bluuebunny/crossref_metadata_2025 huggingface dataset:
The Decline in Attitudes Toward Physician–Nurse Collaboration From Medical School to Residency
Authors: Kempner Samantha , Morgan Helen , Kobernik Emily , Brackmann Melissa
Published: September 2017

BACKGROUND:

Interprofessional education is often part of early medical school curricula; however, as learners progress through their training, there is often less instruction in this important area. Little is known of the impact of clinical exposure on medical students' and residents' attitudes toward physician–nurse collaboration.

METHODS:

Third-year medical students and residents completed the validated Jefferson Survey of Attitudes Toward Physician–Nurse Collaboration. This instrument has 20 questions in which trainees indicate their level of agreement with statements regarding physician–nurse collaboration. All items were scored on a 4-point Likert scale (1=strongly disagree to 4=strongly agree). Student and resident scores were compared using Student's t tests.

RESULTS:

The survey was completed by 129 medical students and 260 residents. The response rate for medical students was 75% and for residents was 16.5%. Resident respondents agreed more strongly with the notion of physician as dominant authority, “the primary function of the nurse is to carry out the physician's orders” (students: 2.02±0.72 versus residents: 2.45±0.82; P=.0001) and “doctors should be the dominant authority in all health care matters” (students: 2.36±0.84 versus residents: 2.67±0.89; P=.0011).

DISCUSSION:

Resident physicians' perceptions of the physician–nurse relationship are significantly less favorable than the views of 3rd-year medical students, particularly in the area of authority. There may be some aspects of the hidden curriculum which contribute to the development of these interprofessional attitudes.
The FLAME Initiative: “Five-Minute Lectures Accelerating Medical Education” Empowering Resident Teaching
Authors: Steller Jonathan , Burns Roshan , Crosland Adam , Fitzmaurice Laura
Published: September 2017

BACKGROUND:

The ever-increasing volume of medical knowledge and time available to acquire it are inversely proportional, creating a conundrum for resident-educators of medical students during clerkships. As learners themselves, resident teaching opportunities can be stifled by self-confidence, time, and accessibility of resources. The FLAME initiative seeks to increase the frequency and quality of teachable encounters while catalyzing resident learning through teaching.

METHODS:

FLAME seeks to create a short presentation for each APGO medical student learning objective. These can be readily accessed on www.flame.rocks and through an iPhone application. Our primary hypothesis, assessed by confidential survey before and after FLAME implementation, is that residents will be better able to meet their own teaching goals with FLAME as a resource. Secondary hypotheses include: residents will be more comfortable teaching, residents will teach medical students more frequently, students will be more satisfied with resident teaching, and student Shelf scores will improve.

RESULTS:

Of 28 residents surveyed pre-FLAME, 92% find medical student teaching important, and 88% wished they taught more. Major barriers impeding teaching are: time/clinical duties (100%), comfort with teaching (23%) and accessibility of resources (18%). The survey will be repeated in January 2017 and compared to the pre-FLAME baseline. Medical student postclerkship survey scores and Shelf scores for 12 months following FLAME introduction will be compared to the 12 months prior.

DISCUSSION:

FLAME's philosophy is simple: empower residents to teach by making relevant, efficient, and reliable teaching resources immediately accessible.
Using Interprofessional OSCE-Based Simulation Collaboration to Teach Obstetrics to Second-Year Medical Students
Authors: Berg Jordan , Ogunyemi Dotun , Venuti Judith , Ferrari Thomas
Published: September 2017

BACKGROUND:

We have shown that it is possible to introduce an obstetric simulation program to preclinical 2nd-year medical students. In the second year of our obstetrics simulation curriculum for 2nd-year medical students, we introduced OSCE assessment in collaboration with the nursing school educator with the program occurring in the nursing school simulation center in November 2015.

METHODS:

Students rotated through three stations: 1) simulated vaginal delivery demonstrated by nurse educator and OBGYN resident; 2) MFM faculty gave interactive presentation on fetal heart rate (FHR), a student nurse then role played with students and they were assessed by OSCE format; and 3) OBGYN resident and faculty taught and assessed students on cervical dilation using cervical models. Students completed surveys on attitude, knowledge before, after and 7 months postcurriculum.

RESULTS:

Of 95 students, mean scores for the FHR OSCE were: identifies FHR baseline=0.97, identifies FHR variability=0.92, provides accurate identification of periodic pattern=0.73, identifies FHR category=0.67 and orders appropriate medical interventions=0.93. For the cervical station OSCE, the mean score on cervical examination skills after training was 75%. For the knowledge questions on obstetrics and fetal heart rate monitoring, students obtained a mean prescore of 2.57±0.09, postsimulation the mean score increased to 3.24±0.11 (P=.12). Presimulation; students scored their comfort level with obstetric procedures as 12.2±0.63, after simulation the mean score increased to 28±0.63 (P<.001).

DISCUSSION:

We have demonstrated the feasibility of an OSCE-based inter-professional educational curriculum utilizing nursing, physician and resident faculty instructing medical students and nursing students jointly. For FHR teaching, the concept of FHR category was the most challenging for the students to grasp. The course improved students' short-term knowledge but had dropped back to baseline by 7 months. Students' comfort level increased immediately posttraining and decreased but was still higher than baseline at 7 months. Further curriculum development is undergoing on increasing long term knowledge gain.
Willing and Able: A New Model for Resident Research
Authors: Doyle Nora , Gardner Michael
Published: September 2017

BACKGROUND:

OB/GYN programs rely on resident research projects for the ACGME scholarly requirements. Recently, ACGME has shifted to requesting better definitions/additional curriculums. This obligation shift represents a major change for residencies. The Six-Source Model of Influence (SSM) is a well-studied model for change based on Motivation and Ability of three forces: Personal, Social, and Structural. We established a team-based resident research program using SSM. We then evaluated the success of our program.

METHODS:

We developed a resident research program over a 7-year period in an OB/GYN resident program on probation in part due to lack of scholarly activities. Using SSM we identified personal motivation/ability, social motivation/ability, and structural motivation/ability factors for intervention. Personal motivation—research required for graduation. Personal ability-supported by monthly learning sessions. Learning topics included types of research studies, statistics, research design, and abstract/manuscript writing. Social motivation and social ability were obtained by using a team research approach. Each team was comprised of a PGY-1, -2, -3, and -4. Roles were delegated by year, with team interaction and support. Structural motivation—monetary rewards for project presentation and free trips if abstracts were accepted. Structural ability—designated research program director and support staff for statistics/project completion. Monthly sessions were built into the academic schedule for group research. A designated resident research office was created.

RESULTS:

All 28 residents completed their projects on schedule. Eight of 28 residents went on to fellowship programs. Eight of 28 obtained positions in academic departments. Eight residents presented posters at national OB/GYN meetings, including the Association of Professors of Gynecology and Obstetrics, the American College of Obstetricians and Gynecologists (the College), the Central Association of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. Four of 28 residents gave oral presentations at one of these meetings. One resident was awarded the national College prize for best resident research project.

DISCUSSION:

Resident research requirements are changing. Accepting that people do things for two reasons: motivation—because they want to, and ability—because they can, provides the basis for SSM. By applying these two reasons to the three forces of personal, social, and structural; a sound resident research model can be constructed. Our research presentations support SSM can produce positive, productive, and sustainable change.
Neglect in Undergraduate Medical Education: A Systematic Review
Authors: Bazella Corinne , El-Nashar Sherif A. , Gupta Aekta , Gecsi Kimberly , Learman Lee A.
Published: September 2017

OBJECTIVE:

To describe and compare the definitions of neglect used in the medical education literature and the estimated prevalence of neglect reported on clinical rotations.

DATA SOURCES:

EMBASE and Ovid MEDLINE were searched using these terms: lack of appreciation, lack of guidance, ignored, passed over, unintentional mistreat, unintentional mistreatment, missed learning opportunity, environment-based mistreatment, insidious mistreatment, marginalized learner, neglect, social dominance, medical education, undergraduate medical education, medical student.

METHODS OF STUDY SELECTION:

Non-English language articles, editorials, commentaries, and letters were excluded using search filters or by hand. Publications were selected for full-text review if they commented on medical students’ perceptions of being ignored, neglected, mistreated, or experiencing an unwelcoming learning environment. Further screening of 1,698 identified only three that focused specifically on neglect. Three additional studies were identified from reference lists or findings of prior literature searches.

TABULATION, INTEGRATION AND RESULTS:

The six publications included in the review reported the results of three qualitative and three cross-sectional studies. Medical Education Research Study Quality Instrument scores for the cross-sectional studies were low due to limitations in study design: single institution, no comparison group, and unknown validity of evaluation instruments. A discrete definition of neglect was not found, but several authors described a spectrum including “covert, status related abuse” and “environment-based mistreatment” to describe this phenomenon.

CONCLUSION:

Poor study quality and missing or inconsistent definitions and measures limit the validity of efforts to estimate the prevalence of neglect on different clinical rotations for medical students.
Whole exome sequencing in inborn errors of immunity: use the power but mind the limits
Authors: Bucciol Giorgia , Van Nieuwenhove Erika , Moens Leen , Itan Yuval , Meyts Isabelle
Published: September 2017

Purpose of review

Next-generation sequencing, especially whole exome sequencing (WES), has revolutionized the molecular diagnosis of inborn errors of immunity. This review summarizes the generation and analysis of next-generation sequencing data.

Recent findings

The focus is on prioritizing strategies for unveiling the potential disease-causing variant. We also highlighted oversights and imperfections of WES and targeted panel sequencing, as well as the need for functional validation.

The information is crucial for a judicious use of WES by researchers, but even more so by the clinical immunologist.
Obstetricians and Gynecologists of the Future
Authors: Alston Meredith J. , Autry Amy (Meg) , Wagner Sarah A. , Winkel Abigail , Allshouse Amanda A. , Stephenson-Famy Alyssa
Published: September 2017

OBJECTIVE:

To understand the characteristics and career goals of medical students selecting a career in obstetrics and gynecology.

METHODS:

In 2015–2016, medical students invited for interviews for obstetrics and gynecology residency at the University of Colorado, University of Washington, University of California San Francisco, Loyola University, and New York University received a voluntary 20-item electronic survey regarding factors influencing their choice of medical specialty.

RESULTS:

Two hundred twenty-six of 356 students responded (63%). Mean age was 27 years, and 88% (n=199) were women. General surgery was the most common alternate specialty (36%, n=81). The most commonly cited drawback to obstetrics and gynecology was “long hours” (66%, n=148). After residency, 157 (70%) applicants planned to complete fellowship training, 127 (56%) pursue international work, 156 (69%) seek an academic position, and 207 (92%) practice in an urban setting. One hundred twenty-four applicants (55%) planned to work 51–60 hours per week and 111 (49%) planned to take 2–3 nights of call per month. Two thirds (n=150) predicted they will have greater than $100,000 educational debt on graduation.

CONCLUSION:

Contemporary residency applicants have high educational debt and disproportionately plan to pursue fellowship, international work, careers in academic medicine, and work in urban centers. Based on the projected career plans among obstetrics and gynecology applicants, the workforce needs of the population may not be met.
Entrustment Evidence Used by Expert Gynecologic Surgical Teachers to Determine Residents' Autonomy
Authors: Chen Xiaodong (Phoenix) , Sullivan Amy M. , Bengtson Joan M. , Dalrymple John L.
Published: September 2017

OBJECTIVE:

To identify entrustment evidence used by expert gynecologic surgical teachers to determine obstetrics and gynecology residents' level of autonomy in the operating room.

METHODS:

A qualitative interview study was undertaken from March to November 2016. Four selection criteria were used to define and purposefully sample expert gynecologic surgical teachers across the United States to represent all four geographic regions. All interviews were audio-recorded and transcribed. We applied the Framework Method of content analysis. Transcripts were iteratively analyzed and emergent themes identified.

RESULTS:

Twenty-seven expert gynecologic surgical teachers from 15 institutions across the United States participated in 30-minute interviews. We identified four domains of entrustment evidence (resident characteristics, medical knowledge, technical performance, and “beyond current surgical case”) commonly reported by expert gynecologic surgical teachers to determine residents' autonomy as well as the particular evidence associated with expert gynecologic surgical teachers' determination of resident autonomy at two decision-making points (surgical time-out and taking over certain intraoperative steps) in the operating room. Onsite direct observation and conversation were two common methods used by expert gynecologic surgical teachers to obtain this evidence.

CONCLUSION:

Entrustment evidence from resident characteristics, medical knowledge, and technical performance domains and from “beyond current surgical case” was commonly used by expert gynecologic surgical teachers to determine residents' autonomy. Our findings provide a potential framework for designing educational interventions that aim to increase residents' readiness for autonomy and entrustment in the operating room.
Is Night Float a Poison Apple to Shelf Exam Performance? Evaluating the Impact of Night Float During the Last Week of the Clerkship on Shelf Examination Score
Authors: Baecher-Lind Laura , Maxwell Sue , Ramesh Saradha
Published: September 2017

BACKGROUND:

Obstetrics and Gynecology clerkships often incorporate a week of night float in which students work overnight and sleep during the day. Night float systems allow a team atmosphere for students and also portray practice trends within Ob/Gyn. However, sleep deprivation has been shown to negatively impact examination performance in many settings. We sought to determine whether students completing their clerkship on night float—culminating in their shelf examination at the end of that week—performed differently on the examination compared with students completing night float earlier in the clerkship.

METHODS:

We evaluated students completing the Ob/Gyn clerkship at our institution over the past 3 academic years. Student's t test was used to compare mean shelf exam scores between students who completed night float week on the last week of the Ob/Gyn clerkship and students not on night float during the last week.

RESULTS:

Thirty-four of 190 students completed night float during the last week of the clerkship (17.9%). Mean shelf exam score during the 3 academic years reviewed (2013–2016) was 77.6 (range 59–99, SD 7.9). Students on night float during the last week of the clerkship did not score differently from students not on nights during that final week (mean 76.6 versus 77.8, P=.42).

DISCUSSION:

Students completing a week of night float during the last week of the Ob/Gyn clerkship scored similarly to students completing night float earlier in the clerkship. Clerkship directors can comfortably schedule students for night float even during the last week of the clerkship, and can reassure students that having night float during the final week of the clerkship does not negatively impact shelf exam performance.
Validation of Ultrasound Guidance Targeting Tasks
Authors: Nitsche Joshua F. , Shumard Kristina M. , Brost Brian C.
Published: September 2017

OBJECTIVE:

To assess whether health care provider performance on a novel task trainer and a set of newly created ultrasound guidance targeting tasks relates with their level of clinical experience.

METHODS:

In a prospective cohort study, two assessment sessions were carried out in which inexperienced (n=21 and n=15) and experienced (n=14 and n=10) health care providers completed five previously described ultrasound guidance targeting tasks. Raw completion time, number of targeting errors, and error-adjusted completion time for each task were compared between groups with a t test for independent measures. Receiver operating characteristic analyses were performed to estimate whether error-adjusted completion time or number of errors could accurately differentiate between groups.

RESULTS:

Raw completion time was similar between groups. The number of errors and error-adjusted completion time were significantly lower in the experienced health care providers in all but the out-of-plane dowel task. The receiver operating characteristic analyses of number of errors demonstrated very high areas under the curve (0.93–0.98), sensitivities (100%), specificities (76–86%), positive likelihood ratios (4.2–7.0), and negative likelihood ratios (<0.001) indicating excellent differentiation between experienced and inexperienced health care providers. These values were notably lower in the receiver operating characteristic analyses of error-adjusted completion times.

CONCLUSION:

Task performance related well with a health care provider's level of clinical experience providing evidence of construct validity. For each task, we were able to determine a cutoff for number of errors that categorized experienced and inexperienced health care providers with very favorable sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios. Our findings suggest it may be possible to use these cutoffs to objectively classify trainees as competent or not competent.
Listening Effort: How the Cognitive Consequences of Acoustic Challenge Are Reflected in Brain and Behavior
Authors: Peelle Jonathan E.
Published: September 2017

Everyday conversation frequently includes challenges to the clarity of the acoustic speech signal, including hearing impairment, background noise, and foreign accents. Although an obvious problem is the increased risk of making word identification errors, extracting meaning from a degraded acoustic signal is also cognitively demanding, which contributes to increased listening effort. The concepts of cognitive demand and listening effort are critical in understanding the challenges listeners face in comprehension, which are not fully predicted by audiometric measures. In this article, the authors review converging behavioral, pupillometric, and neuroimaging evidence that understanding acoustically degraded speech requires additional cognitive support and that this cognitive load can interfere with other operations such as language processing and memory for what has been heard. Behaviorally, acoustic challenge is associated with increased errors in speech understanding, poorer performance on concurrent secondary tasks, more difficulty processing linguistically complex sentences, and reduced memory for verbal material. Measures of pupil dilation support the challenge associated with processing a degraded acoustic signal, indirectly reflecting an increase in neural activity. Finally, functional brain imaging reveals that the neural resources required to understand degraded speech extend beyond traditional perisylvian language networks, most commonly including regions of prefrontal cortex, premotor cortex, and the cingulo-opercular network. Far from being exclusively an auditory problem, acoustic degradation presents listeners with a systems-level challenge that requires the allocation of executive cognitive resources. An important point is that a number of dissociable processes can be engaged to understand degraded speech, including verbal working memory and attention-based performance monitoring. The specific resources required likely differ as a function of the acoustic, linguistic, and cognitive demands of the task, as well as individual differences in listeners’ abilities. A greater appreciation of cognitive contributions to processing degraded speech is critical in understanding individual differences in comprehension ability, variability in the efficacy of assistive devices, and guiding rehabilitation approaches to reducing listening effort and facilitating communication.
An Anatomic Study on Whether Femoral Version Originates in the Neck or the Shaft
Authors: Archibald Hunter D. , Petro Kathleen F. , Liu Raymond W.
Published: September 2017

Background:

Femoral anteversion is generally asymptomatic but can result in lower extremity issues like patellofemoral instability and pain. Surgical correction of anteversion can be performed proximal, mid shaft or distal. A better understanding of the specific location of the rotational deformity can help guide the optimal location of the osteotomy. In this study we examine the contribution of the femoral neck and shaft to total femoral version.

Methods:

We studied 590 pairs of well-preserved cadaveric femurs. Total femoral version was defined as the axial plane angle between the femoral neck and posterior femoral condyles. Femoral shaft torsion was defined as the axial plane angle between the lesser trochanter and posterior femoral condyles. Neck version was the mathematical difference between total femoral version and shaft version.

Results:

Neck version (right femur R=0.582; left femur R=0.632) contributed slightly more than shaft version (right femur R=0.505; left femur R=0.480) to overall femoral version, but both were substantial and neither completely predicted overall femoral version. Age was not found to contribute to femoral version, and sex and race had statistically significant but small contributions.

Conclusions:

Our data show that both the femoral neck and femoral shaft substantially contribute to femoral version, and to our knowledge is the first to statistically demonstrate that neither level can be used to predict total femoral version. This suggests that one cannot generalize a single optimal site for correction or prediction of femoral version from an osteological perspective, and that individualized assessment may be beneficial.

Clinical Relevance:

This study suggests that methodologies for determining the level of femoral version might be important as the level in any given patient can vary.
Two-Stage Prosthetic Breast Reconstruction after Mastectomy with or without Prior Postmastectomy Radiotherapy
Authors: Lam Thomas C. , Hsieh Frank , Salinas James , Boyages John
Published: September 2017

Background:

Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by an implant after a period of inflation is a well-established breast reconstruction option. Most of the current literature concentrates on the immediate setting, and there are only a few reports into delayed cases, especially after postmastectomy radiotherapy (RT). We performed a retrospective review of our experience over a 12.5-year period.

Methods:

Between June 1998 and December 2010, a total of 671 patients received prosthetic-only breast reconstruction. Of these, 170 (25.3%) underwent delayed 2-stage prosthetic breast reconstruction after mastectomy for cancer. Patients were divided into group A, no postmastectomy RT (n = 150), and group B, postmastectomy RT (n = 20). The primary factor examined was the failure of the reconstruction from loss of prosthesis with or without smoking. Other complications, as well as rates of revisional surgery were also recorded.

Results:

Expander or implant loss occurred in 3 of 150 patients in group A (2.0%) and 3 of 20 patients in group B (15%; P = 0.02). For nonsmokers, implant loss was 1.6% and 5.6%, respectively (P = NS). Smoking was associated with 1 of the 3 losses in group A and 2 of the 3 in group B (smokers, n = 2; P < 0.01). There was no significant difference in other complications such as seromas or minor wound infections.

Conclusions:

Delayed 2-stage prosthetic breast reconstruction has a low failure rate. It can also be successfully completed in selected patients after postmastectomy RT, but care must be taken with patients who smoke.
Enabling Remote Monitoring Using Free Apps and Smart Devices for a Free-Flap Adjunct Monitor
Authors: Yuen James C.
Published: September 2017

Remote monitoring capability does not currently exist for Periflux (Perimed AB, Järfälla, Sweden) laser Doppler and other perfusion monitors. Two simple adaptations using free apps (applications) and smart devices can enable transmission of the perfusion readout to the surgeon's smartphone. A literature review was conducted to identify reports relating to remote free flap monitoring. In addition, 2 wireless methodologies are devised: One method uses a free app that converts a smart device into a camera, stationed next to the perfusion monitor, to stream live video of the laser Doppler readout to the surgeon's smartphone; a second method uses a free app installed on a bedside laptop computer, which is connected to the laser Doppler flowmeter via a data cord. A live feed of the computer's desktop as a teleconference host is transmitted to the surgeon's smart device over the Internet. These 2 methodologies were employed on 9 and 8 free flaps, respectively, as a pilot study. All free flaps were monitored remotely for 4–6 days with near 100% reliability. The Internet connectivity became disrupted only on several occasions, requiring simple Wi-Fi and software reset. Minor mechanical issues were encountered with the video streaming method. Literature review identified very few articles describing remote monitoring of free flaps. The 2 methodologies reported here provided reliable continuous transmission of quantitative data of flap perfusion to smart devices via Internet connection, which can revolutionize the microsurgeon's practice if his/her adjunctive perfusion monitor with display does not yet have Wi-Fi capability.
New Models of Care
Authors: LAWRENCE HAL C.
Published: September 2017

The practice of obstetrics and gynecology continues to evolve. Changes in the obstetrician-gynecologists workforce, reimbursement, governmental regulations, and technology all drive new models of care. The advent of the obstetric hospitalist is one new model, and the development of team-based care is another. Increasingly, obstetrician-gynecologists are becoming employees of health care delivery systems, and others are focusing the scope of their practices to subspecialites. As new practice models emerge, the specialty of obstetrics and gynecology will continue to change to meet the health care needs of women.
Dark Endothelial Spots After Descemet Membrane Endothelial Keratoplasty May Appear as Recurrent Fuchs Dystrophy or Herald Graft Failure or Rejection
Authors: Zygoura Vasiliki , Baydoun Lamis , Monnereau Claire , Satué Maria , Oellerich Silke , Melles Gerrit R. J.
Published: September 2017

Purpose:

To evaluate the clinical significance of dark spots in the donor endothelial cell layer as observed with specular microscopy, in patients who underwent Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy (FED).

Methods:

Specular microscopy images of 83 consecutive eyes up to 7 years after DMEK were retrospectively reviewed in a masked fashion for the presence of dark spots and morphologic changes in the endothelial cell layer and processed for endothelial cell density (ECD) measurements.

Results:

A normal endothelial cell layer was found in 52/83 eyes (62.7%) (group 0). In the remaining 31/83 eyes, various dark discolorations with or without altered endothelial cell morphology were categorized into 4 groups. Dark spots were classified as artifacts in 10/83 (12.0%) eyes (group I) and as “superimposed” dots in 10/83 (12.0%) eyes (group II), that is, optical irregularities slightly anterior to a healthy endothelial cell layer. In 11/83 (13.3%) eyes, endothelial stress was characterized by dark grayish discolorations and/or nuclear activation (group III). Most of the latter eyes also had a significant ECD decrease; 3 of these eyes later developed secondary graft failure, of which one was preceded by allograft rejection. None of the eyes showed recurrent guttae typical for FED (group IV).

Conclusions:

Dark endothelial spots after DMEK for FED may not represent a recurrent disease, but tissue irregularities just anterior to the graft. However, if associated with changes in endothelial cell morphology, nuclear activation and/or ECD decrease, dark discolorations may reflect “cellular stress” heralding secondary graft failure or (subclinical) allograft rejection.
NASPGHAN Clinical Report on Postoperative Recurrence in Pediatric Crohn Disease
Authors: Splawski Judy B. , Pffefferkorn Marian D. , Schaefer Marc E. , Day Andrew S. , Soldes Oliver S. , Ponsky Todd A. , Stein Philip , Kaplan Jess L. , Saeed Shehzad A.
Published: September 2017

Pediatric Crohn disease is characterized by clinical and endoscopic relapses. The inflammatory process is considered to be progressive and may lead to strictures, fistulas, and penetrating disease that may require surgery. In addition, medically refractory disease may be treated by surgical resection of inflamed bowel in an effort to reverse growth failure. The need for surgery in childhood suggests severe disease and these patients have an increased risk for recurrent disease and potentially more surgery. Data show that up to 55% of patients had clinical recurrence in the first 2 years after initial surgery. The current clinical report on postoperative recurrence in pediatric Crohn disease reviews the risk factors for early surgery and postoperative recurrence, operative risk factors for recurrence, and prevention and monitoring strategies for postoperative recurrence. We also propose an algorithm for postoperative management in pediatric Crohn disease.
Second Neoplasms in Children Following a Treatment for Acute Leukemia and/or Lymphoma: 29 Years of Experience in a Single Institution in Argentina
Authors: Felice María S. , Rossi Jorge G. , Alonso Cristina N. , Rubio Patricia , Gallego Marta S. , Galluzzo María L. , Lubieniecki Fabiana , Gutiérrez Gladys , Guitter Myriam R. , Alderete Daniel H. , Rose Adriana B. , Cacciavillano Walter D. , Herzovich Viviana , Alfaro Elizabeth M. , Sánchez La Rosa Cristian G. , Millán Natalia , Chantada Guillermo L. , Figueroa Turienzo Carlos M. , Zubizarreta Pedro A.
Published: September 2017

Introduction:

Childhood acute leukemias (AL) and lymphomas achieve good survival rates. However, second neoplasms (SN) are a devastating event.

Methods:

From August 1987 to December 2016, 34 of 3321 (1%) patients with diagnosis of AL or lymphoma developed SN. SN were AL (n=16), CNS tumors (n=5), endocrinal tumors (n=3), lymphomas (n=2), schwannoma (n=2) assorted sarcomas (n=4), retinal melanoma (n=1), and Vanek tumor (n=1). Median latency was 51 (range, 10 to 110) months for hematological malignancies and 119 (range, 25 to 236) months for solid tumors (P=0.001).

Results:

A total of 33 patients with SN were treated taking into account cumulative doses of anthracyclines and radiotherapy. Twenty-three (67.6%) patients achieved complete remission (CR), 5 died early during therapy and 5 were refractory or partial responders. Six patients presented relapses of the SN and 1 died in CR. Seventeen patients remain alive in CR, with a median follow-up of 110 (range, 4 to 276) months.

Conclusions:

(1) The latency period was significantly longer for patients developing solid tumors than for those developing AL. (2) AL was the most frequent SN. (3) Our results strongly encourage giving standard therapy to SN, considering cumulative doses of previous treatment, since similar probabilities of surviving as “de novo” counterparts can be achieved.
Hormone Therapy and Venous Thromboembolism in a Transgender Adolescent
Authors: Stanley Kaitlin , Cooper James
Published: September 2017

Venous thromboembolism can be precipitated by both genetic and acquired factors, but the role of testosterone therapy is less clear. Here, we present a 17-year-old transgender adolescent, transitioning from female to male, receiving both estrogen and testosterone therapy, who developed a pulmonary embolism without an underlying genetic thrombophilic condition. As transgender medical care evolves, the use of testosterone as cross-sex hormone therapy in adolescents is likely to increase. Our review suggests that care must be taken when initiating treatment with testosterone, and modification of other thrombophilic risks should be explored before starting therapy in this population.
C-Reactive Protein (CRP) is a Promising Diagnostic Immunohistochemical Marker for Intrahepatic Cholangiocarcinoma and is Associated With Better Prognosis
Authors: Yeh Yi-Chen , Lei Hao-Jan , Chen Ming-Huang , Ho Hsiang-Ling , Chiu Ling-Ya , Li Chung-Pin , Wang Yu-Chao
Published: September 2017

Differential diagnosis of intrahepatic cholangiocarcinoma (iCCA) from its histologic mimickers, especially metastatic adenocarcinomas of gastric and pancreatic origin, is a great challenge for pathologists. In this study, through bioinformatics analysis of data from The Cancer Genome Atlas and Gene Expression Omnibus, we identified C-reactive protein (CRP) as a candidate marker to differentiate iCCA from other adenocarcinomas and validated its diagnostic performance by immunohistochemistry in a large cohort of clinical samples including 103 iCCAs, 384 other adenocarcinomas, and 34 liver metastases of various origins. The sensitivity and specificity of CRP expression in the diagnosis of iCCA were 75.7% and 91.1% when using tissue microarrays and 93.3% and 88.2% when using whole tissue sections, respectively. We also compared the diagnostic performance of CRP with N-cadherin, a previously reported marker for iCCA. The sensitivity and specificity of N-cadherin were 54.4% and 92.2% when using tissue microarrays and 80.0% and 88.2% when using whole tissue sections, respectively. The sensitivity of CRP was higher than that of N-cadherin, whereas their specificity was similar. CRP expression was associated with mass-forming gross type (P<0.001), absence of perineural invasion (P=0.002), and N-cadherin expression (P<0.001). CRP expression was also associated with better overall survival (P=0.002) and longer recurrence-free time (P=0.032) after surgery. Our study suggests that CRP is a promising immunohistochemical marker to differentiate iCCA from other adenocarcinomas. Compared with N-cadherin, CRP showed higher sensitivity and similar specificity. CRP expression was associated with better prognosis in iCCA.
The Role of Tranexamic Acid in Plastic Surgery: Review and Technical Considerations
Authors: Rohrich Rod J. , Cho Min-Jeong
Published: September 2017

Minimizing blood loss during surgery is critical, and many modalities have been used to decrease unwanted surgical bleeding. Among many methods, use of pharmacologic agents such as antifibrinolytic drugs has been shown to significantly reduce blood loss and the rates of postoperative blood transfusion in many articles. Tranexamic acid is an antifibrinolytic agent that has been widely used in other surgical specialties, especially in cardiac, orthopedic, and trauma surgery. Despite its known benefits, the use of tranexamic acid in plastic surgery is extremely limited, primarily because most plastic surgery procedures do not involve the extent of blood loss that can lead to anemia and the need for blood transfusion, as is common in major orthopedic and cardiac surgery procedures. Nevertheless, there are significant benefits to be gained from the use of antifibrinolytic drugs in the full range of plastic surgery. In this article, the authors introduce the benefits, dosages, and technical considerations of using tranexamic acid in plastic surgery procedures.
Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis
Authors: Cho Eugenia H. , Shammas Ronnie L. , Carney Martin J. , Weissler Jason M. , Bauder Andrew R. , Glener Adam D. , Kovach Stephen J. , Hollenbeck Scott T. , Levin L. Scott
Published: September 2017

Background:

Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes.

Methods:

A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes.

Results:

A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity.

Conclusions:

Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Why the p Value Alone Is Not Enough: The Need for Confidence Intervals in Plastic Surgery Research
Authors: Samargandi Osama A. , Al-Taha Mona , Moran Kit , Al Youha Sarah , Bezuhly Michael
Published: September 2017

Background:

The p value is one of the most used descriptors in statistical analysis; however, when reported in isolation, it does not convey the effect size of a treatment. The reporting of confidence intervals is an essential adjunct to determine the clinical value of treatment, as it permits an assessment of the effect size. The authors assessed the reporting of confidence intervals in clinical trials within the plastic surgery literature.

Methods:

The seven highest impact plastic surgery journals were screened using MEDLINE for clinical trials in the years 2006, 2009, 2012, and 2015. Studies were randomized based on a predetermined sample size, and various characteristics (e.g., Jadad quality score, reporting of statistical significance, journal impact factor, and participation of an individual with formal research training) were documented.

Results:

Two independent reviewers analyzed 135 articles. There was substantial interrater agreement (kappa = 0.78). Although 86.7 percent of studies reported a p value, only 25.2 percent reported confidence intervals. Of all journals assessed, Plastic and Reconstructive Surgery most frequently reported confidence intervals. The quality of the studies had a median Jadad score of 2 of 5. Bivariate analysis revealed that higher Jadad score and involvement of an individual with formal research training were associated with reporting of confidence intervals. Multivariate analysis revealed similar findings, whereas journal impact factor, year of publication, and statistical significance were not correlated with confidence interval reporting.

Conclusions:

Confidence intervals are underreported in the plastic surgery literature. To improve reporting quality of clinical trials, results should always include the confidence intervals to avoid misinterpretation of the effect size of a statistically significant result.
Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap: Clinical Experience with 28 Cases
Authors: Scaglioni Mario F. , Rittirsch Daniel , Giovanoli Pietro
Published: September 2017

Background:

Defects in the weight-bearing region of the foot sole can represent a substantial restriction in quality of life and pose a challenge for reconstructive plastic surgery. The purpose of this article is to report the authors’ experience with the use of the medial plantar artery perforator flap for reconstruction of defects of the foot sole in three different regions: heel, middle foot sole, and plantar forefoot.

Methods:

From January of 2003 to May of 2016, 28 patients (13 male and 15 female patients) with an average age of 54 years (range, 12 to 84 years) underwent reconstruction with 28 medial plantar artery perforator flaps. Twenty-six flaps were harvested as pedicle perforator flaps and two as free perforator flaps. All flaps were raised from the ipsilateral instep area. The defect locations included the heel (20 cases), middle foot sole (four cases), and forefoot (four cases). The causes of reconstruction were tumors in 18 patients, decubitus in eight patients, and trauma in two patients.

Results:

The flap sizes varied from 2.5 × 2.5 cm to 5.5 × 9.5 cm. All of the flaps survived completely after surgery, apart from one. The donor sites were all covered with a split-thickness skin graft. Follow-up observations were conducted for 4 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results.

Conclusion:

The medial plantar artery perforator flap can be considered an optimal method of foot sole reconstruction not only for covering the weight-bearing area of the heel but also for the middle and forefoot plantar region.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Endotheliopathy of Trauma is an on-Scene Phenomenon, and is Associated with Multiple Organ Dysfunction Syndrome: A Prospective Observational Study
Authors: Naumann David N. , Hazeldine Jon , Davies David J. , Bishop Jon , Midwinter Mark J. , Belli Antonio , Harrison Paul , Lord Janet M.
Published: September 2017

Background:

Trauma patients are vulnerable to coagulopathy and inflammatory dysfunction associated with endotheliopathy of trauma (EoT). In vitro evidence has suggested that tranexamic acid (TXA) may ameliorate endotheliopathy. We aimed to investigate how soon after injury EoT occurs, its association with multiple organ dysfunction syndrome (MODS), and whether TXA ameliorates it.

Methods:

A prospective observational study included 91 trauma patients enrolled within 60 min of injury and 19 healthy controls. Blood was sampled on enrolment and again 4 to 12 h later. ELISAs measured serum concentrations of syndecan-1 and thrombomodulin as biomarkers of EoT. MODS was compared between groups according to biomarker dynamics: persistently abnormal; abnormal to normal; and persistently normal. Timing of EoT was estimated by plotting biomarker data against time, and then fitting generalized additive models. Biomarker dynamics were compared between those who did or did not receive prehospital TXA.

Results:

Median age was 38 (interquartile range [IQR] 24–55) years; 78 of 91 were male. Median injury severity score (ISS) was 22 (IQR 12–36). EoT was estimated to occur at 5 to 8 min after injury. There were no significant differences in ISS between those with or without prehospital EoT. Forty-two patients developed MODS; 31 of 42 with persistently abnormal; 8 of 42 with abnormal to normal; and 3 of 42 with persistently normal biomarkers; P < 0.05. There were no significant differences between TXA and non-TXA groups.

Conclusions:

EoT was present at the scene of injury. MODS was more likely when biomarkers of EoT were persistently raised. There were no significant differences between TXA and non-TXA groups. Prehospital interventions aimed at endothelial restoration may represent a clinically meaningful target for prehospital resuscitation.
Robotic-Assisted Live Donor Ileal Segmentectomy for Intestinal Transplantation
Authors: Wu Guosheng , Li Qianjing , Zhao Qingchuan , Wang Weizhong , Shi Hai , Wang Mian , Zheng Jianyong , Li Mengbing , Fan Daiming
Published: September 2017

Background

Every effort should be made to optimize surgical techniques and to minimize potential morbidity rates associated with live donor operations. Advances in a minimally invasive approach by robotic surgery to donor nephrectomy have raised the possibility of applying this technique to live donor bowel resections for intestinal transplantation.

Methods

We report the first 5 consecutive cases of a robotic-assisted live donor ileal segmentectomy. We describe the technical aspects of the procedure, discuss the rationale for considering this option, and evaluate potential advantages of this approach.

Results

We found that this new approach is associated with less postoperative discomfort, a shorter hospital length of stay, and a faster recovery of bowel function compared to our previous open surgery.

Conclusions

Our initial experience suggests that robotic surgery is a safe and feasible procedure for live donor ileal resection for intestinal transplantation and is a useful alternative to conventional open surgery.