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What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare

Richard Young, MD - Wed, 03/24/2021 - 05:00

J Eval Clin Pract. 2021 Mar 24. doi: 10.1111/jep.13545. Online ahead of print.

ABSTRACT

Sturmberg and Martin make a compelling case for primary healthcare (PHC) to be the foundation for universal healthcare (UHC). They state that a system should have necessary resources, but what does that mean? Basic economic theory postulates that all resources are limited and that choices must be made between competing options. For a UHC system to be successful and resilient, it must accept that healthcare is a limited right, there will always be inequalities in healthcare delivery and outcomes, primary care physicians and their teams must accept the added burden of balancing the needs of their personal patients with the greater system, leaders and observers of healthcare systems must accept that moderation and balance will often be the best outcome even though they are difficult to measure, and leaders of healthcare systems must accept that they cannot control the system, but contribute by providing context and limited constraints, information, and resources. A deeper understanding of complex adaptive systems will best guide these necessary changes.

PMID:33760312 | DOI:10.1111/jep.13545

What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare

J Eval Clin Pract. 2021 Mar 24. doi: 10.1111/jep.13545. Online ahead of print.

ABSTRACT

Sturmberg and Martin make a compelling case for primary healthcare (PHC) to be the foundation for universal healthcare (UHC). They state that a system should have necessary resources, but what does that mean? Basic economic theory postulates that all resources are limited and that choices must be made between competing options. For a UHC system to be successful and resilient, it must accept that healthcare is a limited right, there will always be inequalities in healthcare delivery and outcomes, primary care physicians and their teams must accept the added burden of balancing the needs of their personal patients with the greater system, leaders and observers of healthcare systems must accept that moderation and balance will often be the best outcome even though they are difficult to measure, and leaders of healthcare systems must accept that they cannot control the system, but contribute by providing context and limited constraints, information, and resources. A deeper understanding of complex adaptive systems will best guide these necessary changes.

PMID:33760312 | DOI:10.1111/jep.13545

Plantar Fasciitis/Fasciosis

Travis Motley, DPM - Mon, 03/22/2021 - 05:00

Clin Podiatr Med Surg. 2021 Apr;38(2):193-200. doi: 10.1016/j.cpm.2020.12.005. Epub 2021 Feb 13.

ABSTRACT

Many randomized controlled trials demonstrate the effectiveness of conservative treatment of plantar fasciitis. Patients with acute plantar fasciitis generally respond to treatment more rapidly and more predictably than patients with chronic plantar fasciitis. If conservative treatment fails, endoscopic plantar fasciotomy offers patients a more prompt return to activity compared with open procedures.

PMID:33745651 | DOI:10.1016/j.cpm.2020.12.005

Financial constraints on genetic counseling and further risk-management decisions among U.S. women at elevated breast cancer risk

J Genet Couns. 2021 Mar 21. doi: 10.1002/jgc4.1413. Online ahead of print.

ABSTRACT

Clinical guidelines recommend that women at high risk of breast cancer should consider various risk-management options, which remain widely underutilized. We conducted semi-structured, qualitative interviews with 50 high-risk women to understand how financial constraints affect use of genetic counseling, genetic testing, and further risk-management decisions. Inductive analyses revealed three categories of health-related financial constraint: (a) lack of insurance, (b) underinsurance, and (c) other financial constraints (e.g., medical debt, raising children, managing comorbidities). Various breast cancer risk-management actions were limited by these financial constraints, including genetic counseling, genetic testing, enhanced screening, and prophylactic surgeries. Women's narratives also identified complex relationships between financial constraint and perceptions of healthcare providers and insurance companies, particularly as related to bias, price transparency, and potential genetic discrimination. Results from this study have implications for further research and expansion of genetic counseling services delivery to more economically and racially diverse women.

PMID:33749063 | DOI:10.1002/jgc4.1413

Plantar Fasciitis/Fasciosis

Clin Podiatr Med Surg. 2021 Apr;38(2):193-200. doi: 10.1016/j.cpm.2020.12.005. Epub 2021 Feb 13.

ABSTRACT

Many randomized controlled trials demonstrate the effectiveness of conservative treatment of plantar fasciitis. Patients with acute plantar fasciitis generally respond to treatment more rapidly and more predictably than patients with chronic plantar fasciitis. If conservative treatment fails, endoscopic plantar fasciotomy offers patients a more prompt return to activity compared with open procedures.

PMID:33745651 | DOI:10.1016/j.cpm.2020.12.005

Adverse drug reactions in the era of COVID-19

Intern Emerg Med. 2021 Mar 13. doi: 10.1007/s11739-020-02603-w. Online ahead of print.

NO ABSTRACT

PMID:33713283 | DOI:10.1007/s11739-020-02603-w

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

James d'Etienne, MD - Tue, 03/09/2021 - 05:00

Scand J Trauma Resusc Emerg Med. 2021 Mar 8;29(1):44. doi: 10.1186/s13049-021-00858-6.

ABSTRACT

INTRODUCTION: This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS: We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.

RESULTS: Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42-11.02, p: 0.02). That is, when the studies not accounting for the variable of "time to intervention" in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.

CONCLUSIONS: The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

PMID:33685486 | PMC:PMC7938460 | DOI:10.1186/s13049-021-00858-6

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

Scand J Trauma Resusc Emerg Med. 2021 Mar 8;29(1):44. doi: 10.1186/s13049-021-00858-6.

ABSTRACT

INTRODUCTION: This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS: We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.

RESULTS: Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42-11.02, p: 0.02). That is, when the studies not accounting for the variable of "time to intervention" in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.

CONCLUSIONS: The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

PMID:33685486 | DOI:10.1186/s13049-021-00858-6

Nephrotoxicity and antibiotics

Intern Emerg Med. 2021 Mar 3. doi: 10.1007/s11739-021-02673-4. Online ahead of print.

NO ABSTRACT

PMID:33656684 | DOI:10.1007/s11739-021-02673-4

Approach to Formalized Ultrasound Credentialing in a Community Hospital Health System with both Academic and Non-Academic Clinical Settings

Spartan Med Res J. 2020 Jun 8;5(1):12748.

ABSTRACT

INTRODUCTION: In the US, ultrasound in Emergency Medicine (EM) is widely considered the standard of care in clinical practice amongst most Emergency Department providers. At the authors' institution and affiliates, there were a variety of health care providers utilizing ultrasound for clinical practice, and their skill levels varied, dependent on training and exposure. As an attempt to standardize credentialing practice and determine need for additional training thresholds, the authors endeavored to perform a skills assessment utilizing both written and clinical based practical assessments.

METHODS: A 7 point questionnaire was administered to a convenience sample of providers requesting formal training information, number of ultrasounds performed, and self-assessed competency. A 10 point written assessment with ultrasound knowledge and clinical application questions was also administered. A subsequent clinical assessment on live humans and models was then performed with multiple stations assessing 15 different instrumentation skills and technique, as well as image interpretation and evaluation.

RESULTS: A total of 23 attending EM board-certified physicians, and four advanced practice providers (PA and NP) took the credentialing assessments scoring an average of 7.3 out of 10 (SD 0.83) for the written assessment. Twenty (71%) of the 28 tested passed the clinical evaluation on their initial attempt. Five (17%) passed on a first remediation. Three (10%) required more than one initial revision attempt. All those who did remediate were able to complete the revision with a passing score.

CONCLUSIONS: Overall, the testing was considered a successful process. This program appears to have offered a level of standardization that was appealing to the credentialing body at our institution. We were able to assess to a level of competence considered standard of care by national credentialing bodies.

PMID:33655179 | PMC:PMC7746098

A slow-growing anterior maxillary mass

Roderick Y. Kim DDS, MD - Mon, 03/01/2021 - 05:00

Oral Surg Oral Med Oral Pathol Oral Radiol. 2021 Jan 29:S2212-4403(21)00068-7. doi: 10.1016/j.oooo.2021.01.021. Online ahead of print.

ABSTRACT

A 43-year-old-male with no medical conditions presented to his dentist with a left maxillary swelling present for 1 year. His physical exam revealed a 2-cm × 2-cm, poorly demarcated, firm mass in the left anterior maxilla causing mobility of the associated teeth. He had a bluish discoloration of the anterior maxillary mucosa. A computed tomographic scan demonstrated a homogeneous and uniformly radiolucent, well-defined mass in the left anterior maxilla primarily involving the alveolus and the roots of teeth 7-12. The mass caused expansion and tooth displacement. An incisional biopsy was done and MUC 4 staining was diffusely positive so the diagnosis of low-grade fibromyxoid sarcoma (LGFMS) was made. He underwent wide local excision and reconstruction with a fibula free flap and a three-dimensionally printed, implant-retained prosthesis. The final pathology confirmed the diagnosis of LGFMS, stage pT4aN0M0, with negative margins. The patient had no evidence of recurrence at 1-year follow-up.

PMID:33642230 | DOI:10.1016/j.oooo.2021.01.021

A slow-growing anterior maxillary mass

Fayette C. Williams, DDS, MD, FACS - Mon, 03/01/2021 - 05:00

Oral Surg Oral Med Oral Pathol Oral Radiol. 2021 Jan 29:S2212-4403(21)00068-7. doi: 10.1016/j.oooo.2021.01.021. Online ahead of print.

ABSTRACT

A 43-year-old-male with no medical conditions presented to his dentist with a left maxillary swelling present for 1 year. His physical exam revealed a 2-cm × 2-cm, poorly demarcated, firm mass in the left anterior maxilla causing mobility of the associated teeth. He had a bluish discoloration of the anterior maxillary mucosa. A computed tomographic scan demonstrated a homogeneous and uniformly radiolucent, well-defined mass in the left anterior maxilla primarily involving the alveolus and the roots of teeth 7-12. The mass caused expansion and tooth displacement. An incisional biopsy was done and MUC 4 staining was diffusely positive so the diagnosis of low-grade fibromyxoid sarcoma (LGFMS) was made. He underwent wide local excision and reconstruction with a fibula free flap and a three-dimensionally printed, implant-retained prosthesis. The final pathology confirmed the diagnosis of LGFMS, stage pT4aN0M0, with negative margins. The patient had no evidence of recurrence at 1-year follow-up.

PMID:33642230 | DOI:10.1016/j.oooo.2021.01.021

A slow-growing anterior maxillary mass

Oral Surg Oral Med Oral Pathol Oral Radiol. 2021 Jan 29:S2212-4403(21)00068-7. doi: 10.1016/j.oooo.2021.01.021. Online ahead of print.

ABSTRACT

A 43-year-old-male with no medical conditions presented to his dentist with a left maxillary swelling present for 1 year. His physical exam revealed a 2-cm × 2-cm, poorly demarcated, firm mass in the left anterior maxilla causing mobility of the associated teeth. He had a bluish discoloration of the anterior maxillary mucosa. A computed tomographic scan demonstrated a homogeneous and uniformly radiolucent, well-defined mass in the left anterior maxilla primarily involving the alveolus and the roots of teeth 7-12. The mass caused expansion and tooth displacement. An incisional biopsy was done and MUC 4 staining was diffusely positive so the diagnosis of low-grade fibromyxoid sarcoma (LGFMS) was made. He underwent wide local excision and reconstruction with a fibula free flap and a three-dimensionally printed, implant-retained prosthesis. The final pathology confirmed the diagnosis of LGFMS, stage pT4aN0M0, with negative margins. The patient had no evidence of recurrence at 1-year follow-up.

PMID:33642230 | DOI:10.1016/j.oooo.2021.01.021

Reporting and Tracking Objective Functional Outcome Measures: Implementation of a Summary Report for Gait and Balance Measures

Spine J. 2021 Feb 22:S1529-9430(21)00086-3. doi: 10.1016/j.spinee.2021.02.015. Online ahead of print.

ABSTRACT

The aim of this manuscript is to describe knowledge gaps in the literature, future directions, and emerging applications of gait and balance analysis in spine surgery with regard to functional outcomes measurement. Functional outcome measurement has been established as a useful clinical and research investigational tool in musculoskeletal disease. Evidence currently supports its use in the diagnosis, treatment, and outcome measurement of multiple musculoskeletal disease states, including spinal disease, and its usefulness continues to grow as literature develops. Gait and balance analysis has proven to be broadly applicable, but most clinicians remain unfamiliar and untrained in its usage. The logistical and communication barriers are also described with the potential solutions that are on the near horizon of research. This article describes our methodology for improving conveyance of functional outcome measures in spine surgery. Additionally, we provide a case example of an adult patient with spinal deformity who is examined pre and post operatively using our methodology.

PMID:33631256 | DOI:10.1016/j.spinee.2021.02.015

Considerations in Free Flap Reconstruction of the Midface.

Fayette C. Williams, DDS, MD, FACS - Sat, 02/20/2021 - 17:49
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Considerations in Free Flap Reconstruction of the Midface.

Facial Plast Surg. 2021 Feb 15;:

Authors: Hammer D, Vincent AG, Williams F, Ducic Y

Abstract
Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

PMID: 33588473 [PubMed - as supplied by publisher]

Risk Factors for Abdominal Surgical Site Infection after Exploratory Laparotomy among Combat Casualties.

Related Articles

Risk Factors for Abdominal Surgical Site Infection after Exploratory Laparotomy among Combat Casualties.

J Trauma Acute Care Surg. 2021 Feb 16;:

Authors: Bozzay JD, Walker PF, Schechtman DW, Shaikh F, Stewart L, Carson ML, Tribble DR, Rodriguez CJ, Bradley MJ, Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group

Abstract
BACKGROUND: Surgical site infections (SSI) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties.
METHODS: Military personnel with combat injuries sustained in Iraq and Afghanistan (6/2009-5/2014) who underwent laparotomy and were evacuated to participating U.S. military hospitals were included. Log-binominal regression was used to identify SSI risk factors.
RESULTS: Of 4304 combat casualties, 341 patients underwent a total of 1053 laparotomies. Abdominal SSIs were diagnosed in 49 (14.4%) patients; 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p<0.001), small bowel (p=0.010), duodenum (p=0.006), pancreas (p=0.032), and abdominal vascular injuries (p=0.040), as well as prolonged open abdomen (p=0.004) and more infections diagnosed before the SSI (or final ex-lap) versus non-SSI patients (p<0.001). Sustaining colorectal injuries (risk ratio [RR]: 3.20; 95% CI: 1.58-6.45), duodenum injuries (RR: 6.71; 95% CI: 1.73-25.58), and being diagnosed with prior infections (RR: 10.34; 95% CI: 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intraabdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device (IED) was associated with reduced likelihood compared to penetrating non-blast (e.g., gunshot wounds) injuries. Non-intraabdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood.
CONCLUSIONS: Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14% and is comparable to risk factors and rates reported following severe civilian trauma.
LEVEL OF EVIDENCE: Epidemiological, Level III.

PMID: 33605707 [PubMed - as supplied by publisher]

Considerations in Free Flap Reconstruction of the Midface.

Related Articles

Considerations in Free Flap Reconstruction of the Midface.

Facial Plast Surg. 2021 Feb 15;:

Authors: Hammer D, Vincent AG, Williams F, Ducic Y

Abstract
Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

PMID: 33588473 [PubMed - as supplied by publisher]

PCSK9 Inhibitors

2021 Feb 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.

ABSTRACT

Familial hypercholesterolemia is characterized by extremely high levels of total and LDL-cholesterol, premature vascular disease, and tendon xanthomas. In the vast majority of cases, this is due to a genetic mutation of the LDL receptor, rarely mutations of the apoprotein B100 or PCSK9 genes. At present, there are two pharmaceutical products available in the United States that reduce PCSK9 activity: alirocumab and evolocumab, which reduce PCSK9 activity, lowering LDL-cholesterol levels, and decrease the risk of cardiovascular disease. This activity outlines the indications, mechanism of action, administration methods, significant adverse effects, contraindications, monitoring, and toxicity of PCSK9 inhibitors so providers can direct patient therapy to optimal outcomes in serum lipid management with these agents and obtain improved cardiovascular outcomes.

PMID:28846236 | Bookshelf:NBK448100

Be the Change.

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Be the Change.

Fam Med. 2021 Feb;53(2):159

Authors: Elliott TC

PMID: 33566357 [PubMed - as supplied by publisher]

Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma.

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Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma.

Am J Surg. 2021 Feb 01;:

Authors: Appelbaum R, Martin S, Tinkoff G, Pascual JL, Gandhi RR

Abstract
BACKGROUND: Handoffs are defined as the transfer of patient information, professional responsibility, and accountability between caregivers. This work aims to clarify the current state of transitions of care related to the management of trauma patients.
METHODS: A PubMed database and web search were performed for articles published between 2000 and 2020 related to handoffs and transitions of care. The key search terms used were: handoff(s), handoff(s) AND healthcare, and handoff(s) AND trauma. A total of 55 studies were included in qualitative synthesis.
RESULTS: This systematic review explores the current state of healthcare handoffs for trauma patients. Factors found to impact successful handoffs included process standardization, team member accountability, effective communication, and the incorporation of culture. This review was limited by the small number of prospective randomized studies available on the topic.
CONCLUSION: Handoffs in trauma care have been studied and should be utilized in the context of published experience and practice. Standardization when applied with accountability has proven benefit to reduce communication errors during these transfers of care.

PMID: 33558061 [PubMed - as supplied by publisher]

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