National trends in surgical subspecialisation in ophthalmology in the USA

Background/aimsTo assess surgical patterns in ophthalmology by subspecialty in the USA.MethodsOphthalmic surgeons were categorised as comprehensive/subspecialist based on billed procedures in the 2017–2018 Medicare Provider Utilization and Payment Data. Poisson regression models assessed factors associated with physicians performing surgeries in the core domain (eg, cataract extractions) and subspecialty domain. Models were adjusted for provider gender, time since graduation, geographical region, practice setting and hospital affiliation.ResultsThere were 10 346 ophthalmic surgeons, 74.7% comprehensive and 25.3% subspecialists. Cataract extractions were performed by 6.0%, 9.9%, 21.0%, 88.1% and 95.3% of specialists in surgical retina, neuro-ophthalmology/paediatrics, oculoplastics, glaucoma and cornea, respectively. Retina specialists were more likely to perform cataract surgery if they were 20–30 or>30 years in practice (relative risk: 2.20 (95% CI: 1.17 to 4.12) and 3.74 (95% CI: 1.80 to 7.76), respectively) or in a non-metropolitan setting (3.78 (95% CI: 1.71 to 8.38)). Among oculoplastics specialists, male surgeons (2.71 (95% CI: 1.36 to 5.42)), those in practice 10–20 years or 20–30 years (1.93 (95% CI: 1.15 to 3.26) and 1.91 (95% CI: 1.11 to 3.27), respectively) and in non-metropolitan settings (3.07 (95% CI: 1.88 to 5.02)) were more likely to perform cataract surgery. Only 26 of the 2620 subspecialists performed surgeries in two or more subspecialty domains.ConclusionsThere is a trend towards surgical subspecialisation in ophthalmology in the USA whereby some surgeons focus their surgical practice on subspecialty procedures and rarely perform surgeries in the core domain.

The Application of Islamic Spiritual Methods in Nursing Program Curriculum at UIN Syarif Hidayatullah Jakarta and UIN Alauddin Makasar

<p class="abstrak">This research focuses on describing the implementation of Islamic spiritual care of the clinical nursing students at the State Islamic University (UIN). The implementation of Islamic spiritual care has not been done well by nurses. Clinical nursing students are the forerunners of nurses, but no one has examined the description of the application of Islamic spiritual care carried out by clinical nursing students in State Islamic University (UIN). This research method was descriptive quantitative. Samples were students of the clinical nursing students of UIN Jakarta and UIN Alauddin Makassar, 40 respondents. The results showed that most respondents applied Islamic spiritual care well (52.5%). The most well-implemented component is instilling optimism for healing that comes from God (60%). Students need to improve their self-competence in Islamic religious knowledge to become more competent in providing Islamic care to patients. The head of the clinical nursing program needs to emphasize efforts to increase Islamic spiritual competence in the clinical practice setting of learning guidelines through the guidance process and learning achievement targets.</p><p><em>Penelitian ini berfokus untuk mengetahui penerapan perawatan spiritual Islam mahasiswa Ners di Universitas Islam Negeri (UIN). Penerapan asuhan keperawatan secara holistik khususnya dalam aspek spiritual karena masih sangat minim </em><em>dilakukan oleh perawat di tatanan pelayanan keperawatan.</em><em> Mahasiswa merupakan cikal bakal perawat dan peneliti belum menemukan penelitian tentang penerapan perawatan Islam oleh mahasiswa Ners di lingkungan UIN.</em><em> </em><em>Metode yang digunakan yaitu deskriptif kuantitatif. Sampel yang digunakan yaitu mahasiswa Ners UIN Jakarta dan UIN Makassar masing-masing 40 responden. Hasil menunjukkan sebagian responden menerapkan perawatan spiritual Islam dengan baik (52,5%). Komponen yang paling banyak diterapkan dengan baik yaitu menanamkan optimisme kesembuhan yang datang dari Allah (60%). Mahasiswa perlu meningkatkan kompetensi diri dalam ilmu agama islam sehingga menjadi lebih kompeten dalam mebrikan perawatah islam kepada paeien, program studi Ners perlu lebih menekankan pada upaya peningkatan kompetensi spiritual islam pada tatanan praktik klini pedoman pembelajaran, melalui proses bimbingan maupu target capaian pembelajaran.</em></p>

Experiences of telehealth in general practice in Australia: research protocol for a mixed methods study

BackgroundDue to the COVID-19 pandemic, use of telehealth has expanded rapidly. However, little is known about the impact of delivering care through telehealth on communication between clinicians and patients. At an interactional level, the ways in which clinicians establish rapport and connection with their patients in telehealth consultations is not well understood.AimThis study will explore interactional practices of general practitioners (GPs) and patients in telehealth consultations to develop evidence-based resources to improve communication.Design & settingThe study will be conducted within the Australian general practice setting.MethodConversation analysis and sociolinguistic discourse analysis of recorded telehealth consultations will provide direct evidence of specific elements contributing to successful and less successful instances of telehealth communication. This analysis will be complemented by co-design techniques such as qualitative and reflective interviews and collaborative workshops with telehealth users, including both general practitioners and patients.ConclusionEffective communication is critical for telehealth consultations and is central to achieving optimal clinical outcomes and patient satisfaction. This study will co-develop with end-users, evidence-based guidelines encompassing effective telehealth communication strategies.

Venetoclax, Actinomycin D and Low Dose Cytarabine for Relapsed or Refractory Acute Myeloid Leukemia in Clinical Practice Setting

Background Venetoclax based therapies have produced varying results in the relapsed or refractory acute myeloid leukemia (R/R AML) setting. Highest response rates were demonstrated after Venetoclax in combination with high dose chemotherapy. However, this approach is feasible mainly in fit, younger patients. Herein, we present a lower intensity combination therapy consisting of Venetoclax, low dose Cytarabine and Actinomycin D (ACTIVE) in patients with R/R AML administered in real-life clinical practice setting. Methods We performed an observational, retrospective, single centre study. The patients were at least 18 years of age and had R/R AML. All patients provided informed consent for treatment as well as data collection. Venetoclax ramp-up was administered over either 3 or 5 days until the daily dose of 600mg/d was reached. The ACTIVE regimen consisted of Venetoclax 600mg/d p/o on days 1-28, Cytarabine 20mg/m 2 s/c on days 1-10, Actinomycin D 12.5 µg/kg i/v on days 1, 2 and 3 (on days 1 and 2 for patients ≥65 years). Strong/moderate CYP3A inhibitors/inducers or Venetoclax dose reductions were not allowed. Indications for stopping Venetoclax before Day 28 were life threatening infectious complications or faster hematological recovery with the addition of G-CSF in responders. A second ACTIVE cycle was administered in non-responders without evidence of progressive disease after Cycle 1 or in responders with positive minimal residual disease (MRD). We evaluated baseline characteristics, composite CR (CRc = CR + CRi + CRp), overall response (ORR = CRc + MLFS), MRD negativity rates, overall survival (OS), relapse-free survival (RFS), event-free survival (EFS), Grade 3-5 non-hematological toxicities and Day 30 and Day 60 mortality rates. Results Fifty R/R AML patients were treated with ACTIVE and 56% (28/50) were male. The median age was 65 years (20-84). The median Eastern Cooperative Oncology Group (ECOG) status was 1 (0-3) and 40% (20/50) had ECOG status of 2 or 3. Secondary AML was confirmed in 48% (24/50) of cases. Adverse cytogenetics were identified in 28% (14/50) of patients whereas 60% (30/50) were stratified to adverse risk group in accordance with ELN 2017 guidelines. The most common gene mutations were IDH1/2 30% (15/50), FLT3 28% (14/50), ASXL1 22% (11/50), NPM1 14% (7/50), N/KRAS 12% (6/50) and RUNX1 12% (6/50). The median number of prior therapies was 2 (1-5). Intensive chemotherapy was administered in 80% (40/50) of whom 38% (15/40) had primary refractory disease and 48% (19/40) had previously received Fludarabine + Cytarabine + Idarubicin (FLAG-Ida) or Cytarabine + Mitoxantrone (HAM). Eight percent (4/50) had had prior Venetoclax exposure. Thirty-six percent (18/50) had relapsed after allogeneic stem cell transplantation (alloSCT) with a median time of 7.4 months (1.6-37.3) from transplant to relapse. One cycle of ACTIVE therapy was administered in 76% (38/50) of cases, whereas 24% (12/50) received 2 cycles. The median number of Venetoclax 600mg/d days per cycle was 18 (8-28). Additional FLT3/RAS/BCR-ABL1 inhibitors Gilteritinib, Trametinib or Dasatinib were administered in 12% (6/50). Forty-nine patients were evaluable for response and one patient died of sepsis before response evaluation (Table 1). The ORR was 73% (36/49) and the CRc rate was 67% (31/46). MRD negativity was confirmed in 61% (19/31) of CRc patients. Sixteen patients had undergone additional early bone marrow evaluations. Blast count reduction to &lt;5% was observed in 50% (8/16) after Venetoclax ramp-up and in 88% (14/16) on Day 4. Half of the ACTIVE responders (18/36) continued maintenance therapy with Venetoclax + low dose Cytarabine and optional DLI, whereas 36% (13/36) proceeded to either first or second alloSCT. After 16.4 months of median follow-up, the median OS, RFS and EFS were 13.1, 7.2 and 4.5 months, respectively (Figure 1A). Median OS was not reached in MRD negative patients (Figure 1B). In multivariable Cox regression analysis, adverse cytogenetics (HR 3.48, 95% CI 1.39 -8.55) and primary refractory disease (HR 2.54, 95% CI 1.05-6.12) were associated with worse OS. The most common grade 3-5 non-hematological adverse events were febrile neutropenia (54%, 27/50) and bacteremia/sepsis (34%, 17/50). Day 30 and Day 60 mortality rates were 8% (4/50) and 16% (8/50), respectively. Conclusions ACTIVE was effective and well tolerated in this unselected prognostically unfavourable older R/R AML patient population. Figure 1 Figure 1. Disclosures Zucenka: Jannsen: Honoraria, Other: Travel-expenses; Takeda: Other: Travel Expenses; Novartis: Honoraria, Other: Travel Expenses; Pfizer: Honoraria, Other: Travel Expenses; Astellas: Honoraria; Abbvie: Honoraria, Other: Travel Expenses. Maneikis: Abbvie: Honoraria. Pileckytė: Abbvie: Honoraria, Other: Travel Expenses. Griškevičius: Abbvie: Other: Travel Expenses. OffLabel Disclosure: Venetoclax has been used off-label for the treatment of R/R AML

Frontline Venetoclax (ven) Based Combination Therapy in Older Adults with Acute Myeloid Leukemia Treated in the Real-World Setting; A Multi-Institutional Retrospective Study

Introduction: Acute myeloid leukemia (AML) is a disease of the older population, with a median age at diagnosis of 68 years. Outcomes remain poor for patients (pts) older than 60 years of age who are unfit to receive intensive chemotherapy. Ven based combination therapy has become the standard of care based on the results of the Viale-A and Viale-C in combination with hypomethylating agents (HMA) or low dose cytarabine (LDAC), respectively. This combination therapy is myelosuppressive leading to multiple dose adjustments in the real-world setting, which may impact the validity of the trial responses and overall survival (OS) in a community-based practice. We therefore sought to investigate the outcomes of pts treated with ven based combination therapy in the real-world setting to better understand efficacy and patterns of adverse events. Methods: Pts 65 years of age or older, diagnosed with AML on or after January 1, 2019, and who received frontline ven based combination therapy with azacitidine (aza), decitabine (dac) or LDAC were identified in the COTA real-world database. The COTA database is a USA-based dataset comprised of longitudinal, Health Insurance Portability and Accountability Act (HIPAA)-compliant data on the diagnosis, clinical management, and outcomes of pts with cancer. Clinical outcomes, including real-world overall response rate (rwORR), OS and adverse events were calculated by treatment group. Responses were defined per treating physician as complete response (CR) or partial (PR) or progressive disease (PD). Categorical variables and rwORR were compared using Fisher's exact test. Survival outcomes were calculated using the Kaplan-Meier method and compared amongst groups using log-rank test. Results: A cohort of 112 pts were treated with ven based combination: ven/aza (n=54), ven/dac (n=52) and ven/LDAC (n=6). Across all treatment groups, the majority (91.1%) of pts were treated in the community setting. The median age at diagnosis was 77 yrs (IQR: 71-81 yrs). Per ELN risk, 6.2% had favorable, 19.6% had intermediate and 62.5% had high-risk AML. Five of the 6 pts receiving ven/LDAC had secondary AML (Table 1). The most common molecular abnormalities across the cohort were TP53 (38.4%), TET2 (26.8%), ASXL1 (27.7%), and DNMT3A (20.5%). The rwORR by treatment was 57.7% for ven/dac, 55.6% for ven/aza and 33.3% for ven/LDAC (ven/dac vs. ven/aza, p=0.85). Median OS (mOS) was similar for ven/dac with a longest mOS of 13.9 mo, followed by ven/aza with a mOS of 11.3 mo, and ven/LDAC mOS of 6.5 mo (ven/dac vs. ven/aza, p=0.77). The most common reasons for treatment discontinuation were toxicity (32.1%) followed by progression/inadequate response (10.7%). The most common toxicities were related to myelosuppression/cytopenias (Table 3). In this cohort, only 6 pts underwent an allogeneic stem cell transplant in first remission and no pts underwent an allogeneic transplant in second remission. Conclusions: To our knowledge, this dataset represents the largest cohort of pts treated with ven based combination therapy in the real world setting across multiple community practices. As less intense regimens are used to treat AML, more pts are receiving induction in the community setting, making these findings relevant in clinical practice. Although ven/dac combination had the longest OS, this was not significantly different from ven/aza. The ven/HMA response rates were lower and survival outcomes were shorter than those reported in the Viale-A trial, which raises concerns about early discontinuation of therapy in the real world setting due to myelosuppression. Ven/LDAC combination had the shortest OS, though most of these patients had sAML. Despite this enriched population for targeted therapies, the outcomes remained poor overall. There are drawbacks to interpreting retrospective outcomes data. First, there were no treatment related AML cases in this dataset, which would be highly unusual in an elderly population of 112 cases of AML. It is more plausible that the diagnosis of treatment related AML was not utilized in the patient's chart. Other data points that were not adequately captured were cause of death and International Working Group response criteria. Mutational panel testing remains underutilized for AML patients in a community-based practice setting. However, this dataset highlights the need for larger datasets to compare the outcomes of AML therapy by practice setting. Figure 1 Figure 1. Disclosures Madanat: Blue Print Pharmaceutical: Honoraria; Stem line pharmaceutical: Honoraria; Onc Live: Honoraria; Geron Pharmaceutical: Consultancy. Belli: COTA, Inc.: Current Employment, Other: Equity ownership. Hansen: COTA, Inc.: Current Employment. Foss: COTA, Inc.: Current Employment. Schulte: COTA, Inc.: Current Employment. Wang: COTA, Inc.: Current Employment, Other: Equity ownership.

An Exploration of Language and Nursing Practice to Improve Communication in the Context of Ear Syringing

<p>Action research is a critical reflective process that involves spirals of cycles if of planning, acting, reflecting/evaluating and replanning the next cycle. This action research inquiry explores communication and nursing practice in an effort to improve practice and enhance patient care. Implications of this study indicate that action research is a method that works, and it is a satisfying way of challenging and changing nursing practice. Using ear syringing as a procedure, in the general practice setting and at two separate surgeries, another Practice Nurse and I co-researched this study during working hours. 12 people consented to participate in the research that involved the audiotaping of each ear syringing interaction. Following each transcription of the recording, my co-researcher and I read our own and then each other's transcripts, and listened to the recordings. We then met to discuss and reflect on our findings and to plan the next cycle. Throughout the process, my co researcher and I found a number of areas of practice we could change or enhance. Changes included the use of technical language such as "contraindications" and "auditory meatus", the side effects of syringing, improvements in communicating situations where ear syringing is not recommended and the options available, and post procedure information. These changes became a significant challenge and areas for improvement when both my co-researcher and I forgot the changes, thus repeating previous errors and omissions. This factor highlighted the need to practise any changes prior to interactions, and to have a cue card on hand to facilitate recollection and to cement improvements into practice. Although time constraints limited this inquiry to three cycles, at the final meeting we agreed to continue the reflective process we had begun to explore our practice.</p>

An Exploration of Language and Nursing Practice to Improve Communication in the Context of Ear Syringing

<p>Action research is a critical reflective process that involves spirals of cycles if of planning, acting, reflecting/evaluating and replanning the next cycle. This action research inquiry explores communication and nursing practice in an effort to improve practice and enhance patient care. Implications of this study indicate that action research is a method that works, and it is a satisfying way of challenging and changing nursing practice. Using ear syringing as a procedure, in the general practice setting and at two separate surgeries, another Practice Nurse and I co-researched this study during working hours. 12 people consented to participate in the research that involved the audiotaping of each ear syringing interaction. Following each transcription of the recording, my co-researcher and I read our own and then each other's transcripts, and listened to the recordings. We then met to discuss and reflect on our findings and to plan the next cycle. Throughout the process, my co researcher and I found a number of areas of practice we could change or enhance. Changes included the use of technical language such as "contraindications" and "auditory meatus", the side effects of syringing, improvements in communicating situations where ear syringing is not recommended and the options available, and post procedure information. These changes became a significant challenge and areas for improvement when both my co-researcher and I forgot the changes, thus repeating previous errors and omissions. This factor highlighted the need to practise any changes prior to interactions, and to have a cue card on hand to facilitate recollection and to cement improvements into practice. Although time constraints limited this inquiry to three cycles, at the final meeting we agreed to continue the reflective process we had begun to explore our practice.</p>

General hospital specialists’ attitudes toward psychiatry: a cross-sectional survey in seven countries

ObjectivePsychiatric comorbidities are common in physical illness and significantly affect health outcomes. Attitudes of general hospital doctors toward psychiatry are important as they influence referral patterns and quality of care. Little is known about these attitudes and their cultural correlates. The aim of this study was to identify attitudes toward psychiatry among general hospital specialists in relation to culture of the practice setting and other clinician factors (gender, age, seniority and specialty).MethodsA cross-sectional, descriptive study was carried out in seven countries (New Zealand, China, Sri Lanka, Russia, Israel, Brazil, the Netherlands). Data were collected from senior medical staff of various disciplines using an updated version of Mayou and Smith’s (1986) self-administered questionnaire.ResultsA total of 889 hospital doctors participated. While favourable attitudes toward both psychiatric consultation and management were endorsed by a majority, significant differences were also observed between countries. Subgroup differences were mostly confined to gender, acuity of practice setting and specialty. For example, female doctors in Russia (χ2=7.7, p=0.0056), China (χ2=9.2, p=0.0025) and the Netherlands (χ2=5.7, p=0.0174) endorsed more positive attitudes compared with their male counterparts, but this gender effect was not replicated in the total sample. Chronic care specialists were overall more inclined to manage patients’ emotional problems compared with those working in acute care (χ2=70.8, p (adjusted)<0.0001), a significant finding seen also in individual countries (China, New Zealand, the Netherlands, Russia). Physicians were more favourably disposed toward psychiatry compared with other specialists, especially surgeons, in all countries except Israel.ConclusionsThis study adds to evidence for the association of medical attitudes with individual clinician factors and demonstrates that the influence of these factors varies by country. Understanding these issues may help to overcome barriers and improve quality of care provided to general hospital patients.