Background: Prolonged hospital lengths of stay increase costs, delay rehabilitation, and expose acute ischemic stroke patients to hospital-acquired infections. We designed and implemented a nurse-driven transitions of care coordinator (TOCC) program to facilitate the transition of care from the acute care hospital setting to rehabilitation centers and home.Methods: This was a single-blinded, prospective, randomized pilot study of 40 participants to evaluate the feasibility of implementing a TOCC program led by a stroke nurse navigator in hospitalized acute ischemic stroke patients. The intervention consisted of a stroke nurse navigator completing eight specific tasks, including meeting with stroke patients and their families, facilitating communication between team members at multi-disciplinary rounds, assisting with referrals to rehabilitation facilities, providing stroke education, and arranging stroke clinic follow-up appointments, which were confirmed to be completed by independent study personnel. The primary outcome was to assess the feasibility of the program. The secondary outcomes included comparing hospital length of stay (LOS) and patient satisfaction between the TOCC and usual care groups. We also explored the association between patient-level variables and LOS.Results: The TOCC program was feasible with all pre-specified components completed in 84.2% (95% CI: 60.4–96.6%) and was not significantly different from the assumed completion rate of 75% (p = 0.438). There was no significant difference in median LOS between the two groups [TOCC 5.95 days (4.02, 9.57) vs. usual care 4.01 days (2.00, 10.45), false discovery rate (FDR)-adjusted p = 0.138]. There was a trend toward higher patient median satisfaction in the TOCC group [TOCC 35.00 (33.00, 35.00) vs. usual care 30 (26.00, 35.00), FDR-adjusted p = 0.1] as assessed by a questionnaire at 30 days after discharge. The TOCC study allowed us to identify patient variables (gender, insurance, stroke severity, and discharge disposition) that were significantly associated with longer hospital LOS.Conclusion: A TOCC program is feasible and can serve as a guide for future allocation of resources to facilitate transitions of care and avoid prolonged hospital stays.
■ Describe the pathophysiology of GERD.■ List the complications of GERD and their histologic, endoscopic, and radiologic features.■ Discuss the current role of multimodality imaging in diagnosis and surveillance of GERD.
PURPOSE Platinum-based doublets with concurrent and maintenance bevacizumab are standard therapy for ovarian cancer (OC) relapsing after a platinum-free interval (PFI) >6 months. Immunotherapy may be synergistic with bevacizumab and chemotherapy. PATIENTS AND METHODS ATALANTE/ENGOT-ov29 (ClinicalTrials.gov identifier: NCT02891824 ), a placebo-controlled double-blinded randomized phase III trial, enrolled patients with recurrent epithelial OC, one to two previous chemotherapy lines, and PFI >6 months. Eligible patients were randomly assigned 2:1 to atezolizumab (1,200 mg once every 3 weeks or equivalent) or placebo for up to 24 months, combined with bevacizumab and six cycles of chemotherapy doublet, stratified by PFI, PD-L1 status, and chemotherapy regimen. Coprimary end points were investigator-assessed progression-free survival (PFS) in the intention-to-treat (ITT) and PD-L1–positive populations (alpha .025 for each population). RESULTS Between September 2016 and October 2019, 614 patients were randomly assigned: 410 to atezolizumab and 204 to placebo. Only 38% had PD-L1–positive tumors. After 3 years' median follow-up, the PFS difference between atezolizumab and placebo did not reach statistical significance in the ITT (hazard ratio [HR], 0.83; 95% CI, 0.69 to 0.99; P = .041; median 13.5 v 11.3 months, respectively) or PD-L1–positive (HR, 0.86; 95% CI, 0.63 to 1.16; P = .30; median 15.2 v 13.1 months, respectively) populations. The immature overall survival (OS) HR was 0.81 (95% CI, 0.65 to 1.01; median 35.5 v 30.6 months with atezolizumab v placebo, respectively). Global health-related quality of life did not differ between treatment arms. Grade ≥3 adverse events (AEs) occurred in 88% of atezolizumab-treated and 87% of placebo-treated patients; grade ≥3 AEs typical of immunotherapy were more common with atezolizumab (13% v 8%, respectively). CONCLUSION ATALANTE/ENGOT-ov29 did not meet its coprimary PFS objectives in the ITT or PD-L1–positive populations. OS follow-up continues. Further research on biopsy samples is warranted to decipher the immunologic landscape of late-relapsing OC.
Introduction: Delay in discharge of acute stroke patients considered medically ready for discharge increases costs and exposure to nosocomial infections, and is frustrating for patients. We evaluated factors associated with delays in discharge in acute ischemic stroke (AIS) patients in a Transitions of Care Coordination (TOCC) study. Methods: From April to July 2018, 29 AIS patients (pts) were randomized to TOCC (n=13) or usual care (n=16) groups. Intracerebral hemorrhage, transient ischemic attack and subarachnoid hemorrhage pts were excluded. In TOCC, a nurse navigator met patient/family, identified barriers to discharge, checked status of diagnostics, attended multi-disciplinary rounds to facilitate rehab referrals, provided stroke education, and coordinated clinic follow-up. Delayed length of stay (dLOS) was defined as the difference between date/time medically ready for discharge and date/time of actual discharge. Demographic variables, NIHSS, mRS and discharge disposition were collected. Continuous variables were analyzed with Wilcoxon rank-sum or Kruskal-Wallis test, and categorical variables with Fisher’s exact test. Results: Pts in the TOCC group were older, but other baseline characteristics were well matched (Table 1). dLOS was significantly correlated with NIHSS ( r s 0.65, p=0.00037. There was a difference in dLOS by insurance type (Medicare 4.05 d vs. Medicaid 17.7 d vs. Commercial 3.0 days, p=0.0250). There was a difference in mean dLOS by discharge disposition (acute rehab 6.5 d, home 1 d, home with home health 1.4 d, subacute rehab 17 d, (and patient death 9 d), p=0.007. There was a difference in distribution of dLOS by distance from home zip code to hospital but no difference was found in the post-hoc analysis. There was no difference in mean dLOS between TOCC and usual care groups (6.5 vs. 4.5 days, p=0.256). Conclusion: Higher NIHSS, Medicaid insurance, and discharge to acute rehab were significantly associated with dLOS in AIS patients.
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