Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors.

Objective: Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship. Study Design: A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019. Results: Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties. Discussion: Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.

Smartphone application technique for localising magnetically controlled growth rod actuators: the Oxford Magnetic Counter App Technique (TOMCAT).

PURPOSE: The purpose of this study is to report a novel smartphone app technique to localise a magnetically controlled growing rod (MCGR) actuator, along with determining this novel technique accuracy compared to current tactile localisation techniques through an experimental study. METHODS: Five spinal surgery fellows recorded attempts localising the MCGR magnetic actuator using a novel smartphone app technique, MAGEC Wand and magnetic disc. Three attempts per technique were performed and repeated in both the average and overweight patient models. RESULTS: In total, 90 separate localisation attempts were recorded. The smartphone app produced less localisation error than both the MAGEC Wand and magnetic disc. Mean difference was - 0.71 cm (95% CI - 1.24 to - 0.18 cm p = 0.06) and - 0.58 cm (95% CI - 1.11 to - 0.04 cm p = 0.031), respectively. Mean localisation error for the smartphone app, MAGEC Wand and magnetic disc, was 0.9 cm, 1.61 cm, 1.47 cm, respectively, for both average and overweight models combined. CONCLUSIONS: This novel smartphone app localisation technique is accurate. Current MAGEC Wand and magnetic disc techniques produced more localisation error than the reported tolerance of the external remote control lengthening unit in this experiment.

High field structural MRI in the management of degenerative cervical myelopathy.

Introduction: This is a narrative overview of the pathophysiology, investigation and management of Degenerative Cervical Myelopathy (DCM). This review article also takes a look ahead to the impact high resolution MRI may have on treatment.Background: DCM is the most common cause of spinal dysfunction and yet it remains poorly understood. It is becoming increasingly common in our ageing population. Disc and facet joint abnormalities, osteophytes, spondylothisthesis and ligamentous hypertrophy all act together to produce spinal canal and neuronal foramina stenosis which in turn causes neural compromise. Its impact on the quality of life of this patient group and the wider economy is vast. Some patients with overt cord compression and MRI signal change in their cervical cord may only have subtle clinical signs whilst others with less striking imaging may be profoundly myelopathic. Who to operate on and when remains a neurosurgical dilemma in this group of patients.Methods: A number of articles with a broad variation in methodology were reviewed and referenced during the production of this paper.Results: This paper is a narrative review. The results presented in all the referenced articles were considered.Conclusion: The process of developing new imaging techniques will give a greater understanding of the causes of the symptoms of DCM and in a wider context facilitate further surgical and medical strategies that are more cost effective and beneficial to patients. The advent of 7T MRI or further optimisation of safer 3T MRI sequences may soon provide this opportunity and the diagnostic gap in spinal cord imaging can begin to close.

A pediatric chronic subdural hematoma: More than meets the eye.

We present an unusual case of a 13-year-old child who following minor head injury presented with what appeared to be a thin chronic subdural hematoma on plain computed tomography imaging. The child was found to have an underlying arachnoid cyst. Intra- and extra-cystic bleeding had occurred simultaneously causing an isodense cyst with an accompanying subdural collection. This radiographically occult pathology should be excluded using magnetic resonance imaging in any child presenting with a subdural collection.

Migration pathways, behavioural thermoregulation and overwintering grounds of blue sharks in the Northwest Atlantic.

The blue shark Prionace glauca is the most abundant large pelagic shark in the Atlantic Ocean. Although recaptures of tagged sharks have shown that the species is highly migratory, migration pathways towards the overwintering grounds remain poorly understood. We used archival satellite pop-up tags to track 23 blue sharks over a mean period of 88 days as they departed the coastal waters of North America in the autumn. Within 1-2 days of entering the Gulf Stream (median date of 21 Oct), all sharks initiated a striking diel vertical migration, taking them from a mean nighttime depth of 74 m to a mean depth of 412 m during the day as they appeared to pursue vertically migrating squid and fish prey. Although functionally blind at depth, calculations suggest that there would be a ~2.5-fold thermoregulatory advantage to swimming and feeding in the markedly cooler deep waters, even if there was any reduced foraging success associated with the extreme depth. Noting that the Gulf Stream current speeds are reduced at depth, we used a detailed circulation model of the North Atlantic to examine the influence of the diving behaviour on the advection experienced by the sharks. However, there was no indication that the shark diving resulted in a significant modification of their net migratory pathway. The relative abundance of deep-diving sharks, swordfish, and sperm whales in the Gulf Stream and adjacent waters suggests that it may serve as a key winter feeding ground for large pelagic predators in the North Atlantic.

A new cystic fibrosis newborn screening algorithm: IRT/IRT1 upward arrow/DNA.

OBJECTIVE: To evaluate an immunoreactive trypsinogen (IRT) IRT/IRT1 upward arrow/DNA algorithm, aimed at improving sensitivity while decreasing cystic fibrosis (CF) carrier identification. STUDY DESIGN: New technologies allow the measurement of the second IRT level solely in infants with an elevated first IRT level. Specimens with an elevated second IRT level undergo mutation analysis. We tested the projected efficacy with retrospective data from Colorado. RESULTS: All known infants with CF would have been identified with our proposed IRT cutoff points, and 3 would have been missed with our mutation panel. Two of 3 missed cases would have been identified by using a failsafe method (IRT >99.9th percentile), yielding a sensitivity rate of 99.7% (95% CI, 98.4-99.9). Estimated reduction in carrier detection was 80% compared with IRT/DNA. CONCLUSION: IRT/IRT1 upward arrow/DNA appears to improve cystic fibrosis newborn screen sensitivity while decreasing carrier identification, providing an alternative to IRT/IRT in states that obtain 2 blood spots.

Biological information specialists for biological informatics.

Data management and integration are complicated and ongoing problems that will require commitment of resources and expertise from the various biological science communities. Primary components of successful cross-scale integration are smooth information management and migration from one context to another. We call for a broadening of the definition of bioinformatics and bioinformatics training to span biological disciplines and biological scales. Training programs are needed that educate a new kind of informatics professional, Biological Information Specialists, to work in collaboration with various discipline-specific research personnel. Biological Information Specialists are an extension of the informationist movement that began within library and information science (LIS) over 30 years ago as a professional position to fill a gap in clinical medicine. These professionals will help advance science by improving access to scientific information and by freeing scientists who are not interested in data management to concentrate on their science.

MultiSeq: unifying sequence and structure data for evolutionary analysis.

BACKGROUND: Since the publication of the first draft of the human genome in 2000, bioinformatic data have been accumulating at an overwhelming pace. Currently, more than 3 million sequences and 35 thousand structures of proteins and nucleic acids are available in public databases. Finding correlations in and between these data to answer critical research questions is extremely challenging. This problem needs to be approached from several directions: information science to organize and search the data; information visualization to assist in recognizing correlations; mathematics to formulate statistical inferences; and biology to analyze chemical and physical properties in terms of sequence and structure changes. RESULTS: Here we present MultiSeq, a unified bioinformatics analysis environment that allows one to organize, display, align and analyze both sequence and structure data for proteins and nucleic acids. While special emphasis is placed on analyzing the data within the framework of evolutionary biology, the environment is also flexible enough to accommodate other usage patterns. The evolutionary approach is supported by the use of predefined metadata, adherence to standard ontological mappings, and the ability for the user to adjust these classifications using an electronic notebook. MultiSeq contains a new algorithm to generate complete evolutionary profiles that represent the topology of the molecular phylogenetic tree of a homologous group of distantly related proteins. The method, based on the multidimensional QR factorization of multiple sequence and structure alignments, removes redundancy from the alignments and orders the protein sequences by increasing linear dependence, resulting in the identification of a minimal basis set of sequences that spans the evolutionary space of the homologous group of proteins. CONCLUSION: MultiSeq is a major extension of the Multiple Alignment tool that is provided as part of VMD, a structural visualization program for analyzing molecular dynamics simulations. Both are freely distributed by the NIH Resource for Macromolecular Modeling and Bioinformatics and MultiSeq is included with VMD starting with version 1.8.5. The MultiSeq website has details on how to download and use the software: http://www.scs.uiuc.edu/~schulten/multiseq/

Multiple Alignment of protein structures and sequences for VMD.

Multiple Alignment is a new interface for performing and analyzing multiple protein structure alignments. It enables viewing levels of sequence and structure similarity on the aligned structures and performing a variety of evolutionary and bioinformatic tasks, including the construction of structure-based phylogenetic trees and minimal basis sets of structures that best represent the topology of the phylogenetic tree. It is implemented as a plugin for VMD (Visual Molecular Dynamics), which is distributed by the NIH Resource for Macromolecular Modeling and Bioinformatics at the University of Illinois.