The impact of changes in opioid dependency treatment upon COVID-19 transmission in Sydney, Australia: a retrospective longitudinal observational study.

BACKGROUND: In April 2020, in response to the COVID-19 public health emergency, South Eastern Sydney Local Health District (SESLHD) Drug and Alcohol services modified their delivery of opioid dependency treatment (ODT) to reduce spread of COVID-19 and maintain continuity of care by increasing use of takeaway doses (TADs), transferring clients to local community pharmacies for dosing and encouraging the use of long-acting depot buprenorphine (LADB) which enabled once a month dosing. METHODS: This study was a retrospective longitudinal case-control study conducted from August 1st, to November 30th, 2021. Eligible clients were those admitted for treatment with SESLHD ODT Services prior to August 1st,2021 and who remained in treatment beyond November 30th, 2021. COVID-19 diagnoses were determined by a COVID-19 PCR and extracted from the electronic Medical Records (eMR) Discern Reporting Portal. Demographic, clinical and dosing related data were collected from eMR and the Australian Immunisation Register (AIR). RESULTS: Clients attending SESLHD ODT services had significantly greater odds of acquiring COVID-19 than the NSW adult population at large (OR: 13.63, 95%CI: 9.64,18.88). Additionally, amongst SESLHD ODT clients, being of Aboriginal and Torres Strait Islander origin was associated with greater odds of acquiring COVID-19 (OR = 2.18, CI: 1.05,4.53); whilst being employed (OR = 0.06, CI:0.01,0.46), receiving doses at pharmacy (OR = 0.43, CI: 0.21,0.89), and being vaccinated (OR = 0.12, CI: 0.06,0.26) were associated with lower odds. Every additional day of attendance required for dosing was associated with a 5% increase in odds of acquiring COVID-19 (OR = 1.05, CI: 1.02,1.08). CONCLUSIONS: Clients attending SESLHD ODT services are significantly more likely to acquire COVID-19 than the NSW population at large. Promoting vaccination uptake, transferring clients to pharmacy, and reducing the frequency of dosing (by use of takeaway doses or long-acting depot buprenorphine) are all potential methods to reduce this risk.

Writing an External Letter of Review for Promotion.

Academic promotion, representing achievement of a level of distinction in one's body of work, is an honorable accomplishment in a faculty member's career. External letters of review written by faculty at higher ranks are a critical component of the promotion portfolio. We discuss key considerations for writing external letters. These considerations can be used to mentor this skill for less experienced letter writers. We also highlight how professional societies can aid faculty in developing and strengthening writing and mentoring capabilities for this vital task.

Meteorological Influence on Atrial Fibrillation and Flutter: A Nationwide Observational Study in South Korea (2010-2022).

Background and rationale The impact of meteorological factors, including atmospheric temperature, humidity, and wind speed, on the incidence of atrial fibrillation and flutter (AF) has been the subject of several studies, but the findings have been inconsistent. Given the complex and multifaceted nature of this relationship, a larger-scale study was necessary to provide sufficient statistical power and elucidate potential associations between them. The aim of this study was, thus, to investigate the potential associations between meteorological factors and the incidence of AF. Methods The South Korean government provides open access to national health insurance and weather data for its citizens; the data was available from January 2010 to July 2022. The national health insurance data includes the monthly number of patients diagnosed with a specific condition, reflecting the incidence and prevalence of the condition. Pearson correlation analyses were performed using the statistical analysis software, SAS® OnDemand for Academics (SAS Institute Inc., Cary, North Carolina, United States), to examine the association between each month's national average climate data and the number of patients diagnosed with AF. Results The number of patients diagnosed with AF in the total population showed a statistically significant correlation only with average wind speed (correlation coefficient (r)=-0.42, 95%CI -0.55 to -0.28, p<0.001) and sunshine duration (r=0.27, 95%CI 0.12 to 0.41, p<0.001). Among females aged 20-24 years, there was a statistically significant association with other variables, including average temperature, precipitation, humidity, and atmospheric pressure (p<0.05). Diurnal temperature variation showed inconsistent associations across different age and sex groups. Conclusion The number of patients diagnosed with AF is negatively correlated with average wind speed and positively correlated with sunshine duration in the general population, particularly among the elderly. There was no significant association between the number of patients diagnosed with AF and average temperature, precipitation, or humidity, except for females aged 20-24 years, who exhibited a significant association with these variables. However, it is important to note that these correlations do not establish causality.

Opioid agonist treatment and patient outcomes during the COVID-19 pandemic in south east Sydney, Australia.

INTRODUCTION: In early 2020, many services modified their delivery of opioid treatment in response to the COVID-19 pandemic, to limit viral spread and maintain treatment continuity. We describe the changes to treatment and preliminary analysis of the association with patients' substance use and well-being. METHODS: A pre-post comparison of treatment conditions and patient self-reported outcomes using data extracted from electronic medical records in the 5 months before (December 2019-April 2020) and after (May 2020-September 2020) changes were implemented in three public treatment services in South Eastern Sydney Local Health District. RESULTS: Data are available for 429/460 (93%) patients. Few (21, 5%) dropped out of treatment. In the 'post' period there was significantly more use of depot buprenorphine (12-24%), access to any take-away doses (TAD; 24-69%), access to ≥6 TAD per week (7-31%), pharmacy dosing (24-52%) and telehealth services. There were significant reductions in average opioid and benzodiazepine use, increases in cannabis use, with limited group changes in social conditions, or quality of life, psychological and physical health. At an individual level, 22% of patients reported increases in their use of either alcohol, opioids, benzodiazepines or stimulants of ≥4 days in the past 4 weeks. Regression analysis indicates increases in substance use were associated with higher levels of supervised dosing. DISCUSSION AND CONCLUSIONS: These preliminary findings suggest that the modified model of care continued to provide safe and effective treatment, during the pandemic. Notably, there was no association between more TAD and significant increases in substance use. Limitations are discussed and further evaluation is needed.

Clinical Case Conference: Strategies for Transferring From Methadone to Buprenorphine.

The mainstay of treatment for opioid use disorder are medications, methadone (a full opioid agonist), or buprenorphine (a partial opioid agonist), in conjunction with psychosocial interventions. Both treatments are effective but safety, efficacy, and patient preference can lead to a decision to change from one treatment to the other. Transfer from buprenorphine to methadone is not clinically challenging; however, changing from methadone to buprenorphine is more complex. Published reports describe varied approaches to manage this transfer to both minimize patient symptoms associated with withdrawal from methadone and reduce risk of precipitating withdrawal symptoms with introduction of the partial agonist buprenorphine [Lintzeris et al. J Addict Med. 2020; in press]. There is no single approach for methadone to buprenorphine that is superior to others and no approach that is suitable for all case presentations. This case conference describes three different approaches to achieve a successful methadone to buprenorphine transfer and provides commentary on how the case may be managed based on published transfer "strategies."

Patient-Reported Outcomes of Treatment of Opioid Dependence With Weekly and Monthly Subcutaneous Depot vs Daily Sublingual Buprenorphine: A Randomized Clinical Trial.

Importance: Patient-reported outcomes in the treatment of opioid dependence may differ between subcutaneously administered depot buprenorphine and daily sublingual buprenorphine. Objective: To compare patient satisfaction between depot buprenorphine and sublingual buprenorphine in adult outpatients with opioid dependence. Design, Setting, and Participants: This open-label, randomized clinical trial was conducted among adult patients with opioid dependence at 6 outpatient clinical sites in Australia from October 2018 to September 2019. Data analysis was conducted from October 2019 to May 2020. Interventions: Participants were randomized to receive treatment with weekly or monthly depot buprenorphine or daily sublingual buprenorphine over 24 weeks. Main Outcomes and Measures: The primary end point was the difference in global treatment satisfaction, assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM) version 1.4 (range, 0-100; higher score indicates greater satisfaction) at week 24. Secondary end points included other patient-reported outcomes, including quality of life, treatment burden, and health-related outcomes, as well as measures of opioid use, retention in treatment, and safety. Results: A total of 119 participants (70 [58.8%] men; mean [SD] age, 44.4 [10.5] years) were enrolled, randomized to, and received either depot buprenorphine (60 participants [50.4%]) or sublingual buprenorphine (59 participants [49.6%]). From the initial sample of 120, a participant (0.8%) in the sublingual buprenorphine group withdrew consent and did not receive study treatment. All participants were receiving sublingual buprenorphine when enrolled. The mean TSQM global satisfaction score was significantly higher for the depot group compared with the sublingual group at week 24 (mean [SE] score, 82.5 [2.3] vs 74.3 [2.3]; difference, 8.2; 95% CI, 1.7 to 14.6; P = .01). Improved outcomes were also observed for several secondary end points after treatment with depot buprenorphine (eg, mean [SE] treatment burden assessed by the Treatment Burden Questionnaire global score, on which lower scores indicate lower burden: 13.2 [2.6] vs 28.6 [2.5]; difference, -15.4; 95% CI, -22.6 to -8.2; P < .001). Thirty-nine participants (65.0%) in the depot buprenorphine group experienced 117 adverse drug reactions, mainly injection site reactions of mild intensity following subcutaneous administration, and 12 participants (20.3%) in the sublingual buprenorphine group experienced 21 adverse drug reactions. No participants withdrew from the trial medication or the trial due to adverse events. Conclusions and Relevance: In this study, participants receiving depot buprenorphine reported improved treatment satisfaction compared with those receiving sublingual buprenorphine. The results highlight the application of patient-reported outcomes as alternative end points to traditional markers of substance use in addiction treatment outcome studies. Trial Registration: anzctr.org.au Identifier: ANZCTR12618001759280.

Managing opioid withdrawal precipitated by buprenorphine with buprenorphine.

Buprenorphine is a partial opioid agonist commonly used to treat opioid dependence. The pharmacology of buprenorphine increases the risk of a precipitated opioid withdrawal when commencing patients on buprenorphine treatment, particularly when transferring from long acting opioids (e.g. methadone). There is little documented experience regarding the management of precipitated withdrawal. In our case, a patient developed a significant precipitated opioid withdrawal following buprenorphine administration, and was able to be successfully treated in hospital with further buprenorphine. This demonstrates that rapid increases in buprenorphine dose can be used as an effective treatment for buprenorphine-induced precipitated opioid withdrawal. The use of buprenorphine to manage withdrawal then allows the individual to continue on this highly effective treatment.

Integrating Interprofessional Case Scenarios, Allied Embedded Actors, and Teaching Into Formative Observed Structured Clinical Exams.

BACKGROUND AND OBJECTIVES: Interprofessional education is a critical component of medical student training, yet it is often difficult to implement. Medical students who learn with, from, and about learners from other disciplines have been shown to create more effective and safe health care teams. The investigators wanted to know how participating in two interprofessional observed structured clinical exams (OSCEs) at Tufts University School of Medicine (TUSM) would affect changes in medical students' attitudes and values in interprofessional teamwork. METHODS: For the academic years 2017 and 2018, two interprofessional case scenarios were integrated into OSCEs for third-year medical students at TUSM, with an allied embedded actor (AEA) playing a social worker to an end-of-life scenario, and an AEA playing the role of a pharmacy student added to a chronic pain scenario. Students participated in didactic training about interprofessional teamwork and received structured feedback regarding interprofessional competencies following simulation cases. Changes in interprofessional knowledge and attitudes were assessed by comparing student pre- and postscenario mean scores on the Interprofessional Socialization and Valuing Scale (ISVS-21, a 21-item scale survey), with students rating themselves on a Likert scale from 1 (not at all) to 7 (to a very great extent). We performed paired t-test analysis on individual pre- and post-ISVS-21 means. RESULTS: Three hundred fifty-three of the 417 participating medical students fully completed pre- and postsurveys. Students reported significant changes in interprofessional knowledge and attitudes (mean change=1.3, P<.0001). Students and faculty regarded the interprofessional cases very highly. CONCLUSIONS: Placing interprofessional cases involving AEAs into OSCE events is easily replicated, and positively impacts students' attitudes and values in interprofessional knowledge.

The interplay between residency program culture and feedback culture: a cross-sectional study exploring perceptions of residents at three institutions.

BACKGROUND: Giving and receiving feedback that changes performance is influenced significantly by the clinical learning environment. This environment is multi-dimensional but includes both organizational and feedback specific dimensions. OBJECTIVE: The objectives of this research were to investigate the relationship between residents' perceptions of residency program culture and feedback culture; and whether there were differences in resident perceptions of their programs' and feedback cultures based on their disciplines and institution. We hypothesized that residents preferred certain program culture types and that certain aspects of a residency program's culture were related to the feedback culture. DESIGN: Residents from six specialties at three institutions voluntarily completed two validated survey instruments (Organizational Culture Assessment Instrument [OCAI] and Feedback in Medical Education [FEEDME]-Culture survey) to assess the residency program and feedback cultures, respectively. Descriptive statistics were calculated and non-parametric tests were used to analyze the data. RESULTS: The overall response rate was 37.9% (116/306 residents). 'Clan' culture was both the current and preferred culture by 49.3% and 56.8%, respectively, of the residents overall. There were differences across programs with more current 'clan' culture in pediatrics than in surgery (P = 0.01). Multiple regression analysis showed the Hierarchy Now culture type was significantly related to the feedback culture mean score (p = <.01). For every one unit increase in the Hierarchy Now culture type, the FEEDME-Culture mean score decreases by 0.023 units. CONCLUSIONS: The findings of this study add to the literature by describing residents' preferences of their residency program's culture, and providing insights into the interplay between the residency program and feedback cultures.

The Art (and Artifice) of Seeking Feedback: Clerkship Students' Approaches to Asking for Feedback.

PURPOSE: As attention has shifted to learners as significant partners in feedback interactions, it is important to explore what feedback-seeking behaviors medical students use and how the faculty-student relationship affects feedback-seeking behaviors. METHOD: This qualitative study was inspired by the organizational psychology literature. Third-year medical students were interviewed at Maine Medical Center in April-May 2017 after completing a traditional block rotation clerkship or a nine-month longitudinal integrated clerkship (LIC). A constructivist grounded theory approach was used to analyze transcripts and develop themes. RESULTS: Fourteen students participated (eight LIC, six block rotation). Themes associated with why students sought feedback included goal orientations, perceived benefits and costs, and student and feedback provider characteristics. Factors influencing the way students sought feedback included busy environments, timing, and cues students were attuned to. Students described more inquiry than monitoring approaches and used various indirect and noninquiry techniques (artifice) in asking for feedback. Students did not find summative feedback as helpful as seeking feedback themselves, and they suggested training in seeking feedback would be beneficial. Faculty-student relationship dynamics included several aspects affecting feedback-seeking behaviors, and relationship differences in the LIC and block models affected feedback-seeking behaviors. CONCLUSIONS: Medical students have many motives to seek feedback and adapt their feedback-seeking behaviors to actively participate in an intricate dialogic interaction with feedback providers. Students gradually refine the art (and artifice) of obtaining the specific feedback information that meets their needs. The authors offer a prototype curriculum that may facilitate students' development of feedback-seeking skills.

The research contributions of predominantly North American Family Medicine educators to medical learner feedback: a descriptive analysis following a scoping review.

BACKGROUND AND OBJECTIVES: In 2016, we performed a scoping review as a means of mapping what is known in the literature about feedback to medical learners. In this descriptive analysis, we explore a subset of the results to assess the contributions of predominantly North American family medicine educators to the feedback literature. METHODS: Nineteen articles extracted from our original scoping review plus six articles identified from an additional search of the journal Family Medicine are described in-depth. RESULTS: The proportion of articles involving family medicine educators identified in our scoping review is small (n=19/650, 3%) and the total remains low (25) after including additional articles (n=6) from a Family Medicine search. They encompass a broad range of feedback methods and content areas. They primarily originated in the United States (n=19) and Canada (n=3) within Family Medicine Departments (n=20) and encompass a variety of scientific and educational research methodologies. CONCLUSIONS: The contributions of predominantly North American Family Medicine educators to the literature on feedback to learners are sparse in number and employ a variety of focus areas and methodological approaches. More studies are needed to assess for areas of education research where family physicians could make valuable contributions.

Trainees' Perceptions of Feedback: Validity Evidence for Two FEEDME (Feedback in Medical Education) Instruments.

Construct: Medical educators consider feedback a core component of the educational process. Effective feedback allows learners to acquire new skills, knowledge, and attitudes. Learners' perceptions of feedback are an important aspect to assess with valid methods in order to improve the feedback skills of educators and the feedback culture. BACKGROUND: Although guidelines for delivering effective feedback have existed for several decades, medical students and residents often indicate that they receive little feedback. A recent scoping review on feedback in medical education did not reveal any validity evidence on instruments to assess learner's perceptions of feedback. The purpose of our study was to gather validity evidence on two novel FEEDME (Feedback in Medical Education) instruments to assess medical students' and residents' perceptions of the feedback that they receive. APPROACH: After the authors developed an initial instrument with 54 items, cognitive interviews with medical students and residents suggested that 2 separate instruments were needed, one focused on the feedback culture (FEEDME-Culture) and the other on the provider of feedback (FEEDME-Provider). A Delphi study with 17 medical education experts and faculty members assessed content validity. The response process was explored involving 31 medical students and residents at 2 academic institutions. Exploratory factor analysis and reliability analyses were performed on completed instruments. RESULTS: Two Delphi consultation rounds refined the wording of items and eliminated several items. Learners found both instruments easy and quick to answer; it took them less than 5 minutes to complete. Learners preferred an electronic format of the instruments over paper. Factor analysis revealed a two- and three-factor solution for the FEEDME-Culture and FEEDME-Provider instruments, respectively. Cronbach's alpha was greater than 0.80 for all factors. Items on both instruments were moderately to highly correlated (range, r = .3-.7). CONCLUSIONS: Our results provide preliminary validity evidence of 2 novel feedback instruments. After further validation of both FEEDME instruments, sharing the results of the FEEDME-Culture instrument with educational leaders and faculty may improve the culture of feedback on specific educational rotations and at the institutional level. The FEEDME-Provider instrument could be useful for faculty development targeting feedback skills. Additional research studies could assess whether both instruments may be used to help learners receive feedback and prompt reflective learning.

The Benefits of Honoring Patients as Teachers: A Qualitative Study.

INTRODUCTION: Medical training could not occur without the contributions of patients. Few programs are available that recognize patients for their essential role in medical education, and even fewer explore their impact. The Patients as Teachers (PaT) program was developed to provide an opportunity for medical students to formally honor patients for their contributions and to evaluate their effect on students' medical education. METHODS: This qualitative study involved the evaluation of transcripts of audiotaped interviews conducted with students and their honorees following participation in the PaT program in 2015 and 2016. Two different sets of authors independently examined transcripts from each year utilizing a descriptive coding strategy. Consensus was reached on theme selection and relationships between themes explored for theory development. A third author ensured grounding of the concepts in the data analyzed. RESULTS: Four themes emerged: (1) appreciating humanism in medicine, (2) expressing gratitude, (3) connecting patients and students, and (4) experiencing a unique event. CONCLUSION: The Patients as Teachers program provides meaningful benefits to both students and patients and has the potential to infuse elements of humanism into medical training.

The Feedback Tango: An Integrative Review and Analysis of the Content of the Teacher-Learner Feedback Exchange.

PURPOSE: To conduct an integrative review and analysis of the literature on the content of feedback to learners in medical education. METHOD: Following completion of a scoping review in 2016, the authors analyzed a subset of articles published through 2015 describing the analysis of feedback exchange content in various contexts: audiotapes, clinical examination, feedback cards, multisource feedback, videotapes, and written feedback. Two reviewers extracted data from these articles and identified common themes. RESULTS: Of the 51 included articles, about half (49%) were published since 2011. Most involved medical students (43%) or residents (43%). A leniency bias was noted in many (37%), as there was frequently reluctance to provide constructive feedback. More than one-quarter (29%) indicated the feedback was low in quality (e.g., too general, limited amount, no action plans). Some (16%) indicated faculty dominated conversations, did not use feedback forms appropriately, or provided inadequate feedback, even after training. Multiple feedback tools were used, with some articles (14%) describing varying degrees of use, completion, or legibility. Some articles (14%) noted the impact of the gender of the feedback provider or learner. CONCLUSIONS: The findings reveal that the exchange of feedback is troubled by low-quality feedback, leniency bias, faculty deficient in feedback competencies, challenges with multiple feedback tools, and gender impacts. Using the tango dance form as a metaphor for this dynamic partnership, the authors recommend ways to improve feedback for teachers and learners willing to partner with each other and engage in the complexities of the feedback exchange.

Is feedback to medical learners associated with characteristics of improved patient care?

PURPOSE: To investigate the association of medical learner feedback with patient management and outcomes. METHODS: The authors investigated 27 articles that utilized patient data or chart reviews as a subset of a prior feedback scoping review. Data extraction was completed by two authors and all authors reviewed the descriptive data analysis. RESULTS: The studies were predominantly short-term investigations conducted in the US at academic teaching hospitals (89%) with one medical discipline (78%), most commonly internal medicine (56%). Patient-related outcomes primarily involved improved documentation (26%) and adherence to practice guidelines (19%) and were mostly measured through chart reviews (56%) or direct observation (15%). The primary method of feedback delivery involved a written format (30%). The majority of the studies showed a positive effect of feedback on the patient-oriented study outcomes (82%), although most involved a non-rigorous study design. CONCLUSIONS: Published studies focusing on the relationship between medical learner feedback and patient care are sparse. Most involve a single discipline at a single institution and are of a non-rigorous design. Measurements of improved patient outcomes are restricted to changes in management, procedures and documentation. Well-designed studies that directly link learner feedback to patient outcomes may help to support the use of feedback in teaching clinical outcomes improvement in alignment with competency-based milestones.

High Prevalence and Clinical/Sociodemographic Correlates of Miscarriages Among Flight Attendants.

BACKGROUND: There are many occupational health hazards associated with long hours of air travel, including cosmic radiation exposure, circadian rhythm disruptions, prior and secondhand smoke exposure, for flight attendants who flew before smoking bans were initiated in the 1990s. Previous studies in flight attendants have found increased incidence of breast cancer and melanoma. However, there is little information on the relationship of airline travel and reproductive health in flight attendants. Secondhand smoke exposure has numerous negative health effects, such as increased cardiac events and respiratory infections, but its effect on reproductive health is not known. This study seeks to examine the role of secondhand smoke exposure on the miscarriage rate in flight attendants who flew before the smoking ban. METHODS: Flight attendants who flew before the smoking ban and participating in a study of health effects of secondhand smoke were asked to complete a reproductive health survey. We compared miscarriage rates of flight attendants to the general population using 2010 data from the Centers for Disease Control and Prevention. RESULTS: In our cohort of 145 female flight attendants exposed to secondhand smoke, there were 45 miscarriages (26%), compared with a 17.1% rate in the Centers for Disease Control and Prevention report (P = .002). There was no difference in secondhand smoke exposure between the flight attendants with miscarriage and the group without miscarriage (P = .93). CONCLUSIONS: This study found an increased incidence of miscarriage in flight attendants, which was unrelated to secondhand smoke exposure. Other factors, such as circadian rhythm disruption and radiation, may be related to these reproductive health findings and require further investigation.

Feedback for Learners in Medical Education: What Is Known? A Scoping Review.

PURPOSE: To conduct a scoping review of the literature on feedback for learners in medical education. METHOD: In 2015-2016, the authors searched the Ovid MEDLINE, ERIC, CINAHL, ProQuest Dissertations and Theses Global, Web of Science, and Scopus databases and seven medical education journals (via OvidSP) for articles published January 1980-December 2015. Two reviewers screened articles for eligibility with inclusion criteria. All authors extracted key data and analyzed data descriptively. RESULTS: The authors included 650 articles in the review. More than half (n = 341) were published during 2010-2015. Many centered on medical students (n = 274) or residents (n = 192); some included learners from other disciplines (n = 57). Most (n = 633) described methods used for giving feedback; some (n = 95) described opinions and recommendations regarding feedback. Few studies assessed approaches to feedback with randomized, educational trials (n = 49) or described changes in learner behavior after feedback (n = 49). Even fewer assessed the impact of feedback on patient outcomes (n = 28). CONCLUSIONS: Feedback is considered an important means of improving learner performance, as evidenced by the number of articles outlining recommendations for feedback approaches. The literature on feedback for learners in medical education is broad, fairly recent, and generally describes new or altered curricular approaches that involve feedback for learners. High-quality, evidence-based recommendations for feedback are lacking. In addition to highlighting calls to reassess the concepts and complex nature of feedback interactions, the authors identify several areas that require further investigation.