Association of Epidemiologic Factors and Genetic Variants Influencing Hypothalamic-Pituitary-Adrenocortical Axis Function With Postconcussive Symptoms After Minor Motor Vehicle Collision.

OBJECTIVES: To determine the influence of epidemiologic factors and the influence of genetic variants affecting FKBP5, a protein known to modulate hypothalamic-pituitary-adrenocortical axis function, on the severity of somatic symptoms commonly termed "postconcussive" 6 and 12 months after motor vehicle collision (MVC). METHODS: European Americans 18 to 65 years of age who presented to one of eight emergency departments (EDs) after MVC were enrolled. Exclusion criteria included hospital admission. Blood samples were collected in the ED for genotyping. Participants completed evaluations including an adapted Rivermead Post-Concussive Symptoms Questionnaire in the ED and at 6 weeks, 6 months, and 1 year. Repeated-measures analysis of covariance was used to evaluate the association between epidemiologic factors (sociodemographic, pre-MVC health, collision characteristics, head injury, peritraumatic pain, and stress), FKBP5 genetic variants, and postconcussive symptom severity. RESULTS: Among 943 patients recruited in the ED, follow-up was completed on 835 (88%) at 6 months and 857 (90%) at 1 year. Self-reported head impact during collision was not associated with chronic postconcussive symptom severity. After correction for multiple testing, three FKBP5 single-nucleotide polymorphisms (rs3800373, rs7753746, and rs9380526) predicted chronic postconcussive symptom severity, with an average symptom severity of 1.10 (95% confidence interval = 0.96-1.24), 1.36 (1.21-1.51), and 1.55 (1.23-1.88) for one, two, or three copies of minor allele at rs3800373 (p = .001). Similar effect sizes were observed for the minor alleles of rs7753746 and rs9380526. CONCLUSIONS: Postconcussive symptoms after minor MVC are not generally related to the severity of mild brain injury. This study shows that neurobiologic stress systems may play a role in the pathogenesis of postconcussive symptoms.

A qualitative analysis of career transitions made by internal medicine-pediatrics residency training graduates.

BACKGROUND: Physicians who complete combined residency training in internal medicine and pediatrics (med-peds) have a variety of career options after training. Little is known about career transitions among this group or among other broadly trained physicians. METHODS: To better understand these career transitions, we conducted semistructured, in-depth, telephone interviews of graduates of the University of North Carolina-Chapel Hill School of Medicine med-peds program who self-identified as having had a career transition since completing training. We qualitatively analyzed interview transcripts, to develop themes describing their career transitions. RESULTS: Of 106 physicians who graduated during 1980-2007, 20 participated in interviews. Participants identified factors such as personality, work environment, lifestyle, family, and finances as important to career transition. Five other themes emerged from the data; the following 4 were confirmed by follow-up interviews: (1) experiences during residency were not sufficient to predict future job satisfaction; work after the completion of training was necessary to discover career preferences; (2) a major factor motivating job change was a perceived lack of control in the workplace; (3) participants described a sense of regret if they did not continue to see both adult and pediatric patients as a result of their career change; (4) participants appreciated their broad training and, regardless of career path, would choose to pursue combined residency training again. LIMITATIONS: We included only a small number of graduates from a single institution. We did not interview graduates who had no career transitions after training. CONCLUSIONS: There are many professional opportunities for physicians trained in med-peds. Four consistent themes surfaced during interviews about med-peds career transitions. Future research should explore how to use these themes to help physicians make career choices and employers retain physicians.

Aspergillus mediastinitis after cardiac surgery.

BACKGROUND: Mediastinitis is a serious complication after cardiac surgery. While bacteria are the more common pathogens, fungal infections are rare. In particular, several cases of postoperative Aspergillus mediastinitis have been reported, the majority of which had an extremely poor outcome. METHODS: A case of mediastinitis in a 42-year-old patient due to Aspergillus fumigatus after cardiac surgery is described. Two main risk factors were found: cardiogenic shock requiring veno-arterial extracorporeal life support and failure of primary closure of the sternum. A full recovery was attained after surgical drainage and antifungal therapy with liposomal amphotericin B, followed by a combination of voriconazole and caspofungin. The patient was followed for 18 months without relapse. RESULTS: This is an extremely rare case of postoperative Aspergillus mediastinitis exhibiting a favourable outcome. Based on a systematic review of the literature, previous cases were examined with a focus on risk factors, antifungal therapies, and outcomes. CONCLUSION: The clinical features of postoperative Aspergillus mediastinitis may be paucisymptomatic, emphasizing the need for a low index of suspicion in cases of culture-negative mediastinitis or in indolent wound infections. In addition to surgical debridement, the central component of antifungal therapy should include amphotericin B or voriconazole.

Quantitative and qualitative analysis of performance during advanced laparoscopic fellowship: a curriculum based on structured assessment and feedback.

BACKGROUND: The objective of this study was to examine the acquisition of advanced laparoscopic technical and cognitive skills during a fellowship. METHODS: During a yearlong fellowship, consecutive assessments were completed by a fellow and 1 attending for 3 advanced procedures. The Global Operative Assessment of Laparoscopic Skills, Objective Structured Assessment of Technical Skills, and procedure-specific rating tools and free-text feedback were used. Descriptive statistics, the t test, linear mixed-effects regression, and qualitative analysis of feedback were performed. RESULTS: Seventy-six cases were included. Average ratings increased for each assessment area every month (P < .001). There were significant differences between ratings by assessors with more stringent ratings by the fellow. While the attending focused on efficiency and safety, the fellow focused on technical issues, with later expanded attention to advanced cognitive aspects. CONCLUSIONS: These assessment tools can be used as a quantitative index to monitor fellows' learning curve. In combination with narrative feedback, such data can provide measures to direct improvement during self-directed learning.

Low-Income Individuals' Perceptions About Fruit and Vegetable Access Programs: A Qualitative Study.

OBJECTIVE: To examine how fruit and vegetable (FV) programs address barriers to FV access and consumption as perceived by low-income individuals. DESIGN: From 2011 to 2012, the researchers used 13 focus groups to better understand low-income individuals' perceptions about FV programs. SETTING: Five North Carolina counties at community-serving organizations. PARTICIPANTS: Low-income participants aged ≥ 18 years were included in the study. A majority were African American women with a high school education or less, and received government assistance. PHENOMENON OF INTEREST: Low-income individuals' perceptions about how FV access programs can reduce barriers and increase consumption. ANALYSIS: A socio-ecological framework guided data analysis, and 2 trained researchers coded transcripts, identified major themes, and summarized findings. RESULTS: A total of 105 participants discussed how mobile markets could overcome barriers such as availability, convenience, transportation, and quality/variety. Some were worried about safety in higher-crime communities. Participants' opinions about how successful food assistance programs were at overcoming cost barriers were mixed. Participants agreed that community gardens could increase access to affordable, conveniently located produce but worried about feasibility and implementation issues. IMPLICATIONS FOR RESEARCH AND PRACTICE: Addressing access barriers through FV programs could improve consumption. Programs have the potential to be successful if they address multiple access barriers.

Sensory impairment in obese patients? Sensitivity and pain detection thresholds for electrical stimulation after surgery-induced weight loss, and comparison with a nonobese population.

INTRODUCTION: Obese patients have a high prevalence of painful musculoskeletal disorders that may decrease after massive weight loss. Pain thresholds may be different in obese participants. OBJECTIVES: To assess the sensitivity and pain detection thresholds, through the application of an electrical sensitivity, before and after massive weight loss, and to compare the thresholds obtained with those in a control population. METHODS: The sensitivity and pain detection thresholds obtained in participants subjected to electrical stimulation were determined in 31 obese individuals (age: 40.3 ± 10.5 y) before (body mass index: 45.7 ± 6.8 kg/m) and 6 months after a mean weight loss of 32 kg induced by gastric bypass. The results obtained were compared with those for 49 nonobese control participants (38.5 ± 11.2 y; body mass index: 22.6 ± 2.6 kg/m). Body composition and metabolic biomarkers, such as leptin, adiponectin, insulin, and interleukin 6, were assessed and single-nucleotide polymorphisms of the mu opioid receptor [OPRM1 (c.118A > G) and COMT (p.Val158Met)] were genotyped in obese patients. RESULTS: Sensitivity and pain detection thresholds (3.9 ± 1.1; 11.6 ± 6.0) were significantly higher in obese than in nonobese participants (3.1 ± 1.1; 6.0 ± 3.0), respectively (P < 0.0001), and were not affected by drastic weight loss (mean change: 32 kg). Pain thresholds in obese participants were not correlated with any of the clinical and biological variables studied. The obese participants in the highest quartile for both sensitivity and pain detection thresholds were significantly older than those in the lowest quartile. CONCLUSIONS: Further studies are required to explore sensory dysfunction in obese individuals and to investigate the implications of this dysfunction for pain management.

Preoperative assessment for children requiring dental treatment under general anesthesia.

OBJECTIVE: This study aimed to describe children <6 years requiring general anesthesia for dental treatment and factors associated with a change in medical management prior to surgery. STUDY DESIGN: This case series reviewed the past medical history and preoperative assessment of patients referred for dental preoperative evaluations at a single institution (2005-2008). A "deflection" was defined as a recommendation to change preoperative or operative care based on the preoperative assessment. The sample was analyzed using descriptive, bivariate, and multivariate analyses. RESULTS: Of 648 subjects (aged 9 months to 6 years, mean 3.9 years), 63% had a past medical history abnormality and 38% had previous surgery. In total, 14% were deflected, most commonly because of the addition of infective endocarditis prophylaxis (29%). A history of coagulation disorder had the strongest association with deflection (P < .0001, odds ratio = 10.0, 95% confidence interval = 4.6-22.1), followed by cardiac anomalies. CONCLUSION: Preoperative assessments for pediatric dental treatment frequently identify medical problems resulting in treatment plan alterations.