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OBJECTIVE: Multicancer early detection panels have recently become available to patients with healthcare provider prescriptions and available funds. These tests utilize circulating tumor DNA (ctDNA) to screen more than 50 cancers using a single blood sample. However, perspectives and data on how the deployment of these tests may impact the practices of primary care providers in terms of implementation, interpretation, documentation, and costs are limited. This study aimed to assess the perspectives of primary care providers regarding the integration of multicancer early detection panels into clinical practice. METHODS: We used a survey to assess the opinions and perspectives of primary care providers, including physicians, nurse practitioners, and physician assistants, across a multistate, tertiary healthcare system. We used a single form consisting of novel questions on familiarity with multi-cancer early detection panels, cost, healthcare equity, documentation, medicolegal, and other concerns. The subgroup analysis was consistent with stratification based on familiarity with ctDNA-based tests and their roles in clinical practice. RESULTS: Most respondents were unfamiliar with multicancer early detection panels and had not used ctDNA-based tests. Most primary care providers suggested that they would reorder multicancer early detection panel testing at 1- to 5-year intervals and prefer subspecialists for both ordering multicancer early detection panels as well as interpreting their results. Relative concerns differed between physicians and nonphysicians. CONCLUSION: The integration of multicancer early detection panels into primary care practice requires careful planning and consideration for the management of increased clinical load, interpretation of results, and cost management.
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Detecção Precoce de Câncer , Atenção Primária à Saúde , Humanos , Detecção Precoce de Câncer/métodos , Neoplasias/diagnóstico , Inquéritos e Questionários , Atitude do Pessoal de Saúde , DNA Tumoral Circulante/sangue , DNA Tumoral Circulante/genética , Feminino , Masculino , Adulto , Pessoal de SaúdeRESUMO
Multicancer early detection panels have recently become available to patients with a provider's prescription and an out-of-pocket fee. Beyond theoretical modeling, little is known about how these assays will impact primary care practices despite a high likelihood that primary care providers (PCPs) will be ordering these tests with some frequency. In particular, there are concerns about patient counseling, costs, frequency of testing, patient anxiety, and subsequent testing for a positive result. This review aims to appraise the current literature and provide a framework that PCPs can use to discuss these tests with patients and streamline their ordering, interpretation, and overall use into everyday practice.
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Detecção Precoce de Câncer , Neoplasias , Ansiedade , Aconselhamento , Humanos , Neoplasias/diagnóstico , Atenção Primária à SaúdeAssuntos
Síndrome Coronariana Aguda , Fibrilação Atrial , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/tratamento farmacológico , Anticoagulantes , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Humanos , Inibidores da Agregação PlaquetáriaRESUMO
1. What is the clinical question? What combination antithrombotic therapy is recommended for patients with atrial fibrillation with acute coronary syndrome or patients undergoing percutaneous coronary intervention? 2. What does the evidence say? Double therapy (DT) with clopidogrel and direct oral anticoagulants (specifically, dabigatran, rivaroxaban, and apixaban) is noninferior to warfarin-based therapies for most patients. Double therapy is noninferior to triple therapy (TT) and has less bleeding complications. 3. What is the take-home message for physicians? According to the latest guidelines by the ACC, AHA, ESC, and HRS, in patients with AF undergoing PCI, DT with DOACs (specifically dabigatran, rivaroxaban and apixaban) plus clopidogrel is acceptable. Patients undergoing PCI or with high ischemic risk may still benefit from TT for at least 1 month and up to 6 months before switching to DT. Currently, there is no specific guidance on long-term antiplatelet therapy in these patients. Duration of antiplatelet therapy, whether with DT or TT, should be based on current DAPT guidelines (depending on indication and type of intervention) and discussions with each patient's cardiologist.
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Síndrome Coronariana Aguda , Fibrilação Atrial , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/tratamento farmacológico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Quimioterapia Combinada , Fibrinolíticos/uso terapêutico , Hemorragia , Humanos , Inibidores da Agregação Plaquetária/uso terapêuticoRESUMO
The nonpharmacologic management of irritable bowel syndrome focuses on dietary modification through the concept of food sensitivity or intolerance. Currently, testing for food allergies is not recommended in the absence of a clinical history consistent with an immunoglobulin E-mediated reaction. Objective means of determining food sensitivity, such as individualized diets, are being studied, but testing for food sensitivity is limited to certain food groups. Diets such as the low-FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet may provide benefit.
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Hipersensibilidade Alimentar/dietoterapia , Hipersensibilidade Alimentar/diagnóstico , Síndrome do Intestino Irritável/dietoterapia , HumanosRESUMO
The 2004 American Heart Association expert opinion-based guidelines restrict telemetry use primarily to patients with current or high-risk cardiac conditions. Respiratory infections have emerged as a common source of hospitalization, and telemetry is frequently applied without indication in efforts to monitor patient decompensation. In this retrospective study, we aimed to determine whether telemetry impacts mortality risk, length of stay (LOS), or readmission rates in hospitalized patients with acute respiratory infection not meeting American Heart Association criteria. A total of 765 respiratory infection patient encounters with Diagnosis-Related Groups 193, 194, 195, 177, 178 and 179 admitted in 2013 to 2015 to 2 tertiary community-based medical centers (Mayo Clinic, Arizona, and Mayo Clinic, Florida) were evaluated, and outcomes between patients who underwent or did not undergo telemetry were compared. Overall, the median LOS was longer in patients who underwent telemetry (3.0 days vs 2.0 days, p <0.0001). No differences between cohorts were noted in 30-day readmission rates (0.6% vs 1.3%, p = 0.32), patient mortality while hospitalized (0.6% vs 1.3%, p = 0.44), mortality at 30 days (7.9% vs 7.7%, p = 0.94), or mortality at 90 days (13.5% vs 13.5%, p = 0.99). Telemetry predicted LOS for both univariate (estimate 1.18, 95% confidence interval 1.06 to 1.32, p = 0.003) and multivariate (estimate 1.17, 95% confidence interval 1.06 to 1.30, p = 0.003) analyses after controlling for severity of illness but did not predict patient mortality. In conclusion, this study identified that patients with respiratory infection who underwent telemetry without clear indications may face increased LOS without reducing their readmission risk or improving the overall mortality.
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Doenças Cardiovasculares/epidemiologia , Tempo de Internação/tendências , Readmissão do Paciente/tendências , Doenças Respiratórias/diagnóstico , Medição de Risco , Telemetria/métodos , Doença Aguda , Idoso , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etiologia , Grupos Diagnósticos Relacionados , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Doenças Respiratórias/mortalidade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
The purpose of this special article is to describe a new, 4-year Science of Health Care Delivery curriculum at Mayo Clinic School of Medicine, including curricular content and structure, methods for instruction, partnership with Arizona State University, and implementation challenges. This curriculum is intended to ensure that graduating medical students enter residency prepared to train and eventually practice within person-centered, community- and population-oriented, science-driven, collaborative care teams delivering high-value care. A Science of Health Care Delivery curriculum in undergraduate medical education is necessary to successfully prepare physicians so as to ensure the best clinical outcomes and patient experience of care, at the lowest cost.
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Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).
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Cirurgia Bariátrica , Cirrose Hepática/complicações , Infecções por Mycobacterium não Tuberculosas , Micobactérias não Tuberculosas , Infecções Relacionadas à Prótese , Adulto , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/instrumentação , Feminino , Humanos , Infecções por Mycobacterium não Tuberculosas/complicações , Infecções por Mycobacterium não Tuberculosas/microbiologia , Infecções Relacionadas à Prótese/complicações , Infecções Relacionadas à Prótese/microbiologia , Estômago/cirurgiaRESUMO
Pulmonary epithelioid hemangioendothelioma (PEHE) is a rare vascular tumor of endothelial origin first described in 1975 as intravascular bronchioloalveolar tumor. Since then, >100 cases have been reported, and most cases require surgical lung biopsy for diagnosis. We report the case of a 46-year-old man with a diagnosis of PEHE from endobronchial biopsies of an intraluminal nodule, a rare presentation of this disease. We summarize a review of the literature and the bronchoscopic findings of PEHE.
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Broncoscopia/métodos , Hemangioendotelioma Epitelioide/diagnóstico , Neoplasias Pulmonares/diagnóstico , Adulto , Idoso , Biópsia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better (P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) (P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) (P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.
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Antibacterianos/uso terapêutico , Pneumonia Bacteriana/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Farmacorresistência Bacteriana/genética , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Fatores de RiscoAssuntos
Neoplasias do Colo/diagnóstico , Colonoscopia/estatística & dados numéricos , Doença Diverticular do Colo/complicações , Pólipos/diagnóstico , Neoplasias do Colo/etiologia , Neoplasias do Colo/cirurgia , Doença Diverticular do Colo/diagnóstico , Humanos , Pólipos/etiologia , Pólipos/cirurgiaRESUMO
BACKGROUND: Residents' shift length reduction and communication errors in transitions of care necessitate educating residents on handoff communication. PURPOSE: We examined the change in knowledge, attitudes, and practices of 1st-year residents after implementing a curriculum using deliberate practice to teach handoff communication. METHODS: First-year residents completed a needs assessment survey and a video assessment of handoff practices. They participated in a brief curriculum using lecture and deliberate practice with feedback to teach a standardized approach to handoff communication. Change in knowledge, attitudes, and practices were measured with survey and video assessments. RESULTS: Eleven 1st-year residents completed the course and final assessments. Residents' comfort with performing handoffs and their perceived efficiency indicated improvement. Practices improved, with increased inclusion of important features of handoffs (6.31 to 7.64, p < .001). CONCLUSIONS: A brief curriculum utilizing deliberate practice is an effective way to improve handoff practices of 1st-year residents.
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Comunicação , Retroalimentação , Conhecimentos, Atitudes e Prática em Saúde , Internato e Residência , Corpo Clínico Hospitalar , Transferência da Responsabilidade pelo Paciente , Ensino/métodos , Currículo , Humanos , Avaliação das Necessidades , Inquéritos e Questionários , Gravação em VídeoRESUMO
BACKGROUND: The 2005 ATS/IDSA guidelines defined healthcare-associated pneumonia (HCAP) as a novel category of pneumonia in patients with significant healthcare exposure in whom the risk of drug resistant bacteria may be higher. In this study, we compare clinical outcomes in patients with HCAP who were treated with guideline-concordant antibiotic regimens with those who were not. METHODS: Medical records of 100 patients meeting HCAP criteria admitted to an academic tertiary care hospital between January 2009 and January 2011 were retrospectively reviewed. Cases were divided into guideline-concordant and guideline-discordant groups based on antibiotic therapy. Demographic, microbiological and clinical outcome data were compared for both groups. RESULTS: Patients in this cohort had multiple co-morbidities, severe pneumonia (mean PSI score 124.1), and significant mortality (22%). 21 of the 100 cases (21.0%) were culture positive, of which 11 (53.8%) represented drug-resistant pathogens. No statistically significant differences for any of the four clinical outcome measures were detected between the guideline-concordant therapy group and guideline-discordant group. In multivariate regression analysis controlling for possible confounders, similar results were observed, with the exception that length of stay was significantly longer (3.99 days, p < 0.001) in the discordant group. Three or more HCAP criteria (OR 10.89) and wound care (OR 6.32) were characteristics found to be associated with increased risk for drug-resistant pathogens. CONCLUSION: In our cohort, the HCAP model identified a population with significant co-morbidities and increased risk for drug-resistant pathogens, severe pneumonia, and increased mortality. However, clinical outcomes were not significantly improved with guideline-concordant antibiotic therapy.
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Antibacterianos/uso terapêutico , Infecção Hospitalar/tratamento farmacológico , Pneumonia Bacteriana/tratamento farmacológico , Idoso , Infecções Comunitárias Adquiridas/tratamento farmacológico , Farmacorresistência Bacteriana Múltipla , Feminino , Fidelidade a Diretrizes , Humanos , Tempo de Internação , Masculino , Guias de Prática Clínica como Assunto , Análise de Regressão , Resultado do TratamentoRESUMO
CONTEXT: Treatment for patients with congenital adrenal hyperplasia (CAH) may affect the final height of these patients. OBJECTIVE: Our objective was to determine the distribution of achieved height in patients with classic CAH diagnosed at infancy or early childhood and treated with glucocorticoids. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Library, ISI Web of Science, and Scopus through September 2008; the reference sections of included studies; and expert files. STUDY SELECTION: Eligible studies included patients diagnosed with CAH before age 5 and followed to final height. DATA EXTRACTION: Reviewers working in duplicate independently extracted data on study characteristics and outcomes and determined each study's risk of bias. DATA SYNTHESIS: The sd score (SDS) for final height and corrected height (defined as final height SDS - midparental height SDS) were estimated from each study and pooled using random-effects metaanalysis. The I(2) statistic was used to assess inconsistency in results across studies. RESULTS: We found 35 eligible studies, most of which were retrospective single-cohort studies. The final height SDS achieved by CAH patients was -1.38 (-1.56 to -1.20; I(2) = 90.2%), and the corrected height SDS was -1.03 (-1.20 to -0.86; I(2) = 63.1%). This was not significantly associated with age at diagnosis, gender, type and dose of steroid, and age of onset of puberty. Mineralocorticoid users had a better height outcome in comparison with the nonusers (P = 0.02). CONCLUSION: Evidence derived from observational studies suggests that the final height of CAH patients treated with glucocorticoids is lower than the population norm and is lower than expected given parental height.
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Hiperplasia Suprarrenal Congênita/fisiopatologia , Estatura , Hiperplasia Suprarrenal Congênita/complicações , Adulto , Algoritmos , Estatura/fisiologia , Glucocorticoides/uso terapêutico , Transtornos do Crescimento/complicações , Transtornos do Crescimento/terapia , Hormônio do Crescimento Humano/uso terapêutico , Humanos , Mineralocorticoides/uso terapêutico , Resultado do TratamentoRESUMO
INTRODUCTION: Carisoprodol is a centrally acting muscle relaxant used in the treatment of various musculoskeletal disorders whose main metabolite, meprobamate, is a controlled substance in the United States due to its sedative properties and potential for abuse. CASE DESCRIPTION: We report a case of a 51-year-old man with cognitive impairment and tremor who developed worsening tremor, anxiety, myoclonus, ataxia, and psychosis on abrupt cessation of carisoprodol. At hospital discharge, his cognitive function significantly improved compared with when he was on carisoprodol. CONCLUSION: Carisoprodol withdrawal is an important and under-recognized syndrome that should be considered in patients presenting with neurologic symptoms who are taking the medication. Carisoprodol withdrawal can be successfully treated with the use of benzodiazepines, although further studies are needed to identify the most appropriate treatment protocol.