Experienced Physicians Research Articles

Perceptions of gender equity in emergency medicine in Canada.

Women-identifying emergency physicians face gender-based discrimination throughout their careers. The purpose of this study was to explore emergency physician's perceptions and experiences of gender equity in emergency medicine. We conducted a secondary analysis of data from a previously conducted survey of Canadian emergency physicians on barriers to gender equity in emergency medicine. Survey responses were analyzed using logistic regression to determine the impact that gender, practice setting, years since graduation, race, equity-seeking status, and parental status had on agreement about gender equity in emergency medicine and five of the problem statements. A total of 710 participants completed the survey. Most identified as women (58.8%), white (77.4%), graduated between 2010 and 2019 (40%), had CCFP (Emergency Medicine) designation (47.9%), an urban practice (84.4%), were parents (62.4%) and did not identify as equity-seeking (79.9%). Women-identifying physicians were less likely to perceive gender equity in emergency medicine, OR 0.52, CI [0.38, 0.73]. Women-identifying physicians were more likely to agree with statements about microaggressions, OR 4.39, CI [2.66, 7.23]; barriers to leadership, OR 3.51, CI [2.25, 5.50]; gender wage gap, OR 13.46, CI [8.27, 21.91]; lack of support for parental leave, OR 2.85, CI [1.82, 4.44]; and education on allyship, OR 2.23 CI [1.44, 3.45] than men-identifying physicians. In this study, women-identifying physicians were less likely to perceive that there was gender equity in emergency medicine than men-identifying physicians. Women-identifying physicians agreed that there are greater barriers for career advancement including fewer opportunities for leadership, a gender wage gap, a lack of parental leave policies to support a return to work and a lack of education for men to become allies. Men-identifying physicians were less aware of these inequities. Health systems must work to improve gender equity in emergency medicine and this will require education and allyship from men-identifying physicians.

(200) The Fertility and Childbearing Experiences of US Male Physicians

Abstract Introduction Recent attention has been brought to physician fertility in the last decade, most notably amongst female physicians who suffer an increased risk of infertility compared to the general population. Various factors related to a career in medicine play a role, such as a delay in pursuit of childbearing, a demanding work schedule, shift work, and stress associated with the profession. However, risk of infertility in the male physician population has yet to be studied. Objective Therefore, we sought to evaluate the experiences and childbearing patterns of a sample of American male physicians with special attention to timing of conception and childbearing, reflections upon professional and personal decision-making, and general knowledge regarding fertility. The primary objective of this study was to determine the incidence of infertility among American male physicians. Methods Utilizing a third party to access the American Medical Association (AMA) database, licensed US physicians registered as male and between the ages of 18-65 were identified. Within this cohort, 690 men were randomly selected and contacted via paper mail (340) or email (350) and asked to participate in the survey study. Surveys were administered electronically via REDCap (obtained through a QR code) and included questions regarding the physicians’ demographics, medical specialty, and whether they have attempted to conceive. Those who have attempted to conceive were also surveyed on their work experience at the time of their first attempt at conception and their experience and partner’s experience with fertility and childbearing. Internal Review Board approval was obtained for this study (STUDY 20211036). Results Fifty-three men responded to the survey (7.7%). All respondents were cisgender males with cisgender female partners. The majority (94.3%) had attempted to conceive and occurred most during residency (46.0%). The average age when first attempting conception was 31.6 years, and this was most commonly during residency (46.0%) or after training (30.0%). During this time, many (72.0%) were responsible for night shifts, overnight call duties, or both. In addition, as many as 34 men (68.0%) had no access to paid parental leave during this time. Of 50 men who attempted conception, 14 (28.0%) of their partners experienced a miscarriage. Eight men (17.0%) underwent a fertility workup, and 6 underwent infertility treatment(s). Only 4 respondents had insurance partially covering their infertility treatments, while the other two had no insurance coverage. Conclusions Male physicians are often exposed to long work hours, nighttime duties, and sparse paid parental leave during the time of their first attempt at conception, most commonly in residency. Our cohort shows a high rate of miscarriage (28.0%) and infertility assessment (16.0%) among this population. Future studies are needed to continue characterizing fertility amongst physicians. Disclosure No.

Experiences of physicians on defensive medicine: a qualitative study from Türkiye

ABSTRACT This study aimed to investigate the experiences of physicians regarding defensive medicine (DM) practices. A qualitative study was developed with a descriptive phenomenological approach and the study was conducted in a university hospital in Türkiye. Data were collected between 1 February 2022 and 15 March 2022 via face-to-face, in-depth interviews from 21 participants. Inductive content analysis, which is very suitable for use in health-related research, was used. The analysis of the interview data resulted in 3 main themes, 9 themes, and 24 sub-themes. Main themes described the experiences of physicians: reasons for DM practices, consequences of DM practices, and measures to prevent DM practices. The findings showed the multidimensional nature of DM practices that must be considered in the strategies to be developed to prevent this behavior.

Training program for primary care physicians in medical rehabilitation at the Pacifi c Medical University

This article describes the experience of training primary care physicians in the field of medical rehabilitation. The existing procedure for the arrangement of medical rehabilitation prescribes its rules and order of implementation in medical primary health care organizations both in outpatient and day patient settings. The Pacific State Medical University (PSMU) runs training programs for primary care physicians within the 31.05.01 educational program “General Medicine”, direction “02 Healthcare”. In accordance with the curriculum, a training program “Medical Rehabilitation” that includes both lectures and training sessions was developed. This program is aimed at forming the necessary competencies of future primary care physicians in implementing and monitoring the effectiveness of the patient’s medical rehabilitation. Training is carried out at the facilities of the PSMU Institute of Clinical Neurology and Rehabilitation Medicine by specialists having experience in medical rehabilitation and having completed the program “Modern aspects of specialist training in the field of physical and rehabilitation medicine”.

Enhancing Physicians' Autonomy through Practical Trainings.

In medical emergencies adherence to standardized clinical protocols is crucial to ensure a better outcome for patients. Newly qualified physicians may play several roles in serving the National Health Service (substituting general practitioners, on-call duty, working in emergency rooms, etc.) in Italy. In these situations, the physician may have to manage critical patients autonomously. Moreover, newly qualified physicians may show a considerable deficiency in routine medical activities. In fact, many universities do not provide a practical simulation training programme, which is why a substantial number of students only face clinical emergencies when they start working after graduation. A cross-sectional study was performed by engaging medical doctors. Both experienced physicians and newly licensed physicians (graduated less than 24 months ago) were included in the study. A questionnaire was distributed to each participant during SIMED's Courses from June 2021 to December 2022. The questionnaire consisted of two sections. The first one analyzed participation in standardized practical courses on medical emer-gencies (Basic Life Support, Advanced Cardiac Life Support, International Trauma Life Support and a course on Advanced Airway Management). The second section analyzed the perceived autonomy of health professionals in the management of five different work settings, using a 5-point likert scale. 2,168 questionnaires were analyzed, of which 68.7% were from newly qualified doctors and 31.3% from more experienced doctors. The highest rate of physicians who undertook training courses was achieved for the basic life support course (77.5%) and the lowest rate for the advanced trauma course (15.9%). Physicians perceive themselves the highest autonomy in Primary Care setting (63.1%), while in the Emergency Department they perceive themselves with less autonomy (24.0%). In the analyzed sample, experienced physicians show a higher percentage of autonomy than newly qualified doctors (31.4% vs 8.1%) in all scenarios.

Real-world applicability of differentiated thyroid cancer guidelines.

Thyroid cancer (TC) is the most common endocrine malignancy with constantly growing incidence. Radioiodine ablation is a safe and effective method for managing TC. Recently various Guidelines (GL) have been published on whom should be ablated, when and under which circumstances. Our study compares 6 GL with a given patient cohort. Additionally, we evaluated each GL's quality via an independent tool. We compared six Guidelines (GL) for TC ablation on a cohort of 336 patients, implementing GL retrospectively: 2009 and 2016 American Thyroid Association (ATA), European Thyroid Association's (ETA) Consensus Statement, UK's National Institute for Health and Care Excellence (NICE), German position paper from Surgery and Nuclear Medicine (German) and European Association of Nuclear Medicine and Society of Nuclear Medicine and Molecular Image (EANM/SNMMI). Quality assessment was conducted using the Appraisal of Guidelines, Research and Evaluation instrument II (AGREE II). Results showed significant variability among GL. American Thyroid Association 2016, a clear improvement of the ATA 2009, presents a large grey area of "probable ablation candidates". European Thyroid Association and NICE agree that only a small portion of our ablated patients would benefit from it and the AGREE II tool shows a lack of applicability, but very good scores elsewhere. German and EANM/SNMMI GL agree that most of our clinical decisions to ablate were correct and their AGREE II scores are the highest in all six domains. Considering that dynamic risk classification plays a major role in determining the most appropriate treatment, it appears that the guidelines should be updated in order to support individualized patient management. However, it is the experience of the individual physician that will determine the final decision.

Head-to-Head Comparison Between 18F-FDG PET and Leukocyte Scintigraphy to Monitor Treatment Responses in Necrotizing Otitis Externa.

Necrotizing otitis externa (NOE) is a rare disease associated with high morbidity and mortality, and there is currently no available accurate biomarker to assess treatment responses. The aim of the current study was to evaluate and directly compare the diagnostic performances of 18-Fluoro-deoxyglucose positron emission tomography (18F-FDG PET) and labeled leukocyte scintigraphy (LS) to monitor treatment responses in NOE. Consecutive patients with NOE who underwent 18F-FDG PET at the end of antibiotic therapy and planar as well as single photon emission computed tomography-labeled leukocyte scintigraphy after completing the initial antibiotic treatment were retrospectively included. Semiquantitative analyses were performed to determine the ratios of affected/nonaffected sides for PET and 4 hour and 24 hour LS acquisitions as well as the kinetic PET ratios (at diagnosis and post-treatment) and LS (4 and 24 hours). The final treatment responses were assessed by 2 experienced ENT physicians based on clinical, otoscopic, and biological data and subsequent 3-month follow-up. Seventeen patients (74.0 ± 10.6 years old, 5 women) were included. The best diagnostic performances were obtained with the PET maximum standardized uptake value (SUVmax)-lesion-to-background ratio and the tomographic LS lesion-to-background ratio at the 4-hour acquisition timepoint (thresholds of 4.1 and 1.19, yielding accuracies of 100% and 88%, respectively). In the multivariate analysis, the PET SUVmax-lesion-to-background ratio was the only predictive factor of recovery when associated with all clinical parameters (P < .001). 18F-FDG PET is the first-line imaging modality for evaluating NOE treatment responses, with excellent diagnostic performances. LS with only 4-hour acquisitions appeared to suffice to evaluate NOE treatment responses. Both biomarkers constitute early prognostic biomarkers for predicting antibiotic treatment response in patients with NOE. The institutional ethics committee (Comité d'Ethique du CHRU de Nancy) approved the evaluation of retrospective patient data, and the trial was registered at ClinicalTrials.gov (n°2023PI003-404).

Updated automated PROMISE assessment: Treatment response evaluation based on PSMA PET/CT.

48 Background: PSMA PETs can track treatment response in patients with prostate cancer. Recent integration of the RECIP framework with PROMISE v2 allows quantitative assessment of PSMA PETs. While useful for assessing differentially responding lesions, manual measurement and tracking is cumbersome and PSA reliance can be misleading. We evaluated an automated AI-enabled platform, aPROMISE, for longitudinal lesion tracking to evaluate treatment response based solely upon tumor volume. Methods: Patients with castration sensitive or resistant disease undergoing 18F-DCFPyL PET/CTs during workup and at ≥3 months after treatment were included. Tracer-avid lesions were identified using the aPROMISE algorithm. Detected lesions were manually approved by an experienced nuclear medicine physician. After lesion identification and approval, the total tumor volume was calculated. The corresponding low-dose CT was auto-segmented, allowing anatomic compartment (prostate/bed, node, bone, or visceral) annotation of 18F-DCFPyL-avid lesions. Baseline and follow-up PETs were deformably co-registered to automatically match individual lesions if they were in the same anatomic compartment, and had overlap &lt;10 mm center-to-center (&lt;50 mm for rib lesions). Unmatched lesions on follow-up PET were noted as new. Response was assessed as CR (no avidity in follow-up), PR (volume decrease ≥30% without new lesions), SD (volume decrease ≥30% with new lesions), or PD (volume increase ≥20% plus new lesions). Volume changes at the total tumor and individual lesion levels were also assessed independent of RECIP imaging criteria. Results: The automated algorithm assigned the correct RECIP classification in 97% of the 67 cases with 14 as CR, 14 as PR, 20 as SD, and 19 as PD. 1027 of the 1686 lesions identified on baseline PET were seen on follow-up. 673 of the 1700 lesions identified on follow-up PET were new. Conclusions: For response assessment using 18F-DCFPyL PET/CT and RECIP imaging criteria, the automated algorithm and manual detection achieved the same clinical classifications. Automated approaches may allow more granular lesion analysis The precision and accuracy this automated process is being validated in prospective clinical studies.

Prostate-specific membrane antigen SPECT-CT in patients with intermediate and high-risk prostate cancer in primary diagnosis: A comparative analysis with 18F-PSMA PET/CT.

43 Background: Prostate cancer (PC) is a leading cause of cancer death in men worldwide. Imaging plays a key role in disease detection and initial staging. Emerging data has shown the superiority of 68Gallium and 18Fluorine labeled-PSMA imaging with PET/CT over conventional imaging for primary diagnosis. Despite the success, there are challenges in meeting the high demand and expensive costs especially in low-income countries. These challenges stimulated interest in 99mTechnetium-labeled-PSMA agents. Single photon emission computer tomography (SPECT/CT) is more worldwide available, and the imaging agent is low cost, which is more promising. The aim of this study is to compare the diagnostic accuracy of 99mTc‐PSMA-SPECT/CT to 18F-PSMA-PET/CT in the primary diagnosis of PC and impact on clinical staging. Methods: Prospective controlled study, total of 16 patients with histologically confirmed PC (intermediate unfavorable and high risk) were recruited to undergo 18F-PSMA-PET/CT and 99mTc-HYNIC-PSMA-SPECT/CT. Mean age of patients was 71 (54-75) years and the median PSA level was 31.5 (4.3-920) ng/ml. Lesions were divided into prostate, seminal vesicles, lymph nodes (LN) (locoregional [LR] and non-locoregional [NLR]), bone, and visceral metastases. The size of LN with PSMA avidity on 99mTc‐PSMA-SPECT/CT were determined. Lesions detected were read independently of PET/CT findings with two experienced nuclear medicine physicians. Volumetric analysis was also performed between the two imaging modalities (Tumoral Total Volume [TTV]) and correlated with PSA levels. Results: A total of 233 lesions were detected on 18F-PSMA-PET/CT; prostate (n=16), seminal vesicles (n=11), LN LR (n=54), NLR (n=66), bone (n=82) and visceral (n=4); of these 99mTc‐PSMA-SPECT/CT both reviewers detected 100% of the lesions in prostate (16/16), seminal vesicles (11/11) and visceral (4/4); LN LR (51/54; 94%), NLR (51/66; 77%) and bone (70/82; 85%). Between reviewers there was discordance in just 3 LN (&lt;4 mm) and 1 bone metastases. The lowest diameter of positive LN detected by SPECT/CT was 4 mm (range 4-18). Pearson-correlation coefficient between PSA and TTV SPECT was r=0.68 (p=0.003) and for TTV PET r=0.71 (p=0.002). There were not statistically significant differences between TTV SPECT and TTV PET (T-student p=0.48). Five cases with high volume disease were detected by both methods. All patients were classified according to miTNM showing no difference. Conclusions: 99mTc‐PSMA-SPECT/CT may be a useful in primary diagnosis of PC. Despite it showed a slightly lower lesion detection rate compared to 18F-PSMA-PET/CT, it exhibited no impact on clinical staging and consequently the initial treatment intension. Our results show that 99mTc‐PSMA-SPECT/CT could be used as a cost-efficient alternative with wider availability and no significant difference.

Information Technology and Value-Based Healthcare Systems: A Strategy and Framework.

Value-based healthcare offers a pathway for enhancing patient satisfaction and population health and reducing healthcare costs. In addition, it provides a means to enhance physicians' perception and experience in healthcare delivery. The foundation of the said systemis the notion that community wellness can only be benefited when the health effects of many people are also addressed. The provision of healthcare services incurs costs. However, a value-based model addresses this issue by establishing teams that cater to individuals with similar needs. This approach fosters expertise and efficiency, ultimately leading to cost savings without rationing. Furthermore, entrusting decision-making authority regarding healthcare delivery to the clinical team enhances doctors' professionalism and the integrity of clinician-patient interactions, resulting in more effective and relevant treatments. Currently, various information technology (IT)-based solutions are the main focus for accomplishing the desired value-based healthcare system. The establishment of a coordinated framework that can help organizations create value-based healthcare systems is covered in the current article. Additionally listed are many IT-based solutions used to create a value-based healthcare system.

Cancer detection and classification using a simplified binary state vector machine.

Cancer is an invasive and malignant growth of cells and is known to be one of the most fatal diseases. Its early detection is essential for decreasing the mortality rate and increasing the probability of survival. This study presents an efficient machine learning approach based on the state vector machine (SVM) to diagnose and classify tumors into malignant or benign cancer using the online lymphographic data. Further, two types of neural network architectures are also implemented to evaluate the performance of the proposed SVM-based approach. The optimal structures of the classifiers are obtained by varying the architecture, topology, learning rate, and kernel function and recording the results' accuracy. The classifiers are trained with the preprocessed data examples after noise removal and tested on the unknown cases to diagnose each example as positive or negative. Further, the positive cases are classified into different stages including metastases, malign lymph, and fibrosis. The results are evaluated against the feed-forward and generalized regression neural networks. It is found that the proposed SVM-based approach significantly improves the early detection and classification accuracy in comparison to the experienced physicians and the other machine learning approaches. The proposed approach is robust and can perform sub-class divisions for multipurpose tasks. Experimental results demonstrate that the two-class SVM gives the best results and can effectively be used for the classification of cancer. It has outperformed all other classifiers with an average accuracy of 94.90%.

Comparison of Pressure Control Ventilation and Palpation Methods to Protect the Endotracheal Tube Cuff During Tracheotomy: A Manikin Simulation Study.

Objective This study aims to evaluate and compare the suitability and safety of palpation and pressure control ventilation (PCV) methods for the accurate positioning of an endotracheal tube (ETT) cuff. Methods We conducted a pilot simulation randomized crossover study using a medical manikin. Twenty junior resident physicians who had completed anesthesiology training participated in the study. Airway management was performed using a modified manikin designed to simulate palpation and PCV methods. Participants performed both methods in a randomized order. The primary outcome was the number of successful ETT placements. The secondary outcomes were procedure duration and the perceived difficulty of each procedure. Results Five successful procedures were observed in the palpation method group (PALG), while 19 were observed in the PCV method group (PCVG). The duration of the trial was 98 s (standard deviation [SD], 41) in the PALG and 93 s (SD, 49) in the PCVG. The visual analog scale score for difficulty encountered during the trial was 30 (SD, 21) in the PALG and 69 (SD, 19) in the PCVG. Conclusions Our findings suggest that the PCV method had a higher success rate than the palpation method. Thus, the PCV method may be more suitable for inexperienced physicians to perform the procedure with greater confidence.

Ways to solve the problem of training highly qualified internists

Training a highly qualified internist in residency is a multifaceted task facing the teaching staff of the Kuban State Medical University.The aim of the study was to analyze the long-term experience of training internal medicine physicians (from 2019 to 2022) at the Kuban State Medical University.Conclusion. A developed methodological system for personalized preparation of internists, the integration of theoretical and practical training, the individual work of students with ongoing progress monitoring of each resident, the mentor system, as well as the active use of modern technical equipment, novel methodological techniques, digital and simulation technologies, introduced organizational measures and material incentives for students have made it possible to achieve 100% employment of General Medicine residency graduates of the Kuban State Medical University in recent years.

Acute otitis media diagnosis in childhood: still a problem in 2023?

BackgroundDiagnosis of acute otitis media (AOM) in children can be challenging, given that symptoms are often non-specific or absent, and that the direct observation of the tympanic membrane in its entirety through otoscopy can sometimes be difficult. The aim of this study is to assess the diagnostic concordance in detection of AOM episodes between primary care paediatricians and physicians especially trained in paediatric otoscopy, and to characterize the most misleading elements in diagnostic failure.MethodsConsecutive clinical charts of children regularly followed for recurrent AOM (RAOM, i.e.: >3 episodes in 6 months or > 4 episodes in 1 year) at our Otitis Media paediatric outpatient clinic were retrospectively screened, in order to collect any diagnosis of AOM episode (and the related clinical findings/middle ear complaints) performed by primary care paediatricians/emergency room paediatricians. Diagnosis of AOM episode was validated by the same experienced physician (FF) in case of otoscopic relief of a bulging eardrum with at least one of the following: hyperaemia or yellow-like colour. The diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was expressed as the percentage of matching diagnosis.ResultsOne hundred and thirty-four single AOM episodes occurring in 87 children (mean age: 26.9 +/- 18.9 months) were included in the analysis. Diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was reported in 72.4% of cases. The most common pitfall found in our study was the misleading diagnosis of AOM in case of hyperaemic tympanic membrane without bulging (32/37 out of non-validated diagnoses).ConclusionsAOM diagnosis still represents a relevant issue among paediatricians in our country, and the presence of tympanic membrane hyperaemia without concomitant bulging can be confusing.

Novel AI-Based Algorithm for the Automated Measurement of Cervical Sagittal Balance Parameters. A Validation Study on Pre- and Postoperative Radiographs of 129 Patients.

Retrospective, mono-centric cohort research study. The analysis of cervical sagittal balance parameters is essential for preoperative planning and dependent on the physician's experience. A fully automated artificial intelligence-based algorithm could contribute to an objective analysis and save time. Therefore, this algorithm should be validated in this study. Two surgeons measured C2-C7 lordosis, C1-C7 Sagittal Vertical Axis (SVA), C2-C7-SVA, C7-slope and T1-slope in pre- and postoperative lateral cervical X-rays of 129 patients undergoing anterior cervical surgery. All parameters were measured twice by surgeons and compared to the measurements by the AI algorithm consisting of 4 deep convolutional neural networks. Agreement between raters was quantified, among other metrics, by mean errors and single measure intraclass correlation coefficients for absolute agreement. ICC-values for intra- (range: .92-1.0) and inter-rater (.91-1.0) reliability reflect excellent agreement between human raters. The AI-algorithm could determine all parameters with excellent ICC-values (preop:0.80-1.0; postop:0.86-.99). For a comparison between the AI algorithm and 1 surgeon, mean errors were smallest for C1-C7 SVA (preop: -.3mm (95% CI:-.6 to -.1mm), post: .3mm (.0-.7mm)) and largest for C2-C7 lordosis (preop:-2.2° (-2.9 to -1.6°), postop: 2.3°(-3.0 to -1.7°)). The automatic measurement was possible in 99% and 98% of pre- and postoperative images for all parameters except T1 slope, which had a detection rate of 48% and 51% in pre- and postoperative images. This study validates that an AI-algorithm can reliably measure cervical sagittal balance parameters automatically in patients suffering from degenerative spinal diseases. It may simplify manual measurements and autonomously analyze large-scale datasets. Further studies are required to validate the algorithm on a larger and more diverse patient cohort.

P1023 Variability in Mesalazine Management for Ulcerative Proctitis Include Doses, Route of Administration and Use of Fecal Calprotectin: Insights from Clinical Practice Across Spain Beyond Clinical Guidelines

Abstract Background Despite universal use of mesalazine in ulcerative colitis treatment, many aspects of clinical practice remain unclear or are not even addressed in clinical guidelines, leading to significant variations in mesalazine management among clinicians. We aimed to gather different approaches of mesalazine use in ulcerative proctitis (UP). Methods After discussion of a clinical case, a predefined questionnaire was anonymously answered throughout a series of meetings held at 10 different locations in Spain. Results were categorized according to experience levels and inflammatory bowel disease (IBD) focus. Results 259 IBD treating gastroenterologists were engaged; 84% had &amp;lt;10 years of experience and 25% had a specific focus on IBD. Most participants (84%) manage UP based on clinical symptoms (i.e. fecal urgency). In case of a clinically moderate-severe UP, 81% would initiate treatment with high dose of combined mesalazine, while 11% proposed only suppositories. 60% of participants would assess response at 4 weeks. If clinical remission achieved, 85% would use fecal calprotectin (FC) to assess deep remission. Upon initial failure of combined mesalazine treatment at standard dose, 59% attempt optimizing mesalazine doses, while 38% add beclomethasone dipropionate. Younger physicians without specific focus on IBD prefer modifying mesalazine doses (70.5% vs 37.1%), (P=0,006), whereas more experienced physicians with monographic dedication prefer adding beclomethasone dipropionate (60% vs 29.4%), (P=0,006). For maintenance therapy (oral or topical mesalazine) the most important drivers in therapeutic decision-making were severity of the initial flare (40%) and patient preferences (36%). After a moderate-severe flare of UP, 80% would recommend maintenance therapy with high dose oral mesalazine and 3 suppositories/week. For monitoring, less experienced physicians and those not working in IBD units more frequently relied only on clinical parameters (26.6% vs. 8.7%, p=0.01), using FC to a lesser extent (73% vs. 88%, p=0.1) compared to more experienced and IBD focused physicians. In the case of elevated FC in asymptomatic patients, 49% would prefer to scope, while 47% increase mesalazine dose directly. The preferred high dose of mesalazine was 4g (55%) or 4-5g (44%). 73% would not reduce the dose upon achieving remission. Only 75% actively investigate therapeutic adherence. Conclusion Management of mesalazine in UP patients is highly heterogeneous, and clinical guidelines do not address all issues arising in clinical practice. Nevertheless, clinicians in our setting often use high oral and rectal mesalazine doses for both induction and maintenance and they commonly monitor patients using FC.

Radiation Exposure in Interventional Pain Management Physicians: A Systematic Review of the Current Literature

BACKGROUND: Millions of interventional pain procedures are performed each year to address chronic pain. The increase in these procedures also raises the concern of health risks associated with ionizing radiation for interventional pain management physicians who perform fluoroscopy-guided operations. Some health concerns include cancers, cataracts, and even pregnancy abnormalities. Little is known regarding the long-term and cumulative effects of small radiation doses. OBJECTIVES: The objective of this systematic review was to identify common body parts that are exposed to ionizing radiation during interventional pain procedures and examine methods to help physicians reduce their radiation exposure. STUDY DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was used to comprehensively identify articles from 2 medical databases. The radiation dose to interventional pain management physicians obtained from relevant peer-reviewed articles were aggregated and used for analysis. METHODS: PubMed was first used to collect the articles for two broad keyword searches of “radiation exposure pain management” and “radiation exposure interventionalist” with years ranging from 1956 – February 2023. EMBASE was also used to collect the articles for the two keyword searches of “radiation exposure pain management” and “radiation exposure interventionalist” with years ranging from 1969 – February 2023. This systematic approach yielded a total of 2,736 articles; 24 were included in our paper. The risk of bias for these articles was performed using the Cochrane Risk of Bias tool and the National Institutes of Health tool. RESULTS: Through our systematic literature search, more than 3,577 patients were treated by 30 interventional pain management physicians. Some areas of exposure to radiation include the physician’s neck, chest, groin, hands, and eyes. One common body region that is exposed to radiation is the chest; our review found that wearing lead aprons can lower the radiation dose by more than 95%. Wearing protective equipment and managing the distance between the operator and fluoroscope can both independently lower the radiation dose by more than 90% as well. Our literature review also found that other body parts that are often overlooked in regard to radiation exposure are the eyes and hands. In our study, the radiation dose to the outside (unprotected) chest ranged from 0.008 ± 27 mrem to 1,345 mrem, the outside neck ranged from 572 mrem to 2,032 mrem, the outside groin ranged from 176 mrem to 1,292 mrem, the hands ranged from 0.006 ± 27.4 mrem to 0.114 ± 269 mrem, and the eyes ranged from 40 mrem to 369 mrem. When protective equipment was worn, the radiation exposure to the inside chest ranged from 0 mrem to 108 mrem, the inside neck ranged from 0 mrem to 68 mrem, and the inside groin ranged from 0 mrem to 15 mrem. LIMITATIONS: Limitations of this study include its small sample size; only the radiation exposure of 30 interventional pain management physicians were examined. Furthermore, this review mainly consisted of observational studies rather than randomized clinical trials. CONCLUSION: Implementing safety precautions, such as wearing protective gear, providing educational programs, and keeping a safe distance, demonstrated a significant decrease in radiation exposure. The experience of interventional pain management physicians also factored into their radiation exposure during procedures. Radiation is a known carcinogen, and more research is needed to better understand its risk to interventional pain management physicians. KEY WORDS: Chronic pain management, radiation exposure, fluoroscopy, anesthesiology, nerve blocks, x-ray, ultrasound

Validation of a novel web-based application for hepatic arterial infusion floxuridine dosing.

15 Background: Hepatic arterial infusion (HAI) floxuridine (FUDR) dosing is a complex, multifactorial process with weight-based dosing dependent on the fold change of aspartate aminotransferase, alkaline phosphatase, and total bilirubin relative to reference values from preceding cycles and compounded over time. Given the complexity of dosing calculations and lack of experience with this treatment in community centers, HAI is typically administered only at tertiary oncology centers with limited access for rural disadvantaged patients. We developed an online tool to automate the dosing of FUDR to broaden safe and effective administration of HAI. Methods: The FUDR dosing algorithm developed at Memorial Sloan Kettering Cancer Center was digitalized as eDoseHAI, a novel multi-layer architecture web application tool featuring JavaScript (front-end), C# RESTful API (back-end) and Azure SQL server (data storage with Splunk data lake event registration). To validate this tool, manual dosing from patients who received ≥1 dose of HAI FUDR at our institution 6/2020-8/2023 was retrospectively compared to app-based dosing. Mismatch between app-based dosing and historical manual dosing was designated as dosing errors, excluding intentional adjustments based on physician discretion. Results: Internal validity was tested by entering records into eDoseHAI from 54 patients who received a total of 370 FUDR cycles (median 6; range 1-19). Ten patients (18.5%) were found to have unintentional dosing errors (e.g., delayed dose reductions) during treatment, impacting 52 cycles (14.1%). The median cycle at first error was 3 (range 2-6), impacting a median of 5 cycles (range 3-12). Dosing errors occurred in only 11.1% of the 45 patients supervised by a senior HAI physician, compared to 55.6% of the 9 patients supervised by three less experienced HAI physicians. Dosing accuracy improved over time; among the 14 patients on active HAI therapy, only 1 had an identified dosing error. eDoseHAI was able to reliably and accurately calculate dosing for all patients. Conclusions: HAI FUDR dosing is nuanced and complex, such that dosing errors occurred even with senior HAI oncologists. eDoseHAI is a web-based application tool designed to improve accuracy and thus safety of HAI dosing. We plan to further validate eDoseHAI using external data from an international HAI consortium, and to conduct a phase II clinical trial in which our team supervises FUDR dosing by community oncologists using eDoseHAI's supervisory mode with a goal to disseminate HAI therapy to disadvantaged rural patients who lack access.

Radiation exposure in augmented fluoroscopic bronchoscopy procedures: a comprehensive analysis for patients and physicians

Cancer is a major health challenge and causes millions of deaths worldwide each year, and the incidence of lung cancer has increased. Augmented fluoroscopic bronchoscopy (AFB) procedures, which combine bronchoscopy and fluoroscopy, are crucial for diagnosing and treating lung cancer. However, fluoroscopy exposes patients and physicians to radiation, and therefore, the procedure requires careful monitoring. The National Council on Radiation Protection and Measurement and the International Commission on Radiological Protection have emphasised the importance of monitoring patient doses and ensuring occupational radiation safety. The present study evaluated radiation doses during AFB procedures, focusing on patient skin doses, the effective dose, and the personal dose equivalent to the eye lens for physicians. Skin doses were measured using thermoluminescent dosimeters. Peak skin doses were observed on the sides of the patients’ arms, particularly on the side closest to the x-ray tube. Differences in the procedures and experience of physicians between the two hospitals involved in this study were investigated. AFB procedures were conducted more efficiently at Hospital A than at Hospital B, resulting in lower effective doses. Cone-beam computed tomography (CT) contributes significantly to patient effective doses because it has higher radiographic parameters. Despite their higher radiographic parameters, AFB procedures resulted in smaller skin doses than did image-guided interventional and CT fluoroscopy procedures. The effective doses differed between the two hospitals of this study due to workflow differences, with cone-beam CT playing a dominant role. No significant differences in left and right eye Hp (3) values were observed between the hospitals. For both hospitals, the Hp (3) values were below the recommended limits, indicating that radiation monitoring may not be required for AFB procedures. This study provides insights into radiation exposure during AFB procedures, concerning radiation dosimetry, and safety for patients and physicians.

A position statement on the post gene-therapy rehabilitation of aromatic I-amino acid decarboxylase deficiency patients

Aromatic l-amino acid decarboxylase (AADC) deficiency is a rare genetic disorder of monoamine neurotransmitter synthesis that presents with a range of symptoms, including motor dysfunction and limited attainment of developmental motor milestones. The approval of eladocagene exuparvovec, a gene therapy for AADC deficiency with demonstrated efficacy for motor improvements, now expands the range of motor outcomes possible for patients with this disorder. However, recommendations and guidelines for therapy following treatment with gene therapy are lacking. To ensure patients can reach their full potential following treatment with gene therapy, it is essential they receive rehabilitation therapies designed specifically with their impairments and goals in mind. Therefore, we highlight specific rehabilitative needs of patients following gene therapy and propose a set of recommendations for the post-treatment period based on collective experiences of therapists, physicians, and caregivers treating and caring for patients with AADC deficiency who have been treated with gene therapy. These recommendations include a focus on periods of intensive therapy, facilitating active movements, training for functional abilities, cognitive and communication training, parent/caregiver empowerment, collaboration between therapists and caregivers to develop in-home programs, and the incorporation of supplemental forms of therapy that patients and their families may find more enjoyable and engaging. Many of these rehabilitative strategies may be employed prior to gene therapy. However, these recommendations will be valuable for therapists, caregivers, and wider treatment teams as they prepare for the post-treatment journey with these patients. Furthermore, the considerations and recommendations presented here may prove beneficial outside the AADC deficiency community as gene therapies and other treatments are developed and approved for other rare diseases.