bluuebunny/crossref_metadata_2025 huggingface dataset:
Flipping the Quality Improvement Classroom in Residency Education
Authors: Bonnes Sara L. , Ratelle John T. , Halvorsen Andrew J. , Carter Kimberly J. , Hafdahl Luke T. , Wang Amy T. , Mandrekar Jayawant N. , Oxentenko Amy S. , Beckman Thomas J. , Wittich Christopher M.
Published: September 2016

Purpose

The flipped classroom (FC), in which instructional content is delivered before class with class time devoted to knowledge application, has the potential to engage residents. A Mayo Clinic Internal Medicine Residency Program study was conducted to validate an FC perception instrument (FCPI); determine whether participation improved FC perceptions; and determine associations between resident characteristics, change in quality improvement (QI) knowledge, and FC perception scores.

Method

All 143 internal medicine residents at Mayo Clinic, Rochester participated from 2014 to 2015; some experienced a flipped QI curriculum and others completed the traditional nonflipped course. The FCPI was developed, and factor analysis revealed an intuitive two-factor structure: preclass activity and in-class application. Residents were surveyed before and after the monthlong curriculum to measure changes in perception, and the QI Knowledge Assessment Tool was employed to measure knowledge improvement.

Results

Postcourse FCPI scores significantly increased for three of the eight items. QI knowledge increased significantly among residents who experienced the FC compared with residents who completed the non-FC curriculum. Those without prior FC exposure demonstrated a significant increase in QI knowledge compared with those with previous FC experience. The FCPI had compelling validity evidence with improved scores after curriculum exposure and associations with greater engagement in online modules.

Conclusions

Residents who participated in the FC demonstrated improved QI knowledge compared with the control group. Residents valued the in-class application sessions more than the online component. These findings have important implications for graduate medical education as residency training programs increasingly use FC models.
A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity
Authors: Benvenuti Michael A. , An Thomas J. , Mignemi Megan E. , Martus Jeffrey E. , Mencio Gregory A. , Lovejoy Stephen A. , Schoenecker Jonathan G. , Williams Derek J.
Published: September 2016

Objective:

There are currently no algorithms for early stratification of pediatric musculoskeletal infection (MSKI) severity that are applicable to all types of tissue involvement. In this study, the authors sought to develop a clinical prediction algorithm that accurately stratifies infection severity based on clinical and laboratory data at presentation to the emergency department.

Methods:

An IRB-approved retrospective review was conducted to identify patients aged 0 to 18 who presented to the pediatric emergency department at a tertiary care children’s hospital with concern for acute MSKI over a 5-year period (2008 to 2013). Qualifying records were reviewed to obtain clinical and laboratory data and to classify in-hospital outcomes using a 3-tiered severity stratification system. Ordinal regression was used to estimate risk for each outcome. Candidate predictors included age, temperature, respiratory rate, heart rate, C-reactive protein (CRP), and peripheral white blood cell count. We fit fully specified (all predictors) and reduced models (retaining predictors with a P-value ≤0.2). Discriminatory power of the models was assessed using the concordance (c)-index.

Results:

Of the 273 identified children, 191 (70%) met inclusion criteria. Median age was 5.8 years. Outcomes included 47 (25%) children with inflammation only, 41 (21%) with local infection, and 103 (54%) with disseminated infection. Both the full and reduced models accurately demonstrated excellent performance (full model c-index 0.83; 95% confidence interval, 0.79-0.88; reduced model 0.83; 95% confidence interval, 0.78-0.87). Model fit was also similar, indicating preference for the reduced model. Variables in this model included CRP, pulse, temperature, and an interaction term for pulse and temperature. The odds of a more severe outcome increased by 30% for every 10 U increase in CRP.

Conclusions:

Clinical and laboratory data obtained in the emergency department may be used to accurately differentiate pediatric MSKI severity. The predictive algorithm in this study stratifies pediatric MSKI severity at presentation irrespective of tissue involvement and anatomic diagnosis. Prospective studies are needed to validate model performance and clinical utility.

Level of Evidence:

Level II—prognostic study.
Augmented Renal Clearance in Patients With Febrile Neutropenia is Associated With Increased Risk for Subtherapeutic Concentrations of Vancomycin
Authors: Hirai Keita , Ishii Hidetoshi , Shimoshikiryo Takayuki , Shimomura Tatsuki , Tsuji Daiki , Inoue Kazuyuki , Kadoiri Toshihiko , Itoh Kunihiko
Published: September 2016

Background:

Augmented renal clearance (ARC) has frequently been observed in critically ill patients. The risk factors for ARC in patients, including those in the general ward, and their influences on vancomycin (VCM) treatment remain unclear. The aims of this study were to investigate the risk factors for ARC and to evaluate the influence of ARC on the pharmacokinetic parameters of VCM.

Methods:

This study included a total of 292 patients with VCM treatment who had normal serum creatinine concentrations. ARC was defined by an estimated creatinine clearance ≥130 mL·min−1·1.73 m−2. The risk factors for ARC were determined with stepwise logistic regression analysis. The pharmacokinetic parameters of VCM were estimated through the Bayesian method using a 2-compartment model.

Results:

ARC was observed in 48 patients (16.4%). Age ≤65 years [odds ratio (OR): 5.77; 95% CI: 2.89–11.97; P < 0.0001], brain injury (OR: 5.11; 95% CI: 1.49–17.57; P = 0.0086), febrile neutropenia (OR: 2.76; 95% CI: 1.11–6.67; P = 0.0254), and a mean volume of infusion fluid ≥1500 mL/d (OR: 2.53; 95% CI: 1.27–5.16; P = 0.0091) were independent risk factors for the occurrence of ARC. The patients with ARC exhibited higher VCM clearance values than the non-ARC patients. The median trough serum concentrations of VCM were 7.4 (interquartile range: 5.2–11.6) mcg/mL in the ARC patients and 12.2 (8.9–16.3) mcg/mL in the non-ARC patients (P < 0.0001). Subtherapeutic trough concentrations of VCM (<10.0 mcg/mL) were found in 68.8% of the ARC patients and in 32.8% of the non-ARC patients (P < 0.0001).

Conclusions:

This observational study investigated the influence of febrile neutropenia on the emergency of ARC for the first time. ARC was strongly associated with VCM pharmacokinetics, and two-thirds of the ARC patients had subtherapeutic VCM concentrations. In patients with ARC, individualized dosing regimens are required to achieve the target trough concentration.
3D Printed Models of Cleft Palate Pathology for Surgical Education
Authors: Lioufas Peter A. , Quayle Michelle R. , Leong James C. , McMenamin Paul G.
Published: September 2016

Objective:

To explore the potential viability and limitations of 3D printed models of children with cleft palate deformity.

Background:

The advantages of 3D printed replicas of normal anatomical specimens have previously been described. The creation of 3D prints displaying patient-specific anatomical pathology for surgical planning and interventions is an emerging field. Here we explored the possibility of taking rare pediatric radiographic data sets to create 3D prints for surgical education.

Methods:

Magnetic resonance imaging data of 2 children (8 and 14 months) were segmented, colored, and anonymized, and stereolothographic files were prepared for 3D printing on either multicolor plastic or powder 3D printers and multimaterial 3D printers.

Results:

Two models were deemed of sufficient quality and anatomical accuracy to print unamended. One data set was further manipulated digitally to artificially extend the length of the cleft. Thus, 3 models were printed: 1 incomplete soft-palate deformity, 1 incomplete anterior palate deformity, and 1 complete cleft palate. All had cleft lip deformity. The single-material 3D prints are of sufficient quality to accurately identify the nature and extent of the deformities. Multimaterial prints were subsequently created, which could be valuable in surgical training.

Conclusion:

Improvements in the quality and resolution of radiographic imaging combined with the advent of multicolor multiproperty printer technology will make it feasible in the near future to print 3D replicas in materials that mimic the mechanical properties and color of live human tissue making them potentially suitable for surgical training.
Fu-Chan Wei—Surgeon, Innovator, and Leader of the Legendary Chang Gung Microsurgery Center
Authors: AL Deek Nidal Farhan , Lalonde Donald H.
Published: September 2016

Fu-Chan Wei is a world-renowned plastic and reconstructive surgeon. He is clearly one of the most influential and innovative surgeons in the history of plastic surgery. The Taiwanese legend is the innovator of the osteoseptocutaneous fibula flap, which revolutionized the reconstruction of composite bone and soft tissue defects in the jaw and extremities. He has pioneered several perforator flaps, including the free style variety. He has taken toe-to-hand microsurgical transplantation to a whole new level. He is not only recognized for his surgical skills and clinical innovations, but also for his vision, leadership, and teaching. The establishment and development of the famous Microsurgery Center at Chang Gung Memorial Hospital is unparalleled anywhere. The international fellowship program in microsurgery there remains the envy of all microsurgical trainees. Dr. Wei and his colleagues have trained and influenced more than 1,500 surgeons from all over the world. The aim of this video article is to share what we learned by interviewing Fu-Chan Wei at Chang Gung. The story of Fu Chan Wei, his colleagues, and the development of the Microsurgery Center in Taiwan is worth knowing.
A Prognostic Dilemma of Basal Cell Carcinoma with Intravascular Invasion
Authors: Lonie Sarah , Niumsawatt Vachara , Castley Andrew
Published: September 2016

Basal cell carcinoma is the most common malignancy; however, it very rarely metastasizes. Despite the low mortality caused by this cancer, once it spreads, it has dim prognosis. We report a case of basal cell carcinoma with rare intravascular invasion and review the literature for risk factors and management of metastasis.
Pathologic High-risk Lesions, Diagnosis and Management
Authors: MURRAY MELISSA
Published: September 2016

Percutaneous imaging-guided core needle biopsy (CNB) is a less invasive and less expensive alternative to surgical biopsy for the evaluation of breast lesions. After a CNB the radiologist determine if there is concordance between the pathology, imaging, and clinical findings. Patient management after CNB diagnosis of high-risk breast lesion varies. Surgical excision is warranted for lesions yielding a CNB diagnosis of ADH; however controversy exists regarding the need for surgical excision after CNB diagnosis of radial scar, papillary lesion, atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS). Repeat CNB or surgical excision is warranted if histologic findings and imaging findings are discordant.
Breast Cancer Epidemiology and Risk Factors
Authors: ROJAS KRISTIN , STUCKEY ASHLEY
Published: September 2016

Between the years 2010 and 2012, the lifetime probability of developing female breast cancer was 12.3%, or approximately 1 in 8. Worldwide, breast cancer is the most common cancer in women. Survival is increasing. Between 2005 and 2011, the 5-year relative survival was found to be 89%. This is thought to be due to both the increase in utilization of population-wide screening, as well as advances in treatment. Less than 10% of breast cancers can be attributed to an inherited genetic mutation. Breast cancer is more commonly associated with environmental, reproductive, and lifestyle factors, some of which are potentially modifiable.
Long-term outcomes from training in self-management of chronic pain in an elderly population: a randomized controlled trial
Authors: Nicholas Michael K. , Asghari Ali , Blyth Fiona M. , Wood Bradley M. , Murray Robin , McCabe Rebecca , Brnabic Alan , Beeston Lee , Corbett Mandy , Sherrington Catherine , Overton Sarah
Published: September 2016

This study compares the outcomes, from pretreatment to 1-year follow-up, of an outpatient, CBT-based pain self-management program (PSM) that included exercises, pain education, and pain coping strategies, with a control condition (exercise-attention control, EAC) that included exercises and a control for the attention of the treatment team. We previously reported short-term results (to 1-month follow-up) from the same study. This new paper considers the important issue of maintenance of treatment-related gains. The participants (n = 141) were a heterogeneous sample of ambulant, community-dwelling older adult patients with chronic pain (mean age: 73.90 [6.5] years [range: 65-87 years]). The long-term results indicate the pain self-management program group achieved and maintained significantly better results than the exercise-attention control group on the primary outcome, pain-related disability, as well as on usual pain, pain distress, depression, and fear-avoidance beliefs. The mean effect size for these gains by the pain self-management program group over the exercise-attention control group was 0.37 (range: 0.29-0.45), which is in the small effect size range. While statistically and clinically meaningful, these findings do indicate some weakening in effects over time but not to a significant degree. The study has implications for the provision of pain management interventions for community-dwelling older adults with chronic pain.
Racial and ethnic differences in experimental pain sensitivity: systematic review and meta-analysis
Authors: Kim Hee Jun , Yang Gee Su , Greenspan Joel D. , Downton Katherine D. , Griffith Kathleen A. , Renn Cynthia L. , Johantgen Meg , Dorsey Susan G.
Published: September 2016

Our objective was to describe the racial and ethnic differences in experimental pain sensitivity. Four databases (PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and PsycINFO) were searched for studies examining racial/ethnic differences in experimental pain sensitivity. Thermal–heat, cold–pressor, pressure, ischemic, mechanical cutaneous, electrical, and chemical experimental pain modalities were assessed. Risk of bias was assessed using the Agency for Healthcare Research and Quality guideline. Meta-analysis was used to calculate standardized mean differences (SMDs) by pain sensitivity measures. Studies comparing African Americans (AAs) and non-Hispanic whites (NHWs) were included for meta-analyses because of high heterogeneity in other racial/ethnic group comparisons. Statistical heterogeneity was assessed by subgroup analyses by sex, sample size, sample characteristics, and pain modalities. A total of 41 studies met the review criteria. Overall, AAs, Asians, and Hispanics had higher pain sensitivity compared with NHWs, particularly lower pain tolerance, higher pain ratings, and greater temporal summation of pain. Meta-analyses revealed that AAs had lower pain tolerance (SMD: −0.90, 95% confidence intervals [CIs]: −1.10 to −0.70) and higher pain ratings (SMD: 0.50, 95% CI: 0.30–0.69) but no significant differences in pain threshold (SMD: −0.06, 95% CI: −0.23 to 0.10) compared with NHWs. Estimates did not vary by pain modalities, nor by other demographic factors; however, SMDs were significantly different based on the sample size. Racial/ethnic differences in experimental pain sensitivity were more pronounced with suprathreshold than with threshold stimuli, which is important in clinical pain treatment. Additional studies examining mechanisms to explain such differences in pain tolerance and pain ratings are needed.
Recruitment Strategies and Costs Associated With Enrolling People With Insomnia and High Blood Pressure Into an Online Behavioral Sleep Intervention
Authors: Routledge Faye S. , Davis Tara D. , Dunbar Sandra B.
Published: September 2016

Background:

Recruitment in clinical research is a common challenge and source of study failure. The reporting of recruitment methods and costs in hypertension trials is limited especially for smaller, single-site trials, online intervention trials, and trials using newer online recruitment strategies.

Objective:

The aims of this study are to describe and examine the feasibility of newer online-e-mail recruitment strategies and traditional recruitment strategies used to enroll participants with insomnia and high blood pressure into an online behavioral sleep intervention study (Sleeping for Heart Health).

Methods:

The 16 online-e-mail–based and traditional recruitment strategies used are described. Recruitment strategy feasibility was examined by study interest and enrollee yields, conversion rates, and costs (direct, remuneration, labor, and cost per enrollee).

Results:

From August 2014 to October 2015, 183 people were screened and 58 (31.7%) enrolled in the study (51.1 ± 12.9 years, 63.8% female, 72.4% African American, 136 ± 12/88 ± 7 mm Hg, 87.9% self-reported hypertension, 67.2% self-reported antihypertensive medication use). The recruitment strategies yielding the highest enrollees were the university hospital phone waiting message system (25.4%), Craigslist (22.4%), and flyers (20.3%) at a per enrollee cost of $42.84, $98.90, and $128.27, respectively. The university hospital phone waiting message system (55.6%) and flyers (54.5%) had the highest interested participant to enrolled participant conversion rate of all recruitment strategies.

Conclusion:

Approximately 70% of all enrolled participants were recruited from the university hospital phone waiting message system, Craigslist, or flyers. Given the recruitment challenges that most researchers face, we encourage the documenting, assessing, and reporting of detailed recruitment strategies and associated recruitment costs so that other researchers may benefit.
Perceptions of Disease-Related Stress
Authors: Jackson Jamie L. , Gerardo Gina M. , Daniels Curt J. , Vannatta Kathryn
Published: September 2016

Background:

Disease-related stressors for survivors of congenital heart disease (CHD) have been qualitatively described but not quantified nor examined in relationship to important patient-reported outcomes (PROs).

Objective:

The aims of this study are to (1) identify the types and degree of disease-related stress experienced by CHD survivors based on age, functional status, and sex, (2) examine differences in stress and PROs by age, functional status, and sex, and (3) determine the unique contribution of perceived stress to variability in PROs.

Methods:

A cross-sectional study of 173 adolescents and emerging and young adults who were recruited from both pediatric and adult CHD clinics was conducted. Participants rated the degree to which they found various aspects of CHD stressful and completed PROs of health-related quality of life and emotional distress. Differences in perceptions of stress across predictors were determined using analyses of variance andχ2analyses. The relative contribution of perceived stress predicting PROs was examined using stepwise linear regression.

Results:

Two items emerged as being stressful for almost half of the sample, including concerns about future health and having scars or other signs of medical procedures. Adolescents reported less perceived stress than emerging or young adults, and survivors with even mild functional limitations reported higher perceived stress than did those without any symptoms. Perceptions of stress significantly contributed to variability in PROs above and beyond other predictors and was the only variable to explain unique variance in emotional distress.

Conclusions:

Having even mild functional impairment may have significant deleterious consequences on PROs via increased perceptions of stress. Stress may be modifiable using cognitive behavioral therapy.
Nutrition Research Integrity
Authors: Myers Esther F.
Published: September 2016

Nutrition research integrity has become a hotly debated topic. How much confidence we can place in the results of either an individual research study or the recommendations derived from a systematic review that combines multiple studies is crucial in interpreting the research findings. Using research as the basis of public policy is dependent upon the critical appraisal and description of the amount of confidence that can be placed in the research results. In the early 2000s, this was referred to as the “quality” of the individual research study. The methodology has continued to be refined, and more recently, this has been referred to as evaluating the “risk of bias.” This refinement focuses more on the aspects of the research that are likely to compromise whether we can “believe the results” and set the stage for a thoughtful dialogue about the strengths and weaknesses of nutrition research itself, versus focusing on study funding.
CK7 Immunohistochemistry as a Predictor of CIN1 Progression
Authors: Mills Anne M. , Paquette Cherie , Terzic Tatjana , Castle Philip E. , Stoler Mark H.
Published: September 2016

Cervical high-grade squamous intraepithelial lesion (CIN2-3) is thought to arise from a distinct population of cells at the squamocolumnar junction (SCJ). Immunohistochemical (IHC) biomarkers that characterize the SCJ phenotype, including CK7, have been proposed as tools to separate the subset of low-grade squamous intraepithelial lesions (LSILs) (CIN1) that will progress to high-grade squamous intraepithelial lesion from the majority of cases, which will resolve without further intervention. We conducted a retrospective study of CK7 IHC on adjudicated CIN1 tissue from women in the placebo arm of the quadrivalent human papillomavirus (HPV) vaccine trials. Tissue sections were stained with CK7 IHC and scored as negative, patchy, gradation (ie, top-down), or full-thickness pattern. Results were assessed for the prediction of future diagnosis of CIN2-3/AIS (eg, CIN2+ progression) along with p16 IHC, antecedent high-grade cytology, and HPV16 status. A total of 517 patients with CIN1 biopsies and complete data were identified, 12% of whom showed CIN2+ progression on follow-up. Full-thickness CK7 staining showed the highest correlation with CIN2+ progression (odds ratio [OR] 2.8, P=0.021) relative to the other risk factors (HPV16: OR 2.0, P=0.035; antecedent high-grade cytology: OR 2.2, P=0.028; p16 IHC: OR 1.5, P=0.16). Inclusion of the gradation/“top-down” CK7 pattern resulted in a less robust association with progression (CIN2+: OR 2.0, P=0.028; CIN3+: OR 1.3, P=0.74). Interobserver variability ranged from slight to substantial and was not contingent on gynecologic pathology training experience (κ=0.7078 for negative/patchy vs. gradation/full thickness; κ=0.5672 for negative/patchy/gradation vs. full thickness). These data support the theory that SCJ-derived LSILs are precursors to a potentially aggressive subset of cervical SILs and that CK7 staining may inform risk stratification for LSIL (CIN1). However, clinical utility is significantly tempered by the relatively low amplitude of the risk increase, interpretative variability, and limitations of colposcopic sampling.
State Public Health Enabling Authorities: Results of a Fundamental Activities Assessment Examining Core and Essential Services
Authors: Hoss Aila , Menon Akshara , Corso Liza
Published: September 2016

Context:

Public health enabling authorities establish the legal foundation for financing, organizing, and delivering public health services. State laws vary in terms of the content, depth, and breadth of these fundamental public health activities. Given this variance, the Institute of Medicine has identified state public health laws as an area that requires further examination. To respond to this call for further examination, the Centers for Disease Control and Prevention's Public Health Law Program conducted a fundamental activities legal assessment on state public health laws.

Objective:

The goal of the legal assessment was to examine state laws referencing frameworks representing public health department fundamental activities (ie, core and essential services) in an effort to identify, catalog, and describe enabling authorities of state governmental public health systems.

Design:

In 2013, Public Health Law Program staff compiled a list of state statutes and regulations referencing different commonly-recognized public health frameworks of fundamental activities. The legal assessment included state fundamental activities laws available on WestlawNext as of July 2013. The results related to the 10 essential public health services and the 3 core public health functions were confirmed and updated in June 2016.

Results:

Eighteen states reference commonly-recognized frameworks of fundamental activities in their laws. Thirteen states have listed the 10 essential public health services in their laws. Eight of these states have also referenced the 3 core public health functions in their laws. Five states reference only the core public health functions.

Conclusions:

Several states reference fundamental activities in their state laws, particularly through use of the essential services framework. Further work is needed to capture the public health laws and practices of states that may be performing fundamental activities but without reference to a common framework.
Implementing Health Impact Assessment Programs in State Health Agencies: Lessons Learned From Pilot Programs, 2009-2011
Authors: Goff Nancy , Wyss Kerry , Wendel Arthur , Jarris Paul
Published: September 2016

Context:

Health Impact Assessment (HIA) has emerged as a promising tool to integrate health considerations into decision making. The growth and success of HIA practice in the United States will be dependent on building the capacity of practitioners.

Objective:

This article seeks to identify the role of state health agencies (SHAs) in building capacity for conducting HIAs and the key components of initiatives that produced effective HIAs and HIA programs. The authors proposed to answer 3 research questions: (1) What can be the role of the SHA in HIA? (2) What are the characteristics of successful state HIA programs? and (3) What are some effective strategies for building capacity for HIA in SHAs and local health departments?

Design:

The authors reviewed program reports from the ASTHO's pilot state health agencies (California, Minnesota, Oregon, and Wisconsin) that, between 2009 and 2011, created HIA programs to provide HIA training, conduct HIAs, and build practitioner networks.

Main Outcome Measures:

Program reports were examined for shared themes on the role of SHAs in a statewide HIA initiative, the characteristics of successful programs, and effective strategies for building capacity.

Results:

Despite differences among the programs, many shared themes existed. These include stressing the importance of a basic, sustained infrastructure for HIA practice; leveraging existing programs and networks; and working in partnership with diverse stakeholders.

Conclusions:

SHAs can build capacity for HIA, and SHAs can both lead and support the completion of individual HIAs. States and territories interested in starting comprehensive statewide HIA initiatives could consider implementing the strategies identified by the pilot programs.
Succession Planning and Management Practice in Washington State Local Public Health Agencies
Authors: Wiesman John M. , Babich Suzanne M. , Umble Karl , Baker Edward L.
Published: September 2016

Context:

Turnover of top local public health officials is expected to be great, with 23% being 60 years of age or older, and another 42% being 50 to 59 years of age. Yet, we know little about the use of succession planning in public health agencies.

Objective:

Describe succession planning practices in local public health agencies.

Design:

We conducted a Web-based, cross-sectional survey of succession planning practices and followed the career paths of public health officials for 40 months.

Setting and Participants:

The top local public health officials from Washington State's 35 local governmental public health agencies.

Main Outcome Measures:

Twenty-five succession planning best practices.

Results:

All 35 agencies responded, resulting in a 100% response rate. Our study found evidence of succession planning practices in Washington State local public health agencies: 85% of agencies selected high-performing high potential employees for development, 76% sent them to formal technical and management/leadership training, 70% used cross-functional team projects, and 67% used stretch assignments to develop their employees. Impetuses to implement succession planning were discovering that large percentages of employees were able to retire soon and that national accreditation requires workforce development plans. Barriers to implementing succession planning included other competing demands for time, belief that the agency's workforce was too small for a formal program, and concerns that there would be union barriers. In 2012, 50% of the officials surveyed said that it would be at least possible that they would leave their current jobs within 5 years. Forty months later, 12 (34%) had left their positions.

Conclusions:

We were encouraged by the level of succession planning in Washington State and recommend creating a greater sense of urgency by focusing on agency retirement profiles and emphasizing the need for workforce development plans for accreditation. Developing the public health leaders of tomorrow is too important to be left to chance.
Development and Usefulness of a District Health Systems Tool for Performance Improvement in Essential Public Health Functions in Botswana and Mozambique
Authors: Bishai David , Sherry Melissa , Pereira Claudia C. , Chicumbe Sergio , Mbofana Francisco , Boore Amy , Smith Monica , Nhambi Leonel , Borse Nagesh N.
Published: September 2016

Introduction:

This study describes the development of a self-audit tool for public health and the associated methodology for implementing a district health system self-audit tool that can provide quantitative data on how district governments perceive their performance of the essential public health functions.

Methods:

Development began with a consensus-building process to engage Ministry of Health and provincial health officers in Mozambique and Botswana. We then worked with lists of relevant public health functions as determined by these stakeholders to adapt a self-audit tool describing essential public health functions to each country's health system. We then piloted the tool across districts in both countries and conducted interviews with district health personnel to determine health workers' perception of the usefulness of the approach.

Results:

Country stakeholders were able to develop consensus around 11 essential public health functions that were relevant in each country. Pilots of the self-audit tool enabled the tool to be effectively shortened. Pilots also disclosed a tendency to upcode during self-audits that was checked by group deliberation. Convening sessions at the district enabled better attendance and representative deliberation. Instant feedback from the audit was a feature that 100% of pilot respondents found most useful.

Conclusion:

The development of metrics that provide feedback on public health performance can be used as an aid in the self-assessment of health system performance at the district level. Measurements of practice can open the door to future applications for practice improvement and research into the determinants and consequences of better public health practice. The current tool can be assessed for its usefulness to district health managers in improving their public health practice. The tool can also be used by the Ministry of Health or external donors in the African region for monitoring the district-level performance of the essential public health functions.
A Century in the Life of the Control of Communicable Diseases Manual: 1917 to 2017
Authors: Marr John S. , Cathey John T.
Published: September 2016

The Control of Communicable Diseases Manual, a premier publication of the American Public Health Association, celebrates its centennial in 2017. The Control of Communicable Diseases Manual has evolved in format and content through 20 separate editions. This article is a follow-up to an earlier article, titled “Evolution of the Control of Communicable Disease Manual: 1917 to 2000,” that appeared in the Journal of Public Health Management & Practice in 2001. Our update focuses on the period since the 17th edition, which is characterized by dramatic changes. The 20th edition (2014) added a few arboviral diseases (Banna, Cache Valley, Eyach, Heartland, severe fever with thrombocytopenia syndrome virus, Iquitos, and Me Tri), but mostly contracted, leaving 65 arboviral entries. Other categories of pathogens also declined in the most recent editions, indicating an apparent trend to make the manual less encyclopedic. We attempt to explain these and other changes and ask the reader to comment whether they are aware of other related facts or history based on personal experience.
Flexor Tendon Sheath Engineering Using Decellularized Porcine Pericardium
Authors: Megerle Kai , Woon Colin , Kraus Armin , Raghavan Shyam , Pham Hung , Chang James
Published: September 2016

Background:

The flexor tendon sheath is an ideal target for tissue engineering because it is difficult to reconstruct by conventional surgical methods. The authors hypothesized that decellularized porcine pericardium can be used as a scaffold for engineering a biologically active tendon sheath.

Methods:

The authors’ protocol removed cellular material from the pericardium and preserved the structural architecture in addition to the collagen and glycosaminoglycan content. The scaffold was successfully reseeded with human sheath synoviocytes and human adipose-derived stem cells. Cells were evaluated for 8 weeks after reseeding.

Results:

The reseeded construct demonstrated continuous production of hyaluronic acid, the main component of synovial fluid. After being seeded on the membrane, adipose-derived stem cells demonstrated down-regulation of collagen I and III and up-regulation of hyaluronan synthase 2.

Conclusion:

The results indicate that decellularized porcine pericardium may be a potential scaffold for engineering a biologically active human tendon sheath.
Hemodynamic Study of Three Patterns of Flaps on Rats with a Novel Panoramic Photographing Technique Involved
Authors: Zhuang Yuehong , Xie Yun , Wu Zhihai , Xue Lan , Tang Yingying , Zheng Heping , Fang Fang
Published: September 2016

Background:

No study heretofore has been conducted to investigate the hemodynamic characteristics of the perforator, perforator-plus, and random flaps on an animal model.

Methods:

Thirty Sprague-Dawley rats were equally divided into three groups: the perforator group, the perforator-plus group, and the random group. Laser Doppler flowmetry was adopted for measurement of blood perfusion of the flaps at six time points. Another nine rats were equally divided into three groups and underwent the corresponding surgery. On day 7, the flaps were photographed for calculation of the necrosis rate. The vascular network of flaps in each group was photographed immediately postoperatively and at days 3 and 7 after surgery with a special technique first proposed by us.

Results:

No significant difference in flap necrosis could be detected in the perforator and perforator-plus flaps. Other than on day 1, when perfusion of the perforator was significantly stronger than that of the perforator-plus flap, there was no significant difference between the perforator and perforator-plus flaps. The three perforasomes in the perforator and perforator-plus flaps could all survive because of considerable dilation of vessels. On day 7, the vascular network between the iliolumbar perforator and the sacrococcygeal perforators underwent tremendous enlargement in diameter in the random flap group.

Conclusions:

The perforator flap and the perforator-plus flap are equal in blood perfusion. The survival of the random flap depends on the dilation of the vascular network between the pedicle and the nearest potential perforator.
Impact of Prior Unilateral Chest Wall Radiotherapy on Outcomes in Bilateral Breast Reconstruction
Authors: de Araujo Thiago B. , Jue Xu Mary , Susarla Srinivas M. , Shmelev Karen , Jiang Wei , Pribaz Julian J. , Hergrueter Charles , Carty Matthew J. , Caterson Stephanie , Chun Yoon S.
Published: September 2016

Background:

The purpose of this study was to evaluate the impact of prior unilateral chest wall radiotherapy on reconstructive outcomes among patients undergoing bilateral immediate breast reconstruction.

Methods:

A retrospective evaluation of patients with a history of unilateral chest wall radiotherapy was performed. In each patient, the previously irradiated and reconstructed breast was compared to the contralateral nonirradiated side, which served as an internal control. Descriptive and bivariate statistics were computed. Multiple regression statistics were computed to identify adjusted associations between chest wall radiotherapy and complications.

Results:

Seventy patients were included in the study. The mean follow-up period was 51.8 months (range, 10 to 113 months). Thirty-eight patients underwent implant-based breast reconstruction; 32 patients underwent abdominal autologous flap reconstruction. Previously irradiated breast had a significantly higher rate of overall complications (51 percent versus 27 percent; p < 0.0001), infection (13 percent versus 6 percent; p = 0.026), and major skin necrosis (9 percent versus 3 percent; p = 0.046). After adjusting for age, body mass index, reconstruction method, and medical comorbidities, prior chest wall radiotherapy was a significant risk factor for breast-related complications (OR, 2.98; p < 0.0001), infection (OR, 2.59; p = 0.027), and major skin necrosis (OR, 3.47; p = 0.0266). There were no differences between implant-based and autologous reconstructions with regard to complications (p = 0.76).

Conclusion:

Prior chest wall radiotherapy is associated with a 3-fold increased risk of postoperative complications following immediate breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
How Should Results of Nonsurgical Subcutaneous Fat Removal Be Assessed? Accuracy of B-Mode Ultrasound
Authors: Barton Fritz E. , Dauwe Phillip B. , Stone Tara , Newman Elizabeth
Published: September 2016

Background:

Nonsurgical fat reduction has become extremely popular among patients; however, a reliable method of measuring its efficacy has not been established.

Methods:

Ultrasound measurement of human female abdominal subcutaneous fat thickness was carried out on five volunteers. Forty-seven measurements were performed using a GE Venue 40 diagnostic ultrasound device with a 12-MHz transducer. Transducer pressure measurements were recorded simultaneously according to the protocol described by Toomey et al..

Results:

Reproducible measurements of abdomen subcutaneous fat could be consistently achieved with a margin of error (95 percent CI) of ±0.558 mm.

Conclusions:

Using a protocol with a transducer pressure less than 1 N (Toomey protocol) allows accurate and reliable measurement of subcutaneous fat. The authors further conclude that such a protocol is practically reproducible in the clinical setting and should be the standard for evaluating the results of nonsurgical fat removal, particularly in the abdomen.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Diagnostic, IV.
The Feasibility and Validity of PROMIS: A Novel Measure of Quality of Life among Children with Cleft Lip and Palate
Authors: Ranganathan Kavitha , Shapiro Danielle , Carlozzi Noelle E. , Baker Michaella , Vercler Christian J. , Kasten Steven J. , Warschausky Seth A. , Buchman Steven R. , Waljee Jennifer F.
Published: September 2016

Background:

Health-related quality of life is inconsistently captured among children with cleft lip and palate. The Patient-Reported Outcomes Measurement Information System (PROMIS) captures health-related quality of life, with the added benefit of comparability across clinical conditions. In this study, the authors define the validity and feasibility of PROMIS among children with clefts.

Methods:

Children with cleft lip and palate who were at least 5 years old and able to complete instruments independently were eligible for inclusion (n= 93). Children completed PROMIS anxiety, depression, and peer relationship item banks as short forms or computerized adaptive tests. Participants also completed the Pediatric Quality of Life Inventory. Construct validity was measured by Spearman correlations between PROMIS and the Pediatric Quality of Life Inventory controlling for race, sex, age, and income. Feasibility was measured using instrument completion time, reading level, and floor/ceiling effects.

Results:

PROMIS computerized adaptive tests (peer relationship,r= 0.49; depression,r= −0.56; and anxiety,r= −0.36) and short forms (peer relationship,r= 0.65; depression,r= −0.54; and anxiety,r= −0.56) demonstrated moderate correlation with the Pediatric Quality of Life Inventory. Computerized adaptive tests had fewer floor (0 percent versus 0 percent) and ceiling (8.6 to 19.3 percent versus 21.8 to 41.9 percent) effects than short forms, and demonstrated better readability. Computerized adaptive tests required more time than short forms (peer relationship, 0.84 ± 0.67 versus 1.3 ± 0.92; depression, 0.52 ± 0.38 versus 1.1 ± 0.73; and anxiety, 0.53 ± 0.23 versus 1.1 ± 0.62;p= 0.001), as each computerized adaptive test included on average four more questions.

Conclusions:

PROMIS correlates well with the Pediatric Quality of Life Inventory and demonstrates similar accuracy, with better readability and efficiency. Use of PROMIS will improve our ability to compare children with cleft lip and palate to diverse populations and clinical conditions.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Diagnostic, II.
Making the End as Good as the Beginning: Financial Planning and Retirement for Women Plastic Surgeons
Authors: Johnson Debra J. , Shenaq Deana , Thakor Manisha
Published: September 2016

Financial planning is critically important to ensure financial security both during a plastic surgical career and in retirement. Unfortunately, plastic surgery training includes very little in the way of financial planning. The information that is available in the literature is mostly geared toward men. Women, with longer lifespans and more family care responsibilities, have unique needs when it comes to financial planning. Adequate attention must also be paid to life after retirement. A plastic surgical career can be all-encompassing, and thus women need to carefully plan volunteer activities, new hobbies, and even a second career to make their retirement years fulfilling and enjoyable. Key points regarding financial planning during the various phases of a woman plastic surgeon’s career are discussed. Options for retirement are presented.
Computer Simulation and Digital Resources for Plastic Surgery Psychomotor Education
Authors: Diaz-Siso J. Rodrigo , Plana Natalie M. , Stranix John T. , Cutting Court B. , McCarthy Joseph G. , Flores Roberto L.
Published: September 2016

Contemporary plastic surgery residents are increasingly challenged to learn a greater number of complex surgical techniques within a limited period. Surgical simulation and digital education resources have the potential to address some limitations of the traditional training model, and have been shown to accelerate knowledge and skills acquisition. Although animal, cadaver, and bench models are widely used for skills and procedure-specific training, digital simulation has not been fully embraced within plastic surgery. Digital educational resources may play a future role in a multistage strategy for skills and procedures training. The authors present two virtual surgical simulators addressing procedural cognition for cleft repair and craniofacial surgery. Furthermore, the authors describe how partnerships among surgical educators, industry, and philanthropy can be a successful strategy for the development and maintenance of digital simulators and educational resources relevant to plastic surgery training. It is our responsibility as surgical educators not only to create these resources, but to demonstrate their utility for enhanced trainee knowledge and technical skills development. Currently available digital resources should be evaluated in partnership with plastic surgery educational societies to guide trainees and practitioners toward effective digital content.
Biomechanical Analysis of Barbed Suture in Flexor Tendon Repair versus Conventional Method: Systematic Review and Meta-Analysis
Authors: Shin Jin Yong , Kim Jin Soo , Roh Si-Gyun , Lee Nae-Ho , Yang Kyung-Moo
Published: September 2016

Background:

The barbed suture technique uses newly developed materials for flexor tendon repair. In this study, the authors examine the effectiveness of using barbed sutures in flexor tendon repair compared with conventional methods.

Methods:

A systematic literature review and meta-analysis was performed using MEDLINE, Embase, and Cochrane databases. Barbed suture and conventional suture methods were extracted as predictor variables, and maximum force, gap formation force, and cross-sectional area were extracted as outcome variables. Subgroup analyses were performed according to the source of suture materials and the number of strands. The Newcastle-Ottawa Scale was used to assess the quality of studies. Publication bias was evaluated using funnel plots.

Results:

The search strategy identified 86 publications. After screening, 12 articles were selected for review. Barbed sutures are comparable in effectiveness to conventional methods in terms of maximum force, gap formation force, and cross-sectional area. In the subgroup analysis, barbed sutures also have comparable effects to conventional methods in terms of maximum force and gap formation force.

Conclusions:

The authors’ meta-analysis found that the use of barbed sutures in flexor tendon repair was competitive compared to conventional methods in terms of maximum force and gap formation force. Long-term in vivo studies are needed to confirm these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.