Physician Intervention Research Articles

Mental health survey of medical personnel during pre-job training in a closed-loop management system during the COVID-19 pandemic.

With the aim of enhancing prevention and regional control of epidemics, the mental health status of medical personnel was analyzed before the implementation of closed-loop management during the COVID-19 pandemic in the regional hospital representative. In accordance with directives from the unified deployment of the national and regional health bureaus, and following the inclusion and exclusion criteria, from September 2021 to November 2022, all medical personnel assigned to a closed-loop working environment by Guangzhou Panyu Central Hospital were enrolled as research subjects through cluster sampling method. Using a cross-sectional survey method, relevant data such as age, gender, professional title, and mental health status were collected. The Patient Health Questionnaire-9 (PHQ-9) scale, the Generalized Anxiety Disorder-7 (GAD-7) scale, and the Insomnia Severity Index (ISI) scale were administered. Logistic regression analysis was used to study the influencing factors of depression, anxiety, and insomnia. Single factor logistic regression analysis was performed first, followed by multiple factor logistic regression analysis. A total of 500 valid responses were received. Depression was reported by a higher proportion of physicians than nurses. Anxiety was reported by higher proportion of men than women and by a higher proportion of physicians than nurses. Medical personnel under the age of 30 years reported fewer symptoms of insomnia than those over the age of 41 years, and medical personnel with intermediate professional titles reported more severe symptoms of insomnia than junior personnel. There was no significant difference between the results of the three questionnaires for medical personnel from other hospital departments or in the different type of closed-loop work environments. During the pandemic, conducting psychological health assessments for medical personnel undergoing pre-job training in closed-loop management was beneficial for the timely detection of psychological problems. Although this study only conducted a cluster sampling survey and lacked comparative analysis on other medical institutions, it still suggested that it was necessary to strengthen timely psychological counseling and intervention for senior male physicians.

BE-A-PAL: Behavioral economics and automated analytics to improve palliative care among patients with advanced cancer.

268 Background: Patients with advanced solid malignancies often experience high symptom burden and aggressive end-of-life care. Early specialist palliative care (PC) can improve symptom management, mood, and quality of life. However, many patients do not receive PC before they die, with clinician inertia and difficulty identifying high-risk patients being barriers to initiating PC referrals. Methods: In a 2-arm pragmatic randomized clinical trial among patients with stage 3 or 4 lung or non-colorectal gastrointestinal malignancies, oncology clinics were randomly assigned to intervention or usual practice. In the intervention arm, oncologists received automated algorithm-based default notifications prompting specialty PC referral. The control arm received usual care, in which oncologists could refer to PC at their discretion. The algorithm was adapted from NCCN guidelines, identified high-risk patients based on prognosis or symptom/psychosocial burden, and was integrated into the EHR. Oncologists were alerted weekly about eligible patients and had the option to opt-out of PC referral. If there was no response or agreement, a PC coordinator introduced and offered a PC visit to the patient. The primary outcome was a completed PC visit within three months of identification among high-risk patients. We report descriptive results from an interim analysis of the trial. Results: 15 practices (7 clinics and 32 physicians in intervention; 8 clinics and 31 physicians in control) and 567 patients (299 intervention; 268 control) were randomized. Rates of completed early PC visits were 46.4% (139/299) the intervention arm and 11.2% (30/268) in the control arm. The opt-out rate in the intervention arm was 10.7%. Among clinicians who did not opt-out, 79% of their patients agreed to an initial PC visit. Adjusted analyses and demographic data will be completed and available by September 2023. Conclusions: Algorithm-based default PC referrals meaningfully increased utilization of specialty PC within a community oncology practice. Targeting high-risk patients using guideline-based risk stratification prevented overwhelming PC capacity. Further analyses will assess the impact of the intervention on end-of-life care, acute care utilization, patient-reported outcomes, and explore clinician perspectives. Clinical trial information: NCT05590962 .

Interventional pain physician beliefs on climate change: A Spine Intervention Society (SIS) survey

Summary of background dataAlthough evaluated within other specialties, physicians’ beliefs towards climate change and human health have not been described within Interventional Pain Medicine (IPM). Understanding belief systems is essential for developing solutions to build sustainable practices. ObjectivesAssess beliefs toward climate change within the field of IPM. MethodsSpine Intervention Society (SIS) members were invited to participate in an anonymous RedCap survey by email, social media, and advertisement at the 2022 SIS Annual Meeting. Descriptive statistics were calculated, and associations were estimated using Chi-Square (significance: p < 0.05). ResultsOne hundred and seventy-five participants responded to the survey. Participants most often identified as white (66 %; 95 % CI 57–73 %), male (78 %; 95 % CI 71–84 %), and from the United States (US) (76 %; CI 95 % 58–72 %), with 87 % (n = 123/141; 95 % CI 82–93 %) agreeing that climate change is happening (agree or strongly agree). While 78 % (95 % CI 80–92 %) agree that climate change and sustainability are important to them, only 47 % (95 % CI 34–51 %) agree that these are important to their patients. Those beliefs did not differ by age or geographical area (p > 0.05). However, physicians in non-leadership positions are more likely to disagree or strongly disagree that climate change is important to them (χ2(2) = 15.98; p < 0.05), to their patients (χ2(2) = 17.21; p < 0.05), or that societies should advocate for climate policies (χ2(2) = 9.19; p < 0.05). Non-US physicians were more likely to believe that physicians have responsibilities to bring awareness to the health effects of climate change (χ2(2) = 6.58; p < 0.05) and to agree that climate change is important to their patients (χ2(2) = 10.50; p < 0.05). Discussion/conclusionUnderstanding specialty-specific physician views on climate change is essential for developing solutions to reduce the carbon footprint of medical practice and improve sustainability. The majority of SIS members believe that climate change is happening. Non-US physicians and physician-leaders are more likely to believe that climate change impacts their patients and that societies should advocate for climate policies.

An update on technical and safety practice patterns in transforaminal epidural steroid injections

IntroductionPrevious studies have suggested variability in practice patterns for transforaminal epidural steroid injections (TFESIs) despite published safety guidance. The purpose of this study was to understand recent trends in periprocedural safety practices in TFESIs and how some aspects of interventional pain practice may have been influenced by the coronavirus disease 2019 (COVID-19) pandemic and related supply chain shortages. MethodsA 91-item survey was distributed to 111 program directors of Accreditation Council for Graduate Medical Education accredited Pain Management fellowships, 42 North American Spine Society and Interventional Spine and Musculoskeletal Medicine recognized fellowship directors, and 100 private practice interventional pain physicians to capture current practices in epidural steroid injections from March 2021 to March 2022. Additional responses were obtained through advertising on social media platforms consisting of interventional pain physicians. Cross sectional data from survey responses specific to TFESI-related practices were gathered and analyzed. ResultsOf 103 complete survey responses, 102 physicians perform TFESIs (cervical, 33.3%; thoracic, 40.2%; lumbar, 100%; sacral, 89.2%). There was variability in preprocedural imaging review, sedation practices, contrast and fluoroscopy techniques, and type and dose of steroid preferred. Many physicians saw a decrease in number of procedures performed weekly as a result of the COVID-19 pandemic. ConclusionsThere remains practice variability in various periprocedural aspects of TFESIs despite existing safety recommendations. Further research is needed to identify ongoing barriers to adherence to established guidelines. Recent practice trends may have been affected by unique challenges posed by the COVID-19 pandemic, and these trends should be considered in the event of future supply chain limitations and/or need for disaster response.

Brand Loyalty and Customer Retention Among Pharmaceutical Distributors in Lagos State, Nigeria

Studies on brand loyalty posit that customers are motivated by factors external and internal to them. The former deals with items driven by brand makers and intermediate partnership; the latter is driven by cognitive and behavioral disposition. Against this backdrop, the study was conducted to examine moderating role of physician and pharmaceutical distributors in customer brand loyalty in Ikeja-Lagos. The study adopted descriptive survey, 25 sample size and qualitative method. Key informant interviews and semi structure interview were used as instrument of data collection. Study population consisted of middle class residents, who were brand customers, and pharmacy stores. Moderating role of physicians and brand customers in pharmacy stores were dominantly influenced by doctor’s prescriptions, history of illness, satisfaction and trust. Purchase intention of customers was driven by attachment and commitment to doctor’s brand prescription. Satisfaction predicted trust. Brand medicine which offered satisfaction was retained whether or not the price changed upward. Trust for brand depended on consistent satisfaction and this significantly predicted loyalty. Pharmacy distributors had little capacity to change purchase intention. Brand decision was predicted by moderating role of physician. This study recommended that the role of physicians should be mainstreamed in brand patronage in pharmaceutical distribution. Loyalty to brand was predicted by customer knowledge of efficacy in disease history. Physician intervention was valued by customers.

Rib region detection for scanning path planning for fully automated robotic abdominal ultrasonography.

Scanning path planning is an essential technology for fully automated ultrasound (US) robotics. During biliary scanning, the subcostal boundary is critical body surface landmarks for scanning path planning but are often invisible, depending on the individual. This study developed a method of estimating the rib region for scanning path planning toward fully automated robotic US systems. We proposed a method for determining the rib region using RGB-D images and respiratory variation. We hypothesized that detecting the rib region would be possible based on changes in body surface position due to breathing. We generated a depth difference image by finding the difference between the depth image taken at the resting inspiratory position and the depth image taken at the maximum inspiratory position, which clearly shows the rib region. The boundary position of the subcostal was then determined by applying training using the YOLOv5 object detection model to this depth difference image. In the experiments with healthy subjects, the proposed method of rib detection using the depth difference image marked an intersection over union (IoU) of 0.951 and average confidence of 0.77. The average error between the ground truth and predicted positions was 16.5 mm in 3D space. The results were superior to rib detection using only the RGB image. The proposed depth difference imaging method, which measures respiratory variation, was able to accurately estimate the rib region without contact and physician intervention. It will be useful for planning the scan path during the biliary imaging.

Fulminant Cervical Epidural Hematomas: Why Do They Happen, How Can We Minimize Their Occurrence, and What Can We Do When They Do Occur? A Perspective

BACKGROUND: Epidural hematomas after appropriately performed cervicothoracic interlaminar epidural injections have been associated with the rapid onset of neurological symptoms and devastating outcomes, despite prompt identification and treatment. Anticoagulation issues were initially felt to be the problem, but the occurrence of fulminant hematomas in patients without coagulation forced a reassessment of the causes and responses to this problem. OBJECTIVES: To evaluate why fulminant epidural hematomas occur after cervicothoracic epidural injections, with a literature review to survey knowledge about them in the surgical literature, and to offer comments as to what the interventional pain physician can do to minimize their occurrence. STUDY DESIGN: A perspective piece with a literature review. SETTINGS: Interventional pain management practices. METHODS: A perspective on the issue of fulminant cervical hematomas and an associated literature review. RESULTS: Anatomical studies show that there are no meaningful arteries in the posterior epidural spaces which would explain hematomas. There is a dense posterior intravertebral epidural venous plexus at C1 and also at C6-C7 extending caudally to the upper thoracic region. A venous origin has been questioned because venous pressure was felt to be too low to explain the bleeding. The surgical literature, going back 80 years, contains numerous reports of engorged epidural veins causing radiculopathy and myelopathy. These engorged veins can occur in the presence or absence of spinal pathology. There is no known means of reliably identifying these engorged veins; they have been mistaken for disc protrusions. At least one report documents massive bleeding from these veins. Studies done on a feline model of cervical stenosis suggest that the epidural pressure can reach arterial levels. LIMITATIONS: No direct documentation of arterialized posterior intravertebral epidural venous pressures has been made. While anatomical anomalies and degeneration contribute to epidural scarring, we do not have a full understanding as to the cause of arterialization of veins, particularly in younger patients with no obvious intraspinal pathology. CONCLUSION: Fulminant cervicothoracic epidural hematomas after an epidural injection appear to arise from the unintentional and unavoidable puncture of arterialized veins with sharp needles. A technique to open a path out from the foramen so that the blood can escape is described. Alternatively, providers should consider injecting more cephalad, between C2-C3 and C6-C7 in the cervical spine, or an alternative procedure, such as a selective nerve root injection. A cervical transforaminal approach should only be attempted with a blunt needle, which cannot enter an artery. Should symptoms occur, cervical flexion rotation maneuvers should be implemented while awaiting prompt transfer to a facility where an appropriate diagnosis and treatment can be provided. KEY WORDS: Cervical epidural hematoma, cervical epidural injection, posterior intravertebral venous plexus, arterialized epidural veins, pressurized epidural veins

Validation of an automated contouring and treatment planning tool for pediatric craniospinal radiation therapy.

Treatment planning for craniospinal irradiation (CSI) is complex and time-consuming, especially for resource-constrained centers. To alleviate demanding workflows, we successfully automated the pediatric CSI planning pipeline in previous work. In this work, we validated our CSI autosegmentation and autoplanning tool on a large dataset from St. Jude Children's Research Hospital. Sixty-three CSI patient CT scans were involved in the study. Pre-planning scripts were used to automatically verify anatomical compatibility with the autoplanning tool. The autoplanning pipeline generated 15 contours and a composite CSI treatment plan for each of the compatible test patients (n=51). Plan quality was evaluated quantitatively with target coverage and dose to normal tissue metrics and qualitatively with physician review, using a 5-point Likert scale. Three pediatric radiation oncologists from 3 institutions reviewed and scored 15 contours and a corresponding composite CSI plan for the final 51 test patients. One patient was scored by 3 physicians, resulting in 53 plans scored total. The algorithm automatically detected 12 incompatible patients due to insufficient junction spacing or head tilt and removed them from the study. Of the 795 autosegmented contours reviewed, 97% were scored as clinically acceptable, with 92% requiring no edits. Of the 53 plans scored, all 51 brain dose distributions were scored as clinically acceptable. For the spine dose distributions, 92%, 100%, and 68% of single, extended, and multiple-field cases, respectively, were scored as clinically acceptable. In all cases (major or minor edits), the physicians noted that they would rather edit the autoplan than create a new plan. We successfully validated an autoplanning pipeline on 51 patients from another institution, indicating that our algorithm is robust in its adjustment to differing patient populations. We automatically generated 15 contours and a comprehensive CSI treatment plan for each patient without physician intervention, indicating the potential for increased treatment planning efficiency and global access to high-quality radiation therapy.

Case report: total leftmain occlusion after radiofrequency ablation of premature ventricular complexes

Coronary injury following radiofrequency ablation is uncommon due to the high safety of ablation procedures. Injuries to the left coronary artery are uncommon, and total occlusion of the left coronary artery is even less commonly seen. The approach and management of this situation require a certain level of the interventional vascular physician's experience, as well as the immediate and efficient coordination of all intervention personnels.

Guideline for clinical practice of ultrasound examination in liver transplantation (2023 edition)

Liver transplantation is currently the only effective treatment for end-stage liver disease. Ultrasound examination has the advantages of non-invasive, convenient, and real-time display the intrahepatic vascular hemodynamic changes, and has become one of the preferred evaluation methods in the entire management process of liver transplantation. To further standardize the ultrasound examinations before and after liver transplantation, multiple-disciplinary experts in the field of liver transplantation, including specialists in ultrasound, liver surgery, and intervention medicine, were organized by the Chinese Medical Association Ultrasound Medicine Branch, the Chinese Medical Doctor Association Surgery Physician Branch, the Chinese Medical Doctor Association Interventional Physician Branch, and the Shanghai Medical Association Ultrasound Medicine Branch. Combined with the latest research practice in ultrasound diagnosis and treatment of liver transplantation, the ultrasound clinical practice guidelines for liver transplantation (2023 edition) was formulated. The contents of this guideline include ultrasound evaluation of liver transplantation donors and recipients, intraoperative and postoperative ultrasound examination of transplant livers, ultrasound applications in pediatric liver transplantation, and ultrasound-guided liver puncture biopsy and treatment, aiming to promote the standardized and high-quality development of liver transplantation ultrasound examination in China.

Impact of Clinical Pharmacist in Collaboration with Physicians in Minimizing Drug Therapy Problems among Hypertension and Diabetes Mellitus

It is estimated that one in six people worldwide, or nearly one billion, are affected by high blood pressure(1).7.6 million deaths per annum worldwide(1). Globally, an estimated 462 million individuals are affected by type 2 diabetes, corresponding to 6.28% of the world's population(2). More than 1 million deaths were attributed to this condition in 2017 alone, ranking it as the ninth leading cause of mortality(2). The clinical pharmacist’s role is to assess the status of the patient's health problems and determine whether the prescribed medications are optimally meeting the patient's needs and goals of care(3). To study the impact of Clinical pharmacists in collaboration with Physicians in minimizing drug-therapy problems among Hypertension and Type 2 Diabetes Mellitus. A Prospective interventional study was carried out at Sangareddy District Government Hospital for a period of 6 months. A structured proforma was designed to collect patient data. Descriptive analysis was analyzed using MS Excel 2019 MSO to describe demographics, Drug-Related problems, Clinical pharmacist -Physician Intervention, Antihypertensive Drugs, and oral hypoglycemic drug usage. Out of 133 study individuals, the majority of subjects had a Sub-therapeutic goal (44%), followed by an Inappropriate Drug[41%]. The majority of patients had at least one DRP(82%). The most common Intervention performed was the addition of appropriate drugs(31%), followed by cessation of drugs(30%). Our study concludes that the collaboration of Clinical Pharmacists with Physicians can assist in identifying and preventing drug-related problems through interventions and their expertise in pharmacotherapy can assist in providing rational drug therapy.

Radiation exposure in fluoroscopy guided spinal interventions: A prospective observational study of standard practice in a physiatry academic center

ContextFluoroscopy is the recommended image guidance modality for most spinal pain interventions. However, it exposes interventional pain physicians to chronic ionizing radiation, with known risks to the eye, skin, and hand. The use of protective glasses and gloves is variable among pain physicians. ObjectivesTo document the total radiation exposure (mSv) by pain physicians to their eyes, hands and chest in an academic setting including various spinal interventions. MethodsFour pain physicians wore a finger, head/collar (equivalent to eye exposure) and chest dosimeter over and under their lead apron during a three-month period where they performed their usual fluoroscopy-guided interventions, including close supervision of trainees. We calculated an average exposure per intervention and extrapolated the recorded exposure to a maximum, worst-case scenario of a caseload of 13 procedures per day, 5 days a week and 52 weeks per year. ResultsFour pain physicians of variable experience performed 15 different types of procedures on 607 patients throughout the study period. The yearly maximum exposure scenarios for each pain physician were all below the Canadian Nuclear Safety Commission thresholds for nuclear energy workers: for the hands (31.56 mSv, 25.67 mSv, 20.59 mSv, 21.51 mSv; threshold = 500 mSv), eyes (16.01 mSv, 18.64 mSv, 24.08 mSv, 18.68 mSv; threshold = 50 mSv) and chest over the lead apron (28.27 mSv, 46.91 mSv, 30.00 mSv, 40,03 mSv; whole body threshold = 50 mSv), with some doses even below general population thresholds. The exposure under the lead apron was 0 mSv for each pain physician. ConclusionThe standard practice of an interventional pain physician using fluoroscopy in this academic setting is below radiation exposure regulations, even in a theoretical, worst-case, maximum exposure scenario. Standard radiation protection practices such as the use of lead aprons and thyroid shields should still be used. However, this data is reassuring for pain physicians with a practice in fluoroscopy-guided interventions who wish to not use protective glasses or gloves.

Survey of COVID-19 Vaccine Attitudes in Predominately Minority Pregnant Women.

Despite recommendations for coronavirus disease (COVID-19) vaccination during pregnancy, some pregnant women are concerned about COVID-19 vaccines and decline to be vaccinated. This study focuses on attitudes in a sample of mostly minority pregnant Hispanic and Black women that may influence vaccine hesitancy. This was a cross-sectional survey of 400 pregnant women. Participants were provided with a one-page information sheet on pregnancy health, COVID-19 health, and COVID-19 vaccines. They were then asked to complete a survey on attitudes about these topics. We found that attitudes for knowing about the health topics were in the range from agree to strongly agree, whereas attitudes for knowing about topics pertaining to COVID-19 messenger RNA (mRNA) vaccines were in a lower-level range from neutral to agree. Negative vaccine attitudes were significantly associated with decreased agreement for knowing about health attitudes, but not significantly associated with COVID-19 mRNA vaccine attitudes. COVID-19 vaccine mRNA technology was a lesser understood topic than attitudes for knowing about other health topics. This finding suggests the need for physician intervention and that further education about COVID-19 vaccine mRNA technology may influence patient attitudes toward acceptance of the COVID-19 mRNA vaccine in pregnancy.

A day-to-day management model improves patient compliance to treatment for Helicobacter pylori infection: a prospective, randomized controlled study

BackgroundThe day-to-day (DTD) management model encourages patients to actively participate in their healthcare by setting goals. We determined the effectiveness of the DTD model in the treatment of Helicobacter pylori (H. pylori) infection, as compared with conventional outpatient education (OE).MethodsWe randomized 254 H. pylori-positive patients into a DTD group (127 patients) and an OE group (127 patients) prior to primary treatment with 14-day bismuth-containing quadruple therapy, including esomeprazole, amoxicillin, and clarithromycin. Both groups received consistent medication instructions. Patients in the DTD group recorded daily attendance after completing their daily medication plan from day 1 to day 14. The medication compliance, follow-up compliance, H. pylori eradication rates, and adverse events (AEs) were evaluated.ResultsIn the modified intention-to-treat (MITT) and per-protocol (PP) analyses, the DTD group showed significantly higher medication compliance than the OE group (P = 0.001 and P = 0.031, respectively). Both the MITT and PP analyses showed significant differences in follow-up compliance (P < 0.001 and P = 0.003, respectively) and timing of the review urea breath test (P < 0.001 and P = 0.001, respectively) between the two groups. However, no significant differences were observed in the H. pylori eradication rates (95.8% vs. 93.8%, P = 0.529) in the PP analysis, or AEs incidence (25.4% vs. 28.3%, P = 0.603) between the two groups.ConclusionThis study demonstrated the novel application of the DTD model in the treatment of H. pylori infection, which enabled patients to develop habitual medication-taking behaviors without physician intervention.

Effects of an academic detailing service on benzodiazepine prescribing patterns in primary care.

Benzodiazepines are commonly used to treat anxiety and/or insomnia but are associated with substantial safety risks. Changes to prescribing patterns in primary care may be facilitated through tailored quality improvement strategies. Academic detailing (AD) may be an effective method of promoting safe benzodiazepine prescribing. The objective of this study was to evaluate the effectiveness of AD on benzodiazepine prescribing among family physicians. We used an interrupted time series matched cohort design using population-based administrative claims databases. Participants were family physicians practicing in Ontario, Canada. The intervention was a voluntary AD service which involves brief service-oriented educational outreach visits by a trained pharmacist. The focus was on key messages for safer benzodiazepine prescribing in primary care with an emphasis on judicious prescribing to older adults aged 65 and older. Physicians in the intervention group were those who received at least one AD visit on benzodiazepine use between June 2019 and February 2020. Physicians in the control group were included if they did not receive an AD visit during the study period. Intervention physicians were matched to control physicians 1:4, on a variety of characteristics. Physicians were excluded if they had inactive billing or billing of less than 100 unique patient visits in the calendar year prior to the index date. The primary outcome was mean total benzodiazepine prescriptions at the level of the physician. Secondary outcomes were rate (per 100) of patients with long-term prescriptions, high-risk prescriptions, newly started prescriptions, and benzodiazepine-related patient harms. Data were analyzed using a repeated measures pre-post comparison with an intention-to-treat. Analyses were then stratified to focus on effects within higher-prescribing physicians. There were 1337 physicians were included in the study; 237 who received AD and 1064 who did not. There was no significant change in benzodiazepine prescribing when considering all physicians in the intervention and matched control groups. Although not significant, a greater reduction in total benzodiazepine prescriptions was observed amongst the highest-volume prescribing physicians who received the intervention (% change in slope = -0.53, 95%CI = -2.34 to 1.30, p > .05). The main limitation of our study was the voluntary nature of the AD intervention, which may have introduced a self-selection bias of physicians most open to changing their prescribing. This study suggests that future AD interventions should focus on physicians with the greatest room for improvement to their prescribing.

Linking leadership development programs for physicians with organization-level outcomes: a realist review

BackgroundHospitals invest in Leadership Development Programs (LDPs) for physicians, assuming they benefit the organization’s performance. Researchers have listed the advantages of LDPs, but knowledge of how and why organization-level outcomes are achieved is missing.ObjectiveTo investigate how, why and under which circumstances LDPs for physicians can impact organization-level outcomes.MethodsWe conducted a realist review, following the RAMESES guidelines. Scientific articles and grey literature published between January 2010 and March 2021 evaluating a leadership intervention for physicians in the hospital setting were considered for inclusion. The following databases were searched: Medline, PsycInfo, ERIC, Web of Science, and Academic Search Premier. Based on the included documents, we developed a LDP middle-range program theory (MRPT) consisting of Context-Mechanism-Outcome configurations (CMOs) describing how specific contexts (C) trigger certain mechanisms (M) to generate organization-level outcomes (O).ResultsIn total, 3904 titles and abstracts and, subsequently, 100 full-text documents were inspected; 38 documents with LDPs from multiple countries informed our MRPT. The MRPT includes five CMOs that describe how LDPs can impact the organization-level outcomes categories ‘culture’, ‘quality improvement’, and ‘the leadership pipeline’: 'Acquiring self-insight and people skills (CMO1)', 'Intentionally building professional networks (CMO2)', 'Supporting quality improvement projects (CMO3)', 'Tailored LDP content prepares physicians (CMO4)', and 'Valuing physician leaders and organizational commitment (CMO5)'. Culture was the outcome of CMO1 and CMO2, quality improvement of CMO2 and CMO3, and the leadership pipeline of CMO2, CMO4, and CMO5. These CMOs operated within an overarching context, the leadership ecosystem, that determined realizing and sustaining organization-level outcomes.ConclusionsLDPs benefit organization-level outcomes through multiple mechanisms. Creating the contexts to trigger these mechanisms depends on the resources invested in LDPs and adequately supporting physicians. LDP providers can use the presented MRPT to guide the development of LDPs when aiming for specific organization-level outcomes.

Interventional Pain Physician Burnout During the COVID-19 Pandemic: A Survey from the American Society of Pain and Neuroscience.

The study sought to assess the prevalence of physician burnout among interventional pain physicians in 2022. Physician burnout is major psychosocial and occupational health issue. Prior to the coronavirus disease of 2019 (COVID-19) pandemic, over 60% of physicians reported emotional exhaustion and burnout. Physician burnout was reported to become more prevalent in multiple medical specialties during the COVID-19 pandemic. An 18-question survey was distributed electronically to all ASPN members (n = 7809) in the summer of 2022 to assess demographics, burnout characteristics (e.g., Have you felt burned out due to COVID?), and strategies to cope with burnout and stress (e.g., reached out for mental health assistance). Members were able to complete the survey once and were unable to make changes to their responses once submitted. Descriptive statistics were used to assess the prevalence and severity of physician burnout within the ASPN community. Chi-square tests were used to examine differences in burnout by provider characteristics (age, gender, years practicing, and practice type) with p-values less than 0.05 indicating statistical significance. There were 7809 ASPN members that received the survey email, 164 of those members completed the survey, a response rate of 2.1%. The majority of respondents were male (74.1%, n = 120), 94% were attending physicians (n = 152), and 26% (n = 43) have been in practice for twenty years or longer. Most respondents expressed having experienced burnout during the COVID pandemic (73.5%, n = 119), 21.6% of the sample reported reduced hours and responsibilities during the pandemic, and 6.2% of surveyed physicians quit or retired due to burnout. Nearly half of responders reported negative impacts to their family and social lives as well as personal physical and mental health. A variety of negative (e.g., changes in diet, smoking/vaping) and positive coping strategies (e.g., exercise and training, spiritual enrichment) were employed in response to stress and burnout; 33.5% felt they should or had reached out for mental health assistance and suicidal ideations were expressed in 6.2% due to burnout. A high percentage of interventional pain physicians continue to experience mental symptoms that may lead to risk for significant issues going forward. Our findings should be interpreted with caution based on the low response rate. Evaluation of burnout should be incorporated into annual assessments given issues of survey fatigue and low survey response rates. Interventions and strategies to address burnout are warranted.

"EM Doc On Call:" A Pilot Study to Improve Interhospital Transfers in Rwanda.

Treatment of seriously ill patients is often complicated by prolonged or complex transfers between hospitals in sub-Saharan Africa. Difficulties or inefficiency in these transfers can lead to poor outcomes for patients. "On-call" triage systems have been utilized to facilitate communication between facilities and to avoid poor outcomes associated with patient transfer. This study attempts to examine the effects of a pilot study to implement such a system in Rwanda. Data collection occurred prospectively in two stages, pre-intervention and intervention, in the emergency department (ED) at Kigali University Teaching Hospital (CHUK). All patients transferred during the pre-determined timeframe were enrolled. Data were collected by ED research staff via a standardized form. Statistical analysis was performed using STATA version 15.0. Differences in characteristics were assessed using χ2 or Fisher's exact tests for categorical variables and independent sample t-tests for normally distributed continuous variables. During the "on call" physician intervention, the indication for transfer was significantly more likely to be for critical care (P <.001), transfer times were faster (P <.001), patients were more likely to be displaying emergency signs (P <.001), and vital signs were more likely to be collected prior to transport (P <.001) when compared to the pre-interventional phase. The "[Emergency Medicine] EM Doc On Call" intervention was associated with improved timely interhospital transfer and clinical documentation in Rwanda. While these data are not definitive due to multiple limitations, it is extremely promising and worthy of further study.

Superior Cluneal Nerve Schwannoma as a Cause of Intractable Ipsilateral Low Back Pain: A Case Report

BACKGROUND: Superior cluneal nerve (SCN) entrapment is an infrequent, yet commonly missed etiology of low back pain (LBP). The SCN is prone to entrapment as it travels through the iliocostalis muscle and exits thoracolumbar fascia via an osseofibrous tunnel as it courses over the iliac crest. CASE REPORT: A patient with chronic LBP exhibited new provocative sacroiliac joint testing not responsive to injections. Subsequent pelvis magnetic resonance imaging revealed a peripheral nerve sheath tumor of the right SCN. Although she exhibited an excellent response to therapeutic nerve blocks, her silicone allergy excluded her from peripheral nerve stimulation as a treatment option. She underwent SCN neurolysis and tumor resection by the neurosurgery department resulting in symptom resolution. CONCLUSION: Interventional pain physicians should consider SCN entrapment when diagnosing intractable LBP. In the event of rare etiologies of SCN entrapment, such as neurogenic tumors, a multidisciplinary patient-centered care approach should be sought for symptom management. KEY WORDS: Superior cluneal nerve, pain management, chronic pain, nerve block, schwannoma

Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage

Diagnostic errors made during triage at nontrauma centers contribute to preventable morbidity and mortality after injury. To test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to improve diagnostic reasoning in trauma triage. This pilot randomized clinical trial was conducted online in a national convenience sample of 72 emergency physicians between January 1 and March 31, 2022, without follow-up. Participants were randomly assigned to receive either usual care (ie, passive control) or a deliberate practice intervention, consisting of 3 weekly, 30-minute, video-conferenced sessions during which physicians played a customized, theory-based video game while being observed by content experts (coaches) who provided immediate, personalized feedback on diagnostic reasoning. Using the Proctor framework of outcomes for implementation research, the feasibility, fidelity, acceptability, adoption, and appropriateness of the intervention was assessed by reviewing videos of the coaching sessions and conducting debriefing interviews with participants. A validated online simulation was used to assess the intervention's effect on behavior, and triage among control and intervention physicians was compared using mixed-effects logistic regression. Implementation outcomes were analyzed using an intention-to-treat approach, but participants who did not use the simulation were excluded from the efficacy analysis. The study enrolled 72 physicians (mean [SD] age, 43.3 [9.4] years; 44 men [61%]) but limited registration of physicians in the intervention group to 30 because of the availability of the coaches. Physicians worked in 20 states; 62 (86%) were board certified in emergency medicine. The intervention was delivered with high fidelity, with 28 of 30 physicians (93%) completing 3 coaching sessions and with coaches delivering 95% of session components (642 of 674). A total of 21 of 36 physicians (58%) in the control group participated in outcome assessment; 28 of 30 physicians (93%) in the intervention group participated in semistructured interviews, and 26 of 30 physicians (87%) in the intervention group participated in outcome assessment. Most physicians in the intervention group (93% [26 of 28]) described the sessions as entertaining and valuable; most (88% [22 of 25]) affirmed the intention to adopt the principles discussed. Suggestions for refinement included providing more time with the coach and addressing contextual barriers to triage. During the simulation, the triage decisions of physicians in the intervention group were more likely to adhere to clinical practice guidelines than those in the control group (odds ratio; 13.8, 95% CI, 2.8-69.6; P = .001). In this pilot randomized clinical trial, coaching was feasible and acceptable and had a large effect on simulated trauma triage decisions, setting the stage for a phase 3 trial. ClinicalTrials.gov Identifier: NCT05168579.