Predictors of Success With Chronic Antibiotic Suppression for Prosthetic Joint Infections.

BACKGROUND: Management of recurrent prosthetic joint infection (PJI) after attempted surgical eradication remains a challenge. Chronic antibiotic suppression (CAS) is regarded as a reasonable treatment option for select patients with persistent infection or multiple comorbidities. The study seeks to compare cohorts who succeed and fail with CAS. METHODS: This retrospective cohort study assesses patients who were treated with CAS for a PJI. Patients were included if they had a culture-proven PJI and received chronic suppressive antibiotics. Failure of suppression was defined as reoperation after initiating CAS or death occurring as result of infection. A Cox proportional hazards multivariate regression model was used to estimate risk of reoperation as a function of risk factors related to patient comorbidities, surgical history, affected joint, and infecting organism. RESULTS: We identified 45 PJIs (31 knees, 14 hips) managed with CAS with a median follow-up of 50 (95% confidence interval [CI] 33.61-74.02) months. The overall success rate of managing PJI with CAS was 67% (30/45). Controlling for body mass index and Gram status of the organism, total hip arthroplasty patients were less likely than total knee arthroplasty patients to require reoperation (hazard ratio 0.18, 95% CI 0.01-0.96, P = .04). Patients with Gram-positive infections were less likely than those with a Gram-negative infections to require reoperation (hazard ratio 0.22, 95% CI 0.05-0.88, P = .03). Severe antibiotic side effects were rare. Patients who experienced multiple changes to their antibiotic regimen were more likely to fail with CAS. CONCLUSION: CAS is a reasonable strategy in patients with PJI who lack or refuse further surgical treatment options. Most hips and Gram-positive infections treated with CAS successfully avoided reoperation in this cohort.

A Multivariate Analysis to Predict Total Hip Arthroplasty Dislocation With Preoperative Diagnosis, Surgical Approach, Spinal Pathology, Cup Orientation, and Head Size.

BACKGROUND: There are several risk factors for dislocation after total hip arthroplasty (THA), but few studies include radiographic assessment of implants, with spine pathology and patient characteristics. This study estimates the rate of dislocation by patient gender, age, race/ethnicity, body mass index, Charlson Comorbidity Index, spine pathology, prior spine fusion, levels affected, radiographic Kellgren-Lawrence score of spine osteoarthritis, THA indication, surgical approach, and femoral head size. METHODS: Seventy-six primary THA patients between January 2007 and 2020 with a dislocation were matched on age and gender to subjects without a known history of dislocation using a 2:1 allocation. Univariable and multivariable survival models that account for matched strata were used to estimate the rate of dislocation. RESULTS: Median follow-up of patients at risk for dislocation was 26.48 months (95% confidence interval [CI] 23.75-36.40). On multivariable analysis, patients with an indication other than primary osteoarthritis were 3.69 (95% CI 2.22-6.13, P < .001) times more likely to dislocate than those with osteoarthritis. Patients with a spine pathology were also nominally more likely to dislocate (hazard ratio 1.76, 95% CI 0.97-3.18, P = .06), and patients receiving a posterior surgical approach were 2.74 (95% CI 1.11-6.76, P = .03) times more likely than those receiving a non-posterior approach to dislocate. CONCLUSION: Patients with THA indication other than primary osteoarthritis and receiving a posterior surgical approach, and to a lesser degree spinal pathology, were identified as affecting the rate of dislocation. After correcting for other variables, femoral head size, cup orientation, and patient factors were not predictive. LEVEL OF EVIDENCE: Level IV, case-control study.

Validation of Second-Generation Motion-Correction Software for Computed Tomography Coronary Angiography With Novel Quantitative Approach.

INTRODUCTION: Computed tomography of the coronary arteries (CTCA) is an important diagnostic tool. However, motion degradation is sometimes a challenge to interpretation and quantification, particularly with elevated heart rates. Here, a novel quantitative method is presented as part of an evaluation of one particular motion correction algorithm. METHODS: Computed tomography of the coronary arteries scans from 49 patients, with heart rates of >70 bpm, were identified with motion artifacts in multiple coronary segments. At these foci (196), an objective measure of motion degradation, defined here by cross-section eccentricity, was determined before and after image processing with second-generation GE SnapShot Freeze software (SSF-2.0). In addition, a subjective scoring was applied by an expert cardiothoracic radiologist both before and after processing. RESULTS: An overall decrease in vessel eccentricity strongly correlated (P < 0.001) with processing of the images by motion-correction software. A concurrent overall increase in subjective vessel clarity correlated (P < 0.001) with application of the software as well. CONCLUSIONS: A novel quantitative method (and subjective analysis) for evaluation of CTCA motion has been described and applied to validation of SSF-2.0 motion-correction software. Both the technique and software demonstrate promise for robust clinical utility in CTCA evaluation.

Fluorine-18-Labeled Fluciclovine PET/CT in Clinical Practice: Factors Affecting the Rate of Detection of Recurrent Prostate Cancer.

OBJECTIVE. The purpose of this study is to show the performance and evaluate the factors influencing the positivity rate (PR) of commercially produced 18F-fluciclovine PET/CT in the detection of recurrent prostate cancer in clinical practice. MATERIALS AND METHODS. We performed a retrospective cohort study of 152 men who had suspected biochemical recurrence of prostate cancer after receiving initial treatment and underwent fluciclovine PET/CT. PRs were calculated for whole-body, prostate and prostate bed, and extraprostatic locations. The influence of different factors, such as the absolute prostate-specific antigen (PSA) level, PSA kinetics, the Gleason score, and Gleason grade groups, on the PR was evaluated. RESULTS. The overall PR was 81% (123/152) for the whole body, 61% (92/152) for the prostate and prostate bed, and 55% (83/152) for extraprostatic locations. There was a linear increase in the PR with an increasing PSA level (p < 0.001). For the whole body, the PR for PSA levels of less than 1 ng/mL, 1 to less than 2 ng/mL, 2 to less than 5 ng/mL, and 5 or more ng/mL were 58% (32/55), 87% (13/15), 100% (39/39), and 92% (35/38), respectively. No statistically significant linear trend was found between the PR and the PSA level doubling time (p > 0.05). In addition, no statistically significant linear trend was found between the PR and increasing Gleason grade group. However, for every 1-unit increase in a patient's Gleason score, the odds of a positive finding in the extraprostatic location increased by 49% (p < 0.05). CONCLUSION. Commercially produced fluciclovine PET/CT has a high PR for detection of prostate cancer recurrence and is positively correlated with increasing PSA levels. For extraprostatic disease, the PR increases with higher Gleason scores.

Effect of Simulation on Undergraduate Nursing Students' Knowledge of Nursing Ethics Principles.

Background Undergraduate nursing education standards include acquisition of knowledge of ethics principles and the prevalence of health-care ethical dilemmas mandates that nursing students study ethics. However, little research has been published to support best practices for teaching/learning ethics principles. Purpose This study sought to determine if participation in an ethics consultation simulation increased nursing students' knowledge of nursing ethics principles compared to students who were taught ethics principles in the traditional didactic format. Methods This quasi-experimental study utilized a pre-test/post-test design with randomized assignment of students at three universities into both control and experimental groups. Results Nursing students' knowledge of nursing ethics principles significantly improved from pre-test to post-test ( p = .002); however, there was no significant difference between the experimental and control groups knowledge scores ( p = .13). Conclusion Further research into use of simulation to teach ethics principles is indicated.

A Synthesis of Hepatitis C prevalence estimates in Sub-Saharan Africa: 2000-2013.

BACKGROUND: Hepatitis C (HCV) is a deleterious virus that can be cured with new, highly effective anti-viral treatments, yet more than 185 million individuals worldwide remain HCV positive (with the vast majority un-diagnosed or untreated). Of importance, HCV is a leading cause of chronic liver disease and liver cancer, especially in Sub-Saharan Africa (SSA) where the prevalence remains high but uncertain due to little population-based evidence of the epidemic. We aimed to synthesize available data to calculate and highlight the HCV disease burden in SSA. METHODS: Weighted random-effects generalized linear mixed models were used to estimate prevalence by risk cohort, African region (Southern, Eastern, Western, and Central Africa), type of assay used, publication year, and whether the estimate included children. A pooled prevalence estimate was also calculated. Multi-variable analyses were limited to cohort and region specific prevalence estimates in the adult population due to limited studies including children. Prevalence estimates were additionally weighted using the known adult population size within each region. RESULTS: We included more than 10 years of data. Almost half of the studies on HCV prevalence in SSA were from the Western region (49 %), and over half of all studies were from either blood donor (25 %) or general population cohorts (31 %). In uni-variable analyses, prevalence was lowest in Southern Africa (0.72 %), followed by Eastern Africa at 3.00 %, Western Africa at 4.14 %, and Central Africa at 7.82 %. Blood donors consistently had the lowest prevalence (1.78 %), followed by pregnant women (2.51 %), individuals with comorbid HIV (3.57 %), individuals from the general population (5.41 %), those with a chronic illness (7.99 %), and those at high risk for infection (10.18 %). After adjusting for the population size in each region, the overall adult prevalence of HCV in SSA rose from 3.82 to 3.94 %. CONCLUSION: This meta-analysis offers a timely update to the HCV disease burden in SSA and offers additional evidence of the burgeoning epidemic. The study highlights the need to account for type of cohort and region variation when describing the HCV epidemic in SSA, the need for more studies that include children, as well as the need to factor in such variations when planning public health interventions.

Results of the citalopram to enhance cognition in Huntington disease trial.

BACKGROUND: The objective of this study was to evaluate citalopram for executive functioning in Huntington's disease (HD). METHODS: The study was randomized, double-blind, and placebo-controlled. Thirty-three adults with HD, cognitive complaints, and no depression (Hamilton Depression [HAM-D] rating scale ≤ 12) were administered citalopram 20 mg or placebo (7 visits, 20 weeks), with practice and placebo run-ins. The primary outcome was change in executive functioning. RESULTS: The intent to treat analysis was controlled for practice effects, comparing visits 1 and 2 to visits 5 and 6 for citalopram versus placebo. There were no significant benefits on the executive function composite (treatment-placebo mean difference -0.167; 95% confidence interval [CI], -0.361 to 0.028; P = .092). Citalopram participants showed improved clinician-rated depression symptoms on the HAM-D (t = -2.02; P = 0.05). There were no group differences on motor ratings, self-reported executive functions, psychiatric symptoms, or functional status. CONCLUSIONS: There was no evidence that short-term treatment with citalopram improved executive functions in HD. Despite excluding patients with active depression, participants on citalopram showed improved mood, raising the possibility of efficacy for subsyndromal depression in HD.

Medical Student Ultrasound-Guided Intravenous Catheter Education: A Randomized Controlled Trial of Overtraining in a Simulation-Based Mastery Learning Setting.

INTRODUCTION: Simulation-based mastery learning (SBML) improves skill transfer to humans. However, limited data exist to support the practice of performing additional training attempts once mastery has been achieved. We explored whether implementing this concept in an SBML model improves skill transfer in ultrasound-guided peripheral intravenous (USGPIV) catheter placement from simulator to humans. METHODS: Forty-eight first- and second-year medical students underwent SBML for USGPIV placement to mastery standards on a simulator once to achieve minimum passing standard based on a 19-item checklist. Next, they completed either 0, 4, or 8 additional mastery level simulated performances in nonconsecutive order before attempting USGPIV placement on a human. An unplanned post hoc retention phase occurred 6 months later where participants' USGPIV skills were reassessed on a second human volunteer using the same checklist. RESULTS: In this sample, the success rate among the 3 training cohorts did not improve as the number of additional training sessions increased (exact P = 0.60) and were comparable among the 3 cohorts (exact P = 0.82). The overall checklist performance was also comparable among the 3 cohorts (exact P = 0.57). In an unplanned (small) sample of returning participants, the USGPIV retention rate exceeded 80% for those originally assigned to 4 or 8 sessions, whereas the retention rate fell less than 50% for those originally assigned to control. Among these returning participants, the overall success rate was 58% on the initial assessment and was 68% on retention. CONCLUSIONS: In this sample of novices, we were unable to show that up to 8 additional mastery level performances of USGPIV placement on a simulator following SBML training improve skill transfer for both USGPIV placement success and total checklist performance.

The impact of a sacroiliac joint belt on function and pain using the active straight leg raise in pregnancy-related pelvic girdle pain.

INTRODUCTION: Pelvic girdle pain (PGP) is the most common musculoskeletal concern in pregnancy. The Active Straight Leg Raise (ASLR) test is diagnostic. Sacroiliac joint (SIJ) belts are included in multimodal therapy, but there is no established predictive measure to determine which pregnant women will benefit. OBJECTIVE: To determine if the ASLR score is immediately reduced by SIJ belt application and whether PGP pain and function improves after 4 weeks of belt use. DESIGN: Prospective observational cohort study. SETTING: Academic medical center. PARTICIPANTS: Pregnant women at least 18 years of age in the second or third trimester of pregnancy with posterior PGP and ASLR score of 2 to 10. INTERVENTIONS: Four-week SIJ belt use. MAIN OUTCOME MEASURES: ASLR, Numerical Rating Scale (NRS), Pelvic Girdle Questionnaire (PGQ), Perceived Global Impression of Improvement (PGII). RESULTS: Sixty-three women enrolled. On multivariable analysis, immediate belted ASLR score was -2.70 points lower than the non-belted ASLR score (P < .001). Four weeks later there was significant improvement in the ASLR score with a belt (Mdiff = -0.99; P = .001) and without a belt (Mdiff = -1.94; P < .001); the decline was more precipitous for the non-belted response (Mdiff = -0.96; P = .02). Current NRS pain scores declined from baseline by approximately -0.94 points (P < .001). This decline did not depend on ASLR scores (interaction P = .43) or wearing a belt at the time of testing (interaction P = .51). Similar conclusions held for participants' usual NRS score and average PGQ score. After 4 weeks, 82% reported improvement based on the PGII. CONCLUSIONS: SIJ belts are a safe, well-tolerated, and effective therapeutic option for pregnancy-related PGP. The ASLR score is immediately reduced following SIJ belt application but does not predict pain score 4 weeks later. SIJ belt leads to significant improvements in pain and function over time.

Clinical and imaging findings in five dogs with intracranial blastomycosis (Blastomyces dermatiditis).

Fungal infections affecting the central nervous system are rare. The purpose of this study was to describe clinical and imaging findings in dogs with intracranial blastomycosis (Blastomyces dermatiditis). The radiology database was searched retrospectively for patients with a diagnosis of intracranial blastomycosis which had computed tomography performed as part of their diagnostic work-up. Medical records and imaging studies were reviewed. Five dogs met the inclusion criteria. Major presenting complaints were stertor/nasal discharge (n=2), exophthalmos (n=1), and seizures (n=2). Clinical and laboratory findings were variable. Computed tomographic examination revealed a single contrast-enhancing intra-axial mass (n=1), a nasal mass disrupting the cribriform plate (n=3), and an intracranial mass extending into the orbit and nasal cavity (n=1). Findings in intracranial blastomycosis in dogs are variable, and the disease may mimic other inflammatory disorders or neoplasia.

Psychometric Validation of Central Venous Catheter Insertion Mastery Learning Checklist Data and Decisions.

INTRODUCTION: Resident physicians are expected to acquire competence at central venous catheter (CVC) insertion to a mastery standard. Valid competence decisions about resident physicians' CVC performance rely on reliable data and rigorous achievement standards. This study used data from 3 CVC simulation-based mastery learning studies involving internal medicine (IM) and emergency medicine (EM) residents to address 2 questions: What is the effectiveness of a CVC mastery learning education intervention? Are minimum passing standards (MPSs) set by faculty supported by item response theory (IRT) analyses? METHODS: Pretraining and posttraining skills checklist data were drawn from 3 simulation-based mastery learning research reports about CVC internal jugular (IJ) and subclavian (SC) insertion skill acquisition. Residents were required to meet or exceed a posttest skills MPS. Generalized linear mixed effect models compared checklist performance from pre to postintervention. Minimum passing standards were determined by Angoff and Hofstee standard setting methods. Item response theory models were used for cut-score evaluation. RESULTS: Internal medicine and EM residents improved significantly on every IJ and SC checklist item after mastery learning. Item response theory analyses support the IJ and SC MPSs. CONCLUSIONS: Mastery learning is an effective education intervention to achieve clinical skill acquisition among IM and EM residents. Item response theory analyses reveal desirable measurement properties for the MPSs previously set by expert faculty panels. Item response theory analysis is useful for evaluating standards for mastery learning interventions. The CVC mastery learning curriculum, reliable outcome data, and high achievement standards together contribute to reaching valid decisions about the competence of resident physicians to perform the clinical procedure.

One Dose Versus Two Doses of Intravenous Tranexamic Acid in Total Joint Arthroplasty.

INTRODUCTION: Despite its widespread use, a single formulation or dosing regimen of tranexamic acid (TXA) has not been universally agreed on for total joint arthroplasty. The purpose of this study is to compare previously uninvestigated single-dose and two-dose regimens in postoperative hemoglobin level and secondary outcomes within 30 days of surgery. METHODS: A retrospective search of our institution's database of patients who underwent primary total knee arthroplasty and primary total hip arthroplasty between January 1, 2017, and July 1, 2019, was performed. Patients were divided into two groups: one group received a 1-g bolus of intravenous TXA just before incision and another intravenous 1-g bolus during wound closure, and the second group received a single 1-g intravenous bolus of TXA just before incision. Two doses of TXA were administered in 873 procedures, and a single dose was administered in 647 procedures. RESULTS: A single intravenous TXA dose just before incision was comparable with using two doses of intravenous TXA on patients' postoperative hemoglobin value, length of stay, rate of transfusion, and 30-day postoperative complication rate, although those receiving two doses of TXA trended toward being less likely to require a transfusion (odds ratio = 0.561; 95% confidence interval: 0.296 to 1.062; P = 0.08). A sensitivity analysis was unable to identify a preoperative hemoglobin value that would identify whether patients would benefit from two versus one dose of TXA. DISCUSSION: The use of a single intravenous TXA dose was as efficacious as two doses, without an increase in postoperative complications. Further studies may identify patient subgroups that would benefit from a second dose. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Impact of general surgery rotation exposure on surgery clerkship performance.

BACKGROUND: Medical students often have variable exposures to general surgery (GS) and subspecialty surgery (SS) during their surgical clerkship. We will evaluate the relationship between clinical exposure to GS and performance on the NBME Subject Examination in Surgery. METHODS: Student data was collected retrospectively from 2015 to 2018 at a single academic institution. Students were categorized based on their clinical clerkship exposure to GS. A linear model was used to estimate the mean difference in NBME performance between GS and strictly SS exposed students while controlling for prior standardized examination scores and completion of an internal medicine clerkship prior to surgery. RESULTS: 365 (67%) of 547 students were exposed to a GS rotation prior to their NBME exam. Performance on the NBME exam was comparable between GS versus SS students (µdiff = 0.37, 95% CI: -0.73 to 1.48; p = .51). CONCLUSIONS: Exposure to a GS rotation is not advantageous on the NBME surgery examination. Students who completed the medicine clerkship prior to surgery demonstrated superior performance on the NBME surgery examination.

Minimum twelve-year follow-up of fixed- vs mobile-bearing total knee arthroplasty: Double blinded randomized trial.

BACKGROUND: Total knee arthroplasty (TKA) with fixed-bearing (FB) implants have demonstrated impressive functional results and survival rates. Meanwhile, rotating-platform (RP) constructs have biomechanically shown to reduce polyethylene wear, lower the risk of component loosening, and better replicate anatomic knee motion. There is growing question of the clinical impact these design changes have long-term.Questions/purposes: The aim of this double-blinded prospective randomized trial was to compare function and implant survival in patients who received either FB or RP press-fit condylar Sigma (PFC Sigma, DePuy, Warsaw, IN) total knee replacements at a minimum follow-up of twelve years. PATIENTS AND METHODS: Patient reported outcome measures used included the functional Knee Society Score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) scores, Medical Outcomes Short Form-36 (SF-36) score, and satisfaction assessment on a four-point Likert scale. The data was collected from times preoperative, two-years, and final encounter (mean 13.95 years). A total of 28 RP and 19 FB knees (58.8%) were analyzed at the final follow-up. RESULTS: Among all patients, KSS and WOMAC scores statistically improved from pre-op to 2-year, while KSS statistically worsened from 2-year to final follow-up. The RP group averaged better follow-up scores in all assessments at the final follow-up with exception of overall satisfaction. There was no statistically significant difference in the functional Knee Society Score, Short Form-36, WOMAC scores, patient satisfaction or implant survival between the two groups at any measured period. CONCLUSIONS: The use of a fixed-bearing or rotating-platform design does not convey significant superiority in terms of function or implant longevity at a minimum twelve years after total knee arthroplasty. LEVEL OF EVIDENCE: Level I, Experimental study, randomized controlled trial (RCT).

Validation of the modified telephone interview for cognitive status in amnestic mild cognitive impairment and intact elders.

Although the modified Telephone Interview for Cognitive Status (mTICS) is frequently used as a screening measure of cognition in dementia and aging studies, it has not been validated in individuals with milder cognitive impairments. The current study compared 2 groups [amnestic Mild Cognitive Impairment (n=61) and cognitively intact elders (n=62)] on the mTICS and used regression models to predict baseline scores on standardized memory tests using baseline mTICS scores. Baseline mTICS scores were also used to predict 1-year follow-up scores on memory tests in a subsample (n=91). Large group differences (P<0.01) were found between the amnestic individuals and their healthy peers on the mTICS total score, 2-factor scores, and 3 of 14 individual items. Baseline mTICS scores predicted between 22% and 43% of baseline memory composite scores and 21% and 28% of 1-year memory composite scores. Overall, these results provide additional validation of the mTICS as a valuable screening instrument for cognition in individuals with milder cognitive impairments.

Optimization of selected molecular orbitals in group basis sets.

We derive a local basis equation which may be used to determine the orbitals of a group of electrons in a system when the orbitals of that group are represented by a group basis set, i.e., not the basis set one would normally use but a subset suited to a specific electronic group. The group orbitals determined by the local basis equation minimize the energy of a system when a group basis set is used and the orbitals of other groups are frozen. In contrast, under the constraint of a group basis set, the group orbitals satisfying the Huzinaga equation do not minimize the energy. In a test of the local basis equation on HCl, the group basis set included only 12 of the 21 functions in a basis set one might ordinarily use, but the calculated active orbital energies were within 0.001 hartree of the values obtained by solving the Hartree-Fock-Roothaan (HFR) equation using all 21 basis functions. The total energy found was just 0.003 hartree higher than the HFR value. The errors with the group basis set approximation to the Huzinaga equation were larger by over two orders of magnitude. Similar results were obtained for PCl(3) with the group basis approximation. Retaining more basis functions allows an even higher accuracy as shown by the perfect reproduction of the HFR energy of HCl with 16 out of 21 basis functions in the valence basis set. When the core basis set was also truncated then no additional error was introduced in the calculations performed for HCl with various basis sets. The same calculations with fixed core orbitals taken from isolated heavy atoms added a small error of about 10(-4) hartree. This offers a practical way to calculate wave functions with predetermined fixed core and reduced base valence orbitals at reduced computational costs. The local basis equation can also be used to combine the above approximations with the assignment of local basis sets to groups of localized valence molecular orbitals and to derive a priori localized orbitals. An appropriately chosen localization and basis set assignment allowed a reproduction of the energy of n-hexane with an error of 10(-5) hartree, while the energy difference between its two conformers was reproduced with a similar accuracy for several combinations of localizations and basis set assignments. These calculations include localized orbitals extending to 4-5 heavy atoms and thus they require to solve reduced dimension secular equations. The dimensions are not expected to increase with increasing system size and thus the local basis equation may find use in linear scaling electronic structure calculations.

A Case Report from the Ancient Past.

BACKGROUND Standard translations of Hippocratic works are sometimes misleading because the translators knew less about their subject than did the ancient authors. CASE REPORT A new translation and explication of a chapter from a Hippocratic work of the fifth century before the Common Era (BCE), Diseases II, describes patients with pituitary apoplexy and subsequent myxedema, the 2 events separated by as much as 14 years. CONCLUSIONS The association of myxedema with an intracranial event that occurred years earlier predates by 2400 years the causal association of a pituitary adenoma with hormonal deficiency.

What Is the Minimal Competency for a Clinical Ethics Consult Simulation? Setting a Standard for Use of the Assessing Clinical Ethics Skills (ACES) Tool.

Background: The field of clinical ethics is examining ways of determining competency. The Assessing Clinical Ethics Skills (ACES) tool offers a new approach that identifies a range of skills necessary in the conduct of clinical ethics consultation and provides a consistent framework for evaluating these skills. Through a training website, users learn to apply the ACES tool to clinical ethics consultants (CECs) in simulated ethics consultation videos. The aim is to recognize competent and incompetent clinical ethics consultation skills by watching and evaluating a videotaped CEC performance. We report how we set a criterion cut score (i.e., minimally acceptable score) for judging the ability of users of the ACES tool to evaluate simulated CEC performances. Methods: A modified Angoff standard-setting procedure was used to establish the cut score for an end-of-life case included on the ACES training website. The standard-setting committee viewed the Futility Case and estimated the probability that a minimally competent CEC would correctly answer each item on the ACES tool. The committee further adjusted these estimates by reviewing data from 31 pilot users of the Futility Case before determining the cut score. Results: Averaging over all 31 items, the proposed proportion correct score for minimal competency was 80%, corresponding to a cut score that is between 24 and 25 points out of 31 possible points. The standard-setting committee subsequently set the minimal competency cut score to 24 points. Conclusions: The cut score for the ACES tool identifies the number of correct responses a user of the ACES tool training website must attain to "pass" and reach minimal competency in recognizing competent and incompetent skills of the CECs in the simulated ethics consultation videos. The application of the cut score to live training of CECs and other areas of practice requires further investigation.

Improved outcomes in elderly trauma patients with the implementation of two innovative geriatric-specific protocols-Final report.

BACKGROUND: Elderly trauma care is challenging owing to the unique physiology and comorbidities prevalent in this population. To improve the care of these patients, two practice management guidelines (PMGs) were implemented: high-risk geriatric protocol (HRGP), which triages patients based on injury patterns and comorbid conditions for occult hypotension, and the anticoagulation and trauma (ACT) alert, which is designed to streamline the care of geriatric trauma patients on anticoagulants. We hypothesized that both HRGP and ACT would decrease mortality and complications in geriatric trauma patients. METHODS: Geriatric blunt trauma patients (aged ≥65) presenting to our Level II center from January 2000 to July 2016 were extracted from the trauma registry. Do-not-resuscitate patients were excluded. The study period was divided into three phases: Phase 1, no PMGs in place (2000 to January 2006); Phase 2, HRGP only (February 2006 to February 2012); and Phase 3, HRGP + ACT (March 2012 to July 2016). Multivariate logistic regression models assessed adjusted mortality and complications during these phases to quantify the impact of these protocols. Statistical significance was set at p < 0.05. RESULTS: A total of 8,471 geriatric trauma patients met inclusion criteria. Overall mortality rate was 5.6% (Phase 1, 7.2%; Phase 2, 6.1%; Phase 3, 4.0%). No significant change in mortality was observed during Phase 2 with the HRGP only (adjusted odds ratio (OR), 0.98; 95% confidence interval, 0.73-1.34; p = 0.957); however, a significantly reduced OR of mortality was found during Phase 3 with the combination of both the HRGP and ACT (adjusted OR, 0.67; 95% confidence interval, 0.47-0.94; p = 0.021). No significant changes in incidence of complications was observed over the study duration. CONCLUSIONS: Geriatric trauma patients are not simply older adults. Improved outcomes can be realized with specific PMGs tailored to the geriatric trauma patients' needs. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Practice Effects and Stability of Neuropsychological and UHDRS Tests Over Short Retest Intervals in Huntington Disease.

BACKGROUND: In Huntington disease (HD), cognitive changes due to disease-progression or treatment are potentially confounded by "practice effects" (PE)--performance improvement from prior exposure to test materials. OBJECTIVE: A practice run-in ("dual baseline") was used in an HD cognitive trial to determine if PE could be minimized and evaluate performance trajectories over multiple visits. METHODS: Non-depressed adults (N = 36) with mild to moderate HD-related cognitive deficits participated in a clinical trial to examine the efficacy of citalopram to enhance cognition. Cognitive tests were administered at three visits (2 weeks separating each visit), before active treatment randomization. Some tests were also administered at screening. Therefore 3-4 pre-treatment repetitions were available. We examined test improvement using repeated-measures ANOVAs with planned pairwise comparisons. RESULTS: Despite the practice run-in and use of alternate test forms, results indicated ongoing improvements over at least three test sessions on all three UHDRS cognitive tests. Trails A and B showed improvements between the third and fourth session, which suggests that one pre-baseline visit may not be effective in reducing practice on this important and commonly used test. CONCLUSIONS: Overall, 7 out of 13 variables showed some degree of short-term PE, even after multiple sessions and alternate forms. Tests assessing processing speed and memory may be particularly confounded by ongoing PE across at least 2-3 sessions. Practice run-in periods and alternate forms may help minimize the impact of such effects in HD clinical trials but awareness of which tests are most susceptible to PE is important in clinical trial design.