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Purpose: The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments. Methods: In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface. Results: The interobserver agreement of the classification was “fair” (κ = 0.32; 95% confidence interval [CI] = 0.27–0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013–0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42–0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35–0.48). Conclusions: Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair. Clinical Relevance: The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.

A 2014 study assessed infection prevention (IP) practices in Thai hospitals for catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). This study compares current IP practices to results obtained in 2014.Between February 1, 2021 and August 31, 2021, we resurveyed Thai hospitals regarding practices to prevent CAUTI, CLABSI, and VAP. We also assessed COVID-19 impact and healthcare worker burnout and coping strategies. We distributed 100 surveys to a convenience sample of infection preventionists.Response rate: 100%. One-third (31%) of hospitals reported excellent leadership support for infection control (ie, responses of "good" or "excellent" to one survey question). Some prevention practices increased between 2014 vs 2021 (CAUTI: catheter reminder/stop-order/nurse-initiated discontinuation [50.0% vs 70.0%, P.001]; condom catheters [36.3% vs 51.0%, P = .01]; ultrasound bladder scanner [4.7% vs 12.0%, P = .03]; CLABSI: chlorhexidine gluconate insertion site antisepsis [73.6% vs 85.0%, P = .03]; maximum sterile barrier precautions [63.2% vs 80.0%, P = .003]; VAP: selective digestive tract decontamination [26.9% vs 40.0%, P = .02]). Antimicrobial catheter use decreased since 2014 (10.4% vs 3.0%, P.001). Many other practices remain suboptimal. COVID-19 challenges: staff shortages (71%), financial hardships (67%). Only 46% of infection preventionists felt safe working during COVID-19.More national strategic support is needed for IP programs to prevent CAUTI, CLABSI, VAP and healthcare worker well-being in Thailand during the COVID-19 pandemic.

To characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low-acuity emergency department (ED) visits.Publicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).We systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low-acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreements using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low-acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference.We used the 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk.We identified 15 papers with an original list of ICD codes used to identify preventable or low-acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0 = no overlap, 1 = perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization.Existing algorithms that identify low-acuity ED visits lack congruence and are imperfect predictors of visit acuity.

INTRODUCTION The physician-pharmaceutical industry relationship has been identified as an ethical problem, due to conflicts of interest motivated by the benefits that doctors receive and that can affect their clinical judgment. OBJECTIVE To identify the frequency of physicians participation in activities financed by the pharmaceutical industry (PI), their attitudes towards PI representatives (PIRs), their prescriptive behavior and the association between their characteristics and their workplace with their participation in activities financed by the PI. METHOD Cross-sectional survey to internists and cardiologists. The questionnaire included characteristics of the doctors and their workplace, participation in activities financed by the PI, attitudes towards PIRs, and prescription behavior. RESULTS 455 questionnaires were analyzed; 78.5 % of surveyed subjects were aware of the physician-PI relationship, the majority acknowledged meeting with PIRs, 30 % indicated having received financial subsidies and 10 % considered that gifts affect their prescription. Having prior knowledge of the physician-PI relationship was associated with less participation in PI-financed educational activities. CONCLUSION Practices and preferences towards the PI show the need to design strategies to avoid inappropriate prescription. INTRODUCCION La relacion medico-industria farmaceutica (IF) se ha identificado como un problema etico por favorecer conflictos de interes derivados de los beneficios que reciben los medicos y que pueden afectar su juicio clinico. OBJETIVO Identificar la frecuencia de participacion de medicos en actividades financiadas por la IF, las actitudes de estos profesionales hacia los representantes de la IF, su conducta prescriptiva y la asociacion de sus caracteristicas y del trabajo con la participacion en actividades financiadas por la IF. METODO Encuesta transversal a medicos internistas y cardiologos. El cuestionario incluyo caracteristicas de los medicos y centro de trabajo, participacion en actividades financiadas por la IF, actitudes hacia los representantes y conducta de prescripcion. RESULTADOS Se analizaron 455 cuestionarios, 78.5 % de los encuestados tuvo conocimiento de la relacion medico-IF, la mayoria respondio reunirse con representantes de la IF, 30 % indico haber recibido subsidios financieros y 10 % considero que los obsequios afectan su prescripcion. Tener conocimiento previo de la relacion medico-IF se asocio con menor participacion en actividades educativas financiadas por por la IF. CONCLUSION Las practicas y preferencias hacia la IF muestran la necesidad de disenar estrategias para evitar la prescripcion inapropiada.

Introduction Even with an adequate mechanical ventilation weaning (MVW) protocol, the procedure fails in 15 to 30 % of cases. Objective To assess the association between independent risk factors (IRFs) and post-extubation failure in patients undergoing MVW in an intensive care unit. Method Longitudinal, prospective, analytical cohort study in patients on mechanical ventilation for more than 24 hours and who were extubated. Pre-extubation reports of hemoglobin, albumin, phosphorus, waist-hip ratio and SOFA score were obtained. Extubation failure was defined as resumption of mechanical ventilation within 48 hours or less. Results 123 patients were extubated, out of whom 74 were males (60 %); average age was 50 ± 18 years. Extubation failure occurred in 37 (30 %). Hypoalbuminemia was associated as an independent risk factor in 29 (23.8 %, RR = 1.43, 95 % CI = 1.11-1.85) and hypophosphatemia was in 18 (14.6 %, RR = 2.98, 95 % CI = 1.66-5.35); two or more IRFs were observed in 22.7 % (RR = 1.51, 95 % CI = 1.14-2.00). Conclusions Identifying independent risk factors prior to MVW can help reduce the risk of extubation failure and associated morbidity and mortality. Introduccion Aun con adecuado protocolo de desconexion de la ventilacion mecanica (DVM), el procedimiento falla en 15 a 30 % de los casos. Objetivo Evaluar la asociacion entre factores de riesgo independientes y fracaso posextubacion en pacientes con DVM en una unidad de cuidados intensivos. Metodo Estudio de cohorte, longitudinal, prospectivo, analitico, que incluyo pacientes sometidos a ventilacion mecanica por mas de 24 horas y que fueron extubados. Se obtuvieron reportes preextubacion de hemoglobina, albumina, fosforo, indice cintura-cadera y puntuacion SOFA. Se definio como fracaso de extubacion al reinicio de la ventilacion mecanica en 48 horas o menos. Resultados Se extubaron 123 pacientes, 74 hombres (60 %); la edad promedio fue de 50 ± 18 anos. Ocurrio fracaso de extubacion en 37 (30 %). Como factores de riesgo independentes se asocio hipoalbuminemia en 29 (23.8 %, RR = 1.43, IC 95 % = 1.11-1.85) e hipofosfatemia en 18 (14.6 %, RR = 2.98, IC 95 % = 1.66-5.35); se observaron dos o mas factores de riesgo independientes en 22.7 % (RR = 1.51, IC 95 % = 1.14-2.00). Conclusiones Identificar los factores de riesgo independentes antes de la DVM puede ayudar a reducir el fracaso de la extubacion y la morbimortalidad asociada.

RESUMEN: La estenosis de uretra anterior masculina requiere un manejo especializado. Desarrollamos 3 objetivos relacionados con su tratamiento. Inicialmente, planteamos evaluar las prácticas en su manejo por parte de la comunidad urológica española, y compararlas con las de un grupo internacional de expertos en cirugía reconstructiva. Estas evaluaciones, mediante cuestionarios online, servirán para conocer la situación actual. Adicionalmente, basándonos en que la mucosa oral es actualmente el tejido de elección para reparaciones uretrales, planteamos una nueva técnica de uretroplastia con mucosa oral circunferencial en tiempo único para estenosis de uretra peneana distal. Describimos la experiencia con esta intervención, comparando sus resultados e indicaciones con la uretroplastia clásica en etapas. Finalmente, analizamos histológicamente injertos de mucosa oral para su uso en cirugía uretral procedentes de dos localizaciones – cara interna de mejilla y zona sublingual-. Ambos injertos habían demostrado buenos resultados a largo plazo, pero no se había realizado ningún análisis histológico de injertos sublinguales. Conocer sus características y compararlas con injertos de mejilla servirá para ayudar en la planificación quirúrgica. ABSTRACT: Male anterior urethral strictures require specialized treatment. 3 objectives related with their management are developed. First, we assessed practice patterns on diagnostic and therapeutic approaches for this pathology among Spanish urological community, comparing them with an international group of experts in reconstructive urologic surgery. We used online questionnaires for both assessments of current situation. As a second objective, based on the recommendation of using oral mucosa as tissue of choice for urethral repairs, we describe a novel surgical technique using oral mucosa graft for distal penile urethral tubular substitution in one stage. This new approach is explained, and its outcomes and indications are compared with classical staged approach. As third objective, we histologically compare oral grafts, prepared for urethral surgeries, from different donor areas: inner cheek and sublingual area. Satisfactory long-term outcomes were published using both types of oral grafts but to date, no histological assessment of sublingual grafts was conducted. Detailed knowledge of tissue characteristics, and their comparison with buccal grafts would be relevant to surgical decision making.

Climate change is a global health crisis. In most regions, heat waves are expected to become longer and more frequent and air quality is expected to worsen. Few physicians discuss climate and health with patients, and related guidelines are lacking. Our objective was to quantify the prevalence of risk factors for illness related to climate change in the U.S. ambulatory setting.From the 2018 National Ambulatory Medical Care Survey, a national probability sample of nonfederal, ambulatory encounters, we identified adults with risk factors for illness related to heat or air pollution exposure.We found 91.4% of encounters involved a patient with at least 1 risk factor, while 46.7% had 2 or more.A high prevalence of patients with climate-related health risk factors exists in the ambulatory setting, representing a significant opportunity for evidence-based climate and health patient education and preventative care.

To obtain a nationally representative annualized estimate of the prevalence of pericarditis (inflammation of the pericardium) in the United States (US) in order to better understand the potential burden on the health care system. Three nationally representative datasets were used to estimate the annualized period prevalence and prevalence rate of pericarditis from 2007 to 2016: the National Ambulatory Medical Care Survey (NAMCS), the National Hospital Ambulatory Medical Care Survey (NHAMCS), and the Nationwide Inpatient Sample (NIS). Across all data sources, ICD-9/10 codes were used to identify healthcare encounters with ≥1 primary or secondary diagnosis related to pericarditis irrespective of duration or etiology. The prevalence of pericarditis in 2020 was extrapolated by multiplying the average annualized prevalence rate from 2007 to 2016 by the total US population as of March 2020. Data from NAMCS/NHAMCS (2007–2016) yielded an average annualized estimate of 125,209 patients with pericarditis, resulting in a pooled average annualized prevalence estimate of 40 patients with pericarditis per 100,000 persons. Data from NIS (2007–2016) yielded an average annualized estimate of 34,441 patients with pericarditis, resulting in a pooled average annualized prevalence estimate of 11 hospitalized patients with pericarditis per 100,000 persons. Extrapolation of these results based on the March 2020 population estimates from the US Census Bureau of 329,436,928 resulted in an estimated US prevalence of pericarditis to be approximately160,000. Despite certain methodologic limitations, our analysis of data from nationally representative sources support that pericarditis is a rare disease affecting substantially fewer than 200,000 persons in the US.

The scope of this priority-setting process is communication and collaboration in transitional care for patients with acute stroke. Actively involving persons with stroke and their family caregivers is important both in transitional care and when setting priorities for research. Established priority-setting methods are time-consuming and require extensive resources. They are therefore not feasible in small-scale research. This article describes a pragmatic priority-setting process to identify a prioritized top 10 list of research needs regarding transitional care for patients with acute stroke.A pragmatic priority-setting approach inspired by the James Lind Alliance was developed. It involves establishing a user group, identifying the research needs through an online survey, analysing and checking the research needs against systematic reviews, culminating in an online prioritization of the top 10 list.The process was completed in 7 months. A total of 122 patients, family caregivers, health personnel and caseworkers submitted 484 research needs, and 19 users prioritized the top 10 list. The list includes the categories 'patients and caregivers' needs and health literacy', 'health personnel's common understanding', 'information flow between health personnel and patients and caregivers', 'available interventions and follow-up of patients and caregivers', 'interaction and collaboration between health personnel and caseworkers across hospital and primary healthcare' and 'disabilities after stroke'.This paper outlines a pragmatic approach to identifying and prioritizing users' research needs that was completed in 7 months. The top 10 list resulting from this priority setting process can guide future research relating to communication and collaboration during the transition from hospital to the community for patients with stroke.Members of three stroke organizations participated in the advisory group. They gave feedback on the scope and the process, distributed the surveys and prioritized the top 10 list. Persons with stroke and their caregivers submitted research needs in the survey.

Youth with special health care needs often experience significant difficulty transitioning into adult health care services and adult life. Services supporting youths' transition from pediatric to adult health care (Health Care Transition (HCT)) have been a priority for nearly 30 years to improve this transition process. The Health Resources and Service Administration, Maternal and Child Health Bureau have measured HCT service provision since 2001 but the longitudinal use of this measure has never been examined (Blumberg, 2003; Maternal and Child Health Bureau, n.d.).This manuscript highlights the consistent and inconsistent uses of HCT constructs in two prominent national surveys (the National Survey of Children with Special Health Care Needs (NS-CSHCN) and the National Survey of Children's Health (NSCH)) between 2001 and 2019. All studies utilizing an HCT measure within a national survey between the 18 years were included in this examination.Significant changes have been made to the measurement of HCT service provision resulting in inconsistencies over the last 18 years. Measurement criteria and survey questions have changed substantially from the NS-CSHCN and NSCH limiting one's ability to examine trends in HCT since 2001. Since 2016, few changes have been made, allowing for analysis of trends over time. Importantly, the NSCH includes added questions pertaining to HCT that are not included in the composite HCT outcome measure.Future work should include a validation study of the HCT outcome in the National Survey of Children's Health and inclusion of additional HCT questions to promote continued and extensive use of a measure that more fully represents the needs of youth and their families.

British Pakistani women have exceptionally high rates of obesity and yet are seldom heard in a research priority setting concerning weight management. The objectives of this study were (i) to ascertain what multisectoral professionals perceive to be the most pressing unmet obesity needs or topic areas that need more research in relation to Pakistani women living in deprived areas of Bradford and (ii) to determine the top 10 obesity health priorities for this group to develop an obesity research agenda.A two-step process was adopted using the following: (i) a survey of a wide range of multisectoral professional stakeholders (n = 159) and (ii) a ranking exercise involving Pakistani women living in deprived areas of Bradford (n = 32) to select and prioritize their top 10 obesity health concerns and unmet needs from a list of 31 statements identified in the survey and previous research. Survey data were analysed using inductive content analysis and themes were identified. Themes were translated into statements to be ranked by Pakistani women. The ranking exercise was conducted by telephone either via voice or video call. Data were analysed using a reverse scoring system.Survey responses were grouped into statements reflecting the following three categories: education needs; healthy behaviour barriers and mental well-being. The highest rankings were given by Pakistani women to statements on mental health and the need for education. The top 10 prioritized statements were developed with members of the public into an obesity research agenda that reflected the target population.Actively engaging British Pakistani women in setting research priorities provided a unique opportunity to understand the key areas they think are important for future research. The culminating research agenda can be used by researchers to advance the field of obesity research in Pakistani communities, thus producing research outputs that are relevant to and have impact in this population.Participants in the ranking exercise collected data. Public contributors were involved in developing the prioritized statements into a research agenda.

Emotional education has beneficial effects on physical and/or emotional health, resulting in a better quality of life. Thus, it is beneficial to provide prisoners with emotional education, because of the difficulties they often have, to attain these benefits.The aim of the study was to analyze the effects of a nursing intervention program in emotional education for incarcerated persons.Experimental study with pretest-posttest repeated measures with a control group was conducted at a penitentiary center in the southeast of Spain. Forty-eight prisoners participated in the emotional education intervention program, and another 48 were part of the control group. The emotional intelligence questionnaire 24-item Trait Meta-Mood Scale, the resilience scale Connor-Davidson Resilience Scale, the Rosenberg Self-Esteem Scale, the Rathus Assertiveness Questionnaire, and the 36-item Short Form Health Survey were utilized.The intragroup, preintervention and postintervention comparisons in the study group showed improvements in self-esteem (p = 0.00, r = 0.51), resilience (p = 0.00, r = 0.42), assertiveness (p = 0.00, r = 0.46), and emotional intelligence in its dimensions of repair (p = 0.00, r = 0.32) and clarity (p = 0.02, r = 0.22) as well as in most of the quality of life dimensions. Significant intergroup differences were also found in all of these variables, except for attention and emotional clarity dimensions.The intervention improved the socioemotional health and quality of life of the prisoners, highlighting the importance of these interventions to be performed by the nursing personnel on a regular basis as a programmed activity within prisons.

Constipation is a common diagnosis in adults and children. Emergency department (ED) visits for constipation increased from 1980 to 2010. Since then, efforts have aimed to reduce resource utilization for constipation in the ED setting. Our objective is to examine contemporary ED practice patterns in the context of updated care guidelines.We conducted a cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2006 to 2017. Encounters with a constipation diagnosis were included. We examined rates of ED visits, diagnostic testing, and medication use. We also compared general and pediatric ED practice patterns for children.Approximately 1.3 million ED visits with a diagnosis of constipation occurred annually, with pediatric encounters comprising one-third of all visits. There was a 114% increase in ED visits for constipation over the study period. Urinalysis and imaging increased by 17% and 15%, respectively. Older patients were more likely to undergo diagnostic testing. No significant changes in laboratory testing, radiographs, or osmotic laxative prescriptions were observed among children. Compared to pediatric EDs, general EDs were more likely to perform CBC (29% vs. 15%) and urinalysis testing (42% vs 31%). General EDs were less likely to prescribe osmotic laxatives for children compared to pediatric EDs (26% vs. 37%).ED visits for constipation have increased significantly since 2006. Rates of diagnostic tests and prescriptions have not changed despite published evidence and guidelines that the diagnosis of constipation does not require imaging, and that the management of constipation requires consistent outpatient treatment. Opportunities exist to reduce ED resource utilization through knowledge dissemination and implementation.

Both traumatic and nontraumatic ocular issues often present to the emergency department. Understanding the epidemiology of ocular presentations to the emergency department not only informs current resource allocation, but also provides opportunities to evaluate the efficacy of prior healthcare access interventions.To characterize emergency department utilization in the United States for ophthalmic encounters between 2010 and 2018.Cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey database, a nationally representative sample of United States emergency department visits. 4284 deidentified emergency department patient encounters with an ICD-10 ophthalmic diagnosis from 2010 to 2018 were analyzed. The main outcome measures were the composition and characteristics of ophthalmic emergency department encounters over time.4284 ophthalmic visits were identified which represented an estimated 23.1 million visits (95% CI, 20.8 million-25.5 million). 31.6% (95% CI, 29.6-33.8) of ophthalmic visits were traumatic. Conjunctivitis was the most common non-traumatic diagnosis (32.8%, 95% CI, 30.7-35.0), while superficial injury of the cornea was the most common traumatic diagnosis (13.9%, 95% CI, 12.5-15.3). A greater proportion of emergency department visits involving the sclera and cornea were made by men (58.7%, 95% CI, 53.7%-63.6%; P = 0.02), whereas more women visited for visual disturbances (57.8%, 95% CI, 51.3%-64.4%; P = 0.01). Longitudinal trends of ophthalmic visits revealed an increase in public insurance payers in 2014, which corresponds to Medicaid expansion and implementation of mandated coverage for pediatric vision care. After stratification, this increase continued to be present in nontraumatic visits, but not traumatic ones.Ophthalmic emergency department visits in the United States between 2010 and 2018 were typically for non-traumatic eye issues. Diagnoses varied greatly by patient demographics, such as age and gender. Understanding these variations is valuable for preparing emergency departments for ocular presentations and providing guidance for future practice.

Introduction: Substance use-related visits to the emergency department (ED) have been linked to higher service delivery costs, although little is known about the specific services used. Our goal In this study was to describe the recent trends of substance use-related ED visits and assess the association between substance use and specific ED resource utilization. Methods: We performed a retrospective, cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2013–2018. All ED visits in the United States for patients ≥18 years of age were included. The primary exposure was having substance use included as a chief complaint or diagnosis, which we identified using the International Classification of Diseases, 9th and 10th revisions, codes. The primary outcome was the use of diagnostic services (including laboratory studies and cardiac monitoring) or imaging studies in the ED. Results: The study sample included 95,506 visits in the US, extrapolating to over 619 million ED visits nationwide. The total number of ED visits remained stable during the study period, but substance use-related visits increased by 45%, with these visits making up 2.93% of total ED visits in 2013 and 4.25% in 2018. This increase was primarily driven by stimulant-, sedative- (opioids and benzodiazepines), and hallucinogen-related visits. Mental health-related visits rose in parallel by 66% during the same period. Compared to non-substance use-related visits, substance use-related visits were more likely to undergo any diagnostic study (adjusted odds ratio [aOR] 1.28; 95% confidence interval (CI): 1.11-1.47; P = 0.001), toxicology screening (aOR 10.15; 95% CI: 8.84-11.66), but less likely to have imaging studies (aOR 0.62; 95% CI: 0.56-0.68; P

AIMS Basal cell carcinoma (BCC) is a common cancer, with a high risk of local recurrence. A quantifiable measurement of the histological margins of BCC in excisions is a recurrent demand of clinicians, however there are currently no international guidelines indicating its value. METHODS AND RESULTS A questionnaire validated by four experts in dermatopathology and formatted under a "Google Forms"-type interface was sent by email to physicians specializing in surgical pathology or dermatopathology and practicing in France from March 20, 2018, to May 20, 2018. The results were compared between subgroups according to age and subspecialization, especially dermatopathology. The questionnaire was completed by 225 practitioners. Microscopic margins were systematically measured in 77.3% of cases, sometimes in 19.6% and never in 3.1%. The main reason was to report factually insufficient margins (66.5%), followed by laboratory habits (45%) or clinician requests (43.1%). For 72% of respondents, the clinical or histopathological criteria did not influence their practice. The most used tool was a graduated ruler placed under a microscope (44.3% of cases). Compared to other groups, dermatopathologists measured BCC margins less systematically [only in certain situations (33.3% vs 14.9%) or never (10.5% vs 0.6%) (p < 0.001)] and used an eyepiece reticle more extensively (53.1% vs 29.8%; p = 0.0029). CONCLUSION The measurement of histological margins in BCC is a common practice in France, although there are no recommendations. Our survey suggests that it represents a way for pathologists to specify an insufficient margin and therefore the need for scar revision.

To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin.We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (10%), medium (≥10 to35%), or high (≥35%).Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower cesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of cesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women.After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

The exponential growth in CT utilization in emergency department (ED) until 2008 raised concerns regarding cost and radiation exposure. Head CT was one of the commonest studies. This led to mitigating efforts such as appropriate use guidelines, policy and payment reforms. The impact of these efforts is not fully understood. In addition, disparities in outcomes of acute conditions presenting to the ED is well known however recent trends in imaging utilization patterns and disparities are not well understood. In this study, we describe nationwide trends and disparities associated with head CT in ED settings between 2007 and 2014.We analyzed 2007-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) with the primary goal to assess the rate and patterns of head CT imaging in ED.There were an estimated 117 million in 2007 and 139 million ED visits in 2017. There was a 4% increase in the any CT use in 2017 compared to 2007. No significant change in head CT utilization rate was seen. The 2007 head CT rate was 6.7% (95% CI: 6.1-7.3) compared to 7.7% (95% CI: 6.8-8.6) in 2017. Trauma, Headache and Dizziness are the top three indications for head CT use in the ED respectively. On adjusted analyses, significantly higher head CT utilization was seen in elderly, (age65 yrs) and significantly lower utilization rate was seen in Non-Hispanic Black and Medicaid patients, and patients in rural locations.Previously reported exponential growth of CT use in ED is no longer seen. In particular, there was no significant change in ED head CT use between 2007 and 2017. Headache and Dizziness remain commonly used indications despite limited utility in most clinical scenarios, indicating continued need for appropriate use of imaging. There is significantly lower CT utilization in Non-Hispanic Black, Medicaid patients and those in rural locations, suggesting disparities in diagnostic work-up in marginalized and rural populations. This underscores the need for standardizing care regardless of race, insurance status and location.

Background Unhealthy alcohol use is a significant health issue for the US population. The US Preventive Services Task Force (USPSTF) recommends screening adults 18 years or older for unhealthy alcohol use during primary care visits. Objectives To evaluate alcohol screening among ambulatory visits made by US adult primary care patients and identify characteristics predictive of alcohol screening. Design A series of cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) data collected from 2014 to 2016 was used to examine US primary care providers’ use of alcohol screening questionnaires and delivery of counseling on alcohol use. Participants A total of 19,213 visits made by patients aged 18 years or older to a US primary care physician trained in family medicine or internal medicine. Main Measures Administration of a validated alcohol screening questionnaire and counseling/education on alcohol use. Variation in alcohol screening by patient demographic characteristics, reason for office visit, length of office visit, chronic medical conditions, evaluation by assigned primary care physician, new patient to practice, and region. Key Results Alcohol screening with a validated questionnaire occurred during 2.6% (95% Cl: 0.9%, 4.3%) of visits. Alcohol counseling, provided either by the physician or by referral, was documented in 0.8% (95% Cl: 0.3%, 1.3%) of visits. Screening was significantly more likely if patients were seen by their assigned primary care physician (adjOR 4.38 (95% Cl: 1.41, 13.61)), a new patient to the practice (adjOR 4.18 (95% Cl: 2.30, 7.79)), or had several chronic medical conditions (adjOR 3.40 (95% Cl: 1.48, 7.78)). Patients’ sex, race/ethnicity, age group, or length of appointment time was not associated with screening for unhealthy alcohol use. Conclusions Screening for unhealthy alcohol use using a validated questionnaire is uncommonly performed during US primary care visits. Interventions or incentives may be needed to increase uptake of USPSTF alcohol screening recommendations.

BACKGROUND: Neuromonitoring is the use of continuous measures of brain physiology to detect clinically important events in real-time. Neuromonitoring devices can be invasive or non-invasive and are typically used on patients with acute brain injury or at high risk for brain injury. The goal of this study was to characterize neuromonitoring infrastructure and practices in North American pediatric intensive care units (PICUs). METHODS: An electronic, web-based survey was distributed to 70 North American institutions participating in the Pediatric Neurocritical Care Research Group. Questions related to the clinical use of neuromonitoring devices, integrative multimodality neuromonitoring capabilities, and neuromonitoring infrastructure were included. Survey results were presented using descriptive statistics. RESULTS: The survey was completed by faculty at 74% (52 of 70) of institutions. All 52 institutions measure intracranial pressure and have electroencephalography capability, whereas 87% (45 of 52) use near-infrared spectroscopy and 40% (21/52) use transcranial Doppler. Individual patient monitoring decisions were driven by institutional protocols and collaboration between critical care, neurology, and neurosurgery attendings. Reported device utilization varied by brain injury etiology. Only 15% (eight of 52) of institutions utilized a multimodality neuromonitoring platform to integrate and synchronize data from multiple devices. A database of neuromonitoring patients was maintained at 35% (18 of 52) of institutions. Funding for neuromonitoring programs was variable with contributions from hospitals (19%, 10 of 52), private donations (12%, six of 52), and research funds (12%, six of 52), although 73% (40 of 52) have no dedicated funds. CONCLUSIONS: Neuromonitoring indications, devices, and infrastructure vary by institution in North American pediatric critical care units. Noninvasive modalities were utilized more liberally, although not uniformly, than invasive monitoring. Further studies are needed to standardize the acquisition, interpretation, and reporting of clinical neuromonitoring data, and to determine whether neuromonitoring systems impact neurological outcomes.

Background Early screening and accurately identifying Acute Appendicitis (AA) among patients with undifferentiated symptoms associated with appendicitis during their emergency visit will improve patient safety and health care quality. The aim of the study was to compare models that predict AA among patients with undifferentiated symptoms at emergency visits using both structured data and free-text data from a national survey. Methods We performed a secondary data analysis on the 2005-2017 United States National Hospital Ambulatory Medical Care Survey (NHAMCS) data to estimate the association between emergency department (ED) patients with the diagnosis of AA, and the demographic and clinical factors present at ED visits during a patient’s ED stay. We used binary logistic regression (LR) and random forest (RF) models incorporating natural language processing (NLP) to predict AA diagnosis among patients with undifferentiated symptoms. Results Among the 40,441 ED patients with assigned International Classification of Diseases (ICD) codes of AA and appendicitis-related symptoms between 2005 and 2017, 655 adults (2.3%) and 256 children (2.2%) had AA. For the LR model identifying AA diagnosis among adult ED patients, the c-statistic was 0.72 (95% CI: 0.69–0.75) for structured variables only, 0.72 (95% CI: 0.69–0.75) for unstructured variables only, and 0.78 (95% CI: 0.76–0.80) when including both structured and unstructured variables. For the LR model identifying AA diagnosis among pediatric ED patients, the c-statistic was 0.84 (95% CI: 0.79–0.89) for including structured variables only, 0.78 (95% CI: 0.72–0.84) for unstructured variables, and 0.87 (95% CI: 0.83–0.91) when including both structured and unstructured variables. The RF method showed similar c-statistic to the corresponding LR model. Conclusions We developed predictive models that can predict the AA diagnosis for adult and pediatric ED patients, and the predictive accuracy was improved with the inclusion of NLP elements and approaches.

BackgroundThe novel coronavirus SARS-CoV-2 has caused a global COVID-19 pandemic, leading to worldwide changes in public health measures. In addition to changes in the public sector (lockdowns, contact restrictions), hospitals modified care to minimize risk of infection and to mobilize resources for COVID-19 patients. Our study aimed to assess the impact of these measures on access to care and behaviour of patients with thoracic malignancies.MethodsThoracic oncology patients were surveyed in October 2020 using paper-based questionnaires to assess access to ambulatory care services and tumor-directed therapy during the COVID-19 pandemic. Additionally, behaviour regarding social distancing and wearing of face masks were assessed, as well as COVID-19 exposure, testing and vaccination. Results are presented as absolute and relative frequencies for categorical variables and means with standard deviation for numerical variables. We used t-test, and ANOVA to compare differences in metric variables and Chi2-test to compare proportions between groups.Results93 of 245 (38%) patients surveyed completed the questionnaire. Respiration therapy and physical therapy were unavailable for 57% to 70% of patients during March/April. Appointments for tumor-directed therapy, tumor imaging, and follow-up care were postponed or cancelled for 18.9%, 13.6%, and 14.8% of patients, respectively. Patients reported their general health as mostly unaffected. The majority of patients surveyed did not report reducing their contacts with family. The majority reduced contact with friends. Most patients wore community masks, although a significant proportion reported respiratory difficulties during prolonged mask-wearing. 74 patients (80%) reported willingness to be vaccinated against SARS-CoV-2.ConclusionsThis survey provides insights into the patient experience during the second wave of the COVID-19 pandemic in Munich, Germany. Most patients reported no negative changes to cancer treatments or general health; however, allied health services were greatly impacted. Patients reported gaps in social distancing, but were prepared to wear community masks. The willingness to get vaccinated against SARS-CoV-2 was high. This information is not only of high relevance to policy makers, but also to health care providers.

We conducted the multicenter questionnaire survey targeting patients with Parkinson's disease (PD) in order to investigate the impacts on their daily lives and their requests to hospitals in the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Mainly using open-ended questionnaire, we asked their anxiety, troubles they are facing, and requests toward hospitals in the pandemic of SARS-CoV-2. Two hundred fifth-eight PD patients answered the questionnaire. There were various opinions about anxiety such as "PD patients are susceptible and vulnerable to SARS-CoV-2" (36.8%). Concerning the troubles in the pandemic, the most frequent answer was that they couldn't participate in the rehabilitation and elderly day care (38.4%). Relatively many PD patients requested telemedicine (29.5%), whereas some people hoped face-to-face medical care (8.1%). There were demands about the delivery of medications (50.0%), the establishment of telephone consultations (43.8%), resources for rehabilitation at home (43.8%). The medical care adapted to the anxiety, trouble and requests of PD patients will be required in the era when we have to live with SARS-CoV-2.

A cross-sectional study was conducted using a self-administered questionnaire consisting of demographic, clinical characteristics, and MS spasticity scale (MSSS scale). A total of 286 patients from Saudi Arabia have participated in this survey. The results of the study showed spasticity can have a major impact on the activities of daily living in MS patients with variable degree of botherness. Some of the activities which have been reported be affected include stiffness when staying in the same position for a long time, dressing, cooking, walking speed and level of irritation and nervousness. MS patients are significantly affected by spasticity, in which a considerable percentage of them are weighed down by its interference with personal movements and activities.

The objective of this single-blind randomized controlled trial was to test the hypothesis of no difference in implant treatment outcome and patient-reported outcome measures (PROMs) following osteotome-mediated sinus floor elevation with Bio-Oss Collagen (test) compared with no grafting material (control) after 1 year of implant loading. Forty healthy patients (27 female, 13 male) with a mean age of 49 years (range 24-74 years) were randomly allocated to the test or control group. Outcome measures included survival of the suprastructures and implants, peri-implant marginal bone loss, complications, and PROMs; the latter included the Oral Health Impact Profile-14 and a self-administered questionnaire with visual analogue scales to assess the peri-implant tissue, implant crown, function of the implant, total implant treatment outcome, and oral health-related quality of life. Mean differences were expressed with the standard deviation and 95% confidence interval. The level of significance was 0.05. Survival of the suprastructures and implants was 100% with both treatment modalities. No significant difference in any of the outcome measures was observed between the test and control groups. High patient satisfaction and a significant improvement in quality of life were observed with both treatment modalities. Consequently, no significant difference in implant treatment outcome between the test and control groups was revealed after 1 year of implant loading. Neither of the treatment modalities can therefore be considered better than the other.

The aim of the study was to survey keratoconus management by optometrists in India.A validated online survey questionnaire was circulated to all optometrists from India who had completed 4 years of optometry programs. Practitioners were asked general contact lens practice questions and keratoconus management-related questions. For analysis, data were imported into SPSS (IBM Corp. 2011).A total of 159 optometrists responded to the questionnaire, of whom 10.7% of practitioners had10 years of experience and the remaining 89.3% had10 years. Only 45.3% of respondents had corneal topography in their practice. Approximately 55% of practitioners prescribed gas permeable (GP) lenses. Around 77.4% of practitioners considered that a combination of multiple factors is necessary for keratoconus investigations. In addition, 91.8% of practitioners used the keratoconus severity classification. Also, 73% of practitioners consider that GP contact lens (CL) fitting is more difficult in keratoconic eyes than in healthy eyes. The average number of GP diagnostic lenses used in keratoconus CL fittings was 3.93 ± 1.92. A majority of practitioners calculate back optic zone radius (BOZR) using the manufacturer's guidelines (based on manual keratometry [39.6%] or based on corneal topography [40.3%]). Around 40.3% of respondents prefer to refer patients to another optometrist for CL fitting before consulting an ophthalmologist for surgical intervention. Finally, half of the respondents participate in co-management with ophthalmologists after surgical treatment (54.1%).This study provides details about the management of keratoconus by optometrists in India. Keratoconus patient care could be improved with new evidence-based guidelines for the management and referral of these patients that would provide guidance on GP CL fitting procedures. Furthermore, it determines referral criteria and enhances co-management between optometrists and ophthalmologists.

This paper reports on a project commissioned by the Australian Nursing Council Inc that sought to develop an approach to the maintenance of continuing competence in nursing broadly acceptable to nurses in all states and territories. This project involved extensive consultation with nurses, consumers and key stakeholders on appropriate competence indicators. Findings suggest that a majority of nurses support the development of competence indicators but most are confused about the nature of competence.

BACKGROUND The National Ambulatory Medical Care Survey (NAMCS) is a collection of publicly available and deidentified patient data gathered from participating tertiary medical centers. With it, this study attempts to describe and quantify distribution of patients presenting with a rhinologic reason for visit (RFV) in the ambulatory setting, as well as determine the distribution based on specialty and setting of practice. METHODS Data from years 2014-2016 in the NAMCS were analyzed to determine the overall number of visits for a rhinologic RFV, the distribution according to RFV, the medical specialty of the clinical provider and patient demographics. 20.1 Million ambulatory visits with a rhinologic RFV, annualized, were identified. RESULTS The dominant RFVs were nasal congestion (41.9%), sinus problems (14.5%), sinus pain/pressure (10.6%), hay fever (10.5%), sinus congestion (7.5%), sinus inflammation or infection (5.7%), and epistaxis (4.0%). The majority of the most common complaints were addressed by primary care physicians (64.5% of nasal congestion, 63.9% of sinus problems, and 75.7% of sinus pain/pressure), whereas epistaxis, disturbances of sense, and inflammation of the nose were more likely to be addressed by an otolaryngologist (58.9%, 28.8%, and 63.0%, respectively). Non-metropolitan areas generated more primary care visits (90.1%) than metropolitan areas (50.2%) (p < 0.001). The Northeast garnered the highest number of otolaryngology visits (32.4%) and lowest of primary care (59.1%). CONCLUSION Patients with common rhinologic complaints present to primary care more frequently than to otolaryngology, though this pattern varies depending on the specific rhinologic RFV and depending on region and setting of practice. This article is protected by copyright. All rights reserved.

Objective In Japan, many otolaryngologists provide primary care for patients with coronavirus disease 2019 (COVID-19). The purpose of this study was to analyze the characteristics of otorhinolaryngological findings in order to improve COVID-19 diagnostic systems in a primary care setting. Methods A total of 351 patients (mean age, 36.0 ± 15.4 years) diagnosed with COVID-19 by otolaryngologists who belong to the Japan Otorhinolaryngologists Association were included in the study. A web-based questionnaire was used to collect information regarding the timing of positive identification of COVID-19, the route of infection, symptoms, and findings in the tonsils, nasal cavity, pharynx, ear, and neck. A modified Centor score was calculated for cases in which age, symptoms, and tonsil and neck findings were described. Results Symptoms included fever (56%), olfactory disturbance (46%), and a sore throat (56%). Of the individuals considered, 63% had ordinary rhinoscopic findings, 21% experienced watery rhinorrhea, and 12% had observable mucosal redness. Further, 87% had ordinary tonsillar findings, 13% displayed tonsillar redness, with enlargement and white mucus observe in 2% and 1% of participants, respectively. A total of 193 patients had a calculated Centor score of 3 points in 2%, and scores of the remaining participants were ≤2 points. Conclusion Of all patients considered, 40% had nasal findings and 4% had purulent nasal discharge. In contrast, only 13% of the patients had tonsillar findings, and no patients had Centor scores ≥4 points. Symptom differentiation from that of bacterial infections is difficult. In areas where COVID-19 is prevalent, the disease should be considered in patients presenting with fever, olfactory disturbances, and sore throat with minimal or no clinical findings in the nasal cavity and pharynx.

OBJECTIVE: To examine the use of pharmacotherapy in obesity treatment in the United States from 2011 to 2016 using a large, nationally representative sample. PATIENTS AND METHODS: Data were obtained over six years, 2011 to 2016, from the National Ambulatory Medical Care Survey. There were three types of visits identified: patients with obesity and an anti-obesity drug mention, patients with obesity and no anti-obesity drug mention, and patients without obesity and with anti-obesity drug mention. Chi-square tests were used to compare characteristics across each type of visit. To predict the odds of an anti-obesity medication mention for patients with obesity, a logistic regression analysis was conducted. RESULTS: Of the overall weighted 196,872,870 office-based physician visits made by patients with obesity from 2011 to 2016, one percent mentioned an anti-obesity drug. Additionally, there were 760,470 office-based physician visits by patients without obesity but with an anti-obesity medication mention. An anti-obesity drug mention was more likely for those ages 51 or older and those residing in the South (AOR: 5.31 95% CI: 1.19-23.59). CONCLUSION: There was a slight increase in anti-obesity medication mentions, from 0.26% in 2011 to 0.28% in 2016, but only one percent of office-based visits for patients with obesity received a prescription for an anti-obesity medication. Physicians tended to prescribe anti-obesity medications to those with obesity ages 51 or older and residing in the South. Anti-obesity medication as treatment for obesity is significantly underutilized.

Atopic dermatitis (AD) is a relapsing chronic inflammatory skin disease with a significant public health burden.To conduct a survey in order to gain information on current problems on the care and treatment of AD patients from a wide range of care providers, as well as information on ways of improving AD guidelines.An online survey was conducted via professional associations, focussing on AD health care professionals with regards to current gaps in knowledge of AD management and experience based on the German guidelines (GL).In total, 542 respondents treated a median of 200 AD patients yearly. The most frequent problems in the management of AD concerned emollients (50%), largely due to patient costs and the inability to prescribe emollients/moisturizers. Barriers to prescribing biologics included cost. Respondents stated that the GL lacks information regarding patient education (27%) and use of basic emollients (27%). Consideration should be given to feasibility issues (32%) and the addition of care pathways (41%) to improve the GL.In this survey, we identified inadequate basic AD care mainly due to patient costs and lack of time for counselling as real-life challenges. These issues remain to be addressed in future guidelines.

Background This cross-sectional study performed to clarify the relationship between periodontal disease and non-communicable diseases (NCDs), such as obesity, diabetes mellitus, impaired glucose tolerance (IGT), chronic obstructive pulmonary disease (COPD), and atherosclerotic cardiovascular disease (ASCVD) by introducing dental examinations into the annual health examinations conducted by Japanese companies, and to highlights the importance of a medical system that connects dental and medical professionals. Methods A total of 1.022 Hitachi Ltd. employees were enrolled in this cross-sectional study. We examined correlations and odds ratios (ORs) between the dental and overall health of employees using stratification and multiple logistic regression analyses based on the periodontal health indicators, general health indicators, and occlusal force. Results The adjusted OR of PPD for obesity (OR, 1.42; 95% confidence interval [CI], 1.09–1.84; p = 0.009), IGT (OR, 1.48; 95% CI, 1.00–2.20; p = 0.049), and COPD (OR, 1.38; 95% CI, 1.02–1.88; p = 0.038) significantly differed. The adjusted OR of body mass index (OR, 1.28; 95% CI 1.15–1.42; p p p 1) (OR, 0.95; 95% CI 0.91–1.00; p = 0.031) and smoking (OR, 2.32; 95% CI 1.62–3.33; p 1 was significantly associated with occlusal force among employees with IGT. Conclusions This cross-sectional study revealed mutual relationships among periodontal disease, NCDs, and occlusal force on Japanese corporate workers. We demonstrated that a comprehensive, regional healthcare system centred on annual integrated dental and physical health examinations in the workplace will benefit employees and positively impact corporate health insurance.

Background: Despite successes in the development of innovative anticancer therapies, the fiscal and capacity restraints of the Canadian public healthcare system result in challenges with drug access. A meaningful proportion of systemic therapies ultimately do not receive public funding despite supporting clinical evidence. In this study, we assessed Canadian medical oncologists’ current attitudes toward discussing publicly unfunded cancer treatments with patients and predictors of different practices. Methods: A web-based survey consisting of multiple choice and case-based scenarios was distributed to medical oncologists identified through the Royal College of Physicians and Surgeons of Canada directory. Results: A total of 116 responses were received. Almost all respondents reported discussing publicly unfunded treatments, including those who did so for Health Canada (HC) approved treatments (50%) and those who discussed off-label treatments (i.e., not HC approved) as guided by national guidelines (48%). Respondents in practice for over 15 years versus less than 5 years (OR 0.14, 95% CI 0.04–0.50, p = 0.002) and those who worked in a community practice versus comprehensive cancer center (OR 0.17, 95% CI 0.03–0.91, p = 0.04) were significantly less likely to discuss off-label treatment options with their patients. Almost half of respondents (47%) indicated that their institution did not permit the administration of unfunded treatments. Conclusions: There is variability in medical oncologists’ practices when it comes to discussing unfunded therapies. Given the limitations within Canada’s publicly funded healthcare system, physicians are faced with the challenge of navigating an increasingly complex balance between patient care and available resources. Engagement of relevant stakeholders and policy makers is crucial in the continued evaluation of Canada’s drug funding process.

Background Several Canadian provinces have introduced reimbursement policies mandating substitution of innovator biologics with lower-cost biosimilars. We estimated the number of patients affected and cost implications if such policy changes were to be implemented in Ontario, Canada. Methods We conducted a cross-sectional time series analysis of Ontarians dispensed publicly funded biologics indicated for inflammatory diseases (rheumatic conditions, inflammatory bowel disease: infliximab, etanercept, adalimumab) between January 2018 and December 2019, and forecasted trends to Dec. 31, 2020. The primary source of data was pharmacy claims data for all biologics reimbursed by the public drug program. We modelled the number of patients affected and government expenditures (in nominal Canadian dollars) of several biosimilar policy options, including mandatory nonmedical biosimilar substitution, substitution in new users, introduction of a biosimilar for adalimumab, and price negotiations. In a secondary analysis, we included insulin glargine. Results In 2018, 14 089 individuals were prescribed a publicly funded biologic for inflammatory diseases. A mandatory nonmedical biosimilar substitution would potentially have affected 7209 patients and saved $238.6 million from 2018 to 2020. A new-user substitution would have affected 757 patients and saved $34.2 million. If an adalimumab biosimilar were to become available, 12 928 patients would be affected by a mandatory nonmedical substitution and the 3-year savings would increase to $645.9 million (all biosimilars priced at 25% of innovator biologics). Finally, an expanded nonmedical substitution policy including insulin glargine would affect 115 895 patients and save $288.7 million (not including adalimumab). Interpretation Policies designed to curb rising costs of biologics can have substantially different effects on patients and government expenditures. Such analyses warrant careful consideration of the balance between cost savings and effects on patients.

PURPOSE: Parents of neonates with seizures are at risk of mental health symptoms due to the impact of illness on family life, prognostic uncertainty, and the emotional toll of hospitalization. A family-centered approach is the preferred model to mitigate these challenges. We aimed to identify strategies to promote family-centered care through an analysis of parent-offered advice to clinicians caring for neonates with seizures. BASIC PROCEDURES: This prospective, observational, and multi-center (Neonatal Seizure Registry) study enrolled parents of neonates with acute symptomatic seizures. Parents completed surveys about family well-being at 12 months, 18 months, and 24 months corrected gestational age. Parents were asked open-ended questions eliciting their advice to clinicians caring for neonates with seizures. Responses were analyzed using a conventional content analysis approach. MAIN FINDINGS: Among the 310 parents who completed surveys, 118 (38%) shared advice for clinicians. These parents were predominantly mothers (n=103, 87%). Three overarching themes were identified. (1) Communicate information effectively: Parents appreciate when clinicians offer transparent and balanced information in an accessible way. (2) Understand and validate parent experience: Parents value clinicians who display empathy, compassion, and a commitment to parent-partnered clinical care. (3) Provide support and resources: Parents benefit from emotional support, education, connection with peers, and help navigating the healthcare system. PRINCIPAL CONCLUSIONS: Parents caring for neonates with seizures appreciate a family-centered approach in healthcare encounters, including skilled communication, understanding and validation of the parent experience, and provision of support and resources. Future interventions should focus on building structures to reinforce these priorities.

PURPOSE This study examines oncologist-reported reasons for not using multimarker tumor panel testing and the association between these reasons and oncologist-level, facility-level, and patient-mix characteristics. METHODS We used data collected from a nationally representative sample (N = 1,281) of medical oncologists participating in the National Cancer Institute's National Survey of Precision Medicine in Cancer Treatment. RESULTS In addition to testing not being seen as relevant (87%) and no evidence of test utility (77%), the most frequently reported reasons for not ordering a multimarker tumor panel test was difficulty in obtaining sufficient tissue (57%) and using individual gene tests (72%). These reasons were more likely to be reported by oncologists practicing in rural clinics and less likely to be reported by oncologists with an academic affiliation or with access to genetic services such as on-site genetic counselors and internal genetic testing policies. CONCLUSION Modifiable, organizational factors were associated with ordering multimarker tumor panels. Receipt of genomics training and organizational policies related to the use of genomics were associated with lower reporting of barriers to ordering multimarker tumor panels, pointing to potential targets for future studies aimed at increasing appropriate multimarker tumor panel testing in cancer treatment management.

Background The initial COVID-19 pandemic shutdown led to the canceling of elective surgeries throughout most of the USA and Canada. Objective This survey was carried out on behalf of the Parkinson Study Group (PSG) to understand the impact of the shutdown on deep brain stimulation (DBS) practices in North America. Methods A survey was distributed through RedCap® to the members of the PSG Functional Neurosurgical Working Group. Only one member from each site was asked to respond to the survey. Responses were collected from May 15 to June 6, 2020. Results Twenty-three sites participated; 19 (83%) sites were from the USA and 4 (17%) from Canada. Twenty-one sites were academic medical centers. COVID-19 associated DBS restrictions were in place from 4 to 16 weeks. One-third of sites halted preoperative evaluations, while two-thirds of the sites offered limited preoperative evaluations. Institutional policy was the main contributor for the reported practice changes, with 87% of the sites additionally reporting patient-driven surgical delays secondary to pandemic concerns. Pre-post DBS associated management changes affected preoperative assessments 96%; electrode placement 87%; new implantable pulse generator (IPG) placement 83%; IPG replacement 65%; immediate postoperative DBS programming 74%; and routine DBS programming 91%. Conclusion The COVID-19 pandemic related shutdown resulted in DBS practice changes in almost all North American sites who responded to this large survey. Information learned could inform development of future contingency plans to reduce patient delays in care under similar circumstances.

Purpose This study aims to determine whether there is consensus regarding staging and management of cutaneous squamous cell carcinoma (CSCC) across the various specialties that manage this disease. Materials and Methods A survey regarding CSCC high‐risk features, staging, and management was created and emailed to cutaneous oncology experts including dermatology, head and neck surgery/surgical oncology, radiation oncology, and medical oncology. Results One hundred fifty‐six (46%) of 357 invited physicians completed the survey. Depth of invasion (92%), perineural invasion (99%), histologic differentiation (85%), and patient immunosuppression (90%) achieved consensus (>80%) as high‐risk features of CSCC. Dermatologists were more likely to also choose clinical tumor diameter (79% vs. 54%) and histology (99% vs. 66%) as a high‐risk feature. Dermatologists were also more likely to utilize the Brigham and Women's Hospital (BWH) staging system alone or in conjunction with American Joint Committee on Cancer (AJCC) (71%), whereas other cancer specialists (OCS) tend to use only AJCC (71%). Respondents considered AJCC T3 and higher (90%) and BWH T2b and higher (100%) to be high risk and when they consider radiologic imaging, sentinel lymph node biopsy, post‐operative radiation therapy, and increased follow‐up. Notably, a large number of respondents do not use staging systems or tumor stage to determine treatment options beyond surgery in high‐risk CSCC. Conclusion This survey study highlights areas of consensus and differences regarding the definition of high‐risk features of CSCC, staging approaches, and management patterns between dermatologists and OCS. High‐risk CSCC is defined as, but not limited to, BWH T2b and higher and AJCC T3 and higher, and these thresholds can be used to identify cases for which treatment beyond surgery may be considered. Dermatologists are more likely to utilize BWH staging, likely because BWH validation studies showing advantages over AJCC were published in dermatology journals and discussed at dermatology meetings. Additional data are necessary to develop a comprehensive risk‐based management approach for CSCC., This survey study highlights areas of consensus and differences regarding the definition of high‐risk features of CSCC, staging approaches, and management patterns between dermatologists and OCS. High‐risk CSCC is defined as, but not limited to, BWH T2b and higher and AJCC T3 and higher, and these thresholds can be used to identify cases for which treatment beyond surgery may be considered. Dermatologists are more likely to utilize BWH staging, likely because BWH validation studies showing advantages over AJCC were published in dermatology journals and discussed at dermatology meetings.

Background Although long-acting injectable antipsychotics (LAI-APs) have been considered as a monotherapeutic option in the maintenance treatment of schizophrenia, it has been recently reported that the combination therapy of LAI-APs and oral antipsychotics (OAPs) is common. Methods We conducted a retrospective chart review to examine the situation of the combination therapy of LAI second-generation antipsychotics (LAI-SGAs) and OAPs, and a questionnaire survey to investigate prescribers' attitudes toward the combination therapy. We included patients who received any LAI-SGAs for 1 month or longer and classified them into monotherapy and combination therapy groups. We collected information on age, sex, primary psychiatric diagnosis, and concomitant psychotropic medications. Results Of the 132 patients, 39 (29.5%) received the combination therapy of LAI-SGAs and OAPs. Long-acting injectable risperidone was significantly associated with receiving the combination therapy compared with LAI aripiprazole. Olanzapine was the most common OAP in combination with LAI-SGAs. Only 8 patients (20.5%) concurrently received the same type of OAPs as LAI-SGAs. More than 60% of the patients received OAP polypharmacy before the initiation of LAI-SGAs. The psychiatrists in charge prescribed LAI-SGAs mainly because of a concern about adherence, and OAPs mainly because of insufficient dose of LAI-SGAs, to patients in the combination therapy group. They estimated that adherence to OAPs in two thirds of the patients in the combination therapy group was 80% or higher. Conclusions The present study showed that the combination therapy of LAI-SGAs and OAPs is often conducted in real-world clinical practice. Considering the reason for the introduction of LAI-APs, clinicians should carefully monitor patients' adherence to OAPs concurrently used with LAI-APs.

Immunization is a safe and cost-effective means of preventing illness in young children and interrupting disease transmission within the community.* The Advisory Committee on Immunization Practices (ACIP) recommends vaccination of children against 14 diseases during the first 24 months of life (1). CDC uses National Immunization Survey-Child (NIS-Child) data to monitor routine coverage with ACIP-recommended vaccines in the United States at the national, regional, state, territorial, and selected local levels.† CDC assessed vaccination coverage by age 24 months among children born in 2017 and 2018, with comparisons to children born in 2015 and 2016. Nationally, coverage was highest for ≥3 doses of poliovirus vaccine (92.7%); ≥3 doses of hepatitis B vaccine (HepB) (91.9%); ≥1 dose of measles, mumps, and rubella vaccine (MMR) (91.6%); and ≥1 dose of varicella vaccine (VAR) (90.9%). Coverage was lowest for ≥2 doses of influenza vaccine (60.6%). Coverage among children born in 2017-2018 was 2.1-4.5 percentage points higher than it was among those born in 2015-2016 for rotavirus vaccine, ≥1 dose of hepatitis A vaccine (HepA), the HepB birth dose, and ≥2 doses of influenza vaccine. Only 1.0% of children had received no vaccinations by age 24 months. Disparities in coverage were seen for race/ethnicity, poverty status, and health insurance status. Coverage with most vaccines was lower among children who were not privately insured. The largest disparities between insurance categories were among uninsured children, especially for ≥2 doses of influenza vaccine, the combined 7-vaccine series, § and rotavirus vaccination. Reported estimates reflect vaccination opportunities that mostly occurred before disruptions resulting from the COVID-19 pandemic. Extra efforts are needed to ensure that children who missed vaccinations, including those attributable to the COVID-19 pandemic, receive them as soon as possible to maintain protection against vaccine-preventable illnesses.

Background Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain. Methods We performed a survey-weighted analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing older adults with a chief complaint of abdominal pain to those without. Visits from 2013 to 2017 to nationally representative EDs were included. We analyzed 81,509 visits to 1211 US EDs, which projects to 531,780,629 ED visits after survey weighting. We report the diagnostic testing, evaluation, management, additional reasons for visit, and disposition of ED visits. Results Among older adults (≥65 years), 7% of ED visits were for abdominal pain. Older patients with abdominal pain had a lower probability of being triaged to the "Emergent" (ESI2) acuity on arrival (7.1% vs. 14.8%) yet were more likely to be admitted directly to the operating room than older adults without abdominal pain (3.6% vs. 0.8%), with no statistically significant differences in discharge home, death, or admission to critical care. Ultrasound or CT imaging was performed in 60% of older adults with abdominal pain. A minority (39%) of older patients with abdominal pain received an electrocardiogram (EKG). Conclusions Abdominal pain in older adults presenting to EDs is a serious condition yet is triaged to "emergent" acuity at half the rate of other conditions. Opportunities for improving diagnosis and management may exist. Further research is needed to examine whether improved recognition of abdominal pain as a syndromic presentation would improve patient outcomes.

Background: Emergency general surgery (EGS) patients require urgent surgical evaluation and intervention for various conditions, such as infectious or obstructive diseases of the gastrointestinal tract. We aimed to characterize the structures and processes that are relevant to the delivery of EGS care across Ontario hospitals and to evaluate the availability of critical resources at hospitals with formal EGS models. Methods: Between August 2019 and July 2020, we conducted a cross-sectional survey of Ontario hospitals that offered urgent general surgery (defined as the ability to provide nonelective surgical intervention within 24 to 48 hours of presentation) to adults. People with intimate knowledge of their hospital’s EGS program completed a Web-based or telephone survey characterizing the program’s organizational structure and staffing, operating room availability, interventional radiology and interventional endoscopy availability, intensive care unit availability and staffing, and regional participation. Their responses were compiled and comparisons were made between hospitals with and without formal EGS models of care, as well as between hospitals based on size and academic status. Results: Of the 114 Ontario hospitals identified, 109 responded (95.6% response rate). A third (34.6%; n = 37/107) of hospitals had EGS models of care. Thirty-four of these (91.9%) were large (> 100-bed) institutions that would be likely to have increased resources. However, even for hospitals of similar size, those with EGS models had increased staffing levels compared to those without (clinical associates 17.6% [n = 3/17] v. 10.0% [n = 2/20]; nurse practitioners or physician assistants 27.8% [n = 5/18] v. 14.3% [n = 3/21]). They also had better access to diagnostic and interventional equipment (24/7 access to computed tomography 94.1% [n = 16/17] v. 69.2% [n = 18/26]), interventional radiology (88.9% [n = 16/18] v. 42.3% [n = 11/26]), endoscopy (100% [n = 18/18] v. 69.2% [n = 18/26]) and endoscopic retrograde cholangiopancreatography (77.8% [n = 14/18] v. 42.3% [n = 11/26]), as well as dedicated operating room time (72.2% [n = 13/18] v. 0% [n = 0/25]). Interpretation: The structures and processes available to care for patients requiring EGS in Ontario were highly variable between hospitals. Hospitals with formal EGS models were more likely to have access to key resources.

Summary Surgical site infections (SSI) pose significant morbidity after colorectal surgery. We sought to document current practices in colorectal surgery SSI prevention in British Columbia (BC). Reporting the current provincial landscape on SSI prevention helps to understand the foundation upon which improvements can take place. We surveyed all BC surgeons performing elective colon and rectal resections, and 97 surveys were completed (60% response rate). Eighty-six per cent of respondent hospitals tracked SSI rates. The reported superficial SSI was less than 5% and the anastomotic leak/organ space rate was less than 10%. All respondents gave preoperative prophylactic antibiotics, with 24% continuing antibiotics postoperatively; 62% are using oral antibiotics (OAB) and mechanical bowel preparation (MBP) and 29% use MBP without OAB. Areas for improvement include OAB with MBP and discontinuing prophylactic antibiotics postoperatively, as recommended by the World Health Organization.

OBJECTIVES Quality improvement (QI) requires data, indicators, and national benchmarks. Knowledge about the usefulness of Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) data are lacking. We examined quality leader and frontline staff perceptions about patient experience measurement and use of Child HCAHPS data for QI. METHODS We surveyed children’s hospital leaders and staff about their use of Child HCAHPS for QI, including measures from other studies. We compared scale and item means for leaders and staff and compared means to other studies. RESULTS Almost all leaders, but only one-third of staff, received reports with Child HCAHPS data. Leaders found the data more useful for comparisons to other hospitals than did staff. Both agreed on the validity of Child HCAHPS scores and used these data for improving pediatric care experiences. They agreed the data accurately reflect their hospital’s quality of care, provide specific information for QI, and can be used to improve pediatric care experiences. They also agreed on approaches to improve Child HCAHPS scores. Among staff, QI was reported as essential to their daily work and that Child HCAHPS data were integral to QI. CONCLUSIONS As uptake of the Child HCAHPS survey increases, our study of one medium-sized, urban children’s hospital revealed that leaders and staff believe Child HCAHPS provides actionable metrics for improvement. Our study fills a gap in research about the use of Child HCAHPS for pediatric QI. A multisite evaluation would provide further information about how the Child HCAHPS survey can improve care.

Background: Healthcare disparities negatively impact patient health outcomes; addressing disparities could improve quality of life and decrease overall healthcare cost. The National Ambulatory Medical Care Survey (NAMCS) is an objective and reliable source for collecting information on United States (U.S.) ambulatory medical care service visits and may be a useful tool for identifying potential disparities in care. Objective: The purpose of this literature review is to describe studies utilizing NAMCS to capture U.S. healthcare disparities. Methods: PubMed was searched for scientific articles that utilized NAMCS to determine health disparities in the U.S. The keywords queried included “NAMCS” or “National Ambulatory Medical Care Survey” and “disparity” or “disparities” as a pair or additionally paired with one of the following: “race”, “ethnicity”, “age”, “gender”, “geography”, or “insurance”. Results: 66 studies were found that incorporated NAMCS data from 1980-2016 into their methods to measure outcomes relating to health disparities. Disparities were found in the following categories: race/ethnicity, geographic location, age, insurance type, gender, specialist care versus primary care, body habitus, and preexisting conditions affecting patient outcomes. Disparities were identified in pain management, neurology, dermatology, psychiatry, patient communication access, and non-specialty specific or primary care visits related to disease conditions, screening, and treatment plans. Limitations: Only PubMed was utilized as a search engine and may not encompass all studies on NAMCS and health disparities. NAMCS is a cross-sectional database and does not allow for longitudinal analyses. Conclusions: NAMCS may be an underused tool given the limited number of articles that identify health disparities using it. Research studies utilizing NAMCS may identify potential disparities ultimately leading to better healthcare outcomes.