Critical Care Length of Stay and Support Requirements for Patients Postpancreas Transplant.

Introduction: Pancreas transplant is one of the UK's less commonly done solid abdominal organ transplants. The transplant is reputed for its high-risk postsurgical complications due to multiple patients, procedures, and immunological factors. For this reason, patients are habitually admitted to the intensive care unit for postlaparotomy care, physiological support, and graft function monitoring during their immediate postoperative course. Project Aim: This program evaluation analyzed the trend in critical care length of stay and organ support requirements for patients following whole pancreas transplantation. The aim was to use these baseline data as performance metrics to enable a safer transition and Plan-Do-Study-Act (PDSA) cycles in improving the delivery of enhanced recovery service. Design: A retrospective chart review was performed using records from Phillips IntelliSpace Critical Care and Anaesthesia system to evaluate the institutional outcomes of patients < 18 years admitted to intensive care following pancreas transplantation between January 1, 2018, and December 31, 2021. Islet-cell transplant recipients were excluded as there is a different postoperative recovery. Results: The data suggested that although patients require a higher level of observations, blood pressure management, blood gas, and glucose monitoring during their first week of transplant, these patients did not routinely require the full range of critical care support. Conclusion: The present evaluation reported the organ support requirements for these transplant recipients. The results will generate further interest in enhanced recovery and service evaluation projects to streamline the postoperative care of these patients from the operating theatre back to the transplant wards.

Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care.

BACKGROUND: Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy. METHODS: A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither. RESULTS: Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features. CONCLUSIONS: This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection.

Minimising complications and improving the success of peripheral regional blockade.

Peripheral regional blockade is a type of regional anaesthesia involving depositing local anaesthetics around a specific nerve or bundle of nerves that help transmit nociceptive signals to higher centres, such as the thalamus and somatosensory cortex. It is not only a widely used technique that provides surgical anaesthesia, but also acts as an essential part of the armamentarium against postoperative pain and pain following major skeletal trauma. This article discusses the structure and function of peripheral nerves, the classification and pathophysiology of peripheral nerve injury and, finally, how practising anaesthetists are committed to maximising success and minimising harm when performing peripheral nerve blockade in the operating theatre.

A Multi-Site Survey Study of Patient Satisfaction with Teledermatology.

Introduction: Telemedicine has been of heightened focus due to spikes in usage during the COVID-19 pandemic. Disparities in health care may affect patient satisfaction with this resource depending on factors such as patient race, age, or socioeconomic background. The purpose of this study was to analyze patient satisfaction with teledermatology to identify any differences in satisfaction based on race, age, and income during the COVID-19 pandemic period. Methods: A 21-question, IRB-approved survey was administered to patients at two academic dermatology clinics in Kansas City. Patient satisfaction was measured using a five-point Likert scale. Results: A total of 64 completed surveys were analyzed (17.8% response rate). Most of the participants were female (n = 48, 75%), age 45 to 60 (n = 17, 26.6%), and reported White for race (n = 55, 85.9%). Overall, 73.4% (n = 47) of patients reported being satisfied with their visit. However, only 38.7% (n = 24) of participants were likely to choose a video over an in-person visit. Reasons for low patient satisfaction included concerns regarding ability to perform an accurate physical exam with a video visit (n = 9, 14.1%), receiving inadequate care (n = 4, 6.3%), protected privacy (n = 3, 4.7%), and provider understanding the patient (n = 2, 3.1%). Conclusions: Our findings were similar to prior studies stating no difference in patient satisfaction with regards to age, income, or race and patients reporting high satisfaction with teledermatology appointments despite a preference for in-person dermatology visits. Future studies with a larger diverse cohort of participants are needed to elucidate and address possible disparities associated with teledermatology use.

Adalimumab for treatment of severe ulcerative sarcoidosis.

Ulcerative sarcoidosis is a rare variant of cutaneous sarcoidosis that may present as ulceration with necrotic yellow plaques on the lower extremities, face, arms, trunk, or genital area. Adalimumab, a human monoclonal anti-TNF antibody, is an emerging treatment for recalcitrant cutaneous sarcoidosis. We describe severe ulcerative sarcoidosis in a 60-year-old woman with chronic ulcerative necrobiosis lipoidica-like plaques on her left arm for over 20 years. Her condition had not responded to previous treatments with hydroxychloroquine, methotrexate, and sulfasalazine. After a four-month course of adalimumab therapy in addition to pentoxifylline and prednisone with taper, the patient had significant improvement in her skin disease.

High-Potency Topical Steroid Treatment of Multiple Keratoacanthomas Associated With Prurigo Nodularis.

Patients who present with multiple keratoacanthomas (KAs) associated with prurigo nodularis often pose a treatment challenge. These lesions often require aggressive treatment, such as Mohs micrographic surgery, surgical excision, electrodesiccation and curettage, intralesional steroid injection, and long-term acitretin. 5-Fluorouracil (5-FU) cream 5% has been shown to be effective; however, topical options are limited when 5-FU fails. We have found success using a high-potency topical steroid under occlusion, resulting in resolution of KAs and prurigo nodules.

Implementation and Impact of a Store-and-Forward Teledermatology Platform in an Urban Academic Safety-Net Health Care System.

Background:Minority and low-income patients disproportionately experience dermatologic access challenges. Store-and-forward (SAF) teledermatology has emerged as a model of care delivery that may improve access. We sought to evaluate patterns of utilization and overall impact after SAF teledermatology implementation in a safety-net health care system. Methods:We performed a retrospective review of 3,285 teledermatology consultations from 2014 to 2017 in an urban academic safety-net health care system. Results:A total of 1,680 (51.2%) patients were referred for inflammatory/rash conditions and 967 (29.5%) for skin lesions. The teledermatologist recommended in-person evaluation in 1,199 encounters (36.5%). Median wait time for a subsequent appointment was 36 days (range 0-244 days). Of subsequent in-clinic visits, 237 patients (26.4%) underwent skin biopsy. No-show rate after referral was 11.8%. In comparison, median wait time for dermatology appointment through standard referral was 64 days, with a no-show rate of 18.6%. Biopsy rate of patients referred via teledermatology was 26.4%, in comparison to a rate of 10.9% of patients referred directly from primary care provider. Discussion:Implementation of SAF teledermatology in a safety-net health system resulted in avoidance of 63.5% potential dermatology visits. Consultation typically resulted in a change in suspected diagnosis or management plan. Rates of concordance between teledermatology consults and in-person evaluations were high. Median wait time was reduced by almost half, no-show rate was reduced ∼37%, and biopsy rate was more than double for teledermatology patients compared with standard referral. Conclusion:These findings suggest that SAF teledermatology may improve access to high-quality dermatologic care and increase clinic efficiencies for patients in safety-net health care systems.

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation.

BACKGROUND: Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment? METHODS: To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components. RESULTS: We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions. CONCLUSION: While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.

Wilderness Dermatology: Bugs, Plants, and Other Nuisances That May Ruin Your Hike.

Spending time outdoors can be rewarding. However, exposure to the sun, insect bites, and plant exposures may result in a wide range of dermatologic manifestations. In this article, we describe potential cutaneous manifestations of common wilderness exposures in New England including photodermatoses from prolonged sun exposure, phytodermatoses from plant exposures, and arthropod-bite reactions from common insects (mosquitos, spiders, ticks, hymenoptera, mites and chiggers). The article will also address preventive and treatment strategies which may help physicians and their patients better prepare for spending time in the wilderness. [Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Optimization is required when using linked hospital and laboratory data to investigate respiratory infections.

OBJECTIVE: Despite a recommendation for microbiological testing, only 45% of children hospitalized for respiratory infections in our previous data linkage study linked to a microbiological record. We conducted a chart review to validate linked microbiological data. STUDY DESIGN AND SETTING: The chart review consisted of children aged <5 years admitted to seven selected hospitals for respiratory infections in Western Australia, 2000-2011. We calculated the proportion of admissions where testing was performed and any pathogens detected. We compared these proportions between the chart review and our previous data linkage study. Poisson regression was used to identify factors predicting the likelihood of microbiological tests in the chart review cohort. RESULTS: From the chart review, 77% of 746 records had a microbiological test performed compared with 46% of 18,687 records from our previous data linkage study. Of those undergoing testing, 66% of the chart review and 64% of data linkage records had ≥1 respiratory pathogen(s) detected. In the chart review cohort, frequency of testing was highest in children admitted to metropolitan hospitals. CONCLUSION: Validation studies are essential to ensure the quality of linked data. Our previous data linkage study failed to capture all relevant microbiological records. Findings will be used to optimize extraction protocols for future linkage studies.

Predicting future emergency department visits and hospitalizations for asthma using the Pediatric Asthma Control and Communication Instrument - Emergency Department version (PACCI-ED).

OBJECTIVE: Emergency departments (EDs) are potential settings for interventions to improve asthma outcomes. Screening tools can identify children at risk of future morbidity. Our objective was to determine the predictive validity of the Pediatric Asthma Control and Communication Instrument - Emergency Department version (PACCI-ED) for future asthma-related ED visits and hospitalizations. METHODS: This was a retrospective cohort study of 108 children 1-17 years old who visited an ED for asthma and completed the PACCI-ED. The PACCI-ED queries parents about prior 12-month ED visits, hospitalizations, steroid use, perceived asthma morbidity and burden, and asthma control (over prior 1-2 weeks). The primary outcome was subsequent ED visits and hospitalizations within 1 year of enrollment. Poisson regression was used to model PACCI-ED questions for future ED visits controlling for age and socioeconomic status. RESULTS: Reported ED visits predicted future ED visits (adjusted incidence rate ratio (aIRR) 3.1, 95% confidence interval (CI): 1.3-7.2) but not future hospitalizations. Reported hospitalizations predicted future ED visits (aIRR 3.3; 95% CI 1.7-6.3) and hospitalizations (aIRR 6.4; 95% CI 2.3-17.6). The remaining PACCI-ED questions did not predict future ED visits or hospitalizations. CONCLUSIONS: The PACCI-ED risk domain was the only domain that predicted future asthma ED visits and hospitalizations. Questions about previous ED visits and hospitalizations are the most effective questions when screening children with asthma in EDs for the risk of future health-care use.

A Self-Directed Preclinical Course in Ophthalmic Surgery.

OBJECTIVE: Medical students receive limited exposure to ophthalmology and ophthalmic surgery in the preclinical curriculum. To address this gap, the authors designed a self-directed preclinical elective course in ophthalmic surgery offered in the 2013-2014 academic year to all first- and second-year students at the study institution. DESIGN: Prospective cohort study with anonymous Likert-style questionnaires and qualitative responses. SETTING: Warren Alpert Medical School of Brown University, Providence, RI. PARTICIPANTS: All current first- and second-year medical students at the Warren Alpert Medical School of Brown University enrolled in the preclinical elective in 2013-2014 were eligible to participate in the study. METHODS: The course had 3 components: (1) 4 web-based didactic modules on common ophthalmic conditions with slide sets, surgical procedure videos and animations, and mandatory premodule and postmodule quizzes to assess for competency; (2) a 3-hour interactive virtual surgery simulation session on cataract surgery-related tasks; (3) a total of 2 shadowing experiences in the clinic and in the operating room. Each student completed an anonymous precourse and postcourse Likert-style questionnaire that assessed exposure to ophthalmology, favored components of the course, and interest in ophthalmology as a career. RESULTS: Of the 22 students who signed up, 18 (81.8%) completed the course. Most students (76.5%; 14/18) felt there was inadequate exposure to ophthalmology in the medical curriculum. Students scored a mean of 44.0% on premodule assessments and 97.0% on postmodule assessments. All students completed the postcourse questionnaire: they all recommended the course to other medical students and increased their understanding of ophthalmology as a career. The most popular components of the course were the practical aspects of the elective (44.4%; 8/18) and virtual surgery simulation (44.4%; 8/18). CONCLUSIONS: This course increased preclinical medical students' knowledge of ophthalmic surgery and suggests that flexible preclinical electives can help medical students explore clinical interests and career choices earlier in their medical education.

An Appraisal of Clinical Practice Guidelines for Diabetic Retinopathy.

The objective is to evaluate the methodological quality of clinical practice guidelines (CPGs) published by the American Academy of Ophthalmology (AAO), Canadian Ophthalmological Society (COS), and Royal College of Ophthalmologists (RCO) for diabetic retinopathy. Four evaluators independently appraised the CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which covers 6 domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence). Scores ranged from 35% to 78% (AAO), 60% to 92% (COS), and 35% to 82% (RCO). Intraclass correlation coefficients for the reliability of mean scores were 0.78, 0.78, and 0.79, respectively. The strongest domains were Scope and Purpose, and Clarity of Presentation (COS). The weakest were Stakeholder Involvement (AAO), Rigor of Development (AAO, RCO), Applicability, and Editorial Independence (RCO). Diabetic retinopathy practice guidelines can be improved by targeting Stakeholder Involvement, Rigor of Development, Applicability, and Editorial Independence.

Critical Appraisal of Clinical Practice Guidelines for Age-Related Macular Degeneration.

Purpose. To evaluate the methodological quality of age-related macular degeneration (AMD) clinical practice guidelines (CPGs). Methods. AMD CPGs published by the American Academy of Ophthalmology (AAO) and Royal College of Ophthalmologists (RCO) were appraised by independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which comprises six domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence), and an Overall Assessment score summarizing methodological quality across all domains. Results. Average domain scores ranged from 35% to 83% for the AAO CPG and from 17% to 83% for the RCO CPG. Intraclass correlation coefficients for the reliability of mean scores for the AAO and RCO CPGs were 0.74 and 0.88, respectively. The strongest domains were Scope and Purpose and Clarity of Presentation. The weakest were Stakeholder Involvement (AAO) and Editorial Independence (RCO). Conclusions. Future AMD CPGs can be improved by involving all relevant stakeholders in guideline development, ensuring transparency of guideline development and review methodology, improving guideline applicability with respect to economic considerations, and addressing potential conflict of interests within the development group.