Doing without the residential component of a blended postgraduate rural medical programme during the 2020 COVID-19 pandemic in New Zealand: student perspectives.

AIM: Rural-targeted postgraduate medical training is a key factor associated with entering rural practice. Rural health professionals often experience geographical and professional isolation, which can impact their training and education. In New Zealand, during the 2020 COVID-19 pandemic, an established distance postgraduate rural medical programme replaced its in-person residentials with virtual workshops. This study aimed to gain insights into the student experience of the virtual workshops, with emphasis on exploring the effects of the absence of an in-person component. METHOD: Qualitative exploratory design. All students who had completed a semester one 2020 University of Otago rural postgraduate module were invited by email to participate. Fifteen semi-structured interviews were conducted by video-conference. A thematic analysis was conducted using a general inductive approach. RESULTS: Three themes captured the main issues. 1. Making sure everyone is in the same boat: the key roles of an in-person component were identified as consolidation of learning, benchmarking and connectedness. 2. Learning but not connecting: virtual workshops were well facilitated, allowed continuation of study and the convenience of staying home, however connectedness faded. 3. We've got to keep a human touch in a digital age: looking beyond the pandemic, opportunities for streamlining virtual content were identified, however there was concern around diminished communication and cultural aspects of learning and the absent connection with rural health services and communities. CONCLUSION: A virtual workshop is valuable in the COVID-19 environment but does not replace an in-person component of a distance postgraduate training programme for rural medicine.

American Society of Breast Surgeons' Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema.

BACKGROUND: In 2017, the American Society of Breast Surgeons (ASBrS) published expert panel recommendations for patients at risk for breast cancer-related lymphedema (BCRL) and those affected by BCRL. This study sought to determine BCRL practice patterns. METHODS: A survey was sent to 2975 ASBrS members. Questions evaluated members' clinical practice type, practice duration, and familiarity with BCRL recommendations. Descriptive statistics, the chi-square test, and Fisher's exact test were used. RESULTS: Of the ASBrS members surveyed, 390 (13.1%) responded. Most of the breast surgeons (58.5%, 228/390) indicated unfamiliarity with recommendations. Nearly all respondents (98.7%, 385/390) educate at-risk patients. Most (60.2%, 234/389) instruct patients to avoid venipuncture, injection or blood pressure measurements in the at-risk arm, and 35.6% (138/388) recommend prophylactic compression sleeve use during air travel. Nearly all (97.7%, 380/389) encourage those at-risk to exercise, including resistance exercise (86.2%, 331/384). Most do not perform axillary reverse mapping (ARM) (67.9%, 264/389) or a lymphatic preventive healing approach (LYMPHA) (84.9%, 331/390). Most (76.1%, 296/389) screen at-risk patients for BCRL. The most frequently used screening tools include self-reported symptoms (81%, 255/315), circumferential tape measure (54%, 170/315) and bioimpedance spectroscopy (27.3%, 86/315). After a BCRL diagnosis, most (90%, 351/390) refer management to a lymphedema-certified physical therapist. For affected patients, nearly all encourage exercise (98.7%, 384/389). Many (49%, 191/390) refer affected patients for consideration of lymphovenous bypass or lymph node transfer. CONCLUSION: Most respondents were unfamiliar with the ASBrS expert panel recommendations for patients at risk for BCRL and those affected by BCRL. Opportunities exist to increase awareness of best practices and to acquire ARM and LYMPHA technical expertise.

Fecal microbiota transplant from a rational stool donor improves hepatic encephalopathy: A randomized clinical trial.

Recurrent hepatic encephalopathy (HE) is a leading cause of readmission despite standard of care (SOC) associated with microbial dysbiosis. Fecal microbiota transplantation (FMT) may improve dysbiosis; however, it has not been studied in HE. We aimed to define whether FMT using a rationally derived stool donor is safe in recurrent HE compared to SOC alone. An open-label, randomized clinical trial with a 5-month follow-up in outpatient men with cirrhosis with recurrent HE on SOC was conducted with 1:1 randomization. FMT-randomized patients received 5 days of broad-spectrum antibiotic pretreatment, then a single FMT enema from the same donor with the optimal microbiota deficient in HE. Follow-up occurred on days 5, 6, 12, 35, and 150 postrandomization. The primary outcome was safety of FMT compared to SOC using FMT-related serious adverse events (SAEs). Secondary outcomes were adverse events, cognition, microbiota, and metabolomic changes. Participants in both arms were similar on all baseline criteria and were followed until study end. FMT with antibiotic pretreatment was well tolerated. Eight (80%) SOC participants had a total of 11 SAEs compared to 2 (20%) FMT participants with SAEs (both FMT unrelated; P = 0.02). Five SOC and no FMT participants developed further HE (P = 0.03). Cognition improved in the FMT, but not the SOC, group. Model for End-Stage Liver Disease (MELD) score transiently worsened postantibiotics, but reverted to baseline post-FMT. Postantibiotics, beneficial taxa, and microbial diversity reduction occurred with Proteobacteria expansion. However, FMT increased diversity and beneficial taxa. SOC microbiota and MELD score remained similar throughout. CONCLUSION: FMT from a rationally selected donor reduced hospitalizations, improved cognition, and dysbiosis in cirrhosis with recurrent HE. (Hepatology 2017;66:1727-1738).

Perioperative Use of Coagulation Factor Concentrates in Patients Undergoing Cardiac Surgery.

Coagulopathy and bleeding are common in patients undergoing cardiac surgery, with a perioperative transfusion rate in excess of 50%. The mechanism of coagulopathy associated with cardiac surgery using cardiopulmonary bypass is multifactorial. Historically, coagulation factor-mediated bleeding in such instances has been treated with allogeneic plasma transfusion. Coagulation factor concentrate use for treatment of hemophilia, congenital factor deficiencies and, more recently, emergency warfarin reversal is common. Formulations of factor concentrates include single and multifactor concentrates and both human and recombinant-derived products. Off-label use of factor concentrates for coagulopathy and bleeding associated with cardiac surgery has been described for decades; however, sound clinical research with regard to this practice is limited. This review highlights the literature discussing the use of factor concentrates in patients undergoing cardiac surgery and provides an overview of reasonable uses or lack thereof for factor concentrates in clinical practice.

Ferric citrate controls phosphorus and delivers iron in patients on dialysis.

Patients on dialysis require phosphorus binders to prevent hyperphosphatemia and are iron deficient. We studied ferric citrate as a phosphorus binder and iron source. In this sequential, randomized trial, 441 subjects on dialysis were randomized to ferric citrate or active control in a 52-week active control period followed by a 4-week placebo control period, in which subjects on ferric citrate who completed the active control period were rerandomized to ferric citrate or placebo. The primary analysis compared the mean change in phosphorus between ferric citrate and placebo during the placebo control period. A sequential gatekeeping strategy controlled study-wise type 1 error for serum ferritin, transferrin saturation, and intravenous iron and erythropoietin-stimulating agent usage as prespecified secondary outcomes in the active control period. Ferric citrate controlled phosphorus compared with placebo, with a mean treatment difference of -2.2±0.2 mg/dl (mean±SEM) (P<0.001). Active control period phosphorus was similar between ferric citrate and active control, with comparable safety profiles. Subjects on ferric citrate achieved higher mean iron parameters (ferritin=899±488 ng/ml [mean±SD]; transferrin saturation=39%±17%) versus subjects on active control (ferritin=628±367 ng/ml [mean±SD]; transferrin saturation=30%±12%; P<0.001 for both). Subjects on ferric citrate received less intravenous elemental iron (median=12.95 mg/wk ferric citrate; 26.88 mg/wk active control; P<0.001) and less erythropoietin-stimulating agent (median epoetin-equivalent units per week: 5306 units/wk ferric citrate; 6951 units/wk active control; P=0.04). Hemoglobin levels were statistically higher on ferric citrate. Thus, ferric citrate is an efficacious and safe phosphate binder that increases iron stores and reduces intravenous iron and erythropoietin-stimulating agent use while maintaining hemoglobin.

Ferric carboxymaltose in patients with iron-deficiency anemia and impaired renal function: the REPAIR-IDA trial.

BACKGROUND: Iron-deficiency anemia in non-dialysis-dependent chronic kidney disease (NDD-CKD) frequently requires parenteral iron replacement, but existing therapies often require multiple administrations. We evaluated the efficacy and cardiovascular safety of ferric carboxymaltose (FCM), a non-dextran parenteral iron permitting large single-dose infusions, versus iron sucrose in patients with iron-deficiency anemia and NDD-CKD. METHODS: A total of 2584 participants were randomized to two doses of FCM 750 mg in one week, or iron sucrose 200 mg administered in up to five infusions in 14 days. The primary efficacy endpoint was the mean change to highest hemoglobin from baseline to Day 56. The primary composite safety endpoint included all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, unstable angina, congestive heart failure, arrhythmias and hyper- and hypotensive events. RESULTS: The mean hemoglobin increase was 1.13 g/dL in the FCM group and 0.92 g/dL in the iron sucrose group (95% CI, 0.13-0.28). Similar results were observed across all subgroups, except Stage 2 CKD. More subjects in the FCM group achieved a hemoglobin increase of ≥ 1.0 g/dL between baseline and Day 56 (48.6 versus 41.0%; 95% CI, 3.6-11.6%). There was no significant difference between FCM and iron sucrose recipients with respect to the primary composite safety endpoint, including the major adverse cardiac events of death, myocardial infarction, or stroke. A significant difference in the number of protocol-defined, predominantly transient hypertensive episodes was observed in the FCM group. CONCLUSIONS: Two 750-mg infusions of FCM are a safe and effective alternative to multiple lower dose iron sucrose infusions in NDD-CKD patients with iron-deficiency anemia.

The effect of neighborhood socioeconomic status on education and health outcomes for children living in social housing.

OBJECTIVES: We explored differences in health and education outcomes between children living in social housing and not, and effects of social housing's neighborhood socioeconomic status. METHODS: In this cohort study, we used the population-based repository of administrative data at the Manitoba Centre for Health Policy. We included children aged 0 to 19 years in Winnipeg, Manitoba, in fiscal years 2006-2007 to 2008-2009 (n = 13,238 social housing; n = 174,017 others). We examined 5 outcomes: age-2 complete immunization, a school-readiness measure, adolescent pregnancy (ages 15-19 years), grade-9 completion, and high-school completion. Logistic regression and generalized estimating equation modeling generated rates. We derived neighborhood income quintiles (Q1 lowest, Q5 highest) from average household income census data. RESULTS: Children in social housing fared worse than comparative children within each neighborhood income quintile. When we compared children in social housing by quintile, preschool indicators (immunization and school readiness) were similar, but adolescent outcomes (grade-9 and high-school completion, adolescent pregnancy) were better in Q3 to Q5. CONCLUSIONS: Children in social housing had poorer health and education outcomes than all others, but living in social housing in wealthier areas was associated with better adolescent outcomes.

Revision of Wise pattern breast reductions with vertical procedures.

A small percentage of patients who undergo Wise pattern mammaplasties request revisions to address recurrent macromastia or poor breast shape. Reuse of the Wise pattern method at times results in disappointing aesthetic results. Recently, in a series of 15 consecutive patients, we used vertical techniques with glandular reshaping to perform these revisions. Advantages include the ability to significantly improve breast shape and to avoid reopening of potentially problematic inframammary scars. No major complications occurred. Patients have been uniformly pleased with the significant improvement in their breast contour, width, and size. In summary, despite the use of the Wise pattern method for the original procedure, consideration should be given to use vertical techniques for revisions in that they are safe and can better address patient goals. Gratifying results can be achieved.

New Zealand postgraduate medical training by distance for Pacific Island country-based general practitioners: a qualitative study.

Introduction New Zealand health training institutions have an important role in supporting health workforce training programmes in the Pacific Region. Aim To explore the experience of Pacific Island country-based doctors from the Cook Islands, Niue, and Samoa, studying in New Zealand's University of Otago distance-taught Rural Postgraduate programme. Methods Document analysis (16 documents) was undertaken. Eight semi-structured interviews were conducted with Pacific Island country-based students. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately, followed by a process to converge and corroborate findings. Results For Pacific Island countries with no previous option for formal general practice training, access to a recognised academic programme represented a milestone. Immediate clinical relevance and applicability of a generalist medical curriculum with rural remote emphasis, delivered mainly at a distance, was identified as a major strength. Although technologies posed some issues, these were generally easily solved. The main challenges identified related to the provision of academic and other support. Traditional university support services and resources were campus focused and not always easily accessed by this group of students who cross educational pedagogies, health systems and national borders to study in a New Zealand programme. Study for individuals worked best when it was part of a recognised and supported Pacific in-country training pathway. Discussion The University of Otago's Rural Postgraduate programme is accessible, relevant and achievable for Pacific Island country-based doctors. The programme offers a partial solution for training in general practice for the Pacific region. Student experience could be improved by tailoring and strengthening support services and ensuring their effective delivery.

Contemporary Perioperative Management of Direct Oral Anticoagulants.

Direct oral anticoagulants (DOACs) have rapidly emerged as popular alternatives to warfarin in the setting of nonvalvular atrial fibrillation, prevention and treatment of venous thromboembolism, and secondary prevention of arterial thrombosis. It is now estimated that more patients in the United States take DOACs than warfarin for approved indications. Studies to date have shown that these drugs are similarly efficacious with perhaps a lower bleeding risk than warfarin. The purpose of this review is to provide insight into the currently available DOACs and discuss the management and reversal strategies for patients in the perioperative period.

Addressing fatigue in medical residents with biomathematical fatigue modeling.

Fatigue in resident physicians has been identified as a factor that contributes to burnout and a decline in overall wellbeing. Fatigue risk exists because of poor sleep habits and demanding work schedules that have only increased due to the COVID-19 pandemic. At this time, it is important not to lose sight of how fatigue can impact residents and how fatigue risk can be mitigated. While fatigue mitigation is currently addressed by duty hour restrictions and education about fatigue, Fatigue Risk Management Systems (FRMSs) offer a more comprehensive strategy for addressing these issues. An important component of FRMS in other shiftwork industries, such as aviation and trucking, is the use of biomathematical models to prospectively identify fatigue risk in work schedules. Such an approach incorporates decades of knowledge of sleep and circadian rhythm research into shift schedules, taking into account not just duty hour restrictions but the temporal placement of work schedules. Recent research has shown that biomathematical models of fatigue can be adapted to a resident physician population and can help address fatigue risk. Such models do not require subject matter experts and can be applied in graduate medical education program shift scheduling. It is important for graduate medical education program providers to consider these alternative methods of fatigue mitigation. These tools can help reduce fatigue risk and may improve wellness as they allow for a more precise fatigue management strategy without reducing overall work hours.

Meta-analysis on continuous nerve monitoring in thyroidectomies.

In the last decade, the introduction of continuous intraoperative recurrent laryngeal nerve (RLN) monitoring (C-IONM) has enabled the operator to verify the functional integrity of the vagus nerve-recurrent laryngeal nerve (VN-RLN) axis in real-time. We aim to present the current evidence on C-IONM utility for thyroid surgery by conducting the first meta-analysis on this technique. A systematic review of literature was conducted by two independent reviewers via Ovid in the Medline, EMBASE, and Cochrane reviews databases. The search was limited to human subject research in peer-reviewed articles of all languages published between Jan 1946 and April 2020. Medical subject headings (MeSH) terms utilized were thyroid surgery, thyroidectomies, recurrent laryngeal nerve, vagal nerve, monitor, and stimulation. Thirty-eight papers were identified from Ovid, another six papers were identified by hand-search. A random effect meta-analysis was performed with assessment of heterogeneity using the I2 value. A total of 23 papers that investigated the use of continuous vagal nerve monitoring during thyroid surgery were identified. The proportion of nerves at risk (NAR) with temporary RLN paralysis postoperation was 2.26% (95% CI: 1.6-2.9, I2  = 37). The proportion of NAR with permanent RLN palsy postoperation was 0.05% (95% CI: 0.08-0.2, I2  = 0). In this meta-analysis, there is one case of temporary vagal nerve paralysis secondary to VN electrode dislodgement, and a case of hemodynamic instability manifested in bradycardia and hypotension in the initial phase of surgery shortly after calibration. C-IONM is a safe and effective means by which RLN paralyses in thyroid surgery can be reduced.

Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial.

CONTEXT: Most smokers with mental illness do not receive tobacco cessation treatment. OBJECTIVE: To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates. DESIGN, SETTING, AND PATIENTS: A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009. INTERVENTION: Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment. MAIN OUTCOME MEASURES: Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status. RESULTS: Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time. CONCLUSION: Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00118534.

Effects of exercise, cognitive, and dual-task interventions on cognition in type 2 diabetes mellitus: A systematic review and meta-analysis.

INTRODUCTION: Previous evidence has shown significant effects of exercise, cognitive and dual-task training for improving cognition in healthy cohorts. The effects of these types of interventions in type 2 diabetes mellitus is unclear. The aim of this research was to systematically review evidence, and estimate the effect, of exercise, cognitive, and dual-task interventions on cognition in type 2 diabetes mellitus. METHOD: Electronic databases including PubMed, EMBASE, CINAHL, PsycINFO, SPORTDiscus, and MEDLINE were searched for ongoing and completed interventional trials investigating the effect of either an exercise, cognitive or dual-task intervention on cognition in type 2 diabetes mellitus. RESULTS: Nine trials met the inclusion criteria-one dual-task, two cognitive, and six exercise. Meta-analyses of exercise trials showed no significant effects of exercise on measures of executive function (Stroop task, SMD = -0.31, 95% CI -0.71-0.09, P = 0.13, trail making test part A SMD = 0.28, 95% CI -0.20-0.77 P = 0.25, trail making test part B SMD = -0.15, 95% CI -0.64-0.34 P = 0.54, digit symbol SMD = 0.09, 95% CI -0.39-0.57 P = 0.72), and memory (immediate memory SMD = 0.20, 95% CI -0.28-0.69, P = 0.41 and delayed memory SMD = -0.06, 95% CI -0.55-0.42, P = 0.80). A meta-analysis could not be conducted using cognitive or dual-task data, but individual trials did report a favourable effect of interventions on cognition. Risk of bias was considered moderate to high for the majority of included trials. CONCLUSIONS: Meta-analyses of exercise trials identified a small effect size (0.31), which whilst not significant warrants further investigation. Larger and more robust trials are needed that report evidence using appropriate reporting guidelines (e.g. CONSORT) to increase confidence in the validity of results. TRIAL REGISTRATION: Protocol was registered (CRD42017058526) on the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO).

Plastic Surgery Chairs and Program Directors: Are the Qualifications Different for Men and Women?

BACKGROUND: The gender disparity between the number of female and male chairs and program directors has been previously established. The aim of this study was to determine whether any differences in objective credentials existed between male and female plastic surgery department chairs/division chiefs and program directors. METHODS: Information about each plastic surgery program director and chair/chief was extracted from the websites of all institutions affiliated with a plastic surgery residency program. For each individual, information about the length of their career, number of fellowships completed, and number of publications was recorded. The two-tailed t test was used to compare differences between male and female chairs and program directors. RESULTS: A total of 99 chairs were recorded, of which nine (9.1 percent) were female. Of the 99 program directors, 13 (13.1 percent) were female. There was no difference in the number of years in practice or number of fellowships between men and women for either position. On average, male chairs had significantly fewer publications than female chairs (71.9 versus 128; p < 0.05). There was no significant difference in the number of publications between male and female program directors. Compared to program directors, chairs had significantly more years in practice and numbers of publications, which held true for both men and women. CONCLUSIONS: Women are not only underrepresented in the department chair and program director positions, but also possess higher qualifications that may reflect differences in standards for promotion and appointment. Additional research is needed to elucidate the reasons behind the observed differences in qualifications.

Implementation of Evidence-Based Recommendations for Preventive Services in the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) is the largest integrated health care system in the United States. To date, there has been scant research on how VHA adopts clinical preventive services guidelines and how U.S. Preventive Services Task Force recommendations factor into the process. METHODS: Researchers conducted semistructured interviews with eight VHA leaders to examine how they adopt, disseminate, and measure adherence to recommendations. Interviews were recorded, transcribed, and aggregated into a database to enable sorting and synthesis. Themes were identified across the key informant interviews. RESULTS: The development of VHA clinical prevention guidelines is coordinated by the National Center for Health Promotion and Disease Prevention. A VHA Advisory Committee discusses and votes to approve or disapprove each guideline. Several factors can impact the ability of a veterans affairs medical center to implement a guideline, such as local system capacity and priorities for quality improvement. Methods to promote implementation include electronic reminders, educational events, and a robust performance measurement system. CONCLUSIONS: Provision of evidence-based clinical preventive services is an important part of VHA's effort to provide high-quality care for Veterans. Recent achievements in lung cancer, colorectal cancer, and Hepatitis C screening highlight VHA's successful approach to implementation of preventive services guidance.

The prognostic value of national early warning scores (NEWS) during transfer of care from community settings to hospital: a retrospective service evaluation.

BACKGROUND: The National Early Warning Score (NEWS) calculated from physiological observations provides a simple away to identify and respond to the deteriorating patient. There is increasing interest in the application of NEWS to facilitate referrals from the community. AIM: To establish whether elevated NEWS are associated with adverse outcomes at 5 and 30 days when obtained in a community setting at the time of transfer to an acute setting. DESIGN & SETTING: A retrospective service evaluation was undertaken using a database of emergency admissions to secondary care from two NHS district general hospitals within the South of England between January 2018 and April 2019. METHOD: The performance of NEWS recorded in a community setting to predict death or critical care admission at 5 and 30 days was calculated using established thresholds. RESULTS: 2786 referrals from primary care were analysed. The 5 day and 30 day mortality was 2.2% (1.7 to 2.8) and 7.1% (6.2 to 8.1). The prevalence of the composite outcome was 3.4% (2.8 to 4.2) at 5 days and 8.5% (7.5 to 9.6) at 30 days. The risk of adverse outcomes increased incrementally with increasing NEWS. When calculated at the point of referral from primary care the positive predictive value of death at 5 and 30 days was 15% (95% confidence intervals [CI] = 12 to 19) and 23% (95% CI = 17 to 30) in the high-risk NEWS group. CONCLUSION: Elevated NEWS obtained in the community during the process of emergency admission are associated with adverse outcomes. Communicating NEWS may allow downstream care to be better calibrated to risk.