Practice Patterns Research Articles

Practice Patterns Vary By Site Of Service For Physicians Who Treat PAD In Both OBL And Hospital Settings

Practice Patterns Vary By Site Of Service For Physicians Who Treat PAD In Both OBL And Hospital Settings

User-Centered Framework for Implementation of Technology (UFIT): Development of an Integrated Framework for Designing Clinical Decision Support Tools Packaged With Tailored Implementation Strategies.

Electronic health record-based clinical decision support (CDS) tools can facilitate the adoption of evidence into practice. Yet, the impact of CDS beyond single-site implementation is often limited by dissemination and implementation barriers related to site- and user-specific variation in workflows and behaviors. The translation of evidence-based CDS from initial development to implementation in heterogeneous environments requires a framework that assures careful balancing of fidelity to core functional elements with adaptations to ensure compatibility with new contexts. This study aims to develop and apply a framework to guide tailoring and implementing CDS across diverse clinical settings. In preparation for a multisite trial implementing CDS for pediatric overweight or obesity in primary care, we developed the User-Centered Framework for Implementation of Technology (UFIT), a framework that integrates principles from user-centered design (UCD), human factors/ergonomics theories, and implementation science to guide both CDS adaptation and tailoring of related implementation strategies. Our transdisciplinary study team conducted semistructured interviews with pediatric primary care clinicians and a diverse group of stakeholders from 3 health systems in the northeastern, midwestern, and southeastern United States to inform and apply the framework for our formative evaluation. We conducted 41 qualitative interviews with primary care clinicians (n=21) and other stakeholders (n=20). Our workflow analysis found 3 primary ways in which clinicians interact with the electronic health record during primary care well-child visits identifying opportunities for decision support. Additionally, we identified differences in practice patterns across contexts necessitating a multiprong design approach to support a variety of workflows, user needs, preferences, and implementation strategies. UFIT integrates theories and guidance from UCD, human factors/ergonomics, and implementation science to promote fit with local contexts for optimal outcomes. The components of UFIT were used to guide the development of Improving Pediatric Obesity Practice Using Prompts, an integrated package comprising CDS for obesity or overweight treatment with tailored implementation strategies. ClinicalTrials.gov NCT05627011; https://clinicaltrials.gov/study/NCT05627011.

Analysis of trends in radiofrequency ablation in a tertiary care center practice.

Radiofrequency ablation (RFA) for thyroid nodules has recently been introduced into the United States healthcare system landscape. Little is known about the process of incorporating this procedure into existing clinical practice. A retrospective chart review of a single institution was conducted to examine referral patterns and decision-making after the introduction of RFA into an endocrine surgery-focused practice. Patient demographics and thyroid-specific data were recorded. Two reviewers abstracted and coded reasons for the noncompletion of RFA. Two-sample t tests were used to compare groups; linear regression was used to assess trends and practice patterns. Chart review identified 451 patients referred for consideration of RFA from January 2020 to December 2022. Only 255 (56.5%) went on to receive the treatment. There was no significant difference in nodule volume between treated and nontreated groups (18.5 vs. 14.9 cm3, p = 0.07). Concern for malignancy on genetic testing, size (too large/too small), recommendation for Ethanol ablation, and multinodular disease without target nodules were the most common reasons for physician deferral. Of patients who declined to proceed, 46% opted to undergo surgical excision. Linear regression showed that referral numbers significantly increased with time; however, the proportion of patients receiving treatment decreased yearly, primarily because of higher rates of physician deferral. This study reflects the complex decision-making in offering minimally invasive thyroid nodule ablation. Despite a greater number of referrals over time, physician criteria became increasingly selective. Optimal candidacy in RFA is an evolving determination requiring patient and physician input to guide ideal practice patterns.

Practice Patterns and Outcomes Among Surgical Oncology Fellowship Graduates Performing Complex Cancer Surgery in the United States Across Different Career Stages.

Practice patterns and potential quality differences among surgical oncology fellowship graduates relative to years of independent practice have not been defined. Medicare claims were used to identify patients who underwent esophagectomy, pancreatectomy, hepatectomy, or rectal resection for cancer between 2016 and 2021. Surgical oncology fellowship graduates were identified, and the association between years of independent practice, serious complications, and 90-day mortality was examined. Overall, 11,746 cancer operations (pancreatectomy [61.2%], hepatectomy [19.5%], rectal resection [13.7%], esophagectomy [5.6%]) were performed by 676 surgical oncology fellowship graduates (females: 17.7%). The operations were performed for 4147 patients (35.3%) by early-career surgeons (1-7 years), for 4104 patients (34.9%) by mid-career surgeons (8-14 years), and for 3495 patients (29.8%) by late-career surgeons (>15 years). The patients who had surgery by early-career surgeons were treated more frequently at a Midwestern (24.9% vs. 14.2%) than at a Northeastern institution (20.6% vs. 26.9%) compared with individuals treated by late-career surgeons (p < 0.05). Surgical oncologists had comparable risk-adjusted serious complications and 90-day mortality rates irrespective of career stage (early career [13.0% and 7.2%], mid-career [12.6% and 6.3%], late career [12.8% and 6.5%], respectively; all p > 0.05). Surgeon case-specific volume independently predicted serious complications across all career stages (high vs. low volume: early career [odds ratio {OR}, 0.80; 95% confidence interval {CI}, 0.65-0.98]; mid-career [OR, 0.81; 95% CI, 0.66-0.99]; late career [OR, 0.78; 95% CI, 0.62-0.97]). Among surgical oncology fellowship graduates performing complex cancer surgery, rates of serious complications and 90-day mortality were comparable between the early-career and mid/late-career stages. Individual surgeon case-specific volume was strongly associated with postoperative outcomes irrespective of years of independent practice or career stage.

Profiles of Teacher-Student Relationships and Classroom Management Practices: How They Relate to Self-Efficacy, Work Stress, and Classroom Climate

&lt;p style="text-align:justify"&gt;Teachers' classroom practice encompasses diverse facets of teacher behavior. Understanding teachers’ classroom practice is important as the literature has been well documented its association with student, teacher, and classroom outcomes. Positive teacher-student relationships and proper classroom management, both are important aspects of teachers’ classroom practices, have been empirically linked to increasing student academic performance and reducing problem behaviors. This study explored patterns of teacher classroom practices across teacher-student relationships and classroom management and validated them using a person-oriented approach, k-means clustering, on three sets of data with over 600 participants. Using indicators of classroom assessment scoring system (CLASS), three distinct teacher profiles were identified: supportive, intermediate, and detached. Supportive teachers demonstrated high levels of teacher-student relationships and classroom management, while detached teachers showed low levels of both. Intermediate teachers fell between these two groups. The study also compared these profiles based on teacher self-efficacy, work stress, and classroom climate. Supportive teachers had the highest classroom climate scores, followed by intermediate and detached. Work stress was comparable for intermediate and supportive teachers, but both were lower than detached. No group differences were found for self-efficacy. This study contributes to the understanding of teacher behaviors with students in the lower grades.&lt;/p&gt;

First‐Line Treatment of Symptomatic Subocclusive Large‐Vessel Stroke: Results of a Nationwide StrokeNet Survey

BACKGROUND Limited evidence is available for the treatment of acute symptomatic subocclusive lesions in ischemic stroke. We sought to identify current treatment patterns of stroke teams at academic health centers. METHODS We conducted an email survey of the National Institutes of Health StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator was asked to nominate a local stroke interventionalist, or a neurologist if the RCC principal investigator was an interventionalist, most aligned with the typical practice pattern of the RCC's lead hospital, to receive a survey. The survey consisted of a clinical vignette and displayed a subocclusive lesion in the left middle cerebral artery on computed tomography angiogram followed by subsequent scenarios, revising only 1 historical, clinical, or radiographic variable at a time. Participants were asked to select initial management for each scenario. Results were reviewed and analyzed by stroke‐trained physicians. RESULTS Responses were received from 42 (77.8%) of 54 surveyed individuals, representing 25 (92.6%) of 27 RCCs nationwide, including 25 (59.5%) interventionalists. The majority (76.2%) of respondents treated the patient in the primary clinical vignette with mechanical thrombectomy. Among all 6 clinical scenarios, respondents chose mechanical thrombectomy with or without medical management as first‐line treatment for 4 (67%) vignettes. Exceptions were low National Institutes of Health Stroke Scale score and known ipsilateral stenosis, where respondents chose medical management as first‐line treatment. CONCLUSION Despite limited evidence to support mechanical thrombectomy versus other treatment strategies, the majority of StrokeNet RCC respondents would use mechanical thrombectomy with or without medical therapy to treat acute ischemic stroke due to intracranial subocclusive lesions.

Characteristics of patients and facility of peritoneal dialysis in Korea: Results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) Korea.

Varying peritoneal dialysis (PD)-related clinical outcomes have been reported in different countries. As a participant of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), this study investigated the characteristics of Korean PD patients, PD facilities and the incidence rates of clinical outcomes including mortality and PD-related outcomes. From July 2019 to December 2021, a total of 766 Korean PD patients were included for analysis. Poisson regression analysis was used to explore the incidence rates of various clinical events including mortality, modality transfer, exit site or catheter tunnel infection and peritonitis. Among the 766 patients (median age 55.5 years, males 59.5%), 276 were incident and 490 were prevalent PD patients. The incidence rates of events were as follows: all-cause mortality (0.048), modality transfer (0.051), exit site or catheter tunnel infection (0.054) and peritonitis (0.136) events per person year. The most common causative organism for exit site or tunnel infection was staphylococcus species (47%) and that for peritonitis was streptococcus (28%) followed by staphylococcus (27%) species. Up to now, PDOPPS Korea has recruited 766 Korean PD patients and started documentation of major PD-related outcomes which occurred during the follow-up period. The overall incidence rates of clinical outcomes in Korean PD patients were relatively favourable. There was no statistically significant difference in the incidence rates of clinical outcomes according to both facility and patient factors.

Long-term prognosis of acute primary angle closure in an east asian cohort.

To provide an updated analysis of the long-term outcomes of patients with acute primary angle closure (APAC) and to investigate the risk factors for visual field (VF) loss progression. Retrospective, clinical cohort study METHODS: One hundred and forty-six APAC patients with a minimum of 1-year follow-up were included. The presenting features and the treatment utilized were recorded. The visual and intraocular pressure (IOP) outcomes were analyzed. The main outcome measures were the proportion of blindness and IOP at the final visit. A subset of patients with sufficient VF results was divided into a stable and progressive group based on mean deviation (MD) loss rate. Univariate and multivariate logistic regression analyses were performed to identify predictors of progression. Nine patients (6.2%) were blind, and 76.0% (111/146) had final decimal visual acuity greater than or equal to 0.5. All patients had normal final IOP, and 65.1% (95/146) were medication-free. 64.4% (94/146) underwent cataract surgery at a median 4months after their APAC attack. The use of topical hypotensive medications (OR = 8.029, P = 0.012) was the only significant predictor of fast MD loss in the multivariate regression. The long-term outcomes of APAC in recent years have been more promising. All patients maintained normal IOP several years following their APAC attack, and fewer than half required hypotensive agents. The incidence of blindness was low. These findings suggest that current practice patterns in the management of APAC are beneficial.

Same evidence different recommendations: a methodological assessment of transatlantic guidelines for the management of valvular heart disease.

To identify methodological variations leading to varied recommendations between the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) valvular heart disease (VHD) Guidelines, and to suggest foundational steps towards standardizing guideline development. An in-depth analysis was conducted to evaluate the methodologies used in developing the Transatlantic Guidelines for managing VHD. The evaluation was benchmarked against the standards proposed by the Institute of Medicine. Substantial discrepancies were noted in the methodologies utilized in development processes, including writing committee composition, evidence evaluation, conflict of interest management, and voting processes. Furthermore, despite their mutual differences, both methodologies also demonstrate notable deviations from the IOM standards in several essential areas, including literature review and evidence grading. These dual variances likely influenced divergent treatment recommendations. For example, the ESC/EACTS recommends transcatheter edge-to-edge repair (TEER) for patients ineligible for mitral valve surgery, while the ACC/AHA recommends TEER based on anatomy, regardless of surgical risk. ESC/EACTS guidelines recommend a mechanical aortic prosthesis for patients under 60, while ACC/AHA guidelines recommend it for patients under 50. Notably, the ACC/AHA and ESC/EACTS guidelines have differing age cut-offs for surgical over transcatheter aortic valve replacement (<65 and <75 years, respectively). Variations in methodologies for developing CPGs have resulted in different treatment recommendations that may significantly impact global practice patterns. Standardization of essential processes is vital to increase the uniformity and credibility of CPGs, ultimately improving healthcare quality, reducing variability and enhancing trust in modern medicine.

Differences in Inpatient Management of Cancer-Related Pain Among Patients with Opioid Use Disorder.

The management of cancer-related pain in patients with opioid use disorder (OUD) remains complex and often challenging for clinicians and patients. There is currently a paucity of data to guide best practices, and the evidence that exists is variably applied. In this hospital-based questionnaire, we sought to understand the variation in practice patterns among clinicians in palliative medicine, addiction medicine, and hospital medicine, in caring for this complex patient population. Sixty-two questionnaire responses were analyzed and variation was found in management of pain, as well as initiation or titration of buprenorphine and methadone. There was also a significant difference in postdischarge subspecialty follow-up. Furthermore, the findings suggest that buprenorphine and methadone may be underutilized in this population. Patients and clinicians may benefit from additional support and standardization of practices to best manage coexisting cancer-related pain and OUD.

Vital infrastructures

Sustaining lives in urban environments depends on infrastructures – buildings, water pipes, sewers, energy distribution, or roads, among others. Their availability is particularly acute in Africa due to rapid urbanization, entrenched inequalities and persistent resource constraints. At the site of my ongoing research, Namibia’s capital Windhoek, the legacy of colonial segregation coupled with low incomes and lack of affordable housing have led to the mushrooming of ‘informal’ settlements with insufficient formal infrastructures. In these conditions, the necessity to satisfy basic needs, as well as aspirations of improvement, lead the residents to rely on improvisational skills, co-presence, and social relationships to innovate do-it-yourself (DIY) solutions as well as to appropriate, bypass and complement formal infrastructures. These arrangements are ‘vital infrastructures’ in two senses: both as facilitating and regenerating lives in the city, and as relying on the energies of the residents for their operation (which blurs the categories of provider and user). I argue that such vital infrastructures are a major force in the making of cities and urban lives, in Africa and beyond. While their immediate purpose is to solve practical problems, the social, transactional and political patterns that they entail lead to profoundly relational, co-constructed infrastructures and everyday governance.

Discharge of Acute Coronary Syndrome Patients on Sub-Optimal Dual Anti-Platelet Therapy: A Single Center Experience.

To identify and quantify the reasons why acute coronary syndrome (ACS) patients undergoing stenting at the University of New Mexico Hospital (UNMH) were prescribed sub-optimal dual antiplatelet therapy (DAPT) at discharge, and to identify practice patterns that could potentially lead to improved DAPT treatment for these patients. We reviewed electronic medical records and cardiac catheterization records of 326 patients who underwent percutaneous coronary intervention (PCI) at UNMH between January 1, 2021, and June 30, 2022 and identified 229 ACS patients who survived until discharge. Demographic and clinical characteristics relevant to P2Y12 inhibitor selection were obtained from a review of medical records. Pharmacists' notes documenting their efforts to secure appropriate insurance coverage and reasons for discharging patients on clopidogrel rather than ticagrelor/prasugrel were reviewed. Patients discharged on aspirin and clopidogrel underwent review of medical records and cardiac catheterization lab records to determine if the discharge P2Y12 drug was appropriate. Reasons for inappropriate discharge on clopidogrel were categorized as cost/insurance, patient preference, concern for daily adherence to a twice-daily medication, and maintenance of pre-hospital clopidogrel therapy rather than switch to ticagrelor after PCI. The 229 ACS patients included 87 (38.0%) appropriately discharged on ticagrelor/prasugrel, 63 (27.5%) appropriately discharged on clopidogrel, 75 (32.8%) discharged on sub-optimal clopidogrel, and 4 (1.7%) not discharged on a P2Y12 inhibitor. For patients inappropriately discharged on clopidogrel (n = 75), the most common reasons were cost or lack of insurance (n = 56) and clinical inertia (taking clopidogrel before PCI and maintained on it afterward) (n = 17). Sub-optimal P2Y12 therapy at discharge was significantly associated with lack of insurance (odds ratio 21.5, 95% confidence interval 5.33-156,p < 0.001) but not with ethnicity, age, sex, or diabetes. At the University of New Mexico, a safety-net hospital, increasing financially restricted access to ticagrelor/prasugrel could help up to 24.5% of ACS patients reduce their risk of ischemic events. For patients admitted on clopidogrel DAPT, escalating to ticagrelor/prasugrel could reduce ischemic risk in 7.4%. Expanding and improving healthcare insurance coverage might reduce the frequency of discharge on sub-optimal P2Y12 therapy.

Occupational Radiation Exposure During Pregnancy: A Survey of Urologists on Perception, Experience, and Practice Patterns.

Introduction: The field of urology is predominantly male; however, there has been an increasing number of women in the workforce. Peak reproductive years frequently overlap with residency training and early attending career timelines. Exposure to ionizing radiation is a common occupational hazard in many procedural specialties. The use of radiation, for example, in interventional cardiology and interventional radiology, has shown little adjustments in practice patterns, with no adverse outcomes reported among pregnant physicians in their fields in the setting of appropriate radiation safety measures. The impact of radiation exposure during pregnancy for urologists is largely unknown. Our objective was to determine attitudes and practices of urologists related to radiation exposure and to characterize the experience of urologists who have previously been pregnant. Methods: An anonymous online survey was distributed through relevant society membership bases, which included the Endourological Society and the Society for Women in Urology, and social media. Demographics, practice patterns, and changes to practice patterns were recorded for respondents. Statistical analysis was performed in R studio. Results: There were 384 respondents, 255 of whom identified as women. Of these, 164 had been previously pregnant. Female respondents were younger, completed training more recently, and were more likely to have adjusted their caseload due to radiation concerns compared with their male counterparts. Of women who had been pregnant, few had access to policies for who to notify (19%), policies for safety precautions (22%), custom-fitted lead (35%), and maternity lead (20%). Most women (66%) relied on their own research for guidance on radiation safety during pregnancy, while some (41%) also used information from colleagues or mentors. Forty-six percent of women would have taken greater precautions during pregnancy than they did. Conclusions: Access to the appropriate tools to safely navigate pregnancy is inconsistent among practicing urologists. Evidence-based guidelines are needed to better empower pregnant urologists.

Open, endovascular, or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options.

The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices. In New York, we have developed a collaborative group named the New York Aortic Consortium (NYAC) as a means of crosslinking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature, as well as the integration of endovascular technology into disease management. In this review article, we summarize the current state of aortic arch surgery. Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve hemostasis, simplify future operations, or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Amongst our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and management strategies of patients with aortic arch disease. It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair, and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.

Practice Patterns in Sternal Closure and Evaluation of Adoption of a Novel Sternal Closure Device

Objective: The technique for sternal closure has remained largely unchanged owing to the efficacy, simplicity, and low cost of stainless-steel sternal wires. Despite their ubiquity, several other closure devices designed to address the complications associated with sternal wires such as sternal bleeding and dehiscence have become popular. We have developed a novel sternal closure device that reduces sternal bleeding and dehiscence. This study quantifies the use of currently available sternal closure devices and determines predicted uptake of the novel device. Methods: An electronic survey, designed to determine practice patterns for sternal closure, was distributed to 70 US cardiac surgeons. The survey included a discrete choice section in which surgeons evaluated relative value of device attributes including cost, ease of emergent sternal reentry, and dehiscence risk. Results: There were 70 surgeons from 30 states who completed the survey. The most frequent means of sternal closure was straight sternal wires (35.8%), followed by straight sternal wires plus figure-of-8 sternal wires (18.1%), double wires (10.9%), plates (10.2%), and other (25%). The relative utilization shifted from sternal wires to sternal plates as the risk for dehiscence increased. The adoption of the novel closure device was estimated at 34.6%. Conclusions: The standard stainless-steel sternal wire remains the most common means of sternal reapproximation, but its utilization is lower in patients at high risk for sternal dehiscence. Based on this survey, there is acceptance in the community for a novel sternal closure device designed to address the limitations of traditional sternal closure methods.

Overview of Mycotic Keratitis

Abstract: Keratomycosis is a serious corneal infection associated with high ocular morbidity that can lead to severe vision loss. It is estimated to affect more than 1 million patients annually, most commonly occurring in tropical climates, and represents a growing threat to patients worldwide. Despite aggressive medical management, fungal infections have a higher rate of perforation requiring surgical intervention compared with other infectious etiologies. Early diagnosis and appropriate treatment are keys to preserving vision and saving patients' eyes. Timely diagnosis of fungal keratitis helps minimize corneal damage and scarring and increases the likelihood of a favorable outcome. Studies have shown that correct identification of fungal infections is often delayed up to 2 to 3 weeks after initial presentation. This leads to incorrect or ineffective treatment for many patients. Diagnostic techniques explored in this study include corneal scrapings with staining and culture, visualization with in vivo confocal microscopy, molecular diagnostic techniques including polymerase chain reaction, and recently developed omics-based technologies. Treatment of fungal keratitis begins with topical antifungals. Medical management has been proven to be effective, but with limitations including poor drug penetration and low bioavailability. Cases that do not respond to topical therapy require more invasive and novel treatments to control the infection. We review the clinical trials that have shaped current practice patterns, with focus on the efficacy of topical natamycin as the primary therapy for filamentous fungal keratitis. We explore additional management strategies such as localized intrastromal and intracameral injections of antifungal medications, photodynamic therapy, and surgical intervention.

Clinical Practice Patterns in Sickle Cell Disease Treatment: Disease-Modifying and Potentially Curative Therapies.

Therapeutic options for sickle cell disease (SCD) have increased recently as well as the development of updated national guidelines. It is not known how these options are being offered or to what degree guidelines are incorporated into clinical practice. This study aimed to describe practice patterns for pediatric hematologists regarding the use of disease-modifying and potentially curative therapies for SCD. A 9-section, cross-sectional electronic survey was disseminated during a 3-month period via SurveyMonkey, to members of the American Society of Pediatric Hematology/Oncology Hemoglobinopathy Special Interest Group (ASPHO HSIG). A total of 88 physician members of the ASPHO HSIG were surveyed. Ninety percent of respondents (72/80) start hydroxyurea routinely in patients with HbSS and HbSβ0 thalassemia, regardless of disease severity. Laboratory monitoring was recommended every 3 months for stable dosing in 63.8% (51/80). New therapies were recommended for patients on hydroxyurea who were still experiencing SCD complications: L-glutamine 68.5% (37/54) or crizanlizumab 93.1% (54/58). Voxelotor was recommended for patients on hydroxyurea with low hemoglobin in 65.1% (43/66) of cases. Matched sibling transplant was considered for any disease severity by 55.1% (38/69). Gene therapy trials are offered on-site by 29% (20/69). Our study demonstrated the enhanced utilization of hydroxyurea while revealing the unexplored potential of other disease-modifying therapies in SCD. These findings underscore the importance of continued knowledge acquisition about the long-term efficacy of new medical therapies and addressing barriers to the use of proven therapies and guide the development of future studies of optimal SCD management.

Genetic Testing Resources and Practice Patterns Among Pediatric Cardiomyopathy Programs.

The use of genetic testing has enhanced the diagnostic accuracy of heritable genetic cardiomyopathies. However, it remains unclear how genetic information is interpreted and incorporated into clinical practice for children with cardiomyopathy. The primary aim of this study was to understand how clinical practice differs regarding sequence variant classifications amongst pediatric cardiologists who treat children with cardiomyopathy. A secondary aim was to understand the availability of genetic testing and counseling resources across participating pediatric cardiomyopathy programs. An electronic survey was distributed to pediatric heart failure, cardiomyopathy, or heart transplantation physicians between August and September 2022. A total of 106 individual providers from 68 unique centers responded to the survey. Resources for genetic testing and genetic counseling vary among large pediatric cardiomyopathy programs. A minority of centers reported having a geneticist (N = 16, 23.5%) or a genetic counselor (N = 21, 31%) on faculty within the division of pediatric cardiology. A total of 9 centers reported having both (13%). Few centers (N = 13, 19%) have a formal process in place to re-engage patients who were previously discharged from cardiology follow-up if variant reclassification would alter clinical management. Clinical practice patterns were uniform in response to pathogenic or likely pathogenic variants but were more variable for variants of uncertain significance. Efforts to better incorporate genetic expertise and resources into the clinical practice of pediatric cardiomyopathy may help to standardize the interpretation of genetic information and better inform clinical decision-making surrounding heritable cardiomyopathies.

A qualitative study on diverse experiences of medication safety among foreign-born persons living in Sweden

BackgroundThe ongoing global migration has led to multicultural societies, with many migrants who do not speak the official language in the host country. This could contribute to communication problems with staff in healthcare and a risk to patient safety. Research on patient safety in medication use in migrants is an under-researched area. The aim was to explore diverse foreign-born people’s experiences and perceptions of self-management of medication and determine if home-based practice patterns have implications on medication safety, and what factors may support safe medication use.MethodsA qualitative explorative study, with individual semi-structured interviews and participant observations in the patients’ home. Qualitative content analysis was applied.ResultsA purposeful sample of 15 foreign-born persons identified by healthcare staff as having language difficulties in Swedish that may pose a safety risk in connection with medication use at home, was selected. Three categories were identified. The first category showed respondents being dependent on another person, having experiences of not receiving information about their medications due to language barriers, having difficulties getting access to the healthcare centre and feeling distrusted/misunderstood. The second category showed respondents being independent and self-motivated Although they struggled, they managed to get access/contact with the healthcare centre themselves and felt understood/listened to by the staff. The last category concerned factors that facilitating medication use; such as having a medication list in the respondents’ own language and offering a choice of language on the answering machine at the healthcare centre. Although they knew it was impossible to get an interpreter at the pharmacy, they felt safe knowing there was always a solution for receiving understandable information.ConclusionThe findings highlighted that language barriers can complicate the communication between migrants and the healthcare, which can affect the medication safety. Understanding of this group is essential to improve the cooperation between patients and staff, leading to culturally congruent care. This knowledge should be used in healthcare to understand the gap in communication to increase patient safety. Further research from other angles, e.g. pharmacy/healthcare staff and relatives is needed to identify and evaluate facilitation to improve the outcome of the intended medication treatment.

Myopia Control: Are We Ready for an Evidence Based Approach?

Myopia and its vision-threatening complications present a significant public health problem. This review aims to provide an updated overview of the multitude of known and emerging interventions to control myopia, including their potential effect, safety, and costs. A systematic literature search of three databases was conducted. Interventions were grouped into four categories: environmental/behavioral (outdoor time, near work), pharmacological (e.g., atropine), optical interventions (spectacles and contact lenses), and novel approaches such as red-light (RLRL) therapies. Review articles and original articles on randomized controlled trials (RCT) were selected. From the initial 3224 retrieved records, 18 reviews and 41 original articles reporting results from RCTs were included. While there is more evidence supporting the efficacy of low-dose atropine and certain myopia-controlling contact lenses in slowing myopia progression, the evidence about the efficacy of the newer interventions, such as spectacle lenses (e.g., defocus incorporated multiple segments and highly aspheric lenslets) is more limited. Behavioral interventions, i.e., increased outdoor time, seem effective for preventing the onset of myopia if implemented successfully in schools and homes. While environmental interventions and spectacles are regarded as generally safe, pharmacological interventions, contact lenses, and RLRL may be associated with adverse effects. All interventions, except for behavioral change, are tied to moderate to high expenditures. Our review suggests that myopia control interventions are recommended and prescribed on the basis of accessibility and clinical practice patterns, which vary widely around the world. Clinical trials indicate short- to medium-term efficacy in reducing myopia progression for various interventions, but none have demonstrated long-term effectiveness in preventing high myopia and potential complications in adulthood. There is an unmet need for a unified consensus for strategies that balance risk and effectiveness for these methods for personalized myopia management.