Understanding practice patterns of glaucoma sub-specialists in India

AIM：To obtain information on the prevailing practice patterns of glaucoma specialists in India.METHODS：Glaucoma specialists attending the Annual Conference of the Glaucoma Society of India（GSI）were surveyed.This survey,conducted in 2013,was based on an interactive audience response system.RESULTS：The information was obtained from 146 glaucoma specialists.Approximately half（n=83;57%）had≥10y of experience in managing glaucoma and were in institutional practice（n=74,51%）.Goldmann applanation tonometry was preferred by 103（72%）specialists whilst n=25（17.4%）used non-contact tonometer.Indentation gonioscopy was favoured by two-thirds（n=90,66%）whereas stereoscopic optic disc examination and visual fields using Humphrey perimeter was performed by a majority of the specialists surveyed（n=115,86%and n=114;83%respectively）.Nearly three quarter specialists（n=96;72%）preferred optical coherence tomography for imaging.The primary choice for treatment of angle closure disease and primary open angle glaucoma was laser（iridotomy,n=117;93%）and medical management（prostaglandin analogue,n=104;78%）,respectively.Approximately only a third of the specialists surveyed（n=37;28%）were performing both trabeculectomy and implantation of a glaucoma drainage device and about half（n=64;47%）were not operating on congenital glaucoma at all.CONCLUSION：This survey has found conformance with preferred practice patterns in several areas of diagnosisand management of glaucoma,but there was diversity in a few areas.The information is a significant step towards improvement of glaucoma care in India,including planning for future strategies.

Assessment of Physicians’ Knowledge, Attitude and Practices of Radiation Safety at Suez Canal University Hospital, Egypt

Doctors who request imaging must be well trained in deciding whether diagnostic imaging is indicated and have an accurate knowledge of the associated risks. Although radiological doses are low and the chance of late effect is minimal, it should be kept as low as reasonably achievable. This cannot be achieved without a proper knowledge and adherence to safe practices. This cross-sectional study investigates the level of physicians’ knowledge about radiation safety and their attitude towards radiation protection. A self-administered questionnaire, for radiation safety was sent to a purposive sample of 120 physicians at Suez Canal University Hospital. Eighty questionnaires were filled by participants (response rate;66.7%). The sample included 22 radiologists, 15 oncologists, 25 surgeons and 18 orthopedists. Most participants did not receive any radiation safety-related training (88.8%). Radiologists and oncologists were exposed to ionizing radiation more frequently;however, their knowledge was as low as that of other physicians. The overall knowledge score ranged from 40% - 60% (mean;56.5 ± 15.2), with a low score among surgeons and orthopedics. The most deficient knowledge was in the dose of background radiation and the radiation dose received by patients in each type of radiation procedure. Adherence to safe radiation practices was violated by most of participants, especially surgeons and orthopedics, but they attributed it to the poor applicability of the protective measures during performing the procedures. This study concluded that physicians at the Suez Canal University Hospital had deficient knowledge, unsafe practices and negative attitude towards radiation safety policies & precautions.

United States-based practice patterns and resource utilization in advanced neuroendocrine tumor treatment

AIM: To assess advanced neuroendocrine tumor (NET) treatment patterns and resource utilization by tumor progression stage and tumor site in the United States. METHODS: United States Physicians meeting eligibility criteria were provided with online data extraction forms to collect patient chart data on recent NET patients. Resource utilization and treatment pattern data were collected over a baseline period (after diagnosis and before tumor progression), as well as initial and secondary progression periods, with progression defined according to measureable radiographic evidence of tumor progression. Resource categories used in the analysis include: Treatments (e.g. , surgery, chemotherapy, radiotherapy, targeted therapies), hospitalizations and physician visits, diagnostic tests (biomarkers, imaging, laboratory tests). Comparisons between categories of resource utilization and tumor progression status were examined using univariate (by tumor site) and multivariate analyses (across all tumor sites). RESULTS: Fifty-five physicians were included in the study and completed online data extraction forms using the charts of 110 patients. The physician sample showed a relatively even distribution for those affiliated with academic versus community hospitals (46% vs 55%). Forty (36.3%) patients were reported to have pancreatic NET (pNET), while 70 (63.6%) patients had gastrointestinal tract (GI)/Lung as the primary NET site. Univariate analysis showed the proportion of patients hospitalized increased from 32.7% during baseline to 42.1% in the progression stages. While surgeries were performed at similar proportions overall at baseline and progression, pNET patients, were more likely than GI/Lung NET patients to have undergone surgery during the baseline (33.3% vs 25.0%) and any progression periods (26.7% vs 23.4%). While peptide-receptor radionuclide and targeted therapy utilization was low across NET types and tumor stages, GI/Lung types exhibited greater utilization of these technologies compared to pNET. Chemotherapy utilization was also greater among GI/Lung types. Multivariate analysis results demonstrated that patients in first progression period were over 3 times more likely to receive chemotherapy when compared to baseline (odds ratio: 3.31; 95%CI: 1.46-7.48, P=0.0041). Further, progression was associated with a greater likelihood of having a study physician visit [relative risk (RR): 1.54; 95%CI: 1.10-2.17, P=0.0117], and an increased frequency of other physician visits (RR: 1.84; 95%CI: 1.10-3.10, P=0.0211). CONCLUSION: Resource utilization in advanced NET in the United States is significant overall and data suggests progression has an impact on resource utilization regardless of NET tumor site.

Intraoperative Nerve Monitoring in Otolaryngology: A Survey of Clinical Practice Patterns

Introduction: Intraoperative nerve monitoring is used in otolaryngology to assist in identification of nerves at risk. It is hoped that this will lead to lower rates of nerve injury. The objective of this study was to quantify the use of monitoring technology in current clinical practice. Method: An electronic survey was distributed to 376 registered fellows of the Australian Society of Head and Neck Surgery. Results: One-hundred and twenty-five responses were obtained. The majority of respondents report using monitoring at least some of the time during thyroid, parotid, and mastoid surgery (80%, 87%, and 73% respectively). Predictors of use include experience with intraoperative monitoring during training, and high caseloads in parotid surgery. Practice setting did not predict use. Conclusion: Despite equivocal evidence that intraoperative nerve monitoring is associated with a reduction in nerve injuries, this study demonstrates that the technology is widely used amongst otolaryngologists.

Adjuvant therapy for hormone receptor-positive breast cancer: Perspective from a survey on breast cancer physicians' acceptance of practice-changing data

A cross-sectional online survey was conducted.A high proportion of the Chinese breast cancer(BC)physician respondents(n=77)would prescribe extended adjuvant endocrine therapy(AET)with aromatase inhibitors(AI)beyond 5 years for postmenopausal females with BC,especially those with higher risk.Respondents with≥15 years of clinical experience were more likely to prescribe a longer duration of AET for low-risk patients.Half of the respondents considered intermittent letrozole as an acceptable option.Most respondents would prescribe adjuvant chemotherapy to genomic high-intermediate risk[Oncotype DX recurrence score(RS)21-25]females aged≤50 years regardless of the clinical risk classification.

Referring Physicians’ Knowledge on Justification of Medical Exposure in Diagnostic Imaging in a Sub-Saharan African Country, Cameroon

Background: Justification is the process of weighing the potential benefit of the exposure against potential detriment for that individual. Its role has been largely delegated to imaging professionals. Nevertheless, justification process involves referring physicians, radiographers and radiologists. Objective: To assess the knowledge of referring physicians regarding justification of irradiating examinations in medical imaging at the university-affiliated hospitals in Yaoundé Cameroon. Materials and Methods: A questionnaire (18 questions) based on the French guide for the proper use of medical imaging tests in relation to the justification of irradiating examinations, was self-administered to 151 referring physicians in Yaounde (Cameroon) between October 2012 and January 2013. The pre-tested questionnaire was completed in the presence of the investigator. A scoring system was then adopted with a total of 15 points from the level of knowledge on justification which could be classified as satisfactory or not. Results: Referring physicians were 75 (49.7%) GPs, 53 (35.1%) residents and 23 (15.2%) specialists. Knowledge on justification was unsatisfactory for 79.5% of referring physicians with no significant difference in terms of professional experience (p = 0.95) or specialty (p = 0.119). The concepts of “useful exam” and “justified exam” were not known by 113 (74.8%) and 95 (62.9%) practitioners. MRI was selected as irradiating by 62 (41.1%), SPECT and PET-scan as non-radiating examinations by 98 (64.9%) and 115 (76.1%) participants. The main reasons for repeating a giving radiology exam were: unsatisfactory interpretation, unknown of where it was performing and poor quality exam respectively for 23 (15.2%), 37 (24.5%) and 43 (28.5%) referring physicians. Justification was the responsibility of the referring physician alone for 57% of respondent. Only 11 clinicians knew the reference of “Justification-Optimization-Limitation” to radiation protection. Conclusion: The knowledge of physicians on radiating medical procedures and justification of requests for these procedures is inadequate. Training in radiation protection and the introduction of guidelines for the proper use of imaging tests could improve physicians’ justification of radiating examinations.

Family physicians’ perception on environmental influences in promoting physical activity in their obese patients

Although many obese patients do not engage in adequate physical activity (PA), little is known about whether physicians discuss environmental barriers in promoting PA. We conducted this study to describe physicians’ views about discussing environmental barriers in promoting PA with obese patients and determine whether counseling varies by years of practice. We conducted an online survey of family physicians practicing in 17 clinics in Central Texas. We performed descriptive analysis on barriers to PA, counseling on meeting PA recommendation, and written prescription for exercise and bivariate analysis by years of practice. Statistical significance was set at p < 0.05. Of 96 physicians invited, 57 (59.4%) completed the survey. Majority reported their obese patients brought up the environment as a barrier to walking (89.3%) or PA (91.2%). Majority (80.7%) also reported asking about environmental barriers to walking, with 84.2% giving specific examples to overcome these barriers. While 96.5% reported advising their obese patients about meeting the PA recommendation, only 26.3% reported giving them a written prescription for exercise. These did not vary significantly by years of practice. Physicians felt having more time with their patients and knowing specific strategies to overcome environmental barriers, safe places in patients’ neighborhoods, and what environmental factors influence PA may help discuss environmental issues with their obese patients. Physicians want and counsel their obese patients to be physically active, but do not generally give prescriptions for exercise irrespective of years of practice. They also want tools to enhance their abilities to better assist these patients.

Mineral and bone disorder and management in the China Dialysis Outcomes and Practice Patterns Study

Background:Despite a growing population of patients starting hemodialysis in China,little is known about markers of mineral bone disease(MBD)and their management.We present data on prevalence and correlates of hypocalcemia,hyperphosphatemia,and secondary hyperparathyroidism from the China Dialysis Outcomes and Practice Patterns Study(DOPPS),with evaluation of whether these laboratory markers triggered changes in management.Methods:We compared the frequency of measurement and prevalence of poor control of MBD markers in China DOPPS with other DOPPS regions.We also used generalized estimating equations to assess correlates of MBD markers,and separate models to assess predictors of vitamin D and phosphate binder prescriptions in the China DOPPS.Results:Severe hyperphosphatemia(>7 mg/dL)and secondary hyperparathyroidism(>600 pg/mL)were common(27%and 21%prevalence,respectively);both were measured infrequently(14.9%and 3.2%of patients received monthly measurements in China).Frequency of dialysis sessions was positively associated with hyperphosphatemia;presence of residual kidney function was negatively associated with both hyperphosphatemia and secondary hyperparathyroidism.Laboratory measures indicating poor control of MBD were not associated with subsequent prescription of active vitamin D or phosphate binder.Conclusions:There are substantial opportunities for improvement and standardization of MBD management in China.Development of country-specific guidelines may yield realistic targets and standardization of medication use accounting for availability and cost.

Trust in Clinical Practice: A Systematic Review

Background: The aim of this study is to gain a better understanding of the true importance of trust in clinical practice by looking at how it is formed, how it affects clinical practice, and how to improve it. Methods: Using the PRISMA-ScR checklist, a review of the literature was performed to identify research evaluating the importance of trust in the doctor-patient relationship. After thorough screening and removal of duplicates, 21 articles were used in the literature review. Results: The classifying themes that emerged in the selected articles were What Makes Trust and Effects of Trust. The theme of What Makes Trust garnered two subthemes as well: Impact of Doctor-Patient Relationship on Trust and Impact of Shared Decision-Making on Trust. Further to that, the overarching themes found were slightly more specific. They were Traits of Trust, Mistrust and Barriers to Trust, Positive Effects of Trust and the Effects of a Lack of Trust. We found that the best way to improve trust was to improve communication between the patient and the doctor. Additionally, we found that the biggest barrier to a trusting doctor patient relationship was a stigmatised condition, followed by a perception of a financially-motivated doctor. Finally, we found that a lack of trust can prevent patients from seeking and receiving proper treatment. Conclusions: With a better understanding of how trust is built and the extent of the role it plays in clinical practice, we hope that this growing knowledge can improve the practice of many doctors in the future. It is certain that more research needs to be done in this area, especially focusing on vulnerable and stigmatised populations such as chronic pain patients.

On Treatment Patterns for Modeling Medical Treatment Processes in Clinical Practice Guidelines

Clinical practice guidelines(CPGs)contain evidence-based and economically reasonable medical treatment processes.Executable medical treatment processes in healthcare information systems can assist the treatment processes.To this end,business process modeling technologies have been exploited to model medical treatment processes.However,medical treatment processes are usually flexible and knowledge-intensive.To reduce the effort in modeling,we summarize several treatment patterns(i.e.,frequent behaviors in medical treatment processes in CPGs),and represent them by three process modeling languages(i.e.,BPMN,DMN,and CMMN).Based on the summarized treatment patterns,we propose a pattern-based integrated framework for modeling medical treatment processes.A modeling platform is implemented to support the use of treatment patterns,by which the feasibility of our approach is validated.An empirical analysis is discussed based on the coverage rates of treatment patterns.Feedback from interviewed physicians in a Chinese hospital shows that executable medical treatment processes of CPGs provide a convenient way to obtain guidance,thus assisting daily work for medical workers.

Under-forest Breeding Pattern and the Practice Form

Through the development in recent years, China's under-forest breeding pattern can be divided into four kinds of practice form of under-forest breeding pattern (the pattern of breeding driven by leading enterprises; the pattern of breeding driven by intermediary economic organizations; the pattern of breeding driven by the professional wholesale market; the pattern of breeding driven by the modern animal husbandry demonstration areas), according to difference in the main body participating in signing the operation contract in breeding pattern. In the production practice of under-forest breeding pattern, the most widely used and successful pattern is the pattern of breeding driven by leading enterprises and its derivative forms.

Physician Perception and Practice of Electroencephalography in Enugu, South East Nigeria

Background: Electroencephalography (EEG) is established for evaluating several acute and chronic medical conditions of neurological basis. In much of Nigeria and Africa, it is largely unavailable and underutilized due to scarcity of neurologists and high costs of the equipment. It offers a relatively simple and efficient way to help manage many encephalopathies if well utilized in trained hands. Aim: This study aimed to determine how physicians practicing in Enugu perceive and utilize electroencephalography routinely. Method: Physicians attending a statewide meeting in Enugu in August 2018 were consecutively recruited and a pretested questionnaire was administered after obtaining prior consent. Sociodemographic data as well as their knowledge, attitude and practice of electroencephalography were documented and analyzed. Results: There were 486 respondents (males 335: females 151) and 345 (71%) were specialists in various disciplines while 141 (29%) were general practitioners. Only 7 doctors (1.4%) claimed ignorance of electroencephalography and 6 (1.2%) stated it was not useful. Majority, 333 doctors (69.1%) believed it had no impact on routine patient management. This perception was highest for Dental Surgery (100%) and lowest for Internal Medicine (23%) specialists. Most doctors (425, 87.4%) agreed that neurologists should analyze recordings. Most physicians had no access to electroencephalography (61.7%) and had no interest in acquiring the machine (50.8%). Conclusion: Electroencephalography is an underappreciated investigative modality amongst physicians in Enugu, despite a high burden of neurological diseases in the population. More education, training and awareness of its utility are needed for medical students and doctors to reverse the trend.

Treating chronic hepatitis B virus:Chinese physicians' awareness of the 2010 guidelines

AIM: To investigate Chinese physicians' awareness of the 2010 guidelines on the treatment of chronic hepatitis B virus(HBV) infection.METHODS: This was a quantitative survey that investigated the characteristics and practices of physicians who were treating patients with hepatitis B, the profile of their patients and physician practices regarding the diagnosis and treatment of HBV at the time of the survey. Participants were randomly selected from available databases of Chinese physicians and requested to complete either an online or paper-based survey. Data from the survey responses were analysed. For data validation and interpretation, qualitative in-depth interviews were conducted with 39 of the respondents.RESULTS: Five-hundred completed surveys, from 663 physicians were available for analysis. A mean of 175 chronic hepatitis B(CHB) patients was seen by each physician every month, of whom 85(49%) were treated in line with therapeutic indications stated in the 2010 guidelines. A total of 444(89%) physicians often(> 60% of the time) adhered to the guidelines. Most physicians used antiviral medications as recommended. For patients with compensated and decompensated cirrhosis, 342(68%) and 336(67%) of physicians, respectively, often followed the recommendation to use potent nucleos(t)ide analogues with a high genetic barrier to resistance, using the appropriate treatment more than 60% of the time. Physicians from infectious disease or liver disease departments were better informed than those from gastrointestinal or other departments.CONCLUSION: The majority of Chinese physicians often adhere to Chinese 2010 CHB guidelines and are well-informed about the use of antiviral medications for hepatitis B.

Digital chromoendoscopy utilization in clinical practice: A survey of gastroenterologists in Connecticut

AIM:To use a survey to characterize and identify potential barriers to the use of digital chromoendoscopy(DC)by practicing gastroenterologists.METHODS:An anonymous,internet-based survey was sent to gastroenterologists in Connecticut who were members of one of three national gastrointestinal organizations.The survey collected demographic information,frequency of DC use,types of procedures that the respondent performs,setting of practice(academic vs community),years out of training,amount of training in DC,desire to have DC training and perceived barriers to DC use.Responses were collected anonymously.The primary endpoint was the proportion of endoscopists utilizing DC.Associations between the various data collected were analyzed usingχ2 test.RESULTS:One hundred and twenty-four gastroenterologists(48%)of 261 who received the online survey responded.Seventy-eight percent of surveyed gastroenterologists have used DC during the performance of upper endoscopy and 81%with lower endoscopy.DC was used in more than half of procedures by only 14%of gastroenterologists during upper endoscopy and 12%during lower endoscopy.Twenty-three percent(upper)and 21%(lower)used DC more than one quarter of the time.DC was used for 10%or less of endoscopies by 60%(upper)and53%(lower)of respondents.Endoscopists reported lack of training as the leading deterrent to DC use with36%reporting it as their primary deterrent.Eighty-nine percent of endoscopists never received formal training in DC.Lack of time(30%of respondents),lack of evidence(24%)and lack of reimbursement(10%)were additional deterrents.There were no differences in DC use relative to academic vs community practice setting or years out of training.CONCLUSION:DC is used infrequently by most endoscopists,primarily due to a lack of training.Training opportunities should be expanded to meet the interest expressed by the majority of endoscopists.

Medical Treatment Process Modeling Based on Process Mining and Treatment Patterns

activities.Ex-periments on a synthetic log of the non-secondary hy-pertension MTP and empirical findings demonstrate the effectiveness of our approach.The results show that the process mining in our approach framework can automatically generate more accurate MTP mod-els,and the subprocess models based on treatment pat-terns make the models easy to understand.

Knowledge and Practice of Fundoscopy among Medical Doctors in Port Harcourt, Nigeria

Background: Many clinical entities manifest early characteristic changes in the fundus of the eye. The value of fundoscopy cannot be overemphasized and every medical doctor is expected to be able to use the ophthalmoscope to detect common pathological changes. However, more often than not fundoscopy is seen as an exclusive specialized skill of the ophthalmologist. Aim: The aim of this study was to evaluate knowledge and practice of fundoscopy among the physicians present at the Ordinary General Meeting of the Nigerian Medical Association (Rivers State branch) held in Port Harcourt on 30th June 2014. Methods: A self administered questionnaire about their knowledge and practice of fundoscopy was administered to 125 medical doctors attending the Ordinary General Meeting of the Nigerian Medical Association (Rivers State branch) held in Port Harcourt on 30th June 2014. Questions asked tested the Knowledge and Practice of the physicians on matters related to fundoscopy. Participants’ knowledge and practice were graded as Good for scores of 75% and above, Fair for 50% - 74% score and Poor for scores less than 50%. Respondents’ demographic data, responses and corresponding scores were entered into computer software—Scientific Package for Social Sciences (SPSS) version 20 and subsequently analyzed. Results: The study participants were 125 physicians;86 males and 39 females (M:F = 2.2:1). Twenty-eight percent of the study participants had good knowledge of fundoscopy while only 15% had good practice. Seventy eight physicians representing 62.4% of the participants could correctly refer patients with the need for fundoscopy to an ophthalmologist, whereas 11 (8.8%) worked in facilities without basic instrument for fundoscopy (ophthalmoscope). Conclusion: Our study demonstrates that knowledge and practice of fundoscopy among medical practitioners in Port Harcourt is poor and far from ideal. Therefore, refresher courses emphasizing the acquisition of the skill in fundoscopy and the provision of ophthalmoscopes in our General Practitioners’ clinics are necessary.

新时期我国结核病防治服务体系建设及展望

中国结核病防治服务体系是随着疫情水平的变化和经济社会的发展不断调整变化的。自2011年,中国逐步推行新型结核病防治服务体系。进入新时代,如何更好地健全和完善结核病防治服务体系,是结核病防治工作面临的重大问题。作者系统总结了中国结核病防治服务体系的演变沿革,阐述了结核病防治服务体系运行现状,分析了其中存在的问题和挑战,对结核病防治服务体系建设提出了工作意见和建议,并展示了未来发展前景。

浅谈住院医师规范化培训的心电图实践教学

住院医师规范化培训(简称住培)是目前较受认可的培养合格临床医师的方式,而心电图作为一项重要的临床常规检查,是临床医生必须掌握的基本技能之一,也是住培中要求掌握的重要内容。昆明医科大学第二附属医院心功能科在不断完善和改进中摸索出了一套更适合住培学员的教学方式,利用多元化的教学形式增强学员学习兴趣,保证学习质量,从而使其更好地将所学知识和技能应用于临床。