bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of Fibrin Sealant for Split-Thickness Skin Grafts in Patients with Hand Burns: A Prospective Cohort Study
Authors: Kim Youngmin , Kym Dohern , Cho Yong Suk , Yoon Jaechul , Yim Haejun , Hur Jun , Chun Wook
Published: October 2018

OBJECTIVE:

To evaluate the efficacy of fibrin sealant as a topical hemostatic agent and for graft fixation during skin grafting of hand burns.

METHODS:

This prospective cohort study enrolled 40 patients with hand burns from January 2013 to December 2016. They were all treated with excision and split-thickness skin graft and divided into the fibrin sealant with tourniquet group (20 patients) and epinephrine tumescence group (20 patients).

MAIN OUTCOME MEASURES:

Demographic and clinical data such as age, sex, burn characteristics, operation time, estimated blood loss, and take rate were collected from each patient.

MAIN RESULTS:

The demographic and burn characteristics were not statistically different between the two groups. Estimated blood loss per cm2 (0.30 vs 1.00; P < .001) was significantly lower and the graft take rate (99.2% vs 98.2%; P = .032) was significantly higher in the fibrin sealant with tourniquet group.

CONCLUSIONS:

The use of fibrin sealants accompanied by tourniquets for hand burns exhibited superior results in terms of decreasing blood loss and had a better graft take rate compared with treatment with epinephrine tumescence.
The Cure for the Racist Patient?
Authors: Kueakomoldej Supakorn
Published: October 2018

In health care, appeasement tends to be the norm. That may be changing.
No Detrimental Effects in Children of Same-Sex Parents
Authors: Mechcatie Elizabeth , Rosenberg Karen
Published: October 2018

According to this study:

Children with same-sex parents did as well as or better than children with heterosexual parents in terms of psychological and social adjustment.
Further LDL Lowering Could Reduce Cardiovascular Risk
Authors: Mechcatie Elizabeth , Rosenberg Karen
Published: October 2018

According to this study:

Even in patients with very low low-density lipoprotein (LDL) cholesterol levels, there is a progressive, corresponding reduction in the risk of major cardiovascular events with further reduction in LDL cholesterol.
Addressing Unsafe Student Behavior
Authors: Chunta Kristy S. , Custer Nicole R.
Published: October 2018

This article is one in a series on the roles of adjunct clinical faculty and preceptors, who teach nursing students and new graduates to apply knowledge in clinical settings. Even students nearing the end of their educational program may struggle in the clinical setting and lack the knowledge and skills necessary to provide safe care. The preceptor serves as a role model and helps ensure that only students who are adequately prepared transition to professional practice. This article discusses the role of the nurse preceptor, identifies examples of unsafe student behavior, and shares strategies for preventing and managing such situations in the clinical setting.
Dimensions of Dorothy
Authors: Bonatch Maureen
Published: October 2018

The healing language of compassion and care can transcend the limitations of words.
Advance care planning
Authors: Tully Jessica
Published: October 2018

Purpose.

To improve the healthcare team's comfort and efficacy with end-of-life conversations at a 474-licensed bed community acute care hospital through training on advance care planning (ACP) and advance directives (ADs).

Methods.

This instructional program utilized training sessions, including pre- and posttests, to demonstrate enhanced knowledge of and confidence in discussing ACP and ADs among healthcare professionals engaging in end-of-life conversations with patients and their families.

Results.

There were 138 participants included in the program. A pretest and a posttest were completed by the attendees at the beginning and end of training, respectively. Data indicated improved preparedness for end-of-life conversations following the training sessions.

Conclusion.

Training specific to ACP and ADs increases confidence with end-of-life conversations. With the proper knowledge and resources, the healthcare staff can foster these difficult conversations. Although the program exceeded expectations, the sample is considered small and more research will be needed.
Electronic Knowledge Resources and Point-of-Care Learning: A Scoping Review
Authors: Aakre Christopher A. , Pencille Laurie J. , Sorensen Kristi J. , Shellum Jane L. , Del Fiol Guilherme , Maggio Lauren A. , Prokop Larry J. , Cook David A.
Published: October 2018

Purpose

The authors sought to summarize quantitative and qualitative research addressing electronic knowledge resources and point-of-care learning in a scoping review.

Method

The authors searched MEDLINE, Embase, PsycINFO, and the Cochrane Database for studies addressing electronic knowledge resources and point-of-care learning. They iteratively revised inclusion criteria and operational definitions of study features and research themes of interest. Two reviewers independently performed each phase of study selection and data extraction.

Results

Of 10,811 studies identified, 305 were included and reviewed. Most studies (225; 74%) included physicians or medical students. The most frequently mentioned electronic resources were UpToDate (88; 29%), Micromedex (59; 19%), Epocrates (50; 16%), WebMD (46; 15%), MD Consult (32; 10%), and LexiComp (31; 10%). Eight studies (3%) evaluated electronic resources or point-of-care learning using outcomes of patient effects, and 36 studies (12%) reported objectively measured clinician behaviors. Twenty-five studies (8%) examined the clinical or educational impact of electronic knowledge resource use on patient care or clinician knowledge, 124 (41%) compared use rates of various knowledge resources, 69 (23%) examined the quality of knowledge resource content, and 115 (38%) explored the process of point-of-care learning. Two conceptual clarifications were identified, distinguishing the impact on clinical or educational outcomes versus the impact on test setting decision support, and the quality of information content versus the correctness of information obtained by a clinician–user.

Conclusions

Research on electronic knowledge resources is dominated by studies involving physicians and evaluating use rates. Studies involving nonphysician users, and evaluating resource impact and implementation, are needed.
Testing Test-Enhanced Continuing Medical Education: A Randomized Controlled Trial
Authors: Feldman Mark , Fernando Oshan , Wan Michelle , Martimianakis Maria Athina , Kulasegaram Kulamakan
Published: October 2018

Purpose

The authors investigated the impact of the use of an efficient multiple-choice question (MCQ) test-enhanced learning (TEL) intervention for continuing professional development (CPD) on knowledge retention as well as self-reported learning behaviors.

Method

The authors conducted a randomized controlled trial comparing knowledge retention among learners who registered for an annual CPD conference at the University of Toronto in April 2016. Participants were randomized to receive an online preworkshop stand-alone MCQ test (no feedback) and a postworkshop MCQ test (with feedback) after a 14-day delay. Controls received no pre-/posttesting. The primary outcome measure was performance on a clinical vignette-based retention and application test delivered to all participants four weeks post conference. Secondary outcomes included self-reported changes in learning behavior, satisfaction, and efficiency of TEL.

Results

Three hundred eight physicians from across Canada registered for the four-day conference; 186 physicians consented to participate in the study and were randomized to receive TEL or to the control group in 1 of 15 workshops, with 126 providing complete data. A random-effects meta-analysis demonstrated a pooled effect size indicating moderate effect of TEL (Hedges g of 0.46; 95% CI: 0.26–0.67). The majority of respondents (65%) reported improved CPD learning resulting from pretesting.

Conclusions

Testing for learning can be leveraged to efficiently and effectively improve outcomes for CPD. Testing remains an underused education intervention in CPD, and the use of formative assessment to enhance professional development should be a key target for research.
Commentary: Paradigms, Axiology, and Praxeology in Medical Education Research
Authors: Zaidi Zareen , Larsen Douglas
Published: October 2018

This supplement includes 11 research papers accepted by the 2018 Research in Medical Education Committee. In this Commentary, the authors draw the attention of medical educators and researchers to questions about the researcher’s philosophical paradigm. Such questions fundamentally guide research—the choice of conceptual frameworks, methods, and methodology. The authors provide a brief overview of research paradigms and the related concept of axiology and praxeology in medical education research. The authors map the 11 accepted research articles, describing the researchers’ stated or implied worldviews and the impact on chosen methods. The authors close by encouraging researchers to state the research paradigm behind their research, comment on how they ensured that the methods used displayed consistency with that paradigm, and highlight the value the research adds to everyday education.
How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development
Authors: Gonzalez Cristina M. , Garba Ramya J. , Liguori Alyssa , Marantz Paul R. , McKee M. Diane , Lypson Monica L.
Published: October 2018

Purpose

To analyze faculty experiences regarding facilitating discussions as part of the institution’s curriculum on racial and ethnic implicit bias recognition and management.

Method

Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts.

Results

Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development.

Conclusions

Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.
Patterns of Hysteresis Between Induction and Emergence of Neuroanesthesia Are Present in Spinal and Intracranial Surgeries
Authors: Ferreira Ana Leitão , Correia Rui , Vide Sérgio , Ferreira Ana Dias , Kelz Max B. , Mendes Joaquim Gabriel , Nunes Catarina S. , Amorim Pedro
Published: October 2018

Background:

Recovery of consciousness is usually seen as a passive process, with emergence from anesthesia depicted as the inverse process of induction resulting from the elimination of anesthetic drugs from their central nervous system sites of action. However, that need not be the case. Recently it has been argued that we might encounter hysteresis to changes in the state of consciousness, known as neural inertia. This phenomenon has been debated in neuroanesthesia, as manipulation of the brain might further influence recovery of consciousness. The present study is aimed at assessing hysteresis between induction and emergence under propofol-opioid neuroanesthesia in humans using estimated propofol concentrations in both spinal and intracranial surgeries.

Methods:

We identified the moments of loss (LOR) and recovery of responsiveness (ROR) in 21 craniotomies and 25 spinal surgeries. Propofol was given slowly until loss of responsiveness and stopped at the end of surgery. An opioid was present at induction and recovery. Propofol infused was recorded and plasma and effect-site concentrations were estimated using 2 pharmacokinetic models. Dose-response curves were generated. Estimated propofol plasma and effect-site concentrations were compared to assess hysteresis.

Results:

Estimated propofol concentrations at LOR and ROR showed hysteresis. Whether for spinal or intracranial surgeries, the EC50 of propofol at which half of the patients entered and exited the state of responsiveness was significantly different.

Conclusions:

Hysteresis was observed between propofol concentrations at LOR and ROR, in both patients presenting for spinal and intracranial surgeries. Manipulation of the brain does not appear to change patterns of hysteresis, suggesting that neural inertia may occur in humans, in a way similar to that found in animal species. These findings justify performing a clinical study in patients using measured propofol concentrations to assess neural inertia.
Cervical Versus Thoracolumbar Spinal Deformities
Authors: Passias Peter G. , Poorman Gregory W. , Lafage Virginie , Smith Justin , Ames Christopher , Schwab Frank , Shaffrey Chris , Segreto Frank A. , Horn Samantha R. , Bortz Cole A. , Varlotta Christopher G. , Hockley Aaron , Wang Charles , Daniels Alan , Neuman Brian , Hart Robert , Burton Douglas , Javidan Yashar , Line Breton , LaFage Renaud , Bess Shay , Sciubba Daniel
Published: October 2018

Study Design:

Retrospective analysis of 2 prospectively collected multicenter databases, one for cervical deformity (CD) and the other for general adult spinal deformity.

Objective:

To investigate the relative quality-of-life and disability burden in patients with uncompensated cervical, thoracolumbar, or cervical and thoracolumbar deformities.

Summary of Background Data:

The relative quality-of-life burden of cervical and thoracolumbar deformities have never been compared with each other. This may have significant implications when deciding on the appropriate treatment intervention for patients with combined thoracolumbar and cervical deformities.

Methods:

When defining CD C2–C7 sagittal vertical axis (SVA)>4 cm was used while a C7–S1 SVA>5 cm was used to defined thoracolumbar deformity. Patients with both SVA criteria were defined as “combined.” Primary analysis compared patients in the different groups by demographic, comorbidity data, and quality-of-life scores [EuroQOL 5 dimensions questionnaire (EQ-5D)] using t tests. Secondary analysis matched deformity groups with propensity scores matching based on baseline EQ-5D scores. Differences in disease-specific metrics [the Oswestry Disability Index, Neck Disability Index, modified Japanese Orthopaedic Association questionnaire (mJOA)] were analyzed using analysis of variance tests and post hoc analysis.

Results:

In total, 212 patients were included in our analysis. Patients with CD only had less neurological deficits (mJOA: 14.6) and better EQ-5D (0.746) scores compared with patients with combined deformities (11.9, 0.716), all P<0.05. Regarding propensity score–matched deformity cohorts, 99 patients were matched with similar quality-of-life burden, 33 per deformity cohort. CD only patients had fewer comorbidities (1.03 vs. 2.12 vs. 2.70; P<0.001), whereas patients with combined deformity had more baseline neurological impairment compared with CD only patients (mJOA: 12.00 vs. 14.25; P=0.050).

Conclusions:

Combined deformity patients were associated with the lowest quality-of-life and highest disability. Furthermore, regarding deformity cohorts matched by similar baseline quality-of-life status (EQ-5D), patients with combined deformities were associated with significantly worse neurological impairments. This finding implies that quality of life may not be a direct reflection of a patient’s disability status, especially in patients with combined cervical and thoracolumbar deformities.

Level of Evidence:

Level III.
Syringotropic Lichen Planus: A Potential Histopathologic Mimicker of Syringotropic Mycosis Fungoides
Authors: Mazzeo Mauro , Saggini Andrea , Rocco Tea , Fargnoli Maria Concetta , Cerroni Lorenzo
Published: October 2018

Perieccrine inflammation may be observed in several different dermatoses, but true permeation of the secretory coil by lymphocytes (lymphocytic syringotropism) is a rather uncommon finding, usually observed in mycosis fungoides (MF—syringotropic MF). Rare cases of syringotropic lichen striatus and lymphocytic autoimmune hidradenitis showing a similar pattern have been described as well. We describe an exceptional case of lichen planus (LP) characterized by marked lymphocytic syringotropism with focal hyperplasia of the eccrine epithelium. Histopathology was characterized by the combination of features of conventional LP, prominent permeation of the secretory portion of the eccrine glands by reactive lymphocytes, and focal involvement of a hair follicle. Syringotropic LP may be regarded as a histologic mimicker of syringotropic MF, thus representing a potential diagnostic pitfall.
Aspirin Attenuates the Bioactivation of and Platelet Response to Vicagrel in Mice
Authors: Jia Yu-Meng , Gu Tong-Tong , Ji Jin-Zi , Tai Ting , Zhang Meng-Ran , Huang Bei-Bei , Zhou Huan , Mi Qiong-Yu , Xie Hong-Guang
Published: October 2018

Vicagrel, a novel acetate analogue of clopidogrel, exerts more potent antiplatelet effect than clopidogrel in rodents. Relevant evidence indicated that aspirin and vicagrel are the drug substrate for carboxylesterase 2. Accordingly, it is deduced that concomitant use of aspirin could attenuate the bioactivation of and platelet response to vicagrel. To clarify whether there could be such an important drug–drug interaction, the differences in both the formation of vicagrel active metabolite H4 and the inhibition of adenosine diphosphate–induced platelet aggregation by vicagrel were measured and compared between mice treated with vicagrel alone or in combination with aspirin. The plasma H4 concentration was determined by liquid chromatography–tandem mass spectrometry, and the inhibition of platelet aggregation by vicagrel was assessed by whole-blood platelet aggregation. Compared with vicagrel (2.5 mg·kg−1) alone, concurrent use of aspirin (5, 10, or 20 mg·kg−1) significantly decreased systemic exposure of H4, an average of 38% and 41% decrease in Cmax and AUC0–∞ in mice when in combination with aspirin at 10 mg·kg−1, respectively. Furthermore, concomitant use of aspirin (10 mg·kg−1) and vicagrel (2.5 mg·kg−1) resulted in an average of 66% reduction in the inhibition of adenosine diphosphate–induced platelet aggregation by vicagrel. We conclude that aspirin significantly attenuates the formation of vicagrel active metabolite H4 and platelet response to vicagrel in mice, and that such an important drug–drug interaction would appear in clinical settings if vicagrel is taken with aspirin concomitantly when marketed in the future.
FIRST-IN-HUMAN CLINICAL STUDY TO INVESTIGATE THE EFFECTIVENESS AND SAFETY OF PARS PLANA VITRECTOMY SURGERY USING A NEW HYPERSONIC TECHNOLOGY
Authors: Stanga Paulo E. , Williams Jon I. , Shaarawy Sherif A. , Agarwal Amar , Venkataraman Anusha , Kumar Dhivya A. , You Timothy T. , Hope Richard S.
Published: October 2018

Purpose:

Investigate the effective performance and safety of a new hypersonic vitrector technology.

Methods:

Postapproval, prospective, single-arm, noncomparative, open-label study at one clinical site in India. Indications: macular hole (9/20), vitreous hemorrhage (7/20), vitreomacular traction (3/20), and vitreomacular traction with pseudomacular hole (1/20). Safety endpoints included intraoperative and postoperative adverse events. Effective performance endpoints were surgeon-rated effectiveness, range of surgical time, and device settings. Other performance measures were preoperative and postoperative best-corrected visual acuity, slit-lamp and indirect ophthalmoscopy, applanation tonometry, color fundus photography, fundus fluorescein angiography, and spectral domain optical coherence tomography.

Results:

Core vitreous removal (20/20 subjects), peripheral vitreous removal (18/20), and posterior vitreous detachment induction (13/15) surgeries were successfully completed. Total surgical time was 22.5 minutes to 106 minutes. Serious adverse events through 3 months were 2 device-associated retinal tears and detachment (one intraoperative) and one unrelated postoperative enlargement of macular hole with subretinal fluid.

Conclusion:

This first-in-human study suggests that this new hypersonic vitrector technology is a promising alternative to commercially available guillotine vitrectors. The hypersonic vitrector was effective in core vitreous removal in all cases. Larger-scale studies are required to expand on our initial findings for induction of a posterior vitreous detachment or peripheral vitrectomy.
High-Dose Steroid Treatment of Bacterial Keratitis
Authors: Green Matthew , Hughes Ian , Hogden John , Sara Sergio , Apel Andrew , Stapleton Fiona
Published: October 2018

Purpose:

To describe the usage patterns of steroids in bacterial keratitis and to analyze the effect of steroids on patients' visual outcomes.

Methods:

This was a single-center retrospective review of patients with culture-positive bacterial keratitis treated between 1999 and 2015 at Princess Alexandra Hospital (Brisbane, Australia). Patients with culture-positive bacterial keratitis were identified through the Queensland Pathology Database, and clinical information was gathered through a subsequent medical record review. High-dose steroid treatment was classified as 6 or more drops of a steroid a day started within 7 days of corneal scraping. The outcome of a patient's episode of keratitis was classified as good if their final visual acuity was 6/12 or better; poor if it was 6/60 or worse or required a corneal transplant, otherwise it was classified as average. Microbiological and clinical variables' association with outcomes was evaluated in univariate analyses. Variables significant at P < 0.1 were examined in a multivariate ordinal logistic regression analysis created with forward variable selection with forced inclusion of steroid treatment (high, regular, low dose, and none).

Results:

A total of 328 patients were included from the 1002 reviewed charts. Of these patients, 164 (50.0%) were treated with steroids. Factors significantly associated with outcomes in the multivariate model were high-dose steroid treatment, visual acuity on presentation, age group, cause of keratitis, infiltrate size, and location. The odds ratio of better outcomes with high-dose steroids was 5.49 (confidence interval, 1.6–19.0, P = 0.007).

Conclusions:

High-dose steroid treatment is significantly associated with better visual outcomes in patients with culture-positive bacterial keratitis in this case series.
Acquired Obliteration of the Proximal Lacrimal Drainage System
Authors: Starks Victoria S. , Yoon Michael K.
Published: October 2018

Purpose:

We present a series of patients with acquired obliteration of one or more components of the proximal lacrimal drainage system, including puncta and canaliculi. This finding was noted with and without other obstructions or stenoses of the lacrimal drainage system. Review of these patients in search of possible risk factors for this condition and histopathology of two patients are presented.

Methods:

Medical records of patients treated at the Massachusetts Eye and Ear Infirmary between 2010 and 2016 with diagnosis codes of lacrimal punctum stenosis, stenosis of unspecified lacrimal punctum, epiphora due to insufficient drainage, and epiphora not otherwise specified were retrospectively reviewed. Patients were excluded if there was a history of congenital punctal agenesis, trauma, or any other identifiable etiology of lacrimal system obstruction.

Results:

Twelve patients were identified with obliterated puncta. Most patients were female (n = 11, 91.7%) and Caucasian (n = 9, 75%). The mean age was 61 years (median 62, range 22–90 years). Clinical findings ranged from one involved punctum to all four puncta, and associated ipsilateral canalicular obstruction was noted in 4 patients (33.3%). The inferior puncta were the more frequently affected structures (61.5%) compared to the superior puncta (38.5%). Nine patients (75%) reported use of topical ophthalmic medications prior to onset of symptoms. The most frequent class of medication implicated was topical antibiotics; however, patients often used a combination of medications. In 2 cases, pathological specimens of the canaliculi revealed absence of a canalicular lumen.

Conclusions:

Although various combinations of lacrimal system stenoses and obstructions have been described, acquired punctal obliteration is an under-recognized entity. These cases differ from typical punctal stenosis in that the puncta are completely obliterated, and no indication of a punctal opening is clinically detectable. In this study, 3 patients had previously documented normal lacrimal irrigation. The ipsilateral canaliculi were also found to be obstructed in a third of patients. Two patients had complete absence of a canalicular lumen on histopathology. The predominance of inferior punctum involvement, patient history of symptom onset after ipsilateral medication use, and known prior patent irrigation in several cases support the hypothesis that these cases represent a severe yet insidious idiosyncratic reaction to topical medication.
Acute Parotitis Due to Candida glabrata Presenting as Syncope
Authors: Turin Christie G. , McCormick David W. , Mahesh Cynthia , Taylor Addison A. , Hamill Richard J. , Constantine Gregory
Published: October 2018

Acute suppurative parotitis is commonly caused by bacterial pathogens, with rare cases reported to be secondary to fungal infections. We present a case ofCandidaparotitis with disseminated infection resulting in carotid sinus hypersensitivity and subsequent syncope. We also present a brief review of literature surrounding this disease and a description of previously reported cases ofCandidaparotitis. To our knowledge, this is the first case ofCandidaparotitis presenting with syncope triggered by mechanical compression of the carotid sinus.
Pain assessment in advanced dementia. Validity of the German PAINAD—a prospective double-blind randomised placebo-controlled trial
Authors: Lukas Albert , Hagg-Grün Ulrich , Mayer Benjamin , Fischer Thomas , Schuler Matthias
Published: October 2018

Pain in combination with dementia is a common condition that makes pain recognition significantly more difficult. This results in undertreatment of pain in those suffering from dementia. The Pain Assessment in Advanced Dementia (PAINAD) scale currently represents one of the best approaches to pain detection in dementia. In a pilot study, strong inter-rater and retest reliability of the German version (PAINAD-G) was proven. However, the available data concerning the validity of this instrument were insufficient. The aim of the study was to validate the PAINAD-G scale by a double-blind randomised placebo-controlled trial in people with advanced dementia expected to be in pain. A second aim was to examine whether other observational tools (BISAD = Observation Instrument for Assessing Pain in the Elderly with Dementia) (German:Beobachtungsintrument für das Schmerzassessment bei alten Menschen mit Demenz, Checklist of Nonverbal Pain Indicators, Algoplus) were also able to demonstrate a significant difference between the study groups. Surprisingly, the study revealed no difference in “pain reduction” between those treated by oxycodone compared with those treated by placebo. Equally, none of the other 3 observational tools were able to demonstrate a significant difference between the study groups. However, correlations among the 4 observational tools were mostly moderate to high. A number of possible reasons for this observation, such as difficulties regarding sensitivity to change/responsiveness, consistence of the fundamental construct, influence of the early onset study, and efficacy of the analgesic in advanced dementia are discussed.
Narcotic Pain Control for Ureterolithiasis Is Associated With Unnecessary Repeat Imaging in the Emergency Department
Authors: Garcia Kyle , Pham Hannah , Sharma Pranav
Published: October 2018

A subset of patients with ureteral stones who present to the emergency department (ED) will return with recurring symptoms and will receive unnecessary repeat imaging. We retrospectively identified 112 patients from 2012 to 2016 diagnosed with at least one ureteral stone on computerized tomography (CT) at our institution who returned to the ED within 30 days. Patients were stratified based on the presence or absence of repeat CT scan imaging. Mean values were compared with independent t-test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of repeat imaging. Sixty-eight patients (60.7%) underwent repeat CT scan imaging upon representation to the ED within 30 days of being diagnosed with ureterolithiasis. Ureteral stone position changed in 34 patients (30.4%) who underwent repeat imaging. On univariate analysis, younger age, nondiabetics, narcotics prescribed on discharge from first ED visit, and longer mean time between ED visits were associated with repeat CT scan imaging being performed (p < .05). Only prescription of narcotic pain medications was an independent predictor of repeat CT scan imaging (odds ratio: 3.18, 95% confidence interval: 1.22–8.28; p = .018). Nonsteroidal anti-inflammatory drugs or nonnarcotic pain medications, therefore, should primarily be used for pain control in these patients to avoid unnecessary testing.
United States Air Force Physician Assistant Postgraduate Specialty Training Factors: A Brief Survey
Authors: Rabener Michael J. , Bonjour Timothy J.
Published: October 2018

Purpose

The purpose of this study was to determine USAF physician assistants' (PAs') concerns regarding postgraduate education and training.

Methods

This was a single-mode, observational, cross-sectional study using an anonymous-structured survey involving a population of 420 active duty USAF PAs. Potential participants were contacted by email and asked to take a one-time survey via a secure survey site link.

Results

One hundred ten USAF PAs participated in the survey seeking their opinions on factors affecting applying for military postgraduate specialty training. The prime factors identified fell into 3 major groups of concern: types of degrees offered, current job satisfaction, and types of specialty training available. The most desired degree and specialty options were the doctorate of science and emergency medicine. Only a small number of respondents (6%) expressed current job satisfaction and the desire to remain in family medicine.

Conclusions

This study revealed important information to senior leaders who fund, recruit, train, and maintain force-readiness requirements. The 3 identified main priorities of respondents were the types of degrees, current level of job satisfaction, and the types of specialty training. The vast majority of those surveyed preferred the doctorate, which is what all of the specialty degrees in the Air Force are, except for ENT.
Wilms Tumor Associated With the 9q22.3 Microdeletion Syndrome: 2 New Case Reports and a Review of The Literature
Authors: Cayrol Julie , Nightingale Michael , Challis Jacqueline , Campbell Martin , Sullivan Michael , Heloury Yves
Published: October 2018

Background:

The 9q22.3 syndrome is an autosomal dominant microdeletion syndrome with similarities to Gorlin syndrome (GS). It encompasses the PTCH1 gene locus that harbors mutations for GS. Although the 9q22.3 syndrome is associated with Wilms tumor (WT), WT is not a GS-associated tumor, implying a different mechanism involving PTCH1, or a different locus in the 9q22.3 region. The goal of this study is to report the association between WT and 9q22.3 syndrome and review the outcome of treatment.

Observations:

We report 2 new cases of WT with 9q22.3 deletion and review the literature. Among the 44 described patients with 9q22.3 deletion, 7 developed WT (16%) at a mean age of 45 months (range, 4 to 84 mo). All patients had dysmorphic features, macrocephaly, and developmental delay, and there was an association with overgrowth (4/7). One patient had bilateral WT, another had a synchronous rhabdomyosarcoma. The outcome was excellent with all cases reported to be in complete remission.

Conclusions:

The 9q22.3 microdeletion syndrome should be considered at diagnosis of WT in children with dysmorphic features. Conversely, patients with a known 9q22.3 deletion syndrome should be considered for a WT predisposition surveillance program, especially those with overgrowth. The management should be individualized and given the excellent prognosis, and the unknown future risk of metachronous disease or other malignancy, the surgical approach should be carefully considered.
National Education Progression in Nursing (NEPIN)
Authors: Jones-Schenk Jan
Published: October 2018

In 2011, the Robert Wood Johnson Foundation and the Center to Champion Nursing in America set a course to address the recommendations of the Institute of Medicine’s Future of Nursing report. In response, the Academic Progression in Nursing (APIN) provided national leadership for advancing nursing academic progression. A new entity, the National Progression in Nursing Education Collaborative, has formed to continue the important work started by APIN.
Changing Primary Care and Growing Nurse Practitioner Workforce: Key Policy and Organizational Issues: An Interview With Dr Lusine Poghosyan
Authors: Reid-Ponte Patricia
Published: October 2018

In this column, nurse scientist Lusine Poghosyan, PhD, MPH, RN, FAAN, is interviewed. Dr Poghosyan has focused her research on advancing the role of nurse practitioners in primary care.
Leveraging Technology to Enhance Doctor of Nursing Practice Student Health Policy Engagement
Authors: Garritano Nicole , Stec Melissa
Published: October 2018

Background

Doctor of nursing practice (DNP) students need to develop health policy competencies. The American Association of Colleges of Nursing formed the Faculty Policy Think Tank (FPTT) in 2015, which developed recommendations about health policy curriculum at all levels of nursing education including the DNP.

Problem

Prior to the FPTT recommendations, there were no standardized examples of health policy competencies and their evaluation.

Approach

A DNP health policy course was redesigned based on the FPTT recommendations. Technological capabilities were leveraged to provide an active and experiential learning environment integrating the concepts of cultural competence, health equity, and social awareness.

Outcomes

At the conclusion of the course, DNP students are actively engaged in health policy and have increased confidence in their advocacy abilities.

Conclusions

Providing DNP students with an experiential, technologically driven learning platform gives students practical tools and applications they can use beyond the classroom to influence health policy.
Tenosynovitis With Psammomatous Calcifications
Authors: Michal Michael , Agaimy Abbas , Folpe Andrew L. , Zambo Iva , Kebrle Radek , Horch Raymund E. , Kinkor Zdenek , Svajdler Marian , Vanecek Tomas , Heidenreich Filip , Kazakov Dmitry V. , Michalova Kvetoslava , Hadravsky Ladislav , Michal Michal
Published: October 2018

The term “idiopathic calcifying tenosynovitis” (ICT) refers to a clinically and radiologically defined syndrome of pain and tendinous calcifications, most often involving the shoulder joint. A distinctive subset of ICT cases, termed “tenosynovitis with psammomatous calcifications” (TPC), occurs in the distal extremities and shows characteristic morphology, in particular psammomatous calcifications. As only 14 cases have been reported to date, TPC remains poorly recognized by both pathologists and clinicians. Twenty-three well-characterized cases of TPC along with all available radiologic and clinical information, including follow-up, were collected. Cases occurred in 21 females and 1 male (1 patient of unknown sex), aged 16 to 75 years (mean: 41), and almost exclusively involved the fingers and toes, except for one case in the elbow and one in the knee joint. The lesions ranged from 2 to 30 mm in size (mean: 10 mm). Pain was the most common presenting symptom (12/16 patients). A history of trauma or repetitive activity was present in 6 of 15 patients. None of the individuals was known to have disorders in calcium or phosphate metabolism. Radiographic studies showed a nonspecific, calcified mass. Typical morphologic features of TPC were invariably present, with degenerating tendinous tissue containing psammomatous calcifications, surrounded by a variably cellular, CD68/CD163/CD4-positive histiocyte-rich granulomatous host reaction. HUMARA assay in one case showed a polyclonal pattern. Clinical follow-up (19 patients; mean: 5.2 y; range: 1 to 14 y) showed no local recurrences. In this, the largest study of TPC to date, we confirm striking predilection of this distinctive pseudoneoplasm for the fingers and toes of young to middle-aged women. TPC should be rigorously distinguished from other forms of ICT, which typically involve large, proximal joints, and show simply dystrophic calcification involving tendinous tissues, and from tumoral calcinosis, which also involves large joints and often is associated with calcium and/or phosphate abnormalities. TPC appears to be related to trauma and/or repetitive activity and is cured with simple excision.
Variation in Adjusted Mortality for Medical Admissions to Pediatric Cardiac ICUs*
Authors: Gaies Michael , Ghanayem Nancy S. , Alten Jeffrey A. , Costello John M. , Lasa Javier J. , Chanani Nikhil K. , Shin Andrew Y. , Retzloff Lauren , Zhang Wenying , Pasquali Sara K. , Banerjee Mousumi , Tabbutt Sarah
Published: October 2018

Objectives:

Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium.

Design:

Observational analysis.

Setting:

Pediatric Cardiac Critical Care Consortium clinical registry.

Patients:

All cardiac ICU admissions that did not include cardiac surgery.

Interventions:

None.

Measurements and Main Results:

The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio <1) and one had higher-than-expected (standardized mortality ratio >1) mortality.

Conclusions:

We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning.
Acute Kidney Injury in Critically Ill Children Admitted to the PICU for Diabetic Ketoacidosis. A Retrospective Study
Authors: Weissbach Avichai , Zur Noy , Kaplan Eytan , Kadmon Gili , Gendler Yulia , Nahum Elhanan
Published: October 2018

Objectives:

Acute kidney injury in the critically ill pediatric population is associated with worse outcome. The aim of this study was to assess the prevalence, associated clinical variables, and outcomes of acute kidney injury in children admitted to the PICU with diabetic ketoacidosis.

Design:

Retrospective cohort.

Setting:

PICU of a tertiary, university affiliated, pediatric medical center.

Patients:

All children less than age 18 years with a primary diagnosis of diabetic ketoacidosis admitted to the PICU between November 2004 and October 2017.

Interventions:

None.

Measurements and Main Results:

Acute kidney injury was categorized into three stages using the Kidney Disease Improving Global Outcomes scale. Of the 82 children who met the inclusion criteria, 24 (30%) had acute kidney injury: 18 (75%) stage 1, five (21%) stage 2, and one (4%) stage 3. None needed renal replacement therapy. Compared with the patients without acute kidney injury, the acute kidney injury group was characterized by higher mean admission serum levels of sodium (143.25 ± 9 vs 138.6 ± 4.9 mmol/L; p = 0.0035), lactate (29.4 ± 17.1 vs 24.1 ± 10.8 mg/dL; p = 0.005), and glucose (652 ± 223 vs 542 ± 151 mg/dL; p = 0.01). There was no between-group difference in length of PICU stay (1.38 ± 0.7 vs 1.4 ± 0.7 d; p = 0.95) or hospitalization (6.1 ± 2.1 vs 5.8 ± 5.6 d; p = 0.45). Kidney injury was documented at discharge in four patients with acute kidney injury (16.7%), all stage 1; all had normal creatinine levels at the first clinical outpatient follow-up. All 82 patients with diabetic ketoacidosis survived.

Conclusions:

In this study, acute kidney injury was not uncommon in children with diabetic ketoacidosis hospitalized in the PICU. However, it was usually mild and not associated with longer hospitalization or residual kidney injury.
Topical Ketoprofen Versus Placebo in Children Presenting With Ankle Sprain to the Emergency Department
Authors: Serinken Mustafa , Eken Cenker , Tünay Kamil , Gölcük Yalcin
Published: October 2018

Objective

Despite the favorable data concerning topical agents use in outpatient clinics, they are not commonly in emergency departments (EDs). The present study aimed to compare the effect of 2.5% topical ketoprofen (gel form) to placebo in children presenting with ankle sprain to the ED.

Study Design

Children between 7 and 18 years old presenting with ankle sprain composed the study population. Study patients were randomized into 2 study arms: 2.5% ketoprofen gel and placebo administered in a 5-cm area locally. Pain improvements at 15 and 30 minutes were measured by visual analog scale.

Results

Median pain reductions at 15 minutes for ketoprofen and placebo groups were 27.5 (16–39) and 5 (4–10), respectively. Median changes in pain intensity at 30 minutes for ketoprofen and placebo gel groups were 48 (43–52) and 9 (6–16), respectively. When compared 2 arms for the pain improvement at 15 and 30 minutes, the differences between 2 study drugs were 20 (13–28) and 35 (29–41), respectively. There were 7 (12.7%) rescue drug needs in the placebo group and 1 (1.7%) in the ketoprofen group (difference, 10.9%; 95% confidence interval, −6% to 7%; P = 0.83). There were no adverse effects in either group.

Conclusions

Ketoprofen gel is superior to placebo in ceasing pain in children presenting with ankle sprain to the ED with a high safety profile.
Walking Speed Is Correlated With the Isokinetic Muscular Strength of the Knee in Patients With Charcot-Marie-Tooth Type 1A
Authors: Reynaud Vivien , Morel Claire , Givron Pascal , Clavelou Pierre , Cornut-Chauvinc Catherine , Pereira Bruno , Taithe Frederic , Coudeyre Emmanuel
Published: October 2018

Charcot-Marie-Tooth disease type 1A is the most common hereditary neuropathy. Affected individuals have a distal motor deficit, initially affecting the lower limbs and impairing walking performance. Isokinetic dynamometry can be used to objectively assess muscle strength of patients with neuromuscular disorders. No studies have evaluated the effect of muscle strength deficits of knee extensors and flexors on walking parameters for patients with Charcot-Marie-Tooth disease type 1A. The purpose of this study was to determine correlations between the isokinetic muscular strength of knee flexors and knee extensors and walk parameters for patients with Charcot-Marie-Tooth disease type 1A. isokinetic muscular strength of the knee was assessed on an isokinetic dynamometer (Cybex) and walking by instrumented walkway analysis (GaitRite). We included 33 patients (23 females, mean ± SD age 46.7 ± 13.3 yrs, mean ± SD body mass index 25.7 ± 4.6 kg/m2). We found a correlation between walking speed and isokinetic muscular strength of knee extensors for the entire population and between walking speed and isokinetic muscular strength of knee extensors and knee flexors for patients younger than 50 yrs. Isokinetic dynamometry can provide objective measures of knee muscle strength, which is correlated with walking speed but not cadence or step/stride length of patients with Charcot-Marie-Tooth disease.
The Timing of Chemoprophylaxis in Autologous Microsurgical Breast Reconstruction
Authors: Bassiri-Tehrani Brian , Karanetz Irena , Bernik Stephanie F. , Dec Wojciech , Lehman Jennifer C. , Lerman Oren Z.
Published: October 2018

Background:

Patients undergoing autologous breast reconstruction are at high risk of perioperative venous thromboembolic events. The efficacy of chemoprophylaxis in decreasing venous thromboembolic events is well established, but the timing of chemoprophylaxis remains controversial. The authors compare the incidence of bleeding following preoperative versus postoperative initiation of chemoprophylaxis in microvascular breast reconstruction.

Methods:

A retrospective chart review was performed from August of 2010 to July of 2016. Initiation of chemoprophylaxis changed from postoperative to preoperative in 2013, dividing subjects into two groups. Patient demographics, comorbidities, and complications were reviewed.

Results:

A total of 196 patients (311 flaps) were included in the study. A total of 105 patients (166 flaps) received preoperative enoxaparin (40 mg) and 91 patients (145 flaps) received postoperative chemoprophylaxis. A total of five patients required hematoma evacuation (2.6 percent). Of these, one hematoma (1 percent) occurred in the preoperative chemoprophylaxis group. Seven patients received blood transfusions: three in the preoperative group and four in the postoperative group (2.9 percent versus 4.4 percent; p = 0.419). There was a total of one flap failure, and there were no documented venous thromboembolic events in any of the groups.

Conclusions:

This study demonstrates that preoperative chemoprophylaxis can be used safely in patients undergoing microvascular breast reconstruction. The higher rate of bleeding in the postoperative group may be related to the onset of action of enoxaparin of 4 to 6 hours, which allows for intraoperative hemostasis in the preoperative group and possibly potentiating postoperative oozing when administered postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.