Comparing outcomes of right verse left hepatic approach percutaneous biliary drainage catheters.

Purpose: Determine if there is a difference in adverse events (AE) between right or left hepatic percutaneous biliary drain placement (PTBD) in patients with biliary strictures. Materials & methods: This retrospective study included patients with benign or malignant biliary stricture treated with PTBD at a single institution from 7/28/2004-3/30/2021. 357 patients met inclusion criteria, 77 (21.6 %) had PTBD on the left and 280 (78.4 %) on the right. AEs associated with the initial drain placement or during subsequent intervention were collected and categorized. AEs that were grouped as periprocedural included: surgery, infection, hemorrhage, and drain failure. AEs in the postprocedural group included: chills, catheter displacement, cholangitis, biliary stones, drain malfunction, fever resolving without treatment, and pericatheter leakage. Surgery was considered a major AE and the remaining AEs were categorized as minor. Statistical analyses were performed using Logistic Regression Analysis and p-values less than 0.05 were considered statistically significant. Results: Overall, there was no statistically significant difference in AEs between right and left drains in the periprocedural and postprocedural period (p = 0.832, OR = 0.95 and p = 0.808, OR = 0.93 respectively). When analyzing minor AEs individually, only cholangitis occurred at a higher rate on the right side (p = 0.033, OR = 0.43). There was no statistical difference in the rate of major AEs in the periprocedural period between left and right drains (p = 0.311, OR = 1.37). Conclusion: Current literature is equivocal when comparing right versus left percutaneous biliary drains. This analysis describes no statistically significant difference in AEs between right and left hepatobiliary drains aside from slightly higher incidence of cholangitis for right sided drains.

Medical Service Quality and Office Rent Premiums: Reputation Spillovers.

Location spillovers are a common theme in real estate and urban economics research, but this is the first test on the relationship between hospital service quality and the demand for proximate medical office space. We hypothesize that hospitals with reputations for high quality service represent an opportunity for physicians, and other service providers, to benefit from reputation spillovers. Further, the reputation benefit is capitalized into the practices' willingness to pay for proximate office locations, thereby driving up the rental rates for nearby space. We find that distance from, and overall quality ranking of the hospital, both independent and in concert, are significantly linked to the base rents. The degradation in rent with distance is significantly greater when the hospital is ranked high in overall service quality, supporting the notion that a rent premium is linked to the high-quality hospital rather than simply an artifact of the neighborhood.

Placement Architectures in Practice: An Exploration of Student Learning during Non-Traditional Work-Integrated Learning in Rural Communities.

BACKGROUND: Work-integrated learning (WIL) in rural communities provides students with important learning opportunities while also providing a service to those communities. To optimise the potential benefits of work-integrated learning for health students and rural communities it is important to explore the practices and outcomes of these experiences. METHODS: This study used a qualitative research design underpinned by the theoretical framework of Theory of Practice Architectures to examine the way students learn during these placements. Purposive sampling was used to identify students for participation in the study. Seven students from the disciplines of paramedicine, physiotherapy, and speech pathology participated in semi-structured interviews. Data were analysed using inductive thematic analysis. RESULTS: The learning described by the students was examined, followed by a critical interrogation of the data to assess how these learnings and associated practices were made possible given the site-specific practice architectures. The findings of the research are represented by three themes: learning affordances related to placement design, learning through relationships between people and professions, and learning through rural embeddedness. CONCLUSION: Being embedded in rural communities gave the students access to several arrangements that fostered learning, particularly through the sayings, relatings and doings that the students engaged with. This research demonstrates the transformative potential of rural WIL opportunities for learning and future rural practice.

Co-designing community-focused rural placements for collaborative practice.

AIMS AND CONTEXT: As a University Department of Rural Health, we have identified recurrent areas of service need among vulnerable rural populations, specifically the need for allied health. Concurrently, we have also identified missed opportunities for deliberate collaborative practice in rural clinical placements. This paper provides a commentary on our work in progress as we work to leverage available opportunities to provide both service from and education for health profession students on rural clinical placements. APPROACH: We developed a transdisciplinary placement model, informed by practice theory, which encompasses pre-placement preparation, student support, host sites and clinicians, and a structured evaluation strategy. This model aims to facilitate service provision alongside of student learning about community and collaborative practice. In particular, the co-design of the model is expected to facilitate student's sense of social accountability and reduce stigma in working with vulnerable population groups. CONCLUSION: This paper highlights the need for greater alignment between rural health education and practice, describes a placement model that is working towards this and showcases how this has been enacted in a remote community in New South Wales. More cross-sector discussion and evaluation is needed to determine the implications of adopting this model more widely if service and learning opportunities are to be equally achieved, and to determine the ways in which training and service provision can be aligned with community need, as recommended in the recent Rural Health Commissioner Report.

Reaching at-risk rural men: An evaluation of a health promotion activity targeting men at a large agricultural event.

ISSUE ADDRESSED: This paper evaluates the effectiveness of an Australian Men's Shed Association's 'Spanner in the Works?' health promotion tent in reaching at-risk rural men during a large agricultural event in rural Australia. METHODS: Men who self-presented to the health promotion tent had basic health measurements and risk scores recorded. These were linked to a short survey asking about their primary health care engagement. To determine the 'reach' afforded to health professionals through their presence at the agricultural event, the mean systolic blood pressure and waist circumference measures of participants were compared to those of rural men nationally using the ABS' National Health Survey 2017-2018 Basic Confidentialised Unit Record File (CURF). RESULTS: Of the 401 men who visited the health promotion tent, 346 (86.3%) consented to participate in the study. The median age of participating men was 56 years. The majority (94.0%) were from rural areas. Of participating men, 58.9% had high blood pressure, and their mean systolic blood pressure was significantly higher than that of rural men nationally: both overall (Mean difference = 15.37 mm Hg), and at all age groups. Participants also had significantly higher waist circumference overall (Mean difference = 2.06 cm), but this was only significantly different for the 45-54 age group. CONCLUSIONS: The 'Spanner in the Works?' initiative was effective in reaching both healthy and at-risk rural men from a range of ages. SO WHAT?: Aligned with the National Men's Heath Strategy 2020-2030, this evidences that agricultural events are an effective social setting for the provision of health promotion to 'at risk' rural men.

Dynamic Leap and Balance Test: Ability to Discriminate Balance Deficits in Individuals With Chronic Ankle Instability.

CONTEXT: The Dynamic Leap Balance Test (DLBT) is a new dynamic balance task that requires serial changes in base of support with alternating limb support and recovery of dynamic stability, as compared with the Y modification of the Star Excursion Balance Test (Y-SEBT), which assesses dynamic stability over an unchanging base of support. OBJECTIVES: To assess the dynamic balance performance in 2 different types of dynamic balance tasks, the DLBT and the SEBT, in subjects with unilateral chronic ankle instability (CAI) when compared with matched controls. The authors hypothesized that the DLBT score would significantly differ between the CAI involved and uninvolved limbs (contralateral and healthy matched) and demonstrate a modest (r = .50) association with the SEBT scores. DESIGN: Case-control. SETTING: Controlled laboratory. PARTICIPANTS: A total of 36 physically active adults, 18 with history of unilateral CAI and 18 without history of ankle injury, were enrolled in the study. CAI subjects were identified using the Identification of Functional Ankle Instability questionnaire. INTERVENTIONS: The DLBT and the SEBT were performed in a randomized order on a randomly selected limb in CAI and healthy subjects. MAIN OUTCOME MEASURES: Time taken to complete the DLBT and the reach distances performed on the SEBT were compared between the CAI and the healthy subjects. RESULTS: There were no statistically significant differences (P < .05) in SEBT reach distances between groups. The DLBT time was greater (P < .01) for unstable ankles compared with the stable ankle. The authors found no correlation (P > .05) between DLBT time and any of the SEBT reach distances suggesting that the DLBT provides unique information in the assessment of patients with CAI. CONCLUSION: The DLBT challenges the ability to maintain postural control in CAI subjects differently than the SEBT. There is a need of more dynamic balance assessment tools that are functional and clinically relevant.

Effects of Hip Strengthening on Neuromuscular Control, Hip Strength, and Self-Reported Functional Deficits in Individuals With Chronic Ankle Instability.

CONTEXT: Deficits in ankle and hip strength and lower-extremity postural control are associated with chronic ankle instability (CAI). Following strength training, muscle groups demonstrate increased strength. This change is partially credited to improved neuromuscular control, and many studies have investigated ankle protocols for subjects with CAI. The effects of isolating hip musculature in strength training protocols in this population are not well understood. OBJECTIVE: To examine the effects of hip strengthening on clinical and self-reported outcomes in patients with CAI. DESIGN: Prospective randomized controlled clinical trial. SETTING: Athletic training facility. PARTICIPANTS: Twenty-six participants with CAI (12 males and 14 females; age = 20.9 [1.5] y, height = 170.0 [12.7] cm, and mass = 77.5 [17.5] kg) were randomly assigned to training or control groups. INTERVENTION: Participants completed either 4 weeks of supervised hip strengthening (resistance bands 3 times a week) or no intervention. MAIN OUTCOME MEASURES: Participants were assessed on 4 clinical measures (Star Excursion Balance Test in the anterior, posteromedial, and posterolateral directions; Balance Error Scoring System; hip external rotation strength; and hip abduction strength) and a patient-reported measure (the Foot and Ankle Ability Measure activities of daily living and sports subscales) before and after the 4-week training period. RESULTS: The training group displayed significantly improved posttest measures compared with the control group for hip abduction strength (training: 446.3 [77.4] N, control: 314.7 [49.6] N, P < .01); hip external rotation strength (training: 222.1 [48.7] N, control: 169.4 [34.6] N, P < .01); Star Excursion Balance Test reach in the anterior (training: 93.1% [7.4%], control: 90.2% [7.9%], P < .01), posteromedial (training: 96.3% [8.9%], control: 88.0% [8.8%], P < .01), and posterolateral (training: 95.4% [11.1%], control: 86.6% [9.6%], P < .01) directions; Balance Error Scoring System total errors (training: 9.9 [6.3] errors, control: 21.2 [6.3] errors, P < .01); and the Foot and Ankle Ability Measure-sports score (training: 88.0 [12.6], control: 84.8 [10.9], P < .01). CONCLUSION: Improved clinical and patient-reported outcomes in the training group suggest hip strengthening is beneficial in the management and prevention of recurrent symptoms associated with CAI.

THE DYNAMIC LEAP AND BALANCE TEST (DLBT): A TEST-RETEST RELIABILITY STUDY.

BACKGROUND: There is a need for new clinical assessment tools to test dynamic balance during typical functional movements. Common methods for assessing dynamic balance, such as the Star Excursion Balance Test, which requires controlled movement of body segments over an unchanged base of support, may not be an adequate measure for testing typical functional movements that involve controlled movement of body segments along with a change in base of support. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the reliability of the Dynamic Leap and Balance Test (DLBT) by assessing its test-retest reliability. It was hypothesized that there would be no statistically significant differences between testing days in time taken to complete the test. STUDY DESIGN: Reliability study. METHODS: Thirty healthy college aged individuals participated in this study. Participants performed a series of leaps in a prescribed sequence, unique to the DLBT test. Time required by the participants to complete the 20-leap task was the dependent variable. Subjects leaped back and forth from peripheral to central targets alternating weight bearing from one leg to the other. Participants landed on the central target with the tested limb and were required to stabilize for two seconds before leaping to the next target. Stability was based upon qualitative measures similar to Balance Error Scoring System. Each assessment was comprised of three trials and performed on two days with a separation of at least six days. RESULTS: Two-way mixed ANOVA was used to analyze the differences in time to complete the sequence between the three trial averages of the two testing sessions. Intraclass Correlation Coefficient (ICC3,1) was used to establish between session test-retest reliability of the test trial averages. Significance was set a priori at p ≤ 0.05. No significant differences (p > 0.05) were detected between the two testing sessions. The ICC was 0.93 with a 95% confidence interval from 0.84 to 0.96. CONCLUSION: This test is a cost-effective, easy to administer and clinically relevant novel measure for assessing dynamic balance that has excellent test-retest reliability. CLINICAL RELEVANCE: As a new measure of dynamic balance, the DLBT has the potential to be a cost-effective, challenging and functional tool for clinicians. LEVEL OF EVIDENCE: 2b.

Management of primary anterior shoulder dislocations using immobilization.

UNLABELLED: Reference/Citation : Paterson WH, Throckmorton TW, Koester M, Azar FM, Kuhn JE. Position and duration of immobilization after primary anterior shoulder dislocation: a systemic review and meta-analysis of the literature. J Bone Joint Surg Am. 2010;92(18):2924-2933. CLINICAL QUESTION: Does an optimum duration and position of immobilization after primary anterior shoulder dislocation exist for reducing recurrence rates? DATA SOURCES: MEDLINE/PubMed, EMBASE, and Cochrane databases were searched up to December 2009 without limitations. The search terms for all databases used were shoulder AND dislocation and shoulder AND immobilization. STUDY SELECTION: Criteria used to include articles were (1) English language, (2) prospective level I or level II studies (according to Journal of Bone & Joint Surgery guidelines), (3) nonoperative management of initial anterior shoulder dislocation, (4) minimum follow-up of 1 year, and (5) rate of recurrent dislocation as a reported outcome. DATA EXTRACTION: A standardized evaluation method was used to extract data to allow assessment of methods issues and statistical analysis to determine sources of bias. The primary outcome was the recurrence rate after nonoperative management of anterior shoulder dislocation. Additional data extracted and used in subanalyses included duration and position of immobilization and age at the time of initial dislocation. Data were analyzed to determine associations among groups using 2-tailed Fisher exact tests. For pooled categorical data, relative risk of recurrent dislocation, 95% confidence intervals, and heterogeneity using the I(2) statistic and χ(2) tests were calculated for individual studies. The Mantel-Haenszel method was used to combine studies and estimate overall relative risk of recurrent dislocation and 95% confidence intervals. The statistical difference between duration of immobilization and position was determined using z tests for overall effect. Pooled results were presented as forest plots. MAIN RESULTS: In the initial search of the databases, the authors identified 2083 articles. A total of 9 studies met all of the criteria and were included in this review. In most of the studies, age was a risk factor for recurrence. Patients less than 30 years of age were more likely to sustain a recurrent dislocation than patients more than 30 years of age. In 5 studies (n = 1215), researchers found no difference in recurrence of shoulder dislocation when immobilized in internal rotation (IR) for less than 1 week (41%, 40 of 97) compared with more than 3 weeks (37%, 34 of 93) in patients less than 30 years of age (P = .52). Authors of 3 studies (n = 289) compared the effect of immobilization in IR versus external rotation (ER), and whereas they found no statistical difference, a trend appeared toward reduced recurrence rates in ER but not IR (P = .07). The rate of recurrent dislocation was 40% (25 of 63) in patients treated with IR sling immobilization and 25% (22 of 88) in patients immobilized in ER. CONCLUSIONS: Overall, the investigators found that younger age (<30 years) was a predictor of recurrent dislocations, immobilization for more than 1 week did not improve recurrence rates, and an apparent trend existed toward decreased recurrence rates with ER rather than IR. According to the review and meta-analysis by Paterson et al, the level of evidence for recommendations regarding optimal duration and position of immobilization to reduce the risk of recurrent dislocation was therapeutic level II. This level of evidence was appropriate because the review included only prospective studies of level I or II and a minimum follow-up of 1 year.

The effect of cognitive debiasing training among family medicine residents.

BACKGROUND: Debiasing education has been recommended for physicians in training. We report on the efficacy of a workshop designed to aid family medicine residents recognize and respond to their risk of misdiagnosis due to cognitive biases during patient care. METHODS: Residents participated in a debiasing workshop in which they were taught to recognize and respond to cognitive biases likely to contribute to misdiagnosis. Metacognition was introduced and cognitive forcing strategies were demonstrated and practiced. While precepting clinic visits, attendings evaluated residents in the following areas: 1) diagnostic concordance between resident and attending, 2) ability of the resident to perceive their risk of cognitive bias, 3) the quality of the resident's plan to mitigate this risk, and 4) the presence of an unrecognized cognitive bias. Pre and post workshop data were compared. RESULTS: Preceptor concurrence with the residents' diagnoses was unchanged - 74% (63 of 85) vs. 78% (45 of 58, p=0.64). Residents' ability to recognize their risk of cognitive bias was unchanged - 51% (43 of 85) vs. 57% (33 of 58, p=0.46). Residents' formulation of an acceptable plan to mitigate the effect of cognitive bias increased from 84% (36 of 43) to 100% (33 of 33, p=0.02). Preceptors' perception of an unrecognized cognitive bias in the residents' presentation was unchanged - 12% (10 of 85) vs. 9% (5 of 58, p=0.55). CONCLUSIONS: A debiasing workshop for family medicine residents demonstrated improvement in one of four studied outcomes.

Suspect myopathy? Take this approach to the work-up.

This practical guide, with handy reference tools, will help you to distinguish between myopathy and nonmyopathic disease and further refine your diagnosis.

Ankle strength and force sense after a progressive, 6-week strength-training program in people with functional ankle instability.

CONTEXT: Although strength training is commonly used to rehabilitate ankle injuries, studies investigating the effects of strength training on proprioception have shown conflicting results. OBJECTIVE: To determine the effects of a 6-week strength-training protocol on force sense and strength development in participants with functional ankle instability. DESIGN: Randomized controlled clinical trial. SETTING: University athletic training research laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 40 participants with functional ankle instability were recruited. They were randomly placed into a training group (10 men, 10 women: age = 20.9 ± 2.2 years, height = 76.4 ± 16.1 cm, mass = 173.0 ± 7.9 kg) or control group (10 men, 10 women: age = 20.2 ± 2.1 years, height = 78.8 ± 24.5 cm, mass = 173.7 ± 8.2 kg). INTERVENTION(S): Participants in the training group performed strength exercises with the injured ankle 3 times per week for 6 weeks. The protocol consisted of a combination of rubber exercise bands and the Multiaxial Ankle Exerciser, both clinically accepted strengthening methods for ankle rehabilitation. The progression of this protocol provided increasingly resistive exercise as participants changed either the number of sets or resistance of the Thera-Band or Multiaxial Ankle Exerciser. Main Outcome Measure(s): A load cell was used to measure strength and force sense. Inversion and eversion strength was recorded to the nearest 0.01 N. Force-sense reproduction was measured at 2 loads: 20% and 30% of maximal voluntary isometric contraction. RESULTS: Increases in inversion (F(1,38) = 11.59, P < 0.01, η(p)(2) = 0.23, power = 0.91) and eversion (F(1,38) = 57.68, P < .01, η(p)(2) = 0.60, power = 0.99) strength were found in the training group at the posttest when compared with the control group. No significant improvements were noted in force-sense reproduction for either group. CONCLUSIONS: Strength training at the ankle increased strength but did not improve force sense.