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Advances in genomics are enhancing our understanding of the genetic basis of cardiovascular diseases, both congenital and acquired, and stroke. These advances include finding genes that cause or increase the risk for childhood and adult-onset diseases, finding genes that influence how patients respond to medications, and the development of genetics-guided therapies for diseases. However, the ability of cardiovascular and stroke clinicians to fully understand and apply this knowledge to the care of their patients has lagged. This statement addresses what the specialist caring for patients with cardiovascular diseases and stroke should know about genetics; how they can gain this knowledge; how they can keep up-to-date with advances in genetics, genomics, and pharmacogenetics; and how they can apply this knowledge to improve the care of patients and families with cardiovascular diseases and stroke.
© 2016 American Heart Association, Inc.
BACKGROUND - Sickle cell disease (SCD) is a rare disorder with cardinal features including hospitalization for vaso-occlusive pain episodes, acute pulmonary injury, and increased infection rates. For physician-trainees, learning optimal SCD management is challenging because of limited exposure to life threatening complications requiring timely interventions.
PROCEDURE - To create, demonstrate reliability, and validate simulation-based, acute care SCD scenarios for physician-trainees, seven scenarios were derived from SCD patient cases. For each scenario, participants had 5 minutes to complete diagnostic and treatment interventions. Participants were divided into two groups based on clinical experience: interns or residents/fellows. Two raters scored performances using diagnostic and therapeutic checklists--indicating whether specific actions were performed and a global, 1 (poor) to 9 (excellent), rating. Scenario scores were calculated by averaging rater scores on each metric. Reliability was defined through uniformity in rater scoring and consistency of participant performance over scenarios. Validity was demonstrated by the performance gradient where the more experienced trainees outperform those early in training.
RESULTS - Twenty-eight pediatric residents and hematology fellows took part in the study. Reliability for assessment scores overall was moderate. Performance on all but one scenario was moderately predictive of overall performance. Senior resident/fellows performed significantly better than interns. Positive associations existed between overall performance scores (P < 0.01) and months of postgraduate training (P < 0.01).
CONCLUSIONS - Mannequin-based simulation is a novel method for teaching pediatric residents SCD-specific acute care skills. The assessment provided reliable and valid measures of trainees' performance. Further studies are needed to determine simulation's utility in education and evaluation.
Copyright © 2013 Wiley Periodicals, Inc.
The NCCN Guidelines for Melanoma provide multidisciplinary recommendations on the clinical management of patients with melanoma. This NCCN Guidelines Insights report highlights notable recent updates. Foremost of these is the exciting addition of the novel agents ipilimumab and vemurafenib for treatment of advanced melanoma. The NCCN panel also included imatinib as a treatment for KIT-mutated tumors and pegylated interferon alfa-2b as an option for adjuvant therapy. Also important are revisions to the initial stratification of early-stage lesions based on the risk of sentinel lymph node metastases, and revised recommendations on the use of sentinel lymph node biopsy for low-risk groups. Finally, the NCCN panel reached clinical consensus on clarifying the role of imaging in the workup of patients with melanoma.
BACKGROUND - Simulation-based bronchoscopy training is increasingly used, but effectiveness remains uncertain. We sought to perform a comprehensive synthesis of published work on simulation-based bronchoscopy training.
METHODS - We searched MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Web of Science, and Scopus for eligible articles through May 11, 2011. We included all original studies involving health professionals that evaluated, in comparison with no intervention or an alternative instructional approach, simulation-based training for flexible or rigid bronchoscopy. Study selection and data abstraction were performed independently and in duplicate. We pooled results using random effects meta-analysis.
RESULTS - From an initial pool of 10,903 articles, we identified 17 studies evaluating simulation-based bronchoscopy training. In comparison with no intervention, simulation training was associated with large benefits on skills and behaviors (pooled effect size, 1.21 [95% CI, 0.82-1.60]; n=8 studies) and moderate benefits on time (0.62 [95% CI, 0.12-1.13]; n=7). In comparison with clinical instruction, behaviors with real patients showed nonsignificant effects favoring simulation for time (0.61 [95% CI, -1.47 to 2.69]) and process (0.33 [95% CI, -1.46 to 2.11]) outcomes (n=2 studies each), although variation in training time might account for these differences. Four studies compared alternate simulation-based training approaches. Inductive analysis to inform instructional design suggested that longer or more structured training is more effective, authentic clinical context adds value, and animal models and plastic part-task models may be superior to more costly virtual-reality simulators.
CONCLUSIONS - Simulation-based bronchoscopy training is effective in comparison with no intervention. Comparative effectiveness studies are few.
BACKGROUND - Physicians often do not provide adequate medication counseling.
PURPOSE - To develop and evaluate an educational program to improve physicians' assessment of adherence and their medication counseling skills, with attention to health literacy.
METHODS - We compared internal medicine residents' confidence and counseling behaviors, measured by self-report at baseline and one month after participation in a two-hour interactive workshop.
RESULTS - Fifty-four residents participated; 35 (65%) completed the follow-up survey. One month after training, residents reported improved confidence in assessing and counseling patients (p<0.001), including those with low health literacy (p<0.001). Residents also reported more frequent use of desirable behaviors, such as assessing patients' medication understanding and adherence barriers (p<0.05 for each), addressing costs when prescribing (p<0.01), suggesting adherence aids (p<0.01), and confirming patient understanding with teach-back (p<0.05).
CONCLUSION - A medication counseling workshop significantly improved residents' self-reported confidence and behaviors regarding medication counseling one month later.
BACKGROUND - Cleveland Clinic has trained 17 physician nutrition specialists since the establishment of its clinical nutrition fellowship (CNF) in 1994. The paths taken by the graduates and whether they continue to practice clinical nutrition are largely unknown.
METHODS - To investigate the professional outcomes of completing a CNF, a survey of graduates was conducted.
RESULTS - Fifty-seven percent of respondents (n = 8) applied to another fellowship prior to applying to a CNF. The 2 most common reasons for applying to a CNF were to increase knowledge of clinical nutrition and increase the chance of acquiring a gastroenterology fellowship. Eighty-five percent (n = 10) of graduates found the CNF to be valuable. Eighty-six percent (n = 12) went on to complete a gastroenterology fellowship, and 67% (n = 8) of graduates believed that completing a CNF increased their chances of gaining acceptance to a gastroenterology fellowship. Only 42% (n = 6) of the graduates currently hold professions that specifically dictate the use of clinical nutrition, but 61% (n = 8) reported using clinical nutrition in their daily or weekly practice. Fifty percent (n = 7) of graduates believed that completing a CNF made them more competitive job candidates, but only 21% (n = 3) said that their extra training is reflected in their current salary.
CONCLUSIONS - It appears that CNFs are being used as a method of subsequently acquiring a gastroenterology or other medical fellowships. Although not working in defined clinical nutrition professions, >50% of graduates continue to apply their CNF skills after completing their training. A small percentage have found dedicated nutrition-based clinical professions.
BACKGROUND & AIMS - Gastroesophageal reflux is common among patients with postnasal drainage. We investigated whether proton pump inhibitor therapy improved symptoms in patients with postnasal drainage without sinusitis or allergies.
METHODS - In a parallel-group, double-blind, multi-specialty trial, we randomly assigned 75 participants with continued symptoms of chronic postnasal drainage to groups that were given 30 mg of lansoprazole twice daily or placebo. Participants were followed up for 16 weeks. Symptoms were assessed at baseline and after 8 and 16 weeks. Ambulatory pH and impedance monitoring assessed presence of baseline reflux. The primary objective of the study was to determine if acid suppressive therapy improved postnasal drainage symptoms. The secondary objective was to assess if pH and impedance monitoring at baseline predicted response to treatment.
RESULTS - Postnasal drainage symptoms improved significantly among patients given lansoprazole compared with placebo. After 8 and 16 weeks, participants given lansoprazole were 3.12-fold (1.28-7.59) and 3.50-fold (1.41-8.67) more likely to respond, respectively, than participants given placebo. After 16 weeks, median (interquartile) percent symptom improvements were 50.0% (10.0%-72.0%) for participants given lansoprazole and 5.0% (0.0%-40.0%) for participants given placebo (P = .006). Neither baseline presence of typical reflux symptoms nor esophageal physiologic parameters predicted response to therapy.
CONCLUSIONS - Among participants with chronic postnasal drainage without evidence of sinusitis and allergies, twice-daily therapy with proton pump inhibitors significantly improved symptoms after 8 and 16 weeks. The presence of heartburn, regurgitation, abnormal levels of esophageal acid, or nonacid reflux did not predict response to therapy.
Copyright © 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
The use of opioids for the treatment of chronic pain has increased dramatically over the past decade. Whether these drugs provide considerable benefits in terms of pain reduction and improved function to balance the risks associated with their use, however, is unclear. Of particular importance to clinicians treating chronic musculoskeletal pain is opioid-induced hyperalgesia, the activation of pronociceptive pathways by exogenous opioids that results in central sensitization to pain. This phenomenon results in an increase in pain sensitivity and can potentially exacerbate pre-existing pain. Opioids also have powerful positive effects on the reward and reinforcing circuits of the brain that might lead to continued drug use, even if there is no abuse or misuse. The societal risk of increased opioid prescription is associated with increased nonmedical use, serious adverse events and death. Patients with chronic musculoskeletal pain should avoid the long-term use of opioids unless the benefits are determined to outweigh risks, in which case, the use of chronic opioids should be regularly re-evaluated.