Hope Kincaid

Career interest and perceptions of nephrology: A repeated cross-sectional survey of internal medicine residents

Background Interest in nephrology careers among internal medicine residents in the United States is declining. Our objective was to assess the impact of the presence of a nephrology fellowship training program on perceptions and career interest in nephrology among internal medicine residents. A secondary objective was to identify commonly endorsed negative perceptions of nephrology among internal medicine residents. Methods This was a repeated cross-sectional survey of internal medicine residents before (Group 1) and 3 years after (Group 2) the establishment of nephrology fellowship programs at two institutions. The primary outcome was the percentage of residents indicating nephrology as a career interest in Group 1 vs. Group 2. Secondary outcomes included the frequency that residents agreed with negative statements about nephrology. Results 131 (80.9%) of 162 residents completed the survey. 19 (14.8%) residents indicated interest in a nephrology career, with 8 (6.3%) indicating nephrology as their first choice. There was no difference in career interest in nephrology between residents who were exposed to nephrology fellows during residency training (Group 2) and residents who were not (Group 1). The most commonly endorsed negative perceptions of nephrology were: nephrology fellows have long hours/burdensome call (36 [28.1%] of residents agreed or strongly agreed), practicing nephrologists must take frequent/difficult call (35 [27.6%] agreed or strongly agreed), and nephrology has few opportunities for procedures (35 [27.3%] agreed or strongly agreed). More residents in Group 2 agreed that nephrology is poorly paid (8.9% in Group 1 vs. 20.8% in Group 2, P = 0.04), whereas more residents in Group 1 agreed that nephrologists must take frequent/difficult call (40.0% in Group 1 vs. 18.1% in Group 2, P = 0.02). Conclusions The initiation of a nephrology fellowship program was not associated with an increase in internal medicine residents’ interest in nephrology careers. Residents endorsed several negative perceptions of nephrology, which may affect career choice.

Open Heart Surgery Does Not Increase the Incidence of Ipsilateral Ischemic Stroke in Patients with Asymptomatic Severe Carotid Stenosis

BACKGROUND AND PURPOSE We evaluated the incidence of perioperative stroke following the institutions 2007 practice change of discontinuing combined carotid endarterectomy and open heart surgery (OHS) for patients with severe carotid stenosis. METHODS In this retrospective cohort study, we compared 113 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both from 2007 to 2011 with data collected from 2001 to 2006 from a similar group of patients. Our aim was to assess whether the practice change led to a greater incidence of stroke. RESULTS A total of 7350 consecutive patients undergoing OHS during the specified time period were screened. Of these, 3030 had OHS between 2007 and 2011 but none were combined with carotid artery surgery (new cohort). The remaining 4320 had OHS before 2007 and 44 had combined procedures (old cohort). Of patients undergoing OHS during the 10-year period of observation, 230 had severe (>80%) carotid stenosis. In the old cohort (before 2007), carotid stenosis was associated with perioperative stroke in 2.5% of cases. None of the 113 patients having cardiac procedures after 2007 received combined carotid artery surgery; only 1 of these patients harboring severe carotid stenosis had an ischemic stroke (.9%) during the perioperative period. The difference in stroke incidence between the 2 cohorts was statistically significant (P = .002). CONCLUSION The incidence of stroke in patients with severe carotid artery stenosis undergoing OHS was lower after combined surgery was discontinued. Combined carotid and OHS itself seems to be an important risk factor for stroke.

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties.

Introduction This study investigated factors that influence emergency medicine (EM) patients’ decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties. Methods A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants’ responses. Results A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient’s gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285–2.389}], ID [OR:3.281, 95% CI{2.293–4.695}], and OB/GYN [OR:2.408, 95% CI{1.741–3.330}]). EM’s rankings of “how well the research was explained” and whether “the knowledge learned would benefit others” as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated “risk of unknown side effects” as their strongest barrier. Regardless of the patients’ race, “time commitment” was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218–2.136}], ID [OR:1.340, 95% CI{1.006–1.784}], or OB/GYN [OR:1.901, 95% CI{1.431–2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked “having all material provided in my own language” as the most helpful resource. Conclusion There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient’s own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials.

Impact of Race Versus Education and Race Versus Income on Patients’ Motivation to Participate in Clinical Trials

Our study investigates whether levels of motivation and barriers to participation in clinical trials vary with patients’ education and income. A self-administered survey asked outpatients to rank potential influential factors on a “0” to “4” significance scale for their motivation to participate in clinical trials. Principal component analysis (PCA), analysis of variance (ANOVA), Kruskal-Wallis, and Mann-Whitney U tests analyzed the impact of race, education, and income on their motivation to participate. Analysis included 1841 surveys; most respondents had a high school education or some college, and listed annual income < 

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus

30,000. There was a significant interaction between race and income on our motivation scale 1 scores (p = .0261). Compared with their counterparts, subjects with less education/lower income ranked monetary compensation (p = .0420 and p < .0001, respectively) as a higher motivator. Minorities and patients with less education and lower income appear to be more influenced by their desire to please the doctor, the race and sex of the doctor, and the language spoken by the doctor being the same as theirs. For all races, education appeared to have a direct relationship with motivation to participate, except for African-Americans, whose motivation appeared to decline with more education. Income appeared to have an inverse relationship with motivation to participate for all races.

Perception and Practice Among Emergency Medicine Health Care Providers Regarding Discharging Patients After Opioid Administration

Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM.

Agreement between endoscopic ultrasound-guided fine-needle aspiration and endobiliary brush cytology in suspected pancreaticobiliary malignancies

PURPOSE This study aimed to determine the current attitudes, perceptions, and practices of emergency medicine providers and nurses (RNs) regarding the discharge of adult patients from the emergency department (ED) after administration of opioid analgesics. METHODS A cross-sectional survey was administered at 3 hospital sites with a combined annual ED census of >180,000 visits per year. All 59 attending emergency physicians (EPs), 233 RNs, and 23 advanced practice clinicians (APCs) who worked at these sites were eligible to participate. FINDINGS Thirty-five EPs (59.3%), 88 RNs (37.8%), and 14 APCs (60.9%) completed the survey for an overall response rate of 51.75%. Most respondents were female (95 [69.9%]). The factor ranked most important to consider when discharging a patient from the ED after administration of opioids was the patients functional status and vital signs (median, 2.00; interquartile range, 2.00-3.50). More RNs (84 [96.6%]) than EPs (29 [82.9%]) reported that developing an ED policy or guideline for safe discharge after administration of opioids is important to clinical practice (P = 0.02). Only 8 physicians (23.5%) reported that they did not prescribe intramuscular morphine, and 15 (42.9%) reported that they did not prescribe intramuscular hydromorphone. EPs (7 [20.0%]) and RNs (3 [3.4%]) differed in regard to whether they were aware if any patients to whom they administered an opioid had experienced an adverse drug-related event (P = 0.01). Most EPs (24 [68.6%]) and RNs (54 [61.4%]) believed that the decision for patient discharge should be left to both the emergency medicine provider and the RN. IMPLICATIONS Most study participants believed that developing a policy or guideline for safe discharge after administration opioids in the ED is important to clinical practice. Only a few physicians reported that they did not prescribe intramuscular hydromorphone or morphine. Most participants believed the discharge decision after administration of opioids in the ED should be primarily determined by both the emergency medicine provider and the RN.

Racial Differences Among Factors Associated with Participation in Clinical Research Trials

Background and study aims  For suspected pancreaticobiliary malignancies, endobiliary brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) remains the diagnostic test of choice despite historically poor and variable sensitivity. This has led to increased use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as an initial test. Recently, our institution began using a cytology brush that was designed specifically to collect a more substantial and higher-quality sample. The aim of this study was to investigate whether this brush design would provide more adequate samples and have high agreement with EUS-FNA in patients who underwent both procedures. Patients and methods  A retrospective chart review was conducted of all patients who underwent both EUS-FNA and endobiliary brush cytology for suspicion of pancreaticobiliary malignancy from January 2013 to May 2015. A total of 41 patients met the inclusion criteria. Initially, sample quality was evaluated. Final cytology results were then assessed for agreement with EUS-FNA using Cohen’s kappa. The effect of considering atypical cytology as negative was also uniquely evaluated by running separate analyses. Results  Brush cytology provided an adequate sample in 95.1 % of cases. Cohen’s Kappa demonstrated moderate agreement between brush cytology and EUS-FNA: κ = 0.42 ( P  = 0.001). When atypical results were excluded, agreement increased: κ = 0.60 ( P  = 0.02), but remained moderate. If atypical results were considered “positive,” the two procedures demonstrated equal cancer detection rates of 80.8 %. Conclusions  The studied brush provided more adequate samples compared with historical rates for brush cytology and had moderate agreement with EUS-FNA. If this brush truly increases sample adequacy, it could potentially provide results comparable to EUS-FNA at lower cost.