Esophageal Dilation for Strictures: A 36-Year Prospective Experience in Private Practice Setting.

The author dilated 3,112 patients with esophageal strictures over 36 years. Most strictures were peptic, esophageal rings, cervical webs or eosinophilic. Strictures were assessed for presence of hiatal hernia, hernia size, stricture diameter, and type and size of dilator used. Complex strictures were present in 19.7% of patients. Re-dilation was needed in 30% of patients within five years. Three adverse reactions occurred, one perforation and two bleeds in 3,112 patients (0.1%) and 5,960 dilations (0.05%).

The importance of the eyes: communication skills in infants of blind parents.

The effects of selectively different experience of eye contact and gaze behaviour on the early development of five sighted infants of blind parents were investigated. Infants were assessed longitudinally at 6-10, 12-15 and 24-47 months. Face scanning and gaze following were assessed using eye tracking. In addition, established measures of autistic-like behaviours and standardized tests of cognitive, motor and linguistic development, as well as observations of naturalistic parent-child interaction were collected. These data were compared with those obtained from a larger group of sighted infants of sighted parents. Infants with blind parents did not show an overall decrease in eye contact or gaze following when they observed sighted adults on video or in live interactions, nor did they show any autistic-like behaviours. However, they directed their own eye gaze somewhat less frequently towards their blind mothers and also showed improved performance in visual memory and attention at younger ages. Being reared with significantly reduced experience of eye contact and gaze behaviour does not preclude sighted infants from developing typical gaze processing and other social-communication skills. Indeed, the need to switch between different types of communication strategy may actually enhance other skills during development.

A matter of trust: Commitment to act for health equity.

We believe these recommendations constitute "minimum requirements" for health care organizations to move toward greater health equity. As health systems, standards-setting organizations, national and private purchaser organizations, and thought leaders, we represent organizations in the health care ecosystem that can both advise on strategies for adopting the recommendations and have the power and leverage to cause their implementation. We commit individually and collectively to use our leverage to propel their implementation at our own institutions and across the county. We very much hope others will join us.

Comparison of Parent Questionnaires, Examiner-Led Assessment and Parents' Concerns at 14 Months of Age as Indicators of Later Diagnosis of Autism.

Parents participating in a prospective longitudinal study of infants with older siblings with autism completed an autism screening questionnaire and were asked about any concerns relating to their child's development, and children were administered an interactive assessment conducted by a researcher at 14 months. Scores on the parent questionnaire were highest for children later diagnosed with autism. Parental concerns and scores from the examiner-led assessment distinguished children with later developmental difficulties (both autism and other developmental atypicalities) from those who were developing typically. Children about whom parents expressed concern scored higher on both the questionnaire and the interactive assessment than those without concerns. There were no significant associations between total or individual item scores from the questionnaire and interactive assessment.

Visual orienting in the early broader autism phenotype: disengagement and facilitation.

BACKGROUND: Recent studies of infant siblings of children diagnosed with autism have allowed for a prospective approach to examine the emergence of symptoms and revealed behavioral differences in the broader autism phenotype within the early years. In the current study we focused on a set of functions associated with visual attention, previously reported to be atypical in autism. METHOD: We compared performance of a group of 9-10-month-old infant siblings of children with autism to a control group with no family history of autism on the 'gap-overlap task', which measures the cost of disengaging from a central stimulus in order to fixate a peripheral one. Two measures were derived on the basis of infants' saccadic reaction times. The first is the Disengagement effect, which measures the efficiency of disengaging from a central stimulus to orient to a peripheral one. The second was a Facilitation effect, which arises when the infant is cued by a temporal gap preceding the onset of the peripheral stimulus, and would orient faster after its onset. RESULTS AND CONCLUSION: Infant siblings of children with autism showed longer Disengagement latencies as well as less Facilitation relative to the control group. The findings are discussed in relation to how differences in visual attention may relate to characteristics observed in autism and the broader phenotype.

Pharmacy patronage: identifying key factors in the decision making process using the determinant attribute approach.

OBJECTIVE: To use the determinant attribute approach, a research method commonly used in marketing to identify the wants of various consumer groups, to evaluate consumer pharmacy choice when having a prescription order filled in different pharmacy settings. DESIGN: Cross sectional. SETTING: Community independent, grocery store, community chain, and discount store pharmacies in Georgia between April 2005 and April 2006. PARTICIPANTS: Convenience sample of adult pharmacy consumers (n = 175). INTERVENTION: Survey measuring consumer preferences on 26 attributes encompassing general pharmacy site features (16 items), pharmacist characteristics (5 items), and pharmacy staff characteristics (5 items). MAIN OUTCOME MEASURE: 26 potential determinant attributes for pharmacy selection. RESULTS: 175 consumers were surveyed at community independent (n = 81), grocery store (n = 44), community chain (n = 27), or discount store (n = 23) pharmacy settings. The attributes of pharmacists and staff at all four pharmacy settings were shown to affect pharmacy patronage motives, although consumers frequenting non-community independent pharmacies were also motivated by secondary convenience factors, e.g., hours of operation, and prescription coverage. CONCLUSION: Most consumers do not perceive pharmacies as merely prescription-distribution centers that vary only by convenience. Prescriptions are not just another economic good. Pharmacy personnel influence pharmacy selection; therefore, optimal staff selection and training is likely the greatest asset and most important investment for ensuring pharmacy success.

Infant neural sensitivity to eye gaze depends on early experience of gaze communication.

A fundamental question in functional brain development is how the brain acquires specialised processing optimised for its individual environment. The current study is the first to demonstrate that distinct experience of eye gaze communication, due to the visual impairment of a parent, affects the specificity of brain responses to dynamic gaze shifts in infants. Event-related potentials (ERPs) from 6 to 10 months old sighted infants with blind parents (SIBP group) and control infants with sighted parents (CTRL group) were recorded while they observed a face with gaze shifting Toward or Away from them. Unlike the CTRL group, ERPs of the SIBP group did not differentiate between the two directions of gaze shift. Thus, selective brain responses to perceived gaze shifts in infants may depend on their eye gaze communication experience with the primary caregiver. This finding highlights the critical role of early communicative experience in the emerging functional specialisation of the human brain.

Development of adaptive communication skills in infants of blind parents.

A fundamental question about the development of communication behavior in early life is how infants acquire adaptive communication behavior that is well-suited to their individual social environment, and how the experience of parent-child communication affects this development. The current study investigated how infants develop communication skills when their parents are visually impaired and cannot see their infants' eye gaze. We analyzed 6-min video recordings of naturalistic interaction between 14 sighted infants of blind parents (SIBP) with (a) their blind parent, and (b) a sighted experimenter. Data coded from these interactions were compared with those from 28 age-matched sighted infants of sighted parents (controls). Each infant completed two visits, at 6-10 months and 12-16 months of age. Within each interaction sample, we coded the function (initiation or response) and form (face gaze, vocalization, or action) of each infant communication behavior. When interacting with their parents, SIBP made relatively more communicative responses than initiations, and used more face gaze and fewer actions to communicate, than did controls. When interacting with a sighted experimenter, by contrast, SIBP made slightly (but significantly) more communicative initiations than controls, but otherwise used similar forms of communication. The differential communication behavior by infants of blind versus sighted parents was already apparent by 6-10 months of age, and was specific to communication with the parent. These results highlight the flexibility in the early development of human communication behavior, which enables infants to optimize their communicative bids and methods to their unique social environment. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Laparoscopic Nissen fundoplication in a community hospital: analysis of 202 patients.

We analyzed 202 patients undergoing Laparoscopic Nissen fundoplication. One hundred and three patients (90.6%) had typical reflux symptoms. Hiatal hernias were present in 84.6%. Most patients had erosive esophagitis; sixty-four patients (31.6%) had strictures. Complications occurred in 38 patients (18.8%), with major complications in 15 patients (7.4%). Major complications included bleeding in six, two requiring transfusion, slipped Nissen in three, pneumothorax in two, and esophageal leak in two patients. Eleven patients had postoperative dysphagia that responded to dilation therapy within three months. There was no mortality.

Autism diagnosis differentiates neurophysiological responses to faces in adults with tuberous sclerosis complex.

BACKGROUND: Autism spectrum disorder (ASD) is a common and highly heritable neurodevelopmental disorder that is likely to be the outcome of complex aetiological mechanisms. One strategy to provide insight is to study ASD within tuberous sclerosis complex (TSC), a rare disorder with a high incidence of ASD, but for which the genetic cause is determined. Individuals with ASD consistently demonstrate face processing impairments, but these have not been examined in adults with TSC using event-related potentials (ERPs) that are able to capture distinct temporal stages of processing. METHODS: For adults with TSC (n = 14), 6 of which had a diagnosis of ASD, and control adults (n = 13) passively viewed upright and inverted human faces with direct or averted gaze, with concurrent EEG recording. Amplitude and latency of the P1 and N170 ERPs were measured. RESULTS: Individuals with TSC + ASD exhibited longer N170 latencies to faces compared to typical adults. Typical adults and adults with TSC-only exhibited longer N170 latency to inverted versus upright faces, whereas individuals with TSC + ASD did not show latency differences according to face orientation. In addition, individuals with TSC + ASD showed increased N170 latency to averted compared to direct gaze, which was not demonstrated in typical adults. A reduced lateralization was shown for the TSC + ASD groups on P1 and N170 amplitude. CONCLUSIONS: The findings suggest that individuals with TSC + ASD may have similar electrophysiological abnormalities to idiopathic ASD and are suggestive of developmental delay. Identifying brain-based markers of ASD that are similar in TSC and idiopathic cases is likely to help elucidate the risk pathways to ASD.

Early Social Experience Affects the Development of Eye Gaze Processing.

Eye gaze is a key channel of non-verbal communication in humans. Eye contact with others is present from birth, and eye gaze processing is crucial for social learning and adult-infant communication. However, little is known about the effect of selectively different experience of eye contact and gaze communication on early social and communicative development. To directly address this question, we assessed 14 sighted infants of blind parents (SIBPs) longitudinally at 6-10 and 12-16 months. Face scanning and gaze following were assessed using eye tracking. In addition, naturalistic observations were made when the infants were interacting with their blind parent and with an unfamiliar sighted adult. Established measures of emergent autistic-like behaviors and standardized tests of cognitive, motor, and linguistic development were also collected. These data were then compared with those obtained from a group of infants of sighted parents. Despite showing typical social skills development overall, infants of blind parents allocated less attention to adult eye movements and gaze direction, an effect that increased between 6-10 and 12-16 months of age. The results suggest that infants adjust their use of adults' eye gaze depending on gaze communication experience from early in life. The results highlight that human functional brain development shows selective experience-dependent plasticity adaptive to the individual's specific social environment.

Behavioural markers for autism in infancy: scores on the Autism Observational Scale for Infants in a prospective study of at-risk siblings.

We investigated early behavioural markers of autism spectrum disorder (ASD) using the Autism Observational Scale for Infants (AOSI) in a prospective familial high-risk (HR) sample of infant siblings (N=54) and low-risk (LR) controls (N=50). The AOSI was completed at 7 and 14 month infant visits and children were seen again at age 24 and 36 months. Diagnostic outcome of ASD (HR-ASD) versus no ASD (HR-No ASD) was determined for the HR sample at the latter timepoint. The HR group scored higher than the LR group at 7 months and marginally but non-significantly higher than the LR group at 14 months, although these differences did not remain when verbal and nonverbal developmental level were covaried. The HR-ASD outcome group had higher AOSI scores than the LR group at 14 months but not 7 months, even when developmental level was taken into account. The HR-No ASD outcome group had scores intermediate between the HR-ASD and LR groups. At both timepoints a few individual items were higher in the HR-ASD and HR-No ASD outcome groups compared to the LR group and these included both social (e.g. orienting to name) and non-social (e.g. visual tracking) behaviours. AOSI scores at 14 months but not at 7 months were moderately correlated with later scores on the autism diagnostic observation schedule (ADOS) suggesting continuity of autistic-like behavioural atypicality but only from the second and not first year of life. The scores of HR siblings who did not go on to have ASD were intermediate between the HR-ASD outcome and LR groups, consistent with the notion of a broader autism phenotype.

Transforming primary care residency training: a collaborative faculty development initiative among family medicine, internal medicine, and pediatric residencies.

PROBLEM: The scope and scale of developments in health care redesign have not been sufficiently adopted in primary care residency programs. APPROACH: The interdisciplinary Primary Care Faculty Development Initiative was created to teach faculty how to accelerate revisions in primary care residency training. The program focused on skill development in teamwork, change management, leadership, population management, clinical microsystems, and competency assessment. The 2013 pilot program involved 36 family medicine, internal medicine, and pediatric faculty members from 12 residencies in four locations. OUTCOMES: The percentage of participants rating intention to implement what was learned as "very likely to" or "absolutely will" was 16/32 (50%) for leadership, 24/33 (72.7%) for change management, 23/33 (69.7%) for systems thinking, 25/32 (75.8%) for population management, 28/33 (84.9%) for teamwork, 29/33 (87.8%) for competency assessment, and 30/31 (96.7%) for patient centeredness.Content analysis revealed five key themes: leadership skills are key drivers of change, but program faculty face big challenges in changing culture and engaging stakeholders; access to data from electronic health records for population management is a universal challenge; readiness to change varies among the three disciplines and among residencies within each discipline; focusing on patients and their needs galvanizes collaborative efforts across disciplines and within residencies; and collaboration among disciplines to develop and use shared measures of residency programs and learner outcomes can guide and inspire program changes and urgently needed educational research. NEXT STEPS: Revise and reevaluate this rapidly evolving program toward widespread engagement with family medicine, internal medicine, and pediatric residencies.

A Summary of the American Society of Echocardiography Foundation Value-Based Healthcare: Summit 2014: The Role of Cardiovascular Ultrasound in the New Paradigm.

Value-Based Healthcare: Summit 2014 clearly achieved the three goals set forth at the beginning of this document. First, the live event informed and educated attendees through a discussion of the evolving value-based healthcare environment, including a collaborative effort to define the important role of cardiovascular ultrasound in that environment. Second, publication of these Summit proceedings in the Journal of the American Society of Echocardiography will inform a wider audience of the important insights gathered. Third, moving forward, the ASE will continue to build a ''living resource'' on its website, http://www.asecho.org, for clinicians, researchers, and administrators to use in advocating for the value of cardiovascular ultrasound in the new value-based healthcare environment. The ASE looks forward to incorporating many of the Summit recommendations as it works with its members, legislators, payers, hospital administrators, and researchers to demonstrate and increase the value of cardiovascular ultrasound. All Summit attendees shared in the infectious enthusiasm generated by this proactive approach to ensuring cardiovascular ultrasound's place as ''The Value Choice'' in cardiac imaging.

Diverticular bleeding: novel treatment with band ligation.

Diverticulosis accounts for 50% of adult cases of lower gastrointestinal bleeding. Recurrent or persistent bleeding usually is treated surgically. Recent studies suggest that 20% of patients with diverticular bleeding can have the site identified and treated endoscopically. Treatment modalities include injection techniques, thermal therapy and hemoclips. This paper reports three cases successfully treated with band ligation, after initial epinephrine injection therapy had failed.

Frontal cortex functioning in the infant broader autism phenotype.

Atypical attention has been proposed as a marker of the broader autism phenotype. In the present study we investigated this and the related process of inhibitory control at the youngest possible age through the study of infant siblings of children with an autism spectrum disorder (Sibs-ASD). Both attention and inhibition have been related to the frontal cortex of the brain. Nine- to ten-month-old Sibs-ASD and low-risk control infants completed the Freeze-Frame task, in which infants are encouraged to inhibit looks to peripherally presented distractors whilst looking at a central animation. The attractiveness of the central stimulus is varied in order to investigate the selectivity of infants' responses. In line with previous studies, it was found that a subset of Sibs-ASD infants had difficulty disengaging attention from a central stimulus in order to orient to a peripheral stimulus. The Sibs-ASD group also showed less Selective Inhibition than controls. However, Sibs-ASD infants did demonstrate Selective Inhibitory Learning. These results provide preliminary evidence for atypical frontal cortex functioning in the infant broader autism phenotype.

Neural correlates of eye gaze processing in the infant broader autism phenotype.

BACKGROUND: Studies of infant siblings of children diagnosed with autism have allowed for a prospective approach to study the emergence of autism in infancy and revealed early behavioral characteristics of the broader autism phenotype. In view of previous findings of atypical eye gaze processing in children and adults with autism, the aim of this study was to examine the early autism phenotype in infant siblings of children diagnosed with autism spectrum disorder (sib-ASD), focusing on the neural correlates of direct compared with averted gaze. METHODS: A group of 19 sib-ASD was compared with 17 control infants with no family history of ASD (mean age=10 months) on their response to direct versus averted gaze in static stimuli. RESULTS: Relative to the control group, the sib-ASD group showed prolonged latency of the occipital P400 event-related potentials component in response to direct gaze, but they did not differ in earlier components. Similarly, time-frequency analysis of high-frequency oscillatory activity in the gamma band showed group differences in response to direct gaze, where induced gamma activity was late and less persistent over the right temporal region in the sib-ASD group. CONCLUSION: This study suggests that a broader autism phenotype, which includes an atypical response to direct gaze, is manifest early in infancy.

Freeze-Frame: a new infant inhibition task and its relation to frontal cortex tasks during infancy and early childhood.

The current study investigated a new, easily administered, visual inhibition task for infants termed the Freeze-Frame task. In the new task, 9-month-olds were encouraged to inhibit looks to peripheral distractors. This was done by briefly freezing a central animated stimulus when infants looked to the distractors. Half of the trials presented an engaging central stimulus, and the other half presented a repetitive central stimulus. Three measures of inhibitory function were derived from the task and compared with performance on a set of frontal cortex tasks administered at 9 and 24 months of age. As expected, infants' ability to learn to selectively inhibit looks to the distractors at 9 months predicted performance at 24 months. However, performance differences in the two Freeze-Frame trial types early in the experiment also turned out to be an important predictor. The results are discussed in terms of the validity of the Freeze-Frame task as an early measure of different components of inhibitory function.

Laparoscopic Nissen fundoplication in a community hospital: patient satisfaction survey.

OBJECTIVES: To assess the efficacy of laparoscopic Nissen fundoplication for esophageal reflux in a community hospital. METHODS: One hundred nineteen patients (76%) of 157 patients having laparoscopic fundoplication for symptomatic reflux disease completed a questionnaire. All patients were evaluated with esophagoscopy, esophageal motility, and pH studies. RESULTS: Mean follow-up was 49 months. Ninety-three patients (78%) no longer had heartburn. Seven patients still had daily heart-burn (5.9%). One hundred three patients (86.6%) had no sour regurgitation. Seventy-five patients (63%) had no dysphagia after surgery. Forty-two patients had some dysphagia after surgery (36.8%). Six patients (5.0%) had significant dysphagia. Only 4 patients stated that dysphagia interfered with their quality of life. Twenty-six patients (22.8%) thought that belching and bloating were worse, whereas 42 patients (36.8%) thought that belching and bloating were better after surgery. Antacids, histamine-2 antagonist, and proton pump inhibitors were still being used by 12.6%, 14.3%, and 21.8% of patients, respectively. CONCLUSIONS: Eighty-seven patients were completely satisfied (73.1%), 26 patients somewhat satisfied (22.8%), and 6 patients unsatisfied (5.3%) with surgery. Overall satisfaction with the surgery was 94.7%. One hundred five patients (88.2%) would recommend the surgery to others. Laparoscopic Nissen fundoplication can be effectively done in a community hospital setting.