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Benchmarking in industrial companies provides benefits which increased customer satisfaction, productivity, quality, market performance, industrial competitiveness and implementation of continuous improvement. Benchmarking as a tool helps the company to position themselves in the market. Benchmarking, in current times occupies an important place and help in quality enhancement. Benchmarking as a basic of competitive positioning and share an important and valuable information from managerial personnel. This review article includes introduction and history of benchmarking, various types of benchmarking, different phases of benchmarking, process of benchmarking, various approaches of benchmarking, benefits, advantages and disadvantages of benchmarking, what are the cost of benchmarking and application of benchmarking.

Introduction: Postnatal period brings many physiological changes in mothers. This period is crucial for the mother as there is a new addition to her life. Hence the health of the postnatal mother is associated with the type of delivery. Objective: This study aims to assess and compare the problems faced during postnatal period among mothers with normal vaginal delivery and cesarean delivery. Methods: Quantitative research approach & a comparative descriptive research design was used with 60 postnatal mothers who had fulfilled the inclusion criteria, among them 30 mothers with normal vaginal delivery and 30 mothers with cesarean delivery were selected using purposive sampling technique. Data was collected using modified standardized observation checklist to assess the problems faced during postnatal period among mothers with normal vaginal delivery and cesarean delivery. Setting: The postnatal ward of selected private maternity care hospital-N.D. Desai medical college and hospital of Nadiad city, Gujarat. Results: There was statistically significant difference found in problems faced during postnatal period in group 1 and group 2 which shows that mean difference between group 1 and group 2 was 1.79 and standard deviation 0.15. In group 1 overall percentage of severity of pain according to mild, moderate, severe and no pain criteria were 57%, 20%, 0% and 23% respectively and in group 2 overall percentage of severity of pain according to mild, moderate, severe and no pain criteria were 0%, 70%, 30% and 13% respectively Conclusion: The study concluded that postnatal mothers with cesarean delivery have to face more problems than those following normal vaginal delivery. The level of pain score was also high in mothers with cesarean delivery.

Cochlear implantation surgery is usually performed in paediatric patient of 1 to 7 years of age with congenital deaf-mutism. Good results in this surgery are obtained by providing bloodless surgical field with controlled hypotension and postoperative smooth outcome. To anaesthetize these patients, we are using Inj Propofol, Inj fentanyl, Sevoflurane, Dexmedetomidine infusion and muscle relaxants. Dexmedetomidine is an active isomer of medetomidine and an agonist at α2 –adreno receptors. Medetomidine provides perioperative sedation and analgesia thus decreasing other general anaesthetic drug requirement, reduced postoperative pain score, postoperative delirium and other complications.To determine that inj. Dexmedetomidine infusion is a suitable agent for haemodynamic stability, decreases need of other general anesthetic drug requirement intraoperatively and improves post-operative outcome in cochlear implant surgery.This study was conducted at a rural tertiary care center, which included 100 samples of pediatric patients (1-7 years of age group) who went through cochlear implant surgeries in last 3 years. Among all patients, heart rate (HR) remained stable and there was no significant difference between baseline HR and intra-op HR (P=0.3098). The systolic blood pressure (SBP) was decreased significantly compared to baseline reading (P value < 0.0001), but the diastolic blood pressure was not decreased significantly (P= 0.0612).Dexmedetomidine provides stable haemodynamics, acceptable hypotensive state, good surgical field and excellent analgesia in pediatric patients undergoing cochlear implant surgery.

Garnered literature points toward the role of the dorsal hippocampus (CA1) in ethanol withdrawal-induced responses, wherein a strong presence of the histaminergic system is also reported. Therefore, the present study investigated the effect of an enhanced CA1 histaminergic transmission on the expression of chronic ethanol withdrawal-induced despair in mice on the tail suspension test (TST). The results revealed that mice who were on an ethanol-fed diet (5.96%, v/v) for 8 days exhibited maximum immobility time on the TST, and decreased locomotion at 24 h post-ethanol withdrawal (10th day), indicating ethanol withdrawal-induced despair. Enhancement of CA1 histaminergic activity achieved by the treatment of intra-CA1 microinjection of histaminergic agents such as histamine (0.1, 10 μg/mouse, bilateral), the histamine precursor l -histidine (1, 10 μg/mouse, bilateral), the histamine neuronal releaser/H3 receptor antagonist thioperamide (2, 10 μg/mouse, bilateral), the histamine H1 receptor agonist FMPH (2, 6.5 μg/mouse, bilateral), or the H2 receptor agonist amthamine (0.1, 0.5 μg/mouse, bilateral) to ethanol-withdrawn mice, 10 min before the 24-h post-ethanol withdrawal time point, significantly alleviated the expression of ethanol withdrawal-induced despair in mice on the TST. On the other hand, only the pre-treatment of the histamine H1 receptor agonist FMPH (2, 6.5 μg/mouse, intra-CA1 bilateral) reversed the reduction in locomotor activity induced in ethanol-withdrawn mice, whereas other employed histaminergic agents were devoid of any effect on this behavior. Therefore, our findings indicate that an enhanced CA1 histaminergic transmission, probably via stimulation of CA1 postsynaptic histamine H1 or H2 receptor, could preclude the behavioral despair, while H1 stimulation affects motor deficit expressed after ethanol withdrawal.

Surgical resection is a mainstay of treatment for colorectal cancer (CRC). Minimally invasive surgery (MIS) has been shown to have improved outcomes compared to open procedures for colorectal malignancy. While use of MIS has been increasing, there remains large variability in its implementation at the hospital and patient level. The purpose of this study was to identify disparities in sex, race, location, patient income status, insurance status, hospital region, bed size and teaching status for the use of MIS in the treatment of CRC. This was a retrospective cohort study using the Nationwide Inpatient Sample Database. Between 2008 and 2017, there were 412,292 hospitalizations of adult patients undergoing elective colectomy for CRC. The primary outcome was use of MIS during hospitalization. Overall, the frequency of open colectomies was higher than MIS (56.56% vs. 43.44%). Black patients were associated with decreased odds of MIS use during hospitalization compared to White patients (OR 0.921, p = 0.0011). As the county population where patients resided decreased, odds of MIS also significantly decreased as compared to central counties of metropolitan areas. As income decreased below the reference of $71,000, odds of MIS also significantly decreased. Medicaid and uninsured patients had decreased odds of MIS use during hospitalization compared to private insurance (OR 0.751, p

Introduction Medical students often have limited exposure to providing care to physically and cognitively disabled patients. To address this gap, Involvement with Disability Education and Advancement (IDEA) was started in 2015 at Rutgers New Jersey Medical School (NJMS). The organization provides NJMS students the opportunity to visit a school dedicated to disabled students and lead educational sessions on health topics. Materials and methods We conducted a survey study in 2018 to compare comfort levels between IDEA members and non-members in eliciting information from and providing medical attention to nonverbal, cognitively impaired, and physically disabled patients. The survey-based study utilized yes/no questions, and a Likert scale questionnaire to determine IDEA member and non-member comfort levels in working with various disabilities. Statistical analysis was performed using SAS Enterprise Guide 7.1; p value Results and discussion A total of 56 responses (19 members, 37 non-members) were analyzed. Regardless of IDEA membership, medical students of all years perceived themselves to have more comfort caring for physically disabled than cognitively impaired or nonverbal patients. IDEA members also recorded higher comfort levels with eliciting information from cognitively impaired patients and lower comfort levels with providing medical attention to physically disabled patients. Implications IDEA members may have increased comfort interacting with cognitively impaired individuals due to their regular experience and lower levels of comfort providing medical attention to physically disabled patients due to awareness of complex problems specific to the population. The current results warrant continued data collection and further evaluation.

Human immunodeficiency virus (HIV) is a retroviral disease in which the viruses copy their genetic material into the genetic material of the human beings. Infected cells remain infected for the whole of their life. First discovered in the year 1981, Human immunodeficiency virus infections is considered to be a pandemic by the World Health organization.

Emergent colectomy is performed in thousands of Americans each year and carries significant morbidity and mortality. Although laparoscopy has gained favor in the elective setting, its impact on failure to rescue has not been studied on a population level for emergent colectomy. The purpose of this study was to compare failure to rescue following laparoscopic versus open colectomy in the emergency setting. This was a retrospective cohort study of The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing emergent colectomy between 2005 and 2018 were selected and stratified into laparoscopic or open surgery groups using the Current Procedural Terminology codes. Propensity matching was performed based on the demographic and comorbidity data. Main outcomes were failure to rescue, mortality, overall morbidity, individual complications, and length of hospital stay. After matching, 11,484 cases were included for analysis, of which 3829 were laparoscopic. Overall, open colectomy conferred higher odds of failure to rescue (OR 1.71, 95% CI 1.42–2.08), mortality (OR 1.72, 95% CI 1.44–2.07), and morbidity (OR 1.73, 95% CI 1.60–1.88) vs laparoscopic cases. Open surgery significantly increased the risk of nearly all measured postoperative complications including return to operating room (OR 1.25, 95% CI 1.08–1.45), ventilator use > 48 h (OR 2.43, 95% CI 2.03–2.93), and septic shock (OR 2.34, 95% CI 1.97–2.80). Hospital length of stay was shorter for patients undergoing laparoscopic (10.4 days) vs open (12.3 days) colectomy (p

INTRODUCTION: Physiotherapists and students may be vulnerable to false information and may learn faulty treatment techniques due to inadequate educational quality and uncertainty about sources and trustworthiness of YouTube videos. OBJECTIVE: To investigate educational quality, trustworthiness, and content completeness of joint mobilization techniques demonstrating videos available on YouTube. DESIGN: This is a descriptive study. METHODS: We performed a YouTube search on 1(st) April 2019, using the keyword ‘Maitland joint mobilization technique for shoulder joint’. Three academic physiotherapists independently rated each video for educational quality, trustworthiness, and content completeness using the Global Quality Score, Journal of American Medical Association (JAMA) Benchmark Criteria and joint mobilization content completeness scale, respectively. RESULTS: Fifteen videos were included in the study. The median number of views for videos was 1263 (IQR 578–1478), and the median duration was 140 seconds (IQR 71–301 seconds). Most videos had low content quality (87%), poor joint mobilization content completeness (80%), and limited trustworthiness. All videos had low source quality (100%). CONCLUSIONS: There is a lack of quality information on shoulder joint mobilization techniques on YouTube, which makes it a limited educational tool for physiotherapists and students.

Mild traumatic brain injury (mTBI) is the most prevalent type of TBI (80–90%). It is characterized by a loss consciousness for less than 30 minutes, post-traumatic amnesia for less than 24 hours, and Glasgow Coma Score of 13–15. Accurately diagnosing mTBIs can be a challenge because the majority of these injuries do not show noticeable or visible changes on neuroimaging studies. Appropriate determination of mTBI is tremendously important because it might lead in some cases to post-concussion syndrome, cognitive impairments including attention, memory, and speed of information processing problems. The scientists have studied different methods to improve mTBI diagnosis and enhanced approaches that would accurately determine the severity of the trauma. The present review focuses on discussing the role of biomarkers as potential key factors in diagnosing mTBI. The present review focuses on 1) protein based peripheral and CNS markers, 2) genetic biomarkers, 3) imaging biomarkers, 4) neurophysiological biomarkers, and 5) clinical trials in mTBI. Each section provides information and characteristics on different biomarkers for mTBI.

Current studies suggest that laparoscopic colorectal surgery is an advantageous alternative to open surgery due to improved post-operative outcomes in high-risk patient groups. Limited data is currently available on the benefits of minimally invasive colectomy for diverticulitis in patients with significant pre-operative respiratory comorbidities. The NSQIP 2005–2017 datasets were used to identify patients that underwent partial colectomies due to diverticulitis. Partial colectomy cases were identified using CPT codes and then filtered to include only ICD 9 and 10 codes for diverticulitis. Pre-operative respiratory comorbidities included dyspnea, chronic obstructive pulmonary disease (COPD), and smoking status. Propensity matching was performed based on patient demographic and pre-operative risk factor data to create comparable groups for each respiratory comorbidity subset. Outcomes of interest were 30-day post-operative mortality and morbidity, incidence of return to operating room (ROR), and hospital length of stay (LoS). Laparoscopy and open surgery groups were compared using Chi square tests for categorical variables and t tests for continuous variables. A p value less than 0.05 was considered statistically significant. Among 70,420 cases with diverticulitis, 15,237 cases were identified as smokers, 3934 had dyspnea, and 3219 had COPD. Patients that had open procedures had significantly greater odds of mortality (OR 2.624 for smokers; OR 2.698 for dyspnea; OR 2.663 for COPD), morbidity (OR 2.590 for smokers; OR 2.344 for dyspnea; OR 2.883 for COPD), wound complication (OR 1.989 for smokers; OR 1.461 for dyspnea; OR 1.956 for COPD), and ROR (OR 1.184 for smokers; OR 1.634 for dyspnea; OR 1.975 for COPD). Laparoscopic procedures resulted in significantly lower average LoS (5.34 vs. 9.46 days for smokers; 6.84 vs. 11.06 days for dyspnea; 7.41 vs. 12.62 days for COPD; all p

Surgical resection is a mainstay of treatment for colorectal cancer (CRC). Minimally invasive surgery (MIS) has been shown to have improved outcomes compared to open procedures for colorectal malignancy. While use of MIS has been increasing, there remains large variability in its implementation at the hospital and patient level.The purpose of this study was to identify disparities in sex, race, location, patient income status, insurance status, hospital region, bed size and teaching status for the use of MIS in the treatment of CRC.This was a retrospective cohort study using the Nationwide Inpatient Sample Database. Between 2008 and 2017, there were 412,292 hospitalizations of adult patients undergoing elective colectomy for CRC. The primary outcome was use of MIS during hospitalization.Overall, the frequency of open colectomies was higher than MIS (56.56% vs. 43.44%). Black patients were associated with decreased odds of MIS use during hospitalization compared to White patients (OR 0.921, p = 0.0011). As the county population where patients resided decreased, odds of MIS also significantly decreased as compared to central counties of metropolitan areas. As income decreased below the reference of $71,000, odds of MIS also significantly decreased. Medicaid and uninsured patients had decreased odds of MIS use during hospitalization compared to private insurance (OR 0.751, p 0.0001 and OR 0.629, p 0.0001 respectively). Rural and urban non-teaching hospitals were associated with decreased odds of MIS as compared to urban teaching hospitals (OR 0.523, p 0.0001 and OR 0.837, p 0.0001 respectively). Hospitals with a small bed size were also associated with decreased MIS during hospitalizations (OR 0.888, p 0.0001).Marked hospital level and socioeconomic disparities exist for utilization of MIS for colorectal cancer. Strategies targeted at reducing these gaps have the potential to improve surgical outcomes and cancer survival.

A thinly built 40-year-old Caucasian man with a past medical history of weight loss, polyuria, and polydipsia was admitted with sudden-onset mild epigastric pain, nausea, dizziness, lightheadedness, and excessive thirst. He also had hyperglycemia, hyponatremia, and elevated transaminases and serum creatinine. Hyperglycemia and hyponatremia resolved after intravenous (IV) hydration and IV insulin. However, he had persistently elevated creatinine and abnormal liver function tests upon discharge the following day and was instructed to establish care with Endocrinology.

Case 1, a 62-year-old female with recurrent invasive ductal carcinoma metastatic to lung and bone, was referred to Endocrinology for management of hyperglycemia. Case 2, a 47-year-old female with history of major depressive disorder, generalized anxiety disorder, and recurrent metastatic breast cancer, was referred to Endocrinology for management of alpelisib-induced diabetes. Case 3, a 59-year-old female with metastatic invasive ductal carcinoma, gastroesophageal reflux disease, and chronic low back pain, was diagnosed with alpelisib-induced diabetes.

The present study investigated the plausible modulatory role of central histaminergic transmission on the expression of nicotine withdrawal induced anxiety and somatic behavior in mice. Abrupt cessation of chronic nicotine (2 mg/kg, i.p. × 3/day) treatment for 12 days to mice, expressed increased anxiety in light & dark test and total abstinence (somatic) score at 24 h post nicotine withdrawal time. The somatic signs includes a composite score of all behaviors such as grooming, rearing, jumping, body shakes, forelimb tremors, head shakes, abdominal constrictions, scratching, empty mouth chewing or teeth chattering, genital licking, tail licking. Mice exhibited higher expression to nicotine withdrawal induced anxiety in light & dark test at 24 h post-nicotine withdrawal time on pre-treatment centrally (i.c.v) with histaminergic agents like histamine (0.1, 50 μg/mouse), histamine H3 receptor inverse agonist, thioperamide (2, 10 μg/mouse), histamine H1 receptor agonist, FMPH (2, 6.5 μg/mouse) or H2 receptor agonist amthamine (0.1, 0.5 μg/mouse) or intraperitoneally (i.p.) with histamine precursor, l-histidine (250, 500 mg/kg) as compared to control nicotine withdrawn animals. Furthermore, mice pre-treated with all these histaminergic agents except histamine H1 receptor agonist, FMPH shows exacerbated expression to post-nicotine withdrawal induced total abstinence (somatic) score in mice. On the other hand, central injection of selective histamine H1 receptor antagonist, cetirizine (0.1 μg/mouse, i.c.v.) or H2 receptor antagonist, ranitidine (50 μg/mouse, i.c.v) to mice 10 min before 24 h post-nicotine withdrawal time completely alleviated the expression of nicotine withdrawal induced anxiety and somatic behavior. Thus, it can be contemplated that the blockade of central histamine H1 or H2 receptor during the nicotine withdrawal phase could be a novel approach to mitigate the nicotine withdrawal associated anxiety-like manifestations. Contribution of endogenous histamine via H1 or H2 receptor stimulation in the nicotine withdrawal induced anxiety and somatic behavior is proposed.

INTRODUCTION The incidence of thyroid cancer has risen steadily over the last decades, in part due to increasing diagnosis of apparently low-risk well-differentiated cancers. The outcomes of well-differentiated thyroid cancers, including follicular variant papillary thyroid carcinoma (PTC), are believed to be quite favorable, with a largely indolent benign course. We examine an encapsulated follicular-variant of micropapillary carcinoma presenting with distant bony metastasis. CASE 55-year-old lady presented to clinic after biopsy of iliac crest (IC) mass revealed thyroid tissue. One year prior she started having dull pain at right hip, attributed to increased physical activity. She noticed a tender “lump” on her right hip. CT revealed destructive right iliac 8 cm mass with extraosseous soft tissue component, central necrosis, and eccentric calcifications; and right ovarian cyst. Right IC biopsy was consistent with thyroid tissue with positive Thyroglobulin and TTF-1 immunostains. Physical exam was normal, except for mild tachycardia, hypertension, right flank large rounded mass fixed to IC, tender to palpation without erythema or warmth on overlying skin. Thyroid ultrasound showed normal thyroid gland except 5.58 x 6.22 x 7.76 mm left lobe nodule without increased vascularity but with coarse peripheral calcification. FNA was unsatisfactory. Thyroid function tests revealed undetectable TSH, elevated FT4, FT3, and markedly elevated thyroglobulin and TSI. PET/CT scan showed focal area of mild FDG avidity, corresponding to the right iliac crest mass, without additional areas of FDG avidity suggestive of metastatic disease or primary neoplastic process. Three weeks after presentation, patient began having symptoms of hyperthyroidism. As FT4 and FT3 continued to rise, she was started on propranolol and methimazole. Due to inadequate response, methimazole was switched to high dose propylthiouracil with mild improvement. Thyroid uptake and scan and SPECT-CT revealed increased thyroid uptake and thyromegaly consistent with Graves’ disease and redemonstrated large right IC lesion with increased uptake in the periphery and central photopenia, suggesting metastatic thyroid malignancy. Pathology from total thyroidectomy reported encapsulated follicular variant of PTC, confined to the left lobe of the thyroid, without extrathyroidal extension, greatest tumor dimension 0.6cm. As metastasis to the IC were unlikely to have originated from this small encapsulated thyroid cancer, it was recommended to proceed with right oophorectomy for suspected malignant struma ovarii and IC lesion debulking. Surgical pathology revealed right ovary and fallopian tube without pathologic changes or features of teratoma and tissue from right iliac mass consistent with PTC. Patient is off all antithyroid medications and remains biochemically euthyroid, awaiting radioactive iodine therapy.

Background: A NSABP B 59 trial is currently underway to check the efficacy of an experimental drug, Atezolizumab (Anti-PDL 1 monoclonal antibody) in the treatment of triple negative breast cancer. In the trail, the drug is added to the usual neoadjuvant chemotherapy given before surgery and prolonged treatment with it is continued after surgery to reduce the recurrence. Listed adverse effects are immune medicated hyperthyroidism in 2% of population. Clinical Case: 32 y old Asian woman was diagnosed with triple negative left breast cancer in May 2018. She was started on paclitaxel, carboplatin and study medication Atezolizumab/Placebo in June 2018 and she received 4 cycles of the same and then it was stopped in August 2018. She was started back on the same in September 2018 which ended in November 2018. Patient tested positive for BRCA1 gene mutation and underwent bilateral mastectomy in December 2018. The study medication was restarted in January 2019. Patient is received a total of 11 doses of study medication and was due to receive 16 doses if she had finished the trial in June 2019. Patient received radiation therapy starting in January 2019 till February 2019. On her oncology visit in April 2019 patient was found to have a suppressed TSH of 0.009 with a high free thyroxine of 1.72 and an elevated free T3 of 5.4. She was referred to endocrinology for evaluation of thyroid abnormalities, as the study medication can cause thyroid problems. She denied symptoms of hyperthyroidism. TPO, TSI and anti-thyroglobulin antibodies were negative. Thyroid uptake scan showed uniformly decreased tracer distribution in both thyroid lobes consistent with thyroiditis. As per the protocol for the study medication as well as recommendations by the American Society of oncology, we waited for normalization of the thyroid function test before resuming the study medication. In July 2019, TSH normalized to 2.99 and free T4 0.97. She was noted to have low random cortisol level of 3.27 at 1000AM. ACTH stimulation test was performed and she responded appropriately. Hence could not take the remainder of the study medication that were scheduled until June 2019. She is on observation phase since June 2019 and currently doing well.

Introduction: Paget’s disease of the bone is characterized by excessive osteoclastic bone resorption followed by formation of disorganized bone; which is often focal. Bone pain and deformities are common features and it often leads to complications such as pathological fractures, deafness or neurologic deficits. Elevated bone turnover markers and alkaline phosphatase reflect ongoing exaggerated bone resorption and osteoblastic activity. We present an unusual scenario of post-menopausal osteoporosis and Paget’s disease occurring in the same patient. Clinical Case: 86-year-old female with history of Type 2 Diabetes Mellitus, Hypertension, Hypothyroidism, degenerative joint disease of lumbar spine with prior interbody fusion and laminectomy was referred to our clinic by Orthopedics for evaluation of newly diagnosed Paget’s disease. 2 months ago, she noticed severe right hip pain limiting daily activities. She denied any history of falls, fractures or family history of Paget’s. Physical exam was notable for tenderness to right sacro-iliac joint and right femoral trochanteric region. Work up included MRI of Lumbar spine and Pelvis, Pelvis X-ray, DEXA scan and routine blood work. Interestingly, her DEXA scan showed T score of +2.9 in Right hip and -3.1 in Left hip. On Pelvis X-ray cortical thickening, coarse trabecula and osteoarthritic changes were noted in right femur and hip, consistent with Paget’s disease. Left femur showed strikingly thinner cortices compared to the right, due to underlying osteoporosis. MRI of lumbar spine and pelvis was consistent with polyostotic Paget’s involving L3-L5, Sacrum and Right femur. Nuclear bone scan showed areas of uptake including anterior calvarium, lumbar spine, right hip, right femur, 8th rib, left mid tibia and 1st metatarsal of left foot. Since the distribution of uptake seemed atypical for Paget’s, a skeletal survey was obtained which was negative for bone lesions suggestive of malignancy. Laboratory testing revealed serum calcium 9.8mg/dL(8.4–10.2), 25-Hydroxy Vitamin D 30ng/dL(20–30), PTH 45.6pg/mL (15–65), Alkaline Phosphatase 370U/L (35–104), Procollagen I intact N-terminal 516mcg/L (16–96) and N-Terminal Telopeptide (NTX) 126.4 nM BCE (6.2–19). Patient received one dose of IV Zoledronic acid with modest improvement in hip and lower back pain. She continues to take Calcium carbonate 600mg twice daily and vitamin D3 1000IU once daily. We plan to see her in follow up in 3 months with repeat levels bone turnover markers. Conclusion: This is a unique case of Paget’s disease and osteoporosis, two very different diseases of metabolic bone disorder spectrum found in one patient. Treatment of Paget’s disease is indicated for pain reduction, prevention of fractures and deformities and to prevent disease progression in weight bearing areas. Bisphosphonates can target pathology of both diseases by reducing osteoclastic bone resorption.

Small bowel obstruction (SBO) continues to be a common indication for acute care surgery. While open procedures are still widely used for treatment, laparoscopic procedures may have important advantages in certain patient populations. We aim to analyze differences in outcomes between the two for treatment of bowel obstruction.The American College of Surgeons National Surgical Quality Improvement Program was used to find patients that underwent emergent or non-elective surgery for SBO. Propensity matching was used to create comparable groups. Logistic regression was used to assess differences in the primary outcome of interest, return to operating room, and morbidity and mortality outcomes. Logistic regression was also used to assess the contribution of various preoperative demographic and comorbidity characteristics to 30-day mortality.A total of 24,028 patients underwent surgery for SBO from 2005 to 2011. Of those, 3391 were laparoscopic. Propensity matching resulted in 6782 matched patients. Laparoscopic cases had significantly decreased odds of experiencing any morbidity and wound complications compared to open cases in bowel-resection and adhesiolysis-only cases. There was no significant difference found for odds of returning to operating room. Laparoscopic cases resulted in significantly shorter hospital stays than open cases (7.18 vs.10.84 days, p 0.0001). Increasing age, American Society of Anesthesiologists class greater than three, and the presence of respiratory comorbidities resulted in increased odds of mortality. Underweight body mass index (BMI) ( 18.5) increased odds of mortality while greater than normal BMI ( 25) decreased odds of mortality.Analysis of emergent SBO cases between 2005 and 2015 demonstrates that laparoscopy is not utilized as often as open approaches in surgical treatment. Laparoscopic surgery resulted in reduced postoperative morbidity and significantly shorter hospital stays compared to open intervention and was not associated with significant differences in odds of reoperation compared to open surgery.

Case Description: A 65 year-old male with initial diagnosis of metastatic colon cancer based on liver biopsy presented for evaluation of severe hypercortisolism with 24-hour urinary free cortisol (UFC) of 1184 mcg/day after presenting to his Oncologist in December 2019 requesting evaluation for muscle weakness and weight gain. On re-evaluation in March, his cortisol had dramatically improved with 24-hr UFC of 120 mcg/day and ACTH of 84 pg/mL and had resolved with 24-hr UFC of 32.6 mcg/day by May. A 2 cm pancreatic lesion was noted during cancer staging; a second opinion was obtained on the liver biopsy which was interpreted as metastatic neuroendocrine tumor, possibly of pancreatic origin. The patient was started on FOLFINIRNOX in December 2019. This was transitioned to carboplatin and etoposide after the revised diagnosis and was continued through May with regression of liver lesions on followup imaging. A 68 Ga-DOTATATE PET CT confirmed uptake in the pancreas, retroperitoneal lymph nodes, and thyroid. A thyroid ultrasound was obtained which did not meet FNA criteria. Given the chronologic association between cortisol levels and chemotherapy response we were suspicious for ectopic Cushing’s syndrome due to metastatic neuroendocrine cancer and the patient was followed for recurrence. In September, the patient endorsed leg weakness and hyperglycemia and was found to have a 24-hr UFC of 4731 mcg/day and an 8 am cortisol of 102 mcg/dL. The patient developed severe hypokalemia requiring admission and was restarted on chemotherapy with moderate improvement in cortisol levels and symptoms. Given the degree of cortisol elevation, we recommended bilateral adrenalectomy, for which the patient established care at a more specialized center. Discussion: Ectopic Cushing’s syndrome is an uncommon variety of ACTH-dependent Cushing’s syndrome caused by CRH or ACTH-producing tumors. The more aggressive form is associated with small-cell lung cancer while the chronic form is associated with indolent tumors. Cyclical Cushing’s syndrome is a rare cause of hypercortisolism characterized by cyclical variations in cortisol levels. The pathophysiology of the cyclical variation is unclear. About half of cases are caused by pituitary corticotrophs but up to 26% can be attributed to ectopic ACTH production, typically due to indolent tumors rather than aggressive malignancies. We present a case of cyclical hypercortisolism with an initial diagnosis of colon cancer. On further review, the cyclical hypercortisolism was likely associated with chemotherapy response. Reevaluation of surgical pathology was consistent with metastatic neuroendocrine cancer, the likely source of ectopic ACTH. Our case highlights the importance of maintaining a broad differential when considering cases of cyclical cortisol elevation, including consideration of concurrent chemotherapy for seemingly unrelated malignancies.

Purpose: The purpose of this study was to determine whether a physical therapy student’s level of grit positively correlates to graduate school grade point average. Methods: Participants were a convenience sample recruited from the class of 2021 in the Doctor of Physical Therapy program at Franklin Pierce University in Goodyear, Arizona. Subjects completed the Short Grit Scale (Grit-S) as a measure of grit. These scores were compared with participants’ graduate school grade point average using a Spearman Rho statistical test with data analysis completed using SPSS software. Results: 27 participants (15 males, 12 females) with mean grit score of 3.76 ± 0.48 and mean grade point average 3.72 ± 0.18. Spearman Rho correlation was .463 (p < .05). Conclusion: A significant moderate positive correlation between grit and graduate school grade point average in physical therapy students was found. These findings indicate preliminary evidence that may be useful for admissions considerations for DPT programs.

Background Diabetes mellitus (DM) is one of the most common chronic diseases in the world. As a disease with long-term complications requiring changes in management, DM requires not only education at the time of diagnosis, but ongoing diabetes self-management education and support (DSME/S). In the United States, however, only a small proportion of people with DM receive DSME/S, although evidence supports benefits of ongoing DSME/S. The diabetes education that providers deliver during follow-up visits may be an important source for DSME/S for many people with DM. Methods We collected 200 clinic notes of follow-up visits for 100 adults with DM and studied the History of Present Illness (HPI) and Impression and Plan (I&P) sections. Using a codebook based on the seven principles of American Association of Diabetes Educators Self-Care Behaviors (AADE7), we conducted a multi-step deductive thematic analysis to determine the patterns of DSME/S information occurrence in clinic notes. Additionally, we used the generalised linear mixed models for investigating whether providers delivered DSME/S to people with DM based on patient characteristics. Results During follow-up visits, Monitoring was the most common self-care behaviour mentioned in both HPI and I&P sections. Being Active was the least common self-care behaviour mentioned in the HPI section and Healthy Coping was the least common self-care behaviour mentioned in the I&P section. We found providers delivered more information on Healthy Eating to men compared to women in I&P section. Generally, providers delivered DSME/S to people with DM regardless of patient characteristics. Conclusions This study focused on the frequency distribution of information providers delivered to the people with DM during follow-up clinic visits based on the AADE7. The results may indicate a lack of patient-centred education when people with DM visit providers for ongoing management. Further studies are needed to identify the underlying reasons why providers have difficulty delivering patient-centred education.

Cardiovascular disease (CVD) is the leading cause of mortality in people with diabetes. Our aim was to review the pathophysiology of CVD in diabetes, review related landmark trials, and discuss the cardiovascular benefit of glucose-lowering agents. We have also discussed the role of controversial anti-platelet therapy. Recent studies have shown the impact of glucose-lowering agents on CVD in people with diabetes. Statins are now recommended for all patients with diabetes over the age of 40 regardless of the LDL level given the cardiovascular benefit of these drugs. Current recommendations suggest a blood pressure

Introduction Physicians are increasingly practicing defensive medicine as a response to society’s litigious climate. This study sought to characterize cardiology malpractice claims and elucidate the allegations underlying the use of defensive medicine. Methods The WestlawNext™ database was queried to obtain state and federal jury verdicts and settlements related to medical malpractice and cardiology that occurred in the United States between 2010 and 2015. Cardiology cases were identified using the search terms “medical malpractice” and “cardiology” and reviewed by two individuals utilizing available case documents. Duplicate and nonpertinent cases were excluded. Binary logistic regression models were created to predict the likelihood of defendant verdict, plaintiff verdict, and settlement based on the various reasons for litigation cited. Results Inclusion criteria were met in 166 cases. The plaintiffs were predominantly male (94 cases; 56.6%), and the average patient age was 53.3±17.5 years. More than half of the cases involved a cardiologist as a defendant. The most common reasons for litigation were: failure to treat (129; 77.7%), failure to diagnose (115; 69.3%), failure to refer/order diagnostic tests (107; 64.5%), and patient death (118; 71.1%). Among cases tried for failure to diagnose, the most commonly missed diagnosis was myocardial infarction. Cases most commonly resulted in a defendant verdict (94; 56.6%). However, odds of a plaintiff verdict were significantly higher when failure to diagnose was alleged with an odds ratio (OR) of 7.60 (95% confidence interval 1.14 - 50.87, p = 0.0365). Conclusions Failure to diagnose remains a commonly alleged base for litigation. In conclusion, our analysis suggests increased training for non-cardiologists in the recognition of the acute coronary syndrome and enhanced awareness of inherent biases among all physicians may facilitate reducing missed diagnoses.

Introduction: Iodine is an essential micronutrient for thyroid hormone synthesis. Its primary source is fortified foods. Supraphysiologic doses of iodine are often found in iodine supplements that are advertised to support thyroid metabolism and reduce goiter size. Normally, excess iodine temporarily inhibits production of thyroid hormone (Wolff-Chaikoff effect), causing goiter and hypothyroidism. In patients with a pre-existing nodular goiter, the auto-regulation of iodine entry into thyroid cells and thyroid hormone synthesis are ineffective. Exposure to high doses of iodine in such cases can precipitate hyperthyroidism (Jod-Basedow phenomenon). Clinical Case: A 50 year-old lady with morbid obesity, chronic lymphedema, longstanding hypothyroidism, and a large retrosternal goiter presented with severe sepsis from cellulitis and tachycardia-induced cardiomyopathy (ejection fraction 30%) from a new-onset atrial flutter with rapid ventricular rate requiring cardioversion. Free (f)T4 was 4.81 ng/dL (0.93-1.7), fT3 6.0 pg/mL (2.0-4.4) and TSH 0.006 mcu/mL (0.27-4.2). Two years ago, she was seen by endocrinology, at which time TSH was 1.58 mcu/mL on desiccated thyroid 30 mg qd. Due to substernal goiter, surgery was recommended then but declined by the patient. Later, she increased desiccated thyroid to 60mg qd and started OTC iodine supplements at 30,000 mcg qd (20,000% RDA) of her own volition, hoping to decrease the size of the goiter. The patient was subsequently lost to follow-up. On this admission, hospital course was complicated by disseminated intravascular coagulation, acute kidney injury needing renal replacement therapy (RRT), encephalopathy, and mechanical ventilation. CT and US demonstrated stable heterogeneous, multinodular goiter (12.5 x 9.3 cm with mediastinal extension), without prominent vascularity. Treatment with PTU, beta-blockers, hydrocortisone, and cholestyramine was initiated on day 1. Serum iodine was markedly elevated at 2,160 ng/ml (40-92) and improved to 221 ng/ml after six days of RRT. Despite PTU 300mg q6h for > 3 weeks, fT4 remained elevated. Eventually fT3 and fT4 normalized to 2.1pg/mL and 1.30ng/dL, respectively, with continued improvement in iodine level. TSH remained undetectable. Severe medical comorbidities precluded surgical resection of the goiter. Conclusion: Dessicated thyroid hormone, markedly supraphysiologic iodine intake, and thyroid autonomy characteristic of MNG contributed to life-threatening thyrotoxicosis in this patient. Extremely high iodine content in the blood and thyroid undoubtedly impeded therapeutic response to PTU, and RRT helped to lower systemic iodine load. This case demonstrates the importance of careful history taking to identify unusual sources of iodine in patients, and patient education regarding possible dangers associated with unregulated OTC and dietary supplements.

Objectives Current imaging techniques have limited ability to quantify thrombus burden in patients with acute deep vein thrombosis (DVT). There is limited ability to objectively measure clot progression or clot resolution over time and with treatment. These critical measures are important determinants of optimal treatment and therapeutic success for thrombolysis or thrombectomy treatment of DVT. In this study, we evaluated the feasibility and reliability of a method of quantifying thrombus volume using freehand three-dimensional (3D) ultrasonography and compared it to a commercially available four-dimensional (4D) transducer for acquiring and analyzing 3D ultrasound images to measure thrombus volume. Methods We studied 10 consecutive patients with a first episode of acute DVT to compare the performance of freehand 3D with 4D transducer imaging (group 1). In addition, we studied five patients with thrombus length >3.8 cm to evaluate the performance of freehand 3D imaging in larger clots (group 2). Scanning was performed with routine grayscale, color-flow, and power-Doppler imaging; followed by freehand 3D and 4D transducer volumetric imaging. Postprocessing was performed using the Stradwin software to measure thrombus volume after each scan. Results The age of patients was 54 ± 13 years (mean ± SD), 73.3% of DVTs were in the upper extremity, and 60% of the patients received anticoagulation. The mean thrombus volume in group 1 measured by freehand 3D and 4D probes was 0.49 ± 0.40 cm3 and 0.52 ± 0.46 cm3, respectively, and there was no significant difference between the measurements ( t = −1.57, p = 0.15). Regression analysis demonstrated good agreement between the two imaging modalities ( R2 = 0.99, regression slope = 1.13, p < 0.001). The freehand 3D technique was also successfully used to quantify thrombus volume (4.71 ± 3.28 cm3) in five patients with DVT >3.8 cm in length (group 2). Conclusions The described freehand 3D imaging protocol reliably measures thrombus volume in patients with acute DVT when compared with the commercially available 4D transducer. The freehand 3D method has the additional benefit of measuring thrombus volume in DVTs >3.8 cm in length. The method is convenient and can be used in clinical practice.

Lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice with a focus on statin treatment in an underserved population based in a large single urban medical center. Among 1042 reviewed records, we identified 464 statin-eligible patients. Age was 61.0 &plusmn, 10.4 years and 53.9% were female. Most patients were black (47.2%), followed by Hispanic (45.7%) and white (5.0%). In total, 82.1% of patients were prescribed a statin. An appropriate statin was not prescribed in 32.4% of statin-eligible patients who qualified based only on a 10-year ASCVD risk of &ge, 7.5%. After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age &gt, 55 years (OR = 4.59 (95% CI 1.09&ndash, 16.66), p = 0.026), hypertension (OR = 2.38 (95% CI 1.29&ndash, 4.38), p = 0.005) and chronic kidney disease (OR = 3.95 (95% CI 1.42&ndash, 14.30), p = 0.017). Factors independently associated with statin undertreatment were black race (OR = 0.42 (95% CI 0.23&ndash, 0.77), p = 0.005) and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 (95% CI 0.07&ndash, 0.25), p &lt, 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to black patients (86.8% vs. 77.2%). Statin underprescription is seen in approximately one out of five eligible patients and is independently associated with black race, younger age, fewer comorbidities and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to black patients.

Current studies suggest that laparoscopic colorectal surgery is an advantageous alternative to open surgery due to improved post-operative outcomes in high-risk patient groups. Limited data is currently available on the benefits of minimally invasive colectomy for diverticulitis in patients with significant pre-operative respiratory comorbidities.The NSQIP 2005-2017 datasets were used to identify patients that underwent partial colectomies due to diverticulitis. Partial colectomy cases were identified using CPT codes and then filtered to include only ICD 9 and 10 codes for diverticulitis. Pre-operative respiratory comorbidities included dyspnea, chronic obstructive pulmonary disease (COPD), and smoking status. Propensity matching was performed based on patient demographic and pre-operative risk factor data to create comparable groups for each respiratory comorbidity subset. Outcomes of interest were 30-day post-operative mortality and morbidity, incidence of return to operating room (ROR), and hospital length of stay (LoS). Laparoscopy and open surgery groups were compared using Chi square tests for categorical variables and t tests for continuous variables. A p value less than 0.05 was considered statistically significant.Among 70,420 cases with diverticulitis, 15,237 cases were identified as smokers, 3934 had dyspnea, and 3219 had COPD. Patients that had open procedures had significantly greater odds of mortality (OR 2.624 for smokers; OR 2.698 for dyspnea; OR 2.663 for COPD), morbidity (OR 2.590 for smokers; OR 2.344 for dyspnea; OR 2.883 for COPD), wound complication (OR 1.989 for smokers; OR 1.461 for dyspnea; OR 1.956 for COPD), and ROR (OR 1.184 for smokers; OR 1.634 for dyspnea; OR 1.975 for COPD). Laparoscopic procedures resulted in significantly lower average LoS (5.34 vs. 9.46 days for smokers; 6.84 vs. 11.06 days for dyspnea; 7.41 vs. 12.62 days for COPD; all p .0001).Laparoscopic colectomy for diverticulitis diagnosis for a matched cohort of patients with pre-operative respiratory comorbidities such as smoking status, dyspnea, and COPD resulted in significantly improved post-operative outcomes, lower odds of mortality and morbidity, and shorter LoS.

We report portable, user-friendly reagents and equipment for visual, hands-on biology activities with supporting curriculum., Synthetic biology offers opportunities for experiential educational activities at the intersection of the life sciences, engineering, and design. However, implementation of hands-on biology activities in classrooms is challenging because of the need for specialized equipment and expertise to grow living cells. We present BioBits™ Bright, a shelf-stable, just-add-water synthetic biology education kit with easy visual outputs enabled by expression of fluorescent proteins in freeze-dried, cell-free reactions. We introduce activities and supporting curricula for teaching the central dogma, tunable protein expression, and design-build-test cycles and report data generated by K-12 teachers and students. We also develop inexpensive incubators and imagers, resulting in a comprehensive kit costing

Background: Cutaneous scar endometriosis is an uncommon pathology, it is rare and difficult to diagnose, mostly follows obstetrical and gynaecological surgeries. Surgical wide excision is the mainstay of treatment. The objective of this study was to evaluate efficacy of preoperative GnRh agonist in scar endometriosis. Methods: This is prospective randomized case control study performed on all cutaneous scar endometriosis cases reporting to our institute as well as consultants from Dhule obstetrics and gynaecology society. All cases were operated and follow up in our institute by same surgeon. Results: Surgical excision accompanied by preoperative GnRh agonist therapy is helpful for easy excision and reduce recurrence of scar endometriosis. Conclusions: Abdominal scar endometriosis is rare gynecological pathology, should be suspected in any women of child bearing age group complaining of cyclical painful nodule in scar following a previous obstetric and gynaecological procedure.

Background: Various tubal pathologies accounts for 10% aetiological factors in infertility couples. Easy availability and accessibility of ultrasonography definitely can prove superior to conventional method of diagnosis of tubal patency in such patient. Aims and objectives of the study were to test the sensitivity and specificity of sonosalpingography (SSG) for tubal patency test in cases of infertility patients attending to our OPD and to compare the result of sonosalpingography v/s HSG. Methods: In a non randomised prospective control trial of 50 women complaining of infertility, suspected tubal pathologies underwent various radiological modalities. Sonosalpingography and hysterosalpingography was performed in all cases. Results: By using binomial proportion test there is no significant difference between results of SSG compare to HSG. Acceptability was 100% in SSG compared to 96% in HSG. Conclusions: Various modalities are suggested to evaluate tubal patency test in infertile women. Among those laparoscopic chromopertubation is gold standard method, but for initial workup as cost effectiveness acceptability, accessibility is concerned SSG is always superior to HSG.