Adult Physicians Research Articles

Transrectal prostate biopsy-associated prophylaxis and infectious complications: report of a query to the emerging infections network of the infectious diseases society of america.

Background. Fluoroquinolone-resistant infections after transrectal prostate biopsy (TRPB) are increasing. Methods. Members of the Emerging Infections Network, a consortium of adult infectious diseases physicians sponsored by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America, were administered an electronic 9-question survey regarding post-TRPB infections and associated prophylaxis. Results were compared with respondent characteristics. Results. The overall response rate was 47% (552 of 1180). Of the 552 respondents, 234 (42%) reported that this problem was not applicable to their practice. The remaining 318 (58%) reported that, despite widespread recent changes in prophylactic regimens, fluoroquinolone monotherapy still was most common, but diverse alternate or supplemental oral and parenteral antibiotics (including imipenem) also were used. Reports of culture-guided prophylaxis were rare (9%). The most common duration of prophylaxis was a single prebiopsy antibiotic dose. However, 16%-23% of respondents reported prophylaxis continuing for ≥24 hours postbiopsy. Post-TRPB infections were reported as being more frequent now than 4 years ago, with sepsis and genitourinary presentations predominating, but with osteomyelitis, endocarditis, and epidural abscess also occurring. Infection isolates reportedly were usually resistant to the prophylactic regimen. Conclusions. Emerging Infections Network members perceive post-TRPB infections as increasingly frequent, caused by resistant strains, and involving serious illness. Prophylactic approaches, although in flux, still usually entail ciprofloxacin monotherapy, which often is given for excessive durations. Multiple opportunities exist for infectious diseases specialists to partner with proceduralists in devising, studying, and implementing improved prophylaxis regimens for TRPB.

Quality of care in inflammatory bowel disease

Since inflammatory bowel disease (IBD) is a chronic and relapsing disorder, maintaining high quality of care plays an important role in the management of patients with IBD. To develop process-based quality indicator set to improve quality of care, the indicator should be based directly on evidence and consensus. Initially, ImproveCareNow group demonstrated quality improvement by learning how to apply quality improvement methods to improve the care of pediatric patients with IBD. The American Gastroenterological Association has developed adult IBD physician performance measures set and Crohn's and Colitis Foundation of America (CCFA) has developed a set of ten most highly rated process and outcome measures. Recently, The Emerging Practice in IBD Collaborative (EPIC) group generated defining quality indicators for best-practice management of IBD in Canada. Quality of Care through the Patient's Eyes (QUOTE-IBD) was developed as a questionnaire to measure quality of care through the eyes of patients with IBD, and it is widely used in European countries. The current concept of quality of care as well as quality indicator will be discussed in this article.

Assessing capacity in psychiatric patients with acute medical illness who refuse care.

Three cases are presented that demonstrate the difficulty of assessing medical decision-making capacity in patients with psychiatric illness who are refusing care. Health professionals often assess capacity differently in practice. Provided their patients have some understanding of their illness and have some plans for meeting basic needs, psychiatrists are often inclined to give patients the freedom to refuse care even if they do not exhibit a full understanding of the medical facts of their case and why they are refusing it. Adult medicine physicians, in contrast, are inclined to require patients to state a more complete understanding of the benefits and burdens of evaluation and treatment before allowing them to refuse care when their refusals might result in adverse medical outcomes. The 3 cases exemplify the tension between these approaches and highlight the role of hospital ethics consultation in addressing this conflict.

Point-of care lung ultrasound in the NICU: uses and limitations of a new tool

Pulmonary imaging in the neonatal intensive care unit (NICU) relies traditionally on the conventional chest radiogram. Translating evidences from adult emergency medicine, pediatricians and neonatologists have recently started to apply lung ultrasonography to the critical infant and child with respiratory problems [1]. Because of the high impedance of a normally aerated lung, an ultrasound scan does not render an anatomical image of the organ. However, ultrasounds clearly define the pleural surface with the normal sliding movement. Pleural effusions and lung consolidations can also be reliably diagnosed with ultrasonography. However, ultrasounds penetrating the lung will also generate artifacts (i.e. structures not naturally present in the living that appear as authentic images). These imagery anomalies come from the machine acquisition of the ultrasound beam path through means with markedly different acoustic impedance in close proximity. The horizontal reverberations of the pleural line (aka the A lines - see Figure ​Figure1A)1A) and the vertical hyperecoic image departing from the pleura (aka the B lines- see Figure ​Figure1B)1B) are commonly seen artifacts. Figure 1 1A: reverberations of the pleural image (aka A-lines) in the normally aerated lung. 1B: the prevalence of vertical B-lines (in between arrows) has been linked to the interstitial syndrome in the adult and to a progressive aeration of the neonatal lung ... Real and artefactual images have been combined in disease specific ultrasound profiles. Using these profiles, adult emergency physicians have shown that lung ultrasound outperforms conventional radiology in relevant diagnoses such as pleural effusion, pneumonia or pneumothorax. Pediatricians have started to use lung ultrasound with success to their patients affected by pneumonia but also by bronchiolitis [2]. In the NICU, lung ultrasound has found its specific applications, not without controversies [3]. Transient Tachypnea of the Newborn and Respiratory Distress Syndrome have been described with ultrasound profiles that are both highly sensitive and specific [4]. A relevant limitation of chest ultrasound is that surfactant administration gives a persistent white lung image rendering any follow-up essentially unfeasible. Ultrasounds can, however, accurately describe the fluid to air transition after birth and identify those neonates who will fail to adapt to extrauterine life needing respiratory support [5]. In a series of preterm neonates with moderate respiratory distress, recent work by our group shows that chest ultrasound is significantly more accurate than conventional radiograph in predicting the failure of non invasive ventilation [6]. Lung ultrasound is a very promising clinical tool in the NICU whose potential applications are well worth future multicenter trials.

Role of Extracorporeal Membrane Oxygenation in Management of Refractory ARDS in the Intensive Care Unit: A National Survey on Perspectives of the Adult Critical Care Physicians and Trainees

Role of Extracorporeal Membrane Oxygenation in Management of Refractory ARDS in the Intensive Care Unit: A National Survey on Perspectives of the Adult Critical Care Physicians and Trainees

Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice.

To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE). An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs. The survey response rate was 72.1% (31 of 43 physicians). For patients < 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5-2.9]) and in patients < 30 years old (87.9% v. CTPA 12.1% [OR 4.8; 95% CI 2.4-9.4]). Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution.

PATIENT-CENTRED SCREENING FOR PRIMARY IMMUNODEFICIENCY, A MULTI-STAGE DIAGNOSTIC PROTOCOL DESIGNED FOR NONIMMUNOLOGISTS: 2011 UPDATE

Members of the European Society for Immunodeficiencies (ESID) and other colleagues have updated themulti-stage expert-opinion-based diagnostic protocol for non-immunologists incorporating newly defined primary immunodeficiency diseases (PIDs). The protocol presented here aims to increase the awareness of PIDs among doctors working in different fields. Prompt identification of PID is important for prognosis, but this may not be an easy task. The protocol therefore starts from the clinical presentation of the patient. Because PIDs may present at all ages, this protocol is aimed at both adult and paediatric physicians. The multi-stage design allows cost-effective screening for PID of the large number of potential cases in the early phases, with more expensive tests reserved for definitive classification in collaboration with a specialist in the field of immunodeficiency at a later stage.

Outpatient Parenteral Antimicrobial Therapy Practices among Adult Infectious Disease Physicians

To identify current outpatient parenteral antibiotic therapy practice patterns and complications. We administered an 11-question survey to adult infectious disease physicians participating in the Emerging Infections Network (EIN), a Centers for Disease Control and Prevention-sponsored sentinel event surveillance network in North America. The survey was distributed electronically or via facsimile in November and December 2012. Respondent demographic characteristics were obtained from EIN enrollment data. Overall, 555 (44.6%) of EIN members responded to the survey, with 450 (81%) indicating that they treated 1 or more patients with outpatient parenteral antimicrobial therapy (OPAT) during an average month. Infectious diseases consultation was reported to be required for a patient to be discharged with OPAT by 99 respondents (22%). Inpatient (282 [63%] of 449) and outpatient (232 [52%] of 449) infectious diseases physicians were frequently identified as being responsible for monitoring laboratory results. Only 26% (118 of 448) had dedicated OPAT teams at their clinical site. Few infectious diseases physicians have systems to track errors, adverse events, or "near misses" associated with OPAT (97 [22%] of 449). OPAT-associated complications were perceived to be rare. Among respondents, 80% reported line occlusion or clotting as the most common complication (occurring in 6% of patients or more), followed by nephrotoxicity and rash (each reported by 61%). Weekly laboratory monitoring of patients who received vancomycin was reported by 77% of respondents (343 of 445), whereas 19% of respondents (84 of 445) reported twice weekly laboratory monitoring for these patients. Although use of OPAT is common, there is significant variation in practice patterns. More uniform OPAT practices may enhance patient safety.

Transitioning Pediatric Surgical Patients to Adult Surgical Care

Over the past 50 years, there has been a significant improvement in the outcomes for children with many complex congenital or acquired surgical conditions such as heart disease, gastroschisis, diaphragmatic hernia, anorectal malformations, spina bifida, and intestinal failure. As a result, the adult health care system is receiving a growing number of young adults, with chronic surgical issues, requiring lifelong assistance within a multidisciplinary model of care. In this emerging scenario, transitional care is vital for adolescents and young adults with active chronic surgical and medical problems who will require care from knowledgeable and well-trained adult physicians. In 2002, the American Academy of Pediatrics established that “the goal of a planned health care transition is to maximize lifelong functioning and well-being for all youth” 1(p1304) and that transitional care is “a purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from childcentered to adult-oriented healthcare systems.” 2(p571) An

Career decisions: factors that influence the Māori doctor

Māori have known health disparities that may be addressed through increasing the cultural competency of New Zealand's medical workforce. There is a paucity of Māori health professionals choosing paediatrics or adult medicine as a career and the factors influencing their career decision are yet to be explored. First, to differentiate factors influencing the medical career choice of non-Māori paediatricians and physicians, Māori paediatricians and physicians and other Māori doctors. Second, to identify ways in which Māori doctors may be encouraged to choose paediatricians or adult medicine. A questionnaire was distributed by email to New Zealand physicians and paediatricians and to Māori doctors. Questions included demographic information, a matrix rating table and open-ended questions. Altogether 199 people accessed the questionnaire. Response rates were 9% (n = 118) for non-Māori paediatricians and physicians, 70% (n = 19) for Māori paediatricians and physicians, and 31% (n = 62) for other Māori doctors. Māori paediatricians and physicians highlighted mentoring as having significant impact on career choice. Non-Māori paediatricians and physicians regarded interest as having the most influence on career choice (P < 0.01). Lifestyle factors influenced other Māori doctors (P < 0.001). All three groups regarded poor lifestyle as having the largest negative influence. No group regarded potential income as important. Mentoring provides an opportunity to attract Māori into paediatric and adult physician training. The use of existing mentoring programmes could facilitate in expanding Māori RACP workforce development. This extended Māori workforce would have benefits for the health of New Zealand as a whole.

Health reform and physician-led accountable care: the paradox of primary care physician leadership.

Even though most adult primary care physicians may not realize it, they each can be seen as a chief executive officer (CEO) in charge of approximately $10 million of annual revenue. Consider that a typical primary care physician has approximately 2000 patients, each of whom annually accounts for about $5000 for health care spending. Although primary care today accounts for only 5% of that spending, the decisions made in the primary care setting have important implications for downstream medical care, such as subspecialty referrals, imaging and other medical testing, invasive procedures, and hospitalizations. A group of 100 adult primary care physicians could potentially influence almost $1 billion in health care spending.

Physicians' Attitudes About Multiplex Tumor Genomic Testing

Although predictive multiplex somatic genomic tests hold the potential to transform care by identifying targetable alterations in multiple cancer genes, little is known about how physicians will use such tests in practice. Before the initiation of enterprise-wide multiplex testing at a major cancer center, we surveyed all clinically active adult cancer physicians to assess their current use of somatic testing, their attitudes about multiplex testing, and their genomic confidence. A total of 160 physicians participated (response rate, 61%): 57% were medical oncologists; 29%, surgeons; 14% radiation oncologists; 37%, women; and 83%, research principal investigators. Twenty-two percent of physicians reported low confidence in their genomic knowledge. Eighteen percent of physicians anticipated testing patients infrequently (≤ 10%), whereas 25% anticipate testing most patients (≥ 90%). Higher genomic confidence was associated with wanting to test a majority of patients (adjusted odds ratio [OR], 6.09; 95% CI, 2.1 to 17.5) and anticipating using actionable (adjusted OR, 2.46; 95% CI, 1.2 to 5.2) or potentially actionable (adjusted OR, 2.89; 95% CI, 1.1 to 7.9) test results to inform treatment recommendations. Forty-two percent of physicians endorsed disclosure of uncertain genomic findings to patients. Physicians at a tertiary-care National Cancer Institute-designated comprehensive cancer center varied considerably in how they planned to incorporate predictive multiplex somatic genomic tests into practice and in their attitudes about the disclosure of genomic information of uncertain significance. Given that many physicians reported low genomic confidence, evidence-based guidelines and enhanced physician genomic education efforts may be needed to ensure that genomically guided cancer care is adequately delivered.

Pediatric chest ultrasound versus conventional radiology: experimental evidence first

Sir, Reading the critical appraisal of chest ultrasound in children by Toma and Owens [1], one has to fully endorse the authors’ word of caution against an uncritical replacement of the standard radiograph by an ultrasound scan. Indeed, recent data from adult and pediatric emergency physicians show that each technique might prevail over the other depending on the clinical issue and that no ultrasonography superiority, per se, can be justified. As an example, US monitors the fluid-to-air transition of the neonatal lung when, to quote Toma and Owens, “under normal circumstances neonates improve rapidly and only one or two chest radiographs are obtained.” Any neonatologist knows that those chest radiographs do not predict the abnormal but often critical circumstance of the newborn failing to adapt to the extrauterine environment. Chest US has been reported to give this important piece of information, and further trials are welcomed [2]. On the other hand, Copetti and Cattarossi [3] correctly underlined that US yields to radiology in the follow-up of neonatal respiratory distress after surfactant administration. The same authors first found the high value of US in diagnosing pediatric pneumonia [4], a finding that has been recently confirmed by a largemulticenter trial in the United States [5]. Unfortunately, in the critical appraisal by Toma and Owens [1] the objective evaluation of these experimental data and of those increasingly produced worldwide is constantly neglected in the fear of “the misuse or the abuse of paediatric chest ultrasound.”Under these circumstances, we would gladly join Galileo in pronouncing “And yet, it moves.”

Adolescent and young adult medicine is a special and specific area of medical practice

Adolescent and young adult medicine is a concept that has gained traction in the last decade or so. The medical literature has come primarily from oncology. Advances in neuroscience that document continuing brain development into the third decade, and research that shows risk behaviours associated with adolescence both remain and may increase in the third decade, have been two of the drivers in the conversation around linking these two age groups together as a medical practice group. A third driver of importance is transition care in chronic illness, where older adolescents and young adults continue to have difficulties making effective linkages with adult care. The case for specific training in adolescent and young adult medicine, including the developmental concepts behind it, the benefits of the delineation and the particular challenges in the Australian health-care system, are discussed. On balance, there is a strong case for managing the health issues of adolescents and young adults together. This scenario does not fit easily with the age demarcations that are in place in acute care facilities. However, this is less the case in community services and can work in focused private practice. Such a situation suggests that both paediatric and adult physicians might be interested in adolescent and young adult medicine training and practice.

Transition of adolescents with chronic health conditions to adult primary care: factors associated with physician acceptance.

To assess the willingness of adult primary-care physicians to transfer young adults with special health care needs (YASHCN) into their practices, and the relative impact of patient characteristics and transition supports. Survey of primary care internists and family practitioners using randomized patient characteristics and transition supports in clinical vignettes to assess physician willingness to accept a YASHCN into their practice. 404 responses were received from 601 surveys (response rate 67%). Only 44% rated themselves "willing" or "enthusiastic" to accept a YASHCN. Using four-way ANOVA testing, provider and practice characteristics significantly associated with willingness to accept included gender, years in practice, presence of YASHCN in current practice and whether the practice was accepting new patients. Patient condition and transition support significantly affected willingness to accept; training in internal medicine versus family practice did not. Physicians providing primary care for adults express limited willingness to accept YASHCN into their practices. Provider, practice and patient characteristics affected willingness to accept. Although transition supports affected willingness to accept, effects varied markedly across diagnoses and physician gender. Findings have implications for patients and healthcare teams and policy planners.

Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates

The Saudi Association for Pulmonary Hypertension (previously called Saudi Advisory Group for Pulmonary Hypertension) has published the first Saudi Guidelines on Diagnosis and Treatment of Pulmonary Arterial Hypertension back in 2008.[1] That guideline was very detailed and extensive and reviewed most aspects of pulmonary hypertension (PH). One of the disadvantages of such detailed guidelines is the difficulty that some of the readers who just want to get a quick guidance or looking for a specific piece of information might face.All efforts were made to develop this guideline in an easy-to-read form, making it very handy and helpful to clinicians dealing with PH patients to select the best management strategies for the typical patient suffering from a specific condition. This Guideline was designed to provide recommendations for problems frequently encountered by practicing clinicians involved in management of PH. This publication targets mainly adult and pediatric PH-treating physicians, but can also be used by other physicians interested in PH.

Direct ultrasound localisation for pleural aspiration: translating evidence into action

There is strong evidence that direct ultrasound localisation for pleural aspiration reduces complications, but this practice is not universal in Australia and New Zealand. To describe the current utilisation and logistical barriers to the use of direct ultrasound localisation for pleural aspiration by respiratory physicians from Australia and New Zealand, and to determine the cost benefits of procuring equipment and training resources in chest ultrasound. We surveyed all adult respiratory physician members of the Thoracic Society of Australia and New Zealand regarding their use of direct ultrasound localisation for pleural aspiration. We performed a cost-benefit analysis for acquiring bedside ultrasound equipment and estimated the capacity of available ultrasound training. One hundred and forty-six of 275 respiratory physicians responded (53% response). One-third (33.6%) of respondents do not undertake direct ultrasound localisation. Lack of training/expertise (44.6%) and lack of access to ultrasound equipment (41%) were the most frequently reported barriers to performing direct ultrasound localisation. An average delay of 2 or more days to obtain an ultrasound performed in radiology was reported in 42.7% of respondents. Decision-tree analysis demonstrated that clinician-performed direct ultrasound localisation for pleural aspiration is cost-beneficial, with recovery of initial capital expenditure within 6 months. Ultrasound training infrastructure is already available to up-skill all respiratory physicians within 2 years and is cost-neutral. Many respiratory physicians have not adopted direct ultrasound localisation for pleural aspiration because they lack equipment and expertise. However, purchase of ultrasound equipment is cost-beneficial, and there is already sufficient capacity to deliver accredited ultrasound training through existing services.

Are We Prepped for Preexposure Prophylaxis (PrEP)? Provider Opinions on the Real-World Use of PrEP in the United States and Canada

Preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (Truvada) has demonstrated efficacy in placebo-controlled clinical trials involving men who have sex with men, high-risk heterosexuals, serodiscordant couples, and intravenous drug users. To assist in the real-world provision of PrEP, the Centers for Disease Control and Prevention (CDC) has released guidance documents for PrEP use. Adult infectious disease physicians were surveyed about their opinions and current practices of PrEP through the Emerging Infections Network (EIN). Geographic information systems analysis was used to map out provider responses across the United States. Of 1175 EIN members across the country, 573 (48.8%) responded to the survey. A majority of clinicians supported PrEP but only 9% had actually provided it. Despite CDC guidance, PrEP practices were variable and clinicians reported many barriers to its real-world provision. The majority of adult infectious disease physicians across the United States and Canada support PrEP but have vast differences of opinion and practice, despite the existence of CDC guidance documents. The success of real-world PrEP will likely require multifaceted programs addressing barriers to its provision and will be assisted with the development of comprehensive guidelines for real-world PrEP.

Spectrum of primary immunodeficiency disorders in Sri Lanka

BackgroundWhile primary immunodeficiencies (PID has been recognized in the west for decades, recognition has been delayed in the third world. This study attempts to detail the spectrum of PID, the therapy provided, and constraints in the diagnosis and treatment in a middle income country such as Sri Lanka.MethodsNine hundred and forty two patients with recurrent infections and features suggestive of immune deficiency, referred from the entire country in a 4 year period, to the sole immunology unit in Sri Lanka were included. The following tests were performed. Full blood counts, serum Immunoglobulin and complement C3 and C4 levels, functional antibody levels, enumeration of lymphocyte subsets, in vitro and in vivo T cell functional assays,, nitroblue tetrazolium assay to diagnose chronic granulomatous disease, hair shaft assay to diagnose Griscelli syndrome. Sequencing of the common gamma chain to identify x linked severe combined immune deficiency, and X linked agammaglobulinemia was confirmed by assaying for Btk mutations by single sequence conformation polymorphism. HIV/AIDS was excluded in all patients.ResultsSeventy three patients were diagnosed with a primary immune deficiency. The majority (60.27%) had antibody deficiency. Common variable immune deficiency was the commonest (28.76%), followed by X linked agammaglobulinemia (XLA) (20.54%). Five patients had possible hyper IgM syndrome.Ten patients had severe combined immune deficiency (SCID), including 2 with x linked SCID, in addition to DiGeorge syndrome (2), ataxia telangiectasia (6), autosomal dominant hyper IgE syndrome (2), chronic granulomatous disease (4), leucocyte adhesion deficiency type 1 (2) and Griscelli syndrome (3).Patients with autoinflammatory, innate immune and complement defects could not be identified due to lack of facilities.ConclusionsAntibody deficiency is the commonest PID, as in the west.IgA deficiency is rare. Autoinflammatory diseases, innate immune and complement deficiencies could not be identified due to lack of diagnostic facilities. Lack of awareness of PID among adult physicians result in delay in treatment of adult patients. While treatment of antibody deficiencies provided in state hospitals has extended life expectancy, there is no treatment available for severe T cell defects.

Adolescence: Challenges and responses

Adolescence: Challenges and responses