Radiologische Diagnostik der Sigmadivertikulitis und Stadieneinteilung

Background and objectives

Radiological imaging is of central importance for diagnosing acute and chronic diverticular disease. The indications for the various radiological imaging modalities and their most important findings are discussed in this review article.

Methods

The current literature on this topic was reviewed and summarized.

Results

Contrast-enhanced computed tomography of the abdomen is the method choice in cases of suspected acute diverticulitis and should enable a differentiation between complicated and uncomplicated forms. In suspected chronic diverticular disease virtual colonoscopy represents an equivalent alternative to classical colonoscopy.

Conclusion

Based on imaging findings therapeutic decisions can be made and the radiological findings can have some prognostic value in the follow-up of patients.

     

Treatment of acute hepatitis C: recommendations from an expert panel of the Italian Society of Infectious and Tropical Diseases

Aim

This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).

Methods

This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.

Results

Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.

Conclusions

Early treatment with DAA should be offered when available.

     

Bactericidal/permeability increasing protein gene polymorphism and inflammatory bowel diseases: meta-analysis of five case–control studies

Objective

Bactericidal/permeability increasing protein (BPI) gene polymorphisms have been extensively investigated in terms of their associations with inflammatory bowel disease (IBD), with contradictory results. The aim of this meta-analysis was to evaluate associations between BPI gene polymorphisms and the risk of IBD, Crohn’s disease (CD), and ulcerative colitis (UC).

Methods

Eligible studies from PubMed, Embase, and Cochrane library databases were identified.

Results

Ten studies (five CD and five UC) published in five papers were included in this meta-analysis. G645A polymorphism was associated with a decreased risk of UC in allele model, dominant model, and homozygous model.

Conclusions

Our data suggested that BPI G645A polymorphism was associated with a decreased risk of UC; the BPI G645A polymorphism was not associated with the risk of CD.

     

Burned Out at the Bedside: Patient Perceptions of Physician Burnout in an Internal Medicine Resident Continuity Clinic

Background

Burnout is high among resident physicians and may be associated with suboptimal patient care and reduced empathy.

Objective

To investigate the relationship between patient perceptions of empathy and enablement and physician burnout in internal medicine residents.

Design

Cross-sectional, survey-based observational study between December 2012 and March 2013 in a resident continuity clinic located within a large urban academic primary care practice in Baltimore, Maryland.

Participants

Study participants were 44 PGY1-3 residents and a convenience sample of their English-speaking adult primary care patients (N?=?244).

Main Measures

Patients rated their resident physicians using the Consultation and Relational Empathy Measure (CARE) and the Patient Enablement Instrument (PEI). Residents completed the Maslach Burnout Inventory (MBI). We tested for associations between resident burnout and patients’ perceptions of resident empathy (CARE) and enablement (PEI) using multilevel regression analysis.

Key Results

Multilevel regression analyses indicated significant positive associations between physician depersonalization scores on the MBI and patient ratings of empathy (B?=?0.28, SE?=?0.17, p?<?0.001) and enablement (B?=?0.11, SE?=?0.11, p?=?0.02). Emotional exhaustion scores on the MBI were not significantly related to either patient outcome.

Conclusions

Patients perceived residents who reported higher levels of depersonalization as more empathic and enabling during their patient care encounters. The relationship between physician distress and patient perceptions of care has important implications for medical education and requires further study.

     

Rating the Quality of Entrustable Professional Activities: Content Validation and Associations with the Clinical Context

BACKGROUND

Entrustable professional activities (EPAs) have been developed to assess resident physicians with respect to Accreditation Council for Graduate Medical Education (ACGME) competencies and milestones. Although the feasibility of using EPAs has been reported, we are unaware of previous validation studies on EPAs and potential associations between EPA quality scores and characteristics of educational programs.

OBJECTIVES

Our aim was to validate an instrument for assessing the quality of EPAs for assessment of internal medicine residents, and to examine associations between EPA quality scores and features of rotations.

DESIGN

This was a prospective content validation study to design an instrument to measure the quality of EPAs that were written for assessing internal medicine residents.

PARTICIPANTS

Residency leadership at Mayo Clinic, Rochester participated in this study. This included the Program Director, Associate program directors and individual rotation directors.

INTERVENTIONS

The authors reviewed salient literature. Items were developed to reflect domains of EPAs useful for assessment. The instrument underwent further testing and refinement. Each participating rotation director created EPAs that they felt would be meaningful to assess learner performance in their area. These 229 EPAs were then assessed with the QUEPA instrument to rate the quality of each EPA.

MAIN MEASURES

Performance characteristics of the QUEPA are reported. Quality ratings of EPAs were compared to the primary ACGME competency, inpatient versus outpatient setting and specialty type.

KEY RESULTS

QUEPA tool scores demonstrated excellent reliability (ICC range 0.72 to 0.94). Higher ratings were given to inpatient versus outpatient (3.88, 3.66; p?=?0.03) focused EPAs. Medical knowledge EPAs scored significantly lower than EPAs assessing other competencies (3.34, 4.00; p?<?0.0001).

CONCLUSIONS

The QUEPA tool is supported by good validity evidence and may help in rating the quality of EPAs developed by individual programs. Programs should take care when writing EPAs for the outpatient setting or to assess medical knowledge, as these tended to be rated lower.

     

Prospektiver Vergleich von Assessments zur Beurteilung der Sturzgefahr bei Pflegeheimbewohnern

Background

Falls represent the main health risk in the over-60 age group. Therefore, evaluation of the individual fall risk and assessment of fall mechanisms are important preventive tools.

Study question

The goal of this study was to validate a new posturographic measurement system [Interactive Balance System (IBS)] in terms of fall prediction.

Materials and methods

In all, 108 subjects (mean age: 81.9±9.5 years) were submitted to the IBS, as well as other fall risk assessment methods [FES-1, Timed-Up-and-Go Test, Performance Oriented Mobility Assessment (Tinetti-Test), Chair-Rising-Test, Tandem stance). The follow-up period of 6 months prospectively recorded all falls using a fall diary.

Results

Of the nursing home residents studied, 25 (23%) fell at least once. The posturographic fall index FI_F1&WDI (sensitivity: 88%) and the Timed-Up-and-Go Test (PPV: 38%) showed the best results regarding sensitivity and positive prediction value (PPV).

Conclusion

The IBS and the Timed-Up-and-Go Test proved to be the most powerful assessment tools for fall prediction. Furthermore, the IBS is able to provide a purposeful adaption of preventive sensomotoric interventions.

     

Effects of a Video on Organ Donation Consent Among Primary Care Patients: A Randomized Controlled Trial

BACKGROUND

Low organ donation rates remain a major barrier to organ transplantation.

OBJECTIVE

We aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.

DESIGN

This was a randomized controlled trial between February 2013 and May 2014.

SETTING

The waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.

PATIENTS

The study included 915 patients over 15.5 years of age who had not previously consented to organ donation.

INTERVENTIONS

Just prior to their clinical encounter, intervention patients (n?=?456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n?=?459) visited their provider per usual routine.

MAIN MEASURES

The primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.

KEY RESULTS

Intervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).

LIMITATION

How the observed increases in organ donation consent might translate into a greater organ supply is unclear.

CONCLUSION

Watching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01697137

     

Effects of the Wars on Smoking Among Veterans

BACKGROUND

Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners’ opinions are vital to the development of future curricula.

DESIGN

Qualitative research using focus group methodology.

OBJECTIVES

Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught.

PARTICIPANTS

Study participants were first year medical students with an interest in health disparities (n?=?17).

APPROACH

Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process.

MAIN RESULTS

The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities.

CONCLUSIONS

While many of the students’ opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.

     

Cost of Transformation among Primary Care Practices Participating in a Medical Home Pilot

Background

Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments.

Objectives

To estimate costs of transformation incurred by primary care practices participating in a medical home pilot.

Design

We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes.

Setting

The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot.

Participants

Twelve practices that participated in the PACCI.

Measurements

One-time and ongoing yearly costs attributed to medical home transformation.

Results

Practices incurred median one-time transformation-associated costs of $30,991 per practice (range, $7694 to $117,810), equivalent to $9814 per clinician ($1497 to $57,476) and $8 per patient ($1 to $30). Median ongoing yearly costs associated with transformation were $147,573 per practice (range, $83,829 to $346,603), equivalent to $64,768 per clinician ($18,585 to $93,856) and $30 per patient ($8 to $136). Care management activities accounted for over 60% of practices’ transformation-associated costs. Per-clinician and per-patient transformation costs were greater for small and independent practices than for large and system-affiliated practices.

Limitations

Error in interviewee recall could affect estimates. Transformation costs in other medical home interventions may be different.

Conclusions

The costs of medical home transformation vary widely, creating potential financial challenges for primary care practices—especially those that are small and independent. Tailored subsidies from payers may help practices make these investments.

Primary Funding Source

Agency for Healthcare Research and Quality

     

Is preoperative physical activity related to post-surgery recovery?—a cohort study of colorectal cancer patients

Introduction

An increasing interest is seen in the role of preoperative physical activity (PA) in enhancing postoperative recovery. The short-term effect of preoperative PA on recovery after colorectal cancer is unknown. The aim of this study was to evaluate the association of the preoperative level of PA with postoperative recovery after surgery due to colorectal cancer disease.

Methods

This is a prospective observational cohort study, with 115 patients scheduled to undergo elective colorectal surgery. The self-reported level of preoperative PA was compared to measures of recovery.

Results

Regular self-reported preoperative PA was associated with a higher chance of feeling highly physically recovered 3 weeks after surgery (relative chance 3.3, p?=?0.038), compared to physical inactivity. No statistically significant associations were seen with length of hospital stay, self-assessed mental recovery, re-admittances or with re-operations.

Discussion

In clinical practice, evaluating the patients’ level of PA is feasible and may potentially be used as a prognostic tool for patients undergoing colorectal cancer surgery. Given the study design, the results from this study cannot prove causality.

Conclusion

The present study found that the preoperative level of PA was associated with a faster self-assessed physical recovery after colorectal cancer surgery. PA did not show any associations with the primary outcome measure length of hospital stay or any of the other secondary outcome measures. Assessment of PA level preoperatively could be used for prognostic reasons. If systematic preoperative/postoperative physical training will enhance recovery, this remains to be studied in a randomized controlled study.

Highlights

• We examined preoperative physical activity and the recovery after colorectal cancer surgery.
• Physically active individuals had faster self-assessed physical recovery.
• Assessment of preoperative physical activity may provide prognostic clinical information.

     

Regional-scale climate-variability synchrony of cholera epidemics in West Africa

Background

The relationship between cholera and climate was explored in Africa, the continent with the most reported cases, by analyzing monthly 20-year cholera time series for five coastal adjoining West African countries: Côte d'Ivoire, Ghana, Togo, Benin and Nigeria.

Methods

We used wavelet analyses and derived methods because these are useful mathematical tools to provide information on the evolution of the periodic component over time and allow quantification of non-stationary associations between time series.

Results

The temporal variability of cholera incidence exhibits an interannual component, and a significant synchrony in cholera epidemics is highlighted at the end of the 1980's. This observed synchrony across countries, even if transient through time, is also coherent with both the local variability of rainfall and the global climate variability quantified by the Indian Oscillation Index.

Conclusion

Results of this study suggest that large and regional scale climate variability influence both the temporal dynamics and the spatial synchrony of cholera epidemics in human populations in the Gulf of Guinea, as has been described for two other tropical regions of the world, western South America and Bangladesh.

     

Fecal microbiota transplantation in a kidney transplant recipient with recurrent urinary tract infection

Purpose

We report on a kidney transplant recipient treated with fecal microbiota transplantation (FMT) for recurrent urinary tract infections.

Methods

FMT was administered via frozen capsulized microbiota. Before and after FMT, urinary, fecal and vaginal microbiota compositions were analyzed.

Results

The patient remained without symptoms after FMT.

Conclusions

Underlying mechanisms of action need to be addressed in depth by future research.

     

Reduced Effectiveness of Interruptive Drug-Drug Interaction Alerts after Conversion to a Commercial Electronic Health Record

Background

Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue.

Objective

To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates.

Design

Two before-and-after studies.

Participants

3277 clinicians who received a DDI alert in the outpatient setting.

Intervention

Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria.

Main Measures

Alert burden and proportion of alerts accepted.

Key Results

Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts (P?<?0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% (P?<?0.01).

Conclusions

Changing from a highly tailored DDI alerting system to a more general one as part of an EHR conversion decreased acceptance of DDI alerts and increased alert burden on users. The decrease in acceptance rates cannot be fully explained by differences in the clinical knowledge base, nor can it be fully explained by alert fatigue associated with increased alert burden. Instead, workflow factors probably predominate, including timing of alerts in the prescribing process, lack of differentiation of more and less severe alerts, and features of how users interact with alerts.

     

Selection of EMR and ESD for Laterally Spreading Lesions of the Colon

Introduction

Colonic laterally spreading lesions (LSL) are increasingly managed using endoscopic methods that comprise two main techniques: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

Purpose of Review

In this review, we aimed to review the most recent literature on selection of the best endoscopic technique in the management of colonic LSL.

Recent Findings

EMR and ESD are complimentary techniques in the management of patients with colonic LSL.

Summary

EMR is safe and effective in most patients with LSL, except for cancers with submucosal invasion in whom R0 resection is favored.

     

Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy

Background

Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.

Objective

To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.

Design

Retrospective cohort.

Setting

Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.

Participants

We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.

Main Measures

Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.

Key Results

A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic?=?0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic?=?0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.

Conclusions

Among patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.

     

Sleep quality of mother-caregivers of Duchenne muscular dystrophy patients

Background

Sleep disturbance is a common problem for caregivers. In general, patients with Duchenne muscular dystrophy (DMD) use noninvasive ventilation to maintain quality of life and improve survival.

Objective

The aim of this study was to evaluate the sleep quality of caregiver-mothers of sons with DMD and factors that are associated with their sleep quality.

Methods

We evaluated 32 caregiver-mothers of sons with DMD and 32 mothers of sons without any neuromuscular or chronic disease (control—CTRL group). The evaluation of quality of sleep was made using the Pittsburgh Sleep Quality Index (PSQI).

Results

Caregiver-mothers had poor sleep quality, specifically longer sleep latency and reduced sleep efficiency. The impaired sleep quality of the caregiver-mothers was associated with the length of time of noninvasive ventilation used by their sons.

Conclusions

Our results suggest that caregiver-mothers of sons with DMD have poor quality of sleep, and the length of use of noninvasive ventilation of their sons is associated with better sleep of caregiver-mothers.

     

Alloplastisches Material in der Prolapschirurgie

Hintergrund

Der Einsatz von Netzen gibt der Rektopexie durch mechanische Unterstützung sowie durch Induktion der Narbenbildung Stabilität. Ein Problem der herkömmlichen Rektopexieverfahren ist allerdings, dass viele Patienten postoperativ unter funktionellen Störungen wie Inkontinenz und v.?a. Stuhlentleerungsstörungen leiden. Ursache ist die zur Netzeinlage erforderliche dorsale und laterale Mobilisation des Rektums, bei der die vegetativen Nerven häufig geschädigt werden. D´Hoore und Penninckx beschrieben im Jahr 2004 eine neue Technik der abdominellen Rektopexie mit Operation des Rektumprolapses unter Schonung der autonomen Nerven – die ventrale Rektopexie.

Fragestellung

Bietet die ventrale Rektopexie Vorteile bezüglich des funktionellen Outcomes, der Komplikations- und Rezidivrate?

Material und Methode

Darstellung und Auswertung der aktuellen Studienlage zur ventralen Rektopexie durch Recherche in medizinischen Datenbanken (PubMED, Medline).

Ergebnisse

Die ventrale Rektopexie zeichnet sich durch eine geringe Komplikationsrate und gute funktionelle Ergebnisse in Bezug auf die Verbesserung der Inkontinenz und Obstipationsneigung bzw. Stuhlentleerungsstörung auf. Als Indikation gilt der äußere Rektumprolaps. Aber auch der innere Rektumprolaps, die große Rektozele sowie die Enterozele mit konsekutivem obstruktivem Defäkationssyndrom stellen bei einem ausgewählten Patientenkollektiv relative Indikationen für die ventrale Rektopexie dar.

Schlussfolgerung

Um eine valide Einschätzung bezüglich der Wertigkeit des Verfahrens zu geben, ist es entscheidend, die derzeit fehlende Evidenz (Level 3), in Zukunft insbesondere durch prospektiv randomisierte Studien, die die ventrale Rektopexie mit anderen Operationsmethoden und auch mit nichtchirurgischen Behandlungsmethoden vergleichen, zu verbessern.