Physician Intervention Research Articles

Effects of different neuraxial analgesia modalities on the need for physician interventions in labour: A network meta-analysis.

Neuraxial labour analgesia can be initiated with epidural (EPL), combined spinal epidural (CSE) or dural puncture epidural (DPE) and maintained with continuous epidural infusion (CEI), patient-controlled epidural analgesia (PCEA) or programmed intermittent epidural bolus (PIEB), but the optimal analgesia modality is still controversial. To compare the effects of commonly used neuraxial analgesia modalities on the proportion of women needing physician interventions, as defined by the need for physician-administered epidural top-ups for inadequate analgesia in labour. Bayesian network meta-analysis. PubMed, Embase, CENTRAL, Web of Science and Wanfang Data were searched from January 1988 to August 2023 without language restriction. Randomised controlled trials comparing two or more modalities of the following six neuraxial analgesia modalities in healthy labouring women: EPL+CEI+PCEA, EPL+PIEB+PCEA, CSE+CEI+PCEA, CSE+PIEB+PCEA, DPE+CEI+PCEA and DPE+PIEB+PCEA. Thirty studies with 8188 women were included. Compared with EPL+CEI+PCEA, EPL+PIEB+PCEA [odds ratio (OR) = 0.44; 95% credible interval (CrI), 0.22 to 0.86], CSE+PIEB+PCEA (OR = 0.29; 95% CrI, 0.12 to 0.71) and DPE+PIEB+PCEA (OR = 0.19; 95% CrI, 0.08 to 0.42) significantly reduced the proportion of women needing physician interventions. DPE+PIEB+PCEA had fewer women needing physician interventions than all other modalities, except for CSE+PIEB+PCEA (OR = 0.63; 95% CrI, 0.25 to 1.62). There were no significant differences in local anaesthetic consumption, maximum pain score, and the incidence of instrumental delivery between the different neuraxial modalities. PIEB+PCEA is associated with a lower risk of physician interventions in labour than CEI+PCEA. DPE or CSE and PIEB+PCEA may be associated with a lower likelihood of physician interventions than other neuraxial modalities. Otherwise, the new neuraxial analgesia techniques do not appear to offer significant advantages over traditional techniques. However, these results should be interpreted with caution due to limited data and methodological limitations. PROSPERO (CRD42023402540).

Technical note: A comparison of physician doses in C-Arm and CT fluoroscopy procedures.

We address the misconception that the typical physician dose is higher for CT fluoroscopy (CTF) procedures compared to C-Arm procedures. We compare physician scatter doses using two methods: a literature review of reported doses and a model based on a modified form of the dose area product (DAP). We define thismodified form of DAP, "cumulative absorbed DAP," as the product of the area of the x-ray beam striking the patient, the dose rate per unit area, and the exposure time. The patient entrance dose rate for C-Arm fluoroscopy (0.2mGy/s) was found to be 15 times lower than for CT fluoroscopy (3mGy/s). A typical beam entrance area for C-Arm fluoroscopy reported in the literature was found to be 10.6×10.6cm (112cm2), whereas for CTF was 0.75×32cm (24cm2). The absorbed DAP rate for C-Arm fluoroscopy (22mGy*cm2/s) was found to be 3.3 times lower than for CTF (72mGy*cm2/s). The mean fluoroscopy time for C-Arm procedures (710s) was found to be 21 times higher than for CT fluoroscopy procedures (23s). The cumulative absorbed DAP for C-Arm procedures was found to be 9.4 times higher when compared to CT procedures (1.59 mGy*m2 vs. 0.17 mGy*m2). The higher fluoroscopy time in C-Arm procedures leads to a much lower cumulative DAP (i.e., physician scatter dose) in CTF procedures. This result can inform interventional physicians deciding on whether to perform inter-procedural imaging inside the room as opposed to retreating from the room.

Abstract P410: Prevalence and Short Term Follow Up Rates Across the Childhood and Adolescent Obesity Population in a Community Hospital

Background: Obesity is a global pandemic, which is 20.7% prevalent among 6-11 yr old and 22.2% prevalent among 12-19 year old(CDC). Aim is to understand the prevalence across different age groups in a community hospital setting. Secondary aim is to assess the variance of follow up rates across childhood and adolescence as follow up is crucial for the success of any physician intervention. Methods: We considered pediatric patients between 5 to 20 years old visiting primary care clinics within a 3-month period with a diagnosis of obesity for our study. We determined the follow up rate for 3 month scheduled weight checks for obese patients relative to the age groups. Results: We identified a total of 264 patients with obesity diagnosis (>95th percentile BMI) visiting outpatient clinics within a three month period. In our sample, the prevalence of obesity in childhood years (5-11) was 58.7%(155 of 264) and prevalence of obesity in the adolescent age group(12-20) was 41.2% (109 of 264). We recorded 30.3%(108 of 155) follow up in childhood years and 33.9%(72 of 109) follow up in the adolescent age group. The calculated p value was >0.05, hence the follow up rates across different age groups are not statistically significant. Conclusions: Focused intervention on the childhood age group will decrease the prevalence rates of obesity in a community hospital setting. This study emphasizes the need to formulate a plan to increase the follow up rates in the pediatric obesity population given its high prevalence in community hospital settings. No statistical significance has been found with follow up rates across various age groups. Further research controlling the confounding factors like environmental and socioeconomic factors help us understand the factors hindering follow ups across various age groups.

Impact of Work Environment on Job Satisfaction among Interventional Radiologists in Japan: A Cross-sectional Study.

This study aims to measure job satisfaction among interventional radiology physicians in Japan and analyze the factors affecting job satisfaction. A web-based survey was conducted among the members of the Japanese Society of Interventional Radiology between October and December 2021. Participants were questioned regarding their job satisfaction, workplace, work status, and demographic information. Principal component analysis was applied to 15 reasons related to job satisfaction, and the factors affecting job satisfaction were analyzed. Valid responses were obtained from 901 (31.9%) of the 2,824 interventional radiology physicians invited to participate. Job satisfaction was reported as "very satisfied" in 79 (8.8%), "moderately satisfied" in 426 (47.3%), "neither satisfied nor dissatisfied" in 230 (25.5%), "moderately dissatisfied" in 133 (14.8%), and "very dissatisfied" in 33 (3.7%) respondents. Thus, there were 505 (56.0%) satisfied physicians. Three principal components were extracted from the reasons for job satisfaction. Job satisfaction tended to be higher among those who reported performing a higher number of interventional radiology procedures and was positively associated with a higher rate of work time dedicated to interventional radiology and the first principal component (the environment of clinical practice, research, and interventional radiology education). The third principal component (salary and work environment) and the absence of an "IkuBoss" [a boss who takes initiative in creating a work environment supportive of the work-life balance of colleagues] were associated with lower job satisfaction. More than half the participants reported high job satisfaction. Job satisfaction of interventional radiology physicians in Japan was positively associated with a favorable clinical, research, and educational environment and negatively associated with the absence of an "IkuBoss," noninterventional radiology work, overtime work, and salary.

Surveillance of antimicrobial awareness among patients visiting community pharmacies

ObjectiveAlthough antimicrobial resistance (AMR) measures have been progressing, cases of patients requesting their doctors to prescribe antimicrobial agents and patients mistakenly believing that these agents are effective against viruses occasionally occur. In the AMR action plan (2023–2027) in Japan, one of the primary goals are public awareness and education. However, public understanding of AMR and antimicrobial agents has been reported to be at an unsatisfactory level. Here, we conducted a surveillance of antimicrobial awareness among patients visiting community pharmacies. Material and methodsA questionnaire survey was conducted among patients visiting nine pharmacies in Hachioji, Tokyo, Japan. A total of 1887 active questionnaires were collected. The relationship between answers was analyzed using logistic regression analysis. ResultsOf the patients, 72% were unaware of AMR, and 68% believed that antimicrobials are effective against viruses. In addition, 28% of the patients answered that they did not take antimicrobial agents as prescribed by their physicians. Seventeen percent of the patients had never received appropriate instruction of antimicrobial use from pharmacists. Analysis of the relationship between answers showed that patients with correct knowledge were 1.65 times more likely to take antimicrobial agents as prescribed by their physicians (P < 0.01). Furthermore, the factors that led to the inappropriate behaviors of patients were associated with preliminary antimicrobial prescriptions from physicians (odds ratio, 3.18; 95% CI, 2.12–4.76) (P < 0.01). ConclusionThis study strongly suggests that physician and pharmacist interventions regarding the appropriate use of antimicrobial agents are important to improve awareness of antimicrobial agents.

Substance use disorders in hospice palliative care: A narrative review of challenges and a case for physician intervention.

Substance use disorders (SUDs) are frequently encountered in hospice palliative care (HPC) and pose substantial quality-of-life issues for patients. However, most HPC physicians do not directly treat their patients' SUDs due to several institutional and personal barriers. This review will expand upon arguments for the integration of SUD treatment into HPC, will elucidate challenges for HPC providers, and will provide recommendations that address these challenges. A thorough review of the literature was conducted. Arguments for the treatment of SUDs and recommendations for physicians have been synthesized and expanded upon. Treating SUD in HPC has the potential to improve adherence to care, access to social support, and outcomes for pain, mental health, and physical health. Barriers to SUD treatment in HPC include difficulties with accurate assessment, insufficient training, attitudes and stigma, and compromised pain management regimens. Recommendations for physicians and training environments to address these challenges include developing familiarity with standardized SUD assessment tools and pain management practice guidelines, creating and disseminating visual campaigns to combat stigma, including SUD assessment and intervention as fellowship competencies, and obtaining additional training in psychosocial interventions. By following these recommendations, HPC physicians can improve their competence and confidence in working with individuals with SUDs, which will help meet the pressing needs of this population.

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

Assessing the debt and current state of financial literacy in a cohort of diagnostic & interventional radiology residents

Rationale and objectivesThe purpose of this study is to assess diagnostic and interventional radiology resident physicians' knowledge of core facets of financial literacy: loans, real estate, investments and retirement, and insurance, with the goal of determining the need for formal financial literacy education within radiology residency programs. MethodsFrom May 2021 to March 2022, surveys were sent to 196 diagnostic and 90 interventional radiology residency programs. Residents were asked 10 knowledge multiple choice questions to assess areas of financial literacy. Custom R programming was used to evaluate responses. ResultsA total of 149 diagnostic radiology residents and 49 interventional radiology residents responded to portions of the survey, for a total of 198 respondents. Of the cohort with demographic data collected, 84 out of 141 residents (60 %) had over $100,000 of debt following medical school graduation, with 115 out of 146 DR residents (79 %) and 41 out of 47 (87 %) IR residents reporting no coursework in finance. ConclusionsMany radiology resident physicians have a significant debt burden, no official financial education, and clear knowledge gaps in areas of financial literacy. A structured financial education curriculum could better prepare residents for the financial realities of post-residency life.

Bridging AI and Clinical Practice: Integrating Automated Sleep Scoring Algorithm with Uncertainty-Guided Physician Review.

This study aims to enhance the clinical use of automated sleep-scoring algorithms by incorporating an uncertainty estimation approach to efficiently assist clinicians in the manual review of predicted hypnograms, a necessity due to the notable inter-scorer variability inherent in polysomnography (PSG) databases. Our efforts target the extent of review required to achieve predefined agreement levels, examining both in-domain (ID) and out-of-domain (OOD) data, and considering subjects' diagnoses. A total of 19,578 PSGs from 13 open-access databases were used to train U-Sleep, a state-of-the-art sleep-scoring algorithm. We leveraged a comprehensive clinical database of an additional 8832 PSGs, covering a full spectrum of ages (0-91 years) and sleep-disorders, to refine the U-Sleep, and to evaluate different uncertainty-quantification approaches, including our novel confidence network. The ID data consisted of PSGs scored by over 50 physicians, and the two OOD sets comprised recordings each scored by a unique senior physician. U-Sleep demonstrated robust performance, with Cohen's kappa (K) at 76.2% on ID and 73.8-78.8% on OOD data. The confidence network excelled at identifying uncertain predictions, achieving AUROC scores of 85.7% on ID and 82.5-85.6% on OOD data. Independently of sleep-disorder status, statistical evaluations revealed significant differences in confidence scores between aligning vs discording predictions, and significant correlations of confidence scores with classification performance metrics. To achieve κ ≥ 90% with physician intervention, examining less than 29.0% of uncertain epochs was required, substantially reducing physicians' workload, and facilitating near-perfect agreement. Inter-scorer variability limits the accuracy of the scoring algorithms to ~80%. By integrating an uncertainty estimation with U-Sleep, we enhance the review of predicted hypnograms, to align with the scoring taste of a responsible physician. Validated across ID and OOD data and various sleep-disorders, our approach offers a strategy to boost automated scoring tools' usability in clinical settings.

Actual issues of secondary prevention of liver cancer in Kazakhstan

Liver cancer is characterized by high mortality and low survival rates in most countries of the world. According to the WHO data, more than 1.3 million people with liver cancer die annually in the world and according to the data of the 9th volume of "Cancer on five continents" - the highest standardized incidence rates are in Korea - 44.9 per 100 thousand population as well as in Thailand, Japan, China. Low rates were in Algeria, India, Belgium and the Netherlands. In Russia 61.5% of patients die of liver cancer progression in the first year after diagnosis [1,2].&lt;br /&gt; Information on the global burden of cancer in 2018 showed that the specific weight of liver cancer in the structure of malignant neoplasms (MN) is 8.2%, and in 2020 - 8.3% [3].&amp;nbsp;&amp;nbsp;&lt;br /&gt; The worldwide peculiarity of liver cancer is its late diagnosis. Several evidence-based treatment options for liver cancer are currently available: liver transplantation for hepatocellular liver cancer (HCC) (according to the Milan criteria), radiofrequency ablation as a radical treatment option (RFA), chemoembolization for intrahepatic cholangiocarcinoma (TACE), and the administration of Sorafenib as systemic therapy [4].&lt;br /&gt; Current approaches for the treatment of early-stage primary liver cancer are represented by hepatic RFA, and the efficacy of this approach depends on the subjective attentiveness and visual acuity of the clinician. The latest technique used in liver RFA is the hyperspectral imaging which utilize objective assessment [2].&lt;br /&gt; Ultrasound is usually used to detect liver lesions, but the detection rate is low for many reasons, such as clinician skills and technical capabilities. Modern approaches of diagnostic capabilities, such as contrast-enhanced ultrasound integrated imaging (CEUS) and comprehensive ultrasound imaging - contrast-enhanced CT (CECT) or contrast-enhanced MRI (CEMRI) for visualization of focal liver lesions (FLL) - increase the confidence of the interventional physician so it should be recommended for use as a routine procedure [5-6].&lt;br /&gt; The ratio of morbidity and mortality in many countries reaches 91.6%, which represents the third most important cause of cancer deaths [7-9].

Design and evaluation of a wearable vascular interventional surgical robot system.

Remote-controlled robotic vascular interventional surgery can reduce radiation exposure to interventional physicians and improve safety. However, inconvenient operation and lack of force feedback limit its application. A new wearable robotic system for vascular interventional surgery is designed, which is more flexible in operation. It ensures the safety of surgery through haptic force feedback. The system was evaluated by human vascular models and animal experiments. The average static error of the system is 0.048mm when the axial motion is 250mm and 1.259° when the rotational motion is 400°. The average error of the force feedback is 0.021N. The results of vascular model experiments and animal experiments demonstrate the feasibility and safety of the system. The proposed robotic system can assist physicians in remotely delivering standard catheters or guidewires. The system is more flexible and uses haptic force feedback to ensure surgical safety.

Mobile Application Increased Nutrition Knowledge Among Brazilian Physicians

ObjectiveTo assess whether using a Dietary Approaches to Stop Hypertension (DASH) diet recommendation application increases primary care physicians’ knowledge and dietary counseling skills. DesignA randomized controlled trial. SettingBrazilian public primary care service. ParticipantsTwo hundred and twenty-two physicians (intervention group: n = 111; control group: n = 111). InterventionThirty days of using the Dieta Dash application. The application provides information about nutritional recommendations for hypertension management. Main Outcome MeasuresNutrition knowledge score. Secondary outcomes: self-assessment of knowledge, self-confidence, assessment of eating habits, and barriers to dietary counseling. AnalysisLinear mixed-effects models for repeated measures and generalized estimating equations for comparing changes between groups. ResultsA total of 66.2% of participants completed the follow-up. There was no significant difference between the groups regarding the mean knowledge score (P = 0.15). The prevalence of high knowledge increased by 12% (prevalence ratio [PR] = 1.12; 95% confidence interval [CI], 1.00–1.25) in the intervention group and showed an improvement in the self-confidence assessment (PR = 1.21; 95% CI, 1.02–1.44), and increased assessment of eating habits (PR = 1.26; 95% CI, 1.10–1.55). Conclusions and ImplicationsThe Dieta Dash application helped address dietary counseling, improving knowledge and self-confidence. However, innovative strategies are needed to minimize the primary care barriers.

Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP)

BACKGROUND: Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES: In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS: The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS: There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION: These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded – and herein recommended – that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments. KEY WORDS: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion DISCLAIMER: The guidelines presented are based upon the best available evidence, and do not constitute or represent inflexible treatment recommendations. This document is not intended to be regarded and/or used as a “standard of care.”

Performance of invasive, non-invasive, and pharmacological measures by emergency physicians in the German emergency medical services. A retrospective cross-sectional study from the rescue association Südwestsachsen

BackgroundEvery citizen in Germany is entitled to qualified emergency medical assistance. Due to annually increasing deployment figures and personnel shortages, it is no longer possible to guarantee 24/7 coverage of all emergency physician locations throughout Germany. Relief can be achieved through changes in the supply structures. Professional field analyses are the basis for the further development of training and care structures.MethodologyAll emergency physician deployments of a location in the rescue association Südwestsachsen that took place between 01.10.2022 and 31.01.2023 were retrospectively evaluated. For this purpose, the analogously created deployment protocols were examined with regard to demographic data as well as the invasive, non-invasive and pharmacological measures performed by emergency physicians.ResultsIn N = 684 emergency missions, n = 471 (100%) invasive or non-invasive measures were performed by an emergency physician. At n = 383 (81.3%), the most frequently performed invasive measure was intravenous (i.v.) access. There were n = 710 (100%) pharmacological measures performed by an emergency physician. The most frequently performed pharmacologic measure was administration of a full electrolyte solution, with n = 223 (31.4%)DiscussionEmergency physician interventions do not necessarily involve invasive, non-invasive, or pharmacologic measures. The emergency paramedic learns a variety of invasive, non-invasive, and pharmacologic measures in his or her training and could contribute to the reduction of emergency physician interventions. An adaptation of prehospital care structures based on evidence-based data and an update of the catalog of indications for emergency physician interventions would be elementary for this goal.

Application of invasive medical and pharmacological measures by German emergency paramedics

IntroductionGerman emergency paramedics are to avert serious damage to the patient's health in the event of acute illness or accidents. For this purpose, they have a variety of invasive medical and pharmacological measures at their disposal in addition to their three-year professional training. The aim of this thesis is to investigate the use of invasive medical and pharmacological measures by emergency paramedics in the German rescue service by means of instruments of professional scientific research. In doing so, the motivations of emergency paramedics to refrain from using these measures will be investigated for the first time.MethodsFor this study, rescue missions were analyzed during the period July 1, 2022, to June 30, 2023. The chosen method involved a quantitative document analysis of the deployment protocols to investigate the use of invasive and pharmacological measures by emergency paramedics and the reasons against their use.ResultsDuring the period, N = 10,102 (100%) rescue missions could be evaluated. Analysis of the data revealed that invasive medical measures were used by emergency paramedics in n = 1,211 (11.9%) missions and pharmacologic measures were used in n = 1,403 (13.8%) missions. Most frequently, emergency paramedics concluded that invasive medical measures were not required.DiscussionIn summary, the use of invasive medical measures is not a standard part of the emergency medical services mission. Rather, the focus is on diagnostics and transport of patients to an appropriate destination hospital. An adjustment of prehospital care structures based on evidence-based data and an update of the catalog of indications for emergency physician interventions would be elementary for this goal. Further studies of professional fields of action in emergency and rescue medicine are necessary in order to analyze and optimize care structures. This would not only allow conclusions to be drawn about the future education, further education and training of rescue service personnel, but also allow care structures to be adapted to the current state of science and the care needs of patients.

An update on technical and safety practice patterns of interlaminar epidural steroid injections

IntroductionInterlaminar epidural steroid injections (ILESIs) are mainstay in the management of low back, neck and radicular pain and are a commonly performed pain management procedure in the United States. Our survey aims to provide an update in practice patterns of ILESIs among interventional pain physicians. MethodsWe distributed a 91-item survey nationwide to private and academic interventional pain physicians who perform epidural steroid injections (ESIs). The survey was distributed via REDCap with a series of questions inquiring about current practices in epidural steroid injections from March 2021 to March 2022. Cross sectional data from survey responses specific to ILESI-related practices were captured and synthesized. ResultsOf 103 complete survey responses, 96 physicians perform ILESIs (cervical, 87.5 %; thoracic, 82.3 %; lumbar 99 %). Nearly all surveyed physicians utilize fluoroscopy (98.1 %) over other modalities like MRI and ultrasound. For CIESIs, dexamethasone was the preferred steroid (52.4 %) over methylprednisolone (23.7 %); the converse was true for LIESIs in which methylprednisolone (44.2 %) was preferred over dexamethasone (32.6 %). The majority of providers performing ILESI's (91.7 %) preferred a Tuohy/Weiss needle while only a small fraction preferred the Quincke needle (7.2 %). Sedation practices were more varied with only about half of providers (47.6 %) offering medications. Furthermore, a great fraction of providers continue to use contrast for LIESIs (97.9 %) and CIESIs (89.6 %). DiscussionOur survey suggests that despite updated consensus recommendations, variability continues to exist in procedural practice patterns. Highlighting areas of variable adherence to current safety guidelines can assist with what is emphasized in the generation of future evidence-based guidelines. Though our survey was conducted in the context of the COVID-19 pandemic with resultant supply chain shortages, more research is needed to elucidate what variables may factor into why proceduralists may stray from guideline concordant care.

Application of Technology in Cardiopulmonary Resuscitation, a Narrative Review

Novel medical technologies are designed to aid in cardiopulmonary resuscitation both in and out of the hospital. Out-of-hospital innovations utilize the skills of paramedics, bystanders, and other prehospital personnel, while in-hospital innovations traditionally aid in physician intervention. Our review of current literature aims to describe the benefits and limitations of six main technologic advancements with wide adoption for their practicality and functionality. The six key technologies include: extracorporeal membrane oxygenation (ECMO), real-time feedback devices, smart devices, video review, point-of-care ultrasound, and unmanned aerial vehicle (drone) automated external defibrillator (AED) delivery. The benefits and limitations of each technology were independently reviewed and expounded upon. Newer technologies like drone AED delivery, paramedic ultrasound use, and smart devices have been demonstrated to be safe and feasible, however, further studies are needed to compellingly demonstrate improved patient outcomes. In-hospital use of ECMO and ultrasound is well established by current literature to aid in cardiopulmonary resuscitation and improve patient outcomes.

A systematic review of pregnancy-related clinical intervention of drug regimens due to pharmacokinetic reasons

Background and objectivePublished works have discussed the pharmacokinetic interactions of drugs with pregnancy, but none comprehensively identify all the approved United States Food and Drug Administration (FDA) and European Medicines Administration (EMA) drugs that have a pregnancy-related intervention. The objective of this systematic review is to comprehensively identify medications that have clinically meaningful interventions due to pharmacokinetic reasons.MethodsAn in-depth search of clinical data using the PDR3D: Reed Tech Navigator™ for Drug Labels was conducted from 1 June to 12 August 2022. The PDR3D was analyzed using the search terms “pregnant” and “pregnancy” within the proper label section. Regarding the US labels, the terms were searched under the “dosage and administration” section, whereas with the EU labels, the terms were searched within the “posology and method of administration” section. If a finding was discovered within the search, the rest of the label was analyzed for further information. Clinical relevance was based on whether an intervention was needed.ResultsUsing the search strategy, 139 US and 20 EU medications were found to have clinically meaningful interventions in pregnancy. The most common explanations for clinical relevance included hepatic metabolism, protein binding, renal elimination, and P-gp influence. Of the US labels: 40 were found to undergo hepatic metabolism, 11 were found to be influenced by renal elimination, 12 were found to be influenced by protein binding, 7 were found to be influenced by P-gp, and the remaining drugs required further research. Of the EU labels: 11 were found to undergo hepatic metabolism, 3 were found to be influenced by renal elimination, 3 were found to be influenced by protein binding, 1 was found to be influenced by P-gp, and the remaining drugs required further research.ConclusionThis comprehensive review of clinically relevant interventions in pregnancy will potentially aid in the treatment of pregnant females when they are undergoing therapy, provide intervention and dosing guidance for physicians, and save time for prescribers and pharmacists. Advances in non-clinical predictions for pregnancy dosing may guide the need for a future clinical evaluation.

Compliance and Documentation for Evaluation and Management Services in Interventional Pain Management Practice

Evaluation of new and established patients is an integral part of interventional pain management. Over the last 3 decades, there has been significant confusion over the proper documentation for evaluation and management (E/M) services in general and for interventional pain management in particular. Interventional pain physicians have learned how to evaluate patients presenting with pain on the basis of their specialty training. Although modern training programs are introducing residents and fellows to the intricacies of E/M services and federal regulations, this has not always been the case. Multiple textbooks about pain management, physiatry, and neurology, and numerous journal articles have described the evaluation of pain patients, but they have not been specific to chronic pain patients and may not meet the regulatory perspective. A multitude of these issues led to the development of guidelines in 1995 and 1997, which were highly complicated and difficult to follow. These also led to significant criticism from clinicians. Consequently, further guidance was developed to be effective January 2021. The crucial concept in the present system of coding for E/M services is medical decision making, which includes 3 elements since 2021: 1. The number and complexity of problems addressed 2. Amount or complexity of data to be reviewed and analyzed 3. Risk of complications and/or morbidity or mortality of patient management In order to select a level of E/M service, 2 of the 3 elements of medical decision making (MDM) must be met or exceeded. This is in contrast to prior guidelines wherein for new patients, all 3 elements with history, physical examination and MDM , and for established patients have been met. For ease of appreciation, an algorithmic approach created by the American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS) approved a new MDM table outlining all of the appropriate criteria. This review systematically describes the changes and provides an algorithmic approach for application in interventional pain management practices. KEY WORDS: Evaluation and management services, new patient, established patient, level of service, CPT coding, medical decision making, complexity of problems

Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality

Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations. To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits. Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023. In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips. The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted. There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials. In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships. ClinicalTrials.gov Identifier: NCT04902664.