Assessment of caregiver burden prior to implantation of left ventricular assist device: A national survey.

BACKGROUND: Guidelines recommend incorporation of caregiver burden assessment and list significant caregiver burden as a relative contraindication when considering left-ventricular assist device (LVAD) implantation. METHODS: To assess national practices regarding caregiver burden assessment, in 2019 we administered a 47-item survey to LVAD clinicians using 4 convenience samples. RESULTS: Responses were obtained from 191 registered nurses, 109 advance practice providers, 71 physicians, 59 social workers, and 40 others representing 132 LVAD programs; 125 of 173 total United States programs were included in the final analysis. While most programs (83.2%) assessed caregiver burden, assessment was most frequently conducted informally during social work evaluation (83.2%), with only 8.8% incorporating validated measures of caregiver burden. Larger programs were more likely to use a validated assessment measure (OR 6.68 [1.33-33.52]). CONCLUSIONS: Future research should focus on how programs can standardize caregiver burden assessment and how the level of burden may impact patient and caregiver outcomes.

Obesity in Total Hip Arthroplasty: Demographic Disparities and Outcome Incongruities.

Introduction As morbid obesity disproportionately affects minorities and those of lower socioeconomic status, body mass index (BMI) restrictions on total hip arthroplasty (THA) may harm populations already facing disparities in care. Therefore, this study analyzed demographics and outcomes in morbidly obese primary THA patients. Methods The National Inpatient Sample was queried for THAs performed between 2009 and 2016. Of 2,676,086 patients identified, 453,250 had a BMI over 25 kg/m2. Patients were stratified by BMI into overweight (BMI=25.0-29.9 kg/m2), non-morbidly obese (BMI=30.0-40.0 kg/m2), and morbidly obese (BMI>40.1 kg/m2). Patient demographics (age, sex, race, insurance, income, and Charlson Comorbidity Index) and outcomes (length of stay [LOS], mortality, disposition, complications, charges, and costs) were assessed. Categorical and continuous data were analyzed with chi-square analyses and one-way analyses of variance, respectively. Results The number of overweight, non-morbidly obese, and morbidly obese patients increased by 299.0%, 109.3%, and 90.9%, respectively, between 2009 and 2016 (p<0.001). Morbidly obese patients were younger than non-morbidly obese and overweight patients (p<0.001) and had a higher proportion of females (p<0.001) and black patients (p<0.001). Morbidly obese patients most frequently used Medicaid and private insurance (p<0.001). Morbidly obese patients demonstrated a longer LOS, a higher mortality rate, a lower rate of home discharges and the most complications (all, p<0.001).  Conclusion These results reflect the worsening obesity epidemic and may be useful in counseling preoperative weight loss to morbidly obese patients to reduce mortality and complications.

Avoid reinventing the wheel: implementation of the Ottawa Clinic Assessment Tool (OCAT) in Internal Medicine.

BACKGROUND: Workplace based assessment (WBA) is crucial to competency-based education. The majority of healthcare is delivered in the ambulatory setting making the ability to run an entire clinic a crucial core competency for Internal Medicine (IM) trainees. Current WBA tools used in IM do not allow a thorough assessment of this skill. Further, most tools are not aligned with the way clinical assessors conceptualize performances. To address this, many tools aligned with entrustment decisions have recently been published. The Ottawa Clinic Assessment Tool (OCAT) is an entrustment-aligned tool that allows for such an assessment but was developed in the surgical setting and it is not known if it can perform well in an entirely different context. The aim of this study was to implement the OCAT in an IM program and collect psychometric data in this different setting. Using one tool across multiple contexts may reduce the need for tool development and ensure that tools used have proper psychometric data to support them. METHODS: Psychometrics characteristics were determined. Descriptive statistics and effect sizes were calculated. Scores were compared between levels of training (juniors (PGY1), seniors (PGY2s and PGY3s) & fellows (PGY4s and PGY5s)) using a one-way ANOVA. Safety for independent practice was analyzed with a dichotomous score. Variance components were generated and used to estimate the reliability of the OCAT. RESULTS: Three hundred ninety OCATs were completed over 52 weeks by 86 physicians assessing 44 residents. The range of ratings varied from 2 (I had to talk them through) to 5 (I did not need to be there) for most items. Mean scores differed significantly by training level (p < .001) with juniors having lower ratings (M = 3.80 (out of 5), SD = 0.49) than seniors (M = 4.22, SD = - 0.47) who had lower ratings than fellows (4.70, SD = 0.36). Trainees deemed safe to run the clinic independently had significantly higher mean scores than those deemed not safe (p < .001). The generalizability coefficient that corresponds to internal consistency is 0.92. CONCLUSIONS: This study's psychometric data demonstrates that we can reliably use the OCAT in IM. We support assessing existing tools within different contexts rather than continuous developing discipline-specific instruments.

Observer reliability of CT angiography in the assessment of acute ischaemic stroke: data from the Third International Stroke Trial.

INTRODUCTION: CT angiography (CTA) is often used for assessing patients with acute ischaemic stroke. Only limited observer reliability data exist. We tested inter- and intra-observer reliability for the assessment of CTA in acute ischaemic stroke. METHODS: We selected 15 cases from the Third International Stroke Trial (IST-3, ISRCTN25765518) with various degrees of arterial obstruction in different intracranial locations on CTA. To assess inter-observer reliability, seven members of the IST-3 expert image reading panel (>5 years experience reading CTA) and seven radiology trainees (<2 years experience) rated all 15 scans independently and blind to clinical data for: presence (versus absence) of any intracranial arterial abnormality (stenosis or occlusion), severity of arterial abnormality using relevant scales (IST-3 angiography score, Thrombolysis in Cerebral Infarction (TICI) score, Clot Burden Score), collateral supply and visibility of a perfusion defect on CTA source images (CTA-SI). Intra-observer reliability was assessed using independently repeated expert panel scan ratings. We assessed observer agreement with Krippendorff's-alpha (K-alpha). RESULTS: Among experienced observers, inter-observer agreement was substantial for the identification of any angiographic abnormality (K-alpha = 0.70) and with an angiography assessment scale (K-alpha = 0.60-0.66). There was less agreement for grades of collateral supply (K-alpha = 0.56) or for identification of a perfusion defect on CTA-SI (K-alpha = 0.32). Radiology trainees performed as well as expert readers when additional training was undertaken (neuroradiology specialist trainees). Intra-observer agreement among experts provided similar results (K-alpha = 0.33-0.72). CONCLUSION: For most imaging characteristics assessed, CTA has moderate to substantial observer agreement in acute ischaemic stroke. Experienced readers and those with specialist training perform best.

Comanagement of coral reef social-ecological systems.

In an effort to deliver better outcomes for people and the ecosystems they depend on, many governments and civil society groups are engaging natural resource users in collaborative management arrangements (frequently called comanagement). However, there are few empirical studies demonstrating the social and institutional conditions conducive to successful comanagement outcomes, especially in small-scale fisheries. Here, we evaluate 42 comanagement arrangements across five countries and show that: (i) comanagement is largely successful at meeting social and ecological goals; (ii) comanagement tends to benefit wealthier resource users; (iii) resource overexploitation is most strongly influenced by market access and users' dependence on resources; and (iv) institutional characteristics strongly influence livelihood and compliance outcomes, yet have little effect on ecological conditions.

Quantitative assessment of intestinal injury using a novel in vivo, near-infrared imaging technique.

Intestinal injury owing to inflammation, severe trauma, and burn is a leading cause of morbidity and mortality. Currently, animal models employed to study the intestinal response to injury and inflammation depend on outdated methods of analysis. Given that these classic intestinal assays are lethal to the experimental animal, there is no ability to study the gut response to injury in the same animal over time. We postulated that by developing an in vivo assay to image intestinal injury using fluorescent dye, it could complement other expensive, time-consuming, and semiquantitative classic means of detecting intestinal injury. We describe a novel in vivo, noninvasive method to image intestinal injury using a charge-coupled device (CCD) camera that allows for serial visual and quantitative analysis of intestinal injury. Our results correlate with traditional, time-consuming, semiquantitative assays of intestinal injury, now allowing the noninvasive, nonlethal assessment of injury over time.

The noninvasive, quantitative, in vivo assessment of adenoviral-mediated gene delivery in skin wound biomaterials.

Because there are few reports using gene delivery in clinically-approved synthetic matrices, we examined the feasibility of using a noninvasive imaging system to study the kinetics of luciferase gene expression when delivered in an adenoviral vector. Using a mouse model of full thickness injury, we quantified the kinetics of gene expression, determined the optimal dose of particle delivery, and established the temporal importance of drug delivery in obtaining optimal gene expression. Specifically, we found that the ideal time to deliver adenovirus to a graft is during the early phase of graft wound closure (days 0-3 post-operatively) for a peak of gene expression to occur 7 days after delivery. Under these conditions, there is a saturating dose of 6 x 10(8) adenoviral particles per graft. In light of these findings, we examined whether the efficacy of delivery could be increased by modulating the composition of the grafts. When a collagen gene-activated matrix (GAM) containing basic fibroblast growth factor (FGF2) was compared to matrix alone, a significant increase in gene expression is observed when identical amounts of vector are delivered (p<0.05). Taken together, these results show how a noninvasive and quantitative assessment of gene expression can be used to optimize gene delivery and that the composition of matrices can dramatically influence gene expression in the wound bed.