The impact of patient-reported outcomes on loss to follow-up care after bariatric surgery.

BACKGROUND: High rates of attrition to post-bariatric surgical care continue to be common, despite recommendations for lifelong follow-up. There is little available work focusing on the etiology of attrition to post-bariatric surgical follow-up. Patient-reported outcomes (PROs) are metrics of patients' perceptions of their own health and have been used for their predictive value in other specialties. The relationships between PROs and loss to follow-up have not been explored. METHODS: PRO data from patients who met the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) definition of loss to follow-up at 1-year postoperatively were reviewed and compared to patients who were compliant with 1-year follow-up. Patient-reported outcomes measurement information system (PROMIS) measures are routinely collected pre- and postoperatively at our institution using a series of validated computer-adaptive tests that assess depression, satisfaction with social roles, pain interference, and physical function. A series of univariate logistic regressions tested whether baseline PROs or change in PROs from baseline to 6-month postoperatively predicted loss to follow-up at 1 year. RESULTS: Neither baseline PROs nor change in depression, satisfaction with social roles, pain interference, or physical function were significant predictors of loss to follow-up. Similarly, patient state of residence, Charlson Comorbidity Index, BMI, and percent excess weight loss were not significant predictors of follow-up attrition. CONCLUSION: The PROs in this study were not significant predictors of loss to follow-up at 1-year postoperatively. The rate of bariatric procedures continues to increase nationally, so does the potential for late post-surgical complications. Given the potential impact of loss to follow-up on adverse late post-surgical outcomes, there is a need to facilitate long-term post-surgical follow-up and more investigation is needed to identify and intervene on underlying causes of bariatric patient follow-up attrition.

Evaluation of a novel mobile phone application for blood pressure monitoring: a proof of concept study.

To provide information about the clinical relevance of blood pressure (BP) measurement differences between a new smartphone application (OptiBP™) and the reference method (automated oscillometric technique) using a noninvasive brachial cuff in patients admitted to the emergency department. We simultaneously recorded three BP measurements using both the reference method and the novel OptiBP™ (test method), except when the inter-arm difference was > 10 mmHg BP. Each OptiBP™ measurement required 1-min and the subsequent reference method values were compared to the values obtained with OptiBP™ using a Bland-Altman analysis and error grid analysis. Among the 110 patients recruited, OptiBP™ BP values could be collected on 61 patients (55%) and were included in the statistical analysis. The mean of differences (95% limits of agreement) between the reference method and the test method were - 0.1(- 22.5 to 22.4 mmHg) for systolic arterial pressure (SAP), - 0.1(- 12.9 to 12.7 mmHg) for diastolic arterial pressure (DAP) and - 0.3(- 18.1 to 17.4 mmHg) for mean arterial pressure (MAP). The proportions of measurements in risk zones A-E were 86.9%, 13.1%, 0%, 0%, and 0% for MAP and 89.3%, 10.7%, 0%, 0%, and 0% for SAP. In this pilot study conducted in stable and awake patients admitted to the emergency department, the absolute agreement between the OptiBP™ and the reference method was moderate. However, when BP measurements were made immediately after an initial calibration, error grid analysis showed that 100% of measurement differences between the OptiBP™ and reference method were categorized as no- or low-risk treatment decisions for all patients.Trial Registration: ClinicalTrials.gov Identifier: NCT04121624.

Monitoring of pulse pressure variation using a new smartphone application (Capstesia) versus stroke volume variation using an uncalibrated pulse wave analysis monitor: a clinical decision making study during major abdominal surgery.

Pulse pressure variation (PPV) and stroke volume variation (SVV) can be used to assess fluid status in the operating room but usually require dedicated advanced hemodynamic monitors. Recently, a smartphone application (Capstesia™), which automatically calculates PPV from a picture of the invasive arterial pressure waveform from any monitor screen (PPVCAP), has been developed. The purpose of this study was to compare PPVCAP with SVV from an uncalibrated pulse wave analysis monitor (SVVPC). In 40 patients undergoing major abdominal surgery, we compared PPVCAP with SVVPC at post-induction, pre-incision, post-incision, end of surgery, and during every hypotensive episode (mean arterial pressure < 65 mmHg). We classified PPVCAP and SVVPC into three categories reflecting the thresholds used for the decision to administer fluids: no fluid administration (PPV and SVV < 9%), gray zone (PPV and SVV 9-13%), and fluid administration (PPV and SVV > 13%). The agreement between SVVPC and PPVCAP for these three categories was measured by the number of concordant paired measurements divided by the total number of paired measurements and Cohen's kappa coefficient. In the 549 pairs of PPV-SVV data obtained, the overall agreement of PPVCAP with SVVPC was 79%, and the kappa coefficient was moderate (0.55). The highest agreement and kappa coefficient value were observed after the induction of anesthesia before surgical incision. PPVCAP and SVVPC would have resulted in completely opposite clinical decisions regarding fluid administration in 1% of the cases. In this clinical decision making study in patients undergoing major abdominal surgery, we observed a moderate agreement between PPVCAP and SVVPC with regard to categories used to guide fluid administration. Trial Registration: Clinical Trials.gov (NCT03137901).

ß-Lactam Dosage Regimens in Septic Patients with Augmented Renal Clearance.

Augmented renal clearance is commonly observed in septic patients and may result in insufficient ß-lactam serum concentrations. The aims of this study were to evaluate potential correlations between drug concentrations or total body clearance of ß-lactam antibiotics and measured creatinine clearance and to quantify the need for drug dosage adjustments in septic patients with different levels of augmented renal clearance. We reviewed 256 antibiotic measurements (512 drug concentrations) from a cohort of 215 critically ill patients who had a measured creatinine clearance of ≥120 ml/min and who received therapeutic drug monitoring of meropenem, cefepime, ceftazidime, or piperacillin from October 2009 until December 2014 at Erasme Hospital. Population pharmacokinetic (PK) analysis of the data was performed using the Pmetrics software package for R. Fifty-five percent of drug concentrations showed insufficient ß-lactam serum concentrations to treat infections due to Pseudomonas aeruginosa There were significant, yet weak, correlations between measured creatinine clearance and trough concentrations of meropenem (r = -0.21, P = 0.01), trough concentrations of piperacillin (r = -0.28, P = 0.0071), concentrations at 50% of the dosage interval (r = -0.41, P < 0.0001), and total body clearance of piperacillin (r = 0.39, P = 0.0002). Measured creatinine clearance adequately explained changes in drug concentrations in population pharmacokinetic models for cefepime, ceftazidime, and meropenem but not for piperacillin. Therefore, specific PK modeling can predict certain ß-lactam concentrations based on renal function but not on absolute values of measured creatinine clearance, easily available for clinicians. Currently, routine therapeutic drug monitoring is required to adjust daily regimens in critically ill patients receiving standard dosing regimens.

Community-guided measurement-based care for autistic youth and adults receiving psychotherapy: A conceptual overview and pilot implementation study of MBC-AUT.

LAY ABSTRACT: Autistic youth and adults are more likely to experience psychiatric symptoms (e.g. depression, anxiety) and to use psychiatric services than non-autistic people, yet research on evidence-based approaches to enhance psychiatric care for autistic people is limited. Measurement-based care is an evidence-based approach to psychotherapy that improves outcomes for clients, clinicians, and organizations by routinely administering and evaluating measures to clients. Despite this, research on measurement-based care systems for autistic clients is sparse. To address this gap, we developed an autism-adapted measurement-based care (MBC-AUT) system for and with autistic people and pilot tested the system in an outpatient psychiatry clinic to investigate the preliminary feasibility, acceptability, benefits, and barriers to this system for clients and clinicians. Findings suggested that the MBC-AUT system was a feasible and acceptable system for the first 18 autistic youth, their caregivers, and autistic adults to use the system. In semi-structured interviews, clients and clinicians discussed the benefits of the MBC-AUT system to various therapeutic processes, as well as several important barriers to the use of the system. We offer potential solutions to address these barriers and to reduce client and clinician burden, and propose future directions for this line of research to increase access to more autistic people. As autistic clients continue to seek psychological services amid social landscapes of increasing complexity (e.g. COVID-19 pandemic), efforts to enhance the delivery of psychotherapy for this population are critical.

Community-guided, autism-adapted group cognitive behavioral therapy for depression in autistic youth (CBT-DAY): Preliminary feasibility, acceptability, and efficacy.

LAY ABSTRACT: Depression in youth is a significant public health problem worldwide, particularly for autistic youth who are over twice as likely to experience depression than their non-autistic peers. Although pathways to depression are complex, emotional reactivity and negative self-esteem are two risk factors for depression in autistic and non-autistic youth. Although autistic youth are more likely to experience depression than their non-autistic peers, psychotherapy options for autistic youth are very limited; community guidance in the development and testing of psychotherapy programs is a promising approach in autism. Therefore, in this study, we designed an autism-adapted CBT-DAY, in collaboration with autistic community members. Specifically, CBT-DAY combined neurodiversity-affirming and cognitive behavioral approaches to target emotional reactivity and self-esteem in youth to improve depressive symptom severity in a group setting across 12 weeks. We examined the preliminary feasibility, acceptability, and efficacy of CBT-DAY in a pilot non-randomized trial. In addition, we implemented a rigorous protocol for assessing, monitoring, and addressing potential harms in this intervention. Results from 24 autistic youth (11-17 years old) suggest that CBT-DAY may be feasible to use in an outpatient clinical setting and generally acceptable to youth and their caregivers. Participation in CBT-DAY may be associated with significant improvements in youth emotional reactivity and self-esteem, as well as depressive symptom severity per self-report only. Exploratory analyses showed that participation in CBT-DAY may also be associated with significant improvements in internalizing symptoms. Findings demonstrate the potential promise of neurodiversity-affirming and cognitive behavioral approaches to treating depressive symptoms in some autistic youth.

Quality improvement education in surgical specialty training: A comparison of Vascular Surgery resident and Urology Resident experiences and attitudes.

BACKGROUND: Academic institutions have increasingly focused on educating physicians and surgeons in concepts of value-based care, including quality improvement (QI). The extent to which QI curricular competencies are addressed in specialty surgical residency training is unclear. METHODS: A survey instrument was developed by content experts and sent to Vascular Surgery and Urology residents electronically. Descriptive statistics and bivariate associations were calculated using StataMP 13.1. RESULTS: Vascular Surgery and Urology residents reported exposure to similar types of QI curriculum. Fewer than half of residents reported achieving targets for graduation (Vascular 31%, Urology 42%) related to QI, and few residents in either group felt very well-prepared to lead a QI initiative (Vascular 13%, Urology 8%). CONCLUSION: QI education in surgical specialty training amongst Vascular Surgery and Urology residencies is similar and insufficient. Surgical specialties may benefit from collaborative efforts to improve the quality of QI education.

High value care education in general surgery residency programs: A multi-institutional needs assessment.

BACKGROUND: The ACGME mandates that residency programs provide training related to high value care (HVC). The purpose of this study was to explore HVC education in general surgery residency programs. METHODS: An electronic survey was distributed to general surgery residents in geographically diverse programs. RESULTS: The response rate was 29% (181/619). Residents reported various HVC components in their curricula. Less than half felt HVC is very important for their future practice (44%) and only 15% felt confident they could lead a QI initiative in practice. Only 20% of residents reported participating in a root cause analysis and less than one-third of residents (30%) were frequently exposed to cost considerations. CONCLUSION: Few residents feel prepared to lead quality improvement initiatives, have participated in patient safety processes, or are aware of patients' costs of care. This underscores the need for improved scope and quality of HVC education and establishment of formal curricula.

Exercise improves high-fat diet- and ovariectomy-induced insulin resistance in rats with altered hepatic fat regulation.

A high-fat diet (HFD) and loss of endogenous estrogens increases the risk for type 2 diabetes (T2D) and insulin resistance. Although exercise is known to prevent and manage insulin resistance, the cellular mechanisms remain largely unknown, especially in the context of a combined HFD and endogenous estrogen loss via ovariectomy (OVX). This study uses female Wistar rats to assess the effect of diet, endogenous estrogens, an exercise on insulin resistance, serum hormones, hepatic AMPK, hepatic regulators of fat metabolism, and expression of signaling molecules of the brain reward pathway. The combination of the HFD/OVX increased the homeostatic model assessment of insulin resistance (HOMA-IR), the glucose-insulin (G-I) index, and the serum adiponectin and leptin values, and exercise decreased these factors. The combination of the HFD/OVX decreased hepatic pAMPK, and exercise restored hepatic pAMPK, an important regulator of fat and glucose metabolism. Furthermore, consumption of the HFD by rats with intact ovaries (and endogenous estrogens) did not result in these drastic changes compared to intact rats fed a standard diet, suggesting that the presence of estrogens provides whole body benefits. Additionally, the HFD decreased the hepatic protein expression of acetyl CoA carboxylase (ACC) and fatty acid synthase (FAS), two proteins involved in de novo lipid synthesis and increased the hepatic protein expression of lipoprotein lipase (LPL), a protein involved in fat storage. Finally, exercise increased mRNA expression of the dopamine D2 receptor and tyrosine hydroxylase in the dopaminergic neuron cell body region of the ventral tegmental area, which is a key component of the brain reward pathway. Overall, this study demonstrates that exercise prevents insulin resistance even when a HFD is combined with OVX, despite hepatic changes in ACC, FAS, and LPL.

Validation of a short questionnaire to assess the degree of complexity and structuredness of PBL problems.

BACKGROUND: In problem-based learning (PBL), problems represent the starting point of students' learning activities. Therefore, the quality of these problems should be high, in that they should be of an adequate level of complexity and structuredness. Previous research has proposed several guidelines for constructing problems, but some of them are rather vague and are not based on empirical evidence. The present study aimed to validate a short questionnaire that can be used to assess the degree of complexity and structuredness of PBL problems. METHOD: This paper outlines Jonassen's theory, on which the questionnaire is based, and its relationship and applicability to PBL problems. The questionnaire was validated by means of confirmatory factor analysis. RESULTS: The results showed that students were able to distinguish PBL problems that were too simple and those that were too well-structured, but found it difficult to distinguish problems that were too complex or too ill-structured. CONCLUSION: The questionnaire may be used to measure the levels of complexity and structuredness of a problem as perceived by students and can provide teachers with feedback about the quality of problems.