Effect of Body Mass Index on Chiari Malformation 1 Tonsil Ectopia Length in Adults.

OBJECTIVE: Diagnosis of Chiari I malformation (CM-1) is based on measurements of the inferior extension of the cerebellar tonsils into the foramen magnum on cranial or cervical spine magnetic resonance imaging. Imaging may be obtained before the patient is referred to the neurosurgical specialist. The length of time raises questions about the possibility that body mass index (BMI) fluctuations could affect the measurement of ectopia length. However, previous literature on BMI and CM-1 has reported conflicting findings on BMI. METHODS: We conducted a retrospective chart review of 161 patients who were referred to a single neurosurgeon for CM-1 consultation. Patients with multiple recorded BMI values (n = 71) were compared to see if BMI changes correlated with changes in ectopia length. In addition, we compared and tested 154 recorded ectopia lengths from the patients (1 per patient) and patient BMI values with Pearson correlation and Welch t tests to determine if BMI changes either influenced or were associated with ectopia changes. RESULTS: For the 71 patients with multiple BMI values, change in ectopia length ranged from -4.6-9.8 mm but was not statistically significant (r = 0.019; P = 0.88). For the 154 measured ectopia lengths, changes in BMI did not correlate with ectopia length (P > 0.05). Likewise, differences in ectopia length between patients in normal, overweight, and obese categories were not statistically significant (|tstat| < |tcrit|, P > 0.05). CONCLUSIONS: In individual patients, we found that BMI and changes in BMI were not accompanied by changes in tonsil ectopia length.

Cranial Versus Cervical Spine Magnetic Resonance Imaging in Adult Chiari Malformation Type I Diagnostics: Is There a Difference in Tonsil Ectopia Length?

BACKGROUND: Chiari malformation type 1 (CM-1) diagnosis is based on measurement of the cerebellar tonsils on cranial or cervical spine magnetic resonance imaging (MRI). However, imaging parameters of cranial and cervical spine MRI could differ because spine MRI has greater resolution. METHODS: We conducted a retrospective chart review of 161 patients of a single neurosurgeon for adult CM-I consultation between February 2006 and March 2019. Patients were selected based on receiving both cranial and cervical spine MRI within a month of each other to determine tonsillar ectopia length for CM-1. Ectopias were measured to determine if differences in values were statistically significant. RESULTS: From the 161 total patients, 81 had cranial and cervical spine MRI for a total of 162 tonsil ectopia measurements (81 cranial and 81 spinal). Average ectopia length on a cranial MRI was 9.1 mm (±5.2 mm); average ectopia length on a spinal MRI was 8.9 mm (±5.3 mm). Average cranial and spinal MRI values were found to be <1 standard deviation apart. Two-tailed, nonequal variances t test determined that differences between the cranial and spinal ectopia measurements were insignificant (P = 0.2403). CONCLUSIONS: This study confirmed that the added resolution offered by spine MRI did not make better or more refined measurements over cranial MRI that could lead to measurement differences, which can instead be attributed to chance. Cranial and cervical spine MRI can be used to determine the degree of the tonsil ectopia.

Perceptions of the Moral Obligations of Pediatric Nurses During an Active Shooter Event in a Children's Hospital.

PURPOSE: To explore and compare the perceptions of nurses and parent/family advisors regarding pediatric nurses' moral obligations to children and families during an active shooter event in a children's hospital. DESIGN AND METHODS: This was a descriptive, exploratory study using survey methodology. A convenience sample of all licensed nurses and parent/family advisors from four children's hospitals across the United States were recruited. Surveys consisted of five primary domains including Appropriateness of National Guidelines, Personal Preparedness, Moral Accountability, Professional/Legal Concerns, and Personal Risk Expectations. Frequency counts and percentages were calculated for each survey item. RESULTS: Data from 874 pediatric nurses and 81 parent/family advisors were analyzed. Most respondents believed the Run-Hide-Fight campaign should be changed to Secure-Preserve-Fight. Only 30% of nurses felt mentally prepared to respond to an active shooter event. Most respondents agreed that nurses have a professional duty to protect their patients, but agreed that it was a personal choice, not a moral obligation, to accept potentially fatal risks. Hospital setting and patient vulnerability often influenced nurses' perceived obligations to patients. Most respondents reported they would not leave their patient/child during an active shooter event. CONCLUSIONS: Nurses feel morally obligated to patients, but must balance their own personal risk tolerance level against the need to protect patients and families. PRACTICE IMPLICATIONS: Hospitals need in-depth active shooter training for both nurses and parents as well as safety plans that address both evacuation protocols and measures to secure in place to protect the lives of patients, families, and staff.

First Do No Harm: Ethical Concerns of Health Researchers That Discourage the Sharing of Results With Research Participants.

Background: Health researchers and health research participants support the sharing of research results; however, results are typically only shared through peer-reviewed publications. Few studies have investigated researchers' ethical concerns related to sharing results with research participants. Methods: An explanatory approach was used to explore the ethical concerns researchers may have with returning aggregate results to research participants. Researchers (N = 414) responded to an online survey of open-ended questions that allowed researchers to provide in-depth explanations regarding their responses to closed-ended questions. Results: Across researchers, the mean percentage of studies for which ethical concerns were reported as a barrier to results sharing was 38.5% (SD= 30.7). Researchers' primary ethical concerns with returning results were articulated as an overarching desire to prevent harm to participants. Three broad ethical concerns emerged, each with underlying subthemes: 1) distress, 2) understanding, and 3) privacy. Conclusions: This is the first study to broadly explore researchers' ethical concerns with sharing aggregate research results with participants and reveals that researchers' ethical concerns are closely tied to the ethical obligation to do no harm. In order to increase results sharing, steps must be taken to help researchers understand how to minimize potential harm when sharing results.

Unilateral Withdrawal of Life-sustaining Therapy in a Severely Impaired Child.

An infant with complex congenital heart disease suffers a prolonged cardiac arrest with minutes of anoxia. He is left with severe brain damage and profound neurologic impairment. He no longer responds to caregivers. Much of the time, he cries and grimaces as if in pain. He has required increasing sedation to control these symptoms. His parents live hours from the hospital and seldom visit. When their infant's situation is explained to them over the telephone, they request that doctors "do everything to keep him alive." His bedside caregivers report high levels of moral and psychological distress and frequently discuss J.S.'s "suffering." An ethics consultation is requested, asking whether it is permissible to withdraw life support despite the parents' request that therapy continue.

Introducing the Medical Ethics Bowl.

Although ethics is an essential component of undergraduate medical education, research suggests that current medical ethics curricula face considerable challenges in improving students' ethical reasoning. This article discusses these challenges and introduces a promising new mode of graduate and professional ethics instruction for overcoming them. We begin by describing common ethics curricula, focusing in particular on established problems with current approaches. Next, we describe a novel method of ethics education and assessment for medical students that we have devised: the Medical Ethics Bowl (MEB). Finally, we suggest the pedagogical advantages of the MEB when compared to other ethics curricula.