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Noninvasive assessment of muscle mechanical properties in clinical and performance settings tends to rely on manual palpation and emphasizes examination of musculotendinous stiffness. However, measurement standards are highly subjective. The purpose of the study was to compare musculotendinous stiffness in adult women with varying resistance training history while exploring the use of multiple tissue compliance measures. We identified relationships between tissue stiffness and morphology, and tested the hypothesis that combining objective measures of mor-phology and stiffness would better predict indices of contractile performance. Resistance-trained (RT) women (n = 11) and nontrained (NT) women (n = 10) participated in the study. Muscle echogenicity and morphology were measured using B-mode ultrasonography (US). Vastus lateralis (VL) and patellar tendon (PT) stiffness were measured using digital palpation and US across submaximal isometric contractions. Muscle function was evaluated during maximal voluntary isometric contraction (MVIC) of the knee extensors (KEs). Resistance trained had significantly greater PT stiffness and reduced echogenicity (p < 0.01). Resistance trained also had greater strength per body mass (p < 0.05). Muscle echogenicity was strongly associated with strength and rate of torque development (RTD). Patellar tendon passive stiffness was associated with RTD normalized to MVIC (RTDrel; r = 0.44, p < 0.05). Patellar tendon stiffness was greater in RT young women. No predictive models of muscle function incorporated both stiffness and echogenicity. Because RTDrel is a clinically relevant measure of rehabilitation in athletes and can be predicted by digital palpation, this might represent a practical and objective measure in settings where RTD may not be easy to measure directly. [ABSTRACT FROM AUTHOR]

BACKGROUND: Maldistribution of pulmonary blood flow in patients with congenital heart disease impacts exertional performance and pulmonary artery growth. Currently, measurement of relative pulmonary perfusion can only be performed outside the catheterization laboratory. We sought to develop a tool for measuring relative lung perfusion using readily available fluoroscopy sequences. METHODS: A retrospective cohort study was conducted on patients with conotruncal anomalies who underwent lung perfusion scans and subsequent cardiac catheterizations between 2011 and 2022. Inclusion criteria were nonselective angiogram of pulmonary vasculature, oblique angulation ≤20°, and an adequate view of both lung fields. A method was developed and implemented in 3D Slicer’s SlicerHeart extension to calculate the amount of contrast that entered each lung field from the start of contrast injection and until the onset of levophase. The predicted perfusion distribution was compared with the measured distribution of pulmonary blood flow and evaluated for correlation, accuracy, and bias. RESULTS: In total, 32% (79/249) of screened studies met the inclusion criteria. A strong correlation between the predicted flow split and the measured flow split was found (R²=0.83; P<0.001). The median absolute error was 6%, and 72% of predictions were within 10% of the true value. Bias was not systematically worse at either extreme of the flow distribution. The prediction was found to be more accurate for either smaller and younger patients (age 0–2 years), for right ventricle injections, or when less cranial angulations were used (≤20°). In these cases (n=40), the prediction achieved R²=0.87, median absolute error of 5.5%, and 78% of predictions were within 10% of the true flow. CONCLUSIONS: The current study demonstrates the feasibility of a novel method for measuring relative lung perfusion using conventional angiograms. Real-time measurement of lung perfusion at the catheterization laboratory has the potential to reduce unnecessary testing, associated costs, and radiation exposure. Further optimization and validation is warranted. [ABSTRACT FROM AUTHOR]

Objective: Develop a predictive model to identify patients with 1 pathologic lymph node (pLN) versus >1 pLN using machine learning applied to gene expression profiles and clinical data as input variables. Background: Standard management for clinically detected melanoma lymph node metastases is complete therapeutic LN dissection (TLND). However, >40% of patients with a clinically detected melanoma lymph node will only have 1 pLN on final review. Recent data suggest that targeted excision of just the single enlarged LN may provide excellent regional control, with less morbidity than TLND. The selection of patients for less morbid surgery requires accurate identification of those with only 1 pLN. Methods: The Cancer Genome Atlas database was used to identify patients who underwent TLND for melanoma. Pathology reports in The Cancer Genome Atlas were reviewed to identify the number of pLNs. Patients were included for machine learning analyses if RNA sequencing data were available from a pLN. After feature selection, the top 20 gene expression and clinical input features were used to train a ridge logistic regression model to predict patients with 1 pLN versus >1 pLN using 10-fold cross-validation on 80% of samples. The model was then tested on the remaining holdout samples. Results: A total of 153 patients met inclusion criteria: 64 with one pLN (42%) and 89 with >1 pLNs (58%). Feature selection identified 1 clinical (extranodal extension) and 19 gene expression variables used to predict patients with 1 pLN versus >1 pLN. The ridge logistic regression model identified patient groups with an accuracy of 90% and an area under the receiver operating characteristic curve of 0.97. Conclusions: Gene expression profiles together with clinical variables can distinguish melanoma metastasis patients with 1 pLN versus >1 pLN. Future models trained using positron emission tomography/computed tomography imaging, gene expression, and relevant clinical variables may further improve accuracy and may predict patients who can be managed with a targeted LN excision rather than a complete TLND. [ABSTRACT FROM AUTHOR]

Do-not-resuscitate (DNR) orders should preclude the use of cardiopulmonary resuscitation and may be associated with patient outcomes for patients hospitalized with heart failure (HF). This study examined the association between DNR and costs, mortality, and length of stay. The study cohort was a national sample of 700 922 hospital admissions of patients aged >65 with a primary diagnosis of HF. Elderly HF patients who died with a DNR had cost-savings of $5640 (P < 0.001). Patients with a DNR order were 8.9% points more likely to die before discharge than patients without (P < 0.001), and patients who died with a DNR had a significantly shorter hospital stay by 1.51 days (P < 0.001). DNR orders among elderly patients with HF are associated with cost-savings, as well as a higher mortality and shorter length of stay. In addition to primary benefits, advance care planning may aid in containing costs of care at end of life for HF. [ABSTRACT FROM AUTHOR]

Interprofessional precepting can advance team-based collaboration. We evaluated the impact of nurse-led precepting of medical students on perceptions of nurse–physician relationships. Forty-six frontline nurses precepted 73 third year medical students in New York for a three-part clinical and classroom experience. Nurse preceptor and medical student attitudes toward healthcare teams and medical student attitudes toward nurse–physician collaboration improved after participation using validated scales. This pilot study suggests nurse-led interprofessional precepting can improve attitudes toward interprofessional collaboration. [ABSTRACT FROM AUTHOR]

Background: Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures.Questions/purposes: (1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission?Methods: Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses.Results: Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only.Conclusion: When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Nearly 1 in 5 medical students reports at least 1 incident of mistreatment, with many occurring in the perioperative environment. We aimed to further define the types of mistreatment occurring perioperatively in a national data set by using a mixed-methods approach.Study Design: A sample of 2,224 responses to the general public humiliation free-text question on the 2015 Association of American Medical College's Graduation Questionnaire were analyzed. Using grounded theory methodology, 4 raters independently created and refined the coding schema. Final coding was determined by majority rating. Descriptive statistics, interrater reliability, and chi-square analysis were performed where appropriate.Results: Among responses, 2,411 events were identified. Interrater reliability was moderate (>0.41) on 94% of variables. Events occurring in a specific setting implicated the surgery clerkship and the operating room 53.2% and 21.8% of the time, respectively. Perioperative events accounted for nearly one-third of verbal abuse reports (30.5%, 324/1059), and almost half of events described yelling (47.0%, 178/379). Mistreatment involving physical contact was significantly more likely to occur in the operating room (59% vs 41%, p < 0.001). Events coded as possibly routine education (n = 379) were significantly less common perioperatively than nonsurgical settings (20.5% vs 79.4%, p = 0.007).Conclusions: A significant proportion of medical student mistreatment events occur in the context of surgery. Surgeons and trainees must play active roles in leading and instituting needed changes to improve the learning environment to support medical students and recruit a sufficient future surgical workforce. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study.Objective: Compare rates of postoperative neural deficits between surgical approaches for thoracic disc herniations (TDHs).Summary Of Background Data: Anterior and posterior approaches for TDH carry high reported neurological risk, albeit comparative risk is not well defined.Methods: Health Care Utilization Project (HCUP) state inpatient databases (NY, FL, CA; 2005-2014) were queried for patients who underwent TDH operation. Demographics, operative details, surgical approach, neural injury, length of stay (LOS), and discharge location were assessed. Multivariate linear regression was used to determine relative risk of neural deficit and skilled nursing facility (SNF) discharge.Results: Six hundred ninety-seven patients (mean age 52.0 yrs, 194 institutions) met inclusion. Majority of operations were elective (76.0%) and one to two levels (80.5%). Overall neural injury rate was 9.0%. Anterior operations had significantly lower rates of neural injury compared with posterior operations on univariate analysis (4.6% vs. 11.4%; P < 0.01). All multilevel operations had similarly high rates of neural injury. On multivariate analysis, posterior approaches (RR 1.78; P = 0.12) and combined approaches (RR 2.15; P = 0.17) had higher neural risk compared with anterior approaches after controlling for younger age, higher Charlson Comorbidity Index, and nonelective admissions. Combined approaches had similar neural injury rates (13.8%) to posterior operations (11.4%) and significantly longer LOS and SNF discharges compared with single approaches. Neural deficit was associated with discharge to SNF (With = 87.3%; Without = 23.7%; P < 0.01) and increased LOS (With = 12.5 days; Without = 6.9 days; P < 0.01).Conclusion: Overall rate of neural deficit after operation for TDH was 9.0%. While anterior approach was associated with a lower neural injury rate, this association was confounded by age, Charlson Comorbidity Index, and admission type. After correcting for these confounders, a nonsignificant trend remained that favored the anterior approach. Neural deficit was associated with increased LOS and discharge to SNF postoperatively.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Introduction: Whether short-term, single-mode exercise training can improve physical fitness before a period of reduced physical activity (e.g., postsurgery recovery) is not well characterized in clinical populations or middle-age adults. We investigated skeletal muscle adaptive responses after endurance exercise training (ENT), high-intensity interval training (HIIT), or resistance exercise training (RET), and a subsequent period of detraining, in sedentary, middle-age men. Methods: Thirty-five sedentary men (39 ± 3 yr) were randomized to parallel groups and undertook 6 wk of either ENT (n = 12), HIIT (n = 12), or RET (n = 11) followed by 2.5 wk of detraining. Skeletal muscle fiber characteristics, body composition, muscle thickness, muscle strength, aerobic capacity, resting energy expenditure, and glucose homeostasis were assessed at baseline, and after exercise training and detraining. Results: Lean mass increased after RET and HIIT (+3.2% ± 1.6% and+1.6% ± 2.1%, P <0.05). Muscle strength (sum of leg press, leg extension, and bench press one-repetition maximums) increased after all training interventions (RET, +25% ± 5%; HIIT, +10% ± 5%; ENT, +7% ± 7%; P < 0.05). Aerobic capacity increased only after HIIT and ENT (+14% ± 7% and +11% ± 11%, P < 0.05). Type I and II muscle fiber size increased for all groups after training (main effect of time, P < 0.05). After a period of detraining, the gains in lean mass and maximal muscle strength were maintained in the RET and HIIT groups, but maximal aerobic capacity declined below posttraining levels in HIIT and ENT (P < 0.05). Conclusions: Six weeks of HIIT induced widespread adaptations before detraining in middle-age men. Exercise training-induced increases in aerobic capacity declined during 2.5 wk of detraining, but gains in lean mass and muscle strength were maintained. [ABSTRACT FROM AUTHOR]

[Figure: see text]. [ABSTRACT FROM AUTHOR]

Introduction. In 2016, faculty at the MGH Institute of Health Professions implemented a new Doctor of Physical Therapy (DPT) curriculum based on constructivist and cognitive load theories. There is recognition that faculty too often overlook the importance of students' perceptions on the effectiveness of teaching methodologies and that student "buy-in" is particularly pivotal in curricula based on contemporary learning theories. Thus, students' perceptions have become a focus in the higher education research literature. The purpose of this article is to explore the perceptions of the first cohort of DPT students in our new curriculum across their academic studies. Participants. Nineteen of 70 students from the first cohort of our new curriculum participated in 1 of the 3 focus groups in year 1 (round 1) and 1 of the 2 focus groups in year 2 (round 2), with 4 students participating in both rounds. Methods. Qualitative thematic analysis was used to identify, summarize, and interpret students' perceptions regarding their experiences in this new curriculum. Results. Six themes emerging from round 1 were class preparation; plusses and minuses of group learning; usefulness of assessments; managing faculty/course differences; finding life balance; and student performance outcomes. A seventh theme emerged from round 2, namely, evolving and adapting approaches to learning. Discussion and Conclusion. Themes and subthemes are discussed in the context of other studies on students' perceptions of courses and curricula applying contemporary learning theories in higher education. Some of the themes emerging from our study are not unique to DPT curricula based on constructivist theories. However, our findings reflect both positive aspects of such approaches from the students' viewpoints and challenges that should be considered in supporting student engagement when designing or modifying such curricula. Findings may inform DPT programs considering similar curricular shifts toward contemporary learning practices, facilitating program curricular planning and transition processes. [ABSTRACT FROM AUTHOR]

Introduction. Faculty perceptions of organizational change and culture shifts created by major curricular revision in higher education have been described. However, there are no similar descriptions for faculty in physical therapist education. Methods. All faculty from one Doctor of Physical Therapy program were recruited and agreed to participate in this study (n = 19). A qualitative thematic approach was applied to deidentified transcripts of faculty interviews conducted at the end of the first year (round 1) of a new curriculum and again after all academic courses had been taught at least once (round 2). Independently coded themes were discussed and further refined iteratively. All data and themes were sent to an external reviewer with feedback incorporated into findings. Results. Ten themes emerged from the analysis of the interviews--7 from round 1 interviews and 3 additional themes from round 2 interviews, including Convoluted Planning Process, Challenging Management Processes & Structure, Overwhelming Workload, New Pedagogy, Integrated Curricular Structure, Crucial Teamwork and Communication, Insufficient Resources, Evolving Attitudes and Approaches, Personal & Professional Growth, and Cautious Optimism. Discussion and Conclusion. The themes that emerged from this study--as well as faculty observations, insights, and concerns--parallel those experienced by non-PT faculty going through similar changes to innovative curricula although with greater levels of angst than evident elsewhere in the literature. The themes also fit the framework by Armenakis and Bedeian that identified 4 common issues across the organizational change literature. Most of our faculty remained hopeful that the original goal of a patient-centered, integrated, active learning curriculum could be reached with continued curricular development and faculty growth. There are increasingly urgent calls to rethink physical therapy education to better prepare graduates for a dynamic health care environment, to respond to emerging biopsychosocial research and pandemic demands, and to reduce graduate indebtedness. These will likely lead to extensive curricular change across programs in the near future. Our findings may facilitate more realistic expectations of physical therapy faculty when facing the challenges of major curriculum change. [ABSTRACT FROM AUTHOR]

Supplemental digital content is available in the text. Background: Some schools and nursing care organizations have implemented 12-hour shifts for students' clinical experiences. Purpose: The aim of this review was to identify how student 12-hour shifts compared to shifts of less than 12 hours influence patient safety, care quality, learning outcomes, and student, faculty, and staff satisfaction. Methods: Searches for academic literature using electronic databases resulted in 13 primary research articles covering the period between 1982 and 2018. Results: During longer clinical shifts, no change in patient safety events occurred. Students and clinical staff perceived care quality was maintained or influenced positively. Faculty were undecided or minimally did not believe care quality improved. While students perceived meeting learning outcomes, faculty perceptions were divided. Students were satisfied with longer shifts; however, the satisfaction of faculty and clinical staff was mixed. Conclusions: Within realms of patient safety, care quality, learning outcomes, and student, faculty, and clinical staff satisfaction, research has been insufficient and inconclusive regarding 12-hour student shifts. [ABSTRACT FROM AUTHOR]

A variety of tubes are placed by the advanced practice provider including endotracheal tubes, nasogastric tubes, feeding tubes, and chest tubes. Recognizing the proper placement of these tubes is critical to prevent complications and allow for intended use including ventilation, nasogastric drainage, providing enteral nutrition, and drainage of air or fluid from the pleural space. The advanced practice provider must be aware of the anatomical landmarks that help indicate correct positioning for safe use and proper functioning of these tubes. This article will discuss how to assess for proper placement of endotracheal, nasogastric, and chest tubes. [ABSTRACT FROM AUTHOR]

The philosophy and practices concerning concussion management have evolved from passive to active strategies that incorporate immediate, guided rest followed by early integration of physical and cognitive activity as tolerated by symptoms. Recent research and clinical evidence support guidance that symptom tolerable and clinically guided activity is beneficial postconcussion both acutely and in the longer term. Furthermore, recent studies illustrate benefits of targeted deficit-based therapies (vestibular, cervicogenic, visual, psychological, etc.) postconcussion subacutely and in those with persistent symptoms. The dissemination of this new information occurs at a fast pace and is often difficult to rapidly integrate into clinical practice due to necessary policy and behavior changes. This review will outline recent evidence concerning both rest and exertion postconcussion through the lens of the socioecological model to more rapidly promote policy and practice changes. [ABSTRACT FROM AUTHOR]

Background: Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty. Given the mortality and morbidity associated with PJI and the challenges in treating it, there has been increased interest in risk factors that can be modified before surgery. In this study, we used a novel mouse model to consider the role of the gut microbiome as a risk factor for PJI.Questions/purposes: (1) Does the state of the gut microbiota before surgery influence the likelihood of developing an established infection in a mouse model of PJI? (2) How does the state of the gut microbiota before surgery influence the local and systemic response to the presence of an established infection in a mouse model of PJI?Methods: Male C57Bl/6 mice were divided into two groups: those with modified microbiome [INCREMENT]microbiome (n = 40) and untreated mice (n = 42). In [INCREMENT]microbiome mice, the gut flora were modified using oral neomycin and ampicillin from 4 weeks to 16 weeks of age. Mice received a titanium tibial implant to mimic a joint implant and a local inoculation of Staphylococcus aureus in the synovial space (10 colony forming units [CFUs]). The proportion of animals developing an established infection in each group was determined by CFU count. The local and systemic response to established infection was determined using CFU counts in surrounding joint tissues, analysis of gait, radiographs, body weight, serum markers of inflammation, and immune cell profiles and was compared with animals that received the inoculation but resisted infection.Results: A greater proportion of animals with disrupted gut microbiota had infection (29 of 40 [73%]) than did untreated animals (21 of 42 [50%]; odds ratio, 2.63, 95% CI, 1.04-6.61; p = 0.035). The immune response to established infection in mice with altered microbiota was muted; serum amyloid A, a marker of systemic infection in mice, was greater than in mice with disrupted gut microbiota with infection (689 µg/dL; range, 68-2437 µg/dL, p < 0.05); infection associated increases in monocytes and neutrophils in the spleen and local lymph node in untreated mice but not were not observed in mice with disrupted gut microbiota.Conclusions: The findings from this in vivo mouse model suggest that the gut microbiota may influence susceptibility to PJI.Clinical Relevance: These preclinical findings support the idea that the state of the gut microbiome before surgery may influence the development of PJI and justify further preclinical and clinical studies to develop appropriate microbiome-based interventions. [ABSTRACT FROM AUTHOR]