Research Spotlight

Paladino, J., Sanders, J., Kilpatrick, L. B., Prabhakar, R., Kumar, P., O’Connor, N., Durieux, B., Fromme, E. K., Benjamin, E. and Mitchell, S. (2022). “Serious Illness Care Programme-contextual factors and implementation strategies: a qualitative study.” BMJ Support Palliat Care.

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OBJECTIVES: The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients’ values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three ‘real-world’ health system SICP initiatives. METHODS: We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey. RESULTS: Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians’ attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities. CONCLUSIONS: Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.

Montano-Loza, A. J., Ronca, V., Ebadi, M., Hansen, B. E., Hirschfield, G., Elwir, S., Alsaed, M., Milkiewicz, P., Janik, M. K., Marschall, H. U., Burza, M. A., Efe, C., Calışkan, A. R., Harputluoglu, M., Kabaçam, G., Terrabuio, D., de Quadros Onofrio, F., Selzner, N., Bonder, A., Parés, A., Llovet, L., Akyıldız, M., Arikan, C., Manns, M. P., Taubert, R., Weber, A. L., Schiano, T. D., Haydel, B., Czubkowski, P., Socha, P., Ołdak, N., Akamatsu, N., Tanaka, A., Levy, C., Martin, E. F., Goel, A., Sedki, M., Jankowska, I., Ikegami, T., Rodriguez, M., Sterneck, M., Weiler-Normann, C., Schramm, C., Donato, M. F., Lohse, A., Andrade, R. J., Patwardhan, V. R., van Hoek, B., Biewenga, M., Kremer, A. E., Ueda, Y., Deneau, M., Pedersen, M., Mayo, M. J., Floreani, A., Burra, P., Secchi, M. F., Beretta-Piccoli, B. T., Sciveres, M., Maggiore, G., Jafri, S. M., Debray, D., Girard, M., Lacaille, F., Lytvyak, E., Mason, A. L., Heneghan, M. and Oo, Y. H. (2022). “Risk factors and outcomes associated with recurrent autoimmune hepatitis following liver transplantation.” J Hepatol.

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BACKGROUND & AIMS: The impact of recurrent autoimmune hepatitis (AIH) post-liver transplant on patient and graft survival is not well characterised. We evaluated a large, international multi-center cohort to identify the probability and risk factors associated with recurrent AIH and the association between recurrent disease and patient and graft survival. METHODS: We included 736 patients (77% female, mean age, 42±1 years) with AIH who underwent LT from January 1987 through June 2020, among 33 centers in North America, South America, Europe and Asia. Clinical data before and after LT, biochemical data within the first 12 months after LT, and immunosuppression after LT were analyzed to identify patients with higher risk of recurrence of AIH based on histological diagnosis. RESULTS: AIH recurred in 20% of patients after 5 years and 31% after 10 years. Age at LT ≤42 years (HR, 3.15; 95% CI, 1.22-8.16; p=0.02), use of mycophenolate mofetil post-LT (HR, 3.06; 95% CI, 1.39-6.73; p=0.005), donor and recipient sex mismatch (HR, 2.57; 95% CI, 1.39-4.76; p=0.003) and high IgG pre-LT (HR, 1.04; 95% CI, 1.01-1.06; p=0.004) were associated with higher risk of AIH recurrence after adjusting for other confounders. In multivariate Cox regression with time-dependent covariate, recurrent AIH significantly associated with graft loss (HR, 10.79, 95% CI 5.37-21.66, p<0.001) and death (HR, 2.53, 95% CI 1.48-4.33, p=0.001). CONCLUSION: Recurrence of AIH following transplant is frequent and is associated with younger age at LT, use of mycophenolate mofetil post-LT, sex mismatch and high IgG pre-LT. We demonstrate an association between disease recurrence and impaired graft and overall survival in patients with AIH, highlighting ongoing efforts to better characterize, prevent and treat recurrent AIH. LAY ABSTRACT: Recurrent autoimmune hepatitis following liver transplant is frequent and is associated with some recipient features and the type of antirejection medications. Recurrent autoimmune hepatitis negatively affects the outcome after liver transplant.

Mikula, C., Kim, J. H., Phenis, R. and Kiselica, A. (2022). “Specific learning disorder in mathematics and moyamoya disease: A case report.” Appl Neuropsychol Child: 1-8.

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Moyamoya disease (MMD) is a rare neurological condition that causes impaired blood flow to the brain, transient ischemic attacks or strokes, and accompanying cognitive impairments, especially in executive functioning. There is little data on the impact of this rare condition on academic outcomes in late childhood and adolescence. Here, we present the case of Ms. X, a 17-year-old white female diagnosed with MMD, who presented with evidence of a specific learning disorder (SLD) in mathematics. Ms. X was diagnosed with MMD at 6 years old and underwent revascularization surgery. Though she recovered well and progressed adequately in home schooling, she and her mother noticed a decline in memory and academic performance around 16 years old, prompting a neuropsychological evaluation. Cognitive testing revealed low average overall cognitive abilities with impaired planning and organizational skills. While her reading and spelling skills were consistent with her 10th grade academic level, she scored in the 1st percentile on the WRAT-5 Math Computation section, and her mathematical skills were estimated to be at a 2nd grade level. This case adds to the literature by documenting a specific area of academic deficit in an adolescent with MMD. The case highlights that individuals with MMD, especially those with similar executive deficits, may experience selective learning challenges in mathematics. Children with MMD may benefit from specialized academic services and interventions in specific areas of difficulty.

McKenna, G. J., Johannesson, L. and Testa, G. (2022). “Technological Advancements in Uterus Transplantation.” Clin Obstet Gynecol 65(1): 44-51.

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Uterus transplantation is barely a decade old and in a young, evolving field it is hard to identify “technological advances” since it is, in of itself, a technological advance. Nonetheless, one can still identify advances in diagnostic imaging that have improved donor screening to avoid graft losses, highlight the adoption of robotic surgery to make the living donor uterus procurement more minimally invasive, and look to a future of biotechnology like perfusion pumps and bioengineering such as synthetic uterus to increase donor supply. Additional technologies are on the horizon and promise to shape the field further.

Masica, A., Brown, R., Farzad, A., Garrett, J. S., Wheelan, K., Nguyen, H. L., Ogola, G. O., Kudyakov, R., McDonald, B., Boyd, B., Patel, A. and Delaughter, C. (2022). “Effectiveness of an algorithm-based care pathway for patients with non-valvular atrial fibrillation presenting to the emergency department.” J Am Coll Emerg Physicians Open 3(1): e12608.

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OBJECTIVE: Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence-based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non-valvular AF (EDAFMP) on hospital use and care process measures. METHODS: We deployed a voluntary-use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous “usual care” controls, using a propensity-score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non-valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion. RESULTS: Preimplementation (January 1, 2016-December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017-June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29-0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46-0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, P < 0.001) and be referred to a cardiologist (93% vs 29%, P < 0.001) versus the comparator group. CONCLUSION: EDAFMP use is associated with decreased hospital admission during an index ED encounter for non-valvular AF, and improved delivery of AF care processes.