Laboratory stewardship perceptions and testing patterns at a pediatric tertiary care center.

BACKGROUND: Despite stewardship efforts, laboratory testing overuse persists across medicine. OBJECTIVES: To understand laboratory stewardship perceptions and testing patterns at a tertiary care pediatric hospital so that we could identify potential improvement opportunities. METHODS: An electronic survey exploring laboratory stewardship was sent to all pediatric medicine resident and staff physicians. Laboratory testing data were also assessed for patterns of testing and overuse. RESULTS: The survey response rate was 54% (43/80). The results indicated good familiarity with stewardship but poor familiarity with testing specifics (eg, cost). A mobile reference application was the most preferred quality improvement intervention, and online modules were the least desired. Overuse was apparent, with as many as 53% of laboratory tests being repeated within 7 days and only half of repeated tests subsequently yielding abnormal results. CONCLUSIONS: Altogether, the data we collated demonstrated poor understanding of laboratory stewardship and substantial repeat testing with few abnormal results. These study findings suggest that laboratory stewardship is lacking at our center, and that multiple improvement opportunities exist.

Adolescents' Cannabis Knowledge and Risk Perception: A Systematic Review.

To systematically review evidence evaluating cannabis-related knowledge and perception of risk in children and adolescents. We systematically searched Medline, PsycINFO, and EMBASE using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. 133 studies from around the world (including ages 10-18 yrs) met inclusion criteria, with 70% meeting grade 2C quality. Increased knowledge and perception of risk of cannabis frequently correlated with lower levels of current use and intent to use. Studies examining correlations over time generally demonstrated increased adolescent cannabis use and decreased perception of risk. Included prevention-based interventions often enhanced knowledge and/or perception of risk in adolescents exposed to the intervention. Studies exploring outcomes relating to legislative changes for recreational marijuana use demonstrated considerable heterogeneity regarding knowledge and perception of risk whereas studies that focused on medicinal marijuana legislative changes overwhelmingly demonstrated a decrease in perception of risk post legalization. Increased knowledge and perception of risk of cannabis in adolescents often correlate with lower levels of current use and intention to use in the future. Further study and implementation of public health and clinically-oriented strategies that seek to increase knowledge among youth about the potential health harms of cannabis use should continue and be prioritized.

Atypical Immunoglobulin A Vasculitis in a Pediatric Patient With Ulcerative Colitis.

Rates of pediatric inflammatory bowel disease and biologic therapy use continue to rise. Consequently, specialists and generalists should recognize potential complications and side effects. We report the unique case of an adolescent with ulcerative colitis (UC) on vedolizumab presenting with severe abdominal pain, hematochezia, and subsequent purpura. After extensive investigation and a complex clinical course, diagnosis of atypical immunoglobulin A vasculitis was made. This is the first pediatric case of vasculitis in a patient with UC on vedolizumab and only the second reported case overall in UC. This case illustrates the emerging diagnostic challenge of distinguishing inflammatory bowel disease treatment complications from other common pediatric conditions.

Analysis of image-guided superficial radiation therapy (IGSRT) on the treatment of early-stage non-melanoma skin cancer (NMSC) in the outpatient dermatology setting.

BACKGROUND: Interest in image-guidance superficial radiation therapy (IGSRT) for the treatment of early-stage non-melanoma skin cancer (NMSC) has resurfaced given its low complication rates, superior cosmesis and local control and cure rates. In addition, it has been recommended by the American Academy of Dermatology (AAD) for early-stage NMSC in patients who are considered poor surgical candidates. METHODS: 1899 NMSC lesions were treated with energies ranging from 50 to 100 kilovoltage (kV), for a mean of 20.2 fractions, and treatment dose of 5364.4 centigray (cGy). Lesions were treated for a mean of 7.5 weeks and followed for 65.5 weeks. SAS studio was used to conduct Kaplan-Meier analysis to calculate local control rates and account for differences in follow-up intervals. A log-rank test was used to calculate statistical differences between histologies. RESULTS: Absolute lesion control was achieved in 99.7% of the patients after an average of 7.5 weeks of treatment, with a stable control rate of 99.6% when the follow-up duration was over 12 months. 95% of lesions with toxicity scoring received a Radiation Treatment Oncology Group Toxicity (RTOG) score of 1 or 2. CONCLUSION: IGSRT has a high safety profile, can achieve superior cosmesis and should be considered first-line for treating early-stage NMSC tumors as cure rates have been shown to be effective in all NMSC on early follow-up.

Gender interactions on Twitter and medical education: how is nephrology doing?

Gender inequities negatively impact productivity and career advancement for women. Social media platforms like Twitter can be used to achieve greater parity and address underrepresentation by providing a medium for education, research and mentorship, however, it is unknown how it may contribute to gender inequity. Our aim was to examine gender interactions during a nephrology medical conference.

Nicotinamide Mononucleotide Prevents Free Fatty Acid-Induced Reduction in Glucose Tolerance by Decreasing Insulin Clearance.

The NAD-dependent deacetylase SIRT1 improves ß cell function. Accordingly, nicotinamide mononucleotide (NMN), the product of the rate-limiting step in NAD synthesis, prevents ß cell dysfunction and glucose intolerance in mice fed a high-fat diet. The current study was performed to assess the effects of NMN on ß cell dysfunction and glucose intolerance that are caused specifically by increased circulating free fatty acids (FFAs). NMN was intravenously infused, with or without oleate, in C57BL/6J mice over a 48-h-period to elevate intracellular NAD levels and consequently increase SIRT1 activity. Administration of NMN in the context of elevated plasma FFA levels considerably improved glucose tolerance. This was due not only to partial protection from FFA-induced ß cell dysfunction but also, unexpectedly, to a significant decrease in insulin clearance. However, in conditions of normal FFA levels, NMN impaired glucose tolerance due to decreased ß cell function. The presence of this dual action of NMN suggests caution in its proposed therapeutic use in humans.

Tweet me: conferencing in the era of COVID-19 and 280 characters.

The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Social Media (SoMe) Team provides Twitter coverage of the annual congress. During the coronavirus disease 2019 (COVID-19) pandemic, #ERAEDTA20 was the first major Nephrology congress to be delivered virtually. The effect of The SoMe Team and the consequences of the COVID-19 pandemic have not been explored previously. Tweets of the ERA-EDTA congresses 2016-20, using official hashtags, were evaluated. Metadata of each tweet were collected prospectively; original tweets, retweets and evidence-based tweets were identified. The gender of tweet author and location of Twitter activity were established. Network maps were created to ascertain the degree of polarization between the 2019 and 2020 Twitter activity, using Gephi 0.9.2. Between 2016 and 2019, the total number of tweets and the number of tweet authors increased, as did the proportion of female authors (20% versus 27%). In 2019, there were fewer multimedia and evidence-based tweets: 8% versus 20% in 2016. Globally, there were fewer Nephrology conferences in 2020 and the number of tweets per day reduced by 53% from 2019. In 2020, The ERA-EDTA congress saw an increase in authors of 9% and only an 8% reduction in tweets. It was easier to disseminate information in 2020, measured by increased correlation coefficient (0.14 versus 0.12 in 2019). A higher proportion of countries was represented (n = 55 versus n = 48 in 2019) and a higher proportion of tweets came from women. In conclusion, the introduction of SoMe Team was associated with increased usage of Twitter and ease of information dissemination. Compared with #nephtwitter activity as a whole in 2020, SoMe Team has mitigated some of the pandemic's deleterious effects in scientific dissemination, relevant to Nephrology.

Pharmacologic or genetic activation of SIRT1 attenuates the fat-induced decrease in beta-cell function in vivo.

BACKGROUND: There is evidence that sirtuin 1 (SIRT1), a key regulator of nutrient metabolism, increases ß-cell secretory function. Excess circulating fat, as seen in obesity, has been shown to decrease ß-cell function, an effect that may involve decreased SIRT1 activity. Consequently, SIRT1 activation may increase ß-cell function in conditions of elevated plasma-free fatty acid levels. Here we attempted to attenuate the lipid-induced decrease in ß-cell function in vivo using pharmacological and genetic models of SIRT1 activation. METHODS: Our pharmacologic model involved 48 h intravenous infusion of Wistar rats with either saline or oleate with or without the SIRT1 activator resveratrol. Additionally, we used ß-cell-specific SIRT1 overexpressing (BESTO) mice and wild-type littermates infused for 48 h intravenously with either saline or oleate. In both models, the infusion period was followed by assessment of ß-cell function using the hyperglycemic clamp method. RESULTS: Lipid infusion resulted in a significant decrease in ß-cell function as expected in both rats (p < 0.05) and mice (p < 0.001). Both models of SIRT1 activation, which did not alter ß-cell function in the absence of fat, resulted in partial protection from the fat-induced decrease in ß-cell function (NS vs. control). CONCLUSION: These results suggest that SIRT1 is a therapeutic target in decreased ß-cell function specifically induced by fat.

Acquired cystic kidney disease and renal tumor.

Immunosuppression is a well-known risk factor for malignancy. Renal transplant patients are at high risk for cancer in the native kidneys especially in the presence of acquired cystic disease. We report a case highlighting the importance of screening for renal malignancy in renal transplant patients.

Exploring the uncharted territory of social media: the next frontier of medical education in nephrology.

Social media is gaining popularity amongst both medical educators and life-long learners. One of the most popular social media platforms used by the medical community is Twitter, which is popular amongst physicians, students and patients, and particularly in medical societies. Major international and regional societies commonly use Twitter to amplify their reach beyond what their live annual meetings can achieve. There has been a unique and notable effort by Nephrology societies to craft a structured social media strategy that results in the broadest reach to the community of nephrology providers. We report on the first three such experiments performed by three separate nephrology organizations.

Analysis of the Use and Impact of Twitter During American Society of Clinical Oncology Annual Meetings From 2011 to 2016: Focus on Advanced Metrics and User Trends.

PURPOSE: The use of social media, in particular Twitter, has substantially increased among health care stakeholders in the field of hematology and oncology, with an especially sharp increase in the use of Twitter during times of major national meetings. The most attended meeting in the oncology field is the ASCO annual meeting. Little is known about the detailed metrics involved in the use, volume, and impact of Twitter during the ASCO annual meeting. METHODS: We conducted a retrospective review of tweets during the ASCO annual meetings from 2011 to 2016. The total data set encompassed 190,732 tweets from 39,745 authors over six consecutive ASCO meetings from 2011 to 2016 (inclusive). Tweets, all publically available, were collected by Nephrology On-Demand Analytics. RESULTS: The number of individual authors increased from 1,429 during the 2011 ASCO meeting to 15,796 during the 2016 ASCO meeting, an 11-fold increase over the total 5-year period. There was a notable increase in tweets from the 2011 ASCO meeting (n = 7,746) to the 2016 ASCO meeting (n = 72,698), a nine-fold increase during the study period. The most commonly tweeted term or topic changed over time, generally reflecting the breakthroughs of each designated year; these terms were "melanoma" for both the 2011 and 2012 ASCO meetings; "breast cancer" for the 2013 ASCO meeting; "lung cancer" for the 2014 ASCO meeting; and "ImmunOnc" or "immunotherapy/immuno-oncology" for both the 2015 and 2016 ASCO meetings. CONCLUSION: The use of Twitter among health care stakeholders during the ASCO meeting has markedly increased over time, demonstrating the increasing role of social media in the dissemination of findings at the most highly attended hematology and oncology conference of the year.

Quantifying the Twitter Influence of Third Party Commercial Entities versus Healthcare Providers in Thirteen Medical Conferences from 2011 - 2013.

INTRODUCTION: Twitter channels are increasingly popular at medical conferences. Many groups, including healthcare providers and third party entities (e.g., pharmaceutical or medical device companies) use these channels to communicate with one another. These channels are unregulated and can allow third party commercial entities to exert an equal or greater amount of Twitter influence than healthcare providers. Third parties can use this influence to promote their products or services instead of sharing unbiased, evidence-based information. In this investigation we quantified the Twitter influence that third party commercial entities had in 13 major medical conferences. METHODS: We analyzed tweets contained in the official Twitter hashtags of thirteen medical conferences from 2011 to 2013. We placed tweet authors into one of four categories based on their account profile: healthcare provider, third party commercial entity, none of the above and unknown. We measured Twitter activity by the number of tweet authors per category and the tweet-to-author ratio by category. We measured Twitter influence by the PageRank of tweet authors by category. RESULTS: We analyzed 51159 tweets authored by 8778 Twitter account holders in 13 conferences that were sponsored by 5 medical societies. A quarter of all authors identified themselves as healthcare providers, while only 18% could be identified as third party commercial entities. Healthcare providers had a greater tweet-to-author ratio than their third party commercial entity counterparts (8.98 versus 6.93 tweets). Despite having less authors and composing less tweets, third party commercial entities had a statistically similar PageRank as healthcare providers (0.761 versus 0.797). CONCLUSION: The Twitter influence of third party commercial entities (PageRank) is similar to that of healthcare providers. This finding is interesting because the number of tweets and third party commercial entity authors required to achieve this PageRank is far fewer than that needed by healthcare providers. Without safety mechanisms in place, the Twitter channels of medical conferences can devolve into a venue for the spread of biased information rather than evidence-based medical knowledge that is expected at live conferences. Continuing to measure the Twitter influence that third parties exert can help conference organizers develop reasonable guidelines for Twitter channel activity.

Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States.

INTRODUCTION: Gender disparities in income continue to exist, and many studies have quantified the gap between male and female workers. These studies paint an incomplete picture of gender income disparity because of their reliance on notoriously inaccurate or incomplete surveys. We quantified gender reimbursement disparity between female and male healthcare providers using objective, non-self-reported data and attempted to adjust the disparity against commonly held beliefs as to why it exists. METHODS: We analysed over three million publicly available Medicare reimbursement claims for calendar year 2012 and compared the reimbursements received by male and female healthcare providers in 13 medical specialties. We adjusted these reimbursement totals against how hard providers worked, how productive each provider was, and their level of experience. We calculated a reimbursement differential between male and female providers by primary medical specialty. RESULTS: The overall adjusted reimbursement differential against female providers was -US$18 677.23 (95% CI -US$19 301.94 to -US$18 052.53). All 13 specialties displayed a negative reimbursement differential against female providers. Only two specialties had reimbursement differentials that were not statistically significant. CONCLUSIONS: After adjustment for how hard a physician works, his/her years of experience and his/her productivity, female healthcare providers are still reimbursed less than male providers. Using objective, non-survey data will provide a more accurate understanding of this reimbursement inequity and perhaps lead the medical profession (as a whole) towards a solution that can reverse this decades-old injustice.