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Aim: To describe initial treatment patterns and survival of patients diagnosed with non-small-cell lung cancer (NSCLC) in Denmark, before immune checkpoint inhibitor and later-generation tyrosine kinase inhibitor use. Patients & methods: Adults diagnosed with incident NSCLC (2005–2015; follow-up: 2016). Initial treatments and overall survival (OS) are reported. Results: 31,939 NSCLC patients (51.6% stage IV) were included. Increasing use of curative radiotherapy/chemoradiation for stage I, II/IIIA and IIIB NSCLC coincided with improved 2-year OS. Systemic anticancer therapy use increased for patients with stage IV non-squamous NSCLC (53.0–60.6%) but not squamous NSCLC (44.9–47.3%). 1-year OS improved in patients with stage IV non-squamous NSCLC (23–31%) but not squamous NSCLC (22–25%). Conclusion: Trends indicated improved OS as treatments evolved between 2005 and 2015, but the effect was limited to 1-year OS in stage IV disease.

Green infrastructure (GI) practices are an effective means for improving the sustainability of stormwater management. Optimized combinations of GI practices with other management practices,...

Although traditional small animal and cell culture models of neurodegenerative disease have been valuable in foundational discoveries, their inherent imprecision may have biased our understanding of etiology in humans and hindered translation of therapeutics. Recent breakthroughs to generate human stem cell–derived brain organoids — including from patient-specific cell sources — provide powerful platforms to improve disease modeling accuracy. However, brain organoids do not recapitulate crucial anatomical structures such as long bundled axon tracts — a central systems-level feature of human brains — critical to neurodegenerative disease pathogenesis, including Parkinson's disease. To address this challenge, advances in tissue engineering recapitulate brain pathways with three-dimensional anatomical fidelity to discrete systems-level brain structures, such as the first tissue engineered nigrostriatal pathway. Promulgating anatomically inspired human-derived engineered microtissue may improve translational relevance, empower personalized medicine, and ultimately reduce costs compared to conventional model systems, thus proving useful for targeted development and screening of new therapeutic strategies.

We sought to determine the effect of transitioning between electronic health record (EHR) systems on the quality of preventive care in a large pediatric primary care network. To study this, we performed a retrospective chart analysis of 42 primary care practices from the Pediatric Physicians’ Organization at Children’s who transitioned EHRs. We reviewed 24 random encounters per week distributed evenly across 6 age categories before, during, and after a transition period. We reviewed encounter documentation for age-appropriate well child services, per American Academy of Pediatrics/Bright Futures guidelines. Logistic regression and statistical process control analysis were used. In the pretransition period, 84.5% of all recommended elements were documented versus 86.4% posttransition ( P = .04). Documentation of age-appropriate anticipatory guidance showed significant positive change (69.0% to 80.2%, P = .005), but it was the only subdomain with a statistically significant increase. These increases suggest that EHR transitions have the opportunity to affect the delivery of preventive care.

Mild traumatic brain injury affects millions of individuals annually primarily through falls, traffic collisions, or blunt trauma and can generate symptoms that persist for years. Closed-head rotational loading is the most common cause of mild traumatic brain injury and is defined by a rapid rotational acceleration of brain tissue within an intact skull. Injury kinematics—the mechanical descriptors of injury-inducing motion—explain movement of the head, which govern energy transfer, and, therefore, determine injury severity. However, the relationship between closed-head rotational injury kinematics—such as angular velocity, angular acceleration, and injury duration—and outcome after mild traumatic brain injury is not completely understood. To address this gap in knowledge, we analysed archived surgical records of 24 swine experiencing a diffuse closed-head rotational acceleration mild traumatic brain injury against 12 sham animals. Kinematics were contrasted against acute recovery outcomes, specifically apnea time, extubation time, standing time, and recovery duration. Compared to controls, animals experiencing a mild traumatic brain injury were far more likely to have apnea (P < 0.001), shorter time to extubation (P = 0.023), and longer time from extubation to standing (P = 0.006). Using least absolute shrinkage and selection operator-based regressions, kinematic parameters, including maximum negative angular velocity and time from peak angular velocity to maximum angular deceleration, were selected to explain variation in apnea time, standing time, and recovery duration. Simplified linear models employing the least absolute shrinkage and selection operator-selected variables explained a modest degree of variation in apnea time (adjusted R2 = 0.18), standing time (adjusted R2 = 0.19), and recovery duration (adjusted R2 = 0.27). Neuropathology was correlated with multiple injury kinematics, with maximum angular acceleration exhibiting the strongest correlation (R2 = 0.66). Together, these data suggest the interplay between multiple injury kinematics, including maximum negative angular velocity (immediately preceding cessation of head motion) and time from peak angular velocity to maximum angular deceleration, best explain acute recovery metrics and neuropathology after mild traumatic brain injury in swine. Future experiments that independently manipulate individual kinematic parameters could be instrumental in developing translational diagnostics for clinical mild traumatic brain injury.

ObjectivesTo assess how a decade of developments in systematic anticancer therapy (SACT) for advanced non-small cell lung cancer (NSCLC) affected overall survival (OS) in a large UK University Hospital.DesignReal-world retrospective observational cohort study using existing data recorded in electronic medical records.SettingA large National Health Service (NHS) university teaching hospital serving 800 000 people living in a diverse metropolitan area of the UK.Participants2119 adults diagnosed with advanced NSCLC (tumour, node, metastasis stage IIIB or IV) between 2007 and 2017 at Leeds Teaching Hospitals NHS Trust.Main outcomes and measuresOS following diagnosis and the analysis of factors associated with receiving SACT.ResultsMedian OS for all participants was 2.9 months, increasing for the SACT-treated subcohort from 8.4 months (2007–2012) to 9.1 months (2013–2017) (p=0.02); 1-year OS increased from 33% to 39% over the same period for the SACT-treated group. Median OS for the untreated subcohort was 1.6 months in both time periods. Overall, 30.6% (648/2119) patients received SACT; treatment rates increased from 28.6% (338/1181) in 2007–2012 to 33.0% (310/938) in 2013–2017 (p=0.03). Age and performance status were independent predictors for SACT treatment; advanced age and higher performance status were associated with lower SACT treatment rates.ConclusionAlthough developments in SACT during 2007–2017 correspond to some changes in survival for treated patients with advanced NSCLC, treatment rates remain low and the prognosis for all patients remains poor.

Background and aims Given the enormous global burden of depressive illness, there is an urgent need to develop novel and more effective treatments for major depressive disorder (MDD). Recent findings have suggested that psychedelic drugs may have a role in the treatment of depressive symptoms, and a number of groups are in the process of developing protocols to study this question systematically. Given the subjective quality of both the psychedelic experience and depressive symptomatology, great care must be taken when designing a protocol to study the clinical efficacy of psychedelic drugs. This study will discuss many factors to consider when designing a clinical trial of psilocybin for MDD. Methods We provide a thorough review of pertinent research into antidepressant clinical trial methodology and review practical considerations that are relevant to the study of psychedelic-assisted treatment for depression. Results We discuss participant selection (including diagnostic accuracy, exclusion criteria, characteristics of the depressive episode, and the use of concurrent medications), study interventions (including dosing regimens, placebo selection, non-pharmacological components of treatment, and the importance of blinding), trial duration, outcome measures, and safety considerations. Conclusions Careful and transparent study design and data analysis will maximize the likelihood of generating meaningful, reproducible results, and identifying a treatment-specific effect. Meeting the highest standards for contemporary trial design may also broaden the acceptance of psychedelic research in the scientific community at large.

Background: Diagnostic errors contribute to the large burden of healthcare-associated harm experienced by children. Primary care settings involve high diagnostic uncertainty and limited time and information, creating ideal conditions for diagnostic errors. We report on the design and conduct of Project RedDE, a stepped-wedge, cluster-randomized controlled trial of a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care. Methods: Project RedDE cluster-randomized pediatric primary care practices into one of three groups. Each group participated in a quality improvement collaborative targeting the same three diagnostic errors (missed diagnoses of elevated blood pressure and adolescent depression and delayed diagnoses of abnormal laboratory studies), but in a different sequence. During the quality improvement collaborative, practices worked both independently and collaboratively, leveraging general quality improvement strategies (e.g. process mapping) in addition to error-specific content (e.g. pocket guides for blood pressure norms) delivered during the intervention phase for each error. The quality improvement collaborative intervention included interactive learning sessions and webinars, quality improvement coaching at the team level, and repeated evaluation of failures via root cause analyses. Pragmatic data were collected monthly, submitted to a centralized data aggregator, and returned to the practices in the form of run charts comparing each practice’s progress over time to that of the group. The primary analysis used patients as the unit of analysis and compared diagnostic error proportions between the intervention and baseline periods, while secondary analyses evaluated the sustainability of observed reductions in diagnostic errors after the intervention period ended. Results: A total of 43 practices were recruited and randomized into Project RedDE. Eleven practices withdrew before submitting any data, and one practice merged with another participating practice, leaving 31 practices that began work on Project RedDE. All but one of the diverse, national pediatric primary care practices that participated ultimately submitted complete data. Quality improvement collaborative participation was robust, with an average of 63% of practices present on quality improvement collaborative webinars and 85% of practices present for quality improvement collaborative learning sessions. Complete data included 30 months of outcome data for the first diagnostic error worked on, 24 months of outcome data for the second, and 16 months of data for the third. Lessons learned and limitations: Contamination across study groups was a recurring concern; concerted efforts were made to mitigate this risk. Electronic health records played a large role in teams’ success. Conclusion: Project RedDE, a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care, successfully recruited and retained a diverse, national group of pediatric primary care practices. The stepped-wedge, cluster-randomized controlled trial design allowed for enhanced scientific efficiency.

Mild traumatic brain injury (mTBI) affects millions of individuals annually primarily through falls, traffic collisions, or blunt trauma and can generate symptoms that persist for years. Closed-head rotational injury is the most common form of mTBI and is defined by a rapid change in acceleration within an intact skull. Injury kinematics – the mechanical descriptors of injury-inducing motion – explain movement of the head, energy transfer to the brain, and, therefore, determine injury severity. However, the relationship between closed-head rotational injury kinematics – such as angular velocity, angular acceleration, and injury duration – and outcome after mTBI is currently unknown. To address this gap in knowledge, we analyzed archived surgical records of 24 swine experiencing a diffuse closed-head rotational acceleration mTBI against 12 sham animals. Kinematics were contrasted against acute recovery outcomes, specifically apnea, extubation time, standing time, and recovery duration. Compared to controls, animals with mTBI were far more likely to have apnea (p2=0.27), standing time (R2=0.39) and recovery duration (R2=0.42). Neuropathology was correlated with multiple kinematics, with maximum acceleration exhibiting the strongest correlation (R2=0.66). Together, these data suggest the interplay between multiple injury kinematics, including minimum velocity and middle to minimum acceleration time, best explain acute recovery parameters and neuropathology after mTBI in swine. Future experiments that independently manipulate individual kinematics could be instrumental in developing translational diagnostics for clinical mTBI.HIGHLIGHTSAcute recovery parameters including apnea, extubation time, and recovery duration were altered after a single closed-head mTBI in swine.Lasso-based regressions utilized kinematic parameters, including minimum velocity and middle to minimum acceleration time, to relate kinematics to apnea time, standing time, and recovery duration.Lasso regression equations were able to modestly predict apnea time (R2=0.27) and moderately predict standing time (R2=0.39) and recovery duration (R2=0.42).Injury kinematic parameters, primarily maximum acceleration, were correlated with white matter pathology after mTBI.

Aim: This observational study evaluated treatment patterns and survival for patients with stage I–IIIA non-small-cell lung cancer (NSCLC). Materials & methods: Adults newly diagnosed with NSCLC in 2012–2016 at IPO-Porto hospital were included. Treatment data were available for patients diagnosed in 2015–2016. Results: 495 patients were included (median age: 67 years). The most common treatments were surgery alone or with another therapy (stage I: 66%) and systemic anticancer therapy plus radiotherapy (stage II: 54%; stage IIIA: 59%). One-year OS (95% CI) for patients with stage I, II and IIIA NSCLC (diagnosed 2012–2016) were 92% (88–96), 71% (62–82) and 69% (63–75), respectively; one-year OS (95% CI) for treated patients with stage I–II or stage IIIA NSCLC (diagnosed 2015–2016) were 89% (81–97) and 86% (75–98) for non-squamous cell and 76% (60–95) and 49% (34–70) for squamous cell NSCLC. Conclusion: Treatment advances are strongly needed for stage I–IIIA NSCLC, especially for patients with squamous cell histology.

In recent years, regulatory bodies have increasingly recognized the utility of real-world evidence (RWE) for supplementing and supporting clinical trial data in new drug applications. Nevertheless, the integration of RWE into established regulatory processes is complex and the generation of ‘regulatory-grade’ real-world data faces operational, methodological, data-related and policy-related challenges. In parallel with this evolving role for RWE, immuno-oncology therapies have emerged as leading cancer treatments and are expected to continue to play a central role in the future. In this article, we review the current literature on the use of RWE for regulatory submissions, with a focus on novel anticancer immunotherapies, and discuss the utility and current limitations of RWE in the context of drug development and regulatory approvals.

Background As part of the multinational I-O Optimise research initiative, this retrospective cohort study of patients with advanced non-small cell lung cancer (NSCLC) evaluated real-world treatment patterns and survival prior to immunotherapy reimbursement in Portugal. Methods This study utilized a database held by IPO-Porto, Portugal’s largest oncology hospital. Adult patients diagnosed with stage IIIB or IV NSCLC from January 2012 to December 2016 at IPO-Porto, with follow-up to June 2017, were included. Treatment analyses were performed from 2015 onwards. Kaplan–Meier methods were used for overall survival (OS). Factors associated with OS and systemic anti-cancer therapy (SACT) treatment were assessed using multivariate statistical models. Results Of 1524 patients diagnosed with NSCLC at IPO-Porto, 1008 patients had advanced disease (stage IIIB: 10.1%, 154/1524, stage IV: 56.0%, 854/1524). For those with advanced disease, median age was 65 years (range: 21–92) and 75.6% (762/1008) were male. Median OS (interquartile range [IQR]) was 11.4 (5.2–26.9) months for stage IIIB and 6.3 (2.4–15.0) months for stage IV. Factors associated with decreased risk of death included female sex and epidermal growth factor receptor gene (EGFR)/anaplastic lymphoma kinase gene (ALK) mutations/rearrangements; factors associated with increased risk of death included older age and stage IV disease. Among patients diagnosed in 2015 or 2016, 75.8% (297/392) received ≥1 line of SACT. Platinum-based chemotherapy was the most common first-line therapy (non-squamous cell carcinoma [NSQ]: 72.9%; squamous cell carcinoma [SQ] 87.3%, 55/63; patients with EGFR/ALK mutations/rearrangements primarily received tyrosine kinase inhibitors). The likelihood of receiving SACT was lower in older patients and those diagnosed with stage IV disease. Patients not receiving SACT had poor survival outcomes (median OS [IQR]: NSQ, 1.8 [1.1–3.1] months; SQ, 2.3 (1.3–3.4) months), while median OS (IQR) in SACT-treated patients was 12.6 (6.1–24.5) months for NSQ and 10.3 (5.7–15.9) months for SQ. Conclusions This real-world data analysis from a large Portuguese oncology hospital demonstrates a high disease burden for advanced NSCLC in the pre-immunotherapy era, with nearly one-quarter of patients not receiving SACT. Even in patients receiving SACT, median survival was only about 1 year.

Clinical documentation is a fundamental component of the practice of medicine. It has significantly evolved over the past decade, largely because of the growth of health information technology and electronic health records. Although government agencies and other professional organizations have published position statements on the structure and use of electronic documentation, few have specifically addressed the documentation needs for the care of children. A policy statement on electronic documentation of clinical care by general pediatric and subspecialist providers by the American Academy of Pediatrics is needed. This statement provides insight on the unmet needs of key stakeholders to direct future research and development of the electronic media necessary to enhance the wellness of children and improve health care delivery. It also addresses the challenges and opportunities for efficient and effective clinical documentation in pediatrics.

OBJECTIVE: Diagnostic errors (DEs), “the failure to establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation,” cause appreciable morbidity, but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/sub-acute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/sub-acute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics. METHODS: As part of a national quality improvement collaborative, 25 primary care pediatric practices were randomized to collect five months of retrospective data on one DE or MOD: elevated blood pressure(BP) and abnormal laboratory values(DEs), or adolescent depression evaluation(MOD). Relationships between DE or MOD proportions and patient age, gender, and insurance status were explored with mixed-effects logistic regression models. RESULTS: DE or MOD rates in pediatric primary care were found to be 54% for patients with elevated BP(N=389), 11% for patients with abnormal laboratory values(N=381) and 62% for adolescents with an opportunity to evaluate for depression(N=400). When examining the number of times a pediatrician may have recognized an abnormal condition, but either knowingly or unknowingly did not act according to recommended guidelines: providers did not document recognition of an elevated BP in 51% of patients with elevated BP, and did not document recognition of an abnormal laboratory value without a delay in 9% of patients with abnormal laboratory values. CONCLUSION: DEs and MODs occur at an appreciable frequency in pediatric primary care. These errors may contribute to care delays and patient harm.

Epilepsy of infancy with migrating focal seizures is a devastating pediatric neurologic disorder that often results in treatment-resistant seizure activity and developmental delay. The condition has been associated with mutations in the KCNT1 gene that cause a gain of function in neuronal sodium-activated potassium channels. Quinidine has been shown to reverse this gain of function and has recently been used to reduce seizure activity in patients with these mutations. We report the case of an infant with 2 KCNT1 mutations who experienced minor relief with quinidine and discuss the drug's important interaction with phenobarbital. Keywords: KCNT1, Pediatrics, Phenobarbital, Quinidine, Seizures

Supplemental Digital Content is available in the text., Background: Adolescent depression causes appreciable morbidity and is underdiagnosed in primary care. This study investigated whether a quality improvement collaborative (QIC) increases the frequency of adolescent depression diagnoses, thus reducing missed diagnoses. Methods: During a cluster-randomized clinical trial, a national cohort of primary care pediatric practices worked in different orders based on randomization to improve performance on each of three different diagnoses; one was increasing adolescent depression diagnoses. While improving their first diagnosis during an 8-month action period, practices collected control data for a different diagnosis. In two subsequent 8-month periods, practices worked to improve two additional diagnoses and continued to provide data on the ability to sustain and maintain improvements. The QIC intervention included day-long video conferences, transparent data sharing, analysis of failures, QI coaching, and tools to help improve diagnostic performance, including the Patient Health Questionnaire-9 Modified. The primary outcome was the measured frequency of depression diagnoses in adolescent health supervision visits compared via generalized mixed-effects regression models. Results: Forty-three practices were randomized with 31 in the final analysis. We included 3,394 patient visits in the control and 4,114 in the intervention phases. The adjusted percentage of patients with depression diagnoses increased from 6.6% in the control to 10.5% in intervention phase (Risk Difference (RD) 3.9%; 95% CI 2.4%, 5.3%). Practices sustained these increases while working on different diagnoses during the second (RD -0.4%; 95% CI -2.3, 1.4%), and third action periods (RD -0.1%; 95% CI -2.7%, 2.4%). Conclusions: A QIC intervention can sustainably increase adolescent depression diagnoses.

Open science practices such as publishing data and code are transforming water science by enabling synthesis and enhancing reproducibility. However, as research increasingly bridges the physical and social science domains (e.g., socio?hydrology), there is the potential for well?meaning researchers to unintentionally violate the privacy and security of individuals or communities by sharing sensitive information. Here, we identify the contexts in which privacy violations are most likely to occur, such as working with high?resolution spatial data (e.g., from remote sensing), consumer data (e.g., from smart meters), and/or digital trace data (e.g., from social media). We also suggest practices for identifying and addressing privacy concerns at the individual, institutional, and disciplinary levels. We strongly advocate that the water science community continue moving toward open science and socio?environmental research and that progress toward these goals be rooted in open and ethical data management., by Udit Bhatia et al.

Aim: To describe I-O Optimise, a multinational program providing real-world insights into lung cancer management. Materials & methods: Real-world data source selection for I-O Optimise followed a structured approach focused on population coverage, key variable capture, continuous/consistent data availability, record duration and data latency, and database expertise. Results: As of 31 October 2018, seven real-world data sources were included in I-O Optimise, providing data on characteristics, treatment patterns and clinical outcomes from more than 45,000 patients/year with non-small-cell lung cancer, small-cell lung cancer and mesothelioma across Denmark, Norway, Portugal, Spain, Sweden and the UK. Conclusion: The ongoing I-O Optimise initiative has the potential to provide a broad, robust and dynamic research platform to continually address numerous research objectives in the lung cancer arena. This article describes the design and creation of I-O Optimise, a project that will collect real-world evidence about patients with lung cancer across many different countries. A specific structured approach was followed to select real-world data sources for inclusion in I-O Optimise and, as of 31 October 2018, seven real-world data sources were included, providing information on more than 45,000 patients per year with lung cancer in Denmark, Norway, Portugal, Spain, Sweden and the UK. I-O Optimise is an ongoing project that has the potential to provide information that will be important in improving the care of patients with lung cancer.

Introduction Regional anaesthesia, usually in the form of caudal epidural, is a foundation of analgesia for hypospadias repairs. Recent publications have demonstrated a strong association between caudal blockade and fistula formation or glanular dehiscence. If caudals were causing complications, abandonment of caudals would necessitate a plausible and efficacious alternative that may itself be associated with side effects. We sought to review our own institutions’ outcomes in this area. Methods Retrospective case note review in partnership with University College Hospital (UCH). Data analysed in Microsoft Excel using XLSTAT. Results A total of 177 boy’s notes were reviewed; 116 from Great Ormond Street Hospital (GOSH). Median age was 18 months (IQR 11) and median weight 11.5 kg (IQR 3.5). Median duration of surgery was 90 min (IQR 48.25). 94% received caudal anaesthesia with a median volume of 0.7 ml/kg (IQR 0.2). Clonidine was an adjunct in 41% of caudals but was only used at GOSH. There were 40 wound complications including 21 fistulae and 7 dehisced wounds. 5 were lost to follow-up. OR for wound complication with caudal anaesthetic was 0.41 (95% CI −0.1–1.5). Significantly less intra-operative fentanyl was administered to boys receiving caudals, p Conclusion Complication rates were similar to previously published studies with respect to urethrocutaneous fistula. Surgical duration was markedly lower. Usage of caudal block was much greater than in previously published work; 58% and 63%. The complication rate for caudal recipients was in line with other studies. The use of clonidine to prolong analgesia was not universal, despite strong evidence to support its use. The complication rate was higher for the children that did not receive any regional anaesthesia. The efficacy of caudal anaesthesia in hypospadias repair is demonstrated by the significantly lower opioid doses received in the caudal group. Our results do not support the abandonment of caudal anaesthesia for hypospadias repair.

Background I-O Optimise is a new multinational data platform developed to enable real-world insights into the management of thoracic malignancies. As part of this initiative, the current analysis reports the characteristics and treatment patterns for adult patients diagnosed with stage IIIB or IV NSCLC at one of the largest integrated cancer centres in the UK. Methods Retrospective cohort study using longitudinal data already collected from electronic medical records, including all adult patients diagnosed with stage IIIB-IV NSCLC between January 2007 and August 2017. Minimum follow-up was 6 months. Distinct lines of therapy (LoT) were identified using a clinically-verified algorithm based on the name and date of systemic anti-cancer therapy (SACT) administered and the gap between two treatments. Results Overall, 2119 patients were included. Mean age at diagnosis was 71.4±11.2 years. Nearly one-third (32.7%) were clinically diagnosed without pathological confirmation (table 1) and very few of these patients have SACT administration recorded. Following diagnosis, 648 patients (30.6%) received ≥1 LoT, 223 (10.5%)≥2 LoT and 60 (2.8%)≥3 LoT. Proportions of patients treated decreased with age (73.5% [25/34] aged 18–44 years; 52.7% [267/507] aged 45–64 years; 29.8% [310/1040] aged 65–79 years; 8.6% [46/538] aged 80+years) and performance score (58.5% [387/662] PS0–1; 38.2% [158/414] PS2; 6.1% [52/848] PS3–4). Between the periods 2007–2011 and 2012–2017, increased proportions were treated (28.2% [263/933] and 32.5% [385/1186] respectively). Patient characteristics of the treated cohort and regimens administered for 1st and 2nd LoT are shown (table 1). Conclusions Around 70% of this real-world cohort did not receive any SACT, and the administration of treatment was strongly associated with age and performance status. The changing availability of treatment options over time (including the emergence of immunotherapy) and survival outcomes by LoT will be presented in more detail for the cohort described.

Following severe traumatic brain injury (TBI), many patients experience coma - an unresponsive state lacking wakefulness or awareness. Coma rarely lasts more than two weeks, and emergence involves passing through a state of wakefulness without awareness of self or environment. Patients that linger in these Disorders of Consciousness (DoC) undergo clinical assessments of awareness for diagnosis into Unresponsive Wakefulness Syndrome (no awareness, also called vegetative state) or Minimally Conscious State (periodic increases in awareness). These diagnoses are notoriously inaccurate, offering little prognostic value. Recovery of awareness is unpredictable, returning within weeks, years, or never. This leaves patients' families with difficult decisions and little information on which to base them. Clinical studies have made significant advancements, but remain encumbered by high variability, limited data output, and a lack of necessary controls. Herein we discuss the clear and present need to establish a preclinical model of TBI-induced DoC, the significant challenges involved, and how such a model can be applied to support DoC research.

Background Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus. Methods and Results A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments. Conclusions Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Background and aims: Recent decades have seen material shifts in global migration flows. Migrants now come to the UK for an increasing number of reasons and from an increasing number of countries. This presents a challenge for health services that must provide care to individuals with a broad range of needs. In particular, there is concern that asylum seekers and refugees (ASRs) are at heightened risk of poor wellbeing and of receiving suboptimal healthcare. Concurrent with these shifts in migration, increasing attention is being paid to noncommunicable diseases (NCDs), which are now the most significant drivers of morbidity and mortality in most regions of the world. In the UK, the burden of NCDs is not evenly distributed, with inequalities related to ethnicity and socioeconomic status shaping an individual’s risk of ill health. Little is known, however, about how diverse migrant groups, including ASRs, conceptualise health and respond to health prevention messaging. Against this backdrop, this thesis aims to understand the health-related experiences of one such group – asylum seekers and refugees (ASRs) from Sub Saharan Africa living in Glasgow Scotland. Specifically, it explores: a) perceptions of health, wellbeing, and illness causation, b) experiences of accessing primary and preventive healthcare, and c) the factors influencing these perceptions and experiences. It also seeks to elucidate professional perspectives on ASR health. Methods: To gain an in depth understanding of ASR health perceptions and experiences, as well as professional perspectives, a focused ethnography was undertaken. This approach utilised four qualitative methods: community engagement, participatory focus groups, semistructured interviews, and go- along interviews. In total 12 primary care and public health professionals were interviewed, and 27 ASRs took part in either a focus group, an interview, or both. The thesis took a theoretically informed approach, seeking to determine whether and how two theories – ‘candidacy’ (Dixon-Woods et al 2005) and ‘structural vulnerability’ (Quesada et al 2011) – might deepen our understanding of ASR health. Results: Candidacy enhanced understanding of how ASRs identified and responded to messages about ‘healthy lifestyles’. ASR participants considered keeping healthy to be an individual responsibility, with diet and exercise highlighted as especially important. At the same time, however, perceptions and experiences of health and wellbeing were shaped by a number of structural influences, which limited the capacity of ASRs to engage in health practices. Therefore, while ASRs considered health to be an individual choice in theory, they did not necessarily feel they had the ability to be healthy in practice. The theory of structural vulnerability proved useful in identifying the wider structural determinants that impacted on an individual’s capacity to respond. There were several important structural influences, including poverty, racism, discrimination, and language barriers. The greatest negative influence, however, and one that compounded all the others, was the asylum process. This diminished individuals’ capacity to identify as candidates for prevention messages, engage in preventive health practices, and/ or access care in an optimal fashion. Conclusions: Efforts to engage ASRs in preventive health programmes and practices must take into account the ways in which the immigration and asylum system acts as a determinant of health, affecting both what it means to be healthy and what capacity individuals have to engage. The NHS, together with non statutory bodies, has a role to play in mitigating some of the vulnerabilities to which ASRs are subject.

Background: As part of I-O Optimise, a multinational research platform providing real-world insights into the management of lung cancers, the SCAN-LEAF study aims to describe the epidemiology, clinical care, and outcomes for pts with NSCLC in Scandinavia. Here, we report temporal OS trends among pts diagnosed with incident NSCLC from 2005 to 2015 in Denmark and Sweden. Methods: The SCAN-LEAF Danish and Swedish cohorts were established by linking respective national registries and include all adult pts diagnosed with incident NSCLC from Jan 2005 to Dec 2015 (follow-up to Dec 2016). The Kaplan–Meier method was used to estimate OS at 1, 3, and 5 yrs by histology (non-squamous cell [NSQ] or squamous cell [SQ]), TNM stage, and yr of diagnosis; changes in OS over time were assessed using the Cochrane–Armitage test. Results: 31,939 pts in Denmark and 30,067 pts in Sweden were diagnosed with NSCLC from 2005 to 2015. Most were diagnosed at stage IV (51.6% and 48.4%, respectively) and had NSQ histology (54.4% and 60.4%). Statistically significant trends (P 5% over the analysis period were seen for NSQ pts at 1 yr for all stages in both countries (Table); at 3 yrs for stages I–IIIB in Denmark (P ≤ 0.027), and stages I–II (P ≤ 0.0013) in Sweden; and at 5 yrs for stages I–II (P ≤ 0.026) in both countries. For SQ pts, this was seen only at 1 yr for stage IIIA in Denmark and stage I in Sweden (Table), and at 5 yrs for stage IIIA in Denmark (p = 0.02). Conclusions: Despite some improvements between 2005 and 2015, mainly in the short-term survival of pts with early-stage NSCLC, long-term OS rates for pts with late-stage disease did not change significantly and remained low. Even in pts with early-stage disease, OS outcomes were suboptimal, with a particular unmet need in the SQ population. Future analyses including data after 2015 will evaluate the potential impact on OS of increased use of new TKIs and immune checkpoint inhibitors.

Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting.This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups.Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023).TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN.Level III, this was a retrospective comparative study.

Study hypothesis Level 1 trauma centers reduce mortality and improve functional outcomes in major trauma. Despite this, many countries, including Ireland, do not have officially designated major trauma centers (MTC). This study aimed to examine international trauma systems, and determine how to ‘‘best fit’’ trauma care in a small country (Ireland) to international models. Methods The literature was reviewed to examine international models of trauma systems. An estimate of Irish trauma burden and distribution was made using data from the Road Safety Authority (RSA) on serious or fatal RTAs. Models of a restructured trauma service were constructed and compared with international best practice. Results Internationally, a major trauma center surrounded by a regional trauma network has emerged as the gold standard in trauma care. In Ireland, there are no nationally coordinated trauma networks and care is provided by 26 acute hospitals with a mean distance to hospital from RTAs of 20.6 km ± 15.6. Based on our population, Ireland needs two Level 1 MTCs (in the two areas of major population density in the east and south), with robust surrounding trauma networks including Level 2 or 3 trauma centers. With this model, the estimated mean number of cases per Level 1 MTC per year would be 628, with a mean distance to MTC of 80.5 ± 59.2 km, (maximum distance 263.5 km). Conclusion Clearly designated and adequately resourced MTCs with trauma networks are needed to improve trauma outcomes, with concomitant investment in pre-hospital infrastructure.

Objective To determine whether newborn first outpatient visit (FOV) within 3 days of discharge is associated with reduced rates of emergency department (ED) visits and hospital readmissions. Methods Retrospective cohort analysis was performed of all newborns who were born and had outpatient follow-up within a large academic medical center to determine whether they had ED visits or hospital readmission within 2 weeks after hospital discharge. Multivariable regression using an instrumental variable for timing of FOV was conducted to estimate the relationship between FOV within 3 days of discharge and ED visits and hospital readmissions within 2 weeks of discharge, adjusting for potential confounders. Stratified analyses assessed this relationship in subpopulations with medical or social risk factors. Results Of 3282 newborns, 178 (5%) had 1 or more ED visits or hospital readmissions within 2 weeks of hospital discharge. FOV within 3 days was not significantly associated with ED visits and readmissions in the instrumental variable analysis (IVA) (−0.035, P = .11) or the ordinary least squares analysis (OLS) (0.006, P = .52). The difference in coefficients between these analyses, however, suggests that IVA successfully adjusted for some unmeasured bias. In stratified analyses, only newborns born to African American mothers or discharged by family medicine providers demonstrated a significant relationship between FOV within 3 days and reduced odds of ED visits and readmissions. Conclusions No significant relationship between outpatient visit timing and ED visits and hospital readmissions was found. Further study is needed to assess the impact of early outpatient visits on other newborn outcomes.

Background The benefits of ICIs for patients (pts) with NSCLC have been shown in several clinical trials, but real-world data are limited. We describe the early impact of 2L ICI Tx on clinical practice at the Leeds Cancer Centre (LCC), a UK site of I-O Optimise, a multinational research platform providing insights into real-world lung cancer management. Methods This retrospective cohort study used longitudinal data from electronic medical records of adults diagnosed with advanced NSCLC (stage IIIB/IV) between Jan 2013 and Oct 2018 (2-month minimum follow-up). Pts with EGFR or ALK mutations were excluded from the analysis due to different Tx patterns expected in this population eligible for targeted Tx. Pre- and post-ICI sub-cohorts were defined by date of first 2L ICI use at LCC (Mar 2016). Distinct lines of Tx were identified using a clinically verified algorithm based on date of prescribed systemic anti-cancer therapy (SACT) and time between prescriptions. Age and ECOG performance score (PS) at time of initial diagnosis were recorded. Results Of 1196 pts with advanced NSCLC during the study period, 409 (34.2%) received SACT; (annual rates were 33.5–38.1%). In all, 103 pts (8.6%) received 2L Tx, of which 26 (25.2%) had EGFR/ALK mutations; of the remaining 77 pts without EGFR/ALK mutations, 29 were treated pre-ICI and 48 post-ICI. In the pre-ICI sub-cohort, median age was 65.0 yrs and 82.8% had an ECOG PS Conclusions Two years on from the introduction of ICIs as a 2L option in UK clinical practice, their use is well established among eligible pts, but overall 2L SACT Tx remains very low. The impact on survival will be presented. Editorial acknowledgement Richard Daniel, PhD and Kate Bradford, PhD of PAREXEL, funded by Bristol-Myers Squibb. Legal entity responsible for the study Bristol-Myers Squibb. Funding Bristol-Myers Squibb. Disclosure M. Snee: Research grant / Funding (institution), I am a paid consultant to IQVIA. My employer Leeds teaching hospitals NHS trust has received a grant from IQVIA: IQVIA. L. Lacoin: Advisory / Consultancy, Consultant for BMS: Bristol-Myers Squibb. W. Sopwith: Full / Part-time employment, I am employed by IQVIA to work on this project: IQVIA. C. Chaib: Full / Part-time employment, Employee: Bristol-Myers Squibb. J.R. Penrod: Shareholder / Stockholder / Stock options, Full / Part-time employment: Bristol-Myers Squibb. J.C. O’Donnell: Shareholder / Stockholder / Stock options, Full / Part-time employment: Bristol-Myers Squibb. All other authors have declared no conflicts of interest.

Background: As part of I-O Optimise, a multinational research platform providing real-world insights into the management of lung cancers, the SCAN-LEAF study aims to describe the epidemiology, clinical care and outcomes for pts with NSCLC in Scandinavia. We report initial Tx and OS for pts with NSCLC prior to the availability of immunotherapies in Sweden. Methods: The analysis includes all adult pts diagnosed with NSCLC at Uppsala and Karolinska (Stockholm) University Hospitals from 2012 to 2015 (follow-up to Dec 2016). Electronic medical record data were extracted using Pygargus CXP software and linked with national registries. Bespoke rule-based algorithms were applied to describe Tx patterns; Kaplan–Meier methods were used to estimate OS. Results: 2779 pts were diagnosed with incident NSCLC (median age, 70 yrs [range: 22–96; 14.2% ≥80]; male, 48.5%; histology: non-squamous (NSQ), 70.9%, squamous (SQ), 17.7%, other, 11.4%; stage distribution: I, 19.3%; II, 7.7%; IIIA, 12.3%; IIIB, 7.2%; IV, 51.2%). Initial Tx (≤6 months from diagnosis) by stage and yr of diagnosis is shown in the table. Median OS (months) for NSQ and SQ pts: not reached and 52.8 in stage I, 43.2 and 23.6 in stage II, 26.7 and 20.4 in stage IIIA, 12.5 and 12.9 in stage IIIB, and 7.6 and 6.1 in stage IV, respectively. Among stage IIIB–IV pts, 60.7% (NSQ) and 53.5% (SQ) had ≥1 line of systemic anti-cancer therapy (SACT); median OS was 12.2 (NSQ) and 10.4 (SQ) months in pts on SACT, and 3.1 (NSQ) and 3.7 (SQ) months in pts not on SACT. Ongoing analyses will assess factors associated with SACT receipt in stage IIIB–IV pts. Conclusions: Swedish pts with NSCLC had a high burden of disease, with most diagnosed at stage IV and a median OS of 1 yr in late-stage pts receiving SACT. There is also scope for improved prognosis in pts diagnosed at early stages, particularly in SQ pts. Future analyses will assess the potential impact of recent improvements in diagnostics and therapeutics on Tx patterns and OS in Swedish NSCLC pts. (Less)

BACKGROUND Electronic communication between providers occurs daily in clinical practice but has not been well studied. PURPOSE To assess the impact of provider-to-provider electronic communication tools on communication and healthcare outcomes through literature review. DATA SOURCES Ovid MEDLINE, PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, and Academic Search Premier. STUDY SELECTION Publication in English-language peer-reviewed journals. Studies provided quantitative provider-to-provider communication data, provider satisfaction statistics, or electronic health record (EHR) communication data. DATA EXTRACTION Literature review. DATA SYNTHESIS Two reviewers conducted the title review to determine eligible studies from initial search results. Three reviewers independently reviewed titles, abstracts, and full text (where appropriate) against inclusion and exclusion criteria. LIMITATIONS Small number of eligible studies; few described trial design (20%). Homogeneous provider type (physicians). English-only studies. CONCLUSIONS Of 25 included studies, all focused on physicians; most were observational (68%). Most (60%) described electronic specialist referral tools. Although overall use has been measured, there were no studies of the effectiveness of intra-EHR messaging. Literature describing the effectiveness of provider-to-provider electronic communications is sparse and narrow in scope. Complex care, such as that envisioned for the Patient Centered Medical Home, necessitates further research. Journal of Hospital Medicine 2013;8:589–597. © 2013 Society of Hospital Medicine

Background Limb lengthening by callotasis as described by Ilizarov has become the standard method of lower extremity lengthening. Lengthening over an intramedullary nail to allow early removal of the external fixator has also become common in adults but few studies have addressed the efficacy in children. Methods A retrospective review of 37 consecutive children who had undergone femoral lengthening with external fixator over an intramedullary nail was performed. Charts were reviewed for demographics, surgical details, and complications. Radiographs were examined to determine magnitude of lengthening and to calculate lengthening index. Results The average age of the 37 patients was 11.6 years (range, 8.1 to 17.0). The amount of lengthening averaged 7.0 cm (range, 3.0 to 11.4 cm), which represented a mean 20.4% increase in length. The mean time in the fixator was 81 days. The lengthening index was 1.21 days/mm. Thirteen patients developed major complications (37.8%) including 4 limbs that failed to lengthen initially, 3 fractures (1 before fixator removal and 3 after fixator removal), 2 nail failures, 4 deep infections, and 2 joint subluxations requiring operative care. The 3 fractures after fixator removal were treated with exchange nailing as were the 2 intramedullary nail failures. Four patients (10.8%) developed deep infections requiring irrigation, debridement, and IV antibiotics. One patient developed a late hip subluxation, which was treated with a shelf osteotomy but resulted in pain and limitation of motion. One patient developed knee subluxation during lengthening requiring operative intervention. The technique was successful in obtaining a good result with a functional lengthened femur without unresolved problems in 94% of the patients despite a significant rate of major complications, particularly in those with a congenital etiology. Only 2 of the 37 patients ultimately had results that were ultimately compromised by complications. Conclusions Femoral lengthening over an intramedullary nail with the aid of an external fixator has shown to be an effective method for correcting limb length discrepancy. The technique has a high complication rate similar to other methods of lengthening. Level of evidence Level IV-Case Series.

Background: Diagnostic errors causing harm in children are understudied, resulting in a knowledge gap regarding pediatricians’ interest in reducing their incidence. Methods: Electronic survey of general pediatricians focusing on diagnostic error incidence, errors they were interested in trying to improve, and errors reduced by their electronic health record (EHR). Results: Of 300 contacted pediatricians, 77 (26%) responded, 58 (19%) served ambulatory patients, and 48 (16%) completed the entire questionnaire. Of these 48, 17 (35%) reported making a diagnostic error at least monthly, and 16 (33%) reported making a diagnostic error resulting in an adverse event at least annually. Pediatricians were “most” interested in “trying to improve” missed diagnosis of hypertension (17%), delayed diagnosis due to missed subspecialty referral (15%), and errors associated with delayed follow-up of abnormal laboratory values (13%). Among the 44 pediatricians with an EHR, 16 (36%) said it reduced the likelihood of missing obesity and 14 (32%) said it reduced the likelihood of missing hypertension. Also, 15 (34%) said it helped avoid delays in follow-up of abnormal laboratory values. A third (36%) reported no help in diagnostic error reduction from their EHR. Conclusions: Pediatricians self-report an appreciable number of diagnostic errors and were most interested in preventing high frequency, non-life-threatening errors. There exists a need to leverage EHRs to support error reduction efforts.

Over the last 40 years, anatomic reduction with plate stabilization has become the standard in adult patients with diaphyseal fractures of the radius and ulna. When operative fixation has been indicated in skeletally immature patients with these fractures, a variety of techniques have been reported, with intramedullary fixation becoming increasingly accepted. There is currently significant variability in the treatment of adolescents with forearm fractures. The purpose of this study was to investigate the clinical and radiographic outcomes in the adolescent population after intramedullary fixation of both bone forearm fractures. A retrospective review identified 32 patients 12-18 years of age who had undergone intramedullary fixation of both forearm bones in the past 20 years at our institution. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded. Radiographic evaluation was performed to determine union and postoperative radial bow. Clinical follow-up was carried out for postoperative complications and range of motion of the wrist, forearm, and elbow. The mean age of the patients was 14.1 years. A total of 19 fractures were closed injuries, nine were grade 1, three were grade 2, and one fracture was a grade 3b. Of the patients, 15.6% had limited postoperative range of motion. All patients in the older age group, 15-18 years of age, had a normal range of motion. A decrease in radial bow was not associated with limitation in motion. There was a 98% union rate, and all unions occurred by 7.5 months. Only three major complications occurred, two refractures and one ulnar hardware migration, and subsequent radius nonunion occurred in the one grade 3b injury. Flexible intramedullary nailing of both bone forearm fractures provides reliable bony union and excellent postoperative clinical results in adolescents. Level of evidence, IV.

PURPOSE Consumer buy-in is important for the success of widespread federal initiatives to promote the use of health information exchange (HIE). Little is known, however, of consumers’ preferences around the storing and sharing of electronic health information. We conducted a study to better understand consumer preferences regarding the privacy and security of HIE. METHODS In 2008 we conducted a cross-sectional, random digit dial telephone survey of residents in the Hudson Valley of New York State, a state where patients must affirmatively consent to having their data accessed through HIE. RESULTS There was an 85% response rate (N = 170) for the survey. Most consumers would prefer that permission be obtained before various parties, including their clinician, could view their health information through HIE. Most consumers wanted any method of sharing their health information to have safeguards in place to protect against unauthorized viewing (86%). They also wanted to be able to see who has viewed their information (86%), to stop electronic storage of their data (84%), to stop all viewing (83%), and to select which parts of their health information are shared (78%). Among the approximately one-third (n = 54) of consumers who were uncomfortable with automatic inclusion of their health information in an electronic database for HIE, 78% wished to approve all information explicitly, and most preferred restricting information by clinician (83%), visit (81%), or information type (88%). CONCLUSION Consumers in a state with an opt-in consent policy are interested in having greater control over the privacy and security of their electronic health information. These preferences should be considered when developing and implementing systems, standards and policies.

Juveniles' competency to participate in delinquency proceedings has received increased attention in recent years. Developmental incompetence, whereby juveniles' incompetency is based upon their immaturity, as opposed to a mental disorder or developmental disability, is an evolving and important aspect of this area of law. The following paper reviews theories used to support the notion of developmental incompetence, as well as the extant empirical research on juveniles' competency-related abilities. Using a LexisNexis search, statutory and case laws pertaining to juvenile competency were identified across the 50 states and the District of Columbia. Only six states clearly allow developmental incompetence, whereas 17 have laws that do not include developmental immaturity as an acceptable basis of incompetence in juvenile courts. Developmental incompetence is likely to affect a relatively small proportion of juvenile cases, but has important implications for juvenile forensic practice. Recommendations are offered for forensic practitioners conducting this type of evaluation. Language: en

Purpose The erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count are frequently obtained in the work-up of post-operative fever. However, their diagnostic utility depends upon comparison with normative peri-operative trends which have not yet been described. The purpose of this study is to define a range of erythrocyte sedimentation rates and white blood cell counts following spinal instrumentation and fusion in non-infected patients. Methods Seventy-five patients underwent spinal instrumentation and fusion. The erythrocyte sedimentation rate and white blood cell count were recorded pre-operatively, at 3 and 7 days post-operatively, and at 1 and 3 months post-operatively. Results Both erythrocyte sedimentation rate and white blood cell count trends demonstrated an early peak, followed by a gradual return to normal. Peak erythrocyte sedimentation rates occurred within the first week post-operatively in 98% of patients. Peak white blood cell counts occurred with the first week in 85% of patients. In the absence of infection, the erythrocyte sedimentation rate was abnormally elevated in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively. The white blood cell count was abnormally elevated in only 6% of patients at 1 month post-operatively. Longer surgical time was associated with elevated white cell count at 1 week post-operatively. The fusion of more vertebral levels had a negative relationship with elevated erythrocyte sedimentation rate at 1 week post-operatively. The anterior surgical approach was associated with significantly lower erythrocyte sedimentation rate at 1 month post-operatively and with lower white cell count at 1 week post-operatively. Conclusion In non-infected spinal fusion surgeries, erythrocyte sedimentation rates are in the abnormal range in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively, suggesting that the erythrocyte sedimentation rate is of limited diagnostic value in the early post-operative period.

BACKGROUND Circumferential casts can contribute to elevated compartment pressures in the setting of acute swelling. We have developed a novel casting method (A-frame cast) that allows cast placement while leaving the antecubital fossa free of casting material. The purpose of this study was to evaluate the safety, efficacy, and complications associated with acute placement of this definitive cast after closed reduction percutaneous pinning (CRPP) of acute supracondylar distal humerus fractures. METHODS A retrospective medical record reviewed 436 patients treated with CRPP of supracondylar fractures by 3 surgeons who routinely used an A-frame cast over a 12-year period. All complications or the need for cast modification were noted. Patients with open reduction, ipsilateral fractures, or patients lost to follow-up were excluded. RESULTS There were 387 patients who met inclusion criteria, including 204 type 2 fractures and 183 type 3 fractures. Forty-three patients had preoperative nerve palsy and 1 had preoperative vascular injury. Of these 387 patients, 369 (95.3%) had an uneventful postoperative course. Nineteen patients (4.9%) required either cast splitting (15) or strict elevation (4) secondary to pain and swelling. Seven of these 19 patients had preoperative nerve palsy and 1 had preoperative vascular injury. The average time from procedure to cast splitting was 17.6 hours. No patients lost their reduction or required a second surgical procedure related to a complication from casting. CONCLUSIONS An "A-frame" cast provides sturdy immobilization without increased risk of compartment syndrome after CRPP of supracondylar fractures in the pediatric population. Consideration should be given to splitting the cast prophylactically in patients with preoperative neurological or vascular deficits. LEVEL OF EVIDENCE IV-Case Series.

Health information exchange (HIE), the electronic transmission of patient medical information across healthcare institutions, is on the forefront of the national agenda for healthcare reform. As healthcare consumers are critical participants in HIE, understanding their attitudes toward HIE is essential.To determine healthcare consumers' attitudes toward physician and personal use of HIE, and factors associated with their attitudes.Cross-sectional telephone survey.English-speaking residents of the Hudson Valley of New York.Consumer reported attitudes towards HIE.Of 199 eligible residents contacted, 170 (85%) completed the survey: 67% supported physician HIE use and 58% reported interest in using HIE themselves. Multivariate analysis suggested supporters of physician HIE were more likely to be caregivers for chronically ill individuals (OR 4.6, 95% CI 1.06, 19.6), earn more than $100,000 yearly (OR 3.5, 95% CI 1.2, 10.0), and believe physician HIE would improve the privacy and security of their medical records (OR 2.9, 95% CI 1.05, 7.9). Respondents interested in using personal HIE were less likely to be female (OR 0.4, 95% CI 0.1, 0.98), and more likely to be frequent Internet-users (OR 3.3, 95% CI 1.03, 10.6), feel communication among their physicians was inadequate (OR 6.7, 95% CI 1.7, 25.3), and believe personal HIE use would improve communication with their physicians (OR 4.7, 95% CI 1.7, 12.8).Consumer outreach to gain further support for ongoing personal and physician HIE efforts is needed and should address consumer security concerns and potential disparities in HIE acceptance and use.