Persistence to anti-CGRP monoclonal antibodies and onabotulinumtoxinA among patients with migraine: a retrospective cohort study.

BACKGROUND: To date, real-world evidence on persistence to anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAbs) or onabotulinumtoxinA have excluded eptinezumab. This retrospective cohort study was performed to compare treatment persistency among patients with migraine on anti-CGRP mAbs (erenumab, fremanezumab, galcanezumab, or eptinezumab) or onabotulinumtoxinA. METHODS: This retrospective study used IQVIA PharmMetrics data. Adult patients with migraine treated with an anti-CGRP mAb or onabotulinumtoxinA who had 12 months of continuous insurance enrollment before starting treatment were included. A "most recent treatment episode" analysis was used in which the most recent episode was defined as the latest treatment period with the same drug (anti-CGRP mAb or onabotulinumtoxinA) without a ≥ 15-day gap in medication supply on/after June 25, 2020, to December 31, 2021. Patients were indexed at the start of their most recent episode. Patients were considered non-persistent and discontinued the therapy associated with their most recent episode if there was ≥ 15-day gap in medication supply. A Cox proportional-hazards model estimated the discontinuation hazard between treatments. The gap periods and cohort definition were varied in sensitivity analyses. RESULTS: The study included 66,576 patients (median age 46 years, 88.6% female). More eptinezumab-treated patients had chronic migraine (727/1074), ≥ 3 previous acute (323/1074) or preventive (333/1074) therapies, and more prior treatment episodes (3) than other treatment groups. Based on a 15-day treatment gap, patients on subcutaneous anti-CGRP mAbs had a 32% (95% CI: 1.19, 1.49; erenumab), 42% (95% CI: 1.27, 1.61; galcanezumab), and 58% (95% CI: 1.42, 1.80; fremanezumab) higher discontinuation hazard than those receiving eptinezumab, with this relationship attenuated, but still statistically significant based on 30-day and 60-day treatment gaps. There was no significant difference in the discontinuation hazard between eptinezumab and onabotulinumtoxinA. Based on a 15-day treatment gap among patients who newly initiated therapy, the discontinuation hazard of subcutaneous anti-CGRP mAbs remained significantly higher compared to eptinezumab and onabotulinumtoxinA. CONCLUSION: Patients treated with eptinezumab demonstrated persistency that was higher than subcutaneous anti-CGRP mAbs and similar to onabotulinumtoxinA.

Evaluation and Management of Reduced Dietary Diversity in Children with Pediatric Feeding Disorder.

Pediatric Feeding Disorder, a common problem in children, is commoner in children with various developmental disorders. Children with pediatric feeding disorder can have food selectivity and lack dietary diversity (DD). In this paper, an understanding of DD in these children is provided along with a dietary diversity index that can be helpful in measuring and understanding the risks posed by this lack of DD. An overview of a management strategy to address decreased DD is proposed. In these children, improving DD can improve growth, micronutrient status, long-term metabolic health, and potentially quality of life.

Dose-response analysis of Bacillus thuringiensis HD-1 cry- spore reduction on surfaces using formaldehyde with pre-germination.

AIM: To establish a basis for rapid remediation of large areas contaminated with Bacillus anthracis spores. METHODS AND RESULTS: Representative surfaces of wood, steel and cement were coated by nebulization with B. thuringiensis HD-1 cry- (a simulant for B. anthracis) at 5.9 ± 0.2, 6.3 ± 0.2 and 5.8 ± 0.2 log10 CFU per cm2 , respectively. These were sprayed with formaldehyde, either with or without pre-germination. Low volume (equivalent to ≤2500 L ha-1 ) applications of formaldehyde at 30 g l-1 to steel or cement surfaces resulted in ≥4 or ≤2 log10 CFU per cm2 reductions respectively, after 2 h exposure. Pre-germinating spores (500 mmol l-1 l-alanine and 25 mmol l-1 inosine, pH 7) followed by formaldehyde application showed higher levels of spore inactivation than formaldehyde alone with gains of up to 3.4 log10 CFU per cm2 for a given dose. No loss in B. thuringiensis cry- viability was measured after the 2 h germination period, however, a pre-heat shock log10 reduction was seen for B. anthracis strains: LSU149 (1.7 log10), Vollum and LSU465 (both 0.9 log10), LSU442 (0.2 log10), Sterne (0.8 log10) and Ames (0.6 log10). CONCLUSIONS: A methodology was developed to produce representative spore contamination of surfaces along with a laboratory-based technique to measure the efficacy of decontamination. Dose-response analysis was used to optimize decontamination. Pre-germinating spores was found to increase effectiveness of decontamination but requires careful consideration of total volume used (germinant and decontaminant) by surface type. SIGNIFICANCE AND IMPACT OF THE STUDY: To be practically achievable, decontamination of a wide area contaminated with B. anthracis spores must be effective, timely and minimize the amount of materials required. This study uses systematic dose-response methodology to demonstrate that such an approach is feasible.

Real-world droxidopa or midodrine treatment persistence in patients with neurogenic orthostatic hypotension or orthostatic hypotension.

BACKGROUND: Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension (OH) observed in the presence of neuropathy and is associated with increased risk of falling, impaired function, and poor quality of life. Droxidopa and midodrine are approved in the United States to treat symptomatic nOH and OH in adults, respectively. In this study, we compared the treatment persistence of droxidopa and midodrine. METHODS: A retrospective analysis of patients prescribed either droxidopa or midodrine was conducted using the Symphony Health Solutions database (Symphony Health Solutions, Phoenix, AZ, USA). Inclusion criteria were (1) a pharmacy insurance claim in at least 16 consecutive quarters from mid-2014 to 2018 and (2) an active prescription for droxidopa or midodrine of ≥30 days' duration during that period. Treatment persistence was defined as the time to the first break in drug coverage of ≥45 days and was capped at 365 days. RESULTS: Data from 2305 patients who received droxidopa and 117,243 patients who received midodrine were included in this analysis. Median (95% CI) treatment persistence was significantly longer in the droxidopa cohort versus the midodrine cohort (303 [274-325] vs 172 [169-176] days; P < 0.001). After adjustment for confounding factors, patients using droxidopa monotherapy (i.e., without any concomitant midodrine and/or fludrocortisone use) were 16% more likely to be persistent at any time point than patients using midodrine (P < 0.001). CONCLUSIONS: In this real-world data analysis, patients using droxidopa without concomitant medications for OH were more likely to remain on treatment than patients on midodrine.

A standardised bioassay method using a bench-top spray tower to evaluate entomopathogenic fungi for control of the greenhouse whitefly, Trialeurodes vaporariorum.

BACKGROUND: Bioassays evaluating entomopathogenic fungi (EPF) isolates for effective microbial control of whitefly are a fundamental part of the screening process for bioprotectants, but development of repeatable, robust bioassays is not straightforward. Currently, there is no readily available standardised method to test the efficacy of EPF on whitefly. Here, we describe the calibration and use of a spray tower to deliver a standardised protocol to assess EPF activity; the method was validated using 18 EPF from four genera in tests against greenhouse whitefly, Trialeurodes vaporariorum (Westwood). RESULTS: At 138 kPa, the sprayer delivered 0.062 mL mm-2 (620 L ha-1 ) and an even deposition of spray across the central 1590 mm2 of the spray area. Average conidial deposition for all EPF was 252 conidia mm-2 and equivalent to 2.5 × 1012 conidia ha-1 at an application concentration of 1 × 107 conidia mL-1 . Conidial deposition of a test Beauveria bassiana suspension increased with increasing application concentration. Egg laying by T. vaporariorum adults was restricted to 177 mm2 using clip cages specifically designed to ensure that third-instar T. vaporariorum received a uniform spray coverage. Nymphs occupied 373 ± 5 mm2 of the leaf after migrating during the first instar. Average T. vaporariorum mortality totaled 8-89% 14 days after application of 1 × 107 conidia mL-1 of each EPF isolate. CONCLUSION: Combining the calibrated sprayer and bioassay method provides a reliable, standardised approach to test the virulence of EPF against whitefly nymphs. This laboratory-based assay is affordable, replicable and allows the user to alter the dose of conidia applied to the target.

A Free-Market Approach to the Match: A Proposal Whose Time Has Not Yet Come.

The authors respond to a proposal in this issue of Academic Medicine by Ray, Bishop, and Dow, who recommend adopting a free-market approach to the Match in which applicants and programs negotiate directly with each other to find and fill residency positions year-round. This Invited Commentary examines and responds to the reasons Ray and colleagues give for changing the Match and explores their proposal's implications and likelihood of success.The authors question Ray and colleagues' argument that assumptions underlying the National Resident Matching Program algorithm have been violated. The authors suggest there is insufficient evidence for the "July effect" and that the possibility for improvement in physician supply due to the year-round entry of graduates into the workforce ultimately faces the rate-limiting step of caps on residency positions allocated to programs. Most important, competency-based medical education, on which the free-market proposal depends, is not yet sufficiently developed.Nonetheless, the imbalanced ratio of applicants to positions in the Match is contributing to a rise in the numbers of student applications and program interviews. Although the proposed free-market approach might, as Ray and colleagues envision, curtail applications as well as reduce time and financial resources currently expended on the process, it would require significant changes on the part of applicants, residency programs, medical schools, and other stakeholders.Because the proposed free-market approach could reduce some negative effects of the imbalance of applicants and positions, it merits ongoing discussion along with other more immediate practical solutions to issues with the Match.

Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program.

Importance: Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation. Objective: To evaluate the association of the ERIN pilot with LOS after colectomy. Design, Setting, and Participants: Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals. Interventions: Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration. Main Outcomes and Measures: The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite. Results: There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P < .001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P < .001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P < .001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P < .001). Conclusions and Relevance: Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot may inform efforts to scale this effective and evidence-based intervention.

Evaluating the effects of herbicide drift on nontarget terrestrial plants: A case study with mesotrione.

Nature of exposure is a fundamental driver in nontarget terrestrial plant risk assessment for pesticides; consequently a novel study was designed to generate field-based drift exposure and evaluate corresponding biological effects of the herbicide mesotrione. The approach used a combination of US guideline drift reduction technology and vegetative vigor approaches. In each of 3 independent replicate spray application trials, 10 pots each of lettuce and tomato were placed at distances of 10, 20, 30, 40, and 50 ft (∼3, 6, 9, 12, and 15 m) from the downwind edge of the spray boom. Each application was conducted using a commercial 60-ft (18-m) boom sprayer fitted with TeeJet® Technologies TTI110025 nozzles, with a nominal application rate of 0.2 lb a.i./A (224 g a.i./ha). The environmental conditions required by the protocol (air temperature 10-30 °C and wind perpendicular to the swath (±30°) blowing toward the plants at a mean wind speed of ≥10 mph [≥4.5 m/s] measured at 2.0 m above the ground) were met for each application. Following exposure, plants were transferred to a greenhouse for the 21-d vegetative vigor phase of the study. Symptoms of phytotoxicity and plant height were assessed at 7, 14, and 21 d after treatment. On completion of the 21-d after treatment assessment, all plants were harvested and dried in an oven to determine shoot dry weight. The biological data indicated that no statistically significant effects were observed at a distance of 30 ft (∼9 m) from mesotrione drift at wind speeds of ≥10 mph (10.9-12.4 mph); this endpoint (30 ft) is defined as the no observed effects distance (NOED). Environ Toxicol Chem 2017;36:2465-2475. © 2017 SETAC.

EXPLORING SELF-EFFICACY AND PERCEIVED HIV RISK AMONG SOCIOECONOMICALLY DISADVANTAGED HISPANIC MEN.

The prevalence of HIV in Chile predominately affects the male population with the primary mode of transmission (99%) through sexual contact. In order to engage in safe sexual practices, men must have high sexual self-efficacy and perceived risk of infection, however, little research examines these variables with respect to HIV prevention. The purpose of this article is to review existing literature on self-efficacy and its connection with perceived HIV risk among Hispanic men, in order to direct future HIV prevention interventions among Chilean men. A literature search was conducted to identify studies for this review using three databases. A combination of keywords was used to conduct the search and a total of 34 articles were analyzed. All of the articles reviewed examined the Hispanic male population with respect to either self-efficacy or perceived risk, or a combination of the two. Major themes emerging from the review include: substance use, condom use, cultural norms, relationship communication, negotiation, and homonegativity. The existing studies provide evidence for preventing future HIV infection among low socioeconomic status Chilean males and begin to establish a positive relationship between self-efficacy and perceived HIV risk. While additional studies are needed to provide further support, self-efficacy and perceived risk should be integral aspects of future prevention interventions.

Exploring self-efficacy and perceived HIV risk among socioeconomically disadvantaged hispanic men / Exploración de la autoeficacia y la percepción de riesgo de VIH entre hombres hispanos de desventaja socioeconómica

The prevalence of HIV in Chile predominately affects the male population with the primary mode of transmission (99%) through sexual contact. In order to engage in safe sexual practices, men must have high sexual self-efficacy and perceived risk of infection, however, little research examines these variables with respect to HIV prevention. The purpose of this article is to review existing literature on self-efficacy and its connection with perceived HIV risk among Hispanic men, in order to direct future HIV prevention interventions among Chilean men. A literature search was conducted to identify studies for this review using three databases. A combination of Sullivan C., Ferrer l., Irarrázabal L., Villegas C., Cianelli R., Peragallo N. 43 2017, Horiz Enferm, 28,1,42-50 keywords was used to conduct the search and a total of 34 articles were analyzed. All of the articles reviewed examined the Hispanic male population with respect to either self-efficacy or perceived risk, or a combination of the two. Major themes emerging from the review include: substance use, condom use, cultural norms, relationship communication, negotiation, and homonegativity. The existing studies provide evidence for preventing future HIV infection among low socioeconomic status Chilean males and begin to establish a positive relationship between self-efficacy and perceived HIV risk. While additional studies are needed to provide further support, self-efficacy and perceived risk should be integral aspects of future prevention interventions.

La prevalencia del VIH en Chile afecta predominantemente a la población masculina con el principal modo de transmisión (99%) a través del contacto sexual. Para practicar el sexo seguro, los hombres deben teneruna alta autoeficacia sexual y la percepción del riesgo de infección, sin embargo, poca investigación examina estas variables con respecto a la prevención del VIH. El objetivo de este artículo es revisar la literatura existente sobre la autoeficacia y su relación con el riesgo de VIH percibida entre los hombres hispanos, a dirigir las futuras intervenciones de prevención del VIH entre los hombres chilenos. Una búsqueda bibliográfica se realizó para identificar los estudios para esta revisión utilizando tres bases de datos. Una combinación de palabras clave se utiliza para llevar a cabo la búsqueda y se analizaron un total de 34 artículos. Todos los artículos revisados examinaron la población masculina hispana con respecto a auto-eficacia y percepción de riesgofrente al VIH. Los temas principales que surgieronde la revisión incluyen: el uso de sustancias, el uso del condón, las normas culturales, la comunicación y la relación de negociación, y homonegatividad. Los estudios existentes proporcionan evidencia para prevenir una futura infección por VIH entre los hombres de estado socioeconómico bajo chilenas y comenzar a establecer una relación positiva entre la autoeficacia y el riesgo de VIH percibido. Se necesitan estudios adicionales para proporcionar más apoyo, autoeficacia y el riesgo percibido debe ser parte integrante de las intervenciones de prevención para el futuro.

Transitions in Care: When Words Can Save Lives.

Among the myriad of skills required of emergency medicine (EM) physicians, communicating concise and effective transitions in care is one of the most critical for patient safety. EM physicians transition care daily, both within their own department and among other specialties. We will discuss the crucial link between care transitions and patient safety, the processes and challenges in the hand-over exchange, and recommend an approach to improve your current system with transitions in care.

No longer waiting for an accident to happen: Simulation in emergency medicine.

The practice of emergency medicine (EM) requires proficient and expert skills in multiple high risk procedures. The emergency physician in-training needs a safe and realistic environment in which to practice and perfect the skills necessary to care for patients ranging from the critically ill to the patient with difficult intravenous access. Undergraduate medical, education overall has a need for training that enables students to develop the knowledge, skills and attitudes to practice in a variety of specialties. This article provides an overview of simulation in a three-year emergency medicine residency at Truman Medical Center, in a required final year clerkship for all medical students at the University of Missouri-Kansas City, and discusses national trends for the use of simulation in emergency medicine.

Use of a noninvasive electromagnetic device to place transpyloric feeding tubes in critically ill children.

BACKGROUND: The start of transpyloric feedings is often delayed because of challenges in reliably placing tubes blindly at the bedside. OBJECTIVE: To determine whether tube placement with the guidance of a noninvasive computerized electromagnetic device shortens the time needed to achieve accurate placement of transpyloric feeding tubes in critically ill children. METHODS: In a prospective, randomized trial in a tertiary-care, university-affiliated pediatric intensive care unit, 49 children requiring transpyloric feeding tube placement were randomized to have their tube placed by using conventional blind technique or with the assistance of a noninvasive electromagnetic device. RESULTS: Twenty-seven patients were randomized to blind placement, and 22 were randomized to the electromagnetic device group. The time required to place the tubes successfully was significantly longer (P < .03) in the electromagnetic device group (median, 9.5 minutes; 95% confidence interval, 7-13 minutes) compared with the conventional placement group (median, 5 minutes; 95% confidence interval, 4.0-7.0 minutes). CONCLUSIONS: Placement of transpyloric feeding tubes with the guidance of a noninvasive electromagnetic device significantly increases the time required for accurate placement. Because placement of transpyloric feeding tubes in critically ill children is common practice in many pediatric intensive care units, technology that delays satisfactory placement may be counterproductive in experienced hands.

Emergency medicine directors' perceptions on professionalism: a Council of Emergency Medicine Residency Directors survey.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires residency training programs to teach and assess professionalism in residents; however, programs may struggle to successfully remediate residents not meeting professionalism standards. To assist programs with this complex issue, a Professionalism Remediation Task Force was formed by the Council of Emergency Medicine Residency Directors (CORD-EM), which surveyed program directors (PDs) concerning their experiences. The purpose of this study is to report survey results regarding the identification and rating of unprofessional behaviors and challenges in the evaluation and remediation of professionalism. METHODS: In June 2010, the task force sent an anonymous survey via the CORD-EM listserv to PDs with active EM programs. RESULTS: Fifty percent (77/154) of eligible PDs responded to the survey. Most PDs rated the unprofessional behaviors of interpersonal/communication conflicts, lack of responsibility during patient care, lack of respect of coworkers, and reports of impairment as "critical"; repeated tardiness, incomplete work, poor ability to accept feedback, poor attitude, and repetitive unresponsiveness to aid colleagues were rated as "very serious"; frequent missed deadlines were "serious"; and repetitive failure to complete medical records was rated as "mildly serious." A resident with "less serious" professionalism issues was also felt to be likely to have "serious" or "critical" issues "often" (33.8% of respondents) or "always" (6.5%). The most common methods of assessment were clinical/advisor evaluations. However, existing assessment methods were described as inadequate in identifying serious professionalism issues by 50.7% of responding PDs. Unprofessionalism was most commonly discovered by unofficial faculty complaint (54.5%). Eighty percent report that professionalism is more difficult to remediate than other core competencies. Resident ownership of the problem was reported as most critical to remediation success (84.4%). PDs perceived the greatest challenges in residency remediation to be lack of resident insight or responsibility for the problem (45.2%) and personality/behavioral issues (32.9%). CONCLUSIONS: Identification and remediation of professionalism in EM residents is challenging. A future goal is to create a system by which PDs can use standardized pathways as a guide to identify and remediate unprofessional conduct.

The arterial switch operation: 25-year experience with 258 patients.

BACKGROUND: At our institution, the arterial switch operation for transposition of the great arteries has transitioned from the Gore-Tex patch (W.L. Gore & Associates, Flagstaff, AZ) for pulmonary artery reconstruction to redundant pantaloon pericardial patch (RPPP). The (U-shaped) coronary artery button was used for coronary reimplantation. This study investigates overall mortality and factors for neopulmonary artery, neoaortic, and coronary artery surgical reintervention. METHODS: We performed a retrospective chart review of all patients who underwent arterial switch between 1983 and 2007. Our surgical database, operative reports, and cardiology clinic charts were reviewed. Time to event was plotted as Kaplan-Meier curves. Predictors of time-to-event were examined using Cox proportional hazard modeling. RESULTS: A total of 258 patients underwent arterial switch during the study. Mortality declined from 15% (era I: 1983 to 1990) to 11% (era II: 1991 to 1998) to 7% (era III: 1999 to 2007). Era III had a significantly later time to death compared with era I (hazard ratio [HR] 0.62, p = 0.04). The RPPP had a lower neopulmonary artery reintervention rate compared with Gore-Tex; 9 of 225 (4%) versus 3 of 21 (14%), p = 0.008. Complex anatomy increased risk for neopulmonary reintervention (HR 3.3, p = 0.03). Surgical reintervention rate for coronary arteries was 2%. Complex coronary anatomy (HR 17.9, p = 0.01) predicted coronary reintervention. Predictors of neoaortic reintervention were prior pulmonary artery band (HR 4.3, p = 0.03), complex anatomy (HR 3.5, p = 0.01), and coronary artery anatomy (HR 3.5, p = 0.04). CONCLUSIONS: Arterial switch operation mortality has decreased. Conversion to RPPP reduced neopulmonary artery reintervention. The (U-shaped) coronary artery button technique is associated with low coronary reintervention rates. Complex coronary anatomy increases coronary and aortic reintervention. Prior pulmonary artery banding and complex anatomy increase aortic reintervention.