Physician Preference Research Articles

Student and Physician Views of How the Dobbs Decision Affects Training and Practice Location Preferences: Cross-Sectional Questionnaire Study.

By allowing for abortion bans and restrictions to take effect in the majority of US states, the 2022 Dobbs v Jackson Women's Health Organization decision portends to have lasting impacts on patient care and the physician workforce. Notably, it is already beginning to impact practice location preferences of US health care workers, evidenced by declining application rates to residency programs in abortion-restrictive states since 2022. Yet, there remains a gap in the literature regarding why this trend exists. This study aims to describe what factors are driving the practice location preferences of medical students and physicians after the Dobbs decision. This study analyzes qualitative data from a web-based, cross-sectional study. In August 2022, a nonprobabilistic sample of physicians and medical students were surveyed on social media about the impact of overturning Roe v Wade on practice location preferences, which included the free-text question "Please share your thoughts about the overturning of Roe v Wade and how it will affect your decision about your (residency/job or fellowship) programs." A total of 3 independent team members completed an inductive thematic analysis of 524 free responses, resolving differences by discussion. Approximately 1 in 4 survey respondents also completed the free-response item (524/2063, 25.4%); a total of 219 were medical students, 129 were residents and fellows, and 176 were practicing physicians. Of them, approximately half (261/524, 50.5%) resided in states where abortion bans were in place or anticipated. Those who answered the free-response item were relatively more likely to hail from states with restrictive abortion bans (P<.001) compared to those who did not, with other demographic characteristics being largely similar between the groups. Inductive thematic analysis yielded 2 broad thematic categories: patient-related and workforce-related factors influencing practice decision preferences. The 3 most common themes overall were respondent concerns regarding their patient's access to care (249/524, 47.5%), their desire not to practice or train in a state with abortion restrictions regardless of current residence (249/524, 47.5%), and their personal belief that abortion bans are human rights and/or body autonomy violation (197/524, 37.6%). Some respondents stated that the Dobbs decision would not impact their choice of practice location (41/524, 7.8%), and some supported it (35/594, 6.7%). This study shows that abortion restrictions are having an impact on the practice location preferences of the physician workforce due to both patient care and personal factors. It is important that state policy makers and others who are considering abortion restrictions also consider how to address these concerns of physicians and medical students, to avoid worsening geographic maldistribution of physicians and worsening access to care from physicians for their citizens.

Choice of therapy for HER2-positive metastatic breast cancer in real clinical practice: analysis of physician preferences in Russian Federation

Metastatic breast cancer still remains an incurable disease, requiring lifelong treatment. Introduction of targeted therapy into clinical practice has radically changed treatment approaches of HER2-positive breast cancer, making it possible to significantly increase the life expectancy. The treatment algorithm for HER2-positive metastatic breast cancer appears to be quite clear and is reflected in both international and Russian recommendations. To assess actual clinical practice in the Russian Federation, a survey study “Therapy of Her2-positive breast cancer” was conducted. This publication presents results dedicated to the treatment of metastatic HER2-positive breast cancer. 50 specialists from 43 cities took part in the survey. Only heads of departments or their deputies who were personally involved in determining the treatment for patients were allowed to participate. Expertise of this level allows us to reliably assess the actual clinical practice that has developed in the Russian Federation and determine directions for optimizing therapeutic approaches. Despite ongoing questions about the availability of drugs, doctors primarily focus on the effectiveness of treatment. The main first-line therapy in the Russian Federation is the combination of trastuzumab with pertuzumab. However, experts noted that in conditions of unlimited access to drugs, the number of prescriptions for this regimen in the first line would increase by 13%. Doctors also agree that the use of a subcutaneous form of this combination of drugs would optimize the treatment process. Trastuzumab emtansine remains the standard of second-line therapy and, according to the survey results, almost all patients for whom it is indicated receive this type of therapy. Experts predict more frequent use of trastuzumab emtansine in first-line therapy, given the widespread use of neoadjuvant regimens with pertuzumab. The most significant changes are expected in the third line of therapy with the introduction of the new conjugate – trastuzumab deruxtecan. The survey results demonstrate high awareness and commitment of physicians to modern principles of treatment of HER2-positive mBC.

Physician and Patient Preferences for Oral Anticoagulation Therapy Decision Making in Atrial Fibrillation: Results From a National Best-Worst Scaling Survey in Türkiye.

Atrial fibrillation (AF) is the most common cardiac dysrhythmia and a common cause of ischemic stroke. Stroke prevention with oral anticoagulation (OAC) is the cornerstone of AF management. Patients and their treating physicians may have different views on different attributes of OACs. The objective of this study was to quantify the relative importance that patients and physicians in Turkey place on different OAC attributes when making treatment decisions in AF. A cross-sectional survey was administered to AF patients (≥ 50 years) receiving OAC and practising cardiologists, including residents with ≥ 2 years of experience in Turkey. For both patients (N = 230; 50% male) and physicians (N = 194; 74% male), the most important attributes for OAC treatment decision making in AF were "success in preventing stroke" (57% and 73.9% or overall importance, respectively) and "risk of major bleeding" (20% and 23.4%, respectively). For patients, other attributes were much less important, but not altogether unimportant: reversal agent availability (7%), monitoring (5%), food or drug interactions (3%), minor bleeding (3%), and ease of swallowing (2%). For physicians, among the other attributes, only the need for monitoring (1.3%) had a relative importance of > 1%. For all Turkish participants, efficacy and safety were found to be the most important attributes influencing OAC choice in AF with these two attributes accounting for 77% and 97.3% of overall importance for patients and physicians, respectively. Certain considerations, especially reversal agent availability and monitoring appear to be more important to patients than to physicians This is the first study to use BWS to quantify patient and physician preferences for OAC treatments in AF in Turkey.

Identifying Hip Arthroscopy Trends in Turkey.

Hip arthroscopy (HA) procedures have continued to increase worldwide. However, no data are currently available regarding the increasing HA case volume and trends in Turkey. To identify trends in postoperative care habits and incidence of HA in Turkey using data from the national Health Coding Reference Server (SKRS) database. Cross-sectional study. Patients who underwent HA and were recorded in the SKRS database between 2016 and 2023 were identified and retrospectively analyzed. Age, sex, institution type, geographic zone, and number of procedures were determined. The incidence of HA, overall annual case volume, chemoprophylaxis prescriptions, and postoperative care habits were also evaluated. The International Classification of Diseases, 10th Revision codes for femoral neck fracture after the index procedure and total hip arthroplasty conversion rate were analyzed. The authors utilized Poisson regression to determine the ratios of before and after periods in comparison with the same periods. Statistical analysis was performed using the statistical package SPSS software. In total, 1580 HA procedures were identified. The mean age of the included patients was 39.2 ± 11.0 years (range, 18-65 years). Throughout the research period, an 833% increase in the number of surgeries was observed, whereas the incidence increased from 0.37 to 2.86 per 100,000 cases (P = .001). A significant annual increase in incidence was noted from 2017, 2018 and 2021 compared with the respective prior year. Moreover, 56.1% of all HA cases were performed in the Marmara region, whereas 47.7% of the cases were treated in private hospitals. Femoral neck fractures were encountered in 2 (0.1%) cases throughout the study duration. Enoxaparin sodium was the most preferred chemoprophylactic drug (99.4%). The 2-year total hip arthroplasty conversion rate was 3.5%. This study describes the current trends in HA across Turkey and provides a perspective on physician preferences. Notably, HA procedure counts, the ratio between HA and other orthopaedic procedures, and the incidence of HA demonstrated an increasing trend, with enormous potential for further advancement. These findings highlight the need for the creation of a national registry capable of obtaining more specific and accurate data.

Physician Preferences in Using Novel Digital Devices for the Management of Atrial Fibrillation-A DAS-CAM III Survey.

A recent European Heart Rhythm Association (EHRA) practical guide provides guidance on the use of novel digital devices for heart rhythm analysis using either electrocardiogram (ECG) or photoplethysmography (PPG) technology for the diagnosis of atrial fibrillation (AF). This survey assesses physicians' preferences to use digital devices in patients with possible AF and their impact on clinical decision-making. Participants of the DAS-CAM III initiated and distributed an online survey assessing physician preferences in using digital devices for the management of AF in different clinical scenarios. A total of 505 physicians (median age: 38 [IQR 33-46] years) from 30 countries completed the survey. A third of respondents were electrophysiologists, the others were cardiologists, cardiology residents, or general practitioners. Electrophysiologists were more likely to have experience with both ECG-based (92% vs. 68%, p < 0.001) and PPG-based (60% vs. 34%, p < 0.001) digital devices. The initial diagnostic approach to each scenario (symptomatic low-risk, symptomatic high-risk, or asymptomatic high-risk patient) was heterogeneous. Electrophysiologists preferred intermittent single-lead ECG monitoring to traditional Holter ECGs to screen for AF. Both electrophysiologists and non-electrophysiologists would rarely use PPG-based devices to diagnose and screen for AF (8.2%-9.8%). Electrophysiologists and non-electrophysiologists use ECG-based technology to confirm PPG-documented tracings suggestive of AF. While PPG-based digital devices are rarely used for diagnosis and screening for AF, intermittent ECG-based digital devices are beginning to be implemented in clinical practice. More education on the potential of novel digital devices is required to achieve diagnostic pathways as suggested by the EHRA practical guide.

Medical treatment of primary sclerosing cholangitis: What have we learned and where are we going?

It has proven difficult to establish robust evidence for significant clinical benefits of medical treatment in primary sclerosing cholangitis (PSC). For ursodeoxycholic acid, clinical practice guidelines only offer vague recommendations, leading to a situation of variable prescription rates depending on local reimbursement policies and physician preference. The difficulty in drug development in PSC is partly related to poor understanding of critical disease processes with failure to identify relevant mechanisms of action of putative drugs. The variable disease course, both intra-individually and between individuals, and lack of robust definitions of what success looks like for clinical trials in PSC have also contributed to the negative outcomes of trials performed. In this review article we will discuss these uncertainties and challenges, building on key previous and ongoing clinical trials. Despite the lack of consensus for an ideal phase II and phase III study design, several trials for diverse compounds are currently ongoing, indicating a shift from therapeutic nihilism towards hope for people with PSC. While waiting for robust efficacy data for drugs currently being tested, the current lack of effective interventions should not motivate prescription of compounds to people with PSC based on low-quality evidence.

Physician preferences of biomarker testing strategies in newly diagnosed stage IV non-small cell lung cancer patients.

Aim: To understand physicians' attitudes and behaviors regarding EGFR testing and retesting strategies in newly diagnosed metastatic non-small cell lung cancer patients.Materials & methods: Oncologists and pathologists completed an online, cross-sectional survey.Results: Most oncologists (73.3%) and pathologists (53.4%) agreed that concurrent testing increases sensitivity for detecting EGFR mutations. Upon tissue insufficiency, oncologists and pathologists reported using liquid biopsy 77.0% and 39.0% of the time, respectively. Tumor accessibility, smoking status, patient willingness and age were key drivers of tissue re-biopsy. Most oncologists reported high confidence in proceeding to first-line therapy based solely on liquid biopsy (60.7-80.0%); fewer pathologists (37.9%) were comfortable with this decision.Conclusion: Variation in physicians' perceptions of testing and retesting highlights the need for greater stakeholder consensus.

Treatment Preferences of Physicians Treating Adult Patients with Attention-Deficit/Hyperactivity Disorderin the United States and Canada: A Discrete Choice Experiment.

Factors influencing attention-deficit/hyperactivity disorder (ADHD) treatment preferences have been studied among patients but not physicians in the United States (US) and Canada. This study assessed treatment preferences of physicians treating adult patients with ADHD in both countries. An online discrete choice experiment (DCE) was conducted (October 4-20, 2023) among physicians from Dynata's US and Canadian panel who treated adult patients with ADHD. Preference weights for efficacy (improvement in ADHD symptoms) and safety [risks of adverse events (AEs)] attributes were estimated using a conditional logistic regression model, and were used to calculate the willingness to trade-off and relative importance of the attributes. Among 510 US and 347 Canadian physicians (64.1% and 69.2% male, respectively), improvement in ADHD symptoms had a significant positive impact, and the risks of AEs (except the risk of feeling jittery in Canada) had a significant negative impact on physician preferences for ADHD treatments. US physicians were willing to tradeoff 0.44, 0.35, 0.20, 0.17, and 0.17 percentage points of improvement in ADHD symptoms to avoid a one-percentage-point risk of insomnia, nausea, feeling jittery, anxiety, and dry mouth, respectively; among Canadian physicians, these were 0.31, 0.21, 0.12, 0.20, and 0.07, respectively. The relative importance of the efficacy versus safety attributes (i.e., the risks of AEs included in the DCE taken together) was 45.5% versus 54.5% in the US and 56.3% versus 43.7% in Canada. Efficacy was the most important single attribute for physicians treating adult patients with ADHD in both the US and Canada; however, the risks of AEs taken together had greater relative importance than efficacy alone among US but not Canadian physicians. These findings highlight potential discrepancies in physician and patient preferences based on existing evidence and underscore the importance of shared decision-making, which may in turn increase patients' treatment satisfaction.

Utilization of telemedicine for diagnosis and follow-up within foot and ankle orthopaedic surgery: A narrative review of the literature.

Telemedicine has seen increasing adoption in healthcare over the past two decades, with proven clinical efficacy in several medical specialties. Orthopedics surgery has shown potential benefits from telemedicine implementation. This review aims to evaluate the impact of telemedicine on clinical outcomes and patient and physician preferences in foot and ankle orthopedics, providing insight into the potential role of telemedicine within this subspecialty. Multiple databases were searched for relevant articles on telemedicine in foot and ankle orthopedics. Inclusion criteria encompassed articles on telemedicine use and foot and ankle orthopedic care. Data included patient demographics, reasons for visits, duration of telemedicine, and outcomes. Analysis involved descriptive statistics, and a narrative approach to describe outcomes. Out of 218 articles, 12 met the inclusion criteria, comprising a total of 1,535 patients. Telemedicine visits were used for follow-up care, opinion consultations, monitoring, postoperative care, and treatment of various orthopedic conditions. Clinical outcomes demonstrated equivalence to in-person care. Patients expressed satisfaction with telemedicine but preferred in-person visits for future appointments. Physicians held neutral attitudes towards telemedicine, with concerns about the lack of physical examination. This review highlights the benefits of telemedicine in foot and ankle orthopedics. Telemedicine provides an alternative to in-person visits, improving patient access to care and offering cost and time savings. However, patient and physician preferences for in-person visits suggest a need to address concerns related to physical examination limitations. Telemedicine can supplement traditional care, but further research is required to explore its applicability in new patient consultations and optimize physician engagement.

Diagnostic Test Accuracy of Fat Pad Sampling and Bone Marrow Biopsies in the Diagnosis of AL Amyloidosis: A Systematic Review and Meta-Analysis

Introduction: Tissue biopsies are needed to establish a diagnosis of systemic AL amyloidosis. Biopsy can be obtained from an involved organ with suspected amyloid deposition (target biopsy) or from sites in which amyloid commonly deposits (surrogate biopsy). The choice of biopsy site depends on institutional and physician preference. Two commonly used sites for surrogate biopsies are abdominal fat pad and bone marrow. The present systematic review and meta-analysis aims to evaluate the diagnostic test accuracy of fat pad and bone marrow biopsies as surrogate biopsy sites in the diagnosis of AL amyloidosis. Methods: As part of the ASH AL Amyloidosis Diagnostic Guideline, we performed systematic reviews for seven prioritized PICO questions related to the screening, diagnosis and organ involvement evaluation of AL amyloidosis. We conducted electronic searches on PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception until January 2024. Two reviewers independently and in duplicate performed title and abstract screening and full text article screening on LASER AI, with conflicts resolved by a third reviewer. Studies were eligible if they included patients that had a fat pad sample or bone marrow biopsy and a target organ biopsy for suspicion of AL amyloidosis allowing for the calculation of diagnostic test accuracy measures. Diagnostic test accuracy measures of interest were sensitivity, specificity, positive and negative predictive value. Statistical analysis was performed on OpenMeta[Analyst]. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the certainty of evidence. Results: After deduplication, we retrieved 29,237 studies.. 20 studies with 2955 patients reporting on bone marrow biopsy, 25 with 4702 patients on fat pad sampling were included. The pooled sensitivity for bone marrow biopsy was 55.1% (95% CI 45.8-64.0, I2 = 94%) (Certainty of evidence: Low ⨁⨁◯◯), For fat pad sampling sensitivity was 76.6% (95% CI 72.1-80.8, I2 = 84.2%) (Certainty of evidence: Moderate ⨁⨁⨁◯). Among the included studies, 1 evaluated the sensitivity of fat pad sampling and bone marrow biopsy combined and found it to be 89%. No included studies evaluated specificity for bone marrow biopsy or fat pad sample. Conclusion: Combination of fat pad and bone marrow biopsy together significantly improve sensitivity for amyloid detection compared to either fat pad sampling or bone marrow biopsy alone.

Blinded Ex-Vivo testing in AML Reveals Differences between Hypomethylating Agents When Combined with Venetoclax

Introduction The therapeutic strategy of combining the hypomethylating agents (HMAs) Azacitidine (Aza) and Decitabine (Deci) with the BCL-2 inhibitor Venetoclax (Ven) has significantly improved the clinical outcomes of patients with Acute Myeloid Leukemia (AML), reaching overall response rates of up to 70% in clinical trials (Wei et al, JCO 2021). Still, on an individual basis, clinicians struggle to predict which patients will respond to Ven/HMA treatment. Furthermore, there is little data to guide selection of which HMA to use and the decision is generally based on physician preference and logistics. Functional ex-vivo testing using patient-derived primary cells has emerged as a promising approach to guide clinical decision (Letai et al, Cancer Cell 2022). This is particularly relevant for heme malignancies, given the ease of access to patient-derived cells from peripheral blood and/or bone marrow. We conducted a blinded study using OncoPrecision's proprietary Patient Micro-Avatars (PMAs) to predict clinical responses to Ven/HMA treatment. Methods De-identified diagnostic bone marrow aspirate samples from the leukemia program biobank at Weill Cornell Medicine that received Ven/HMA were provided to OncoPrecision for ex-vivo testing without information about the specific HMA used for treatment nor clinical response. PMAs are based on a triple co-culture platform that, by promoting the long term ex-vivo survival of Patient-Derived Cells (PDCs), allows testing the performance of different treatments. PDCs are co-cultured with two types of heterologous engineered cells: i) bone marrow stroma cells that act as a feed layer and as a control of non-specific toxicity (Tox-Control) and ii) a known outcome AML cell line that serves as an internal control of the system robustness and reproducibility in the response to drugs (System-Control). PMAs also leverage a multi-tagging approach coupled to high-throughput flow cytometry to track the differential response to treatments in subpopulations of pathological and healthy cells from each patient. This technology previously showed robust predictive power in observational studies in AML (García et al, Blood - 2022 ; Andino et al, Blood - 2023). Results PMAs were used to screen 39 AML patients who were treated with either Aza+Ven or Deci+Ven and from whom bone marrow or peripheral blood samples were stored prior to the start of treatment. OncoPrecision blindly tested these samples ex-vivo against a full dose-response curve of Aza+Ven and used their machine learning algorithm to predict clinical outcomes. When the predictions were matched against the clinical outcomes of the 27 patients of the cohort that received Aza+Ven at the clinic, the predictive accuracy (85%) was similar to the one previously reported in OncoPrecision's observational study (80%). Remarkably, however, when Aza+Ven predictions were matched to the clinical outcomes of the 12 patients in the cohort who received Deci+Ven, the predictive accuracy dropped to 50%. Interestingly, such a dramatic drop in the predictive power cannot be explained by a decrease in the negative predictive value (which remained &amp;gt;80%), but rather to a subpar positive predictive value (&amp;lt;30%), thus indicating that Aza may clinically outperform Deci in several of these patients. It is clear that ex-vivo testing using PMAs may have the ability to discern treatment sensitivity between Aza vs. Deci, and that there is potential to utilize this technology to tailor Ven/HMA therapy for individual patients. This is valuable not only to maximize potential disease response in a patient, but to also better prioritize patient quality of life during treatment, considering that Aza more commonly causes adverse effects like nausea and constipation than Deci. Conclusions Ex-vivo testing using PMAs has the potential to identify patients likely to respond to Ven/HMA and to discern treatment sensitivity between Aza vs. Deci. Our findings suggest that Aza and Deci may not always have equivalent efficacy for patients. This variation between Aza and Deci merits further exploration, especially since the therapeutic landscape for AML is likely to further expand with additional HMAs.

Abstract 388: Real World Experience Using the Balt Carrier Delivery Catheter for Intracranial Access During Mechanical Thrombectomy

Introduction Delivery catheters that reduce the ledge effect of aspiration catheters while maintaining a tapered atraumatic tip have recently become a focus for intracranial access during treatment of acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). Most companies package their proprietary insert catheter with their own aspiration catheter. The Balt Carrier (The Balt Group, Montmorency, France) is the only separately packaged delivery catheter which comes in three sizes and is designed to safely and efficiently deliver the operator's aspiration catheter of choice to the face of the thrombus with or without the use of a wire. In this study, we share our experience using the Balt Carrier delivery catheter for patients undergoing MT for AIS. Methods We conducted a retrospective case series study of prospectively collected AIS patients undergoing MT at two comprehensive stroke centers. Patients were included in the study if Carrier was utilized to advance an aspiration catheter to the face of an intracranial thrombus. First pass was defined as the time at which the aspiration catheter engaged the clot. We defined successful recanalization as a reperfusion score of TICI 2b or greater. Carrier complications were defined as any vessel injury detected on angiogram during intervention or symptomatic hemorrhage detected on head CT with a change in NIHSS greater than 3 points. Results In nineteen patients, 4 ICA, 12 M1, 2 M2, and 1 basilar artery occlusion were targeted for MT. Four different 6F aspiration catheters were utilized ranging in ID from 0.070” to 0.071.” All three sizes of Carrier were utilized: 4 small, 13 medium, 2 large. The aspiration catheter successfully reached the target lesion in all cases (19/19) on first attempt. A wire was used in nine cases. Of those nine cases, 6 were physician preference and 3 required a wire because the Carrier tip atraumatically entered two fetal Pcomms and one posterior meningeal artery. The median puncture time to first pass and puncture time to successful reperfusion was 16 minutes and 25 minutes respectively. There were no complications. Conclusion The Balt Carrier delivery catheter was successful in delivering various aspiration catheters for intracranial access to the target occlusion with no complications. Reducing the ledge effect of various aspiration catheters during MT while maintaining an atraumatic tip may help safely expedite intracranial access with even larger catheters. More studies are needed to confirm the results of this small two center retrospective study.

Teledermatology and Virtual Visits for Acne Management: A Review.

Acne vulgaris is a common dermatological condition requiring individualized management. Teledermatology provides convenience and accessibility that is highly suitable for this dermatological condition. Herein, our review aimed to describe the current state of teledermatology in the context of acne management and to assess patient satisfaction, adherence to virtual care, and the experiences of health care providers in delivering remote dermatological services. A systematic search for articles was conducted in Medline, Embase, and PubMed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Title, abstract, full-text screening, and data abstraction were carried out in duplicate. One thousand one hundred three nonduplicate articles were screened based on title and abstract review. A total of 21 studies were included in the review. It was found that teledermatology is well-suited to the effective management of acne vulgaris. When compared to in-person care, teledermatology resulted in similar outcomes on several acne-grading scales. Additionally, patient satisfaction was comparable, with a large proportion of patients preferring virtual care to traditional in-person visits. However, compliance was found to be lower for virtual care. There are several secondary benefits to telemedicine, including time savings and greater accessibility to care for rural patients. Teledermatology is an evolving, promising medium for acne management for both clinicians and patients. Future research comparing the effectiveness of different teledermatology platforms, its limitations and pitfalls, and integration of patient and physician preferences to improve treatment outcomes is warranted.

Anesteziyoloji ve Reanimasyon Hekimleri Arasında Sezaryen Cerrahisi ve Doğum Sonrası Ağrı Yönetiminde; Prosedüre Özgü Ağrı Yönetimi (PROSPECT) Farkındalığı Anket Çalışması

Objective: Procedure-specific pain management (PROSPECT) provides clinicians with evidence-based recommendations for postoperative pain management. It was aimed to evaluate the preferences of Anesthesiology and Reanimation physicians for postpartum analgesia management. Methods: A questionnaire consisting of 19 questions was prepared, including demographic data, cesarean surgery and postpartum analgesia practices, and whether PROSPECT recommendations were followed. This questionnaire was sent to participants via e-mail. Results: The study included 247 participants. Thirtysix percent of participants reported following PROSPECT recommendations and 55.1% of participants reported prefering opioids routinely or in combination with other techniques for cesarean surgery and postpartum analgesia. Eightyfive percent of the participants think that inadequate postpartum analgesic treatment was performed. Conclusion: Inadequate postpartum analgesia appears to be a common problem. The potential of maternofetal interaction is reported to be the most important reason for this situation. We think that training on postoperative pain management following cesarean surgery will make a significant contribution to eliminating concerns about maternal-fetal interaction. Keywords: Cesarean section, postpartum analgesia, prospect, anesthesiology and reanimation, questionnaire study

Causes of Coronary Angioplasty Denial in Patients Diagnosed with Significant Coronary Artery Disease in East Afghanistan

Coronary Artery Disease (CAD) is a leading cause of mortality worldwide, with coronary angioplasty being a crucial intervention for patients with significant disease. This study aimed to identify and analyze the causes of coronary angioplasty denial in patients with significant coronary artery disease in Afghanistan, focusing on demographic, socioeconomic, and clinical factors. A case-control study was conducted with a sample size of 213 patients diagnosed with significant CAD at tertiary care center in Afghanistan. The case group consisted of 106 patients who were denied angioplasty, and the control group included 107 patients who underwent the procedure. Data were collected on demographic characteristics, comorbidities, education, residence, functional status, income, and the reasons for angioplasty denial. Descriptive statistics and comparative analyses were performed to assess the factors associated with denial. The primary reasons for angioplasty denial were financial constraints (45.3%, p &lt; 0.001), limited hospital facilities (15.1%, p = 0.045), patient refusal (23.6%, p &lt; 0.001), and physician preference for conservative management (12.3%, p = 0.091). Denial rates were higher among patients who were older, had multiple comorbidities, were from rural areas, and had lower education and income levels. Illiteracy and cultural beliefs contributed significantly to patient refusal, while inadequate healthcare infrastructure disproportionately affected rural populations. Financial and infrastructural barriers are the leading causes of coronary angioplasty denial in Afghanistan, exacerbating disparities in healthcare access, particularly among low-income and rural patients. Addressing these issues through policy reforms, improved healthcare infrastructure, and targeted public health education is essential to reducing CAD-related morbidity and mortality in the country.

Utilizing cluster analysis of biomarkers alongside echocardiographic deformation parameters to forecast the outcome of atrial fibrillation post-ablation

Abstract Background Atrial fibrillation (AF) management often involves catheter ablation, but its recurrence necessitates careful clinical management and potential adjustments in medication or further ablation procedures. This study aims to investigate the predictive value of biomarkers and echocardiographic parameters for early AF recurrence. Methods In the prospective study, we enrolled patients with symptomatic paroxysmal or persistent atrial fibrillation undergoing catheter ablation. Pulmonary vein isolation was performed in every index procedure, with additional ablation or substrate modification as per physician preference. Blood samples were collected from both the atrium and peripheral vein to assess levels of tumor endothelial marker 1 (TEM1), galectin 3, connective tissue growth factor (CTGF), transforming growth factor-beta (TGF-β), C-terminal propeptide of procollagen type I (PICP), and Smad3. Pre-procedural echocardiographic parameters, including the E/e’ ratio, peak atrial longitudinal strain (PALS), and peak atrial contractile strain (PACS), were recorded. Clustering models with sparse canonical association analysis (CCA) were employed to develop predictive models integrating biomarker and echocardiographic data for early atrial fibrillation recurrence. Results Out of 80 prospectively enrolled patients, 68 completed the study, with six cases of early atrial fibrillation recurrence observed. Following dimension reduction and clustering, we found that the combined use of biomarkers and echocardiography significantly predicted atrial fibrillation recurrence (HR: 9.44, p=0.05, 95% CI: 1.0-88.9). Notably, among these parameters, TEM1 biomarker sampled from the peripheral vein (p=0.02), left atrium dimension (p=0.07), and left ventricle dimension (p=0.02) exhibited the most significant predictive power. Conclusions Our study highlights the effectiveness of integrating biomarkers and echocardiography parameters in predicting early recurrence of atrial fibrillation post-ablation in patients undergoing catheter ablation.main_figure

Biologics and oral systemic treatment preferences in patients and physicians for moderate-to-severe atopic dermatitis: a discrete choice experiment in the United Kingdom and Germany

Background: As the available treatments for moderate-to-severe atopic dermatitis (AD) expand, understanding patient and physician preferences becomes crucial for informed decision-making. Objective: To quantify patient and physician preferences for biologics and oral systemic AD treatment attributes. Materials and methods: We conducted a cross-sectional, online discrete choice experiment (DCE) involving 306 AD patients and 206 physicians throughout the United Kingdom and Germany. Qualitative interviews identified the key attributes for inclusion in the DCE. Each choice task comprised two hypothetical patient profiles. Data were analyzed using a random-parameters logit model. Results: Results indicated a significant emphasis on efficacy, with reducing sleep disturbance and itch ranking first and second among patients, and the reverse for physicians. Time to itch relief was the third most important efficacy attribute for both groups, but relatively more important for patients than for physicians. For both groups, the risk of eye problems was the most important safety concern of those included. Mode of administration was not of great importance compared to efficacy and safety attributes. Conclusions: Our findings suggest patients prioritize sleep disturbance, an attribute not captured in prior preference studies in AD, time to itch relief and itch. These findings emphasize the importance of addressing sleep-related issues, whilst also targeting fast itch control, to enhance patients’ well-being.

Comparison of Drug-Assisted Tracheal Intubation Using Benzodiazepines and Induction Agents for First-Pass Intubation Success in Emergency Airway Management: A Retrospective Cohort Study

Objective: To determine first-pass intubation success between benzodiazepines and induction agents in adult patients who underwent drug-assisted intubation in the emergency department (ED). Materials and Methods: A retrospective chart review observational study collected the data of patients who underwent drug-assisted intubation in the ED of a university teaching hospital between January 1, 2021 and August 31, 2022. Two hundred seven patients were enrolled in the present study. The benzodiazepine and induction agent groups were compared in terms of baseline characteristics, and clinical management. Each benzodiazepine and induction agent were compared in first-pass intubation success, time to intubation success, adverse events, and 24-hour mortality. Results: Of the 207 patients included in the present study, 35 patients used benzodiazepine, and 172 patients used induction agents. The two groups had no differences in baseline characteristics. The first-pass intubation success rate was not significantly different among the medications with 90% in nine diazepam patients, 92% in 23 midazolam patients, 89.8% in 79 etomidate patients, and 94% in 79 propofol patients (p=0.553). Complications associated with intubation included hypotension, desaturation, tachycardia, bradycardia, arrhythmia, cardiac arrest, and pneumonia. No differences in 24-hour survival were observed. Conclusion: The sedative medications used during drug-assisted intubation should be chosen based on patient comorbidities and characteristics, as well as physician preferences and experiences. There were no differences between the benzodiazepine and induction agent groups in terms of first-pass intubation success, adverse events, or 24-hour survival. The use of benzodiazepines in settings with limited resources may be considered.

Characteristics of patients with liver tumors deemed ineligible for enrollment on Children's Oncology Group trial AHEP1531: An opportunity to expand inclusion criteria and improve outcome.

Specific patients with hepatoblastoma (HB) and hepatocellular carcinoma (HCC) do not meet eligibility criteria for Children's Oncology Group (COG) trials, limiting an understanding of how comorbidities affect the outcome. We define such a population for future-focused care improvements. A questionnaire was sent to COG institutional principal investigators to obtain anonymized data regarding patients with a liver tumor diagnosis not enrolled on AHEP1531 due to ineligibility by trial criteria or other reasons (excluding parent/patient preference). Responses received for 55 patients (38 HB, 4 HCC, and 13 not reported) included 12 excluded from further analysis due to various factors, including lack of additional information. Five patients were eligible but not enrolled due to pandemic-related staffing issues (n=1) or the best interest of the patient (physician preference, n=1; risk for poor tolerance of chemotherapy, n=1; not specified, n=2). The remaining 38 patients included 1 ineligible due to a prior malignancy, 9 due to performance status, and 4 due to timing requirements. Thirty-five of 38 patients were ineligible due to organ function criteria (pulmonary/oxygen requirement, n=25; renal, n=10; liver, n=4; cardiac, n=3). Seven patients were ineligible due to two or more organ function criteria. Twenty-five of 38 patients were reported to have a preexisting condition including 4 patients with trisomy 18. Patients with HB, and potentially HCC, who are ineligible for COG trials are primarily patients with an oxygen requirement and/or renal insufficiency, often associated with preexisting congenital conditions. Such patients would benefit from future studies to improve outcomes.

Cervical osteomyelitis in the setting of multiple comorbidities: a complex anatomical approach. Illustrative case.

Vertebral osteomyelitis (VO), also known as spinal osteomyelitis or spondylodiscitis, is a rather rare yet serious disease comprising 3%-5% of all osteomyelitis cases, with only 3%-6% of this subset affecting the cervical spine. Risk factors include an advanced age, diabetes, immunosuppression, and intravenous (IV) drug use. The incidence of VO has increased over recent decades, with high-risk patients experiencing higher mortality rates. Treatment guidelines for VO are not standardized and rely on physician preference, often starting with IV antibiotics and progressing to surgery, if necessary. A 54-year-old female with tracheostomy-dependent obesity hypoventilation syndrome, hypertension, and morbid obesity presented with upper back pain after a fall. Imaging revealed early C6-7 discitis osteomyelitis, which was initially managed conservatively with IV antibiotics. Her condition worsened, leading to anterior corpectomy of C6-7, followed by posterior cervical fusion from C5 to T2 in the sitting position. This approach was chosen due to the patient's complex anatomy and tracheostomy. This case underscores the need for unique surgical approaches in high-risk patients with complex anatomy. It highlights the importance of interdisciplinary care when managing VO, especially in patients with multiple comorbidities. Given the increasing rates of morbid obesity, this case provides valuable insights for neurosurgical decision-making in similar future cases. https://thejns.org/doi/10.3171/CASE24448.