Reduction of Postoperative Delirium and Opioid Use in Hip Fracture Patients Through Utilization of Emergency Department Physician Administered Regional Nerve Blocks

Introduction The complication of delirium for hip fracture patients is a predictor of mortality. Use of opioid medication increases the incidence of delirium in the pre- and postoperative periods. Regional nerve blocks are effective in managing acute pain for acute hip fractures. This study aims to evaluate the utilization of ED physicians to perform fascia iliaca nerve blocks on hip fracture patients to decrease the incidence of delirium by decreasing usage of opioid medication. Methods A quality improvement project for performing regional nerve blocks on patients with femoral neck fractures was implemented during fiscal year 2019. Data was collected retrospectively for frequency of ED nerve block procedures, amount of opioid medication use, and incidence of delirium in patients diagnosed with hip fracture. This data was compared to baseline data to determine success of the intervention. Results Utilization of regional nerve blocks in the ED increased from 2% in 2018 to 96% in 2021 and 89% in 2022. Preoperative opioid usage decreased from 38 MMEs to 16.9 and 18 MMEs respectively. Daily average MMEs decreased from 34 to 12.1 and 14 respectively. Postoperative delirium decreased from 6% in 2018 to 0% from 2020 to 2022. Discussion ED provider administration of fascia iliaca blocks and follow-up is a novel practice in our region to decrease the adverse effects of opiate use and decrease delirium rates. There was a reduction in length of stay and increased discharge home rate despite the Covid-19 pandemic. Conclusion Administration of regional nerve blocks by ED physicians to hip fracture patients presenting to the ED results in a decrease in opioid medication usage. This also results in a decreased delirium rates in the hip fracture patient population

Cervical cancer screening and adherence to follow-up among Hispanic women study protocol: a randomized controlled trial to increase the uptake of cervical cancer screening in Hispanic women

Abstract Background In the US, Hispanic women have a higher incidence of, and mortality from, cervical cancer than non-Hispanic white women. The reason for this disparity may be attributable to both low rates of screening and poor adherence to recommended diagnostic follow-up after an abnormal Pap test. The 'Cervical Cancer Screening and Adherence to Follow-up Among Hispanic Women' study is a collaboration between a research institution and community partners made up of members from community based organizations, the Yakima Valley Farm Workers Clinic and the Breast, Cervical, and Colon Health Program of the Yakima District . The study will assess the efficacy of two culturally-appropriate, tailored educational programs designed to increase cervical cancer screening among Hispanic women, based in the Yakima Valley, Washington, US. Methods/design A parallel randomized-controlled trial of 600 Hispanic women aged 21–64, who are non-compliant with Papanicolau (Pap) test screening guidelines. Participants will be randomized using block randomization to (1) a control arm (usual care); (2) a low-intensity information program, consisting of a Spanish-language video that educates women on the importance of cervical cancer screening; or (3) a high-intensity program consisting of the video plus a ‘promotora’ or lay-community health educator-led, home based intervention to encourage cervical cancer screening. Participants who attend cervical cancer screening, and receive a diagnosis of an abnormal Pap test will be assigned to a patient navigator who will provide support and information to promote adherence to follow-up tests, and any necessary surgery or treatment. Primary endpoint: Participants will be tracked via medical record review at community-based clinics, to identify women who have had a Pap test within 7 months of baseline assessment. Medical record reviewers will be blinded to randomization arm. Secondary endpoint: An evaluation of the patient navigator program as a method to improve adherence and reduce time to follow-up among participants who receive an abnormal Pap test result. An additional secondary endpoint is the cost-effectiveness of the two different intensity intervention programs. Discussion This culturally sensitive intervention aims to increase compliance and adherence to cervical screening in a Hispanic population. If effective, such interventions may reduce incidence of cervical cancer. Trial registration NCT01525433</p

Characterizing the kinetics of lymphocytosis in patients with chronic lymphocytic leukemia treated with single-agent ibrutinib

Increased absolute lymphocyte count (ALC) is a key feature of chronic lymphocytic leukemia (CLL) but is also observed during treatment with B-cell receptor pathway inhibitors including ibrutinib, a first-in-class inhibitor of Bruton’s tyrosine kinase. In patients with CLL treated with single-agent ibrutinib in two multicenter, open-label, randomized, phase 3 studies (RESONATE-2, NCT01722487; RESONATE, NCT01578707), lymphocytosis was observed in 77 of 136 (57%) patients treated in first-line and 133 of 195 (69%) relapsed/refractory patients. On treatment, lymphocytosis resolved in 95% of patients in the first-line and 94% in the relapsed/refractory setting. The median duration of lymphocytosis was 12 and 14 weeks in the first-line and relapsed/refractory settings, respectively. Lymphocytosis is a common and predictable pharmacodynamic effect of ibrutinib treatment, and in the absence of other signs of progression, does not represent disease progression. Lymphocytosis resolves in the majority of patients and does not require interruption or discontinuation of ibrutinib therapy

Patterns and practices in fisheries assessment peer review systems

With wild-capture fisheries, important globally as a source of food and livelihood, and facing chronic overfishing, development of the best available science can reduce scientific uncertainty and improve the quality of science-based advice and the credibility to stakeholders of the management decisions based on that science. Fish stock assessments are complex scientific analyses used to provide critical, science-based advice for decision-making, such as quota setting. Building on findings from a 2017 American Fisheries Society (AFS) symposium, this paper describes and compares different national, multilateral, and private peer review systems to assess peer review characteristics and the role of peer review in the development of best available science and science-based advice. There is considerable diversity in how peer review systems are organized in terms of how reviewers are selected, use of internal or external expertise, the level of independence required of reviewers, and the steps in the assessment process at which peer review is conducted. Peer review systems face a number of challenges, including limited funding, a small pool of available expertise and the often highly technical nature of reviews, and trade-offs related to competing demands such as thoroughness versus timeliness, independent technical expertise versus local knowledge, and efficiency versus transparency, among others. The prevalence of peer review systems underscores the importance of objective, peer-reviewed, scientific-based advice across fishery management systems. The diversity of approaches to peer review demonstrates that there is no one ideal way to implement peer review, and there are tradeoffs inherent in designing a peer-review system.•Peer review of stock assessments is a key component of fishery management systems.•Transparent peer review enhances stakeholder acceptance of science-based advice.•Systems differ in reviewer source and compensation, throughput, consensus.•Systems can avoid reviewer conflicts of interest, or seek and acknowledge them.•System trade-offs include thoroughness/timeliness, independence/local knowledge

Evaluation of 230 patients with relapsed/refractory deletion 17p chronic lymphocytic&nbsp;leukaemia treated with ibrutinib from 3 clinical trials.

Patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL) with deletion 17p [del(17p)] have poor outcomes with chemoimmunotherapy. Ibrutinib is indicated for the treatment of CLL/SLL, including del(17p) CLL/SLL, and allows for treatment without chemotherapy. This integrated analysis was performed to evaluate outcomes in 230 patients with relapsed/refractory del(17p) CLL/SLL from three ibrutinib studies. With a median of 2 prior therapies (range, 1-12), 18% and 79% of evaluable patients had del(11q) or unmutated IGHV, respectively. With a median follow-up of 28&nbsp;months, overall response rate was 85% and estimated 30-month progression-free and overall survival rates were 57% [95% confidence interval (CI) 50-64] and 69% (95% CI 61-75), respectively. Patients with normal lactate dehydrogenase or no bulky disease had the most favourable survival outcomes. Sustained haematological improvements in haemoglobin, platelet count and absolute neutrophil count occurred in 61%, 67% and 70% of patients with baseline cytopenias, respectively. New onset severe cytopenias and infections decreased in frequency over time. Progression-free and overall survival with ibrutinib surpass those of other therapies for patients with del(17p) CLL/SLL. These results provide further evidence of the robust clinical activity of ibrutinib in difficult-to-treat CLL/SLL populations