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Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Mark Koch, MD - Thu, 05/16/2019 - 11:20
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Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Clin Gastroenterol Hepatol. 2019 May 11;:

Authors: Berry E, Miller S, Koch M, Balasubramanian B, Argenbright K, Gupta S

Abstract
BACKGROUND & AIMS: Non-invasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cutoff concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program.
METHODS: We performed a prospective study of 17,017 uninsured patients, 50-64 years old, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cutoff value for an abnormal FIT result from ≥ 20 to ≥ 10 μg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions with abnormal FIT results and neoplasia yield for standard vs lower cutoff values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cutoff on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared to the standard, higher, hemoglobin concentration cutoff value.
RESULTS: The proportions of patients with abnormal FIT results were 12.3% at the ≥ 10 μg hemoglobin/g feces and 6.6% at the standard ≥ 20 μg hemoglobin/g feces cutoff value (P=.0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P=.12) and 0.9% vs 1.2% for CRC (P=.718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P=.053) and 1.7% vs 2.4% for CRC (P=.659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations ≥ 20 μg/g feces. In the 10-19 μg hemoglobin/g feces range, there were 3 patients with CRC (3/11, 27.3%) and 36 with advanced adenoma (36/110, 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison <.001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cutoff value (44.4%) than the standard cutoff (39.1%) (P=.1103).
CONCLUSION: In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cutoff value (to the ≥ 10 μg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cutoff value, to optimize CRC detection and prevention. ClinicalTrials.gov no: NCT01946282.

PMID: 31085338 [PubMed - as supplied by publisher]

Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Related Articles

Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Clin Gastroenterol Hepatol. 2019 May 11;:

Authors: Berry E, Miller S, Koch M, Balasubramanian B, Argenbright K, Gupta S

Abstract
BACKGROUND & AIMS: Non-invasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cutoff concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program.
METHODS: We performed a prospective study of 17,017 uninsured patients, 50-64 years old, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cutoff value for an abnormal FIT result from ≥ 20 to ≥ 10 μg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions with abnormal FIT results and neoplasia yield for standard vs lower cutoff values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cutoff on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared to the standard, higher, hemoglobin concentration cutoff value.
RESULTS: The proportions of patients with abnormal FIT results were 12.3% at the ≥ 10 μg hemoglobin/g feces and 6.6% at the standard ≥ 20 μg hemoglobin/g feces cutoff value (P=.0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P=.12) and 0.9% vs 1.2% for CRC (P=.718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P=.053) and 1.7% vs 2.4% for CRC (P=.659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations ≥ 20 μg/g feces. In the 10-19 μg hemoglobin/g feces range, there were 3 patients with CRC (3/11, 27.3%) and 36 with advanced adenoma (36/110, 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison <.001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cutoff value (44.4%) than the standard cutoff (39.1%) (P=.1103).
CONCLUSION: In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cutoff value (to the ≥ 10 μg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cutoff value, to optimize CRC detection and prevention. ClinicalTrials.gov no: NCT01946282.

PMID: 31085338 [PubMed - as supplied by publisher]

Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft.

Related Articles

Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft.

Plast Reconstr Surg Glob Open. 2019 Mar;7(3):e2163

Authors: Safa B, Shores JT, Ingari JV, Weber RV, Cho M, Zoldos J, Niacaras TR, Nesti LJ, Thayer WP, Buncke GM

Abstract
Background: Severe trauma often results in the transection of major peripheral nerves. The RANGER Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (PNAs; Avance Nerve Graft, AxoGen, Inc., Alachua, Fla.). Here, we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature.
Methods: The RANGER database was queried for mixed and motor nerve injuries in the upper extremities, head, and neck area having completed greater than 1 year of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the Medical Research Council scale. Demographics, outcomes, and covariate analysis were performed to further characterize this subgroup.
Results: The subgroup included 20 subjects with 22 nerve repairs. The mean ± SD (minimum-maximum) age was 38 ± 19 (16-77) years. The median repair time was 9 (0-133) days. The mean graft length was 33 ± 17 (10-70) mm with a mean follow-up of 779 ± 480 (371-2,423) days. Meaningful motor recovery was observed in 73%. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events.
Conclusions: PNAs were safe and provided functional motor recovery in mixed and motor nerve repairs. Outcomes compare favorably to historical controls for nerve autograft and exceed those for hollow tube conduit. PNA may be considered as an option when reconstructing major peripheral nerve injuries.

PMID: 31044125 [PubMed]

Real-world data on antiviral treatments for hepatitis C virus infections: Can we define intention to treat or per protocol analyses?

Related Articles

Real-world data on antiviral treatments for hepatitis C virus infections: Can we define intention to treat or per protocol analyses?

J Hepatol. 2018 08;69(2):551-553

Authors: Ojha RP, Steyerberg EW

PMID: 29843905 [PubMed - indexed for MEDLINE]

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Russell Wagner, MD - Thu, 05/02/2019 - 07:44
Related Articles

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Arthroplast Today. 2019 Mar;5(1):26-31

Authors: Neal DC, Sambhariya V, Tran A, Rahman SK, Dean TJ, Wagner RA, Sanchez HB

Abstract
Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

PMID: 31020017 [PubMed]

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Hugo Sanchez, MD - Thu, 05/02/2019 - 07:44
Related Articles

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Arthroplast Today. 2019 Mar;5(1):26-31

Authors: Neal DC, Sambhariya V, Tran A, Rahman SK, Dean TJ, Wagner RA, Sanchez HB

Abstract
Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

PMID: 31020017 [PubMed]

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Richard Robinson, MD - Thu, 05/02/2019 - 07:44
Related Articles

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Clin Exp Emerg Med. 2019 May 07;:

Authors: Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H

Abstract
Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.
Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.
Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.
Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

PMID: 31036785 [PubMed - as supplied by publisher]

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Hao Wang, MD - Thu, 05/02/2019 - 07:44
Related Articles

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Clin Exp Emerg Med. 2019 May 07;:

Authors: Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H

Abstract
Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.
Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.
Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.
Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

PMID: 31036785 [PubMed - as supplied by publisher]

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Chet Schrader, MD - Thu, 05/02/2019 - 07:44
Related Articles

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Clin Exp Emerg Med. 2019 May 07;:

Authors: Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H

Abstract
Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.
Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.
Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.
Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

PMID: 31036785 [PubMed - as supplied by publisher]

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Charles Huggins, MD - Thu, 05/02/2019 - 07:44
Related Articles

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Clin Exp Emerg Med. 2019 May 07;:

Authors: Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H

Abstract
Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.
Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.
Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.
Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

PMID: 31036785 [PubMed - as supplied by publisher]

Deconstructing dogma: Nonoperative management of small bowel obstruction in the virgin abdomen.

Related Articles

Deconstructing dogma: Nonoperative management of small bowel obstruction in the virgin abdomen.

J Trauma Acute Care Surg. 2018 07;85(1):33-36

Authors: Collom ML, Duane TM, Campbell-Furtick M, Moore BJ, Haddad NN, Zielinski MD, Ray-Zack MD, Yeh DD, Choudhry AJ, Cullinane DC, Inaba K, Escalante A, Wydo S, Turay D, Pakula A, Watras J, EAST SBO Workgroup:

Abstract
BACKGROUND: Management of small bowel obstruction (SBO) has become more conservative, especially in those patients with previous abdominal surgery (PAS). However, surgical dogma continues to recommend operative exploration for SBO with no PAS. With the increased use of computed tomography imaging resulting in more SBO diagnoses, it is important to reevaluate the role of mandatory operative exploration. Gastrografin (GG) administration decreases the need for operative exploration and may be an option for SBO without PAS. We hypothesized that the use of GG for SBO without PAS will be equally effective in reducing the operative exploration rate compared with that for SBO with PAS.
METHODS: A post hoc analysis of prospectively collected data was conducted for patients with SBO from February 2015 through December 2016. Patients younger than 18 years, pregnant patients, and patients with evidence of hypotension, bowel strangulation, peritonitis, closed loop obstruction or pneumatosis intestinalis were excluded. The primary outcome was operative exploration rate for SBO with or without PAS. Rate adjustment was accomplished through multivariate logistic regression.
RESULTS: Overall, 601 patients with SBO were included in the study, 500 with PAS and 101 patients without PAS. The two groups were similar except for age, sex, prior abdominal surgery including colon surgery, prior SBO admission, and history of cancer. Multivariate analysis showed that PAS (odds ratio [OR], 0.47; p = 0.03) and the use of GG (OR, 0.11; p < 0.01) were independent predictors of successful nonoperative management, whereas intensive care unit admission (OR, 16.0; p < 0.01) was associated with a higher likelihood of need for operation. The use of GG significantly decreased the need for operation in patients with and without PAS.
CONCLUSIONS: Patients with and without PAS who received GG had lower rates of operative exploration for SBO compared with those who did not receive GG. Patients with a diagnosis of SBO without PAS should be considered for the nonoperative management approach using GG.
LEVEL OF EVIDENCE: Therapeutic, level IV.

PMID: 29965940 [PubMed - indexed for MEDLINE]

Aromatase Inhibitors Such as Letrozole (Femara) vs. Clomiphene (Clomid) for Subfertile Women with PCOS.

Aromatase Inhibitors Such as Letrozole (Femara) vs. Clomiphene (Clomid) for Subfertile Women with PCOS.

Am Fam Physician. 2019 May 01;99(9):545-546

Authors: LeFevre N

PMID: 31038903 [PubMed - in process]

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Related Articles

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Clin Exp Emerg Med. 2019 May 07;:

Authors: Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H

Abstract
Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.
Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.
Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.
Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

PMID: 31036785 [PubMed - as supplied by publisher]

Cancer Screening in Li-Fraumeni Syndrome.

Related Articles

Cancer Screening in Li-Fraumeni Syndrome.

JAMA Oncol. 2017 12 01;3(12):1645-1646

Authors: Asdahl PH, Ojha RP, Hasle H

PMID: 28772307 [PubMed - indexed for MEDLINE]

Edwardsiella tarda Bacteremia in Untreated Hepatitis C: Alterations in Antimicrobial Therapy for a Pan-Susceptible Pathogen in a Critically Ill Patient.

Edwardsiella tarda Bacteremia in Untreated Hepatitis C: Alterations in Antimicrobial Therapy for a Pan-Susceptible Pathogen in a Critically Ill Patient.

Am J Ther. 2019 Feb 28;:

Authors: Morrisette T, Hewgley WP, Hewgley H

PMID: 31033487 [PubMed - as supplied by publisher]

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Related Articles

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Arthroplast Today. 2019 Mar;5(1):26-31

Authors: Neal DC, Sambhariya V, Tran A, Rahman SK, Dean TJ, Wagner RA, Sanchez HB

Abstract
Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

PMID: 31020017 [PubMed]

Predicting bacterial infections among pediatric cancer patients with febrile neutropenia: External validation of the PICNICC model.

Related Articles

Predicting bacterial infections among pediatric cancer patients with febrile neutropenia: External validation of the PICNICC model.

Pediatr Blood Cancer. 2018 04;65(4):

Authors: Ojha RP, Asdahl PH, Steyerberg EW, Schroeder H

Abstract
INTRODUCTION: The Predicting Infectious Complications in Neutropenic Children and Young People with Cancer (PICNICC) model was recently developed for antibiotic stewardship among pediatric cancer patients, but limited information is available about its clinical usefulness. We aimed to assess the performance of the PICNICC model for predicting microbiologically documented bacterial infections among pediatric cancer patients with febrile neutropenia.
MATERIALS AND METHODS: We used data for febrile neutropenia episodes at a pediatric cancer center in Aarhus, Denmark between 2000 and 2016. We assessed the area under the receiver operating characteristic curve (AUC), calibration, and clinical usefulness (i.e., net benefit). We also recalibrated the model using statistical updating methods.
RESULTS: We observed 306 microbiologically documented bacterial infections among 1,892 episodes of febrile neutropenia. The AUC of the model was 0.73 (95% confidence limits [CL]: 0.71-0.75). The calibration intercept (calibration-in-the-large) was -0.69 (95% CL: -0.86 to -0.51) and the slope was 0.77 (95% CL: 0.65-0.89). Modest net benefit was observed at a decision threshold of 5%. Recalibration improved calibration but did not improve net benefit.
CONCLUSIONS: The PICNICC model has potential for reducing unnecessary antibiotic exposure for pediatric cancer patients with febrile neutropenia, but continued validation and refinement is necessary to optimize clinical usefulness.

PMID: 29286572 [PubMed - indexed for MEDLINE]

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care.

Hao Wang, MD - Thu, 04/25/2019 - 04:56
Related Articles

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care.

AEM Educ Train. 2019 Apr;3(2):136-144

Authors: Pettit KE, Rattray NA, Wang H, Stuckey S, Mark Courtney D, Messman AM, Kline JA

Abstract
Background: Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers.
Methods: We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter-rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants.
Results: Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the "Empathy Circle."
Conclusions: Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.

PMID: 31008425 [PubMed]

Coding Family Medicine Residency Clinic Visits, 99213 or 99214? A Residency Research Network of Texas Study.

Richard Young, MD - Thu, 04/25/2019 - 04:56
Related Articles

Coding Family Medicine Residency Clinic Visits, 99213 or 99214? A Residency Research Network of Texas Study.

Fam Med. 2019 Apr 23;:

Authors: Young RA, Holder S, Kale N, Burge SK, Kumar KA

Abstract
BACKGROUND AND OBJECTIVES: The purpose of this study was to characterize Current Procedural Terminology (CPT) coding patterns for professional services in family physician (FP) residency clinics.
METHODS: Trained assistants directly observed during every other FP-patient encounter in 10 clinics affiliated with eight residencies of the Residency Research Network of Texas. Three investigators later independently coded each visit for the highest code level reasonably allowed. The primary outcome was the number of clinic visits that were actually coded as a CPT 99203/213 that could have been coded at a higher level.
RESULTS: In 850 physician-patient encounters where the CPT code billed was identified, the investigators completely agreed on the allowable code 93% of the time. Overall, a 99203/13 or lower or preventive services code was billed in 651 visits (76.6%), more commonly in resident visits (515/570 [90.4%] vs 136/280 for faculty [48.6%], P&lt;.001). There were 476/660 (72.1%) visits coded at a 99213 or less that could have been coded as a 99204/214 or higher. This was more common in resident visits 385/434 (88.7%), but there was undercoding in faculty patients as well 91/226 (40.3%). We found very few cases of overcoding-16 total.
CONCLUSIONS AND RELEVANCE: FPs coding patient encounters in residency clinics undercode for their work, which leads to decreased clinic revenue. This may be because the primary care exception is felt to be too onerous to bill for higher-paid codes, or a lack of knowledge of CMS coding rules among residents and faculty, or other reasons.

PMID: 31013346 [PubMed - as supplied by publisher]

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care.

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care.

AEM Educ Train. 2019 Apr;3(2):136-144

Authors: Pettit KE, Rattray NA, Wang H, Stuckey S, Mark Courtney D, Messman AM, Kline JA

Abstract
Background: Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers.
Methods: We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter-rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants.
Results: Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the "Empathy Circle."
Conclusions: Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.

PMID: 31008425 [PubMed]

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