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JAMA Surgery Mar 2020Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure.
IMPORTANCE
Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure.
OBJECTIVE
To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure.
DESIGN, SETTING, AND PARTICIPANTS
This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019.
INTERVENTIONS
Standard- or low-dose WBCT.
MAIN OUTCOMES AND MEASURES
The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy.
RESULTS
Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, -2.0% [95% CI, -7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001).
CONCLUSIONS AND RELEVANCE
Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Missed Diagnosis; Multiple Trauma; Prospective Studies; Radiation Dosage; Radiation Exposure; Tomography, X-Ray Computed; Wounds, Nonpenetrating
PubMed: 31940019
DOI: 10.1001/jamasurg.2019.5468 -
Journal of Radiological Protection :... Dec 2021The potential for unintended and adverse radiation exposure in radiotherapy (RT) is real and should be studied because RT is a highly complex, multistep process, which...
BACKGROUND AND PURPOSE
The potential for unintended and adverse radiation exposure in radiotherapy (RT) is real and should be studied because RT is a highly complex, multistep process, which requires input from numerous individuals from different areas and steps of the RT workflow. The 'Incident' (I) is an event the consequence of which is not negligible from the point of view of protection or safety. A 'near miss' (NM) is defined as an event that is highly likely to happen but did not occur. The purpose of this work is to show that through systematic reporting and analysis of these adverse events, their occurrence can be reduced.
MATERIALS AND METHODS
Staff were trained to report every type of unintended and adverse radiation exposure and to provide a full description of it.
RESULTS
By 2018, 110 worksheets had been collected, with an average of 6.1 adverse events per year (with 780 patients treated per year, meaning an average incident rate of 0.78%). In 2001-2009, 37 events were registered (13 I and 24 NM), the majority of them were in the decision phase (12/37), while in 2010-2013, there were 42 (1 I and 41 NM) in both the dose-calculation and transfer phase (19/42). In 2014-2018, 31 events (1 I and 30 NM) were equally distributed across the phases of the RT process. In 9/15 cases of I, some checkpoint was introduced.
CONCLUSION
The complexity of the RT workflow is prone to errors, and this must be taken into account by encouraging a safety culture. The aim of this paper is to present the collected incidents and near misses and to show how organization and practice were modified by the acquired knowledge.
Topics: Humans; Medical Errors; Patient Safety; Radiation Oncology; Radiotherapy; Risk Management; Safety Management; Workflow
PubMed: 34134092
DOI: 10.1088/1361-6498/ac0c01 -
Asia-Pacific Journal of Clinical... Jun 2018Toxicities of systemic cancer therapies are often less frequently observed in clinical trials than in clinical practice, due to the careful selection of patients with... (Review)
Review
Toxicities of systemic cancer therapies are often less frequently observed in clinical trials than in clinical practice, due to the careful selection of patients with fewer comorbidities. Although guidelines exist for the estimation of chemotherapy dose, clinical factors like age, comorbid illness and extremes of body habitus are not considered in the method of dose calculation, which can result in significant toxicity. We reviewed the referenced clinical trials from which the evidence-based curative-intent cancer treatment protocols were developed for EVIQ, which is an Australian government, online resource. This review shows that a significant proportion of patients in curative-intent clinical trials experience toxicities that result in dose modifications-dose reduction, dose delays or missed doses-despite strict selection criteria and intense monitoring. Thus, even in ideal, clinical-trial settings chemotherapy dose calculation remains imprecise and subject to adjustment as clinically appropriate. In real-world clinical practice, dose alterations or modifications in response to toxicities need to be thoroughly discussed and implemented with clear understanding of the patient with appropriate documentation. This review may be used as a reference in these situations to elaborate the extent of toxicities seen in clinical trials with optimal settings.
Topics: Antineoplastic Combined Chemotherapy Protocols; Chemotherapy, Adjuvant; Humans; Maximum Tolerated Dose; Neoplasms
PubMed: 29498201
DOI: 10.1111/ajco.12864 -
Journal of Acquired Immune Deficiency... Dec 2021Although HIV antiretroviral treatment (ART) access and uptake have increased among racial/ethnic minority individuals, lower rates of ART adherence and viral suppression...
BACKGROUND
Although HIV antiretroviral treatment (ART) access and uptake have increased among racial/ethnic minority individuals, lower rates of ART adherence and viral suppression persist, especially among Black men who have sex with men (BMSM) compared with their White counterparts.
SETTING
Black men who have sex with men living with HIV (BMSM+) residing in Los Angeles County (N = 124) were recruited in-person (eg, clinic) and online (eg, social networking apps).
METHODS
Participants completed a cross-sectional survey measuring demographic characteristics, structural syndemics (poverty, criminal justice involvement, and housing instability), and psychosocial syndemics (mental health and substance use). A text message survey assessed missed doses of ART over the past week. Zero-inflated Poisson regression models were used to evaluate variables associated with the number of missed doses of ART.
RESULTS
On average, participants missed 1.30 doses of ART (SD = 2.09) and reported structural syndemics: poverty (56.1%), criminal justice involvement (36.6%), housing instability (26.3%), and psychosocial syndemics: childhood sexual abuse (51.8%), intimate partner violence (16.9%), depression (39%), and problem alcohol use (15.5%). After controlling for employment, age, education, and psychosocial syndemics, participants with a one-point increase in structural syndemic indicators were found to be 1.63 times more likely to have missed a dose of ART.
CONCLUSIONS
Structural syndemic were associated with ART nonadherence among BMSM+ after adjusting for demographic and psychosocial factors. HIV treatment interventions that incorporate financial incentives, legal support, and housing may help improve ART adherence among BMSM+. Findings suggest that key priorities to ending the HIV epidemic must include structural interventions that alleviate poverty, eliminate disproportionate policing and criminalization, and end homelessness.
Topics: Child; Cross-Sectional Studies; Ethnicity; HIV Infections; Homosexuality, Male; Humans; Male; Medication Adherence; Minority Groups; Sexual and Gender Minorities; Syndemic
PubMed: 34757988
DOI: 10.1097/QAI.0000000000002806 -
The Journal of Surgical Research Jan 2019Missing doses of antibiotics in hospitalized patients is a well-described but inadequately recognized issue. We hypothesized that missing doses of antibiotics decreases...
BACKGROUND
Missing doses of antibiotics in hospitalized patients is a well-described but inadequately recognized issue. We hypothesized that missing doses of antibiotics decreases quality of care.
METHODS
Retrospective study on patients admitted to the Shock Trauma ICU from February to June 2015. Patients prescribed a multidose course of antibiotics were evaluated. A missed antibiotic dose was one ordered but never given (a completely missed dose) or a dose that was not given within an hour before or after the planned time (an off-schedule missed dose). Patient outcomes included a positive culture, ventilator, ICU and hospital length of stay (LOS), and mortality. Multiple statistical methods were used as appropriate; significance was set as P < 0.05.
RESULTS
For the 5-mo study period, 280 patients were admitted and 200 met inclusion criteria. Eight percent of patients (16/200) did not miss any antibiotic doses, 39% (77/200) had only off-schedule doses, 2% (4/200) had only completely missed doses, and 51% (103/200) had both off-schedule and completely missed doses. For the 200 patients, 8167 doses were ordered and 2096 (26%) were missed. Adjusting for age, gender, BMI, injury severity score, and doses of antibiotics showed that those who miss doses off-schedule had longer LOS than those who do not miss doses of antibiotics. There was a significant nonlinear relationship between LOS and frequency of early (P-value = 0.02) and late (P-value = 0.01) doses.
CONCLUSIONS
To reduce length of hospital stay and optimize quality, methods to improve compliance with antibiotic dosing schedules should be investigated.
Topics: Adult; Aged; Anti-Bacterial Agents; Drug Prescriptions; Female; Hospital Mortality; Humans; Injury Severity Score; Intensive Care Units; Length of Stay; Male; Medication Errors; Middle Aged; Outcome and Process Assessment, Health Care; Quality of Health Care; Retrospective Studies; Trauma Centers; Wounds and Injuries
PubMed: 30502260
DOI: 10.1016/j.jss.2018.08.015 -
Journal of Research in Pharmacy Practice 2020The objectives of this study were to investigate the frequency and reasons for missing doses and impact of a pharmacist-led intervention to reduce the missed doses in...
OBJECTIVE
The objectives of this study were to investigate the frequency and reasons for missing doses and impact of a pharmacist-led intervention to reduce the missed doses in intensive care units.
METHODS
This study was completed in two phases. In the first phase, a retrospective quality assurance audit was conducted to quantify the problem of missed doses from the pharmacist/nurse communication slip record. The frequency and potential reasons for missing dose occurrences were identified and listed, and respective solutions were finalized by a joint health-care team. In the second phase of the study, post-intervention analysis was done for a period of 1 month to check the impact of intervention. The data were recorded from pharmacy/nursing communication forms for medication, dosage form, route of administration (ROA), frequency of missed doses, and underlying reasons for missing doses.
FINDINGS
There was a substantial reduction in the number of incidences of missed doses in post-intervention phase. The number of events decreased from 190 (pre-intervention; 2 months) to 11 (post-intervention; 1 month), 389 to 87, and 133 to 12 for automatic stop order, unknown reason, and late mix medication, respectively. No missed dose event was recorded secondary to order overseen and inactive patient status in post-intervention phase. Moreover, identified reasons, ROA, frequency, and the system status were the significant predictors of missing doses.
CONCLUSION
The findings of this study emphasized the need to introduce better documentation procedures and continuous surveillance system to decrease the number of missing doses and further improve already established drug distribution service.
PubMed: 32489959
DOI: 10.4103/jrpp.JRPP_19_95 -
Journal of Pediatric and Adolescent... Apr 2016To examine human papillomavirus (HPV) series completion in older adolescents and assess vaccination completion opportunities missed by providers. DESIGN, SETTING,...
STUDY OBJECTIVE
To examine human papillomavirus (HPV) series completion in older adolescents and assess vaccination completion opportunities missed by providers. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Electronic medical records were queried for women 18-24 years old who initiated the HPV vaccine in the Adolescent Medicine, Young Mother's, or Family Planning clinics at Children's Hospital Colorado from January 1, 2010-December 31, 2012. Clinic visits during appropriate dosing intervals of HPV vaccine at which the second (4-14 weeks after first dose) or third (21-40 weeks after first dose and >12 weeks after second dose) doses were not administered were counted as "missed opportunities."
RESULTS
A total of 1072 female adolescents initiated the HPV series during the study period; 20.9% completed the series within 1 year. Of these, 33.7% who did not receive their second dose had at least 1 missed opportunity and 25.5% who received the second but not the third had a missed opportunity. Women who initiated the vaccine in the Family Planning clinic were less likely to have missed opportunities than those in other adolescent clinics (36.2% vs 56.4%; P < .001).
CONCLUSION
A significant number of female adolescents who initiated the HPV vaccine attended clinic visits at which opportunities for vaccine continuation and completion were missed. This emphasizes the importance of provider awareness of vaccine updates at every adolescent visit. Our overall completion rate is significantly lower than published rates and might reflect older adolescents' inexperience in managing their own preventive health care. Our results clearly identify the need for provider and patient interventions to improve vaccine series completion.
Topics: Adolescent; Adolescent Behavior; Ambulatory Care Facilities; Colorado; Female; Health Behavior; Humans; Immunization Schedule; Medication Adherence; Papillomaviridae; Papillomavirus Infections; Papillomavirus Vaccines; Vaccination; Young Adult
PubMed: 26300233
DOI: 10.1016/j.jpag.2015.08.003 -
AIDS Education and Prevention :... Aug 2018HIV pre-exposure prophylaxis (PrEP) is being adopted by members of key populations, such as gay and bisexual men (GBM). Since adherence to a daily PrEP regimen ensures a...
HIV pre-exposure prophylaxis (PrEP) is being adopted by members of key populations, such as gay and bisexual men (GBM). Since adherence to a daily PrEP regimen ensures a maximum protection, it is critical to understand GBM's behavioral responses to having missed PrEP doses. We report on qualitative interviews with GBM taking PrEP. We identified three behavioral responses: (1) 59% continued with their next scheduled dose; (2) 49% described "making up" for a missed dose by taking medication as soon as possible; and (3) 11% reported "doubling" the next PrEP dose. Participants provided potentially contradictory narratives about their sexual behavior after a missed dose: (1) 54% described making no changes; (2) 49% described adjusting their sexual behavior to reduce HIV risk; and (3) 10% said their decision would be contingent upon how many doses were missed. For PrEP prescribers, our data provide a useful lens to understand patients' lived experiences with PrEP.
Topics: Adult; Bisexuality; HIV Infections; Homosexuality, Male; Humans; Interviews as Topic; Male; Medication Adherence; New York City; Pre-Exposure Prophylaxis; Qualitative Research; Sexual Behavior
PubMed: 30148670
DOI: 10.1521/aeap.2018.30.4.275 -
Journal of Women's Health (2002) Jan 2023Most women take medication during pregnancy despite limited scientific evidence on safety. We investigated medication use, including changes in and reasons for changes...
Most women take medication during pregnancy despite limited scientific evidence on safety. We investigated medication use, including changes in and reasons for changes in use during pregnancy, with attention to medication use in pregnant women with chronic conditions. We conducted an online survey of pregnant women aged ≥18 years ( = 1,226). We calculated descriptive statistics for aspects of medication use and performed multivariable logistic regression to examine associations between change in use and chronic conditions. Seventy-nine percent of women took at least one medication during pregnancy. Among those, 63.2% made at least one medication change: 42.0% started, 34.9% stopped, 30.0% missed dose(s), and 18.1% lowered dose(s) from that originally prescribed or recommended. More than a third (36.5%) of women who stopped, lowered, or missed medication did so independent of health care provider advice; 54.0% cited concern about birth or developmental defects as reasons for change. Odds of medication change were higher for women with chronic conditions: digestive conditions-starting (adjusted odds ratio [AOR] = 1.8, 95% confidence interval [CI] = 1.1-2.7), stopping (AOR = 2.1, 95% CI = 1.4-3.3), and lowering (AOR = 2.4, 95% CI = 1.7-3.3) medication; mental health conditions-starting (AOR = 1.6, 95% CI = 1.2-2.2), stopping (AOR = 3.0, 95% CI = 2.3-4.0), or missing (AOR = 2.1, 95% CI = 1.6-2.8) medication; pain conditions-stopping (AOR = 2.9, 95% CI = 2.0-4.2); and respiratory conditions-starting (AOR = 2.0, 95% CI = 1.3-3.1), stopping (AOR = 1.7, 95% CI = 1.1-2.6), and missing (AOR = 2.2, 95% CI = 1.4-3.4) medication. Most pregnant women take medication and many, including those with chronic conditions, change their medication use during pregnancy. Medication change may occur independent of health care provider advice and due to women's safety concerns.
Topics: Female; Humans; Pregnancy; Adolescent; Adult; Pregnant Women; Chronic Disease; Surveys and Questionnaires; Mental Disorders
PubMed: 36251939
DOI: 10.1089/jwh.2022.0205