bluuebunny/crossref_metadata_2025 huggingface dataset:
Basivertebral Nerve Ablation
Authors: Giuffrida Anthony , Westerhaus Benjamin D.
Published: September 2024

This chapter focuses on chronic low back pain caused by degenerative endplate disease. Animal and cadaver studies have shown this pain is transmitted from the vertebral endplate through the basivertebral nerve (BVN). In the setting of vertebral endplate disruption, there is an upregulation in the nerve endings of the BVN, and thus an increase in pain at this location. MRI in patients with degenerative endplate disease shows edema, which is characterized as Modic type I and type II change. Patients with chronic low back pain who have failed 6 months of conservative care and who have active Modic changes on MRI can be treated with a BVN ablation. The BVN is accessed with a cannula via a transpedicular approach. The target for the ablation is near the center of the lumbar and sacral vertebral bodies before the BVN arborizes to each endplate. Once proper access is obtained, ablation is performed at a constant 85°C for 15 minutes. The procedure takes approximately 30 minutes per level treated, and the patient returns home the same day. The evidence for BVN ablation is supported by two Level l randomized clinical trials. At this time, BVN ablation is approved for vertebral levels L3 to S1. Given the robust evidence and its relatively low risk profile, BVN ablation should be considered in patients who present with chronic low back pain.
Sacroiliac Joint Fusion—Posterior Approach
Authors: Buchanan Patrick , Diep Jack
Published: September 2024

Sacroiliac joint pain is one of the most common causes of low back pain, accounting for 15% to 30% of all cases. The incidence of sacroiliac joint degeneration in patients who have undergone lumbar fusion surgery is 75% at 5 years after surgery. Minimally invasive posterior sacroiliac joint fusion is a treatment option for patients who have failed conservative management, including intra-articular steroid injections, and it is an alternative to radiofrequency ablation.
Percutaneous Spinal Cord Stimulator Implantation (Cervical/Lumbar)
Authors: Francio Vinicius Tieppo , Abd-Elsayed Alaa , Deer Timothy , Westerhaus Benjamin D.
Published: September 2024

The use of electrical stimulation for pain relief has been described since 15 AD, with the earliest documentation for gout treatment by contact with a torpedo fish (electric fish), discovered by the Roman physician Scribonius Largus.1 Since, many other scientists and physicians have experimented with electrical stimulation and pain relief, but it wasn't until 1967 that Dr. Norman Shealy, the pioneer of contemporary neuromodulation, decided to stimulate large fibers in the dorsal column of the spinal cord2, based on a new theory of pain mechanisms called the "gate-control" theory proposed a few years earlier.
Neuropsychological Evaluation
Authors: Hromas Gabrielle A. , Davis Jeremy J.
Published: September 2024

This chapter provides an introduction to neuropsychological assessment, commonly used tests, and guidance on referrals. Neuropsychological evaluation involves systematic assessment of brain-behavior relationships in individuals with a history of cerebral insult, neurodevelopmental disorders, and/or neurologic or psychiatric conditions. The evaluation process is multidimensional, with collection and interpretation of data from sources including medical records, interviews, observations, and standardized tests of cognitive and emotional status. Comprehensive neuropsychological evaluation typically covers multiple cognitive domains including attention, language, visuospatial ability, memory, and executive function, in addition to examining the validity of obtained data and estimating premorbid and current general cognitive ability. Test raw scores are converted to standardized scores based on normative comparison groups. The goals of neuropsychological evaluation may include comprehensive description of cognitive ability, diagnosis, treatment planning, identification of needed work or school accommodations, assessment of safety concerns, and determining cognitive capacity (e.g., for healthcare decisions, financial management, and legal matters).
Differential Diagnosis
Authors: MacKillop Emily J. , McNeely Heather E.
Published: September 2024

Diagnostic accuracy is the first step to proper treatment, management, and future planning in dementia. Diagnostic challenges arise due to the co-occurrence of a multitude of conditions that contribute to cognitive changes in aging. Improving differential diagnostic skills is critical for detection, intervention, and treatment, in addition to the reduction of harm associated with missed and misdiagnoses. This chapter reviews differential diagnosis between the three main categories of conditions known to promote cognitive impairment in older adults and mimic neurodegenerative conditions: delirium; medical conditions; and psychiatric conditions. In addition, a framework is provided to assist the clinician broadly in making a differential diagnosis.
Vascular Dementia
Authors: Chandrasekhara Seetha , Zevy Danna L.
Published: September 2024

Vascular dementia (VaD) is one of the four major dementias. It is associated with white matter lesions in the brain from direct injury to the blood vessels, leading to multiple subtypes based on injury type and location. Risk factors are understandably similar to that of a stroke, as stroke can be a cause of VaD. These risk factors include smoking, hypertension, diabetes mellitus, hyperlipidemia, and other cardiac factors. Neuropsychiatric symptoms may be present, along with cognitive and motor changes, with depression being the most common. Management strategies often are based on controlling modifiable risk factors as pharmacologic interventions have limited benefit.
Lewy Body Disease and Atypical Parkinsonian Conditions
Authors: Scott Bonnie M. , Benge Jared F.
Published: September 2024

Parkinsonian conditions impact more than movement. A host of cognitive and behavioral features can occur with or even precede the onset of motor dysfunction, and the myriad symptoms can make classification challenging. This chapter reviews these conditions through the lens of neuropsychiatric features, while orienting students and providers to the cognitive background of the characteristic motor and imaging findings that co-occur with these diseases. It begins by reviewing conditions caused by abnormal accumulation of alpha-synuclein, including Parkinson’s disease, dementia with Lewy bodies, and multiple system atrophy. Characteristic cognitive, motoric, and other symptom presentations are reviewed, along with case examples to help differentiate these conditions. Next, the authors discuss the characteristic cognitive and behavioral features of the atypical parkinsonian conditions known as progressive supranuclear palsy and corticobasal ganglionic degeneration, and conclude with a discussion of the continued diagnostic uncertainties and heterogeneities in the presentation of these types of movement disorders.
Nonpharmacological Interventions for Symptoms and Related Contextual Difficulties in Dementia
Authors: Serrano Yesenia , Weil Marie C. , Tuncel Stephanie A.
Published: September 2024

Age-related neurocognitive disorders (NCDs) present with complex, heterogeneous, and inter-dynamic sets of symptoms across multiple domains of functioning (e.g., motor, affective, cognitive, behavioral), which are often influenced by medical, personal, contextual, sociocultural, and time factors. Assessment and interventions should therefore be person-centered and holistic, and involve the person, their families, and an interdisciplinary team. Treatment should respond to interacting medical and non-medical systems and emphasize nonpharmacological interventions (NPIs) to manage symptoms, improve function, promote independence, maintain quality of life (QoL), and prevent secondary complications such as pressure ulcers, contractures, pneumonia, and depression. This chapter provides a framework for the biopsychosocial evaluation of symptoms of NCDs postdiagnosis and a conceptualization model to aid in selecting interventions. It includes an introduction to commonly used NPIs for NCDs, and two illustrative cases.
Attending to the Caregiver
Authors: Reilly Shannon , Daranciang Brianna , Fuchs Kathleen
Published: September 2024

Individuals who are incapable of caring for themselves due to a neurocognitive disorder rely upon caregivers (CGs) for support with basic and/or complex activities of daily living (ADLs). CGs are often family members, who may struggle to meet their own needs given the health risks associated with caregiving. This chapter offers healthcare providers guidance in assessing the changing needs of CGs over time, along with practical tips about obtaining information and supporting their well-being. Information is provided about evidence-based interventions and brief therapeutic strategies that providers can employ or recommend. The authors describe how caregiving tasks may change with disease progression, as well as special CG circumstances for providers to consider. This chapter highlights that healthcare providers play an important, consistent role in helping CGs to navigate the unpredictable challenges of disease progression and offers guidance about individualizing support and resources.
Bioethics
Authors: Bulger Jeffrey W.
Published: September 2024

This book discusses ethical and moral issues facing practitioners and provides the reader with the steps to identify the best pathway for maximizing the patient’s best interest. It contains 60 healthcare education topics and includes references for clinical practice and academic writings. Each topic addresses specific high-yield content for healthcare licensing exams and provides a framework for the healthcare profession’s behavioral expectations. The approach used in this book is the tripartite process—think, assess, and conclude—in which the practitioner considers the ethical issue, specifies and balances the four principles of bioethics—autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair)—and determines answers that are consistent with the standards of care. This approach also emphasizes the importance of effective communication and empathy in establishing a patient–practitioner relationship that maximizes the patient’s best interests.
Abuse
Authors: Bulger Jeffrey W.
Published: September 2024

Abstract: Practitioners are required by law to report any suspected child or elder abuse to protective services. This is to protect vulnerable populations who cannot give informed consent or make treatment decisions. This reporting is part of the patient–practitioner social contract and is not considered a breach of confidentiality. Intimate partners with decisional capacity are not considered vulnerable populations, and the practitioner must get their expressed consent before reporting abuse. If the victim is being coerced, the practitioner can make an exception based on professional principles of doing good and not causing harm. The government’s role in healthcare is to implement justice by protecting vulnerable populations and reducing healthcare disparities. In 1974, Congress passed the Child Abuse Prevention and Treatment Act, which requires all states to prevent, identify, and treat child abuse and neglect.
Euthanasia
Authors: Bulger Jeffrey W.
Published: September 2024

Abstract: Euthanasia, meaning “good death” in Greek, is administering a lethal agent by another person to relieve a patient’s incurable and intolerable suffering. The American Medical Association’s Code of Medical Ethics considers euthanasia incompatible with the role of a practitioner as a healer and states it would cause more harm than good. The American College of Physicians does not support practitioner-assisted suicide or euthanasia. Although some states have legalized practitioner-assisted death, also known as “death with dignity,” the healthcare profession has made it clear that euthanasia is never permissible for a practitioner to engage in. The healthcare profession recommends palliative care and a supportive patient environment to control a patient’s pain and suffering instead of euthanasia.
Genetic Information Nondiscrimination Act
Authors: Bulger Jeffrey W.
Published: September 2024

Abstract: The requirement of genetic testing for insurance and employment in the 1970s violated the principles of autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair). Congress responded by enacting the 1972 National Sickle Cell Anemia Control Act and Title II of the 2008 Genetic Information Nondiscrimination Act (GINA) to prevent discrimination in health insurance and employment, making it illegal for insurance companies to use genetic information for adjusting premiums, denying coverage, or for companies with 15 or more employees to use genetic information for hiring, firing, job placement, or promotion decisions. The implementation of GINA ensures that individuals are protected from discrimination based on their genetic information.
Immunization—Vaccine Hesitancy
Authors: Bulger Jeffrey W.
Published: September 2024

Abstract: There is a professional and social obligation of practitioners toward their patients that they take reasonable measures to reduce and prevent the spread of infectious diseases, including being vaccinated. The American Medical Association states that in the context of a highly transmissible disease, practitioners should accept immunization if a safe and effective vaccine is available. The justification for this is based on the principles of patient autonomy (informed consent), professional beneficence (do good), nonmaleficence (do no harm), and social justice (be fair) and how they apply in the patient–practitioner relationship. It is concluded that vaccine hesitancy based on the individual liberty of the practitioner is a violation of the patient–practitioner social contract and, therefore, a violation of all four principles of bioethics. Practitioners must stay up-to-date on vaccinations; not doing so is professional misconduct. Patient-centered healthcare for the patient’s best interest is the ultimate goal.
Media Communications
Authors: Bulger Jeffrey W.
Published: September 2024

Abstract:Practitioners interacting with the media must navigate the delicate balance of promoting public health awareness and maintaining patient confidentiality. Ensuring compliance with professional and institutional media policies, obtaining informed consent from patients before disclosing any protected health information, and prioritizing patient autonomy and privacy are all critical aspects of this interaction. The practitioner’s primary allegiance lies within the patient–practitioner relationship and their pursuit of the patient’s best interests. As ambassadors of the healthcare profession, practitioners bear the social responsibility of informing the media about evidence-based care and existing healthcare disparities while protecting the patient’s right to confidentiality. Understanding the sanctity of the patient–practitioner relationship and the severe consequences of privacy breaches is essential for ethically sound media communications.
Organ Donations
Authors: Bulger Jeffrey W.
Published: September 2024

Abstract: Informed consent for organ and tissue donation emphasizes the autonomy and rights of the individual. The sale of nonrenewable vital organs and tissues is prohibited, thus preventing the exploitation of vulnerable individuals. Renewable tissues, such as blood, sperm, and unfertilized ova, can be reimbursed for donor costs and compensation for services, with specific financial prospects for each. The U.S. Food and Drug Administration sets guidelines for plasma donations, allowing potential earnings of $260–$650 per year. Sperm donations may yield up to $18,000 annually, whereas egg donations can result in payments ranging from $5,000 to $35,000 per cycle. Minors can donate nonvital organs, but it requires the minor’s informed assent and the parent or guardian’s informed consent. Legally, practitioners cannot pursue organ donation consent from their own patients. Federal law stipulates that families must be presented with the option to donate a deceased relative’s organs.
Pregnant Patients
Authors: Bulger Jeffrey W.
Published: September 2024

Abstract: The right of a pregnant patient to refuse or withdraw from healthcare treatment has been a matter of controversy, as state laws differ. The American College of Obstetricians and Gynecologists (ACOG) states that a pregnant woman’s decision to refuse treatment should be respected, and any fetal intervention must have explicit informed consent from the pregnant woman. ACOG argues that the patient–practitioner relationship is with the pregnant woman and not with the fetus to ensure the woman’s autonomy (informed consent) and prevent her from being viewed as a “fetal container.” The practitioner must obtain informed consent from the pregnant patient and prioritize the patient’s best interests, informed by principles of beneficence (do good) and nonmaleficence (do no harm). State laws on the status of the fetus as a person vary, but once the fetus is born, it becomes a child and has all the protective rights.
Sexually Transmitted Infections
Authors: Bulger Jeffrey W.
Published: September 2024

Because the term “venereal disease” carries social stigma, the term “sexually transmitted infection” (STI) has been adopted for use instead. STIs are usually transmitted through sexual contact and can be caused by various bacteria, viruses, or protozoa. Mandatory reporting laws require practitioners to report STIs to the health department, which is not a breach of confidentiality. The professional principles of beneficence (do good) and nonmaleficence (do no harm) apply in treating STIs, emphasizing the need to treat both the patient’s and the partner’s infection to break the cycle of reinfection. The concept of expedited partner therapy (EPT), wherein a practitioner treats the patient’s partner without a direct consultation, is also discussed in this chapter. The practitioner should utilize alternative methods such as telemedicine to mitigate EPT concerns about informed consent, continuity of care, privacy, and other potential issues.
Strikes—Unionization
Authors: Bulger Jeffrey W.
Published: September 2024

The issue of practitioners unionizing and engaging in collective bargaining has become a subject of renewed interest as the number of salaried practitioners increases and the number of private practices decreases. It is argued that such actions are justifiable only if they strengthen the patient–practitioner relationship, prioritize the patient’s best interests, and decrease healthcare disparities. It is important to assess the impact of practitioner unionization and strikes on patient autonomy (informed consent), practitioners’ duty of beneficence (do good) and nonmaleficence (do no harm), and public policy’s principle of justice (be fair). The conclusion is that unionization and strikes can only be justified if they are not motivated by self-interested reasons, do not violate the patient–practitioner relationship, do not increase the risk of harm to patients, and prioritize the patient’s best interests while decreasing healthcare disparities.
Terminal and Palliative Sedation
Authors: Bulger Jeffrey W.
Published: September 2024

Terminal sedation, also referred to as palliative sedation, is a healthcare practice in which medication is used to relieve refractory symptoms and decrease a patient’s consciousness in the final stages of life. The aim is to improve the quality of life by reducing suffering and not hastening death. It is considered morally acceptable by many professional associations, including the American Medical Association and the American College of Physicians. Informed consent is essential for the practice of terminal sedation, and the decision to undergo continuous sedation to unconsciousness is considered permanent and irrevocable. It is the responsibility of both the practitioner and the surrogate to act in the patient’s best interests, in accordance with the patient’s reasonable goals, values, and priorities, while following the principles of beneficence (do good) and nonmaleficence (do no harm).
Epidemiological aspects of suicide and suicidality
Authors: Rössler Wulf , Schreiter Stefanie , Gutwinski Stefan
Published: September 2024

Epidemiological research on suicide can be traced back almost 100 years. Despite a large number of empirical findings, our theoretical understanding of suicide is still limited. One of the best known conceptualizations of suicide is found in the monograph by Emile Durkheim, who described suicide not from an individual, but from a psychosocial perspective. To this date, we still try to find a common denominator for the causes of suicide. But as suicidal acts obviously represent a very complex behaviour, similarly the number of factors involved are large, with each factor contributing a small effect. This chapter looks at some of those effects, and the epidemiological aspects of suicide and suicidality.
Suicide in Nepal
Authors: Wenzel Thomas , Risal Ajay
Published: September 2024

Nepal is one of the poorest countries in the world, but with a rich culture and a multi-religious history. Suicide rates, especially in women, are high and might reflect discriminative practices against women in general. Over the last decades, many subgroups of the population, but also the population as a whole, have suffered a number of severe social and economic stressors that should be considered in this context. The complex multi-ethnic and multi-religious setting does not permit simplified conclusions as to the influence of these factors on suicide rates. Preventive strategies are part of the government’s agenda, and initiatives by universities and non-governmental organizations have started but suffer from limited resources and complex challenges in the country.
Suicide scripts of the Nacirema (aka American)
Authors: Sara Canetto Silvia
Published: September 2024

Taking as a model a satirical account of Nacirema (‘American’ spelt backwards) body beliefs and rituals, as observed by a fictional anthropologist, in a 1956 article by Miner, this chapter provides an analysis of Nacirema/American suicide patterns and beliefs from the point of view of an imaginary outsider. Specifically, Nacirema/American suicide patterns by sex, age, and ‘race’, and Nacirema/American beliefs about these patterns are narrated from the standpoint of the imaginary outsider, and in light of Nacirema/American dominant scripts of femininity and masculinity. This reversal of perspectives aims to facilitate recognition of how in ‘America’, as everywhere, suicide is a deeply cultural act. This chapter ends with a discussion of the necessity of a cultural perspective in suicide theory, research, and prevention, especially in relation to dominant ‘American’ suicide theory, research, and prevention, because of how rarely dominant ‘American’ suicide theory, research, and prevention are the focus of a cultural analysis.
Critical care
Authors: Nethercott Daniel , Shelley Maire
Published: September 2024

Communication skills are fundamental to critical care. Structured communication is essential in crisis situations. Similarly, handover requires focused communication.

Communicating with patients with tracheostomies can be a challenge. It helps to communicate regularly in short sessions using closed questions. Communication with patient’s families involves active listening, development of rapport, and empathy with avoidance of information overload and jargon. Ensure that the messages delivered are clear and consistent. Be aware that miscommunication is a common issue as patients and families tend to seize on any information without necessarily understanding context. At the end of life it is important to communicate sensitively with a focus on the patient’s and family’s needs rather than our own. Silence is a very effective tool to promote rapport and allow space for people to speak. Even withdrawal of active therapy can be framed in a positive way along with emphasis on non-abandonment and ongoing supportive care.
When bad things happen
Authors: Strange Khursandi Diana C. , Tan Suyin G.M.
Published: September 2024

Breaking bad news is never easy whether the incident is minor and predictable or a major unforeseen event. The ‘LAURS’ principles and ‘GREAT’ template support the development of communication skills in this context. The anaesthetist needs to listen attentively, recognize, and respect the diversity of possible emotional responses. They should be prepared to apologize without attributing blame and be able to provide not only factual information, but also emotional support including dealing with anger and acknowledging uncertainty. Disclosure interviews should be planned with avoidance of jargon and information delivered in small chunks. To avoid creating the impression of a ‘cover up’, communication needs to be open and factual with time allowed for the recipient to digest information and ask questions. Staff involved in an incident resulting in patient harm may also be affected by burn-out and mental health issues, especially if litigation occurs. They also need to receive support.
Media
Authors: Selak Tanya , Prineas Stavros
Published: September 2024

Medical professionals increasingly use online media in their interactions with patients, and form relationships with the community in the public health setting. When we meet patients in the anaesthetic bay, many have been influenced by information on the internet. Discussion of such information during consultation may be perceived by some doctors as a threat to their knowledge and experience, however social media use can lead to more equal and active communication as patients feel empowered by knowledge and preparation. Social media platforms can also be used for doctor–patient interactions, but they bring ethical considerations such as patient confidentiality, privacy, and the maintenance of appropriate patient–doctor boundaries. During electronic communication there is a diminution of non-verbal cues, which can lead to misinterpretations and misunderstandings. Given that social media is ubiquitous in our community we need to optimize communication to maximize impact and minimize misunderstandings.
Hypnotic techniques
Authors: Hansen Ernil , Faymonville Marie-Elisabeth , Bejenke Christel J. , Vanhaudenhuyse Audrey
Published: September 2024

Hypnosis acts as a vehicle through which advanced communication techniques can be utilized in a highly effective way with important benefits in anaesthesia, pain medicine, emergency, and intensive care. Information overwhelm in acute medical situations results in patients going into a natural trance where they become highly focused and extremely suggestible. Therefore, the subconscious with its regulation of involuntary psychological and physiological functions can respond therapeutically to suggestion even without a formal hypnotic induction. Basic principles of such hypnotic communication are a dissociation to an inner safe and comfortable place or situation, the reframing of disturbing noises, sensations, or conversations, non-verbal expressions of support and reassurance, specific suggestions against pain or bleeding, and addressing basic psychological needs to neutralize stressors. Of utmost importance is the development and maintenance of a trustful therapeutic alliance without whitewashing or concealment. Hypnosis is complementary and supportive to treatment rather than an alternative or replacement.
Upper airway obstruction
Authors: Swami Himanshu , Hawthorne Maurice
Published: September 2024

Common causes of sudden onset upper airway obstruction include allergy, trauma, infection, inhaled foreign body; slow onset obstruction is usually due to tumours. Speedy assessment of the severity and level of the obstruction is a key skill. Poiseulle’s equation indicates that small changes in diameter of the airway have dramatic effects on the flow of air through the upper airway. This as lead to the aphorism—‘if you are thinking about a tracheostomy you probably should be doing one right now.’ It is important to recognize prodromal symptoms in airway-threatening infections (e.g. pain and swallowing problems) before the airway is compromised and stridor starts. Valuable time can be bought in the acute situation with administration of oxygen, (or heliox), steroids while preparations are made to secure the airway. It should be remembered that since Hib vaccination, acute epiglottitis leading to death is now nearly always a disease of adults.
Military-Civilian Partnership to Improve Combat Casualty Care Readiness Among Non-physician Providers
Authors: Na Hyun Kyoung , Cacchione Pamela Z , Cannon Jeremy , Schwab C William , Yelon Jay A
Published: September 2024

Background

Military-civilian partnerships (MCP) provide a bidirectional exchange of information and trauma best practices. In 2021, Penn Presbyterian Medical Center and the U.S. Navy signed a 3-year memorandum of understanding to embed active duty trauma providers into the Trauma Division to facilitate the training and sustainment of combat casualty care (CCC) skills. To date, there is little evidence to demonstrate the efficacy of military-civilian partnerships in maintaining combat casualty readiness in non-physician trauma providers.

Methods

We evaluated the impact of combat casualty readiness for non-physician providers by mapping clinical experiences in an urban Level I trauma center against the Defense Health Agency’s Joint Trauma Systems (JTS) Clinical Practice Guidelines (CPG). The JTS CPGs provide best practices for CCCand highlight the critical skills providers need to know before deploying to an austere environment. Patient acuity data and specific JTS CPG skills performed by a non-physician providers were collected in their respective specialties for each patient seen between January 2023 to January 2024. Analyses were performed using descriptive statistics via Redcap.

Results

A sample of 6 Navy personnel in different specialties: 1 Physician Assistant, 3 Registered Nurses (emergency medicine, perioperative, critical care), and 2 corpsmen (scrub tech and search & rescue/prehospital medic) completed 1299 records on patients treated. In all, 685 (52.7%) were trauma patients and 614 (47.3%) were non-trauma patients. Categories of injuries seen, listed from the most frequent to the least, were as follows: Other (764), Falls (250), Motor Vehicle Crashes (164), Gunshot Wound (126), Stab-related injuries (41). Category 1 skills, defined as “essential to know,” were performed in 921 (36.1%) of the patients treated. In Category 2, skills described as “important to know” were performed in 889 (34.8%) of the patients treated. Category 3 skills, identified as “less urgent” as they are rare among trauma patients, were performed in 486 (19.0%) of the patients treated, and 252 (9.8%) required none of the JTS CPG skills. These categories were further broken down based on the frequency of the skills performed. Analysis revealed strengths and identified opportunities to direct clinical experience for underperforming skills.

Conclusion

Military-civilian partnerships support CCC readiness. The data presented and the continuation of mapping personnel’s clinical experience to military CPGs can gauge readiness in non-physician trauma providers. Notably, several skills in each category were identified as opportunities to modify the clinical exposure of the military provider. These findings indicate that modifications in clinical assignments could enhance active duty combat casualty readiness in these critical skills.
A pilocytic astrocytoma with novel ATG16L1::NTRK2 fusion responsive to larotrectinib: a case report with genomic and functional analysis
Authors: Deland Lily , Keane Simon , Olsson Bontell Thomas , Sjöberg Bexelius Tomas , Gudinaviciene Inga , De La Cuesta Esther , De Luca Francesca , Nilsson Jonas A , Carén Helena , Mörse Helena , Abel Frida
Published: September 2024

The outcome of pilocytic astrocytoma (PA) depends heavily on the success of surgery. In cases where surgery alone is not curative, genetic analysis can be used to identify treatment targets for precision medicine. Here, we report a pediatric PA case that underwent incomplete surgical resection due to the tumor location. Clinical routine analyses demonstrated that the tumor did not carry any BRAF alteration. After postoperative surveillance, according to the low-grade glioma (LGG) protocol, recurrent tumor progressions resulted in multiple chemotherapy regimens. Screening formalin-fixed paraffin-embedded tumor material using an open-ended RNA sequencing panel revealed a novel in-frame autophagy related 16 like 1-neurotrophic receptor tyrosine kinase 2 (ATG16L1::NTRK2) fusion gene. The NTRK2 rearrangement was subsequently confirmed by fluorescent in situ hybridization on tumor tissue sections. Functional validation was performed by in vitro transient transfection of HEK293 cells and showed the ATG16L1::TRKB fusion protein to activate both the mitogen-activated protein kinase pathway and the phosphoinositide 3-kinase oncogenic pathways through increased phosphorylation of extracellular signal-regulated kinase, AKT, and S6. As a result of the identification of the NTRK fusion, the patient was enrolled in a phase I/II clinical trial of the highly selective TRK inhibitor larotrectinib. The patient responded well without significant side effects, and 8 months after the start of treatment, the contrast-enhancing tumor lesions were no longer detectable, consistent with a complete response as per Response Assessment in Neuro-Oncology (RANO) criteria. Presently, after 22 months of treatment, the patient’s complete remission is sustained. Our findings highlight the importance of screening for other oncogenic drivers in BRAF-negative LGGs since rare fusion genes may serve as targets for precision oncology therapy.
Hospitals Offer Immersive Nursing Camps for High School Students
Authors: Roush Karen
Published: September 2024

The programs aim to attract young people to the profession.
U.S. Children Die at Higher Rates Overall Than Children in Other Wealthy Countries
Authors: Roush Karen
Published: September 2024

Infant mortality and teen deaths from firearms drive the disparity.
A Dedicated Graduate Certificate in Health Equity: A Novel Approach to Increase the Future Physician Capacity to Address Health Inequities
Authors: Wilkins Consuelo H. , Friedman Elisa C. , Posada-Castaneda Rocio , Marshall Brian I. , Miller Bonnie M. , Spalluto Lucy B.
Published: September 2024

Problem

Pervasive health inequities require new approaches to medical education to equip future physicians to address unjust disparities in health outcomes. Few curricula exist that focus on development of competencies and leadership skills in health equity, and little is known about the content that should be included.

Approach

Vanderbilt University Medical Center and Vanderbilt University School of Medicine developed and implemented the Graduate Certificate in Health Equity (CHE) to address this educational gap. The CHE proposal was approved in summer 2019, enrollment began in October 2019, and the first course was offered in February 2020. The CHE includes 11 objectives, and programming spans medical school years 2 to 4. Students must complete 2 foundational courses, 2 health equity–focused electives, and a health equity immersion experience.

Outcomes

Seventy-three students have enrolled since the CHE launched in academic year 2019 to 2020. In year 1, 14 third-year students enrolled in an inaugural condensed version and 16 second-year students enrolled in the full program. In subsequent years, 16 students (year 2), 15 students (year 3), and 12 students (year 4) enrolled. To date, 38 medical students have graduated. The CHE has engaged 16 community partners, including community health centers, immigrant and refugee services, rural health programs, and the LGBTQI+ community, as lecturers and hosts for immersion experiences.

Next Steps

Future work will include updating objectives and developing a rigorous evaluation scheme. The CHE team will follow up with graduates to determine how the CHE influenced their care for marginalized and minoritized patients, ability to identify and address systemic and structural barriers, and career development. The CHE is a potential model for other institutions to adapt and implement. Accruing a critical mass of institutions with health equity–focused programming for medical students is necessary to develop future leaders in health equity.
Uterine Leiomyomas and Reproduction
Authors: Pritts Elizabeth A.
Published: September 2024

There is a prevailing opinion by gynecologists, much of it based on expert opinion or anecdotal evidence, that myomas are detrimental to pregnancy. Newer data challenge much of this dogma, but incorrect assumptions remain. Although not impeccable, multiple data address the correlation between myomas and reproduction, and some emerging evidence addresses surgical removal of these myomas and subsequent outcomes. A thorough literature search was performed, and the amassed data were analyzed to answer some of our most important queries about the role that myomas play in pregnancy and delivery. Uterine leiomyomas ultimately decrease in size during late pregnancy and postpartum. Spontaneous abortion rates are similar in women with and without leiomyomas. The data addressing leiomyoma effects on preterm prelabor rupture of membranes, placental abruption, cesarean delivery, and postpartum hemorrhage rates are conflicting, but the best evidence does not show a significant correlation compared with women without myomas. Preterm delivery rates are elevated in women with leiomyomas. Myomectomy does not decrease preterm deliveries and may increase this risk. Women with myomectomies have increased elective cesarean delivery rates and more blood loss at delivery compared with women with leiomyomas in situ.
Positive end-expiratory pressure and emergence preoxygenation after bariatric surgery: effect on postoperative oxygenation
Authors: Östberg Erland , Larsson Alexander , Wagner Philippe , Eriksson Staffan , Edmark Lennart
Published: September 2024

BACKGROUND

Positive end-expiratory pressure (PEEP) is important to increase lung volume and counteract airway closure during anaesthesia, especially in obese patients. However, maintaining PEEP during emergence preoxygenation might increase postoperative atelectasis by allowing susceptible lung areas to be filled with highly absorbable oxygen that gets entrapped when small airways collapse due to the sudden loss of PEEP at extubation.

OBJECTIVE

This study aimed to test the hypothesis that withdrawing PEEP just before emergence preoxygenation would better maintain postoperative oxygenation.

DESIGN

Prospective, randomised controlled trial.

SETTING

Single centre secondary hospital in Sweden between December 2019 and January 2023.

PATIENTS

A total of 60 patients, with body mass index between 35 and 50 kg m−2, undergoing laparoscopic bariatric surgery.

INTERVENTION

Intraoperative ventilation was the same for all patients with a fixed PEEP of 12 or 14 cmH2O depending on body mass index. No recruitment manoeuvres were used. After surgery, patients were allocated to maintained PEEP or zero PEEP during emergence preoxygenation.

MAIN OUTCOME MEASURES

The primary outcome was change in oxygenation from before awakening to 45 min postoperatively as measured by estimated venous admixture calculated from arterial blood gases.

RESULTS

Both groups had impaired oxygenation postoperatively; in the group with PEEP maintained during awakening, estimated venous admixture increased by mean 9.1%, and for the group with zero PEEP during awakening, estimated venous admixture increased by mean 10.6%, difference −1.5% (95% confidence interval −4.6 to 1.7%), P = 0.354. Throughout anaesthesia, both groups exhibited low driving pressures and superior oxygenation compared with the awake state.

CONCLUSIONS

Withdrawing PEEP before emergence preoxygenation, did not alter early postoperative oxygenation in obese patients undergoing laparoscopic bariatric surgery. Intraoperative oxygenation was excellent despite using fixed PEEP and no recruitment manoeuvres, but deteriorated after extubation, indicating a need for future studies aimed at improving the emergence procedure.

CLINICAL TRIAL NUMBER AND REGISTRY

www.clinicaltrials.gov, NCT 04150276.
Corneal Endothelial Cell Loss During Uneventful Cataract Surgery in Hispanics Versus Non-Hispanics
Authors: Heinz Montoya Rafael , Edmundo Vasquez Luis , Lee Christian , Hancock Saxon , Kheirkhah Ahmad
Published: September 2024

Purpose:

Limited information exists on the possible effects of ethnicity on corneal endothelial cell parameters and their changes during cataract surgery. Thus, we evaluated corneal endothelial cell density (ECD) and endothelial cell loss (ECL) during surgery for senile cataract in Hispanic and non-Hispanic White adults.

Methods:

This retrospective study included 312 eyes of 227 patients ≥50 years who underwent phacoemulsification with intraocular lens implantation for senile cataract. Preoperatively and 1 to 2 months after surgery, specular microscopy was performed to measure ECD, coefficient of variation (CV), and hexagonal cell percentage (HEX). Regression analysis was used to compare baseline values as well as surgery-related changes in corneal endothelial cell parameters between Hispanic and non-Hispanic patients considering demographics, biometric parameters, and intraoperative cumulative dissipated energy (CDE).

Results:

There were 109 Hispanics and 118 non-Hispanics. Anterior chamber depth (ACD) was significantly lower in Hispanics (3.12±0.36 mm) compared with non-Hispanics (3.25±0.37 mm,P=0.009). There were no significant differences in baseline ECD between Hispanics (2,547±365 cells/mm2) and non-Hispanics (2,483±380 cells/mm2,P=0.17). There were also no significant differences in ECL (16.8%±17.0% vs. 17.4%±18.1%,P=0.46), increase in CV (3.8%±20.7% vs. 1.5%±21.6%,P=0.51), and decrease in HEX (−2.7%±8.5% vs. −1.8%±7.0%,P=0.33) between these two groups. Regression analysis showed that ECL was associated with a shallower ACD (P=0.003), a higher CDE (P<0.001), but not with ethnicity (P=0.46).

Conclusion:

There are no significant differences in ECD and ECL between Hispanics and non-Hispanics undergoing cataract surgery. Although Hispanics have a shallower ACD, the ethnic difference seems to be clinically insignificant.
The Association Between Increasing Vasoactive Medication Dose and Adverse Events During Physical and Occupational Therapy Sessions
Authors: Johnson Rebecca P. , Beagle Caroline , Kaeser Christa , Mitchell Sara , Lambright Joseph , Overton Matthew , Taylor Savannah
Published: September 2024

Introduction:

The purpose of this study was to examine the incidence of adverse events (AEs) during physical and occupational therapy sessions in which the doses of vasoactive medications were increased to allow for maintenance of blood pressure during mobility progression. A secondary purpose was to determine factors associated with AEs.

Review of Literature:

Recent research has found a low rate of AEs when mobilization is performed on high doses of vasoactive medications. There has been no published work regarding the feasibility or safety of increasing vasoactive medication dose to progress mobility, though this practice occurs frequently in some intensive care units.

Methods:

A retrospective medical record review of 44 patients participating in 100 physical and/or occupational therapy sessions was performed. Data regarding patient demographics, illness severity, medication and medication titration, comorbid conditions, mobility level, and AEs were collected. Descriptive statistics were calculated, and relationships between variables were explored.

Results:

Eight patients (18%) experienced nine AEs across nine physical therapy sessions (9%). AEs were not correlated with illness severity (r
pb = .024, P = .81), medication dose during the session (τb = .051, P = .55), amount of medication dose increase during the session (τb = −.027, P = .75), or mobility level (P = .755). There was a higher incidence of AEs in patients with chronic respiratory disease compared to those without (P = .011).

Discussion and Conclusion:

This was the first study to investigate the practice of titrating vasoactive medications to allow for increased mobility. While this sample had a higher rate of AEs than observed in previous studies involving early mobilization, all AEs were transient and without long-term consequence. Titration of vasoactive medications to allow for increased levels of mobility may be done without AEs in some patients, though further investigation is needed.
The primary cause of markedly elevated aminotransferases in hospitalized patients with cirrhosis in ischemic hepatitis
Authors: Allam Jad , Ibrahim Ahmed , Rockey Don C.
Published: September 2024

Background

Marked elevation in aminotransferases (≥1000 IU/l) is typically associated with acute liver injury. Here, we hypothesized that the cause of elevation in aminotransferases ≥1000 in patients with cirrhosis is likely due to a limited number of disorders and may be associated with poor outcomes.

Aim

We aimed to investigate the most common etiologies of acute elevations in aminotransferases in patients with cirrhosis, and to examine their associated outcomes.

Methods

From May 2012 to December 2022, all hospitalized patients with cirrhosis and an aspartate aminotransferase or alanine aminotransferase ≥ 1000 IU/l were identified through Medical University of South Carolina’s Clinical Data Warehouse. Complete clinical data were abstracted for each patient, and in-hospital mortality was examined.

Results

The cohort was made up of 152 patients, who were 57 ± 12 years old, with 51 (34%) women. Underlying liver disease included mainly hepatitis C cirrhosis, alcohol-related cirrhosis, metabolic dysfunction-associated steatohepatitis cirrhosis, autoimmune cirrhosis, primary sclerosing cholangitis cirrhosis, and cryptogenic cirrhosis. The most common cause of marked elevation in aminotransferases in cirrhotic patients was ischemic hepatitis (71%), followed by chemoembolization (7%), autoimmune hepatitis (6%), drug-induced liver injury (3%), post-transjugular intrahepatic portosystemic shunt placement (3%), rhabdomyolysis (3%), and hepatitis C (2%). During hospitalization and over a 1-month follow-up period, the mortality rate in patients with ischemic hepatitis was 73% (79/108), while that for other causes of liver injury was 20% (9/44).

Conclusion

Ischemic hepatitis is the leading cause of marked elevation of aminotransferases in patients with cirrhosis, with distinctive clinical characteristics than other etiologies, and significantly poorer outcomes.