Pandemic Hastens Cleveland Clinic's Unified Well-Being Strategy.

SUMMARY: Across the healthcare landscape, the COVID-19 pandemic has been incredibly challenging. It also has been a catalyst for change. It has ignited a redesign of the US health system and presented opportunities in areas such as caregiver and patient communication, digital practice, telehealth and virtual care, and more. Notably, the pandemic also has shined a new light on caregiver well-being. As executive leaders of Cleveland Clinic's Caregiver Office, our top priority throughout the pandemic has been to support our caregivers professionally and personally-to help them be their best for themselves and for their fellow caregivers, our patients, our organization, and our communities. Today, Cleveland Clinic is realizing the profound impact of many of the strategies put in place during the pandemic and seeing how COVID-19 accelerated our organization's unified vision for caregiver well-being. This article offers insight into Cleveland Clinic's commitment to caregiver well-being, highlights actions we undertook during the pandemic, shares the resulting lessons we learned, and showcases how those lessons are shaping our future caregiver well-being strategy.

Supraphysiologic estradiol is an independent predictor of low birth weight in full-term singletons born after fresh embryo transfer.

STUDY QUESTION: Is supraphysiologic estradiol (E2) an independent predictor of low birth weight (LBW) in singletons born after fresh IVF-embryo transfer (ET) cycles? SUMMARY ANSWER: Our results suggest that E2 > 2500 pg/ml is an independent predictor for LBW in full-term singletons born to normal responder patients undergoing fresh IVF-ET cycles. WHAT IS KNOWN ALREADY: The pathogenesis of LBW in IVF singletons remains unknown. However, recent studies have suggested that the hyperestrogenic milieu generated during ovarian stimulation may create a sub-optimal peri-implantation environment, leading to placental dysfunction, and therefore, LBW. STUDY DESIGN, SIZE, DURATION: Retrospective cohort study of normal responder patients, <40 years old, undergoing fresh IVF-ET cycles resulting in live singleton births between January 2005 and June 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 6419 patients had live births after fresh IVF-ET during the study period, of which 2348 (36.6%) patients were excluded due to multiple gestation, vanishing twins or incomplete records. Perinatal outcomes recorded for all patients included birth weight, gestational age (GA) at delivery, mode of delivery and gender. Term birth, preterm birth (PTB) and LBW incidence proportions were plotted against E2 level on the day of trigger. The term LBW incidence proportion (i.e. singletons born at GA ≥ 37 weeks with birth weight <2500 g) was considered the primary outcome of interest. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 4071 patients with live singleton births were included. The median age, BMI, E2 level and birth weight for the study cohort was 36 (33-39) years, 22.3 (20.4-25.0) kg/m2, 1554 (1112.7-2179) pg/ml and 3289 (2920-3628) g, respectively. The incidence proportion of LBW rose from 6.4% (E2 2001-2500 pg/ml) to 20.7% (E2 3501-4000 pg/ml), without a corresponding rise in the incidence proportion of PTB. The odds of term LBW with E2 > 2500 pg/ml were 6.1-7.9 times higher compared to the referent E2 group. Multivariable logistic regression analysis revealed that E2 was an independent predictor for term LBW, even after adjusting for age, BMI, race, parity, infertility diagnosis, duration of ovarian stimulation, gonadotropin dosage and method of insemination (adjusted odds ratio 10.8, 95% CI 9.2-12.5). Receiver operating characteristic analysis generated an AUC estimate of 0.85 for E2 level as a predictor of LBW. LIMITATIONS REASONS FOR CAUTION: The current study did not include analyses of hypertensive disorders of pregnancy or placental abnormalities. Furthermore, all patients were normal responders and of normal BMI, possibly limiting the overall generalizability of the study. Finally, as with any retrospective study, prospective data are required to validate the role of E2 in predicting LBW. WIDER IMPLICATIONS OF THE FINDINGS: Our results emphasize the importance of minimizing the supraphysiologic elevations of E2 levels during ovarian stimulation in fresh IVF-ET cycles. This, in turn, can optimize the early peri-implantation environment and mitigate adverse perinatal outcomes such as LBW. STUDY FUNDING/COMPETING INTEREST(S): Dr Paul J. Christos was partially supported by the following grant: Clinical and Translational Science Center at Weill Cornell Medical College (UL1-TR000457-06). TRIAL REGISTRATION NUMBER: N/A.

Initial UK experience with transversus abdominis muscle release for posterior components separation in abdominal wall reconstruction of large or complex ventral hernias: a combined approach by general and plastic surgeons.

Introduction Large, complicated ventral hernias are an increasingly common problem. The transversus abdominis muscle release (TAMR) is a recently described modification of posterior components separation for repair of such hernias. We describe our initial experience with TAMR and sublay mesh to facilitate abdominal wall reconstruction. Methods The study is a retrospective review of patients undergoing TAMR performed synchronously by gastrointestinal and plastic surgeons. Results Twelve consecutive patients had their ventral hernias repaired using the TAMR technique from June 2013 to June 2014. Median body mass index was 30.8kg/m2 (range 19.0-34.4kg/m2). Four had a previous ventral hernia repair. Three had previous laparostomies. Four had previous stomas and three had stomas created at the time of the abdominal wall reconstruction. Average transverse distance between the recti was 13cm (3-20cm). Median operative time was 383 minutes (150-550 minutes) and mesh size was 950cm2 (532-2400cm2). Primary midline fascial closure was possible in all cases, with no bridging. Median length of hospital stay was 7.5 days (4-17 days). Three developed minor abdominal wall wound complications. At median review of 24 months (18-37 months), there have been no significant wound problems, mesh infections or explants, and none has developed recurrence of their midline ventral hernia. Visual analogue scales revealed high patient satisfaction levels overall and with their final aesthetic appearance. Conclusions We believe that TAMR offers significant advantages over other forms of components separation in this patient group. The technique can be adopted successfully in UK practice and combined gastrointestinal and plastic surgeon operating yields good results.

A Leadership Education and Development Program for Clinical Nurses.

OBJECTIVE: The Leadership Education and Development (LEAD) Program was designed to transform care at the bedside by empowering clinical nurses as leaders. BACKGROUND: The heart of LEAD was enhancing communication skills of clinical nurses with clinical colleagues and, most importantly, patients and families. Key concepts of leadership/management were included: personal awareness, personal leadership skills/abilities, leading change, leading others individually and in teams, enhancing the patient/provider experience, and the leadership role in outcomes management. METHODS: A quantitative, longitudinal, survey design was used with 2 cohorts. The program consisted of six 4-hour sessions for 3 to 6 months. Leadership practices were measured before program implementation, at the end of the program, and 3 months after program completion. RESULTS: There were significant increases in leadership practices sustained 3 months after program completion. A range of other outcome measures was included. CONCLUSIONS: There is a need for additional leadership development programs for clinical nurses.

A case of mesothelioma masquerading pre-operatively as ovarian cancer and brief review of the literature.

BACKGROUND: Malignant peritoneal mesothelioma (MPM) can masquerade as an ovarian epithelial neoplasm, with very similar presenting clinical symptoms and imaging findings. The gold standard in differentiating between these two diagnoses lies in tissue pathology. CASE REPORT: This is a case of MPM that was initially misdiagnosed as ovarian cancer based on family history, imaging, and surgical findings. Tissue diagnosis preoperatively would have changed the planned procedure. Retrospectively, after the diagnosis of MPM, the patient was found to have had an indirect exposure to asbestos through her father. CONCLUSIONS: This case highlights the importance of keeping a broad differential when diagnosing ovarian malignancies, collecting both family and social histories (including screening for exposure to asbestos), and the benefit of obtaining tissue diagnosis when MPM is suspected.

Medial olivocochlear efferent reflex inhibition of human cochlear nerve responses.

Inhibition of cochlear amplifier gain by the medial olivocochlear (MOC) efferent system has several putative roles: aiding listening in noise, protection against damage from acoustic overexposure, and slowing age-induced hearing loss. The human MOC reflex has been studied almost exclusively by measuring changes in otoacoustic emissions. However, to help understand how the MOC system influences what we hear, it is important to have measurements of the MOC effect on the total output of the organ of Corti, i.e., on cochlear nerve responses that couple sounds to the brain. In this work we measured the inhibition produced by the MOC reflex on the amplitude of cochlear nerve compound action potentials (CAPs) in response to moderate level (52-60 dB peSPL) clicks from five, young, normal hearing, awake, alert, human adults. MOC activity was elicited by 65 dB SPL, contralateral broadband noise (CAS). Using tympanic membrane electrodes, approximately 10 h of data collection were needed from each subject to yield reliable measurements of the MOC reflex inhibition on CAP amplitudes from one click level. The CAS produced a 16% reduction of CAP amplitude, equivalent to a 1.98 dB effective attenuation (averaged over five subjects). Based on previous reports of efferent effects as functions of level and frequency, it is possible that much larger effective attenuations would be observed at lower sound levels or with clicks of higher frequency content. For a preliminary comparison, we also measured MOC reflex inhibition of DPOAEs evoked from the same ears with f2's near 4 kHz. The resulting effective attenuations on DPOAEs were, on average, less than half the effective attenuations on CAPs.

Does the use of the revised psychosocial assessment tool (PATrev) result in improved quality of life and reduced psychosocial risk in Canadian families with a child newly diagnosed with cancer?

OBJECTIVES: Early psychosocial screening may guide interventions and ameliorate the adverse psychosocial effects of childhood cancer. The revised psychosocial assessment tool provides risk information - Universal (typical distress), Targeted (additional specific distress), and Clinical (severe distress) - about the child with cancer and his or her family. This pilot study investigated the benefits of providing a summary of family psychosocial risk information to the medical team treating the newly diagnosed child (Experimental Group, EG). METHOD: We conducted a pilot randomized control trial with a sample of 67 parents, comparing the EG to the control group (CG) on parental perception of family psychosocial difficulties (revised psychosocial assessment tool risk levels), child behavior (behavior assessment scale for children-2), pediatric quality of life (PedsQL), and parental anxiety (state-anxiety scale of the state-trait anxiety inventory ), 2-4 weeks after diagnosis (Time 1) and 6 months later (Time 2). RESULTS: Compared to the CG, participants in the EG had significantly reduced targeted and clinical risk (p < 0.001), and improved pain related PedsQL at Time 2 (p < 0.05). Scores for PedsQL total and nearly all subscales improved over time in both groups (p < 0.05 to p < 0.001). No changes in behavior scores were noted. CONCLUSION: Preliminary findings suggest that providing a summary of the Psychosocial Assessment Tool to the treating team shortly after diagnosis may help reduce family wide psychosocial risk 6 months later and improve quality of life related to pain for children who are undergoing treatment for cancer.

External validity and reliability of the Psychosocial Assessment Tool (PAT) among Canadian parents of children newly diagnosed with cancer.

BACKGROUND: The Psychosocial Screening Tool (PAT) was developed and validated with a sample of caregivers of children newly diagnosed with cancer in the United States. This study aimed to assess cultural adaptation (Phase 1) and validity and reliability of the revised PAT (PATrev) with a Canadian sample (Phase 2). PROCEDURE: In Phase 1, a convenience sample of seven parents of children who were treated for cancer and six pediatric oncology healthcare experts participated. In Phase 2, 67 parents of children newly diagnosed with cancer from 4 Canadian pediatric cancer centers participated. To assess reliability and validity of the PATrev, parents completed behavioral (BASC-2) and quality of life (PedsQL) instruments about the child and an anxiety inventory (STAI) about themselves. RESULTS: The PAT required minor changes to be culturally adapted for the Canadian population. The PATrev had strong inter-rater (0.77) test-retest (0.75), and internal consistency reliability (0.85), as well as moderate to strong validity comparing PATrev child's problems and PedsQL total (-0.49), PedsQL anxiety (-0.47), BASC-2 internalizing (0.64), behavioral (0.63), and adaptive scores (-0.56). PATrev discriminative validity was confirmed with BASC-2 scores (AUR scores of 0.70-0.74). PATrev parental stressors were strongly correlated to STAI scores (0.53). Finally, agreement between PATrev child's problems and parental anxiety scores was moderate (0.47). CONCLUSION: This study supports the original PAT, demonstrates PATrev is a reliable and valid psychosocial screening tool, and provides unique evidence regarding early psychosocial risk in the family, which have important implications for guiding psychosocial practice.

Differences in mothers' and fathers' health-related quality of life after pediatric SCT: a longitudinal study.

The purpose of this study was to examine longitudinally health-related quality of life (HRQOL) and related factors in mothers and fathers of children who undergo SCT, before, and 1 and 2 years after SCT. A total of 84 parents (49 mothers/35 fathers) of patients diagnosed mainly with leukemia completed a HRQOL measure before SCT, 46 at 1 year (26 mothers/20 fathers) and 50 parents (31 mothers/19 fathers) at 2 years post SCT. Physical and psychosocial HRQOL summary scores are reported. Parents' age and gender, child's diagnosis, radiation history, age, behavior and physical health were examined. Linear mixed models for repeated measures with a covariate structure were used for analysis. Physical HRQOL did not differ between mothers and fathers or over time. Maternal and paternal psychosocial HRQOL scores improved by 2 years post SCT. Child's behavior problems and poor health, and maternal age (younger) predicted poor maternal psychosocial HRQOL 2 years post SCT. Child's behavior problems, diagnosis and treatment severity predicted poor paternal psychosocial HRQOL. These findings identify similar (child's poor behavior) and differential risk factors (parental young age, disease and treatment severity, and child's poor health status) for poor HRQOL for mothers and fathers. These findings can guide comprehensive family-care interventions before, during and after pediatric SCT.

Differences in mothers' and fathers' psychological distress after pediatric SCT: a longitudinal study.

The purpose of this study was to examine longitudinally psychological distress and its correlates in mothers and fathers of children who undergo SCT, up to 2 years post SCT. A total of 111 parents of patients diagnosed mainly with leukemia completed standardized measures of depression and anxiety symptoms as indicators of psychological distress, 85 at 1 year pre-SCT and 81 at 2 years post SCT. Parents' age and gender, child's age, diagnosis, radiation history, behavior and physical health were examined as potential related factors. Linear mixed models for repeated measures with appropriate covariance structure were used in the analysis. Depression and anxiety scores significantly decreased by 2 years for mothers and fathers. Mothers reported significantly more depression symptoms than did fathers, but reported comparable symptoms of anxiety. Pre-SCT depression and anxiety scores, mother's age (younger), child's behavior problems, radiation history and diagnosis of neuroblastoma predicted maternal distress 2 years post SCT; pre-SCT depression and anxiety scores, father's age (older) and child's diagnosis predicted father's distress. This study highlights differences and similarities in mothers' and fathers' psychological distress and identifies related risk factors. The results can guide interventions for mothers and fathers whose children undergo SCT based on their pre-SCT psychosocial risk.

A true pilonidal sinus in the hand of a sheep shearer.

Occupationally acquired inter-digital pilonidal sinuses are seldom seen and typically found on the hands of hair dressers. Sheep shearing has traditionally been believed to be a cause of inter-digital pilonidal sinuses; although in reality it is infrequently so with only two previously reported cases in 1951 and 1966. We present a rare case of a shearer who worked with a variety of sheep and presented with a chronic pilonidal sinus in the 3(rd) web space of his hand. This work demonstrates for the first time a histological confirmation of the presence of wool, and in this case different varieties and coloured fibres within the sinus. The report presents our investigations into the aetiology and the mechanical theories supporting it. The clinical presentation and surgical management of this condition are discussed alongside occupational realities and expectations.

The public health impact of avian influenza viruses.

Influenza viruses with novel hemagglutinin and 1 or more accompanying genes derived from avian influenza viruses sporadically emerge in humans and have the potential to result in a pandemic if the virus causes disease and spreads efficiently in a population that lacks immunity to the novel hemagglutinin. Since 1997, multiple avian influenza virus subtypes have been transmitted directly from domestic poultry to humans and have caused a spectrum of human disease, from asymptomatic to severe and fatal. To assess the pandemic risk that avian influenza viruses pose, we have used multiple strategies to better understand the capacity of avian viruses to infect, cause disease, and transmit among mammals, including humans. Seroepidemiologic studies that evaluate the frequency and risk of human infection with avian influenza viruses in populations with exposure to domestic or wild birds can provide a better understanding of the pandemic potential of avian influenza subtypes. Investigations conducted in Hong Kong following the first H5N1 outbreak in humans in 1997 determined that exposure to poultry in live bird markets was a key risk factor for human disease. Among poultry workers, butchering and exposure to sick poultry were risk factors for antibody to H5 virus, which provided evidence for infection. A second risk assessment tool, the ferret, can be used to evaluate the level of virulence and potential for host-to-host transmission of avian influenza viruses in this naturally susceptible host. Avian viruses isolated from humans exhibit a level of virulence and transmissibility in ferrets that generally reflects that seen in humans. The ferret model thus provides a means to monitor emerging avian influenza viruses for pandemic risk, as well as to evaluate laboratory-generated reassortants and mutants to better understand the molecular basis of influenza virus transmissibility. Taken together, such studies provide valuable information with which we can assess the public health risk of avian influenza viruses.

Longitudinal health-related quality of life outcomes and related factors after pediatric SCT.

Our purpose was to investigate longitudinally health-related quality of life (HRQOL) outcomes and related factors up to 2 years post-pediatric SCT. A total of 99 mothers of patients, aged 1.5-17 years, completed two standardized HRQOL questionnaires, generic and disease specific (DS), about the child, and reported on their own symptoms of depression and family function pre-SCT, 12 and 24 months post-SCT. Clinical (diagnosis, radiation), child (age) and family (maternal depression) information was also obtained. Significant improvement in physical and psychosocial HRQOL from pre-SCT to 1 or 2 years post-SCT was reported. Survivors of ALL were reported to have poorer physical and psychosocial HRQOL than survivors of solid tumors on the DS measure. Maternal depression was negatively associated with physical and psychosocial HRQOL. Maternal education (higher) at pre-SCT predicted improvements in physical domains 2 years post-SCT; mother's age (older) and child's age (younger) also predicted improvements of physical and emotional HRQOL. We conclude that survivors of pediatric SCT improved physical and psychosocial HRQOL by 1 and 2 years post-SCT. Older survivors whose mothers are younger and distressed, with lower education at SCT have compromised HRQOL compared to other survivors. This study has important implications for the care of SCT survivors and their families.

Aesthetic surgical training in the UK independent sector--the clients' view: Results of a survey on 155 private patients.

As training opportunities in cosmetic surgery become less frequent in teaching hospitals, this survey set out to examine the attitudes of patients towards extending this training into the independent health sector. We questioned 155 private patients, 95% of who were happy for trainees to sit in during their consultations. Of these, 85% were comfortable with the presence of the trainee throughout their appointments and 92% said they saw advantages in having such trainees present. However, patients were less enthusiastic about trainees carrying out procedures, under consultant supervision and for a reduced fee. The survey found that while 49% felt it was a good idea, only 32% would consider it for themselves. Seventeen percent of patients thought this offer alone was inappropriate. This survey has shown that while the vast majority of private patients supported and were happy to participate in higher surgical training during private consultations, fewer would consider the possibility of cosmetic surgery performed by supervised trainees for reduced fees. The implications of these findings for higher surgical training in Plastic Surgery in the UK are discussed.

Closed-field titanium magnets for the retention of complex craniofacial prostheses.

Where reconstruction with autogenous tissue is contraindicated in craniofacial reconstruction, or declined by the patient, a prosthesis may be used. Originally made from latex, cellulose or acrylic resins, prostheses are now largely made of silicone. These prostheses were traditionally retained using adhesives, natural undercuts at retention sites or spectacles. However, these methods were unsatisfactory because of frequent loss of retention, skin reactions to adhesives or unnatural movements of the prosthesis. Osseointegration became a popular method of prosthesis retention, initially using a bar-and-clip device. The use of a bar attached to the implant has certain shortcomings, however, including rigidity of the prosthesis and the difficulty in maintaining hygiene at the implant site. We present our experience with the use of magnets to hold the prosthesis in place, which allows ease of use, improved hygiene and a more natural mobility of the prosthesis.

Histological examination of the capsules surrounding Trilucent breast implants.

Following a statement by the UK Medical Devices Agency (MDA), soya-oil-filled Trilucent implants for breast augmentation were withdrawn from sale in March 1999. The most recent report on the toxicity of the Trilucent implant suggests that one of the breakdown products of the filler is an aldehyde with an explicit risk of genotoxic and teratogenic effects. Explantation of all these prostheses was advised by the MDA in June 2000. No guidance regarding capsulectomy was put forward by any publication. The operation of capsulectomy confers an increased morbidity compared with simple prosthetic replacement. This study looks at the capsules of 18 consecutive patients who had received Trilucent implants for cosmetic breast augmentation, and who had undergone explantation and capsulectomy. The mean duration of implantation was 3 years (range: 2 years to 4 years 9 months). The capsules were examined histologically. The significant features of all the capsules included a florid foreign-body type reaction, synovial metaplasia, a villous hyperplasia and the presence of refractile material within the substance of the capsule. It is postulated that the refractile material is filler material that has bled through the wall of the intact Trilucent implant, and as such would represent a potential genotoxic hazard. Until such time as this potential hazard has been investigated fully and a conclusion reached, we recommend acceptance of the increased morbidity, and the performance of capsulectomies when explanting Trilucent implants.

Sequence variation in the cytochrome oxidase I, internal transcribed spacer 1, and Ts14 diagnostic antigen sequences of Taenia solium isolates from South and Central America, India, and Asia.

We examined the genetic variability in the pig-human tapeworm, Taenia solium, by sequencing the genes for cytochrome oxidase I, internal transcribed spacer 1, and a diagnostic antigen, Ts14, from individual cysts isolated from Peru, Colombia, Mexico, India, China, and the Philippines. For these genes, the rate of nucleotide variation was minimal. Isolates from these countries can be distinguished based on one to eight nucleotide differences in the 396 nucleotide cytochrome oxidase I (COI) sequence. However, all of the 15 isolates from within Peru had identical COI sequences. The Ts14 sequences from India and China were identical and differed from the Peru sequence by three nucleotides in 333. These data indicate that there is minimal genetic variability within the species T. solium. Minimal variability was also seen in the ITS1 sequence, but this variation was observed within the individual. Twenty-two cloned sequences from six isolates sorted into 13 unique sequences. The variability observed within the sequences from individual cysts was as great as the variability between the isolates.