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To assess the prevalence and potential risk factors for polypharmacy and prescribing of the potentially inappropriate medications, opioids and benzodiazepines/Z-drugs, in older adults with systemic lupus erythematosus (SLE).The study population comprised adults age ≥50 years meeting American College of Rheumatology or Systemic Lupus International Collaborating Clinics classification criteria followed at a tertiary care rheumatology clinic. Information on prescriptions filled in the 4 months preceding chart review was obtained from the Manitoba Drug Program Information Network. Clinical data, including age, sex, Charlson Comorbidity Index (CCI) score, Systemic Lupus Erythematosus Disease Activity Index 2000 score, prednisone use, SLE duration, and rural residence were abstracted from electronic medical records. Logistic regression analyses were performed to assess any association between polypharmacy (using 2 definitions: ≥5 and ≥10 medications), potentially inappropriate medication use, and clinical features.A total of 206 patients (mean age 62 years, 91% female, 36% rural) were included: 148 (72%) filled ≥5 medications, 71 (35%) filled ≥10 medications, 63 (31%) used benzodiazepines/Z-drugs, and 50 (24%) used opioids. Among the 77 patients age ≥65 years, 57 (74%) filled ≥5 medications, and 26 (34%) filled ≥10 medications, compared to 30% and 4%, respectively, of Manitobans age ≥65 years (National Prescription Drug Utilization Information System, 2016). The odds of polypharmacy were greater with prednisone use (adjusted odds ratio [OR] 3.70 [95% confidence interval (95% CI) 1.40-9.79] for ≥5 medications), CCI score (adjusted OR 1.62 [95% CI 1.20-2.17]), and rural residence (adjusted OR 2.05 [95% CI 1.01-4.18]). Odds of benzodiazepine/Z-drug use were increased with polypharmacy (adjusted OR 4.35 [95% CI 1.69-11.22]), and odds of opioid use were increased with polypharmacy (adjusted OR 6.75 [95% CI 1.93-23.69]) and CCI score (adjusted OR 1.29 [95% CI 1.08-1.54]).The prevalence of polypharmacy in this SLE cohort was higher than in the general Manitoban population. Polypharmacy is a strong marker for use of prescription benzodiazepines/Z-drugs and opioids.

Introduction: As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. Methods: In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. Results: Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p = 0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. Conclusion: Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.

Long-term treatment with warfarin is recommended for patients with atrial fibrillation at risk of stroke and those with recurrent venous thrombosis or prosthetic heart valves. Patient education before commencing warfarin − regarding signs and symptoms of bleeding, the impact of diet, potential drug interactions and the actions to take if a dose is missed − is pivotal to successful use. Scoring systems such as the CHADS2 score are used to determine if patients with atrial fibrillation are suitable for warfarin treatment. To rapidly achieve stable anticoagulation, use an age-adjusted protocol for starting warfarin. Regular monitoring of the anticoagulant effect is required. Evidence suggests that patients who self-monitor using point-of-care testing have better outcomes than other patients.

PurposeThis study furthers one’s understanding of the motivations of the crowdfunding crowd by empirically examining critical factors that influence the crowd's decision to support a crowdfunding project.Design/methodology/approachBacker's comments from a sample of the top 100 most funded technology product projects on KickStarter were collected. A latent Dirichlet allocation (LDA) analysis strategy was adopted to investigate critical motivational factors. Three experts mapped those factors to the known theoretical constructs of social exchange theory (SET).FindingsAlthough backers are motivated by value, they are also motivated by far less tangible social factors including trust and a feeling of psychological ownership. Findings suggest that the crowd is far more than a passive group of investors or customers and should be viewed as participatory stakeholders. This study serves as guidance for project owners hoping to motivate the crowd and for future investigators examining backer motivations in other types of crowdsourcing projects.Research limitations/implicationsOnline chatter in the form of user-generated comments is an excellent data source for researchers to mine for value and meaning.Practical implicationsGiven strong feelings of psychological ownership, project owners should actively engage the crowd and solicit the crowd for advice and help in order to motivate them.Originality/valueThe study presents the first empirical exploration of backer motivations using LDA guided by theory and the knowledge of experts. A framework of latent motivational factors is proposed.

Purpose: This study provides a contemporary assessment of the treatment patterns, health care resource utilization (HRU) and costs among metastatic castration-sensitive prostate cancer (mCSPC) patients in the U.S. Materials and Methods: Adults with mCSPC were selected from Optum's de-identified Clinformatics® Data Mart Database (Commercial insurance/Medicare Advantage [COM/MA]; January 1, 2014–July 31, 2019) or Medicare Fee-for-Service (FFS; January 1, 2014–December 31, 2017). The index date was the first metastatic disease diagnosis date on/after the first prostate cancer diagnosis (without prior evidence of castration resistance). Patients were observed for 12 months pre-index (baseline) through their mCSPC period (from index until castration resistance or followup end). First-line (1L) mCSPC therapy was assessed during the mCSPC period; all-cause HRU and health plan-paid costs per-patient-per-year (PPPY) were measured during baseline and mCSPC periods. Results: Among 6,517 COM/MA and 13,324 Medicare-FFS mCSPC patients over ∼10 months (median mCSPC period), 38% and 48% remained untreated/deferred treatment, and 45% and 46% received 1L androgen deprivation therapy (ADT) monotherapy, respectively. 1L abiraterone acetate and docetaxel were used among 7% and 6% of COM/MA and 1% and 2% of Medicare-FFS patients, respectively. HRU increased from baseline to mCSPC period, resulting in increased health plan-paid costs from $21,201 to $108,767 in COM/MA and from $16,819 to $69,639 PPPY in Medicare-FFS. Conclusions: This study highlights the limited use of newer therapies that improve survival in men with mCSPC in the U.S. HRU and costs increased substantially after onset of metastasis. Given the emergence of newer effective mCSPC therapies, further evaluation of future real-world mCSPC treatment patterns and outcomes is warranted.

BACKGROUND More patients are turning to the internet for their health information than ever before. This is a growing problem as it is well recognized that medical information on the internet is highly variable. We assessed the quality of information on the internet regarding the anti-reflux procedure, Nissen Fundoplication. Three commonly used measures of website quality are the Health On the Net code, the Journal of the American Medical Association Benchmark criteria, and the DISCERN tool. The HON code is a seal of approval awarded by an independent organization where the JAMA Benchmark and DISCERN Tool are a set of standards that can be utilized by an internet user or webpage creator. METHODS We performed a Google search using the term "Nissen Fundoplication", where we analyzed the top 75 websites. We included English language websites and excluded advertisements, websites for medical professionals, duplicates, and requiring a login. Each website included was evaluated for presence of the HON seal and scored with the JAMA Benchmark and DISCERN criteria to determine quality. RESULTS Only 16.28% of websites were found to be HON code certified. The average JAMA benchmark score was 1.23, with 9.3% websites scoring the maximum 4 points and 39.53% receiving a score of 0. The average DISCERN score was 34.65 out of a total possible score of 75, where the mean score for the overall quality of the website (question 16) was 2.19 out of a maximal score of 5. CONCLUSION This study, using 3 commonly used validated measures, has found that the quality of online information pertaining to Nissen Fundoplication is sorely lacking. The implications of these results are twofold as an important reference for institutions to update their source material and a guide when providing patients with adequate resources.

Background Calciphylaxis is a rare disorder characterized by skin necrosis caused by calcium deposition within vessels, thrombosis, and subsequent tissue ischemia. Penile involvement may rarely occur. Objective To identify risk factors, diagnosis, management, and mortality of patients with penile calciphylaxis. Methods A retrospective medical record review was conducted of 16 patients with penile calciphylaxis treated at 2 large urban tertiary care centers between January 2001 and December 2019. A control group of 44 male patients with nonpenile calciphylaxis at the same institution was included. Results The median survival of patients with penile calciphylaxis was 3.8 months (interquartile range, 27.0 months). Mortality was 50% at 3 months and 62.5% at 6 months for penile calciphylaxis, and 13.6% at 3 months and 29.5% at 6 months for controls (P = .008). Patients with penile calciphylaxis were less likely to be obese (P = .04) but more likely to have hyperparathyroidism (P = .0003) and end-stage renal disease (P = .049). Limitations Retrospective study design and small sample size. Conclusions This study further defines the disease course of penile calciphylaxis, which has high mortality. Imaging may be used to aid diagnosis. Risk factors include end-stage renal disease, hyperparathyroidism, and normal body mass index.

Sustainable growth in the Allied Health Professions (AHP) workforce is an ambition of the United Kingdom’s NHS Long Term Plan. However historically, access to good quality placements has been a barrier to increasing pre-registration training numbers. This article focuses on work carried out by Health Education England (HEE) to gain insights on the impact of the COVID-19 pandemic on capacity. Using a pragmatic, embedded mixed-methods approach, insights were gathered using an online workshop, crowdsourcing, open for two weeks in the summer of 2020. AHP placement stakeholders could vote, share ideas or comment. Descriptive data were extracted, and comments made were analysed using inductive thematic analysis. Participants (N = 1,800) made over 8,500 comments. The themes identified included: diversity of placement opportunity, improved placement coordination, a more joined-up system, supervision models and educator capacity. Alongside considering the challenges to placement capacity, several areas of innovative practice owing to the pandemic were highlighted. Generated insights have shaped the aims and objectives of the Health Education (HEE) pre-registration AHP student practice learning programme for 2020/2021 and beyond. The COVID-19 pandemic has disrupted the delivery of AHP placements. In the absence of face-to-face activities, crowdsourcing provided an online data collection tool offering stakeholders an opportunity to engage with the placement capacity agenda and share learning. Findings have shaped the HEE approach to short-term placement recovery and long-term growth.

Comprehensive education regarding human papillomavirus (HPV) pathogenesis, vaccination, and patient counseling are not routinely included in the medical school curriculum; consequently, student and provider knowledge, especially concerning head and neck pathology, remains low. The objective of this study was to demonstrate long-term retention of HPV knowledge and positive attitudes towards HPV vaccination after attending our novel HPV workshop, with a focus on knowledge of oropharyngeal cancer. A follow-up survey was administered to medical students 1.5 years after the initial completion of the workshop. HPV vaccination records from the student-led clinic were collected from the immunization information system. Awareness that HPV causes oropharyngeal cancer was present in 33% of medical students pre-curriculum; immediate and long-term post-curricular awareness of this association remained at 90% or higher (p

OBJECTIVE/HYPOTHESIS Utilization of flaps for reconstruction of large head and neck cancer (HNCA) defects has become more prevalent. The present study aimed to assess the impact of center experience as measured by annual hospital caseload on mortality, major complications, resource utilization, and 90-day readmissions following HNCA resection with flap reconstruction. STUDY DESIGN Non-Randomized Controlled Cohort Study. METHODS All adult patients undergoing elective HNCA resection with flap reconstruction were identified utilizing the 2010 to 2018 Nationwide Readmissions Database. Hospitals were subsequently classified as low-, medium-, or high-volume based on annual institutional surgical caseload tertiles. Multivariable regression models were implemented to assess the independent association of hospital volume with the outcomes of interest. RESULTS Over the nine-year study period, the proportion of HNCA resection with flap reconstruction gradually increased (12.8% in 2010 vs. 17.3% in 2018, P

The Radiation Therapy Oncology Group 91-11 trial and US Veterans Affairs trial revolutionized the way locally advanced laryngeal cancers are treated. Adjuvant therapies exist aimed toward laryngeal preservation using docetaxel, cisplatin, and fluorouracil. Cetuximab is a cornerstone of treatment due to the large role of epidermal growth factor receptor in laryngeal and hypopharyngeal carcinomas. In addition, the immune system is vital in the prevention of recurrence, and various immunomodulators against programmed cell death receptor 1 are being investigated. Multidisciplinary management of the patient with laryngeal and hypopharyngeal is key, as many vital functions are affected by this devastating disease.

Significant variation in the utilisation of medical tests is known to have an adverse impact on health outcomes and analysis of this variation is an important tool for quality assurance in healthcare. The introduction of a new medical test into a care pathway requires two distinct processes, termed adoption and implementation. One cause of the unwarranted variation in the use of medical tests is poor adoption and implementation. Adoption is the decision to acquire a technology and make it available to the users and is supported with evidence of clinical and cost effectiveness. Implementation is delivering the benefits promised in the business case, based on evidence of the impact of a test on each stakeholder involved in delivering the care pathway. The business case will have identified the benefits delivered to all stakeholders, as set out in a value proposition, and according to the quality domains typically addressed in quality improvement, namely clinical, process and structure (resource utilisation) outcomes. The outcome measures extend beyond those of clinical and cost effectiveness required for adoption. We describe an implementation framework which is designed to document the changes to the care pathway, the resource inputs and the expected outcomes with associated quality metrics.

RATIONALE, AIMS AND OBJECTIVES: The primary purpose of this study was to test both classic and novel FM pain and non-pain symptoms to determine their practical efficacy in aiding clinicians to distinguish FM pain from other chronic pain disorders. METHODS: 158 pain patients from two primary care clinics were evaluated with history, physical exam, chart review, and a questionnaire containing 26 exploratory symptoms (10 from the Symptom Impact Questionnaire (SIQR) and 16 from the FM literature)). The symptoms were rated on a 0-10 VAS for severity by those patients reporting pain over the past week. Somers' D and mean severity differences between FM and chronic pain patients without FM were used to rank the discriminatory and diagnostic contributions of symptoms. RESULTS: Fifty patients (14.2%) carried a chart diagnosis of FM, 108 (30.7%) had pain but not FM, and 192 (54.5%) who had neither pain nor FM. Comparing means between the two pain groups, the 5 best differentiating symptoms (all, P < .0001) were: a persistent deep aching over most of my body, poor balance (7.4 vs 3.1), environmental sensitivity (6.8 vs 3.0), tenderness to touch (6.8 vs 3.6) and pain after exercise (8.1 vs 4.1). Notably, VAS pain though significantly higher for FM was least discriminatory (6.5 vs 5.1, P < .001). The five best symptoms generated a ROC = 0.85 and Somers' D = 0.69, an accuracy of 81%, and an odd's ratio of 14.4. CONCLUSIONS: Our results herein suggest that clinicians may be well-served to consider symptoms in addition to those contained in current diagnostic criteria when recognizing FM in their chronic pain patients.

Background Patients with SARS-CoV-2 infection could develop severe disease requiring critical care admission. Case reports indicated high incidence of hypertriglyceridemia (HTG) in critically ill patients infected with SARS-CoV-2, which might be related to the drugs. Objective We sought to determine the risk factors associated with HTG in this population and to investigate the relationship between HTG and lipase. Methods A retrospective observational study was conducted at our hospital between March 1 and June 30, 2020. Patients were included if they were ≥18 years old, admitted to the intensive care unit (ICU), tested positive for SARS-CoV-2, and had triglycerides (TG) checked during their hospital stay. Results Of the 111 critically ill patients, 103 patients were included. Males comprised 88.3% of the sample. The median TG at baseline was 197.4 (IQR: 139.8-283) mg/dL. The lipase median level at baseline was 23.00 (IQR: 0.00-69.50) IU/L. The results of the mixed-effects logistic regression analysis indicated that patient-level variables, favipiravir use, blood glucose level, and propofol use were significantly associated with HTG. There was no relationship between lipase and TG levels over time. Furthermore, TG concentrations over time showed a similar trend to inflammatory markers. Conclusion and Relevance The incidence of clinically significant HTG was high and was associated with propofol and favipiravir use. HTG might reflect the high inflammatory state in these patients. Clinicians should look at the full picture before changing therapies based only on HTG. Our findings need to be replicated in a larger prospective study.

Background: Successful bariatric surgery involves expertise from a multidisciplinary team. However, compliance with postoperative follow-up is often suboptimal and may impact weight loss. This stud...

Enterprises need to trust that data they share with other enterprises is not exploited maliciously and cause harm. We describe the development and evaluation of a decision support tool for assessing trust in a partner enterprise. The tool is composed of ten statements spanning four well-established organizational trust factors: ability, integrity, benevolence, and vulnerability. Users rate the statements about a partner enterprise and then rate their trust in the partner enterprise. The tool focuses users on these trust factors and mentally prepares them to make the trust rating. As a first evaluation of the tool, participants read 25 statements each about enterprises in three fictional countries and rated their trust without the tool, using only their intuitions. Then they rated three more enterprises while using the tool. The tool led to trust ratings that were significantly closer to the constructed, expected ratings, and participants rated the tool as useful.