Frequency of outpatient antibiotic prescription on discharge to hospice care.

The use of antibiotics is common in hospice care despite limited evidence that it improves symptoms or quality of life. Patients receiving antibiotics upon discharge from a hospital may be more likely to continue use following transition to hospice care despite a shift in the goals of care. We quantified the frequency and characteristics for receiving a prescription for antibiotics on discharge from acute care to hospice care. This was a cross-sectional study among adult inpatients (≥18 years old) discharged to hospice care from Oregon Health & Science University (OHSU) from 1 January 2010 to 31 December 2012. Data were collected from an electronic data repository and from the Department of Care Management. Among 62,792 discharges, 845 (1.3%) patients were discharged directly to hospice care (60.0% home and 40.0% inpatient). Most patients discharged to hospice were >65 years old (50.9%) and male (54.6%) and had stayed in the hospital for ≤7 days (56.6%). The prevalence of antibiotic prescription upon discharge to hospice was 21.1%. Among patients discharged with an antibiotic prescription, 70.8% had a documented infection during their index admission. Among documented infections, 40.3% were bloodstream infections, septicemia, or endocarditis, and 38.9% were pneumonia. Independent risk factors for receiving an antibiotic prescription were documented infection during the index admission (adjusted odds ratio [AOR]=7.00; 95% confidence interval [95% CI]=4.68 to 10.46), discharge to home hospice care (AOR=2.86; 95% CI=1.92 to 4.28), and having a cancer diagnosis (AOR=2.19; 95% CI=1.48 to 3.23). These data suggest that a high proportion of patients discharged from acute care to hospice care receive an antibiotic prescription upon discharge.

A brief inpatient measure of global psychiatric symptom severity: initial validation of the Brief Symptom Measure-25 for an adolescent inpatient sample.

Adolescent psychiatry is experiencing a growing need for brief yet psychometrically robust outcome measures for inpatient settings. Outcome measures currently available present limitations to clinicians and patients alike in terms of their excessive length, time of completion, difficulty to score, and focus on specific clusters of symptoms. The present study sought to validate the Brief Symptom Measure-25 (BSM-25) as a brief and easily administered measure of global psychiatric symptom severity in adolescent inpatient samples. This study evaluated the results from 154 adolescent inpatients who completed several self-report measures at admission. The findings demonstrate that the instrument has good construct validity when compared with validated measures of psychological health and well-being, behavioral problems, and interpersonal distress. We also showed the sensitivity to change of the BSM-25 from admission to discharge, and we showed that this healthy change was paralleled in several measures (self-reports and clinician ratings), using data from 75 adolescent psychiatric inpatients who were assessed at admission and also at discharge. Although this is only the first step in the validation of this measure for an adolescent inpatient setting, the BSM-25 shows promise as a brief outcome measure of global psychiatric symptom severity while maintaining validity and instrument sensitivity.

A brief measure of psychological health and well-being: initial validation of the schwartz outcome scale for an adolescent inpatient sample.

The present study evaluated whether the Schwartz Outcome Scale-10 (SOS-10), a well-validated self-report measure of psychological health and well-being in the adult population, would tap this construct similarly in an adolescent inpatient sample. This study looked to compared scores on the SOS-10 with the Youth Self-Report (YSR) and the Inventory of Interpersonal Problems (IIP), two well-validated self-report measures of behavioral problems and interpersonal distress. A total of 154 adolescent psychiatric inpatients completed the SOS-10, YSR self-report, and the IIP-32 at or within a day of admission to the inpatient unit. The results showed that the SOS-10 was negatively related to the subscales of the YSR and the scales of the IIP-32. Although just the first step in the validation of this measure for the adolescent inpatient population, the SOS-10 shows promise as a measure of psychological health and well-being and, possibly, as a brief outcome measure.

Computer-assisted navigation of volar percutaneous scaphoid placement.

PURPOSE: To investigate a computer-assisted technique for retrograde insertion of a percutaneous scaphoid screw and compare insertion time, accuracy, and radiation exposure to the traditional technique. We hypothesize that computer-assisted navigation of volar percutaneous scaphoid screw placement would improve accuracy, require less time, and diminish radiation exposure when compared to the traditional technique. METHODS: Ten matched pairs of cadaveric wrists were randomized to computer-assisted versus traditional volar percutaneous scaphoid screw placement. Time of the overall procedure, set-up time, time for ideal guide wire placement, and radiation time were recorded. Number of K-wire attempts was also recorded. Finally, accuracy of planned screw axis and actual screw axis were compared. Student's t-tests and rank sums were used to determine whether the differences in outcome variables between computer-assisted and traditional techniques was significant, with an alpha level of 0.05. RESULTS: Although the overall time of the 2 procedures and the set-up time were not different between the 2 groups, the time for placement of the K-wire was halved in the computer-assisted percutaneous scaphoid fixation group, and the number of K-wire attempts needed for accurate screw placement approached clinical significance. Although the radiation exposures for the individual components of set-up time and final check time were not different, the radiation exposures for global time of the procedure, K-wire placement, and screw placement were clinically significant. CONCLUSIONS: Computer-assisted navigation of volar percutaneous scaphoid screw placement takes no more time that traditional methods and significantly reduces the amount of radiation exposure to the patient. Although not statistically significant, the technique reduced the number of incorrect passes of the K-wire, requiring a single attempt in 4 of the 5 specimens.

A computational approach to the "optimal" screw axis location and orientation in the scaphoid bone.

PURPOSE: The development of small cannulated screws permitted minimally invasive percutaneous fixation of acute scaphoid fractures. There are known mechanical advantages to increased screw length and central screw placement, as well as documented deleterious effects of screw malposition, including articular protrusion, proximal pole fracture, and nonunion. The purpose of this study was to compare 2 methods of calculating a screw axis accessible via a volar surgical approach. METHODS: To prevent screw protrusion through the surface of the scaphoid, we required the central screw axis to be contained completely within a "safe zone," defined as a 3-dimensional region located a fixed distance from the inner cortical surface. Safe zones were calculated based on computed tomography-generated models of the right scaphoid from 10 healthy subjects. Two methods for screw axis calculation were compared: (1) maximum screw length (MSL) within the safe zone and (2) a cylinder best-fit (CYL) to the safe zone. The volar approach was defined as percutaneous screw placement through the scaphoid tubercle without violation of the trapezium. Resultant screw axes were compared between the 2 methods for volar accessibility, screw length, and location of the screw axis. RESULTS: The MSL axes were completely accessible without violating the trapezium in all but 2 subjects. The average MSL axes were 11% longer than the CYL axes and passed significantly closer to the scaphoid tubercle than did the CYL axes (1.8 mm vs 6.4 mm). The MSL axes passed significantly farther (1.6 mm) from the bone centroid than did the CYL axes (0.4 mm). All 10 MSL axes were located in the central one-third of the proximal pole. CONCLUSIONS: Without violation of the trapezium, MSL axis can be attained via the volar percutaneous approach to the scaphoid. Using this approach, the ideal starting point for maximal screw length was located 1.7 mm dorsal and 0.2 mm radial to the apex of the scaphoid tubercle.

An integration framework for linking avifauna niche and forest landscape models.

Avian cavity nesters (ACN) are viable indicators of forest structure, composition, and diversity. Utilizing these species responses in multi-disciplinary climate-avian-forest modeling can improve climate adaptive management. We propose a framework for integrating and evaluating climate-avian-forest models by linking two ACN niche models with a forest landscape model (FLM), LANDIS-II. The framework facilitates the selection of available ACN models for integration, evaluation of model transferability, and evaluation of successful integration of ACN models with a FLM. We found selecting a model for integration depended on its transferability to the study area (Northern Rockies Ecoregion of Idaho in the United States), which limited the species and model types available for transfer. However, transfer evaluation of the tested ACN models indicated a good fit for the study area. Several niche model variables (canopy cover, snag density, and forest cover type) were not directly informed by the LANDIS-II model, which required secondary modeling (Random Forest) to derive values from the FLM outputs. In instances where the Random Forest models performed with a moderate classification accuracy, the overall effect on niche predictions was negligible. Predictions based on LANDIS-II simulations performed similarly to predictions based on the niche model's original training input types. This supported the conclusion that the proposed framework is viable for informing avian niche models with FLM simulations. Even models that poorly approximate habitat suitability, due to the inherent constraints of predicting spatial niche use of irruptive species produced informative results by identifying areas of management focus. This is primarily because LANDIS-II estimates spatially explicit variables that were unavailable over large spatial extents from alternative datasets. Thus, without integration, one of the ACN niche models was not applicable to the study area. The framework will be useful for integrating avifauna niche and forest ecosystem models, which can inform management of contemporary and future landscapes under differing management and climate scenarios.

Climate change, woodpeckers, and forests: Current trends and future modeling needs.

The structure and composition of forest ecosystems are expected to shift with climate-induced changes in precipitation, temperature, fire, carbon mitigation strategies, and biological disturbance. These factors are likely to have biodiversity implications. However, climate-driven forest ecosystem models used to predict changes to forest structure and composition are not coupled to models used to predict changes to biodiversity. We proposed integrating woodpecker response (biodiversity indicator) with forest ecosystem models. Woodpeckers are a good indicator species of forest ecosystem dynamics, because they are ecologically constrained by landscape-scale forest components, such as composition, structure, disturbance regimes, and management activities. In addition, they are correlated with forest avifauna community diversity. In this study, we explore integrating woodpecker and forest ecosystem climate models. We review climate-woodpecker models and compare the predicted responses to observed climate-induced changes. We identify inconsistencies between observed and predicted responses, explore the modeling causes, and identify the models pertinent to integration that address the inconsistencies. We found that predictions in the short term are not in agreement with observed trends for 7 of 15 evaluated species. Because niche constraints associated with woodpeckers are a result of complex interactions between climate, vegetation, and disturbance, we hypothesize that the lack of adequate representation of these processes in the current broad-scale climate-woodpecker models results in model-data mismatch. As a first step toward improvement, we suggest a conceptual model of climate-woodpecker-forest modeling for integration. The integration model provides climate-driven forest ecosystem modeling with a measure of biodiversity while retaining the feedback between climate and vegetation in woodpecker climate change modeling.

A Random Forest approach to predict the spatial distribution of sediment pollution in an estuarine system.

Modeling the magnitude and distribution of sediment-bound pollutants in estuaries is often limited by incomplete knowledge of the site and inadequate sample density. To address these modeling limitations, a decision-support tool framework was conceived that predicts sediment contamination from the sub-estuary to broader estuary extent. For this study, a Random Forest (RF) model was implemented to predict the distribution of a model contaminant, triclosan (5-chloro-2-(2,4-dichlorophenoxy)phenol) (TCS), in Narragansett Bay, Rhode Island, USA. TCS is an unregulated contaminant used in many personal care products. The RF explanatory variables were associated with TCS transport and fate (proxies) and direct and indirect environmental entry. The continuous RF TCS concentration predictions were discretized into three levels of contamination (low, medium, and high) for three different quantile thresholds. The RF model explained 63% of the variance with a minimum number of variables. Total organic carbon (TOC) (transport and fate proxy) was a strong predictor of TCS contamination causing a mean squared error increase of 59% when compared to permutations of randomized values of TOC. Additionally, combined sewer overflow discharge (environmental entry) and sand (transport and fate proxy) were strong predictors. The discretization models identified a TCS area of greatest concern in the northern reach of Narragansett Bay (Providence River sub-estuary), which was validated with independent test samples. This decision-support tool performed well at the sub-estuary extent and provided the means to identify areas of concern and prioritize bay-wide sampling.

Residency applicants' perspectives on family medicine residency training length.

BACKGROUND AND OBJECTIVES: The Future of Family Medicine report advocated experimentation with 4-year residency training models. This study examines residency applicants' opinions about extending the length of residency training and seeks to determine which features of an extended program would be most desirable to applicants. METHODS: We conducted a cross-sectional, descriptive, self-administered survey of residency applicant interviewees at Oregon's three family medicine residency training programs in 2004-2005. The survey included questions about demographics, factors influencing specialty choice, desirability of longer training programs, and desirability of certain types of additional training. RESULTS: A total of 155 surveys were returned, for an 89.1% response rate. Only 6% of respondents indicated that length of training was "very important" to their specialty choice; 85.0% indicated a preference for a 4-year program with or without specific experiences; 77.2% indicated that extended training would either increase their likelihood of choosing family medicine or would not affect their decision; and 79.3% indicated that a 4-year residency would not make them less likely to choose family medicine over other primary care specialties. Pregnancy care, trauma care, adolescent/child health, and procedural skills were the most commonly desired areas for additional training. CONCLUSIONS: Lengthening training to 4 years would have a neutral or positive effect on applicants' interest in family medicine training in Oregon.

Microbial colonization of tourniquets used in orthopedic surgery.

This study analyzed tourniquets used for orthopedic surgery in our hospital to determine the frequency and type of microbial contamination. Group A tourniquets were from our main operating room, Group B tourniquets were from our ambulatory surgicenter, Group C tourniquets were unused, prepackaged, sterile tourniquets from our main operating room, and Group D tourniquets were sterilely packed tourniquets from our ambulatory surgicenter. Tourniquets from Groups A, B, C, and D had 100%, 40%, 0%, and 0% microbial growth, respectively. For Group A tourniquets, coagulase-negative staphylococci, Bacillus, and Staphylococcus aureus were present in 100%, 60%, and 20% of tourniquets, respectively. Twenty percent were contaminated either with Streptococcus sanguis, Aerococcus viridans, or Cornyebacterium species. Coagulase-negative staphylococci and Bacillus were present in 40% and 30% of Group B tourniquets, respectively. Tourniquet contamination may be a risk factor for the development of surgical site infection in orthopedic surgery.

Use of intravenous insulin aspart for treatment of naturally occurring diabetic ketoacidosis in dogs.

OBJECTIVES: To characterize the utility and safety of IV insulin aspart in the treatment of diabetes ketoacidosis (DKA) in dogs and to determine the times to resolution of hyperglycemia, ketonemia, and acidemia in dogs treated with IV insulin aspart. DESIGN: Prospective noncontrolled single arm study of dogs with DKA between February 2010 and March 2011. SETTING: University teaching hospital. ANIMALS: Six dogs with spontaneous DKA and blood glucose (BG) concentration >13.8 mmol/L (250 mg/dL), pH between 7.0 and 7.35, and blood beta-hydroxybutyrate >2.0 mmol/L were treated with an IV continuous rate infusion (CRI) of aspart insulin. The time to biochemical resolution of DKA was defined as the time interval from when the IV CRI of aspart insulin began until marked hyperglycemia (BG concentration >13.8 mmol/L [250 mg/dL]), acidemia (venous pH <7.35), and ketonemia (beta-hydroxybutyrate concentration >2.0 mmol/L) resolved. Aspart insulin was administered as an IV CRI at an initial dose of 0.09 U/kg/h. The dose was adjusted according to a previously published protocol. MEASUREMENTS AND MAIN RESULTS: The median time to biochemical resolution of DKA in dogs treated with insulin aspart was 28 hours (range, 20-116 h). Mean BG concentration decreased significantly from the time IV fluid resuscitation began (32.0 mmol/L [576 mg/dL]; range, 14.9-38.9 mmol/L [268-700 mg/dL]) until 6 hours later when IV aspart insulin CRI began (20.1 mmol/L [363 mg/dL]; range, 9.4-26.1 mmol/L [169-470 mg/dL], P = 0.03). No adverse effects were observed in association with IV insulin aspart administration. Median cost of hospitalization was US$3,477 (range, US$1,483-10,469). Median total units per kilogram of administered IV insulin aspart was 2.97 U/kg (range, 2.04-10.52 U/kg). CONCLUSIONS: Intravenous CRI of insulin aspart is a safe and effective treatment for DKA in dogs. IV fluid resuscitation is recommended prior to insulin administration.

Who's in Our Neighborhood? Healthcare Disparities Experiential Education for Residents.

BACKGROUND: Residents and fellows frequently care for patients from diverse populations but often have limited familiarity with the cultural preferences and social determinants that contribute to the health of their patients and communities. Faculty physicians at academic health centers are increasingly interested in incorporating the topics of cultural diversity and healthcare disparities into experiential education activities; however, examples have not been readily available. In this report, we describe a variety of experiential education models that were developed to improve resident and fellow physician understanding of cultural diversity and healthcare disparities. METHODS: Experiential education, an educational philosophy that infuses direct experience with the learning environment and content, is an effective adult learning method. This report summarizes the experiences of multiple sponsors of Accreditation Council for Graduate Medical Education-accredited residency and fellowship programs that used experiential education to inform residents about cultural diversity and healthcare disparities. The 9 innovative experiential education activities described were selected to demonstrate a wide range of complexity, resource requirements, and community engagement and to stimulate further creativity and innovation in educational design. RESULTS: Each of the 9 models is characterized by residents' active participation and varies in length from minutes to months. In general, the communities in which these models were deployed were urban centers with diverse populations. Various formats were used to introduce targeted learners to the populations and communities they serve. Measures of educational and clinical outcomes for these early innovations and pilot programs are not available. CONCLUSION: The breadth of the types of activities described suggests that a wide latitude is available to organizations in creating experiential education programs that reflect their individual program and institutional needs and resources.

Giant cell tumor of tendon sheath.

Neoplasms of the hand are not common. Giant cell tumor of tendon sheath (GCTTS) is the most common primary tumor of the hand. Many different theories have recently been proposed as to whether GCTTS is a neoplasm or a localized reactive process. We believe the evidence supports a neoplastic origin. Although the origin is still not proved, the presentation, diagnosis, and treatment of GCTTS have been clear for a long time.

Traumatic brain injury: considering collaborative strategies for early detection and interventional research.

Mild traumatic brain injury (mTBI) is a graded sequence of injuries, which is clinically defined based on subjective symptoms observed by clinicians and/or those reported by patients. Much of the focus on research and prevention of mTBI has been on professional or collegiate-level athletes, despite children and young teenagers being at greatest risk for mTBI. Further, continued involvement in sports across the lifespan, increases the likelihood that youth athletes may sustain repetitive brain trauma, which may result in permanent neurological and psychological deficits. Thus, there is a clear need for a population health initiative and research efforts that focus on the juvenile athlete population; in order to fill in the gap in knowledge about the long-term physiological effects of injury and social outcomes, as well as devise strategies that can help in early detection, prevention and treatment; and in the setting of evidence-based Return-To-Play guidelines.

Fibular nonunion after closed rotational ankle fracture.

BACKGROUND: Historically, the standard of care for minimally or nondisplaced, closed, distal fibula fractures has been short-term immobilization and progressive weightbearing. The vast majority of such patients are expected to heal with excellent functional outcome after such treatment. There exists a subpopulation of patients sustaining these fibular fractures who develop symptomatic incomplete union or nonunion despite appropriate management, and later require operative intervention to eliminate pain. METHODS: A retrospective review of 17 referred patients with rotational fibular fractures between August 1999 and July 2003 identified six persistently symptomatic distal fibular fractures after an adequate trial of conservative treatment. Due to their persistent localized pain and difficulty with ambulation, five patients underwent operative treatment of the nonunion with autologous bone grafting with plate and screw osteosynthesis. The sixth patient has refused operative intervention despite persistent symptoms. RESULTS: All six of these patients were identified as low risk for nonunion. Two fibular nonunions were found to be complete and four were partial nonunions. One hundred percent of these patients presented with a chief complaint of pain, had reproducible tenderness with palpation directly at the fracture site, and exhibited a persistent antalgic gait pattern. Four of six patients who underwent surgery noticed complete resolution of their pain and return of their normal gait within an average of 2.3 months postoperatively, with an average follow-up of 19.5 months (range, 2-53 months). CONCLUSIONS: Distal fibula nonunion appears to be a relatively common cause of persistent lateral ankle symptoms in patients who do not enjoy a satisfactory recovery after appropriate conservative treatment. The authors believe that the persistent lateral pain in such patients results from micromotion strain at the incomplete fracture union site. Surgical stabilization of fibular nonunion seems to be a reliable means of resolving these symptoms when conservative measures fail.