Integrating transition readiness assessment into clinical practice: Adaptation of the UNC TRXANSITION index into the Cerner electronic medical record.

PURPOSE: To describe the process of developing, and evaluating the feasibility and acceptability of, an EMR-based transition readiness assessment. DESIGN AND METHODS: A Cerner-based version of the UNC TRxANSITION Index was implemented across four pediatric subspecialty clinics: epilepsy, inflammatory bowel disease; type 1 diabetes, oncology survivorship. The feasibility was assessed by each's clinic's ability to meet form completion goals and their assessment rate. Acceptability was assessed via family refusal rate, a staff-completed feedback questionnaire, and whether the form was adopted into routine clinical care after completion of the pilot study. RESULTS: All clinics met form completion goals (N = 10/clinic). The assessment rate ranged from 66 to 100% across clinics. No families refused completion of the form. Most staff (70%) reported completing the form in <10 min. Staff reported on challenges experienced and provided recommendations to streamline administration and enhance clinical care. All staff reported the form helped them identify knowledge gaps in their patients. Two clinics continued using the form following completion of the pilot study. CONCLUSIONS: Implementation was most feasible in clinics that were well-staffed and had lengthier patient visits, however, time and staff resources were the biggest challenges to implementation across clinics. Based on staff feedback to improve efficiency and developmentally-tailor assessment, the form will be divided into Beginner Skills and Advanced Skills. PRACTICAL IMPLICATIONS: Integrating transition readiness assessment into the EMR has the potential to improve clinical care by facilitating staff's ability to efficiently identify knowledge gaps in their transition-aged patients and intervene.

Coriocarcinoma no gestacional: reporte de un caso / No gestational choriocarcinoma: case report

Resumen ANTECEDENTES: El coriocarcinoma es una neoplasia maligna del epitelio trofoblástico, agresiva pero susceptible de curación, incluso cuando hay metástasis. Puede ser de origen gestacional o no, el primero aparece después de un embarazo molar o aborto. CASO CLÍNICO: Paciente de 14 años, acudió a Urgencias debido a un cuadro de abdomen agudo, con prueba en orina positiva de embarazo; además, una tumoración en la región anexial derecha. En la laparotomía se encontró una tumoración dependiente del anexo derecho, con la cápsula rota, adherida al colon. Un día después de la intervención quirúrgica (por no contar con recursos en la unidad) se tomó la fracción beta de gonadotropina coriónica. El diagnóstico definitivo se estableció con base en el reporte del estudio histopatológico de la pieza quirúrgica. CONCLUSIÓN: El coriocarcinoma es una neoplasia maligna del epitelio trofoblástico, muy agresiva pero susceptible de curación, incluso cuando se detectan metástasis. La incidencia en México de coriocarcinoma gestacional es de 0.133 por cada 100,000 mujeres, mientras que la incidencia del cariocarcinoma no gestacional se desconoce. Se reporta como un tumor muy raro; por ello el diagnóstico preciso y oportuno es difícil en este tipo de tumores; la presentación más habitual es el abdomen agudo.

Abstract BACKGROUND: Choriocarcinoma is a malignant neoplasm of the trophoblastic epithelium, very aggressive but highly curable, even when there is metastasis. It can be of gestational and non-gestational origin, the first one can develop after a pregnancy, abortion or molar pregnancy; in Mexico it is calculated with an incidence of 0.133 per 100,000 women. While the incidence of non-gestational choriocarcinoma is unknown as it is reported as a very rare tumor. The objective is present the first case reported in our hospital, there are few cases reported in Mexico, it is important to know them in order to identify, diagnose and refer them on time. CLINICAL CASE: A 14-year-old patient who presented to the emergency department with a picture of acute abdomen with pregnancy test in positive urine and tumor in the right adnexal region, laparotomy was performed, finding a tumor dependent on the right annex with a broken capsule attached to the colon, one day after the surgical event (due to lack of resources in the unit) beta fraction of chorionic gonadotropin, the definitive diagnosis was made by the histopathological study of the surgical piece. CONCLUSION: Choriocarcinoma is a malignant neoplasm of the trophoblastic epithelium, very aggressive but highly curable, even when metastases are detected. In Mexico, the incidence of gestational choriocarcinoma is 0.133 per 100,000 women, while the incidence of non-gestational cariocarcinoma is unknown, it is reported as a very rare tumor, which is why accurate and early diagnosis is difficult in this type of tumors. , since the most common presentation is an acute abdomen.

Optimal timing for a second ERCP after failure of initial biliary cannulation following precut sphincterotomy: an analysis of experience at two tertiary centers.

BACKGROUND AND STUDY AIMS: Precut sphincterotomy increases the success of deep biliary cannulation, but the method fails at the initial ERCP in 5-12% of cases. Although other invasive strategies are often used to access the bile duct, a second ERCP may be effective and safe. We evaluated the efficacy, safety, and factors related to a second ERCP after failed cannulation using a precut sphincterotomy. PATIENTS AND METHODS: We reviewed all patients that underwent an ERCP with native papilla from 2006 to 2014 at two tertiary institutions. Efficacy was based on the cannulation rate of the second ERCP, and safety was assessed in terms of adverse events. RESULTS: We identified 112 patients with failed cannulation after precut, and a second ERCP was performed in 72 (64.3%). Median time between procedures was 7 days (IQR 5-11). Deep cannulation was achieved in 54 cases (75%). The only factor associated with cannulation failure was an ERCP within 4 days after the initial precut (cannulation success 44.4 vs. 79.4% after 4 days, p = 0.026). Adverse events were recorded after the first ERCP in 13 of 112 patients (11.8%): delayed bleeding in four, pancreatitis in five, and perforation in four. After the second ERCP, three of 72 patients (4.2%) presented adverse events: two delayed bleeding and one pancreatitis. CONCLUSIONS: A second ERCP after failure of initial biliary cannulation following precut appears to be safe and effective. A second ERCP should be delayed at least 4 days if feasible.

Gender biased immune-biomarkers in active tuberculosis and correlation of their profiles to efficacy of therapy.

Active pulmonary TB is an inflammatory disease and is increasingly viewed as an imbalance of immune responses to Mycobacterium tuberculosis (M. tb.) infection. In addition, this immune imbalance may be gender biased (males have a higher prevalence of TB) but reasons for such bias are uncertain. We hypothesized that studies on profiles of immune-biomarkers will not only provide insight into molecular basis of gender bias but may also help identify biomarkers to monitor efficacy of TB therapy. We examined 10 plasma cytokine/chemokine/growth-factor and 8 antibody (against 8 M. tb. antigens) biomarkers (elevated in TB patients) by multiplex microbead immunoassays. In addition, we examined these biomarkers in patients under anti-tuberculosis therapy (ATT). The results showed that female patients contained significantly higher levels of CXCL9 (MIG) and CXCL10 (IP-10), while males contained higher levels of PDGF-BB. In contrast, more males than females contained antibodies against several antigens. Our results also show that there are progressive and substantial decreases in plasma levels of CXCL9, CXCL10, PDGF-BB, IFNγ, and IL-18, correlating with treatment success. Our results suggest that studies on gender bias in immunebiomarkers will enhance understanding of host responses in TB and would be valuable as biomarkers for monitoring efficacy of ATT.

Estados hipertensivos del embarazo en adolescentes, hospital maternidad Enrique C. Sotomayor, año 2004 / Hypertensive states of pregnancy in adolescents at the maternity hospital Enrique C. Sotomayor in 2004

Estudio realizado en el hospital-maternidad “Enrique C. Sotomayor” en pacientes adolescentes que se diagnosticó hipertensión arterial, año 2004. Tipo de estudio: retrospectivo descriptivo. Objetivo: conocer la incidencia y resultantes materno-neonatales que nos lleve a controlar esta patología. Metodología: análisis de historias clínicas en pacientes adolescentes e hijos de las mismas, atendidos en el hospital-maternidad, año 2004. Resultados: hubo 146 casos (10,6 de embarazadas), con predominio de preeclampsia severa; promedio de edad: 16 años; la desproporción cefalopélvica y distocias de presentación fueron los defectos más comunes; al 96 se le realizó cesárea, las presiones arteriales se normalizaron 8 horas posparto. Neonatos: fue en 85 aptos para la edad gestacional; y fallecieron el 4. Conclusiones: a pesar de la gran cantidad de casos, se ha logrado controlarlos en casi su totalidad con rápido diagnóstico y eficaz terapéutica a través de cesáreas e hidralazinaStudy carried out at the maternity hospital “Enrique G. Sotomayor” in adolescent patients who were diagnosed arterial hypertension in 2004.

Study type: retrospective and descriptive. Objective: identify the incidence and maternal-neonatal results which could help us control this pathology. Methodology: analyses of clinical history in adolescent patients and their children attended at the maternity hospital in the year 2004. Results: there were 146 cases (10.6 of pregnant women), in whom severe preeclampsia was predominant; average age: 16 years old; cephalopelvic disproportion and presentation dystocias were the most common defects (96). They had a cesarean section. Arterial pressures were normalized 8 hours after delivery. Neonates: 85 were appropriate for gestational age; and 4 passed away. Conclusions: despite the big amount of cases, almost all of them were under control through fast diagnosis and efficient therapy of cesarean section and hydralazine.

Modelo de aplicación del test de valoración hemodinámica del abdomen en pacientes pediátricos en el hospital de niños Alejandro Mann, junio 1998 - mayo 1999 / Application model of abdominal hemodynamics valoration test in pediatric patients at Aljandro Mann Hospital, June 1998 - May 1999

El test de valoración Hemodinámica del Abdomen diselado por el autor de este artículo, al que los colaboradores lo llamaremos Test de Valhaad, permite identificar y cetegorizar con precisión y veracidad a los niños con Abdomen Agudo, en patología de resolución clínica, en clínica con potencialidad quirúrgica y quirúrgica propiamente dicha, de acuerdo a un score determinado para cada uno de ellos, que van de 0-7 para el primero, 7-14 al segundo, y 15 o + para el tercero. Constituyéndose en un test diagnóstico con sensibilidad, especificidad y confiabilidad valedero para el análisis clínico del médico pediatra generalista, cirujanos y/o demás especialistas. Se aplicó el Test de Valhaad, en un estudio prospectivo de 140 pacientes, en el Hospital de Niños Alejandro Mann durante junio 1998 a mayo de 1999, cuyos resultados nos permiten considerar que el mismo es más sensible para lo clínico y más específico para lo quirúrgico. Se analizaron además las variables de sexo, edad, patologías clínicas y quirúrgicas más frecuentes, y letalidad de los pacientes con patologías abdominales.

The abdominal hemodynamic Test, created by Dr. Bosco Alcívar Dueñas and his collaborators, which called the Test of VAHAAD, allows us to identify and classify accurately the episodes of acute abdominal pain in pediatrics patients. Therefore, we classify this episodes in three different groups: Pathology with clinical resolution, pathology with a high suspicious of surgical resolution and pathology with surgical resolution. According to this classification, we assess the pathology with a determined score : 0-7 for the first group; 7-14 for the second group and 15 or + for the third group. This test has been performed as a specific and reliable guide, not only to Pediatricians, but also to surgeons and General physicians. This is a prospective study, we included 140 patients; in was done in the Alejandro Mann Pediatric Hospital from june 1998 to may 1999. According to the results obtain we consider that it has a high sensibility to surgical ones. Also we include variables such as sex, age, clinical and surgical pathology more frequent with abdominal pain.