bluuebunny/crossref_metadata_2025 huggingface dataset:
Integrated prodrug micelles with two-photon bioimaging and pH-triggered drug delivery for cancer theranostics
Authors: Xu Hong , Ma Boxuan , Jiang Jizhou , Xiao Sutong , Peng Rongrong , Zhuang Weihua , Li Gaocan , Wang Yunbing
Published: November 2019

Nanodrug carriers with fluorescence radiation are widely used in cancer diagnosis and therapy due to their real-time imaging, less side effect, better drug utilization as well as the good bioimaging ability. However, traditional nanocarriers still suffer from unexpectable drug leakage, unsatisfactory tumor-targeted drug delivery and shallow imaging depth, which limit their further application in cancer theranostics. In this study, an integrated nanoplatform is constructed by polymeric prodrug micelles with two-photon and aggregation-induced emission bioimaging, charge reversal and drug delivery triggered by acidic pH. The prodrug micelles can be self-assembled by the TP-PEI (DA/DOX)-PEG prodrug polymer, which consists of the two-photon fluorophore (TP), dimethylmaleic anhydride (DA) grafted polyethyleneimine (PEI) and polyethylene glycol (PEG). The PEG segment, DOX and DA are bridged to polymer by acid cleavable bonds, which provides the micelles a ‘stealth’ property and a satisfactory stability during blood circulation, while the outside PEG segment is abandoned along with the DA protection in the tumor acidic microenvironment, thus leading to charge reversal-mediated accelerated endocytosis and tumor-targeted drug delivery. The great antitumor efficacy and reduced side effect of these pH-sensitive prodrug micelles are confirmed by antitumor assays in vitro and in vivo. Meanwhile, these micelles exhibited great deep-tissue two-photon bioimaging ability up to 150 μm in depth. The great antitumor efficacy, reduced side effect and deep two-photon tissue imaging make the TP-PEI (DA/DOX)-PEG prodrug micelles would be an efficient strategy for theranostic nanoplatform in cancer treatment.
Job satisfaction and workplace stressors among surgical providers at a single institution
Authors: Gates Rebecca , Workman Allison , Collier Bryan
Published: November 2019

Objective:

Job satisfaction and work stress are associated with provider health and patient outcomes. This study aimed to evaluate job satisfaction and workplace stressors in surgical providers (surgeons, physician assistants [PAs], and NPs).

Methods:

A survey was distributed to providers within a single surgical department. Job satisfaction and workplace stressors were evaluated by sex, age, profession, career length, and work hours.

Results:

Providers practicing for 11 to 15 years had greater job satisfaction than those practicing for more than 20 years, with no other differences by demographic group. Females cited supervisory support as a top workplace stressor more than did males (P = .01) and PAs and NPs cited supervisory support (P < .01) and compensation/finances more than surgeons (P = .05). Workplace stressors varied by practice years and work hours.

Conclusions:

Healthcare organizations should be aware of diversity in perceived workplace stressors. A “one size fits all” approach to provider well-being is likely to be ineffective.
The loop technique for abscess management
Authors: Dettmar Robyn
Published: November 2019

First used in the surgical suite in children, the loop technique is a simple method for managing abscesses that does not require postprocedural packing. The procedure is safe and effective for children and adults and can be used in a broad range of settings, including EDs, urgent cares, and outpatient clinics.
How Do Attending Physicians Prepare Residents to Deliver High-Value, Cost-Conscious Care?
Authors: Stammen Lorette A. , Driessen Erik W. , Notermans Celine C.V.I. , Scheele Fedde , Stassen Laurents P.S. , Stalmeijer Renée E.
Published: November 2019

Purpose

An estimated 20% of health care expenditures are wasteful. Educational interventions aimed at reducing waste by delivering high-value, cost-conscious care (HV3C) often focus on the role of the physician. This study sought to understand how attending physicians, who have a central role in the workplace, prepare residents to provide HV3C.

Method

Researchers from Maastricht University in Maastricht, the Netherlands, conducted semistructured interviews between September 2016 and August 2017 with 12 attending physicians who supervise residents in the workplace. Participants were purposefully sampled from 5 institutions throughout the Netherlands to include surgical and nonsurgical attending physicians and hospital- and nonhospital-based physicians. Data collection and analysis were iterative, using principles of grounded theory.

Results

The attending physician’s approach to providing HV3C was an important factor in preparing residents in the workplace. Three differences became apparent: priority of HV3C training, feedback on HV3C, and obstacles to HV3C delivery. Results indicate that attending physicians use 3 teaching methods to teach HV3C delivery: Socratic questioning, role modeling, and setting limits. Training was often implicit and ad hoc.

Conclusions

How attending physicians deal with HV3C themselves influences how they prepare residents in the workplace. To optimize resident training, it may be important to create a supportive environment for HV3C delivery and training. Delivery could be supported by making HV3C a shared goal for attending physicians and residents, thereby providing insight into clinical practice behavior and minimizing the influence of obstacles. Training could be optimized by supporting a variety of teaching methods suitable for daily teaching to stimulate continuous learning in residents.
The Effectiveness of Teaching Clinical Empathy to Medical Students: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Authors: Fragkos Konstantinos C. , Crampton Paul E.S.
Published: November 2019

Purpose

Clinical empathy is a necessary trait to provide effective patient care, despite differences in how it is defined and constructed. The aim of this study was to examine whether empathy interventions in medical students are effective and how confounding factors potentially moderate this effect.

Method

The authors performed a systematic review and meta-analysis. They searched the literature published between 1948 and 2018 for randomized controlled trials that examined empathy interventions in medical students. The search (database searching, citation tracking, hand-searching relevant journals) yielded 380 studies, which they culled to 16 that met the inclusion criteria. For the meta-analysis, they used a random effects model to produce a pooled estimate of the standardized mean difference (SMD), then completed subgroup analyses.

Results

The authors found evidence of the possibility of response and reporting bias. The pooled SMD was 0.68 (95% confidence interval 0.43, 0.93), indicating a moderately positive effect of students developing empathy after an intervention compared with those in the control groups. There was no evidence of publication bias, but heterogeneity was significantly high (I
2 = 88.5%, P < .01). Subgroup analyses indicated that significant moderating factors for developing empathy were age, country, scope of empathy measurement, type of empathy intervention, and presence of rehearsal. Moderating factors with limited evidence were sex, study quality, journal impact factor, and intervention characteristics.

Conclusions

Despite heterogeneity and biases, empathy interventions in medical students are effective. These findings reinforce arguments in the literature and add considerable rigor from the meta-analysis. The authors propose a conceptual model for educators to follow when designing empathy interventions in medical students.
Wideband Acoustic Immittance in Cochlear Implant Recipients: Reflectance and Stapedial Reflexes
Authors: Scheperle Rachel A. , Hajicek Joshua J.
Published: November 2019

Objectives:

to characterize differences in wideband power reflectance for ears with and without cochlear implants (CIs), to describe electrically evoked stapedial reflex (eSR)-induced changes in reflectance, and to evaluate the benefit of a broadband probe for reflex threshold determination for CI recipients. It was hypothesized that reflectance patterns in ears with CIs would be consistent with increased middle ear stiffness and that reflex thresholds measured with a broadband probe would be lower compared with thresholds obtained with a single-frequency probe.

Design:

Eleven CI recipients participated in both wideband reflectance and eSR testing. Ipsilateral reflexes were measured with three probes: a broadband chirp (swept from 200 to 8000 Hz), a 226 Hz tone, and a 678 Hz tone. Wideband reflectance measures acquired from 28 adults without CIs and with normal middle ear function served as a normative data set for comparison.

Results:

Considering the group data, average reflectance was significantly greater for ears with CIs across 250 to 891 Hz and 4238 to 4490 Hz compared with the normative data set, although individual reflectance curves were variable. Some CI recipients also had low 226 Hz admittance, which contributed to the group finding, considering the control group had clinically normal 226 Hz admittance by design. Electrically evoked stapedial reflexes were measurable in nine of 14 ears (64.3%) and in 24 of 46 electrodes (52.5%) tested. Reflex-induced changes in reflectance patterns were unique to the participant/ear, but similar across activators (electrodes) within a given ear. In addition, reflectance values at or above 1000 Hz were affected most by activating the stapedial reflex, even in ears with clinically normal 226 Hz admittance. This is a higher-frequency range than has been reported for acoustically evoked reflex-induced reflectance changes and is consistent with increased middle ear stiffness at rest. Electrically evoked reflexes could be measured more often with the 678 Hz or the broadband probe compared with the 226 Hz probe tone. Although reflex thresholds were lower with the broadband probe compared with the 678 Hz probe in 16 of 24 conditions, this was not a statistically significant finding (Wilcoxon signed-rank test; p = 0.072).

Conclusions:

The applications of wideband acoustic immittance measurements (reflectance and reflexes) should also be considered for ears with CIs. Further work is needed to describe changes across time in ears with CIs to more fully understand the reflectance pattern indicating increased middle ear stiffness and to optimize measuring eSRs with a broadband probe.
Bone Conduction Stimulation Applied Directly to the Otic Capsule: Intraoperative Assessment in Humans
Authors: Lachowska Magdalena , Niemczyk Kazimierz , Kwacz Monika , Małkowska Maria , Sokołowski Jacek
Published: November 2019

Objectives:

Aim was to investigate the innovative method of direct acoustic bone conduction (BC) stimulation applied directly to the otic capsule and measured intraoperatively by promontory displacement in living humans. The objective was to find the best stimulation site that provides the greatest transmission of vibratory energy in a living human and compare it with the results previously obtained in cadavers.

Design:

The measurements were performed in 4 adult patients referred to our department for vestibular schwannoma removal via translabyrinthine approach. The measurements were performed in the operated site. The cadaver data were obtained in our previous study and here they are reanalyzed for comparison. Promontory displacement was measured using a commercial scanning laser Doppler vibrometer. The laser Doppler vibrometer points located on the promontory were used to analyze the promontory displacement amplitude. Cochlear stimulation was induced with BC stimulation through an implant positioned at three sites. The first site was on the skull surface at the squamous part of the temporal bone (BC No. 1), the second at the bone forming the ampulla of the lateral semicircular canal (BC No. 2), and the third between the superior and lateral semicircular canals (BC No. 3). BC No. 2 and BC No. 3 were located directly on the otic capsule. Four frequencies in total were tested (500, 1000, 2000, and 4000 Hz), one at a time.

Results:

In patients, the detailed analysis of promontory displacement amplitudes revealed the BC No. 1 magnitude to be the smallest and significantly different from BC No. 2 and No. 3 at all measured frequencies. Transmission of vibratory energy at BC No. 2 and BC No. 3 was the most effective and similar with a small and insignificant difference at 500, 1000, and 4000 Hz, and a significant difference at 2000 Hz. The results observed in cadavers were similar to those in living humans. However, a few differences were observed when comparing patients and cadavers. Small and insignificant differences were found for BC No. 1. Almost the same results were obtained for BC No. 2 and BC No. 3 in cadavers as in living humans, with only BC No. 3 measurements results at 500 Hz at the limit of statistical significance, with no other significant differences observed.

Conclusions:

The results of this study indicate that the promontory vibration amplitude increases when the BC stimulation location approaches the cochlea. BC No. 1 stimulation located on the squama caused overall smaller displacement than both BC No. 2 and No. 3 screwed to the ampulla of the lateral semicircular canal and to the midpoint between the semicircular canals, respectively. In our opinion, the results of BC stimulation applied directly to the otic capsule present a potential new stimulation site that could be introduced in the field of BC hearing rehabilitation.
Do Hospital or Surgeon Volume Affect Outcomes After Surgical Management of Tibial Shaft Fractures?
Authors: Clement R. Carter , Strassle Paula D. , Ostrum Robert F.
Published: November 2019

Objectives:

To determine whether hospital and surgeon volume are associated with outcomes after operative fixation of tibial shaft fractures.

Methods:

Adults (≥18 year old) who underwent operative fixation of diaphyseal tibial fractures were identified in the New York Statewide Planning and Research Cooperative System data set from 2001 to 2015. Reoperation, nonunion, and other adverse event rates were compared across surgeon and hospital volume using multivariable Cox proportional hazards regression, adjusting for clinical and demographic factors. Low-volume providers (lowest 20%) were compared with high-volume providers (highest 20%). Low volume constituted <5 cases/year for hospitals and 1 case/year for surgeons. High volume constituted ≥40 cases/year for hospitals and ≥8 cases/year for surgeons.

Results:

Nine thousand one hundred forty-seven patients were included. Relative to high-volume surgeons, low-volume surgeons experienced slightly higher rates of pneumonia [2% vs. 1%, hazard ratio (HR) 2.50, 95% confidence interval (CI) 1.38–4.53, P = 0.003], and respiratory failure (5% vs. 3%, HR 1.88, 95% CI 1.30–2.71, P = 0.001). Compared with high-volume hospitals, low-volume hospitals experienced slightly lower rates of compartment syndrome (1% vs. 3%, HR 0.45, 95% CI 0.24–0.85, P = 0.01) and fasciotomies (3% vs. 7%, HR 0.57, 95% CI 0.38–0.85, P = 0.005). The rates of all other reoperations and adverse events compared among hospitals and surgeons were not significantly different.

Conclusions:

We did not detect a clinically meaningful volume–outcome relationship for either surgeons or hospitals despite the use of a robust database with rigorous statistical methodology. Of note, these findings should not be applied to rare complex injuries such as those with extensive bone loss or articular extension, which are not well represented by this study population. Therefore, we conclude that typical tibial shaft fracture, including open or closed injuries, can be safely managed in the vast majority of orthopaedic settings and that this care does not necessarily require transfer to a specialty centers. Future research into orthopaedic volume–outcome relationships could be strengthened by the use of functional outcomes (which would likely require well-organized multicenter prospective registries).

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Impact of Resident Training Level on Radiation Exposure During Fixation of Proximal Femur Fractures
Authors: Buxbaum Eric J. , Ponzio Danielle Y. , Griffiths Sean , Wu Eddie S. , Duque Andres F. , Post Zachary D. , Orozco Fabio R. , Ong Alvin C.
Published: November 2019

Objective:

To identify whether residents are at greater risk of radiation exposure from intraoperative fluoroscopy while earlier in their training and during more complex procedures.

Methods:

We analyzed 852 extracapsular proximal femur fracture fixation cases. We compared fluoroscopy times by various levels of resident training, fracture type, and implant used. Attending-only cases were used as a control group.

Results:

Fluoroscopy times during subtrochanteric fracture fixation (176.1 ± 11.27 seconds) were longer than intertrochanteric (111.4 ± 2.44 seconds) and basicervical fractures (91.49 ± 5.77 seconds). Long nail (150.2 ± 3.75 seconds) times were longer than short (92.3 ± 3.15 seconds) and intermediate (76.45 ± 3.01 seconds) nails. Significantly, more fluoroscopy was used in junior (115.9 ± 4.24 seconds), senior (123.0 ± 6.08 seconds), junior combo (130.6 ± 7.74 seconds), and senior combo cases (131.8 ± 6.11 seconds) compared with the control (94.91 ± 3.91).

Conclusion:

Orthopaedic surgery residents and attendings must remain aware of radiation exposure secondary to intraoperative fluoroscopy. Appropriate personal protective equipment should be worn, and more experienced surgeons should take a more active role in the complex cases to decrease exposure risk.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Treatment of Ipsilateral Femoral Neck and Shaft Fractures With Cannulated Screws and Antegrade Reconstruction Nail
Authors: Spitler Clay A. , Kiner Dirk , Swafford Rachel , Bruce Jeremy , Nowotarski Peter
Published: November 2019

Ipsilateral femoral neck and shaft fractures are challenging injuries, and there are different fixation options but no consensus on a superior construct. Our preferred method is cannulated screw fixation of the femoral neck and antegrade reconstruction nailing of the shaft. Compressive fixation of the femoral neck fracture with cancellous lag screws followed by reconstruction nail placement provides compressive fixation and fixed angle support of the neck fracture while allowing for more optimal treatment of femoral shaft fractures at or above the isthmus. The purpose of this submission is to describe the surgical decision-making, surgical technique, and all surgically related complications of this technique.
What’s New in Pediatric Limb Lengthening and Deformity Correction?
Authors: Socci Adrienne R. , Horn David , Fornari Eric D. , Lakra Akshay , Schulz Jacob F. , Sharkey Melinda S.
Published: November 2019

Over the past 5 years, published literature regarding treatment of pediatric limb deformity and limb length discrepancy demonstrates much interest in better understanding, categorizing and treating these challenging problems. Many studies explore expanding and refining indications for traditional treatment methods like guided growth techniques. Other studies have evaluated the results of new techniques such as lengthening via mechanized intramedullary nails. Additionally, series comparing older and newer techniques such as lengthening with external devices versus mechanized nails are becoming increasingly available.
Rates of Contralateral SCFE in the United States: Analysis of the Pediatric Health Information System
Authors: Swarup Ishaan , Williams Brendan A. , Talwar Divya , Sankar Wudbhav N.
Published: November 2019

Background:

Slipped capital femoral epiphysis (SCFE) is relatively common in pediatric patients. Subsequent contralateral SCFE is also common and rates of bilateral SCFE have been reported to range from 12% to 80% in the literature. The purpose of this study was to determine the rates of subsequent contralateral SCFE in patients who present with unilateral SCFE in the United States and determine risk factors for the development of subsequent contralateral SCFE.

Methods:

The authors performed a retrospective study using data from the Pediatric Health Information System (PHIS). Patients who underwent in situ pinning of a unilateral SCFE between 2004 and 2016 were included in this study and followed prospectively to determine subsequent contralateral SCFE. They excluded patients who underwent bilateral pinning at index admission. Descriptive, univariate, and multivariate statistics were used to determine rates of subsequent contralateral SCFE and identify factors associated with contralateral SCFE.

Results:

This study included 9755 patients who underwent in situ pinning for unilateral SCFE. The mean age at the time of index SCFE was 11.9 years (SD, 1.7) and ~62% of patients were male individuals. Subsequent contralateral SCFE occurred in 1077 (11%) patients at an average of 277 days (range, 7 to 1523 d) after the index procedure. Patients who developed a subsequent contralateral SCFE were younger at the time of index SCFE than patients who did not develop a contralateral SCFE (11.3 vs. 12 y old, P<0.01). In multivariate analysis, older children had a lower risk of subsequent contralateral SCFE (adjusted odds ratio, 0.8; 95% confidence interval, 0.77-0.83), and the odds of subsequent contralateral SCFE decreased by 20% with each increasing year in age.

Conclusions:

The rate of subsequent contralateral SCFE is ~11% in the United States, and younger patients are more likely to develop a contralateral SCFE than older patients. Prophylactic pinning should be considered in younger patients with unilateral SCFE, and patients should be followed until skeletal maturity to monitor for subsequent contralateral SCFE.

Level of Evidence:

Level III.
Evaluation of Spanish Language Proficiency and Resources Available in Academic Pediatric Orthopaedic Centers
Authors: Sobel Andrew D. , Ramirez Jose M. , Walsh Devin F. , Defroda Steven F. , Cruz Aristides I.
Published: November 2019

Introduction:

Given the rapidly increasing population of Spanish-speaking patients in the United States, medical providers must have the capability to effectively communicate both with pediatric patients and their caregivers. The purpose of this study was to query the Spanish language proficiency of pediatric orthopaedic surgeons, assess the educational resources available to Spanish-speaking patients and their families, and identify the barriers to care at academic pediatric orthopaedic centers.

Methods:

The Web sites of medical centers within the United States that have pediatric orthopaedic surgery fellowships recognized by the Pediatric Orthopaedic Society of North America (POSNA) were accessed. Web sites were investigated for a health library as well as the availability of interpreter services. Profiles of attending surgeons within each Pediatric Orthopaedic Department were evaluated for evidence of Spanish proficiency as well as educational qualifications. Centers were contacted by phone to determine if the resources and physicians who could converse in Spanish were different than what was readily available online and if automated instructions in Spanish or a person who could converse in Spanish were available.

Results:

Forty-six centers with 44 fellowship programs were identified. The profiles of 12 of 334 (3.6%) surgeons who completed pediatric orthopaedic fellowships indicated Spanish proficiency. Seventeen physicians (5.1%) were identified as proficient in Spanish after phone calls. Thirty-eight pediatric orthopaedic centers (82.6%) noted interpreter service availability online, although services varied from around-the-clock availability of live interpreters to interpreter phones. When contacted by phone, 45 of 46 centers (97.8%) confirmed the availability of any interpreter service for both inpatient and outpatient settings. Sixteen centers (34.8%) had online information on orthopaedic conditions or surgical care translated into Spanish. Twenty centers (43.5%) did not have automated phone messages in Spanish or live operators that spoke Spanish.

Conclusions:

There is a scarcity of surgical providers in pediatric orthopaedic centers proficient in Spanish, demonstrating a large discrepancy with the growing Hispanic population. Interpreter services are widely available, although there is variability in the services provided. Considerable barriers exist to Spanish-speaking patients who attempt to access care by phone or online.
Development and Validation of a Mobile Application for Measuring Femoral Anteversion in Patients With Cerebral Palsy
Authors: Sung Ki Hyuk , Youn Kibeom , Chung Chin Youb , Kitta Muhammad I. , Kumara Hendra C. , Min Jae Jung , Lee Jehee , Park Moon Seok
Published: November 2019

Background:

Computed tomography (CT) provides benefits for 3-dimensional (3D) visualization of femur deformities. However, the potential adverse effects of radiation exposure have become a concern. Consequently, a biplanar imaging system EOS has been proposed to enable reconstruction of the 3D model of the femur. However, this system requires a calibrated apparatus, the cost of which is high, and the area occupied by it is substantial. The purpose of this study was to develop a mobile application that included a new method of 3D reconstruction of the femur from conventional radiographic images and to evaluate the validity and reliability of mobile the application when measuring femoral anteversion.

Methods:

The statistical shape model, graph-cut algorithm, and iterative Perspective-n-Point algorithm were utilized to develop the application. The anteroposterior and lateral images of a femur can be input using the embedded camera or by file transfer, and the touch interface aids accurate contouring of the femur. Regarding validation, the CT scans and conventional radiographic images of 36 patients with cerebral palsy were used. To evaluate concurrent validity, the femoral anteversion measurements on the images reconstructed from the mobile application were compared with those from the 3D CT images. Three clinicians assessed interobserver reliability.

Results:

The mobile application, which reconstructs the 3D image from conventional radiographs, was successfully developed. Regarding concurrent validity, the correlation coefficient between femoral anteversion measured using 3D CT and the mobile application was 0.968 (P<0.001). In terms of interobserver reliability, the intraclass correlation coefficient among the 3 clinicians was 0.953.

Conclusions:

The measurement of femoral anteversion with the mobile application showed excellent concurrent validity and reliability in patients with cerebral palsy. The proposed mobile application can be used with conventional radiographs and does not require additional apparatus. It can be used as a convenient technique in hospitals that cannot afford a CT machine or an EOS system.

Level of Evidence:

Level III—diagnostic.
Online Learning and Residents’ Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters
Authors: Wolbrink Traci A. , van Schaik Sandrijn M. , Turner David A. , Staffa Steven J. , Keller Eleanor , Boyer Donald L. , Chong Grace , Cross Jarrod , del Castillo Sylvia , Feng Andrew , Hum R. Stanley , Jacob James Ebor , Johnson Amanda , Kandil Sarah , Kneyber Martin , Rameshkumar Ramachandran , Levin Amanda , Lodha Rakesh , Jayashree Muralidharan , Olivero Anthony , Oberender Felix , Panesar Rahul S. , Pooni Puneet A. , Rehder Kyle J. , Sankaranarayanan Shuba , Scheffler Margaret , Sharara-Chami Rana , Siems Ashley L. , Padur Sivaraman Rajakumar , Tegtmeyer Ken , Valentine Stacey , Villois Florencia , von Saint Andre-von Arnim Amelie , Winkler Margaret , Dede Chris , Burns Jeffrey P.
Published: November 2019

Objective:

Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents’ knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains.

Design:

A prospective, interventional crossover study conducted from October 2015 to December 2017.

Setting:

Multicenter study conducted in 33 PICUs across eight countries.

Subjects:

Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation.

Interventions:

Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions.

Measurements and Main Results:

Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; sd, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; sd, 18.9; difference, 0.8%; 95% CI, –5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7–14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; sd, 15.4) rather than after (average knowledge gain, 7.0%; sd, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01–12.97;p = 0.008).

Conclusions:

Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.
Epithelioid Rhabdomyosarcoma: Report of a Cutaneous Case and Literature Review of a Recently Described Variant of Rhabdomyosarcoma
Authors: Valério Ediel , Almeida Gisele C. , Neotti Tatiane , Nascimento Antonio G. , Bezerra Stephania M. , Costa Felipe D.
Published: November 2019

Rhabdomyosarcoma affects mainly pediatric patients and is currently classified into 4 categories: embryonal, alveolar, pleomorphic, and spindle cell/sclerosing. Epithelioid rhabdomyosarcoma is a recently described variant of rhabdomyosarcoma in which primary cutaneous presentation is infrequent. In this brief report, we describe a rare case of epithelioid rhabdomyosarcoma in an 81-year-old man, presenting as a skin lesion in the neck, which increased in size in 1 month. After imaging evaluation, a solid cervical mass was discovered. A biopsy was performed, and the diagnosis of epithelioid rhabdomyosarcoma was rendered. The patient died due to rapid progression of the tumor. To make an accurate diagnosis and ensure appropriate patient management, it is necessary to be aware of this variant and use proper immunohistochemical stains when facing an epithelioid malignancy, expanding the differential diagnosis of epithelioid neoplasms.
More than Mental Health: Parent Physical Health and Early Childhood Behavior Problems
Authors: Poppert Cordts Katrina M. , Wilson Anna C. , Riley Andrew R.
Published: November 2019

Objective:

Caring for young children is a physically demanding task, and some evidence suggests parental physical limitations may impact the parent-child relationship and child behavioral development, but research examining this dynamic is nascent.

Methods:

This study aims to explicate the role of general parent physical health problems in child disruptive behavior outcomes. A model that included physical and mental health, parenting style and self-efficacy, and child behavior symptom ratings was derived. The tenability of the model was assessed using Pearson's correlations, followed by structural equation modeling using data from 375 parents with a child between 18 months and 5 years.

Results:

After several modifications to the initial model, findings revealed that higher levels of parent self-reported physical and mental health concerns indirectly influence child behavior symptoms through different pathways. Impaired parent physical health was associated with poorer parental self-efficacy and more disruptive child behavior, whereas increased parent mental health concerns were associated with a more negative parenting style and lower self-efficacy, which was related to more child behavior symptoms.

Conclusion:

Findings elucidate the need for increased awareness and screening of parent physical health limitations in pediatric primary care. Furthermore, appropriate interventions among parents with physical health problems may target different aspects of parenting than routinely discussed.
Quantitative Analysis of Frozen Section Histology in Mohs Micrographic Surgery
Authors: LeBoeuf Matthew , Bieber Karen , Cooper Sherrie , Isenor Amanda
Published: November 2019

BACKGROUND

Mohs micrographic surgery (MMS) relies on complete frozen tissue sections for the unique combination of high cure rates and tissue preservation.

OBJECTIVE

To quantify and characterize the tissue sectioning process in MMS.

MATERIALS AND METHODS

Two hundred eighty-four tissue blocks were analyzed. The histotechnician measured the depth cut into the tissue block for every section placed on the slide. The surgeon identified complete sections.

RESULTS

First-stage complete sections were achieved at 285 μm. The ear and hair-bearing cheek required increased depth of sectioning compared with other sites. Small pieces of tissue achieved complete sections at a decreased depth compared with medium or large pieces of tissue. The methodology used in this study was able to identify statistically significant differences between histotechnicians.

CONCLUSION

More than 2,000 measurements on 284 tissue blocks provided quantitative data of the tissue sectioning process in MMS, confirming that MMS allows evaluation of both peripheral and deep margins within hundreds of microns of the margin. Results from this study indicate a methodology that is easily implemented providing interpretable data that can be used to assess and improve tissue sectioning ensuring MMS remains the gold standard for removal of challenging cutaneous tumors.
Effect of Cytochrome P450 7A1 (CYP7A1) Polymorphism on Lipid Responses to Simvastatin Treatment
Authors: Liu Na , Yang Guihua , Liu Yingping , Hu Mei , Cai Yuyu , Hu Zhiying , Jia Chundi , Zhang Man
Published: November 2019

Background:

Identifying patients with high risk of low response to statin therapy is important for optimization of lipid-lowering therapy. Cholesterol 7α-hydroxylase, a rate-limiting enzyme encoded by cytochrome P450 7A1 (CYP7A1) gene, is considered to be associated with statin efficacy. This study aimed to investigate the association between a novel CYP7A1 single nucleotide polymorphism rs3824260 and statin treatment response for hypercholesteremic patients in Chinese Han population.

Methods:

A total of 336 subjects were prescribed with simvastatin for 12 weeks after enrollment. Plasma lipid parameters were measured at enrollment and after 12-week simvastatin treatment separately. Subjects were classified into high- and low-response groups depending on their total cholesterol, low-density lipoprotein cholesterol (LDL-C) and TG changes and increase or reduction groups according to their high-density lipoprotein cholesterol (HDL-C) levels changing after simvastatin treatment. The CYP7A1 rs3824260 was genotyped from blood samples with a SNaPshot assay.

Results:

At baseline, the LDL-C level and TG level were significantly higher in the AA genotype, while the HDL-C level was significantly higher in the GG genotype of CYP7A1 rs3824260. Patients carrying AA genotype are at an increased risk of low response for LDL-C reduction (odds ratio = 2.295, 95% confidence interval = 1.164–4.524, P = 0.016). Furthermore, the GG genotype of rs3824260 was significantly associated with a high risk of HDL-C reduction response after simvastatin therapy (odds ratio = 2.240, 95% confidence interval = 1.137–4.413, P = 0.025).

Conclusions:

The CYP7A1 gene polymorphism rs3824260 is related to inappropriate response of simvastatin treatment for hypercholesterolemia patients in Chinese Han population.
Identification and management of urinary incontinence in midlife women
Authors: Brubaker Linda
Published: November 2019

Urinary incontinence is a common bladder health problem that disproportionately affects women, especially midlife women. In the absence of alarming signs or symptoms, a step-wise evaluation aligned with patient treatment preferences is appropriate. Initial interventions can include simple behavior therapies, lifestyle modifications, and toileting habits. Systemic medication, surgery, and specialty treatment also can be offered.
Patient-reported Outcome Measures: The FACE-Q Skin Cancer Module: The Dutch Translation and Linguistic Validation
Authors: Ottenhof Maarten J. , Lardinois Aimee J.P.M. , Brouwer Philip , Lee Erica H. , Deibel Dionne S. , van der Hulst René R.W.J. , Pusic Andrea , Sidey-Gibbons Chris , Hoogbergen Maarten M.
Published: November 2019

Background:

Patient-reported outcome measures are becoming a standard component in the evaluation of surgical treatments. In 2010, the FACE-Q skin cancer module was developed: an English psychometric validated questionnaire that measures both patient quality of life and satisfaction with the surgical experience. The questionnaire consists of 11 subscales with a total of 96 questions. An officially translated version in Dutch is needed for accepted use in the Netherlands.

Methods:

We translated the FACE-Q skin cancer module from English into Dutch in accordance with to the International Society for Pharmacoeconomics and Outcomes Research and World Health Organization guidelines. The translation occurs in three stages. First, a forward translation is performed by two independent professional translators, where discrepancies are solved by a third translator, a subject area expert. Secondly, a backward translation is performed and is compared with the original. Any discrepancies are solved by an expert panel. Version two is then pretested (cognitive debriefing) by 30 patients who have had a resection (Mohs surgery) of non-melanoma skin cancer in the face followed by reconstruction. The results of the pretesting exercise are evaluated and a final version of the translation was produced by the expert panel.

Results:

In the first step, a conceptually equivalent Dutch translation of the FACE-Q was translated. In the second phase, the comparison between the forward and backward translation led to multiple retranslations. In step three, 48 annotations were evaluated by the expert panel, which led to 26 minor changes in items or instructions.

Conclusion:

We created a conceptually and linguistically similar translation of the FACE-Q Skin Cancer Module through a thorough translation and linguistic validation process.
Personality Traits, Anxiety, and Self-esteem in Patients Seeking Cosmetic Surgery in Mexico City
Authors: Del Aguila Estephania , Martínez Jorge R. , Pablos José L. , Huánuco Marino , Encina Victor M. , Rhenals Ana L.
Published: November 2019

Background:

There are reports on high psychological morbidity, mainly personality disorders, among people opting for cosmetic surgery. This study aims to describe the personality traits, level of self-esteem, and anxiety in women seeking cosmetic surgery with body contouring, such as liposculpture or lipoabdominoplasty with or without placement of breast implants.

Methods:

Subjects were 87 women between 18 and 60 years of age in Mexico City who went to a private clinic with the intention of undergoing cosmetic surgery with body contouring. A psychiatric interview was performed using three scales: the Salamanca questionnaire for screening for personality disorders, the Hamilton Anxiety Rating Scale, and the Rosenberg Self Esteem Scale.

Results:

The average age was 31 years, with 35% of participants having previously undergone body-contouring surgery. Regarding personality, the patients did not show a psychopathology level for diagnosing a personality disorder. Regarding anxiety, 92% of the patients showed an average level of anxiety. High level of self-esteem was exhibited by 81 participants (93.15%), and six participants (6.9%) exhibited average self-esteem. Notably, no participant exhibited low self-esteem.

Conclusions:

The level of psychopathology of the patients was lower than expected, the self-esteem was not affected prior to the surgical procedure, and the level of anxiety did not cause dysfunction.
Percutaneous Fasciotomies versus Traditional Keystone Flap: Evaluating Tension in Complex Wound Closure
Authors: Goggin James D. , Rodriguez-Unda Nelson A. , Altman Andrew , Saint-Cyr Michel
Published: November 2019

Background:

The keystone flap is a popular reconstructive option for closure of cutaneous defects. Traditionally, this is a perforator-based fasciocutaneous advancement flap that uses both skin incision and fascial release. We propose a limited skin incision technique that utilizes percutaneous fasciotomies to accomplish wound closure.

Methods:

Fresh cadavers were used to compare closure techniques in traditional keystone flaps versus percutaneous fasciotomy technique. Each cadaver served as its own control; traditional keystone flaps were performed on the right side, experimental fasciotomy technique on the left. Bilateral large wound defects were created in 6 anatomical locations: anterior leg, lateral thigh, buttocks, lower back, upper back, and brachium. These defects could not be closed primarily, as defined by tension >25 Newtons or rupture of a 2-0 nylon suture. Twenty-four flaps were created. Keystone flaps were designed on the right side using a 1:1 ratio of defect size to flap width, incorporating both skin and fascial incisions. On the left, percutaneous fasciotomies were drawn using a mirror template and performed through two small access incisions. If wound closure could not be achieved by fasciotomy alone, additional incisional release was performed incrementally until closure was obtained. The tension of closure was measured using a PESOLA (10 N, 25 N) tensiometer (Chandelle, Switzerland), and the average of three recordings was used. Tension was measured at various stages of flap development including: keystone flap (posterior fascia, lateral fascia, V-Y skin closure) versus percutaneous fasciotomy (posterior fascia, lateral fascia, posterior skin). Statistical analysis was completed using Wilcoxon Signed Rank test to compare the two techniques.

Results:

Lower tension closures were achieved through release of the posterior fascia in the traditional keystone flap compared to the percutaneous fasciotomy technique. These differences in tension were statistically significant (P< 0.001). Release of the lateral fascia in the keystone flap resulted in a similar decrease in tension (P< 0.01). The percentage drop in tension before and after each particular intervention was measured. No significant difference was found between these 2 groups.

Conclusions:

When compared with the traditional keystone flap, the percutaneous fasciotomy technique displayed higher tensions in closure. However, this technique showed the ability to close defects in certain locations of the body without excessive tension and should be considered as an option in soft-tissue reconstruction.
Canthal V-plasty for Floppy Eyelid Surgery
Authors: Phillips Margaret E. , Fowler Brian T. , Dryden Stephen C. , Fleming James C.
Published: November 2019

The purpose of this article is to present a modified approach to the reconstruction of the upper and lower eyelids in floppy eyelid syndrome. A retrospective chart review was performed on all floppy eyelid patients who underwent simultaneous tightening of the upper and lower eyelid with a lateral tarsal strip, using a V-shaped incision in the lateral canthus, at University of Tennessee Hamilton Eye Institute from 2011 to 2012. Preoperative symptoms, surgical outcomes, complication rates, and postoperative symptoms were recorded. Nine eyes of 7 patients who underwent surgical correction for symptomatic floppy eyelids were included. All patients noted improvement in symptoms postoperatively, after reduction in the laxity of the upper and lower eyelid. Postoperative complications included buried lashes in the lateral canthus in 1 eye and a pyogenic granuloma in the lateral canthus of 1 eye. An excellent cosmetic outcome was noted in 78% (7/9) of eyes. No patients reported dissatisfaction nor required secondary surgical correction. The lateral canthal “V” incision provides an additional approach in the successful management of floppy eyelid syndrome involving the upper and lower eyelids. The design of the incision allows for excellent exposure of the lateral canthus for shortening of the eyelids with tarsal strip fixation, and it preserves the lateral canthal skin and canthus architecture. Further, the “V” incision is easily continued into the eyelid crease for blepharoplasty and ptosis repair when necessary.
A Novel Method of Treatment of Macrodactyly with Digital Nerve Resection and Nerve Allograft
Authors: Kobraei Edward M. , Dusch Marie N. , Meisel Erin M. , Stevanovic Milan
Published: November 2019

Macrodactyly is a rare and debilitating pediatric hand anomaly that has historically been treated with amputation. Recent advances in our understanding of macrodactyly have increasingly implicated the digital nerve as the underlying cause of the condition. In addition, much progress has been made toward digital salvage in treating macrodactyly. Modern techniques often advocate for digital nerve resection to prevent recurrence and treat the underlying etiology. However, little if any emphasis has been given to sensory reconstruction for purposes of protective sensation and acceptable 2-point discrimination at the volar digital pulp. We report 2 cases of macrodactyly treated with digital nerve resection and nerve allograft reconstruction of large sensory nerve gaps which show early promising sensory outcomes. There remain little if any data on the use of nerve allograft in pediatric populations, and its application in the treatment of macrodactyly. This technique permits digit salvage with the potential for improved sensory outcomes without the donor morbidity of autologous nerve harvest.
STRIDE BP: an international initiative for accurate blood pressure measurement
Authors: Stergiou George S. , O’Brien Eoin , Myers Martin , Palatini Paolo , Parati Gianfranco
Published: November 2019

The diagnosis and management of hypertension is dependent upon accurate blood pressure (BP) measurement. Despite intense efforts over several decades by the international medical community worldwide, the use of inaccurate devices has resulted in the misdiagnosis and poor management of hypertension, which remains a largely unresolved public health problem. STRIDE BP (www.stridebp.org) is an international nonprofit organization the mission of which is to improve the accuracy of BP measurement and the diagnosis of hypertension. STRIDE BP comprises a group of 24 recognized experts in BP monitoring from across the world and operates in affiliation with the European Society of Hypertension, the International Society of Hypertension, and the World Hypertension League. In the first stage, STRIDE BP has reviewed 419 validations of 260 devices and approved 69% of them, providing recommendations on accurate devices for office, ambulatory and home BP measurement in adults, children and during pregnancy. At the next stage, STRIDE BP intends to develop programs for on-line training and tools for use in clinical practice leading to improved measurement of BP and better diagnosis of hypertension world-wide.