Systematic reviews of guidelines and studies for single versus multiple unit transfusion strategies.

BACKGROUND: Recent recommendations indicate that one red blood cell (RBC) unit should be transfused at a time, with reassessment after each transfusion, which may be extrapolated from literature supporting restrictive transfusion triggers rather than specific evidence. Therefore, two systematic reviews were performed to identify the following: 1) RBC transfusion guidelines and review articles to determine if single- or multiple-unit transfusion strategies are recommended and 2) studies comparing strategies for evidence of benefit. STUDY DESIGN AND METHODS: MEDLINE, EMBASE, CINAHL, Web of Science, National Guideline Clearinghouse, and Trip Database were searched (inception to June 2017). For the first review, the proportion of articles with single/multiple-unit recommendations was assessed and stratified by article type. For the second review, the primary outcome was RBC use. Secondary outcomes included proportion of transfusion episodes using a single-unit strategy, length of stay, and mortality. RESULTS: The first review identified 145 articles for analysis, with 51 transfusion guidelines. Only 14 guidelines (27%) made a recommendation, with most (93%) recommending single-unit transfusions. The second review identified seven cohort studies comparing preimplementation and postimplementation of a policy encouraging single-unit transfusion strategies. Meta-analysis could not be performed for outcomes given inconsistencies in reporting. RBC use decreased by approximately 10 to 41% across studies. CONCLUSION: Transfusion guidelines lack recommendations to transfuse to a single-unit strategy. Mostly retrospective cohort studies (six of seven) are inconsistent in outcome reporting but suggest improved RBC use. Further high-quality studies could identify the benefits of a single-unit transfusion strategy, determine the applicability to different clinical settings, and inform future practice guidelines.

Landolt Ring-Shaped Epithelial Keratopathy: A Novel Corneal Disease in a Non-Japanese White Patient.

PURPOSE: Landolt ring-shaped epithelial keratopathy is a corneal disease that has only been reported in 11 Japanese patients in 2014.1 We describe the first case of Landolt ring-shaped epithelial keratopathy in the United States in a patient of European background. METHODS: This is a single case report with longitudinal care. RESULTS: A 35-year-old White patient presented with a history of ocular burning, photophobia, and decreased vision. Corneal examination showed bilateral and asymmetric microcystic lesions in a unique Landolt ring (or the letter "C") shape, distributed randomly in the epithelium. Confocal microscopy revealed cellular ballooning and hyperreflective opacities in the basal layer of the corneal epithelium. The patient has had multiple recurrences of her symptoms year-round, each lasting 4 to 8 days. Topical treatment with cyclosporine, steroids, and lubrication resolved her symptoms but without complete resolution of signs on examination. CONCLUSIONS: Our patient's clinical signs and symptoms are similar to those described previously in 11 Japanese patients. However, unlike those patients, our patient demonstrates symptomatic response to topical treatment, no seasonal association to her condition, and to date, incomplete resolution of her disease after more than 2 years. This case highlights that Landolt ring-shaped epithelial keratopathy, a novel corneal disease of unclear origin, has relevance outside of the Japanese population.

Impact of Fellowship Training on Practice Patterns of Glaucoma Surgeons Treating Medicare fee-for-service Beneficiaries.

PURPOSE: Analyze practice patterns of glaucoma surgeons with and without fellowship training. MATERIALS AND METHODS: Physician-specific 2017 Medicare data were obtained from the Centers for Medicare & Medicaid Services website. Current Procedural Terminology codes identified procedures including iStent, tube shunts, trabeculectomy, complicated trabeculectomy, endoscopic cyclophotocoagulation, internal Xen Implant, external Xen or Express shunt, Gonioscopy-Assisted Transluminal Trabeculotomy, and Kahook Dual Blade Goniotomy. Physicians with fellowship training were identified via the American Glaucoma Society website. RESULTS: A total of 1547 glaucoma surgeons were identified, of which 319 had completed fellowship training. Overall, fellowship-trained glaucoma surgeons performed more services (50.4 ± 47.0 vs 40.5 ± 35.3, P < .001) with a larger variety of procedures (1.8 ± 1.0 vs 1.3 ± 0.6, P < .001) than those without fellowship training. Surgeons without fellowship training were more likely to perform iStent and endoscopic cyclophotocoagulation and less likely to perform the remaining procedures than their fellowship-trained counterparts. Medicare payments did not differ between groups and the number of Medicare beneficiaries only differed for internal Xen implant (P = .03). Patient comorbidity burden was similar between groups with about one-third of patients being diagnosed with ischemic heart disease. CONCLUSIONS: Surgeons without fellowship training can treat a similar volume of glaucoma patients as those with fellowship training. However, based on surgical procedures employed, their practices are skewed towards mild and moderate glaucoma and they are more limited in their breadth of procedures. In addition, ischemic heart disease was prevalent in the glaucoma patient population.

Analysis of ophthalmology subspecialty opioid prescribing patterns during the opioid public health crisis.

OBJECTIVE: To describe opioid prescribing practices of ophthalmology subspecialties and determine whether opioid prescribing has decreased during the public health crisis. DESIGN: Retrospective cohort study. PARTICIPANTS: Ophthalmologists prescribing at least 11 medications billed to the Medicare Part D prescription drug plan. METHODS: Publicly available Medicare data sets based on claims from the years 2016, 2017, and 2018 were used. Fellowship status was assumed based on subspecialty society membership or use of specified Current Procedural Terminology codes. The main outcome was the percentage of physicians in each subspecialty prescribing opioids. RESULTS: The database included 19,762, 19,790, and 19,840 ophthalmologists in the years 2016, 2017, and 2018, respectively. Only the subspecialties of comprehensive ophthalmology (43.5% vs 39.6% vs 35.7%; p < 0.001; φc = 0.066), retina (66.5% vs 60.7% vs 54.5%; p < 0.001; φc = 0.101), cornea (82.8% vs 83.9% vs 77.2%; p = 0.03; φc = 0.076), and glaucoma (53.4% vs 46.4% vs 42.0%; p < 0.001; φc = 0.094) underwent a small but significant reduction in the proportion of physicians prescribing opioids. The subspecialties of oculoplastics (86%-88.8%), cornea (77.2%-82.8%), retina (54.5%-66.5%), and pediatrics (51.5%-57.9%) had the highest percentage of physicians prescribing opioids. The subspecialties of glaucoma, uveitis, and comprehensive ophthalmology had the lowest percentage of opioid prescribers. Among physicians with more than 10 opioid claims, median opioid claims did not change drastically. Opioids contributed only a small proportion of medication claims for all subspecialties. CONCLUSION: All subspecialties experienced either a small reduction or no significant change in the percentage of opioid prescribers during the period analyzed. We hope to encourage collaboration between ophthalmology subspecialties in striving to reduce opioid prescribing. Further studies are needed to better fine-tune opioid prescribing practices.

Quality metrics for head and neck cancer treated with definitive radiotherapy and/or chemotherapy.

BACKGROUND: The standardization of quality measures has been key in advancing the aims of the National Quality Forum established to improve health outcomes. METHODS: The National Cancer Database was used to identify eligible patients. Two quality metrics were evaluated including time to treatment initiation (TTI) and chemotherapy in locoregionally head and neck squamous cell carcinoma (HNSCC). RESULTS: TTI was significantly associated with mortality reflected by a hazard ratio (HR) of 1.13 for 60-90 days of TTI (95% CI 1.08-1.17), 1.19 for >90 days of TTI (95% CI 1.13-1.26). Patients with locoregionally advanced HNSCC had an 87% adherence to chemotherapy, which correlated with reduced mortality (HR 0.57; 95% CI 0.55-0.59). Patients treated at high quality centers had a 9% increase in survival (HR 0.91; 95% CI 0.88-0.93). CONCLUSION: We identified that both TTI and chemotherapy for locoregionally advanced HNSCC meet criteria for valid quality metrics potentially suitable for national adoption.

Fellow Selection Protocols in Facial Plastic Surgery: A National Survey of Facial Plastic Surgery Program Directors.

Background: Despite its popularity among otolaryngology residents, there is currently a paucity of knowledge on the match in facial plastics surgery fellowships and the selection criteria that drive the match process. To increase the understanding of this process and to improve the manner in which candidates are vetted, a survey study was designed. Methods: A 24-question online survey was designed to discern desired qualities regarding fellow selection, interview processes, fellow participation, and program director satisfaction with the current process. This survey was sent to all American Academy of Facial Plastic and Reconstructive Surgery fellowship program directors in the United States. Results: Overall, 40 of the 64 fellowship directors responded to the survey for a total response rate of 62.5%. Most fellowship directors reported that the reputation of an applicant's residency was an important component of the selection criteria with 34 of 40 of those who responded rating it at least "somewhat important." With regard to the otolaryngology trainee examination, nearly all fellowship directors (39/40) reported that there was no minimum cutoff score to be offered an interview. When fellowship directors were asked to rank the academic components of an application that they viewed as most important, they most commonly reported that the strength of an applicant's letters of recommendation were most important. Conclusions: With the increasing popularity of fellowships within the field of otolaryngology, having an understanding of which components of the application process are viewed as most important by fellowship directors is crucial in applicants matching into the fellowship of their choice.

Barriers, beliefs, and practices regarding hygiene and vaccination among the homeless during a hepatitis A outbreak in Detroit, MI.

Appropriate hygiene practices and vaccine acceptance are key factors impacting the health of homeless individuals. A recent outbreak of hepatitis A in Michigan, especially impacting Detroit, prompted us to investigate the practices and attitudes of Detroit's homeless population toward hygiene measures and vaccinations, as well as barriers to such resources. We developed a questionnaire as a means to collect our data, and participants were interviewed at shelters and soup kitchens. While the majority of participants adhered to healthy hygiene practices, approximately 89% reported barriers to accessing public showers. More than half the participants (64%) reported receiving their hepatitis A vaccine prior to the study, while 23% reported previously refusing or hesitating to receive vaccinations. Despite an overall favorable adherence to hygiene practices, substantial barriers are yet to be overcome. Moreover, active measures should be taken to establish higher levels of trust between providers and the homeless to encourage vaccine acceptance.

Medical students' challenges and suggestions regarding research training: a synthesis of comments from a cross- sectional survey.

BACKGROUND: We previously reported on a cross-sectional study of students from the Michael G. DeGroote School of Medicine at McMaster University that found most respondents wanted more opportunities to participate in research. Students provided additional comments that we synthesized to enrich the findings of our quantitative analysis. METHODS: From our previously administered 13-item, online questionnaire, run across three campuses in Ontario, Canada, 498 of 618 medical students completed our survey and 360 (72%) provided optional written comments, which we synthesized using thematic analysis in this current study. RESULTS: Major themes that emerged were: (1) Active student participation to identify research opportunities and interested mentors are needed; (2) Types of research involvement; (3) Uncertainty whether research training translates into useable skills; (4) Desire for a formalized research curriculum and centralization of research opportunities across campuses. CONCLUSION: Programs should stress to interested students the importance of actively looking for research opportunities and consider both large and small-group educational sessions.

Predictors of medical student interest and confidence in research during medical school.

BACKGROUND: Research education and opportunities are an important part of undergraduate medical education. This study's objectives were to determine students' interest in research, student self-rated research skills, and to assess potential predictors of research interest and confidence. METHODS: Stakeholder consultation and literature informed a 13-item cross-sectional survey. In 2014, all students enrolled in McMaster University's School of Medicine in Ontario, Canada were sent an electronic survey and two subsequent reminder e-mails. RESULTS: The response rate was 81% (498 of 618). Most (n=445, 89%) had prior research experiences. The majority of students (n=383, 86%) wanted more research education and opportunities. Higher rating of their supervisors' understanding of research was associated with greater interest in research (OR=2.08; 95% CI=1.27-3.41). Home campus (distributed vs. main) was not a significant predictor of research interest. In our adjusted linear regression model, the most significant predictors of higher self-rated research ability were prior thesis work and other prior research experience. CONCLUSION: In a survey of a three-year medical school, medical student interest in further research education and opportunities was high and positively predicted by student-rated supervisors' understanding of research, but not campus location. This study also identified several predictors of student self-rated research ability.

Targeted metabolomics in colorectal cancer: a strategic approach using standardized laboratory tests of the blood and urine.

BACKGROUND: Glycolytic markers have been detected in colorectal cancer (CRC) using advanced analytical methods. METHODS: Using commercially available assays, by-products of anaerobic metabolism were prospectively measured in the blood and urine of 20 patients with metastatic colorectal cancer (mCRC) and 20 patients with local disease. Twenty-four-hour urine citrate, plasma lactate, ketones, venous blood gas, anion gap, and osmolar gap were investigated. Results of patients with metastatic and local CRC were compared using two-sample t-tests or equivalent nonparametric tests. In addition, plasma total CO2 concentrations in our local hospital (5,931 inpatients and 1,783 outpatients) were compared retrospectively with those in our dedicated cancer center (1,825 outpatients) over 1 year. RESULTS: The average venous pCO2 was higher in patients with mCRC (50.2 mmHg; standard deviation [SD]=9.36) compared with those with local disease (42.8 mmHg; SD=8.98), p=0.045. Calculated serum osmolarity was higher in mCRC and attributed to concomitant sodium and urea elevations. In our retrospective analysis, plasma total CO2 concentrations (median=27 mmol/L) were higher in cancer patients compared to both hospital inpatients (median=23 mmol/L) and outpatients (median=24 mmol/L), p<0.0001. CONCLUSION: Patients with mCRC had higher venous pCO2 levels than those with local disease. Although causation cannot be established, we hypothesize that pCO2 elevation may stem from a perturbed metabolism in mCRC.