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Financial planning and satisfaction across life domains among retired emergency physicians in the United States.

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Financial planning and satisfaction across life domains among retired emergency physicians in the United States.

Am J Emerg Med. 2018 Mar;36(3):508-510

Authors: Kuhn GJ, Marco CA, Mallory MNS, Blanda M, Kaplan JA, Schneider SM, Joldersma KB, Martin SI, Choo EK

PMID: 28784258 [PubMed - indexed for MEDLINE]

Reliability of the classification of proximal femur fractures: Does clinical experience matter?

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Reliability of the classification of proximal femur fractures: Does clinical experience matter?

Injury. 2018 Apr;49(4):819-823

Authors: Crijns TJ, Janssen SJ, Davis JT, Ring D, Sanchez HB, Science of Variation Group

Abstract
BACKGROUND: Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master.
QUESTIONS/PURPOSES: We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup.
METHODS: This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss' kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons.
RESULTS: There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001).
CONCLUSIONS: This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.

PMID: 29549969 [PubMed - indexed for MEDLINE]

An international perspective on hospitalized patients with viral community-acquired pneumonia.

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An international perspective on hospitalized patients with viral community-acquired pneumonia.

Eur J Intern Med. 2018 Nov 03;:

Authors: Radovanovic D, Sotgiu G, Jankovic M, Mahesh PA, Marcos PJ, Abdalla MI, Di Pasquale MF, Gramegna A, Terraneo S, Blasi F, Santus P, Aliberti S, Reyes LF, Restrepo MI, GLIMP Study Group, Aruj PK, Attorri S, Barimboim E, Caeiro JP, Garzón MI, Cambursano VH, Ceccato A, Chertcoff J, Cordon Díaz A, de Vedia L, Ganaha MC, Lambert S, Lopardo G, Luna CM, Malberti AG, Morcillo N, Tartara S, Pensotti C, Pereyra B, Scapellato PG, Stagnaro JP, Shah S, Lötsch F, Thalhammer F, Anseeuw K, Francois CA, Van Braeckel E, Vincent JL, Djimon MZ, Aranha Nouér S, Chipev P, Encheva M, Miteva D, Petkova D, Balkissou AD, Pefura Yone EW, Mbatchou Ngahane BH, Shen N, Xu JF, Bustamante Rico CA, Buitrago R, Pereira Paternina FJ, Kayembe Ntumba JM, Vladic-Carevic V, Jakopovic M, Matkovic Z, Mitrecic I, Bouchy Jacobsson ML, Bro Christensen A, Heitmann Bødtger UC, Meyer CN, Vestergaard Jensen A, El-Said Abd El-Wahhab I, Elsayed Morsy N, Shafiek H, Sobh E, Abdulsemed KA, Bertrand F, Brun-Buisson C, de Montmollin E, Fartoukh M, Messika J, Tattevin P, Khoury A, Ebruke B, Dreher M, Kolditz M, Meisinger M, Pletz MW, Hagel S, Rupp J, Schaberg T, Spielmanns M, Creutz P, Suttorp N, Siaw-Lartey B, Dimakou K, Papapetrou D, Tsigou E, Ampazis D, Kaimakamis E, Bhatia M, Dhar R, D'Souza G, Garg R, Koul PA, Jayaraj BS, Narayan KV, Udnur HB, Krishnamurthy SB, Kant S, Swarnakar R, Salvi S, Limaye S, Golshani K, Keatings VM, Martin-Loeches I, Maor Y, Strahilevitz J, Battaglia S, Carrabba M, Ceriana P, Confalonieri M, d'Arminio Monforte A, Del Prato B, De Rosa M, Fantini R, Fiorentino G, Gammino MA, Menzella F, Milani G, Nava S, Palmiero G, Petrino R, Gabrielli B, Rossi P, Sorino C, Steinhilber G, Zanforlin A, Franzetti F, Carone M, Patella V, Scarlata S, Comel A, Kurahashi K, Aoun Bacha Z, Barajas Ugalde D, Ceballos Zuñiga O, Villegas JF, Medenica M, van de Garde EMW, Raj Mihsra D, Shrestha P, Ridgeon E, Ishola Awokola B, Nwankwo ONO, Olufunlola AB, Olumide S, Ukwaja KN, Irfan M, Minarowski L, Szymon S, Froes F, Leuschner P, Meireles M, Ferrão C, Leuschner P, Neves J, Ravara SB, Brocovschii V, Ion C, Rusu D, Toma C, Chirita D, Dorobat CM, Birkun A, Kaluzhenina A, Almotairi A, Bukhary ZAA, Edathodu J, Fathy A, Mushira Abdulaziz Enani A, Eltayeb Mohamed N, Ulhadi Memon J, Bella A, Bogdanović N, Milenkovic B, Pesut D, Borderìas L, Bordon Garcia NM, Cabello Alarcón H, Cilloniz C, Torres A, Diaz-Brito V, Casas X, Encabo González A, Fernández-Almira ML, Gallego M, Gaspar-GarcÍa I, González Del Castillo J, Javaloyes Victoria P, Laserna Martínez E, Malo de Molina R, Menéndez R, Pando-Sandoval A, Prat Aymerich C, Lacoma de la Torre A, García-Olivé I, Rello J, Moyano S, Sanz F, Sibila O, Rodrigo-Troyano A, Solé-Violán J, Uranga A, van Boven JFM, Vendrell Torra E, Pujol JA, Feldman C, Kee Yum H, Fiogbe AA, Yangui F, Bilaceroglu S, Dalar L, Yilmaz U, Bogomolov A, Elahi N, Dhasmana DJ, Feneley A, Hancock C, Hill AT, Rudran B, Ruiz-Buitrago S, Campbell M, Whitaker P, Youzguin A, Singanayagam A, Allen KS, Brito V, Dietz J, Dysart CE, Kellie SM, Franco-Sadud RA, Meier G, Gaga M, Holland TL, Bergin SP, Kheir F, Landmeier M, Lois M, Nair GB, Patel H, Reyes K, Rodriguez-Cintron W, Saito S, Soni NJ, Noda J, Hinojosa CI, Levine SM, Angel LF, Anzueto A, Scott Whitlow K, Hipskind J, Sukhija K, Totten V, Wunderink RG, Shah RD, Mateyo KJ, Carugati M, Morosi M, Monge E

Abstract
BACKGROUND: Who should be tested for viruses in patients with community acquired pneumonia (CAP), prevalence and risk factors for viral CAP are still debated. We evaluated the frequency of viral testing, virus prevalence, risk factors and treatment coverage with oseltamivir in patients admitted for CAP.
METHODS: Secondary analysis of GLIMP, an international, multicenter, point-prevalence study of hospitalized adults with CAP. Testing frequency, prevalence of viral CAP and treatment with oseltamivir were assessed among patients who underwent a viral swab. Univariate and multivariate analysis was used to evaluate risk factors.
RESULTS: 553 (14.9%) patients with CAP underwent nasal swab. Viral CAP was diagnosed in 157 (28.4%) patients. Influenza virus was isolated in 80.9% of cases. Testing frequency and viral CAP prevalence were inhomogeneous across the participating centers. Obesity (OR 1.59, 95%CI: 1.01-2.48; p = 0.043) and need for invasive mechanical ventilation (OR 1.62, 95%CI: 1.02-2.56; p = 0.040) were independently associated with viral CAP. Prevalence of empirical treatment with oseltamivir was 5.1%.
CONCLUSION: In an international scenario, testing frequency for viruses in CAP is very low. The most common cause of viral CAP is Influenza virus. Obesity and need for invasive ventilation represent independent risk factors for viral CAP. Adherence to recommendations for treatment with oseltamivir is poor.

PMID: 30401576 [PubMed - as supplied by publisher]

Lay navigation across the cancer continuum for older cancer survivors: Equally beneficial for Black and White survivors?

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Lay navigation across the cancer continuum for older cancer survivors: Equally beneficial for Black and White survivors?

J Geriatr Oncol. 2018 Oct 30;:

Authors: Pisu M, Rocque GB, Jackson BE, Kenzik KM, Sharma P, Williams CP, Kvale EA, Taylor RA, Williams GR, Azuero A, Li Y, Acemgil A, Martin MY, Demark-Wahnefried W, Turkman Y, Fouad M, Rocconi RP, Sullivan M, Cantuaria G, Partridge EE, Meneses K

Abstract
OBJECTIVES: The Patient Care Connect Program (PCCP), through lay navigators' distress assessments and assistance, was shown to lower healthcare utilization and costs in older cancer survivors. PCCP benefits and assistance needs for disadvantaged minorities (e.g., Black) vs. Whites are unknown.
MATERIALS AND METHODS: We examined the PCCP impact with retrospective analyses of Medicare claims (2012-2015). Outcomes were quarterly costs and utilization (emergency room (ER), hospitalizations) for navigated and matched survivors. Repeated measures generalized linear models with normal (costs), and Poisson (utilization) distributions assessed differences in trends overall and separately for Blacks and Whites. With distress data for navigated survivors, we assessed high distress (score > 3), ≥1 distress cause (overall, by domain), and ≥ 1 assistance request by minority group.
RESULTS: Beneficiaries were: 772 Black and 5350 White navigated, and 770 Black and 5348 White matched survivors. Impact was: i) costs: -$557.5 Blacks (p < .001), -$813.4 Whites (p < .001); ii) ER: Incidence Rate Ratio (IRR) 0.97 Blacks (NS), 0.93 Whites (p < .001); iii) hospitalizations: IRR 0.97 Blacks (NS), 0.91 Whites (p < .001). There was no significant difference in impact across minority groups. No significant differences were found in high distress (29% Black, 25.1% White), ≥1 distress cause (61.6% Black, 57.8% White), or ≥ 1 assistance request (64.5% Black, 59.1% White). Blacks were more likely to have ≥1 distress cause in the Practical domain.
CONCLUSION: The PCCP may benefit both Black and White older cancer survivors. Programs should consider the proportion of older survivors with high distress, and the specific needs of minorities.

PMID: 30389494 [PubMed - as supplied by publisher]

Clinical Outcomes for Diabetic Foot Ulcers Treated with Clostridial Collagenase Ointment or with a Product Containing Silver.

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Clinical Outcomes for Diabetic Foot Ulcers Treated with Clostridial Collagenase Ointment or with a Product Containing Silver.

Adv Wound Care (New Rochelle). 2018 Oct 01;7(10):339-348

Authors: Motley TA, Caporusso JM, Lange DL, Eichelkraut RA, Cargill DI, Dickerson JE

Abstract
Objective: To compare outcomes of diabetic foot ulcers (DFUs) treated with clostridial collagenase ointment (CCO) or silver-containing products, both in combination with sharp debridement as needed. Approach: One hundred two subjects with qualifying DFUs were randomized to daily treatment with either CCO or a silver-containing product for 6 weeks followed by a 4 -week follow-up period. The primary outcome was the mean percent reduction in DFU area. A secondary outcome was the incidence of ulcer infections between groups. Results: At the end of treatment, the mean percent reduction in area from baseline of DFUs treated with CCO was 62% (p < 0.0001) and with silver was 40% (p < 0.0001). The difference between groups-22%-was not statistically significant (p = 0.071). Among ulcers closed by the end of treatment, the mean time to closure was 31.1 ± 9.0 days versus 37.1 ± 7.7 days, respectively (not statistically significant). There was a numerically greater incidence of target ulcer infections in the silver group (11, 21.6%) than in the CCO group (5, 9.8%; p = 0.208). No clinically relevant safety signals were identified in either group. Innovation: CCO treatment can progress a wound toward closure. Ulcer infection prophylaxis may not be sacrificed when treating DFU with CCO in lieu of silver-containing products. Conclusion: Both CCO and silver-containing products promote significant reduction in DFU area over 6 weeks of treatment with no clinically relevant safety concerns. Mean percent reduction in lesion area was numerically (22%) but not significantly greater with CCO compared to silver, as was time to ulcer closure, with an incidence of ulcer infection at least as low as for silver-containing products.

PMID: 30374419 [PubMed]

Measuring childhood cancer late effects: evidence of a healthy survivor effect.

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Measuring childhood cancer late effects: evidence of a healthy survivor effect.

Eur J Epidemiol. 2017 12;32(12):1089-1096

Authors: Asdahl PH, Ojha RP, Winther JF, Holmqvist AS, de Fine Licht S, Gudmundsdottir T, Madanat-Harjuoja L, Tryggvadottir L, Andersen KK, Hasle H, ALiCCS study group

Abstract
INTRODUCTION: Given considerable focus on health outcomes among childhood cancer survivors, we aimed to explore whether survivor bias is apparent during long-term follow-up of childhood cancer survivors.
METHODS: We identified all 1-year survivors of cancer diagnosed before 20 years of age in Denmark, Finland, Iceland, and Sweden. From the general population, we randomly sampled a comparison cohort. Study individuals were followed for hospitalizations for diseases of the gastroenterological tract, endocrine system, cardiovascular system, or urinary tract from the start of the cancer registries to 2010. We estimated cumulative incidence with death as competing risk and used threshold regression to compare the hazards of the diseases of interest at ages 20, 40, 60, and 75 years.
RESULTS: Our study included 27,007 one-year survivors of childhood cancer and 165,620 individuals from the general population. The cumulative incidence of all four outcomes was higher for childhood cancer survivors during early adulthood, but for three outcomes, the cumulative incidence was higher for the general population after age 55 years. The hazard ratios (HRs) decreased for all outcomes with increasing age, and for two of the outcomes, the hazards were higher for the general population at older ages (endocrine diseases: age-specific HRs = 3.0, 1.4, 1.0, 0.87; Cardiovascular diseases: age-specific HRs = 4.1, 1.4, 0.97, 0.84).
CONCLUSIONS: Our findings provide empirical evidence that survivor bias attenuates measures of association when comparing survivors with the general population. The design and analysis of studies among childhood cancer survivors, particularly as this population attains older ages, should account for survivor bias to avoid misinterpreting estimates of disease burden.

PMID: 29185125 [PubMed - indexed for MEDLINE]

Late-Onset T1DM and Older Age Predict Risk of Additional Autoimmune Disease.

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Late-Onset T1DM and Older Age Predict Risk of Additional Autoimmune Disease.

Diabetes Care. 2018 Oct 25;:

Authors: Hughes JW, Bao YK, Salam M, Joshi P, Kilpatrick CR, Juneja K, Nieves D, Bouhairie V, Jordan OJ, Blustein EC, Tobin GS, McGill JB

Abstract
OBJECTIVE: Type 1 diabetes (T1DM) is associated with other autoimmune diseases (AIDs), which may have serious health consequences. The epidemiology of AIDs in T1DM is not well defined in adults with T1DM. In this cross-sectional cohort study, we sought to characterize the incident ages and prevalence of AIDs in adults with T1DM across a wide age spectrum.
RESEARCH DESIGN AND METHODS: A total of 1,212 adults seen at the Washington University Diabetes Center from 2011 to 2018 provided informed consent for the collection of their age, sex, race, and disease onset data. We performed paired association analyses based on age onset of T1DM. Multivariate logistic regression was used to evaluate the independent effects of sex, race, T1DM age of onset, and T1DM duration on the prevalence of an additional AID.
RESULTS: Mean age of T1DM onset was 21.2 ± 14.4 years. AID incidence and prevalence increased with age. Female sex strongly predicted AID risk. The most prevalent T1DM-associated AIDs were thyroid disease, collagen vascular diseases, and pernicious anemia. T1DM age of onset and T1DM duration predicted AID risk. Patients with late-onset T1DM after 30 years of age had higher risks of developing additional AIDs compared with patients with younger T1DM onset.
CONCLUSIONS: The prevalence of AIDs in patients with T1DM increases with age and female sex. Later onset of T1DM is an independent and significant risk factor for developing additional AIDs. Individuals who are diagnosed with T1DM at older ages, particularly women, should be monitored for other autoimmune conditions.

PMID: 30361208 [PubMed - as supplied by publisher]

Healthcare utilization, Medicare spending, and sources of patient distress identified during implementation of a lay navigation program for older patients with breast cancer.

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Healthcare utilization, Medicare spending, and sources of patient distress identified during implementation of a lay navigation program for older patients with breast cancer.

Breast Cancer Res Treat. 2018 01;167(1):215-223

Authors: Rocque GB, Williams CP, Jones MI, Kenzik KM, Williams GR, Azuero A, Jackson BE, Halilova KI, Meneses K, Taylor RA, Partridge E, Pisu M, Kvale EA

Abstract
PURPOSE: Despite benefits for patients, sustainability of breast cancer navigation programs is challenging due to the lack of reimbursement for navigators. This analysis describes distress reported by breast cancer patients to navigators and the impact of navigation on healthcare utilization for older adults with breast cancer.
METHODS: We conducted a retrospective cohort study of Medicare administrative claims data and patient-reported distress assessments. The primary outcome was Medicare spending per beneficiary per quarter. Secondary outcomes included (1) the number of hospitalizations or ER visits in each quarter; (2) distress levels; and (3) causes of distress reported by patients to their navigators. A subset analysis was conducted for stage I/II/III versus stage IV patients.
RESULTS: 776 navigated and 776 control patients were included in the analysis. The average age at diagnosis was 74 years; 13% of the subjects were African American; 95% of patients had stage I-III. Medicare spending declined faster for the navigated group than the matched comparison group by $528 per quarter per patient (95% CL -$667, -$388). Stage I/II/III navigated patients showed a statistically significant decline in Medicare spending, ER visits, and hospitalizations over time compared to the matched comparison group. No differences were observed for stage IV patients. Eighteen percent of patients reported moderate distress. Informational and physical distress were more common in late stage than in early-stage breast cancer.
CONCLUSIONS: Lay navigation reduced healthcare utilization in older adults with breast cancer, with the greatest impact observed in early-stage breast cancer patients.

PMID: 28900752 [PubMed - indexed for MEDLINE]

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.

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American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.

J Am Coll Surg. 2017 01;224(1):59-74

Authors: Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, Itani KM, Dellinger EP, Ko CY, Duane TM

PMID: 27915053 [PubMed - indexed for MEDLINE]

StatPearls

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StatPearls

Book. 2018 01

Authors:

Abstract
Chorioamnionitis is an infection that can occur before labor, during labor, or after delivery. It can be acute, subacute, or chronic. Subacute chorioamnionitis is associated with chronic lung disease in the infant.[1] Chronic chorioamnionitis is associated with retinopathy of prematurity, very low birth weight, and impaired brain development in the premature infant. Chronic chorioamnionitis is common.[2][3][4] This terminology refers to histologic chorioamnionitis. Histologic chorioamnionitis at term is rarely infectious. In general, the clinical presentation of chorioamnionitis is defined as acute chorioamnionitis. The Greek etymology of the words chorion and amnion mean fetal membrane and itis means inflammation. Further description denotes chorioamnionitis includes the amniotic fluid. Chorioamnionitis may be identified postdelivery or postmortem on a pathologic review of the placenta and cord. In histologic chorioamnionitis, symptoms may be absent, and the placenta or cultures may not show evidence of chorioamnionitis. Most commonly, chorioamnionitis is associated with preterm labor, prolonged rupture of membranes, prolonged labor, tobacco use, nulliparous pregnancy, meconium stained fluid, multiple vaginal exams post rupture of membranes, and in women with known bacterial or viral infections. However, it can occur at term and in women without prior infections. Left untreated, chorioamnionitis can lead to morbidity and mortality for the mother and neonate. Neonatal morbidity and mortality increase in severity and occurrence with earlier gestations. Antibiotic therapy has been shown to reduce the incidence and severity of the infection in both the mother and neonate. However, antibiotics do not eradicate the infection in all cases.


PMID: 30335284

Gabapentin-induced eczematous drug eruption of the bilateral foot.

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Gabapentin-induced eczematous drug eruption of the bilateral foot.

Foot (Edinb). 2018 Jun 18;37:45-47

Authors: Ernst JJ, Ryba D

Abstract
Drug eruptions represent a wide spectrum of cutaneous reactions to various pharmaceutical agents. Given their complexity and varied patterns of presentation, these phenomena are the subject of study of many fields of medicine. Gabapentin is a widely prescribed medication, with numerous drug reactions previously reported. We present what we believe to be a unique presentation of a gabapentin-induced drug eruption primarily affecting the feet.

PMID: 30326409 [PubMed - as supplied by publisher]

Stability of Locking Plate and Compression Screws for Lapidus Arthrodesis: A Biomechanical Comparison of Plate Position.

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Stability of Locking Plate and Compression Screws for Lapidus Arthrodesis: A Biomechanical Comparison of Plate Position.

J Foot Ankle Surg. 2018 May - Jun;57(3):466-470

Authors: Drummond D, Motley T, Kosmopoulos V, Ernst J

Abstract
Lapidus (first tarsometatarsal joint) arthrodesis is an established and widely used procedure for the management of moderate to severe hallux valgus, especially in cases involving hypermobility of the first tarsometatarsal joint. Multiple fixation methods are available, and several previous investigations have studied the relative strengths of these methods, including dorsomedial and plantar plating comparisons. However, these studies compared plates of varying designs and mechanical properties and used varying modes of compression and interfragmentary screw techniques. The present study mechanically investigated the resulting motion, stiffness, and strength of identical locking plate constructs fixed at various anatomic positions around the first tarsometatarsal joint. In a bench-top study, fourth-generation composite bones were divided into 3 fixation groups, each having identical interfragmentary screw applications, and randomized to 1 of 3 plate positions: dorsal, medial, or plantar. The plates applied in each case were identical locking plates, precontoured to fit the anatomy. Each construct was experimentally tested using a cantilever bending approach. The outcomes obtained were stiffness, yield force, displacement at yield, ultimate force, and displacement at ultimate force. The plantar plate position showed superior initial stiffness and force to ultimate failure. The plantar and medial plate positions exhibited superior force to yield. The medial plate position was superior regarding displacement tolerated before the yield point and catastrophic failure. The dorsal plate position was not superior for any outcome measured. Plantar and medial plating each offered biomechanical benefits. Clinical studies using similarly matched constructs are required to show whether these findings translate into improved clinical outcomes.

PMID: 29472168 [PubMed - indexed for MEDLINE]

Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis.

Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis.

Cancer. 2018 Oct 14;:

Authors: Rocque GB, Williams CP, Kenzik KM, Jackson BE, Azuero A, Halilova KI, Ingram SA, Pisu M, Forero A, Bhatia S

Abstract
BACKGROUND: The impact of National Comprehensive Cancer Network (NCCN) treatment guideline concordance on costs, health care utilization, and mortality for patients with breast cancer and secondary metastases is unknown.
METHODS: From 2007 to 2013, women with early-stage breast cancer who received treatment for secondary metastases (n = 5651) were evaluated for first recorded systemic therapy concordance with NCCN guidelines within the Surveillance, Epidemiology, and End Results Program-Medicare linked database. Generalized linear and mixed effects models evaluated factors associated with nonconcordance and the relation between concordance status and health care utilization and costs. Mortality risk was estimated with Cox regression.
RESULTS: Eighteen percent of the patients received nonconcordant therapy, with the most common being single-agent, human epidermal growth factor receptor 2 (HER2)-targeted therapy (36%), therapy mismatched with the estrogen receptor/HER2 status (11%), unapproved bevacizumab regimens (10%), and adjuvant regimens in a metastatic setting (6%). A younger age, a hormone receptor-negative status, and a HER2-positive status were associated with nonconcordance (P < .05). Nonconcordance was associated with 22% and 21% increased rates of emergency department visits and hospitalizations, respectively, and $1765 higher average monthly Medicare costs. Differences in adjusted mortality risk were noted by the category of nonconcordance; single-agent, HER2-targeted therapy was associated with decreased mortality risk (hazard ratio [HR], 0.66; 95% confidence limit [CL], 0.57-0.76), and increased mortality risk was observed with unapproved bevacizumab use (HR, 1.40; 95% CL, 1.13-1.74).
CONCLUSIONS: Most patients (82%) received treatment consistent with NCCN guidelines. Nonconcordant treatment was associated with higher health care utilization and costs, with mortality differences observed by the type of guideline deviation. Consideration of both patient and financial outcomes will be important as health systems increase the emphasis on guideline-based care.

PMID: 30317547 [PubMed - as supplied by publisher]

Novel Use of an Image-Guided Stereotactic Approach in Trauma for Localization of Transcranial Bullet.

George Cravens, MD - Wed, 10/10/2018 - 11:21
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Novel Use of an Image-Guided Stereotactic Approach in Trauma for Localization of Transcranial Bullet.

Cureus. 2017 Jul 21;9(7):e1501

Authors: Vo DT, Cravens GF, Germann RE

Abstract
Penetrating brain injuries from gunshot wounds can carry a poor prognosis and require an aggressive, multifaceted approach to obtain a good prognosis and outcome. An initial evaluation requires appropriate imaging studies followed by management and prophylaxis against increased intracranial pressure, infection, and seizures. Surgical management is then followed to ensure the watertight closure of any wounds, removal of any areas of hematoma, and removal of any potential areas of infection. In this paper, we report the case of a patient who presented with a self-inflicted gunshot wound to the head and then received aggressive medical and surgical management. This case presents that an image-guided stereotactic approach with suitable medical management should be used in patients with penetrating missile injuries to the head.

PMID: 28948121 [PubMed]

Streptococcus pneumoniae meningitis complicated by an intramedullary abscess: a case report and review of the literature.

George Cravens, MD - Wed, 10/10/2018 - 11:21
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Streptococcus pneumoniae meningitis complicated by an intramedullary abscess: a case report and review of the literature.

J Med Case Rep. 2016 Oct 19;10(1):290

Authors: Vo DT, Cravens GF, Germann RE

Abstract
BACKGROUND: Intramedullary abscess is a rare neurosurgical condition that usually arises in the setting of penetrating trauma to the spinal cord, infected congenital dural sinuses, or tuberculosis.
CASE PRESENTATION: We describe a case of a 35-year-old African American male who presented with sepsis and a clinical picture of meningitis. The patient continued to have declining neurological status with decreasing sensation and worsening motor strength in all four extremities. He was found to have an intramedullary abscess in the cervical spinal cord that was treated with a decompressive posterior cervical laminectomy and drainage. The patient began to have a partial recovery of neurological function postoperatively. We also review the literature on intramedullary abscess that suggests the clinical presentation of our patient was a rare complication of acute meningitis.
CONCLUSIONS: Intramedullary abscess formation is a rare entity, and a high index of suspicion for intramedullary abscess is the key for making the diagnosis and expediting treatment for these patients.

PMID: 27756423 [PubMed - indexed for MEDLINE]

Isolated hemangioblastoma of the cervical spinal cord: A case report and literature review.

George Cravens, MD - Wed, 10/10/2018 - 11:21
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Isolated hemangioblastoma of the cervical spinal cord: A case report and literature review.

Int J Surg Case Rep. 2016;26:7-11

Authors: Vo DT, Cravens GF, Germann RE

Abstract
INTRODUCTION: Hemangioblastomas are benign, slow growing but highly vascularized tumors of the central nervous system, with the most common location of occurrence in the posterior fossa. Hemangioblastomas usually have an associated with patients that have Von-Hippel Lindau disease, resulting a germline mutation in the VHL tumor suppressor gene. Isolated or sporadic occurrences of hemangioblastomas are much more infrequent and typically respond well after surgery.
PRESENTATION OF CASE: We present case of a 22year old female with worsening shoulder pain, decreased sensation in the hands and feet, and decreasing strength and was found to have a hemangioblastoma of the cervical spine.
DISCUSSION: The patient was treated with surgery and responded well to treatment. We also present a review of the literature on isolated occurrences of hemangioblastomas of the spinal cord.
CONCLUSION: Isolated hemangioblastoma are a rare tumor of the central nervous system and can be managed with surgery.

PMID: 27424104 [PubMed]

Use of Transcranial Doppler in Patients with Severe Traumatic Brain Injuries.

George Cravens, MD - Wed, 10/10/2018 - 11:21
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Use of Transcranial Doppler in Patients with Severe Traumatic Brain Injuries.

J Neurotrauma. 2017 Jan 01;34(1):121-127

Authors: Ziegler D, Cravens G, Poche G, Gandhi R, Tellez M

Abstract
Severe traumatic brain injuries (TBI) are associated with a high rate of mortality and disability. Transcranial Doppler (TCD) sonography permits a noninvasive measurement of cerebral blood flow. The purpose of this study is to determine the usefulness of TCD in patients with severe TBI. TCD was performed, from April 2008 to April 2013, on 255 patients with severe TBI, defined as a Glasgow Coma Scale score of ≤8 on admission. TCD was performed on hospital days 1, 2, 3, and 7. Hypoperfusion was defined by having two out of three of the following: 1) mean velocity (Vm) of the middle cerebral artery <35 cm/sec, 2) diastolic velocity (Vd) of the middle cerebral artery <20 cm/sec, or 3) pulsatility index (PI) of >1.4. Vasospasm was defined by the following: Vm of the middle cerebral artery >120 cm/sec and/or a Lindegaard index (LI) >3. One hundred fourteen (45%) had normal measurements. Of these, 92 (80.7%) had a good outcome, 6 (5.3%) had moderate disability, and 16 (14%) died, 4 from brain death. Seventy-two patients (28%) had hypoperfusion and 71 (98.6%) died, 65 from brain death, and 1 patient survived with moderate disability. Sixty-nine patients (27%) had vasospasm, 31 (44.9%) had a good outcome, 16 (23.2%) had severe disability, and 22 (31.9%) died, 13 from brain death. The vasospasm was detected on hospital day 1 in 8 patients, on day 2 in 23 patients, on day 3 in 22 patients, and on day 7 in 16 patients. Patients with normal measurements can be expected to survive. Patients with hypoperfusion have a poor prognosis. Patients with vasospasm have a high incidence of mortality and severe disability. TCD is useful in determining early prognosis.

PMID: 26913374 [PubMed - indexed for MEDLINE]

Can trauma surgeons manage mild traumatic brain injuries?

George Cravens, MD - Wed, 10/10/2018 - 11:21
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Can trauma surgeons manage mild traumatic brain injuries?

Am J Surg. 2014 Nov;208(5):806-810

Authors: Overton TL, Shafi S, Cravens GF, Gandhi RR

Abstract
BACKGROUND: Current practices suggest that patients with mild traumatic brain injuries (MTBI) receive neurosurgical consultations, while less than 1% require neurosurgical intervention. We implemented a policy of selective neurosurgical consultation with the hypothesis that trauma surgeons alone may manage such patients with no impact on patient outcomes.
METHODS: Data from a level I trauma registry were analyzed. Patients with MTBI resulting in an intracranial hemorrhage of 1 cm or less and a Glasgow Coma Score of 13 or greater were included. Patients with additional intracranial injuries were excluded. Multivariate regression was used to determine the relationship between neurosurgical management and good neurologic outcomes, while controlling for injury severity, demographics, and comorbidities.
RESULTS: Implementation of the neurosurgical policy significantly reduced the number of such consults (94% before vs 65% after, P < .002). Multivariate analysis revealed that neurosurgical consultation was not associated with neurologic outcomes of patients.
CONCLUSIONS: Implementation of a selective neurosurgical consultation policy for patients with MTBI reduced neurosurgical consultations without any impact on patient outcomes, suggesting that trauma surgeons can effectively manage these patients.

PMID: 24933668 [PubMed - indexed for MEDLINE]

Management of embedded foreign body: penetrating stab wound to the head.

George Cravens, MD - Wed, 10/10/2018 - 11:21
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Management of embedded foreign body: penetrating stab wound to the head.

J Trauma Nurs. 2009 Apr-Jun;16(2):82-6

Authors: Martin S, Raup GH, Cravens G, Arena-Marshall C

Abstract
Penetrating craniocerebral trauma is an injury in which a projectile violates the skull but does not exit. The significance of penetrating injuries to the head depends largely on the circumstances of the injury, the velocity of impact, and attributes of the projectile. While most penetrating head injuries are caused by firearms, lower-velocity mechanisms of penetrating brain injury present unique challenges for the multidisciplinary team involved with the delivery of care. Appropriate management can lead to optimal outcomes and limit secondary brain injury.

PMID: 19543016 [PubMed - indexed for MEDLINE]

Association between emergency physician self-reported empathy and patient satisfaction

Richard Robinson, MD - Fri, 09/14/2018 - 05:00

PLoS One. 2018 Sep 13;13(9):e0204113. doi: 10.1371/journal.pone.0204113. eCollection 2018.

ABSTRACT

BACKGROUND: Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting.

OBJECTIVE: To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience.

RESEARCH DESIGN: A prospective observational study conducted in a tertiary care hospital ED.

METHODS: Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models.

RESULTS: Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107-122) and senior physicians had the highest scores (median 119.5; IQR: 111-129). Similarly, EM residents had the lowest percentage of "very satisfied" responses (65%) and senior physicians had the highest reported percentage of "very satisfied" responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07).

CONCLUSION: This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

PMID:30212564 | PMC:PMC6136813 | DOI:10.1371/journal.pone.0204113

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