Variability of Pediatric Cervical Spine Clearance Protocols: A Systematic Review.

OBJECTIVE: The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. BACKGROUND DATA: Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. METHODS: A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N=14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. CONCLUSIONS: Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

Contemporary practice patterns in the treatment of pediatric stone disease.

INTRODUCTION: To compare endourology versus pediatric urology exposure to pediatric stone cases during fellowship, comfortability in treating pediatric stone cases, and access to pediatric surgical equipment. MATERIALS AND METHODS: A survey was distributed to all pediatric urology fellowship programs and the Endourological Society. Age was stratified into < 12 months old, 12 months-4 years, 5-12 years, and 13-18 years. Exposure and comfortability performing extracorporeal shock wave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) were assessed across age groups. Exposure was assessed as 'yes/no' and comfortability was scaled from 1-5 ('would not do' to 'very comfortable'). RESULTS: Seventy-two surveys met inclusion criteria, with 23 (31.9%) from pediatric urologists and 49 (68.1%) by endourologists. During fellowship, pediatric urologists had more exposure to SWL in toddlers (p = 0.03) and school age children (p = 0.045), URS in toddlers (p = 0.012) and school age children (p = 0.002), and PCNL in infants (p = 0.031) and school age children (p = 0.025) compared to endourologists. Pediatric urologists were significantly more comfortable performing SWL in toddlers (p = 0.04), URS in toddlers (p = 0.04) and school age children (p = 0.04), and PCNL in school age children (p = 0.02) compared to endourologists. Endourologists were significantly more uncomfortable than pediatric urologists in performing URS in toddlers (p = 0.03) and PCNL in infants (p = 0.04) and school age children (p = 0.03). There were no differences in availability of pediatric equipment. CONCLUSIONS: Pediatric urologists, have significantly more exposure than endourologists during fellowship and are more comfortable performing surgical treatment for urolithiasis in most pediatric ages. Endourology fellowships may benefit from greater exposure to pediatric patients with stones.

The use of IV lipid emulsion for lipophilic drug toxicities.

IV lipid emulsion (ILE) therapy is emerging as a potential antidote for lipophilic drug toxicities in both human and veterinary medicine. ILE has already gained acceptance in human medicine as a treatment of local anesthetic systemic toxicity, but its mechanism of action, safety margins, and standardized dosing information remains undetermined at this time. Experimental and anecdotal use of ILE in the human and veterinary literature, theorized mechanisms of action, current dosing recommendations, potential adverse effects, and indications for use in human and veterinary emergency medicine are reviewed herein.

Does Shared Decision-Making for Prostate Cancer Screening Among African American Men Happen? It Depends on Who You Ask.

BACKGROUND: Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known about how this process is perceived by patients and providers. SDM is especially important for African American men, who are at high risk for the disease. OBJECTIVE: To evaluate agreement in SDM ratings among patients, providers, and objective observers. METHOD: African American men ages 45-70 were recruited from primary care practices to participate in a study evaluating a decision aid (DA). Immediately after using the DA, patients proceeded to primary care appointments. Afterwards, patients and physicians completed surveys assessing perceptions about SDM. Clinical visits were also audio-recorded and coded to assess SDM. RESULTS: Mean scores on SDM measures among patients were 73.2 (SD = 27.5, 95% CI 55.71-90.62), 83.1 among physicians (SD = 7.8 95% CI 78.14-88.06), and 67.1 among objective raters (SD = 36.8 95% CI 43.72-90.45). Among patient-provider dyads, mean agreement was 49.9%. CONCLUSION: Patients, physicians, and objective observers perceived SDM differently. Understanding discordant experiences of SDM is vital for improving clinical guidance about SDM especially among African Americans who have historically faced healthcare discrimination and mistrust. DAs, particularly for African American men, should incorporate strategies to empower patients to advocate for their communication needs and preferences. TRIAL REGISTRATION: Clinical trials identifier number: NCT02787434.

Understanding Health Priorities, Behaviors, and Service Utilization Among Brazilian Immigrant Women: Implications for Designing Community-Based Interventions.

Brazilians represent a growing proportion of immigrants in the USA. Little is known about their health or healthcare utilization after their arrival. This study aimed to gather formative data to understand the needs of Brazilian immigrant women to guide public health interventions. We conducted five focus groups with Brazilian women born in Brazil (n = 47) and 13 key informant interviews with representatives from Brazilian-serving organizations. Participants were recruited from churches and social service organizations in the Greater Boston area. Findings revealed that mental health was the most pressing health priority; many attributed high levels of anxiety and depression to worries about undocumented status, separation from social networks, and strenuous work schedules. Occupational health issues were frequently mentioned, including musculoskeletal complaints, skin rashes, and respiratory problems. Domestic violence was also a concern, and many women feared reporting to police due to undocumented status. Most reported good access to medical care and described the quality of healthcare services as superior to that available in Brazil. However, many reported challenges with interpersonal communication with providers, dissatisfaction with a perceived unwillingness from providers to order medical tests or prescribe treatment, and limited access to mental health services. There was agreement that effective intervention strategies should use social media, radio, and group education in churches.

Factors Mediating Type 2 Diabetes Remission and Relapse after Gastric Bypass Surgery.

BACKGROUND: Defining factors associated with remission and relapse of type 2 diabetes (T2D) after Roux-en-Y gastric bypass (RYGB) can allow targeting modifiable factors. We investigated factors associated with T2D remission and relapse after RYGB. STUDY DESIGN: We conducted a retrospective review of consecutive patients with T2D who underwent RYGB between 1993 and 2017. T2D remission was defined as medication discontinuation and/or hemoglobin A1c <6.5%. Relapse was defined as recurrence medication use and/or hemoglobin A1c ≥6.5%. Independent correlates of T2D remission and relapse were identified using logistic regression. RESULTS: Six hundred and twenty-one patients (aged 46.7 ± 10.6 years; 30% on insulin; BMI 49.8 ± 8.3 kg/m2) had at least 1-year follow-up. Median follow-up was 4.9 years (range 1 to 23.6 years). Prevalence of T2D remission was 74% at 1 year, 73% from 1 to 3 years, 63% between 3 and 10 years, and 47% beyond 10 years. Ninety-three percent of remissions occurred within 3 years of RYGB, 25% relapsed. Median time to relapse was 5.3 years (interquartile range 3 to 7.8 years) after remission. Higher 1-year percentage total body weight loss, lack of preoperative insulin use, and younger age at operation were independently associated with T2D remission. Preoperative insulin use, lower percentage total body weight loss at 1 year, and greater percentage total body weight regain after 1 year were independently associated with T2D relapse. CONCLUSIONS: This longitudinal retrospective analysis shows that preoperative insulin use and age, 1-year weight loss, and regain after that influence T2D remission and relapse after RYGB. Referring patients at a younger age, before insulin is needed, and optimizing weight loss and preventing weight regain after RYGB can improve the rates and durability of T2D remission.

The Urology Match Process and the Limited Value of Post-Interview Communication for Program Directors.

OBJECTIVE: To understand the urology Match process from the perspective of residency program directors, with a particular focus on the role of postinterview communication. Recent surveys of urology applicants revealed that postinterview communication from programs often violates the rules of the American Urological Association Urology Residency Matching Program (the "Match"), and that such communication may influence applicant rank lists. METHODS: An anonymous, electronic survey seeking information regarding postinterview communication during the Match was sent to all program directors of urology residency programs participating in the 2017 AUA Match cycle. RESULTS: Of 138 surveys sent, 84 were completed for a 61% response rate. Among respondents, 97.6% percent of programs received postinterview communication from applicants, 76.2% of programs received an informal commitment from an applicant, and 38.3% failed to match an applicant who made an informal commitment. Most program directors (81.7%) responded that promises by applicants did not influence their rank list, and 57.1% state that participating in a second look does not have the potential to influence an applicant's rank order. Cumulatively, 76.2% of program directors felt that it was appropriate for applicants to cancel an interview if they provided 2 or more weeks' notice. CONCLUSION: The current study suggests that urology program directors do not ascribe significant value to continued contact with applicants after the interview, regardless of whether such contact is in the form of postinterview communication or in the form of second-look visits.

The Urology Match and Postinterview Communication.

OBJECTIVE: To understand the frequency and nature of postinterview communication as it relates to the rules and regulations of the American Urological Association Urology Residency Match, as well as the impact of such communication on the outcomes of the match. METHODS: An anonymous, electronic survey questionnaire was sent to all applicants to a single urology residency training program during the 2017 American Urological Association match cycle. The survey was administered 1 month after the release of match results and queried applicants regarding their experiences with postinterview communication. RESULTS: Of 231 surveys sent, 78 were returned completed for a 34% response rate. Among respondents, 47 (60%) reported receiving postinterview communication from at least one residency program, 20 (26%) were asked to reveal where they would be ranking a program on their rank list, and 15 (19%) reported that postinterview communication caused them to rank a program higher than initially planned, or to keep the program ranked at #1 if currently ranked there. Postinterview communication via telephone was associated with significantly increased odds of matching at the contacting program (odds ratio 20.0, 95% confidence interval 2.12-188.66, P = 0.003). CONCLUSION: Postinterview communication between applicants and urology residency programs is prevalent, with numerous violations of the rules of the match. Prohibited communication may impact the rank lists of urology applicants.

Development and validation of a competitive enzyme-linked immunosorbent assay for the measurement of total plasma immunoglobulins in healthy loggerhead sea (Caretta caretta) and green turtles (Chelonia mydas).

The quantification of circulating plasma immunoglobulins represents a valuable diagnostic tool in human and veterinary immunology, although its application is very limited in reptile medicine to date. The objectives of our study were the development and standardization of a competitive enzyme-linked immunosorbent assay (cELISA) for the measurement of total plasma immunoglobulins (Igs; both IgM and IgY) in loggerhead sea turtles (LST; Caretta caretta; n = 254) and green turtles (GT; Chelonia mydas; n = 111), the establishment of reference intervals for Ig for both species, and the examination of associations between Ig and total protein (TP), condition index, and water temperature. The cELISA for Ig was successfully developed and optimized. Reference intervals for Ig were 0.38-0.94 g/dL in LST (median: 0.59 g/dL; range: 0.16-2.15 g/dL) and 0.40-0.85 g/dL in GT (median: 0.58 g/dL; range: 0.18-1.80 g/dL). In LST, there were positive linear relationships of Ig with TP, and TP with Ig and condition index, and a negative relationship of Ig with condition index. The positive linear relationships of Ig with TP, and TP with Ig were also identified in GT. These positive associations of Ig and TP were expected, as Ig represents fractions of TP, and TP reportedly increases with straight carapace length and weight. The negative association of Ig with condition index may indicate potential biological variations. The cELISA and reference intervals for total Ig of LST and GT presented herein have the potential to be useful as a diagnostic and research tool for sea turtle immunology.

Evaluation of NOC standardized outcome of "health seeking behavior" in nurse-managed clinics.

This study evaluated the accomplishment of the Nursing Outcomes Classification (NOC) outcome "Health Seeking Behavior" in 5 nurse-managed clinics. Nurse practitioners and registered nurses rated patients on 11 indicators of health seeking behaviors, and recorded their level of knowledge of the patient. A total of 556 evaluations were collected. Health seeking behavior scores were lowest in a rural county school-based clinic and highest in a federally qualified health center. Ratings increased with nurses' knowledge of patients and for older patients.