A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure

Background: Performance-measurement systems may work best when they account for the reasons why physicians do not provide guideline-recommended interventions.Objective: This article develops a conceptual framework for understanding the proximate, patient-centered reasons why physicians do not prescribe angiotensin-converting enzyme (ACE) inhibitors or β-blockers to patients with heart failure and reduced systolic function.Methods: This was a focus group study using a 2-stage design. Academically affiliated clinicians of different specialties and levels of training were recruited by e-mailed invitations sent to clinicians within each target group. To be included, candidates needed to be currently practicing in an ambulatory care setting in which they encountered patients with heart failure. In the first part of each group, participants were asked to describe reasons for not prescribing ACE inhibitors or â-blockers for patients with heart failure. Next, participants were asked to develop concept maps that organized these reasons into categories and described the relationships between these categories. The concept maps from each group were synthesized to develop a consensus scheme for categorizing reasons for nonprescribing.Results: There were 31 participants in 7 focus groups; median age was 31 years and 55% (17/31) were women. Two broad themes emerged. First, clinicians hinted at their own attitude-related barriers to prescribing. However, they framed their comments largely in terms of patient-centered reasons for nonprescribing that arose in individual patient encounters. Second, decision making about heart failure drug therapy often involved a complex and overlapping series of considerations. Five categories of reasons for not prescribing ACE inhibitors or â-blockers emerged: (1) adverse effects of drug therapy; (2) nonadherence to therapeutic and monitoring plan; (3) patients' preferences and beliefs; (4) comanagement and transitions of care; and (5) prioritization and patient benefit.Conclusions: Physicians' reasons for not prescribing guideline-recommended drugs for heart failure are complex but can be organized into a useful taxonomy. This taxonomy may be helpful for performance-measurement and quality-improvement programs that seek to understand reasons for physicians' nonadherence to guidelines.     

Influences of electromagnetic articulography sensors on speech produced by healthy adults and individuals with aphasia and apraxia.

PURPOSE: This study examined whether the intraoral transducers used in electromagnetic articulography (EMA) interfere with speech and whether there is an added risk of interference when EMA systems are used to study individuals with aphasia and apraxia. METHOD: Ten adult talkers (5 individuals with aphasia/apraxia, 5 controls) produced 12 American English vowels in /hVd/ words, the fricative-vowel (FV) words (/si/, /su/, /ei/, /eu/), and the sentence She had your dark suit in greasy wash water all year, in EMA sensors-on and sensors-off conditions. Segmental durations, vowel formant frequencies, and fricative spectral moments were measured to address possible acoustic effects of sensor placement. A perceptual experiment examined whether FV words produced in the sensors-on condition were less identifiable than those produced in the sensors-off condition. RESULTS: EMA sensors caused no consistent acoustic effects across all talkers, although significant within-subject effects were noted for a small subset of the talkers. The perceptual results revealed some instances of sensor-related intelligibility loss for FV words produced by individuals with aphasia and apraxia. CONCLUSIONS: The findings support previous suggestions that acoustic screening procedures be used to protect articulatory experiments from those individuals who may show consistent effects of having devices placed on intraoral structures. The findings further suggest that studies of fricatives produced by individuals with aphasia and apraxia may require additional safeguards to ensure that results are not adversely affected by intraoral sensor interference.     

Is colonic lavage a suitable alternative for left-sided colonic emergencies?

BACKGROUNDThe use of intra-operative colonic lavage (IOCL) with primary anastomosis remains controversial in the emergency left-sided large bowel pathologies, with alternatives including Hartmann’s procedure, manual decompression and subtotal colectomy.AIMTo compare the peri-operative outcomes of IOCL to other procedures.METHODSElectronic databases were searched for articles employing IOCL from inception till July 13, 2020. Odds ratio and weighted mean differences (WMD) were estimated for dichotomous and continuous outcomes respectively. Single-arm meta-analysis was conducted using DerSimonian and Laird random effects. RESULTSOf 28 studies were included in this meta-analysis, involving 1142 undergoing IOCL, and 634 other interventions. IOCL leads to comparable rates of wound infection when compared to Hartmann’s procedure, and anastomotic leak and wound infection when compared to manual decompression. There was a decreased length of hospital stay (WMD = -7.750; 95%CI: -13.504 to -1.996; P = 0.008) compared to manual decompression and an increased operating time. Single-arm meta-analysis found that overall mortality rates with IOCL was 4% (CI: 0.03-0.05). Rates of anastomotic leak and wound infection were 3% (CI: 0.02-0.04) and 12% (CI: 0.09-0.16) respectively.CONCLUSIONIOCL leads to similar rates of post-operative complications compared to other procedures. More extensive studies are needed to assess the outcomes of IOCL for emergency left-sided colonic surgeries.     

Facts and Fallacies of Kidd Antibodies: Experience in a Tertiary Care Hospital in North India

We have analyzed the method used in our laboratory to detect the most elusive, clinically significant alloantibody: the Kidd alloantibodies and find the most convenient procedure. A retrospective analysis of the method used in our laboratory for determining Kidd alloantibodies from January 2013 to May 2015 was conducted. The details of the event that sensitized the patient for red cell antibody formation and procedure used to detect the alloantibody were retrieved from the departmental records. Of 405 red cell antibody identification cases, 24 (5.9 %) had Kidd antibody (anti-Jka in 12: 50 % cases; anti-Jkb in 4: 16.7 % cases; multiple antibodies in 8: 32 % cases). Thirteen of 24 patients (54.2 %) had autocontrol positive of which 6 cases needed adsorption procedures whereas antibody/ies could be identified without adsorption procedure in the remaining 7 cases. All the 7 cases had autocontrol of 1+ strength. Of the 11 patients (45.8 %) with autocontrol negative, the antibody was identified using solid phase in 7 cases whereas tube panels were also used in the remaining 4 cases. Kidd alloantibodies though deceptive can be identified by sensitive techniques like the solid phase and simple but laborious techniques using the tube cell panels. Depending upon the reaction strength of the autocontrol, the routine autoadsorption process may be skipped and tube cell enzyme treated cells or solid phase techniques be used to get the results.     

Corticospinal tract degeneration in ALS unmasked in T1‐weighted images using texture analysis

The purpose of this study was to investigate whether textures computed from T1‐weighted (T1W) images of the corticospinal tract (CST) in amyotrophic lateral sclerosis (ALS) are associated with degenerative changes evaluated by diffusion tensor imaging (DTI). Nineteen patients with ALS and 14 controls were prospectively recruited and underwent T1W and diffusion‐weighted magnetic resonance imaging. Three‐dimensional texture maps were computed from T1W images and correlated with the DTI metrics within the CST. Significantly correlated textures were selected and compared within the CST for group differences between patients and controls using voxel‐wise analysis. Textures were correlated with the patients' clinical upper motor neuron (UMN) signs and their diagnostic accuracy was evaluated. Voxel‐wise analysis of textures and their diagnostic performance were then assessed in an independent cohort with 26 patients and 13 controls. Results showed that textures autocorrelation, energy, and inverse difference normalized significantly correlated with DTI metrics (p < .05) and these textures were selected for further analyses. The textures demonstrated significant voxel‐wise differences between patients and controls in the centrum semiovale and the posterior limb of the internal capsule bilaterally (p < .05). Autocorrelation and energy significantly correlated with UMN burden in patients (p < .05) and classified patients and controls with 97% accuracy (100% sensitivity, 92.9% specificity). In the independent cohort, the selected textures demonstrated similar regional differences between patients and controls and classified participants with 94.9% accuracy. These results provide evidence that T1‐based textures are associated with degenerative changes in the CST.