Evidence-based HMO care for prostate specific antigen testing.

BACKGROUND: There is pressure in the U.S. system to move away from fee-for-service models to a more pre-paid system, which may result in decreased costs, but the impact on evidence-based care is unclear. We examined a large pre-paid Health Maintenance Organizations (HMO) in Israel to see if evidence-based guidelines are followed for prostate specific antigen (PSA) testing. METHODS: A retrospective cohort of ambulatory visits from 2002 to 2011 of patients age >75 receiving care from Clalit Health Services was conducted. Historically reported U.S. cohorts were used for comparison. The main measure was the percent of patients who had at least one PSA after age 75. RESULTS: In each of the 10 years of follow-up, 22% of the yearly Israeli cohort, with no known malignancy or benign prostatic hyperplasia, had at least one PSA, while for the total 10 years, 30% of the men had at least one PSA. These rates are considerably lower than previously reported U.S. rates. CONCLUSIONS: In a pre-paid system in which physicians have no incentive to order tests, they appear to order PSA tests at a lower rate than has been observed in the U.S. system. Additional quality of measures should continue to be examined as the U.S. shifts away from a fee-for-service model. Copyright © 2016 John Wiley & Sons, Ltd.

Safety of Bifidobacterium animalis Subsp. Lactis (B. lactis) Strain BB-12-Supplemented Yogurt in Healthy Children.

OBJECTIVES: Probiotics are live microorganisms that may provide health benefits to the individual when consumed in sufficient quantities. For studies conducted on health or disease endpoints on probiotics in the United States, the Food and Administration has required those studies to be conducted as investigational new drugs. This phase I, double-blinded, randomized, controlled safety study represents the first requirement of this pathway. The purpose of the study was to determine the safety of Bifidobacterium animalis subsp. lactis (B lactis) strain BB-12 (BB-12)-supplemented yogurt when consumed by a generally healthy group of children. The secondary aim was to assess the effect of BB-12-supplemented yogurt on the gut microbiota of the children. METHODS: Sixty children ages 1 to 5 years were randomly assigned to consume 4 ounces of either BB-12-supplemented yogurt or nonsupplemented control yogurt daily for 10 days. The primary outcome was to assess safety and tolerability, as determined by the number of reported adverse events. RESULTS: A total of 186 nonserious adverse events were reported, with no significant differences between the control and BB-12 groups. No significant changes due to probiotic treatment were observed in the gut microbiota of the study cohort. CONCLUSIONS: BB-12-supplemented yogurt is safe and well-tolerated when consumed by healthy children. The present study will form the basis for future randomized clinical trials investigating the potential effects of BB-12-supplemented yogurt in different disease states.

Comparison of haloperidol, non-haloperidol antipsychotics, and no pharmacotherapy for the management of delirium in an inpatient geriatric palliative care population.

Antipsychotics are frequently used for treatment of delirium, although little evidence exists that they improve delirium outcomes. Our objective was to evaluate haloperidol (HAL) compared to non-haloperidol antipsychotics (NHAP) or no pharmacologic treatment (NP) in the management of delirium in older adults under the care of a palliative care consult service across a large, integrated health care system. A retrospective chart review examined data from September 2014-September 2015. All hospitalized patients ≥65 years old with a diagnosis of delirium during palliative care consultation were included (n = 304). Primary outcome was length of stay after delirium diagnosis. Secondary outcomes included delirium symptom length, sedation, and QTc prolongation. Univariate statistical tests, analysis of covariance, and multiple regression methods were used to compare groups. Post-delirium length of stay in the HAL, NHAP, and NP groups were 8.5, 7.0, and 6.8 days, respectively (p = 0.19). Delirium duration in the HAL, NHAP, and NP groups were 6.7, 6.0, and 4.9 days, respectively (p = 0.05). Safety outcomes were statistically different than the reference group (NHAP). Congruent with existing literature in other generalized patient populations, no significant difference in post-delirium length of stay existed in geriatric, palliative care population.

Injection rate threshold of triple-lumen central venous catheters: an in vitro study.

RATIONALE AND OBJECTIVES: Computed tomographic angiography (CTA) requires the rapid injection of contrast media ideally through an 18-gauge intravenous line in the antecubital fossa. Patients with CVCs undergoing CTA, however, are typically injected at low rates for two reasons: the potential for catheter failure and because of the lack of manufacturer recommendations for high injection rates typically used during CTA. The purpose of the study is to measure the injection rate thresholds of CVC. The results suggest that CVC can be used at high injection rates that are now typically used with peripheral intravenous catheters during CTA. MATERIALS AND METHODS: We used 16-cm-long catheters and 20-cm-long catheters in six groups (n = 5 for each catheter length). After the catheters were placed into a water bath, each group was injected at 5, 10, 15, 20, 25, and 30 ml/sec. New contrast, pressure tubing, and catheters were used for each test. RESULTS: No catheter ruptures were encountered during the experiment, but there was one episode of power injector tubing rupture during the injection of a 16-cm catheter at an injection rate of 30 ml/sec. CONCLUSION: No catheter failures were demonstrated in this study using injection rates well above those used in conventional CTA. Power injector tubing failure was demonstrated at an injection rate of 30 ml/sec, which generated mean pressures in the 16-cm catheters of 920 psi (tubing rating per manufacturer is 300 psi). This study demonstrated no catheter or injector tubing failure at injection rates of 5 to 25 ml/sec.

FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change.

INTRODUCTION: Brief tools are needed to help physicians and parents reach consensus on body mass index (BMI) categories for children and to discuss health-improving behaviors. This study tested the FitwitsTM intervention with interactive flashcards and before and- after surveys to improve parents' perceptions of children's BMI status. METHODS: We enrolled 140 parents and their 9- to 12-year-old children presenting for well child care, regardless of BMI status, scheduled with 53 Fitwits-trained physicians. The Fitwits tool guided a conversation with all parent-child dyads regarding understanding BMI, nutrition, activity, and portion sizes. A survey addressed BMI category perceptions before and after the intervention, requested 2 goal selections, and included open-ended comment areas. RESULTS: Fifty-three percent of children were overweight or obese. The primary outcome variable was the rate of correct parental identification of their child's weight status (underweight, healthy, overweight, or obese). The survey before the intervention resulted in 50.0% correct BMI category designations. This changed to 60.6% correct perceptions after the intervention, with movement between correct overweight (34.5% to 51.7%) and obese (4.4% to 24.4%) categories. Secondary outcome variables included specific behavior change goals and the qualitative responses of parents, children, and physicians to the intervention. Parent-child dyads predominantly commented favorably and chose (75.8%) goals corresponding to Fitwits card suggestions. CONCLUSIONS: An improvement was observed in parental ability to identify the correct BMI category after the intervention during a preadolescent well child visit. Parent underrecognition of overweight/obese children was also observed. Most parent comments were appreciative of the physician interaction, Fitwits flashcards, and health improvement exchange.

Patient Preferences for Receiving Reports of Test Results.

INTRODUCTION: The general public's preferences for modes of communication (other than in-person communication) for medical test results were investigated. We hypothesized that patients would prefer a variety of methods to receive common tests results (blood cholesterol and colonoscopy) compared with genetics test results. METHODS: This study was a cross-sectional survey. RESULTS: A total of 409 participants responded to the survey. Among these participants, ≥50% reported that they were comfortable receiving results for a blood cholesterol test or colonoscopy via 4 of the 7 non-in-person communication methods (password-protected website, personal voicemail, personal E-mail, and letter were preferred over home voicemail, fax, and mobile phone text message). In comparison, >50% of participants were comfortable with only 1 non-in-person communication method for non-HIV sexually transmitted infections (STIs) and none for genetic tests. Patients were least comfortable receiving any information via fax, regardless of test type. There were statistical differences among comfort levels for blood cholesterol and colonoscopy tests and both STIs and genetic testing for personal voicemail, personal E-mail, mobile phone text message, and password-protected website, but there were no differences between STIs and genetic testing. No correlation was found between "familiarity" with test and "comfort" of receiving information about specific test. CONCLUSIONS: Participants demonstrated preferences in how they received test results by non-in-person communication methods, preferring personal E-mail and password-protected websites, but did not prefer fax. Importantly, participants also demonstrated that preference was dependent on test type.

Assessing statistical analyses of clinical trials: primer in statistical methods for thoracic surgeons.

Each year there are many randomized controlled trials published for thoracic surgeons. To apply the results of these articles to their patients, surgeons need to have an understanding of the criteria for assessing the validity of these articles. They need to be able to recognize both methodological and statistical flaws a study may have. This article presents a published "validity" tool that can be used for assessment, gives flowcharts to show which statistical tests can be used, and also presents the assessment findings of a review of 52 published randomized controlled trials. Key issues discussed include documentation of validity items in the methods section, overuse of P values, and correct statistical analyses for patients measured at various times. The article concludes with suggestions for future assessment and publication.

The effect of medical student feedback about resident teaching on resident teaching identity: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Residents often teach medical students, other residents, and patients. However, few residents get feedback about their teaching. This study's objective was to determine if feedback from medical students increases resident teaching identity. METHODS: This was a stratified, single blinded, randomized controlled trial of an educational intervention. Residents were stratified based on year of residency and then randomized to receive feedback by medical students or not. Medical students evaluated resident teaching effectiveness by ranking resident ability to apply the five microskills for clinical teaching and to role model being an effective clinician. Residents were surveyed to determine their level of teacher identity before and after the intervention. Allocation concealment and intention to treat principles were used. RESULTS: All residents (n=32) that met inclusion criteria participated with complete response rate to both pre-intervention and post-intervention surveys. There was no difference in teaching identity between residents who received feedback and those who did not, except in one subscale of the Teacher Identity Scale-global teaching identity, where residents who received medical student feedback scored lower. CONCLUSIONS: There was no difference between intervention and control group in resident teaching identity over time. The residents found feedback important. This was a randomized controlled trial with strong methodology that helps advance understanding of the importance of medical student feedback on resident teaching.

Fitwits: preparing residency-based physicians to discuss childhood obesity with preteens.

OBJECTIVE: To evaluate the Fitwits MD office tool and games for obesity discussions with 9- to 12-year-olds. METHODS: A nonrandomized intervention study using pre- and posttest assessments in 2 residency programs compared 31 control group and 55 intervention physicians (34 previously trained, 21 newly trained to use Fitwits). Surveys addressed comfort and competence regarding: obesity prevention and treatment, nutrition, exercise, portion size, body mass index (BMI), and the term "obesity." We surveyed all groups at baseline and 5 months (post 1) and new trainees 3 months later (post 2). RESULTS: In post 1, prior trainees reported significantly increased comfort and competence for discussing obesity prevention, portion size, BMI, and "obesity." In post 2, new trainees reported significantly increased comfort and competence discussing obesity prevention and treatment, portion size, and BMI. CONCLUSIONS: Experience using Fitwits improved residency-based physician comfort and competence in obesity prevention and treatment, portion size, BMI, and "obesity" discussions with preadolescents.

Cyclobenzaprine with ibuprofen versus ibuprofen alone in acute myofascial strain: a randomized, double-blind clinical trial.

STUDY OBJECTIVE: We evaluate the analgesic and side effects of adding cyclobenzaprine to ibuprofen in emergency department patients with acute myofascial strain. METHODS: A randomized, prospective, double-blind study was conducted at an urban teaching ED with an annual census of 44,000. One hundred two patients aged 18 to 70 years with acute myofascial strain caused by minor trauma within the prior 48 hours were included, and 77 patients completed the protocol. Each patient received a single dose of 800 mg of ibuprofen in the ED and a vial of 6 capsules containing 800 mg of ibuprofen to take every 8 hours as needed after discharge from the ED. In addition, 51 patients received a single dose of 10 mg of cyclobenzaprine and a vial of 6 capsules containing 10 mg of cyclobenzaprine to take every 8 hours as needed after discharge from the ED; the remaining 51 patients received an identically labeled placebo capsule and vial of placebo capsules to take every 8 hours as needed after discharge from the ED. Patients rated the intensity of their pain on a 100-mm visual analog scale (VAS) at baseline; 30, 60, 90, 120, and 180 minutes; and 24 and 48 hours after treatment. Telephone follow-up was obtained at 24 and 48 hours, and side effects were elicited at 24 and 48 hours by means of open-ended questioning. RESULTS: The patients in each group were similar with regard to diagnosis and baseline pain score. The number of patients who did not complete the protocol and the number of those who required additional analgesia were similar in both groups. Over the 48 hours of the protocol, the mean VAS score for the combination group decreased from 60.4 to 35.6, and the mean VAS score for the ibuprofen alone group decreased from 62.2 to 35.4. The mean VAS scores between groups across time was not statistically significant (P =.962, repeated-measures analysis of variance). At both 24 and 48 hours, central nervous system side effects were reported more frequently in the patients receiving cyclobenzaprine (16 [42%] versus 7 [18%] at 24 hours and 15 [39%] versus 5 [13%] at 48 hours, respectively). CONCLUSION: In ED patients with acute myofascial strain, the addition of cyclobenzaprine to ibuprofen does not improve analgesia but is associated with a greater prevalence of central nervous system side effects.