Racial, Ethnic, and Rural Disparities in US Veteran COVID-19 Vaccine Rates.

Background: Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). Objective: We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Design Settings Participants Measurements: Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Results: Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99]; AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95]; AI/AN-Rural HR=0.76 [0.74-0.78]. Conclusions: Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination; all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution.

Pulmonary artery angiomatoid fibrous histiocytoma mimicking pulmonary embolism.

A young man presented to the emergency department with pleuritic chest pain and shortness of breath. Of note, he recently went on a long-distance flight of about 9 hours. Given his recent long-distance travel and clinical symptoms, a pulmonary embolism was suspected. However, pathological examination of the excised pulmonary artery intraluminal mass demonstrated an angiomatoid fibrous histiocytoma. This case describes the clinicopathological and immunohistochemical features and molecular profile of a rare type of pulmonary artery tumour, a pulmonary artery angiomatoid fibrous histiocytoma.

The utility of air on computed tomography scans in the assessment of type 1 open fractures.

PURPOSE: The presence of air on computed tomography (CT) scans has been demonstrated to accurately diagnose occult traumatic arthrotomies. The purpose of this study was to determine if the presence of air on CT scans also has diagnostic utility for type 1 open fractures. METHODS: A retrospective review at a level 1 trauma center identified twenty-eight patients with Gustilo-Anderson Type 1 open fractures and preoperative CT scans. These patients were matched 2:1 with 56 closed fractures who also had CT scans. CT scans were reviewed to determine the presence of suprafascial and subfascial air. RESULTS: Air near the fracture site on CT scan was more common in open fractures then closed fractures (21 (75%) vs. 9 (16%) patients, proportional difference: 59% (37-75%), p < 0.0001). In the open fracture group, 18 (64.2%) patients had both supra- and subfascial air, 2 (7.1%) patients had isolated subfascial air, and 1 (3.5%) patient had isolated suprafascial air. In the closed fracture group, 3 (5.3%) patients had supra- and subfascial air, 4 (7.1%) had isolated subfascial air, and 2 (3.5%) had isolated suprafascial air. The sensitivity and specificity of air on CT for identifying a type 1 open fracture was 75 and 84%, respectively. CONCLUSIONS: This study found that the presence of air on CT scan was more likely in type 1 open versus closed fractures; however, the sensitivity or specificity was too low to be used reliably to identify occult open fractures in isolation. LEVEL OF EVIDENCE: Diagnostic Level III.

Barriers and facilitators to lung cancer screening and follow-up.

Two randomized trials have shown that lung cancer screening (LCS) with low dose computed tomography (LDCT) reduces lung cancer mortality in patients at high-risk for lung malignancy by identifying early-stage cancers, when local cure and control is achievable. The implementation of LCS in the United States has revealed multiple barriers to preventive cancer care. Rates of LCS are disappointingly low with estimates between 5%-18% of eligible patients screened. Equally concerning, follow-up after baseline screening is far lower than that of clinical trials (44-66% v >90%). To optimize the benefits of LCS, programs must identify and address factors related to LCS participation and follow-up while concurrently recognizing and mitigating barriers. As a relatively new screening test, the most effective processes for LCS are uncertain. Therefore, LCS programs have adopted a wide range of approaches without clearly established best practices to guide them, particularly in rural and resource-limited settings. In this narrative review, we identify barriers and facilitators to LCS, focusing on those studies in non-clinical trial settings - reflecting "real world" challenges. Our goal is to identify effective and scalable LCS practices that will increase LCS participation, improve adherence to follow-up, inform strategies for quality improvement, and support new research approaches.

Femoral Neck Stress Fractures: An Updated Review.

Femoral neck stress fractures represent a relatively rare spectrum of injuries that most commonly affect military recruits and endurance athletes. If unrecognized and if proper treatment is not initiated, this condition carries potentially devastating consequences. Patients will typically present with an insidious onset, atraumatic hip, and groin pain that is relieved with rest. The condition may be initially misdiagnosed because radiographs are often normal. Magnetic resonance imaging has demonstrated superior specificity, sensitivity, and accuracy compared with other diagnostic modalities in identifying and classifying stress fractures of the femoral neck. Treatment algorithms are based on the MRI fracture morphology and presence of an intra-articular effusion. Nonsurgical management consists of a period of non-weight-bearing followed by gradual return to activity. Surgical management consists of prophylactic fracture fixation with cannulated screws to prevent fracture progression. If left untreated, patients may progress to a complete displaced femoral neck fracture, which can be associated with complications that include nonunion, osteonecrosis of the femoral head, and long-term disability. These poor outcomes emphasize the importance of early diagnosis and treatment of incomplete femoral neck stress fractures.

Incorporation of Whipstitch Suture in Tibial Interference Fixation Improves Pullout in Anterior Cruciate Ligament Soft Tissue Grafts.

INTRODUCTION: Interference screw fixation of soft tissue grafts is commonly used in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to determine whether including suture material at the graft-screw interface affects ultimate fixation strength of soft tissue grafts using a tibialis anterior tendon allograft model. MATERIALS AND METHODS: Forty fresh-frozen human tibialis anterior tendon allografts were fixed to rigid polyurethane foam simulating the tibial tunnel. Twenty grafts underwent fixation with interference screws and 20 with interference bolts. Within each group, 10 grafts had suture in contact with either the screw or bolt. A load-to-failure test was then performed at a rate of 200 mm/min. RESULTS: The group of allografts with sutures in the tibial tunnel had significantly higher load to failure than the group without sutures. Using interference screw fixation, failure load of the grafts without sutures in the tunnel (535.2 ± 73.40 N) was significantly lower (P = .001) than with sutures in the tunnel (696.3 ± 110.0 N). Using interference bolt fixation, failure load of the grafts without sutures in the tunnel (613.0 ± 83.46 N) was significantly lower (P <.0001) than with sutures in the tunnel (845.8 ± 87.23 N). CONCLUSIONS: In a biomechanical model, suture within the tibial tunnel enhances fixation strength with both interference screw and bolt fixation for soft tissue tibialis anterior allografts. Additionally, there was no difference in load to failure when comparing failure of a screw with suture in the tunnel with an interference bolt without suture. Due to improved biomechanical properties, incorporation of suture in the bone-graft interface should be considered when performing soft tissue ACL allograft reconstructions. Failure at the tibial bone-graft interface is a known complication of ACL reconstruction, and incorporation of suture within the interface should be considered for improved biomechanical properties.

Multifactorial Wrist Pain Treated with Tenotomy of Anomalous Flexor Carpi Radialis Brevis: A Case Report.

CASE: We present a case of a 33-year-old left hand-dominant/right hand-involved active duty Navy sailor woman with volar radial wrist pain. She underwent scaphoid cyst excision and bone grafting as well as tenotomy. Intraoperatively, she was noted to have a flexor carpi radialis brevis (FCRB) tendon that was transected. After surgery, her 1-year outcomes demonstrated range of motion improved equivalent with her contralateral side, her visual analogue scale (VAS) pain score had decreased to 1, and her QuickDASH and Patient-Rated Wrist Evaluation improved. CONCLUSIONS: Our case represents 1-year outcome after surgical release of a FCRB. Our patient's pain and functional scores exceeded the minimal clinically important difference.

Aspirin for Deep-Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction.

AIM: To evaluate whether a daily full-dose aspirin regimen after anterior cruciate ligament (ACL) reconstruction reduces the risk of postoperative symptomatic deep-venous thrombosis (DVT). MATERIALS AND METHODS: Single-center retrospective cohort study of patients who underwent ACL reconstruction from 2007 to 2016. One thousand two hundred thirty-three patients met inclusion criteria: 821 patients received no chemoprophylaxis and 412 patients received daily full-dose aspirin. RESULTS: A total of 10 patients, seven receiving no chemoprophylaxis and three using aspirin, sustained a postoperative symptomatic DVT. Calculated adjusted odds ratio for symptomatic postoperative DVT for aspirin versus no chemoprophylaxis was 0.928 (95% CI 0.237-3.629, P value = 0.91). Odds ratio for symptomatic postoperative DVT occurrence among tobacco users versus non-tobacco users was 3.76 (95% CI 1.077-13.124, P = 0.04). CONCLUSIONS: No statistically significant difference was observed in postoperative symptomatic DVT after ACL reconstruction in those who received full-dose aspirin chemoprophylaxis versus those with no chemoprophylaxis. Additionally, there was a significantly increased risk of postoperative symptomatic DVT with tobacco use.

Development and Evaluation of Resident-Championed Point-of-Care Ultrasound Curriculum for Internal Medicine Residents.

Introduction: Point-of-care ultrasound (POCUS) is a powerful clinical tool that has seen widespread adoption, including in Internal Medicine (IM), yet standardized curricula designed by trained faculty are scant. To address the demand for POCUS education at our institution, we created a resident-championed curriculum with support from skilled faculty across multiple specialties. Our objective was to teach postgraduate year (PGY)-3 IM residents the basics of POCUS for evaluation of the pulmonary, cardiac, and abdominal systems through resident-developed workshops. The goal of acquisition of these skills was for resident education and to inform decisions to pursue further patient testing. Methods: Three half-day workshops were created to teach residents how to obtain and interpret ultrasound images of the pulmonary, cardiac, and abdominal systems. Workshops were comprised of didactic teaching and practical ultrasound instruction with expert supervision of clinicians within and outside of IM. Residents were asked to complete a written survey before and after each workshop to assess confidence, knowledge, and likelihood of future POCUS use. Results: Across the three workshops (pulmonary, cardiac, and abdominal), 66 sets of pre- and post-workshop surveys (32 pulmonary, 25 cardiac, and 9 abdominal) were obtained and analyzed. Confidence in and knowledge regarding POCUS use increased significantly across all three workshops. Likelihood of future use increased in the cardiac workshop. Conclusions: We implemented a resident-championed POCUS curriculum that led to improved attitudes and increased knowledge of POCUS for PGY-3 IM residents.

Improved Functional Outcomes Following Operative Treatment of Midshaft Clavicle Fractures in an Active Duty Population.

Clavicle fractures are common orthopedic injuries that occur in a young active population and are even more common in the military. Military fitness test data presents the unique opportunity to analyze functional ability with regard to military-specific activities. The primary goal of this study was to compare functional outcomes using military fitness test data between operative and non-operative treatment of midshaft clavicle fractures.  We performed a retrospective review of active-duty U.S. Navy and Marine patients with midshaft clavicle fractures treated at our institution over a seven-year period. There were 94 and 153 patients in our operative and non-operative cohorts, respectively. Average follow-up time from the date of injury or surgery was 28 months. The rate of infection in the operative group (4%) was significantly greater than in the non-operative group (0%, p = 0.023). The rate of non-union in the operative group (3%) was significantly lower than in the non-operative group (14.5%, p = 0.004). The rate of symptomatic malunion in the operative group (0%) was significantly different from that in the non-operative group (4.6%, p = 0.036). There was no significant difference in the rate of revision surgery between the operative (9.2%) and non-operative (13.2%) groups (p = 0.105). A total of 51 marines met inclusion criteria for our functional outcome analysis using Marine Corps Physical Fitness Test (PFT) data. Of those who underwent operative fixation, 68% were able to meet or surpass their pre-injury average amount of pull-ups in their first PFT after surgery and 88% by the next PFT at least one year after surgery. While 69% of non-operative patients met their pre-injury average in their first PFT, only 57% maintained this level at least one year after surgery. This difference was statistically significant. In our functional outcome subgroup analysis, we found improved outcomes for pull-ups at least one year out when midshaft clavicle fractures are treated operatively compared to non-operatively. While similar findings in the literature are based on functional outcome questionnaires, physical fitness performance data has not been reported on to our knowledge.

Do Spatiotemporal Gait Parameters Improve After Pilon Fracture in Patients Who Use the Intrepid Dynamic Exoskeletal Orthosis?

BACKGROUND: Pilon fractures are high-energy fractures about the ankle observed commonly in both civilian and military trauma populations. Despite surgical management, outcomes are predictably poorly characterized by functional deficits secondary to pain and stiffness. The Intrepid Dynamic Exoskeletal Orthosis (IDEO) and Return-to-Run clinical pathway were initially designed to treat military service members after complex battlefield lower extremity injuries. The IDEO has been used to treat nonbattlefield injuries, but, to our knowledge, it has not been studied specifically among patients with pilon fractures. By studying the use of the IDEO in this patient population, we hope to learn how it might improve ambulation in the community, relieve pain, and return patients to work to better identify patients who might benefit from its use. QUESTIONS/PURPOSES: The purpose of this study was to determine whether the IDEO would improve gait parameters including velocity, cadence, stride length, and single-leg stance duration in patients with pilon fractures. Our secondary endpoints of interest were reductions in pain and return to duty. METHODS: A prospectively collected database of all active-duty IDEO users at a single institution was queried for all patients using the IDEO after a pilon fracture. Patients were included if they were using the IDEO after sustaining a surgically treated pilon fracture and had exhausted all nonoperative therapies. Exclusions were patients with an incomplete gait analysis at the two study time points. Seven patients meeting these criteria were identified. Three-dimensional gait analysis was performed two times: first wearing shoes at a self-selected speed and second after a custom-made IDEO was fabricated for the patient and completion of the Return-to-Run pathway. Patients reported their average pain while ambulating using a numeric rating scale. Gait variables of interest were velocity, cadence, stride length, and single stance time. Return to military service was assessed through the military medical record. To return to duty, a service-specific physical readiness test must be completed. RESULTS: Median gait velocity improved from 1.1 (interquartile range [IQR], 0.9-1.2) to 1.3 m/s (IQR, 1.2-1.5; p = 0.01). All other variables did not change: cadence 98.4 (IQR, 93.0-107.2) to 104.5 steps/min (IQR, 103.0-109.0; p = 0.13), affected stride length 1.3 (IQR, 1.0-1.4 m) to 1.4 m (IQR, 1.3-1.6 m; p = 0.07), and affected single stance 0.42 (IQR, 0.41-0.47) to 0.43 (IQR, 0.42-0.44; p = 0.80). Pain did not change between time points: 3 (IQR, 2-3) to 2.5 (IQR, 1-3.5; p = 0.90). Three of seven patients returned to duty. CONCLUSIONS: At self-selected walking speeds, we observed no improvements in gait parameters or pain after application of the IDEO that would likely be considered clinically important, and so the device is unlikely to be worth the cost in this setting. It is possible that for higher demand users such as elite athletes, the IDEO could have a role after severe lower extremity trauma; however, this must be considered speculative until or unless proven in future studies. LEVEL OF EVIDENCE: Level III, therapeutic study.

How intermittent breaks in interaction improve collective intelligence.

People influence each other when they interact to solve problems. Such social influence introduces both benefits (higher average solution quality due to exploitation of existing answers through social learning) and costs (lower maximum solution quality due to a reduction in individual exploration for novel answers) relative to independent problem solving. In contrast to prior work, which has focused on how the presence and network structure of social influence affect performance, here we investigate the effects of time. We show that when social influence is intermittent it provides the benefits of constant social influence without the costs. Human subjects solved the canonical traveling salesperson problem in groups of three, randomized into treatments with constant social influence, intermittent social influence, or no social influence. Groups in the intermittent social-influence treatment found the optimum solution frequently (like groups without influence) but had a high mean performance (like groups with constant influence); they learned from each other, while maintaining a high level of exploration. Solutions improved most on rounds with social influence after a period of separation. We also show that storing subjects' best solutions so that they could be reloaded and possibly modified in subsequent rounds-a ubiquitous feature of personal productivity software-is similar to constant social influence: It increases mean performance but decreases exploration.

The impact of the 'open' workspace on human collaboration.

Organizations' pursuit of increased workplace collaboration has led managers to transform traditional office spaces into 'open', transparency-enhancing architectures with fewer walls, doors and other spatial boundaries, yet there is scant direct empirical research on how human interaction patterns change as a result of these architectural changes. In two intervention-based field studies of corporate headquarters transitioning to more open office spaces, we empirically examined-using digital data from advanced wearable devices and from electronic communication servers-the effect of open office architectures on employees' face-to-face, email and instant messaging (IM) interaction patterns. Contrary to common belief, the volume of face-to-face interaction decreased significantly (approx. 70%) in both cases, with an associated increase in electronic interaction. In short, rather than prompting increasingly vibrant face-to-face collaboration, open architecture appeared to trigger a natural human response to socially withdraw from officemates and interact instead over email and IM. This is the first study to empirically measure both face-to-face and electronic interaction before and after the adoption of open office architecture. The results inform our understanding of the impact on human behaviour of workspaces that trend towards fewer spatial boundaries.This article is part of the theme issue 'Interdisciplinary approaches for uncovering the impacts of architecture on collective behaviour'.

Atypical case of classical polyarteritis nodosa: alveolar hemorrhage and positive antineutrophil cytoplasmic antibody
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Classical polyarteritis nodosa (PAN) is a necrotizing arteritis affecting medium-sized vessels. A 73-year-old gentleman who presented with progressive anemia and scant hemoptysis developed acute kidney injury over the course of hospital admission. Kidney biopsy was initially interpreted as consistent with cephalosporin-associated acute interstitial nephritis (AIN) and acute tubular injury (ATI). After oral prednisone (5 days), the patient was discharged with improving serum creatinine. Two days later, he presented with diffuse alveolar hemorrhage. C-ANCA, ANA, anti-GBM, C4, cryoglobulin, HIV, HBV, and HCV studies were negative. P-ANCA was positive. Biopsy tissue was revisited, in addition to AIN, ATI, and non-caseating interstitial granulomas, lymphocytic infiltration of medium-sized vessels with endothelitis consistent with a diagnosis of PAN was noted. This case is notable for its atypical clinical presentation - alveolar hemorrhage - and atypical laboratory presentation - P-ANCA positivity for classical PAN. We describe an atypical presentation of PAN as a means of reviewing the range of clinical presentations, criteria for diagnosis, and treatment approaches for PAN and drug-induced vasculitis, which may present similar to PAN.
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Hip Arthroscopy for Femoroacetabular Impingement in a Military Population.

BACKGROUND: Femoroacetabular impingement (FAI) can lead to hip pain and early joint degeneration. There have been few reports to date on the outcomes of hip arthroscopy for the treatment of FAI in the military population. Purpose/Hypothesis: The purpose of this study was to compare patient demographics with postoperative outcomes after hip arthroscopy for symptomatic FAI and to identify preoperative risk factors for poor outcomes. The hypothesis was that certain preoperative patient characteristics will be predictive of poorer outcomes and that lower outcomes scores will be associated with a higher likelihood of medical separation from the military. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Retrospective chart review of active-duty and dependent patients older than 18 years who underwent hip arthroscopy for symptomatic FAI from 2009 to 2014 at a single institution. RESULTS: A total of 469 (309 males and 160 females) surgeries were performed on 456 active-duty personnel and 13 dependent civilians, with a mean 2.5-year follow-up. Overall, 39% (n = 179) were able to return to duty (RTD), 18% (n = 82) were medically cleared to return to normal daily activities but did not remain on active duty, and 43% (n = 195) required referral to the Disability Evaluation System (DES). Increasing rank and male sex were positive predictors and Axis 1 psychiatric diagnosis, revision surgery, concomitant psoas tenotomy, multiple medical comorbidities, and complaints of generalized pelvic pain were negative predictors for returning to duty. US Marine Infantry and Special Forces showed improved RTD rates (50%-86%) compared with administrative, more sedentary, occupations (22%). On average, Single Alpha Numeric Evaluation (SANE) and visual analog scale (VAS) scores improved after surgery, with SANE scores improving 37 ± 28 points and VAS scores improving 2.6 ± 2.5 points. The mean postoperative SANE and VAS scores differed significantly between the RTD group and those not returning to duty; 87 and 1.2 points compared with 69 and 3.6 points, respectively ( P < .0001). CONCLUSION: Hip arthroscopy for the treatment of symptomatic FAI effectively improves pain symptoms and self-reported overall function but shows a much lower than expected return to full, unrestricted active duty in the general active-duty military population. Underlying psychiatric diagnoses, female sex, and more sedentary occupations are associated with lower RTD rates. Furthermore, lower postoperative SANE and VAS scores are associated with lower RTD rates. Only the more active and elite components of the military study population showed RTD rates consistent with previously reported outcomes of return to competitive sports after hip arthroscopy for FAI.

Blood Culture in Evaluation of Pediatric Community-Acquired Pneumonia: A Systematic Review and Meta-analysis.

BACKGROUND AND OBJECTIVE: Current guidelines strongly recommend collection of blood cultures (BCs) in children requiring hospitalization for presumed moderate to severe bacterial community-acquired pneumonia (CAP). Our objective was to systematically review the international pediatric literature to evaluate how often BCs are positive in hospitalized children with CAP, identify the most commonly isolated pathogens, and determine the impact of positive BCs on clinical management. METHODS: We identified articles in PubMed and Scopus published from January 1970 through December 2013 that addressed BCs in children with CAP. We extracted total number of BCs collected and prevalence of positive BCs and used meta-regression to evaluate whether subgroups had any impact on prevalence. RESULTS: Meta-analysis showed that the overall prevalence of positive BCs was 5.14% (95% confidence interval 3.61-7.28). Studies focusing on severe CAP had a significant effect on prevalence (P=.008), at 9.89% (95% CI 6.79-14.19) compared with 4.17% (95% confidence interval 2.79-6.18) for studies not focusing on severe CAP. The most commonly isolated organisms were Streptococcus pneumoniae (76.7%) followed by Haemophilus influenzae (3.1%) and Staphylococcus aureus (2.1%). Contaminants accounted for 14.7%. Only 3 studies reported on BC-driven change in management, with contrasting findings. CONCLUSIONS: BCs in pediatric CAP identified organisms in only a small percentage of patients, predominantly S. pneumoniae. False-positive BC rates can be substantial. The 3 studies that examined BC-driven changes in management had conflicting results. This systematic review was limited by heterogeneous case definitions, which may overestimate the true prevalence of positive BCs in hospitalized children.

Microblog use and student engagement in the large-classroom setting.

BACKGROUND AND OBJECTIVES: Encouraging student engagement in the large-classroom setting can be difficult. Challenges include the depersonalized nature of the environment and the fact that students frequently find asking questions and participating in class discussion intimidating. Social media has the potential to address these barriers, but this has not yet been formally evaluated. Our study analyzed the impact of microblog use on students' question-asking behaviors (an indicator of student engagement) in a large-classroom setting. METHODS: Formative evaluation of a large-classroom medical humanities course identified microblog use as a potential tool to facilitate greater student engagement. A microblog was thereafter incorporated into the course. Student engagement was operationalized as question-asking behaviors before and after microblog incorporation. RESULTS: Paired t tests showed that the total number of questions asked was significantly greater in the microblog-available classes, t (2)=12.12. In addition, significantly more individual students asked questions in the microblog-available classes, t (2)=17.39. CONCLUSIONS: Our study, demonstrating an increase in question-asking behavior after incorporation of a microblog, has important implications for educators who seek to enhance student engagement and learning in the large-classroom setting. In addition, innovative use of emerging technologies (such as microblogs) as educational tools requires continuous assessment and iterative change to maximize benefit. More research is needed to evaluate what specific barriers to engagement are overcome by microblog use and whether microblog use can similarly benefit other courses.

Preoperative brain natriuretic peptide and atrial arrhythmias after coronary artery bypass graft surgery.

OBJECTIVE: To assess the association of preoperative brain natriuretic peptide with atrial arrhythmias and length of stay after cardiac surgery. DESIGN: A retrospective data analysis. SETTING: All data were collected from patients who underwent cardiac surgery at a single institution, an academic hospital, between 2005 and 2010. PARTICIPANTS: Patient data were collected from the authors' institution's Perioperative Health Documentation System of cardiac surgeries. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The major findings were that individuals with a 10-pg/mL increase in brain natriuretic peptide were 1.005 (95% CI: 1.002, 1.009) times more likely to have an atrial arrhythmia than those with no increase in brain natriuretic peptide. A brain natriuretic peptide value ≥306 pg/mL was calculated to best predict an atrial arrhythmia. Those above the threshold were 1.455 (95% CI: 1.087, 1.947) times more likely to have an atrial arrhythmia than those below the threshold. Individuals above the threshold had a median of 3 days in the intensive care unit compared to 1 day for those below the threshold, as well as median hospital stays of 11 days for those below the threshold. CONCLUSIONS: The results indicated that elevated brain natriuretic peptide was associated with increased risk of atrial arrhythmias and prolonged length of hospital stay after cardiac surgery. Identifying at-risk patients is important to guide preventative strategies for postoperative atrial arrhythmias.

The transparency trap.

To promote accountability, productivity, and shared learning, many organizations create open work environments and gather reams of data on how individuals spend their time. A few years ago, HBS professor Ethan Bernstein set out to find empirical evidence that such approaches improve organizational performance. What he discovered is that this kind of transparency often has an unintended consequence: It can leave employees feeling vulnerable and exposed. When that happens, they conceal any conduct that deviates from the norm so that they won't have to explain it. Unrehearsed, experimental behaviors sometimes stop altogether. But Bernstein also discovered organizations that had established zones of privacy within open environments by setting four types of boundaries: around teams, between feedback and evaluation, between decision rights and improvement rights, and around periods of experimentation. Moreover, across several studies, the companies that had done all this were the ones that consistently got the most creative, efficient, and thoughtful work from their employees. Bernstein's conclusion? By balancing transparency and privacy, organizations can capture the benefits of both, and encourage just the right amount of "positive deviance" needed to increase innovation and productivity.