Search

Purpose: To design and validate a new miniaturized open-field wavefront device that can be attached to an ophthalmic surgical microscope or slitlamp. Setting: Solihull Hospital and Aston University, Birmingham, United Kingdom. Design: Comparative noninterventional study. Methods: The dynamic range of the Aston aberrometer was assessed using a calibrated model eye. The validity was compared with that of a conventional desk-mounted Hartmann-Shack aberrometer (Topcon KR1W) in dilated eyes. The instruments were used in random order, with measurements repeated 5 times to assess intrasession repeatability. Results: The open-field aberrometer had a large dynamic range of at least +21.0 diopters (D) to −25.0 D. It gave similar measurements to the conventional aberrometer for mean spherical equivalent (SE) (mean difference 0.02 D ± 0.49 [95% confidence interval]; correlation r = 0.995; P<.001), astigmatic components (J0: 0.02 ± 0.15 D; r = 0.977, P<.001; J45: 0.03 ± 0.28, r = 0.666, P<.001), and higher-order aberration (HOA) root mean square (RMS) (0.02 ± 0.20 D, r = 0.620, P<.001). Intraclass correlation coefficient assessments of intrasession repeatability were excellent (SE = 1.000, P<.001; J0 = 0.998, P<.001; J45 = 0.980, P<.01; HOA RMS = 0.961, P<.001). Conclusions: The new aberrometer gave valid, repeatable measurements of refractive error and HOAs over a large range. It can measure continuously, thus providing direct feedback on the optical status of the visual system to surgeons during intraocular lens implantation and corneal surgery. Financial Disclosure: The Aston aberrometer is jointly patented by Topcon Corp. and Prof. Wolffsohn. Drs. Mihashi and Yamaguchi are employees of Topcon Corp., Tokyo, Japan. No other author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

The article presents a study which identified the risk factors for endometrial cancer following benign results of endometrial biopsy or dilation and curettage (D&C). In the study, a multivariable conditional logistic regression model was used to examine the data from the Rochester Epidemiology Project. The study was authorized by the Mayo Clinic and the Olmsted Medical Center Institutional Review Board in the U.S.

Background: Stability and mobility represent the paradoxical demands of the human thumb carpometacarpal joint, yet the structural origin of each functional demand is poorly defined. As many as sixteen and as few as four ligaments have been described as primary stabilizers, but controversy exists as to which ligaments are most important. We hypothesized that a comparative macroscopic and microscopic analysis of the ligaments of the thumb carpometacarpal joint would further define their role in joint stability. Methods: Thirty cadaveric hands (ten fresh-frozen and twenty embalmed) from nineteen cadavers (eight female and eleven male; average age at the time of death, seventy-six years) were dissected, and the supporting ligaments of the thumb carpometacarpal joint were identified. Ligament width, length, and thickness were recorded for morphometric analysis and were compared with use of the Student t test. The dorsal and volar ligaments were excised from the fresh- frozen specimens and were stained with use of a triple-staining immunofluorescent technique and underwent semi-quantitative analysis of sensory innervation; half of these specimens were additionally analyzed for histomorphometric data. Mixed-effects linear regression was used to estimate differences between ligaments. Results: Seven principal ligaments of the thumb carpometacarpal joint were identified: three dorsal deltoid-shaped ligaments (dorsal radial, dorsal central, posterior oblique), two volar ligaments (anterior oblique and ulnar collateral), and two ulnar ligaments (dorsal trapeziometacarpal and intermetacarpal). The dorsal ligaments were significantly thicker (p < 0.001) than the volar ligaments, with a significantly greater cellularity and greater sensory innervation compared with the anterior oblique ligament (p < 0.001). The anterior oblique ligament was consistently a thin structure with a histologic appearance of capsular tissue with low cellularity. Conclusions: The dorsal deltoid ligament complex is uniformly stout and robust; this ligament complex is the thickest morphometrically, has the highest cellularity histologically, and shows the greatest degree of sensory nerve endings. The hypocellular anterior oblique ligament is thin, is variable in its location, and is more structurally consistent with a capsular structure than a proper ligament. [ABSTRACT FROM AUTHOR]

Purpose: To study the visual and refractive outcomes after laser-assisted subepithelial keratectomy (LASEK) performed with a 213 nm solid-state laser for a broad range of refractive errors. Setting: Private practice, Jersey, United Kingdom. Design: Case series. Methods: The LASEK was performed using a Pulzar Z1 213 nm solid-state laser. Manifest refraction and uncorrected (UDVA) and corrected (CDVA) distance visual acuities were measured preoperatively and 2 and 6 months postoperatively. Accuracy, safety, efficacy, and stability were assessed at 6 months. Results: The study enrolled 245 eyes (134 patients). The preoperative spherical equivalent (SE) refractive errors ranged from −9.50 to +6.50 diopters (D); 24 eyes had more than 2.50 D of astigmatism. At 6 months, 60.4% of eyes were within ±0.25 D of the intended SE, 89.4% were within ±0.50 D, and 97.9% were within ±1.00 D. No eye lost 2 or more lines of CDVA; 95.5% of eyes were unchanged or gained 1 line. The mean cylinder power decreased from −0.98 ± 1.17 D to −0.14 ± 0.28 DC at 6 months. The mean SE was unchanged over the follow-up period; −0.01 ± 0.57 D and −0.01 ± 0.55 D at 2 months and 6 months, respectively. Conclusion: Laser-assisted subepithelial keratectomy performed using the 213 nm wavelength solid-state laser was safe, accurate, and effective for the treatment of myopia, hyperopia, and astigmatism. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [Copyright &y& Elsevier]

The article discusses the policies, examples of approaches, and rationale for engaging parents directly in intervention targeting social skills in natural environments. It provides an overview of key concepts of social communication, and explains why and how speech-language pathologists and other professionals can help parents teach social communication skills to their young children with special needs. The cultural differences represented by the families served are considered.

The article presents a study which assesses substance use disorders (SUDs) among youth as a risk factor in the prevalence of sexually transmitted diseases (STDs). The study uses exact logistic regression and path analysis to examine the mediation effect of sexually partner characteristics such as alcohol and marijuana problem on the relationship between SUD and STD. It ends that despite controlling for demographics and condom use, partner behaviors partly explain the association in SUD and STD.

The article presents a study on workplace social capital if it cushions the relationship between job stress and smoking. It states that interviewer-administered questionnaires were conducted to 1,740 employees and 288 managers in 26 manufacturing firms while multilevel logistic regression was utilized to estimate the connection between job stressors and smoking. It was found out that social capital can alter the effects of psychosocial working conditions on health behaviors of these employees.

The article explores a multiple method approach to assess health-related productivity loss (HRPL) for certain types of occupations such as knowledge workers or managerial posts in the U.S. It tackles the significance of measuring HARP and offers an overview of the available tools for measuring HRPL. Implications of the new methodology for measuring HRPL, including increased costs and the balance between increased accuracy, are also discussed.

Study Design. Meta-analysis. Objective. To assess the robustness of randomized controlled trials (RCTs) that compared cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic degenerative cervical pathology by using fragility indices. Summary of Background Data. RCTs comparing these surgical approaches have shown that CDA may be equivalent or even superior to ACDF due to better preservation of normal spinal kinematics. Materials and Methods. RCTs reporting clinical outcomes after CDA versus ACDF for degenerative cervical disc disease were evaluated. Data for outcome measures were classified as continuous or dichotomous. Continuous outcomes included: Neck Disability Index, overall pain, neck pain, radicular arm pain, and modified Japanese Orthopedic Association scores. Dichotomous outcomes included: any adjacent segment disease (ASD), superior-level ASD, and inferior-level ASD. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively. The corresponding fragility quotient (FQ) and continuous FQ were calculated by dividing FI/CFI by sample size. Results. Twenty-five studies (78 outcome events) were included. Thirteen dichotomous events had a median FI of 7 [interquartile range (IQR): 3–10], and the median FQ was 0.043 (IQR: 0.035–0.066). Sixty-five continuous events had a median CFI of 14 (IQR: 9–22) and a median continuous FQ of 0.145 (IQR: 0.074–0.188). This indicates that, on average, altering the outcome of 4.3 patients out of 100 for the dichotomous outcomes and 14.5 out of 100 for continuous outcomes would reverse trial significance. Of the 13 dichotomous events that included a loss to follow-up data, 8 (61.5%) represented ≥7 patients lost. Of the 65 continuous events reporting the loss to follow-up data, 22 (33.8%) represented ≥ 14 patients lost. Conclusion. RCTs comparing ACDF and CDA have fair to moderate statistical robustness and do not suffer from statistical fragility. [ABSTRACT FROM AUTHOR]

Abstract: Mu-opioid receptor (MOPr) agonists, such as morphine, produce greater antinociception in male compared to female rats. The ventolateral periaqueductal gray (vlPAG) appears to contribute to this sex-difference despite fewer vlPAG output neurons projecting to the rostral ventromedial medulla in male compared to female rats. This greater projection in female rats suggests that non-opioid activation of vlPAG output neurons should produce greater antinociception in female compared to male rats. This hypothesis was tested by comparing the time course and antinociceptive potency of microinjecting MOPr agonists (morphine, DAMGO, fentanyl) and non-opioid compounds (bicuculline, kainic acid) into the vlPAG of female and male rats. Microinjection of morphine or DAMGO produced antinociception that had a slow onset (peak from 15 to 30min) and long duration (60min) compared to the antinociception produced following microinjection of fentanyl, bicuculline, or kainic acid (peak effect at 3min; duration less than 30min). No sex-differences in the time courses were evident. All five compounds caused a dose-dependent antinociception when microinjected into the vlPAG. Antinociceptive potency was significantly greater in male compared to female rats following microinjection of morphine, DAMGO, and bicuculline, but not following microinjection of fentanyl or kainic acid. In no case did activation of the vlPAG produce greater antinocicepiton in female compared to male rats. These findings demonstrate that the vlPAG can produce comparable antinociception in female and male rats, but antinociception produced by inhibition of GABAergic neurons (whether by morphine or the GABAA receptor antagonist bicuculline) produces greater antinociception in males. [Copyright &y& Elsevier]

The article discusses an alternative solution to graft-tunnel mismatch using an Endobutton fixation device to secure the bone-patella tendon-bone autograft in the femoral tunnel. The technique is applied during anterior cruciate ligament (ACL) reconstruction. The procedure allows reconstruction that maintains the structural and biomechanical integrity of the graft. The procedure for installing the fixation device is described.

Background: Lateral tibial hemiepiphysiodesis is an accepted surgical treatment for skeletally immature patients with adolescent tibia vara. However, the results of this procedure are unpredictable. This study was conducted to identify the risk factors associated with failure of herniepiphysiodesis. Methods: We studied patients with adolescent tibia vara who were at least ten years of age, had open physes, had been treated with a lateral hemiepiphysiodesis, and had been followed for at least two years. The mechanical axis deviation, medial proximal tibial angle, and lateral distal femoral angle were measured on radiographs preoperatively, at six months postoperatively, and at the time of final follow-up. Failure was defined as a residual varus deformity requiring osteotomy or a mechanical axis deviation exceeding 40 mm (moderate or severe varus) at the time of final follow-up. Results: Forty-nine patients (forty-six male) with a total of sixty-four involved extremities met the inclusion criteria. The average age was 13.4 years, the average body mass index was 40.7 kg/m2, and the average duration of follow-up was 3.3 years. The lateral hemiepiphysiodesis was unsuccessful in 66% of the patients. In a multivariate Cox proportional hazards regression analysis, the variables associated with a higher risk of failure included an age of fourteen years or more (hazard ratio = 3.9, p = 0.0009) and a body mass index of ⩾45 kg/m2 (hazard ratio = 2.8, p = 0.01). Greater deformity at baseline as indicated by a smaller medial proximal tibial angle was also found to be a significant factor in the multivariate analysis (p = 0.03). Conclusions: Lateral herniepiphysiodesis may be a valuable treatment option for non-morbidly obese patients with less severe adolescent tibia vara, but it is likely to fail in older adolescents with a high body mass index and greater deformity. [ABSTRACT FROM AUTHOR]

The article presents a study that investigates the risk of perioactive and postactive morbidity among women having vaginal hysterectomy with reconstructive pelvic surgery. The study collected surgical data of women ages 18 years and above who undergo vaginal hysterectomy at Mayo Clinic, Rochester, Minnesota. The results prove that women undergoing vaginal hysterectomy with additional reconstructive pelvic surgery have higher risk of having perioperate complication.

The article focuses on the evidences to the evolutionary theories and hypothesis of congenital anomalies of the hand and upper extremities. It cited the phylogenic templates as the basis of explanation of the several hand and wrist cognates such as polydactyly and Madelung deformity. It notes that identifying the gene's role in evolution and the discovery of genetic aberrations associated with anomalies provides a clue to the normal development of the limb bud.

An editor foreword to the journal "Topics in Language Disorders" is presented.

Background: Loosening of a cemented glenoid component is an important cause of failure in shoulder arthroplasty. This study was developed to examine the outcome of patients managed with a metal-backed, bone-ingrowth glenoid component as an alternative to a cemented component. Methods: The study group included eighty-three total shoulder arthroplasties with a metal-backed, bone-ingrowth glenoid component performed between 1989 and 1994. Seventy-four shoulders had a diagnosis of primary osteoarthritis, and nine shoulders had other diagnoses. All patients were followed radiographically and clinically for a minimum of two years or until the time of revision surgery. Kaplan-Meier survival estimates were performed with revision and/or radiographic failure as the end points. Results: The mean clinical follow-up was 9.5 years, and the mean radiographic follow-up was 7.1 years. Pain ratings (on a scale of 1 to 5) decreased from a mean of 4.7 preoperatively to 2.0 postoperatively. The mean range of motion in active elevation increased from 102° preoperatively to 135° postoperatively; the mean external rotation increased from 27° to 56°. Glenohumeral joint instability developed in fourteen shoulders. Radiographic changes consistent with glenoid component loosening were present in thirty-three shoulders. Polyethylene wear with metal wear of the glenoid component was noted in twenty-one shoulders, and humeral component loosening was seen in fifteen shoulders. Revision procedures were performed in twenty-six shoulders. There were no identifiable patient, disease, or surgical characteristics associated with failure, either clinically or radiographically. The five-year survival estimate free of revision or radiographic failure was 79.9% (95% confidence interval, 71.6% to 89.3%), and the ten-year survival estimate was 51.9% (95% confidence interval, 41.0% to 65.8%). Conclusions: The high rate of failure of total shoulder arthroplasties performed with this metal-backed, bone-ingrowth glenoid component raises concerns as to its use, and perhaps the use of other types of metal-backed components, in shoulder arthroplasty, other than for special situations. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article cites a study which determines the frequency and reasons of patient call light use, the effects of nursing rounds on patient satisfaction and patient safety. The analyses conducted on data gathered from several nursing units in 14 hospitals showed that nursing rounds had reduced patient use of call light, reduced patient fall and increased patient satisfaction. The researchers suggested for an effective patient-care management to improve patient satisfaction and safety.

OBJECTIVE: Cytologic screening is commonly used in follow-up of women with uterine cancer to detect vaginal recurrence. The study objective was to assess the efficacy and costs associated with Pap tests in routine surveillance of women with uterine cancer. METHODS: Medical records and pathology databases identified patients with uterine cancer at one institution from 1990 to 2002. Patients with their cytologic follow-up at our institution were selected for a subset analysis of Pap tests to estimate the number of Paps and associated charges and costs during follow-up. RESULTS: Seven hundred seventeen women were diagnosed with uterine cancer; the mean age was 60.9 years and the median follow-up was 46 months. A total of 36 women had a recurrence in the vagina; 31 (86%) were apparent clinically, and only 5 (14%) were asymptomatic and identified by Pap test. Women with grade 1 tumors had decreased risk of vaginal recurrence, with an odds ratio of 0.186 (95% confidence interval 0.49–0.712) on multivariate analysis (stage and histology were not significant factors for vaginal recurrence). A subset of 435 patients received cytologic follow-up at our institution, with a median 3 Pap tests/patient (mean 4.25, range 1–24). Estimates based on our data demonstrate that 430 Pap tests are required to detect one asymptomatic vaginal recurrence, and the addition of the Pap test increases the cost of surveillance by $15,142 per asymptomatic recurrence detected (but a charge to insurance of $23,487). Pap tests identified an asymptomatic vaginal recurrence in only 0.7% of this uterine cancer population. CONCLUSION: Pap tests after diagnosis and treatment of uterine cancer infrequently detect asymptomatic vaginal recurrences and may not be cost-effective. [ABSTRACT FROM AUTHOR]

Examines the contribution of the activity of HIV-1 integrases to the rate of disease progression in an infected person. Review of a report on the description of 102 HIV-1 integrase sequences amplified from ten individuals with varied rates of disease progression; Purification process of natural integrase protein; Comparison of DNA and predicted protein sequences of 102 natural ingrases.

Background: Adherence to bundled interventions can reduce surgical site infection (SSI) rates; however, predictors of successful implementation are poorly characterized. We studied the association of patient and hospital characteristics with adherence to a colorectal SSI reduction bundle across a statewide surgical collaborative.Study Design: A 16-component colorectal SSI reduction bundle was introduced in 2016 across a statewide quality improvement collaborative. Bundle adherence was measured for patients who underwent colorectal operations at participating institutions. Multivariable mixed-effects logistic regression models were constructed to estimate associations of patient and hospital factors with bundle adherence and quantify sources of variation.Results: Among 2,403 patients at 35 hospitals, a median of 11 of 16 (68.8%, interquartile range 8 to 13) bundle elements were completed. The likelihood of completing 11 or more elements was increased for obese patients (56.8% vs 51.5%, odds ratio [OR] 1.39, 95% CI 1.05 to 1.86, p = 0.022) but reduced for underweight patients (31.0% vs 51.5%, OR 0.51, 95% CI 0.26 to 1.00, p = 0.048) compared with patients with a normal BMI. Lower adherence was noted for patients treated at safety net hospitals (n = 9 hospitals, 24.4% vs 54.4%, OR 0.08, 95% CI 0.01 to 0.44, p = 0.004). The largest proportion of adherence variation was attributable to hospital factors for six bundle elements, surgeon factors for no elements, and patient factors for nine elements.Conclusion: Adherence to an SSI reduction bundle is associated with patient BMI and hospital safety net status. Quality improvement groups should consider institutional traits for optimal implementation of SSI bundles. Safety net hospitals may require additional focus to overcome unique implementation barriers. [ABSTRACT FROM AUTHOR]

Presents information on a study which examined whether continuous employment at a smokefree worksite was associated with higher rates of cessation. Relationship between policy experience and exposure to environmental tobacco smoke (ETS) at work; Effect of worksite policy on reports of ETS exposure and availability of smoking areas; Methodology of the study; Results and discussion.

We feel that our article highlights that, although there may be minor biologic differences between black and white women, these small differences do not account for the disproportionate care. Examining disparities in route of surgery and postoperative complications in black race and hysterectomy. Advancing health disparities research within the health care system: a conceptual framework. [Extracted from the article]

Musculoskeletal injury is a leading cause of pain and disability worldwide; 35% to 75% of people experience persistent pain for months and years after injury. Psychological treatments can reduce pain, functional impairment, and psychological distress but are not widely used after injury. This systematic review and meta-analysis (PROSPERO ID: CRD42021236807) aimed to synthesize the literature testing psychological treatments for pain after musculoskeletal injury. We searched EMBASE, MEDLINE, PubMed, PsycINFO, and CENTRAL from inception to May 2022. We extracted participant, treatment, and injury characteristics and primary (eg, pain intensity, functional impairment, depression, anxiety, and PTSD symptoms) and secondary (treatment feasibility and acceptability) outcomes. Twenty-four randomized controlled trials (N = 1966) were included. Immediately posttreatment, people who received psychological treatments (versus any control) reported lower pain intensity (standardized mean differences [SMD] = −0.25, 95% confidence interval [−0.49, −0.02]), functional impairment (SMD = −0.32 [−0.55, −0.09]), and symptoms of depression (SMD = −0.46 [−0.64, −0.29]), anxiety (SMD = −0.34 [−0.65, −0.04]), and PTSD (SMD = −0.43 [−0.70, −0.15]); at 6-month follow-up, only depression symptoms were significantly lower. Included trials varied widely in treatment and injury characteristics. The certainty of evidence was low or very low for most effects and heterogeneity moderate to substantial. Most studies had risk of bias domains judged to be high or unclear. Owing to very low certainty of results, we are unsure whether psychological therapies reduce pain and functional impairment after musculoskeletal injury; they may result in improved depression immediately posttreatment and at follow-up. More research is needed to identify treatments that result in enduring effects. [ABSTRACT FROM AUTHOR]

The article describes the transformation of Maine Medical Center's (MMC's) clinical ladder program into the Clinical Nurse Advancement Program (CNAP), which formally recognizes and rewards nurses for advancing their clinical expertise and commitment to patient care. It explains that the CNAP comprises of four levels of nurse advancement and remains flexible to changes in nursing practice. It notes that the program has increased MMC's retention rate by more than 80 percent. INSET: Clinical exemplars.

The article describes an educational plan developed by the staff-development specialists at Christiana Care Health System in Wilmington, Delaware using a nursing professional practice care delivery model. Their goal is to boost the comfort of staff in their abilities to do tasks during crisis. Code blue scenarios were used through high-fidelity human patient simulators that are realistic. A review of literature indicated that simulation is being utilized for education more often. INSETS: Getting to know "Stan";Setting up objectives.

The article focuses on anterior cruciate ligament (ACL) tears which are said to be common injuries among athletes. It discusses a technique for holistic ACL reconstruction that preserves the residual, native ACL and minimizes the total disruption to the intra-articular environment and anatomy. It also presents postsurgical concerns, such as the development of a Cyclops lesion.

The article describes three cases of gonadal dysgenesis where three separate histologic subtypes of tumors were identified, namely, dysgerminoma, seminoma and gonadoblastoma. Two of the patients have Swyers' syndrome while the third has mosaic Turner's syndrome and all three were recommended for prophylactic gonadectomy. Considering the risk of gonadal malignancy in these cases, early identification of gonadal dysgenesis is crucial to expedite timely prophylactic gonadectomy and hormone replacement therapy.

Objectives: The purpose of this study was to determine the prevalence of depression among active-duty low-risk pregnant women using the Edinburgh Postnatal Depression Scale, Rates for depression have been reported to be as high as 13% during pregnancy and 12 to 22% postpartum, with postpartum suicidal ideation at nearly 7%, Methods: From April 2002 through March 2003, 82 women receiving prenatal care at Madigan Army Medical Center completed screening questionnaires during pregnancy and/or postpartum visits. Results: A total of 97 questionnaires were administered (71 antepartum and 26 postpartum). During pregnancy, 24% of individuals screened scored positive. During the postpartum, 19% scored positive, A total of 15 women were screened twice during the study period. One woman was screened twice during pregnancy and the remaining 14 were screened once antepartum and once postpartum. Suicidal ideation was present in 11% of those screened during pregnancy and in 15% postpartum. Conclusions: Active-duty women appear to have a higher rate of depression and suicidal ideation compared with rates in nonmilitary populations; perhaps such screening should become a standard practice. [ABSTRACT FROM AUTHOR]

Cites a study to determine risk factors associated with pelvic inflammatory disease (PID) among inner-city adolescents. Association of younger age at first intercourse, alcohol use and Chlamydia trachomatis infection with PID; Relationship of the involvement in a child protection agency and prior suicide attempts with PID.

Objectives: Physician trainees in obstetrics and gynecology (OBGYN) experience unexpected outcomes similar to those of supervising physicians. A relative lack of experience and perspective may make them more vulnerable to second victim experience (SVE), however. The objectives of our study were to contrast the prevalence of SVE between supervising physicians and trainees and to identify their preferred methods of support.Methods: In 2019, the Second Victim Experience and Support Tool, a validated survey with supplemental questions, was administered to healthcare workers caring for OBGYN patients at a large academic center in the midwestern United States.Results: The survey was sent to 571 healthcare workers working in OBGYN. A total of 205 healthcare workers completed the survey, including 18 (43.9% of 41) supervising physicians and 12 (48.0% of 25) resident/fellow physicians. The mean scores for the Second Victim Experience and Support Tool dimensions and outcomes were similar between the two groups. Seven (58.3%) trainees reported feeling like a second victim after an adverse patient safety event at some point in their work experience compared with 10 (55.6%) of the supervising physicians. Five (41.7%) trainees identified as a second victim in the previous 12 months compared with 3 (16.7%) supervising physicians (P = 0.21). The most common form of desired support for both groups was conversations with their peers.Conclusions: Trainees and supervising physicians are both at risk of SVE after an unexpected medical event and prefer conversations with peers as a desired form of support. Because trainees commonly encounter SVEs early in their careers, program directors should consider implementing a program for peer support after an unexpected event. [ABSTRACT FROM AUTHOR]

The article offers several surgical or professional tips that can be used by surgeons to help surmount important or interesting problems. Topics discussed include considering glass half-full approach; role of entire team was responsible for executed excellence in the operating theatre; and importance of final stage of surgery includes returning the patient's anatomy to its rightful owner.

Introduction: Sitosterolemia is an atherogenic sterol storage disorder with <100 cases reported worldwide. Due to lack of genetic and lifestyle variability, we hypothesized that in a nuclear family with homozygous sitosterolemia, (i) sitosterol levels and clinical features would be similar and that (ii) atherosclerosis burden would be associated with serum sitosterol levels. Methods: We studied an Old Order Amish nuclear family homozygous for mutations in ABCG8. Clinical features were assessed by a physician. Sitosterol and campesterol testing were performed by Mayo Medical Laboratories using ion-monitoring electron impact gas chromatography-mass spectrometry. High-resolution B-mode ultrasound of each carotid artery was performed to determine far wall intima-media thickness (IMT) and plaque score (S2000, Siemens Medical Solutions, Malvern, PA). Associations between age, sterol levels, carotid IMT, and plaque score were performed using Spearman's ρ. Results: There were 7 participants: 4 females, median age 20 years (range 11-50 years; see Table). Their sitosterol and campesterol levels at presentation were very high: 150.0 (141.4-226.8) mg/dL (reference 0-5 mg/dL) and 77.2 (44.4-110.2) mg/dL (reference 0-7 mg/dL), respectively. Three had clinical symptoms of easy fatigability or exertional dyspnea and had tendon xanthomata and carotid plaques. Neither sitosterol (ρ=-0.36, p=0.39) nor campesterol levels (ρ=-0.39, p=0.34) were associated with carotid IMT or carotid plaque score (p>0.12). Conclusions: In an Old-Order Amish family, individuals with homozygous sitosterolemia had marked phenotypic variability. Sitosterol and campesterol levels were not associated with carotid IMT or carotid plaque burden, suggesting that heterogeneity in genetic modifiers or environmental exposure may modify risk of arterial disease. [ABSTRACT FROM AUTHOR]

BACKGROUND: Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes. STUDY DESIGN: Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control. RESULTS: There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance. CONCLUSIONS: Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Delirium is a common, underdetected problem that has short- and long-term negative sequelae for critically ill patients. Prompt and accurate delirium identification by nurses can ensure early intervention and treatment to help minimize adverse outcomes. Objectives: To evaluate the relationship between an educational program and the accuracy of registered nurses' (RNs') documentation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a delirium screening tool. Methods: In a medical ICU at a tertiary academic medical center from September 2015 to March 2016, RNs were reinstructed on use of the CAM-ICU. Registered nurse assessment data were collected retrospectively for 12 months before and after intervention and were compared against the CAM-ICU algorithm using χ² analysis. Results: A total of 10 736 RN assessments in 1020 patients preintervention and 11 068 in 951 patients postintervention were evaluated. Overall RN accuracy improved from 78% to 80% (P = .054). The algorithm determined delirium to be present in 32% versus 30% of all patients preintervention and postintervention, respectively; there was no difference in rate of nurse detection of delirium preintervention and postintervention (54% vs 55%, not statistically significant). The percentage of "inappropriate unable to assess" ratings by nurses decreased from 42% to 37% postintervention (P < .05). Conclusions: After a comprehensive training initiative, there was no significant improvement in CAM-ICU documentation and no improvements in patient delirium identification. Future quality improvement efforts should target reducing the number of assessments that RNs judge to be "unable to assess." Clinical practice must evolve to routinely incorporate RN delirium assessments into the patient's plan of care. [ABSTRACT FROM AUTHOR]

The release of the American Heart Association's 2030 Impact Goal and associated metrics for success underscores the importance of cardiovascular health and cardiovascular disease surveillance systems for the acquisition of information sufficient to support implementation and evaluation. The aim of this policy statement is to review and comment on existing recommendations for and current approaches to cardiovascular surveillance, identify gaps, and formulate policy implications and pragmatic recommendations for transforming surveillance of cardiovascular disease and cardiovascular health in the United States. The development of community platforms coupled with widespread use of digital technologies, electronic health records, and mobile health has created new opportunities that could greatly modernize surveillance if coordinated in a pragmatic matter. However, technology and public health and scientific mandates must be merged into action. We describe the action and components necessary to create the cardiovascular health and cardiovascular disease surveillance system of the future, steps in development, and challenges that federal, state, and local governments will need to address. Development of robust policies and commitment to collaboration among professional organizations, community partners, and policy makers are critical to ultimately reduce the burden of cardiovascular disease and improve cardiovascular health and to evaluate whether national health goals are achieved. [ABSTRACT FROM AUTHOR]

Objective: To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures.Methods: We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure.Results: We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups.Conclusion: Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention. [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of tubal ligation on age at natural menopause, as a marker of long-term ovarian function.Methods: Three preexisting population-based cohorts were included in this cross-sectional study. Data from each cohort was analyzed separately. The cohorts were restricted to women who never smoked and had reached natural menopause, without prior hysterectomy or oophorectomy. The following variables were collected: race, age at menarche, age at menopause, history of hysterectomy or oophorectomy, gravidity and parity, tobacco use, and ever use of hormonal contraception. The type of tubal ligation and age at tubal ligation were manually abstracted in cohort 1. For cohorts 2 and 3, history of tubal ligation was obtained from an institutional form, completed by patient report. The primary outcome, age at natural menopause, was compared between the two groups (those with and without a history of tubal ligation).Results: Inclusion criteria was met by 555 women from cohort 1, 1,816 women from cohort 2, and 1,534 women from cohort 3. Baseline characteristics did not differ between cohorts. The percentage with tubal ligation was the same in all cohorts: 26.0%, 25.5%, and 25.0%, respectively. Women with a tubal ligation were more likely to have had at least one pregnancy and to have used hormonal contraception compared with women without a tubal ligation. There was no significant difference in age at natural menopause in women who underwent tubal ligation (50.1, 49.9, 50.0 years, respectively) compared with those who did not (50.7, 49.6, 50.0 years, respectively). The type of tubal ligation (cohort 1 only) had no effect on age at menopause.Conclusions: Tubal ligation did not affect age at natural menopause in the three large cohorts included in this study. [ABSTRACT FROM AUTHOR]

The lack of sex and racial diversity of the physicians within the specialty of orthopaedic surgery was recognized decades ago, and formal steps to address these issues began in 1983 with the founding of the Ruth Jackson Orthopaedic Society and the J. Robert Gladden Orthopaedic Society. Despite the efforts of these organizations, the work of other interested groups, and the growing diversity in medical student demographics, physician diversity in orthopaedic surgery remains disproportionately poor relative to the populations that we serve as a specialty. [ABSTRACT FROM AUTHOR]

Objective: To compare postpartum contraception use between Somali and non-Somali women.Methods: A retrospective cohort study was performed using the Rochester Epidemiology Project. All Somali women aged 18 and older with live singleton births in Olmsted County, Minnesota, in 2009-2015 (n=317) were included, and a group of age-matched non-Somali women (n=317) were identified. Postpartum contraception was defined as the use of any method within 12 months after the first delivery within the study period. Rates of contraception use and types of contraception used were compared between groups using χ analysis. Among Somali women, an a priori list of factors was evaluated for associations with postpartum contraception use by including these factors in a multivariable logistic regression model.Results: After the index birth, 33 Somali women did not present for follow-up, compared with 12 non-Somali women (10.4% vs 3.8%, difference 6.6%, 95% CI 2.3-10.9%). Somali women were less likely to use postpartum contraception than non-Somali women (69.4% vs 92.8%, odds ratio [OR] 0.18, 95% CI 0.11-0.29). Among those using postpartum contraception, both groups had comparable use of long-acting reversible contraception (LARC) (19.9% vs 23.7%, difference -3.8%, 95% CI -11.8% to 4.0%) and non-LARC hormonal contraception (39.3% vs 42.4%, difference -3.1%, 95% CI -12.7% to 6.0%). However, Somali women were more likely to use less reliable methods (40.3% vs 20.8%, difference 19.5%, 95% CI 11.0-28.5%). Among Somali women, contraception use was less likely with older maternal age (OR 0.12 for oldest vs youngest quartile, 95% CI 0.04-0.37) and more likely with prepregnancy contraception use (OR 15.46, 95% CI 5.18-46.18).Conclusion: Somali women were less likely to use postpartum contraception. Similar practices and beliefs may also be present in other immigrant populations. Recognition of sociocultural differences in immigrant populations and potential health care provider biases may improve patient-provider relationships and counseling practices. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the co-editors discuss various reports published within the issue, including one about the incorporation of caregivers in therapy addressing social communication skills in young children, one about a multidisciplinary team approach to parent-centered treatments, and one about the transactional relationship between social communication interventions.

The authors reflect on the effectiveness of genital chlamydia trachomatis (Ct) screening programs. They argue that patients who underwent Ct screening programs became afflicted by the disease. They suggest the need to treat males first in order to avoid the disease prevalence to their female partners.

➤ There are a growing number of opportunities within the field of orthopaedic surgery to address climate change and investigate ways to promote sustainability. ➤ Orthopaedic surgeons can take a proactive role in addressing climate change and its impacts within the areas of operating-room waste, carbon emissions from transportation and implant manufacturing, anesthetic gases, and water usage. ➤ Future studies are needed to further these initiatives on quantifying and decreasing environmental impact and furthering sustainable use of our resources. [ABSTRACT FROM AUTHOR]

Objectives: To determine, using systematic review of the biomedical literature, whether pacing reduces risk of recurrent syncope and relevant clinical outcomes among adult patients with reflex-mediated syncope.Methods: MEDLINE (through PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials (through October 7, 2015) were searched for randomized trials and observational studies examining pacing and syncope, and the bibliographies of known systematic reviews were also examined. Studies were rejected for poor-quality study methods and for the lack of the population, intervention, comparator, or outcome(s) of interest.Results: Of 3188 citations reviewed, 10 studies met the inclusion criteria for systematic review, including a total of 676 patients. These included 9 randomized trials and 1 observational study. Of the 10 studies, 4 addressed patients with carotid sinus hypersensitivity, and the remaining 6 addressed vasovagal syncope. Among the 6 open-label (unblinded) studies, we found that pacing was associated with a 70% reduction in recurrent syncope (relative risk [RR]: 0.30; 95% confidence interval [CI]: 0.15-0.60). When the 2 analyzable studies with double-blinded methodology were considered separately, there was no clear benefit (RR: 0.73; 95% CI: 0.25-2.1), but confidence intervals were wide. The strongest evidence was from the randomized, double-blinded ISSUE-3 (Third International Study on Syncope of Uncertain Etiology) trial, which demonstrated a benefit of pacing among patients with recurrent syncope and asystole documented by implantable loop recorder.Conclusions: There are limited data with substantive evidence of outcome ascertainment bias, and only 2 studies with a double-blinded study design have been conducted. The evidence does not support the use of pacing for reflex-mediated syncope beyond patients with recurrent vasovagal syncope and asystole documented by implantable loop recorder. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association of primary infertility with subsequent bilateral oophorectomy and hysterectomy, using a population-based cohort of women with primary infertility and age-matched women in a referent group.Methods: The Rochester Epidemiology Project record-linkage system was used to assemble a population-based cohort of women with primary infertility diagnosed between 1980 and 1999 (index date). Women were age-matched (±1 year) 1:1 to women without a history of infertility or hysterectomy at the index date (referent group). Cox proportional hazards models were fit to compare long-term risks of bilateral oophorectomy and hysterectomy, respectively, between women with infertility and women in the referent group.Results: Among both groups of 1,001 women, the mean age at the index date was 29.2±4.4 years. Median duration of follow-up was 23.7 years for both groups. Women with primary infertility were 1.7 times (adjusted hazard ratio [aHR] 1.69, 95% CI 1.22-2.33) more likely to undergo bilateral oophorectomy compared with women in the referent group. In a sensitivity analysis that excluded women with a diagnosis of infertility related to endometriosis and their matched referent group participants, this association persisted (aHR 1.50, 95% CI 1.06-2.14). Women with primary infertility did not have a significant increased risk of hysterectomy (aHR 0.98, 95% CI 0.79-1.23). However, risk of hysterectomy was increased in those with primary infertility related to endometriosis (aHR 1.94, 95% CI 1.12-3.34). We observed that women with primary infertility were more likely to undergo hysterectomy with bilateral oophorectomy. Women in the referent group were more likely to undergo hysterectomy with ovarian conservation. Few women in either group had isolated bilateral oophorectomy.Conclusion: Primary infertility, with and without a diagnosis of endometriosis, is associated with an increased risk of bilateral oophorectomy. In women with endometriosis-related infertility, there is an association with future hysterectomy. These findings represent important confounders in the evaluation of long-term health outcomes related to primary infertility. [ABSTRACT FROM AUTHOR]

Suicide rates are elevated in individuals with schizophrenia, yet evidence is mixed regarding the roles of positive and negative symptoms as risk factors for suicide in this population, suggesting that there may be other influential variables. One such variable may be personal recovery. Therefore, the purpose of this study was to test the hypothesis that personal recovery would moderate the relationship between symptoms of schizophrenia and suicide ideation. This hypothesis was tested in a sample of 169 individuals diagnosed with schizophrenia or schizoaffective disorder using a Poisson regression model. Results suggested that there was no significant interaction between recovery and symptoms of schizophrenia. However, recovery was a significant predictor of suicide ideation after controlling for psychiatric symptoms. These findings indicate that recovery is associated with lower suicide ideation and thus may protect against it. Thus, recovery should be assessed, and potentially intervened upon, to reduce suicide risk in individuals with schizophrenia. [ABSTRACT FROM AUTHOR]

Objective: To investigate opioid use and pain scores associated with incisional injection of liposomal bupivacaine compared with bupivacaine hydrochloride after laparotomy for gynecologic malignancies.Methods: A retrospective cohort study was conducted to compare abdominal incision infiltration with liposomal bupivacaine with bupivacaine hydrochloride after modification of a pre-existing enhanced recovery pathway. Patients undergoing staging laparotomy or complex cytoreductive surgery under the updated pathway were compared with patients treated under the original pathway (historic controls). Endpoints included cumulative opioid use (primary outcome) in oral morphine equivalents and cumulative pain score.Results: In the complex cytoreductive cohort, median oral morphine equivalents were lower in the liposomal bupivacaine group through 24 hours (30 compared with 53.5 mg, P=.002), 48 hours (37.5 compared with 82.5 mg, P=.005), and the length of stay (62 compared with 100.5 mg, P=.006). Fewer liposomal bupivacaine patients required intravenous rescue opioids (28.9% compared with 55.6%, P<.001) or patient-controlled analgesia (4.1% compared with 33.3%, P<.001). Cumulative pain score was no different between groups through 48 hours (161 compared with 158, P=.69). Postoperative nausea and ileus were less frequent in patients receiving liposomal bupivacaine. Median hospital stay was 5 days in both groups. In the staging laparotomy cohort, cumulative opioids and cumulative pain score were no different between groups (through 48 hours: 162 compared with 161, P=.62; 38 compared with 38, P=.68, respectively). Intravenous rescue opioids (15.3% compared with 28.6%, P=.05) and patient-controlled analgesia (1.4% compared with 8.3%, P=.05) were used less frequently in the liposomal bupivacaine group. Median hospital stay was 4 days in both groups. Despite the higher cost of liposomal bupivacaine, total pharmacy costs did not differ between groups.Conclusion: Abdominal incision infiltration with liposomal bupivacaine was associated with less opioid and patient-controlled analgesia use with no change in pain scores compared with bupivacaine hydrochloride after complex cytoreductive surgery for gynecologic malignancies. Improvements were also seen in patients undergoing staging laparotomy. [ABSTRACT FROM AUTHOR]

Objectives: Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population.Design: This was a multicenter, observational cohort study.Setting: Twenty-eight ICUs in the United States.Patients: Adult ICU patients.Interventions: Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay [LOS]) were recorded retrospectively.Measurements and Main Results: A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (β coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (β coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (β coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (β coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (β coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (β coefficient, -0.05; 95% CI, -0.09 to -0.01).Conclusions: Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes. [ABSTRACT FROM AUTHOR]