Fecal Keratin 8 Is a Noninvasive and Specific Marker for Intestinal Injury in Necrotizing Enterocolitis.

Specific biomarkers of intestinal injury associated with necrotizing enterocolitis (NEC) are needed to diagnose and monitor intestinal mucosal injury and recovery. This study aims to develop and test a modified enzyme-linked immunosorbent assay (ELISA) protocol to detect the total keratin 8 (K8) in the stool of newborns with NEC and investigate the clinical value of fecal K8 as a marker of intestinal injury specifically associated with NEC. We collected fecal samples from five newborns with NEC and five gestational age-matched premature neonates without NEC at the Lucile Packard Children's Hospital Stanford and Washington University School of Medicine, respectively. Fecal K8 levels were measured using a modified ELISA protocol and Western blot, and fecal calprotectin was measured using a commercial ELISA kit. Clinical data, including gestational age, birth weight, Bell stage for NEC, feeding strategies, total white blood cell (WBC) count, and other pertinent clinical variables, were collected and analyzed. Fecal K8 levels were significantly higher in the pre-NEC group (1-2 days before diagnosis of NEC) and NEC group than those in the non-NEC group (p = 0.013, p = 0.041). Moreover, fecal K8 was relatively higher at the onset of NEC and declined after the resolution of the disease (p = 0.019). Results with similar trends to fecal K8 were also seen in fecal calprotectin (p = 0.046), but not seen in total WBC count (p = 0.182). In conclusion, a modified ELISA protocol for the total K8 protein was successfully developed for the detection of fecal K8 in the clinical setting of premature newborns with NEC. Fecal K8 is noted to be significantly increased in premature newborns with NEC and may, therefore, serve as a noninvasive and specific marker for intestinal epithelial injury associated with NEC.

Assessment of an In-Sourced Patient Assistance Program at a Health System in West Virginia.

Background: Lack of insurance coverage in conjunction with the high cost of prescription drugs plays a large role in patient's obtaining and properly taking their medications. Many drug manufacturers provide assistance opportunities for indigent patients lacking the financial means to obtain the medication. It is hypothesized that providing a dedicated insourced team to coordinate this process can successfully increase medication access for indigent patient populations. Methods: Patients with little or no means for payment whom the patient assistance team was contacted to obtain a medication were included. Information collected included the medication requested, the drug manufacturer, the cost of the medication, the dose required, the number of doses approved, and whether the request was approved or denied. This data was analyzed for approval rate, most common medications requested, total cost of medications provided, as well as which system hospitals are utilizing the program most frequently. Results: In total, 153 patients were assessed to obtain medication assistance through the program. With an overall approval rate of 59.5%, 91 patients were provided medication through this program. 58% of patients received insurance approval and were therefore denied no-cost drug. The program was able to obtain 283 fills of no-cost medications for patients with a total value of $2 060 633.83. Conclusion: A dedicated patient assistance program is effective in obtaining financial assistance for patients to obtain high-cost medications for which they otherwise could not provide payment. With the continued expansion of biologic medication development, the necessity for programs to aid indigent populations increases exponentially.

Identifying Priorities and Strategies for Improving Colorectal Cancer Screening in Tribal Clinics.

BACKGROUND: Colorectal cancer (CRC) is the 3rd most frequently diagnosed cancer and the 2nd leading cause of cancer death in the United States (US), and incidence and mortality rates in Oklahoma are higher for many American Indian (AI) populations than other populations. The AI CRC Screening Consortium addresses major regional CRC screening disparities among AIs with shared objectives to increase CRC screening delivery and uptake in AIs aged 50 to 75 years at average risk for CRC and to assess the effectiveness of implementations of the interventions. This manuscript reports environmental scan findings related to current practices and multi-stakeholder experiences with CRC screening in two Oklahoma Indian health care systems. METHOD: We conducted a mixed methods environmental scan across five clinical sites and with multiple stakeholders to determine the scope and scale of colorectal cancer screening in two separate AI health care delivery systems in Oklahoma. Data collection consisted of a mixture of individual interviews and group discussions at an urban site, and four clinical care sites within a tribal health system. RESULTS: Sixty-two individuals completed interviews. Data from these interviews will inform the development of evidence-based intervention strategies to increase provider delivery, community access to, and community priority for CRC screening in diverse AI health care delivery systems. Conversations with patients, providers, and clinical leadership point to individual and system-level opportunities for improvement at each site, shaped in part by differences in the delivery of services, structure of the health care system, and capacity to implement new intervention strategies. The thematic areas most central to the process of evidenced-based intervention development included: current practices, needs and recommendations, and CRC site priorities. CONCLUSION: Environmental scan data indicated clear opportunities for individual and system-level interventions to enhance CRC screening and was critical for understanding readiness for EBI implementation at each site.

Ultrasound Verification of Laparoscopic-Assisted Transversus Abdominis Plane Blocks in Children Undergoing Laparoscopic Procedures.

Purpose: Ultrasound-guided transversus abdominis plane (TAP) blocks have been demonstrated to decrease postoperative pain; however, laparoscopic-assisted TAP (L-TAP) blocks have not been well studied in children. Our study utilized intraoperative ultrasound to verify whether surgeon-administered blocks using only laparoscopic visualization were reliably delivered into the correct plane. Materials and Methods: Patients undergoing laparoscopic procedures were enrolled to receive L-TAP blocks. Preblock and postblock ultrasounds were performed to document the plane of local anesthetic delivery. Ultrasound images were reviewed by two blinded anesthesiologists to determine whether the L-TAP block was administered into the desired plane. Results: Fifty-one patients were enrolled. The average age was 5.9 years (range: 2 days to 17 years) and the mean weight was 25.4 kg (range: 2.64-118.8 kg). The most common procedures were inguinal hernia repair (n = 19), appendectomy (n = 10), and gastrostomy-tube placements (n = 13). Nine surgeons performed 93 L-TAP blocks (average: 10.3 blocks/surgeon). Ultrasound confirmed distribution in the correct plane in 53.5/93 blocks (57.5%; 58.0% for attending surgeons), with 77.4% concurrence between the anesthesiologist reviewers. Conclusion: L-TAP achieves delivery of local anesthetic into the correct tissue plane in over half the cases with minimal training. Further studies are needed to examine the effect of L-TAP blocks on reducing postoperative pain in pediatric patients.

Small surgeries, big smiles: using virtual reality to reduce the need for sedation or general anesthesia during minor surgical procedures.

PURPOSE: Children often require anesthesia for simple diagnostic and therapeutic procedures. The aim of this study was to evaluate the feasibility of using virtual reality (VR) to reduce sedation in children undergoing minor surgical procedures. METHOD: In this prospective, non-randomized clinical trial, pediatric patients at a free-standing children's hospital undergoing hormone implant placement, removal, or exchange were recruited to use VR and local anesthesia instead of procedural sedation or general anesthesia (GA). Patients were enrolled between November 2017 and March 2020, and were compared to historic controls who underwent similar procedures without VR between April 2016 and February 2020. Primary outcome measure was successful procedure completion without sedation or GA. Secondary measures included assessments of pain, fear and anxiety, patient compliance, procedural and recovery times. RESULTS: Twenty-eight patients underwent 29 procedures with VR. Hormone implants (72%), removals (7%), or exchanges (21%) were completed without GA, sedation or IV placement. Procedure lengths and pain scores were similar between VR patients and historic controls, but recovery times were significantly shorter in VR patients (18 vs 65 min, p < 0.001). Participant satisfaction scores were high, with 95% recommending VR to others. CONCLUSIONS: VR is a feasible alternative to sedation or GA for select pediatric patients undergoing minor surgical procedures.

Laparoscopic versus ultrasound-guided visualization of transversus abdominis plane blocks.

BACKGROUND: Ultrasound-guided (US) transversus abdominis plane (TAP) block is commonly utilized as part of a multi-modal approach for postoperative pain management. This study seeks to determine whether laparoscopic-guided TAP blocks are as effective as US-guided TAP blocks among pediatric patients. METHOD: In this prospective, randomized controlled trial, pediatric patients undergoing laparoscopic procedures were randomly assigned to one of two treatment arms: US-guided TAP block (US-arm) or laparoscopic-guided TAP block (LAP-arm). Primary outcome was PACU pain scores. Secondary outcomes included PACU opioid consumption, block completion time and block accuracy. RESULTS: Twenty-five patients were enrolled in each arm. In the LAP-arm, 59% of blocks were in the transversus abdominis plane compared to 74% of TAP blocks in the US-arm (p = 0.18). Blocks were completed faster in the LAP-arm (2.1 ± 1.9 vs. 7.9 ± 3.4 min, p<0.001). The average highest PACU pain score was 3.4 ± 3.1 for the LAP-arm and 4.3 ± 3.8 for the US-arm (p = 0.37). Overall PACU pain scores and opioid consumption were similar between the groups (1.2 ± 1.3 vs. 1.6 ± 1.6, p = 0.24; 2.2 ± 5.8 vs. 0.9 ± 1.4MME, p = 0.26). CONCLUSION: Laparoscopic TAP blocks have equivalent efficacy in post-operative pain scores, narcotic use, and tissue plane accuracy as compared to US-guided TAP blocks. They are also completed faster and may result in less operating room and general anesthetic time for the pediatric patient.

Pre-symptomatic detection of COVID-19 from smartwatch data.

Consumer wearable devices that continuously measure vital signs have been used to monitor the onset of infectious disease. Here, we show that data from consumer smartwatches can be used for the pre-symptomatic detection of coronavirus disease 2019 (COVID-19). We analysed physiological and activity data from 32 individuals infected with COVID-19, identified from a cohort of nearly 5,300 participants, and found that 26 of them (81%) had alterations in their heart rate, number of daily steps or time asleep. Of the 25 cases of COVID-19 with detected physiological alterations for which we had symptom information, 22 were detected before (or at) symptom onset, with four cases detected at least nine days earlier. Using retrospective smartwatch data, we show that 63% of the COVID-19 cases could have been detected before symptom onset in real time via a two-tiered warning system based on the occurrence of extreme elevations in resting heart rate relative to the individual baseline. Our findings suggest that activity tracking and health monitoring via consumer wearable devices may be used for the large-scale, real-time detection of respiratory infections, often pre-symptomatically.

Prescribing competency assessment for Canadian medical students: a pilot evaluation.

BACKGROUND: The knowledge and ability to prescribe safely and effectively is a core competency for every graduating medical student. Our previous research suggested concerns about medical student prescribing abilities, and interest in a standardized assessment process. METHODS: A multi-year cross-sectional study evaluating the feasibility, acceptability, and discriminative ability of an online prescribing competency assessment for final year Canadian medical students was conducted. Students at nine sites of four Ontario medical schools were invited to participate in an online one-hour exam of eight domains related to prescribing safely. Student feedback on perceived fairness, clarity, and ease of use formed the primary outcome. Exam performance and parity between schools were the secondary outcome. RESULTS: A total of 714 students completed the assessment during spring final review courses between 2016 and 2018. Student feedback was more favourable than not for appropriateness of content (53.5% agreement vs 18.3% disagreement), clarity of questions (65.5% agreement vs 11.6% disagreement), question layout and presentation (70.8% agreement vs 12.2% disagreement), and ease of use of online interface (67.1% agreement vs 13.6% disagreement). Few (23.6% believed their course work had prepared them for the assessment. Mean total exam score was 70.0% overall (SD 10.4%), with 47.6% scoring at or above the pass threshold of 70%.Conclusion: Our prescribing competency assessment proved feasible, acceptable, and discriminative, and indicated a need for better medical school training to improve prescribing competency. Further evaluation in a larger sample of medical schools is warranted.

Standing up to the black cloud: case example of narrative therapy in the motor vehicle sector.

Using a case study, this article presents narrative therapy as an effective psychotherapy practice for work with victims of motor vehicle accidents. By troubling the standard cognitive behavioral approaches as deficit focused, narrative therapy is outlined as an approach that is focused on the skills and values present in the client's life; it is an approach that allows the client to take authorship over his or her concerns and enact change. This article is meant to be an example of narrative therapy's usefulness and open space for conversation about rehabilitation therapies that focus less on structure and more on strength.

Pre-Clerkship Observerships to Increase Early Exposure to Geriatric Medicine.

BACKGROUND AND PURPOSE: To foster interest in geriatric care, the Queen's Geriatrics Interest Group (QGIG) collaborated with the Division of Geriatric Medicine to arrange a Geriatrics Pre-Clerkship Observership Program. METHODS: Forty-two pre-clerkship medical students participated in the program between October 2013 and May 2014. Participants were paired with a resident and/or attending physician for a four-hour weekend observership on an inpatient geriatric rehabilitation unit. The program was assessed using: (1) internally developed Likert scales assessing student's experiences and interest in geriatric medicine before and after the observership; (2) University of California Los Angeles-Geriatric Attitudes Scale (UCLA-GAS); and (3) narrative feedback. RESULTS: All participants found the process of setting up the observership easy. Some 72.7% described the observership experience as leading to positive changes in their attitude toward geriatric medicine and 54.5% felt that it stimulated their interest in the specialty. No statistically significant change in UCLA-GAS scores was detected (mean score pre- versus post-observership: 3.5 ± 0.5 versus 3.7 ± 0.4; p=.35). All participants agreed that the program should continue, and 90% stated that they would participate again. CONCLUSIONS: The observership program was positively received by students. Structured pre-clerkship observerships may be a feasible method for increasing exposure to geriatric medicine.

Development of a direct observation Measure of Environmental Qualities of Activity Settings.

AIM: The aim of this study was to develop an observer-rated measure of aesthetic, physical, social, and opportunity-related qualities of leisure activity settings for young people (with or without disabilities). METHOD: Eighty questionnaires were completed by sets of raters who independently rated 22 community/home activity settings. The scales of the 32-item Measure of Environmental Qualities of Activity Settings (MEQAS; Opportunities for Social Activities, Opportunities for Physical Activities, Pleasant Physical Environment, Opportunities for Choice, Opportunities for Personal Growth, and Opportunities to Interact with Adults) were determined using principal components analyses. Test-retest reliability was determined for eight activity settings, rated twice (4-6wk interval) by a trained rater. RESULTS: The factor structure accounted for 80% of the variance. The Kaiser-Meyer-Olkin Measure of Sampling Adequacy was 0.73. Cronbach's alphas for the scales ranged from 0.76 to 0.96, and interrater reliabilities (ICCs) ranged from 0.60 to 0.93. Test-retest reliabilities ranged from 0.70 to 0.90. INTERPRETATION: Results suggest that the MEQAS has a sound factor structure and preliminary evidence of internal consistency, interrater, and test-retest reliability. The MEQAS is the first observer-completed measure of environmental qualities of activity settings. The MEQAS allows researchers to assess comprehensively qualities and affordances of activity settings, and can be used to design and assess environmental qualities of programs for young people.

Approach to inappropriate sexual behaviour in people with dementia.

OBJECTIVE: To provide family physicians with an update on the approach to diagnosis and management of inappropriate sexual behaviour (ISB) in persons with dementia. SOURCES OF INFORMATION: MEDLINE and EMBASE were searched for relevant articles published before June 2012. No level I studies were identified; most articles provided level III evidence. MAIN MESSAGE: Inappropriate sexual behaviour is common in people with dementia. A variety of factors (eg, cultural, religious, societal views of geriatric sexuality, medicolegal issues) might complicate evaluation of this behaviour, and must be considered to allow suitable management of individual patients. Tools to assist in documenting ISB are available. Creative nonpharmacologic interventions for ISB might be effective when tailored to individual patients. A number of drug treatments (eg, antidepressant, antiandrogen, antipsychotic, and anticonvulsant medications) have been proposed for symptoms that do not adequately respond to nonpharmacologic interventions. However, evidence to support drug treatments is limited, adverse effects remain an important consideration, and it is unclear which should be used as first-line versus second-line treatments. CONCLUSION: Although there is no empirically established treatment algorithm for dementia-related ISB, existing literature provides some evidence for various nonpharmacologic and pharmacologic treatments. Further high-quality research is urgently needed to guide family physicians who manage patients with dementia-related ISB.

Performing transformation: reflections of a lesbian academic couple.

We experience queer literacy as a kind of collision between the traditional and the transformative. Queer literacy is an acquired literacy of transformation, where the established rules of behavior and discourse are both challenged and transcended. As a lesbian academic couple in a privileged intellectual, political, and social location, we can move out of the traditional realm (through the closet) into an otherworldly queer space where knowledge and identity are destabilized. Moving in and out of queer transformative space requires a kind of blind faith-faith that believes in what the mind can neither see nor prove.

Antenatal voluntary counseling and testing for HIV in Barbados. Success and barriers to implementation.

OBJECTIVE: To determine the success of voluntary counseling and testing (VCT) for HIV and to identify the barriers to implementation when VCT is offered as a package integrated with antenatal care. METHODS: In this descriptive study we investigated antenatal VCT and HIV testing in all post-parturient women at the Queen Elizabeth Hospital, Bridgetown, Barbados, who gave birth between April and September 2002. Data were collected retrospectively from the antenatal care record and by recall during one-on-one interview. RESULTS: Of 1 342 women surveyed, 954 (71.1%) received antenatal counseling and were offered an HIV test. Of the 954 women offered HIV test after counseling, 914 (95.8%) agreed to have the test. Among the women surveyed, 1 106 (82.4%) had a documented HIV test, 914 (85.7%) were tested after documented pretest counseling, and another 192 (14.3%) were tested without documented pretest counseling. Overall, 822 of the 1 342 women surveyed (61.2%) had a documented HIV test result in their antenatal case record at the time of delivery. Of the 1 106 women who had a documented HIV test, the test results were unavailable at the time of delivery in only 284 (21.2%). Among the reasons for unavailability of a documented HIV test result, the most common (45.0%) was that no test was done, followed by unclear documentation of the result. CONCLUSIONS: Twenty-nine percent of surveyed women failed to receive antenatal VCT and this is a cause of concern, for both the high coverage and good quality counseling are key to the overall success and cost effectiveness of the VCT program. Fourteen percent of the women surveyed who did not receive VCT were tested for HIV, a situation that is undesirable because some women may be tested without understanding the full implication of this policy, and as a result the overall impact of VCT may be reduced.

Antenatal voluntary counseling and testing for HIV in Barbados: success and barriers to implementation

OBJETIVO: Determinar los resultados del asesoramiento y de la prueba detectora de infección por VIH aceptados voluntariamente (APV) e identificar las barreras que impiden llevar el APV a la práctica cuando se ofrece como parte integral de la atención prenatal. MÉTODOS: En este estudio descriptivo investigamos los antecedentes de APV prenatal y de haber recibido la prueba detectora de infección por VIH en todas las mujeres que habían dado a luz en el Hospital Reina Isabel en Bridgetown, Barbados, entre abril y septiembre de 2002. Se recolectaron datos retrospectivamente a partir de las fichas de atención prenatal y por recordación durante entrevistas de cara a cara. RESULTADOS: De las 1 342 mujeres entrevistadas, a 954 (71,1%) se les había dado asesoramiento prenatal y se les había ofrecido la prueba detectora de infección por VIH. De las 954 mujeres encuestadas a quienes se les ofreció la prueba después del asesoramiento, 914 (95,8%) la aceptaron. De las mujeres encuestadas, 1 106 (82,4%) tenían documentada en su ficha una prueba detectora de infección por VIH, 914 (85,7%) recibieron la prueba después de un asesoramiento documentado, y otras 192 (14,3%) recibieron la prueba sin ninguna documentación de haber recibido un asesoramiento previo. En total, 822 (61,2%) de las 1 342 mujeres entrevistadas tenían documentado en su ficha el resultado de la prueba detectora de VIH en el momento de dar a luz. De las 1 106 mujeres con documentación de haber recibido la prueba, 284 (21,2%) no tenían anotado el resultado en el momento de dar a luz. La falta de un resultado documentado se debió principalmente a que la prueba nunca se realizó (45,0%), y en segundo lugar, a la falta de certeza en cuanto a la documentación. CONCLUSIONES: Veintinueve por ciento de las mujeres encuestadas no recibieron APV, lo cual es alarmante porque la alta cobertura y la buena calidad son imprescindibles para que el APV dé buenos resultados y rinda la debida eficacia en función de su costo. Catorce por ciento de las mujeres encuestadas que no quisieron recibir ningún asesoramiento recibieron la prueba detectora de infección por VIH. Esta situación no es aconsejable porque significa que a algunas mujeres se les aplica la prueba sin que entiendan a fondo las implicaciones de esta política. Esto, a su vez, podría reducir el impacto general del APV.