unilateral DIEPs, 32 bilateral). Group II (standard expectations) had 74 patients (21 unilateral, 53 bilateral). LOS for unilateral DIEP was 2.9 days for Group I compared with 3.7 days for Group II (p = 0.004). Group I bilateral DIEP patients had LOS of 3.5 days compared with 3.9 days for Group II (p = 0.02). Immediate timing of DIEP (Group I 42.9 vs. Group II 52.7%) and BMI (Group I 32.1 vs. Group II 30.8) were similar (p = 0.25). CONCLUSION: Our study found significantly shorter hospital stay after DIEP flap for patients who expected an earlier discharge date despite similar patient characteristics and uniform ERAS protocol. Patient expectations should be considered during patient counseling and as a confounding variable when analyzing ERAS protocols.

Clinical Factors Associated With Accurate Presumptive Treatment of Neisseria gonorrhoeae Infections in Men Who Have Sex with Men and Transgender Women.

BACKGROUND: Neisseria gonorrhoeae (N. gonorrhoeae) infections have increased among men who have sex with men and are high among transgender women. Presumptive treatment guidelines may lead to inaccurate treatments and possible antibiotic resistance. Using patient data from AIDS Healthcare Foundation sexually transmitted infection (STI) testing clinics in California and Florida, we identified clinical factors associated with accurate presumptive N. gonorrhoeae treatment. METHODS: Multivariable logistic regression analyses were conducted using patient visit data from 2013 to 2017. A sample of 42 050 patient encounters were analyzed. The primary outcome variable included accurate versus inaccurate presumptive treatment. Risk ratios were generated for particular symptoms, high-risk sexual behavior, and history of N. gonorrhoeae. RESULTS: Twelve percent (5051/42 050) of patients received presumptive N. gonorrhoeae treatment, and 46% (2329/5051) of presumptively treated patients tested positive for N. gonorrhoeae infection. Patients presenting with discharge or patients presenting with dysuria were more likely to receive accurate presumptive treatment. CONCLUSIONS: Providers should continue to follow the Centers for Disease Control and Prevention guidelines and consider presumptive N. gonorrhoeae treatment based on specific symptoms. As the STI epidemic continues to rise in the United States, along with increased antibiotic resistance, it is imperative to accurately test, diagnose, and treat populations at risk for N. gonorrhoeae and other STIs.

Comparative Evaluation of 2 Nucleic Acid Amplification Tests for the Detection of Chlamydia trachomatis and Neisseria gonorrhoeae at Extragenital Sites.

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are frequently asymptomatic, requiring highly accurate diagnostic tests and proper management to prevent further transmission. We compared two nucleic acid tests, Xpert® CT/NG (Cepheid, Sunnyvale, CA) point-of-care platform and at an offsite clinical laboratory with Aptima Combo 2® (Hologic, Inc., San Diego, CA) assay, for the detection of extragenital infection in patients at an STI clinic in Hollywood, CA.We calculated concordance between the two assays and used the exact binomial method to calculate 95% confidence intervals (CIs) for each specimen type and pathogen.The concordance between the two assays was 97.7% (95% CI: 95.7%,99.0%) for 393 paired CT rectal results, 98.2% (95% CI: 96.4%,99.3%) for 391 paired NG rectal results and 98.4% (95% CI: 96.8%,99.4%) for 448 paired NG pharyngeal results.The performance of Xpert® CT/NG assay in point-of-care testing in extragenital specimens was highly similar to the laboratory-based platform.

The readability of psychosocial wellness patient resources: improving surgical outcomes.

BACKGROUND: Patient education is increasingly accessed with online resources and is essential for patient satisfaction and clinical outcomes. The average American adult reads at a seventh grade level, and the National Institute of Health (NIH) and the American Medical Association (AMA) recommend that information be written at a sixth-grade reading level. Health literacy plays an important role in the disease course and outcomes of all patients, including those with depression and likely other psychiatric disorders, although this is an area in need of further study. The purpose of this study was to collect and analyze written, online mental health resources on the Veterans Health Administration (VA) website, and other websites, using readability assessment instruments. METHODS: An internet search was performed to identify written patient education information regarding mental health from the VA (the VA Mental Health Website) and top-rated psychiatric hospitals. Seven mental health topics were included in the analysis: generalized anxiety disorder, bipolar, major depressive disorder, posttraumatic stress disorder, schizophrenia, substance abuse, and suicide. Readability analyses were performed using the Gunning Fog Index, the Flesch-Kincaid Grade Level, the Coleman-Liau Index, the SMOG Readability Formula, and the Automated Readability Index. These scores were then combined into a Readability Consensus score. A two-tailed t-test was used to compare the mean values, and statistical significance was set at P < 0.05. RESULTS: Twelve of the best hospitals for psychiatry 2016-2017 were identified. Nine had educational material. Six of the nine cited the same resource, The StayWell Company, LLC (StayWell Company, LLC; Yardley, PA), for at least one of the mental health topics analyzed. The VA mental health website (http://www.mentalhealth.va.gov) had a significantly higher readability consensus than six of the top psychiatric hospitals (P < 0.05, P = 0.0067, P = 0.019, P = 0.041, P = 0.0093, P = 0.0054, and P = 0.0093). The overall average readability consensus for mental health information on all websites analyzed was 9.52. CONCLUSIONS: Online resources for mental health disorders are more complex than recommended by the NIH and AMA. Efforts to improve readability of mental health and psychosocial wellness resources could benefit patient understanding and outcomes, especially in patients with lower literacy. Surgical outcomes are correlated with patient mental health and psychosocial wellness and thus can be improved with more appropriate levels of readability of psychosocial wellness resources.

Australia's first cardiac emergency department: Patient profile, activity and performance in the initial 6 months.

OBJECTIVE: To profile the initial 6-month experience at the Victorian Heart Hospital (VHH) cardiac emergency (CE). The primary objective was to describe VHH CE patient characteristics, including presenting complaint, final diagnosis and disposition. Secondary objectives were to report on patient numbers, patient source and quality indicator performance including ambulance off-load by 40 min, waiting time and length of stay (LOS). METHODS: A retrospective review included all patients who presented to the VHH CE from 9 March 2023 to 8 September 2023. Patient reports containing the relevant clinical information were generated from the CE electronic medical record system. Diagnoses of MI were checked for accuracy by full record review. RESULTS: There were 3303 CE presentations in the first 6 months of operation, of which 6% were transferred from other sites. Median age was 65 years (interquartile range [IQR]: 53-77), 56% were males; the most common presenting complaints were presumed cardiac chest pain (67%) and arrhythmia (17%). The admission, discharge and transfer rates were 38%, 54% and 8%, respectively. In total, 15% were diagnosed with MI. The most common diagnoses for discharged and admitted patients were non-specific chest pain (57%) and ST-elevation MI (22%), respectively. Ambulance off-load by 40 min was met for 96%. Median waiting time was 6 min (IQR: 3-10). Median CE LOS for discharged and admitted patients was 3.2 h (IQR: 2.5-4.0) and 3.7 h (IQR: 1.8-6.0), with 75% and 56% being <4 h, respectively. CONCLUSIONS: The population predominantly had cardiovascular disease as expected. Some performance indicators, including ED LOS, were identified as requiring intervention.

Digital directly observed therapy to monitor adherence to medications: a scoping review.

Background: Technology-based directly observed therapy (DOT) is more cost-effective and efficient compared with in-person monitoring visits for medication adherence. While some evidence shows these technologies are feasible and acceptable, there is limited evidence collating information across medical conditions or in the context of HIV prevention, care, and treatment.Objectives: We conducted a scoping review to understand the current evidence on the acceptability, feasibility, and efficacy of digital DOT to improve medication adherence and, specifically, to determine if digital DOT had been used to improve adherence for HIV prevention, care, and treatmentMethods: We searched the electronic databases PubMed, Embase, and the Web of Science in January 2021 for any published studies with terms related to digital technologies and DOT. We included peer-reviewed studies in any population, from any country, for any outcome, and excluded conference abstracts. We included three types of digital DOT interventions: synchronous DOT, asynchronous DOT, and automated DOT. We provide an assessment of the current evidence, gaps in literature, and opportunities for intervention development regarding the use digital DOT to improve antiretroviral therapy (ART) adherence, specifically in the field of HIV.Results: We identified 28 studies that examined digital DOT. All studies found digital DOT to be acceptable and feasible. Patients using digital DOT had higher rates of treatment completion, observed doses, and adherence compared with in-person DOT, although data were limited on adherence. Only one study examined HIV prevention, and none examined ART adherence for HIV treatment.Conclusions: Digital DOT is acceptable and feasible but has not been used to remotely monitor and support ART adherence for people living with HIV.

A pilot clinical study to Evaluate Liraglutide-mediated Anti-platelet activity in patients with type-2 Diabetes (ELAID study).

BACKGROUND: Liraglutide is an effective treatment for the management of type 2 diabetes mellitus (T2DM). In addition to glycemic control and potential cardioprotective effects, recent studies suggest a possible role for liraglutide in the inhibition of platelet reactivity, further attenuating atherothrombotic risk in patients with T2DM. We evaluated the in-vivo antiplatelet effect of liraglutide in T2DM patients without macrovascular disease or concurrent anti-platelet therapy. METHODS: A double-blind, placebo-controlled pilot study of 16 T2DM patients, 51-69 y/o, (mean age 60.4 y/o, 63.0% male) randomised to receive liraglutide (1.8 mg/day) or placebo (saline) for 6 months was conducted. Platelet aggregation studies at baseline and after initiation of the study intervention: days 1, 7, and 14 and months 1, 3 and 6 were performed. RESULTS: Liraglutide (n = 7) and placebo (n = 9) treated patients demonstrated normal platelet aggregation responses although transient and significant attenuation in maximum slope of platelet aggregation in response to collagen (p ≤ 0.05), arachidonic acid (p ≤ 0.05) and ADP (p ≤ 0.02) was observed in liraglutide compared to placebo treated patients in the first week. CONCLUSIONS: In this pilot study of patients with T2DM liraglutide treatment was associated with a significant, early and transient decrease in maximum slope of platelet aggregation. The clinical significance of this effect is currently unknown and may warrant further investigation. CLINICAL TRIAL REGISTRATION NUMBER: UTN 1111-1181-9567.

Tourniquet Use in Wide-Awake Carpal Tunnel Release.

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

Comparing mail-in self-collected specimens sent via United States Postal Service versus clinic-collected specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in extra-genital sites.

OBJECTIVES: To evaluate the concordance between clinic-collected extra-genital specimens and self-collected mailed-in extra-genital specimens among participants seeking sexually transmitted infection testing at a free clinic in Hollywood, CA. METHODS: A convenience sample of 210 men who have sex with men were enrolled between February 29, 2016 and December 21, 2016 and received mail-in testing kits for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). All testing was performed using the GeneXpert® CT/NG (Cepheid, Sunnyvale, CA). RESULTS: From the 210 mail-in kits distributed, 149 mail-in kits (71.0%) were returned to the laboratory, resulting in 145 pairs (clinic-collected and mail-in) of rectal test results and 148 pairs of pharyngeal test results for both CT and NG detection. The concordance was 95.0% for all CT rectal tests, 99.3% for all CT pharyngeal tests, 95.7% for all NG rectal tests, and 97.2% for all NG pharyngeal tests. CONCLUSION: Roughly two-thirds of mail-in test kits were returned and concordance was generally high, however more than one-third of positive results were missed in mail-in samples. The prevalence of potential false-negative results among mail-in samples warrants caution when implementing mail-in STI testing strategies.

Topical ibopamine in the treatment of chronic ocular hypotony attributable to vitreoretinal surgery, uveitis, or penetrating trauma.

PURPOSE: To study whether topical ibopamine effectively increases the intraocular pressure in patients with ocular hypotony after vitreoretinal surgery, uveitis, or penetrating trauma. DESIGN: A prospective randomized, double-blind, placebo controlled, crossover study. METHODS: In ten patients with ocular hypotony, an ibopamine 2% solution or placebo eyedrop was administered at 8 am and frequent applanation tonometry was performed during 10 hours on 2 days, 2 weeks apart. RESULTS: The mean IOP integral after administration of ibopamine was 2.4 mm Hg higher (95% CI for median difference in AUC over 480 minutes [P = .010]) compared with placebo. CONCLUSIONS: The results of the study show that an ibopamine 2% eyedrop twice a day may increase the IOP for a period of over 8 hours in patients with hypotony.