Impacts of an Electronic Health Record Transition on Veterans Health Administration Health Professions Trainee Experience.

BACKGROUND: Adoption of electronic health care records (EHRs) has proliferated since 2000. While EHR transitions are widely understood to be disruptive, little attention has been paid to their effect on health professions trainees' (HPTs) ability to learn and conduct work. Veterans Health Administration's (VA) massive transition from its homegrown EHR (CPRS/Vista) to the commercial Oracle Cerner presents an unparalleled-in-scope opportunity to gain insight on trainee work functions and their ability to obtain requisite experience during transitions. OBJECTIVE: To identify how an organizational EHR transition affected HPT work and learning at the third VA go-live site. DESIGN: A formative mixed-method evaluation of HPT experiences with VHA's EHR transition including interviews with HPTs and supervisors at Chalmers P. Wylie VA Outpatient Clinic in Columbus, OH, before (~60 min), during (15-30 min), and after (~60 min) go-live (December 2021-July 2022). We also conducted pre- (March 2022-April 2022) and post-go live (May 2022-June 2022) HPT and employee surveys. PARTICIPANTS: We conducted 24 interviews with HPTs (n=4), site leaders (n=2), and academic affiliates (n=2) using snowball sampling. We recruited HPTs in pre- (n=13) and post-go-live (n=10) surveys and employees in pre- (n=408) and post-go-live (n=458) surveys. APPROACH: We conducted interviews using a semi-structured guide and grounded prompts. We coded interviews and survey free text data using a priori and emergent codes, subsequently conducting thematic analysis. We conducted descriptive statistical analysis of survey responses and merged interview and survey data streams. KEY RESULTS: Our preliminary findings indicate that the EHR transition comprehensively affected HPT experiences, disrupting processes from onboarding and training to clinical care contributions and training-to-career retention. CONCLUSIONS: Understanding HPTs' challenges during EHR transitions is critical to effective training. Mitigating the identified barriers to HPT training and providing patient care may lessen their dissatisfaction and ensure quality patient care during EHR transitions.

Predictors of occult lymph node metastases in lip cancer.

OBJECTIVE: The incidence of lymph node metastases (LNM) in squamous cell carcinoma of the lip is modest (8%), making it challenging to identify patients that may benefit from elective pathologic staging evaluation of the neck. We evaluated predictors of LNM in patients with lip cancer in order to potentially refine selection of patients for pathologic staging evaluation of the neck. STUDY DESIGN: Retrospective cohort study. SUBJECTS: Clinically N0 patients with squamous cell carcinoma of the lip that underwent definitive surgical resection and pathologic evaluation of lymph node metastases in the National Cancer Data Base from 2006 to 2013. METHODS: Multivariable binomial logistic-regression was used to assess the relationship between occult pathologic lymph node metastasis and potential preoperative predictors including; patient demographics, T-stage, location, and pathologic details. RESULTS: Among 786 patients the overall rate of LNM was 12.1%. Patients were more likely to have LNM with T2 (odds ratio (OR) 2.05; (95% confidence interval (CI) 1.19-3.54) or T3-4 (OR 2.36; CI 1.32-4.22) moderately differentiated (OR 2.65; CI 1.30-5.38) or poorly differentiated (OR 4.37; CI 1.97-9.71), or involvement of the mucosal surface (OR 1.82; CI 1.09-3.03). We created a prediction model based on proportional odd ratios from multivariant binomial logistic-regression analysis from statistically significant factors; incorporating T2-4, moderate/poorly differentiated, or mucosal site. CONCLUSION: Our prediction model found that patients with two or more risk factors were the best candidates for elective pathologic nodal evaluation.

When Bad Things Happen: Training Medical Students to Anticipate the Aftermath of Medical Errors.

OBJECTIVE: Medical errors affect trainees. Existing curricula emphasize tenets of patient safety but rarely address the impact of medical errors on health care providers, particularly at the undergraduate level. The authors developed an interactive session exploring the professional and personal effects of medical errors for 300 second-year medical students. METHODS: The session utilized case-based learning, small group discussion, and video vignettes. Physicians in multiple specialties were interviewed, sharing narrative accounts of their experience with medical errors and adverse events. Discussions were facilitated by local physicians, who delivered content and shared personal anecdotes. Surveys using a 5-point Likert scale were conducted before and after the session. RESULTS: Pre- and post-test surveys resulted in 91 responses in 2016 and 174 in 2017. In 2016, results showed significant change in student responses by 0.34 units (SD 0.35 units; p < 0.001). Two survey items addressing student awareness and three items addressing confidence were significant. The domains assessing students' attitudes and knowledge regarding medical errors were not significant. In 2017, the overall mean change was 0.33 with a lower standard error, 0.03 (p < 0.001), showing significance in both years the session was delivered. CONCLUSION: A 1-h, small-group session increased medical students' understanding of the impact of medical errors and adverse events on providers and the supportive resources available. Recruitment of local faculty to facilitate discussions and share personal anecdotes enhanced the success of the session.

Incarceration of the medial collateral ligament in the intercondylar notch following proximal avulsion.

Intra-articular entrapment of the medial collateral ligament (MCL) is a rare but recognised complication of traumatic injury to the posteromedial corner (PMC) of the knee. Considering the MCL is the most commonly injured ligament of the knee this complication is extremely rare with only a handful of cases describing MCL entrapment following distal avulsion of the MCL. We present the first known case of MCL entrapment following proximal avulsion of the MCL and posterior oblique ligament (POL) with the mid-substance of the MCL becoming entrapped in the joint, lying on the superior surface of the medial meniscus and extending up into the intercondylar notch. In addition, the medial patellar retinaculum was also entrapped in the medial aspect of the medial patellofemoral joint. MCL entrapment is best treated with expeditious surgical intervention and it is therefore crucial that the MRI findings are not overlooked. Details of the clinical assessment, MRI and operative findings are presented with a literature review of MCL entrapment.

Topical phytochemicals: applications for wound healing.

To maximize the effectiveness of any complementary therapy in treating chronic wounds, the clinician must fully appreciate the scientific basis in which this treatment modality influences wound healing. The biological changes influenced by phytochemical compounds can have a positive effect on wound healing, which often depends on extract selection and clinical application. A sound understanding of the physiological changes that are associated with phytochemical compounds will help the clinician to make an appropriate extract selection and guide treatment decisions.Tissue adhesion has long been considered a key step in determining a bacterium's pathogenicity. The process of preventing infections by decreasing bacterial-tissue adhesion has been reported in the literature, with particular focus on the antibacterial effects of ingested cranberry juice. Cranberry juice has been studied primarily as a "home remedy" in the treatment of urinary tract infection with its antiadhesion and/or antibacterial effects in a chronic wound needing further investigation.

Assessment and Recommendations for Website Platforms of Neuroanesthesiology Fellowship Programs.

BACKGROUND: Websites serve as recruitment and educational tools for many fellowship programs, including neuroanesthesiology. Since the COVID-19 pandemic, when interviews, conferences, and institutional visits were moved online, websites have become more important for applicants when deciding on their preferred fellowship program. This study evaluated the content of the websites of neuroanesthesiology fellowship programs. METHODS: Neuroanesthesiology fellowship program websites were identified from the websites of the International Council on Perioperative Neuroscience Training and the Society for Neuroscience in Anesthesiology and Critical Care. The content was assessed against 24 predefined criteria. RESULTS: Fifty-three fellowship programs were identified, of which 42 websites were accessible through a Google search and available for evaluation. The mean number of criteria met by the 42 fellowship websites was 12/24 (50%), with a range of 6 to 18 criteria. None of the evaluated fellowship websites met all 24 predefined criteria; 20 included more than 50% of the criteria, whereas 7 included fewer than 30% of the criteria. Having a functional website, accessibility through a single click from Google, and a detailed description of the fellowship program were the features of most websites. Information about salary and life in the area, concise program summaries, and biographical information of past and current fellows were missing from a majority of websites. CONCLUSION: Important information was missing from most of the 42 evaluated neuroanesthesiology fellowship program websites, potentially hindering applicants from making informed choices about their career plans.

Electroacupuncture: applications in the treatment of chronic nonhealing wounds.

Maximizing the effectiveness of any wound treatment requires that normal wound-healing dynamics are appreciated. In considering adjuvant wound therapies, the clinical evidence supporting a therapy must be fully understood. The biological changes associated with electroacupuncture can have a positive effect on wound healing, although limited clinical data are available.

Uniformed Services and the Field Hospital Experience During Coronovirus Disease 2019 (SARS-CoV-2) Pandemic: Open to Closure in 30 Days With 1,100 Patients: The Javits New York Medical Station.

INTRODUCTION: The surge of SARS-CoV-2-virus infected (COVID-19) patients presenting to New York City (NYC) hospitals quickly overwhelmed and outnumbered the available acute care and intensive care resources in NYC in early March 2020. Upon the arrival of military medical assets to the Javits Convention Center in NYC, the planned mission to care for non-SARS-CoV-2 patients was immediately changed to manage patients with (SARS-CoV-2)COVID-19 and their comorbid conditions.Healthcare professionals from every branch of the uniformed services, augmented by state and local resources, staffed the Javits New York Medical Station (JNYMS) from April 2020. METHODS: The data review reported aggregated summary statistics and participant observations collected by N.Y. State and U.S. military officials. RESULTS: During the 28 days of patient intake at the JNYMS, 1,095 SARS-CoV-2-positive patients were transferred from NYC hospitals to the JNYMS. At its peak, the JNYMS accepted 119 patients in a single day, had a maximum census of 453, and had a peak intensive care unit census of 35. The median length of stay was 4.6 days (interquartile range: 3.1-6.9 days). A total of 103 patients were transferred back to local hospitals, and there were 6 deaths, with an overall mortality rate of 0.6% (95% CI, 0.3-1.2). DISCUSSION AND CONCLUSIONS: This is the first report of the care provided at the JNYMS. Within 2 weeks, this multi-agency effort was able to mobilize to care for over 1,000 SARS-CoV-2 patients with varying degrees of illness in a 1-month period. This was the largest field hospital mobilization in the U.S. medical history in response to a non-wartime pandemic. Its success with huge patient throughput including disposition and low mortality relieved critical overcrowding and supply deficiencies throughout NYC hospitals. The downstream impact likely saved additional hundreds of lives and reduced stress on the system during this healthcare crisis.

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration.

OBJECTIVES: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy. METHODS: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff. RESULTS: Of the 281 bleeding events reviewed, 188 (67%) were unwitnessed and 54 (19%) were associated with an alteration in mental status. Most deaths (n = 11; 79%) were associated with central venous catheter access. Root cause analyses reported 83 root causes, of which 33% identified physical barriers to direct observation or an equipment issue.Action plans addressed policy/procedures (30%), training/education (20%), and changes to environment/equipment (19%). Patient Safety Advisory publication was associated with a significant increase in low-harm PS reports, from 9 to 18 per year (P = 0.001). CONCLUSIONS: Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting.

Meniscal "Ramp" Lesions: Surgical Incidence and the Development of Magnetic Resonance Imaging Diagnostic Criteria.

PURPOSE: To establish the magnetic resonance imaging (MRI) and operative incidence of ramp lesions in a consecutive group of patients who had undergone anterior cruciate ligament reconstruction (ACLR) and to propose a graded radiologic classification that seeks to define key preoperative features that most strongly correlate with arthroscopically confirmed ramp lesions. METHODS: After retrospective review, all consecutive patients who underwent ACLR with preoperative MRI over a 16-month period were included in the study. Diagnostic arthroscopy with direct visualization of the posteromedial compartment was used to establish the true incidence of ramp lesions. Three radiologists, blinded to the surgical findings, independently analyzed the MRI scans of all patients and classified the signal intensity at the posterior meniscocapsular junction using 4 criteria (type 1, diffuse increased signal equal to adjacent femoral cartilage; type 2, diffuse increased signal greater than cartilage; type 3, diffuse increased signal plus full-height linear fluid-signal cleft; and type 4, full-height fluid-signal meniscocapsular separation). Interobserver reliability, in addition to sensitivity, specificity, and positive and negative predictive values, was calculated. RESULTS: Of the 93 patients included (mean age, 26.7 years), 11 (11.8%) were confirmed to have ramp lesions on arthroscopy. Inter-rater reliability for the MRI diagnosis of the positive ramp lesions was good, at 0.75. Type 3 criteria were the most accurate, producing average sensitivity and specificity values of 85% and 82%, respectively. CONCLUSIONS: Ramp lesions are not infrequently encountered in ACLR and, if not recognized at the time of surgery, may contribute to inferior outcomes. MRI is an effective method of preoperative assessment, and the presence of type 3 changes should be used as criteria for radiologically definitive ramp lesion diagnosis. CLINICAL RELEVANCE: This study highlights the incidence of meniscal ramp lesions encountered in ACLR surgery and the effectiveness of MRI as a preoperative imaging modality.

Combinatorial Exploration and Mapping of Phase Transformation in a Ni-Ti-Co Thin Film Library.

Combinatorial synthesis and high-throughput characterization of a Ni-Ti-Co thin film materials library are reported for exploration of reversible martensitic transformation. The library was prepared by magnetron co-sputtering, annealed in vacuum at 500 °C without atmospheric exposure, and evaluated for shape memory behavior as an indicator of transformation. Composition, structure, and transformation behavior of the 177 pads in the library were characterized using high-throughput wavelength dispersive spectroscopy (WDS), X-ray photoelectron spectroscopy (XPS), X-ray diffraction (XRD), and four-point probe temperature-dependent resistance (R(T)) measurements. A new, expanded composition space having phase transformation with low thermal hysteresis and Co > 10 at. % is found. Unsupervised machine learning methods of hierarchical clustering were employed to streamline data processing of the large XRD and XPS data sets. Through cluster analysis of XRD data, we identified and mapped the constituent structural phases. Composition-structure-property maps for the ternary system are made to correlate the functional properties to the local microstructure and composition of the Ni-Ti-Co thin film library.

Improving Health and Safety at Camp.

The American Academy of Pediatrics has created recommendations for health appraisal and preparation of young people before participation in day, resident, or family camps and to guide health and safety practices at camp. These recommendations are intended for parents and families, primary health care providers, and camp administration and health center staff. Although camps have diverse environments, there are general guidelines that apply to all situations and specific recommendations that are appropriate under special conditions. This policy statement has been reviewed and is supported by the American Camp Association and Association of Camp Nursing.

VIBE MRI: an alternative to CT in the imaging of sports-related osseous pathology?

MRI is an excellent diagnostic tool in the imaging of sports-related musculoskeletal pathology; however, standard slice thickness acquisitions can lack the spatial resolution to accurately define and characterise osseous abnormalities. Standard MRI sequences may be supplemented with CT to reduce diagnostic uncertainty. We provide a clinical perspective, in the form of pictorial review, on the potential applications of 3D MRI sequences, specifically using volumetric interpolated breath-hold examination in the characterisation of various musculoskeletal osseous pathologies. The potential to negate the requirement for CT in a young radiation sensitive cohort is a clinically significant concept and suggests the requirement for further studies comparing the performance of volumetric MRI to CT.

Summer Camps for Children with Sickle Cell Disease.

BACKGROUND: Children with sickle cell disease (SCD) face unique problems that attendance at a camp with their peers is well suited to address. However, because the staff members at ordinary summer camps are not accustomed to accommodating children with chronic diseases, the potential for significant health consequences exists. METHODS: We searched the literature in PubMed and CINAHL using the keywords summer camp, camp, sickle, and anemia to identify the unique characteristics of camps for children with SCD and the recommendations for care and/or lessons learned. RESULTS: Published data are limited. Accommodations to avoid triggering sickle vaso-occlusive pain have been developed empirically and extrapolated from other settings. Camp experiences provide peer learning opportunities, positive role models, and a safe area to explore personal growth. The supportive atmosphere of the camp and escape from social stigma are welcome changes from the daily routine. Camp experiences can help with education on self-care and the transition from adolescent to adult healthcare. CONCLUSION: Camp offers unique opportunities for care coordination. Camps for children with SCD provide a setting for dissemination of best practices for the disease. Community-based organizations should partner in recruiting young adults with SCD as counselors. Educational material now available could be modified for use in the camp setting. All stakeholders in the care of children with SCD should work in unison to ensure these children enjoy the benefits of summer camp.

Preventing and treating homesickness.

Homesickness is a normative pathology that ranges from benign to severe. It is defined as the distress or impairment caused by an actual or anticipated separation from home and attachment objects. Symptoms of homesickness, including preoccupying thoughts of home, can be predicted, prevented, and treated. This article summarizes the latest clinical research and practice surrounding homesickness in children and adolescents. Equipped with this knowledge, health care providers can train and consult with summer camp directors and staff to properly prepare and treat new and returning campers.

Record keeping in radiology: are we doing enough?

In modern medical practice, there is an ever-increasing rise in litigation. A strong emphasis is placed on good record keeping as an integral part of patient care and the clinician legal defence. This commentary describes the potential flaws and vulnerabilities in the radiologist record keeping and the potential implications for patient care.

Thrombus length estimation in acute ischemic stroke: a potential role for delayed contrast enhanced CT.

PURPOSE: Thrombus length has been shown to be an important determinant of recanalization using intravenous thrombolysis in hyperacute ischemic stroke. Various studies have attempted to quantify thrombus based on non-contrast CT (NCCT) or CT angiography (CTA). However, thrombus may not be seen on NCCT, and CTA may fail to delineate the distal extent of the thrombus. Contrast enhanced CT (CECT) following CTA can be used to estimate infarct core, but we investigated whether the angiographic data available on these images provided reliable information on thrombus length. MATERIALS AND METHODS: 15 consecutive patients, mean age 81 years (range 63-93), with terminal internal carotid artery or M1-middle cerebral artery occlusions underwent NCCT, CTA (bolus tracked technique), and CECT (acquired 80 s post initial CTA injection). Three radiologists assessed thrombus length on thin slice NCCT, and CTA and CECT. RESULTS: CTA overestimated thrombus length relative to NCCT (p<0.001) and CECT (p<0.001). There was less difference between CTA and CECT estimation in patients with good collateral scores (p<0.05). There was good correlation between NCCT and CECT (Pearson's correlation coefficient=0.90, 95% CI 0.81 to 0.95, p<0.001). Inter-rater reliability assessed using intraclass correlation was 0.95 (95% CI 0.87 to 0.98) for NCCT and 0.98 (95% CI 0.94 to 0.99) for CECT. CONCLUSIONS: CTA regularly overestimates thrombus length as the distal end of the thrombus is not delineated. This can be overcome through the use of a CECT acquisition which can reliably be used to estimate thrombus length.

Cardiac arrests in schools: assessing use of automated external defibrillators (AED) on school campuses.

BACKGROUND: Sudden cardiac arrest in schools are infrequent, but emotionally charged events. The purpose of our study was to: (1) describe characteristics and outcomes of school cardiac arrests; and (2) assess the feasibility of conducting school bystander interviews to describe the events surrounding cardiac arrests, assess AED availability and use, and identify barriers to AED use. METHODS: We performed a telephone survey of bystanders to cardiac arrests occurring in K-12 schools in communities participating in the Cardiac Arrest Registry to Enhance Survival (CARES) database and a local cardiac arrest database. The study period was from 8/2005 to 8/2011 and continued in one community through 2011. Utstein style descriptive data and outcomes were collected. A structured telephone interview of a bystander or administrative personnel was conducted for each cardiac arrest event. We collected a descriptive event summary, including provision of bystander CPR, presence of an AED and information regarding AED deployment, training, and use and perceived barriers to AED use. Descriptive data are reported. RESULTS: During the study period there were 30,603 cardiac arrests identified at study communities, of which 47 (0.15%) events were at K-12 schools. Of these, 21 (45.7%) were at high schools, a minority (16, 34.0%) were children (

Homesickness and adjustment in university students.

The transition to college or university can be an exciting new experience for many young adults. For some, intense homesickness can make this move difficult, even unsustainable. Homesickness--defined as the distress or impairment caused by an actual or anticipated separation from home--carries the unique hallmark of preoccupying thoughts of home and attachment objects. Sufferers typically report depression and anxiety, withdrawn behavior, and difficulty focusing on topics unrelated to home. For domestic and international university students, intense homesickness is particularly problematic. It can exacerbate preexisting mood and anxiety disorders, precipitate new mental and physical health problems, and sometimes lead to withdrawal from school. New research, consolidated here for the first time, points to promising prevention and treatment strategies for homesick students, the result of which can be a healthy, gratifying, and productive educational experience.