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We systematically reviewed quantitative studies of phenomena at the nexus of Human Resource Management (HRM) and interpersonal relationships. We report on the overall prevalence and trends in research methods relating to construct, internal, external, and statistical conclusion validity. The review draws attention to areas of emphasis (positive relationships, instrumental ties, nonnetwork structures, employee respondents, samples drawn from Asia, HR perceptions). We also identify a growing emphasis on particularly desirable approaches to examining relational HRM (a more balanced consideration of positive and negative relationships, studies that examine more than one HR practice, multilevel analyses). Together, the identified areas of emphasis, gaps, and associated trends, inform our elucidation of research directions around 15 specific work relationships—along with more general directions for better accounting for dynamic, multilevel, measurement, and analytical considerations central to HRM and interpersonal relationships. [ABSTRACT FROM AUTHOR]

Background: When doctors seek medical care, there is evidence that the treating doctor can struggle to provide optimal treatment. Guidelines state that doctor-patients should be treated like any other patient, but this is challenging for the treating doctor. This study set out to explore both the positive experiences general practitioners (GPs) have when caring for doctor-patients, and the challenges they confront. It sought to identify whether GPs believe they treat doctor-patients differently to other patients and if so, in what ways, for what reasons, and how this impacts their provision of care. The study also aimed to develop a model that makes sense of GPs' experiences when caring for a patient who is also a medical doctor. Method: Qualitative in-depth interviews with 26 GPs were carried out, with analysis of de-identified transcripts using pragmatic grounded theory. Evolving understandings were used to develop a model to make sense of GPs' experiences caring for their doctor-patients. Results: The core aspects of GPs' experiences of treating fellow doctors centred around concepts of respect and collegiality. These play a central role in mediating how a treating doctor experiences a consultation with a doctor-patient, influencing the quality of care provided. GPs shared that the use of medical language (and assumptions about the doctor-patient's knowledge/behaviours), testing, the exploration of sensitive issues, and the degree of shared decision-making were areas where their treatment might vary when treating a doctor-patient. Treating doctors often experience anxiety about errors and the likely scrutiny from the medical, and wider community. The decision to treat the doctor-patient differently was driven by a desire to maintain a sense of collegiality, to not offend, to meet their doctor-patient's expectations, and to appear competent. Conclusion: The professional socialisation of doctors, with its emphasis on collegiality and respect, plays a significant role in the dynamics of the therapeutic relationship when a doctor treats a doctor-patient. Current guidelines make little reference to these dynamics with the over-simplified 'keep it normal' recommendations. Treating doctors need evidence-informed training to navigate these challenges and ensure they can effectively deliver quality care to their doctor-patients. [ABSTRACT FROM AUTHOR]

Background: Increasing numbers of patients treated in the emergency departments pose challenges to delivering timely and high-quality care. Particularly, the presentation of patients with low-urgency complaints consumes resources needed for patients with higher urgency. In this context, patients with non-specific back pain (NSBP) often present to emergency departments instead of primary care providers. While patient perspectives are well understood, this study aims to add a provider perspective on the diagnostic and therapeutic approach for NSBP in emergency and primary care settings. Methods: In a qualitative content analysis, we interviewed seven Emergency Physicians (EP) and nine General Practitioners (GP) using a semi-structured interview to assess the diagnostic and therapeutic approach to patients with NSBP in emergency departments and primary care practices. A hypothetical case of NSBP was presented to the interviewees, followed by questions on their diagnostic and therapeutic approaches. Recruitment was stopped after reaching saturation of the qualitative content analysis. Reporting this work follows the consolidated criteria for reporting qualitative research (COREQ) checklist. Results: EPs applied two different strategies for the workup of NSBP. A subset pursued a guideline-compliant diagnostic approach, ruling out critical conditions and managing pain without extensive diagnostics. Another group of EPs applied a more extensive approach, including extensive diagnostic resources and specialist consultations. GPs emphasized physical examinations and stepwise treatment, including scheduled follow-ups and a better knowledge of the patient history to guide diagnostics and therapy. Both groups attribute ED visits for NSBP to patient related and healthcare system related factors: lack of understanding of healthcare structures, convenience, demand for immediate diagnostics, and fear of serious conditions. Furthermore, both groups reported an ill-suited healthcare infrastructure with insufficiently available primary care services as a contributing factor. Conclusions: The study highlights a need for improving guideline adherence in younger EPs and better patient education on the healthcare infrastructure. Furthermore, improving access and availability of primary care services could reduce ED visits of patients with NSBP. Trial registration: No trial registration needed. [ABSTRACT FROM AUTHOR]

Background: As the demand for mental health and substance use (MHSU) services increases, there will be an even greater need for health human resources to deliver this care. This study investigates how family physicians' (FP) contact volume, and more specifically, MHSU contact volume, is shaped by demographic trends among FPs in British Columbia, Canada. Methods: We used annual physician-level administrative billing data and demographic information on FPs in British Columbia between 1996 and 2017. This study analyzes trends in primary care service provision among graduating cohorts of FPs, FPs of different ages (as measured by years since graduation), and FPs practicing during different time periods. Additionally, analyses are stratified by FP sex to account for potential differences in labour supply patterns between male and female FPs. Results: Our results show that while FPs' overall contacts with patients decreased between 1996 and 2017, their annual number of MHSU contacts increased, which was largely driven by an increase in substance use visits. Demographically, the proportion of female FPs in the labour force rose over time. Observed trends were similar, though not identical in male and female FPs, as males tended to have higher overall contact volume (both total contacts and MHSU), but also steeper declines in contact volume in later careers. The number of contacts (both total and MHSU) changed across career stage - rising steadily from start to mid-career, peaking at 20–30 years in practice, and decreasing steadily thereafter. This was evident for all cohorts and consistent over the 21-year study period but flattened in amplitude over time. Our findings also point to potential cohort effects on labour supply. The inverse U-shaped career trend extended to MHSU contacts, but its peak seems to have shifted to a later career stage (peaking at 30–40 years of practice) over time. Conclusions: Our study shows changing dynamics in MHSU service delivery among FPs over time, across the life span and between FP sexes that are likely to influence access to care beyond simply the number of FPs. Given the healthcare needs of the population, these findings point to potential future changes in provision of MHSU services. [ABSTRACT FROM AUTHOR]

Objective Background Methods Results Conclusion The objective of this pilot study was to assess physical therapists’ (PTs) knowledge and needs regarding headache diagnosis and management.While there is significant research on physical therapy and cervicogenic headache, studies suggest that migraine is often under‐recognized, misdiagnosed, and inadequately treated across society despite its high prevalence and burden. Because migraine commonly includes concurrent neck pain and/or vestibular symptoms, patients with migraine may present to PTs for treatment. Very little is known about PTs' headache and migraine education, knowledge, and clinical practices.A team of headache specialists and PTs adapted a previously used headache knowledge and needs assessment survey to help ascertain PTs' knowledge and needs regarding headache treatment. The cross‐sectional survey was distributed online via Research Electronic Data Capture (REDCap) to PTs within a large healthcare system in Connecticut.An estimated 50.5% (101/200) of PTs invited to complete the survey did so. Only 37.6% (38/101) of respondents reported receiving any formal headache or migraine education in their professional training, leading to knowledge gaps in differentiating and responding to headache subtypes. Only 45.5% (46/101) were able to identify that migraine is characterized by greater pain intensity than tension‐type headache, and 22.8% (23/101) reported not knowing the duration of untreated migraine. When asked about the aspects of care they believe their patients with headache would like to see improved, PTs reported education around prevention and appropriate medication use (61/100 [61.0%]), provider awareness of the degree of disability associated with migraine (51/100 [51.0%]), and diagnostics (47/100 [47.0%]).This sample of PTs from one healthcare system demonstrates knowledge gaps and variations in clinical practice for managing their patients with headache. Future research on integrating additional opportunities for headache education for physical therapists, including evidence‐based behavioral therapies, is needed to ascertain whether it is likely to improve patient care. [ABSTRACT FROM AUTHOR]

Background: Bleeding in early pregnancy is a common emergency department (ED) presentation. Although variability in approaches has been demonstrated, research is relatively uncommon on practices and outcomes. This study investigated the influence of clinical pattern of care, utility, and contribution of pelvic examination aimed at diagnosing and managing bleeding in early pregnancy at three Canadian EDs. Methods: After obtaining informed consent, data were collected from adult women who were pregnant and from treating ED physicians using a structured questionnaire. We defined the change in management based on the initial clinical plan at the time of the initial physician assessment in the ED and any subsequent changes made after the pelvic examination was performed. Patient telephone follow-up was supplemented by linking with provincial administrative data for births. Univariable and multivariable binary logistic regression analyses were performed to identify factors associated with a change in patient management following pelvic examination in the ED. Results: Overall, 200 women were enrolled. The mean age was 31 years, patients had been bleeding for a median of 1 day and stayed in the ED for a median of 5 h. Of these, 166 (83.0%) received a pelvic examination, including speculum examination and/or bimanual palpation. Pregnancy outcome data were available for 192 pregnancies; 107 (56%) experienced a miscarriage. Factors significantly associated with a change in management after pelvic examination in the univariate logistic regression analysis were brown/dark-red bleeding per vaginam (physician determined), tachycardia, right lower quadrant tenderness, and bimanual palpation. In the multivariate logistic regression analysis, brown/dark-red bleeding per vaginam was independently associated with a reduced likelihood of a change in management after pelvic examination (aOR = 0.37; 95% CI: 0.14–0.98). Conclusion: Among women presenting to the ED with bleeding in early pregnancy prior to 20 weeks gestation, only brown/dark-red vaginal bleeding, potentially indicative of bleeding resolution, significantly independently influenced the baseline odds of a change in management after pelvic examination. Until the debate on the utility of pelvic examination in the ED for this presentation is resolved, physician preferences and shared decision making with patients should guide practice regarding speculum examination/bimanual palpation for the management of bleeding in early pregnancy. [ABSTRACT FROM AUTHOR]

The management of cancer-related pain in patients with opioid use disorder (OUD) remains complex and often challenging for clinicians and patients. There is currently a paucity of data to guide best practices, and the evidence that exists is variably applied. In this hospital-based questionnaire, we sought to understand the variation in practice patterns among clinicians in palliative medicine, addiction medicine, and hospital medicine, in caring for this complex patient population. Sixty-two questionnaire responses were analyzed and variation was found in management of pain, as well as initiation or titration of buprenorphine and methadone. There was also a significant difference in postdischarge subspecialty follow-up. Furthermore, the findings suggest that buprenorphine and methadone may be underutilized in this population. Patients and clinicians may benefit from additional support and standardization of practices to best manage coexisting cancer-related pain and OUD. [ABSTRACT FROM AUTHOR]

Simple Summary: Plasmacytoid urothelial carcinoma (PUC) is a rare and aggressive histologic subtype of urothelial carcinoma of the bladder (BC) with high rates of upstaging and metastases. The aim of our study was to characterize treatment patterns and outcomes using a large national database and our institutional experiences, combating the challenge posed by the rarity of this variant. We demonstrated that, despite an improved pT0 rate associated with NAC, there remains an inconclusive overall survival increase. Additionally, PUC demonstrated a high predilection for peritoneal metastasis, further highlighting the need for investigation into more effective and subtype-tailored treatment options. Background: Plasmacytoid urothelial carcinoma (PUC) is a rare histologic subtype of urothelial carcinoma of the bladder (BC). Our objective was to characterize treatment patterns and outcomes of PUC in the NCDB and our recent institutional experience. Methods: The NCDB was queried for localized PUC cases between 2004 and 2020. Patients with PUC from a single institution (Yale School of Medicine) were also incorporated from 2021 onwards to not double-count patients. The primary outcomes were overall survival and treatment trends. Results: A total of 146 patients were included, 123 from NCDB and 23 from Yale. The median overall survival (mOS) was 28 [IQR 7.5, 50.3] months, 23 [IQR 8.4, 46.3] months for the NCDB patients, and 36 [IQR 4.3, 68.1] for the Yale patients. The mOS for patients receiving neoadjuvant chemotherapy (NAC) was 60.0 [28.0, 91.9] vs. 14.8 months [0, 34.3] for patients without NAC, p = 0.038, though the benefit was not preserved in a Cox proportional hazard analysis incorporating the clinical stage, receipt of NAC, and age. The peritoneum was the most common site of metastasis (78.3%), followed by the liver and bones. Conclusion: Our findings underscore the formidable challenge posed by PUC, emphasizing its limited response to current therapies. Despite higher pT0 rates with NAC, the OS benefit remains inconclusive, highlighting the need for more effective treatments. [ABSTRACT FROM AUTHOR]

While there has been an increase in the use of the transradial approach when performing percutaneous coronary angiography and intervention, there is evidence of variations in international practice. Ensuring that operators' practices are supported by evidence is important to ensure optimal outcomes. Interventional cardiologists and advanced trainees completed a cross-sectional survey followed by semi-structured interviews to map current practices for transradial coronary artery procedures in Australia and New Zealand and explore factors that influence clinical decision-making around procedural practice. The right radial artery was the preferred access site (88%). Over a third (37%) of the participants indicated that they tested the hand circulation pre-procedure. Over a quarter of respondents (28.6%) reported that they would carry out transradial procedures regardless of the patient's coagulation status. Most participants (77.8%) described radial artery spasm in around 10% of transradial procedures performed. Only 62% of participants assessed for radial artery occlusion post-catheterisation. Interview data revealed four themes that guided clinical decision-making, namely (1) Decision-making based on research, (2) Using clinical experience, (3) Being led by their training, and (4) Individual patient factors. This study has demonstrated that despite clinical guidelines, substantial practice variation exists in transradial coronary artery catheterisation across Australia and New Zealand. The variation in practice and factors impacting clinical decision-making highlight a need for future strategies to optimise evidence translation and implementation across clinical settings. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Despite recent consensus guidelines, there is substantial variability in the management of pheochromocytomas. Our study aimed to characterize the current state of perioperative pheochromocytoma management by Canadian surgeons. METHODS: A 23-item online survey was sent to Canadian surgeons who perform adrenalectomies for pheochromocytoma. We assessed personal and institutional practices, including preoperative and postoperative management. RESULTS: National response rate was 51.8%. Surgeons from nine provinces responded; the majority were general surgeons (70.4%). Reviewing pheochromocytoma patients at a multidisciplinary tumor board was not routine practice (12%) and only 42.3% consistently referred patients for genetic testing. Preoperative α- and β-blockade at half of the respondent institutions were performed by endocrinology alone (53.8%), with the other half employing a multidisciplinary approach. Half of respondents admitted their pheochromocytoma patients to hospital prior to the day of surgery. Postoperatively, 11.5% of respondents routinely admitted their patients to the intensive care unit (ICU) for monitoring based on personal preference or institutional convention. Multivariate analyses found no significant relationships between demographics or preoperative factors and perioperative management. CONCLUSIONS: Perioperative surgical management of patients undergoing adrenalectomy for pheochromocytoma was highly variable across Canada. Less than half of respondents routinely refer patients for genetic testing, despite recent practice guidelines. Surgeon preference and institutional convention are the main drivers behind preoperative admission and routine postoperative ICU admission, despite a lack of evidence to support this practice. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Patients with type 2 diabetes (T2D) are at high risk for developing chronic kidney disease (CKD). The onset of incident CKD may complicate glycemic control among these patients. This study aimed to characterize antihyperglycemic medication use after incident CKD onset among patients with T2D to inform disease management. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with incident CKD and prior T2D were identified from the Optum electronic health records database between March 2013 and September 2021. Patterns of antihyperglycemic use were assessed during the 1-year baseline period and after incident CKD diagnosis and described by baseline hemoglobin A1C (HbA1C) level (controlled [< 7%] vs elevated [≥ 7%]) and CKD severity. RESULTS: The study consisted of 262,395 patients, of whom 51% had elevated HbA1C. After CKD onset, 23.9% of patients initiated new antihyperglycemics within 1 year. Patients with elevated HbA1C had shorter time to new treatment initiation compared with those with controlled HbA1C (median, 28.7 vs 83.7 months). Patients with elevated urine albumin-to-creatinine ratio (uACR) had shorter median time to new treatment initiation (39.9-42.4 months) than those with normal uACR (59.8 months). Less than 7% of patients with stage 3 CKD and even smaller percentages of patients with higher stages of CKD utilized glucagon-like peptide1 receptor agonists and sodium-glucose cotransporter 2 inhibitors. CONCLUSIONS: Treatment of T2D was considerably heterogenous by HbA1C level and CKD severity in patients with incident CKD. Current agents may not sufficiently fulfill the unmet need of T2D management in patients with CKD. [ABSTRACT FROM AUTHOR]

Objectives To present a new method for displaying blood utilization data based on analysis of decision time intervals (DTIs). Methods Retrospective study of patients treated in a medical intensive care unit (ICU), surgical ICU, or postcardiac surgery ICU at an academic hospital between January 2018 and June 2023. Each patient's episode of care was divided into a series of DTIs. Transfusions during each time interval were recorded. Results In total, 16,562 patients received 6980 units of plasma and 21,034 units of red blood cells during 111,557 time intervals of care. Patients had international normalized ratio (INR) values ranging from less than 1.0 to more than 4.0. Data on plasma transfusion at different INR values were displayed as the number of transfusion episodes, number of units given, or the proportion of DTIs with transfusion. Clinicians transfused plasma on 1.5% of occasions when the INR was 1.5 or less and on 2.2% of occasions when the INR was less than 2.0. Plasma was transfused without red blood cells in only 0.75% of DTIs. Transfusion practice was statistically different among the 3 ICUs. Conclusions Compared with traditional methods of displaying the results of blood audits, DTI analysis displays information regarding the decision both to transfuse and to not transfuse. Utilization reviews that display data based on decision time analysis reveal clinical practice patterns very different from those suggested by traditional displays of plasma audit data. [ABSTRACT FROM AUTHOR]

Background: Sodium‐glucose cotransporter‐2 inhibitors (SGLT2is) are novel agents for heart failure (HF) and are now recommended in guidelines. Understanding general physicians' perspectives can help to optimise utilisation of this new medication. Aim: To understand the clinical concerns and barriers from general physicians about prescribing SGLT2is in a general medicine cohort. Methods: A questionnaire exploring clinicians' experience, comfort level and barriers to prescribing SGLT2is in patients with HF, incorporating two clinical scenarios, was disseminated to Internal Medicine Society of Australia and New Zealand members over a 2‐month period. Results: Ninety‐eight participants responded to the questionnaire (10.8% response rate). Most respondents (66.3%) were senior medical staff. Most participants worked in metropolitan settings (64.3%) and in public hospital settings (83.7%). For HF with reduced ejection fraction, 23.5% of participants reported prescribing SGLT2is frequently (defined as prescribing SGLT2is frequently over 75% of occasions). For HF with preserved ejection fraction, 57.1% of participants reported prescribing SGLT2is less than 25% of the time. Almost half of the participants (44%) expressed a high level of familiarity with therapeutic knowledge of SGLT2is, while 47% indicated high familiarity with potential side effects. Patient complexity, cost of medications and discontinuity of care were identified as important barriers. Euglycemic diabetic ketoacidosis was the side effect that caused the most hesitancy to prescribe SGLT2is in 48% of the respondents. Conclusion: General physicians in Australia and Aotearoa New Zealand are familiar with the therapeutic knowledge and side effects of SGLT2is. Patient complexity, medication cost and discontinuity of care were significant barriers to the use of SGLT2is for HF among general physicians. [ABSTRACT FROM AUTHOR]

Background: The short Synacthen test (SST) is widely used to investigate adrenal insufficiency, but it can be time‐consuming, costly and labour‐intensive to perform and is not without risk of adverse events. Aim: To review SST requesting patterns and practices across public hospitals in Queensland. Methods: The electronic medical records of patients who underwent a SST with Pathology Queensland between January 2020 and December 2020 were reviewed to collect data regarding the indication for the test, the requesting speciality, SST results and any adverse events. Results: Six hundred and fifty‐two SSTs were identified, of which 363 individual patients were included in the analysis. The majority of the tests (n = 198, 54.5%) were performed in the inpatient setting. Endocrinology most commonly ordered SSTs (n = 188, 51.8%). The suspected aetiology of adrenal insufficiency was unclear in a large proportion of requests (n = 167, 46.0%). Static testing of morning cortisol prior to SST was performed in only 249 (68.6%) patients. Of 140 inpatients data, 17.9% (n = 25) showed a robust static cortisol of ≥400 nmol/L and were treated as having normal adrenal function, suggesting SST was unnecessary in these patients. Twenty‐two (6.1%) patients had a documented adverse event occurring during or after the SST. Conclusions: There was wide variability in requesting patterns and practices for SSTs across Queensland. More than one in six SSTs could have been avoided if a static morning cortisol had been performed prior. Clinician education and the adoption of a structured referral form may improve testing practices. [ABSTRACT FROM AUTHOR]

Purpose: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an integral part of the management algorithm of patients with severe respiratory failure refractory to evidence-based conventional treatments. Right ventricular injury (RVI) pertaining to abnormalities in the dimensions and/or function of the right ventricle (RV) in the context of VV-ECMO significantly influences mortality. However, in the absence of a universally accepted RVI definition and evidence-based guidance for the management of RVI in this very high-risk patient cohort, variations in clinical practice continue to exist. Methods: Following a systematic search of the literature, an international Steering Committee consisting of eight healthcare professionals involved in the management of patients receiving ECMO identified domains and knowledge gaps pertaining to RVI definition and management where the evidence is limited or ambiguous. Using a Delphi process, an international panel of 52 Experts developed Expert position statements in those areas. The process also conferred RV-centric overarching open questions for future research. Consensus was defined as achieved when 70% or more of the Experts agreed or disagreed on a Likert-scale statement or when 80% or more of the Experts agreed on a particular option in multiple‐choice questions. Results: The Delphi process was conducted through four rounds and consensus was achieved on 31 (89%) of 35 statements from which 24 Expert position statements were derived. Expert position statements provided recommendations for RVI nomenclature in the setting of VV-ECMO, a multi-modal diagnostic approach to RVI, the timing and parameters of diagnostic echocardiography, and VV-ECMO settings during RVI assessment and management. Consensus was not reached on RV-protective driving pressure thresholds or the effect of prone positioning on patient-centric outcomes. Conclusion: The proposed definition of RVI in the context of VV-ECMO needs to be validated through a systematic aggregation of data across studies. Until further evidence emerges, the Expert position statements can guide informed decision-making in the management of these patients. [ABSTRACT FROM AUTHOR]

Background: Individuals with disabilities may require specific medications in pregnancy. The prevalence and patterns of medication use, overall and for medications with known teratogenic risks, are largely unknown. Methods: This population-based cohort study in Ontario, Canada, 2004–2021, comprised all recognized pregnancies among individuals eligible for public drug plan coverage. Included were those with a physical (n = 44,136), sensory (n = 13,633), intellectual or developmental (n = 2,446) disability, or multiple disabilities (n = 5,064), compared with those without a disability (n = 299,944). Prescription medication use in pregnancy, overall and by type, was described. Modified Poisson regression generated relative risks (aRR) for the use of medications with known teratogenic risks and use of ≥2 and ≥5 medications concurrently in pregnancy, comparing those with versus without a disability, adjusting for sociodemographic and clinical factors. Results: Medication use in pregnancy was more common in people with intellectual or developmental (82.1%), multiple (80.4%), physical (73.9%), and sensory (71.9%) disabilities, than in those with no known disability (67.4%). Compared with those without a disability (5.7%), teratogenic medication use in pregnancy was especially higher in people with multiple disabilities (14.2%; aRR 2.03, 95% confidence interval [CI]: 1.88–2.20). Furthermore, compared with people without a disability (3.2%), the use of ≥5 medications concurrently was more common in those with multiple disabilities (13.4%; aRR 2.21, 95% CI: 2.02–2.41) and an intellectual or developmental disability (9.3%; aRR 2.13, 95% CI: 1.86–2.45). Interpretation: Among people with disabilities, medication use in pregnancy is prevalent, especially for potentially teratogenic medications and polypharmacy, highlighting the need for preconception counseling/monitoring to reduce medication-related harm in pregnancy. [ABSTRACT FROM AUTHOR]

Background: Antipsychotic prescribing in United States nursing homes (NHs) has decreased since the Center for Medicare & Medicaid Service debuted the National Partnership to Improve Dementia Care in Nursing Homes (NP); however, reductions have stalled. To help explain persistent antipsychotic use despite the NP's reduction efforts, the perspectives of diverse NP stakeholders were qualitatively assessed. This study aimed to re‐evaluate these individual perspectives in combined thematic synthesis to discover NP improvement opportunities undetectable in single stakeholder assessments. Methods: Thematic synthesis. Through immersive crystallisation, original source coding results were organised into related descriptive themes. Similarities and differences were identified, and descriptive themes were regrouped into new, increasingly abstract, analytical themes. This cycle continued until variances were resolved and analytic themes sufficiently described and explained all initial descriptive themes. Results: Three analytic themes emerged regarding NP improvement opportunities. The NP's positive impacts would be augmented by: (i) a deeper and expanded appreciation of stakeholder perspectives; (ii) more urgent and rapid adaptation to unintended adverse outcomes; and (iii) greater recognition of the contextual and environmental factors influencing decisions to prescribe or not prescribe antipsychotic medications. Stakeholder groups described: perspectives they perceived as inadequately considered by the NP; insufficient NP engagement with the stakeholders capable of creating evidenced, affordable, and available non‐pharmacologic therapies for dementia symptoms; recognition that dementia interventions effective for a specific individual at a specific time in a specific community may not generalise; and diverse ongoing undesirable outcomes from NP policies that could be mitigated by NP modifications. Conclusions: The NP has done much to advance dementia care in NHs. Notwithstanding, these results suggest the NP would only be improved through increasingly comprehensive inclusion of stakeholder perspectives, enhanced incorporation of individual contextual factors, and a more decisive mechanism for ongoing and continual adaptation. [ABSTRACT FROM AUTHOR]

The article discusses research which examined the effects of policy interventions on psychotropics polypharmacy among Japanese older adults. The study determined the proportion of patients prescribed with psychotropics, antidepressants, antipsychotics, hypnotics and anxiolytics. Study limitations include the use of the DeSC Healthcare Inc. database, estimated number of patients who switched medications, and impact of the coronavirus pandemic.

Background: Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system. Methods: A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed. Results: From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8–57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20–91% between individual surgeons (p < 0.001). Conclusion: Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals. [ABSTRACT FROM AUTHOR]

Background: Ambulatory Blood Pressure Monitoring (ABPM) is recommended for diagnosis and management of hypertension. We aimed to identify characteristics associated with physician action after receipt of abnormal findings. Methods: This was a retrospective cross-sectional analysis of patients 5–22 years old who underwent 24-h ABPM between 2003–2022, met criteria for masked or ambulatory hypertension, and had a pediatric nephrology clinic visit within 2 weeks of ABPM. "Action" was defined as medication change/initiation, lifestyle or adherence counseling, evaluation ordered, or interpretation with no change. Characteristics of children with/without 1 or more actions were compared using Student t-tests and Chi-square. Regression analyses explored the independent association of patient characteristics with physician action. Results: 115 patients with masked (n = 53) and ambulatory (n = 62) hypertension were included: mean age 13.0 years, 48% female, 38% Black race, 21% with chronic kidney disease, and 25% overweight/obesity. 97 (84%) encounters had a documented physician action. Medication change (52%), evaluation ordered (40%), and prescribed lifestyle change (35%) were the most common actions. Adherence counseling for medication and lifestyle recommendations were documented in 3% of encounters. 24-h, wake SBP load, and sleep DBP load were significantly higher among those with physician action. Patients with > 1 action had greater adiposity, SBP, and dipping. Neither age, obesity, nor kidney disease were independently associated with physician action. Conclusions: While most abnormal ABPMs were acted upon, 16% did not have a documented action. Greater BP load was one of the few characteristics associated with physician action. Of potential actions, adherence counseling was underutilized. [ABSTRACT FROM AUTHOR]

It is critical that clinical social workers become actively aware of the endemic processes and manifestations of racism, social inequities, structures and dynamics of white supremacy within and across organizational, supervisory and clinical relationships. The Structural-Clinical Model (SCM) is presented, providing a multi-layered and theoretically rich pathway for clinical social workers to examine the intricate, and multifaceted interconnections expressing racialized oppressive forces across macro, meso and micro systems that impact the totality of clinical practice. SCM integrates critical race theory, liberation psychology, and relational theories bridging long standing theoretical and conceptual divides. The SCM aims to de-pathologize clients, recognizing instead the pathology of white supremacy, racism, and other oppressive structural forces affecting organizations, relationships and people's lives, particularly those most racially, ethnically and historically marginalized within our society. The SCM is introduced with a structural assessment framework designed to explore how structural social inequalities produced by white supremacy impact social work organizations, the clinical supervisory relationship and the supervisor-therapist-client relationship. A multilevel case example is provided to demonstrate how structural power dynamics that influence service delivery can be identified through critical dialogue using the SCM in the clinical supervisory relationship and between the clinical social worker and client. [ABSTRACT FROM AUTHOR]

Background: Heart failure (HF) is a pervasive global health concern, with acute decompensated heart failure (ADHF) contributing significantly to morbidity and mortality. Medications used in patients with HF may exacerbate HF or prolong the QT interval, posing additional risks. Objective: The objective is to assess the prevalence and utilization patterns of medications known to cause or exacerbate HF and prolong the QT interval among patients with ADHF. Understanding these patterns is crucial for optimizing patient care and minimizing potential risks. Methods: A retrospective chart review was conducted at Huntsville Hospital, Huntsville, USA, covering 602 patients with ADHF over a 40-month period. Inclusion criteria involved age ≥ 18 years, a history of HF, and ADHF admission. The 2016 American Heart Association Scientific Statement was used to identify drugs that may cause or exacerbate HF and those that could prolong the QT interval Results: Among the 602 patients, 57.3% received medications causing or exacerbating HF, notably albuterol (34.9%) and diabetes medications (20.4%), primarily metformin, followed by urologic agents (14.3%), mostly tamsulosin, and nonsteroidal anti-inflammatory drugs (NSAIDs) (6.1%). Moreover, 82.9% were on medications prolonging the QT interval, with loop diuretics, amiodarone, ondansetron, and famotidine most prevalent. Furthermore, 42.1% of the patients received more than two concomitant medications that prolong the QT interval, which can further exacerbate the risk of torsades de pointes. Conclusion: This study underscores the high prevalence of HF-causing or HF-exacerbating medications and QT-prolonging drugs in patients with ADHF. Healthcare professionals must be cognizant of these patterns, advocating for safer prescribing practices to optimize patient outcomes and reduce the burden of HF-related hospitalizations. [ABSTRACT FROM AUTHOR]

Research on Open Science practices in Health Psychology is lacking. This meta-research study aimed to identify research question priorities and obtain consensus on the Top 5 prioritised research questions for Open Science in Health Psychology. An international Delphi consensus study was conducted. Twenty-three experts in Open Science and Health Psychology within the European Health Psychology Society (EHPS) suggested research question priorities to create a 'long-list' of items (Phase 1). Forty-three EHPS members rated the importance of these items, ranked their top five and suggested their own additional items (Phase 2). Twenty-four EHPS members received feedback on Phase 2 responses and then re-rated and re-ranked their top five research questions (Phase 3). The top five ranked research question priorities were: 1. 'To what extent are Open Science behaviours currently practised in Health Psychology?', 2. 'How can we maximise the usefulness of Open Data and Open Code resources?', 3. 'How can Open Data be increased within Health Psychology?', 4. 'What interventions are effective for increasing the adoption of Open Science in Health Psychology?' and 5. 'How can we increase free Open Access publishing in Health Psychology?'. Funding and resources should prioritise the research questions identified here. [ABSTRACT FROM AUTHOR]

Purpose This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2021 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring, and monitoring/medication reconciliation. Articles evaluating at least one step of the MUP were assessed for their usefulness toward practice improvement. Summary A PubMed search was conducted in January 2022 for articles published in calendar year 2021 using targeted Medical Subject Headings (MeSH) keywords, and searches of the table of contents of selected pharmacy journals were conducted, providing a total of 7,178 articles. A thorough review identified 79 potentially practice-enhancing articles: 15 for prescribing/transcribing, 17 for dispensing, 4 for administration, 21 for monitoring, and 22 for monitoring/medication reconciliation. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of their importance within health-system pharmacy. The other articles are listed for further review and evaluation. Conclusion It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful publications. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level. [ABSTRACT FROM AUTHOR]

Background: We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. Methods: We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner‐ and hospital‐level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. Results: Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient‐level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8–1066.7) and third−/fourth‐degree perineal laceration (aOR 25.7, 95% CI 17.4–37.9). Receiving care from a certified nurse‐midwife (aOR 0.63, 95% CI 0.48–0.82) or family medicine physician (aOR 0.60, 95%CI 0.39–0.91) was associated with lower prescribing rates. Hospital‐level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61–15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15–0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). Discussion: Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner‐ and hospital‐level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms. [ABSTRACT FROM AUTHOR]

Background: There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years. Objective: To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors. Design and setting: A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006–2014. The data were divided into three 3-year periods. Subjects: The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group. Main outcome measures: For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics. Results: The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days. Conclusion: Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship. KEY POINTS: High prescribers used antibiotics at lower CRP levels and were more likely to identify a potential bacterial diagnosis. Many physicians reduced their antibiotic prescribing during the study period. Nine out of ten low prescribers remained low prescribers. Seeing a low-prescribing physician did not lead to more return visits or antibiotic changes. [ABSTRACT FROM AUTHOR]

BACKGROUND: This project aims to characterize the extent and nature of impostor phenomenon (IP) among women surgeons in Canada. IP is well documented among medical professionals and trainees. It is known to have significant impacts on mental health and career trajectory. STUDY DESIGN: We conducted a cross-sectional survey of self-identifying women who have completed a surgical residency and currently or most recently practiced in Canada. RESULTS: Among 387 respondents, 98.7% have experienced IP. Median IP score corresponded to frequent impostor feelings or high impostorism. Self-doubt affects most women surgeons for the first time during training. It tends to be most intense in the first 5 years of practice and lessens over time. One hundred twelve (31.5%) surgeons experience self-doubt in the operating room (OR). Due to self-doubt, 110 (28.4%) respondents preferred to work with a more experienced assistant in the OR, whereas 40 (10.4%) stated that they would only operate with an experienced assistant. Few surgeons take on less OR time due to self-doubt (29 [7.5%]), but 60 (16.5%) take on fewer complex cases due to self-doubt. A small but important number of surgeons (11 [2.8%]) had given up operating altogether due to self-doubt. Due to feelings of self-doubt, 107 (21.4%) respondents were hesitant to take on a leadership role in the workplace. CONCLUSIONS: IP is a nearly universal experience among women surgeons and is influential in their professional lives. This study contributes to scientific knowledge that can advance gender equity in medicine and leadership. [ABSTRACT FROM AUTHOR]

BACKGROUND: Misuse of prescription opioids is a well-established contributor to the US opioid epidemic. The primary objective of this study was to identify which level of care delivery (ie patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures. STUDY DESIGN: Electronic health record data from a large multihospital healthcare system were used in conjunction with random-effect models to examine variation in opioid prescribing practices after similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation. RESULTS: Among 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5 mg oxycodone tablets after surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic Black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider. CONCLUSIONS: Given the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing. [ABSTRACT FROM AUTHOR]

Rationale: Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication. Aims and Objectives: In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart. Methods: We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review. Results: There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%−57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry. Conclusion: The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication. [ABSTRACT FROM AUTHOR]

Rationale: This study presents the first comprehensive analysis and mapping of scientific research on point‐of‐care testing (POCT) in infectious diseases, filling a gap in understanding the evolving landscape of this field. The identification of research themes and global contributions offers valuable insights. Aims and Objectives: This manuscript aims to analyse and map scientific research on POCT in the context of infectious diseases. Methods: The study employed a comprehensive search strategy using terms related to POCT and infectious diseases. The search was conducted on the Scopus database, refining results based on inclusion and exclusion criteria. The dataset of 1719 research articles was then subjected to descriptive analysis and mapping using VOSviewer. Results: The research findings indicate an exponential growth in POCT‐related publications, with 46.8% published post the COVID‐19 pandemic. Plos One journal led in publication frequency, and Biosensors and Bioelectronics received the highest citations per article. North America and Western Europe dominated contributions, with notable participation from China, South Africa, and India. The research landscape revealed the following research themes: detection technologies, human immunodeficiency virus (HIV)/sexually transmitted infection (STI) diagnosis, antibiotic optimisation, and schistosomiasis. Clinical trials focused on antibiotic prescribing, HIV, STIs, and specific infections. The findings suggest a shifting landscape towards POCT, emphasising the need for future planning and investment in healthcare systems. The research identifies areas for future exploration, such as the impact of POCT on antibiotic prescribing and its role in combating infectious diseases in low‐ and middle‐income countries. Conclusion: Implementation of POCT has the potential to revolutionise infectious disease management, improve patient outcomes, and reduce the global burden of diseases. Better public awareness, healthcare team management, and planning for POCT at entry points are crucial for societal benefit. Results demonstrated the evolving role of POCT in infectious disease management and prevention. [ABSTRACT FROM AUTHOR]

Importance: Large educational transitions occur when students enter and exit school or move between grades or divisions within the kindergarten to Grade 12 (K–12) school system. For students with disabilities, the quality of large educational transitions affects academic and postschool outcomes, which is germane to school-based occupational therapists. Objective: To explore the school-based occupational therapy literature to describe the roles of occupational therapists in supporting large educational transitions and to identify relevant terminology. Data Sources: We searched six databases (CINAHL, EMCare, Embase, ERIC, MEDLINE, and PsycINFO) for peer-reviewed publications in English with no date limitations. Study Selection and Data Collection: We included articles focused on children and youth with disabilities and school-based occupational therapy services supporting large transitions within K to 12 education. Using directed content analysis, we reported on publication characteristics, occupational therapy roles, and terminology. Findings: We included 46 publications spanning 37 yr that addressed transitions into school (n = 3), within K to 12 grades or divisions (n = 10), or to exit secondary education (n = 33). Occupational therapists assumed many roles in supporting large transitions, some much more frequently than others; 125 transition terms were used across included articles with few terms explicitly defined. Conclusions and Relevance: School-based occupational therapists' involvement in educational transitions is extensive, with potential for expansion. Consistency in terminology would support future research and practice. Plain-Language Summary: A large educational transition occurs when students move between a school, grade, or division as part of their K to 12 education. For students with disabilities, the quality of a large educational transition affects their academic and postschool outcomes. This review provides an understanding of how school-based occupational therapists support educational transitions for youth with disabilities. The review found that occupational therapists took on many roles, with the potential for expanding their roles. The review also identified 125 transition terms that were used across the literature review and found that few terms were explicitly defined. Consistency in terminology would support future research and expanded occupational therapy practice in this area. This review explored literature to describe school-based occupational therapists' roles in supporting students with disabilities who experience large educational transitions. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective Study. Objective: At the North American Spine Society (NASS) conference, participants may influence spine surgery practices and patient care through their contributions. Therefore, their financial conflicts of interest are of notable interest. This study aims to compare the demographics and payments made to participating surgeons. Methods: A list of 151 spine surgeons was created based on those who participated in the 2022 NASS conference. Demographic information was obtained from public physician profiles. General payments, research payments, associated research funding, and ownership interest were collected for each physician. Descriptive statistics and two-tailed t-tests were used. Results: In 2021, 151 spine surgeon participants received industry payments, totaling USD 48 294 115. The top 10% of orthopedic surgeons receiving payments accounted for 58.7% of total orthopedic general value, while the top 10% of neurosurgeons accounted for 70.1%. There was no significant difference between these groups' general payment amounts. Surgeons with 21-30 years of experience received the most general funding. There was no difference in funding between surgeons in academic or private settings. For all surgeons, royalties accounted for the largest percentage of the general value exchanged, while food/beverage accounted for the largest percentage of transactions. Conclusion: Our study found that only years of experience had a positive association with general payments, and most monetary value belonged to a small handful of surgeons. These participants receiving significant money may promote techniques requiring products of companies providing their compensation. Future conferences may require disclosure policy changes so attendees understand the degree of funding participants receive. [ABSTRACT FROM AUTHOR]

BACKGROUND: Firearm injuries (FI) remain a significant cause of morbidity and mortality globally. Antibiotic use, supported by guideline recommendations for preventing post-injury infections in FI cases, encounters uncertainties regarding the selection of antimicrobial agents and associated outcomes. This study aimed to investigate the relationship between Injury Severity Scores (ISS) for FI cases presented to the emergency department. METHODS: We empirically revised antimicrobial treatment protocols based on culture results and mortality rates. In the study, 164 firearm injury cases, admitted to the emergency department in 2022 and subsequently hospitalized in clinics and intensive care units (ICU), were evaluated. Cases included in the study were categorized into four groups based on ISS: mild, moderate, severe, and profound injury severity. The study compared the timing of hospital presentation following the injury, hospital length of stay, tissue or blood culture positivity, empirical treatment administered, antimicrobial revision based on culture results, need for ICU admission, mortality status, and ISS among the cases. Data were analyzed using IBM SPSS Statistics 22.0 (SPSS Inc., Chicago, IL). Variables in trauma patients were compared among various groups using Pearson Chi-Square tests. Binary logistic regression tests were performed to identify independent risk factors. A significance level of p<0.05 was considered statistically significant. RESULTS: The study included 164 patients, all of whom were male. The mean age was calculated as 28.9±4.51 years. The average hospital length of stay was 25.54±21.81 days. Eighty-three patients (50.6%) required intensive care. Tissue cultures were obtained from 79 patients (48%). Bacterial growth was observed in 45 of these 79 patients (57%). The appropriate empirical antibiotic treatment rate, assessed among patients who received empirical treatment followed by culture-based antibiotic sensitivity testing, was 48.9%. It was observed that empirical antibiotic regimens were appropriate in 80% of cases in the mild group and 16.7% in the profound severe group (p=0.005). Our study compared the relationship between hospitalization duration and ISS groups. It was observed that hospitalization duration was significantly shorter in the mild group compared to the other groups (p=0.003, p=0.000, p=0.000). It was also observed that the need for ICU admission was higher in groups with higher ISS, indicating a correlation between higher ISS and increased ICU requirements (p=0.000). CONCLUSION: In conclusion, for cases of firearm injuries, we believe empirical antimicrobial therapy should be initiated with narrow-spectrum agents such as beta-lactam + beta-lactamase inhibitor or third-generation cephalosporin + nitroimidazole in the mild group, considering the lack of Pseudomonal activity. [ABSTRACT FROM AUTHOR]

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The introduction of the Initial Education and Training Standards for Pharmacists reforms outlined that trainee pharmacists will be able to qualify as independent prescribers (IPs) on registration from 2026. To enable this transformation, sufficient numbers of designated prescribing practitioners (DPPs) are required to supervise the IP element of their training. A regional survey identified 12 DPPs, which highlights a potential workforce challenge. This study expanded on the findings of the survey, aiming to explore the experiences of DPPs to understand how to increase capacity and inform the next steps towards implementing the reforms. In a descriptive, qualitative study, a series of two focus groups were conducted with DPPs and a chief pharmacist. Training and funding of DPPs was reported as the key enabler to increasing capacity whilst time constraints was the most significant barrier. Cross-sector supervision was considered possible provided there was time and funding. NHS England Workforce, Transformation and Education Directorate (NHSE WT&E) are a national organisation leading on this work stream and should consider targeting some of the immediate enablers (training and funding) and barriers (time) as identified from this study to increase DPP capacity in preparation for 2026. NHSE WT&E should consider developing plans to address other important themes identified such as whether DPPs can provide supervision cross-sector supervision as well as funding showing that the themes identified do not exist in isolation but intricately linked to one another. [ABSTRACT FROM AUTHOR]

As the population ages, understanding the unique pharmacokinetic profiles of older adults is crucial for effective and safe medication management. This article provides an overview of the pharmacokinetic changes that occur with ageing, including alterations in absorption, distribution, metabolism, and excretion. Emphasising the implications for prescribing practice, the article highlights common challenges and strategies for optimising pharmacotherapy in older patients. By recognising the physiological changes and potential drug interactions, healthcare providers can tailor their prescribing practices to improve therapeutic outcomes and minimise adverse effects in this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Increases in migration patterns in the recent years have led to a continuously growing number of unaccompanied foreign minors (UFMs) entering Italy. As part of processing and integration, age assessment is performed by pediatricians upon request of regulatory bodies. Updated guidelines for age estimation procedures were published in 2020 in order to prioritize the well-being of the minors and the accuracy of the assessment. Nonetheless, literature suggests that the recently established multidisciplinary approach has not yet been widely adopted by physicians. Methods: A cross-sectional exploratory survey was distributed to pediatricians in Italy in order to gauge their range of experience with UFMs and age assessment protocols. Results: In total 344 pediatricians participated in the survey, originating from varied regions in Italy. Out of pediatricians who reported conducting age assessment procedures (38.9%), only a small fraction (14.2%) confirmed being knowledgeable about the methodology. Instead, a significant portion (28.8% and 56.4%) either had partial awareness or lacked knowledge of these procedures. These responses significantly differed when comparing hospital and outpatient pediatricians or according to their geographical area of work (p <0.05). Conclusion: Survey responses suggest that a gap in awareness and experience regarding a multidisciplinary approach to age estimations still exists, likely in part due to a lack of resources, especially at the regional level. In the future, efforts towards the education of professionals and mobilization of resources for investment in the field will be crucial for the improvement of work with UFMs and other migrant populations. [ABSTRACT FROM AUTHOR]

Background: Women with gynecologic disorders requiring a hysterectomy often have co-existing psychiatric diagnoses. A change in the dispensing pattern of antidepressant (AD) and antianxiety (AA) medications around the time of hysterectomy may be due to improvement in gynecologic symptoms, such as pelvic pain and abnormal bleeding, or the emotional impact of the hysterectomy. Unfortunately, these dispensing patterns before and after hysterectomy are currently undescribed. Objectives: To model the dispensing patterns of AD and AA medications over time among women with psychiatric disorders before and after benign hysterectomy for endometriosis and uterine fibroids; and to characterize clusters of patients with various dispensing behaviors based on these patterns. Design: Retrospective cohort study. Methods: This is a study of women who underwent a benign hysterectomy using data from the Merative MarkertScan® Research Databases (Ann Arbor, MI, USA). Inclusion criteria were reproductive-aged women (18–50 years), diagnosis of at least one mood or anxiety disorder, and at least one dispensing of AD or AA medications. We measured monthly adherence and persistence of AD/AA medication use over 12 months after hysterectomy. Group-based-trajectory modeling (GBTM) was used to identify trajectory groups of monthly AD/AA medication dispensing over the study period. Multinomial logistic regression was used to identify factors independently associated with individual dispensing trajectory patterns. Results: For a total of 11,607 patients, 6 dispensing trajectory groups were identified during the study period: continuously high (27.0%), continuously moderate (21.9%), continuously low (17.9%), low-to-high (10.0%), moderate-to-low (9.8%), and low-to-moderate (13.4%). Compared with the continuously high group, younger age, no history of a mood disorder, and uterine fibroids were clinical predictors of low dispensing. The discontinuation rate at 3 months after hysterectomy was higher at 88.6% in the continuously low group and at 66.5% in the continuously low-to-moderate group. Conclusions: This study demonstrates that GBTM identified six distinct trajectories of AD/AA medication dispensing in the perioperative period. Trajectory models could be used to identify specific dispensing patterns for targeting interventions. Plain language summary: Dispensing patterns of antidepressant and antianxiety medications for psychiatric disorders after benign hysterectomy in reproductive-aged women: Results from the group-based trajectory modeling Women with gynecologic disorders often have coexisting psychiatric diagnoses. A change in the dispensing pattern of antidepressant and antianxiety medications may be due to improvement in gynecologic symptoms or the emotional impact of the hysterectomy. However, static measures, such as the proportion of days covered or medication possession ratio, may not adequately predict meaningful dispensing patterns. Using the group-based trajectory modeling, 6 distinct patterns of medication dispensing over the perioperative periods of women with benign hysterectomy are identified and therefore used to assess how certain clinical characteristics influence these dispensing patterns. This study concludes that trajectory modeling may be a more appropriate approach to investigating dispensing patterns among women with preexisting psychiatric conditions. [ABSTRACT FROM AUTHOR]

Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients. [ABSTRACT FROM AUTHOR]

Simple Summary: This study investigated whether certain features of appendiceal neuroendocrine tumors, beyond tumor size, can help predict the risk of lymph node invasion. We reviewed over 5000 cases from a national cancer database and found that in addition to the size of the tumor, lymphovascular invasion is a very strong risk predictor. Interestingly, we discovered that the growth of the tumor into deeper layers, which is usually considered a critical factor in evaluating small tumors, did not significantly affect the risk of lymph node invasion. This study aims to refine how we assess the risk of local spreading, encouraging a more tailored surgical approach, which could prevent unnecessary procedures and better focus on what is truly necessary for patient care. This study aimed to evaluate the role of pathological features beyond tumor size in the risk of lymph node metastasis in appendiceal neuroendocrine tumors. Analyzing data from the national cancer database, we found that among 5353 cases, 18.8% had lymph node metastasis. Focusing on tumors smaller than 2 cm, a subject of considerable debate in treatment strategies, we identified lymphovascular invasion as one of the strongest predictors of lymph node disease. Interestingly, extension into the subserosa and beyond, a current factor in the staging system, was not a strong predictor. These findings suggest that careful interpretation of pathological features is needed when selecting therapeutic approaches using current staging systems. [ABSTRACT FROM AUTHOR]

Background Coronavirus disease 2019 (COVID-19) vaccination has been associated with reduced outpatient antibiotic prescribing among older adults with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We assessed the impact of COVID-19 vaccination on outpatient antibiotic prescribing in the broader population of older adults, regardless of SARS-CoV-2 infection status. Methods We included adults aged ≥65 years who received their first, second, and/or third COVID-19 vaccine dose from December 2020 to December 2022. We used a self-controlled risk-interval design and included cases who received an antibiotic prescription 2–6 weeks before vaccination (pre-vaccination or control interval) or after vaccination (post-vaccination or risk interval). We used conditional logistic regression to estimate the odds of being prescribed (1) any antibiotic, (2) a typical "respiratory" infection antibiotic, or (3) a typical "urinary tract" infection antibiotic (negative control) in the post-vaccination interval versus the pre-vaccination interval. We accounted for temporal changes in antibiotic prescribing using background monthly antibiotic prescribing counts. Results 469 923 vaccine doses met inclusion criteria. The odds of receiving any antibiotic or a respiratory antibiotic prescription were lower in the post-vaccination versus pre-vaccination interval (aOR,.973; 95% CI,.968–.978; aOR,.961; 95% CI,.953–.968, respectively). There was no association between vaccination and urinary antibiotic prescriptions (aOR,.996; 95% CI,.987–1.006). Periods with high (>10%) versus low (<5%) SARS-CoV-2 test positivity demonstrated greater reductions in antibiotic prescribing (aOR,.875; 95% CI,.845–.905; aOR,.996; 95% CI,.989–1.003, respectively). Conclusions COVID-19 vaccination was associated with reduced outpatient antibiotic prescribing in older adults, especially during periods of high SARS-CoV-2 circulation. [ABSTRACT FROM AUTHOR]

In a retrospective, ecological analysis of US medical claims, visit rates explained more of the geographic variation in outpatient antibiotic prescribing rates than per-visit prescribing. Efforts to reduce antibiotic use may benefit from addressing the factors that drive higher rates of outpatient visits, in addition to continued focus on stewardship. [ABSTRACT FROM AUTHOR]

Purpose We describe the implementation and ongoing maintenance of CYP2C19 and CYP2D6 focused pharmacogenetic (PGx) testing to guide antidepressant and antianxiety medication prescriptions in a large rural, nonprofit health system. Summary Depression and anxiety are common psychiatric conditions. Sanford Health implemented PGx testing for metabolism of cytochrome P450 (CYP) isozymes 2C19 and 2D6 in 2014 to inform prescribing for multiple medications, including antidepressant and antianxiety therapies. As guidelines, genotype to phenotype translation, panel offerings, and other resources are updated, we adapt our approach. We make educational and informational materials available to providers and patients. Pharmacogenomic clinical pharmacists review PGx results with discrete values and provide guidance documentation in the electronic medical record. A robust clinical decision support system is in place to provide interruptive alerts, noninterruptive alerts, and genomic indicators. A referral-based interdisciplinary clinic is also available to provide in-depth education to patients regarding PGx results and implications. Additionally, partnering with our health plan has expanded access to PGx testing for patients with anxiety or depression. Conclusion The implementation and maintenance of Sanford Health's PGx program to guide antidepressant and antianxiety medication use continues to evolve and requires a multipronged approach relying on both human and informatics-based resources. [ABSTRACT FROM AUTHOR]

(1) Background: The escalating use of opioids contributes to social, health, and economic crises. In Spain, a notable surge in the medical prescription of opioids in recent years has been observed. The aim of this work was to assess the consumption rate of fentanyl, categorised by the different administration routes, in Primary Care in the province of Salamanca (Spain) spanning the years 2011 to 2022, and to compare it with the national trend and with data from the US. (2) Methods: Doses per inhabitant per day (DHD) were calculated, and interannual variations, as well as consumption rates, were subject to thorough analysis. (3) Results: The prevalence of fentanyl use in Salamanca has doubled from 1.21 DHD in 2011 to 2.56 DHD in 2022, with the transdermal system (TD) as the predominant administration route. This upward trajectory mirrors the national trend, yet the rise in fentanyl use is markedly lower than the reported data in the US. This finding may be attributed to an ageing population and potentially inappropriate fentanyl prescriptions, i.e., for the management of chronic non-cancer pain and other off-label prescriptions. (4) Conclusions: The use of fentanyl in Salamanca, particularly through transdermal systems, doubled from 2011 to 2022, aligning with the national trend. Preventive measures are imperative to prevent fentanyl misuse and moderate the observed escalation in consumption rates. [ABSTRACT FROM AUTHOR]

Introduction: Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA. Materials and Methods: This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models. Results: The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants. Discussion: Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures. Conclusions: Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing. [ABSTRACT FROM AUTHOR]

Background: Misuse and overuse of antibiotics comprise leading causes of antimicrobial resistance. The study aims to assess the pattern of antibiotic prescription among primary healthcare general practitioners in the South Batinah Governorate of Oman. Method: A cross-sectional study of 600 antibiotic prescriptions issued in the South Batinah Governorate in 2019 was conducted to verify the triggering diagnoses and determine the appropriateness of the prescribed antibiotic. Logistic regression analysis was used to determine the association between predictors and inappropriate use. Results: Respiratory infections accounted for 62% of antibiotic prescriptions, of which 92.2% were inappropriately prescribed. Extended-spectrum antibiotics were inappropriately prescribed in 33.3% of cystitis cases, while 14.3% of gastroenteritis received incorrect spectrum of antibiotics. Amoxicillin represented 46.2% of antibiotic prescriptions, of which 84.4% were unnecessarily prescribed. Lower inappropriate antibiotic prescribing rate was linked to patients ≥ 18 years (OR = 0.46, 95% CI: [0.26, 0.82]), those who underwent laboratory tests (OR = 0.22, 95% CI: [0.12, 0.39]), and consultations at health centers (OR = 0.44, 95% CI: [0.24, 0.79]). Arabic-speaking physicians were more likely to prescribe antibiotics inappropriately. Conclusion: Inappropriate antibiotic prescription was frequently observed in mild respiratory infections and associated with specific patient and physician characteristics. Appropriateness of antibiotic prescriptions issued can be improved through enhanced testing capacities as well as implementation of physician and community awareness campaigns. Highlights: • Inappropriate prescriptions were common among respiratory symptoms. • Amoxicillin was the most common antibiotic prescribed inappropriately. • Laboratory–tested patients were less likely to receive inappropriate antibiotics. • Inappropriate antibiotics were commonly prescribed by Arabic-speaking physicians. • Health centers' primary care physicians rarely prescribe inappropriate antibiotics. [ABSTRACT FROM AUTHOR]