Laparoscopic insertion of pelvic tissue expander to prevent radiation enteritis prior to radiotherapy for prostate cancer

Radiation enteritis is a significant complication of external beam radiotherapy (EBRT) to the pelvis, particularly in patients having high dose radiotherapy (>80 Gy) and in those with a low pelvic peritoneal reflection allowing loops of small bowel to enter the radiation field. Laparoscopic insertion and subsequent removal of a pelvic tissue expander before and after external beam radiotherapy is a relatively convenient, safe and effective method for displacing loops of bowel out of the pelvis. We report on a patient with prostate cancer who ordinarily would not have been a candidate for EBRT due to loops of bowel low in the pelvis. With laparoscopic insertion and subsequent removal of a tissue expander, he was able to have radiotherapy to the prostate without developing radiation enteritis

Outcomes following anastomotic leak from rectal resections, including bowel function and quality of life

Purpose Anastomotic leak (AL) is an uncommon but potentially devastating complication after rectal resection. We aim to provide an updated assessment of bowel function and quality of life after AL, as well as associated short- and long-term outcomes. Methods A retrospective audit of all rectal resections performed at a colorectal unit and associated private hospitals over the past 10 years was performed. Relevant demographic, operative, and histopathological data were collected. A prospective survey was performed regarding patients’ quality of life and fecal continence. These patients were matched with nonAL patients who completed the same survey. Results One hundred patients (out of 1,394 resections) were included. AL was contained in 66.0%, not contained in 10.0%, and only anastomotic stricture in 24.0%. Management was antibiotics only in 39.0%, percutaneous drainage in 9.0%, operative abdominal drainage in 19.0%, transrectal drainage in 6.0%, combination of percutaneous drainage and transrectal drainage in 2.0%, and combination abdominal/transrectal drainage in 1.0%. The 1-year stoma rate was 15.0%. Overall, mean Fecal Incontinence Severity Instrument scores were higher for AL patients than their matched counterparts (8.06±10.5 vs. 2.92±4.92, P=0.002). Patients with an AL had a mean EuroQol visual analogue scale (EQ-VAS) of 76.23±19.85; this was lower than the matched mean EQ-VAS for non-AL patients of 81.64±18.07, although not statistically significant (P=0.180). Conclusion The majority of AL patients in this study were managed with antibiotics only. AL was associated with higher fecal incontinence scores in the long-term; however, this did not equate to lower quality of life scores

Educational intervention to improve antibiotic knowledge at Kamuzu Central Hospital, Malawi

Background: Antibiotic resistance is a global issue that has the potential to significantly affect countries with limited antibiotic choices. At many government hospitals in Malawi, including Kamuzu Central Hospital (KCH), limited laboratory data and antibiotic options are barriers to providing appropriate antibiotics to patients. We aimed to design an educational intervention targeted to Malawian clinician trainees, including registrars, interns, and medical students, with the goal of improving their knowledge of appropriate antibiotic use based on available clinical information and Malawian guidelines. Methods: As part of an institutional partnership between the University of California—Los Angeles (UCLA) and KCH, an educational intervention was carried out at KCH in January, 2017. The intervention was designed and conducted by UCLA internal medicine-paediatrics residents, with supervision from a UCLA infectious disease specialist and KCH medical leadership. The intervention included a teaching session that reviewed common clinical infections, antibiotic options, duration of therapy, and detailed information regarding antibiotics commonly used in Malawi. Malawian trainees were supplied with an antibiotic prescribing pocket guide which summarised best practices from the Malawi Standard Treatment Guidelines, taking into account the hospital's drug formulary. Trainees were also provided with an algorithmic guide to aid decision-making for initiation of empirical antibiotics based on a patient's clinical presentation. Prior to the educational module, participants completed a multiple-choice survey to assess their baseline knowledge of appropriate antibiotic use for multiple case-based scenarios. A post-intervention survey was performed 2 weeks later, followed by a didactic session to review the correct answers for the cases and reinforce the intervention content. Findings: 33 pre-intervention surveys and 31 post-intervention surveys were completed. Of the 22 trainees who completed both surveys, the majority were medical students (n=16) and interns (n=4). Paired t-test analysis of the pre-test and post-test results showed a mean 17% increase in test scores (p<0·0001), which equates to an average of 2·4 more cases treated correctly. Interpretation: Brief, focused global health educational initiatives such as this may be able to provide local trainees with the knowledge to achieve best practices regarding antibiotic use. Ongoing educational initiatives are planned related to antimicrobial stewardship and other key clinical topics relevant to Malawi. Funding: None

Association between unemployment rates and prescription drug utilization in the United States, 2007–2010

Abstract Background While extensive evidence suggests that the economic recession has had far reaching effects on many economic sectors, little is known regarding its impact on prescription drug utilization. The purpose of this study is to describe the association between state-level unemployment rates and retail sales of seven therapeutic classes (statins, antidepressants, antipsychotics, angiotensin-converting enzyme [ACE] inhibitors, opiates, phosphodiesterase [PDE] inhibitors and oral contraceptives) in the United States. Methods Using a retrospective mixed ecological design, we examined retail prescription sales using IMS Health Xponent™ from September 2007 through July 2010, and we used the Bureau of Labor Statistics to derive population-based rates and mixed-effects modeling with state-level controls to examine the association between unemployment and utilization. Our main outcome measure was state-level utilization per 100,000 people for each class. Results Monthly unemployment levels and rates of use of each class varied substantially across the states. There were no statistically significant associations between use of ACE inhibitors or SSRIs/SNRIs and average unemployment in analyses across states, while for opioids and PDE inhibitors there were small statistically significant direct associations, and for the remaining classes inverse associations. Analyses using each state as its own control collectively exhibited statistically significant positive associations between increases in unemployment and prescription drug utilization for five of seven areas examined. This relationship was greatest for statins (on average, a 4% increase in utilization per 1% increased unemployment) and PDE inhibitors (3% increase in utilization per 1% increased unemployment), and lower for oral contraceptives and atypical antipsychotics. Conclusion We found no evidence of an association between increasing unemployment and decreasing prescription utilization, suggesting that any effects of the recent economic recession have been mitigated by other market forces.</p

Renal Denervation in Heart Failure: A New Therapeutic Paradigm

Heart failure constitutes a significant source of morbidity and mortality in the United States, and its incidence and prevalence continue to grow, increasing its burden on the health care system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This complex interaction is characterized by a pathophysiological disequilibrium between the heart and the kidney, in which cardiac malfunction promotes renal impairment, which in turn feeds back, resulting in further deterioration of cardiovascular function. Multiple neurohumoral and hemodynamic mechanisms are involved in this cardiorenal dyshomeostasis, including resistance to compensatory cardiac natriuretic peptides, leading to sodium retention, volume overload, and organ remodeling. Previous studies in animal models of heart failure have demonstrated that renal denervation promotes a robust natriuresis and diuresis as well as increased response of endogenous and exogenous natriuretic agents. With the recent development of minimally invasive renal denervation in humans, it is possible to suggest that this technique may become effective and important in the management of renal sodium and water metabolism in heart failure

For us by us: Instituting mentorship models that credit minoritized medical faculty expertise and lived experience

The woefully low proportion of scientists and clinicians underrepresented in medicine (UIM), including members of African-American/Black, Hispanic/Latinx, American Indian/Alaska Native or Native Hawaiian/Pacific Islander communities, is well characterized and documented. Diversity in medicine is not only just, but it improves quality and outcomes. Yet, diversity in academic medicine remains stagnant, despite national recognition and urgent calls to improve diversity, equity, and inclusion across health sciences. One strategy that has shown to improve diversity in many sectors is high quality mentoring. While many institutions have adopted mentoring programs, there remains a lack of mentorship that is equitable, individualized, and sets a clear timeline for academic milestones that will position UIM mentees at the optimal trajectory for promotion and retention. A barrier to assembling these programs is the small number of UIM among the senior faculty ranks who are able to serve in this role, given the disproportionate burden to serve on a multitude of academic committees, task forces, and workgroups to fulfill institutional mandates to diversify representation. These time-consuming services, documented in the literature as the "minority tax," are generally uncompensated and unaccounted for in terms of consideration for promotion, leadership positions, and other measures of career advancement. The Justice, Equity, Diversity, and Inclusion Academic Mentors (JAM) Council represents a novel, culturally responsive, and anti-racist approach to achieve a more equitable and inclusive institutional environment. This approach strategically leverages the intergenerational wisdom and experience of senior UIM faculty via time-protected effort with the overall goals of improving rates of promotion, retention, and career satisfaction of early career UIM colleagues. This community case study describes the rationale, resources needed, processes, and proposed workflow required to launch the JAM Council, as well as the major roles and responsibilities for JAM mentors and mentees, which may be considered by academic medical centers focused on improving diversity among the faculty ranks

Comparing Journalistic Role Performance Across Thematic Beats: A 37-Country Study

Studies suggest that, at the routine level, news beats function as unique “micro-cultures.” Exploring this “particularist” approach in news content, we compare how the interventionist, watchdog, loyal, service, infotainment, and civic roles materialize across 11 thematic news beats and analyze the moderating effect of platforms, ownership, and levels of political freedom on journalistic role performance in hard and soft news. Based on the second wave of the Journalistic Role Performance (JRP) project, this article reports the findings of a content analysis of 148,474 news items from 37 countries. Our results reveal the transversality of interventionism, the strong associations of some topics and roles, and the limited reach of news beat particularism in the face of moderating variables

Comparing journalistic role performance across thematic beats : a 37-country study

Abstract: Studies suggest that, at the routine level, news beats function as unique “microcultures.” Exploring this “particularist” approach in news content, we compare how the interventionist, watchdog, loyal, service, infotainment, and civic roles materialize across 11 thematic news beats and analyze the moderating effect of platforms, ownership, and levels of political freedom on journalistic role performance in hard and soft news. Based on the second wave of the Journalistic Role Performance (JRP) project, this article reports the findings of a content analysis of 148,474 news items from 37 countries. Our results reveal the transversality of interventionism, the strong associations of some topics and roles, and the limited reach of news beat particularism in the face of moderating variables