Training and teaching of vagus nerve stimulation surgery: Worldwide survey and future perspectives

ObjectiveVagus nerve stimulation (VNS) therapy has been used for more than two decades to treat drug resistant epilepsy and depression and most recently received FDA approval for stroke rehabilitation. Expanding indications will renew the interest in the technique and increase the number of surgeons to be trained. The aim of this study was to survey surgeons with substantial expertise on optimal teaching and training approaches.MethodsAnonymous forms comprising 16 questions were sent by e-mail to surgeons with substantial expertise. Statistical analyses were used to compare the answers of the most experienced surgeons (>5 years) with the less experienced ones (<5 years).ResultsFully-completed forms were collected from 57 experts from 20 countries. The placement of the helical coils was deemed to be the most difficult step by 36 (63.2%) experts, and the use of optical magnification during this step was deemed necessary by 39 (68.4%) experts. Vocal cord palsy should be largely avoidable with proper surgical technique according to 44 (77.2%) experts. The teaching tool considered the most useful was mentoring (38, 66.7%). The future of VNS surgery teaching was deemed to be in anatomical workshops (29, 50.9%) and surgical simulation (26, 45.6%). Overall, answers did not vary significantly according to experience.ConclusionsVNS surgery should be mastered by actively participating in dedicated practical training courses and by individual mentoring during actual surgery, which is still the best way to learn. This study highlights the need for a formal training course and possible specific accreditation.     

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation

ObjectiveThe use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation.MethodsThe AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement.ResultsThe expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively.ConclusionsAchieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.     

Out of the boxes,out of the silos: The need of interdisciplinary collaboration to reduce poor-quality medical products in the supply chain

In this paper, we argue that understanding and addressing the problem of poor-quality medical products requires a more interdisciplinary approach than has been evident to date. While prospective studies based on rigorous standardized methodologies are the gold standard for measuring the prevalence of poor-quality medical products and understanding their distribution nationally and internationally, they should be complemented by social science research to unpack the complex set of social, economic, and governance factors that underlie these patterns. In the following sections, we discuss specific examples of prospective quality surveys and of social science studies, highlighting the value of cross-sector partnerships in driving high-quality, policy-relevant research in this area.     

Economic impact of pharmaceutical services on polymedicated patients: A systematic review

BackgroundPolypharmacy is commonly related to poor drug adherence, decreased quality of life and inappropriate prescribing in eldery. Furthermore, this condition also leads to a higher utilization of health services resources, due to the increased risk of adverse drug events, length of stays in hospitals and readmissions rates after discharge.ObjectiveThis Systematic Review aimed to synthesize the current evidence that evaluates pharmaceutical services on polymedicated patients, from an economic perspective.MethodsSystematic searches were conducted in MEDLINE, SCOPUS and Cochrane Library databases to identify studies that were published until January 2021. Experimental and observational studies were included in this review, using strict inclusion/exclusion criteria and were assessed for quality using the following tools: RoB and ROBINS-I. Two independent reviewers selected the articles and extracted the data.Results3,662 articles were retrieved from the databases. After the screening, 18 studies were included: 9 experimental and 9 observational studies. The studies reported that the integration of the pharmacist as a member of the healthcare team provides an optimized use of pharmacotherapy to polymedicated patients and contributes to health promotion, providing reduction of spending on medication, reduction of expenses related to emergency care and hospitalizations and other medical expenses. The ECRs made cost-effectiveness or cost-benefit analysis, and most of the Non Randomized studies had statistically significant cost savings even considering the expenses of pharmaceutical assistance. Experimental studies reported a cost reduction varying between US$ 193 to US$ 4,966 per patient per year. Furthermore, observational studies estimated a cost reduction of varying from US$ 3 to US$ 2,505 per patient per year. The cost savings are related to decrease in emergency visits and hospitalizations, through pharmacist intervention (medication review and pharmacotherapy follow-up).ConclusionsConsidering the set of studies included, pharmaceutical care services directed to polymedicated patients may cooperate to save financial resources. Most of the interventions showed positive economic trends and also contributed to improving clinical parameters and quality of life. However, due to the majority of the studies having exploratory or qualitative methodology, it is essential to carry out more robust studies, based on full economic evaluation.     

Where are the labor markets?: Examining the association between structural racism in labor markets and infant birth weight

Racist policies and practices that restrict Black, as compared to white workers, from employment may drive racial inequities in birth outcomes among workers. This study examined the association between structural racism in labor markets, measured at a commuting zone where workers live and commute to work, and low-birthweight birth. We found the deleterious effect of structural racism in labor markets among US-born Southern Black pregnant people of working age, but not among African- or Caribbean-born counterparts in any US region. Our analysis highlights the intersections of structural racism, culture, migration, and history of racial oppression that vary across regions and birth outcomes of Black workers.     

Confounded association between proton pump inhibitor use and risk of biliary tract cancer: Result from three cohorts

Recent epidemiological studies suggested that proton pump inhibitor (PPI) use was associated with an increased risk of biliary tract cancer (BTC), however, confounders were not adequately controlled. Our study aimed to evaluate PPI use and subsequent risk of BTC and its subtypes in three well-established cohorts. We conducted a pooled analysis of the subjects free of cancers in UK Biobank (n = 463 643), Nurses' Health Study (NHS, n = 80 235) and NHS II (n = 95 869). Propensity score weighted Cox models were used to estimate marginal HRs of PPIs use on BTC risk, accounting for potential confounders. We documented 284 BTC cases in UK Biobank (median follow-up: 7.6 years), and 91 cases in NHS and NHS II cohorts (median follow-up: 15.8 years). In UK biobank, PPI users had a 96% higher risk of BTC compared to nonusers in crude model (HR 1.96, 95% CI 1.44-2.66), but the effect was attenuated to null after adjusting for potential confounders (HR 0.95, 95% CI 0.60-1.49). PPI use was not associated with risk of BTC in the pooled analysis of three cohorts (HR 0.93, 95% CI 0.60-1.43). We also observed no associations between PPI use with risk of intrahepatic (HR 1.00, 95% CI 0.49-2.04), extrahepatic bile duct (HR 1.09, 95% CI 0.52-2.27) and gallbladder cancers (HR 0.66, 95% CI 0.26-1.66) in UK Biobank. In summary, regular use of PPIs was not associated with the risk of BTC and its subtypes.     

我国家庭医生签约服务政策执行的制约因素与优化路径：基于史密斯政策执行过程模型

深化家庭医生签约服务是深化医药卫生体制改革、强化基层医疗卫生服务、实现"健康中国"战略目标的重要选择，也是当前更好维护人民群众健康的重要途径。为有效推进签约服务工作，国家陆续推出各项政策，全国各地也在积极进行实践探索，成效明显。但是，签约服务仍面临诸多问题，其中"执行难"是签约服务深度推进的一大困境。通过史密斯政策执行过程模型，结合签约服务政策执行过程，发现签约服务仍存在法治性不足、政策执行人员水平不高、激励不足、政策环境影响等诸多制约因素。因此，需要从法律和制度方面进行顶层设计、提升执行人员素质和职业认同、建立医患互信、优化政策执行环境等角度进行政策创新，探索家庭医生签约服务可持续发展的路径。     

Species,tissue and gender-related metal and element accumulation in fish species in a large reservoir (Turkey) and health risks and nutritional benefits for consumers

Concentrations of 18 metals and elements (MEs) in the gills, skin, muscle and liver of Carasobarbus luteus and Cyprinus carpio from the Atatürk Reservoir in Turkey were investigated. The results revealed that variations in the ME contents between fish species can be attributed to different diets. The highest contents of most MEs were recorded in the gills. Gender had no significant effect on the contents of most MEs in the tissues of fish species investigated. The relations between MEs in tissues and fish size were not clear and consistent. Health risk assessment methods indicated that consumption of the studied fish species is safe. It was estimated that daily consumption of 140 g of C. carpio or 170 g of C. luteus would not be expected to cause any health risks. Furthermore, it was found that fish species would provide significant benefits in terms of intake of essential MEs.