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Positioning the Surgical Patient
No full textFor patients undergoing surgery does implementation of AORN standard for safe positioning practice compared toa non-standardized approach improve surgical outcomes?https://knowledgeconnection.mainehealth.org/nurseresidency/1147/thumbnail.jp
Improving Sepsis Bundle Compliance Through a Structured Emergency Department Rapid Response Protocol
No full textIn adult patients presenting to the Emergency Department with suspected sepsis, does the implementation of structured sepsis rapid response protocol or team, compared to standard care, improve compliance with sepsis bundles and attainment of sepsis benchmark performance measures?https://knowledgeconnection.mainehealth.org/nurseresidency/1143/thumbnail.jp
The diagnostic test characteristics of the rule of thirds on the parasternal long axis view: A cross-sectional study
No full textOBJECTIVE: The Rule of Thirds (RoT) estimates the relationship between right ventricular outflow tract (RVOT), aortic outflow tract (AOT), and left atrium (LA) on parasternal long-axis echocardiography, proposing a 1:1:1 size ratio. Enlargement of any of the structures may reflect pathology. Despite common teaching, RoT\u27s diagnostic performance has not been evaluated. METHODS: This retrospective cohort study involved two blinded emergency ultrasound fellows independently reviewing 272 consecutive comprehensive echocardiograms obtained by cardiology technicians. RoT assessment from parasternal long-axis view was recorded as normal (1:1:1 ratio) or abnormal (disproportionate structure size). This assessment of RoT-predicted pathology was compared in blinded fashion to cardiology-determined RVSP \u3e40 mmHg, AOT \u3e 4 cm, and the presence of LV systolic or diastolic dysfunction. Percent agreement and Cohen\u27s kappa assessed interobserver variability. RESULTS: Abnormal RVOT on RoT showed 12.9 % sensitivity (95 % CI 9.2-17.3 %) and 84 % specificity (74.1-91.2 %). Abnormal AOT demonstrated 22.7 % sensitivity (11.5-37.8 %) and 94.9 % specificity (92.6-96.6 %). Abnormal LA had 43.9 % sensitivity (37.5-50.3 %) and 84.3 % specificity (79.8-88.2 %). Evaluator agreement was 69.9 % with Cohen\u27s kappa of 0.36 (95 % CI 0.25-0.47), indicating fair agreement. CONCLUSION: The Rule of Thirds functions best as a rule-in tool but should not be used alone when evaluating critically ill patients. Interobserver agreement was only fair. Although broadly taught, caution should be exercised when utilizing RoT screening results
ACMT Position Statement: Determining Brain Death in Adults and Children after Drug Overdose
No full textExternal Validation of the Fraser Equation for Estimation of Free Valproate Concentrations in Critically Ill Adults
No full textBACKGROUND: Critically ill patients may be overexposed to valproate because altered protein binding leads to a disproportionate free valproate fraction. The Fraser equation was derived and internally validated to estimate critically ill patients\u27 free valproate concentrations, but it requires external validation. METHODS: Adult intensive care unit (ICU) patients at two academic centers with concurrently measured free and total valproate concentrations were included. Free valproate concentrations were estimated using the Fraser equation which includes total valproate, albumin and BUN concentration, and whether the patient received propofol or aspirin. The primary outcome was Fraser equation performance, assessed using Bland-Altman methods. Comparative performance against estimates from the Doré equation (an alternative predictive equation), therapeutic concordance using a target free valproate range of 5-15 mg/L, and equation improvements were explored. RESULTS: Overall, 315 patients and 556 free-total valproate concentration pairs were included. The mean (±SD) age was 58 (±17) years and 90 (29%) patients were on valproate prior to hospital admission. The Fraser equation estimated free valproate concentrations were correlated with measured concentrations (r = 0.728) with a negative bias (mean bias -2.77 mg/L, 95% LOA -18.9, 13.4). The Fraser equation increasingly underestimated measured concentrations as measured concentrations increased. 71% of Fraser equation estimates were therapeutically concordant (e.g., estimate and measured both within reference range) compared to 61.9% of Doré estimates (p = 0.001). Fraser equation modifications led to minor performance improvements but did not overcome worsening underestimation with higher measured free valproate concentrations. CONCLUSION: The Fraser equation was moderately accurate and corresponded with an appropriate interpretation for 71% of free valproate concentrations. Worse underestimation with higher measured free valproate concentrations suggests direct measurement of free valproate concentrations is warranted. While the Fraser equation could complement therapeutic decision making at centers where direct free valproate measurements are unavailable or slow to return, its accuracy is currently insufficient to replace direct measurement
Correction: Spatial and temporal distribution of Ixodes scapularis and tick-borne pathogens across the northeastern United States
No full textTrends in Orthopaedic Surgeon Compensation: A Comparative Analysis over Twenty Years
No full textINTRODUCTION: Healthcare finance in the United States is continually changing with increased consolidation of healthcare organizations, fluctuating reimbursement cycles, and shifting institutional and federal policy. The economics of practicing medicine are dynamic and challenging relative to other professions. The purpose of this study is to analyze compensation trends in orthopaedic surgery over the past 20 years compared to other professions. METHODS: Income data for orthopaedic surgeons and other professions every five years from 2000 to 2020 was collected from the United States Bureau of Labor Statistics and peer-reviewed literature. Income data were adjusted for inflation and analyzed to identify trends in compensation. RESULTS: The rate of absolute income trajectory over two decades for orthopaedic surgeons when adjusted for inflation was -38%. Outside of healthcare professions, economists, lawyers, and engineers saw some of the highest increases with inflation-adjusted increases at +31, 26, 24%, respectively. Orthopaedic surgeon salary rates declined the most of all professions analyzed, including all healthcare workers. CONCLUSION: Adjusted orthopaedic surgeon compensation has declined significantly in the two decades between 2000 to 2020. Compared to other high-skilled professions, orthopaedic compensation showed the greatest decline in adjusted rates over time. This trend carries major implications for the future of the field, potentially affecting recruitment, satisfaction, burnout, and patient access to care. It underscores the need for a re-evaluation of compensation models in orthopaedic surgery to ensure sustainability
Telehealth for the study of palliative care communication: opportunities, methodological challenges, and recommendations
No full textBACKGROUND: While telehealth may offer promise for accessible, efficient palliative care delivery, leveraging telehealth technologies as an opportunity to better understand and advance the science of palliative care communication has been less well explored. Without identifying solutions to overcome challenges to conducting research in the virtual environment, we are unable to conduct the foundational work to offer evidence-based recommendations for high-quality telehealth, particularly in the context of palliative care. Our objective is to highlight methodological challenges in the use of telehealth for the study of palliative care communication and share lessons learned from using these methods. METHODS: This paper is the result of a reflective process and experience across three ongoing observational communication research studies focused on the use of telehealth during serious illness. These research datasets have been collected from multiple sites and represent rural and urban telehealth palliative care consultations for patients receiving dialysis (n = 34), patients with cancer (n = 13), and seriously ill, home-bound patients (n = 9). We illustrate challenges, insights, and recommendations with case studies from these studies. RESULTS: We identify key challenges, and offer recommendations to address them, in telehealth palliative care communication research. Key insights fall within three themes: 1) addressing accessibility barriers to enrollment in telehealth research; 2) technical considerations regarding how software and hardware choices have implications for data collection and analysis; and 3) ethical considerations regarding the nuances of consent and privacy in telehealth encounters. CONCLUSIONS: Overall, our approach demonstrates possibilities for the use of telehealth to study palliative care communication and provides a how-to example for unique telehealth considerations from data collection through analysis. These strategies can facilitate success with large-scale health communication research studies in the telehealth context
Trends Before and After the Removal of Race and Ethnicity from the Vaginal Birth After Cesarean Calculator
No full textWe conducted a population-based retrospective cohort study and performed interrupted time series analyses to examine whether the removal of race and ethnicity from the vaginal birth after cesarean (VBAC) calculator was associated with changes in rates of trial of labor after cesarean (TOLAC) and VBAC in the United States. After the calculator revision, rates of TOLAC and VBAC in the overall eligible population and among the four largest racial and ethnic groups (Hispanic, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White) (rate ratios ranged from 0.99 to 1.04, and all 95% CIs included the null) were unchanged. Rates of successful VBAC among Hispanic (75.0%), non-Hispanic Asian (71.0%), and non-Hispanic Black (67.0%) people remained lower compared with non-Hispanic White people (77.2%). More work is needed to address the significant racial disparities that persist for TOLAC outcomes
CTHRC1 Expression Results in Secretion-Mediated, SOX9-Dependent Suppression of Adipogenesis: Implications for the Regulatory Role of Newly Identified CTHRC1/PDGFR-Alpha Stromal Cells of Adipose
No full textAdipogenesis is regulated by the coordinated activity of adipogenic transcription factors including PPAR-gamma and C/EBP alpha, while dysregulated adipogenesis can predispose adipose tissues to adipocyte hypertrophy and hyperplasia. We have previously reported that Cthrc1-null mice have increased adiposity compared to wildtype mice, supporting the notion that CTHRC1 regulates body composition. Herein, we derived conditioned medium from 3T3-L1 cells expressing human CTHRC1 and investigated its anti-adipogenic activity. This constituent significantly reduced 3T3-L1 cell adipogenic differentiation commensurate to the marked suppression of Cebpa and Pparg gene expression. It also increased the expression of the anti-adipogenic transcription factor SOX9 and promoted its nuclear translocation. Importantly, Sox9 gene knockdown demonstrated that the anti-adipogenic effect produced by this conditioned medium is dependent on SOX9 expression, while its ability to positively regulate SOX9 was attenuated by the application of Rho and Rac1 signaling pathway inhibitors. We also identified the selective expression of CTHRC1 in PDGFRA-expressing cell populations in human white adipose tissue, but not brown or perivascular adipose tissues. Congruently, flow cytometry revealed CTHRC1 expression in PDGFR-alpha stromal cells of mouse white adipose tissue, thus defining a novel stromal cell population that could underpin the ability of CTHRC1 to regulate adiposity