Interobserver reproducibility of criteria for vertebral body exclusion.

We studied reproducibility of the ISCD vertebral exclusion criteria among four interpreters. Surprisingly, agreement among interpreters was only moderate, because of differences in threshold for diagnosing focal structural defects and choice of which vertebra among a pair discordant for T-score, area, or BMC to exclude. Our results suggest that reproducibility may be improved by specifically addressing the sources of interobserver disagreement. INTRODUCTION: Although DXA is widely used to measure vertebral BMD, its interpretation is subject to multiple confounders including osteoarthritis, aortic calcification, and scoliosis. In an attempt to standardize interpretation and minimize the impact of artifacts, the International Society for Clinical Densitometry (ISCD) established criteria for vertebral exclusion, including the presence of a focal structural defect (FSD), discrepancy of >1 SD in T-score between adjacent vertebrae, and a lack of increase in BMC or area from L1 to L4. Whereas the efforts of the ISCD represent an important advance in BMD interpretation, the interobserver reproducibility with application of these criteria is unknown. We hypothesized that there would be substantial agreement among four interpreters regarding application of the exclusion criteria and the final lumbar spine T-score. MATERIALS AND METHODS: Each interpreter read a set of 200 lumbar DXA scans obtained on male veterans, applying the ISCD vertebral body exclusion criteria. RESULTS: Surprisingly, agreement among interpreters was only moderate. Differences in interpretation resulted from differing thresholds for recognition of FSD and the choice of excluding the upper or lower vertebral body for the criteria requiring comparison between adjacent vertebrae. CONCLUSIONS: Despite their apparent simplicity, the ISCD vertebral exclusion criteria are difficult to apply consistently. In principle, appropriate refinement of the exclusion criteria may significantly improve interobserver agreement.     

Industry relationships between physicians and professional medical associations: corrupt or essential?

Congress and others have called into question the propriety of relationships between professional medical associations (PMAs) and industry. These relationships are critical to the continued development of new and better devices and procedures for patients. Better guidelines are needed to help guide these relationships. Overrestrictive regulatory oversight risks overconstraint of these relationships and hindrance to medical progress.     

The 15-minute dumping provocation test

Following gastric surgery, the diagnosis of the dumping syndrome (DS) has never been precise. The importance of diagnosis is not only in deciding management, but also in comparing series of incidences. The mainstay of diagnosis has been the gastric emptying and dumping provocation test (DPT); however it requires expensive equipment and the interpretation of the results is subjective and therefore variable. In 38 DPTs the percentage plasma volume and pulse rate changes, 15 min after the ingestion of 150 ml of hypertonic glucose, were expressed as percentages of the maximum values encountered and summed to form a score. The tests were independently interpreted by the authors and where they disagreed the result was defined as equivocal. The score was used with the symptoms provoked to follow a simple algorithm to divide the patients into those with and those without DS. There were six suffering from DS on our current interpretation; the new method identified all of these. Three tests were positive on the scoring scheme only and on review the interpreters agreed that all of these patients were suffering from the dumping syndrome. An accurate test using only the baseline and 15 min samples is simple, cheap and has definite rules of interpretation; the only laboratory measurement needed is the haematocrit estimation of three blood samples.     

The use of single-use devices in anaesthesia: balancing the risks to patient safety

Single-use devices are designed, manufactured and sold to be used once and then discarded. This paper addresses growing concerns about the quality of some devices. Single-use devices, manufactured at a lower cost to justify their disposal, are perceived to have a lesser efficacy, which may threaten patient safety through iatrogenic harm. There is, in addition, growing scepticism about the actual risk of contracting variant Creutzfeldt-Jakob disease and other blood-borne diseases from reused surgical instruments. Interview data suggests that when choosing to use a single-use device, clinicians balance concerns about the risk of infection against those about the risk of injury. However, despite reservations about induced harm and the unknown risk of an iatrogenic disease, most clinicians would want single-use devices used on themselves and their family if they were patients.     

Perioperative management of infant inguinal hernia surgery; a review of the recent literature

Inguinal hernia surgery is one of the most common electively performed surgeries in infants. The common nature of inguinal hernia combined with the high-risk population involving a predominance of preterm infants makes this a particular area of interest for those concerned with their perioperative care. Despite a large volume of literature in the area of infant inguinal hernia surgery, there remains much debate amongst anesthetists, surgeons and neonatologists regarding the optimal perioperative management of these patients. The questions asked by clinicians include; when should the surgery occur, how should the surgery be performed (open or laparoscopic), how should the anesthesia be conducted, including regional versus general anesthesia and airway devices used, and what impact does anesthesia choice have on the developing brain? There is a paucity of evidence in the literature on the concerns, priorities or goals of the parents or caregivers but clearly their opinions do and should matter. In this article we review the current clinical surgical and anesthesia practice and evidence for infants undergoing inguinal hernia surgery to help clinicians answer these questions.     

The effects of a language barrier in a South African district hospital.

BACKGROUND: Communication between health workers and patients at Hottentots Holland Hospital (HHH) is hindered by staff and patients not speaking the same language. HHH is a district hospital in the Cape Town Metropolitan District of the Western Cape where staff mainly speak Afrikaans or English and a large number of patients mainly Xhosa. OBJECTIVES: The study aimed to explore the effects of this language barrier on health workers and patients at HHH. DESIGN: Three focus group interviews were held with 21 members of staff and 5 in-depth patient interviews were conducted. RESULTS: The language barrier was found to interfere with working efficiently, create uncertainty about the accuracy of interpretation, be enhanced by a lack of education or training, cause significant ethical dilemmas, negatively influence the attitudes of patients and staff towards each other, decrease the quality of and satisfaction with care, and cause cross-cultural misunderstandings. CONCLUSION: The effects of the language barrier were considerable and persistent despite an official language policy in the province. The training and employment of professional interpreters as well as teaching of basic Xhosa to staff are recommended.     

DXA Quality Matters

The proliferation of devices to measure bone mineral density (BMD), with large numbers of technologists operating these instruments and numerous physicians interpreting/reporting the results, raises concern regarding the quality of the studies. High quality BMD measurement and reporting is essential, since referring healthcare providers rely on these reports to make patient care decisions that include additional medical evaluation (laboratory or imaging tests), drug therapy (starting, stopping, or changing), and possibly referral to an osteoporosis specialist. Incorrect BMD acquisition or reporting may generate unnecessary medical expenses and result in therapeutic decisions that could be harmful to patients. Contrary to the common misperception that BMD measurement and interpretation is a simple procedure requiring no special expertise, densitometer maintenance/operation, data acquisition, and interpretation/reporting of the results are skills that must be acquired and maintained. We recommend that technologists and clinicians involved with performing or interpreting BMD tests be educated and trained in bone densitometry and that they update their skills regularly. We also suggest that they provide demonstration of proficiency in bone densitometry in order to assure patients, referring healthcare providers, and payers of medical services that these skills have been acquired and maintained.     

Structured evaluation of stress triggers in prehospital emergency medical care

Background

Emergency medical services work in the environment of high responsibility teams and have to act under unpredictable working conditions. Stress occurs and has potential of negative effects on tasks, teamwork, prioritization processes and cognitive control. Stress is not exclusively dictated by the situation—the individuals rate the situation of having the necessary skills that a particular situation demands. There are different occupational groups in the emergency medical services in Germany. Training, tasks and legal framework of these groups vary.

Objective

The aim of this study was to identify professional group-specific stressors for emergency medical services. These stress situations can be used to design skills building tools to enable individuals to cope with these stressors.

Material and methods

The participants were invited to the study via posters and social media. An expert group (minimum 6 months of experience) developed a set of items via a two-step online Delphi survey. The experts were recruited from all professional groups represented in the German emergency medical service. We evaluated the resulting parameters for relevance and validity in a larger collective. Lastly, we identified stress factors that could be grouped in relevant scales. In total 1017 participants (paramedics, physicians) took part in the final validation survey.

Results

After validation, we identified a catalogue of stressors with 7 scales and 25 items for EMT (Emergency Medical Technician) paramedics (KMO [Kayser-Meyer-Olkin criterion] 0.81), 6 scales and 24 items for advanced paramedics (KMO 0.82) and 6 scales and 24 items for EMS (Emergency Medical Service) physicians (KMO 0.82). For the professional group of EMT basic, the quality parameters did not allow further processing of the items.

Professional group-specific scales for EMT paramedics are “professional limitations”, “organizational framework”, “expectations” and “questions of meaning”. For advanced paramedics “appreciation”, “exceptional circumstances” and “legal certainty” were identified. The EMT physicians named “handling third parties”, “tolerance to ambiguity”, “task management” and “pressure to act”. A scale that is representative for all professional groups is “teamwork”. Organizational circumstances occur in all groups. The item “unnecessary missions” for EMT paramedics and “legal concerns with the application of methods” for advanced paramedics are examples.

Discussion

Different stressors are relevant for the individual professional groups in the German emergency medical service. The developed catalogue can be used in the future to evaluate the subjective stress load of emergency service professionals. There are stressors that are inherent in the working environment (e.g. pressure to act) and others that can be improved through training (teamwork). We recommend training of general resistance as well as training of specific items (e.g., technical, nontechnical skills). All professionals mentioned items with respect to organizational factors. The responsible persons can identify potential for improvement based on the legal and organizational items. The EMT basic requires further subdivision according to task areas due to its variable applicability.

     

Humanization in oncology care: A necessary change

Developments in cancer care, automation of care, rationing of time and fragmentation of the work process for institutional imperatives can often lead to the dehumanization of care. Although, it is indisputable that these interventions have significantly improved outcomes in oncology, they may have caused the emotional needs of patients, families, and health professionals to be considered secondary concerns. Therefore, humanized care can help dispel the negative emotions associated with cancer diagnosis and treatment and may even contribute to improve patient outcomes. This empathetic and respectful approach to patients leads to increase patient expectations of recovery, accountability, control over their own health, satisfaction, safer care, patient happiness and healthcare professional resilience, resulting in time and cost savings. The humanization of care has emerged as a response to the needs and concerns of patients and their families that go beyond the biological.     

Men,depression and masculinities: A review and recommendations

Fewer men than women are diagnosed with depression, although commentaries about men's depression suggest that the lower reported rates may be due to the widespread use of generic diagnostic criteria that are not sensitive to depression in men, as well as men's reluctance to express concerns about their mental health or access professional health care services. This article provides an overview of the connections between depression and masculinities and, based on that literature, recommendations are made for how we might better understand, identify and treat men's depression in gender-sensitive ways.     

Inferior vena cava filters for the cerebrovascular patient

Acute cerebrovascular disease is often complicated by deep venous thrombosis and pulmonary embolism. Many of these patients are at high risk of intracranial hemorrhage with therapeutic anticoagulation. These patients may benefit from insertion of inferior vena cava filters. Studies specifically dealing with stroke patients are lacking, but it is the authors' opinion that filters reduce the incidence of pulmonary embolism. There is little evidence to support the use of these devices prophylactically in patients who do not have venous thromboembolism. Retrievable filters are an attractive option but there are concerns about their safety; and if regularly used, a system for successful filter retrieval in all patients should be instituted. The role of concurrent anticoagulation with filters is not clear. However, we believe anticoagulation, in the absence of a contraindication, is beneficial in patients with active venous thromboembolism.     

Psychosocial, socio-cultural, and environmental influences on mental health help-seeking among African-American men

The social determinants unique to African-American men's health contribute to limited access and utilization of health and mental health care services and can have a deleterious effect on their overall health and well-being. There is a need to examine the complex issues concerning African-American men's help-seeking behaviors relative to mental health concerns. Current research estimates that African-American men are approximately 30% more likely to report having a mental illness compared to non-Hispanic Whites and are less likely to receive proper diagnosis and treatment. There is an extensive body of research that supports the view that women are more likely to seek help for psychological problems than African-American men. This review explores the psychosocial, environmental and socio-cultural factors that influence mental health help-seeking behavior among African-American men and explains the urgency to engage various stakeholders to pursue effective behavioral strategies. Research literature concerning the relationships between social determinants of health and their mental health help-seeking behaviors is reviewed and discussed in this paper. The article illustrates the need for mental health providers and researchers to establish feasible, culturally competent prevention and intervention strategies to increase help seeking behavior among African-American men, thereby contributing to the reduction of mental health disparities.     

Management of general surgical problems in patients with left ventricular assist devices

Congestive heart failure (CHF) is a major health issue resulting in significant patient morbidity and mortality. Left ventricular assist devices (LVADs) are becoming an increasingly popular method of treatment for patients with end-stage CHF. As the use of LVADs increases, there is a greater likelihood that some of these patients will live to develop general surgical problems. It is important for general surgeons to be aware of the often complex evaluation and treatment of patients with these problems. We retrospectively reviewed the charts of three patients with LVADs who underwent nonthoracic general surgical procedures. We reviewed duration of LVAD, time from LVAD implantation to operation, type of anesthesia, and any postoperative complications. Three patients with LVADs underwent five nonthoracic general surgical procedures. Anticoagulation was reversed with heparinization in four cases, the fifth case requiring fresh-frozen plasma. There was no perioperative mortality. Two morbidities occurred in separate patients, a wound infection and driveline site infection. These were managed nonoperatively. These patients raise several important concerns. They are often anticoagulated and require reversal. Staff needs to be familiar with these devices, their operation and physiology. The placement of the LVAD imposes limitations on surgical site location that require the surgeon to be prepared, flexible, and often creative.     

Surviving colorectal cancer

About a quarter of a million people in the UK are living with a diagnosis of colorectal cancer. As more patients are being diagnosed and subsequently cured, the demands on currently available follow-up services will increase. We know that cure can come at the cost of bowel, urinary, neurological and sexual problems - most of these issues are underestimated, poorly understood and inadequately managed by clinicians. At this point in time follow-up services neither meet patients’ needs for rehabilitation and support, nor are they the most cost-effective way to pick up treatable recurrence. As part of the survivorship program the diagnosis of cancer can also be an important opportunity to stimulate lifestyle changes to help reduce recurrence rates and improve quality of life. There is now a shift in management of these people with a greater focus on recovery, health and well-being after cancer treatment. Through the National Cancer Survivorship Initiative (NCSI) a model of change addressing these issues has been outlined.     

MRI-related heating near deep brain stimulation electrodes: more data are needed

Magnetic resonance imaging (MRI) of patients with implanted deep brain stimulation (DBS) devices poses a challenge for healthcare providers. As a consequence of safety concerns about magnetic field interactions with the device, induced electrical currents and thermal damage due to radiofrequency heating, a number of stringent guidelines have been proposed by the device manufacturer. Very few detailed investigations of these safety issues have been published to date, and the stringent manufacturer guidelines have gone unchallenged, leading some hospitals and imaging centers around the world to ban or restrict the use of MRI in DBS patients. The purpose of this review is to stimulate research towards defining appropriate guidelines for the use of MRI in patients with DBS. Additionally, this review is intended to help healthcare providers and researchers make sound clinical judgments about the use of MRI in the setting of implanted DBS devices.     

When stress is mental illness: A study of anxiety and depression in employees who use occupational stress counselling schemes

A previous study found that 86 per cent of employees (n = 111) who experience stress in the workplace and sought help from their workplace counselling schemes (Employee Assistance Programmes) had serious mental health problems, but the low participation rate (24 per cent) restricted generalizability and the measure used [General Health Questionnaire (GHQ‐12)] did not allow diagnosis. The present study (n = 58) improved the participation rate to 35 per cent and used a different version of the original measure (GHQ‐28) that allowed diagnostic differentiation as well as validation of the original findings. This new study found almost exactly the same high levels of mental health problems existed (86 per cent) in employees who remained at their work and that participants had higher rates of anxiety than depression. This finding is at variance with the usual co‐morbid presentation of anxiety and depression found in community based mental health services and suggests that depression may be an important differentiating factor between those who can remain at work and use counselling and those who cannot. There are implications for those who provide mental health services. The results of this study further reinforce the suggestion that workplace stress may be yet another name for common mental health problems that require professional help and treatment. Copyright © 2005 John Wiley & Sons, Ltd.     

Development and measurement properties of the Orthotics and Prosthetics Users' Survey (OPUS): a comprehensive set of clinical outcome instruments

The need to measure and evaluate orthotics and prosthetics (O&P) practice has received growing recognition in the past several years. Reliable and valid self-report instruments are needed that can help facilities evaluate patient outcomes. The objective of this project was to develop a set of self-report instruments that assess functional status, quality of life, and satisfaction with devices and services that can be used in an orthotics and prosthetics clinic. Selecting items from a variety of existing instruments, the authors developed and revised four instruments that differentiate patients with varying levels of lower limb function, quality of life, and satisfaction with devices and services. Evidence of construct validity is provided by hierarchies of item difficulty that are consistent with clinical experience. For example, with the lower limb function instrument, running one block was much more difficult than walking indoors. The instruments demonstrate adequate internal consistency (0.88 for lower limb function, 0.88 for quality of life, 0.74 for service satisfaction, 0.78 for device satisfaction). The next steps in their research programme are to evaluate sensitivity and construct validity. The Orthotics and Prosthetics Users' Survey (OPUS) is a promising self-report instrument which may, with further development, allow orthotic and prosthetic practitioners to evaluate the quality and effectiveness of their services as required by accreditation standards such as those of the American Board for Certification in Orthotics and Prosthetics that mandate quality assessment.     

Who's buying lunch: are gifts to surgeons from industry bad for patients?

Why does gifting exist in the medical marketplace? It provides a sales advantage in a competitive marketplace by establishing crucial relationships with the patients' fiduciary: the physician and surgeon. Do gifts to physicians from industry harm patients? One can cite mountains of indirect evidence that they do, and maybe in the case of recalled devices and drugs there are actual corpses, but these examples are retrospective and it is impossible to prove that removing detailing eliminates the harm. Banning gifts to surgeons would not completely fix the ethical problem of pharmaceutical and device marketing. Gifts are important because they buy access and foster relationships, but inherent bias in research and the medical literature makes it very difficult to remain objective. It is a race, and education has not kept pace with advertising; only 10% of 575 internal medicine physicians thought they had had sufficient training during medical school and residency regarding professional interaction with sales representatives. Would banning gifts help at all? Would enforcing an unpopular ethical code protect patients? There might be a small improvement, but not as significant as eliminating representatives and product samples altogether. This is not likely to happen without an enormous fight against the wealthiest industry in America. The solution is education. To borrow industry's argument, physicians and surgeons are ethical creatures with capacity for judgment and integrity. They need to understand and believe the magnitude of the problem. Detailing exists because there is a market for it, empowering surgeons with ethical training reduces the demand for goodies, and at some point the popular choice will be to buy their own lunch. Business ethics are not medical ethics. Industry is behaving exactly as it must to maximize profits. Although it is painful for some surgeons, surgical residencies, and professional organizations to envision a future with diminished corporate gifts, it is every surgeon's responsibility to consider whether their dealings with the pharmaceutical and medical equipment industries withstand the harsh light of realities presented herein.     

Strategic planning of burn care services and the role of information systems

An information system to support strategic planning for burn care services could help to structure decisions and help indicate to planners those areas of critical relevance to the issue of which burn patients will survive and which will not. This is, therefore, the essence of the need for information system support for strategic planning for appropriate burn care services: to help to identify those critical areas that reflect the real needs of burn patients in terms of survival and nonsurvival that are amenable to changes through planning.Strategic planning for appropriate burn care services involves highly unstructured decision problems, that must be made by individuals who have a thinkingintuition psychological mode. Planning for the real needs of patients with burn injuries necessitates not only formalized, structured information systems, but information systems that are designed for the psychological modes of these planners of burn care services.     

Outcomes research in nephrology

The field of clinical research in nephrology should be and is being broadened beyond clinical trials by incorporating epidemiologic designs and subjective patients' assessments of their own health and the degree to which they are satisfied with services they receive. The advantages of these changes include increased relevance to the concerns of patients and increased relevance to the real world of clinical practice.