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Congenital constriction band syndrome has varied clinical presentations ranging from small, incomplete skin deep constriction band to in utero amputation. Pseudarthrosis of underlying bone most commonly tibia has been reported by many authors. We report the first case of congenital pseudarthrosis of the femur with congenital constriction band syndrome. Nine-day-old female presented with the constriction band in the left thigh with open pseudarthrosis of the femur. The left femur had gross recurvatum deformity and the posterior apex of the pseudarthrosis was exposed via skin ulceration. She had an ipsilateral paralytic clubfoot. She was treated with single-stage excision of constriction band and Z-plasty. Spontaneous union of the femur was achieved at 3 months. Procurvatum deformity of the femur improved gradually over 3 years. This happens to be the first and only reported case of congenital pseudarthrosis of the femur with sciatic nerve palsy due to congenital constriction band.

BACKGROUND AND OBJECTIVES Inability to obtain timely medications is a patient safety concern that can lead to delayed or incomplete treatment of illness. While there are many patient and system factors contributing to postdischarge medication nonadherence, availability and insurance-related barriers are preventable. PURPOSE To implement a systematic process ensuring review of discharge prescriptions to ensure availability and resolve insurance barriers before patient discharge. METHODS A prospective single-arm quality improvement intervention study to identify and address insurance-related prescription barriers using nonclinical staff. Intervention was pilot tested with sequential spread across general medicine resident teams. The primary outcome was successful obtainment of postdischarge prescriptions confirmed by phone calls to patients or their pharmacies. RESULTS From April to August 2015, 59 of 161 patients included in the improvement process (36.6%) had one or more insurance or availability-related barriers with their prescriptions, totaling 89 issues. Forty-three of the 59 patients (72.9%) responded to postdischarge phone calls, 39 of whom (39/43, 90.7%) successfully filled their prescriptions on the first pharmacy visit. CONCLUSIONS In our study, we preemptively identified that over a third of patients discharged would have encountered barriers filling their prescriptions. This interdisciplinary quality improvement project using nonclinical team members removed barriers for over 90% of our patients to ensure continuation of medical therapy without disruption and a safer postdischarge plan.

Introduction: It is generally admitted that most humeral shaft fractures can be managed successfully by non-operative methods. Whenever operative treatment is required, a choice has to be made between plate osteosynthesis and intramedullary nailing. Fixation with plates requires extensive dissection and is complicated by the proximity of the radial nerve and the risk of mechanical failure in osteopenia bones. Biomechanically intramedullary nail is a better implant. They are subjected to smaller bending loads and are less likely to fail by fatigue, they act as load sharing devices, stress shielding with resultant cortical osteopenia is minimum, refracture after implant removal is rare and they do not require extensive exposure Methods: We have done a prospective study of 30 patients with Fracture shaft Humerus stabilized with intramedullary nail of Enders type by antegrade approach. These nails were available in 3 & 3.5 mm diameter and in lengths ranging from 18-28 Cms. The nail by design had proximal band of 6 degrees (apex medial band) to accommodate offset of the infusion portal with the medullary canal. Results: Study shows more incidences of Humerus fractures in young patients as it is active age group in the society, more prone to vehicle accidents and falls. Most of the fracture of shaft humerus unites in 10-14 weeks and in minor cases more than 18 weeks were observed for union. Most common complication associated with operative method of fracture shaft humerus is non union. Joint involvement in form of shoulder or elbow stiffness can occur in small number of cases. There are no cases of infection noted in our study Interpretation and Conclusion: Internal fixation by close intramedullary nail for fractures involving middle two third shaft of humerus is a good technique if facilities are provided for image internsifier machine in operation theater. In comparision to other operative techniques close intramedullary nailing is less invasive with minimal blood loss and hardly any chance of infection. This technique gives rotational as well as torsional stability to fractured bone humerus, allowing faster practice of physiotherapy to achieve full range of motion and power.

Background and objectives: Definition: A fracture in which one side of a bone is broken and the other is bent John Insall, a British-American orthopedist and Michal Slupecki, a Polish-American orthopedist, described the fracture like that of a breakage of green wood, which simply breaks outer side when bent. Ligaments and Tendons are stronger than bone when young. Bone is more likely to be injured than soft tissue. Periosteal is biologically active in children and often stays intact with injury. This stabilizes fractures and promotes healing. Force to side of bone may cause break in only one cortex–Greenstick fracture. The outer cortex only bends. In very young children none of the cortex may break–Plastic deformation. Methods: Out of 35 cases treated in our instate 23 were male and 12 female child. Patients pre and post reduction serial follow up x-rays were studied. Follow up period ranges from 3 months to 3 year. In greenstick fracture reduction done according to angulation of fracture. When the apex of the fracture is towards dorsum of the forearm (apex dorsal- pronation injury), the forearm supinated to achieve reduction. When the apex of the fracture is towards volar aspect of the forearm (apex volar- supination injury), the forearm pronated to achieve reduction. Results: Out of twenty patients treated, overall good to excellent results were obtained in 96% patients. The results was fair in one patient each. There were no intraoperative complications. Interpretation and conclusion: Maximum fractures were in age group of 5-10 year with predominance in males. Most of the fractures were on subordinate side. Average union time in greenstick fracture was 6 week. In this series the highest degree of angulation (at final follow up) which got corrected was in radius 18° and in ulna 13°. Remodeling and returning of final range of motion is excellent.

INTRODUCTION Medical centers have dramatically increased the use of magnetic resonance imaging (MRI). At 2 large academic tertiary care centers in New York City, nearly half of inpatient MRI orders took more than 12 h to complete, delaying patient discharge and increasing avoidable hospital days. We posited that transitioning inpatient MRIs to outpatient facilities, when safe and appropriate, could reduce inpatient MRI orders and avoidable hospital days. METHODS We manually reviewed 59 inpatient MRI orders delayed on the estimated date of discharge (EDD). These orders were often delayed due to no standard process to escalate orders for medical reasons or no system to coordinate outpatient orders. We developed a revised workflow involving an automation platform that flagged inpatient MRI orders requested within 24 h of the EDD and emailed the care team to request a second review of the order. The care team reconsidered whether the order was (1) required for discharge, (2) non-urgent and could be converted to an outpatient order, or (3) unnecessary and could be canceled. RESULTS Over 9 months, the automation platform flagged 618 inpatient MRI orders, of which 53.9% (333/618) were reviewed by the care team. Among the orders, 24.0% (80/333) of reviewed orders and 12.9% (80/618) of all orders were transitioned to either outpatient or canceled orders. These transitioned orders were associated with 267 fewer avoidable hospital days and a cost savings of $199,194. CONCLUSION A standardized process and second review of inpatient MRI orders on the EDD can reduce inappropriate orders and more effectively use inpatient imaging resources. PRECIS A standardized workflow and automation platform encouraged a second review of inpatient MRI orders to reduce inappropriate orders, avoidable hospital days, and hospital costs.

Objective Patients with pulmonary hypertension and right heart failure have a high risk of clinical deterioration and death during or soon after endotracheal intubation. The effects of sedation, hypoxia, hypoventilation, and changes in intrathoracic pressure can lead to severe hemodynamic instability. In search for safer approach to endotracheal intubation in this cohort of patients, we evaluate the safety and feasibility of an alternative intubation technique. Data sources Retrospective data analysis. Study selection Two medical ICUs in large university hospitals in the United States. Data extraction We report a case series of nine nonconsecutive patients with compromised right heart function, pulmonary hypertension, and severe acute hypoxemic respiratory failure who underwent endotracheal intubation with a novel technique combining awake bronchoscopic intubation supported with nasally delivered noninvasive positive pressure ventilation or high-flow nasal cannula. Data synthesis All patients were intubated in the first attempt without major complications and eight patients (88%) were alive 24 hours after intubation. Systemic hypotension was the most frequent complication following the procedure. Conclusions Awake bronchoscopic intubation supported with a noninvasive positive pressure delivery systems may be feasible alternative to standard direct laryngoscopy approach. Further studies are needed to better assess its safety and applicability.

The emergence of drug-resistant tuberculosis (DR-TB) has become a significant health problem in India. Delays in diagnosis and treatment initiation are frequently observed among patients with DR-TB, resulting in an increased risk of disease complications and high mortality and pretreatment lost to follow-up rates. To understand the factors associated with delays between the diagnosis and treatment, the study was carried out in Ahmedabad Municipal Corporation Area. A total of 177 DR-TB patients diagnosed in the year 2014 who had a delay in the initiation of treatment, and 23 initial defaulters were studied using a structured questionnaire. Fifty-four DOTS providers were also interviewed. Of 177 patients, 62.15% initiated treatment between 7 and 15 days and nearly 12% of them started the treatment after a month. The median duration of delay was 12 days (range: 8-144 days and interquartile range: 9-20 days). The most common reason for the delay in the initiation and initial default was the social and personal factors (48.80%), and in 34 (20%) of the patients, the delay was attributed to the effect of the previous treatment.

AIM: To investigate the optimal intravenous fluid for resuscitation of hospitalized patients with cirrhosis and hyponatremia and analyze their outcomes. MATERIALS AND METHODS: In this retrospective cohort study, consecutive patients with hyponatremia and cirrhosis, portal hypertension, ascites, or hepatic encephalopathy receiving resuscitative fluids and hospitalized between 1/2011 and 12/2014 were analyzed. Patient characteristics, quantity and type of fluid administered, change in serum sodium, and 6-month mortality were recorded. RESULTS: A total of 146 eligible patients were identified, of which 62% (91/146) received primarily crystalloid and 38% (55/146) primarily albumin resuscitative fluid. Those within the albumin cohort were more likely to receive diuretics (82% vs 56%, p = 0.001), have a history of refractory ascites (56% vs 21%, p < 0.001), ascites on admission (96% vs 60%, p < 0.001), higher admission body mass (81.6 kg vs 75.5 kg, p = 0.04), higher creatinine (152.9 µmol/L vs 130.8 µmol/L, p = 0.03), and higher model for end-stage liver disease (MELD) score (23.0 vs 18.9, p = 0.002) compared to those in the crystalloid cohort. Fluid selection did not impact sodium correction (p = 0.67). In multivariate analysis, receiving albumin and having higher baseline serum albumin were both associated with reduced 6-month mortality, odds ratio of 0.06 (p = 0.013) and 0.13 (p = 0.035), respectively. CONCLUSIONS: Fluid selection in patients with cirrhosis and hyponatremia insignificantly impacted sodium correction. Albumin infusion was associated with reduced 6-month mortality. Larger prospective trials are required to investigate this relationship.

Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes.A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5).Total antibiotic use decreased by 16.8% (p0.001), 6.8% (p = 0.08), and 33.0% (p0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p0.001), 7.8% (p = 0.09), and 32.4% (p0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team.Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

This research undertaken at the foreign subsidiary level explores how multinational enterprises (MNEs) from advanced nations harness global network-integrated R&D when it is extended to emerging markets. In both developed and developing country contexts, organizations are momentously devising strategies to integrate global innovation networks (GIN). Still a clear understanding of this rapidly emerging phenomenon is lacking. Case studies of 26 R&D Centres located in India and China belonging to 18 European MNEs in high-technology sectors enabled us to explore the underlying process. An integrated framework developed to position various R&D strategies that MNEs pursued in host facilities, enabled us to identify key dimensions. The core argument is that strategies are not static and can evolve in many ways. We are able to identify that this results from the inter-play between – the level of capabilities that have evolved in host R&D facilities, and the extent of integration in the GIN of parent MNE. Further,...

Zirconium diethylene triamine pentamethylene phosphonate and titanium diethylene triamine pentamethylene phosphonate, novel hybrid cation exchange materials of the class of tetravalent metal acid salts, synthesized by sol-gel method has been characterized by spectroscopy and thermal analysis. Distribution coefficient and breakthrough capacity for La3+, Ce3+, Pr3+, Nd3+, Sm3+ (lanthanides) and Th4+, (actinides) have been studied. Based on the differential affinity/selectivity and elution behavior of various metal ions, a few binary and ternary metal ion separations have been carried out.