Scoping Review on Educational Programs for Medical Professionals on the Management of Acute Agitation

BACKGROUND

Agitation is a common reason for psychiatric consultation in the general hospital. The consultation-liaison (CL) psychiatrist is often tasked with teaching the medical team how to manage agitation.

OBJECTIVE

The purpose of this scoping review is to explore what resources the CL psychiatrist has for educational tools on teaching about agitation management. Given the frequency with which CL psychiatrists help with on-the-ground management of agitation, we hypothesized that there would be a scarcity of educational resources to teach front-line providers how to manage agitation.

METHODS

Following current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a scoping review was conducted. The literature search focused on the electronic databases MEDLINE (PubMed), Embase (Embase.com), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), PsycInfo (EbscoHost), Cumulated Index to Nursing and Allied Health Literature (CINAHL) (EbscoHost), and Web of Science. Using Covidence software, after screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, we created a predefined set of criteria according to which each article was analyzed. We then grouped the articles in the full-text review according to which patient population a curriculum was designed for.

RESULTS

The search yielded a total of 3250 articles. After removing duplicates and reviewing procedures, we included 51 articles. Data extraction captured article type and details; educational program information (staff training, web modules, instructor led seminar); learner population; patient population; and setting. The curricula were further divided based on their target patient population, specifically the acute psychiatric patient (n = 10), the general medical patient (n = 9), and the patient with a major neurocognitive disorder such as dementia or traumatic brain injury (n = 32). Learner outcomes included staff comfort, confidence, skills, and knowledge. Patient outcomes included measurements of agitation or violence using validated scales, PRN medication use, and restraint use.

CONCLUSIONS

Despite there being numerous agitation curricula in existence, we found that a large majority of these educational programs were done for patients with major neurocognitive disorders in the long-term care setting. This review highlights the gap in education related to agitation management for both patients and providers in the general medical setting, as less than 20% of total studies are focused on this population. The CL psychiatrist plays a critical role in assisting in agitation management in this setting, which often requires collaboration between technicians, nurses, and nonpsychiatric providers. It calls into question whether the lack of educational programs makes the implementation of management interventions more difficult and less effective, even with the assistance of the CL psychiatrist.

The Utility of Biomarkers in the Clinical Management of Syphilis: A Systematic Review

BACKGROUND

Routinely available laboratory tests for Treponema pallidum remain suboptimal for diagnostic, prognostic, predictive, and monitoring purposes. Biomarkers with enhanced performance characteristics can improve diagnostic confidence and facilitate management. We conducted a systematic review to examine the utility of biomarkers in the diagnosis and management of syphilis.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to identify articles for inclusion and independently reviewed them for eligibility and study quality using a three-stage procedure. The search, conducted by a senior library informationist, used PubMed, Embase, Cochrane Library, and Scopus and included any study published prior to May 2022.

RESULTS

Of the 111 studies identified, 31 (27.9%) were included in our review. Most studies were cross-sectional or prospective. The data were strikingly heterogeneous examining a variety of biomarkers across different syphilis stages, using different methodologies and definitions of treatment success. Available publications chiefly focused on diagnosing various syphilis stages, neurosyphilis and congenital syphilis, serological cure, the serofast state, and reinfection.

CONCLUSIONS

Despite increasing attempts to identify novel biomarkers, we found limited evidence to support the use of any biomarker in clinical decision making at this time; the syphilis biomarker literature is heterogenous and lacks measurement of clinically meaningful endpoints. We recommend the formation of a working group to set priorities for syphilis biomarker research and to guide future study of clinically meaningful biomarkers.

Factors Leading to Successful Performance on U.S. National Licensure Exams for Medical Students: A Scoping Review

PURPOSE

To synthesize the evidence of the factors leading to successful performance on knowledge-based national licensure exams (NLEs) for medical students.

METHOD

The authors conducted a scoping review to summarize the peer-reviewed empiric literature that used United States Medical Licensing Examination (USMLE) Step 1 or Step 2 Clinical Knowledge or Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 1 or Level 2 Cognitive Evaluation scores as outcomes. The authors searched PubMed and Scopus without date restrictions through April 30, 2021. Two reviewers independently screened and selected studies for inclusion. Data were summarized narratively and with descriptive statistics.

RESULTS

The authors screened 1,185 unique citations and included 233 full-text studies in their review. Of these, 201 (86%) were studies of USMLE exams, 31 (13%) were studies of COMLEX exams, and 1 (0.4%) reported on both. The authors classified 29 studies (12%) as informing NLE preparation, 163 (70%) as attempting to identify predictive variables, and 76 (33%) as using NLE scores for program evaluation. Preparation studies found that the number of practice test items, practice exam scores, and less time in dedicated preparation correlated with higher NLE scores. Use of other commercial resources or study strategies was not consistently associated with higher scores. Predictive studies found the strongest relationships between individuals' performance on past assessments and their NLE scores.

CONCLUSIONS

The factors leading to successful performance on knowledge-based NLEs align with well-known principles from the cognitive sciences. Learners build on existing foundations of knowledge (reflected in their prior academic performance) and are likely to learn more efficiently with testing and spaced learning over time. While commercial test preparation resources are ubiquitous, there is no evidence that a single resource gives students a competitive advantage on NLEs. Developing habits of regular and continuous learning is necessary for clinical practice and successful NLE performance.

The Association of Preoperative Frailty and Postoperative Delirium: A Meta-analysis

BACKGROUND

Both frailty and postoperative delirium (POD) are common in elective surgical patients 65 years of age and older. However, the association between preoperative frailty and POD remains difficult to characterize owing to the large number of frailty and POD assessment tools used in the literature, only a few of which are validated. Furthermore, some validated frailty tools fail to provide clear score cutoffs for distinguishing frail and nonfrail patients. We performed a meta-analysis to estimate the relationship between preoperative frailty and POD.

METHODS

We searched several major databases for articles that investigated the relationship between preoperative frailty and POD in patients with mean age ≥65 years who were undergoing elective, nonemergent inpatient surgery. Inclusion criteria included articles published in English no earlier than 1999. Both preoperative frailty and POD must have been measured with validated tools using clear cutoff scores for frailty and delirium. Articles were selected and data extracted independently by 2 researchers. Risk of bias (ROBINS-I) and presence of confounders were summarized. Odds ratios (ORs) for POD associated with frailty relative to nonfrailty were computed with adjusted ORs when available. Original estimates were pooled by random effects analysis. Statistical significance was set at 2-sided P < .05.

RESULTS

Nine studies qualified for meta-analysis. The Fried score or a modified version of it was used in 5 studies. Frailty prevalence ranged from 18.6% to 56%. Delirium was assessed with the Confusion Assessment Method (CAM) or Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in 7 studies, Delirium Observation Scale in 1 study, and Intensive Care Delirium Screening Checklist in 1 study. The incidence of POD ranged from 7% to 56%. ROBINS-I risk of bias was low in 1 study, moderate in 4 studies, serious in 3 studies, and critical in 1 study. Random effects analysis (n = 794) of the OR for POD in frail versus nonfrail patients based on adjusted OR estimates was significant with an OR of 2.14 and a 95% confidence interval of 1.43-3.19. The I2 value was in the low range at 5.5, suggesting small variability from random effects. Funnel-plot analysis did not definitively support either the presence or absence of publication bias.

CONCLUSIONS

This meta-analysis provides evidence for a significant association between preoperative frailty and POD in elective surgical patients age 65 years or older.

Mortality outcomes of patients on chronic mechanical ventilation in different care settings: A systematic review

Objectives

To determine the outcomes of chronically ventilated patients outside the setting of intensive care units.

Design

Systematic review.

Setting and participants

Studies evaluating patients on chronic invasive mechanical ventilation in different care settings.

Methods

A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion.

Results

Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death.

Conclusions and implications

Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources.

Comparison of universal screening in major lynch-associated tumors: a systematic review of literature

Lynch syndrome (LS) is associated with an increased lifetime risk of several cancers including colorectal (CRC), endometrial (EC), ovarian (OC), urinary (UT) and sebaceous tumors (ST). The benefit for universal screening in CRC and EC is well known. However, this benefit in other major lynch-associated tumors is unclear. We performed a systematic review of all published articles in the MEDLINE database between 2005 to 2017 to identify studies performing universal screening for LS in unselected CRC, EC, OC, UT and ST. All cases with MSI-H (instability in two or more markers) or missing one or more proteins on IHC testing were considered screening positive. Cases with MLH1 promoter hypermethylation or BRAF mutation positive were considered to have somatic mutations. A total of 3788 articles were identified in MEDLINE yielding 129 study arms from 113 studies. The overall pooled yield of universal LS screening and germline mismatch gene mutation was significantly different across the major LS-associated tumors (Mann Whitney test, p < 0.001). The pooled screening yield was highest in ST [52.5% (355/676), 95% CI 48.74-56.26%] followed by EC [22.65% (1142/5041), 95% CI 21.54-23.86%], CRC [11.9% (5649/47,545), 95% CI 11.61-12.19%], OC [11.29% (320/2833), 95% CI 10.13-12.47%] and UT [11.2% (31/276), 95% CI 7.48-14.92%]. ST also had the highest pooled germline positivity for mismatch repair gene mutation [18.8%, 33/176, 95%CI 13.03-24.57], followed by EC [2.6% (97/3765), 95% CI 2.09-3.11], CRC [1.8% (682/37,220), 95% CI 1.66-1.94%], UT [1.8%(3/164), 95% CI - 0.24-3.83%] and OC [0.83%(25/2983), 95% CI 0.48-1.12%]. LS screening in EC yielded significantly higher somatic mutations compared to CRC [pooled percentage 16.94% [(538/3176), 95%CI 15.60-18.20%] vs. 5.23% [(1639/26,152), 95% CI 4.93-5.47%], Mann Whitney test, p < 0.0001. Universal LS testing should be routinely performed in OC, UT and STs in addition to CRC and EC. Our findings also support consideration for IHC and somatic mutation testing before germline testing in EC due to higher prevalence of somatic mutations as well as germline testing in all patients with ST. Our results have implications for future design of LS screening programs and further studies are needed to assess the cost effectiveness and burden on genetic counselling services with expanded universal testing for LS.

Cannabinoid effects on responses to quantitative sensory testing among individuals with and without clinical pain: a systematic review

There has been an explosion of interest in the utility of cannabinoids as potential analgesics. This systematic review critically synthesizes the evidence for cannabinoid analgesic effects on quantitative sensory testing outcomes in both healthy adults and patients with chronic noncancer pain. Our systematic review protocol is preregistered on PROSPERO (CRD42018117367). An electronic search was made in PsycINFO, Cochrane, Google Scholar, Embase, and Pubmed of all literature published until August 2018. Of the 1217 studies found from the search, a total 39 placebo-controlled studies that met the eligibility criteria were synthesized for this study. Because of substantial heterogeneity of study designs, populations, cannabinoid compounds, and quantitative sensory testing outcomes, meta-analysis was not conducted. More consistent evidence of cannabinoid analgesia was observed for inhaled cannabis than synthetic cannabinoids. Analgesic effects were most commonly observed in tests of cold pain sensitivity, and hyperalgesic effects were most commonly observed in tests of electrical stimulation. Patterns of findings from studies with healthy subjects did not substantively differ from those with chronic noncancer pain. However, these observations are qualified by the high degree of inconsistency across studies and methodological heterogeneity. We offer recommendations for future studies to improve study rigor and reproducibility.

Describing the Evidence Base for Accreditation in Undergraduate Medical Education Internationally: A Scoping Review

PURPOSE

To summarize the state of evidence related to undergraduate medical education (UME) accreditation internationally, describe from whom and where the evidence has come, and identify opportunities for further investigation.

METHOD

The authors searched Embase, ERIC, PubMed, and Scopus from inception through January 31, 2018, without language restrictions, to identify peer-reviewed articles on UME accreditation. Articles were classified as scholarship if all Glassick's criteria were met and as nonscholarship if not all were met. Author, accrediting agency, and study characteristics were analyzed.

RESULTS

Database searching identified 1,379 nonduplicate citations, resulting in 203 unique, accessible articles for full-text review. Of these and with articles from hand searching added, 36 articles were classified as scholarship (30 as research) and 85 as nonscholarship. Of the 36 scholarship and 85 nonscholarship articles, respectively, 21 (58%) and 44 (52%) had an author from the United States or Canada, 8 (22%) and 11 (13%) had an author from a low- or middle-income country, and 16 (44%) and 43 (51%) had an author affiliated with a regulatory authority. Agencies from high-income countries were featured most often (scholarship: 28/60 [47%]; nonscholarship: 70/101 [69%]). Six (17%) scholarship articles reported receiving funding. All 30 research studies were cross-sectional or retrospective, 12 (40%) reported only analysis of accreditation documents, and 5 (17%) attempted to link accreditation with educational outcomes.

CONCLUSIONS

Limited evidence exists to support current UME accreditation practices or guide accreditation system creation or enhancement. More research is required to optimize UME accreditation systems' value for students, programs, and society.

Women's Health Curricula in Internal Medicine Residency Programs: A Scoping Review

Background: Despite national efforts to expand women's health education, internal medicine (IM) residents remain unprepared to provide comprehensive care to women. The objectives of this scoping review are to provide an overview of published women's health curricula in IM residency programs and to identify potential areas for improvement. Materials and Methods: Studies were identified using PubMed, Embase, Cochrane Library, Scopus, Education Resources Information Center (ERIC), Web of Science, and MedEdPORTAL. Inclusion criteria included the following: (1) women's health as defined by the authors (2) description of a curriculum (3) designed for IM residents (4) based in North America, and (5) published between 1998 and 2018. Data abstracted included content, educational and assessment methods, and quality. Descriptive analysis was used to compare data. Results: Sixteen articles met the inclusion criteria. The most common women's health topics were intimate partner violence (31%) and menopause (31%). Twelve curricula (75%) were implemented in the outpatient setting. Of the teaching methods, didactics (69%) and in-clinic teaching (44%) were most commonly used. All studies that assessed attitudes, knowledge, and/or behavior showed an improvement post-intervention. No studies evaluated patient outcomes. Conclusion: To our knowledge, this is the first review summarizing published women's health curricula in IM residency. There were a limited number of published articles describing women's health curricula. Although content varied, the curricula were effective in improving attitudes, knowledge, and/or behavior with regard to women's health topics. We encourage IM residency programs to develop and disseminate women's health curricula to inform future improvements and advancements in women's health education.

Using the visual arts to teach clinical excellence

This article was migrated. The article was marked as recommended. Introduction: The authors conducted a review of the literature to identify curricula that incorporate the visual arts into undergraduate, graduate, and continuing medical education to facilitate the teaching of clinical excellence. Methods: The authors searched the PubMed and ERIC electronic databases in May 2017, using search terms such as "paintings," "visual arts," and "medical education," along with terms corresponding to previously defined domains of clinical excellence. Search results were reviewed to select articles published in the highest impact general medicine and medical education journals describing the use of visual arts to teach clinical excellence to all levels of medical trainees and practicing physicians. Results: Fifteen articles met inclusion criteria. Each article addressed at least one of the following clinical excellence domains: communication and interpersonal skills, humanism and professionalism, diagnostic acumen, and knowledge. No articles described the use of the visual arts to teach the skillful negotiation of the health care system, a scholarly approach to clinical practice, or a passion for patient care. Conclusions: This review supports the use of visual arts in medical education to facilitate the teaching of clinical excellence. However, research designed specifically to evaluate the impact of the visual arts on clinical excellence outcomes is needed.