Capnographic Monitoring of Moderate Sedation During Low-Risk Screening Colonoscopy Does Not Improve Safety or Patient Satisfaction: A Prospective Cohort Study.

OBJECTIVES: Appropriate monitoring during sedation has been recognized as vital to patient safety in procedures outside of the operating room. Capnography can identify hypoventilation prior to hypoxemia; however, it is not clear whether the addition of capnography improves safety or is cost effective during routine colonoscopy, a high volume, low-risk procedure. Our aim was to evaluate the value of EtCO2 monitoring during colonoscopy with moderate sedation. METHODS: We conducted a prospective study of sedation safety and patient satisfaction before and after the introduction of EtCO2 monitoring during outpatient colonoscopy with midazolam and fentanyl using the validated PROcedural Sedation Assessment Survey (PROSAS). Complications of sedation and PROSAS scores were compared among colonoscopies with and without capnography. RESULTS: A total of 966 patients participated in our study, 465 in the pre-EtCO2 group and 501 in the EtCO2 group. On multivariate analysis, patients and nurses reported higher levels of procedural discomfort after adoption of capnography (1.71 vs. 1.00, P<0.001). No serious adverse events were seen, and minor sedation-related adverse events occurred with similar frequency in both groups (8.2% pre-EtCO2 vs. 11.2% EtCO2, P=0.115). The cost of implementing EtCO2 in our unit was $40,169.95 and added $11.68 per case. CONCLUSIONS: Colonoscopy with moderate sedation is a low-risk procedure, and the addition of EtCO2 did not improve safety or patient satisfaction but did increase cost. These data suggest that routine capnography in this setting may not be cost effective and that EtCO2 might be reserved for patients at higher risk of adverse events.

Reducing Pediatric Readmissions: Using a Discharge Bundle Combined With Teach-back Methodology.

The authors describe a quality improvement initiative aimed at decreasing unplanned 7- and 30-day readmission rates in an urban, pediatric, tertiary care hospital. A stepwise approach was used to disseminate the pilot initiative across 16 inpatient units. Use of a teach-back methodology combined with a discharge bundle resulted in an 8% reduction in 7-day readmission and 10% reduction in 30-day readmission over 16 months.

Development and validation of the PROcedural Sedation Assessment Survey (PROSAS) for assessment of procedural sedation quality.

BACKGROUND: More than 20 million invasive procedures are performed annually in the United States. The vast majority are performed with moderate sedation or deep sedation, yet there is limited understanding of the drivers of sedation quality and patient satisfaction. Currently, the major gap in quality assurance for invasive procedures is the lack of procedural sedation quality measures. OBJECTIVE: To develop and validate a robust, patient-centered measure of procedural sedation quality, the PROcedural Sedation Assessment Survey (PROSAS). DESIGN: Through a series of interviews with patients, proceduralists, nurses, anesthesiologists, and an interactive patient focus group, major domains influencing procedural sedation quality were used to create a multipart survey. The pilot survey was administered and revised in sequential cohorts of adults receiving moderate sedation for GI endoscopy. After revision, the PROSAS was administered to a validation cohort. SETTING: GI endoscopy unit. PATIENTS: A expert panel of proceduralists, nurses, and anesthesiologists, an initial survey development cohort of 40 patients, and a validation cohort of 858 patients undergoing sedation for outpatient GI endoscopy with additional surveys completed by the gastroenterologist, procedure nurse, and recovery nurse. MAIN OUTCOMES AND MEASUREMENTS: Survey characteristics of the PROSAS. RESULTS: Patients were able to independently complete the PROSAS after procedural sedation before discharge. Of the patients, 91.6% reported minimal discomfort; however, 8.4% of patients reported significant discomfort and 2.4% of patients experienced hemodynamic and/or respiratory instability. There was a high correlation between patient-reported intraprocedure discomfort and both clinician assessments of procedural discomfort and patient recall of procedural pain 24 to 48 hours post procedure (P < .001 for all), suggesting high external validity. LIMITATIONS: Single-center study, variability of sedation technique between providers, inclusion of patients with chronic pain taking analgesics. CONCLUSIONS: The PROSAS is a clinically relevant, patient-centered, easily administered instrument that allows for standardized evaluation of procedural sedation quality. The PROSAS may be useful in both research and clinical settings.

Incidentally detected lung nodules: clinical predictors of adherence to Fleischner Society surveillance guidelines.

OBJECTIVE: The objective of this study was to determine adherence to incidentally detected lung nodule computed tomographic (CT) surveillance recommendations and identify demographic and clinical factors that increase the likelihood of CT surveillance. MATERIALS AND METHODS: A total of 419 patients with incidentally detected lung nodules were included. Recorded data included patient demographic, radiologic, and clinical characteristics and outcomes at a 4-year follow-up. Multivariate logistic regression models determined the factors associated with likelihood of recommended CT surveillance. RESULTS: At least 1 recommended surveillance chest CT was performed on 48% of the patients (148/310). Computed tomographic result communication to the patient (odds ratio [OR], 2.2; P = 0.006; confidence interval [CI], 1.3-4.0) or to the referring physician (OR, 2.8; P = 0.001; CI, 1.7-4.5) and recommendation of a specific surveillance time interval (OR, 1.7; P = 0.023; CI, 1.08-2.72) increased the likelihood of surveillance. Other demographic, radiologic, and clinical factors did not influence surveillance. CONCLUSIONS: Documented physician and patient result communication as well as the recommendation of a specific surveillance time interval increased the likelihood of CT surveillance of incidentally detected lung nodules.

Computed tomography angiography for suspected pulmonary embolism: comparison of 2 adaptive statistical iterative reconstruction blends to filtered back-projection alone.

OBJECTIVE: The objective of this study was to analyze pulmonary computed tomography angiography image quality and pulmonary embolism (PE) depiction comparing 2 blends of adaptive statistical iterative reconstruction (ASIR) to filtered back-projection alone. METHODS: Seventy-nine consecutive patients (49 women, 30 men; 52 ± 18 years) underwent pulmonary computed tomography angiography (120 kVp, 100-600 mA) reconstructed with filtered back-projection alone (ASIR0), 30% ASIR (ASIR30), and 50% ASIR (ASIR50) for this institutional review board-approved study. Two radiologists independently assessed PE depiction and vascular characterization, which was correlated with body mass index. RESULTS: Twelve patients (15%) had PE. No difference in PE depiction (P = 0.536), pulmonary arterial attenuation (P = 0.22-0.99), or subjective vascular characterization score (P = 0.58-.016) was observed for either blend. ASIR30 and ASIR50 achieved higher signal-to-noise ratio (P = 0.001-0.003). Body mass index inversely correlated with vascular characterization scores (P < 0.001). CONCLUSIONS: ASIR0, ASIR30, and ASIR50 accurately depict PE using the imaging parameters described. ASIR30 and ASIR50 improve objective image quality without altering subjective vascular characterization scores particularly when body mass index was less than 30 kg/m.

Risk of topical anesthetic-induced methemoglobinemia: a 10-year retrospective case-control study.

IMPORTANCE: Methemoglobinemia is a rare but serious disorder, defined as an increase in oxidized hemoglobin resulting in a reduction of oxygen-carrying capacity. Although methemoglobinemia is a known complication of topical anesthetic use, few data exist on the incidence of and risk factors for this potentially life-threatening disorder. OBJECTIVE: To examine the incidence of and risk factors for procedure-related methemoglobinemia to identify patient populations at high risk for this complication. DESIGN AND SETTING: Retrospective study in an academic research setting. PARTICIPANTS: Medical records for all patients diagnosed as having methemoglobinemia during a 10-year period were reviewed. EXPOSURES: All cases of methemoglobinemia that occurred after the following procedures were included in the analysis: bronchoscopy, nasogastric tube placement, esophagogastroduodenoscopy, transesophageal echocardiography, and endoscopic retrograde cholangiopancreatography. MAIN OUTCOMES AND MEASURES: Comorbidities, demographics, concurrent laboratory values, and specific topical anesthetic used were recorded for all cases. Each case was compared with matched inpatient and outpatient cases. RESULTS: In total, 33 cases of methemoglobinemia were identified during the 10-year period among 94,694 total procedures. The mean (SD) methemoglobin concentration was 32.0% (12.4%). The methemoglobinemia prevalence rates were 0.160% for bronchoscopy, 0.005% for esophagogastroduodenoscopy, 0.250% for transesophageal echocardiogram, and 0.030% for endoscopic retrograde cholangiopancreatography. Hospitalization at the time of the procedure was a major risk factor for the development of methemoglobinemia (0.14 cases per 10,000 outpatient procedures vs 13.7 cases per 10,000 inpatient procedures, P < .001). CONCLUSIONS AND RELEVANCE: The overall prevalence of methemoglobinemia is low at 0.035%; however, an increased risk was seen in hospitalized patients and with benzocaine-based anesthetics. Given the potential severity of methemoglobinemia, the risks and benefits of the use of topical anesthetics should be carefully considered in inpatient populations.

Thioredoxin-like 2 regulates human cancer cell growth and metastasis via redox homeostasis and NF-κB signaling.

Cancer cells have an efficient antioxidant system to counteract their increased generation of ROS. However, whether this ability to survive high levels of ROS has an important role in the growth and metastasis of tumors is not well understood. Here, we demonstrate that the redox protein thioredoxin-like 2 (TXNL2) regulates the growth and metastasis of human breast cancer cells through a redox signaling mechanism. TXNL2 was found to be overexpressed in human cancers, including breast cancers. Knockdown of TXNL2 in human breast cancer cell lines increased ROS levels and reduced NF-κB activity, resulting in inhibition of in vitro proliferation, survival, and invasion. In addition, TXNL2 knockdown inhibited tumorigenesis and metastasis of these cells upon transplantation into immunodeficient mice. Furthermore, analysis of primary breast cancer samples demonstrated that enhanced TXNL2 expression correlated with metastasis to the lung and brain and with decreased overall patient survival. Our studies provided insight into redox-based mechanisms underlying tumor growth and metastasis and suggest that TXNL2 could be a target for treatment of breast cancer.