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Chest wall injuries are very common in blunt trauma and development of treatment protocols can significantly improve outcomes. Surgical stabilisation of rib fractures (SSRF) is an adjunct for the most severe chest injuries and can be used as a part of a comprehensive approach to chest injuries care. We hypothesized that implementation of a SSRF programme program would result in improved short-term outcomes.The characteristics of the initial group of SSRF patients (Early-SSRF) were used to identify matching factors. Patients prior to SSRF protocol underwent a propensity score match, followed by screening for operative indications and contraindications. After exclusions, a non-operative (Non-Op) cohort was defined (n=36) resulting in an approximately 1:1 match. An overall operative cohort, inclusive of Early-SSRF and all subsequent operative patients, was defined (All- SSRF). A before-and-after analysis using chi-squared, Students T-tests, and Mann-Whitney U-tests were used to assess significance at the level of 0.05.Early-SSRF (n=22) and All-SSRF (n=45) were compared to Non-Op (n=36). The selection process resulted in well matched groups, and equally well-balanced operative indications between the groups. The Early-SSRF group demonstrated shortened duration of mechanical ventilation and a decreased frequency of being discharged a long-term acute care hospital. The All-SSRF group again demonstrated markedly shorter duration of mechanical ventilation compared to Non-Op (median 6 days vs 16 days, p0.01), more decrease discharge to a long-term acute care hospital (9% vs. 36%, p=0.01), and reduced risk for tracheostomy (8.9% vs. 33.3% respectively, p0.01) CONCLUSION: The introduction of an operative rib fixation to a comprehensive chest wall injury protocol can produce improvements in clinical outcomes that decrease time on the ventilator and tracheostomy rates, and result in more patients being discharged to home. Creation and implementation of a chest wall injury protocol to include SSRF requires a multidisciplinary approach and thoughtful patient selection.

Background There is no consensus on what dose of norepinephrine corresponds with futility. The purpose of this study was to investigate the maximum infusion and cumulative doses of norepinephrine associated with survival for patients in medical and surgical intensive care units (MICU and SICU). Materials and Methods A retrospective review was conducted of 661 critically ill patients admitted to a large academic medical center who received norepinephrine. Univariate, multivariate, and area under the curve analyses with optimal cut offs for maximum infusion rate and cumulative dosage were determined by Youden Index. Results The population was 54.9% male, 75.8% white, and 58.7 ± 16.1 y old with 384 (69.8%) admitted to the MICU and 166 (30.2%) admitted to the SICU, including 38 trauma patients. Inflection points in mortality were seen at 18 mcg/min and 17.6 mg. The inflection point was higher in MICU patients at 21 mcg/min and lower in SICU patients at 11 mcg/min. MICU patients also had a higher maximum cumulative dosage of 30.7 mg, compared to 2.7 mg in SICU patients. In trauma patients, norepinephrine infusions up to 5 mcg/min were associated with a 41.7% mortality rate. Conclusion A maximum rate of 18 mcg/min and cumulative dose of 17.6 mg were the inflection points for mortality risk in ICU patients, with SICU patients tolerating lower doses. In trauma patients, even low doses of norepinephrine were associated with higher mortality. These data suggest that MICU, SICU, and trauma patients differ in need for, response to, and outcome from escalating norepinephrine doses.

Background This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. Methods Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. Results We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. Conclusion Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. Level of evidence Therapeutic, level III.

Background There is interest in methods of measuring noninvasive intracranial pressure (ICP), including pupillometry, ultrasonographic transcranial Doppler (TCD), and optic nerve sheath diameter (ONSD), for diagnosing traumatic brain injury (TBI) in limited resource environments. Whether these technologies have diagnostic agreement is unknown. We hypothesized that ONSD, pupillometry, and TCD could both distinguish severe TBI and correlate with ICP. Methods A prospective study of 135 patients was conducted at a level 1 trauma center. Four test groups were established: nontrauma patients with ICP monitoring, trauma patients without TBI, trauma patients with mild TBI, and trauma patients with severe TBI with ICP monitoring. All patients underwent daily measurements of ONSD, pupillometry, and TCD with both CX50 Sonosite and the Spencer ST3 Yi Pencil probe. Results ONSD differed significantly in patients with severe TBI compared with patients with mild and no TBI, but did not correlate with ICP. Pupillometric constriction velocity, dilation velocity, and percent change in pupil diameter were significantly different in patients with severe TBI, but also did not correlate with ICP. TCD did not differ among TBI severities, but middle cerebral artery peak systolic velocity, middle cerebral artery flow velocity, and carotid flow velocity correlated with ICP. Conclusions This is a novel study of four noninvasive tests to screen for severity of TBI and measure ICP. Our analysis indicates that no single device can do both. However, ONSD and pupillometry may be used as a supplementary screening tool for severe TBI, whereas TCD could be used to estimate and follow ICP in patients with severe TBI.

Background In response to duty hour restrictions, hospitals expanded residency programs and added advanced practice providers. We sought to determine if type of clinical support was associated with emergency general surgery outcomes. Methods As part of our 2015 survey of acute care hospitals, we asked hospitals whether residents and advanced practice providers participate in emergency general surgery care. Data from responding hospitals were linked to patient data (≥18 years old admitted with an emergency general surgery diagnosis) from 17 State Inpatient Databases using American Hospital Association identifiers. Analyses compared emergency general surgery patient and hospital characteristics based on type of providers assisting emergency general surgery surgeons (none, only advanced practice providers, only residents, or both). Multivariable analysis determined if presence of advanced practice providers and/or residents was associated with type of management, mortality, or complications. Results Eighty-three hospitals and 49,271 unique emergency general surgery admissions were included. Hospitals without residents and advanced practice providers were most likely to manage patients operatively. However, hospitals with residents (alone or with advanced practice providers) had reduced odds of systemic complication compared with hospitals without clinical support (adjusted odds ratio 0.77 [95% confidence interval 0.60–0.98] and adjusted odds ratio 0.77 [95% confidence interval 0.62–0.95], respectively), while hospitals with only residents had the lowest odds of operative complication. Conclusion Our findings highlight the positive effect residents (alone or partnering with advanced practice providers) can have on emergency general surgery patient outcomes.

The Boston Criteria and the Abbreviated Burn Severity Index are two widely accepted models for predicting mortality in burn patients. We aimed to elucidate whether these models are able to predict the risk of mortality in patients who sustain burns while smoking on home oxygen given their clinical fragility. We conducted a retrospective chart review of 48 patients admitted to our burn center from November 2013 to September 2017 who sustained a burn while smoking on home oxygen. Yearlong mortality was the primary outcome of the investigation; secondary outcomes included discharge to facility, length of stay, and need for tracheostomy. We calculated the expected mortality rate for each patient based on Boston Criteria and Abbreviated Burn Severity Index and compared the mortality rate observed in our cohort. Patients in our cohort suffered a 54% mortality rate within a year of injury, compared to a 23.5% mortality predicted by Boston Criteria, which was found to be statistically significant by chi-square analysis (P < .05). Abbreviated Burn Severity Index predicted mortality was 19.7%. While the absolute value of the difference in mortality was greater, this was not significant on chi-square analysis due to sample size. Our secondary outcomes revealed 42% discharge to facility, the average length of stay of 6.2 days, and 6.25% required tracheostomy. Patients whose burns are attributable to smoking on home oxygen may have an increased risk of mortality than prognostication models would suggest. This bears significant clinical impact, particularly regarding family and provider decision making in pursuing aggressive management.

Background Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. Methods We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. Results Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. Discussion Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. Conclusions Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

Introduction Trauma to the chest wall is one of the most common injuries suffered. Knowing whether there are regular and reproducible changes in frequency or severity of certain injury types may help resource allocation and improve prevention efforts or outcomes; however, no prior studies have evaluated seasonal variation in chest wall injuries (CWIs). We aimed to determine if CWIs vary annually in a consistent distinct temporal variation. Methods Using an established traumatic blunt CWI database at a single urban level 1 trauma center, patients with a moderate-to-severe (chest wall Abbreviated Injury Score (AIS) ≥2) CWI were reviewed. A subpopulation of predominant chest wall injury (pCWI) was defined as those with a chest wall AIS ≥3 and no other anatomic region having a higher AIS. Demographics, injury patterns, mechanisms of injury, and AIS were collected in addition to date of injury over a 4-y period. Data were analyzed using descriptive statistics as well as Poisson time-series regression for periodicity. Seasonal comparison of populations was performed using Student's t-tests and Analysis of Variance (ANOVA) with significance assessed at a level of P Results Over a 4-y period nearly 16,000 patients presented with injury, of which 3042 patients were found to have a blunt CWI. Total CWI patients per year from 2014 to 2017 ranged from 571 to 947. Over this period, August had the highest incidence for patients with any CWI, moderate-to-severe injuries, and pCWI. February had the lowest overall injury incidence as well as lowest moderate-to-severe injury incidence. January had the lowest pCWI incidence. Yearly changes followed a quadratic sinusoid model that predicted a peak between incidence, between June and October, and the low season. A low season was found to be December–April. Comparing low to high seasons of injured patient monthly means revealed significant differences: total injuries (69.94 versus 85.56, P = 0.04), moderate to severe (62.25 versus 78.19, P = 0.06), and pCWI (25.25 versus 34.44, P = 0.01). Analysis of injuries by mechanism revealed a concomitant increase in motorcycle collisions during this period. Conclusions There appears to be a significant seasonal variation in the overall incidence of CWI as well as severe pCWI, with a high-volume injury season in summer months (June–October) and low-volume season in winter (December–April). Motorcycle accidents were the major blunt injury mechanism that changed with this seasonality. These findings may help guide resource utilization and injury prevention.

Background Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or “acute abdomen,” in older Americans. Methods Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. Results We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). Conclusions Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.

Background Chest wall injuries have serious clinical consequences. It is presumed a higher severity of injury correlates with worse outcomes. The 2 most common chest wall injury severity scores, the Organ Injury Scale and the Abbreviated Injury Scale, are based on expert opinion with unknown clinical endpoints. Our aim was to determine if either the Organ Injury Scale or the Abbreviated Injury Scale are associated with clinical outcomes. Methods A single institution, 4-year retrospective study of all patients with rib or sternal fractures was conducted. All patients were assessed for both Organ Injury Scale and Abbreviated Injury Scale scores. Outcomes assessed included mortality, complications, tracheostomy, and readmissions. Receiver operating characteristic areas under the curve were calculated to measure discriminatory accuracy of scoring systems for outcomes in chest wall injury. Results Overall, 3,033 patients presented with a total of 16,055 rib fractures. The median chest wall scores were 2 for Organ Injury Scale and 3 for Abbreviated Injury Scale. Abbreviated Injury Scale scores for the same patients were greater than the Organ Injury Scale in 48.7%, equivalent in 46.7%, and lower in 4.6%. The receiver operating characteristic areas under the curve for in-hospital outcomes were weakly predictive for the Organ Injury Scale over the Abbreviated Injury Scale. The receiver operating characteristic areas under the curve for readmissions were very weakly predictive for the Abbreviated Injury Scale over the Organ Injury Scale. Conclusion There is a very weak association between chest wall Organ Injury Scale score and in-hospital outcomes. The Abbreviated Injury Scale score outperformed the Organ Injury Scale, only being weakly predictive of readmission. Chest wall injury scoring systems may need revision for future outcomes-based research and practice improvements.

Background Increasing demand for total hip arthroplasty (THA) in a climate of increasing focus on clinical outcomes, patient satisfaction, and cost has created a need for better acute postoperative pain control for patients. An ideal pain control method would have few side effects, decreased opioid consumption, improved pain control, early ambulation, and decreased hospital length of stay (LOS). Methods We performed a prospective randomized, controlled study involving 79 patients undergoing elective THA between June 2015 and February 2016. Forty patients received liposomal bupivacaine and 39 patients received a fascia iliaca compartment block (FICB). In addition, the medical records of 28 patients who underwent elective THA between May 2015 and December 2015 were retrospectively examined. The primary outcome was visual analog scale pain scores and the secondary outcomes were LOS and total opioid consumption. SPSS, version 22, was used to run 1-way analysis of variance with contrast and Mood's median test on the data. Results There were statistically significant decreases in pain intensity (P = .019) and LOS (P = .041) in both the liposomal bupivacaine group and the FICB group compared with those in the retrospective control group. In addition, only the FICB group showed statistically significant decreased total opioid consumption compared with that in the retrospective group (P = .028). Conclusion Patients undergoing elective THA have decreased overall pain intensity and a shorter LOS with multimodal pain management regimen that includes either liposomal bupivacaine or FICB. Patients who received FICB required less overall total opioids than the control group.

BACKGROUND: Small bowel obstruction (SBO) no longer mandates urgent surgical evaluation raising the question of the role of operating room (OR) access on SBO outcomes. METHODS: Data from our 2015 survey on emergency general surgery (EGS) practices, including queries on OR availability and surgical staffing, were anonymously linked to adult SBO patient data from 17 Statewide Inpatient Databases (SIDs). Univariate and multivariable associations between OR access and timing of operation, complications, length of stay (LOS), and in-hospital mortality were measured. RESULTS: Of 32,422 SBO patients, 83% were treated non-operatively. Operative patients were older (median 66 vs 65 years), had more comorbidities (53% vs 46% with ≥ 3), and experienced moresystemic complications (36% vs 23%), higher mortality (2.8% vs 1.4%), and longer LOS (median 10 vs 4 days). Patients had lower odds of operation if treated at hospitals lacking processes to tier urgent cases (aOR 0.90, 95% CI [0.83–0.99]) and defer elective cases (aOR 0.87 [0.80–0.94]). Patients had higher odds of operation if treated at hospitals with surgeons sometimes (aOR 1.14 [1.04–1.26]) or rarely/never (aOR 1.16 [1.06–1.26]) covering EGS at more than one location compared to always. Odds of systemic complication (OR 2.0 [1.6–2.4]), operative complication (OR 1.5 [1.2–1.8]), and mortality were increased for very late versus early operation (OR 2.6 [1.7–4.0]). CONCLUSIONS: Although few patients with SBO require emergency surgery, we identified EGS structures and processes that are important for providing timely and appropriate intervention for patients whose SBO remains unresolved and requires surgery.

Purpose We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care. Methods 2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models. Results 272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols. Conclusions Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.

Background There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury. Methods A retrospective review was performed based on trauma patients evaluated at an urban Level I trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with more than one rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only one rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p less than 0.05. Results During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. One hundred forty-two (8.3%) patients were reevaluated specifically for chest-related complaints, and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score greater than 15, hospital length of stay longer than 7 days, intensive care unit (ICU) length of stay longer than 3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age of 15 years to 35 years, Risk Assessment Profile score greater than 8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation. Conclusion Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission. Level of evidence Level IV, Prognostic and Epidemiologic.

BACKGROUND Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach. METHODS We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics). RESULTS Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values

Objectives To examine loss of community-dwelling status 9 months after hospitalization for high-acuity emergency general surgery (HA-EGS) disease among older Americans. Design Retrospective analysis of claims data. Setting US communities with Medicare beneficiaries. Participants Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra-abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319). Measurements Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long-term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community-dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan-Meier plots, and χ2 tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community-dwelling status at 9 months. Results A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in-hospital complications. Overall, 418 (14.3%) HA-EGS survivors died during the follow-up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA-EGS. Conclusion Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA-EGS. Long-term expectations after surviving HA-EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality-of-life burden of EGS survivorship prospectively. J Am Geriatr Soc 67:2289-2297, 2019.

Objective : To determine the association between family-centered rounds (FCR) and medical student knowledge acquisition as assessed by the National Board of Medical Examiners (NBME) pediatric subject (shelf) exam. Methods : A retrospective cohort study was conducted of third-year medical students who graduated from Virginia Commonwealth University School of Medicine between 2009 and 2014. This timeframe represented the transition from ‘traditional’ rounds to FCR on the pediatric inpatient unit. Data collected included demographics, United States Medical Licensing Examination (USMLE) Step 1 and 2 scores, and NBME subject examinations in pediatrics (PSE), medicine (MSE), and surgery (SSE). Results : Eight hundred and sixteen participants were included in the analysis. Student performance on the PSE could not be statistically differentiated from performance on the MSE for any year except 2011 ( z -score=−0.17, p =0.02). Average scores on PSE for years 2009, 2010, 2013, and 2014 were significantly higher than for SSE, but not significantly different for all other years. The PSE was highly correlated with USMLE Step 1 and Step 2 examinations (correlation range 0.56–0.77) for all years. Conclusions : Our results showed no difference in PSE performance during a time in which our institution transitioned to FCR. These findings should be reassuring for students, attending physicians, and medical educators. Keywords: family-centered rounds; NBME subject examination; undergraduate medical education (Published: 15 April 2016) Citation: Med Educ Online 2016, 21: 30919 - http://dx.doi.org/10.3402/meo.v21.30919

Intimate partner violence (IPV) is a pervasive public health problem in the U.S., affecting nearly one in every three women over their lifetimes. Using structural equation modeling, we evaluated the association between IPV and unintended pregnancy, mediated by condom use and perceived spousal/partner support among Latina and Asian women. Data came from the 2002-2003 National Latino and Asian American Study (NLAAS). The analysis was restricted to married or cohabiting female respondents aged 18+ years (n = 1,595). Dependent variables included unintended pregnancy, condom use, and perceived partner support. Independent variables included physical abuse or threats by current partner and primary decision-maker. Weighted least squares was used to fit path models to data comprising dichotomous and ordinal variables. More than 13% of women reported IPV during their relationship with their partner/spouse. Abused women were twice as likely as non-abused women to have had an unintended pregnancy. This association was partially mediated by perceived partner support. Condom use had a positive, but non-significant association with unintended pregnancy, and IPV had a negative, but non-significant association with condom use. Results highlight the importance of IPV screening for minority women. Efforts to combine family planning and violence prevention services may help reduce unintended pregnancy.

OBJECTIVE Cohort studies suggest that the relationship between major depression (MD) and Type 2 diabetes (T2DM) is bidirectional. However, this association may be confounded by shared genetic or environmental factors. The objective of this study was to use a twin design to investigate the association between MD and T2DM. METHODS Data come from the Screening Across the Lifespan Twin Study, a sample of monozygotic and dizygotic twins 40 years or older sampled from the Swedish Twin Registry (n = 37,043). MD was assessed by using the Composite International Diagnostic Inventory. Structural equation twin modeling and Cox proportional hazards modeling were used to assess the relationship between MD and T2DM. RESULTS Approximately 19% of respondents had a history of MD and 5% had a history of T2DM. MD was associated with 32% increased likelihood of T2DM (95% confidence interval = 1.00-1.80) among twins aged 40 to 55 years, even after accounting for genetic risk, but was not associated with T2DM among twins older than 55 years. T2DM was associated with 33% increased likelihood of MD (95% confidence interval = 1.02-1.72) among younger, but not older twins. Cholesky decomposition twin modeling indicated that common unique environmental factors contribute to the association between MD and T2DM. CONCLUSIONS Environmental factors that are unique to individuals (i.e., not shared within families) but common to both MD and T2DM contribute to their co-occurrence in midlife. However, we cannot exclude the possibility of bidirectional causation as an alternate explanation. It is likely that multiple processes are operating to effect the relation between psychiatric and medical conditions in midlife.

Based on anecdotal and qualitative reports a general assumption is that caregiving negatively impacts grandparents in Africa. OBJECTIVES: The purpose of this article is to determine how caregiving and gender impact nutritional status over four waves of data from Luo elders. METHODS: Luo elders aged 60 and over (age 73.6 +/- 7.9) were sampled. Participant recruitment was rolling and included 287 Luo grandparents in 2005 396 in 2006 389 in 2007 and 390 in 2009. A total of 689 elders participated in at least 1 year. Standard anthropometric measures were used to determine nutritional status. Impact of caregiving was examined using structural equation models. RESULTS: Caregiving positively associated with nutritional status among women. This main effect was mediated by caregiving intensity which also positively associated with nutritional status. Among men caregiving negatively associated with nutritional status although caregiving intensity did not significantly associate with most anthropometric measures. Socioeconomic status (SES) positively associated with five of nine anthropometric measures in women and all measures in men. Several measures indicated that both men and women became larger over time but few of the variables tested predicted growth. CONCLUSIONS: The beneficial impact on grandmothers might indicate a coping strategy. These results indicated that researchers should shift away from comparing caregivers to noncaregivers and instead look at the multiple factors which may make some families resilient and others at risk. Human biologists can contribute to this literature by examining the ecological and cultural contexts under which caregiving represents a burden with physiological repercussions. Copyright (c) 2011 Wiley-Liss Inc.

This research tested if a 12-session coping improvement group intervention (n = 104) reduced depressive symptoms in HIV-infected older adults compared to an interpersonal support group intervention (n = 105) and an individual therapy upon request (ITUR) control condition (n = 86). Participants were 295 HIV-infected men and women 50-plus years of age living in New York City, Cincinnati, OH, and Columbus, OH. Using A-CASI assessment methodology, participants provided data on their depressive symptoms using the Geriatric Depression Screening Scale (GDS) at pre-intervention, post-intervention, and 4- and 8-month follow-up. Whether conducted with all participants (N = 295) or only a subset of participants diagnosed with mild, moderate, or severe depressive symptoms (N = 171), mixed models analyses of repeated measures found that both coping improvement and interpersonal support group intervention participants reported fewer depressive symptoms than ITUR controls at post-intervention, 4-month follow-up, and 8-month follow-up. The effect sizes of the differences between the two active interventions and the control group were greater when outcome analyses were limited to those participants with mild, moderate, or severe depressive symptoms. At no assessment period did coping improvement and interpersonal support group intervention participants differ in depressive symptoms.

In rural regions of the United States of America, estimates of pediatric obesity often exceed national averages. This problem may be particularly pronounced in Appalachian regions, where significant health and economic disparities abound. This study presents the findings of a body mass index (BMI) screening program for 6-11 year old children living in a rural Appalachian community. County-wide estimates of high BMI (or=85th percentile) were obtained to understand the health status and needs of our pediatric community and to compare obesity prevalence rates with national averages. An additional aim was to identify subpopulations of children who may warrant clinical intervention due to demographic and behavioral risks factors of high BMI.A school-based BMI screening was conducted of 6-11 year old children in southeastern Ohio. Investigators collected 3 sets of height and weight measurements from approximately 2000 elementary school students between 2006 and 2007. Caregivers for a subset of this population also completed a health behaviors questionnaire.Thirty-eight percent of children had high BMI, with 17% at risk for overweight and 20.9% overweight. Boys were 23% more likely than girls to be overweight (chi(2)(1) = 95% CI = 1.08, 1.40) and 11% more likely to become overweight with each year of age (OR = 1.11, 95% CI = 1.07, 1.15). Overweight children were more likely to view television, eat meals at school, and live with a caregiver who smokes.Consistent with expectations, prevalence of high BMI in this sample of rural Appalachian children exceeds national averages. Prevalence of overweight varied by age and sex; boys are particularly vulnerable to developing obesity, especially as they age. Preliminary survey data suggest that eating breakfast at home and at school and increased hours of television viewing may be associated with higher BMI, especially in younger boys.

Objectives To assess the reliability of applying a radiographic scoring system in estimating the severity of stool retention (SR) in hospitalized older adults with constipation, and to identify risk factors associated with clinical constipation and SR scores. Design Retrospective, case series study. Setting Southeast Ohio community hospital. Participants Adults 65 years or older with constipation or fecal impaction and abdominal radiographs available (N = 122). Bowel obstruction was excluded. Measurement Radiographs were independently scored by four readers twice, “5” being the most severe, for each quadrant of an abdominal film; possible total score was 0 to 20. Clinical constipation was defined as an average SR score of 13 or higher. Intra-class correlation was used to measure inter-rater agreement. Results The overall inter-rater agreement on abdominal radiograph readings was 0.91, 95% confidence interval (CI) = 0.88–0.93. Clinical constipation was associated with the use of statins and antimuscarinics by univariate logistic regression analysis. After adjusting for age, sex, residency, smoking history, oral laxatives, and self-reported constipation, the use of statins remained significantly associated with clinical constipation (OR = 3.86, 95% CI = 1.08–13.77, P = .036). Univariate linear regression analysis revealed that higher SR scores were associated with community residency, self-reported constipation, and the use of statins and antimuscarinics. After adjusting for the above confounders by multiple linear regression analyses, the use of antimuscarinics was independently associated with higher SR score (β = 1.769, 95% CI = 0.008–3.531, P = .049). Conclusion Abdominal radiography was reliable in assessing the severity of SR in older adults with constipation. The use of statins and antimuscarinics was associated with clinical constipation and greater SR.

Proton pump inhibitor (PPI) may suppress adrenal cortical steroid synthesis and release, thereby leading to electrolyte disturbances. Both hyponatremia and hyperkalemia in the setting of PPI therapy have been documented in case reports. The objective of this study was to examine the association between serum potassium (K(+)) level and PPI use.A retrospective data analysis of hospitalized adults agedor = 65 years during 2006, including PPI users (N = 257) and PPI non-users (N = 388), was conducted. Multiple linear and logistic regression analyses were used to assess the association between PPI use and serum K(+) level.PPI users [mean age (SD):79.7 (8.0) years; 70% female] had significantly higher serum K(+) levels than PPI non-users [80.2 (8.8) years; 64% female] on admission [4.13 (0.62) vs. 3.97 (0.57) mmol/L; p0.001]. The linear regression model revealed thator = 2 defined daily dose (DDD) units of PPI use were a significantly positive contributor to serum K(+) levels (p = 0.021) after adjusting for age, serum creatinine levels, sex, history of diabetes, and uses of the following drugs: angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta blocker, diuretics, spironolactone, K(+) supplement, non-steroidal anti-inflammatory drugs, atypical antipsychotics, and narcotics. However, multiple logistic regression model revealed that high dose PPI therapy was not associated with an increased risk for hyperkalemia occurrence (p = 0.762).Higher serum K(+) levels were observed among PPI users when compared to PPI non-users. High daily dose PPI therapy may be an independent positive predictor of serum potassium levels.

Although bacteriuria with acute coexisting illness is common in hospitalized older adults, distinguishing it from urinary tract infection (UTI) can be challenging.To examine the rate of agreement between two geriatricians in distinguishing UTI from asymptomatic bacteriuria (ASB). To analyze the incidence of associated acute comorbidities and determine if an association exists between clinical manifestations and bacteriuria status on acute hospital admission.Two physicians conducted a retrospective analysis of 296 inpatient records, including 142 records from age- and condition-matched nonbacteriuria control subjects. Using consensus criteria to diagnose UTI vs ASB, these independent experts evaluated inpatient records, including admission and discharge diagnoses as well as urinalysis results. A kappa statistic was used to determine reviewer agreement. Risk assessment was measured by odds ratio with a 95% confidence interval.Expert agreement for the diagnosis of UTI and ASB was 98% and 44%, respectively. Agreement was reached at a level greater than chance (z=6.74, P.001, kappa=0.49). In the 30 cases where interexpert agreement was not reached, half of the subjects had acute pulmonary disease. Symptom crossover for this comorbid condition is the likely cause for lack of diagnostic agreement. Among other conditions observed, delirium was most common in UTI subjects.Limited interexpert agreement seemed to result from difficulty in diagnosing patients who had no local symptoms but acute comorbid conditions with potential symptom crossover. Among the conditions observed in our sample population, delirium was most closely associated with UTI.

Progressively more osteopathic graduates are seeking training opportunities in programs accredited by the Accreditation Council on Graduate Medical Education (ACGME).To determine if family medicine residency training program choice (ie, allopathic [ACGME], osteopathic, or dually accredited) has an impact on professional satisfaction levels among recent osteopathic medical school graduates.The authors designed a survey instrument to gather data on professional satisfaction levels. Osteopathic family physicians who completed residency training from 1999-2003 were asked to participate in the study.The survey was sent to 2284 individuals with an adjusted response rate of 37%. One hundred and one (15.8%) of the osteopathic family physicians who responded reported completing residency training programs approved by the American Osteopathic Association (AOA); 335 (52.3%), ACGME-accredited programs; 198 (30.9%), dually accredited programs. One hundred forty-three surveyed osteopathic physicians (22.3%) were less than happy with their career choice. In addition, 219 (34.2%) reported that they were "thinking of changing...specialty," and 30 (4.7%) reported that they were not "currently practicing family medicine." Individuals trained in ACGME programs reported slightly higher levels of professional satisfaction than individuals trained in AOA-approved or dually accredited programs--though these differences were deemed trivial (ie, low effect size, 0.01; P.05).The authors found no statistically significant differences in professional satisfaction levels among osteopathic family physicians who were recent medical school graduates regardless of residency training program choice.

Background Some forms of pharmacotherapy are shown to increase the risk of community-acquired pneumonia (CAP). The purpose of this study is to investigate whether pharmacotherapy with proton pump inhibitors (PPI), inhaled corticosteroids, and atypical antipsychotics was associated with the increased risk for CAP in hospitalized older adults with the adjustment of known risk factors (such as smoking status and serum albumin levels). Methods A retrospective case-control study of adults aged 65 years or older at a rural community hospital during 2004 and 2006 was conducted. Cases (N = 194) were those with radiographic evidence of pneumonia on admission. The controls were patients without the discharge diagnosis of pneumonia or acute exacerbation of chronic obstructive pulmonary disease (COPD) (N = 952). Patients with gastric tube feeding, ventilator support, requiring hemodialysis, metastatic diseases or active lung cancers were excluded. Results Multiple logistic regression analysis revealed that the current use of inhaled corticosteroids (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.56-5.35) and atypical antipsychotics (AOR = 2.26, 95% CI = 1.23-4.15) was an independent risk factor for CAP after adjusting for confounders, including age, serum albumin levels, sex, smoking status, a history of congestive heart failure, coronary artery disease, and COPD, the current use of PPI, β2 agonist and anticholinergic bronchodilators, antibiotic(s), iron supplement, narcotics, and non-steroidal anti-inflammatory drugs. The crude OR and the AOR of PPI use for CAP was 1.41 [95% CI = 1.03 - 1.93] and 1.18 [95% CI = 0.80 - 1.74] after adjusting for the above confounders, respectively. Lower serum albumin levels independently increased the risk of CAP 1.89- fold by decreasing a gram per deciliter (AOR = 2.89, 95% CI = 2.01 - 4.16). Conclusion Our study reaffirmed that the use of inhaled corticosteroids and atypical antipsychotics was both associated with an increased risk for CAP in hospitalized older adults of a rural community. No association was found between current PPI use and the risk for CAP in this patient population of our study.