Identification of the Critical Nontechnical Skills for Surgeons Needed for High Performance in a Variable-resource Context (NOTSS-VRC).

OBJECTIVE: To identify the critical nontechnical skills (NTS) required for high performance in variable-resource contexts (VRC). BACKGROUND: As surgical training and capacity increase in low- and middle-income countries (LMICs), new strategies for improving surgical education and care in these settings are required. NTS are critical for high performance in surgery around the world. However, the essential NTS used by surgeons operating in LMICs to overcome the challenges specific to their contexts have never been described. METHOD: Using a constructivist grounded theory approach, 52 intraoperative team observations as well as 34 critical incident interviews with surgical providers (surgeons, anesthetists, and nurses) were performed at the 4 tertiary referral hospitals in Rwanda. Interview transcripts and field notes from observations were analyzed using line-by-line coding to identify emerging themes until thematic saturation was achieved. RESULTS: Four skill categories of situation awareness, decision-making, communication/teamwork, and leadership emerged. This provided the framework for a contextually informed skills taxonomy consisting of 12 skill elements with examples of specific behaviors indicative of high performance. While the main skill categories were consistent with those encountered in high-income countries, the specific behaviors associated with these skills often focused on overcoming the frequently encountered variability in resources, staff, systems support, and language in this context. CONCLUSION: This is the first description of the critical nontechnical skills, and associated example behaviors, used by surgeons in a VRC to overcome common challenges to safe and effective surgical patient care. Improvements in the NTS used by surgeons operating in VRCs have the potential to improve surgical care delivery worldwide.

Sex- and Age-Related Differences in Post-Concussive Symptom Reporting Among Children and Their Parents.

Pediatric mild traumatic brain injury (pmTBI) has received increased public attention over the past decade, especially for children who experience persistent post-concussive symptoms (PCS). Common methods for obtaining pediatric PCS rely on both self- and parental report, exhibit moderate test-retest reliability, and variable child-parent agreement, and may yield high false positives. The current study investigated the impact of age and biological sex on PCS reporting (Post-Concussion Symptom Inventory) in patients with pmTBI (n = 286) at retrospective, 1 week, 4 months, and 1 year post-injury time points, as well as reported symptoms in healthy controls (HC; n = 218) at equivalent assessment times. HC and their parents reported higher PCS for their retrospective rating relative to the other three other study visits. Child-parent agreement was highest for female adolescents, but only approached acceptable ranges (≥ 0.75) immediately post-injury. Poor-to-fair child/parental agreement was observed for most other study visits for pmTBI and at all visits for HC. Parents rated female adolescents as being more symptomatic than their male counterparts in spite of small (pmTBI) or no (HC) sex-related differences in self-reported ratings, suggestive of a potential cultural bias in parental ratings. Test-retest reliability for self-report was typically below acceptable ranges for both pmTBI and HC groups, with reliability decreasing for HC and increasing for pmTBI as a function of time between visits. Parental test-retest reliability was higher for females. Although continued research is needed, current results support the use of child self-report over parental ratings for estimating PCS burden. Results also highlight the perils of relying on symptom self-report for diagnostic and prognostic purposes.

Seminal vesicle abscess following prostate biopsy requiring transgluteal percutaneous drainage.

Transrectal ultrasound guided biopsy (TRUSB) of the prostate directly contaminates the prostate with rectal flora. Patients commonly receive fluoroquinolone (FQ) antibiotics to prevent infection. Infectious complications following TRUSB are increasing. The most common offending organism is Escherichia coli (E. coli), with isolates of this bacteria showing growing resistance to FQs. We present to our knowledge the first reported case of seminal vesicle abscess formation after TRUSB. The abscess was initially not seen on computed tomography and eventually treated with percutaneous drainage by a transgluteal approach. We review literature on infectious complications following TRUSB with implications for future antibiotic prophylaxis.

In-Season Management of Acute and Subacute Sports Foot Injuries.

In athletes, foot injuries present with a variety of mechanisms, severity, and implications for return to play. Although potentially given less attention than knee and shoulder injuries by the team physician, foot injuries are common and thus require knowledgeable consideration. In this article, we review the anatomy, presentation, workup, and management of several of the most common athletic foot injuries, including turf toe, Lisfranc injuries, Jones fractures, and navicular stress fractures. The goal is to provide the team physician with the information necessary to evaluate and manage these injuries on the sideline and in the training room.

The Use of Intrinsic Markers for Studying the Migratory Movements of Bats.

Mortality of migratory bat species at wind energy facilities is a well-documented phenomenon, and mitigation and management are partially constrained by the current limited knowledge of bat migratory movements. Analyses of biochemical signatures in bat tissues ("intrinsic markers") can provide information about the migratory origins of individual bats. Many tissue samples for intrinsic marker analysis may be collected from living and dead bats, including carcasses collected at wind energy facilities. In this paper, we review the full suite of available intrinsic marker analysis techniques that may be used to study bat migration, with the goal of summarizing the current literature and highlighting knowledge gaps and opportunities. We discuss applications of the stable isotopes of hydrogen, oxygen, nitrogen, carbon, sulfur; radiogenic strontium isotopes; trace elements and contaminants; and the combination of these markers with each other and with other extrinsic markers. We further discuss the tissue types that may be analyzed for each and provide a synthesis of the generalized workflow required to link bats to origins using intrinsic markers. While stable hydrogen isotope techniques have clearly been the leading approach to infer migratory bat movement patterns across the landscape, here we emphasize a variety of lesser used intrinsic markers (i.e., strontium, trace elements, contaminants) that may address new study areas or answer novel research questions.

A Novel Medial Collateral Ligament Reconstruction Technique Using Internally Braced Semitendinosus Autograft.

Medial collateral ligament reconstruction is often performed in knees with multiligamentous injury, and numerous techniques have been previously described. A novel method of internally bracing and reconstructing the medial collateral ligament with a semitendinosus autograft is described. This provides several advantages, including reproducible isometric graft placement, optimized fixation strength, and internal bracing. [Orthopedics. 2018; 41(5):e738-e740.].

Can participation in a health affairs interdisciplinary case conference improve medical students' knowledge and attitudes?

PURPOSE: To explore whether participation in a three-hour health affairs interdisciplinary case conference (HAICC) changed medical students' knowledge and attitudes about the role of interdisciplinary teams in health care. METHOD: Faculty from ten University of North Carolina at Chapel Hill health professions' schools helped to design the HAICC. Conference goals included improving students' knowledge and attitudes about the skills of various health professions and the benefits of interdisciplinary care. From 2001-04, 2,005 health professions students, including 615 second-year medical students, participated in the HAICC. Working in teams, students, using the World Health Organization's International Classification of Function and Disability, interviewed a standardized patient and, then, developed a patient-centered management plan. A self-report instrument to assess medical students' knowledge about each of the ten health professions and to assess students' attitudes about working with other health professionals was administered before and after the conference. Repeated measures were used to assess whether medical students' knowledge and attitudes about interdisciplinary teams changed as a result of participating in HAICC. RESULTS: A total of 605 medical students (98.5%) completed both instruments. Following participation in the HAICC, there were significant increases in students' knowledge about the training and skills of all ten professions, the advantages of working in an interdisciplinary team, and the importance of care provided by these professions. In general, there were significant improvements in students' attitudes toward the value of interdisciplinary team work and leadership by all health professionals. CONCLUSIONS: Participation in a three-hour HAICC resulted in medical students' increased knowledge about and attitudes toward the role of interdisciplinary teams in health care.

Oral ovulation induction agents combined with low-dose gonadotropin injections and intrauterine insemination: cost- and clinical effectiveness.

OBJECTIVE: To compare the efficacy and cost-effectiveness of different induction protocols involving gonadotropins with intrauterine insemination (IUI). STUDY DESIGN: We performed a retrospective chart review of 648 IUI cycles. Some patients had gonadotropin injections alone before human chorionic gonadotropin (hCG) and IUI (human menopausal gonadotropin protocol); others were given oral medications, then gonadotropins before hCG and IUI (combination protocol). Outcomes included pregnancy rates, multiple birth rates, endometrial thickness, number of ovarian follicles, injection days, ampules of gonadotropins and cost. RESULTS: The combination protocol was more cost-effective. In first cycles, pregnancy rates, multiple birth rates, number of large follicles produced and cancellation rates were similar. The combination group had fewer days of injections and fewer ampules used. When all cycles were analyzed, the multiple birth rate was lower in the combination group. Comparing the different oral medications in the combination protocols, letrozole yielded higher pregnancy rates than tamoxifen or clomiphene. Multiple birth rates were similar for all oral medications. CONCLUSION: Combination protocols are less costly and equally effective, with potentially fewer multiple births than with gonadotropins alone. Letrozole may be more effective than clomiphene and tamoxifen in a combination protocol.

Natural history of uterine polyps and leiomyomata.

OBJECTIVE: To estimate the incidence and regression rates of uterine leiomyomata and polyps in a cohort of asymptomatic, premenopausal women. METHODS: Saline infusion sonography was performed twice, 2.5 years apart, in a cohort of 64 initially asymptomatic women. Subjects completed a questionnaire that assessed the development of abnormal uterine bleeding. RESULTS: The mean age of women (at second ultrasound) was 44 years. In four of seven women with polyps at the original ultrasound, their polyps regressed. Polyps that regressed tended to be smaller than polyps that persisted. Ten women had endometrial polyps at the second ultrasound for a point prevalence of 16% and a cumulative incidence rate of 12% per 2.5 years. A higher percentage of women with uterine polyps had complaints of abnormal uterine bleeding than women with no uterine abnormalities (70% versus 33%, P =.04). Six leiomyomata in four women were no longer detected in the second ultrasound. Leiomyomata that regressed were in older premenopausal women and were smaller than leiomyomata that persisted. The point prevalence and incidence rates of leiomyomata were 27% and 13% per 2.5 years, respectively. Leiomyomata grew an average of 1.2 cm per 2.5 years, but great variation in growth rates were noted. CONCLUSION: Small uterine polyps frequently regressed spontaneously, whereas larger polyps were more likely to persist and were associated with the development of abnormal bleeding. Smaller leiomyomata in older premenopausal women also regressed whereas larger leiomyomata tended to grow while often remaining asymptomatic.

A prospective randomized trial comparing anastrozole and clomiphene citrate in an ovulation induction protocol using gonadotropins.

OBJECTIVE: To compare the ovarian and endometrial effects of anastrozole and clomiphene when used with gonadotropins in a combination protocol. DESIGN: Prospective randomized trial. SETTING: Academic infertility center. PATIENT(S): Fifty infertile women. INTERVENTIONS(S): Women were randomized to receive either 1 mg anastrozole or 100 mg clomiphene citrate for 5 days (cycle days 3-7) followed by FSH injections (days 7-11) for ovulation induction. A subset participated in a crossover arm of the study. MAIN OUTCOME MEASURE(S): Ovarian follicle number and size, E(2) levels, endometrial thickness, pregnancy, and cancellation rates. RESULT(S): On cycle day 12, anastrozole cycles were associated with fewer total follicles (1.4 vs. 3.6, P=0.01), fewer mature follicles (0.6 vs. 1.6, P<.01), lower serum E(2) (131 pg/mL vs. 613 pg/mL, P<.01,) and the same endometrial stripe thickness compared with clomiphene citrate cycles. Cycle cancellation rates were similar between the two groups. On the day of hCG administration in noncancelled cycles, anastrozole cycles were associated with fewer total follicles (1.6 vs. 3.8, P<.01), fewer mature follicles (1.3 vs. 2.1, P<.01), and an equal endometrial stripe thickness compared with clomiphene citrate cycles. Pregnancy rates were similar between clomiphene (20%) and anastrozole (12%) cycles. CONCLUSION(S): Anastrozole when used in conjunction with gonadotropins results in lower E(2) levels and fewer follicles than clomiphene citrate. A combination protocol of anastrozole and gonadotropins may be a safer protocol for patients at higher risk of hyperstimulation and multiple births after infertility treatments.

Implementation of assisted reproductive technologies following conservative management of FIGO grade I endometrial adenocarcinoma and/or complex hyperplasia with atypia.

OBJECTIVE: The objective was to report a series of infertility therapy outcomes following conservative management of endometrial adenocarcinoma and/or complex hyperplasia with atypia. METHODS: A retrospective review of the University of Iowa assisted reproductive technology database was performed. All women presenting with International Federation of Obstetrics and Gynecology (FIGO) grade I uterine adenocarcinoma and/or complex hyperplasia with atypia were assessed for type and duration of medical management, initial, interim treatment, and preinfertility treatment endometrial biopsy (BX) findings. Assessment of infertility treatment outcomes and postinfertility endometrial biopsy findings were performed. All of the pathology samples were re-reviewed at the Gynecologic Oncology Tumor Board to confirm the diagnosis by a pathologist with a particular expertise in gynecologic pathology. RESULTS: Four infertile women, three nulligravid and one primigravid, were evaluated with the diagnosis of FIGO grade 1 endometrial adenocarcinoma and/or complex hyperplasia with atypia desiring to preserve fertility. Two women with FIGO grade 1 endometrial adenocarcinoma were successfully treated with high-dose progestational agents resulting in normal proliferative endometrium. In addition, both women with complex hyperplasia with atypia were successfully treated with progestins and/or ovulation induction. Successful pregnancy outcomes were achieved for three of the four women with assisted reproductive technology. A total of five successful pregnancies and eight healthy live-born infants were achieved among three women. One of the four women was unable to conceive despite three cycles of in vitro fertilization. Hysterectomy was performed for recurrent complex hyperplasia with atypia. In our series, we found it can take 3-10 months (mean, 6.25 months; median, 6 months) to obtain benign endometrium preceding infertility therapy. CONCLUSION: This report demonstrates that conservative management of well-differentiated endometrial adenocarcinoma and/or complex hyperplasia with atypia followed by aggressive assisted reproduction is an option to highly motivated and carefully selected women.