Walking at work: Maximum gait speed is related to work ability in hospital nursing staff.

OBJECTIVES: Like the concept of work ability in occupational health, gait speed is a measure of general fitness and can predict functional decline and morbidity. This is especially important when our care-takers, i.e. nurses, show decline in fitness and become care-receivers. The study aims to describe the demographics of hospital nurses in the context of gait speed and work ability as well as to determine the association between them. METHODS: Three-hundred and twelve inpatient nurses and nursing assistants were sampled from a level 1 trauma and teaching hospital from several service lines and acuity levels. Spearman correlation tests were utilized to determine the relationship of gait speed and ratings of item 1 on the Work Ability Index (WAI) as well as Cochran-Armitage test for linear trend of gait speed. RESULTS: Maximum gait speed has a significant positive association with work ability with a Rho coefficient of 0.217 (P < .0001). Additionally, the linear trend test of gait speed tertiles was significant (P < .001) for work ability categories of Moderate to Poor (0-7) and Good to Excellent (8-10). CONCLUSIONS: Gait speed is correlated with the item 1 self-rating of the WAI in hospital nursing staff. The 10-m walk test is a practical and easy measure that can be utilized in occupational health. More research is required to validate gait speed in other occupational health populations and investigate gait speed changes and its interaction with the work environment longitudinally.

Failure on a Vascular Surgery Board-American Board of Surgery Examination does not predict cardiovascular outcomes in the Society for Vascular Surgery Vascular Quality Initiative.

OBJECTIVE: The Vascular Surgery Board of the American Board of Surgery (VSB-ABS) Qualifying and Certifying examinations are meant to assess qualifications to independently practice vascular surgery, but it is unclear whether examination performance correlates with clinical outcomes. We assessed this relationship using clinical outcomes data for VSB-ABS diplomates from the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI). METHODS: VSB-ABS examination performance for vascular surgeons participating in the SVS-VQI registry was characterized according to pass/fail status. Surgical experience was measured by number of years since completion of training. Examination performance and experience were compared with a composite clinical outcome (in-patient major adverse cardiac events or postoperative death [MACE+POD]) after arterial reconstructions (carotid stenting or endarterectomy, aortic aneurysm repair, open peripheral surgical bypasses) registered in the SVS-VQI. Multivariate mixed effects regression was performed adjusting for sex and surgery type, as well as clustering by surgeon and by hospital. RESULTS: From 2003 to 2017, complete data were available for 776 vascular surgeons who performed 124,171 arterial reconstructions (carotid n = 56,650; aortic n = 34,764; peripheral n = 32,757) registered in the SVS-VQI. Patient characteristics associated with higher odds of MACE+POD were female sex (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12; P = .006) and advancing age (OR, 1.04; 95% CI, 1.03-1.04; P < .001). Of the 776 surgeons, 149 (17%) had failed at least one VSB-ABS examination (group F). The unadjusted primary composite outcome of MACE+POD was marginally higher after operations performed by surgeons who never failed an examination (group P; 7% vs 6%; P = .03). This difference seems to be driven by higher rates of postoperative congestive heart failure in the aortic and lower extremity bypass cohorts as well as more postoperative myocardial infarctions after lower extremity bypass by group P surgeons. Following multivariable analyses, examination pass status was not associated with MACE+POD (OR, 0.98; 95% CI, 0.89-1.50; P = .517). However, increasing surgical experience correlated with significantly lower odds of MACE+POD (2% lower odds/year of experience since training [OR, 0.98; 95% CI, 0.98-0.99; P < .001]). CONCLUSIONS: VSB-ABS examination performance by SVS-VQI surgeons does not correlate with registry-reported mortality or cardiovascular complications. Increasing surgical experience is strongly associated with lower odds of cardiovascular morbidity and death.

Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

Future of Implantable Auditory Devices.

The advances in technology leading to rapid developments in implantable auditory devices are constantly evolving. Devices are becoming smaller, less visible, and more efficient. The ability to preserve hearing outcomes with cochlear implantation will continue to evolve as surgical techniques improve with the use of continuous feedback during the procedure as well as with intraoperative delivery of drugs and robot assistance. As engineering methods improve, there may one day be a totally implantable aid that is self-sustaining in hearing-impaired patients making them indistinguishable from patients without hearing loss.

Are you sure the patient is a CYP2D6 ultra-rapid metabolizer?

AIM: This study investigated the possible cause of false-positive detection of CYP2D6 gene duplication (CYP2D6XN) using the standard TaqMan-based real-time PCR assay from Thermo Fisher Scientific. METHODS: Used samples of two copy carriers as control to evaluate the effect of sample storage condition and the reference genes with respect to test accuracy. RESULTS: The standard test from Thermo Fisher Scientific produced false-positive results of the CYP2D6XN detection when samples were exposed to high temperature and high humidity. The unbalanced template stability between the CYP2D6 testing target and the RNase P reference target was likely the source of error. The problem was reduced but not eliminated when the telomerase reverse transcriptase gene was used as the reference. CONCLUSION: Special care is required in sample handling, testing and data verification to ensure accurate test results and avoid misdiagnosis of an individual as a CYP2D6 ultra-rapid metabolizer.

Surgical Training and the Early Specialization Program: Analysis of a National Program.

BACKGROUND: The Early Specialization Program (ESP) in surgery was designed by the American Board of Surgery, the American Board of Thoracic Surgery, and the Residency Review Committees for Surgery and Thoracic Surgery to allow surgical trainees dual certification in general surgery (GS) and either vascular surgery (VS) or cardiothoracic surgery (CTS) after 6 to 7 years of training. After more than 10 years' experience, this analysis was undertaken to evaluate efficacy. STUDY DESIGN: American Board of Surgery and American Board of Thoracic Surgery records of VS and CTS ESP trainees were queried to evaluate qualifying exam and certifying exam performance. Case logs were examined and compared with contemporaneous non-ESP trainees. Opinions of programs directors of GS, VS, and CTS and ESP participants were solicited via survey. RESULTS: Twenty-six CTS ESP residents have completed training at 10 programs and 16 VS ESP at 6 programs. First-time pass rates on American Board of Surgery qualifying and certifying exams were superior to time-matched peers; greater success in specialty specific examinations was also found. Trainees met required case minimums for GS despite shortened time in GS. By survey, 85% of programs directors endorsed satisfaction with ESP, and 90% endorsed graduate readiness for independent practice. Early Specialization Program participants report increased mentorship and independence, greater competence for practice, and overall satisfaction with ESP. CONCLUSIONS: Individuals in ESP programs in VS and CTS were successful in passing GS and specialty exams and achieving required operative cases, despite an accelerated training track. Programs directors and participants report satisfaction with the training and confidence that ESP graduates are prepared for independent practice. This documented success supports ESP training in any surgical subspecialty, including comprehensive GS.

Patient Opinion on the Affordable Care Act in an Otolaryngology Practice: the Ideological Divide.

OBJECTIVE: To assess patient opinion on the Patient Protection and Affordable Care Act (PPACA) in an Otolaryngology practice and the factors that influence those opinions. STUDY DESIGN: Observational study. METHODS: An anonymous survey assessing patient opinion on the PPACA, demographic information, political affiliation, medical diagnosis, and insurance status was distributed to patients in three separate Otolaryngology clinics (General, cancer, and Low-income/Indigent) from April to June 2014. A total of 300 surveys were distributed and 207 were used for final analysis. The primary study outcome measures were patient opinion of the PPACA and statistically significant variables affecting that opinion. The association of Support for the PPACA and variables were tested using the Chi-square test. RESULTS: The only variables that showed a significant association with support for the PPACA were Political Party (p<0.0001) and Ethnicity (p=0.0050). Specifically, a higher proportion of Democrats support the PPACA than Republicans and a higher proportion of African Americans and Hispanic/Latinos support the PPACA than Whites and Native Americans. CONCLUSION: Our survey of current Otolaryngology patients mirrors national findings of the division between Republicans and Democrats in their attitudes towards the Affordable Care Act. Political party appears to be the most significant factor in shaping patient opinion on this controversial subject regardless of insurance status or cancer diagnosis and a higher proportion of African Americans and Hispanic/Latinos support the PPACA than Whites and Native Americans. LEVEL OF EVIDENCE: IV.

Informal Peer Interaction and Practice Type as Predictors of Physician Performance on Maintenance of Certification Examinations.

IMPORTANCE: Physicians can demonstrate mastery of the knowledge that supports continued clinical competence by passing a maintenance of certification examination (MOCEX). Performance depends on professional learning and development, which may be enhanced by informal routine interactions with colleagues. Some physicians, such as those in solo practice, may have less opportunity for peer interaction, thus negatively influencing their examination performance. OBJECTIVE: To determine the relationship among level of peer interaction, group and solo practice, and MOCEX performance. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal cohort study of 568 surgeons taking the 2008 MOCEX. Survey responses reporting the level of physicians' peer interactions and their practice type were related to MOCEX scores, controlling for initial qualifying examination scores, practice type, and personal characteristics. EXPOSURES: Solo practice and amount of peer interaction. MAIN OUTCOMES AND MEASURES: Scores on the MOCEX and pass-fail status. RESULTS: Of the 568 surgeons in the study sample, 557 (98.1%) passed the examination. Higher levels of peer interaction were associated with a higher score (ß = 0.91 [95% CI, 0.31-1.52]) and higher likelihood of passing the examination (odds ratio, 2.58 [1.08-6.16]). Physicians in solo (vs group) practice had fewer peer interactions (ß = -0.49 [95% CI, -0.64 to -0.33), received lower scores (ß = -1.82 [-2.94 to -0.82]), and were less likely to pass the examination (odds ratio, 0.22 [0.06-0.77]). Level of peer interaction moderated the relationship between solo practice and MOCEX score; solo practitioners with high levels of peer interaction achieved an MOCEX performance on a par with that of group practitioners. CONCLUSIONS AND RELEVANCE: Physicians in solo practice had poorer MOCEX performance. However, solo practitioners who reported high levels of peer interaction performed as well as those in group practice. Peer interaction is important for professional learning and quality of care.

Assessment of Physicians' Perceived Risk of Inflammatory Bowel Disease Medications in Pregnant Patients.

UNLABELLED: Many female patients with inflammatory bowel disease (IBD) are affected during their reproductive years, and the benefits of continuing medical therapy to maintain remission during pregnancy generally outweigh the risks of therapy cessation. Knowledge of the current guidelines is important to maximize maternal and fetal outcomes. METHODS: A total of 116 practitioners (family medicine [FM], n = 35; internal medicine [IM], n = 22; obstetrics/gynecol-ogy [Ob/Gyn], n=23; gastroenterology [GI], n = 36) responded to a survey. Respondents were asked about the US Food and Drug Administration classifications of common IBD drugs, the need for caution when administering live vaccines to neonates exposed to biologic agents in utero, and 2 scenarios of patients with IBD who wanted to become pregnant. RESULTS: Compared with GI physicians, FM + IM physicians were less likely to correctly identify infliximab (Remicade, Janssen Biotech) as a pregnancy category B drug (67% vs 30%; P=.0005). Among all respondents, 38% were unaware of the need to delay administration of live vaccines to infants exposed to anti-tumor necrosis factor agents in utero. GI specialists were more likely to advise patients to continue their IBD regimen (biologic agents and thiopurines) during pregnancy than non-GI (IM, FM, and Ob/Gyn) physicians (biologic agents: 86% vs 46%; P<.0001 and thiopurines: 69% vs 15%; P<.0001). Overall, 78% of non-GI physicians said that they would change their practice based on the survey. CONCLUSION: Practitioners caring for pregnant patients may lack awareness regarding the safety and management of IBD drugs during pregnancy. Bringing awareness through education may increase the number of physicians following best practice guidelines.

Evolving patterns of vascular surgery care in the United States: a report from the American Board of Surgery.

BACKGROUND: The purpose of this study was to analyze the distribution of major vascular procedures among general and vascular surgeons and to compare the evolution of vascular surgical practice of general and vascular surgeons at specific points in their careers. STUDY DESIGN: Case logs of surgeons seeking recertification in surgery from 2007 to 2009 were reviewed. Data from 3,362 physicians certified only in surgery (GS) were compared with 363 additionally certified in vascular surgery (VS). Independent variables were compared using factorial ANOVA. RESULTS: The mean numbers of major vascular procedures (±SD) were 10 ± 51 for GS and 192 ± 209 for VS (p < 0.001). Thirty-three percent of the total vascular procedures reported were performed by GS. Compared with VS, GS performed significantly fewer vascular procedures in all major procedure categories, and GS certifying at 10 years performed fewer vascular procedures (6.7 ± 47) than those recertifying at 20 years (11.5 ± 48) and 30 years (13.6 ± 59) (p < 0.01). In contrast, VS certifying at 10 years performed more vascular procedures (235 ± 237) compared with those recertifying at 20 years (157 ± 173) and 30 years (104 ± 115). The mean number of vascular procedures was not different for sex, geographic location, or practice type, after controlling for other variables in the study. CONCLUSIONS: The majority of GS currently do not perform any major vascular procedures, and younger GS are performing fewer such procedures than their older counterparts. The opposite is true for VS. These opposing trends indicate that vascular procedures are shifting from GS to VS in modern surgical practice, and this may have important implications for patient access to vascular surgery care, considering the limited capacity for VS to assume the excess case load.

General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery.

OBJECTIVE: To assess changes in general surgery workloads and practice patterns in the past decade. BACKGROUND: Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. METHODS: The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. RESULTS: GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. CONCLUSIONS: GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access.

[Evolution of vascular surgery and vascular surgery training: lessons learned.]

Over the last decade, surgery as a discipline, and vascular surgery in particular, has been faced with a rapid growth in the scope of knowledge and array of techniques to be mastered by the graduating resident and the constraints of work hour limitations. In response, the U.S. vascular surgery community significantly altered its surgical training curriculum. This article will discuss the factors that prompted these changes, the challenges that continue to face vascular surgery education and the expectations for the future. We will also comment on the relevance of this experience to other surgical specialties.

Anxiety and depression severity are related to right but not left onset Parkinson's disease duration.

Depression and anxiety have both been associated with relative left frontal hypoactivation and the motor symptoms of Parkinson's disease typically begin in a lateral or asymmetrical fashion. Hence, PD patients with right hemibody onset may experience heightened depression and anxiety. However, research is mixed regarding whether right or left hemibody onset PD is associated with elevated levels of depression and anxiety. This literature, though, has not considered the potential moderating variable of disease duration. We hypothesized that disease duration would be positively correlated with measures of depression and anxiety in right but not left hemibody onset PD patients. The results indicated that scores on the Geriatric Depression Scale, Beck Depression Inventory-II, and the State Trait Anxiety Scale - State correlated positively with disease duration, but only in the right hemibody onset group of PD patients. Thus, right hemibody onset PD is associated with more severe depressive and anxiety symptoms, but only when disease duration is considered.

Factors that influence general internists' and surgeons' performance on maintenance of certification exams.

PURPOSE: Good clinical judgment is important to providing high-quality patient care. Keeping current in one's field is challenged by rapid advances in health care and demanding practices. Understanding the collective factors that influence a practicing physician's clinical judgment could help medical educators design improvement programs that target specific audiences. METHOD: Data from two medical specialty boards, the American Board of Internal Medicine and American Board of Surgery, were used. Multiple regression analyses were conducted relating first-attempt performance on the maintenance of certification (MOC) exam with physician age, amount of continuing medical education (CME) undertaken, number of physicians in the practice, medical school type, and prior exam performance. Data were based on demographics and exam scores of 18,447 general internists and 4,961 general surgeons who took the MOC exam for the first time between 2003 and 2007. RESULTS: Similar findings were obtained for general internists and surgeons. Younger physicians, those with higher scores on initial certification, physicians in group not solo practice, and U.S. medical graduates were significantly more likely to pass the MOC exam (P<.001). Effect sizes were small except for performance on the initial certification exam. General internists with higher internal medicine program directors' ratings and more CME activities were also significantly more likely to pass (P<.001). CONCLUSIONS: Medical educators may target improvement programs for those who practice in isolation, are older, are international medical graduates, and performed poorly on their initial certification exam. Practicing without sustaining requisite clinical judgment has serious implications for patient care.

Comparison of surgical operative experience of trainees and practicing vascular surgeons: a report from the Vascular Surgery Board of the American Board of Surgery.

INTRODUCTION: The Vascular Surgery Board (VSB) of the American Board of Surgery sought to answer the following questions: what is the scope of contemporary vascular surgery practice? Do current vascular surgery residents obtain training that is appropriate for their future career expectations and for successful Board certification? How effectively do practicing vascular surgeons incorporate emerging technologies and procedures into practice? METHODS: We analyzed the operative logs submitted to the VSB by recent vascular surgery residents applying for the Vascular Surgery Qualifying Examination (QE; 2006-2009) or by practicing vascular surgeons applying for the Vascular Surgery Recertification Examination (RE; 1995-2009). The relationship between reported operative experience and performance of the QE and RE was examined. RESULTS: There has been a threefold increase in the mean number of primary cases reported by both RE and QE applicants over the past 15 years and the increase in case volume has been driven largely by an increase in the number of endovascular procedures. Endovascular procedures have been broadly incorporated into the practice of most vascular surgeons applying for recertification. The number of major open surgical cases reported by recent QE applicants has remained unchanged over the period of observation. For QE applicants, the number of endovascular aneurysm repairs (EVARs) has reached a plateau at approximately 50 cases, whereas the mean number of open infrarenal aneurysm repairs has decreased for both QE and RE applicants, reflecting national trends favoring EVAR. There was a significant association between case volume and performance on the QE but not on the RE. CONCLUSION: Over the past 15 years, there has been a significant increase in the total number of operative cases reported to the VSB by both QE and RE applicants. Contrary to popular belief, the volume of major open vascular surgery reported by recent vascular surgery residents has remained relatively stable since 1994. Over the same time period, endovascular procedures have been rapidly incorporated into clinical practice by the majority of vascular surgeons applying for recertification by the VSB. Current vascular surgery residents receive a rich operative experience in both open and endovascular procedures that is reflective of contemporary practice.

Motivations to pursue fellowships are gender neutral.

OBJECTIVE: To determine the importance of factors in decision making by general surgery chief residents to pursue fellowships and to relate factor importance to gender and residency characteristics. DESIGN: Prospective, voluntary, national survey conducted April through May, 2008, in which finishing chief residents rated the importance of 12 factors in their decision making to pursue fellowships. SETTING: General surgery chief residents who applied for admission to the American Board of Surgery Qualifying Examination process. PARTICIPANTS: All 1034 first-time applicants. MAIN OUTCOME MEASURES: chi(2) tests and 1-way analyses of variance were used to correlate gender and residency type, size, and location with summed values and scaled mean scores for ratings of the importance of 12 potential factors in fellowship decision making. RESULTS: The fellowship rate was 77% and correlated with residency size and location. Women were dispersed asymmetrically across residencies overall but future female fellows were distributed similarly to male ones. Survey item response rates for future fellows were 96% to 98%. Clinical mastery and specialty activities were valued most highly by more than 90% of men and women. Men placed more value on income potential and spousal influence. Lifestyle factors reached only midrange importance for both genders. Program size had more significant relationships to decision-making factors than did gender. CONCLUSIONS: The ability to master an area of clinical practice and the clinical activities of a specialty are the most important factors for chief residents in fellowship decision making, regardless of gender. Lifestyle factors are of midrange importance. Program size is as influential as is gender.