Classifying outcomes in secondary and tertiary care clinical quality registries—an organizational case study with the COMET taxonomy

The choice of what patient outcomes are included in clinical quality registries is crucial for comparable and relevant data collection. Ideally, a uniform outcome framework could be used to classify the outcomes included in registries, steer the development of outcome measurement, and ultimately enable better patient care through benchmarking and registry research. The aim of this study was to compare clinical quality registry outcomes against the COMET taxonomy to assess its suitability in the registry context.Peer reviewe

Novel Biomarkers for Diagnosing Periprosthetic Joint Infection from Synovial Fluid and Serum

Background:Synovial fluid bacterial culture is the cornerstone of confirmation or exclusion of periprosthetic joint infection (PJI). The aim of this study was to assess synovial fluid and serum biomarker patterns of patients with total joint arthroplasty (TJA), and the association of these patterns with PJI.Methods:Synovial fluid and serum samples were collected from 35 patients who were admitted to the Arthroplasty Unit of the Department of Orthopaedics and Traumatology at Turku University Hospital. Of the 25 patients who were included in the study, 10 healthy patients with an elective TJA for osteoarthritis served as the control group, and 15 patients who were admitted due to clinical suspicion of PJI with local redness, swelling, wound drainage, pain, and/or fever and who had a positive synovial fluid bacterial culture served as the study group. Logistic regression was used to assess the ability of 37 biomarkers (including cytokines, chemokines, and growth factors) with commercially available tests to detect PJIs.Results:In synovial fluid, the concentrations of sTNF-R1 and sTNF-R2 (soluble tumor necrosis factor receptors 1 and 2) and BAFF (B-cell activating factor, also known as TNFSF13B) were significantly higher in the PJI group (p Conclusions:Synovial sTNF-R2 is a promising new biomarker for detecting PJI. We are not aware of any previous reports of the use of sTNF-R2 in PJI diagnosis. More research is needed to assess the clinical importance of our findings.Level of Evidence:Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.</p

Vaikuttavuustieto jalostuu havainnollistamalla

Terveystaloustiede

Alpha band frontal connectivity is a state-specific electroencephalographic correlate of unresponsiveness during exposure to dexmedetomidine and propofol

Background: Coherent alpha electroencephalogram (EEG) rhythms in the frontal cortex have been correlated with the hypnotic effects of propofol and dexmedetomidine, but less is known about frontal connectivity as a state-specific correlate of unresponsiveness as compared with long-range connectivity. We aimed to distinguish dose- and state-dependent effects of dexmedetomidine and propofol on EEG connectivity.Methods: Forty-seven healthy males received either dexmedetomidine (n=23) or propofol (n =24) as target-controlled infusion with stepwise increments until loss of responsiveness (LOR). We attempted to arouse participants during constant dosing (return of responsiveness [ROR]), and the target concentration was then increased 50% to achieve presumed loss of consciousness. We collected 64-channel EEG data and prefrontal-frontal and anterior-posterior functional connectivity in the alpha band (8-14 Hz) was measured using coherence and weighted phase lag index (wPLI). Directed connectivity was measured with directed phase lag index (dPLI).Results: Prefrontal-frontal EEG-based connectivity discriminated the states at the different drug concentrations. At ROR, prefrontal-frontal connectivity reversed to the level observed before LOR, indicating that connectivity changes were related to unresponsiveness rather than drug concentration. Unresponsiveness was associated with emergence of frontal-to-prefrontal dominance (dPLI: -0.13 to -0.40) in contrast to baseline (dPLI: 0.01-0.02). Coherence, wPLI, and dPLI had similar capability to discriminate the states that differed in terms of responsiveness and drug concentration. In contrast, anterior-posterior connectivity in the alpha band did not differentiate LOR and ROR.Conclusions: Local prefrontal-frontal EEG-based connectivity reflects unresponsiveness induced by propofol or dexmedetomidine, suggesting its utility in monitoring the anaesthetised state with these agents.Clinical trial registration:NCT01889004</div

On no man’s land: Subjective experiences during unresponsive and responsive sedative states induced by four different anesthetic agents

To understand how anesthetics with different molecular mechanisms affect consciousness, we explored subjective experiences recalled after responsive and unresponsive sedation induced with equisedative doses of dexmedetomidine, propofol, sevoflurane, and S-ketamine in healthy male participants (N = 140). The anesthetics were administered in experimental setting using target-controlled infusion or vapouriser for one hour. Interviews conducted after anesthetic administration revealed that 46.9% (n = 46) of arousable participants (n = 98) reported experiences, most frequently dreaming or memory incorporation of the setting. Participants receiving dexmedetomidine reported experiences most often while S-ketamine induced the most multimodal experiences. Responsiveness at the end of anesthetic administration did not affect the prevalence or content of reported experiences. These results demonstrate that subjective experiences during responsive and unresponsive sedation are common and anesthetic agents with different molecular mechanisms of action may have different effects on the prevalence and complexity of the experiences, albeit in the present sample the differences between drugs were minute.</p

Kliinisen tutkimuksen hoitotulosten taksonomia soveltui laaturekistereiden hoitotulosten mittaamisen arviointiin

Tausta: Hoitotulosmittareiden valinta kliinisissä laaturekistereissä on kriittistä olennaisen ja vertailtavan tiedon keräämiseksi. Hoitotulosmittareiden arviointiin tulisi käyttää yhtenäistä hoitotulosten viitekehystä. Tutkimuksen tavoitteena oli tunnistaa sopiva viitekehys ja validoida sitä rekisteriympäristössä. Menetelmät: Kirjallisuudesta etsittiin järjestelmällisesti hoitotulosten viitekehystä, joka on potilaskeskeinen, helppokäyttöinen, yhteinen kliinisen tutkimuksen viitekehysten kanssa ja mahdollistaa rekistereiden arvioinnin. Valittu viitekehys validoitiin HUS Yliopistollisen sairaalan 63 laaturekisteristä kerätyillä hoitotulosmittareilla, jotka poimittiin ja luokiteltiin viitekehyksen avulla. Tulokset: Kirjallisuudesta löytyneistä 23 hoitotulosviitekehyksestä valittiin COMET-taksonomia. HUS:ssa oli suuria eroja laaturekistereiden välillä hoitotulososa-alueissa ja mittareiden määrässä. Fysiologisia mittareita löytyi 98%, resurssikäytön kaikissa ja toimintakyvyn mittareita 62% rekistereistä. Potilaan raportoimia mittareita esiintyi 48% rekistereistä. Pohdinta: COMET-taksonomia oli soveltuva viitekehys laaturekistereiden hoitotulosten mittaamisen arvioimiseksi muutamilla parannusehdotuksilla. HUS:n laaturekisterit ovat erilaisilla kypsyystasoilla, ja kehitettävää löytyi erityisesti potilaan elämään liittyvien vaikutusten mittaamisessa ja hoitotulosmittareiden priorisoinnissa. Tutkimus tarjoaa muille rekistereiden arvioijille vertailukohdan.Objective: The choice of patient outcomes in clinical quality registries is crucial for comparable and relevant data collection. Ideally, a uniform outcome framework would guide the assessment of outcomes. We set out to find a suitable published framework and validate it in clinical quality registries. Study design and Setting: A literature review was conducted to find an outcome framework that is patient-centric, easy-to-use, shared with clinical research, and allows registry evaluation. Chosen outcome framework was validated by extracting and classifying outcomes from 63 clinical quality registries at HUS Helsinki University Hospital, Finland. Results: COMET taxonomy was chosen from 23 published frameworks. HUS Clinical quality registries showed great variation in outcome domains and in number of measures. Physiological outcomes were present in 98%, resource use in all, and functioning domains in 62% of the registries. Patient-reported outcome measures were found in 48% of the registries. Conclusions: The COMET taxonomy was suitable for evaluating the choice of outcomes in clinical quality registries while some improvements are suggested. HUS Helsinki University Hospital clinical quality registries exist at different maturity levels showing room for improvement in life impact outcomes and in outcome prioritization. This article offers a comparison point for other registry evaluators

Directional connectivity between frontal and posterior brain regions is altered with increasing concentrations of propofol.

Recent studies using electroencephalography (EEG) suggest that alteration of coherent activity between the anterior and posterior brain regions might be used as a neurophysiologic correlate of anesthetic-induced unconsciousness. One way to assess causal relationships between brain regions is given by renormalized partial directed coherence (rPDC). Importantly, directional connectivity is evaluated in the frequency domain by taking into account the whole multichannel EEG, as opposed to time domain or two channel approaches. rPDC was applied here in order to investigate propofol induced changes in causal connectivity between four states of consciousness: awake (AWA), deep sedation (SED), loss (LOC) and return of consciousness (ROC) by gathering full 10/20 system human EEG data in ten healthy male subjects. The target-controlled drug infusion was started at low rate with subsequent gradual stepwise increases at 10 min intervals in order to carefully approach LOC (defined as loss of motor responsiveness to a verbal stimulus). The direction of the causal EEG-network connections clearly changed from AWA to SED and LOC. Propofol induced a decrease (p = 0.002-0.004) in occipital-to-frontal rPDC of 8-16 Hz EEG activity and an increase (p = 0.001-0.040) in frontal-to-occipital rPDC of 10-20 Hz activity on both sides of the brain during SED and LOC. In addition, frontal-to-parietal rPDC within 1-12 Hz increased in the left hemisphere at LOC compared to AWA (p = 0.003). However, no significant changes were detected between the SED and the LOC states. The observed decrease in back-to-front EEG connectivity appears compatible with impaired information flow from the posterior sensory and association cortices to the executive prefrontal areas, possibly related to decreased ability to perceive the surrounding world during sedation. The observed increase in the opposite (front-to-back) connectivity suggests a propofol concentration dependent association and is not directly related to the level of consciousness per se

The influence of dexmedetomidine and propofol on circulating cytokine levels in healthy subjects

Background: Surgery and diseases modify inflammatory responses and the immune system. Anesthetic agents also have effects on the human immune system but the responses they induce may be altered or masked by the surgical procedures or underlying illnesses. The aim of this study was to assess how single-drug dexmedetomidine and propofol anesthesia without any surgical intervention alter acute immunological biomarkers in healthy subjects. Methods: Thirty-five healthy, young male subjects were anesthetized using increasing concentrations of dexmedetomidine (n = 18) or propofol (n = 17) until loss of responsiveness (LOR) was detected. The treatment allocation was randomized. Multi-parametric immunoassays for the detection of 48 cytokines, chemokines and growth factors were used. Concentrations were determined at baseline and at the highest drug concentration for each subject. Results: The changes in the concentration of eotaxin (decrease after dexmedetomidine) and platelet-derived growth factor (PDGF, increase after propofol) were statistically significantly different between the groups. Significant changes were detected within both groups; the concentrations of monocyte chemotactic protein 1, chemokine ligand 27 and macrophage migration inhibitory factor were lower in both groups after the drug administration. Dexmedetomidine decreased the concentration of eotaxin, interleukin-18, interleukin-2Ra, stem cell factor, stem cell growth factor and vascular endothelial growth factor, and propofol decreased significantly the levels of hepatocyte growth factor, IFN-.-induced protein 10 and monokine induced by IFN-gamma, and increased the levels of interleukin-17, interleukin-5, interleukin-7 and PDGF. Conclusions: Dexmedetomidine seemed to have an immunosuppressive effect on the immune system whereas propofol seemed to induce mixed pro- and anti-inflammatory effects on the immune system. The choice of anesthetic agent could be relevant when treating patients with compromised immunological defense mechanisms. Trial registration: Before subject enrollment, the study was registered in the European Clinical Trials database (EudraCT number 2013-001496-21, The Neural Mechanisms of Anesthesia and Human Consciousness) and in ClinicalTrials.gov (Principal Investigator: Harry Scheinin, number NCT01889004, The Neural Mechanisms of Anesthesia and Human Consciousness, Part 2, on the 23rd of June 2013)

Individual and mean rPDC values at different stages of the study.

<p>Individual fronto-occipital (F3–O1, F4–O2) 10–20 Hz and occipito-frontal (O1–F3, O2–F4) 8–16 Hz rPDC values during stepwise increased propofol infusion during the awake (AWA) state, sedation (SED), loss of consciousness (LOC) and return of consciousness (ROC). Individual and mean rPDC values are presented with thin and thick lines, respectively.</p