Successful radical surgical resection of a giant neurofibroma.

Large neurofibromas often cause significant patient morbidity and present a unique challenge to dermatologists and surgeons. Radical resection offers the lowest rate of recurrence but is not often pursued due to the high risk of intraoperative hemorrhage and difficulty in repairing large defects. Subtotal resection and debulking are more frequently performed, leading to higher rates of recurrence. This case highlights a particularly large neurofibroma and demonstrates how surgical techniques like preoperative embolization and advancement flaps can improve outcomes in the radical resection of large neurofibromas.

Delayed diagnosis of DRESS syndrome in a patient with skin of color.

We describe a particularly severe case of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome with hemodynamic instability, erythroderma, profound eosinophilia, and severe organ dysfunction. We attribute the severity in part to a delay in diagnosis due to patient's skin of color, as the erythroderma was not noticed until a dermatologist was consulted. This case highlights how even severe skin disease can present less conspicuously in patients with darker skin types. We outline several strategies that can help clinicians to recognize DRESS and other skin disease phenotypes in patients of color, thereby avoiding delays in diagnosis as seen in this case.

Urgent Care Through Telehealth.

Urgent care as a distinct clinical care entity began in the 1970s to treat low-acuity conditions. Virtual urgent care (VUC) can be provided by the primary care physician (PCP) or home health system of the patient, and many commercial direct-to-consumer (DTC) companies have emerged to provide this service. Quality of care continues to be evaluated, but some studies suggest that DTC providers prescribe antibiotics at a higher rate than PCPs. VUC has been proposed to improve equity and access to care, but early evidence is mixed. New utilization owing to convenience may lead to overall higher health care costs.

Rapid Point-of-Care Test for Determination of C-Peptide Levels.

C-peptide is co-secreted with insulin and is not subject to hepatic clearance and thus reflects functional ß-cell mass. Assessment of C-peptide levels can identify individuals at risk for or with type 1 diabetes with residual ß-cell function in whom ß cell-sparing interventions can be evaluated, and can aid in distinguishing type 2 diabetes from Latent Autoimmune Diabetes in Adults and late-onset type 1 diabetes. To facilitate C-peptide testing, we describe a quantitative point-of-care C-peptide test. C-peptide levels as low as 0.2 ng/ml were measurable in a fingerstick sample, and the test was accurate over a range of 0.17 to 12.0 ng/ml. This test exhibited a correlation of r = 0.98 with a high-sensitivity commercial ELISA assay and a correlation of r = 0.90 between matched serum and fingerstick samples.

Acral Changes in pediatric patients during COVID 19 pandemic: Registry report from the COVID 19 response task force of the society of pediatric dermatology (SPD) and pediatric dermatology research alliance (PeDRA).

BACKGROUND/OBJECTIVE: In spring 2020, high numbers of children presented with acral pernio-like skin rashes, concurrent with the coronavirus disease 2019 (COVID-19) pandemic. Understanding their clinical characteristics/ infection status may provide prognostic information and facilitate decisions about management. METHODS: A pediatric-specific dermatology registry was created by the Pediatric Dermatology COVID-19 Response Task Force of the Society for Pediatric Dermatology (SPD) and Pediatric Dermatology Research Alliance (PeDRA) and was managed by Children's Hospital of Philadelphia using REDCap. RESULTS: Data from 378 children 0-18 years entered into the registry between April 13 and July 17, 2020 were analyzed. Data were drawn from a standardized questionnaire completed by clinicians which asked for demographics, description of acral lesions, symptoms before and after acral changes, COVID-19 positive contacts, treatment, duration of skin changes, laboratory testing including SARS-CoV-2 PCR and antibody testing, as well as histopathology. 229 (60.6%) were male with mean age of 13.0 years (± 3.6 years). Six (1.6%) tested positive for SARS-CoV-2. Pedal lesions (often with pruritus and/or pain) were present in 96%. 30% (114/378) had COVID-19 symptoms during the 30 days prior to presentation. Most (69%) had no other symptoms and an uneventful course with complete recovery. CONCLUSIONS AND RELEVANCE: Children with acral pernio-like changes were healthy and all recovered with no short-term sequelae. We believe these acral changes are not just a temporal epiphenomenon of shelter in place during the spring months of the first wave of the COVID-19 pandemic and may be a late phase reaction that needs further study.

Optimizing learner engagement during mental skills training: A pilot study of small group vs. individualized training.

BACKGROUND: Mental skills limit surgical residents' skill decay resulting from stress. However, optimal mental skills delivery is unknown. We sought to compare the impact of implementing our curriculum in small groups and individually. METHODS: At baseline, residents completed assessments of mental skills and laparoscopic suturing. Residents then participated in a comprehensive mental skills curriculum at two institutions. At the first institution, residents completed small group training, whereas residents at the second institution trained individually. Following mental skills training, residents completed FLS training, at which time they completed the Short State Stress Questionnaire detailing their engagement. At post-test, residents completed baseline assessments again. RESULTS: Twenty-one residents completed training. Small groups were less engaged after training than individuals (Group average engagement: 26.4 vs. Individual average engagement: 29.6, p = 0.06). CONCLUSIONS: Delivering mental skills individually facilitates greater engagement than training in small groups, but regardless of delivery method, our MSC can achieve the same outcomes on surgical performance.

Mental skills training limits the decay in operative technical skill under stressful conditions: Results of a multisite, randomized controlled study.

BACKGROUND: Overwhelming stress in the operating room can lead to decay in operative performance, particularly for residents who lack experience. Mental skills training can minimize deterioration in performance during challenging situations. We hypothesized that residents trained on mental skills would outperform controls under increased stress conditions in the simulated operating room. METHODS: Residents from Indiana University enrolled voluntarily in this institutional review board-approved study. Residents were stratified according to baseline characteristics and randomized into a mental skills and control group. Both groups trained to proficiency in laparoscopic suturing, but only the mental skills group received mental skills training. After training, technical skill transfer was assessed under regular and stressful conditions on a porcine model. Performance was assessed using an objective suturing score. The Test of Performance Strategies was used to assess the use of mental skills. Data were combined and compared with data that had been collected at Carolinas Healthcare System because residents underwent the same protocol. RESULTS: A total of 38 residents completed all study elements. There were no differences in the effects observed between sites. We observed no group differences at baseline. The groups achieved similar technical performance at baseline, posttest, and transfer test under low-stress conditions, but the mental skills group outperformed the control group during the transfer test under high-stress conditions. CONCLUSION: Our comprehensive mental skills curriculum implemented with surgery residents at two institutions was effective at minimizing the deterioration of resident technical performance under stressful conditions compared with controls. These results provide further evidence for the effectiveness of mental skills training to optimize surgery trainees' technical performance during challenging clinical situations.

Mumps: Resurgence of a once-dormant disease.

Mumps is a systemic viral illness, preventable by vaccination, that typically affects children and is characterized by unilateral or bilateral swelling of the parotid glands. Uncommon complications such as orchitis, oophoritis, deafness, pancreatitis, aseptic meningitis, and encephalitis occur more often in adults. Recent outbreaks of the disease appear to be caused by a failure to maintain herd immunity in certain populations, particularly in affluent white communities. This article reviews the clinical manifestations, diagnosis, and potential complications in patients with mumps.

Using Medical Student Quality Improvement Projects to Promote Evidence-Based Care in the Emergency Department.

INTRODUCTION: The Association of American Medical Colleges' (AAMC) initiative for Core Entrustable Professional Activities for Entering Residency includes as an element of Entrustable Professional Activity 13 to "identify system failures and contribute to a culture of safety and improvement." We set out to determine the feasibility of using medical students' action learning projects (ALPs) to expedite implementation of evidence-based pathways for three common patient diagnoses in the emergency department (ED) setting (Atrial fibrillation, congestive heart failure, and pulmonary embolism). METHODS: These prospective quality improvement (QI) initiatives were performed over six months in three Northeastern PA hospitals. Emergency physician mentors were recruited to facilitate a QI experience for third-year medical students for each project. Six students were assigned to each mentor and given class time and network infrastructure support (information technology, consultant experts in lean management) to work on their projects. Students had access to background network data that revealed potential for improvement in disposition (home) for patients. RESULTS: Under the leadership of their mentors, students accomplished standard QI processes such as performing the background literature search and assessing key stakeholders' positions that were involved in the respective patient's care. Students effectively developed flow diagrams, computer aids for clinicians and educational programs, and participated in recruiting champions for the new practice standard. They met with other departmental clinicians to determine barriers to implementation and used this feedback to help set specific parameters to make clinicians more comfortable with the changes in practice that were recommended. All three clinical practice guidelines were initiated at consummation of the students' projects. After implementation, 86% (38/44) of queried ED providers felt comfortable with medical students being a part of future ED QI initiatives, and 84% (26/31) of the providers who recalled communicating with students on these projects felt they were effective. CONCLUSION: Using this novel technique of aligning small groups of medical students with seasoned mentors, it is feasible for medical students to learn important aspects of QI implementation and allows for their engagement to more efficiently move evidence-based medicine from the literature to the bedside.

Effects of a novel mental skills curriculum on surgical novices' attention.

BACKGROUND: Surgery is very cognitively demanding, particularly for novices. Novices are required to direct full attention on the procedure at hand, and additional demands can lead to cognitive overload. Through extensive practice, experts develop spare attentional capacity (SAC) for simultaneous tasks. However, little effort has been made to enhance novices' SAC. Mental skills may enhance attention management and increase SAC. The purpose of this study was to determine the efficacy of a novel mental skills curriculum (MSC) to enhance novices' attention management. METHODS: Sixty novice volunteers were randomly stratified to a control or MSC group based on baseline laparoscopic skill and mental skill use (assessed with the Test of Performance Strategies version 2 [TOPS-2]). All participants received laparoscopic training, whereas the MSC group received additional mental skills training. At all sessions, participants completed a secondary task during laparoscopy, which assessed SAC. Participants also completed the D2 Test of Attention and the TOPS-2 attention control subscale, which are valid attention measures. RESULTS: Fifty-five novices completed the study. Both groups displayed significantly improved laparoscopic suturing ability (P < 0.001) and D2 performance (control: P < 0.005, MSC: P < 0.01), but there were no between-group differences in D2 or TOPS attention control scores. However, only the MSC group displayed significantly improved hit rate on the secondary task (P < 0.05). CONCLUSIONS: The novel MSC implemented in this study enhanced surgical novices' SAC compared to controls, and it is clear that this curriculum may be effective at enhancing learners' ability to attend multiple task-relevant stimuli concurrently. Additional study of the impact of this MSC on learners' attentional capacity is currently underway.

Application of Mental Skills Training in Surgery: A Review of Its Effectiveness and Proposed Next Steps.

INTRODUCTION: Mental skills training, which refers to the teaching of performance enhancement and stress management psychological strategies, may benefit surgeons. Our objective was to review the application of mental skills training in surgery and contrast it to other domains, examine the effectiveness of this approach in enhancing surgical performance and reducing stress, and provide future directions for mental skills training in surgery. MATERIALS AND METHODS: A systematic literature search of MEDLINE, PubMed, PsycINFO, and ClinicalKey was performed between 1996 and 2016. Keywords included were mental readiness, mental competency, mental skill, mental practice, imagery, mental imagery, mental rehearsal, stress management training, stress coping, mental training, performance enhancement, and surgery. Reviews of mental skills interventions in sport and well-regarded sport psychology textbooks were also reviewed. Primary outcome of interest was the effect of mental skills on surgical performance in the simulated or clinical environment. RESULTS: Of 490 identified abstracts, 28 articles met inclusion criteria and were reviewed. The majority of the literature provides evidence that mental imagery and stress management training programs are effective at enhancing surgical performance and reducing stress. Studies from other disciplines suggest that comprehensive mental skills programs may be more effective than imagery and stress management techniques alone. CONCLUSIONS: Given the demonstrated efficacy of mental imagery and stress management training in surgery and the incremental value of comprehensive mental skills curricula used in other domains, a concerted effort should be made to apply comprehensive mental skills curricula during surgical training.

Effectiveness of a comprehensive mental skills curriculum in enhancing surgical performance: Results of a randomized controlled trial.

INTRODUCTION: We hypothesized that the implementation of a novel mental skills curriculum (MSC) during laparoscopic simulator training would improve mental skills and performance, and decrease stress. METHODS: Sixty volunteer novices were randomized into intervention and control groups. All participants received FLS training while the intervention group also participated in the MSC. Skill transfer and retention were assessed on a live porcine model after training and 2 months later, respectively. Performance was assessed using the Test of Performance Strategies-2 (TOPS-2) for mental skills, FLS metrics for laparoscopic performance, and the State Trait Anxiety Inventory (STAI-6) and heart rate (HR) for stress. RESULTS: Fifty-five participants (92%) completed training and the transfer test, and 46 (77%) the retention test. There were no significant differences between groups at baseline. Compared to controls the intervention group significantly improved their mental skill use, demonstrated higher laparoscopic skill improvement during retention, and reported less stress during the transfer test. CONCLUSIONS: The MSC implemented in this study effectively enhanced participants' mental skill use, reduced cognitive stress in the operating room with a small impact on laparoscopic performance.

Salivary protein glycosylation as a noninvasive biomarker for assessment of glycemia.

Assessment of short-term glycemic control can facilitate monitoring of diabetes development in at-risk individuals and monitoring response to lifestyle modification or medication. We evaluated salivary protein glycosylation levels as a novel, noninvasive, short-term glycemic index in comparison to hemoglobin A1c (HbA1c), fructosamine, 1,5-anhydroglucitol (1,5-AG), and continuous glucose monitoring (CGM). Ten subjects with type 2 diabetes were monitored by CGM and saliva and blood were collected at baseline and days 1, 7, 14, 21, and 28 for determination of salivary protein glycosylation, serum fructosamine, and serum 1,5-anhydroglucitol (1,5-AG) levels, as well as HbA1c (baseline and day 28). Weekly, 14-day, 21-day, and 28-day summary blood glucose measures from CGM were computed and matched to the time of each study visit. Salivary protein glycosylation exhibited a moderate correlation with fructosamine (r = .65) and 1,5-AG (r = -.48) at baseline, and weak correlation with HbA1c (r = .3). Salivary protein glycosylation exhibited a stronger correlation than fructosamine and 1,5-AG with 7-, 14-, and 21-day average BG (r = .84, .84, and .69, respectively, vs -.37, -.28, and .00 [fructosamine] and .00, -.21, and -.57 [1,5-AG]), maximum BG (r = .79, .76, and .53 vs -.09, -.21, and -.05 [fructosamine] and -.32, -.27, and -.52 [1,5-AG]), and percentage of time over 140 mg/dL (r = .87, .79, and .59 vs -.26, -.32, and .07 [fructosamine] and -.04, -.10, and -.50 [1,5-AG]). Salivary protein glycosylation represents a promising noninvasive technology for monitoring short-term glycemic control.

Maternal serum glycosylated fibronectin as a point-of-care biomarker for assessment of preeclampsia.

OBJECTIVE: We assessed the association of glycosylated fibronectin (GlyFn) with preeclampsia and its performance in a point-of-care (POC) test. STUDY DESIGN: GlyFn, placental growth factor (PlGF), and soluble vascular endothelial growth factor receptor 1 (sFlt1) levels were determined in serum samples from 107 pregnant women. In all, 45 were normotensive and 62 were diagnosed with preeclampsia. The ability of GlyFn to assess preeclampsia status and relationships between GlyFn and maternal characteristics and pregnancy outcomes were analyzed. RESULTS: GlyFn serum levels in the first trimester were significantly higher in women with preeclampsia (P < .01) and remained higher throughout pregnancy (P < .01). GlyFn, sFlt1, PlGF, and the sFlt1/PlGF ratio were significantly associated (P < .01) with preeclampsia status, and the classification performance of these analytes represented by area under the receiver operating characteristic curve was 0.99, 0.96, 0.94, and 0.98, respectively, with 95% confidence intervals of 0.98-1.00, 0.89-1.00, 0.86-1.00, and 0.94-1.00, respectively. Increased GlyFn levels were significantly associated with gestational age at delivery (P < .01), blood pressure (P = .04), and small-for-gestational-age neonates. Repeated-measures analysis of the difference in weekly GlyFn change in the third trimester demonstrated that mild preeclampsia was associated with a weekly change of 81.7 µg/mL (SE 94.1) vs 195.2 µg/mL (SE 88.2) for severe preeclampsia. The GlyFn POC demonstrated similar performance to a plate assay with an area under the receiver operating characteristic curve of 0.93 and 95% confidence interval of 0.85-1.00. CONCLUSION: GlyFn is a robust biomarker for monitoring of preeclampsia in both a standard and POC format, which supports its utility in diverse settings.

Evaluation of a novel atrial retractor for exposure of the mitral valve in a porcine model.

OBJECTIVES: To describe a novel atrial retractor and compare 2 methods of intraoperative left atrial retraction for minimally invasive mitral valve repair. METHODS: Left atrial retraction was performed on 5 swine cadavers to evaluate performance (percent of mitral valve annulus accessible), complications encountered, ease of use, and surgical time for the minimally invasive atrial retractor and a HeartPort atrial retractor. RESULTS: Estimated accessibilities were 93.0% (standard error = 3.2) and 92.7% (standard error = 3.3) for the HeartPort and minimally invasive atrial retractor retractors, respectively, with a difference of 0.3% (standard error = 2.2%, P = .8832, df = 34). Tissue damage occurred in 1 case for the minimally invasive atrial retractor and 2 cases for the HeartPort retractor. The mean surgical times for retractor placement and mitral valve annulus exposure were 107.4 and 39.2 seconds for the HeartPort and minimally invasive atrial retractor retractors, respectively, with a difference of 68.2 seconds (P = .0092, df = 4). CONCLUSIONS: The minimally invasive atrial retractor is a suitable alternative for atrial retraction compared with standard techniques of retraction. It provides comparable exposure of the mitral valve annulus, is less time consuming to place, provides subjectively more working volume within the left atrium, and has the advantage of minimal atriotomy incision length and customizable retraction.

Procedure documentation in emergency medicine residencies: a time of change.

OBJECTIVES: The purpose of this study was to identify the methods of procedure documentation (PD) used by emergency medicine residency programs and to ascertain the number of programs that are transitioning to a more advanced system. METHODS: All 122 ACGME-approved allopathic emergency medicine programs were contacted by telephone in December 2001. Survey information was obtained from the program director, an attending physician, a resident, or the residency coordinator. RESULTS: The response rate was 92.6%. Seventeen programs (15%) reported using multiple methods of PD, with only 8% utilizing a formal database. Fifty-five percent reported that PD was manual. One third of all programs utilized a Web-based system for PD, while 13% required the use of personal digital assistants (PDAs). Nearly one fifth of programs stated they were changing to another form of PD, with the majority of those changing to a PDA format. Fifteen percent of programs purchased PDAs for their residents, and a similar proportion reported that the PDA was used by "most or all" of their residents to document procedures. Nearly four times as many programs (64%) reported that "most or all" of their residents utilized PDAs for clinical purposes. CONCLUSIONS: PDAs are used by a majority of residents for clinical purposes, although fewer utilize this resource for PD. Although most emergency medicine residency programs still utilize a manual system for PD, many programs are in transition to a more technologically advanced method.