The latest medical research on Hospital

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Influence of Socioeconomic Deprivation on Surgical Outcomes for Patients With Sigmoid Diverticulitis in France: A Multicenter Retrospective Study.

Annals of Surgery

To evaluate the relationship between socioeconomic deprivation and postoperative outcomes in patients who underwent colonic resection for sigmoid diverticulitis (SD).

The potential impact of socioeconomic inequalities on the management of SD has been scarcely studied in the literature. Considering other gastrointestinal pathologies for which lesser access to optimal treatment and poorer survival have been shown, we hypothesize that deprivation could be associated with outcomes for SD.

This multicenter retrospective study was conducted at 41 French hospitals between January 1, 2010, and August 31, 2021. The main outcome was the occurrence of severe postoperative complications on postoperative day 90, according to the Clavien-Dindo scale (≥3). The European Deprivation Index was used to approximate deprivation for each patient. Multiple imputations by a chained equation were performed to consider the influence of missing data on the results.

Twenty percent of the 6415 patients operated on had severe postoperative complications at 90 days. In the multivariate regression analysis, increasing age, male sex, American Society of Anesthesiologists score ≥3, conversion to laparotomy or upfront open approach, surgical procedures, and perioperative transfusion were independent risk factors for severe postoperative complications. After adjusting for age, sex, body mass index, American Society of Anesthesiologists score, emergent setting, blood transfusion, indications for surgery, surgical approach, and procedures, the probability of severe postoperative complications increased with socioeconomic deprivation (P=0.026) by day 90.

This study highlights the potential influence of socioeconomic deprivation on the surgical outcomes of SD. Socioeconomic deprivation should be considered as a risk factor for severe postoperative complications during the preoperative assessment of the patient's medical conditions.

Trends in Timely Access to High-Quality and Affordable Surgical Care in the United States.

Annals of Surgery

To quantify recent trends in access to timely, high-quality, affordable surgical care in the US.

Insufficient access to surgical care remains an ongoing concern in the US. Previous attempts to understand and quantify barriers in access to surgical care in the US lack a comprehensive, policy-relevant lens.

This observational cross-sectional study evaluates multiple domains of access to surgical care across the US from 2011-2015 and 2016-2020. Our stepwise model included timeliness (<60-minute drive time), quality (surgically capable hospital with ≥3 CMS stars), and affordability (neither uninsured nor underinsured) of access to surgical care using a novel combination of data from the American Hospital Association, Medicare claims, CMS's Five-Star Quality Rating System, the American Community Survey, and the Medical Expenditure Panel Survey.

The number of Americans lacking access to timely, high-quality, affordable surgical care increased from 97.7 million in 2010-2015 to 98.7 million in 2016-2020. Comparing these two periods, we found improvements in the number of Americans lacking access due to being uninsured (decrease from 38.5 to 26.5 million). However, these improvements were offset by increasing numbers of Americans for whom timeliness (increase from 9.5 to 14.1 million), quality (increase from 3.4 to 4.9 million), and underinsured status (increase from 46.3 to 53.1 million) increased as barriers to access. Multiple sensitivity analyses using alternative thresholds for each access domain demonstrated similar trends. Those with insufficient access to care tended to be more rural (6.7% vs. 2.0%, P<0.001), lower income (40.7% vs. 30.0%, P<0.001), and of Hispanic ethnicity (35.9% vs. 15.8%, P<0.001).

Nearly one-in-three Americans lack access to surgical care that is timely, high-quality, and affordable. This study identifies the multiple actionable drivers of access to surgical care that notably can each be addressed with specific policy interventions.

Interdisciplinary Operating Room Ergonomics Needs and Priorities: A Survey of Operating Room Staff.

Annals of Surgery

To examine perceived OR ergonomics facilitators and barriers, with a focus on the interdisciplinary team.

Poor ergonomics causes musculoskeletal injuries affecting all operating room (OR) staff with repercussions on patient care, outcomes, and sustainability. Lack of ergonomic awareness and education are risk factors.

We conducted a self-administered web-based survey of OR nurses, surgeons, and anesthesiologists at a single centre (n=238). We developed a questionnaire through items generation and reduction, followed by reliability and validity testing.

Response rate was 53.8%. Respondents perceived that on average 80% of nurses, 70% of surgeons, and 40% anesthesiologists experienced MSK injuries, with no difference in professional groups' perceptions. Guideline ergonomics interventions were rarely used (<25%) except for specialized clothing (33%), equipment repositioning (59%), and seating (37%), though perceived beneficial by 80-90%. Reported barriers to optimal ergonomics were organizational/structural (lack of time, space, equipment, funding), whereas solutions were individual. Fear of unfavourable perception from others was a concern for 62%. Teams discussing, prioritizing, monitoring, or helping with ergonomics was indicated by <50%. Individual ergonomic adaptations were perceived as convenience by other staff.

While structural/organizational issues are reported as barriers to ergonomics, solutions appeared as individual responsibilities. Team dynamics did not prioritize nor support ergonomics. Education tools leveraging the interdisciplinary team are warranted. This work will be supplemented by interviews and live observations to build tailored educational tools for OR teams.

The efficacy of valproate in acute mania, bipolar depression and maintenance therapy for bipolar disorder: an overview of systematic reviews with meta-analyses.

BMJ Open

This study aims to conduct an overview on the comparative efficacy of valproate in acute mania, bipolar depression and maintenance treatment of bipolar disorder (BD).

We performed an overview of systematic reviews with meta-analyses of randomised controlled trials (RCTs), registered in PROSPERO (CRD42024497749). We searched Medline and Cochrane Database of Systematic Reviews. Summary measures comparing valproate with placebo or other active drugs were described.

We included 26 systematic reviews. For acute mania (31 RCTs, n=4376), valproate showed a significantly better response than placebo in two high-quality systematic reviews (RR=1.42; 95% CI: 1.19 to 1.71) (OR=2.05; 95% CI: 1.32 to 3.20). No significant differences with lithium were found in most outcomes. Valproate had similar efficacy to quetiapine and lower efficacy compared with risperidone, with conflicting results when compared with olanzapine. In bipolar depression (7 RCTs, n=399), valproate was more effective than placebo in reducing depressive symptoms (OR=2.80; 95% CI: 1.26 to 6.18) and achieving remission (OR=2.4; 95% CI: 1.09 to 5.29) (OR=2.15; 95% CI: 0.82 to 5.6), considering the results of three high-quality systematic reviews. No significant difference was observed with lithium, lurasidone, quetiapine or olanzapine plus fluoxetine, but valproate showed superior efficacy to aripiprazole, ziprasidone and agomelatine. In maintenance treatment (11 RCTs, n=1063), valproate was superior to placebo in preventing relapse of any mood episode in two high-quality systematic reviews (RR=0.63; 95% CI: 0.48 to 0.83) (RR=0.63; 95% CI: 0.47 to 0.83). No significant difference was found with lithium, olanzapine or lamotrigine.

This overview highlights favourable results for valproate compared with placebo in all phases of BD, as well as presenting specific results in comparison with other active drugs. However, these results must be interpreted considering the methodological limitations of our study.

Efficacy of a computer vision-based system for exercise management in patients with knee osteoarthritis: a study protocol for a randomised controlled pilot trial.

BMJ Open

ChiCTR2300070319.

This is a prospective, single-blind, randomised controlled trial of 60 patients with knee OA who will be randomly assigned to exercise therapy (n=30) or control (n=30) . Both groups will receive treatment two times per week for 12 weeks. The primary outcome of the study will be assessed using the University of Western Ontario and McMaster University Osteoarthritis Index (WOMAC). The Knee Injury and Osteoarthritis Outcome Score will be assessed, as well as the visual analogue scale, quality of life score and physical fitness score. All observations will be collected at baseline and at weeks 4, 8 and 12 during the intervention period, as well as at weeks 4, 8, 12 and 24 during the follow-up visits after the end of the intervention.

Intra-arterial alteplase for acute ischaemic stroke after mechanical thrombectomy (PEARL): rationale and design of a multicentre, prospective, open-label, blinded-endpoint, randomised controlled trial.

BMJ Open

NCT05856851.

The Intra-arterial Alteplase for Acute Ischaemic Stroke After Mechanical Thrombectomy (PEARL) study is a multicentre, prospective, open-label, blinded-endpoint, randomised controlled trial. We consecutively screen AIS patients with anterior circulation LVO and National Institute of Health Stroke Scale of 6-25, who reach stable expanded Thrombolysis in Cerebral Infarction scores of 2b50-3 on angiography after MT. Eligible participants are 1:1 randomly assigned to the experimental group and the control group. Participants in the experimental group will receive intra-arterial alteplase (0.225 mg/kg and a maximum dose of 20 mg) after MT and standard medical treatment, while those in the control group will receive standard medical treatment alone after the procedure. The primary outcome is the proportion of patients with a 90-day modified Rankin scale of 0-1. A total of 324 participants are required to test the superiority hypothesis with 80% power at a two-tailed significance level of 0.05.

Quality appraisal of clinical guidelines for peripherally inserted central catheter-related thrombosis prophylaxis in patients: a systematic review.

BMJ Open

To evaluate and analyse the quality of clinical practice guidelines for Peripherally Inserted Central Catheter-related thrombosis (PICC-related thrombosis) to identify the most current and effective prophylactic measures recommended in the guidelines.

Two reviewers independently screened the searched items and extracted data and scored documents using AGREE II. Findings were summarised in Grading of Recommendation, Assessment, Development and Evaluation (GRADE) evidence profiles and synthesised qualitatively.

The analysis incorporated a total of nine guidelines, all rated as 'recommended' or 'recommended with modifications'. Standardised scores revealed elevated performance in the domains of Scope and Purpose, Clarity of Presentation and Editorial Independence. Conversely, the Stakeholder Involvement and Applicability domains yielded the lowest average standardised scores. Disparities in standardised scores across guidelines were particularly evident in the domains of Rigour of Development, Stakeholder Involvement and Applicability. The agreement between the two appraisers was almost perfect (intraclass correlation coefficients higher than 0.80). A considerable proportion of recommendations relied on evidence of low-quality, in certain instances, were derived from expert opinions within working groups.

The review reveals that a significant portion of recommendations relies on low-quality evidence. Guideline developers are urged to prioritise methodological quality, with a specific focus on refining Stakeholder Involvement and Applicability domains. Addressing these aspects will enhance the overall quality and reliability of PICC-related thrombosis prevention guidelines. One potential way to mitigate these challenges is to endorse a standardised approach to guideline development and to synthesise reliable clinical evidence to reduce variation in recommendations.

CRD42023495519.

Scoping review of enablers and challenges of implementing pharmacogenomics testing in the primary care settings.

BMJ Open

Pharmacogenomic testing (PGx) plays a crucial role in improving patient medication safety, yet ethical concerns and limitations impede its clinical implementation in the primary care settings.

To systematically review the current state of PGx in the primary care settings and determine the enablers and challenges of its implementation.

All peer-reviewed studies in English, reporting the enablers and the challenges of implementing PGx in the primary care settings were included.

Two independent reviewers extracted the data. Information was synthesised based on the reported enablers and the challenges of implementing PGx testing in the primary care settings. Information was then presented to stakeholders for their inputs.

78 studies discussing the implementation of PGx testing are included, of which 57% were published between 2019 and 2023. 68% of the studies discussed PGx testing in the primary care setting as a disease-specific themes. Healthcare professionals were the major stakeholders, with primary care physicians (55%) being the most represented. Enablers encompassed various advantages such as diagnostic and therapeutic benefits, cost reduction and the empowerment of healthcare professionals. Challenges included the absence of sufficient scientific evidence, insufficient training for healthcare professionals, ethical and legal aspects of PGx data, low patient awareness and acceptance and the high costs linked to PGx testing.

PGx testing integration in primary care requires increased consumer awareness, comprehensive healthcare provider training on legal and ethical aspects and global feasibility studies to better understand its implementation challenges. Managing high costs entails streamlining processes, advocating for reimbursement policies and investing in research on innovation and affordability research to improve life expectancy.

Patient-reported harm following cancellation of planned surgery at a Danish university hospital: a cross-sectional study.

BMJ Open

To estimate the prevalence and severity of patient-reported physical and non-physical harm following surgery cancellation.

Patients (≥18 years) from various surgical specialities, such as orthopaedic, spinal, abdominal, gynaecological, thoracic, vascular and urological surgery whose surgery was cancelled <2 weeks prior to the scheduled date due to hospital-related causes.OutcomePatient-reported physical and non-physical harm, defined as physical worsening, emotional strain and other consequences, measured using a patient-reported survey.

We identified 785 patients whose surgery was cancelled from 1 December 2021 to 1 June 2022, of whom 436 (55.5%) responded to the electronic survey. Physical worsening was reported by 42% and emotional strain by 48% of patients. One-third of patients reported an inability to continue daily activities, and 28% reported a need for an increased dose of analgesics. Emotional strain included various negative feelings such as being disappointed (59%) and lonely (31%). Furthermore, 44% of the respondents feared deterioration of their disease and 9% experienced anxiety of dying. The relative risk of emotional strain was higher in females than in males (54% vs 41%, adjusted relative risk (RR)=1.32 (1.08; 1.63)). A waiting period >30 days compared with ≤30 days was associated with a higher risk of physical worsening (25.3% vs 48.9%, adjusted RR=1.93 (1.42; 2.63)).

Harm, measured as physical worsening and emotional strain, is reported with severity by nearly half of respondents following cancellation.

Assessing global access to continuing professional development for rehabilitation professionals: a mixed methods study of current practices and perceived needs.

BMJ Open

This study aimed to understand the current state of continuing professional development (CPD) for rehabilitation professionals globally and identify perceived requirements to enhance education to guide efforts to develop internationally relevant, interprofessional, rehabilitation coursework adaptable to the various professions and contexts to support workforce development.

A total of 445 professionals completed the survey. Additionally, interviews were performed with 104 participants from Myanmar, Pakistan, Uganda and Ukraine to clarify and expand on survey responses.

The CPD requirements for practising clinicians and regulation of CPD activities varied widely across countries and professions. Participants expressed a need for additional resources and educational opportunities, particularly for multidisciplinary rehabilitation focusing on neurological conditions. However, there were multiple barriers to accessing technological resources and professional development in low and middle-income countries that must be navigated alongside low engagement and motivation for lifelong learning.

There is an opportunity to enhance global rehabilitation workforce development by fostering partnerships focused on the efficient delivery of training. This includes developing CPD programmes that consider cultural contexts, patient populations, and practice settings. Support for CPD can be improved through both internal and external motivators and by regulating CPD activities to ensure effective, evidence-based practice.

Perceptions, attitudes and beliefs on antenatal exercises among primiparous pregnant women: a qualitative study in Sri Lanka.

BMJ Open

Even if promoting antenatal exercises is an evolving concept worldwide, there is a scarcity of qualitative exploratory studies which directly focus on pregnant mothers' views about exercises. So, this study was designed to (1) explore pregnant women's perceptions, attitudes and beliefs about antenatal exercises, and (2) provide significant annotations prior to constituting interventions for antenatal exercises.

A qualitative survey was carried out with 19 primiparous pregnant women using stratified purposive sampling at the antenatal clinic, in a tertiary care hospital, Sri Lanka. In-depth interviews were conducted through a predesigned, semistructured interview guide from January to April 2021. Data were transcribed, examined and organised, then subjected to thematic analysis using inductive approach.

Most of the pregnant women described numerous benefits and had optimistic views on exercises. However, the absence of a comprehensive understanding on the impact of exercise on a healthy pregnancy is apparent, primarily caused by a dearth of health education and reliable information sources. Also, they were unlikely to initiate exercises in their pregnancy period due to a lack of guidance through the antenatal clinic and/or health professionals. Concerning beliefs, main stream-believed exercises provide assistance for normal labour process and exercises advantageous in both antenatal and post-partum periods. Besides, few of them restricted their conversations on the drawbacks of exercises by illuminating erroneous beliefs.

The majority of participants realised the importance of exercises and had positive attitudes while the minority presenting misconceptions. The need for healthcare providers' support and guidance is highly anticipated by pregnant women to engage in antenatal exercises.

Risk-stratified hepatocellular carcinoma screening according to the degree of obesity and progression to cirrhosis for diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD) in Japan: a cost-effectiveness study.

BMJ Open

To evaluate the cost-effectiveness of risk-stratified hepatocellular carcinoma (HCC) screening in diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

Costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), early-stage HCC cases, advanced-stage HCC cases and HCC-related deaths.

EOB-MRI is the most cost-effective screening method for non-obese diabetic patients with MASH cirrhosis and for obese diabetic patients with MASH and MASH cirrhosis. Cost-effectiveness was sensitive to HCC incidence in non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH, and the adherence rate of HCC screening in obese diabetic patients with MASH. When the semiannual HCC incidence was between 0.008 and 0.0138 in non-obese diabetic patients with MASH cirrhosis, US with AFP was more cost-effective than EOB-MRI. Cost-effectiveness acceptability curves showed that EOB-MRI was 50.7%, 96.0% and 99.9% cost-effective in obese diabetic patients with MASH and non-obese diabetic patients with MASH cirrhosis, and obese diabetic patients with MASH cirrhosis at a willingness-to-pay level of $50 000 per QALY gained. Compared with no screening in 100 000 non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH cirrhosis, EOB-MRI reduced total costs by US$69 million and by US$142 million, increased lifetime effectiveness by 12 546 QALYs and by 15 815 QALYs, detected 17 873 and 21 014 early-stage HCC cases, and averted 2068 and 2471 HCC-related deaths, respectively.

Of all HCC screening methods for diabetic patients with MASH cirrhosis, EOB-MRI yields the greatest cost-saving with the highest QALYs, detects the greatest number of early-stage HCC cases and averts the greatest number of advanced-stage HCC cases and HCC-related deaths. The findings provide important insights for the precise implementation of risk-stratified HCC surveillance to reduce morbidity and mortality and improve the quality of life in diabetic patients with MASLD.