Inappropriate Testing of Streptococcal Pharyngitis in Children Aged Below 3 Years: Application of Statistical Process Control.

Group A strep tests in patients aged below 3 years are not recommended unless the patient has appropriate symptoms and a positive contact or signs of complications. The purpose of this quality improvement project was to increase the percentage of appropriately ordered strep tests among providers. Data were collected retrospectively and prospectively from 1163 patient visits. Providers were exposed to educational interventions, an electronic medical record order change, and provider feedback. Proportional control charts characterized the providers' behaviors and determined significant improvement among testing. The result was an increase in appropriate tests (13.7% to 37.8%), and the control charts showed sustainable results over time. This project demonstrates the efficacy of these methods to encourage antibiotic stewardship among providers. Furthermore, the interventions used here can be applied to other areas with low-value diagnostic testing. Future studies should investigate whether parental anxiety and educational programs influence testing and evaluate the efficacy of certain strategies.

Non-traumatic Spontaneous Paraplegia Secondary to Thoracic Disc Herniations in the Setting of Tobacco Abuse and COVID-19: A Case Report and Literature Review.

Thoracic disc herniations (TDHs) are very rare. While most common in the setting of trauma, other etiologies have been documented. Here, we present a case of spontaneous TDHs in the setting of tobacco abuse and coronavirus disease 2019 (COVID-19) causing acute paraplegia. We review spontaneous TDHs, associated risk factors, and the possible role of COVID-19 in the pathophysiology.

Diagnoses and Treatment in Juvenile Detention Before and After Evaluation by Facility-Based Mental Health Service.

As of 2018, more than 37,000 American youth were residing in juvenile detention or residential placement facilities.1 Prevalence studies have demonstrated high rates of psychiatric illness in this population, with estimates ranging from 50% to 75%.2,3 Comorbidity is common: Abram et al. found that 75% of juvenile detainees meeting criteria for one disorder met criteria for two or more disorders.4 Compared to psychiatric morbidity in justice-involved youth, there is a paucity of data describing mental health services within juvenile justice settings, treatments delivered by these services, or outcomes following treatment. We performed a retrospective study to compare diagnoses and medications prescribed to youth in the community prior to detention with those received after evaluation by the facility-based juvenile justice mental health service (JJMHS) staffing secure detention facilities in New York, NY.

Optic Disc Edema and Elevated Intracranial Pressure (ICP): A Comprehensive Review of Papilledema.

Papilledema is a swelling of the optic disc secondary to elevated intracranial pressure (ICP). We analyzed 79 peer-review journal articles and provided a concise summary of the etiology, epidemiology, pathophysiology, clinical presentation, evaluation, natural history, differential diagnosis, treatment, and prognosis of papilledema. Only studies written in English with the full text available were included. Although many etiologies of papilledema exist, idiopathic intracranial hypertension is the most common and, thus, a large focus of this review.

Maintenance fluid management in pediatrics: Current practice and quality improvement achievements.

The long-standing use of hypotonic fluids in pediatric maintenance fluids has been challenged in recent years due to concerns over iatrogenic hyponatremia causing morbidity and mortality. Newer research has highlighted the safety of isotonic fluid alternatives. The American Academy of Pediatrics published an evidenced-based Clinical Practice Guideline in December of 2018 (Feld et al., 2018) to support the routine use of isotonic solutions in pediatric maintenance fluids. This article will also highlight relevant history, current practice, and a quality improvement project to standardize isotonic fluid use in the inpatient pediatric setting.

Antibiotic stewardship-Basic principles in urinary tract infections, community acquired pneumonia, and skin and soft tissue infections.

Antimicrobial stewardship is vital to prevent the deleterious effects of inappropriate antibiotic use: increasing antibiotic resistance, drug adverse effects, selection of pathogenic organisms, and unnecessary costs. This article reviews basic elements of antibiotic stewardship and applies them to three common infectious diseases for which patients are often hospitalized.

Contrast Extravasation Post Thrombectomy in Patients With Acute Cerebral Stroke: A Review and Recommendations for Future Studies.

Mechanical thrombectomy (MT) for cerebral revascularization in acute stroke is now considered standard of care in select patients. Patients are assessed routinely after MT with CT scanning. The phenomenon of contrast staining is well documented in the literature and is posited to be related to increased blood-brain barrier (BBB) permeability of susceptible and/or infarcting brain tissue allowing angiographic contrast to be visualized outside the normal cerebral vasculature. In some cases, this can progress to include frank blood/contrast extravasation or even more seriously lead to intraparenchymal hemorrhage (IPH) with less favorable clinical outcomes. The relationship of this staining phenomenon and how it may have a cause or effect relationship with progression to hemorrhage is unclear. Many studies have been performed trying to better characterize this radiographic finding in terms of accurate diagnosis and potential for influencing prognosis. A literature review included a glaring lack of standardization in the application of terminology and quantitative/qualitative analysis. Dual energy CT (DECT) appears to be the best imaging modality to differentiate blood from contrast, but its application is limited since it is not as available as conventional CT. The possibility that risk factors are associated with progression of mixed density (blood and contrast) extravasations to frank IPH with resultant poorer outcomes is suggested in some studies. Overall, there remains a lack of consensus on how to best interpret this radiographic finding in altering any future stroke treatment(s). Recommendations of how to overcome this are postulated by the authors, which include standardization of terminology, progression toward more DECT use.

Primary Cranial Vault Non-Hodgkin's Lymphoma Mimicking Meningioma With Positive Angiography.

Primary non-Hodgkin's lymphoma of the bone remains an uncommon presentation of non-Hodgkin's lymphoma. Primary lymphoma of the cranial vault is exceptionally rare. Here, we present a 62-year-old immunocompetent male presenting with the rapid growth of a left parietal scalp lesion and new-onset seizure. In addition to his imaging, which showed an extracranial, cranial, and intracranial mass with bony destruction, sagittal sinus involvement, and parenchymal invasion, his diagnostic angiogram demonstrated extensive vascular supply from both the right and left external carotid branches. Intraoperatively, we confirmed a frank invasion of the posterior sagittal sinus. After subtotal resection followed by R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone therapy, the patient continues to be disease-free at the 10-month follow-up. We report here a case of primary cranial vault lymphoma that very closely mimicked meningioma in many ways, with positive angiography and intraoperatively confirmed venous sinus invasion.

The Influence of Intraoperative Technology on Neurosurgery Training.

Background Intraoperative technology (IOT) is an expanding field designed to produce better patient outcomes and decrease iatrogenic injury. Neurosurgical residents often encounter these machines in the operating room. Therefore, our primary objective was to assess the influence of IOT on neurosurgery residents' surgical skills and training. Methods An electronic survey was created and sent to the neurosurgical residency programs in the state of California. The data were collected and analyzed. Results A majority of residents agreed that IOT helps in learning new concepts important for patient safety. 38% agreed that IOT helps to improve the motivation level of residents. 35% agreed that IOT makes the resident more productive. 31% felt that IOT helped them refine their surgical skills. 54% did not find IOT too stressful. 34% said that IOT helps in learning new concepts important for patient safety. 50% agree that IOT is a valuable tool in training. 42% affirmed that IOT provides good learning experience for clinical skills and knowledge. Conclusion Surgical training and IOT have evolved substantially over the last decade and resulted in increased intraoperative accuracy. Residents agreed that evolving technology improves surgical skills. Further studies elucidating patient outcomes are warranted.

The 100-most Cited Articles About Craniectomy and Hemicraniectomy: A Bibliometric Analysis.

Craniectomy is a life-saving procedure used in the setting of traumatic brain injury, stroke and increased intracranial pressure. The purpose of this study was to analyze and determine the most influential articles and authors in the field of craniectomy. Our study presents an analysis of the articles that include the word "craniectomy" or "hemicraniectomy" in the title and a detailed analysis of the top 100-cited articles in that selection. This search provided insight into how this procedure was initially documented and how it has been utilized over the years. We used the SCOPUS database to search "craniectomy OR hemicraniectomy" in the article title. We then sorted the top 100 most-cited articles. Bibliometric analysis was performed. An H-index was presented with each author. The citation count ranged from 71 to 5310. The most published author was Werner Hacke, a German researcher (n=6). The highest quantity of influential work was published in 2006 and 2007 (n=9/yr). The United States published the most articles (n=42). The Journal of Neurosurgery published 21 of the top 100 most-cited articles. The chronological timeline shows the evolution of decompression as it related to both stroke and trauma. It demonstrated that well-cited articles acted as turning points to direct further scientific endeavors while highlighting the hard work of certain authors. There is, to the best of our knowledge, a shortage of literature on a bibliometric analysis regarding the term craniectomy. Thus, the current bibliometric study was undertaken to highlight the work of authors who have advanced knowledge about this procedure. It provides an analysis of the top 100-cited articles with craniectomy in the title with dates ranging from 1892 to 2016. A review of its publication history shows how interventions in this field have advanced over the last several decades.

C2-3 Fracture Dislocation and Bilateral Vertebral Artery Occlusion Without Neurological Injury: A Case Report.

A 27-year-old female involved a motor vehicle collision as the restrained driver presented to the ER with agonal breathing and a Glasgow Coma Scale (GCS) of 3. Radiographic imaging demonstrated C2-3 craniocaudal dislocation, bilateral C2 comminuted pedicle fractures extending through the transverse foramina, complete bilateral vertebral artery occlusion, and negative signs of stroke with MRI. After halo immobilization, surgical stabilization, and medical treatment the patient was discharged and at her six-month follow up she was without neurological deficit.

Culturally Tailoring a Patient Empowerment and Diabetes Education Curriculum for the African American Church.

Purpose The African American church has long been recognized as a valuable partner for health interventions in the community. While an extensive literature exists documenting the potential efficacy of diabetes education programs in church settings, there has yet to be an effort to leverage spiritual beliefs and practices to promote diabetes self-management and shared decision making within a faith-based framework that is culturally tailored to the African American church. The purpose of this article is to describe the translation of a clinic-based diabetes education program into faith-based education curriculum tailored for use in the African American church. Conclusions Themes extracted from focus groups and input from a faith-based community partner provided a methodical and patient-informed foundation for culturally tailoring and piloting a diabetes self-management curriculum for the African American church setting. This study illustrates how spirituality can be incorporated into interventions to enhance health promotion and behavioral change among African Americans with diabetes. Participants in our study described how religious beliefs play an active role in many aspects of diabetes care, including self-management behaviors, coping strategies, and patient/provider communication. In addition, this intervention can serve as a model for the development of patient-centered health interventions.