bluuebunny/crossref_metadata_2025 huggingface dataset:
Feasibility and Outcomes of Implementing a Portfolio Assessment System Alongside a Traditional Grading System
Authors: O’Brien Celia Laird , Sanguino Sandra M. , Thomas John X. , Green Marianne M.
Published: April 2016

Purpose

Portfolios are a powerful tool to collect and evaluate evidence of medical students’ competence across time. However, comprehensive portfolio assessment systems that are implemented alongside traditional graded curricula at medical schools in the United States have not been described in the literature. This study describes the development and implementation of a longitudinal competency-based electronic portfolio system alongside a graded curriculum at a relatively large U.S. medical school.

Method

In 2009, the authors developed a portfolio system that served as a repository for all student assessments organized by competency domain. Five competencies were selected for a preclerkship summative portfolio review. Students submitted reflections on their performance. In 2014, four clinical faculty members participated in standard-setting activities and used expert judgment and holistic review to rate students’ competency achievement as “progressing toward competence,” “progressing toward competence with some concern,” or “progressing toward competence pending remediation.” Follow-up surveys measured students’ and faculty members’ perceptions of the process.

Results

Faculty evaluated 156 portfolios and showed high levels of agreement in their ratings. The majority of students achieved the “progressing toward competence” benchmark in all competency areas. However, 31 students received at least one concerning rating, which was not reflected in their course grades. Students’ perceptions of the system’s ability to foster self-assessment were mixed.

Conclusions

The portfolio review process allowed faculty to identify students with a concerning rating in a behavioral competency who would not have been identified in a traditional grading system. Identification of these students allows for intervention and early remediation.
When Assessment Data Are Words: Validity Evidence for Qualitative Educational Assessments
Authors: Cook David A. , Kuper Ayelet , Hatala Rose , Ginsburg Shiphra
Published: April 2016

Quantitative scores fail to capture all important features of learner performance. This awareness has led to increased use of qualitative data when assessing health professionals. Yet the use of qualitative assessments is hampered by incomplete understanding of their role in forming judgments, and lack of consensus in how to appraise the rigor of judgments therein derived. The authors articulate the role of qualitative assessment as part of a comprehensive program of assessment, and translate the concept of validity to apply to judgments arising from qualitative assessments. They first identify standards for rigor in qualitative research, and then use two contemporary assessment validity frameworks to reorganize these standards for application to qualitative assessment.

Standards for rigor in qualitative research include responsiveness, reflexivity, purposive sampling, thick description, triangulation, transparency, and transferability. These standards can be reframed using Messick’s five sources of validity evidence (content, response process, internal structure, relationships with other variables, and consequences) and Kane’s four inferences in validation (scoring, generalization, extrapolation, and implications). Evidence can be collected and evaluated for each evidence source or inference. The authors illustrate this approach using published research on learning portfolios.

The authors advocate a “methods-neutral” approach to assessment, in which a clearly stated purpose determines the nature of and approach to data collection and analysis. Increased use of qualitative assessments will necessitate more rigorous judgments of the defensibility (validity) of inferences and decisions. Evidence should be strategically sought to inform a coherent validity argument.
How Prevalent Are Potentially Illegal Questions During Residency Interviews? A Follow-up Study of Applicants to All Specialties in the National Resident Matching Program
Authors: Hern H. Gene , Trivedi Tarak , Alter Harrison J. , Wills Charlotte P.
Published: April 2016

Purpose

To describe the prevalence and effects on applicants of being asked potentially illegal questions during the residency interview process by surveying all residency applicants to all specialties.

Method

The authors surveyed all applicants from U.S. medical schools to residency programs in all specialties in 2012–2013. The survey included questions about the prevalence of potentially illegal questions, applicants’ level of comfort with such questions, and whether such questions affected how applicants ranked programs. Descriptive statistics, tests of proportions, t tests, and logistic regression modeling were used to analyze the data.

Results

Of 21,457 eligible applicants, 10,976 (51.1%) responded to the survey. Overall, 65.9% (7,219/10,967) reported receiving at least one potentially illegal question. More female respondents reported being asked questions about gender (513/5,357 [9.6%] vs. 148/5,098 [2.9%]), marital status (2,895/5,283 [54.8%] vs. 2,592/4,990 [51.9%]), or plans for having children (889/5,241 [17.0%] vs. 521/4,931 [10.6%]) than male respondents (P < .001). Those in surgical specialties were more likely to have received a potentially illegal question than those in nonsurgical specialties (1,908/2,330 [81.9%] vs. 5,311/8,281 [64.1%]). Questions regarding their commitment to the program were reported by 15.5% (1,608/10,378) of respondents. Such potentially illegal questions negatively affected how respondents ranked programs.

Conclusions

Two-thirds of applicants reported being asked potentially illegal questions. More women than men reported receiving questions about marital status or family planning. Potentially illegal questions negatively influence how applicants perceive and rank programs. A formal interview code of conduct or interviewer training could help to address these issues.
Addressing the Irreducible Needs of Interprofessional Education: Creating and Sustaining an Institutional Commons for Health Professions Training
Authors: Earnest Mark A. , Pfeifle Andrea L.
Published: April 2016

Leaders in health professions education schools and programs are under pressure to respond to new accreditation requirements for interprofessional education (IPE). The work of creating and sustaining an IPE program at an academic health center is in many ways analogous to the challenge of creating and sustaining a “commons”—a set of resources shared by many, but owned by none. In this Commentary, the authors borrow from the work of Nobel Laureate Elinor Ostrum to describe the “design principles” necessary to build and maintain the set of common resources needed to successfully implement and sustain an IPE program. They interpret these principles in the context of their own experiences implementing IPE programs and recommend three institutional structural elements necessary to build and sustain an IPE program: (1) a representative governance body, (2) an accountable director or leader, and (3) a structure supporting vertical and horizontal communication and authority.
Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency
Authors: Englander Robert , Flynn Timothy , Call Stephanie , Carraccio Carol , Cleary Lynn , Fulton Tracy B. , Garrity Maureen J. , Lieberman Steven A. , Lindeman Brenessa , Lypson Monica L. , Minter Rebecca M. , Rosenfield Jay , Thomas Joe , Wilson Mark C. , Aschenbrener Carol A.
Published: April 2016

Currently, no standard defines the clinical skills that medical students must demonstrate upon graduation. The Liaison Committee on Medical Education bases its standards on required subject matter and student experiences rather than on observable educational outcomes. The absence of such established outcomes for MD graduates contributes to the gap between program directors’ expectations and new residents’ performance.

In response, in 2013, the Association of American Medical Colleges convened a panel of experts from undergraduate and graduate medical education to define the professional activities that every resident should be able to do without direct supervision on day one of residency, regardless of specialty. Using a conceptual framework of entrustable professional activities (EPAs), this Drafting Panel reviewed the literature and sought input from the health professions education community. The result of this process was the publication of 13 core EPAs for entering residency in 2014. Each EPA includes a description, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both novice learners and learners ready for entrustment.

The medical education community has already begun to develop the curricula, assessment tools, faculty development resources, and pathways to entrustment for each of the 13 EPAs. Adoption of these core EPAs could significantly narrow the gap between program directors’ expectations and new residents’ performance, enhancing patient safety and increasing residents’, educators’, and patients’ confidence in the care these learners provide in the first months of their residency training.
Convergent Validity of Three Methods for Measuring Postoperative Complications
Authors: Fritz Bradley A. , Escallier Krisztina E. , Ben Abdallah Arbi , Oberhaus Jordan , Becker Jennifer , Geczi Kristin , McKinnon Sherry , Helsten Dan L. , Sharma Anshuman , Wildes Troy S. , Avidan Michael S.
Published: April 2016

AbstractAbstract

In a study of over 1,500 subjects more than 30 days after surgery, patient-reported outcomes, compared to automated or manual chart review, demonstrated poor-to-moderate positive agreement (0 to 58%) and excellent negative agreement (82 to 100%). Discrepancies frequently reflected patients reporting events that occurred outside the time period of interest, suggesting that more effective in-hospital communication and thoughtful survey design may improve the value of patient-reported outcomes.

Supplemental Digital Content is available in the text.

Background

Anesthesiologists need tools to accurately track postoperative outcomes. The accuracy of patient report in identifying a wide variety of postoperative complications after diverse surgical procedures has not previously been investigated.

Methods

In this cohort study, 1,578 adult surgical patients completed a survey at least 30 days after their procedure asking if they had experienced any of 18 complications while in the hospital after surgery. Patient responses were compared to the results of an automated electronic chart review and (for a random subset of 750 patients) to a manual chart review. Results from automated chart review were also compared to those from manual chart review. Forty-two randomly selected patients were contacted by telephone to explore reasons for discrepancies between patient report and manual chart review.

Results

Comparisons between patient report, automated chart review, and manual chart review demonstrated poor-to-moderate positive agreement (range, 0 to 58%) and excellent negative agreement (range, 82 to 100%). Discordance between patient report and manual chart review was frequently explicable by patients reporting events that happened outside the time period of interest.

Conclusions

Patient report can provide information about subjective experiences or events that happen after hospital discharge, but often yields different results from chart review for specific in-hospital complications. Effective in-hospital communication with patients and thoughtful survey design may increase the quality of patient-reported complication data.
General Anesthesia Causes Epigenetic Histone Modulation of c-Fos and Brain-derived Neurotrophic Factor, Target Genes Important for Neuronal Development in the Immature Rat Hippocampus
Authors: Dalla Massara Lorenza , Osuru Hari Prasad , Oklopcic Azra , Milanovic Desanka , Joksimovic Srdjan Milan , Caputo Valentina , DiGruccio Michael Robert , Ori Carlo , Wang Guangfu , Todorovic Slobodan Milenko , Jevtovic-Todorovic Vesna
Published: April 2016

AbstractAbstract

Exposure to general anesthesia during critical stages of synaptogenesis modulated expression and function of the key transcription factors, cAMP-responsive element-binding protein (CREB) and CREB-binding protein. CREB-binding protein and CREB modulation may, in turn, cause epigenetic changes manifested as histone hypoacetylation, leading to down-regulated transcription of the target genes cellular Finkel-Biskis-Jinkins murine sarcoma virus osteosarcoma oncogene and brain-derived neurotrophic factor, which play an important role in neuronal development.

Background

Early postnatal exposure to general anesthesia (GA) may be detrimental to brain development, resulting in long-term cognitive impairments. Older literature suggests that in utero exposure of rodents to GA causes cognitive impairments in the first-generation as well as in the second-generation offspring never exposed to GA. Thus, the authors hypothesize that transient exposure to GA during critical stages of synaptogenesis causes epigenetic changes in chromatin with deleterious effects on transcription of target genes crucial for proper synapse formation and cognitive development. They focus on the effects of GA on histone acetyltransferase activity of cAMP-responsive element-binding protein and the histone-3 acetylation status in the promoters of the target genes brain-derived neurotrophic factor and cellular Finkel-Biskis-Jinkins murine sarcoma virus osteosarcoma oncogene (c-Fos) known to regulate the development of neuronal morphology and function.

Methods

Seven-day-old rat pups were exposed to a sedative dose of midazolam followed by combined nitrous oxide and isoflurane anesthesia for 6 h. Hippocampal neurons and organotypic hippocampal slices were cultured in vitro and exposed to GA for 24 h.

Results

GA caused epigenetic modulations manifested as histone-3 hypoacetylation (decrease of 25 to 30%, n = 7 to 9) and fragmentation of cAMP-responsive element-binding protein (two-fold increase, n = 6) with 25% decrease in its histone acetyltransferase activity, which resulted in down-regulated transcription of brain-derived neurotrophic factor (0.2- to 0.4-fold, n = 7 to 8) and cellular Finkel-Biskis-Jinkins murine sarcoma virus osteosarcoma oncogene (about 0.2-fold, n = 10 to 12). Reversal of histone hypoacetylation with sodium butyrate blocked GA-induced morphological and functional impairments of neuronal development and synaptic communication.

Conclusion

Long-term impairments of neuronal development and synaptic communication could be caused by GA-induced epigenetic phenomena.
Postoperative Urinary Catheterization Thresholds of 500 versus 800 ml after Fast-track Total Hip and Knee Arthroplasty
Authors: Bjerregaard Lars S. , Hornum Ulla , Troldborg Charlotte , Bogoe Stina , Bagi Per , Kehlet Henrik
Published: April 2016

AbstractAbstract

Eight hundred patients having major orthopedic surgery were randomized, with 721 providing per-protocol results. Thirteen percent of patients assigned to the 800-ml threshold were catheterized, whereas 32% were in the 500-ml group. Urinary complications did not differ. An 800-ml catheterization threshold thus appears preferable.

Background

No evidence-based threshold exists for postoperative urinary bladder catheterization. The authors hypothesized that a catheterization threshold of 800 ml was superior to 500 ml in reducing postoperative urinary catheterization and urological complications after fast-track total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

This was a randomized, controlled, open-label trial that included patients greater than or equal to 18 yr who underwent THA or TKA in three Danish, fast-track, orthopedic departments. Consenting patients were eligible if they were cooperative and understood Danish. Participants were randomly allocated to a catheterization threshold of 500 or 800 ml, using opaque sealed envelopes. Group assignment was unmasked. Ultrasound bladder scans were performed every second hour until the first voluntary micturition, with subsequent urinary catheterization according to group assignment. The primary outcome was the number of patients catheterized before their first voluntary micturition. Thirty-day telephonic follow-up was on voiding difficulties, urinary tract infections, and readmissions.

Results

Of 800 patients allocated, 721 (90%) were included in a per-protocol analysis (20 did not complete the study and 59 were excluded from the analysis). In the 500-ml group, 32.2% received catheterization (114 of 354) compared to 13.4% (49 of 367) in the 800-ml group (relative risk, 0.4; 95% CI, 0.3 to 0.6; P < 0.0001). The authors found no difference between groups in any secondary outcome.

Conclusions

In fast-track THA and TKA, a catheterization threshold of 800 ml significantly reduced the need for postoperative urinary catheterization, without increasing urological complications. This large randomized, controlled trial may serve as a basis for evidence-based guidelines on perioperative urinary bladder management.
Liposome Bupivacaine Femoral Nerve Block for Postsurgical Analgesia after Total Knee Arthroplasty
Authors: Hadzic Admir , Minkowitz Harold S. , Melson Timothy I. , Berkowitz Richard , Uskova Anna , Ringold Forrest , Lookabaugh Janice , Ilfeld Brian M.
Published: April 2016

AbstractAbstract

In a two-part clinical study designed to meet the U.S. Food and Drug Administration standard for approval of analgesic agents, femoral nerve block with liposome bupivacaine after total knee arthroplasty resulted in modestly reduced average pain and opioid use in the first 72 h after surgery compared with placebo. Side effects were similar in both groups, supporting further investigation.

Background

The authors evaluated the efficacy of liposome bupivacaine in a femoral nerve block (FNB) after total knee arthroplasty.

Methods

Part 1: subjects received FNB with 20 ml liposome bupivacaine (67, 133, or 266 mg) or placebo. Part 2: subjects were randomized to FNB with liposome bupivacaine 266 mg or placebo. The primary outcome measure was area under the curve of the numeric rating scale score for pain intensity at rest through 72 h (AUC NRS-R0–72) with imputed scores after rescue medication.

Results

In part 1, FNB with liposome bupivacaine 266 mg (n = 24) resulted in analgesia similar to that obtained with 133 mg and was chosen for part 2. In part 2, least-squares mean (standard error) AUC NRS-R0–72 was lower with liposome bupivacaine 266 mg (n = 92) than with placebo (n = 91; 419 [17] vs. 516 [17]; P < 0.0001). This outcome remained unchanged in a post hoc analysis without score imputation (221 [12] vs. 282 [12]; P = 0.0005). Least-squares mean AUC NRS-R with imputed scores was lower with liposome bupivacaine during each 24-h interval (0 to 24, 24 to 48, and 48 to 72 h) after surgery; AUC NRS-R without imputed scores was lower during the 0- to 24-h and 24- to 48-h intervals. The liposome bupivacaine group had lower mean total opioid use (76 vs. 103 mg morphine; P = 0.0016). Pain was sufficiently severe to require second-step rescue with opioids via intravenously administered patient-controlled analgesia in 92% of liposome bupivacaine patients and 81% of placebo patients. With patient-controlled analgesia and other forms of rescue analgesia, mean NRS scores with activity were moderate in both liposome bupivacaine and placebo groups throughout the part 2 study period. Incidence of adverse events was similar between the groups (part 1: 90 vs. 96%; part 2: 96 vs. 96%, respectively).

Conclusion

FNB with liposome bupivacaine (266 mg) resulted in modestly lower pain scores and reduced opioid requirements after surgery, with an adverse event profile similar to placebo.
Differential Perceptions of Noninvasive Ventilation in Intensive Care among Medical Caregivers, Patients, and Their Relatives
Authors: Schmidt Matthieu , Boutmy-Deslandes Emmanuelle , Perbet Sébastien , Mongardon Nicolas , Dres Martin , Razazi Keyvan , Guerot Emmanuel , Terzi Nicolas , Andrivet Pierre , Alves Mikael , Sonneville Romain , Cracco Christophe , Peigne Vincent , Collet Francois , Sztrymf Benjamin , Rafat Cedric , Reuter Danielle , Fabre Xavier , Labbe Vincent , Tachon Guillaume , Minet Clémence , Conseil Matthieu , Azoulay Elie , Similowski Thomas , Demoule Alexandre
Published: April 2016

AbstractAbstract

A large-sample questionnaire (396 patients, 1,063 clinicians, and 145 relatives) from 32 intensive care units revealed that concerns about noninvasive ventilation were greatest among nurses (workload) and patients (dyspnea, anxiety). Future research may reveal how to improve the effectiveness and acceptance of noninvasive ventilation.

Supplemental Digital Content is available in the text.

Background

Noninvasive ventilation (NIV) requires a close “partnership” between a conscious patient and the patient’s caregivers. Specific perceptions of NIV stakeholders and their impact have been poorly described to date. The objectives of this study were to compare the perceptions of NIV by intensive care unit (ICU) physicians, nurses, patients, and their relatives and to explore factors associated with caregivers’ willingness to administer NIV and patients’ and relatives’ anxiety in relation to NIV.

Methods

This is a prospective, multicenter questionnaire-based study.

Results

Three hundred and eleven ICU physicians, 752 nurses, 396 patients, and 145 relatives from 32 ICUs answered the questionnaire. Nurses generally reported more negative feelings and more frequent regrets about providing NIV (median score, 3; interquartile range, [1 to 5] vs. 1 [1 to 5]; P < 0.0001) compared to ICU physicians. Sixty-four percent of ICU physicians and only 32% of nurses reported a high level of willingness to administer NIV, which was independently associated with NIV case-volume and workload. A high NIV session–related level of anxiety was observed in 37% of patients and 45% of relatives. “Dyspnea during NIV,” “long NIV session,” and “the need to have someone at the bedside” were identified as independent risk factors of high anxiety in patients.

Conclusions

Lack of willingness of caregivers to administer NIV and a high level of anxiety of patients and relatives in relation to NIV are frequent in the ICU. Most factors associated with low willingness to administer NIV by nurses or anxiety in patients and relatives may be amenable to change. Interventional studies are now warranted to evaluate how to reduce these risk factors and therefore contribute to better management of a potentially traumatic experience. (Anesthesiology 2016; 124:1347-59)
Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial
Authors: Dehghan Niloofar , McKee Michael D. , Jenkinson Richard J. , Schemitsch Emil H. , Stas Venessa , Nauth Aaron , Hall Jeremy A. , Stephen David J. , Kreder Hans J.
Published: April 2016

Objectives:

The aim of this study was to compare early weightbearing and range of motion (ROM) to nonweightbearing and immobilization in a cast after surgical fixation of unstable ankle fractures.

Design:

Multicentre randomized controlled trial.

Setting:

Two-level one trauma centers.

Patients:

One hundred ten patients who underwent open reduction and internal fixation of an unstable ankle fracture were recruited and randomized.

Intervention:

One of 2 rehabilitation protocols: (1) Early weightbearing (weightbearing and ROM at 2 weeks, Early WB) or (2) Late weightbearing (nonweightbearing and cast immobilization for 6 weeks, Late WB).

Main Outcome Measurements:

The primary outcome measure was time to return to work (RTW). Secondary outcome measures included: ankle ROM, SF-36 heath outcome scores, Olerud/Molander ankle function score, and rates of complications.

Results:

There was no difference in RTW. At 6 weeks postoperatively, patients in the Early WB group had significantly improved ankle ROM (41 vs. 29, P < 0.0001); Olerud/Molander ankle function scores (45 vs. 32, P = 0.0007), and SF-36 scores on both the physical (51 vs. 42, P = 0.008) and mental (66 vs. 54, P = 0.0008) components. There were no differences with regard to wound complications or infections and no cases of fixation failure or loss of reduction. Patients in the Late WB group had higher rates of planned/performed hardware removal due to plate irritation (19% vs. 2%, P = 0.005).

Conclusions:

Given the convenience for the patient, early improved functional outcome, and the lack of an increased complication rate, we recommend early postoperative weightbearing and ROM in patients with surgically treated ankle fractures.

Level of Evidence:

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Which Malpositioned Pedicle Screws Should Be Revised?
Authors: Floccari Lorena V. , Larson A. Noelle , Crawford Charles H. , Ledonio Charles G. , Polly David W. , Carreon Leah Y. , Blakemore Laurel
Published: April 2016

Background:

Up to 10% of free-hand pedicle screws are malpositioned, and 1 in 300 patients may undergo return to surgery for revision of malpositioned screws. The indications for revision of asymptomatic malpositioned screws have not been carefully examined in the literature. We sought to evaluate the threshold among spinal deformity surgeons for revision of malpositioned screws.

Methods:

Twelve experienced spine surgeons reviewed x-ray and computed tomographic images of 32 malpositioned pedicle screws with variable degrees of anterior, medial, and lateral breeches. The surgeons were asked whether based on the image they would revise the screw: (1) intraoperatively before rod placement; (2) intraoperatively after rod placement; (3) in clinic with an asymptomatic patient. For each scenario, we assumed stable neuromonitoring and no neurological changes. Agreement and multirater κ was calculated.

Results:

There was good agreement as to which screws were malpositioned (80% agreement, κ=0.703). After the rod was placed or postoperatively (scenarios 2 and 3), surgeons less frequently recommended screw revision, and there was greater variability among the surgeons’ recommendations. For return to surgery from clinic for asymptomatic screw revision, % agreement was only 65% (κ=0.477). The majority recommended revision surgery for screws which approached the dura (10/12) or the aorta (7/12 surgeons). Half of the surgeons recommended revision surgery for an asymptomatic screw if the entire screw diameter was in the canal. Revision surgery was not recommended for asymptomatic patients with screws partially violating the canal (<½ the screw diameter), malpositioned laterally in the rib head, or with small anterior cortical violations remote from a vascular structure.

Conclusions:

There is significant variability of opinion among surgeons regarding which malpositioned screws can be safely observed in an asymptomatic patient. Given the frequency of malpositioned screws and morbidity of surgical return to surgery, more long-term data are needed to develop practice guidelines for determining which screws require revision surgery.

Level of Evidence:

Level III—retrospective comparative study.
Bridge Plating Length-Unstable Pediatric Femoral Shaft Fractures
Authors: Sutphen Sean A. , Beebe Allan C. , Klingele Kevin E.
Published: April 2016

The treatment of pediatric diaphyseal femur fractures, particularly length-unstable fractures, continues to be an area of controversy in patients from age 6 to skeletal maturity. Submuscular bridge plating is an alternative that allows for stable internal fixation while minimizing soft tissue disruption. We describe a surgical technique that has simplified both implantation and removal. This technique provides a stable construct in comminuted and unstable fracture patterns allowing for early mobilization with minimal complications.
Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study*
Authors: Mehta Anuj B. , Cooke Colin R. , Wiener Renda Soylemez , Walkey Allan J.
Published: April 2016

Objective:

Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.

Design:

In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. “Early tracheostomy” was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression.

Setting:

2012 National Inpatient Sample.

Patients:

A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy.

Interventions:

None.

Measurements and Main Results:

Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01–1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98–1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9–81.9%) compared with pneumonia/sepsis (14.9–38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home.

Conclusion:

Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.
Automatic Classification of Sedation Levels in ICU Patients Using Heart Rate Variability
Authors: Nagaraj Sunil B. , McClain Lauren M. , Zhou David W. , Biswal Siddharth , Rosenthal Eric S. , Purdon Patrick L. , Westover M. Brandon
Published: April 2016

Objective:

To explore the potential value of heart rate variability features for automated monitoring of sedation levels in mechanically ventilated ICU patients.

Design:

Multicenter, pilot study.

Setting:

Several ICUs at Massachusetts General Hospital, Boston, MA.

Patients:

Electrocardiogram recordings from 40 mechanically ventilated adult patients receiving sedatives in an ICU setting were used to develop and test the proposed automated system.

Measurements and Main Results:

Richmond Agitation-Sedation Scale scores were acquired prospectively to assess patient sedation levels and were used as ground truth. Richmond Agitation-Sedation Scale scores were grouped into four levels, denoted “unarousable” (Richmond Agitation- Sedation Scale = –5, –4), “sedated” (–3, –2, –1), “awake” (0), “agitated” (+1, +2, +3, +4). A multiclass support vector machine algorithm was used for classification. Classifier training and performance evaluations were carried out using leave-oneout cross validation. An overall accuracy of 69% was achieved for discriminating between the four levels of sedation. The proposed system was able to reliably discriminate (accuracy = 79%) between sedated (Richmond Agitation-Sedation Scale < 0) and nonsedated states (Richmond Agitation-Sedation Scale > 0).

Conclusions:

With further refinement, the methodology reported herein could lead to a fully automated system for depth of sedation monitoring. By enabling monitoring to be continuous, such technology may help clinical staff to monitor sedation levels more effectively and to reduce complications related to over- and undersedation.
A Serious Adult Intraosseous Catheter Complication and Review of the Literature
Authors: Greenstein Yonatan Y. , Koenig Seth J. , Mayo Paul H. , Narasimhan Mangala
Published: April 2016

Objective:

Current guidelines recommend the use of intraosseous access when IV access is not readily attainable. The pediatric literature reports an excellent safety profile, whereas only small prospective studies exist in the adult literature. We report a case of vasopressor extravasation and threatened limb perfusion related to intraosseous access use and our management of the complication. We further report our subsequent systematic review of intraosseous access in the adult population.

Data Sources:

Ovid Medline was searched from 1946 to January 2015.

Study Selection:

Articles pertaining to intraosseous access in the adult population (age greater than or equal to 14 years) were selected. Search terms were “infusion, intraosseous” (all subfields included), and intraosseous access” as key words.

Data Extraction:

One author conducted the initial literature review. All authors assessed the methodological quality of the studies and consensus was used to ensure studies met inclusion criteria.

Data Synthesis:

The case of vasopressor extravasation was successfully treated with pharmacologic interventions, which reversed the effects of the extravasated vasopressors: intraosseous phentolamine, topical nitroglycerin ointment, and intraarterial verapamil and nitroglycerin. Our systematic review of the adult literature found 2,332 instances of intraosseous insertion. A total of 2,106 intraosseous insertion attempts were made into either the tibia or the humerus; 192 were unsuccessful, with an overall success rate of 91%. Five insertions were associated with serious complications. A total of 226 insertion attempts were made into the sternum; 54 were unsuccessful, with an overall success rate of 76%.

Conclusions:

Intraosseous catheter insertion provides a means for rapid delivery of medications to the vascular compartment with a favorable safety profile. Our systematic literature review of adult intraosseous access demonstrates an excellent safety profile with serious complications occurring in 0.3% of attempts. We report an event of vasopressor extravasation that was potentially limb threatening. Therapy included local treatment and injection of intraarterial vasodilators. Intraosseous access complications should continue to be reported, so that the medical community will be better equipped to treat them as they arise.
The Efficacy of Noble Gases in the Attenuation of Ischemia Reperfusion Injury: A Systematic Review and Meta-Analyses
Authors: De Deken Julie , Rex Steffen , Monbaliu Diethard , Pirenne Jacques , Jochmans Ina
Published: April 2016

Objective:

Noble gases have been attributed to organ protective effects in ischemia reperfusion injury in a variety of medical conditions, including cerebral and cardiac ischemia, acute kidney injury, and transplantation. The aim of this study was to appraise the available evidence by systematically reviewing the literature and performing meta-analyses.

Data Sources:

PubMed, EMBASE, and the Cochrane Library.

Study Selection:

Inclusion criteria specified any articles on noble gases and either ischemia reperfusion injury or transplantation. In vitro studies, publications without full text, review articles, and letters were excluded.

Data Extraction:

Information on noble gas, organ, species, model, length of ischemia, conditioning and noble gas dose, duration of administration of the gas, endpoints, and effects was extracted from 79 eligible articles. Study quality was evaluated using the Jadad scale. Effect sizes were extracted from the articles or retrieved from the authors to allow meta-analyses using the random-effects approach.

Data Synthesis:

Argon has been investigated in cerebral, myocardial, and renal ischemia reperfusion injury; helium and xenon have additionally been tested in hepatic ischemia reperfusion injury, whereas neon was only explored in myocardial ischemia reperfusion injury. The majority of studies show a protective effect of these noble gases on ischemia reperfusion injury across a broad range of experimental conditions, organs, and species. Overall study quality was low. Meta-analysis for argon was only possible in cerebral ischemia reperfusion injury and did not show neuroprotective effects. Helium proved neuroprotective in rodents and cardioprotective in rabbits, and there were too few data on renal ischemia reperfusion injury. Xenon had the most consistent effects, being neuroprotective in rodents, cardioprotective in rodents and pigs, and renoprotective in rodents.

Conclusions:

Helium and xenon show organ protective effects mostly in small animal ischemia reperfusion injury models. Additional information on timing, dosing, and comparative efficacy of the different noble gases, as well as confirmation in large animal models, is needed before designing clinical trials.
Paricalcitol Attenuates Cardiac Fibrosis and Expression of Endothelial Cell Transition Markers in Isoproterenol-Induced Cardiomyopathic Rats
Authors: Lai Chi-Cheng , Liu Chun-Peng , Cheng Pei-Wen , Lu Pei-Jung , Hsiao Michael , Lu Wen-Hsien , Sun Gwo-Ching , Liou Jau-Cheng , Tseng Ching-Jiunn
Published: April 2016

Objectives:

Acute cardiomyopathy is a health problem worldwide. Few studies have shown an association between acute cardiomyopathy and low vitamin D status. Paricalcitol, a vitamin D receptor activator, clinically benefits patients with advanced kidney disease. The effect of paricalcitol supplement on cardiac remodeling in cardiomyopathic rats is unknown. This experimental study investigated the effect of paricalcitol in rats with cardiomyopathy induced by isoproterenol.

Design:

Prospective, randomized, controlled experimental study.

Setting:

Hospital-affiliated animal research institution.

Subjects:

Eight-week-old male Wistar-Kyoto rats.

Interventions:

Male Wistar-Kyoto rats were first injected intraperitoneally with isoproterenol to create a rat model of acute cardiomyopathy. Then paricalcitol was administered intraperitoneally to isoproterenol-injected rats at a dosage of 200 ng three times a week for 3 weeks. Relevant cardiomyopathy-related variables were measured regularly in three groups of rats, controls, isoproterenol, and isoproterenol plus paricalcitol. Rat hearts were obtained for evaluation of cardiac fibrosis using Masson trichrome staining and commercially available software, and evaluation of cell transition using immunofluorescence staining analysis.

Measurements and Main Results:

Isoproterenol infusions generated significant cardiac fibrosis (p < 0.001). Subsequent paricalcitol treatment attenuated the isoproterenol-induced cardiac fibrosis (p = 0.006). Fluorescence showed colocalization of endothelial and fibroblast cell markers (cluster differentiation 31 and α-smooth muscle actin, respectively) in the isoproterenol-treated hearts. Paricalcitol injections attenuated the isoproterenol-induced fluorescence intensity of two cell markers (p < 0.01).

Conclusions:

Paricalcitol injections may ameliorate isoproterenol-induced cardiac fibrosis possibly through regulating cell transition.
Cardiac Arrests Associated With Tracheal Intubations in PICUs: A Multicenter Cohort Study*
Authors: Shiima Yuko , Berg Robert A. , Bogner Hillary R. , Morales Knashawn H. , Nadkarni Vinay M. , Nishisaki Akira
Published: April 2016

Objectives:

To determine the incidence and epidemiologic characteristics of cardiac arrests among tracheal intubations in PICUs.

Design:

Retrospective cohort study of prospectively collected data.

Setting:

Twenty-five diverse PICUs.

Patients:

Critically ill children requiring tracheal intubation in PICUs.

Interventions:

Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubations in 25 PICUs from July 2010 to March 2014 using National Emergency Airway Registry for Children registry.

Measurements and Main Results:

Tracheal intubation–associated cardiac arrest was defined as chest compressions more than 1 minute occurring during tracheal intubation or within 20 minutes after tracheal intubation. A total of 5,232 pediatric tracheal intubations were evaluated. Tracheal intubation–associated cardiac arrest was reported in 87 (1.7%). Patient factors (demographics and indications for tracheal intubation), provider factors (discipline and training level), and practice factors (tracheal intubation method and use of neuromuscular blockade) were recorded. Hemodynamic instability and oxygenation failure as tracheal intubation indications were associated with cardiac arrests (adjusted odds ratio, 6.3; 95% CI, 3.9–10.3; and adjusted odds ratio, 4.3; 95% CI, 2.6–6.9, respectively). History of difficult airway and cardiac disease were also associated with cardiac arrests (adjusted odds ratio, 2.1; 95% CI, 1.2–3.5; and adjusted odds ratio, 2.1; 95% CI, 1.2–3.9, respectively). Provider and practice factors were not associated with cardiac arrests, and provider factors did not modify the effect of patient factors on cardiac arrests.

Conclusions:

Tracheal intubation–associated cardiac arrests occurred during 1.7% of PICU tracheal intubations. Tracheal intubation–associated cardiac arrests were much more common with tracheal intubations when the child had acute hemodynamic instability or oxygen failure and when the child had a history of difficult airway or cardiac disease.
Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds*
Authors: Gall Christine , Wetzel Randall , Kolker Alexander , Kanter Robert K. , Toltzis Philip
Published: April 2016

Objectives:

To develop and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented.

Design:

Retrospective observational study using secondary data.

Patients:

Children admitted to VPS-participating PICUs between 2009–2012.

Interventions:

A total of 111,174 randomly selected nonelective cases from the Virtual PICU Systems database were used to estimate each patient’s probability of death and duration of ventilation employing previously derived predictive equations. Using real and projected statistics for the State of Ohio as an example, triage thresholds were established for casualty volumes ranging from 5,000 to 10,000 for a modeled pandemic with peak duration of 6 weeks and 280 pediatric intensive care beds. The goal was to simultaneously maximize casualty survival and bed occupancy. Discrete Event Simulation was used to determine triage thresholds for probability of death and duration of ventilation as a function of casualty volume and the total number of available beds. Simulation was employed to compare survival between the proposed triage algorithm and a first come first served distribution of scarce resources.

Measurements and Main Results:

Population survival was greater using the triage thresholds compared with a first come first served strategy. In this model, for five, six, seven, eight, and 10 thousand casualties, the triage algorithm increased the number of lives saved by 284, 386, 547, 746, and 1,089, respectively, compared with first come first served (all p < 0.001).

Conclusions:

Use of triage thresholds based on probability of death and duration of mechanical ventilation determined from actual critically ill children’s data demonstrated superior population survival during a simulated overwhelming pandemic.
Insights into next developments in advanced gastric cancer
Authors: Obermannová Radka , Lordick Florian
Published: April 2016

Purpose of review

The purpose of the review is to delineate novel approaches for biology-based treatment in advanced gastric cancer. We reviewed the latest translational and clinical research articles and congress presentations.

Recent findings

A new molecular classification of gastric cancer based on histology, genetic and proteomic alterations has evolved. It provides a roadmap for development of new drugs and combinations and for patient stratification. Anti-HER2 treatment, which is an effective strategy in metastatic gastric cancer, is now also being studied in the perioperative setting. However, resistance mechanisms in advanced disease are poorly understood and optimal patient selection remains challenging. Targeting angiogenesis is an emerging concept in the management of advanced gastric cancer, and ramucirumab has prolonged survival in the second line either as a monotherapy or in combination with paclitaxel. Biomarkers for selecting patients who benefit from ramucirumab are still lacking. Immune checkpoint blockade and inhibition of cancer stemness targets are other emerging directions for the medical treatment of gastric cancer. Large-scale international studies are ongoing.

Promising biology-based treatment strategies are evolving. But tumor heterogeneity which is an inherent feature of gastric cancer challenges the development of molecularly targeted and personalized treatment strategies.
MAGE-A is More Highly Expressed Than NY-ESO-1 in a Systematic Immunohistochemical Analysis of 3668 Cases
Authors: Kerkar Sid P. , Wang Zeng-Feng , Lasota Jerzy , Park Tristen , Patel Krishna , Groh Eric , Rosenberg Steven A. , Miettinen Markku M.
Published: April 2016

Two cancer testis antigens, the New York esophageal squamous cell carcinoma-1 (NY-ESO-1) and the melanoma-antigen family A (MAGE-A), represent promising immunotherapy targets due to the low expression of these antigens in nonmalignant tissue. To assess overexpression patterns in various cancers, we performed a systematic immunohistochemical analysis for NY-ESO-1 and MAGE-A on tissue array samples of 3668 common epithelial carcinomas (CA) and germ cell tumors of high prevalence and mortality. Here, we find significantly higher expression of MAGE-A (>50% on tumor cells) compared with NY-ESO-1 in several CAs including cutaneous squamous cell carcinomas (SCC) (52.8%/2.8%), esophageal SCC (50%/0%), head and neck SCC (41.1%/<1%), bladder urothelial CA (40.4%/8.3%), cervical/anal SCC (37.5%/0%), lung SCC (34%/3.8%), lung adenocarcinomas (27.6%/3.9%), ovarian CA (26.4%/3.6%), endometrial CA (26.3%/1.3%), lung small cell CA (24.4%/2.4%), gastric adenocarcinomas (20%/4%), breast mucinous CA (19.3%/0%), hepatocellular CA (18.8%/1.2%), breast infiltrating ductal CA (16.4%/1.8%), colorectal adenocarcinomas (10.7%/<1%), cholangiocarcinomas (9.8%/0%), thymic CA (9%/4.5%), and mesotheliomas (7.9%/<1%). Furthermore, high expression of MAGE-A, but not NY-ESO-1, was seen in whole slide evaluations of an independent cohort of metastatic SCC (45.5%/3.6%) and metastatic CA (13.5%/0%) of various primaries with significantly higher expression of MAGE-A in metastatic SCC compared with other metastatic CA. MAGE-A is also more highly expressed in germ cell tumors, seminomas (69%/3.5%) and nonseminomas (40.1%/4.7%). In summary, MAGE-A is more highly expressed than NY-ESO-1 in a majority of human malignancies, and targeting MAGE-A may benefit a large number of patients.