Forgetting the Frail: National Trends in Vitamin D Prescription After Fragility Fracture-A Large Insurance Claims Database Study.

INTRODUCTION: Vitamin D plays a critical role in bone health, affecting bone mineral density and fracture healing. Insufficient serum vitamin D levels are associated with increased fracture rates. Despite guidelines advocating vitamin D supplementation, little is known about the prescription rates after fragility fractures. This study aims to characterize vitamin D prescription rates after three common fragility fractures in patients older than 50 years and explore potential factors influencing prescription rates. METHODS: The study used the PearlDiver Database, identifying patients older than 50 years with hip fractures, spinal compression fractures, or distal radius fractures between 2010 and 2020. Patient demographics, comorbidities, and vitamin D prescription rates were analyzed. Statistical methods included chi-square analysis and univariate and multivariable analyses. RESULTS: A total of 3,214,294 patients with fragility fractures were included. Vitamin D prescriptions increased from 2.50% to nearly 6% for all fracture types from 2010 to 2020. Regional variations existed, with the Midwest having the highest prescription rate (4.25%) and the West the lowest (3.31%). Patients with comorbidities such as diabetes, tobacco use, obesity, female sex, age older than 60 years, and osteoporosis were more likely to receive vitamin D prescriptions. DISCUSSION: Despite a notable increase in vitamin D prescriptions after fragility fractures, the absolute rates remain low. Patient comorbidities influenced prescription rates, perhaps indicating growing awareness of the link between vitamin D deficiency and these conditions. However, individuals older than 60 years, a high-risk group, were markedly less likely to receive prescriptions, possibly because of practice variations and concerns about polypharmacy. Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fractures. However, there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults, and additional study variations in prescription practices. These findings emphasize the importance of enhancing post-fracture care to reduce morbidity and mortality associated with fragility fractures. LEVEL OF EVIDENCE: III.

Disparities in Oral Nutritional Supplement Usage and Dispensing Patterns across Primary Care in Ireland: ONSPres Project.

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of 'Moderate' (<75th centile), 'High' (75th-89th centile) and 'Very High' ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann-Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). 'Moderate' ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), 'High' users were dispensed 420 units (EUR 806) and 'Very High' users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Factors associated with the appropriate use of ultra-broad spectrum antibiotics, meropenem, for suspected healthcare-associated pneumonia.

ABSTRACT: Pneumonia is a common disease-causing hospitalization. When a healthcare-associated infection is suspected, antibiotics that provide coverage for multi-drug resistant (MDR) or extended-spectrum beta-lactamase (ESBL) bacteria are frequently prescribed. Limited data is available for guidance on using meropenem as a first-line empiric antimicrobial in hospitalized patients with risk factors for MDR/ESBL bacterial infections.This was a single-center, retrospective study designed and conducted to identify factors associated with positive cultures for MDR/ESBL pathogens in hospitalized patients with suspected healthcare-associated pneumonia.Of the 246 patients, 103 patients (41%) received meropenem. Among patients prescribed meropenem, MDR/ESBL pathogens were detected in only 20 patients (13%). Patients admitted from a skilled nursing facility/long-term acute care (SNF/LTAC) or with a history of a positive culture for MDR/ESBL pathogens were significantly associated with positive cultures of MDR/ESBL pathogens during the hospitalization (odds ratio [95% confidence intervals], 31.40 [5.20-189.6] in SNF/LTAC and 18.50 [2.98-115.1] in history of culture-positive MDR/ESBL pathogen). There was no significant difference in mortality between the 3 antibiotic groups.Admission from a SNF/LTAC or having a history of cultures positive for MDR/ESBL pathogens were significantly associated with a positive culture for MDR/ESBL pathogens during the subsequent admission. We did not detect significant association between meropenem use as a first-line drug and morbidity and mortality for patients admitted to the hospital with suspected healthcare-associated pneumonia, and further prospective studies with larger sample size are needed to confirm our findings.

Higher incidence of prescribing rates and utilization of broad spectrum cephalosporin in young patients: A retrospective observational study in a tertiary care hospital.

Frequent use of antibiotics has been developed resistance and the use of broad spectrum cephalosporin must be limited in children. The study evaluated the association of prescribing patterns of third generation cephalosporin with diagnosis, age, availability of cultural sensitivity report and gender. It is an observational study that was carried out in the duration of six months in a low socio-economic tertiary care hospital. The data of six hundred and eighty-five (685) patients were collected from the medical records of the tertiary hospital. The cephalosporin are the most prescribed antibiotics in children 118/217 (54.3%) followed by adults 119/403 (29.5%) and teenagers 18/65 (27.6%). Whereas, 75/217 (34.5%), 126/403 (31.2%) and 22/65 (33.8%) were prescribed cephalosporin with combination in patients respectively. The culture sensitivity was performed only in 25% of patients i.e., 173/685, Of 173 culture reports 70 and 91 cases from children and adults respectively. Blood is mostly examined specimen in children and urine in adults. Escherichia coli was highly recovered pathogen in culture sensitivity report. The study concluded broad spectrum cephalosporin antibiotics were highly prescribed in children. The culture sensitivity was performed in limited number of patients. Antibiotics stewardship programme will be implemented to reduce the prescribing of broad spectrum cephalosporin in young patients.

Vitamin D deficiency, supplementation and testing: have we got it right in New Zealand?

BACKGROUND: Severe prolonged vitamin D deficiency can cause rickets or osteomalacia. Both can be prevented by sunshine exposure or vitamin D supplementation. Although New Zealand guidance does not recommend vitamin D supplementation for the general population, it can be considered for individuals at risk of vitamin D deficiency. Routine measurement of 25-hydroxyvitamin D (25OHD) is also considered unnecessary. METHODS: We investigated the rates of vitamin D supplementation, rickets and osteomalacia in New Zealand, and of 25OHD results in Auckland, over the last two decades. RESULTS: Vitamin D prescriptions increased 14-fold, from 86,295/year to 1,215,507/year, between 2003 and 2019, with medication costs alone in 2019 being >$1 million. Despite these changes, the annual prevalence of hospital admissions for rickets, osteomalacia and unspecified vitamin D deficiency remained low and stable (10-20/year). 25OHD concentrations increased between 2002 and 2003 and between 2009 and 2019, and in the later time-period, 25OHD tests mainly identified individuals without vitamin D deficiency (40-50% >75nmol/L, 65-70% >50nmol/L and only 7-12.5% <25nmol/L). CONCLUSIONS: Osteomalacia and rickets persist at low rates despite widespread, increasingly costly vitamin D supplementation and testing, which largely identifies individuals without vitamin D deficiency. These results suggest that vitamin D guidance and practice in New Zealand should change.

Headache and migraine clinical practice guidelines: a systematic review and assessment of complementary and alternative medicine recommendations.

BACKGROUND: Globally, 3 billion people suffer from either migraine or tension-type headache disorder over their lifetime. Approximately 50% of American adults suffering from headache or migraine have used complementary and alternative medicine (CAM), however, the quality and quantity of recommendations associated with such therapies across clinical practice guidelines (CPGs) for the treatment and/or management of these conditions are unknown. The purpose of this study was to identify the quantity and assess the quality of such CAM recommendations. METHODS: MEDLINE, EMBASE and CINAHL were systematically searched from 2009 to April 2020; the Guidelines International Network and the National Center for Complementary and Integrative Health websites were also searched for eligible CPGs. CPGs were included if they provided any therapy recommendations. Eligible CPGs included those written for adult patients with headache and migraine; CPGs containing CAM recommendations were assessed twice for quality using the AGREE II instrument, once for the overall CPG and once for the CAM sections. RESULTS: Of 486 unique search results, 21 CPGs were eligible and quality assessed; fifteen CPGs mentioned CAM, of which 13 CPGs made CAM recommendations. The overall CPG assessment yielded higher scaled domain percentages than the CAM section across all domains. The results from highest to lowest were as follows (overall, CAM): clarity of presentation (66.7% vs. 50.0%), scope and purpose (63.9% vs. 61.1%), stakeholder involvement (22.2% vs. 13.9%), rigour of development (13.5% vs. 9.4%), applicability (6.3% vs. 0.0%), and editorial independence (0.0% vs. 0.0%). CONCLUSIONS: Of the eligible CPGs, the CAM sections were of lower quality compared to the overall recommendations across all domains of the AGREE II instrument. CPGs that scored well could serve as a framework for discussion between patients and healthcare professionals regarding use of CAM therapies in the context of headache and migraine.

Factors Influencing the Selection of Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients With Non-Valvular Atrial Fibrillation.

BACKGROUND: Major atrial fibrillation (AF) guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin, except in rare clinical circumstances based on 4 randomized controlled trials comparing each NOAC with warfarin. We aimed to investigate the current NOAC prescription behaviors in alignment with the recent clinical evidence available. METHOD: We conducted a cross-sectional analysis of NOAC-using patients with non-valvular atrial fibrillation (NVAF) who were aged ≥65 years on the index date (July 1, 2018) based on nationwide claims data. The types of NOACs being taken were analyzed using chi-squared tests, and factors influencing NOAC selection were identified using multinomial logistic regression analysis. RESULTS: A total of 6,061 patients were included. Among the 4 NOACs, rivaroxaban was the most used NOAC. Patients aged ≥75 years (odds ratio [OR] = 1.270, confidence interval [CI] = 1.089-1.450) and women (OR = 1.148, CI = 1.011-1.284) were more likely to use apixaban relative to rivaroxaban. Patients with prior stroke/transient ischemic attack/thromboembolism had higher odds of using dabigatran (OR = 1.508, CI = 1.312-1.704) and apixaban (OR = 1.186, CI = 1.026-1.346). Patients with renal disease had higher odds of using apixaban (OR = 1.466, 95% CI = 1.238-1.693). These findings are consistent with the efficacy and safety profiles reported in pivotal trials and observational studies comparing individual NOACs. CONCLUSION: Among the 4 NOACs, rivaroxaban was the most commonly used NOAC. Apixaban was preferred for patients aged ≥75 years, females, and patients with renal disease.

Drinking from the firehose - A clinician's perspective on the challenges of delivering biomarker-driven care in routine practice.

Countless biomarkers continue to be identified and analysed in the modern era of omics focused research, with innumerable articles purporting clinical utility and bolstering optimism for truly personalised cancer care. While many commentaries have expounded on the complexities of biomarker development, validation and reporting, the monumental challenge of integrating this research into clinical practice has to date received little attention. The challenges are multitude; variable and sometimes contradictory findings across studies for individual biomarkers, a rapidly evolving landscape with new biomarkers continually being presented and tendency to examine each biomarker in isolation. Here, using examples from colorectal cancer, we explore the difficulties for the practicing clinician in interpreting and integrating novel biomarkers. Here, we present the '4Cs' to interrogate the biomarker literature, including analysis of the credibility, consistency, completeness and context of the biomarker research, and suggest a framework to frame the literature moving forward.

The Early Impact of the IDEA Collaboration Results: How the Results Changed Prescribing Practice.

Background: Traditionally, adjuvant treatment for colon cancer has been 6 months of combination chemotherapy. Six phase III trials tested the hypothesis that 3 months is noninferior in efficacy to 6 months and reduces long-term side effects for patients. The results were pooled in the International Duration Evaluation of Adjuvant therapy (IDEA) collaboration. Although this did not meet the noninferiority endpoint, a preplanned subgroup analysis by chemotherapy regimen did demonstrate noninferiority for capecitabine and oxaliplatin. Additionally, risk stratification by T and N stage was defined. Methods: In an effort to understand the real-life impact of these results, 4 months after the IDEA results, an online survey was distributed to clinicians to ask their approach to the adjuvant treatment of patients with stage III colon cancer. Results: The survey was completed by 458 clinicians from 12 countries. Assuming that 6 months of treatment was the pretrial standard of care, 89.5% of clinicians reported they had changed practice to prescribe 3 months of treatment for some patients. For patients with low-risk stage III disease, there was a preference for 3 months, and for patients with high-risk stage III disease, most clinicians still prescribed 6 months at that time. Overall, capecitabine and oxaliplatin regimen was the most popular. There were important differences in responses depending on the location of respondent and T and N stage of disease. Conclusion: This survey shows that the IDEA collaboration has been practice changing but reveals important differences in the way results are interpreted by individual clinicians.

Chiropractic Practice in the Continent of Africa: A Structured Online Survey of 608 Chiropractors.

OBJECTIVES: The purpose of this study was to assess the status, supply, demographics, and characteristics of chiropractic practice in the continent of Africa. METHODS: A survey consisting of questions on demographics, clinical practice, and patient profile was administered to 608 chiropractors practicing in the different countries of the African continent. Chiropractic association officers of each country were contacted via e-mail for assistance in the distribution of the survey link to chiropractors in their country. The initial questionnaire was pretested with a small group of chiropractors from 2 African countries-4 from Ethiopia and 6 from Botswana-to assess the validity of the questions. The legal status of the chiropractic practice was obtained from online resources. Descriptive statistics were conducted in Microsoft Excel. RESULTS: Of the 54 countries in the continent of Africa, 23 countries were identified to have chiropractors. One hundred twenty-four surveys were returned from 15 countries with an overall response rate of 20.3% by clinicians with varying years in clinical practice. Nearly 84% of the chiropractors were between ages 26 and 50. More than 69% reported being a graduate of 1 of the 2 academic institutions located in Africa. Most chiropractors practice in South Africa. Most chiropractors practice in privately owned clinics, and 38% practice in multidisciplinary clinics. Nearly 92% reported using diversified technique and 27% used McKenzie exercises for treatment. Patients presented with a variety of conditions, predominantly chronic pain (59%). CONCLUSIONS: This study provides a general overview on the status, supply, demographics, and characteristics of chiropractic practice in the continent of Africa. The supply of chiropractors in Africa is scarce and unevenly distributed. Although in the early stages of recognition, chiropractors in Africa are contributing to the care of people with musculoskeletal and spine-related disorders. Considering the high burden of spine pain, there appears to be potential for growth for chiropractic in the continent of Africa.

Laboratory Test Ordering Patterns in Pediatrics From Naturopaths and General Practitioners.

OBJECTIVES: Naturopathic medicine emphasizes prevention and the self-healing process through natural therapies. Naturopathic doctors (NDs) use clinical laboratories as frequently as traditionally trained physicians. Here we evaluated the test-ordering patterns of NDs and general practitioners (GPs). METHODS: A retrospective analysis was performed from a tertiary pediatric hospital. We analyzed tests ordered by NDs who used laboratory services and compared the test ordering patterns with GPs from adolescent medicine, family medicine, or pediatric clinics. Requests were categorized into 10 groups. We determined the tests with the highest ordering frequencies, as well as the percentage of tests that had an abnormal result. RESULTS: NDs ordered more tests per patient per date of specimen collection compared with GPs. The most frequently ordered tests by NDs were trace elements and toxic metals (23.2% of total), allergens (21.8%), and general chemistry (15.3%). For the same test, the percentage of tests with an abnormal result was significantly lower for NDs than GPs. CONCLUSIONS: We observed different ordering patterns between NDs and GPs. NDs ordered more esoteric tests and had lower rates of abnormal test results compared with GPs. Understanding the patterns of testing from different providers' specialties is useful to choose effective laboratory stewardship interventions.

A survey on Koreans' preferred type of collaboration between conventional medical and traditional Korean medicine doctors.

ABSTRACT: Although collaborative treatment by traditional Korean medicine doctors (KMDs) and medical doctors occurs, it is mainly done by referral. As no survey of the general public's preference for the type of collaboration has ever been conducted, we aimed to investigate Koreans' preferences for a collaborative treatment type.The responders were extracted by random digit dialing and then reextracted using the proportional quota sampling method by sex and age. From July to October 2017, telephone interviews were conducted and the participant responses regarding treatment history for spinal or joint diseases, experiences with collaborative treatment, and preferred type of collaborative treatment were recorded.Of the 1008 respondents, 44.64% reported a history of treatment for spinal or joint diseases at a medical institution. The concurrent collaborative treatment system, in which both KMDs and medical doctors are present in one location participating in the treatment concurrently, was the most preferred system among the respondents. Respondents who reported experience with traditional Korean medicine hospitals were more likely to prefer a one-stop treatment approach than those who did not have experience with traditional Korean medicine hospitals (adjusted odds ratio: 1.73; 95% confidence interval: 1.12-2.68). Respondents who were familiar with collaborative treatment but did not report any personal experience with it were more likely to prefer a one-stop treatment approach than those who were not familiar with collaborative treatment (adjusted odds ratio: 1.82; 95% confidence interval: 1.37-2.44).Koreans prefer a concurrent type of collaborative treatment system by KMDs and medical doctors. Therefore, efforts and support are needed to increase the application of the concurrent type of collaborative system.

Changes in Opioid Therapy Use by an Interprofessional Primary Care Team: A Descriptive Study of Opioid Prescription Data.

OBJECTIVE: The purpose of this study was to describe changes in opioid-therapy prescription rates after a family medicine practice included on-site chiropractic services. METHODS: The study design was a retrospective analysis of opioid prescription data. The database included opioid prescriptions written for patients seeking care at the family medicine practice from April 2015 to September 2018. In June 2016, the practice reviewed and changed its opioid medication practices. In April 2017, the practice included on-site chiropractic services. Opiod-therapy use was defined as the average rate of opioid prescriptions over all medical providers at the practice. RESULTS: There was a significant decrease of 22% in the average monthly rate of opioid prescriptions after the inclusion of chiropractic services (F1,40 = 10.69; P < .05). There was a significant decrease of 32% in the prescribing rate of schedule II opioids after the inclusion of chiropractic services (F2,80 = 6.07 for the Group × Schedule interaction; P < .05). The likelihood of writing schedule II opioid prescriptions decreased by 27% after the inclusion of chiropractic services (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Changes in opioid medication practices by the medical providers included prescribing a schedule III or IV opioid rather than a schedule II opioid (F6,76 = 29.81; P < .05) and a 30% decrease in the daily doses of opioid prescriptions (odds ratio, 0.70; 95% confidence interval, 0.50-0.98). CONCLUSION: This study demonstrates that there were decreases in opioid-therapy prescribing rates after a family medicine practice included on-site chiropractic services. This suggests that inclusion of chiropractic services may have had a positive effect on prescribing behaviors of medical physicians, as they may have been able to offer their patients additional nonpharmaceutical options for pain management.

Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing.

Importance: Electronic health records (EHRs) often include default alerts that can influence physician selection of antibiotics, which in turn may be associated with a suboptimal choice of agents and increased antibiotic resistance. Objective: To examine whether removal of a default alert in the EHR to avoid cephalosporin use in patients with penicillin allergies is associated with changes in cephalosporin dispensing or administration in these patients. Design, Setting, and Participants: This retrospective cohort study of a natural experiment included data on patients who had received antibiotic treatment in the hospital or outpatient setting in 2 regions of a large, integrated health system in California from January 1, 2017, to December 31, 2018. Of 4 398 792 patients, 4 206 480 met the eligibility criteria: enrollment in the health system during antibiotic use, availability of complete demographic data, and use of antibiotics outside of the washout period. Interventions or Exposures: Oral or parenteral antibiotics dispensed or administered after removal of an EHR alert to avoid cephalosporin use in patients with a recorded penicillin allergy. Main Outcomes and Measures: Probability that an antibiotic course was a cephalosporin. A multinomial logistic regression model was used to examine the change in rates of cephalosporin use before and after an EHR penicillin allergy alert was removed in 1 of the study regions. Temporal changes in use rates were controlled for by comparing changes in cephalosporin use among patients with or without a penicillin allergy at the site that removed the warning and among patients at a comparison site that retained the warning. Regression models were used to examine adverse events. Results: Of the 4 206 480 patients who met all inclusion criteria, 2 465 849 (58.6%) were women; the mean (SD) age was 40.5 (23.2) years. A total of 10 652 014 antibiotic courses were administered or dispensed, divided approximately evenly between the period before and after removal of the warning. Before removal of an alert in the electronic health record system to avoid prescribing of cephalosporins to patients with a penicillin allergy at 1 of the 2 sites, 58 228 courses of cephalosporins (accounting for 17.9% of all antibiotic use at the site) were used among patients with a penicillin allergy; after removal of the alert, administration or dispensing of cephalosporins increased by 47% compared with cephalosporin administration or dispensing among patients without a penicillin allergy at the same site and patients at the comparison site that retained the warning (ratio of ratios of odds ratios [RROR], 1.47; 95% CI, 1.38-1.56) . No significant differences in anaphylaxis (9 total cases), new allergies (RROR, 1.02; 95% CI, 0.93-1.12), or treatment failures (RROR, 1.02; 95% CI, 0.99-1.05) were found at the course level. No significant differences were found in all-cause mortality (ratio of ratios of rate ratios [RRRR], 1.03; 95% CI, 0.94-1.13), hospital days (RRRR, 1.04; 95% CI, 0.99-1.10), and new infections (Clostridioides difficile: RRRR, 1.02; 95% CI, 0.84-1.22; methicillin-resistant Staphylococcus aureus: RRRR, 0.87; 95% CI, 0.75-1.00; and vancomycin-resistant Enterococcus: RRRR, 0.82; 95% CI, 0.55-1.22) at the patient level. Conclusions and Relevance: In this cohort study, removal of a warning in the electronic health record to avoid cephalosporin use in patients with penicillin allergies was associated with increased administration and dispensing of cephalosporin. This simple and rapidly implementable system-level intervention may be useful for improvement in antibiotic stewardship.

Patient and Physician Attitudes Toward Telemedicine in Cancer Clinics Following the COVID-19 Pandemic.

PURPOSE: COVID-19 has infected more than 94 million people worldwide and caused more than 2 million deaths. Patients with cancer are at significantly increased risk compared with the general population. Telemedicine represents a common strategy to prevent viral spread. We sought to evaluate patient with cancer and physician perceptions of telemedicine during the COVID-19 pandemic. METHODS: A 16-question survey was e-mailed to 1,843 active e-mails of patients presenting to one of the six cancer clinics at a comprehensive cancer care center from January 1, 2020, to June 1, 2020. A six-question survey was e-mailed to attending physicians of those clinics. Specialties included Medical Oncology, Hematology-Oncology, Surgical Oncology, Urological Oncology, and Gynecologic Oncology. RESULTS: Three hundred seventy-four patients (20.3%) and 14 physicians (66.7%) responded. Most (68.2%) currently prefer in-person visits, and 80.4% prefer in-person visits following pandemic resolution. More than half (52.2%) of patients preferring virtual visits do so because of convenience. Most (63.1%) patients with cancer are comfortable with a complete physical examination. Surgical patients are more likely to prefer a complete examination (P = .0476). Physicians prefer in-person visits (64.2%) and believe that virtual visits maybe or probably do not provide comparable care (64.2%). 71.4% believe that virtual visits help prevent the spread of infectious disease. CONCLUSION: Given preferences for in-person visits, cancer care teams should be prepared to continue providing in-person visits for many of their patients. The discrepancy between patient and provider concern for spread of infectious disease represents an area where patients may benefit from increased education. Providers should feel comfortable performing physical examinations at their own discretion.

Assessing the immediate impact of COVID-19 on surgical oncology practice: Experience from an NCI-designated Comprehensive Cancer Center in the Northeastern United States.

BACKGROUND: The effects of the coronavirus disease 2019 (COVID-19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID-19 on surgical oncology practice volume. METHODS: A retrospective study of patients treated at an NCI-Comprehensive Cancer Center was performed. "Pre-COVID" era was defined as January-February 2020 and "COVID" as March-April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. RESULTS: Abouyt 907 new patient visits, 3897 follow-up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed. CONCLUSIONS: The effects of the COVID-19 pandemic are wide-ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice.

The inguinal hernia management in Costa Rica according to a survey between surgeons: result comparison with 2018 International Groin Hernia Guidelines.

BACKGROUND: Inguinal hernia surgery is a frequent procedure among general surgeons in Costa Rica, but the management and technique are not uniform. The International Guideline for Groin Hernia management was published in 2018 to standardize the inguinal hernia surgery, but the diffusion of the guidelines and its adherence have been extremely varied. PURPOSE: Collect and analyze the current reality regarding groin hernia management in Costa Rica. Secondly evaluate the diffusion and development comparing it to the guideline's recommendations. METHOD: Questionnaire of 42 single and multiple answer questions according to the topics of the International Guideline directed to general surgeons. Diffusion of the inquiry through surgical and hernia association chats and email. Timeframe June-December 2019. RESULTS: 64 surveys were collected, which is a representative number of the general surgeons national college. The most frequent procedure between these was the abdominal wall surgery. Every surgeon did more than 52 groin hernia surgeries in one year, most of them outpatients. The epidural anesthesia was used the most and Lichtenstein's technique was the most frequently used (64%). 68% of the surgeons know how to perform a minimally invasive inguinal hernia surgery but with variable volumes. 38% of participants considered themselves experts in groin hernia management and 52% did not know the 2018 International Guideline. The recommendations of such guideline are followed only partially. CONCLUSIONS: The 2018 Hernia Surge International Guidelines have low diffusion among Costa Rican surgeons. The laparoscopic approach is widely accepted but there are no studies to assess the results and the quality. There should be protocols and studies adapted to Costa Rica's national situation.

Patient-Reported Physician Treatment Recommendations and Compliance Among U.S. Adults with Low Back Pain.

Objectives: Numerous recently published clinical care guidelines, including the 2017 American College of Physicians (ACP) Guideline for Low Back Pain (LBP), call for nonpharmacological approaches to pain management. However, little data exist regarding the extent to which these guidelines have been adopted by patients and medical doctors. The study objective was to determine patient-reported treatment recommendations by medical doctors for LBP and patient compliance with those recommendations. Design: This study used a cross-sectional web and mail survey. Settings/Location: The study was conducted among Gallup Panel members across the United States. Subjects: Survey participants included 5377 U.S. adults randomly selected among Gallup Panel members. Of those, 545 reported a visit to a medical doctor within the past year for low back pain and were asked a series of follow-up questions regarding treatment recommendations. Interventions: Participants were asked about medical doctor recommendations for both drug (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, benzodiazepines, Gabapentin, Neurontin, and cortisone injections) and nondrug (self-care treatments, massage, acupuncture, spinal manipulation, and physical therapy) treatments. Outcome Measures: Participants were asked to indicate if their medical doctor recommended each drug and nondrug therapy for their LBP and if they had followed each of those treatment recommendations. Results: Ninety-six percent of patients who visited a medical doctor for LBP received a recommendation for one or more pain treatments, with 81% reporting that their medical doctor recommended both drug and nondrug therapies. Seventy-six percent of respondents were recommended acetaminophen or NSAIDs, 79% were recommended self-care treatments, 37% were recommended massage, acupuncture, or spinal manipulation, and 60% were recommended physical therapy. Nearly two-thirds of our sample reported that their doctor had recommended prescription medications, including opioids, benzodiazepines, Gabapentin, Neurontin, or cortisone injections. Reported adherence to treatment recommendations ranged from 68% for acupuncture to 94% for NSAIDs. Conclusions: One year after publication of the ACP's Guideline on LBP, patients report that medical doctors recommended both pharmacological and nonpharmacological treatment approaches to patients with LBP. In the majority of cases, a combination of prescription medications and self-care were recommended, illustrating the need for additional research on the effectiveness of multi-modal treatment strategies. Patients reported that they were largely compliant with medical doctor recommendations, underscoring the influence that medical doctors have in directing patient care for LBP. These findings indicate that further work is also needed to explore the impact of personal experience, training, clinical evidence, sociocultural factors, and health plans on medical doctors therapeutic recommendations in the context of back pain.

Initial Management of Acute and Chronic Low Back Pain: Responses from Brief Interviews of Primary Care Providers.

Background: In April 2017, the American College of Physicians (ACP) published a clinical practice guideline for low back pain (LBP) recommending nonpharmacologic treatments as first-line therapy for acute, subacute, and chronic LBP. Objective: To assess primary care provider (PCP)-reported initial treatment recommendations for LBP following guideline release. Design: Cross-sectional structured interviews. Participants: Convenience sample of 72 PCPs from 3 community-based outpatient clinics in high- or low-income neighborhoods. Approach: PCPs were interviewed about their familiarity with the ACP guideline, and how they initially manage patients with acute/subacute and chronic LBP. Treatment responses were coded as patient education, nonpharmacologic, pharmacologic, or medical specialty referral. PCPs were also asked about their comfort referring patients to nonpharmacologic treatment providers, and about barriers to referring. Responses were assessed using content analysis. Differences in responses were assessed using descriptive statistics. Key results: Interviews were completed between December 2017 and March 2018. Of 72 participating PCPs (50% male; mean years of practice = 13.8), over three-fourths indicated being familiar with the ACP guideline (76%-87% at 3 clinics). For acute LBP, PCPs typically provided advice to stay active (81%) and pharmacologic management (97%; primarily nonsteroidal anti-inflammatory drugs). For chronic LBP, PCPs were more likely to recommend nonpharmacologic treatments than for acute LBP (85% vs. 0%, p < 0.001). The most common nonpharmacologic treatments recommended for chronic LBP were physical therapy (78%), chiropractic care (21%), massage therapy (18%), and acupuncture (17%) (each compared with 0% for acute LBP, all p < 0.001). The cost of nonpharmacologic treatments was perceived as a barrier. However, PCPs working in low-income neighborhood clinics were as likely to recommend nonpharmacologic approaches as those from a high-income neighborhood clinic. Conclusions: While most PCPs indicated they were familiar with the ACP guideline for LBP, nonpharmacologic treatments were not recommended for patients with acute symptoms. Further dissemination and implementation of the ACP guideline are needed.