Increased fluoroscopy time for central venous catheter placement by radiology residents versus staff radiologists.

PURPOSE: To evaluate differences in interventional radiology procedural fluoroscopy time (FT) for radiology residents versus staff radiologists, using central venous catheter (CVC) placement as an index service. METHODS: To minimize interservice and complexity variables, stand-alone temporary internal jugular CVC procedures were targeted for analysis. Reports and images from 1,067 temporary CVC services from 2 hospitals over 2 years were reviewed as part of a quality improvement initiative. Insertion site, catheter type (eg, smaller triple lumen versus larger hemodialysis), resident identifier, staff identifier, and documented FT were compiled and analyzed. RESULTS: Applying clinical (eg, concomitant venous angioplasty) and anatomic (eg, femoral access) exclusions, 537 cases with complete CVC procedure records were available for analysis. Radiology residents and staff radiologists were primary operators in 128 and 409 procedures, respectively. Distribution of resident procedures (82% right, 66% large lumen) was similar to that of staff (79% right, 63% large lumen). Mean FT of resident services was twice as long as that of staff services (1.24 minutes versus 0.63 minutes, P < .0001). Resident FT was independent of supervising staff radiologist. Increasing years of training for residents did not significantly reduce FT. CONCLUSIONS: When CVCs are placed by radiology residents, FT is double that for identical procedures performed by staff radiologists. Similar discrepancies likely exist for other interventional radiologic procedures. Residency training programs should initiate measures to monitor and manage fluoroscopy during interventional procedures to minimize radiation dose to patients, trainees, and other staff.

Which preoperative factors, including bone bruise, are associated with knee pain/symptoms at index anterior cruciate ligament reconstruction (ACLR)? A Multicenter Orthopaedic Outcomes Network (MOON) ACLR Cohort Study.

BACKGROUND: Increased knee pain at the time of anterior cruciate ligament reconstruction may potentially predict more difficult rehabilitation, prolonged recovery, and/or be predictive of increased knee pain at 2 years. HYPOTHESIS: A bone bruise and/or other preoperative factors are associated with more knee pain/symptoms at the time of index anterior cruciate ligament reconstruction, and the presence of a bone bruise would be associated with specific demographic and injury-related factors. STUDY DESIGN: Cohort study (prevalence); Level of evidence, 2. METHODS: In 2007, the Multicenter Orthopaedic Outcomes Network (MOON) database began to prospectively collect surgeon-reported magnetic resonance imaging bone bruise status. A multivariable analysis was performed to (1) determine if a bone bruise, among other preoperative factors, is associated with more knee symptoms/pain and (2) examine the association of factors related to bone bruise. To evaluate the association of a bone bruise with knee pain/symptoms, linear multiple regression models were fit using the continuous scores of the Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms and pain subscales and the Short Form 36 (SF-36) bodily pain subscale as dependent variables. To examine the association between a bone bruise and risk factors, a logistic regression model was used, in which the dependent variable was the presence or absence of a bone bruise. RESULTS: Baseline data for 525 patients were used for analysis, and a bone bruise was present in 419 (80%). The cohort comprises 58% male patients, with a median age of 23 years. The median Marx activity level was 13. Factors associated with more pain were higher body mass index (P < .0001), female sex (P = .001), lateral collateral ligament injury (P = .012), and older age (P = .038). Factors associated with more symptoms were a concomitant lateral collateral ligament injury (P = .014), higher body mass index (P < .0001), and female sex (P < .0001). Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction. None of the factors included in the SF-36 bodily pain model were found to be significant. After controlling for other baseline factors, the following factors were associated with a bone bruise: younger age (P = .034) and not jumping at the time of injury (P = .006). CONCLUSION: After anterior cruciate ligament injury, risk factors associated with a bone bruise are younger age and not jumping at the time of injury. Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction.

Quantitative analysis of the secretome of TGF-beta signaling-deficient mammary fibroblasts.

Transforming growth factor beta (TGF-beta) is a master regulator of autocrine and paracrine signaling pathways between a tumor and its microenvironment. Decreased expression of TGF-beta type II receptor (TbetaRII) in stromal cells is associated with increased tumor metastasis and shorter patient survival. In this study, SILAC quantitative proteomics was used to identify differentially externalized proteins in the conditioned media from the mammary fibroblasts with or without intact TbetaRII. Over 1000 proteins were identified and their relative differential levels were quantified. Immunoassays were used to further validate identification and quantification of the proteomic results. Differential expression was detected for various extracellular proteins, including proteases and their inhibitors, growth factors, cytokines, and extracellular matrix proteins. CXCL10, a cytokine found to be up-regulated in the TbetaRII knockout mammary fibroblasts, is shown to directly stimulate breast tumor cell proliferation and migration. Overall, this study revealed hundreds of specific extracellular protein changes modulated by deletion of TbetaRII in mammary fibroblasts, which may play important roles in the tumor microenvironment. These results warrant further investigation into the effects of inhibiting the TGF-beta signaling pathway in fibroblasts because systemic inhibition of TGF-beta signaling pathways is being considered as a potential cancer therapy.

Medical malpractice claims risk in urology: an empirical analysis of patient complaint data.

PURPOSE: Patient complaints are associated with physician risk management experience, including medical malpractice claims risk, and small proportions of physicians account for disproportionate shares of claims. We investigated whether patient complaint experience differs among urologists, and whether urological subspecialists generate distinct quantities and types of complaints. MATERIALS AND METHODS: This retrospective study examined 1,516 unsolicited patient complaints filed against 268 urologists. Patient complaint and urological subspecialty data were collected from January 1, 2004 through December 31, 2007 for 15 geographically diverse health systems. The cohort urologists were assigned medical malpractice claims risk scores and complaint type profiles. A weighted sum algorithm produced risk scores from 4 consecutive years of complaint data and complaint type profiles were generated using a standardized coding system. Statistical analyses tested the associations among risk score, complaint type profile and urological subspecialty. Complaint type profile and subspecialty distribution were assessed for urologists in the cohort top decile for risk scores. RESULTS: Overall 125 (47%) urologists were associated with 0 patient complaints, while 30 (11%) urologists were associated with 758 (50%) of the patient complaints. Subspecialty and distribution of risk scores were significantly associated (p <0.001). Calculi and oncology subspecialist distributions suggest greater overall risk. Complaint types also varied among subspecialists (p = 0.02). There was no association between top decile urologists and complaint type profile (p = 0.19). CONCLUSIONS: Unsolicited patient complaints were nonrandomly distributed among urologists and urological subspecialties. Monitoring patient complaints may allow for early identification of and intervention with high risk urologists before malpractice claims accumulate.

Analysis of parental and nurse weight estimates of children in the pediatric emergency department.

OBJECTIVE: To evaluate the accuracy of parent and triage nurse estimates of children's weights in the pediatric emergency department. METHODS: A convenience sample of parents was surveyed before triage regarding their child's chief complaint, when and where the child was last weighed, and an estimate of their child's weight. Children unable to be weighed or with possible dehydration or external orthopedic devices were excluded. Nurses also estimated children's weights before weighing them and were blinded to parent estimates. All nurses were experienced in the department, had participated in a triage course, and had completed a background survey. RESULTS: Nine hundred forty-two patients presenting to pediatric emergency department triage were enrolled, resulting in 812 surveys. Parents were more accurate at weight estimation than nurses, with 79% of parents and 83% of legal guardians estimating weights within 10%. Only 55% of nurse estimates were within 10%. Parents and nurses tended to underestimate patients' weights (P < 0.0001). Parent estimates were not affected by a child's age or sex or the location the child was last weighed (P > 0.05). Accuracy of nurse estimates was not related to nurse education or experience (P > 0.05). Parent estimates of weight were more accurate than nurse estimates 74.6% of the time. CONCLUSIONS: Parents were more accurate at estimating children's weights than triage nurses but were within 10% of the children's actual weights only 79% of the time. Nurse estimates were highly inaccurate. Other methods to estimate patient weights should be used when actual patient weights are unobtainable.