Economic and Clinical Burden of Herpes Zoster Among Patients With Inflammatory Bowel Disease in the United States.

Background: Patients with ulcerative colitis (UC) or Crohn's disease (CD) are at increased risk of herpes zoster (HZ); however, relevant cost and healthcare resource utilization (HCRU) data are limited. Methods: We estimated HCRU (hospitalization, emergency department [ED], and outpatient visits) and costs in patients with UC or CD, with and without HZ, using administrative claims data (October 2015-February 2020). HCRU and costs (2020 US dollars) were compared at 1 month, 1 quarter, and 1 year after the index date, using propensity score adjustment and generalized linear models. Results: In total, 20 948 patients were included: UC+/HZ+ (n = 431), UC+/HZ- (n = 10 285), CD+/HZ+ (n = 435), and CD+/HZ- (n = 9797). Patients with HZ had higher all-cause HCRU rates and all-cause total healthcare costs relative to those without HZ. In the first month, adjusted incidence rate ratios (aIRRs) for hospitalizations and ED visits for patients with UC and HZ compared with UC alone were 2.87 (95% confidence interval [CI], 1.93-4.27) and 2.66 (95% CI,1.74-4.05), respectively; for those with CD and HZ, aIRRs were 3.34 (95% CI, 2.38-4.70) and 3.31 (95% CI, 2.32-4.71), respectively, compared with CD alone (all P < .001). Adjusted cost differences in UC and CD cohorts with HZ over the first month were $2189 and $3774, respectively, chiefly driven by higher inpatient costs. The incremental impact on HCRU and costs in cohorts with HZ predominantly occurred during the first quarter following diagnosis. Conclusions: HZ is associated with increased HCRU and costs in patients with UC and CD, especially shortly after diagnosis.

Incidence and risk of herpes zoster in patients with ulcerative colitis and Crohn's disease in the USA.

Background: Patients with inflammatory bowel disease (IBD) are at increased risk of herpes zoster (HZ). We evaluated the incidence of HZ in ulcerative colitis (UC) and Crohn's disease (CD) patients and compared this with HZ incidence in a non-IBD population. Methods: We conducted a retrospective cohort study (GSK study identifier: VEO-000043) of adults aged ≥18 years with UC and CD and without IBD who were identified from claims recorded in a US healthcare database between October 2015 and February 2020. Crude HZ incidence rates/1,000 person-years (PY) were calculated, and comparisons of HZ incidence rates between UC or CD and non-IBD cohorts were made using adjusted generalized linear models. Results: The study population comprised a total of 29,928 UC, 25,959 CD, and 11,839,329 non-IBD patients. Crude overall HZ incidence rates were 13.64/1,000 PY (UC), 15.94/1,000 PY (CD), and 7.95/1,000 PY (non-IBD). UC and CD patients had increased HZ incidence rates, with adjusted incidence rate ratios of 1.35 (95% confidence interval [CI], 1.26-1.44) and 1.66 (95% CI, 1.56-1.77), respectively, compared with non-IBD patients. Stratified analysis indicated increased relative rates of HZ in progressively younger age strata in the UC and CD patients compared with non-IBD patients. HZ incidence rates were higher in UC and CD patients who had previously received thiopurines or methotrexate, TNF-inhibitors, or corticosteroids than in UC and CD patients who did not take those medicines. Conclusion: UC and CD patients had increased HZ incidence rates compared with patients without IBD, demonstrating the importance of HZ prevention in IBD patients.

Association of Simulation Participation With Diagnostic Reasoning Scores in Preclinical Students.

PURPOSE: The aim of the study was to evaluate for an association between the number of voluntary mannequin simulation sessions completed during the school year with scores on a year-end diagnostic reasoning assessment among second-year medical students. METHOD: This is retrospective analysis of participation in 0 to 8 extracurricular mannequin simulation sessions on diagnostic reasoning assessed among 129 second-year medical students in an end-of-year evaluation. For the final skills assessment, 2 physicians measured students' ability to reason through a standardized case encounter using the Diagnostic Justification (DXJ) instrument (4 categories each scored 0-3 by raters reviewing students' postencounter written summaries). Rater scores were averaged for a total DXJ score (0-12). To provide additional baseline comparison, zero participation students were divided into 2 groups based on intent to participate: those who signed up for extracurricular sessions but never attended versus those who never expressed interest. Scores across the attendance groups were compared with an analysis of variance and trend analysis. RESULTS: The class DXJ mean equaled 7.56, with a standard deviation of 2.78 and range of 0 to 12. Post hoc analysis after a significant analysis of variance (F = 4.91, df = 8, 128, P < 0.001) showed those participating in 1 or more extracurricular sessions had significantly higher DXJ scores than those not participating. Students doing 7 extracurricular sessions had significantly higher DXJ scores than those doing 0 and 2 (P < 0.05). Zero attendance groups were not different. A significant linear trend (R = 0.48, F = 38.0, df = 1, 127, P < 0.001) was found with 9 groups. A significant quadratic effect, like a dose-response pattern, was found (F = 18.1, df = 2, 125, P < 0.001) in an analysis including both zero attendance groups, a low (1-4 extracurricular sessions) group and a high (5-8) group. CONCLUSIONS: Higher year-end diagnostic reasoning scores were associated with increased voluntary participation in extracurricular mannequin-based simulation exercises in an approximate dose-response pattern.

Reducing Wasted Time Prior To Starting Thoracic Surgical Operations.

To design and implement multidisciplinary interventions to decrease the interval between when a patient entered the operating room and when skin incision was made during thoracic surgical operations. Thirty-eight steps that occurred during the pre-incision time were identified during meetings with surgery, anesthesia, and nursing teams. Using a critical path method and Pareto analysis, standardization of intubation and positioning techniques as well as establishing strict guidelines to avoid unnecessary urinary catheter and arterial line placement were identified as high-value interventions. The duration of every step, and the total pre-incision time, was recorded during four phases of this project: (1) a pre-intervention period; (2) a run-in period; (3) a post-intervention period; and (4) a follow-up period five months later. 101 cases were analyzed. The median (IQR) pre-incision time dropped from 42.5(36-61) min prior to intervention to 34.5(29-39.5). This improvement persisted at five months (33 (28-41) min). Median positioning time decreased from 9(7-11) min to 4(3-5) min, with improvement persistent at late analysis 5(3.5-6) min. Median intubation times decreased from 7.5(5-15.5) min to 6(5-8) min post-intervention, with persistent improvement at five months 6(4-8). Engagement of a multidisciplinary team to design interventions to streamline pre-incision steps reduced the pre-incision time by 19%. Persistence of this improvement likely reflects the investment each teams' members had in achieving efficiency. Decreasing variability in the processes helped to achieve these benefits.

Operating room team training using simulation: Hope or hype?

BACKGROUND: This study sought to determine the long-term impact of multidisciplinary simulated operating room (OR) team training. METHOD: Two-wave survey study (immediate post-training survey 2010-2017, follow-up 2018). Differences across time, specialty, and experience with adverse events were assessed using chi-square and t -tests. RESULTS: Immediately after training, more than 90% of respondents found simulation scenarios realistic and reported team training would provide safer patient care. However, follow-up participants reported less enthusiasm toward training, with 58% stating they would like to take similar training again. A majority of participants (77%) experienced adverse events after training; those reporting adverse events reported more positive long-term evaluations. CONCLUSIONS: Simulated OR team training is initially highly valued by participants and is perceived as contributing to patient safety. Diminution of participant enthusiasm over time suggests that repeat training requirements be reconsidered, and less costly, alternative methods (such as asynchronous learning or virtual reality) should be explored.

Anesthesia for interventional pulmonology procedures: a review of advanced diagnostic and therapeutic bronchoscopy.

PURPOSE: Interventional pulmonology is a growing subspecialty of pulmonary medicine with flexible and rigid bronchoscopies increasingly used by interventional pulmonologists for advanced diagnostic and therapeutic purposes. This review discusses different technical aspects of anesthesia for interventional pulmonary procedures with an emphasis placed on pharmacologic combinations, airway management, ventilation techniques, and common complications. SOURCE: Relevant medical literature was identified by searching the PubMed and Google Scholar databases for publications on different anesthesia topics applicable to interventional pulmonary procedures. Cited literature included case reports, original research articles, review articles, meta-analyses, guidelines, and official society statements. PRINCIPAL FINDINGS: Interventional pulmonology is a rapidly growing area of medicine. Anesthesiologists need to be familiar with different considerations required for every procedure, particularly as airway access is a shared responsibility with pulmonologists. Depending on the individual case characteristics, a different selection of airway method, ventilation mode, and pharmacologic combination may be required. Most commonly, airways are managed with supraglottic devices or endotracheal tubes. Nevertheless, patients with central airway obstruction or tracheal stenosis may require rigid bronchoscopy and jet ventilation. Although anesthetic approaches may vary depending on factors such as the length, complexity, and acuity of the procedure, the majority of patients are anesthetized using a total intravenous anesthetic technique. CONCLUSIONS: It is fundamental for the anesthesia provider to be updated on interventional pulmonology procedures in this rapidly growing area of medicine.

Developments in the Transition From Animal Use to Simulation-Based Biomedical Education.

STATEMENT: There has been a significant shift from the use of animals in biomedical training exercises toward simulation-based education methods. The transition has been driven by technological advances, empirical evidence of improved student outcomes, cost-effectiveness, and a growing concern for the welfare of animals. These factors have spurred policy changes worldwide in how medical and science curricula are delivered. We detail how some of these policy changes evolved and comment on the future direction of simulation-based education and its implications for healthcare providers, instructors, and the general public.

Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes.

BACKGROUND: Obtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment. METHODS: Seven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail. RESULTS: Interrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room. CONCLUSIONS: Sensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

Preemptive ultrasound-guided paravertebral block and immediate postoperative lung function.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the effects of preemptive ultrasound-guided thoracic paravertebral block versus intercostal block on postoperative respiratory function and pain control in patients undergoing video-assisted thoracoscopic surgery. SUBJECTS: 50 consecutive patients undergoing video-assisted thoracoscopic surgery. METHOD: A prospective cohort of patients who received either ultrasound-guided thoracic paravertebral block immediately before the procedure or intercostal block placed by the surgeon at the end of the procedure were studied. Pulmonary function was assessed before surgery and 4 h postoperatively. Pain was assessed with the visual analog scale at 2 and 4 h after surgery both at rest and on coughing. RESULTS: 30 patients on the paravertebral block group and 20 on the intercostal block group were studied. Forced vital capacity (p < 0.001), forced expiratory volume at 1 s (p < 0.001) and forced expiratory flow 25-75% (p = 0.001) were significantly higher at 4 h with paravertebral block compared to the intercostal block group. The visual analog score for pain was significantly improved with paravertebral block at rest (p < 0.05) and with cough (p = 0.00). Perioperative narcotic use was significantly reduced with paravertebral block in comparison to intercostal block (p = 0.04). CONCLUSIONS: When compared to intercostal blocks, ultrasound-guided thoracic paravertebral block appears to preserve lung function and provide better pain control in the immediate postoperative period after video-assisted thoracoscopic surgery.

The use of in-situ simulation to improve safety in the plastic surgery office: a feasibility study.

OBJECTIVE: Simulation-based interventions and education can potentially contribute to safer and more effective systems of care. We utilized in-situ simulation to highlight safety issues, regulatory requirements, and assess perceptions of safety processes by the plastic surgery office staff. METHODS: A high-fidelity human patient simulator was brought to an office-based plastic surgery setting to enact a half-day full-scale, multidisciplinary medical emergency. Facilitated group debriefings were conducted after each scenario with special consideration of the principles of team training, communication, crisis management, and adherence to evidence-based protocols and regulatory standards. Abbreviated AHRQ Medical Office Safety Culture Survey was completed by the participants before and after the session. RESULTS: The in-situ simulations had a high degree of acceptance and face validity according to the participants. Areas highlighted by the simulation sessions included rapid communication, delegation of tasks, location of emergency materials, scope of practice, and logistics of transport. The participant survey indicated greater awareness of patient safety issues following participation in simulation and debriefing exercises in 3 areas (P < 0.05): the need to change processes if there is a recognized patient safety issue (100% vs 75%), openness to ideas about improving office processes (100% vs 88%), and the need to discuss ways to prevent errors from recurring (88% vs 62%). CONCLUSIONS: Issues of safety and regulatory compliance can be assessed in an office-based setting through the short-term (half-day) use of in-situ simulation with facilitated debriefing and the review of audiovisual recordings by trained facilities inspectors.

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

OBJECTIVE: To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives. BACKGROUND: Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale. METHODS: A malpractice insurer convened a collaborative with 4 Harvard-affiliated simulation programs to develop a standardized operating room teamwork training curriculum, including principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. Participant teams were compensated for lost operative time via malpractice premium discounts, continuing education credits, and compensation for lost wages. The course was delivered through a simulation program involving the management of intraoperative emergency scenarios. Participants were surveyed for their perceptions of the program and of its impact on clinical practice. RESULTS: A total of 221 active operating room staff members participated in the program. Each team contained at least 1 attending surgeon, 1 attending anesthesiologist, and 1 operating room nurse (mean size per team: 7 ± 2 participants). No study dates were cancelled because of lack of attendance. The survey response rate was 99% (218/221). Overall, the vast majority of participants found the scenarios realistic [94% (95% confidence interval: 90.9%, 97.2%)], appropriately challenging [95.4% (92.6%, 98.2%)], relevant to their practice [96.3% (93.8%, 98.8%)], and found the training would help them provide safer patient care [92.6% (89.1%, 96.1%)]. Surgeons reported their greatest personal deficit as communication skills. Operating room nurses and anesthesiologists reported a greater need than surgeons to work on personal assertiveness. CONCLUSIONS: A standardized multicenter team training program involving full operative teams is feasible with high-fidelity simulation and modest compensation for lost time. The vast majority of the multidisciplinary participants believed the course to have had a meaningful impact on their approach to clinical practice.

Anesthetic considerations for interventional pulmonary procedures.

PURPOSE OF REVIEW: To discuss the anesthetic considerations of various procedures now performed by the interventional pulmonologist. With recent technological advances, many of these procedures represent acceptable alternatives to the invasive surgical procedures. For example, the placement of endobronchial valves can substitute for lung reduction surgery and can greatly reduce the postoperative recovery period. However, many of these complex procedures require anesthesia services. The nature and indication for the procedure as well as the patient's overall health will have an impact on the anesthetic choice. RECENT FINDINGS: New studies have documented common complications from interventional pulmonology procedures and recent ways to avoid these complications have been suggested. Strategies to avoid obstruction, bleeding, pneumothorax and air embolism are discussed in this article. Potential benefits of high frequency jet ventilation in reducing airway pressures and, perhaps, barotraumas are cited. Novel interventional pulmonary procedures are described. SUMMARY: As the array of diagnostic and therapeutic pulmonary interventions is expanding, the types of anesthetic techniques and ventilatory modes are varying to fit the procedural requirements. Some pulmonary procedures are best accomplished in the lightly sedated patient, who is breathing spontaneously, whereas procedures that use the working channel of a rigid bronchoscope are better performed in the patient under general anesthesia and mechanical ventilation that often use jet ventilation to minimize respiratory movements.

Early bedside care during preclinical medical education: can technology-enhanced patient simulation advance the Flexnerian ideal?

Flexner wanted medical students to study at the patient bedside-a remarkable innovation in his time-so that they could apply science to clinical care under the watchful eye of senior physicians. Ever since his report, medical schools have reserved the latter years of their curricula for such an "advanced" apprenticeship, providing clinical clerkship experiences only after an initial period of instruction in basic medical sciences. Although Flexner codified the segregation of preclinical and clinical instruction, he was committed to ensuring that both domains were integrated into a modern medical education. The aspiration to fully integrate preclinical and clinical instruction continues to drive medical education reform even to this day. In this article, the authors revisit the original justification for sequential preclinical-clinical instruction and argue that modern, technology-enhanced patient simulation platforms are uniquely powerful for fostering simultaneous integration of preclinical-clinical content in a way that Flexner would have applauded. To date, medical educators tend to focus on using technology-enhanced medical simulation in clinical and postgraduate medical education; few have devoted significant attention to using immersive clinical simulation among preclinical students. The authors present an argument for the use of dynamic robot-mannequins in teaching basic medical science, and describe their experience with simulator-based preclinical instruction at Harvard Medical School. They discuss common misconceptions and barriers to the approach, describe their curricular responses to the technique, and articulate a unifying theory of cognitive and emotional learning that broadens the view of what is possible, feasible, and desirable with simulator-based medical education.