Large Medical Center Research Articles

Electronic health record implementation and healthcare workers\u2019 work characteristics and autonomous motivation\u2014a before-and-after study

BackgroundTechnological innovation in healthcare is often assumed to contribute to the quality of care. However, the question how technology implementation impacts healthcare workers has received little empirical attention. This study investigates the consequences of Electronic Health Record (EHR) implementation for healthcare workers’ autonomous work motivation. These effects are further hypothesized to be mediated by changes in perceived work characteristics (job autonomy and interdependence). Additionally, a moderating effect of profession on the relationship between EHR implementation and work characteristics is explored.MethodsA quantitative uncontrolled before-and-after study was performed among employees from a large university medical centre in the Netherlands. Data were analysed following the component approach for testing a first stage moderated mediation model, using Generalized Estimating Equations (GEE).ResultsA total of 456 healthcare workers (75 physicians, 154 nurses, 145 allied healthcare professionals, and 82 administrative workers) finished both the baseline and the follow-up survey. After EHR implementation, perceived job autonomy decreased, whereas interdependence increased. In line with our hypothesis, job autonomy was positively associated with autonomous motivation. In contrast to our expectations, interdependence also showed a positive association with autonomous motivation. Autonomous motivation was stable over the course of EHR implementation. This study did not provide support for a moderating effect of profession: no differences were observed between the various professions regarding the changes in their experienced job autonomy and interdependence after EHR implementation.ConclusionsOur study showed that healthcare professionals’ perceptions of their work characteristics, but not their autonomous motivation, were changed after EHR implementation, and that these experiences were relatively similar for physicians, nurses, and allied healthcare professionals. The stability of healthcare workers’ autonomous motivation may be explained by the opposite effects of decreased job autonomy and increased interdependence, and by the EHR being in line with healthcare workers’ values. The changes in job autonomy and interdependence may have consequences beyond motivation, for example by affecting clinical decision-making, proactive behaviour, and the quality of teamwork. These potential consequences of EHR implementation warrant further research.

Knowledge of women during the third trimester of pregnancy regarding pelvic floor disorders.

The objective was to examine knowledge regarding pelvic floor disorders (PFDs) among women during the third trimester of pregnancy. A cross-sectional study was conducted at a large teaching medical center in Israel between June and September 2020. Women in their third trimester (N = 649) were asked to complete the validated Hebrew and Arabic versions of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). The PIKQ instrument examines the knowledge of two major PFDs: urinary incontinence (UI) and pelvic organ prolapse (POP). The study population included women over 18years of age, in the third trimester, who speak and read Hebrew or Arabic fluently. Two separate scores were calculated, one for each section of the PIKQ. The association of questionnaire scores with the different independent variables was examined using Student's t test or one-way ANOVA. Correlations were examined using Pearson's or Spearman's correlation coefficient. The Hebrew version was filled out by 405 women, and 244 women completed the Arabic version. The average questionnaire scores were 7.65 ± 2.8 and 5.32 ± 2 for the UI and POP sections respectively. Significantly higher average scores in both the UI and the POP sections were noted among health care workers (UI: 10.19 ± 2.3 vs 7.34 ± 2.6, p < 0.001; POP: 8.27 ± 2.7 vs 4.97 ± 2.6, p < 0.001), women with higher education (p < 0.001 in both parts) and those with higher incomes (p < 0.001 for both parts). Knowledge of PFD among women in the third trimester of pregnancy in Israel was found to be low. Founding educational programs for targeted groups may improve both the knowledge of PFD and the quality of life for these women.

M105 The journey of the implementation of total laboratory automation – A large Indian medical centre in focus

M105 The journey of the implementation of total laboratory automation – A large Indian medical centre in focus

Sleep Difficulties Among COVID-19 Frontline Healthcare Workers

ObjectiveTo identify COVID-19 work-related stressors and experiences associated with sleep difficulties in HCW, and to assess the role of depression and traumatic stress in this association.MethodsA cross-sectional study of HCW using self-report questionnaires, during the first peak of the pandemic in Israel (April 2020), conducted in a large tertiary medical center in Israel. Study population included 189 physicians and nurses working in designated COVID-19 wards and a comparison group of 643 HCW. Mean age of the total sample was 41.7 ± 11.1, 67% were female, 42.1% physicians, with overall mean number of years of professional experience 14.2 ± 20. The exposure was working in COVID-19 wards and related specific stressors and negative experiences. Primary outcome measurement was the Insomnia Severity Index (ISI). Secondary outcomes included the Primary Care-Post Traumatic Stress Disorder Screen (PC-PTSD-5); the Patient Health Questionnaire-9 (PHQ-9) for depression; the anxiety module of the Patient-Reported Outcomes Measurement Information System (PROMIS); Pandemic-Related Stress Factors (PRSF) and witnessing patient suffering and death.ResultsCompared with non-COVID-19 HCW, COVID-19 HCW were more likely to be male (41.3% vs. 30.7%) and younger (36.91 ± 8.81 vs. 43.14 ± 11.35 years). COVID-19 HCW reported higher prevalence of sleep difficulties: 63% vs. 50.7% in the non-COVID group (OR 1.62, 95% CI 1.15–2.29, p = 0.006), mostly difficulty maintaining sleep: 26.5% vs. 18.5% (OR 1.65, 95% CI 1.11–2.44, p = 0.012). Negative COVID-19 work-related experiences, specifically witnessing patient physical suffering and death, partially explained the association. Although past psychological problems and current depression and PTSD were associated with difficulty maintaining sleep, the main association remained robust also after controlling for those conditions in the full model.Conclusion and RelevanceCOVID-19 frontline HCW were more likely to report sleep difficulties, mainly difficulty maintaining sleep, as compared with non-COVID-19 HCW working at the same hospital. Negative patient-care related experiences likely mediated the increased probability for those difficulties. Future research is needed to elucidate the long-term trajectories of sleep difficulties among HCW during large scale outbreaks, and to identify risk factors for their persistence.

The Added Value of Patch Testing Beyond the Baseline Tray.

The patch test is the standard for diagnosing allergic contact dermatitis. Standardized trays allow the examination of the most prevalent allergens, whereas customized trays are more appropriate for addressing specific allergens and require expertise. They are therefore usually performed in specialized clinics. We assessed the results of 4355 patch tests performed between 2012 and 2020 in a contact dermatitis clinic located in a large tertiary medical center. All patients were tested using the European baseline series and additional trays as clinically indicated. We assessed the frequency of relevant positive reactions outside the European baseline series. We then examined the added value and number of tests (NNTs) that need to be performed to elicit one relevant positive reaction per tray and common allergens. Nine hundred fifty-four patients (21.9%) had 1 or more positive relevant reactions; 43.3% tested positive for an allergen outside the European baseline series (OEBS). The acrylate and fragrance trays were highly represented among the positive and relevant reactions OEBS with NNTs of 4.4 and 6.8, respectively. 2-Hydroxyethyl methacrylate is the most prevalent allergen OEBS and is considered a marker for acrylate sensitivity with a high rate of cross-reactions and concordance rate of 85%, justifying its addition to the EBS in 2018. Other highly represented allergens include chloramphenicol, 2-hydroxyethyl acrylate, and Amerchol L-101, a lanolin derivative. The cosmetics and textile trays, although often tested, have relatively low added values of 3.7% and 2.3%, respectively. Surprisingly, the cutaneous adverse drug reaction series tray (CAD-1000) yielded no positive reactions, whereas testing the patients' medication yielded positive results in 10.9% of the cases. Expanded patch testing is crucial to accurately diagnose allergic contact dermatitis and almost doubles the number of patients with relevant positive reactions. Acrylate sensitivity is an emerging epidemic with a high positive reaction rate and low NNT, as is sensitivity to the allergens in the fragrance tray. 2-Hydroxyethyl methacrylate is a reliable marker for acrylate sensitivity with a concordance rate of 85%. Chloramphenicol is a common culprit and should be added to the standard tray in countries with a high usage rate. A low NNT was also observed when testing the patients' own cosmetics and medications; this should, therefore, be encouraged. The textile tray yielded a relatively high NNT; however, it should be performed when clinically indicated in the absence of a reliable marker in the EBS.

Beyond illness perception: the effects of psychological flexibility when coping with a chronic medical condition

ABSTRACT Several factors have been suggested to affect well-being among patients with a Chronic Medical Condition (CMC). Using self-report questionnaires, the effects of Illness Cognitions (IC) and Psychological Flexibility (PF) on well-being (Subjective Happiness) was explored in two groups of patients at a large medical center in Tel Aviv, Israel. This included 79 patients with psoriasis and 71 patients with End-Stage Renal Disease (ESRD), the former representing moderate, and the latter severe, chronic medical conditions. Significant correlations between IC and PF, and well-being, were observed. In regression analyses, helplessness (an IC factor) and perceiving oneself as flexible (a PF factor) significantly contributed to well-being. Perceiving oneself as open and innovative (another PF factor) was associated with higher levels of well-being only among those with ESRD. This suggests that well-being is associated with both a specific cognitive inference regarding one’s medical condition (IC) and a general attitude about change (PF). Additionally, it appears that the association between PF and well-being changes across different CMCs, possibly depending on the CMC severity. Theoretical and clinical implications are discussed.

COVID-19 severity from Omicron and Delta SARS-CoV-2 variants.

The Omicron variant of SARS‐CoV‐2 achieved worldwide dominance in late 2021. Early work suggests that infections caused by the Omicron variant may be less severe than those caused by the Delta variant. We sought to compare clinical outcomes of infections caused by these two strains, confirmed by whole genome sequencing, over a short period of time, from respiratory samples collected from SARS‐CoV‐2 positive patients at a large medical center. We found that infections caused by the Omicron variant caused significantly less morbidity, including admission to the hospital and requirement for oxygen supplementation, and significantly less mortality than those caused by the Delta variant.

Safety of third SARS-CoV-2 vaccine (booster dose) during pregnancy

BACKGROUNDCOVID-19 during pregnancy is associated with adverse outcomes for both the mother and fetus. SARS-CoV-2 vaccination has significantly reduced the risk for symptomatic disease. Several studies have reported on the safety of SARS-CoV-2 vaccination during pregnancy, with no adverse effects on the obstetrical outcomes. However, data regarding the obstetrical outcomes following a booster dose of the SARS CoV-2 vaccination during pregnancy have not yet to be published.OBJECTIVEThis study aimed to examine the association between the booster dose of the SARS CoV-2 vaccination during pregnancy and obstetrical outcomes.STUDY DESIGNThis was a retrospective cohort study of women who delivered between July and October 2021 at a large tertiary medical center. We compared women who received the booster vaccination dose during pregnancy with women who were not vaccinated and with those who only received 2 vaccination doses. Primary outcomes were the incidence of preterm labor and of small for gestational age neonates. Secondary outcomes were other maternal and neonatal complications. A secondary analysis investigating the association between the time from vaccination to delivery and the outcomes was also performed. Multivariable logistic regression models were used to adjust for potential confounders.RESULTSThere were 6507 women who met the inclusion criteria: 294 women received 3 doses of the vaccination, 2845 women received only 2 doses, and 3368 were unvaccinated. Patients receiving 3 doses of the vaccine were older and more likely to smoke than unvaccinated patients. No differences were noted among the triple-vaccinated, twice-vaccinated, and unvaccinated groups with regards to preterm birth and the incidence of small for gestational age neonates. Regarding the secondary outcomes, women in the triple-vaccinated group had higher rates of postpartum hemorrhage (9.5% vs 3.21%; P<.001) and gestational diabetes mellitus (12.2% vs 8.3%; P=.02) and were less likely to have hypertensive disorders of pregnancy (0% vs 1.4%; P=.041) than the unvaccinated group. Compared with the twice-vaccinated patients, patients with 3 doses of the vaccine were more likely to experience postpartum hemorrhage (9.5% vs 3.5%; P<.001) and were less likely to have a low umbilical artery pH (0.7% vs 6.1%; P<.001). In the sensitivity analysis comparing patients who delivered within 2 weeks of the third vaccination dose (n=53) with those who delivered at least 6 weeks after vaccination (n=96), there were no differences in the rates of small for gestational age neonates, preterm birth, postpartum hemorrhage, or cesarean delivery.CONCLUSIONReceiving the booster dose of the SARS-CoV-2 vaccination during pregnancy was not associated with adverse obstetrical outcomes when compared with unvaccinated or twice-vaccinated women. However, higher rates of postpartum hemorrhage were observed. Further studies on a larger scale are needed to confirm these findings.

Tachycardia is associated with mortality and functional outcome after thrombectomy for acute ischemic stroke

BackgroundThe relationship between cardiac function and mortality after thrombectomy for acute ischemic stroke is not well elucidated. MethodsWe analyzed the relationship between cardiac function and mortality prior to discharge in a cohort of patients who underwent thrombectomy for acute ischemic stroke at two large medical centers in New York City between December 2018 and November 2020. All analyses were performed using Welch's two sample t-test and logistic regression accounting for age, initial NIHSS and post-procedure ASPECTS score, where OR is for each unit increase in the respective variables. ResultsOf 248 patients, 41 (16.5%) died prior to discharge. Mortality was significantly associated with higher initial heart rate (HR; 89 ± 19 bpm vs 80 ± 18 bpm, p = 0.004) and higher maximum HR over entire admission (137 ± 26 bpm vs 114 ± 25 bpm, p < 0.001). Mortality was also associated with presence of NSTEMI/STEMI (63% vs 29%, p < 0.001). When age, initial NIHSS score, and post-procedure ASPECTS score were included in multivariate analysis, there was still a significant relationship between mortality and initial HR (OR 1.03, 95% CI 1.01- 1.05, p = 0.02), highest HR over the entire admission (OR 1.03, 95% CI 1.02-1.05, p < 0.001), and presence of NSTEMI/STEMI (OR 3.76, 95% CI 1.66-8.87, p = 0.002). ConclusionsTachycardia is associated with mortality in patients who undergo thrombectomy. Further investigation is needed to determine whether this risk is modifiable.

Patient- and provider-level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis.

Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration. Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1-year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ-2) from the electronic health record. The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n=162), hepatology (n=45), or both (n=41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co-occurring bipolar disorder (OR 2.94, p=0.03) or depression (1.50, p=0.05) or who were younger (0.97, p=0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p=0.05), prior AUD treatment (9.92, p<0.0001), and a higher PHQ-2 depression score (2.85, p=0.004). We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

Lower socioeconomic status worsens outcome of patients with systemic lupus erythematosus independently of access to healthcare.

Socioeconomic status (SES) has been found to be associated with worse outcomes of systemic lupus erythematosus (SLE). The impact of national health insurance on SLE outcomes has not been explored. A retrospective inception cohort of patients older than 18years with SLE diagnosed and followed in lupus clinics of two large tertiary medical centers were included. Patients were stratified into three groups by SES: lower 25th quantile, middle 25th-75th quantile, and upper 75th quantile. Primary outcomes were all-cause mortality, development of end-stage kidney disease (ESKD), and score ≤ 4 on the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI 2K) at the last visit. We identified 617 patients (548 females, 88.8%) with a median follow-up of 15 years (range, 8.0-23.0). Compared to the middle and upper SES groups, the lower SES group was characterized by younger age at disease onset (31.5years vs. 34.3 and 37.4years, respectively, p = 0.011) and higher rate of lupus nephritis (42.7% vs. 35.7% and 23.8%, respectively, p = 0.002). In multivariate models, patients in the middle and upper SES groups had a significantly lower risk of mortality (HR = 0.45; 95% CI, 0.24-0.82, p = 0.010) and ESKD (HR = 0.24; 95% CI, 0.08-0.73, p = 0.012), with no effect on the rate of SLEDAI 2K ≤ 4 (OR = 1.49; 95% CI, 0.92-2.40, p = 0.09). Even within a health system that provides high and equal accessibility to medical care, low SES is associated with worse outcomes of SLE. Policymakers should focus on managing possible barriers that prevent patients of lower SES from obtaining optimal care.

Minimizing MRONJ after Tooth Extraction in Cancer Patients Receiving Bone-Modifying Agents.

Background: Medication-related osteonecrosis of the jaws (MRONJ) is a mucosal lesion of the maxillofacial region with necrotic bone exposure. MRONJ is believed to be multifactorial. Tooth extraction is debatably a risk factor for MRONJ. The targets of the present study were to examine MRONJ occurrence in patients using bone modifying agents (BMAs) for oncology indications and undergoing a dental extraction, and to assess whether suspected predisposing factors can predict MRONJ. Materials and Methods: This retrospective, cohort study included all patients fitting the inclusion criteria and a large tertiary medical center. Data were obtained from the hospital’s medical records using a structured questionnaire. Results: We performed 103 extractions on 93 patients. Local inflammation/infection of the extraction site was most associated with a complication (p = 0.001) OR = 13.46, 95% CI = (1.71, 105.41), OR = 13.5. When the indication for extraction was periodontal disease, vertical root fracture, or periapical pathosis, the odds of developing MRONJ were 4.29 times higher than for all other indications (p = 0.1), OR = 4.29, 95% CI = (1.16, 15.85). A significant association was found between the time of onset of BMA treatment and time of extraction and the development of MRONJ, OR = 3.34, 95% CI = (1.01, 10.18). Other variables did not correlate with the development of MRONJ. Conclusion: Local inflammation/infection and onset of BMA treatment prior to extraction yield a 10.23 times higher chance of developing MRONJ following tooth extraction. Future protocols should use this information to minimize MRONJ incidence.

Vaginal tumours in childhood: a descriptive analysis from a large paediatric medical centre.

Malignant tumours of the vagina are very rare in children. The purpose of this study was to retrospectively analyse the clinical presentation, treatment, and outcome of vaginal tumours in children treated in a single institution. This study retrospectively analysed the clinical data of children diagnosed with vaginal malignant tumours who were admitted to the Beijing Children's Hospital of Capital Medical University from January 2007 to December 2020 and followed these patients to observe their prognoses and outcomes. During 13years, a total of 33 children were included in this study, including 13 children with rhabdomyosarcoma and 20 children with endodermal sinus tumours. The average age at diagnosis was 20.4months. The main clinical manifestations were vaginal bleeding and protruding masses. Of the 13 children with vaginal rhabdomyosarcoma, 12 were treated with multidrug chemotherapy combined with conservative tumour resection, and their tumours completely resolved; only one child underwent vaginectomy and hysterectomy. Twenty children with vaginal endodermal sinus received PEB chemotherapy. Among these patients, the tumour disappeared after chemotherapy in 12 children, and the remaining nodular tumour foci in 8 children were confirmed to be necrotic tissue by pathology. Our research confirms that chemotherapy combined with conservative surgical treatment is effective for treating children with vaginal malignancies.

Yips: An Investigation of Causes and Treatments in the Context of Golf

<h3>Introduction</h3> Yips are a physical phenomenon, like dystonia, that have plagued athletes and ended careers. They can be difficult to describe specifically given their variable manifestations. They tend to come on suddenly, with no forewarning signs. Mostly recognized in the games of seasoned athletes, Yips are often difficult to visualize by the inexperienced eye. An afflicted professional athlete must fix the problem or abandon their career, thus resulting in significant psychological and neurological distress. While symptoms are well-documented; causes and treatments are not. Taking a break may improve symptoms. In golf, instructors typically suggest developing new muscle memory using a different technique. Overall, golfers do many things to get around Yips, but not much to cure them. The psychological impact of losing a superior skill can be quite disabling. Hence, preventing, treating, and curing Yips is important. The objective of this pilot research was to gather data on Yips for the purpose of guiding future research on causes and treatments. Some research suggests Yips have similarities to focal dystonias which afflict older adults as well. There are concerns regarding association of Yips with age-related changes, and limited findings or treatments for this particular condition highlight the disparity in the elderly community. <h3>Methods</h3> Golf was the chosen platform to study Yips as they are most common in golfers and golfing at higher levels would have a more extensive variety of solutions to investigate. Study participants were recruited for an initial phone screening appointment, and potentially an in-person survey with stroke demonstrations. Analyses of participant survey responses were conducted using Chi-Squared Corrected Yate's Test and Fisher's Exact Test statistical methods. Participants were divided into two groups: Yips and no Yips (controls). Data was collected at a large multi-specialty medical center in New York. <h3>Results</h3> Study had difficulties finding participants. As a result, statistical analyses were hindered. There were some associations calculated between Yips and the categories Infection/Illness and Trauma as depicted in Table 1. Beyond the statistics, important information was documented on treatments used by those with Yips and their outcomes. It was found that "treatments" were more about finding a way to get around a Yip as opposed curing it. Additionally, it was learned that the term Yip is sometimes incorrectly used to describe a bad swing. There was a remarkable observation as to similarities between Yips and Post-Traumatic Stress Disorder symptoms. <h3>Conclusions</h3> A significant outcome of this study was building an initial prototype for continued research and focus on this important subject. Significant associations between Yips and Fever, Yips and Sore Throat and Yips and Trauma were determined, all of which indicated a negative relationship. Additionally, a table was assembled containing methods used by study participants to treat their own Yips along with their outcomes. From observations of participants answering the survey in person, it was noted that the onset of Yips was a stressful event. Despite never being diagnosed with Post-Traumatic Stress Disorder, a Yip has similarities to symptoms of a panic attack. From this observation, a recently published Propranolol study came to mind where emotions involved with a specific trauma were lessened via a therapy/Propranolol protocol. This may prove helpful for treating/curing Yips. Two participant surgeries post Yip onset dealt with overuse. One was a Carpel Tunnel Syndrome procedure and the other was to fix "Trigger Fingers". This finding supports overuse as one suspected etiology of Yips. It was found that participants did attempt using alcohol to improve their games and Yips. No one reported that alcohol helped with Yips. Finally, a concern arose from this study upon realizing that Yips come on unexpectedly, and possibly players need to be more aware and/or educated on what to look for to create prevention strategies. Even in the overuse scenario, no one complained of overuse symptoms occurring before their Yip. Without anything to look for, causes become more difficult to discern and this may be the main reason why causes and treatments of Yips remain so perplexing. <h3>This research was funded by</h3> In addition to the cost of the research program provided by Orange Regional Medical Center/Garnet Health Medical Center, a small amount of funding was provided by Kian-Taj C. Afrassiabian, DO. Chart: https://apps.aagponline.org/abstracts/uploads/2022/59kxam63rrp7c5u.pdf

Who Let All These People In?

Children’s hospitals are wonderful places full of dedicated pediatricians, nurses, respiratory therapists, pharmacists, paramedics, and others focused on optimizing the outcomes for pediatric patients. Over the years, more “free-standing” children’s hospitals have been built that are isolated from adult medicine counterparts to support the specialized staff and programs required for cutting edge clinical care while providing a developmentally appropriate environment for children and families at their most vulnerable time.1 Free-standing children’s hospitals are designed to take care of kids, from the emergency department, to radiology, to the wards, outpatient clinics, and ICUs. The staff are trained experts in caring for kids enabling them to excel at their mission while also creating a unique vulnerability, which includes dealing with the occasional medical emergency of all the adult pediatric providers, support staff, and a majority of the parents, grandparents, and other family members who visit children’s hospitals. The dedicated, highly-trained code response team is usually the one called because of the Emergency Medical Treatment and Labor Act in the United States.2 The response necessary for adult emergencies will be very different than that necessary for a typical hospitalized child, in which thoughts of “could this be a STEMI?” or “what is their Cincinnati Stroke score?” are exceedingly rare.3In this month’s issue, Hoffman et al4 also rightly identify that beyond being a hospital, most children’s hospitals are actually large medical centers with a far larger outpatient population than inpatient. The authors note that their highly qualified emergency response team for managing acutely deteriorating hospitalized children is frequently called on to manage both outpatient children and visiting adults, neither of which match the typical population for which the team was likely designed. Simply calling 9-1-1 is not a good option, partly because of the aforementioned Emergency Medical Treatment and Labor Act rules, but also because many municipalities struggle to fully staff their emergency medical services, and pulling a response to the hospital may delay responses to locations that do not have trained medical personnel handily available (personal communication, local emergency medical services director). Fortunately, actual need for a full resuscitative effort including chest compressions and defibrillation for these nonhospitalized individuals is rare. The authors report only a single event requiring defibrillation; importantly, the shock was delivered before arrival of the code team thanks to the availability of a public access automated external defibrillator.There are two big take home points from this article: first is that there are more nonhospitalized individuals than patients in a children’s hospital; therefore, planning for adult and outpatient responses are important. The second is that because the events are both common and rarely severe, a different level of response may be optimal to decrease the drain on resources in the intensive care units or within the emergency departments. As always, the responding team should be prepared and comfortable with all potential emergencies, including adult emergencies. More notably, the most significant adult event described in the paper was managed by bystanders by using a public access automated external defibrillator before the team’s arrival. No matter the emergency response chosen by a children’s hospital, encouraging all employees to learn basic life support, including cardiopulmonary resuscitation and automated external defibrillator use, can be lifesaving. As we build more free-standing children’s hospital to continue to support pediatric patients and their families, we must continue to care for not just the hospitalized children but also the outpatients and the families and staff that exist within this environment. Hoffman et al4 help us to understand the type of team we might need and the best way to help others.

Measured Corneal Astigmatism Versus Pseudophakic Predicted Refractive Astigmatism in Cataract Surgery Candidates

To compare standard and total corneal astigmatism measurements to the predicted pseudophakic (nontoric) refractive astigmatism in candidates for cataract surgery. A retrospective, cross-sectional study. A single-center analysis of consecutive eyes measured with a swept-source optical coherence tomography biometer at a large tertiary medical center between February 2018 and June 2020. Corneal astigmatism was calculated based on standard keratometry astigmatism (KA), total corneal astigmatism (TCA), and predicted refractive astigmatism (PRA) for a monofocal nontoric intraocular lens (IOL) implantation calculated by the Barrett toric calculator using the predicted posterior corneal astigmatism (PRA(Predicted-PCA)) and the measured posterior corneal astigmatism (PRA(Measured-PCA)) options. Separate analyses were performed for each eye. Ophthalmology Department, Shaare Zedek Medical Center, Jerusalem, Israel. In total, 8152 eyes of 5320 patients (4221 right eyes [OD] and 3931 left eyes [OS], mean age 70.6±12.2 years, 54.2% females) were included in the study. The mean vector values (centroid) for KA, TCA, PRA(Predicted-PCA), and PRA(Measured-PCA) were 0.07 diopters [D] at 19.5°, 0.27 D at 7.5°, 0.44 D at 2.9°, and 0.43 D at 179.3°, respectively (P < .01), for OD and 0.02 D at 150.3°, 0.23 D at 169.7°, 0.40 D at 179.4°, and 0.42 D at 169.5°, respectively (P < .01), for OS. More than 73% of eyes had a PRA >0.5 D. Standard and total corneal astigmatism measurements differ significantly from the PRA by the Barrett toric calculator. The PRA, rather than the KA or TCA, should be used as the reference guide for astigmatism correction with toric IOL implantation.

Clinical and Microbiological Effects of an Antimicrobial Stewardship Program in Urology-A Single Center Before-After Study.

Antimicrobial resistance is a major public health issue caused by antibiotic overuse and misuse. Antimicrobial stewardship (AMS) has been increasingly endorsed worldwide, but its effect has been studied scarcely in urologic settings. A before-after study was performed from 2018 through 2020 to evaluate changes in antimicrobial prescription, resistance rates and clinical safety upon implementation of an AMS audit and feedback program in the Urology Department of a large German academic medical center. The primary endpoints were safety clinical outcomes: the rate of infection-related readmissions and of infectious complications after transrectal prostate biopsies. Resistance rates and antimicrobial consumption rates were the secondary endpoints. The AMS team reviewed 196 cases (12% of all admitted in the department). The overall antibiotic use dropped by 18.7%. Quinolone prescriptions sank by 78.8% (p = 0.02) and 69.8% (p > 0.05) for ciprofloxacin and levofloxacin, respectively. The resistance rate of E. coli isolates declined against ceftriaxone (−9%), ceftazidime (−12%) and quinolones (−25%) in the AMS period. No significant increase in infection-related readmissions or infectious complications after prostate biopsies was observed (p = 0.42). Due to the potential to reduce antibiotic use and resistance rates with no surge of infection-related complications, AMS programs should be widely implemented in urologic departments.

Association between self-management behaviour and quality of life in people with heart failure: a retrospective study

BackgroundThe purpose of this study was to investigate the variables that significantly associated with the quality of life in people with heart failure, and particularly, to identify the association between self-management behaviour and the quality of life.MethodsThis retrospective study used data from heart failure outpatient clinics at two large tertiary medical centres in Seoul and Suwon, South Korea. We enrolled 119 participants who completed echocardiography and stress tests and responded to questionnaires on self-management behaviour and quality of life. We collected more data on sociodemographic and clinical characteristics and anthropometric and serum blood test results through electronic medical record review. We analysed data using multiple linear regression and the classification and regression tree (CART) method to explore the associated factors with the quality of life in participants with heart failure.ResultsParticipants’ mean age was 74.61 years, and women represented 52.1% of the sample. It showed that cardiac systolic function (β = 0.26, p = .013) and self-management behaviour (β = 0.20, p = .048) were two major associated factors with the quality of life in participants with heart failure in the multiple linear regression analysis. Also, cardiac systolic function and self-management behaviour were shown to be the primary determinants for the quality of life in those with heart failure in the CART analysis. Therefore, self-management behaviour of the participants with heart failure was a significant modifiable factor that can improve their quality of life.ConclusionsHealthcare providers should be aware of the importance of self-management in people with heart failure and help promote their quality of life by enhancing their self-management behaviour as own efforts to properly maintain and monitor the health status and prevent further worsening of heart failure.

Feasibility of internet-delivered cognitive-behavior therapy for obsessive-compulsive disorder in youth with autism spectrum disorder: A clinical benchmark study

Obsessive-compulsive disorder (OCD) is a treatable condition that often requires specialist care, particularly when comorbid with autism spectrum disorder (ASD). However, specialist clinics are few and typically located in large medical centers. To increase availability of evidence-based treatment for OCD in individuals with ASD, we adapted an internet-delivered cognitive behavior therapy (ICBT) protocol to suit the needs of these individuals and conducted a feasibility study (N = 22). The primary outcome was the clinician-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), administered at pre- and post-treatment as well as 3 months after treatment. ICBT was deemed acceptable and was associated with clinically significant improvements in CY-BOCS scores, corresponding to a large within-group effect size (Cohen's d = 1.33). Similarly, significant improvements were observed in most of the secondary parent- and self-rated measures. Approximately 60% of the participants were classed as treatment responders and 50% were in remission from their OCD at the 3-month follow-up. To provide a meaningful benchmark, we also analyzed data from a specialist clinic that regularly treats individuals with comorbid OCD and ASD (N = 52). These analyses indicated that specialized in-person CBT produced significantly larger effects (d = 2.69) while being markedly more resource demanding, compared to ICBT. To conclude, ICBT can be successfully adapted to treat OCD in youth with ASD and may be a viable alternative for those who do not have direct access to highly specialized treatment. Further improvements of the treatment protocol based on participant and therapist feedback are warranted, as is a formal test of its efficacy and cost-effectiveness in a randomized controlled trial.

Congenital cholesteatoma: Clinical features and surgical outcomes

ObjectivesA typical presentation of congenital cholesteatoma (CC) is asymmetric conductive hearing loss (CHL). As CHL is usually associated with middle ear effusion, diagnosis of CC is frequently delayed. This study aimed to describe the clinical characteristics, treatment and outcomes of children with CC. MethodsThe medical files of children diagnosed with CC at a large tertiary pediatric medical center during 2000–2019 were reviewed. The primary outcome measures were: presenting symptoms, surgical findings, stage of disease, recurrence rate and hearing outcome. Imaging findings and the size of mastoid air cells were assessed in CT scans. ResultsThirty-nine children were diagnosed with CC. The presenting symptom was unilateral CHL in 85%, with an average speech reception threshold of 41.5 ± 13.7 dB in the affected ear. The mean time from first symptoms to diagnosis was 1.3 years. The surgical approach was exploratory tympanotomy in 25% and canal wall up mastoidectomy in 69%. Seventy percent of the children presented with Potsic stage III-IV. The mean postoperative speech reception threshold was 26.4 ± 12.2 dB (P = 0.002). Recurrence of cholesteatoma occurred in 38% of the patients, mostly in stage III-IV. Mastoid air cell size was significantly smaller on the affected than the unaffected side. ConclusionsIn children with persistent unilateral or asymmetric conductive hearing loss, CC should be suspected. Late diagnosis of CC is associated with a high recurrence rate. This highlights the need to promote awareness to the disease among primary physicians in the community health care system.