Antibiotic stewardship in Indian palliative care: a single-center retrospective study.

Objective: Characterize antibiotic prescribing behaviors at an Indian palliative care center after the initiation of the Antibiotic Order Form (AOF): an antibiotic stewardship program involving a paper form to track antibiotic use and to provide prescription guidelines. Design: Retrospective chart review. Setting: Trivandrum Institute of Palliative Sciences (TIPS) is a palliative care organization in Kerala, India. Methods: Antibiotic prescription data and patient data were collected for adult patients treated at TIPS between January 1, 2017, and October 31, 2019. Descriptive statistics and a Zero-Inflated Poisson regression model were used to analyze antibiotic prescriptions. AOF completion and prescription concordance with institutional guidelines were also evaluated. Results: Out of 7,450 unique patients, 675 (9%) were prescribed 1,448 antibiotics. Age was the strongest factor in determining the number of antibiotic courses with each additional year of age decreasing the expected antibiotic prescription count by 2% per year. The most common antibiotics prescribed were topical metronidazole (44%) and penicillins (29%). Among patients who died, 5% were prescribed antibiotics within the final month of life. In total, 32% of antibiotic prescriptions were documented in AOFs, and 18% were concordant with all institutional antibiotic prescribing guidelines. Conclusions: This study is the first to analyze an antibiotic stewardship intervention in a palliative care setting within a low- and middle-income country. This retrospective study provides a benchmark of antibiotic use within Indian palliative care and highlights areas for future stewardship research including topical metronidazole use within palliative care and higher rates of antibiotic use among younger palliative care patients.

Single low-dose targeted bevacizumab infusion in adult patients with steroid-refractory radiation necrosis of the brain: a phase II open-label prospective clinical trial.

OBJECTIVE: There is an unmet need for safe and rapidly effective therapies for refractory brain radiation necrosis (RN). The aim of this prospective single-arm phase II trial was to evaluate the safety and efficacy of a single low-dose targeted bevacizumab infusion after blood-brain barrier disruption (BBBD) in adult patients with steroid-refractory brain RN. METHODS: Ten adults with steroid-refractory, imaging-confirmed brain RN were enrolled between November 2016 and January 2018 and followed for 12 months after treatment. Bevacizumab 2.5 mg/kg was administered as a one-time targeted intra-arterial infusion immediately after BBBD. Primary outcomes included safety and > 25% decrease in lesion volume. Images were analyzed by a board-certified neuroradiologist blinded to pretrial diagnosis and treatment status. Secondary outcomes included changes in headache, steroid use, and functional status and absence of neurocognitive sequelae. Comparisons were analyzed using the Fisher exact test, Mann-Whitney U-test, linear mixed models, Wilcoxon signed-rank test, and repeated-measures 1-way ANOVA. RESULTS: Ten adults (mean ± SD [range] age 35 ± 15 [22-62] years) participated in this study. No patients died or exhibited serious adverse effects of systemic bevacizumab. At 3 months, 80% (95% CI 44%-98%) and 90% (95% CI 56%-100%) of patients demonstrated > 25% decrease in RN and vasogenic edema volume, respectively. At 12 months, RN volume decreased by 74% (median [range] 76% [53%-96%], p = 0.012), edema volume decreased by 50% (median [range] 70% [-11% to 83%], p = 0.086), and headache decreased by 84% (median [range] 92% [58%-100%], p = 0.022) among the 8 patients without RN recurrence. Only 1 (10%) patient was steroid dependent at the end of the trial. Scores on 12 of 16 (75%) neurocognitive indices increased, thereby supporting a pattern of cerebral white matter recovery. Two (20%) patients exhibited RN recurrence that required further treatment at 10 and 11 months, respectively, after bevacizumab infusion. CONCLUSIONS: For the first time, to the authors' knowledge, the authors demonstrated that a single low-dose targeted bevacizumab infusion resulted in durable clinical and imaging improvements in 80% of patients at 12 months after treatment without adverse events attributed to bevacizumab alone. These findings highlight that targeted bevacizumab may be an efficient one-time treatment for adults with brain RN. Further confirmation with a randomized controlled trial is needed to compare the intra-arterial approach with the conventional multicycle intravenous regimen. Clinical trial registration no.: NCT02819479 (ClinicalTrials.gov).

Teaching basic lung isolation skills on human anatomy simulator: attainment and retention of lung isolation skills.

BACKGROUND: Lung isolation skills, such as correct insertion of double lumen endobronchial tube and bronchial blocker, are essential in anesthesia training; however, how to teach novices these skills is underexplored. Our aims were to determine (1) if novices can be trained to a basic proficiency level of lung isolation skills, (2) whether video-didactic and simulation-based trainings are comparable in teaching lung isolation basic skills, and (3) whether novice learners' lung isolation skills decay over time without practice. METHODS: First, five board certified anesthesiologist with experience of more than 100 successful lung isolations were tested on Human Airway Anatomy Simulator (HAAS) to establish Expert proficiency skill level. Thirty senior medical students, who were naive to bronchoscopy and lung isolation techniques (Novice) were randomized to video-didactic and simulation-based trainings to learn lung isolation skills. Before and after training, Novices' performances were scored for correct placement using pass/fail scoring and a 5-point Global Rating Scale (GRS); and time of insertion was recorded. Fourteen novices were retested 2 months later to assess skill decay. RESULTS: Experts' and novices' double lumen endobronchial tube and bronchial blocker passing rates showed similar success rates after training (P >0.99). There were no differences between the video-didactic and simulation-based methods. Novices' time of insertion decayed within 2 months without practice. CONCLUSION: Novices could be trained to basic skill proficiency level of lung isolation. Video-didactic and simulation-based methods we utilized were found equally successful in training novices for lung isolation skills. Acquired skills partially decayed without practice.

Why physicians should share PDA/smartphone findings with their patients: a brief report.

Many physicians use PDAs/smartphones in the presence of their patients. But how do patients perceive this behavior? This study tested the hypothesis that participants with increased knowledge about medical applications of PDAs/smartphones have more positive perceptions of physicians using them. The authors assigned 250 patients and/or family members in medical or pharmacy waiting rooms at 2 universities to either the control group or the treatment group. The treatment group viewed a brief presentation about how and why physicians use PDAs/smartphones, whereas the control group received no new information. All participants completed a survey about their knowledge (7 items) and perceptions (13 items) of physician use of PDAs/smartphones. The treatment group showed more favorable perceptions (p < .05) on 5 out of 13 survey items. In addition, in the control group, those who showed "high knowledge" had more favorable perceptions (p < .05) on 8 out of 13 survey items compared with control group participants with "low/moderate knowledge" levels. The authors concluded that even a small amount of information increases measurable perceptions. This study suggests that perhaps physicians should take time to share their PDA/smartphone findings with their patients to improve patients' perceptions of their use.

Teaching aseptic technique for central venous access under ultrasound guidance: a randomized trial comparing didactic training alone to didactic plus simulation-based training.

BACKGROUND: Our goal was to determine whether simulation combined with didactic training improves sterile technique during ultrasound (US)-guided central venous catheter (CVC) insertion compared with didactic training alone among novices. We hypothesized that novices who receive combined didactic and simulation-based training would perform similarly to experienced residents in aseptic technique, knowledge, and perception of comfort during US-guided CVC insertion on a simulator. METHODS: Seventy-two subjects were enrolled in a randomized, controlled trial of an educational intervention. Fifty-four novices were randomized into either the didactic group or the simulation combined with didactic group. Both groups received didactic training but the simulation combined with didactic group also received simulation-based CVC insertion training. Both groups were tested by demonstrating US-guided CVC insertion on a simulator. Aseptic technique was scored on 8 steps as "yes/no" and also using a 7-point Likert scale with 7 being "excellent technique" by a rater blinded to subject randomization. After initial testing, the didactic group was offered simulation-based training and retesting. Both groups also took a pre- and posttraining test of knowledge and rated their comfort with US and CVC insertion pre- and posttraining on a 5-point Likert scale. Subsequently, 18 experienced residents also took the test of knowledge, rated their comfort level, and were scored while performing aseptic US-guided CVC insertion using a simulator. RESULTS: The simulation combined with didactic group achieved a 167% (95% confidence interval [CI] 133%-167%) incremental increase in yes/no scores and 115% (CI 112%-127%) incremental increase in Likert scale ratings on aseptic technique compared with novices in the didactic group. Compared with experienced residents, simulation combined with didactic trained novices achieved an increase in aseptic scores with a 33.3% (CI 16.7%-50%) increase in yes/no ratings and a 20% (CI 13.3%-40%) increase in Likert scaled ratings, and scored 2.5-fold higher on the test of knowledge. There was a 3-fold increase in knowledge and 2-fold increase in comfort level among all novices (P < 0.001) after combined didactic and simulation-based training. CONCLUSION: Simulation combined with didactic training is superior to didactic training alone for acquisition of clinical skills such as US-guided CVC insertion. After combined didactic and simulation-based training, novices can outperform experienced residents in aseptic technique as well as in measurements of knowledge.

Closed midshaft femur fractures: are they only for trauma centers?

Trauma centers are limited resources, particularly in rural areas, and availability of emergency care in some parts of the United States may be inadequate. The declining number of orthopedic surgeons willing to care for injured patients has limited access to fracture repair in some communities. We studied the management of closed midshaft femur fractures in both trauma centers (TCs) and nontrauma centers (NTCs) to evaluate outcome for this common orthopedic injury and determine if these issues have affected fracture care in Kentucky. All patients 16-years-old and older who suffered femur fractures in Kentucky from 2004 and 2005 were identified. There were 334 TC patients and 341 NTC patients with closed, midshaft femur fractures. The mean age of TC patients (33 ± 17 years) was significantly lower than that of NTC patients (59 ± 25 years). TC patients were more likely men (71% vs 44%), had more associated injuries (2.4 ± 2.1 vs 0.5 ± 1.2), and had longer lengths of stay (8.3 ± 9.8 vs 6.4 ± 7.1 days) (TCs vs NTCs, all P < 0.005). Although both groups ultimately underwent internal fixation (97% vs 99%, TCs vs NTCs), TC patients were more likely (2.7% vs 0.3%) to receive external fixation than the NTC patients (P < 0.05). There was no significant difference in the percentage of patients that received only a closed reduction. There was no significant difference in hospital mortality (0.3% vs 0.9%, TCs vs NTCs, P = 0.62). Although differences in patient populations exist between TCs and NTCs, both TCs and NTCs manage substantial numbers of patients with closed, midshaft femur fractures with low mortality in this state database.

Teaching the surgical airway using fresh cadavers and confirming placement nonsurgically.

STUDY OBJECTIVE: To determine if teaching cricothyrotomy with fresh cadavers improves confidence with neck anatomy, patient positioning, procedural steps, and familiarity with a cricothyrotomy kit. DESIGN: Prospective pre- and post-educational. SETTING: University medical center. SUBJECTS: 16 anesthesiology residents, one certified registered nurse-anesthetist (CRNA), and 8 medical students. MEASUREMENTS: Subjects received workshop training with a PowerPoint presentation followed by an instructional video. Subjects then performed cricothyrotomy during supervision on cadavers. The comfort levels of 25 subjects before (pre) and after (post) the workshop were assessed using a 7-point Likert scale. Correct placement of the cricothyrotome was confirmed with visualization of the carina fiberoptically. MAIN RESULTS: There was a significant increase (P < 0.001) between pre- and post-training comfort levels in identification of neck anatomy, surgical landmarks, and patient positioning (pre, 2.60 ± 1.56; post, 5.64 ± 1.22; mean ± SD); use of cricothyrotomy kit (pre, 1.72 ± 1.22; post, 5.52 ± 1.26), and surgical steps (pre, 1.76 ± 1.17; post, 5.52 ± 1.26). In 24 of 25 attempts (96% success rate), correct placement of the cricothyrotome was confirmed by visualization of the carina fiberoptically. CONCLUSIONS: A didactic workshop followed by performance of cricothyrotomy on fresh human cadavers may improve both physician and non-physician anesthesiology care providers' confidence in performing cricothyrotomy.

Assessing Medical Students', Residents', and the Public's Perceptions of the Uses of Personal Digital Assistants.

Although medical schools are encouraging the use of personal digital assistants (PDAs), there have been few investigations of attitudes toward their use by students or residents and only one investigation of the public's attitude toward their use by physicians. In 2006, the University of Louisville School of Medicine surveyed 121 third- and fourth-year medical students, 53 residents, and 51 members of the non-medical public about their attitudes toward PDAs. Students were using either the Palm i705 or the Dell Axim X50v; residents were using devices they selected themselves (referred to in the study generically as PDAs). Three survey instruments were designed to investigate attitudes of (a) third- and fourth-year medical students on clinical rotations, (b) Internal Medicine and Pediatrics residents, and (c) volunteer members of the public found in the waiting rooms of three university practice clinics. Both residents and medical students found their devices useful, with more residents (46.8%) than students (16.2%) (p < 0.001) rating PDAs "very useful." While students and residents generally agreed that PDAs improved the quality of their learning, residents' responses were significantly higher (p < 0.05) than students'. Residents also responded more positively than students that PDAs made them more effective as clinicians. Although members of the public were generally supportive of PDA use, they appeared to have some misconceptions about how and why physicians were using them. The next phase of research will be to refine the research questions and survey instruments in collaboration with another medical school.

Lecture versus standardized patient interaction in the surgical clerkship: a randomized prospective cross-over study.

BACKGROUND: Medical schools increasingly are incorporating the standardized patient (SP) interaction as a teaching and testing modality to prepare students for United States Medical Licensing Examination Step 2 Clinical Skills. Although SP interactions provide a safe environment in which to practice clinical skills, little is known about medical students' perceptions of the instructional SP interaction in comparison with the classic didactic lecture. We hypothesized that students would enjoy and value an instructional SP interaction more than a didactic lecture, and that this perception would be enhanced if the lecture immediately preceded the instructional SP interaction. METHODS: Students on the junior surgery clerkship from January to December 2004 were randomized into 2 groups. Group A (n = 71) received an hour-long didactic lecture about peripheral vascular disease followed by a 20-minute instructional SP interaction in which the SP portrayed a patient with lower-extremity claudication. Group B (n = 72) received the SP interaction first, followed by the lecture. All students received an identical quiz about peripheral vascular disease after the second educational encounter, whether the SP interaction or the lecture. Student perceptions were surveyed by written questionnaire before and after the session by using a 5-point Likert scale, with 5 being the most favorable rating. Data (perceptions, performances on the quiz and the SP interaction, clerkship grades) were compared using the Student t test or the Mann-Whitney rank sums test. RESULTS: Although all students on average enjoyed and valued the lecture more than the SP interaction (P <.001), group A students enjoyed the SP interaction more than group B (3.3 +/- .9 vs. 2.8 +/- 1.0, P = .008), and they perceived the SP interaction as having more value to their overall education (3.3 +/- 1.0 vs. 2.8 +/- 1.0, P = .004). Group A students performed statistically better on the physical examination (66% +/- 19% vs. 40% +/- 16%, P <.001) and communication portions (90% +/- 11% vs. 79% +/- 12%, P <.001) of the SP checklist than group B, but not on the history portion. Student confidence in their own history and physical examination skills increased similarly for both groups. CONCLUSIONS: The classic lecture format not only is enjoyed and valued as a learning tool more by our surgical clerkship students than the instructional SP interaction, but having a lecture just before an SP interaction increased perceived enjoyment and value of the SP interaction and enhanced performance on the SP checklist. These data suggest that educators can improve student perceptions and attitudes surrounding the instructional SP interaction by using strategically timed lectures.

A brief private group practice rotation changes junior medical students' perception of the surgical lifestyle.

BACKGROUND: Surgical practice is often perceived by students as a stressful and demanding lifestyle in which personal and family issues take low priority. For students to receive a more balanced view of surgical practice, we instituted a private practice preceptorship during the last week of our junior surgery clerkship in 2001. We hypothesized that a 4-day preceptorship with surgeons in private practice would improve student perception of surgery as a valid career choice without compromising student educational performance. METHODS: From January to December 2002, 107 junior medical students were assigned to a brief preceptorship with volunteer private practice surgeons during the surgery clerkship (group 1), while 28 students did not participate in the preceptorship (group 2). We assessed student satisfaction via questionnaire and compared student grade performance between groups. RESULTS: One hundred two questionnaires (95%) were returned. Overall, the preceptor experience was rated positively (9.0+/-0.1) based on a 10-point Likert scale. All students commented on the educational or enjoyment value of the preceptorship, with 44% specifically stating that the lifestyle in private surgical practice appeared pleasant. Interestingly, 9% of students volunteered that the experience had swayed them to consider surgery as a career. Twenty-four percent of questionnaires contained negative comments, mainly concerning not enough "hands-on" participation. Grades for the clerkship did not decrease in group 1 when compared with group 2 or with historic controls (n=113). CONCLUSIONS: A 4-day private practice preceptorship at the end of the junior surgery clerkship favorably alters student perceptions of a surgical career without diminishing student grade performance.

Didactic lecture versus instructional standardized patient interaction in the surgical clerkship.

BACKGROUND: Medical schools increasingly employ the standardized patient interaction (SPI) as a teaching and testing modality to prepare students for USMLE Step 2 Clinical Skills (Step 2 CS). However, little is known about the perceptions medical students have toward SPIs. We hypothesized that the SPI would increase the self-confidence of surgery students in their history and physical examination (H&P) skills as compared with the classic lecture format and that students would perceive the SPI as a valuable learning tool. METHODS: Students (n = 126) on the junior surgery clerkship were randomized into two groups. Group A (n = 61) received a didactic lecture on acute appendicitis. Group B (n = 65) participated in an SPI in which the portrayed patient had acute appendicitis. Student perceptions were surveyed by written questionnaire pre- and postencounter using a 5-point Likert scale, with 5 being the most favorable rating. Data (perceptions, performances on the SPI, clerkship grades) were compared using a Student t test followed by the Mann-Whitney rank sums test. RESULTS: Group A "enjoyed" the lecture format more than group B "enjoyed" the SPI format (3.4 +/- 0.1 versus 2.6 +/- 0.1, P <.001) and perceived the lecture as having more value to their overall education (3.5 +/- 0.1 versus 2.6 +/- 0.1, P <.001) than the SPI group. Surprisingly, student self-confidence in their H&P skills increased after the didactic lecture (from 3.6 +/- 0.1 to 4.1 +/- 0.1, P = .001) but not after the SPI (from 3.6 +/- 0.1 to 3.8 +/- 0.1, P = not significant). CONCLUSIONS: The didactic lecture format was not only enjoyed and valued more than the SPI, but our surgery students also perceived it as superior to the SPI in building confidence in history and physical examination skills. These findings suggest that surgical educators should develop ways to improve students' perceptions and attitudes surrounding the surgical SPI.