Physician Unfamiliarity Research Articles

Assessment of autologous platelet-rich plasma as a local therapy for female sexual dysfunction

ObjectiveTo evaluate the role of localized injection of autologous platelet-rich plasma (PRP) in the treatment of female sexual dysfunction (FSD).BackgroundFSD is defined as disorders of libido, arousal, orgasm, and sexual pain that lead to personal distress or interpersonal difficulties. Treatment of FSD is complicated by the lack of a single causative factor, limited proven treatment options, physician unfamiliarity with available treatments, overlap of different types of dysfunction, and limited availability of treatment. A safe nonsurgical, cost-effective procedure is the intravaginal and intraclitoral injection of PRP to treat this sexual dysfunction.Patients and methodsThis was a prospective study of 20 female individuals with FSD who underwent intravaginal and intraclitoral injection of PRP. Standardized female sexual function index was administrated before treatment and after treatment to measure the response of treatment.ResultsThere were statistically high significant mean values of desire, arousal, lubrication, orgasm, and satisfaction after treatment (P < 0.001), which is highly significant.ConclusionPRP is an effective treatment of FSD. It is a minimally invasive procedure with very low side effects.

Surgery-associated acquired hemophilia A: a report of 2 cases and review of literature

BackgroundAcquired Hemophilia A (AHA) is a rare bleeding diathesis in patients with no previous personal or family bleeding history. The diagnosis of this disease often delays due to unfamiliarity of physicians with it, which leads to its high mortality rate.Case presentationTwo cases (one 12 years old female and another 18 years old male) were admitted for right upper abdominal mass and right upper abdominal pain respectively at different times. Pre-operative diagnosis of both cases was congenital choledochal cyst. They suffered continuous gastrointestinal bleeding (hematemesis and melena) with reduced hemoglobin to 54 g/L and 60 g/L after Roux-en-Y anastomosis respectively. To investigate the exact bleeding site, Digital subtraction angiography (DSA) of case 1 showed contrast overflow at small branch of proper hepatic artery but had unremarkable result for case 2, whereas gastroscopy of both cases showed unremarkable results. Multiple surgeries were also performed for hemostatic purpose but each time no active bleeding site was found. Finally, hematologists consultation was mandated in both cases and they were diagnosed as acquired haemophilia A. However, unfortunately case 1 patient could not survive because of sever hemorrhage and infection while Case 2 of 18 years old male survived after proper haemophilia treatment catalog.ConclusionAwareness about surgery associated acquired haemophilia A (SAHA) can facilitate quick diagnosis and lifesaving management because the mortality rate in SAHA is high due to lake of knowledge or late recognition of the disease. Bleeding always occurs at surgical sites and it can occur immediately within few hours after surgery in some cases. Hemorrhage may be severe or even life threatening and it presents a special challenge for diagnosis and treatment in a patient who has just undergone a surgical procedure. The treatment strategies for AHA include resumption of hemostasis with either recombinant porcine factor VIII (rpFVIII) or bypassing agents and immunosuppressive therapy to suppress the production of the factor VIII inhibitor.

A Nurse Shadowing Program for Physicians: Bridging the Gap in Understanding Nursing Roles.

A physician-nurse shadow program was established to improve interdisciplinary collaboration. Ineffective communication between physicians and nurses leads to poor outcomes in patient satisfaction, safety, and associate engagement. Physician unfamiliarity of the nursing process is identified as a root cause. First-year resident physicians shadowed nurses for a 4-hour shift. Residents did not function as a physician during the shadowing experience but participated in nursing workflow and tasks. Participants completed a Likert-scale rating and qualitative survey before and after the shift. The survey measured confidence in communication and perception of workflow. Confidence levels increased in all areas by 29% for residents and 34% for nurses. Data demonstrated improved physician understanding of nursing workflow and inspired recommendations to enhance communication. First-year resident physicians practiced direct communication skills and experienced hands-on nursing care during the shadow program. The initiative provided an environment for mutual learning and interdisciplinary relationship-building.

OPAT: proof of concept in a peripheral Belgian hospital after review of the literature

ABSTRACTSince its introduction in the 1970s in the United States, outpatient parenteral antibiotic/antimicrobial therapy (OPAT) has been adopted internationally for long-term intravenous (IV) treatment of stable infectious diseases. The aim is to provide a safe and successful completion of IV antimicrobial treatment at the ambulatory care center or at home without complications and costs associated with hospitalization. OPAT implementation has been accelerated by progress in vascular access devices, newly available antibiotics, the emphasis on cost-savings, as well as an improved patient comfort and a reduced incidence of health care associated infections with a similar outcome. OPAT utilization is supported by an extensive published experience and guidelines of the British Society of Antimicrobial Chemotherapy and the Infectious Diseases Society of America for adults as well as for children. Despite these recommendations and its widespread adoption, in Belgium OPAT is only fully reimbursed and established for cystic fibrosis patients. Possible explanations for this unpopularity include physician unfamiliarity and a lack of uniform funding arrangements with higher costs for the patient. This article aims to briefly review benefits, risks, indications, financial impact for supporting OPAT in a non-university hospital as standard of care. Our experience with OPAT at the ambulatory care center of our hospital and its subsequent recent introduction in the home setting is discussed.

Drug Interaction and Serotonin Toxicity with Opioid Use: Another Reason to Avoid Opioids in Headache and Migraine Treatment.

Treatment of headache, specifically migraine attacks, has always been a challenging subject, especially for neurologist and pain specialists. Triptans are generally underutilized, despite being the gold standard abortive medication for migraine attacks. On the other hand, opioid analgesics are overused as a treatment for headache. One reason for this could be physician unfamiliarity with drug interactions between opioids and other medications, especially the possibility of serotonin toxicity. The general awareness of potential serotonin toxicity with using opioid analgesics is low. In this review, we will conduct a theoretic and evidence-based review of the potential for developing serotonin syndrome in patients who are using opioids analgesics, especially in combination with antidepressants, a common co-prescribed combination. We also review the current diagnostic criteria for serotonin syndrome and identify possible shortcomings of those criteria. Our aim is to increase the awareness of health care providers about potential drug interaction of opioid analgesics with other classes of medication. We place particular emphasis on tramadol since this drug is one of the most commonly used opioid analgesics for headache. The potential for developing serotonin syndrome is relatively high in the patients who are using opioid for pain control. The use of opioids in migraine headache is already discouraged due to the high risk of medication overuse headache and also an increase in headache-related disability (Katsarava et al. Neurology 62:788-790, 2004; Bigal and Lipton. Neurology 71:1821-8, 2008; Casucci and Cevoli. Neurol Sci. 34 Suppl 1:S125-8, 2013). This is another reason that physicians and health care providers should avoid using this class of medication for pain, specifically headache and migraine treatment.

Timing of eculizumab therapy for C3 glomerulonephritis.

Eculizumab is an anti-C5 antibody that inhibits C5 cleavage and prevents the generation of the terminal complement complex C5b-9. Eculizumab is licensed to treat paroxysmal nocturnal haemoglobinuria or atypical haemolytic uraemic syndrome (aHUS). Clinical trials are ongoing for C3 glomerulopathy. Given the unfamiliarity of physicians with these rare diseases and the variability of clinical presentation, a delayed initiation of eculizumab therapy is common. Thus, the question arises as to what extent improvement of kidney function may be expected when patients have been dialysis dependent for weeks or months already when eculizumab is initiated. Furthermore, given the high cost and potential adverse effects of eculizumab, the question arises of when to stop therapy because of futility when patients with kidney-only manifestations remain dialysis dependent. In literature reports, eculizumab was stopped as early as after 3 weeks because the patient remained dialysis dependent. In this issue of CKJ, Inman et al. report on eculizumab-induced reversal of dialysis-dependent kidney failure from C3 glomerulonephritis, illustrating both the potential benefit of eculizumab for this complement-mediated disease and the need for lengthy therapy—dialysis independency was reached after 5 months of eculizumab. Indeed, there are reports of renal function recovery when eculizumab was initiated after 4 months on dialysis and of recovery of renal function 2.0–3.5 months after initiation of eculizumab in dialysis-dependent patients with C3 glomerulopathy or aHUS.

Recent updates and perspectives on leishmaniasis.

Leishmaniasis is a neglected vector-borne tropical infection considered to be a disease of the poor. Concentrated in poverty-stricken countries within Southeast Asia, East Africa, and Latin America, it is also endemic in several Mediterranean countries. The management of the heterogeneous syndromes determined by parasites belonging to the genus Leishmania is particularly difficult in developed, non-endemic countries owing to the unfamiliarity of physicians with clinical symptoms, diagnostic possibilities, and available treatment options. Therefore, travelers and other people who may be exposed to sand flies in endemic areas should receive counseling regarding leishmaniasis and appropriate protective measures. Serological diagnosis is rarely used for cutaneous and mucocutaneous diseases, but it is the most commonly used technique for visceral leishmaniasis. The drugs used to treat this last disease are expensive and sometimes have toxic side effects. This review highlights the diagnostic, chemotherapeutic, and immunizing strategies to control leishmaniasis, though no human vaccine is commercially available currently owing to the complexity of the cellular immune response to this parasite.

G395(P) Experiences of patients on long term ventilation transferring to adult services

Aims Medical advances mean that more children with serious illnesses are surviving into adulthood. Recent legislation and guidelines stress the importance of delivering improved joined-up services for children undergoing transition to adult services. 1,2 A qualitative study was performed to explore the experiences of patients receiving long-term ventilation (LTV). Methods Questionnaire-based telephone interviews were conducted with 21 patients (14 males, median age 26 years, range 14–57) on LTV or their carers. All had previously been within children’s services and were now under adult respiratory care at a UK teaching hospital. The underlying causes for LTV included: Duchenne muscular dystrophy (9), other muscular dystrophies (6), congenital central hypoventilation syndrome (4) and other (2). Results Thematic analysis of the data identified 3 main themes: Variability : the age at which transition occurred varied (17–25), as did the option to attend combined clinics, which was only given to 3 of the 21 patients. There were discrepancies in the provision of community services, which was described as being “post-code dependent”. Unfamiliarity : patients expressed concerns about the unfamiliarity of adult doctors with their background and condition, which was often interpreted as insensitivity or lack of knowledge. They expressed frustration at having to repeat their story to numerous health care professionals. Separation of services : care under children’s services was reported as being more holistic when compared with the single organ approach in adult services. However, the thoroughness of adult physicians in patient management was appreciated. Conclusion Our study highlights the gap that needs to be bridged between children and adult services for patients on LTV. Early transition planning should occur to alleviate the unfamiliarity commonly experienced. This should include information about adult care and the differences in service provision. The utilisation of health care passports can do much to avoid physician unfamiliarity with the patient’s situation. These changes need to be uniformly adopted in order to improve patient satisfaction, care and long term outcome. References Care Act 2014 Care Quality Commission. From the pond into the sea: Children’s transition to adult healthcare services. June 2014

Sinus of Valsalva Aneurysm Rupture: An Unusual Presentation of Chromosome 22q11.2 Deletion: A Case Report

Sinus of Valsalva aneurysm (SVA) is defined as a weakness in the aortic valve wall, immediately above the attachments of each of the aortic cusps. This weakness can rupture and create an aortocardiac fistula. There are many congenital heart defects associated with chromosome 22q11 deletion, especially involving the aortic arch and its branches. SVA is not an anomaly usually associated with chromosome 22 deletion. We report the case of a 19-year-old female who presented to our institution with SVA rupture. She was subsequently diagnosed with chromosome 22q11 deletion syndrome. Despite dysmorphic facial features and a learning disability, our patient had not been diagnosed with the chromosome abnormality. SVA is a rare congenital heart defect and has only once previously been reported in a child with a chromosome 22q11 deletion. We report the first case where aneurysm rupture preceded the chromosomal findings. Chromosome 22q11 deletion could be missed due to either the unfamiliarity of physicians with the syndrome or the variability and subtlety of the phenotype. This was demonstrated by our patient who, at age 19 after presenting with an SVA rupture, prompted physicians to find an explanation for her coexisting dysmorphic features and her learning disability.

Orally Inhaled Dihydroergotamine: Reviving and Improving A Classic

Migraine pathophysiology continues to evolve, and additional therapeutic receptors influencing unrecognized neural networks within the cortex, brainstem and cerebral vasculature likely exist. Following the advent of the triptans, the use of dihydroergotamine (DHE) declined, because of the ease of use and improved side effect profiles of triptans. However, there remain many patients who respond poorly to triptans, yet respond significantly better to DHE. This may be due to the broader neuroreceptor targets that DHE interacts with, as opposed to the selective receptor activity of the triptans. Unfortunately, DHE is still infrequently utilized compared with other acute treatments such as triptans, primarily because of difficulty in administration and physician unfamiliarity and inexperience with its use. However, the new orally inhaled DHE appears to be as effective with a better side effect profile compared with intravenous DHE, thus eliminating the complexities typically associated with DHE administration.

Practice Patterns of Primary Care Providers and Urologists for Use of Medical Expulsion Therapy

Alpha-blockers and calcium channel blockers have shown promise for medical expulsion therapy (MET) of distal ureteral calculi < 1 cm in size. Although MET has been discussed in urology for some time, little has been written about MET in the emergency medicine and primary care literature. We sought to evaluate current practice patterns of MET among urologists, emergency medicine physicians, other primary care providers, and frontline military care providers. Web-based, self-developed survey to assess the current practice patterns of providers for the initial management of uncomplicated ureteral calculi, and specifically, their frequency of using MET. Cross-tabulation strategies utilizing compiled survey results were used to assess survey outcomes and determine prevalence values for understanding, familiarity, and therapeutic interventions for nephrolithiasis. Of 293 medical professionals, 114 (39%) were urologists, 55 (48%) of which were fellowship trained in endourology. Fifty-six (19%) were emergency medicine physicians, 22 (8%) were family practitioners, and 19 (7%) were internists and other primary care physicians. Other physician subspecialists and medical paraprofessionals comprised the remaining 34%. Overall 27% of respondents were unfamiliar with MET for expulsion of uncomplicated ureteral stones, including 13% of staff physicians, 21% of emergency medicine doctors, 56% of family practitioners, 40% of internists, and 43% of other primary care providers. The overall prevalence of use of MET was 45%. All urologists were familiar with MET, but 31% rarely, never, or only sometimes used this therapy. Specifically, urologists, emergency physicians, family practitioners, internists, and other providers, usually or always used MET 69%, 55%, 16%, 16%, and 27%, of the time, respectively. In academic institutions, 71.6% use MET usually or almost always compared to 36% in military healthcare settings and 47% in other practice settings. Tamsulosin is the most widely used medication for MET, accounting for 57% of MET use. Factors identified that inhibit more widespread use of MET include, physician unfamiliarity with MET (72%), the belief that MET is not effective (10%), patient unwillingness to undergo MET (5%), and medications not covered by insurance plans (4%). While MET has been established as a reasonable adjunct for management of uncomplicated ureteral stones, it may be underutilized due to physician unfamiliarity with this type of treatment and perceived ineffectiveness. This therapy may be of particular benefit to forward deployed forces. Education programs and practice-specific guidelines to target this audience may help to improve the dispersion of MET into the medical community.

Achieving effective pain relief in patients with chronic kidney disease: a review of analgesics in renal failure

Increasing evidence in literature shows that chronic pain is a common and disabling symptom in patients with chronic kidney disease (CKD). As the dialysis population all over the world ages and experiences multiple co-morbidities, nephrologists are increasingly faced with the complex task of addressing them effectively to sustain a reasonable health-related quality of life for their patients. The overall symptom burden of these patients is high and is similar to the end-of life cancer population. The complex pharmacokinetics of opioid analgesics in patients with pre-existing renal disease as well as physician unfamiliarity with the use of these drugs is a barrier to providing effective pain relief. This review deals with approaches to the management of pain in patients with CKD.

Fascioliasis in Pregnancy

Fascioliasis is a common zoonotic infection worldwide, although cases in the United States are uncommon, sporadic, and predominantly found in the immigrant population. The small number of cases identified in the United States may reflect the unfamiliarity of physicians with this infection. A 28-year-old Hispanic woman who frequently visited northern Central Mexico presented at 36 weeks of gestation with nausea, vomiting, and right upper quadrant pain. She was diagnosed with cholelithiasis. Postpartum endoscopic retrograde cholangiopancreatography and sphincterotomy were performed, with discovery of the trematode Fasciola hepatica. The patient received triclabendazole, which led to clinical improvement. Fascioliasis often mimics another common problem in pregnancy, cholelithiasis; clinicians need to be aware of this disease in high-risk populations.

Mycoplasmas and ureaplasmas as neonatal pathogens.

The genital mycoplasmas represent a complex and unique group of microorganisms that have been associated with a wide array of infectious diseases in adults and infants. The lack of conclusive knowledge regarding the pathogenic potential of Mycoplasma and Ureaplasma spp. in many conditions is due to a general unfamiliarity of physicians and microbiology laboratories with their fastidious growth requirements, leading to difficulty in their detection; their high prevalence in healthy persons; the poor design of research studies attempting to base association with disease on the mere presence of the organisms in the lower urogenital tract; the failure to consider multifactorial aspects of diseases; and considering these genital mycoplasmas only as a last resort. The situation is now changing because of a greater appreciation of the genital mycoplasmas as perinatal pathogens and improvements in laboratory detection, particularly with regard to the development of powerful molecular nucleic acid amplification tests. This review summarizes the epidemiology of genital mycoplasmas as causes of neonatal infections and premature birth; evidence linking ureaplasmas with bronchopulmonary dysplasia; recent changes in the taxonomy of the genus Ureaplasma; the neonatal host response to mycoplasma and ureaplasma infections; advances in laboratory detection, including molecular methods; and therapeutic considerations for treatment of systemic diseases.

Anal Melanoma

Anal melanoma is a devastating malignancy easily confused with benign hemorrhoids. Physician unfamiliarity with this bleeding rectal lesion can lead to delays in diagnosis and therapy. Four cases of anal melanoma, all initially mistaken for hemorrhoids, have been documented in the past 4 years at our institution. Despite surgical intervention and chemoimmunotherapy, each patient succumbed to widely metastatic disease. Average survival was 15.2 months. The clinical, pathologic, surgical, and oncologic features of anal melanoma are reviewed to enhance physician recognition of this unusual anorectal disorder.

Diagnosis of thoracic outlet syndrome in the emergency department.

The use of the emergency department (ED) as a source for primary care has increased the number of patients seen in this setting with even chronic symptoms such as pain, paresthesias, and weakness in the upper extremity. This group may include individuals with thoracic outlet syndrome (TOS). We were concerned that TOS may be underdiagnosed in the ED because of physician unfamiliarity with the signs and symptoms of TOS. Hence, we retrospectively studied cases of TOS seen at the ED of the University hospital during a 29-year period. We believe this is the first report in the English language literature to reflect the assessment and management of TOS in the ED. The study data include clinical presentation, diagnostic tests, and management of TOS. Lack of thorough evaluation resulted in underdiagnosis of TOS in our ED. We recommend that ED personnel pay close attention to patients with symptoms of long duration and that ED physicians be aware of TOS presentation and its management.

Physicians' negative perception of sclerotherapy for venous disorders: review of a 7-year experience with modern sclerotherapy.

Sclerotherapy is the injection of a sclerosing substance directly into a varicosity or telangiectasia to cause damage, fibrosis, and eventual obliteration of the vessel. Although sclerotherapy has been shown to be effective with a low incidence of side effects, many physicians in the United States are unaware of the technique or view it in a negative way. To better define the extent of physician unfamiliarity or prejudice toward sclerotherapy, we surveyed a local medical community of gynecologists by anonymous written questionnaire. The results indicated that 82% of the responding physicians believed that their knowledge of sclerotherapy was insufficient to advise their patients, leaving patients to learn about sclerotherapy from mass media sources. Sclerotherapy was perceived as only slightly effective therapy for varicose veins and was thought to have a relatively high incidence of side effects. With recent improvements in the technique, our collaborative experience with 3000 patients receiving 50,000 injections over the past 5 years has shown that sclerotherapy is a safe procedure achieving outstanding cosmetic results with concomitant symptomatic relief of painful varicosities and telangiectases. Sclerotherapy, as practiced today, offers an effective, simple, and less costly alternative to surgical stripping for most varicose and telangiectatic veins. The survey data demonstrate the need to educate the American medical community about the technique and merits of modern sclerotherapy so that patients may be properly guided by their physicians to the best sources of care for their aching and unsightly leg veins.

Chilblains (Perniosis)

Unfamiliarity of physicians with chilblains (perniosis) gives rise to unnecessary hospital admissions with expensive laboratory and radiologic evaluations and, at times, hazardous therapy. Seven cases of chilblains were seen in San Francisco from November 1986 through January 1987. The patients presented with pruritic, at times painful, purple acral patches or plaques on the fingers, toes, and nose after exposure to a cool or a cold, damp environment. Histologic examination in two cases revealed a perivascular lymphocytic infiltrate with endothelial swelling of the subcutaneous fat and of the upper and lower dermal plexus.

Vaccine-Associated Paralytic Poliomyelitis

We present 10 cases of vaccine-associated paralytic poliomyelitis from Washington State to better acquaint physicians with the signs and symptoms of this condition. Diagnosis may be delayed, and milder cases may be overlooked, owing to the unfamiliarity of physicians with the condition. Based on these 10 cases, a rate of 6.4 cases (recipient plus contact) per million live births is estimated for the period 1966 through 1988 in Washington. This rate is higher than calculated for the nation as a whole. The explantation for this difference is unknown, although several possibilities exist, including case clustering.

Health status reports in the care of patients with rheumatoid arthritis

We examined the use of formal health status reports every 3 months over 1 year in the clinical care of patients with rheumatoid arthritis (RA). The reports consisted of single-page, computer-generated summaries of scores derived from either the AIMS (Arthritis Impact Measurement Scales) or the MHAQ (Modified Health Assessment Questionnaire) health status questionnaires. A total of 1920 subjects from 27 community practice sites were randomly assigned to three study groups in each practice: intervention, attention placebo and control. Results showed that 55% of the physicians found the reports to be at least moderately useful as an aid to patient management, primarily for improving the doctor-patient relationship. However, no detectable differences among the three groups were seen in terms of medication compliance, number of physician visits, number of referrals, frequency of major medication changes, attitudes towards the physician, patient satisfaction or change in health status over 1 year. The failure to demonstrate objective benefits of health status reports in this study may be due to physician unfamiliarity with health status scores, failure to link the report with an office visit, the relative stability of clinical status in the subjects over 1 year and the relatively short time-frame of the study.