Nevin Manimala

Fam Med. 2022 Mar;54(3):221-225. doi: 10.22454/FamMed.2022.864395.

ABSTRACT

BACKGROUND AND OBJECTIVES: Family physicians play a crucial role in addressing the opioid epidemic. We studied a novel peer-review opioid prescribing educational intervention for family medicine residents that incorporates guided instruction from an interdisciplinary care team.

METHODS: We used a mixed-methods study design in the setting of a family medicine residency program in the Midwestern United States. Residents participated in small group, peer-to-peer discussions of patients chronically prescribed opioids with guidance and input from faculty, a pharmacist, and pharmacy students. Discussions followed a structured approach to evaluation based on guidelines, and written recommendations were given to the patients’ resident primary care physician (PCP). For each patient, we reviewed electronic medical records to assess whether PCPs implemented the written recommendations. We used one-way analyses of variance to determine the statistical significance of changes made. The principal investigator interviewed seven participating residents to survey their satisfaction with the curriculum and collated suggestions for improvement.

RESULTS: Over a 3-year period, we reviewed 59 patients as part of the intervention; of these, 53 had complete records reviewed for this study. Patients’ morphine milligram equivalent dosage (MME) declined modestly (P=.035). The number and proportion of recommendations implemented was correlated with the decline in MME (P=.004 and P=.013, respectively). Interviewed residents unanimously evaluated the curriculum positively, citing that the structured approach helped align their practices with guidelines.

CONCLUSIONS: The guided peer-review intervention effectively decreased chronic opioid use among patients, and residents positively evaluated the curriculum.

PMID:35303305 | DOI:10.22454/FamMed.2022.864395

Fam Med. 2022 Mar;54(3):216-220. doi: 10.22454/FamMed.2022.698419.

ABSTRACT

BACKGROUND AND OBJECTIVES: HIV preexposure prophylaxis (PrEP) has been purposefully incorporated into our family medicine resident training within existing didactic lectures, readings, and routine office visit precepting. This mixed-methods evaluation assesses training strategies for PrEP use via survey and drug use evaluation (DUE).

METHODS: We surveyed 80 current and former family medicine residents (2014-2018) about their exposure to training components, self-reported confidence and competency in PrEP use, and practice behaviors reflecting CDC guidelines for patient eligibility and testing. In addition, we conducted a DUE of patients receiving PrEP from 2012-2018 for adherence to CDC guidelines. We report results with descriptive statistics, with χ2 analysis for group comparisons.

RESULTS: Survey response rate was 56.3%. Among respondents, 46.7% have prescribed PrEP and 55.5% self-assessed as competent to prescribe PrEP, with the majority (84%) rating precepting as most effective for building competence. Those self-assessed as competent were more likely to endorse practice behaviors reflecting CDC guidelines for monitoring PrEP (P<.05). DUE identified 68 patients; 98.5% men who have sex with men. No women with recent sexually transmitted infections, nor persons who inject drugs (PWID) received PrEP. Initial testing completion ranged from 79.4% (HIV) to 54.4% (hepatitis B). Follow-up testing completion ranged from 41.5% (HIV) to 26.4% (syphilis).

CONCLUSIONS: Residents rated precepting as the most effective training. However, DUE demonstrated that PrEP underuse, as well as suboptimal testing, limited experiential training on CDC guidelines. Curricular updates should further emphasize appropriate patient selection for PrEP, including women, minorities, and PWID, as well as robust testing, to continue expanding PrEP access.

PMID:35303304 | DOI:10.22454/FamMed.2022.698419

Curr Nutr Rep. 2022 Mar 18. doi: 10.1007/s13668-022-00405-4. Online ahead of print.

ABSTRACT

PURPOSE OF REVIEW: Drug-resistant epilepsy represents around one-quarter of epilepsies worldwide. Although ketogenic diets (KD) have been used for refractory epilepsy since 1921, the past 15 years have witnessed an explosion of KD use in the management of epilepsy. We aimed to review evidence from randomized controlled trials (RCTs) regarding the efficacy and safety of KD in drug-resistant epilepsy in children and adolescents.

RECENT FINDINGS: A literature search was performed in the Pubmed, Cohrane, Scopus, ClinicalTrials.gov, and Google Scholar databases. Predefined criteria were implemented regarding data extraction and study quality. Data were extracted from 14 RCTs in 1114 children and adolescents aged from 6 months to 18 years. Primary outcome was seizure reduction after the intervention. In 6 out of the 14 studies, there was a statistical significant seizure reduction by > 50% in the KD-treated group compared with the control group over a follow-up of 3-4 months. Secondary outcomes were adverse events, seizure severity, quality of life, and behavior. Gastrointestinal symptoms were the most frequent adverse events. Serious adverse events were rare. We conclude that the KD is an effective treatment for drug-resistant epilepsy in children and adolescents. Accordingly, RCTs investigating long-term impact, cognitive and behavioral effects, and cost-effectiveness are much anticipated.

PMID:35303283 | DOI:10.1007/s13668-022-00405-4

Neurosurg Rev. 2022 Mar 18. doi: 10.1007/s10143-022-01771-x. Online ahead of print.

ABSTRACT

This study aimed to investigate the value of apparent diffusion coefficient (ADC) histogram analysis in differentiating intracranial solitary fibrous tumor/hemangiopericytoma (SFT/HPC) from atypical meningioma (ATM). Retrospective analyzed the clinical, magnetic resonance imaging, and pathological data of 20 and 25 patients with SFT/HPC and ATM, respectively. Histogram analysis was performed on the axial ADC images using MaZda software, and nine histogram parameters were obtained, including mean, variance, skewness, kurtosis, and the 1^st (ADC1), 10^th (ADC10), 50^th (ADC50), 90^th (ADC90), and 99^th (ADC99) percentile ADC. Differences in ADC histogram parameters between SFT/HPC and ATM were compared by an independent t test or Mann-Whitney U test, while the statistically significant histogram parameters were further analyzed by drawing receiver operating characteristic (ROC) curves to evaluate the differential diagnostic performance. Among the nine ADC histogram parameters we extracted, the mean, ADC1, ADC10, ADC50, and ADC90 in the SFT/HPC group were greater than those of ATM, and significant differences were observed (all P < 0.05). ROC analysis showed that the ADC1 generated the highest area under the curve (AUC) value of 0.920 in distinguishing the two tumors, when using 91.00 as the optimal threshold. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value in distinguishing between SFT/HPC and ATM were 84.00%, 85.00%, 84.44%, 87.50%, and 81.00%, respectively. ADC histogram analysis can be a reliable tool to differentiate between SFT/HPC and ATM, with the ADC1 being the most promising potential parameter.

PMID:35303202 | DOI:10.1007/s10143-022-01771-x

Eur J Health Econ. 2022 Mar 18. doi: 10.1007/s10198-022-01443-z. Online ahead of print.

ABSTRACT

The skilled labour shortage in nursing is an issue not unique to Germany. Unattractive characteristics of nursing jobs are one reason for the low supply in nursing personnel. In our study, we analyse the influence of job characteristics on the attractiveness of nursing jobs. We address this issue via factorial survey analysis, an experimental method particularly suited to assessing personal opinions and less prone to social desirability bias than standard interview methods. Around 1300 (current and former) nurses in a distinct region in Germany were asked to rate a set of synthetic job postings, each of which contained information on 9 systematically varied job characteristics. We find that, first, attractiveness of care jobs is most strongly affected by rather “soft” characteristics such as atmosphere within the team and time for patients. “Hard” factors play a considerably smaller role. Second, one hard factor, contract duration, is estimated to be among the most important job factors, however. This is a remarkable finding given that nursing occupations suffer from severe skill shortages. Third, though wage has a statistically significant influence on attractiveness, enormous wage raises would be needed to yield higher attractiveness gains than the top-rated soft factors, or to compensate for less pleasant job characteristics with respect to those factors. Last, even after controlling for other job characteristics, hospital nursing is still rated as more attractive than geriatric nursing.

PMID:35303192 | DOI:10.1007/s10198-022-01443-z

J Orthop Traumatol. 2022 Mar 18;23(1):15. doi: 10.1186/s10195-022-00633-y.

ABSTRACT

STUDY DESIGN: Monocentric, prospective, observational study.

OBJECTIVE: The clinical relevance of bacterial colonization of intervertebral discs is controversial. This study aimed to determine a possible relationship between bacterial and viral colonization and low-grade infection of the discs.

METHODS: We investigated 447 disc samples from 392 patients. Microbiological culture was used to examine the samples for bacterial growth, polymerase chain reaction (PCR) was used for detection of herpes simplex virus types 1 and 2 (HSV-1, HSV-2) and Cytomegalovirus (CMV), and histopathological analysis was used to detect signs of inflammation. The results were compared between subgroups organized according to gender, age, location of the samples, surgical approach, preoperative C-reactive protein (CRP), preoperative and 6 months postoperative Oswestry Disability Index (ODI) and Neck Disability Index (NDI), and Modic changes (MC) of the corresponding endplates. Also, we assessed the occurrence of postoperative infections within 6 months.

RESULTS: Microbiological culture was positive in 38.78% of the analyzed intervertebral discs. Altogether, 180 bacteria were isolated. Coagulase-negative staphylococci (CONS) (23.41%) and Cutibacterium acnes (18.05%) were the most frequently detected microorganisms. None of HSV-1, HSV-2, or CMV were detected. Male patients (p = 0.00036) and cervical segments (p = 0.00001) showed higher rates of positive culture results. Ventral surgical approaches ( p < 0.001) and Type 2 MC (p = 0.0127) were significantly associated with a positive microbiological result ( p< 0.001). Neither pre- nor postoperative ODI and NDI are associated with positive culture results. In 4 (1.02%) patients, postoperative spondylodiscitis occurred.

CONCLUSIONS: With 447 segments from 392 patients, we present one of the largest studies to date. While disc degeneration caused by HSV-1, HSV-2, and CMV seems unlikely, we found positive microbiological culture results in 38.78% of all discs. The role of local skin flora and sample contamination should be the focus of further investigations.

LEVEL OF EVIDENCE: III.

TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (ID: NCT04712487, https://www.

CLINICALTRIALS: gov/ct2/show/study/NCT04712487 ).

PMID:35303173 | DOI:10.1186/s10195-022-00633-y

World J Urol. 2022 Mar 18. doi: 10.1007/s00345-022-03984-7. Online ahead of print.

ABSTRACT

PURPOSE: To investigate acceptance and efficacy of recommended adjuvant radiotherapy in patients with positive lymph nodes at radical prostatectomy.

METHODS: Among 495 patients with positive lymph nodes who consecutively underwent radical prostatectomy between 2007 and 2017, we investigated 347 patients who were recommended to undergo adjuvant radiotherapy by a multidisciplinary post-therapeutic tumor board and in whom information whether such treatment was eventually given was available. The median follow-up for censored patients was 5.4 years. Univariate analyses were performed using Kaplan-Meier curves, Mantel-Haenszel hazard ratios and log rank tests. Proportional hazard models for competing risks were used for multivariable analyses.

RESULTS: Adjuvant radiotherapy was independently associated with lower overall mortality and in high-risk patients (Gleason score 8-10 or three or more involved lymph nodes) also with lower prostate cancer-specific mortality. In patients with a Gleason score of 8-10 or three or more involved lymph nodes, the hazard ratio for adjuvant radiotherapy was 0.455 (95% confidence interval 0.257-0.806, p = 0.0069) for overall and 0.426 (95% confidence interval 0.201-0.902, p = 0.0259) for prostate cancer-specific mortality. Among patients receiving adjuvant radiotherapy, there was a trend to lower mortality when such treatment was combined with adjuvant androgen deprivation.

CONCLUSION: Adjuvant radiotherapy decreased mortality in patients with positive lymph nodes at radical prostatectomy with further disease factors but not in patients with low-risk disease. Simultaneous androgen deprivation might increase efficacy. Multidisciplinary recommendations may possibly increase the use of adjuvant radiotherapy in this setting.

PMID:35303155 | DOI:10.1007/s00345-022-03984-7

Cancer Chemother Pharmacol. 2022 Mar 18. doi: 10.1007/s00280-022-04421-7. Online ahead of print.

NO ABSTRACT

PMID:35303141 | DOI:10.1007/s00280-022-04421-7

Intensive Care Med. 2022 Mar 18. doi: 10.1007/s00134-022-06668-3. Online ahead of print.

NO ABSTRACT

PMID:35303118 | DOI:10.1007/s00134-022-06668-3

Abdom Radiol (NY). 2022 Mar 18. doi: 10.1007/s00261-022-03490-9. Online ahead of print.

ABSTRACT

OBJECTIVE: To (1) compare bladder cancer (BC) muscle invasiveness among three b-values using a contrast-free approach based on Vesical Imaging-Reporting and Data System (VI-RADS), to (2) determine if muscle-invasiveness assessment is affected by the reader experience, and to (3) compare BC conspicuity among three b-values, qualitatively and quantitatively.

METHODS: Thirty-eight patients who underwent a bladder MRI on a 3.0-T scanner were enrolled. The gold standard was histopathology report following transurethral resection of BC. Three sets of images, including T2w and different b-values for DWI, set 1 (b = 1000 s/mm²), set 2 (b = 1500 s/mm²), and set 3 (b = 2000 s/mm²), were reviewed by three differently experienced readers. Descriptive statistics and Intraclass Correlation Coefficient (ICC) were calculated. Comparisons among readers and DWI sets were performed with the Wilcoxon test. Receiver operating characteristic (ROC) analysis was performed. Areas under the curves (AUCs) and pairwise comparison were calculated.

RESULTS: AUCs of muscle-invasiveness assessment ranged from 0.896 to 0.984 (reader 1), 0.952-0.968 (reader 2), and 0.952-0.984 (reader 3) without significant differences among different sets and readers (p > 0.05). The mean conspicuity qualitative scores were higher in Set 1 (2.21-2.33), followed by Set 2 (2-2.16) and Set 3 (1.82-2.14). The quantitative conspicuity assessment showed that mean normalized intensity of tumor was significantly higher in Set 2 (4.217-4.737) than in Set 1 (3.923-4.492) and Set 3 (3.833-3.992) (p < 0.05).

CONCLUSION: Muscle invasiveness can be assessed with high accuracy using a contrast-free protocol with T2W and DWI, regardless of reader’s experience. b = 1500 s/mm² showed the best tumor delineation, while b = 1000 s/mm² allowed for better tumor-wall interface assessment.

PMID:35303112 | DOI:10.1007/s00261-022-03490-9