Best Practices: Burnout Is More Than Binary.

Burnout among radiologists is increasingly prevalent, with potential for substantial negative impact on physician well-being, care delivery, and health outcomes. To evaluate this phenomenon using reliable and accurate means, validated quantitative instruments are essential. Variation in measurement can contribute to wide-ranging findings. This article evaluates radiologist burnout rates globally and dimensions of burnout as reported using different validated instruments and provide guidance on best practices to characterize burnout. Fifty-seven studies between 1990 and 2023 were included in a systematic review, and 43 studies were included in a meta-analysis of burnout prevalence using random effects models. Reported burnout ranged from 5% to 85%. With the Maslach Burnout Inventory (MBI), burnout prevalence varied significantly depending on instrument version. Among MBI subcategories, the prevalence of emotional exhaustion was 54% (95% CI, 45-63%), depersonalization was 52% (95% CI, 41-63%), and low personal accomplishment was 36% (95% CI, 27-47%). Other validated burnout instruments showed less heterogeneous results; studies using the Stanford Professional Fulfillment Index yielded burnout prevalence of 39% (95% CI, 34-45%), whereas the Validated Single-Item instrument yielded 34% (95% CI, 29-39%). Standardized instruments for prevalence alongside multidimensional profiles capturing experiences may better characterize radiologist burnout, including change over time.

Surveillance after resection of non-invasive intraductal papillary mucinous neoplasms (IPMN). A systematic review.

BACKGROUND: The ideal surveillance strategy after partial pancreatectomy for non-invasive IPMN remains undefined and existing guidelines provide conflicting recommendations. The present study was developed in anticipation of the joint meeting of the International Association of Pancreatology (IAP) and the Japan Pancreas Society (JPS) held in Kyoto in July 2022. METHODS: An international team of experts developed the four clinical questions (CQ) to operationalize issues pertaining to surveillance of patients in this context. A systematic review was designed following the PRISMA guidelines and registered in PROSPERO. The search strategy was executed in PubMed/Medline (Ovid), Embase, the Cochrane Library and Web of Science databases. Four investigators individually extracted data from the selected studies and drafted recommendations for each CQ. These were subsequently discussed and agreed upon that the IAP/JPS meeting. RESULTS: From a total of 1098 studies identified through the initial search, 41 studies were included in the review and informed the recommendations. No studies providing level one data were identified in this systematic review, all studies included were cohort or case-control studies. CONCLUSIONS: There is a lack of level 1 data addressing the issue of surveillance of patients following partial pancreatectomy for non-invasive IPMN. The definition of remnant pancreatic lesion in this setting is largely heterogeneous across all studies evaluated. Herein we propose an inclusive definition of remnant pancreatic lesions to guide future prospective efforts for reporting the natural history and long-term outcomes of these patients.

Narrative review of migraine management in patients with renal or hepatic disease.

OBJECTIVES/BACKGROUND: Treatment of migraine in the setting of either renal or hepatic disease can be daunting for clinicians. Not only does the method of metabolism have to be considered, but also the method of elimination/excretion of the parent drug and any active or toxic metabolites. Furthermore, it is difficult to think about liver or kidney disease in isolation, as liver disease can sometimes contribute to impaired renal function and renal disease can sometimes impair hepatic metabolism, through the cytochrome P450 system. METHODS: A detailed search for terms related to liver disease, renal disease, and migraine management was performed in PubMed, Ovid Medline, Embase, and the Cochrane Library.For each medication, product labels were retrieved and reviewed using the US FDA website, with additional review of IBM Micromedex, LiverTox, and the Renal Drug Handbook. RESULTS: This manuscript provides an overview of migraine drug metabolism and how it can be affected by liver and renal impairment. It reviews the standard terminology recommended by the US Food and Drug Administration for the different stages of hepatic and renal failure. The available evidence regarding the use of abortive and preventative medicines in the setting of organ failure is discussed in detail, including more recent therapies such as lasmiditan, gepants, and calcitonin gene-related peptide antibodies. CONCLUSIONS: For acute therapy, the use of NSAIDS should be limited, as these carry risk for both severe hepatic and renal disease. Triptans can be selectively used, often with dose guideline adjustments. Ubrogepant may be used in severe hepatic disease with dose adjustment and lasmiditan can be used in end stage renal disease. Though non-medicine strategies may be the most reasonable initial approach, many preventative medications can be used in the setting of hepatic and renal disease, often with dose adjustment. This review provides tables of guidelines, including reduced dosing recommendations, for the use of abortive and preventative migraine medications in hepatic and renal failure.

A systematic review of randomized controlled trials examining workplace wellness interventions.

BACKGROUND: One of the influencing factors associated with weight gain is overeating as a maladaptive coping strategy to process or avoid the emotional impact of psychological stress. Psychological stress is chronically and pervasively associated with stress stemming from the workplace environment. Workplace wellness interventions have a unique opportunity to change environmental factors impacting psychological stress, which can improve individual food choice and weight management efforts. AIM: To synthesize evidence from randomized controlled trials on workplace wellness interventions that impact employee psychological stress and food choice or weight management. METHODS: A systematic review was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Selected studies were limited to English-language articles exploring randomized interventions at workplaces among adult employees and included measurements of psychometric stress and food choice (qualitative or quantitative) or biometric weight management. From the search, 10 studies were included in the final review. RESULTS: Results were inconsistent across studies. There was no observable association between psychological stress reduction and food choice or weight management. Mid-length interventions (ranging from 6 to 9 months) had more consistent associations between intervention program implementation, reduced psychological stress, and improved food choice or weight management. CONCLUSIONS: The studies examining employee food choices and weight management efforts remained very heterogeneous, indicating that more research is needed in this specific area of employee wellness program planning and measurement. Consistent research methodology and assessment tools are needed to measure dietary intake.

Systematic review of prediction models for gestational hypertension and preeclampsia.

INTRODUCTION: Prediction models for gestational hypertension and preeclampsia have been developed with data and assumptions from developed countries. Their suitability and application for low resource settings have not been tested. This review aimed to identify and assess the methodological quality of prediction models for gestational hypertension and pre-eclampsia with reference to their application in low resource settings. METHODS: Using combinations of keywords for gestational hypertension, preeclampsia and prediction models seven databases were searched to identify prediction models developed with maternal data obtained before 20 weeks of pregnancy and including at least three predictors (Prospero registration CRD 42017078786). Prediction model characteristics and performance measures were extracted using the CHARMS, STROBE and TRIPOD checklists. The National Institute of Health quality assessment tools for observational cohort and cross-sectional studies were used for study quality appraisal. RESULTS: We retrieved 8,309 articles out of which 40 articles were eligible for review. Seventy-seven percent of all the prediction models combined biomarkers with maternal clinical characteristics. Biomarkers used as predictors in most models were pregnancy associated plasma protein-A (PAPP-A) and placental growth factor (PlGF). Only five studies were conducted in a low-and middle income country. CONCLUSIONS: Most of the studies evaluated did not completely follow the CHARMS, TRIPOD and STROBE guidelines in prediction model development and reporting. Adherence to these guidelines will improve prediction modelling studies and subsequent application of prediction models in clinical practice. Prediction models using maternal characteristics, with good discrimination and calibration, should be externally validated for use in low and middle income countries where biomarker assays are not routinely available.

Incidence of Guillain-Barré Syndrome (GBS) in Latin America and the Caribbean before and during the 2015-2016 Zika virus epidemic: A systematic review and meta-analysis.

BACKGROUND: A severe neurological disorder, Guillain-Barré syndrome (GBS) is the leading cause of acute flaccid paralysis. Enhanced surveillance of GBS in Latin America and the Caribbean (LAC) following the 2015-2016 Zika virus (ZIKV) epidemic presents an opportunity to estimate, for the first time, the regional incidence of GBS. METHODS AND FINDINGS: For this systematic review and meta-analysis, we searched nine scientific databases and grey literature from January 1, 1980 to October 1, 2018. Sources with primary data on incident GBS cases in LAC within a well-defined population and timeframe, published in English, Spanish, Portuguese, or French, were included. We calculated the annual GBS incidence rates (IRs) and 95% confidence intervals (CIs) for each source based on published data. Following an assessment of heterogeneity, we used random-effects meta-analysis to calculate the pooled annual IR of GBS. The study is registered with PROSPERO, number CRD42018086659. Of the 6568 initial citation hits, 31 were eligible for inclusion. Background annual GBS IRs in Latin America ranged from 0.40 in Brazil to 2.12/100,000 in Chile. The pooled annual IR in the Caribbean was 1.64 (95% CI 1.29-2.12, I2<0.01, p = 0.44). During the ZIKV epidemic, GBS IRs ranged from 0.62 in Mexico to 9.35/100,000 in Martinique. GBS increased 2.6 (95% CI 2.3-2.9) times during ZIKV and 1.9 (95% CI 1.1-3.4) times during chikungunya outbreaks over background rates. A limitation of this review is that the studies included employed different methodologies to find and ascertain cases of GBS, which could contribute to IR heterogeneity. In addition, it is important to consider that data on GBS are lacking for many countries in the region. CONCLUSIONS: Background IRs of GBS appear to peak during arboviral disease outbreaks. The current review contributes to an understanding of the epidemiology of GBS in the LAC region, which can inform healthcare system planning and preparedness, particularly during arboviral epidemics. TRIAL REGISTRATION: Registered with PROSPERO: CRD42018086659.

Adherence to positive airway pressure treatment among minority populations in the US: A scoping review.

Minority individuals in the United States (US) have an increased prevalence of obstructive sleep apnea (OSA) compared to their white/Caucasian counterparts. In general, adherence to positive airway pressure (PAP) therapy is poor and some studies suggest that PAP use among minority individuals is inferior to that of whites. However, there has not been a review of the evidence that addresses racial-ethnic disparities for PAP adherence in the treatment of OSA, and no review has systematically examined the contributing factors to poor adherence among minority individuals compared to whites. We searched the literature for studies published between January 1990 to July 2016 that included objective PAP use comparisons between adult US minority individuals and whites. Twenty-two studies met the inclusion criteria. All studies compared the PAP adherence of blacks to whites. Seven studies compared the PAP adherence of additional minority groups to that of whites. Sixteen of the 22 studies (73%) showed worse PAP adherence in blacks compared to whites. Four studies found equivalent PAP use in US Hispanics compared to whites. Little is known about the PAP adherence of other US minority groups. We present a framework and research agenda for understanding PAP use barriers among US minority individuals.

Mental Health, Psychosocial Challenges and Resilience in Older Adults Living with HIV.

In addition to physical health challenges, older people living with HIV/AIDS (PLWHA) experience mental health burdens and challenges to their social well-being that diminish their overall health. These health states are synergistic and are driven by HIV and HIV treatments, the aging process itself, and psychosocial and structural conditions of their lives. However, resilience, which we understand as both a trait and a process, may serve to buffer the effects that HIV/HIV treatments, aging, and social/structural conditions may have on the overall well-being of the individual. In this chapter, we examine the extant literate on the mental health and psychosocial challenges experienced by older PLWHA as elements of the total health of the individual. We also provide a contextualization and conceptualization for understanding the significant role that resilience may play in empowering individuals to enact processes which buffer health from the stressors. In this perspective, the health of older PLWHA must be viewed through a lens of power and strength rather than one of deficit. We conclude by outlining a theoretical paradigm for the role of resilience in the health of older HIV-positive adults, which may serve as a guide to clinicians, public health practitioners, and researchers working with this population.

Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease.

BACKGROUND: Exercise testing with echocardiography or myocardial perfusion imaging is widely used to risk-stratify patients with suspected coronary artery disease. However, reports of diagnostic performance rarely adjust for referral bias, and this practice may adversely influence patient care. Therefore, we evaluated the potential impact of referral bias on diagnostic effectiveness and clinical decision-making. METHODS AND RESULTS: Searching PubMed and EMBASE (1990-2012), 2 investigators independently evaluated eligibility and abstracted data on study characteristics and referral patterns. Diagnostic performance reported in 4 previously published meta-analyses of exercise echocardiography and myocardial perfusion imaging was adjusted using pooled referral rates and Bayesian methods. Twenty-one studies reported referral patterns in 49 006 patients (mean age 60.7 years, 39.6% women, and 0.8% prior history of myocardial infarction). Catheterization referral rates after normal and abnormal exercise tests were 4.0% (95% CI, 2.9% to 5.0%) and 42.5% (36.2% to 48.9%), respectively, with odds ratio for referral after an abnormal test of 14.6 (10.7 to 19.9). After adjustment for referral, exercise echocardiography sensitivity fell from 84% (80% to 89%) to 34% (27% to 41%), and specificity rose from 77% (69% to 86%) to 99% (99% to 100%). Similarly, exercise myocardial perfusion imaging sensitivity fell from 85% (81% to 88%) to 38% (31% to 44%), and specificity rose from 69% (61% to 78%) to 99% (99% to 100%). Summary receiver operating curve analysis demonstrated only modest changes in overall discriminatory power but adjusting for referral increased positive-predictive value and reduced negative-predictive value. CONCLUSIONS: Exercise echocardiography and myocardial perfusion imaging are considerably less sensitive and more specific for coronary artery disease after adjustment for referral. Given these findings, future work should assess the comparative ability of these and other tests to rule-in versus rule-out coronary artery disease.

Overcoming barriers to hypertension control in African Americans.

Barriers to blood pressure control exist at the patient, physician, and system levels. We review the current evidence for interventions that target patient- and physician-related barriers, such as patient education, home blood pressure monitoring, and computerized decision-support systems for physicians, and we emphasize the need for more studies that address the effectiveness of these interventions in African American patients.

Peer training in expert searching: the observation effect.

OBJECTIVES: The purpose of this study is to determine if searchers' observing each others' search processes is an effective training method and if sharing through observation can strengthen search skills. METHOD: A shared email account was established among all public services librarians conducting literature searches at the Ehrman Medical Library. Three questionnaires were sent to the public services librarians soliciting input on the shared-search process. The results were analyzed for this study. RESULTS: The shared-search process has helped searchers become more effective in searching. Colleagues' viewing of the search results is a major factor influencing the searchers' performance. CONCLUSIONS: Easy to implement, the peer-training model is an effective way to train searchers as well as help keep skills up to date.