Medium- to long-term results of acromioclavicular joint stabilisation using the Ligament Augmentation Reconstruction System (LARS) ligament.

BACKGROUND: Opinion is divided as to optimum management of grade III acromioclavicular joint injuries that have failed conservative management. We objectively investigated the radiological and functional outcome of acromioclavicular joint reconstruction using the Ligament Augmentation Reconstruction System (LARS®). METHODS: Retrospective review of patients with LARS reconstruction of acromioclavicular joint dislocations with minimum six-year follow-up. Functional assessment was performed using the constant score, Disability of Arm Shoulder and Hand score and simple satisfaction score. Radiological assessment was undertaken using plain radiographs. Results were compared with the uninjured limb. RESULTS: Twenty-four of 25 patients were included. Mean constant score for the injured shoulder was 87.0, Disability of Arm Shoulder and Hand score was 11.6. All patients indicated that they would have the operation again. There were five complications including two patients that suffered small cracks in the clavicle. Coracoid erosion was frequently seen but was most often minor. In two cases, this resulted in a complete dissociation of the coracoid tip but without functional detriment. DISCUSSION: LARS is a safe and effective method of acromioclavicular joint reconstruction producing good results, and we recommend its use for these injuries. We also caution clinicians who use cerclage methods to be aware of coracoid erosion when following up their patients.

A Nurse Shadowing Program for Physicians: Bridging the Gap in Understanding Nursing Roles.

OBJECTIVE: A physician-nurse shadow program was established to improve interdisciplinary collaboration. BACKGROUND: Ineffective communication between physicians and nurses leads to poor outcomes in patient satisfaction, safety, and associate engagement. Physician unfamiliarity of the nursing process is identified as a root cause. METHODS: First-year resident physicians shadowed nurses for a 4-hour shift. Residents did not function as a physician during the shadowing experience but participated in nursing workflow and tasks. Participants completed a Likert-scale rating and qualitative survey before and after the shift. RESULTS: The survey measured confidence in communication and perception of workflow. Confidence levels increased in all areas by 29% for residents and 34% for nurses. Data demonstrated improved physician understanding of nursing workflow and inspired recommendations to enhance communication. CONCLUSIONS: First-year resident physicians practiced direct communication skills and experienced hands-on nursing care during the shadow program. The initiative provided an environment for mutual learning and interdisciplinary relationship-building.

Modified CHA2DS2-VASc score predicts in-hospital mortality and procedural complications in acute coronary syndrome treated with percutaneous coronary intervention.

BACKGROUND: Current risk prediction models in acute coronary syndrome (ACS) patients undergoing PCI are mathematically complex. This study was undertaken to assess the accuracy of a modified CHA2DS2-VASc score, comprised of easily accessible clinical factors in predicting adverse events. METHODS: The National Inpatient Sample (NIS) was queried for ACS patients who underwent PCI between 2010 and 2014. We developed a modified CHA2DS2-VASc score for risk prediction in ACS patients. Multivariate mixed effect logistic regression was utilized to study the adjusted risk for adverse outcomes based on the score. The primary outcome evaluated was in-hospital mortality. Secondary outcomes assessed were stroke, respiratory failure, acute kidney injury, all-cause bleeding, pacemaker insertion, vascular complications, length of stay and cost. RESULTS: There were 252,443 patients admitted with ACS included. Mean age was 62 ± 12 years. The mean CH3A2DS-VASc score was 1.6 ± 1.6. The in-hospital mortality rate was 2.5%. CH3A2DS-VASc score was highly correlated with increased rate of mortality and all secondary outcomes. ROC curve analysis for association of CH3A2DS-VASc score with mortality demonstrates that area under the curve (AUC) = 0.83 (95%C: 0.82-0.84). Stepwise increases in CH3A2DS-VASc score correlated with incremental risk, and total score was an independent predictor of mortality (adjusted OR: 1.99 (95%CI: 1.96-2.03) p < 0.001) and all secondary outcomes. CONCLUSION: This study supports the applicability of the CH3A2DS-VASc score as an accurate risk prediction model for ACS patients undergoing PCI and could supplant more complicated models for quality assurance.

Primary Vaginal Non-Hodgkin Lymphoma.

Non-Hodgkin lymphoma (NHL) is a type of blood cancer and 25% of NHL patients present with a primary extranodal tumor. Primary NHL of the vagina is extremely rare with only a few cases reported. We present the case of a 79-year-old, grand multipara, Peruvian woman with an eleven-month history of symptoms of pelvic and vaginal pain and vaginal bleeding. Vaginal examination revealed an exophytic tumor that involved the labia, right vaginal wall, cervix, parametrium, and pelvic bone. A computed tomography (CT) image showed a 10 x 10 x 9-cm solid tumor in the pelvic cavity with irregular edges in the pelvic floor, parametrium, and the perineal soft tissues. Bilateral pelvic and inguinal adenomegalies were found. No signs of metastases were found. Marrow and bone biopsy studies were negative. The diagnosis was NHL type diffuse large B-cell lymphoma (DLBCL) of vagina stage one. The patient was treated with six courses of CHOP-R (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab). She showed a complete response and remained in remission in follow-up control visits. NHL of the female genital tract is rare. CHOP-R is the first line of treatment for this type of cancer. However, less is known about the follow-up protocol and relapse management. Vaginal lymphoma has an extremely low prevalence, and collaborative studies are required to study the same.

Diffuse Idiopathic Skeletal Hyperostosis: Persistent Sore Throat and Dysphagia in an Elderly Smoker Male.

Diffuse idiopathic skeletal hyperostosis (DISH) is rarely symptomatic. However, it can present with dyspnea, hoarseness, dysphagia, and stridor. An 80-year-old chronic smoker male presented with 6-month history of sore throat and progressive dysphagia. Computed tomography of the neck revealed bulky anterior bridging syndesmophytes along the anterior aspect of the cervical spine and facet effusion involving four contiguous vertebrae consistent with DISH. Dysphagia secondary to DISH was diagnosed. Fiberoptic laryngoscopy showed bilateral vocal cord paralysis. Patient's airway became compromised requiring tracheostomy tube placement. After discussion of therapeutic options, patient agreed on a percutaneous endoscopic gastrostomy tube insertion for nutritional support. Osteophytectomy was left to be discussed further.

Inappropriate use of commercial Antinuclear Antibody Testing in a community-based US hospital: a retrospective study.

Healthcare providers use antinuclear antibodies (ANAs) to screen and diagnose patients with autoimmune diseases. In the recent years, commercial multiplex ANA kits have emerged as a convenient and fast diagnostic method. Diagnostic testing should follow sequenced algorithms: initial screen followed by specific antibody analysis. Second-level testing as an initial screen for autoimmune disease is inappropriate. We reviewed 68 patients with ANA comprehensive panels over a 6-month period from May 2015 to October 2015. We assessed appropriateness and estimated incurred losses from inappropriate testing. We found 92.6% (63 out of 68) of the ANA comprehensive panel results to be negative. Incurred losses from inappropriate ANA comprehensive panel testing were $66,000. Physicians should become familiar with ANA-sequenced diagnostic algorithms to avoid unnecessary higher level testing.