The revised Approved Instructional Resources score: An improved quality evaluation tool for online educational resources.

BACKGROUND: Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. OBJECTIVES: We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. METHODS: As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. RESULTS: Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). CONCLUSIONS: We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

Rationing Rotational Magnet Cochlear Implant Technology in a Single Payer Healthcare System.

INTRODUCTION: In a publicly funded health care system, fiscally responsible management of any program is required. This is especially pertinent as evolving technology and associated incremental costs, places pressure on device availability within a fixed funding envelope. The application of rotational magnet technology and associated escalating surgical wait times must be justified to patients and the single-payer system. We present a single cochlear implant center's attempt at a rationing schema for magnetic resonance compatible cochlear implantation. Contrasting approaches to rationing care are evaluated and deliberated. METHODS: Based on a comparison of magnetic resonance imaging (MRI) rates within the general population to our cochlear implant (CI) cohort, we attempt the development of a decision-making schema that maximizes the number of patients to receive a CI while rationing the distribution of a rotational magnet technology to similarly situated individuals most likely to benefit. RESULTS: We elect to provide rotational magnet technology to select patient cohorts. This is based on the dominant imaging needs of these populations and the probability of requiring recurrent imaging studies. We consider this an ethical approach grounded in the egalitarian principle of equality of opportunity within cohorts of patients. CONCLUSION: Given finite resources, increasing per unit cost will unavoidably extend wait times for adult patients. Our approach does not afford similar implant devices for all patients, but rather all similarly situated individuals. Therefore, access to a scare medical resource requires program rigor and a formalized policy around candidacy for emergent technology.

Examining changes in maternal and child health inequalities in Ethiopia.

BACKGROUND: Ethiopia has made considerable progress in maternal, newborn, and child health in terms of health outcomes and health services coverage. This study examined how different groups have fared in the process. It also looked at possible factors behind the inequalities. METHODS: The study examined 11 maternal and child health outcomes and services: stunting, underweight, wasting, neonatal mortality, infant mortality, under-5 mortality, measles vaccination, full immunization, modern contraceptive use by currently married women, antenatal care visits, and skilled birth attendance. It explored trends in inequalities by household wealth status based on Demographic and Health Surveys conducted in 2000, 2005, 2011, and 2014. The study also investigated the dynamics of inequality, using concentration curves for different years. Decomposition analysis was used to identify the role of proximate determinants. RESULTS: The study found substantial improvements in health outcomes and health services: Although there is still a considerable gap between the rich and the poor, inequalities in health services have been reduced. However, child nutrition outcomes have mainly improved for the rich. The changes observed in wealth-related inequality tend to reflect the changing direct effect of household wealth on child health and health service use. CONCLUSIONS: The country's efforts to improve access to health services have shown some positive results, but attention should now turn to service quality and to identifying multisectoral interventions that can change outcomes for the poorest.

The palisade cartilage tympanoplasty technique: a systematic review and meta-analysis.

BACKGROUND: Tympanoplasty is a common procedure performed by Otolaryngologists. Many types of autologous grafts have been used with variations of techniques with varying results. This is the first systematic review of the literature and meta-analysis with the aim to evaluate the effectiveness of one of the techniques which is gaining popularity, the palisade cartilage tympanoplasty. PubMed, EMBASE, and Cochrane databases were searched for "palisade", "cartilage", "tympanoplasty", "perforation" and their synonyms. In total, 199 articles reporting results of palisade cartilage tympanoplasty were identified. Five articles satisfied the following inclusion criteria: adult patients, minimum 6 months follow-up, hearing and surgical outcomes reported. Studies with patients undergoing combined mastoidectomy, ossicular chain reconstruction, and/or other middle ear surgery were excluded. Perforation closure, rate of complications, and post-operative pure-tone average change were extracted for pooled analysis. Study failure and complication proportions that were used to generate odds ratios were pooled. Fixed effects and random effects weightings were generated. The resulting pooled odds ratios are reported. Palisade cartilage tympanoplasty has an overall take rate of 96% at beyond 6 months and has similar odds of complications compared to temporalis fascia (OR 0.89, 95% CI 0.62, 1.30). The air-bone gap closure is statistically similar to reported results from temporalis fascia tympanoplasty. CONCLUSIONS: Cartilage palisade tympanoplasty offers excellent graft take rates and good postoperative hearing outcomes for perforations of various sizes and for both primary and revision cases. This technique has predictable, long-term results with low complication rates, similar to temporalis fascia tympanoplasty.

Small area estimation of child undernutrition in Ethiopian woredas.

Reducing child undernutrition is a key social policy objective of the Ethiopian government. Despite substantial reduction over the last decade and a half, child undernutrition is still high; with 48 percent of children either stunted, underweight or wasted, undernutrition remains an important child health challenge. The existing literature highlights that targeting of efforts to reduce undernutrition in Ethiopia is inefficient, in part due to lack of data and updated information. This paper remedies some of this shortfall by estimating levels of stunting and underweight in each woreda for 2014. The estimates are small area estimations based on the 2014 Demographic and Health Survey and the latest population census. It is shown that small area estimations are powerful predictors of undernutrition, even compared to household characteristics, such as wealth and education, and hence a valuable targeting metric. The results show large variations in share of children undernourished within each region, more than between regions. The results also show that the locations with larger challenges depend on the chosen undernutrition statistic, as the share, number and concentration of undernourished children point to vastly different locations. There is also limited correlation between share of children underweight and stunted across woredas, indicating that different locations face different challenges.

Transoral robotic surgery with radial forearm free flap reconstruction: case control analysis.

BACKGROUND: The resection of large oropharyngeal tumors traditionally involves a lip-splitting mandibulotomy for adequate margin visualization and free flap reconstruction of the surgical defect. Transoral robotic surgery (TORS) has emerged as a technique that can resect large and complex oropharyngeal tumors, avoiding a lip-splitting approach. The aim of this study is to compare the lip-splitting mandibulotomy approach versus TORS for the management of advanced stage oropharyngeal carcinomas. METHODS: Prospectively collected data from 18 patients with advanced stage oropharyngeal squamous cell carcinoma (OPSCC) who received TORS with radial forearm free flap reconstruction (RFFF) was compared to a matched cohort of 39 patients who received a lip-splitting mandibulotomy and RFFF. Patients were matched for stage, p16 positivity, smoking, age and gender. Length of hospital stay (LOHS), tracheostomy decanulation time, operative time, surgical margin status, and post-operative complications were compared between groups. RESULTS: Patients who received TORS with RFFF had a significantly lower mean LOHS, compared to patients who were treated by lip-splitting mandibulotomy and RFFF (14.4 vs 19.7 days, p = 0.03). No significant differences were seen between groups in terms of operative time, tracheostomy decannulation time, margin positivity and post-operative complications. CONCLUSION: TORS with radial forearm free flap reconstruction is a safe, effective and cost-saving alternative to the lip-splitting mandibulotomy approach for the treatment of advanced stage OPSCC.

Effect of ulnar tunnel location on elbow stability in double-strand lateral collateral ligament reconstruction.

BACKGROUND: Double-strand lateral ulnar collateral ligament (LUCL) reconstruction is an effective treatment for posterolateral rotatory instability (PLRI) of the elbow, but anatomic landmarks for ulnar tunnel placement are often difficult to identify intraoperatively, which potentially can result in a nonanatomic LUCL reconstruction. This study investigated the effect of ulnar tunnel location on joint stability in double-strand LUCL reconstruction. METHODS: PLRI was artificially created in 7 cadaveric elbows, and double-strand LUCL reconstruction was performed. Five different ulnar tunnels were made along the length of the ulna. In each specimen, each possible pair of 2 tunnels (10 total) were used for graft passage. Varus and posterolateral joint gapping was measured after joint loading using a 3-dimensional digitizer system and X-ray image intensifier. RESULTS: No significant gapping was observed at the posterolateral ulnohumeral joint regardless of the location of the ulnar tunnels (P > .05). In contrast, the lateral radiocapitellar joint showed statistically significant varus gapping when both ulnar tunnels were placed proximal to the radial head-neck junction (P < .05). DISCUSSION: This findings of study suggest that the location of the ulnar tunnels may not be as critical as that of the humeral tunnel during double-strand LUCL reconstruction and that posterolateral rotatory elbow stability can be achieved reasonably well as long as at least 1 of the 2 ulnar tunnels is located at or distal to the radial head-neck junction level.

Investigation of EZH2 pathways for novel epigenetic treatment strategies in oropharyngeal cancer.

BACKGROUND: In recent decades, the incidence of oropharyngeal squamous cell carcinoma (OPSCC) has been rising worldwide as a result of increasing oncogenic human papillomavirus (HPV) infections in the oropharynx. EZH2 is an epigenetic regulatory protein associated with tumor aggressiveness and negative survival outcomes in several human cancers. We aimed to determine the role of EZH2 as a potential therapeutic epigenetic target in HPV-positive and negative OPSCC. METHODS: The expression of EZH2 was measured by immunohistochemistry (IHC) and droplet digital PCR (ddPCR) in 2 HPV-positive and 2 HPV-negative cell lines. The cell lines were then cultured and treated with one of 3 EZH2 epigenetic inhibitors (3-deazaneplanocin A, GSK-343 and EPZ005687) or DMSO (control). Following 2, 4 and 7 days of treatment, cells were analyzed and compared by gene expression, cell survival and proliferation assays. RESULTS: EZH2 targeting resulted in greater inhibition of growth and survival in HPV-positive compared to HPV-negative cells lines. The expression profile of genes important in OPSCC also differed according to HPV-positivity for Ki67, CCND1, MET and PTEN/PIK3CA, but remained unchanged for EGFR, CDKN2A and p53. CONCLUSION: Inhibition of EZH2 has anti-tumorigenic effects on OPSCC cells in culture that is more pronounced in HPV-positive cell lines. EZH2 is a promising epigenetic target for the treatment of OPSCC.

Intraoperative Catastrophic Failure of a Mizuho OSI Orthopedic Trauma Table Top: A Case Report.

CASE: During orthopaedic open reduction and internal fixation, early fatigue failure of a Mizuho OSI Orthopedic Trauma Table Top occurred. The patient fell toward the ground but was uninjured. A material failure characterized by a crack in the spar tube leading to complete table component separation was identified. To our knowledge, this report is the first of its kind to specifically highlight surgical table device failure intraoperatively. CONCLUSION: Although rare, early fatigue failure of operating tables is possible, leading to hazardous intraoperative situations and the potential for serious patient injury or death. Operating tables and equipment should be inspected rigorously and with proper documentation to prevent such events.

Expiratory activation of abdominal muscle is associated with improved respiratory stability and an increase in minute ventilation in REM epochs of adult rats.

Breathing is more vulnerable to apneas and irregular breathing patterns during rapid eye movement (REM) sleep in both humans and rodents. We previously reported that robust and recurrent recruitment of expiratory abdominal (ABD) muscle activity is present in rats during REM epochs despite ongoing REM-induced muscle atonia in skeletal musculature. To develop a further understanding of the characteristics of ABD recruitment during REM epochs and their relationship with breathing patterns and irregularities, we sought to compare REM epochs that displayed ABD muscle recruitment with those that did not, within the same rats. Specifically, we investigated respiratory characteristics that preceded and followed recruitment. We hypothesized that ABD muscle recruitment would be likely to occur following respiratory irregularities and would subsequently contribute to respiratory stability and the maintenance of good ventilation following recruitment. Our data demonstrate that epochs of REM sleep containing ABD recruitments (REM(ABD+)) were characterized by increased respiratory rate variability and increased presence of spontaneous brief central apneas. Within these epochs, respiratory events that displayed ABD muscle activation were preceded by periods of increased respiratory rate variability. Onset of ABD muscle activity increased tidal volume, amplitude of diaphragmatic contractions, and minute ventilation compared with the periods preceding ABD muscle activation. These results show that expiratory muscle activity is more likely recruited when respiration is irregular and its recruitment is subsequently associated with an increase in minute ventilation and a more regular respiratory rhythm.

Cerebrovascular disease associated with antiphospholipid antibodies: more questions than answers.

Neurological syndromes occur in a significant number of patients with antiphospholipid antibodies. The optimal management for these patients however remains uncertain. Our study is a descriptive analysis looking retrospectively at 45 patients who presented to the principal tertiary referral centre in the Australian Capital Territory, with either cerebral arterial or venous thrombosis for which there was no obvious cause for their presentation when initially reviewed. The diagnosis was based on the clinical findings made by one of three neurologists attached to our centre. Radiological findings and the presence of either IgM or IgG anticardiolipin antibodies, IgG anti-beta-2 glycoprotein 1 antibodies or a lupus anticoagulant were then documented. In this group of patients three subgroups were identified:1. Individuals that fulfilled the Sapporo Classification Criteria2. Individuals with transiently positive antiphospholipid antibodies and3. Individuals with persistently low positive antiphospholipid antibodies. The most interesting of these three groups are those individuals with transiently positive antiphospholipid antibodies. A potential cause for presentation was identified in only one patient of this group with documented infective endocarditis and bacteraemia. Comparison with the other two groups suggested that there was little in terms of clinical presentation, radiological findings or intercurrent risk factors for thrombotic disease to distinguish between them. With disappearance of antiphospholipid antibodies, the individuals within this group have not had further thrombotic events. Our observations emphasise the problems that continue to exist in relation to the occurrence of cerebrovascular disease in the context of antiphospholipid antibodies and the optimal management of these stratified groups. Our findings also raise an as yet unanswered question as to the signficance of these transiently positive antiphospholipid antibodies. In the absence of significant intercurrent risk factors our findings would suggest that in the group we describe that they are likely to be of clinical significance.