Agreement between patient- and proxy-reported outcome measures in adult musculoskeletal trauma and injury: a scoping review.

PURPOSE: Patient-reported outcome measures (PROMs) are widely used in medicine. As older adults, who may rely on a proxy caregiver for answers due to cognitive impairment, are representing an increasing share of the traumatically injured patient population, proxy-reported outcome measures (proxROMs) offer a valuable alternative source of patient-centered information although its association with PROMs is unclear. The objective of this scoping review is to discuss all available literature comparing PROM and proxROMs in adult patients with musculoskeletal trauma to guide future research in this field. METHODS: The PRISMA extension for Scoping Reviews was used to guide this review. MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched without date limit for articles comparing PROM and proxROMs in setting of musculoskeletal trauma. Abstract and full-text screening were performed by two independent reviewers. Variables included study details, patient and proxy characteristics, and reported findings on agreement between PROMs and proxROMs. RESULTS: Of 574 unique records screened, 13 were included. Patient and proxy characteristics varied greatly, while patients' cognitive status and type of proxy perspective were poorly addressed. 18 different PROMs were evaluated, mostly reporting on physical functioning and disability (nine, 50%) or quality of life (six, 33%). Injury- and proxy-specific tools were rare, and psychometric properties of PROMs were often not described. Studies reported moderate to good agreement between PROMs and proxROMs. There is less agreement on subjective outcome measures (e.g., depression score) compared to observable items, and proxy bias results in in worse outcomes compared to patient self-reports. CONCLUSION: Current literature, though limited, demonstrates moderate to good agreement between injured patients' self- and proxy-reports. Future studies should be mindful of current guidelines on proxy reporting when developing their studies and consider including neglected populations such as cognitively impaired patients to improve clinical validity.

Straightforward method to measure optomechanically induced transparency.

We demonstrate a simple method to measure optomechanically induced transparency (OMIT) in a Fabry-Perot based system using a trampoline resonator. In OMIT, the transmitted intensity of a weak probe beam in the presence of a strong control beam is modified via the optomechanical interaction, leading to an ultra-narrow optical resonance. To retrieve both the magnitude and the phase of the probe beam, a homodyne detection technique is typically used. We have greatly simplified this method by using a single acousto-optical modulator to create a control and two probe beams. The beat signal between the transmitted control and probe beams shows directly the typical OMIT characteristics. This method therefore demonstrates an elegant solution when a homodyne field is needed but experimentally not accessible.

Amputated limb by cerclage wire of femoral diaphyseal fracture: a case report.

An entrapment of the femoral artery by cerclage wiring is a rare complication after spiral diaphyseal femoral fractures. We report the case of an 82-year-old female treated by an antegrade intramedullary nailing and multiple cable augmentation, which was then complicated by injury to the femoral artery that resulted in ipsilateral leg necrosis and amputation. The entrapment was caused by direct belting by the cable and resulted in a total obstruction of the femoral artery.

Optical side-band cooling of a low frequency optomechanical system.

For experimental investigations of macroscopic quantum superpositions and the possible role of gravitational effects on the reduction of the corresponding quantum wave function it is beneficial to consider large mass, low frequency optomechanical systems. We report optical side-band cooling from room temperature for a 1.5×10⁻¹° kg (mode mass), low frequency side-band resolved optomechanical system based on a 5 cm long Fabry-Perot cavity. By using high-quality Bragg mirrors for both the stationary and the micromechanical mirror we are able to construct an optomechanical cavity with an optical linewidth of 23 kHz. This, together with a resonator frequency of 315 kHz, makes the system operate firmly in the side-band resolved regime. With the presented optomechanical system parameters cooling close to the ground state is possible. This brings us one step closer to creating and verifying macroscopic quantum superpositions.

External validation of the U-HIP prediction model for in-hospital mortality in geriatric hip fracture patients.

INTRODUCTION: Identification of high-risk hip fracture patients in an early stage is vital for guiding surgical management and shared decision making. To objective of this study was to perform an external international validation study of the U-HIP prediction model for in-hospital mortality in geriatric patients with a hip fracture undergoing surgery. MATERIALS AND METHODS: In this retrospective cohort study, data were used from The American College of Surgeons National Surgical Quality Improvement Program. Patients aged 70 years or above undergoing hip fracture surgery were included. The discrimination (c-statistic) and calibration of the model were investigated. RESULTS: A total of 25,502 patients were included, of whom 618 (2.4%) died. The mean predicted probability of in-hospital mortality was 3.9% (range 0%-55%). The c-statistic of the model was 0.74 (95% CI 0.72-0.76), which was comparable to the c-statistic of 0.78 (95% CI 0.71-0.85) that was found in the development cohort. The calibration plot indicated that the model was slightly overfitted, with a calibration-in-the-large of 0.015 and a calibration slope of 0.780. Within the subgroup of patients aged between 70 and 85, however, the c-statistic was 0.78 (95% CI 0.75-0.81), with good calibration (calibration slope 0.934). DISCUSSION AND CONCLUSION: The U-HIP model for in-hospital mortality in geriatric hip fractures was externally validated in a large international cohort, and showed a good discrimination and fair calibration. This model is freely available online and can be used to predict the risk of mortality, identify high-risk patients and aid clinical decision making.

The effectiveness of germicidal wipes and ultraviolet irradiation in reducing bacterial loads on electronic tablet devices used to obtain patient information in orthopaedic clinics: evaluation of tablet cleaning methods.

BACKGROUND: Electronic tablet devices are commonly used in outpatient clinics to obtain patient information for both clinical and research purposes. These devices are often colonized with bacteria; there are many cleaning methods to reduce this bacterial load. AIM: The primary purpose of this study was to evaluate whether regular cleaning with either germicidal wipes or ultraviolet (UV) irradiation leads to lower bacterial levels compared with irregular cleaning. METHODS: A randomized blinded trial was conducted of tablet cleaning strategies between each patient encounter in orthopaedic clinics. The cleaning method was randomized to either germicidal wipes, UV irradiation, or cleaning only when the tablet was visibly soiled. Research assistants (blinded to the treatment) obtained bacterial cultures from the tablets at the beginning and end of each clinic day. FINDINGS: Using germicidal wipes between each patient encounter vs no routine cleaning resulted in a marked decrease in the amount of bacterial contamination (risk ratio (RR) = 0.17 (0.04-0.67)). Similarly, using UV irradiation between each patient encounter led to significantly lower bacterial contamination rates (RR = 0.29 (95% confidence interval (CI) = 0.09-0.95)) compared with no routine cleaning. The majority of bacteria identified were normal skin flora. No meticillin-resistant Staphylococcus aureus was identified and only sparse colonies of meticillin-sensitive S. aureus. CONCLUSION: Electronic tablets used in orthopaedic trauma clinics are colonized with bacteria if no routine cleaning is performed. Routine use of either UV irradiation or germicidal wipes significantly decreases this bacterial burden. Providers should implement routine cleaning of tablets between each patient encounter to minimize exposure to potential pathogens.

A randomized trial of nortriptyline for smoking cessation.

BACKGROUND: Smoking cessation rates with current therapy are suboptimal. One class of drugs that may improve cessation is the tricyclics. OBJECTIVE: To add nortriptyline hydrochloride to a behavioral smoking cessation program to enhance cessation rates and reduce withdrawal symptoms. SUBJECTS AND METHODS: We conducted a randomized, double-blind, placebo-controlled trial at an affiliated Department of Veterans Affairs Medical Center and an Army Medical Center. Subjects were aged 18 through 70 years, smoked 10 or more cigarettes per day, and were without current major depression. Nortriptyline hydrochloride or matched placebo was started at 25 mg before bed 10 days prior to quit day and titrated to 75 mg/d or to the maximal tolerated dose. The behavioral intervention consisted of 2 group sessions and 12 individual follow-up visits. Withdrawal symptoms were measured using a daily diary, and smoking cessation was defined as self-reported abstinence, expired carbon monoxide of 9 ppm or less, and a 6-month urine cotinine level of less than 50 ng/mL. RESULTS: A total of 214 patients were randomized (108 to nortriptyline and 106 to placebo). There was a significant reduction in several withdrawal symptoms including anxious/tense, anger/irritability, difficulty concentrating, restlessness, and impatience by day 8 after quit day in the nortriptyline group. The cessation rate at 6 months was 15 (14%) of 108 and 3 (3%) of 106, respectively (P = .003; absolute difference, 11%; 95% confidence interval, -18% to -4%). Nortriptyline caused frequent adverse effects, including dry mouth (64%) and dysgeusia (20%). CONCLUSIONS: We conclude that nortriptyline led to an increased short-term cessation rate compared with placebo. In addition, there were significant, but relatively small, reductions in withdrawal symptoms. Nortriptyline may represent a new therapeutic approach to smoking cessation.

Automating the reluctant physician.

The DISC played an essential role in the development of the organization strategic IS plan and has become a resource of knowledgeable doctors for participation in ongoing IS projects Communications and collaboration among the doctors and other care giver, the administration and the IS department have improved. The DISC model is one that other hospitals and healthcare organizations can use to involve and mobilize their own medical staffs in IS issues. It should be particularly applicable on the medical staff with the time, interest or clinical IS expertise to provide the needed medical staff IS vision and leadership.

Deep venous thrombosis following different isolated lower extremity fractures: what is known about prevalences, locations, risk factors and prophylaxis?

INTRODUCTION: Deep venous thrombosis (DVT) offers a high risk of morbidity and mortality, especially in case of pulmonary embolism. Precise data as to DVT after isolated lower extremity fractures (ILEFs) are rare. Even organizations like the American Academy of Orthopaedic Surgeons or the American College of Chest Physicians do not state exact recommendations as to optimal DVT prophylaxis (ppx) after ILEFs. PREVALENCE: The incidence of DVT ranges from 5 to 86 % depending on the fracture whereas femur fractures offer the highest risk for clotting. The incidence seems to decrease in more distal fractures. LOCATION: The risk to develop proximal clots is likely low, however, especially these are feared by surgeons. DVT can occur in both the injured and uninjured leg with a trend for higher incidences in the injured leg. RISK FACTORS: Risk factors for DVT after ILEF seem to be similar to risk factors for DVT development after orthopaedic surgery and in general. Risk factors caused by surgeons are the use of a tourniquet, prolonged operative time and a delay from injury to surgery. PROPHYLAXIS: Low molecular weight heparin is favoured by many authors, however, warfarin and acetylsalicylic acid are also used. Clear recommendations are still missing. CONCLUSION: The rate of morbidity caused by DVT after ILEF is poorly understood so far. Exact data on prevalences are missing and optimal DVT prophylaxis still has to be defined.

Surface-enhanced Raman scattering on uniform transition-metal films: toward a versatile adsorbate vibrational strategy for solid-nonvacuum interfaces?

Procedures are outlined for the electrodeposition of ultrathin films of Pt-group transition metals onto gold that provide intense surface-enhanced Raman scattering (SERS) for adsorbates bound to the overlayers yet (unlike earlier reports) are sufficiently "pinhole-free" to avoid significant spectral and chemical interferences from the underlying substrate. Constant-current electrodeposition of Pd, Rh, Pt, and Ir from perchloric acid and/or phosphate electrolytes yields essentially layer-by-layer growth, so that near-ideal pinhole-free electrochemical and spectral characteristics are achieved for film thickness of ∼2 monolayers or more. The desired film uniformity is diagnosed from the voltammetric oxide formation-removal behavior and, especially, from the absence of the characteristic C-O stretching (ν(CO)) SERS band at 2110-2120 cm(-)(1) due to CO binding to Au surface sites. Carbon monoxide is also employed as a surface environment-sensitive adsorbate to probe the electrochemical SERS characteristics as a function of the transition-metal film thickness. The Raman enhancement was observed to decrease by 2-fold every 10-20 Å or so, exhibiting a "spacer distance" dependence that is weaker than (but functionally similar to) recently reported organic insulator films. The practical value of the present films for obtaining rich vibrational spectra for diverse adsorbates on transition metals is pointed out and briefly illustrated for benzonitrile on a Pt film electrode. The more general promise of this overlayer film SERS strategy as a versatile vibrational technique for characterizing other types of chemically important surface materials is also noted.

Patient acceptance of an information sheet about cardiopulmonary resuscitation options.

OBJECTIVE: To determine initial patient acceptance of a cardiopulmonary resuscitation/do-not-resuscitate orders (CPR/DNR) information sheet intended to facilitate early discussion of CPR preferences. DESIGN: Attitudinal survey of adults after reading a CPR/DNR information sheet. SETTING: Inpatient wards and outpatient clinics of a tertiary care military teaching hospital. PATIENTS: 230 English-reading, mentally competent, volunteer patients (95%) of 243 eligible patients completed questionnaires. Mean age was 51.5 +/- 17 years; 122 (53%) patients were men; 103 (45%) were inpatients. Self-reported diagnoses were: cancer, 42 (18%); HIV disease, 22 (10%); other medical conditions, 87 (38%); pre- and postoperative cases, 35 (15%); and unknown, 44 (19%). RESULTS: 56% of the patients had previously thought about CPR options. 10% of the patients had actually discussed preferences with their physicians. 90% of the patients desired discussion with their physicians and other health care providers. 91% of the patients reported feeling better or no change after reading the information. 78% of the patients agreed that the information sheet would be helpful in discussing their preferences and most thought the information should be routinely given to all patients. CONCLUSIONS: Written information about CPR options was perceived as helpful and acceptable to most patients surveyed. Since a few patients initially reported feeling worse after reading the CPR/DNR information sheet, written information should not be used alone but may facilitate initial communication and discussion.

Periodic trends in electrode-chemisorbate bonding: benzonitrile on platinum-group and other noble metals as probed by surface-enhanced Raman spectroscopy combined with density functional theory.

Detailed intramolecular vibrational spectra obtained by means of surface-enhanced Raman scattering (SERS) for benzonitrile adsorbed on seven electrode surfaces-four Pt-group metals (platinum, palladium, rhodium, and iridium) and the Group IB metals (copper, silver, and gold)-are reported with the aim of exploring the metal-dependent nature of surface-chemisorbate interactions. The Pt-group surfaces were prepared as ultrathin electrodeposited films on gold, enabling the SERS activity inherent to the substrate to be imparted to the overlayer material. Benzonitrile was selected as a "model" organic adsorbate since it displays a rich array of coupled aromatic ring as well as substituent modes which collectively can provide insight into the various molecular perturbations induced by surface coordination via the nitrile substituent. The experimental spectra are compared with ab initio calculations of vibrational frequencies, bond geometries, and charge distributions obtained by means of Density Functional Theory (DFT), which yields valuable insight into the underlying structural reasons for the sensitivity of the experimental coordination-induced frequency shifts to the nature of the intramolecular mode and the metal surface. The DFT results also form an invaluable aid in making SER spectral assignments, along with providing detailed information on the coupled atomic displacements involved in each vibrational mode. Benzonitrile surface coordination was modeled in the DFT calculations by binding the nitrile group to metal atoms and small metal clusters. While the majority of the aromatic-ring SER frequencies are altered only slightly (approximately < 5 cm(-1)) upon surface coordination, several modes (especially nu(1), nu(6a)) are blue-shifted substantially (by up to 50 cm(-1)). These shifts were identified by DFT as arising from mode coupling to the nitrile substituent, especially involving the C-CN bond that is compressed upon nitrile coordination, associated with metal-adsorbate back-donation. The small (<5 cm(-1)) red-shifts seen for ring vibrations not involving coupled substituent motion apparently arise from increased antibonding aromatic electron density. The metal-dependent frequency shifts seen for these coupled aromatic vibrations as well as for the more localized C-N nitrile stretching mode are consistent with increased back-donation anticipated in the sequence d(10) < d(9) < d(8) within a given Periodic row. Overall, the findings provide a benchmark illustration of the virtues of DFT in interpreting complex vibrational spectra for larger polyatomic adsorbates.

Surface-enhanced Raman scattering on uniform platinum-group overlayers: preparation by redox replacement of underpotential-deposited metals on gold.

The preparation of Pt-group metal films on roughened gold electrodes by utilizing spontaneous redox replacement of an underpotential-deposited (upd) copper or lead monolayer with a Pt-group metal cation solute is described. The resulting films display intense surface-enhanced Raman scattering (SERS) for adsorbates bound to the overlayer and free from substrate interferences. This strategy provides a useful alternative, at least for platinum, to the constant-current electrodeposition method commonly utilized to prepare SERS-active Pt-group metal films (Zou, S.; Weaver, M. J. Anal. Chem. 1988, 70. 2387). Similarly to related earlier studies, the film uniformity (specifically, the absence or otherwise of residual Au "pinhole" sites) was tested by employing carbon monoxide, and also ethylene, as "probe" chemisorbates, since they yield vibrational frequencies on Au that are blue-shifted from the corresponding bands for adsorbate bound to Pt-group metal sites. While a single redox replacement of upd Cu with Pt(IV) yielded incomplete surface coverage, as expected, the use of multiple (up to eight) replacement cycles produced Pt films displaying remarkably intense CO vibrational bands as well as apparently "pinhole-free" properties, although such imperfections were detected with the ethylene probe. A single upd Cu replacement with Pt(II), however, yielded a remarkably uniform Pt layer, as indicated by pinhole-free characteristics using both the CO and ethylene probes along with the voltammetric behavior. The use of additional redox replacement cycles yielded marked progressive attenuation in the SERS signals. Comparable, although less optimal, SERS behavior was obtained for Pd films prepared similarly from Pd(II). The value of the strategy for exploring catalytic as well as equilibrium adsorptive chemistry on Pt surfaces is also illustrated.

Does screening proctosigmoidoscopy result in reduced mortality from colorectal cancer? A critical review of the literature.

OBJECTIVE: To determine the strength of the evidence in the literature that screening proctosigmoidoscopy reduces colorectal cancer mortality. DESIGN: All English-language studies reporting mortality or survival from screening proctosigmoidoscopy published since 1960 were critically reviewed. DATA EXTRACTION: Fifteen references reported on five studies of screening proctosigmoidoscopy. Two authors independently reviewed each reference using explicit methodologic criteria, particularly for potential sources of bias. MEASUREMENTS AND MAIN RESULTS: Of the five studies, four used historical controls and were susceptible to bias, especially self-selection and lead-time bias. Only the Kaiser-Permanente Multiphasic Health Check-up study collected a representative patient sample from a defined population, had randomly allocated controls, and avoided multiple sources of bias. There was a reduction in mortality from a group of seven potentially postponable causes of mortality, including colorectal cancer, although no difference in overall mortality between screened and control groups was found. This study was not designed to determine specifically the impact of screening proctosigmoidoscopy on mortality from colorectal cancer, and suggested that most of the reduction in colorectal cancer deaths was due to a lower incidence in the screened group, which could not be attributed to polypectomy. The benefit of screening proctosigmoidoscopy in this study, if any, was small. CONCLUSIONS: The evidence in the literature is inadequate to determine whether or not screening proctosigmoidoscopy has an impact on colorectal cancer mortality, but the best available data suggest that the benefit is small, at best.

A questionnaire for patients' evaluations of their physicians' humanistic behaviors.

OBJECTIVES: To determine what behaviors patients perceive as reflecting a physician's humanistic qualities, to develop an instrument for patients to use to assess the humanistic behaviors of their own physicians, and to compare patient assessment of residents' humanistic behaviors with patient satisfaction and the assessment of attending physicians. DESIGN: Cross-sectional descriptive study, using patient interviews and questionnaires, and evaluations of residents by attending physicians. SETTING: Inpatient medical service in a tertiary care teaching hospital and in a primary care internal medicine clinic. PARTICIPANTS: Six medical interns and six medical residents, 119 medical patients in the hospital, and 111 patients in the internal medicine clinic. MEASUREMENTS AND MAIN RESULTS: The 25-item Physicians' Humanistic Behaviors Questionnaire (PHBQ) was developed from patients' statements about important humanistic behaviors. The mean PHBQ scores were 4.46 +/- 0.22 (mean +/- SD, on a scale of 1 to 5) in the clinic and 4.18 +/- 18 in the hospital (p = 0.003). The Spearman's rank correlations between the PHBQ and the Medical Interview Satisfaction Scale (MISS) were r = 0.8741 (p < 0.001) in the hospital and r = 0.8751 (p < 0.001) in the internal medicine clinic. The Spearman's rank correlation between the hospital PHBQ and the attending physician evaluations (for the six residents for whom the authors had complete data) was r = 0.5753 (p = 0.232). CONCLUSIONS: Patients can evaluate the humanistic behaviors of their physicians using the PHBQ. There is good correlation between the PHBQ and patient satisfaction, which supports the validity of the PHBQ. The relative lack of agreement between patients and attending physicians suggests different observations, criteria, or standards. The higher ratings from patients in the clinic compared with those from patients in the hospital suggest that residents' behaviors are different or that patients have different observations, criteria, or standards in the two settings. Therefore, a complete assessment of residents' humanistic behaviors may require sampling in both settings.

Sputum gram's stain in community-acquired pneumococcal pneumonia. A meta-analysis.

The usefulness of the sputum Gram's stain is controversial. This meta-analysis was designed to evaluate the sensitivity and specificity of the sputum Gram's stain in community-acquired pneumococcal pneumonia. Using a predetermined protocol, articles were discovered through a MEDLINE search (1966 to 1993) and the examination of bibliographies and were graded for quality by three blinded reviewers. Information on the reference standard, blinding, stain interpreter, control for antibiotic use, and definition of a positive test was collected. We found 12 articles containing 17 test characteristics to evaluate. The number of patients in each study ranged from 16 to 404. Sputum culture was the most common reference standard (10 of 17 estimations). Sensitivity ranged from 15% to 100% and specificity from 11% to 100%. Test characteristics varied markedly among studies and appeared related partly to the test interpreter. The sputum Gram's stain may yield misleading results in community-acquired pneumonia, as its sensitivity and specificity vary substantially in different settings. A practitioner electing to use the study should be well trained and use a specific definition for a positive test.

How accurate are faculty evaluations of clinical competence?

OBJECTIVE: To determine the degree and sources of variability faculty evaluations of residents for the American Board of Internal Medicine (ABIM) Clinical Evaluation Exercise (CEX). DESIGN: Videotaped simulated CEX containing programmed resident strengths and weaknesses shown to faculty evaluators, with responses elicited using the open-ended form recommended by the ABIM followed by detailed questionnaires. SETTING: University hospital. PARTICIPANTS: Thirty-two full-time faculty internists. INTERVENTION: After the open-ended form was completed and collected, faculty members rated the resident's performance on a five-point scale and rated the importance of various aspects of the history and physical examination for the patient shown. MEASUREMENTS AND MAIN RESULTS: Very few of the resident's strengths and weaknesses were mentioned on the open-ended form, although responses to specific questions revealed that faculty members actually had observed many errors and some strengths that they had failed to document. Faculty members also displayed wide variance in the global assessment of the resident: 50% rated him marginal, 25% failed him, and 25% rated him satisfactory. Only for performance areas not directly related to the patient's problems could substantial variability be explained by disagreement on standards. CONCLUSIONS: Faculty internists vary markedly in their observations of a resident and document little. To be useful for resident feedback and evaluation, exercises such as the CEX may need to use more specific and detailed forms to document strengths and weaknesses, and faculty evaluators probably need to be trained as observers.