Use of a Novel Artificial Intelligence System Leads to the Detection of Significantly Higher Number of Adenomas During Screening and Surveillance Colonoscopy: Results From a Large, Prospective, US Multicenter, Randomized Clinical Trial.

INTRODUCTION: Adenoma per colonoscopy (APC) has recently been proposed as a quality measure for colonoscopy. We evaluated the impact of a novel artificial intelligence (AI) system, compared with standard high-definition colonoscopy, for APC measurement. METHODS: This was a US-based, multicenter, prospective randomized trial examining a novel AI detection system (EW10-EC02) that enables a real-time colorectal polyp detection enabled with the colonoscope (CAD-EYE). Eligible average-risk subjects (45 years or older) undergoing screening or surveillance colonoscopy were randomized to undergo either CAD-EYE-assisted colonoscopy (CAC) or conventional colonoscopy (CC). Modified intention-to-treat analysis was performed for all patients who completed colonoscopy with the primary outcome of APC. Secondary outcomes included positive predictive value (total number of adenomas divided by total polyps removed) and adenoma detection rate. RESULTS: In modified intention-to-treat analysis, of 1,031 subjects (age: 59.1 ± 9.8 years; 49.9% male), 510 underwent CAC vs 523 underwent CC with no significant differences in age, gender, ethnicity, or colonoscopy indication between the 2 groups. CAC led to a significantly higher APC compared with CC: 0.99 ± 1.6 vs 0.85 ± 1.5, P = 0.02, incidence rate ratio 1.17 (1.03-1.33, P = 0.02) with no significant difference in the withdrawal time: 11.28 ± 4.59 minutes vs 10.8 ± 4.81 minutes; P = 0.11 between the 2 groups. Difference in positive predictive value of a polyp being an adenoma among CAC and CC was less than 10% threshold established: 48.6% vs 54%, 95% CI -9.56% to -1.48%. There were no significant differences in adenoma detection rate (46.9% vs 42.8%), advanced adenoma (6.5% vs 6.3%), sessile serrated lesion detection rate (12.9% vs 10.1%), and polyp detection rate (63.9% vs 59.3%) between the 2 groups. There was a higher polyp per colonoscopy with CAC compared with CC: 1.68 ± 2.1 vs 1.33 ± 1.8 (incidence rate ratio 1.27; 1.15-1.4; P < 0.01). DISCUSSION: Use of a novel AI detection system showed to a significantly higher number of adenomas per colonoscopy compared with conventional high-definition colonoscopy without any increase in colonoscopy withdrawal time, thus supporting the use of AI-assisted colonoscopy to improve colonoscopy quality ( ClinicalTrials.gov NCT04979962).

Hypoglycemia Associated With Insulin Use During Treatment of Hyperkalemia Among Emergency Department Patients.

Purpose: Hypoglycemia is a common adverse event associated with insulin during treatment of hyperkalemia in hospitalized patients; however, limited data exist regarding hypoglycemia incidence and appropriate dosing strategies for treatment of patients in the emergency department. The study objective was to determine the incidence of hypoglycemia associated with insulin use during treatment of hyperkalemia among patients seen in the emergency department. Methods: This was an Institutional Review Board (IRB)-approved retrospective, chart-review study. All adult patients who received intravenous regular insulin as a result of an order from the emergency department hyperkalemia order set were eligible for inclusion. The main clinical outcomes were incidence of hypoglycemia (blood glucose <70 mg/dL) and severe hypoglycemia (blood glucose <40 mg/dL). Blood glucose was checked within 24 hours of insulin administration. Results: A total of 172 patients were included. The incidence of hypoglycemia was 19.8% (n = 34) and the incidence of severe hypoglycemia was 5.2% (n = 9). Hypoglycemic patients had a significantly lower median blood glucose at baseline compared to those who did not develop hypoglycemia (83.5 [72.0-112.0] mg/dL vs 123.0 [96.0-167.0] mg/dL, P < .0001); however, no difference was noted between groups in the average insulin dose administered (0.11 ± 0.04 units/kg vs 0.12 ± 0.05 units/kg, P = .6175). Conclusion: There is a concerning risk of hypoglycemia associated with insulin use during treatment of hyperkalemia in the emergency department. Standard insulin doses may not be appropriate in some cases like patients with lower baseline blood glucose. Further research is warranted to develop safer hyperkalemia treatment protocols that mitigate this high risk of hypoglycemia associated with insulin use.

Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital.

Objective: The objective of this study was to assess the association between liposomal bupivacaine use in patients undergoing knee or hip arthroplasty and concurrent pain control, length of hospitalization, and physical therapy milestones. Methods: This was a retrospective chart review. Patients receiving liposomal bupivacaine during a 1-year period (study group) were compared with patients seen by the same surgeon in the previous year who did not receive liposomal bupivacaine (control group). Clinical outcomes included concurrent opioid use, average pain scores, length of stay, ambulation, and range of motion. Results: A total of 357 patients were included in the study. Knee study group patients received lower amounts of opioid (209 vs 248 mg; P = .02) and had a delayed time to first rescue medication (6.3 ± 4.7 vs 5.0 ± 4.4 hours; P = .02). Hip study group patients had a delay in time to first rescue medication (7.1 ± 6.3 vs 4.9 ± 4.0 hours; P = .046). Both knee and hip study group patients had higher average pain score during the 72-hour postoperative period (6.38 vs 6.06; P = .01, and 6.32 vs 5.80; P = .02, respectively) but decreased median length of stay (2.0 vs 3.0 days; P < .0001, and 2.0 vs 3.0 days; P = .04, respectively). Conclusions: Use of liposomal bupivacaine produced a modest decrease in opioid use among knee patients and a decreased length of stay in both knee and hip patients; however, this was accompanied by a non-clinically significant increase in pain scores for knee and hip patients suggesting limited utility for orthopedic procedures.

Coinfection of Streptococcus agalactiae and Tuberculous Osteomyelitis of Tibia Mimicking Brodie's Abscess in an Immunocompetent Adult: A Case Report.

Introduction: Coinfection of tuberculous osteomyelitis with Streptococcus agalactiae has not been reported in an immunocompetent adult so far. The slow progress of tuberculous osteomyelitis, due to lack of significant elevations in the laboratory values and changes in the radiographic appearance, often leads to confusion with brodie's abscess. These two clinical conditions often lead to delay in diagnosis and progressive bone destruction. The aim of this report was to highlight recognizing the possibility of coinfections in tuberculous osteomyelitis and early treatment targeting both organisms simultaneously. Case Report: We report a case of a 24-year-old male patient from Kerala, India presented with pain and swelling over distal leg for 2 weeks along with mild fever for 1 month. Imaging showed a brodie's abscess over distal tibia. Pus culture isolated S. Agalactiae. Bone biopsy reported as necrotizing granulomatous lesion. Computed tomography thorax was suggestive of necrotic tuberculous mediastinal and hilar lymphadenopathy. Based on histopathology, microbiology, and radiological findings, coinfection of tuberculous osteomyelitis and bacterial infection was confirmed and antitubercular therapy was started, along with antibiotics for S. agalactiae. Conclusion: Tuberculous osteomyelitis mimicking brodie's abscess is very rare. It is important to consider coinfection in osteomyelitis and it is essential to do tuberculosis-polymerase chain reaction and histopathological examination, along with bacterial and fungal culture of pus in subacute osteomyelitis for the early diagnosis and treatment.

Hepatitis C Prevalence on the Rise but Screening at Safety Net Institutions Lagging behind.

Introduction: In the United States, the hepatitis C virus (HCV) is a leading contributor to liver-related illnesses and fatalities. Despite effective antiviral medications, acute infections have increased in recent years, likely due to IV drug use and the opioid epidemic. Previous guidelines recommended one-time screening for individuals born between 1945 and 1965. The CDC now recommends screening all adults over 18 unless there is a low prevalence in the area. Accurate measurement of HCV prevalence is essential for targeted prevention. In New York, over 100,000 individuals have HCV. We present data on HCV screening at a safety net hospital in Long Island, NY. Objective: To identify screening rates for hepatitis C and the exposure prevalence and specific demographics of a community in Long Island, NY. Methods: We performed a review of all patients seen in our hospital from 2012 to 2019. We identified patients born in the years 1945 to 1965 using our electronic medical record (EMR) system and subsequently analyzed those who were anti-HCV positive. We reviewed their demographics, including age, gender, and ethnicity, as well as their history of intravenous drug use and HIV coinfection status. Basic statistical analysis was used. Results: Our study identified 21,722 patients born between 1945 and 1965 and found that only 8.5% or 1,858 individuals were screened for hepatitis C. Among them, we found that 5.9% (109) tested positive for HCV antibody, with 3.0% (56) having an active infection. Demographic characteristics of those with HCV antibodies included 70.6% male, 53.2% Caucasian, 33.9% Black, and 15.6% persons who inject drugs (PWID). Conclusion: Our study findings suggest that a significant portion of patients in our community had missed opportunities for screening in our hospital. Our community had an estimated 5.9% prevalence, higher than the national and state averages. Caucasian men had higher prevalences. This study suggests the need for broader screening initiatives and more focused resource allocation, perhaps to safety net institutions, to decrease the burden of HCV.

Missed Perilunate Dislocation in a Post-Traumatic Head Injury Patient: A Case Report.

Introduction: Perilunate injuries are rare, complex, and high velocity trauma associated injuries accounting to <10% of wrist joint trauma. Volar peri-lunate dislocations account for <3% of these injuries. Perilunate injuries should, therefore, be focused and ruled out while examining a patient complaining wrist pain after high-energy accidents which are often missed. Case Report: We report a case of, missed dislocation in a patient who presented delayed with wrist pain, post 4 months road traffic accident associated with heterotrophic ossified mass in a united scapular fracture. He underwent open reduction through a combined approach and internal fixation with K-wires. Aggressive wrist physiotherapy retrieved near-normal range of motion at the wrist by the end of 5 months as well as neither revealed recurrence of the dislocation nor signs of avascular necrosis. Conclusion: Successful results in perilunate injuries can be obtained with open reduction, ligament reconstruction with K-wires fixation through a single combined approach in delayed presentation resulting in achieving near normal range of movements.

Double Level Osteotomy in an Overcorrected Distal Femoral Varisation Osteotomy: A Case Report.

CASE: We report a patient who was diagnosed with idiopathic genu valgum at the age of 11 years and underwent bilateral distal femur osteotomies. At age 30 years, she presented with pain around her right knee with a varus deformity. Although the corrective osteotomy was at the distal femur, she was noticed to have a bifocal deformity in both femur and tibia. She was managed with single-stage osteotomies at the distal femur and proximal tibia. CONCLUSION: This case report highlights the importance of preoperative analysis to identify the site of deformity. In bifocal pathology, a 2-level osteotomy is required to prevent an oblique joint line.

Effectiveness of a Student Pharmacist-Led Telephone Follow-Up Intervention to Improve Hemoglobin A1C in Diabetic Patients.

OBJECTIVE: To evaluate the effectiveness of a student pharmacist-led telephone follow-up intervention to improve hemoglobin A1c (HbA1c) in diabetic patients. METHODS: This was a prospective, randomized, pilot study to implement a telephone follow-up intervention for diabetic patients with HbA1c ≥7%. Patients were recruited and randomized into intervention and control groups. All patients received standard of care. Patients in the intervention group additionally received weekly phone calls from a student pharmacist for 12 weeks to encourage medication adherence. HbA1c at baseline and end of study were measured and the data were analyzed using SAS version 9.4. Analysis included descriptive statistics and a multiple regression model to assess the association between the end of study and baseline HbA1c while controlling for demographics. RESULTS: Seventy-eight patients participated and the average age was 62 (±11) years. Baseline HbA1c was 8.2% (±1.4%) in the intervention group and 7.9% (±1.3%) in the control group. HbA1c decreased by 0.35% in the intervention group (P = .027) and increased by 0.338% in the control group (P = .013). The end of study HbA1c were higher in the control group even after controlling for baseline HbA1cs (0.5547, P value .002) in the regression model. CONCLUSION: Incorporating student pharmacists in physician offices to provide clinical care services could lead to improved patient outcomes and students' clinical and research skills.

Pharmacy and Nursing Students' Perceptions Regarding the Role of Spirituality in Professional Education and Practice.

Objective. To compare first-year student pharmacists and nursing students with respect to their spirituality and perceptions of the role of spirituality in professional education and practice. Methods. This was a five-year, cross-sectional study. All first-year student pharmacists and nursing students were invited to participate in the survey during the first week of the fall semester in 2012 through 2016. Descriptive and inferential statistics were used to analyze the data. Results. A total of 1,084 students participated, including 735 student pharmacists and 349 nursing students. Significant differences in baseline demographics were noted between the groups. Students in both groups reported having frequent spiritual experiences. A significantly larger percentage of nursing students reported these experiences compared to student pharmacists. Furthermore, compared with student pharmacists, nursing students were more likely to anticipate that spirituality would play a role in their academic course work (76% vs 58%) and professional practice (90% vs 74%). Conclusion. Student pharmacists and nursing students reported having frequent spiritual experiences, and both groups anticipated that spirituality would be incorporated into their education and professional practice.

An Elective Course for Student Pharmacists on Pharmaceutical Industry Practice.

Objective. To design and implement an elective course on pharmaceutical industry practice and assess its impact on student pharmacists' knowledge and perceptions. Methods. This was a two-credit hour, elective course offered to second- and third-year student pharmacists during the 2015 and 2016 spring semesters. The goal of this course was to provide instruction regarding skills and competencies for pharmaceutical industry practice. Curricular content included didactic instruction, assigned readings, weekly quizzes, classroom discussion of industry-based functions and responsibilities, and three application projects. A 65-item survey instrument was developed to assess changes in student pharmacists' perceptions and understanding of pharmaceutical industry practice. Results. Forty-four students enrolled in the elective course over the two offerings. The average rating on the course evaluation was 4.7 out of 5. Average scores on graded quizzes were 90%, and grades on the application projects ranged from 92% to 99%. There was an increase in the number of students who perceived that they understood various functions and roles in the pharmaceutical industry, and who rated themselves confident in completing unique tasks associated with pharmaceutical industry practice. Furthermore, there was an increase in the number of students who reported improved perceptions regarding the trustworthiness of the pharmaceutical industry, costs of prescription medications, and promotional advertising for branded prescription medication. Conclusion. Student pharmacists' perceptions of the course were positive, and overall perceptions and understanding of the pharmaceutical industry improved. Active collaboration between colleges and pharmaceutical companies can lead to positive educational opportunities for students interested in pharmaceutical industry careers.

A Structured Approach to Intentional Interprofessional Experiential Education at a Non-Academic Community Hospital.

Objective. To develop and implement a multimodal structured approach to intentional interprofessional experiential education at a non-academic community hospital, and to evaluate students' perceptions of the program. Methods. A multimodal structured approach to intentional interprofessional experiential education was designed that consisted of medical and pharmacy students participating together in daily pre-rounds, daily teaching rounds, and once or twice weekly lunch-and-learn sessions at a non-academic community hospital. Pre- and post-experience surveys were administered to assess students' perceptions of physician and pharmacist collaboration in interprofessional education (IPE). The survey instrument included the Student Perceptions of Physician-Pharmacist Interprofessional Clinical Education, Version 2 (SPICE-2) survey. Results. Thirty-nine students, including 18 fourth-year student pharmacists from Mercer University College of Pharmacy and 21 third-year medical students from three medical schools in the Caribbean, provided informed consent and were enrolled in the eight-month study. Students' perceptions of items related to the Interprofessional Education Collaborative (IPEC) competencies, including values/ethics for interprofessional practice, roles/responsibilities, and teams and teamwork, significantly improved from the pre- to the post-experience survey. Conclusion. A multimodal structured approach to intentional interprofessional experiential education had positive effects on students' perceptions of interprofessional clinical education targeting key components of the (IPEC) competencies. This approach may be a useful tool for implementing intentional IPE in the experiential setting.

Time-Motion Analysis of Nurses Utilizing Insulin Pen Devices Compared to Vial and Syringe in an Inpatient Setting.

OBJECTIVE: To compare the time taken and steps completed by nurses in the process of insulin preparation and administration using the pen device compared to the vial and syringe method. METHODS: Observational and exploratory study utilizing a time-motion analysis of nurses' administration of insulin using the pen versus vial and syringe delivery methods. Nurses were observed, video-recorded, and timed during insulin preparation and administration using each delivery method. The steps performed by nurses were observed against recommended processes for preparing and administering insulin, and the percentage of nurses completing each step was noted. RESULTS: A total of 137 (94%) nurses participated. Nurses took less time preparing and administering insulin with the pen device compared with the vial and syringe method (79 ± 18 seconds vs 88 ± 20 seconds, respectively, P < .001). The overall average completion rate of steps with the pen device was 90% ± 7% compared to 88% ± 7% with the vial and syringe method. CONCLUSION: The time taken by nurses to prepare and administer insulin was lower with the pen device compared with vial and syringe. Furthermore, areas were identified for potential nursing education to enhance safe and appropriate use of insulin with both delivery methods.

Evaluation of first year student pharmacists' perceptions of the pharmaceutical industry.

BACKGROUND AND PURPOSE: There are a limited number of pedagogical studies evaluating student pharmacists' perceptions of the pharmaceutical industry. The objective of this two year prospective study was to evaluate changes in student pharmacists' perceptions of the pharmaceutical industry during the first year of enrollment in the doctor of pharmacy curriculum. EDUCATIONAL ACTIVITY AND SETTING: An online survey was developed and offered to all first-year student pharmacists during the 2014 and 2015 Fall semesters prior to didactic instruction on the pharmaceutical industry and then again at the end of the respective academic years. Descriptive and inferential statistics were used to analyze the data. FINDINGS: A majority of students had a positive impression of the pharmaceutical industry in both the fall (75%) and spring semesters (78%). Over the course of the year, significantly greater numbers of student pharmacists reported favorable impressions of the pharmaceutical industry with respect to research innovation, drug safety, and the provision of drug information. On the other hand, findings suggest that many students remain skeptical regarding the benefits of prescription medications relative to cost and there were significant increases in the number of students who perceived pharmaceutical industry-based marketing practices to have a negative impact on patients and society. DISCUSSION AND SUMMARY: Didactic education may influence student pharmacists' perceptions of the pharmaceutical industry. Further research is warranted to evaluate the role of pharmacy curricula and extra-curricular activities in influencing changes in student pharmacists' perceptions and the potential implications of these changes to pharmacy practice.

First-year Student Pharmacists' Spirituality and Perceptions Regarding the Role of Spirituality in Pharmacy Education.

Objective: To measure student pharmacists' spirituality utilizing validated survey instruments and to determine perceptions regarding the anticipated role of spirituality in academic course work and professional practice. Methods: This was a cross-sectional, descriptive study. The survey was offered to all first-year student pharmacists during the first week of the fall semester (2012-2015). Descriptive and inferential statistics were used to analyze data. Results: A total of 580 students (98%) participated. The majority of students reported having each of the spiritual experiences on most days of the week or more frequently (58% to 89% based on individual item). Furthermore, 57% of students anticipate that matters of spirituality would be significant components of academic course work and 75% anticipate they would be incorporated into eventual professional practice settings. These perceptions were positively correlated to measures of spirituality and religiosity. Conclusion: These findings suggest that faculty should evaluate current and future incorporation of topics related to spirituality and health in pharmacy curriculum.

Erosive Esophagitis in the Obese: The Effect of Ethnicity and Gender on Its Association.

Background. Data examining the association between obesity and erosive esophagitis (ErE) have been inconsistent, with very little known about interracial variation. Goals. To examine the association between obesity and ErE among patients of different ethnic/racial backgrounds. Methods. The study sample included 2251 patients who underwent esophagogastroduodenoscopy (EGD). The effects of body mass index (BMI) on ErE were assessed by gender and in different ethnic groups. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multivariate logistic regression analysis. Results. The prevalence of ErE was 29.4% (661/2251). Overweight and obese subjects were significantly more likely to have ErE than individuals with a normal BMI, with the highest risk seen in the morbidly obese (OR 6.26; 95% CI 3.82-10.28; p < 0.0001). Normal weight Black patients were less likely to have ErE as compared to Caucasians (OR 0.46; 95% CI 0.27-0.79; p = 0.005), while the odds ratio comparing normal weight Hispanics to normal weight Whites was not statistically significant. No effect modification was seen between BMI and race/ethnicity or BMI and gender. Significant trends were seen in each gender and ethnicity. Conclusions. The effect of BMI on ErE does not appear to vary by race/ethnicity or gender.

Nurses' perceptions and satisfaction with the use of insulin pen devices compared with insulin vial and syringes in an inpatient setting.

BACKGROUND: The purpose of this study was to compare nurses' perceptions and satisfaction with the use of insulin pen devices versus vial and syringes for insulin delivery in an inpatient setting. MATERIALS AND METHODS: The study used a descriptive design using self-report surveys. Nurses rated their perceptions on a 4-point Likert scale (from 1=strongly disagree to 4=strongly agree) on the ease of use, ease to teach patients, confidence and comfort in use, perceived time efficiency, safety of use, risk of needle sticks, and overall satisfaction and preference with use of each insulin delivery device. RESULTS: In total, 139 (95%) nurses from nine nursing units at one hospital participated in this study. Compared with vial and syringe, nurses felt insulin pens were easier to use to measure insulin dose (mean±SD, 3.7±0.5 vs. 3.1±0.7; P<0.001), were easier to teach patients to use (3.5±0.6 vs. 2.8±0.7; P<0.001), provided more confidence in measuring insulin dose (3.7±0.5 vs. 3.4±0.6, P<0.001), saved on administration and preparation time (3.6±0.5 vs. 2.3±0.8; P<0.001), reduced the risk of giving a wrong dose of insulin (3.2±0.8 vs. 2.2±0.7; P<0.001), and reduced the risk of needle sticks (3.5±0.7 vs. 2.1±0.8; P<0.001). Overall, a majority of nurses preferred the use of insulin pens to vial and syringes in an inpatient setting (83% vs. 15%; P<0.05). CONCLUSIONS: Nurses felt more comfortable and confident with the use of insulin pens compared with vial and syringes and perceived insulin pens to be a safer alternative for both patients and themselves.

Testosterone replacement therapy in males with erectile dysfunction.

Erectile dysfunction (ED) is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Endogenous testosterone is critical for normal libido; however, studies have also demonstrated a potentially important role with respect to the erectile process. The prevalence of testosterone deficiency ranges from 1.7% to 35% in patients with ED, and age is a common factor linking ED and testosterone deficiency. By 2025, global estimates are that there will be 356 million men >65 years. Age-associated testosterone deficiency is characterized by symptoms such as ED, and low serum testosterone. Randomized, placebo controlled studies have established the utility of testosterone replacement therapy (TRT) for the restoration of serum testosterone levels to the normal range in hypogonadal males; however, well designed studies are limited with respect to specific evaluation of the role of TRT as monotherapy in improving erectile function. In addition, recent literature suggests a possible role for TRT in combination with phosphodiesterase-5 (PDE-5) inhibitors for men with ED. The following review describes the potential roles of testosterone in erectile physiology, examines the relationship between testosterone deficiency and ED, and reviews published literature evaluating the use of TRT in hypogonadal males with a diagnosis of ED.