Training and assessment of skills in neuraxial access-Protocol of a scoping review.

BACKGROUND: Access to the neuraxial space, including lumbar punctures and neuraxial anaesthesia, is an everyday procedure in clinical practice. Traditionally these procedures rely on manual palpation technique, but ultrasound is a useful tool when patients prove challenging. Presently, there is a lack of evidence-based guidelines for technical skills acquisition, both with and without ultrasound, and likewise, competency assessment approaches vary globally. Accordingly, we aim to assess the current evidence regarding learning and assessment in neuraxial access ± $$ \pm $$ ultrasound, for future educational recommendations. METHODS: This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) statement, together with the PRISMA Extension for Scoping Reviews. A systematic search strategy will be based on a PICO approach, focusing on physicians, medical students, or nurses being exposed to education, training, or assessment in procedural neuraxial access ± $$ \pm $$ ultrasound. No comparators are obligated, but outcomes should be assessable using the Kirkpatrick four levels of training evaluation. The search will be performed in Cochrane Library, Embase, Medline, Scopus, PubMed, and CINAHL. Independently, two authors will screen the studies and conflicts will be resolved by a third author. Relevant predefined data will be extracted and analysed using a descriptive approach. The quality of the studies will be assessed using the Medical Education Research Study Quality Instrument. DISCUSSION: This scoping review will contribute by presenting gathered evidence of an overview of the different approaches to achieving education and training of technical skills in neuraxial access, and how skills are tested, which could guide research and future recommendations for skills development and assessment.

Evaluating Drug Prescription Patterns in Undiagnosed Common Variable Immunodeficiency Patients.

OBJECTIVE: To compare the consumption of antibiotics (AB), systemic steroids, and inhaled bronchodilators/glucocorticoids in the 3 years preceding the diagnosis of common variable immunodeficiency (CVID) among CVID patients and matched controls and to estimate whether the level of consumption was associated with the risk of a subsequent CVID diagnosis. METHODS: We conducted a nested case-control study, identifying all individuals (n=130 cases) diagnosed with CVID in Denmark (1994-2014) and 45 age- and sex-matched population controls per case (n=5850 controls) from national registers. Drug consumption was estimated as defined daily doses per person-year. We used conditional logistic regression to compute odds ratios and 95% confidence intervals. RESULTS: In the 3 years preceding a CVID diagnosis, we observed more frequent and higher consumption of all three drug classes. The association between consumption and risk of subsequent CVID diagnosis was statistically significant for all drug classes. The association was stronger with higher consumption and shorter time to CVID diagnosis. The fraction of cases compared to the controls redeeming ≥1 prescription of the included drugs during the study period was higher for AB (97% vs 52%), systemic steroids (35% vs 7.4%), and inhaled bronchodilators/glucocorticoids (46% vs 11.7%) (p<0.001). CONCLUSION: CVID patients have significantly higher use of AB, systemic steroids, and inhaled bronchodilators/glucocorticoids in the 3 years preceding CVID diagnosis than controls. Prescribing these drugs in primary healthcare could be an opportunity to consider (proactive) screening for CVID. Further studies are needed to identify optimal prescription cutoffs that could endorse its inclusion in public health policies.

Missed Opportunities to Diagnose Common Variable Immunodeficiency: a Population-Based Case-Control Study Identifying Indicator Diseases for Common Variable Immunodeficiency.

PURPOSE: Delayed diagnosis of common variable immunodeficiency (CVID) remains a serious problem. We investigated whether some diseases diagnosed during out-patient visits or admission to hospitals could act as indicator conditions for CVID diagnosis. METHODS: In this nested case-control study, we identified 128 cases diagnosed with CVID in Denmark (1999-2013) and 640 age-, gender-, and region-matched controls. We obtained data on diseases diagnosed at hospitals in the five years before CVID diagnosis from The National Hospital Registry. We grouped hospital diagnoses in 33 major disease categories and 210 subcategories. We used conditional logistic regression to calculate the odds ratios (OR) and 95% confidence intervals (CI) to estimate associations between disease exposure and subsequent CVID. RESULTS: During the five years preceding a CVID diagnosis, cases had four times as many hospital contacts as the controls (p < 0.001). A diagnosis in 18 major disease categories showed a significant OR for subsequent diagnosis of CVID. The most substantial association with a subsequent CVID diagnosis was a diagnosis of lower respiratory tract infections (OR: 29.9; 95% CI: 14.2-63.2) and lung diseases (35.1; 15.0-82.5). We observed a similar association when we removed the last year before diagnosis from analysis and overall, in the years < 1, ≥ 1-3, and ≥ 3-5 before diagnosis, although the absolute number of exposures was small. Twenty-eight specific diseases displayed an at least 3-fold risk of subsequent CVID diagnosis. CONCLUSION: Targeted screening for antibody deficiency in patients diagnosed with specific diseases associated with CVID may lead to earlier CVID diagnosis and treatment and thereby potentially reduced morbidity and mortality.

How to Identify Common Variable Immunodeficiency Patients Earlier: General Practice Patterns.

PURPOSE: Diagnostic delay is a major problem concerning common variable immunodeficiency (CVID). We aimed to determine the pattern of general practitioner (GP) consultations in individuals diagnosed with CVID within 3 years before the diagnosis and whether the risk of diagnosis was associated with the frequency of consultations or character of examinations. METHODS: We conducted a nested case-control study, identifying 132 adult CVID patients and 5940 age- and gender-matched controls from national registers during 1997-2013. We used conditional logistic regression to calculate the odds ratios (OR) and 95% confidence intervals (95%CI). RESULTS: The median number of consultations among individuals with CVID was more than twice that of the controls in all 3 years (3rd, 10; 2nd, 11.5; and 1st, 15.4 vs. 4). We found a statistically significant association between the number of consultations and the risk of a subsequent CVID diagnosis, independent of age and gender, but strongest in the individuals < 40 years. In the 3rd year before diagnosis, having 9-15 consultations compared with 1-4 was associated with an OR (95%CI) of 5.0 (2.3-10.9), 2.4 (1.1-5.4), and 1.3 (0.3-5.3) for those aged 18-40, 41-60, and > 60, respectively. Several examinations (i.e., blood tests for inflammation/infection and pulmonary function test) were associated with increased odds of a subsequent CVID diagnosis. CONCLUSION: The risk of a CVID diagnosis was highly related to both the number of consultations and the character of examinations performed by the GP. CVID should be a differential diagnosis among patients with multiple consultations, especially in patients < 40 years old.