Search

Background: The Coronavirus disease 2019 (COVID-19) pandemic led to healthcare system changes aimed at minimizing disease transmission that impacted experiences with obstetric healthcare. Objective: To explore experiences of clinicians providing obstetric care during the COVID-19 pandemic. Study Design: Qualitative, in-depth, semi-structured interviews were conducted with five nurse practitioners and 16 obstetrical physicians providing a mix of outpatient and inpatient obstetric care during the COVID-19 pandemic in a mid-sized, Midwestern city in the United States. Interviews elucidated challenges and facilitators of obstetric care provision and vaccination of pregnant patients against COVID-19 during the pandemic. Transcripts were coded inductively then deductively using the Health Equity Implementation Framework (HEIF), which integrates a disparities framework and implementation framework to highlight multilevel factors that influence obstetric care. Thematic analysis was conducted, and thematic saturation was reached. Results: We interviewed 21 clinicians. Clinicians recounted personal challenges such as social isolation and burnout that could be countered by social support. Challenges within the clinical encounter included implementation of infection mitigation efforts, vaccine counseling, and limitations of telehealth. However, when successfully implemented, telehealth facilitated care and circumvented barriers. Clinicians cited challenges at the healthcare system level such as rapidly evolving knowledge and recommendations, restrictive visitor policies, personnel shortage, and inadequate institutional resources to support pandemic-related stressors. However, interdisciplinary care and guidelines available for clinicians facilitated care. Clinicians reported that challenges at the societal level included financial strain, lack of childcare, medical mistrust, politicization of medicine, misinformation, and racism. Societal-level facilitators included insurance access, community outreach, positive policy changes, and fostering trust in medicine. Conclusion: The pandemic produced unique stressors and exacerbated existing challenges for clinicians providing obstetric care. Applying the HEIF to the findings emphasizes the influence of societal factors on all other levels. Identified facilitators can inform interventions to address stressors in obstetric care that have resulted from the changed sociopolitical landscape of the pandemic.

Background: Symptoms in patients with systemic mastocytosis (SM) are associated with an increase in mast cell burden and release of mast cell–derived mediators. The most frequent presentation of SM is indolent SM (ISM), with moderate symptoms and prognosis. Basophil numbers in these patients are generally normal. However, when examining basophil activation in patients with ISM, we noted an abnormal response to N-formylmethione-leucyl-phenylalanine (fMLP). Objective: Our aim was to compare basophil responsiveness to fMLP and anti-IgE in healthy volunteers and patients with ISM and relate the findings to fMLP receptor (FPR) expression. Methods: Basophils isolated from peripheral blood of 15 patients with ISM and 14 healthy volunteers were stimulated with fMLP or anti-IgE. CD63 expression to assess basophil activation and expression of FPRs were assessed by flow cytometry. Results: Baseline expression of CD63 on basophils was similar between the healthy volunteers and patients with ISM. fMLP induced higher expression of CD63 on basophils from patients with ISM, whereas responses to anti-IgE were similar between groups. Basophils from patients with ISM also had higher fMLP1 receptor (FPR1) expression, wheresas FPR2 and FPR3 were not detected. fMLP blocked the binding of anti-FPR1 antibody to FPR1, consistent with the conclusion that fMLP signals through FPR1. Conclusions: Level of fMLP-induced basophil activation is higher in patients with ISM, which is associated with an increase in FPR1 expression. Further investigation is needed to determine why FPR1 expression is elevated, whether such expression might serve as an additional surrogate marker in the diagnosis of ISM, and whether enhanced responses of basophils to fMPL might have some relationship to unexplained episodes of mediator release.

Background: Nearly one-half of patients admitted with acute decompensated heart failure (ADHF) are discharged with unresolved congestion, elevating rehospitalization risk. This may be due to suboptimal intravenous (IV) loop diuretic dosing, which may be influenced by home oral diuretic dose. Objectives: The objective of this study was to determine the association between: 1) home oral loop diuretic dose and optimal initial IV loop diuretic dosing in ADHF; and 2)receiving optimal initial IV loop diuretic dosing and length of stay and 30-day readmission. Methods: Retrospective analysis of adults admitted to a large U.S. hospital for ADHF on home oral loop diuretics from 1 January 2014 to 21 December 2021. Patients were categorized by home dose: low (≤40 mg furosemide equivalents), medium (>40-80 mg furosemide equivalents), and high (>80 mg furosemide equivalents). Optimal initial IV dosing was considered ≥2 times home oral dosing. Poisson regression models estimated prevalence ratios (CIs) for optimal initial IV loop diuretic dosing. Results: Among 3,269 adults admitted for ADHF (mean age 63 years, 62% male), optimal initial IV dosing occurred in 2,218 (67.9%). The prevalence of optimal initial IV dosing among low, medium, and high home dosing was 95.5%, 59.9%, and 4.0%, respectively. Adjusted prevalence ratios for optimal IV dosing with high and medium home dosing, compared to low, were 0.05 (95% CI: 0.03-0.07) and 0.66 (95% CI: 0.62-0.70), respectively. There was no difference in length of stay or 30-day readmission between optimal and suboptimal initial IV diuretic dosing. Conclusions: Among patients with ADHF, higher home loop diuretic dose was strongly associated with a substantially lower likelihood of optimal initial IV diuretic dosing.

Objectives: Many orbital fracture patients are transferred to tertiary care centers for immediate ophthalmology consultation, though few require urgent ophthalmic evaluation or intervention. This overutilizes limited resources and overburdens patients and the health care system with travel and emergency department (ED) expenses. A simple, easy-to-use, clinical decision-making tool is needed to aid local EDs and triage services in effectively identifying orbital fracture patients who need urgent ophthalmic evaluation. Design: Single center, retrospective cohort study. Subjects: Orbital fracture patients aged ≥ 18 years who presented to the study institution’s emergency department and received an ophthalmology consultation. Methods: Ocular injuries that required close monitoring or an intervention within the first few hours after presentation were termed urgent. Two Hawkeye Orbital Fracture Prioritization and Evaluation (HOPE) algorithms were developed to identify orbital fracture patients needing urgent evaluation; including 1 algorithm incorporating computerized tomography (CT) scans interpreted by ophthalmology (HOPE+CT). Algorithms were compared with 3 previously published protocols: the University of Texas Health Science Center at Houston (UTH), the South Texas Orbital Fracture Protocol (STOP), and Massachusetts Eye and Ear (MEE) algorithms. Main Outcome Measures: Correct triage of patients with orbital fractures who have urgent ocular or orbital conditions. Results: In the study institution’s ED, 134 adult patients (145 orbits) were seen with orbital fractures in 2019. Eighteen (13.4%) had ocular or orbital conditions categorized as urgent. The HOPE tool resulted in 100% sensitivity and 78.4% specificity. The HOPE+CT tool resulted in 100.0% sensitivity and 94.0% specificity. The UTH algorithm was 91.7% sensitive and 76.5% specific. South Texas Orbital Fracture Protocol and MEE were both 100% sensitive but only 35.1% and 32.8% specific, respectively. Conclusions: The HOPE and HOPE+CT algorithms were superior or equal to the UTH, STOP, and MEE algorithms in terms of specificity while detecting all urgent cases. Implementation of a triage protocol that uses the HOPE or HOPE+CT algorithms could improve resource utilization and reduce health care costs through identification of orbital fracture patients needing urgent evaluation. An online tool that deploys the HOPE+CT algorithm in a user-friendly interface has been developed and is undergoing prospective validation before public dissemination. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Iatrogenic aortic injury is a rare complication of laparoscopic nephrectomy with potentially catastrophic complications. Delays in recognition and treatment contribute significantly to patient morbidity and mortality. We present the case of a patient with acute limb ischemia and mesenteric ischemia secondary to partial transection of the supraceliac aorta during laparoscopic nephrectomy with a staple ligature. The injury was successfully treated with resection of the stapled aorta and reconstruction of a thoracoabdominal aortic bypass with a jump graft to the celiac artery.

Retrograde aortic dissection is a rare but potentially catastrophic complication after endovascular aortic repair. Reports in the literature regarding retrograde dissection after fenestrated and branched endovascular abdominal aortic repair are rare, and the incidence, risk factors, and treatment options for this complication have not yet been clearly established. Additionally, retrograde dissection after previous intervention can pose technical challenges and increases the risk of spinal cord ischemia during subsequent repair. We present a patient with an acute retrograde dissection after a fenestrated and branched endovascular aortic repair for an extent III thoracoabdominal aortic aneurysm successfully managed with proximal endovascular extension.

Management of unstable injuries was revolutionized by the Internal Joint Stabilizer (IJS). When compared to long-term immobilization, transarticular pinning, and hinge external fixation, the IJS results in decreased complications and improved clinical outcomes. Historically, the IJS was applied via a lateral approach; however, this limited intraoperative visualization and, in some cases, resulted in increased operative times. This technical report describes a posterior approach, for IJS application. The posterior approach involves an 8- to 10-cm incision over the posterior elbow through the deep fascia before identifying the olecranon and lateral capitellum, then proceeding with IJS application through manufacturer instructions. The ulnar and radial nerves must be identified as they could be damaged in this approach. Using the posterior approach at our institution, we have noticed a possible decrease in operative times and an increase in intraoperative visualization of the elbow without a subsequent increase in complications.

OBJECTIVES:. Emerging evidence suggests the potential importance of inspiratory driving pressure (DP) and respiratory system elastance (ERS) on outcomes among patients with the acute respiratory distress syndrome. Their association with outcomes among heterogeneous populations outside of a controlled clinical trial is underexplored. We used electronic health record (EHR) data to characterize the associations of DP and ERS with clinical outcomes in a real-world heterogenous population. DESIGN:. Observational cohort study. SETTING:. Fourteen ICUs in two quaternary academic medical centers. PATIENTS:. Adult patients who received mechanical ventilation for more than 48 hours and less than 30 days. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. EHR data from 4,233 ventilated patients from 2016 to 2018 were extracted, harmonized, and merged. A minority of the analytic cohort (37%) experienced a Pao2/Fio2 of less than 300. A time-weighted mean exposure was calculated for ventilatory variables including tidal volume (VT), plateau pressures (PPLAT), DP, and ERS. Lung-protective ventilation adherence was high (94% with VT < 8.5 mL/kg, time-weighted mean VT = 6. 8 mL/kg, 88% with PPLAT ≤ 30 cm H2O). Although time-weighted mean DP (12.2 cm H2O) and ERS (1.9 cm H2O/[mL/kg]) were modest, 29% and 39% of the cohort experienced a DP greater than 15 cm H2O or an ERS greater than 2 cm H2O/(mL/kg), respectively. Regression modeling with adjustment for relevant covariates determined that exposure to time-weighted mean DP (> 15 cm H2O) was associated with increased adjusted risk of mortality and reduced adjusted ventilator-free days independent of adherence to lung-protective ventilation. Similarly, exposure to time-weighted mean ERS greater than 2 cm H2O/(mL/kg) was associated with increased adjusted risk of mortality. CONCLUSIONS:. Elevated DP and ERS are associated with increased risk of mortality among ventilated patients independent of severity of illness or oxygenation impairment. EHR data can enable assessment of time-weighted ventilator variables and their association with clinical outcomes in a multicenter real-world setting.

Importance:. Existing recommendations for mechanical ventilation are based on studies that under-sampled or excluded obese and severely obese individuals. Objective:. To determine if driving pressure (DP) and total respiratory system elastance (Ers) differ among normal/overweight (body mass index [BMI] < 30 kg/m2), obese, and severely obese ventilator-dependent respiratory failure (VDRF) patients and if there any associations with clinical outcomes. Design, Setting, and Participants:. Retrospective observational cohort study during 2016–2018 at two tertiary care academic medical centers using electronic health record data from the first 2 full days of mechanical ventilation. The cohort was stratified by BMI classes to measure median DP, time-weighted mean tidal volume, plateau pressure, and Ers for each BMI class. Setting and Participants:. Mechanically ventilated patients in medical and surgical ICUs. Main Outcomes and Measures:. Primary outcome and effect measures included relative risk of in-hospital mortality, ventilator-free days, ICU length of stay, and hospital length of stay with multivariable adjustment. Results:. The cohort included 3,204 patients with 976 (30.4%) and 382 (11.9%) obese and severely obese patients, respectively. Severe obesity was associated with a DP greater than or equal to 15 cm H2O (relative risk [RR], 1.51 [95% CI, 1.26–1.82]) and Ers greater than or equal to 2 cm H2O/(mL/kg) (RR, 1.31 [95% CI, 1.14–1.49]). Despite elevated DP and Ers, there were no differences in in-hospital mortality, ventilator-free days, or ICU length of stay among all three groups. Conclusions and Relevance:. Despite higher DP and ERS among obese and severely obese VDRF patients, there were no differences in in-hospital mortality or duration of mechanical ventilation, suggesting that DP has less prognostic value in obese and severely obese VDRF patients.

Objective:. We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data:. Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods:. We utilized Kern’s 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results:. Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions:. We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

Summary: Background: Drug resistance threatens global tuberculosis control. We aimed to examine mortality in patients with tuberculosis from high-burden countries, according to concordance or discordance of results from drug susceptibility testing done locally and whole-genome sequencing (WGS). Methods: In this multicentre cohort study, we collected pulmonary Mycobacterium tuberculosis isolates and clinical data from individuals with tuberculosis from antiretroviral therapy programmes and tuberculosis clinics in Côte d'Ivoire, Democratic Republic of the Congo, Kenya, Nigeria, Peru, South Africa, and Thailand, stratified by HIV status and drug resistance. Sites tested drug susceptibility using routinely available methods. WGS was done on Illumina HiSeq 2500 in the USA and Switzerland, and TBprofiler was used to analyse the genomes. We included individuals aged 16 years or older with pulmonary tuberculosis (bacteriologically confirmed or clinically diagnosed). We analysed mortality in multivariable logistic regression models adjusted for sex, age, HIV status, history of tuberculosis, and sputum positivity. Findings: Between Sept 1, 2014, and July 4, 2016, of 634 patients included in our previous analysis, we included 582 patients with tuberculosis (median age 33 years [IQR 27–43], 225 [39%] women, and 247 [42%] HIV-positive). Based on WGS, 339 (58%) isolates were pan-susceptible, 35 (6%) monoresistant, 146 (25%) multidrug-resistant, and 24 (4%) pre-extensively drug-resistant (pre-XDR) or XDR. The analysis of mortality was based on 530 patients; 63 (12%) died and 77 (15%) patients received inappropriate treatment. Mortality ranged from 6% (18 of 310) in patients with pan-susceptible tuberculosis to 39% (nine of 23) in patients with pre-XDR or XDR tuberculosis. The adjusted odds ratio for mortality was 4·92 (95% CI 2·47–9·78) among undertreated patients, compared with appropriately treated patients. Interpretation: In seven countries with a high burden of tuberculosis, we observed discrepancies between drug resistance patterns obtained locally and WGS. The underdiagnosis of drug resistance resulted in inappropriate treatment and higher mortality. WGS can provide accurate and detailed drug resistance information required to improve the outcomes of drug-resistant tuberculosis in high-burden settings. Our results support WHO's call for point-of-care tests based on WGS. Funding: National Institutes of Allergy and Infectious Diseases, Swiss National Science Foundation, and Swiss National Center for Mycobacteria.

Purpose: To compare ipsilateral breast event (IBE) risks in patients with ductal carcinoma in situ of the breast (DCIS) post-lumpectomy, as estimated by breast radiation oncologists, the Van Nuys Prognostic Index, the Memorial Sloan Kettering Cancer Center (MSKCC) DCIS nomogram, and the 12-gene Oncotype DX DCIS score assay. Methods and Materials: Consecutive DCIS cases treated with lumpectomy from November 2011 to August 2014 with available DCIS score results were identified. Three radiation oncologists independently estimated the 10-year IBE risk. The Van Nuys Prognostic Index and MSKCC nomogram 10-year IBE risk estimates were generated. Differences and correlations between the IBE estimates and clinicopathologic factors were evaluated. Results: Ninety-one patients were identified for inclusion. Forty-eight percent would have been ineligible for the E5194 study. The mean risk of IBE from the DCIS score assay was 12.4%, compared with a range of 18.9% to 26.8% from other sources. The mean IBE risk from the DCIS score assay was lower regardless of E5194 eligibility. The MSKCC nomogram and DCIS score assay risk estimates were weakly correlated with each other (P = .23) and were each moderately correlated with the other risk estimates (P = .41-.56). When applying the radiation oncologists’ treatment recommendations based on their proposed risk cutoffs, evaluating risk according to the DCIS score assay led to the highest proportion of patients recommended excision alone. Conclusions: IBE risk estimates for this general community cohort of DCIS cases vary significantly among commonly available clinical predictive tools and individual radiation oncologist estimates. Surgical margins and tumor size continue to factor prominently in radiation oncologist decision algorithms. The differences found between the IBE risk estimate methods suggests that they are not interchangeable and the methods that rely on clinicopathologic features may tend to overestimate risk.

Background . Pediatric obesity has become a significant public health concern. Pediatricians are the ideal group to help identify and treat this epidemic, but unfortunately, many pediatricians are not trained to discuss obesity with patients and their families. Standardized training initiatives for pediatric residents on prevention and/or management of obesity are needed to equip emerging pediatricians to combat the obesity epidemic. Objectives . This systematic literature review aims to examine the effectiveness of childhood obesity prevention/counseling resident training interventions. Methods . A comprehensive literature search was performed using preidentified search terms and limited to articles published prior to November 6, 2019. Articles were analyzed by 2 reviewers with a standardized evaluation tool. Results . A total of 698 articles were identified by the search. These were reduced to 111 articles after title review and 11 articles following abstract/full paper review. The 11 articles described 10 different obesity training interventions for residents. The articles varied in their size, length of training session, and study design. Despite these variations, all articles outlined positive outcomes, including an increase in physician confidence, positive changes in behavior, and/or improved electronic medical record documentation. Conclusions . With the continued increase in pediatric obesity, there is a need for practical, easy-to-implement, standardized trainings for pediatric residents on obesity prevention and treatment. More investigation needs to be done to look at long-term results of current interventions as well as other outcomes such as whether physicians are correctly identifying patients who are overweight or obese and whether there is improvement in patient follow-up.

Background: Preventable hospital readmissions are costly and erode the quality of care delivery. Few efforts to incorporate the patient perspectives and social factors associated with readmission preventability exist. Objective: To identify patient perceptions and social barriers to care related to readmission. Methods: Prospective cohort study of 202 respondents readmitted within 30 days of hospital discharge from 2 inpatient adult medicine units at Massachusetts General Hospital, Boston, Massachusetts between January 2012 and January 2016. Results: Few participants indicated that their readmission was due to unattainable health care after discharge. Almost half indicated that they needed more general assistance to stay well outside the hospital. Those reporting a barrier related to at least 2 measures of social determinants of health were more likely to have preventable readmissions (34% vs 17%, P = .006). Participants with a history of homelessness or substance use disorder were more likely to have preventable readmissions (44% vs 20%, P = .04 and 32% vs 18%, P = .03, respectively). Conclusion: Strengthening nonmedical support systems and general social policy may be required to reduce preventable readmissions.

Objective: The 2016 update to the World Health Organization (WHO) states that oligoastrocytoma (OA) should be classified as either oligodendroglioma or astrocytoma based on molecular biomarkers. We examined the survival patterns of patients diagnosed with OA in the Surveillance, Epidemiology and End Results (SEER) registry in the context of this revised scheme. Methods: We used data from the SEER database (1999–2010) to identify patients diagnosed with WHO grade II astrocytoma (A2, n = 4113), WHO grade II oligodendroglioma (O2, n = 2378), and oligoastrocytoma (OA, n = 1505). Survival comparison was performed using Kaplan-Meier analysis and multivariate Cox proportional hazards analysis. Results: Similar to O2 patients, gross total resection (GTR) was not associated with improved survival in OA patients. In contrast, GTR is associated with improved survival in A2 patients. For OA patients who did not undergo surgery or radiation therapy (RT), those with tumors

The National Spherical Torus Experiment (NSTX) has made considerable progress in advancing the scientific understanding of high performance long-pulse plasmas needed for future spherical torus (ST) devices and ITER. Plasma durations up to 1.6 s (five current redistribution times) have been achieved at plasma currents of 0.7 MA with non-inductive current fractions above 65% while simultaneously achieving βT and βN values of 17% and 5.7 (%m T MA-1), respectively. A newly available motional Stark effect diagnostic has enabled validation of current-drive sources and improved the understanding of NSTX 'hybrid'-like scenarios. In MHD research, ex-vessel radial field coils have been utilized to infer and correct intrinsic EFs, provide rotation control and actively stabilize the n ≤ 1 resistive wall mode at ITER-relevant low plasma rotation values. In transport and turbulence research, the low aspect ratio and a wide range of achievable β in the NSTX provide unique data for confinement scaling studies, and a new microwave scattering diagnostic is being used to investigate turbulent density fluctuations with wavenumbers extending from ion to electron gyro-scales. In energetic particle research, cyclic neutron rate drops have been associated with the destabilization of multiple large toroidal Alfven eigenmodes (TAEs) analogous to the 'sea-of-TAE' modes predicted for ITER, and three-wave coupling processes have been observed for the first time. In boundary physics research, advanced shape control has enabled studies of the role of magnetic balance in H-mode access and edge localized mode stability. Peak divertor heat flux has been reduced by a factor of 5 using an H-mode-compatible radiative divertor, and lithium conditioning has demonstrated particle pumping and results in improved thermal confinement. Finally, non-solenoidal plasma start-up experiments have achieved plasma currents of 160 kA on closed magnetic flux surfaces utilizing coaxial helicity injection. © 2007 IAEA.

The National Spherical Torus Experiment (NSTX) has explored the effects of shaping on plasma performance as determined by many diverse topics including the stability of global magnetohydrodynamic (MHD) modes (e.g., ideal external kinks and resistive wall modes), edge localized modes (ELMs), bootstrap current drive, divertor flux expansion, and heat transport. Improved shaping capability has been crucial to achieving Βt ∼40%. Precise plasma shape control has been achieved on NSTX using real-time equilibrium reconstruction. NSTX has simultaneously achieved elongation κ∼2.8 and triangularity δ∼0.8. Ideal MHD theory predicts increased stability at high values of shaping factor S≡ q95 Ip (a Bt), which has been observed at large values of the S∼37 [MA (m·T)] on NSTX. The behavior of ELMs is observed to depend on plasma shape. A description of the ELM regimes attained as shape is varied will be presented. Increased shaping is predicted to increase the bootstrap fraction at fixed Ip. The achievement of strong shaping has enabled operation with 1 s pulses with Ip =1 MA, and for 1.6 s for Ip =700 kA. Analysis of the noninductive current fraction as well as empirical analysis of the achievable plasma pulse length as elongation is varied will be presented. Data are presented showing a reduction in peak divertor heat load due to increasing in flux expansion. © 2006 American Institute of Physics.

In order to reduce recirculating power fraction to acceptable levels, the spherical torus concept relies on the simultaneous achievement of high toroidal β and high bootstrap fraction in steady state. In the last year, as a result of plasma control system improvements, the achievable plasma elongation on NSTX has been raised from κ ∼ 2.1 to κ ∼ 2.6 - approximately a 25% increase. This increase in elongation has led to a substantial increase in the toroidal β for long pulse discharges. The increase in β is associated with an increase in plasma current at nearly fixed poloidal β, which enables higher βt with nearly constant bootstrap fraction. As a result, for the first time in a spherical torus, a discharge with a plasma current of 1 MA has been sustained for 1 s (0.8 s current flat-top). Data are presented from NSTX correlating the increase in performance with increased plasma shaping capability. In addition to improved shaping, H-modes induced during the current ramp phase of the plasma discharge have been used to reduce flux consumption and to delay the onset of MHD instabilities. Based on these results, a modelled integrated scenario, which has 100% non-inductive current drive with very high toroidal β, will also be discussed. The NSTX poloidal field coils are currently being modified to produce the plasma shape which is required for this scenario, which requires high triangularity (δ ∼ 0.8) at elevated elongation (κ ∼ 2.5). The other main requirement of steady state on NSTX is the ability to drive a fraction of the total plasma current with RF waves. The results of high harmonic fast wave heating and current drive studies as well as electron Bernstein wave emission studies will be presented. © 2006 IAEA, Vienna.

Research on the spherical torus (or spherical tokamak) (ST) is being pursued to explore the scientific benefits of modifying the field line structue fro that in more moderate aspect ratio devices. The ST experiments are being conducted in various US research facilities. The area of power and particle handling is expected to be challenging because of the higher power density expected in the ST relative to that in conventional aspect-ratio tokamaks.

A major research goal of the national spherical torus experiment is establishing long-pulse, high beta, high confinement operation and its physics basis. This research has been enabled by facility capabilities developed during 2001 and 2002, including neutral beam (up to 7 MW) and high harmonic fast wave (HHFW) heating (up to 6 MW), toroidal fields up to 6 kG, plasma currents up to 1.5 MA, flexible shape control, and wall preparation techniques. These capabilities have enabled the generation of plasmas with βT ≡ /(BT02/2μ0) of up to 35%. Normalized beta values often exceed the no-wall limit, and studies suggest that passive wall mode stabilization enables this for H mode plasmas with broad pressure profiles. The viability of long, high bootstrap current fraction operations has been established for ELMing H mode plasmas with toroidal beta values in excess of 15% and sustained for several current relaxation times. Improvements in wall conditioning and fuelling are likely contributing to a reduction in H mode power thresholds. Electron thermal conduction is the dominant thermal loss channel is auxiliary heated plasmas examined thus far. HHFW effectively heats electrons, and its acceleration of fast beam ions has been observed. Evidence for HHFW current drive is obtained by comparison of the loop voltage evolution in plasmas with matched density and temperature profiles but varying phases of launched HHFW waves. Studies of emissions from electron Bernstein waves indicate a density scale length dependence of their transmission across the upper hybrid resonance near the plasma edge that is consistent with theoretical predictions. A peak heat flux to the divertor targets of 10 MW m-2 has been measured in the H mode, with large asymmetries being observed in the power deposition between the inner and outer strike points. Non-inductive plasma startup studies have focused on coaxial helicity injection. With this technique, toroidal currents up to 400 kA have been driven, and studies to assess flux closure and coupling to other current drive techniques have begun.

A 50-year-old male with right upper quadrant symptoms and hepatic dysfunction was found to have multiple dilated hepatic veins (HVs) with intrahepatic collateralization and membranous occlusion of the intrahepatic inferior vena cava (IVC) consistent with primary Budd–Chiari syndrome. Venacavograms depicted drainage of the intrahepatic collaterals through a left-sided HV entering the IVC above the level of the occlusion. Sharp recanalization of the membranous IVC occlusion was performed with an occlusion balloon as a needle target under echocardiographic monitoring followed by balloon angioplasty with restoration of IVC patency. Clinical, laboratory, and venographic procedural success has been demonstrated to 9 months with minimal residual stenosis.

The purpose of this study was to determine whether a patient satisfaction survey in the outpatient clinic setting using questions with either a positive or negative tone would produce consistent responses. This was a prospective study using a 20-question paper survey delivered to medical students who were asked to rate on a scale of 1 to 10 to what degree they either agree or disagree with statements regarding their most recent personal outpatient clinic health care visit (any medical specialty). The same survey was administered again through an e-mail link 1 week later. One hundred fifty (77%) students completed the 20-item survey and 53 (35%) of the participating students completed the follow-up e-mail survey. Seven of the 10 question pairs on the paper survey revealed statistically significant differences in responses based on tone, with greater values for disagreement with negatively toned questions than values representing agreement with positive-toned questions. The match rates for similar questions posed on the paper survey and then the e-mail survey 1 week later ranged between 27.8% and 56.6%. This study demonstrated that, with an outpatient health care patient satisfaction survey, disagreement with a negative-toned question was stronger than agreement with a positive-toned question. There was poor correlation between survey responses when first posed on a paper survey and then repeated on a digital survey 1 week later. These findings suggest that the wording of survey questions may affect responses and that survey answers change with time and across delivery platforms.

Objective . To evaluate the impact of an obesity didactic session for pediatric physicians on confidence in counseling and identified overweight/obesity and follow-up recommendations. Methods . Pediatric residents underwent training and completed pre/post online surveys evaluating confidence in obesity prevention and identification. A booster training occurred 1 year later. Pre-/post-training scores were compared using χ 2 or Fisher’s exact tests. Electronic medical records data for patients ≥3 years with BMI-for-age percentile ≥85 during 3 months prior/following the training/booster compared frequency of overweight/obesity identification and follow-up recommendations (≤3 months recommended vs longer) using logistic regression adjusting for age and overweight/obese status. Results . Post trainings, improvements in confidence to define/screen for obesity were observed, with a decline between trainings. Overweight/obese identification and follow-up time recommendations improved post-training (identification: 14.2% to 27.4%, adjusted odds ratio [aOR] = 3.16, 95% confidence interval [CI] = 1.54-6.51; follow-up: 48.9% to 58.9%, aOR = 1.63, 95% CI = 1.01-2.64), aOR = 1.77, 95% CI = 1.10-2.85, and identification remained stable/above pre-training rates both pre-/post-booster (25.8%, aOR = 3.14, 95% CI = 1.53-6.45; and 22.1%, aOR = 2.57, 95% CI = 1.25-5.30, respectively). Recommended follow-up time rates continued to rise when measured pre-booster (60.6%, aOR = 1.77, 95% CI = 1.10-2.85), then declined (46.0%, aOR = 0.95, 95% CI = 0.60-1.52). Conclusion . This didactic session improved resident confidence in defining/screening, identification of overweight/obesity and follow-up recommendations; however, rates of identification remained low. The successes of this intervention support similar didactic sessions in residency programs and identifies opportunities for improved resident/attending education.

Nodular fasciitis is a benign proliferation of fibroblasts and myofibroblasts most commonly found in the soft tissues of the upper extremities and the trunk of young to middle-aged adults. Nodular fasciitis is infrequently encountered in the breast and in the elderly. We report a case of a 69-year-old woman presenting with a palpable breast mass with imaging features that mimicked malignancy. Knowledge of this entity is important to allow proper radiological and pathologic concordance and patient management.

For all of the optimism that immunotherapy has engendered, the flip side is that 7/10 patients with susceptible tumor types do not respond, while in nonsusceptible tumor types the response rates are significantly lower. In contradiction of the current orthodoxy against surgery in the setting of unresectable disease, we present 3 examples of immunotherapy-treated patients with widespread recurrence who experienced dramatic clinical improvement following debulking/metastasectomy. Taken together with examples from the literature that correlate longer survival with surgical intervention during treatment with immunotherapy, these 3 cases suggest that a new paradigm involving a wider role for surgery in the management of these patients should be explored. Possible mechanisms by which surgery may synergize with immunotherapy and improve outcomes are also discussed.

Objective: The healthcare chart is becoming ever more complex, serving clinicians, patients, third party payers, regulators, and even medicolegal parties. The purpose of this study was to identify our emergency medicine (EM) resident and attending physicians’ current knowledge and attitudes about billing and documentation practices. We hypothesized that resident and attending physicians would identify billing and documentation as an area in which residents need further education.Methods: We gave a 15-question Likert survey to resident and attending physicians regarding charting practices, knowledge of billing and documentation, and opinions regarding need for further education.Results: We achieved a 100% response rate, with 47% (16/34) of resident physicians disagreeing or strongly disagreeing that they have adequate training in billing and documentation, while 91% (31/34) of residents and 95% (21/22) of attending physicians identified this skill as important to a resident’s future practice. Eighty-two percent (28/34) of resident physicians and 100% of attending physicians recommended further education for residents.Conclusion: Residents in this academic EM department identified a need for further education in billing and documentation practices. [West J Emerg Med. 2010;11(2): 116-119.]

Although medical schools are encouraging the use of personal digital assistants (PDAs), there have been few investigations of attitudes toward their use by students or residents and only one investigation of the public’s attitude toward their use by physicians. In 2006, the University of Louisville School of Medicine surveyed 121 third- and fourth-year medical students, 53 residents, and 51 members of the non-medical public about their attitudes toward PDAs. Students were using either the Palm i705 or the Dell Axim X50v; residents were using devices they selected themselves (referred to in the study generically as PDAs). Three survey instruments were designed to investigate attitudes of (a) third- and fourth-year medical students on clinical rotations, (b) Internal Medicine and Pediatrics residents, and (c) volunteer members of the public found in the waiting rooms of three university practice clinics. Both residents and medical students found their devices useful, with more residents (46.8%) than students (16.2%) (p

Objective: Asthma is common in homeless children with an incidence of 28-40%. There are few published studies investigating asthma in homeless children. This study examines the perspectives of both caregivers and shelter staff regarding challenges and opportunities of caring for children with asthma. Methods: A focus group of sheltered parents ( n = 10) with children who have asthma was conducted to identify barriers to optimal asthma management. Key informant interviews ( n = 6) were conducted with shelter staff to discuss the shelter systems and policies to address childhood asthma. Data were audio-recorded and transcribed. A representative analysis team performed qualitative theme analysis. Results: Key themes across 5 domains were identified: asthma education, access to asthma medication and equipment, asthma action plans, structural barriers to asthma management and environmental triggers. Parents identified multiple asthma triggers present in the shelter environment but cited lack of control as a barrier to remediation. Shelter staff desired elimination of asthma triggers but refer to the lack of resources as the primary barrier. Shelter staff favored a smoking ban on shelter property but named challenges to policy implementation. Both parents and staff identified asthma education and increased access to medications would be helpful. Conclusions: Policies to reduce environmental exposures, such as a smoking ban, to asthma triggers has the potential to improve the health of sheltered children with asthma. [ABSTRACT FROM AUTHOR]