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During the past decade, robotics for cochlear implant electrode array insertion has been limited to manipulation assistance. Going beyond manipulation assistance, this paper presents the new concept of perception augmentation to detect and warn against the onset of intracochlear electrode array tip folding. This online failure detection method uses a combination of intraoperative electrode insertion force data and a predictive model of insertion force profile progression as a function of insertion depth. The predictive model uses statistical characterization of insertion force profiles during normal robotic electrode array insertions as well as the history of intra-operative insertion forces. Online detection of onset of tip folding is achieved using the predictive model as an input into a support vector machine classifier. Results show that the detection of tip folding onset can be achieved with an accuracy of 88% despite the use of intra-operative insertion force data representing incomplete insertion. This result is significant because it allows the surgeon or robot to choose a corrective action for preventing intra-cochlear complications. [ABSTRACT FROM AUTHOR]

Abstract Background Simple ligation of the vas with suture material and excision of a small vas segment is believed to be the most common vasectomy occlusion technique performed in low-resource settings. Ligation and excision (LE) is associated with a risk of occlusion and contraceptive failure which can be reduced by performing fascial interposition (FI) along with LE. Combining FI with intra luminal thermal cautery could be even more effective. The objective of this study was to determine the surgical vasectomy techniques currently used in five Asian countries and to evaluate the facilitating and limiting factors to introduction and assessment of FI and thermal cautery in these countries. Methods Between December 2003 and February 2004, 3 to 6 major vasectomy centers from Cambodia, Thailand, India, Nepal, and Bangladesh were visited and interviews with 5 to 11 key informants in each country were conducted. Vasectomy techniques performed in each center were observed. Vasectomy techniques using hand-held, battery-driven cautery devices and FI were demonstrated and performed under supervision by local providers. Information about interest and open-mindedness regarding the use of thermal cautery and/or FI was gathered. Results The use of vasectomy was marginal in Thailand and Cambodia. In India, Nepal, and Bangladesh, vasectomy was supported by national reproductive health programs. Most vasectomies were performed using the No-Scalpel Vasectomy (NSV) technique and simple LE. The addition of FI to LE, although largely known, was seldom performed. The main reasons reported were: 1) insufficient surgical skills, 2) time needed to perform the technique, and 3) technique not being mandatory according to country standards. Thermal cautery devices for vasectomy were not available in any selected countries. Pilot hands-on assessment showed that the technique could be safely and effectively performed by Asian providers. However, in addition to provision of supplies, introducing cautery with FI could be associated with the same barriers encountered when introducing FI in combination with LE. Conclusion Further studies assessing the effectiveness, safety, and feasibility of implementation are needed before thermal cautery combined with FI is introduced in Asia on a large scale. Until thermal cautery is introduced in a country, vasectomy providers should practice LE with FI to maximize effectiveness of vasectomy procedure.

Background Standardized letters of recommendation (SLOR) have become common features of the medical school to residency transition. Research has shown many advantages over the narrative letter of recommendation including improved letter-writing efficiency, ease of interpretation, and improved reliability as performance predictors. Currently, at least four specialties require fellowship SLORs. Internal medicine adopted its SLOR in 2017. Previous research showed fellowship program directors' satisfaction with the 2017 guidelines. Little is known about residency program directors' acceptance and adherence to the guidelines. Objectives The study sought to assess the adoption rate of each component, barriers to adoption, time commitment, and alignment with intended goals of the guidelines. Methods Anonymous survey links were posted to an internal medicine discussion forum prior to the guidelines in spring 2017 and twice following the guidelines in fall 2018 and winter 2019. Two-sample tests of proportions were used to compare respondent characteristics with known survey population data. Pre- and post-survey comparisons were assessed for statistical significance with Pearson chi-squared statistic. Results The response rate varied from 30% to 35% for each survey period. Medical knowledge, patient care, interpersonal and communication skills, professionalism, and scholarly activity were reported frequently (>96%) at baseline. Inclusion of residency program characteristics, systems-based practice, practice-based learning and improvement, and skills sought to master increased over the study period. Conclusions The new guidelines improved uniform reporting of all core competency data. Overall, the gains were modest, as many pre-survey respondents reported high rates of including components within the guidelines., Competing Interests: No potential conflict of interest was reported by the authors., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of Greater Baltimore Medical Center.)

Objectives: To test the hypothesis that bipolar electrical impedance measurements in perimodiolar cochlear implants (CIs) may be used to differentiate between perimodiolar insertion technique favoring proximity to the modiolus or lateral wall., Study Design and Methods: Bipolar impedances are a measure of electrical resistance between pairs of electrode contacts in a CI. Stimulation is through biphasic pulses at fixed frequency. Impedance measurements were made in real time through sequential sampling of electrode pairs. Perimodiolar electrodes were inserted in temporal bones using one of two techniques: 1) In the standard insertion technique (SIT), the electrode array slides along the lateral wall during insertion. 2) In the Advance Off Stylet (Cochlear Ltd. Sydney) technique (AOS), the electrode maintains modiolar contact throughout the insertion process. A set of 22 insertions were performed in temporal bone specimens using perimodiolar electrode arrays with both AOS and SIT. Buffered saline was used as a substitute for natural perilymph based on similar electrical conductivity properties. Impedance with and without stylet removal were recorded with a 30-second sampling window at final insertion depth., Results: There is a significant difference in bipolar impedance measures between AOS and SIT, with impedances rising in measurements with stylet removal. Evaluation was based on two-sided analysis of variance considering technique and electrode with P < 0.025., Conclusion: Bipolar electrical impedance can be used to detect relative motion toward the modiolus inside the cochlea. This detection method has the potential to optimize intraoperative placement of perimodiolar electrode arrays during implantation. We anticipate that this will result in lower excitation thresholds and improved hearing outcome., Level of Evidence: NA. Laryngoscope, 127:1413-1419, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.

Background: As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important., Objective: To develop and validate a quantifiable definition of academic success for AHPs., Methods: A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey., Results: Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6-18 years) and mean size of 36 faculty (range, 18-95). The mean total grant funding/program was $4 million (range, $0-$15 million), with mean funding/FTE of $364,000 (range, $0-$1.4 million); both were significantly higher than the comparison sample. The majority of SCHOLAR faculty (82%) were junior, a lower percentage than the comparison sample. The mean number of research abstracts presented over 2 years was 10.8 (range, 9-23)., Discussion: Our approach effectively identified a subset of successful AHPs. Despite the relative maturity and large size of the programs in the SCHOLAR cohort, they were comprised of relatively few senior faculty members and varied widely in the quantity of funded research and scholarship. Journal of Hospital Medicine 2016;11:708-713. © 2016 Society of Hospital Medicine., (© 2016 Society of Hospital Medicine.)

Background: Rates of preventable admissions will soon be publicly reported and used in calculating performance-based payments. The current method of assessing preventable admissions, the Agency of Healthcare Research and Quality (AHRQ) Preventable Quality Indicators (PQI) rate, is drawn from claims data and was originally designed to assess population-level access to care., Objective: To identify the prevalence and causes of preventable admissions by attending physician review and to compare its performance with the PQI tool in identifying preventable admissions., Design: Cross-sectional survey., Setting: General medicine service at an academic medical center., Participants: Consecutive inpatient admissions from December 1-15, 2013., Main Measures: Survey of inpatient attending physicians regarding the preventability of the admissions, primary contributing factors and feasibility of prevention. For the same patients, the PQI tool was applied to determine the claims-derived preventable admission rate., Key Results: Physicians rated all 322 admissions and classified 122 (38 %) as preventable, of which 31 (25 %) were readmissions. Readmissions were more likely to be rated preventable than other admissions (49 % vs. 35 %, p = 0.04). Application of the AHRQ PQI methodology identified 75 (23 %) preventable admissions. Thirty-one admissions (10 %) were classified as preventable by both methods, and the majority of admissions considered preventable by the AHRQ PQI method (44/78) were not considered preventable by physician assessment (K = 0.04). Of the preventable admissions, physicians assigned patient factors in 54 (44 %), clinician factors in 36 (30 %) and system factors in 32 (26 %)., Conclusions: A large proportion of admissions to a general medicine service appeared preventable, but AHRQ's PQI tool was unable to identify these admissions. Before initiation of the PQI rate for use in pay-for-performance programs, further study is warranted.

Objective: Minimally invasive image-guided cochlear implantation (CI) utilizes a patient-customized microstereotactic frame to access the cochlea via a single drill-pass. We investigate the average force and trauma associated with the insertion of lateral wall CI electrodes using this technique., Study Design: Assessment using cadaveric temporal bones., Setting: Laboratory setup., Subjects and Methods: Microstereotactic frames for 6 fresh cadaveric temporal bones were built using CT scans to determine an optimal drill path following which drilling was performed. CI electrodes were inserted using surgical forceps to manually advance the CI electrode array, via the drilled tunnel, into the cochlea. Forces were recorded using a 6-axis load sensor placed under the temporal bone during the insertion of lateral wall electrode arrays (2 each of Nucleus CI422, MED-EL standard, and modified MED-EL electrodes with stiffeners). Tissue histology was performed by microdissection of the otic capsule and apical photo documentation of electrode position and intracochlear tissue., Results: After drilling, CT scanning demonstrated successful access to cochlea in all 6 bones. Average insertion forces ranged from 0.009 to 0.078 N. Peak forces were in the range of 0.056 to 0.469 N. Tissue histology showed complete scala tympani insertion in 5 specimens and scala vestibuli insertion in the remaining specimen with depth of insertion ranging from 360° to 600°. No intracochlear trauma was identified., Conclusion: The use of lateral wall electrodes with the minimally invasive image-guided CI approach was associated with insertion forces comparable to traditional CI surgery. Deep insertions were obtained without identifiable trauma.

Objectives: To model clinical and situational variables that may affect likelihood of physicians to order physical restraints., Design: Cross-sectional, factorial survey., Setting: One academic medical center., Participants: One hundred eighty-nine physicians: interns in all specialty practices and resident and attending physicians in departments of surgery, general internal medicine, family practice, emergency medicine, and psychiatry., Measurements: Vignettes were randomly generated using different values of six situational and eight clinical variables. Each physician received five unique vignettes for which they indicated their likelihood to order restraint on a 10-point scale., Results: Nine hundred six distinct vignettes were completed. The mean likelihood that physicians would order restraint was 3.9 + or - 3.0 (range 0 (not at all) to 9 (absolutely)). Exploratory regression analysis on physician's likelihood to restrain with independent variables of secondary diagnosis, patient age, sex, time of day, familiarity and trust with requesting nurse, patient behavior, vital signs, oxygen saturation, and dehydration explained 12.5% of variance (F=5.43, P<.001). Independent factors of unsafe patient behavior (P=.001) and secondary diagnosis of dementia (P=.06) resulted in greater likelihood of ordering restraint, whereas lack of trust in the judgment of the reporting nurse (P=.008) resulted in lower likelihood of ordering restraints., Conclusion: Patients' clinical status had less influence on physicians' likelihood of ordering physical restraints than the working relationship with the requesting nurse or the patient's behavior. Interdisciplinary team approaches with active physician input for nonrestraint strategies in the management of patient behavior is emphasized to minimize restraint use.

A 58-year-old man with Darier disease and end-stage renal failure on hemodialysis who developed disseminated Herpes Zoster is presented. He was cleared with intravenous acyclovir given at the time of dialysis.

Background: Simple ligation of the vas with suture material and excision of a small vas segment is believed to be the most common vasectomy occlusion technique performed in low-resource settings. Ligation and excision (LE) is associated with a risk of occlusion and contraceptive failure which can be reduced by performing fascial interposition (FI) along with LE. Combining FI with intra luminal thermal cautery could be even more effective. The objective of this study was to determine the surgical vasectomy techniques currently used in five Asian countries and to evaluate the facilitating and limiting factors to introduction and assessment of FI and thermal cautery in these countries., Methods: Between December 2003 and February 2004, 3 to 6 major vasectomy centers from Cambodia, Thailand, India, Nepal, and Bangladesh were visited and interviews with 5 to 11 key informants in each country were conducted. Vasectomy techniques performed in each center were observed. Vasectomy techniques using hand-held, battery-driven cautery devices and FI were demonstrated and performed under supervision by local providers. Information about interest and open-mindedness regarding the use of thermal cautery and/or FI was gathered., Results: The use of vasectomy was marginal in Thailand and Cambodia. In India, Nepal, and Bangladesh, vasectomy was supported by national reproductive health programs. Most vasectomies were performed using the No-Scalpel Vasectomy (NSV) technique and simple LE. The addition of FI to LE, although largely known, was seldom performed. The main reasons reported were: 1) insufficient surgical skills, 2) time needed to perform the technique, and 3) technique not being mandatory according to country standards. Thermal cautery devices for vasectomy were not available in any selected countries. Pilot hands-on assessment showed that the technique could be safely and effectively performed by Asian providers. However, in addition to provision of supplies, introducing cautery with FI could be associated with the same barriers encountered when introducing FI in combination with LE., Conclusion: Further studies assessing the effectiveness, safety, and feasibility of implementation are needed before thermal cautery combined with FI is introduced in Asia on a large scale. Until thermal cautery is introduced in a country, vasectomy providers should practice LE with FI to maximize effectiveness of vasectomy procedure.

Anthrax is a zoonotic illness recognized since antiquity. Today, human anthrax has been all but eradicated from the industrialized world, with the vast majority of practitioners in the United States unlikely to have seen a case. Unfortunately, the disease remains endemic in many areas of the world, and anthrax poses a threat as a mass casualty-producing weapon if used in a biological warfare capacity.

The quality of abortion in Turkey's public sector hospitals is investigated using multiple research methods including observations of actual procedures, interviews with medical staff and clients, and an inventory of materials and equipment. The results suggest that women who obtain abortions in public sector hospitals have a higher abortion rate than the general population. They are likely to receive a vacuum aspiration with minimal pain control medication. Clinical infection control procedures are insufficient, as are interpersonal communication practices including counseling on reproductive health issues and providing factual information. Links with family planning services are strong and the majority of abortion patients who desire family planning receive a contraceptive method, either through direct provision of postabortion contraceptives or referral.

Metabolite fractions from the urine of a dog dosed with 3a,4,5,6,7a-hexahydro-3-(1-methyl-5-nitro-1H-imidazol-2-yl)-1,2-benzisoxazole (MK-0436) were obtained by the use of high-performance liquid chromatography. These fractions were of suitable purity for structural elucidation. Data obtained by mass spectrometry and NMR spectroscopy allowed the identification of seven major metabolites of this drug. Biotransformation in each case involved hydroxylation (mono or di) of the hexahydrobenzisoxazole ring.