Multicancer Early detection Panels (MCEDs) in the Primary Care Setting.

Multicancer early detection panels have recently become available to patients with a provider's prescription and an out-of-pocket fee. Beyond theoretical modeling, little is known about how these assays will impact primary care practices despite a high likelihood that primary care providers (PCPs) will be ordering these tests with some frequency. In particular, there are concerns about patient counseling, costs, frequency of testing, patient anxiety, and subsequent testing for a positive result. This review aims to appraise the current literature and provide a framework that PCPs can use to discuss these tests with patients and streamline their ordering, interpretation, and overall use into everyday practice.

Antithrombotic Therapy for Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention.

1. What is the clinical question? What combination antithrombotic therapy is recommended for patients with atrial fibrillation with acute coronary syndrome or patients undergoing percutaneous coronary intervention? 2. What does the evidence say? Double therapy (DT) with clopidogrel and direct oral anticoagulants (specifically, dabigatran, rivaroxaban, and apixaban) is noninferior to warfarin-based therapies for most patients. Double therapy is noninferior to triple therapy (TT) and has less bleeding complications. 3. What is the take-home message for physicians? According to the latest guidelines by the ACC, AHA, ESC, and HRS, in patients with AF undergoing PCI, DT with DOACs (specifically dabigatran, rivaroxaban and apixaban) plus clopidogrel is acceptable. Patients undergoing PCI or with high ischemic risk may still benefit from TT for at least 1 month and up to 6 months before switching to DT. Currently, there is no specific guidance on long-term antiplatelet therapy in these patients. Duration of antiplatelet therapy, whether with DT or TT, should be based on current DAPT guidelines (depending on indication and type of intervention) and discussions with each patient's cardiologist.

Food Sensitivity Testing and Elimination Diets in the Management of Irritable Bowel Syndrome.

The nonpharmacologic management of irritable bowel syndrome focuses on dietary modification through the concept of food sensitivity or intolerance. Currently, testing for food allergies is not recommended in the absence of a clinical history consistent with an immunoglobulin E-mediated reaction. Objective means of determining food sensitivity, such as individualized diets, are being studied, but testing for food sensitivity is limited to certain food groups. Diets such as the low-FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet may provide benefit.

Relation of Telemetry Use and Mortality Risk, Hospital Length of Stay, and Readmission Rates in Patients With Respiratory Illness.

The 2004 American Heart Association expert opinion-based guidelines restrict telemetry use primarily to patients with current or high-risk cardiac conditions. Respiratory infections have emerged as a common source of hospitalization, and telemetry is frequently applied without indication in efforts to monitor patient decompensation. In this retrospective study, we aimed to determine whether telemetry impacts mortality risk, length of stay (LOS), or readmission rates in hospitalized patients with acute respiratory infection not meeting American Heart Association criteria. A total of 765 respiratory infection patient encounters with Diagnosis-Related Groups 193, 194, 195, 177, 178 and 179 admitted in 2013 to 2015 to 2 tertiary community-based medical centers (Mayo Clinic, Arizona, and Mayo Clinic, Florida) were evaluated, and outcomes between patients who underwent or did not undergo telemetry were compared. Overall, the median LOS was longer in patients who underwent telemetry (3.0 days vs 2.0 days, p <0.0001). No differences between cohorts were noted in 30-day readmission rates (0.6% vs 1.3%, p = 0.32), patient mortality while hospitalized (0.6% vs 1.3%, p = 0.44), mortality at 30 days (7.9% vs 7.7%, p = 0.94), or mortality at 90 days (13.5% vs 13.5%, p = 0.99). Telemetry predicted LOS for both univariate (estimate 1.18, 95% confidence interval 1.06 to 1.32, p = 0.003) and multivariate (estimate 1.17, 95% confidence interval 1.06 to 1.30, p = 0.003) analyses after controlling for severity of illness but did not predict patient mortality. In conclusion, this study identified that patients with respiratory infection who underwent telemetry without clear indications may face increased LOS without reducing their readmission risk or improving the overall mortality.

Science of Health Care Delivery: An Innovation in Undergraduate Medical Education to Meet Society's Needs.

The purpose of this special article is to describe a new, 4-year Science of Health Care Delivery curriculum at Mayo Clinic School of Medicine, including curricular content and structure, methods for instruction, partnership with Arizona State University, and implementation challenges. This curriculum is intended to ensure that graduating medical students enter residency prepared to train and eventually practice within person-centered, community- and population-oriented, science-driven, collaborative care teams delivering high-value care. A Science of Health Care Delivery curriculum in undergraduate medical education is necessary to successfully prepare physicians so as to ensure the best clinical outcomes and patient experience of care, at the lowest cost.

Gastric lap-band infection due to Mycobacterium abscessus presenting as new-onset ascites in a cirrhotic patient.

Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).

Pulmonary Epithelioid Hemangioendothelioma Diagnosed With Endobronchial Biopsies: A Case Report and Literature Review.

Pulmonary epithelioid hemangioendothelioma (PEHE) is a rare vascular tumor of endothelial origin first described in 1975 as intravascular bronchioloalveolar tumor. Since then, >100 cases have been reported, and most cases require surgical lung biopsy for diagnosis. We report the case of a 46-year-old man with a diagnosis of PEHE from endobronchial biopsies of an intraluminal nodule, a rare presentation of this disease. We summarize a review of the literature and the bronchoscopic findings of PEHE.

Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score.

The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better (P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) (P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) (P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.

The effects of deliberate practice and feedback to teach standardized handoff communication on the knowledge, attitudes, and practices of first-year residents.

BACKGROUND: Residents' shift length reduction and communication errors in transitions of care necessitate educating residents on handoff communication. PURPOSE: We examined the change in knowledge, attitudes, and practices of 1st-year residents after implementing a curriculum using deliberate practice to teach handoff communication. METHODS: First-year residents completed a needs assessment survey and a video assessment of handoff practices. They participated in a brief curriculum using lecture and deliberate practice with feedback to teach a standardized approach to handoff communication. Change in knowledge, attitudes, and practices were measured with survey and video assessments. RESULTS: Eleven 1st-year residents completed the course and final assessments. Residents' comfort with performing handoffs and their perceived efficiency indicated improvement. Practices improved, with increased inclusion of important features of handoffs (6.31 to 7.64, p < .001). CONCLUSIONS: A brief curriculum utilizing deliberate practice is an effective way to improve handoff practices of 1st-year residents.

Guideline-concordant antibiotic therapy and clinical outcomes in healthcare-associated pneumonia.

BACKGROUND: The 2005 ATS/IDSA guidelines defined healthcare-associated pneumonia (HCAP) as a novel category of pneumonia in patients with significant healthcare exposure in whom the risk of drug resistant bacteria may be higher. In this study, we compare clinical outcomes in patients with HCAP who were treated with guideline-concordant antibiotic regimens with those who were not. METHODS: Medical records of 100 patients meeting HCAP criteria admitted to an academic tertiary care hospital between January 2009 and January 2011 were retrospectively reviewed. Cases were divided into guideline-concordant and guideline-discordant groups based on antibiotic therapy. Demographic, microbiological and clinical outcome data were compared for both groups. RESULTS: Patients in this cohort had multiple co-morbidities, severe pneumonia (mean PSI score 124.1), and significant mortality (22%). 21 of the 100 cases (21.0%) were culture positive, of which 11 (53.8%) represented drug-resistant pathogens. No statistically significant differences for any of the four clinical outcome measures were detected between the guideline-concordant therapy group and guideline-discordant group. In multivariate regression analysis controlling for possible confounders, similar results were observed, with the exception that length of stay was significantly longer (3.99 days, p < 0.001) in the discordant group. Three or more HCAP criteria (OR 10.89) and wound care (OR 6.32) were characteristics found to be associated with increased risk for drug-resistant pathogens. CONCLUSION: In our cohort, the HCAP model identified a population with significant co-morbidities and increased risk for drug-resistant pathogens, severe pneumonia, and increased mortality. However, clinical outcomes were not significantly improved with guideline-concordant antibiotic therapy.

Clinical review: Adult height in patients with congenital adrenal hyperplasia: a systematic review and metaanalysis.

CONTEXT: Treatment for patients with congenital adrenal hyperplasia (CAH) may affect the final height of these patients. OBJECTIVE: Our objective was to determine the distribution of achieved height in patients with classic CAH diagnosed at infancy or early childhood and treated with glucocorticoids. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Library, ISI Web of Science, and Scopus through September 2008; the reference sections of included studies; and expert files. STUDY SELECTION: Eligible studies included patients diagnosed with CAH before age 5 and followed to final height. DATA EXTRACTION: Reviewers working in duplicate independently extracted data on study characteristics and outcomes and determined each study's risk of bias. DATA SYNTHESIS: The sd score (SDS) for final height and corrected height (defined as final height SDS - midparental height SDS) were estimated from each study and pooled using random-effects metaanalysis. The I(2) statistic was used to assess inconsistency in results across studies. RESULTS: We found 35 eligible studies, most of which were retrospective single-cohort studies. The final height SDS achieved by CAH patients was -1.38 (-1.56 to -1.20; I(2) = 90.2%), and the corrected height SDS was -1.03 (-1.20 to -0.86; I(2) = 63.1%). This was not significantly associated with age at diagnosis, gender, type and dose of steroid, and age of onset of puberty. Mineralocorticoid users had a better height outcome in comparison with the nonusers (P = 0.02). CONCLUSION: Evidence derived from observational studies suggests that the final height of CAH patients treated with glucocorticoids is lower than the population norm and is lower than expected given parental height.

Carisoprodol withdrawal after internet purchase.

INTRODUCTION: Carisoprodol is a centrally acting muscle relaxant used in the treatment of various musculoskeletal disorders whose main metabolite, meprobamate, is a controlled substance in the United States due to its sedative properties and potential for abuse. CASE DESCRIPTION: We report a case of a 51-year-old man with cognitive impairment and tremor who developed worsening tremor, anxiety, myoclonus, ataxia, and psychosis on abrupt cessation of carisoprodol. At hospital discharge, his cognitive function significantly improved compared with when he was on carisoprodol. CONCLUSION: Carisoprodol withdrawal is an important and under-recognized syndrome that should be considered in patients presenting with neurologic symptoms who are taking the medication. Carisoprodol withdrawal can be successfully treated with the use of benzodiazepines, although further studies are needed to identify the most appropriate treatment protocol.

Clinical review 1: Adverse effects of testosterone therapy in adult men: a systematic review and meta-analysis.

CONTEXT: The risks of testosterone therapy in men remain poorly understood. OBJECTIVE: The aim of this study was to conduct a systematic review and meta-analyses of testosterone trials to evaluate the adverse effects of testosterone treatment in men. DATA SOURCES: We searched MEDLINE, EMBASE, and Cochrane CENTRAL from 2003 through August 2008. Review of reference lists and contact with experts further identified candidate studies. STUDY SELECTION: Eligible studies were comparative, randomized, and nonrandomized and reported the effects of testosterone on outcomes of interest (death, cardiovascular events and risk factors, prostate outcomes, and erythrocytosis). Reviewers, working independently and in duplicate, determined study eligibility. DATA EXTRACTION: Reviewers working independently and in duplicate determined the methodological quality of studies and collected descriptive, quality, and outcome data. DATA SYNTHESIS: The methodological quality of the 51 included studies varied from low to medium, and follow-up duration ranged from 3 months to 3 yr. Testosterone treatment was associated with a significant increase in hemoglobin [weighted mean difference (WMD), 0.80 g/dl; 95% confidence interval (CI), 0.45 to 1.14] and hematocrit (WMD, 3.18%; 95% CI, 1.35 to 5.01), and a decrease in high-density lipoprotein cholesterol (WMD, -0.49 mg/dl; 95% CI, -0.85 to -0.13). There was no significant effect on mortality, prostate, or cardiovascular outcomes. CONCLUSIONS: The adverse effects of testosterone therapy include an increase in hemoglobin and hematocrit and a small decrease in high-density lipoprotein cholesterol. These findings are of unknown clinical significance. Current evidence about the safety of testosterone treatment in men in terms of patient-important outcomes is of low quality and is hampered by the brief study follow-up.

Prenatal dexamethasone use for the prevention of virilization in pregnancies at risk for classical congenital adrenal hyperplasia because of 21-hydroxylase (CYP21A2) deficiency: a systematic review and meta-analyses.

CONTEXT: Prenatal treatment with dexamethasone to prevent virilization in pregnancies at risk for classical congenital adrenal hyperplasia (CAH) remains controversial. OBJECTIVE: To conduct a systematic review and meta-analyses of studies that evaluated the effects of dexamethasone administration during pregnancies at risk for classical CAH because of 21-hydroxylase deficiency (CYP21A2). DATA SOURCES: We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception through August 2009. Review of reference lists and contact with CAH experts further identified candidate studies. STUDY SELECTION: Reviewers working independently and in duplicate determined trial eligibility. Eligible studies reported the effects on either foetal or maternal outcomes of dexamethasone administered during pregnancy compared to a control group that did not receive any treatment. DATA EXTRACTION: Reviewers working independently and in duplicate determined the methodological quality of studies and collected data on patient characteristics, interventions, and outcomes. DATA SYNTHESIS: We identified only four eligible observational studies (325 pregnancies treated with dexamethasone). The methodological quality of the included studies was overall low. Meta-analysis demonstrates a reduction in foetus virilization measured by Prader score in female foetuses treated with dexamethasone initiated early during pregnancy (weighted mean difference, -2.33, 95% CI, -3.38, -1.27). No deleterious effects of dexamethasone on stillbirths, spontaneous abortions, foetal malformations, neuropsychological or developmental outcomes were found although these data are quite sparse. There was increased oedema and striae in the mothers treated with dexamethasone. There were no data on long-term follow-up of physical and metabolic outcomes in children exposed to dexamethasone. CONCLUSIONS: The observational nature of the available evidence and the overall small sample size of the whole body of the literature significantly weaken inferences about the benefits and harms of dexamethasone in this setting. Dexamethasone seems to be associated with reduction in foetus virilization without significant maternal or foetal adverse effects. However, this review underscores the current uncertainty and further investigation is clearly needed. The decision about initiating treatment should be based on patients' values and preferences and requires fully informed and consenting parents.