Patient Guardians Research Articles

Improving Understanding of Screening Questions for Social Risk and Social Need Among Emergency Department Patients.

IntroductionWith recent healthcare policy changes, including the creation of accountable care organizations, screening for social risks such as food and housing insecurity has become increasingly common in the healthcare system. However, the wide variety of different tools used for screening makes it challenging to compare across systems. In addition, the majority of tools used to measure social risks have only been tested in primary care settings and may not be optimal for emergency department (ED) use. Therefore, the goal of this study was to create a brief social screening tool for use in EDs.MethodsWe developed an initial tool using publicly available questions corresponding to the five core categories of the Centers for Medicare & Medicaid Services’ Accountable Health Communities Screening Tool. Iterative cycles of cognitive interviews with purposively sampled participants were performed using a hybrid model of think-aloud and verbal probing to understand/experience answering questions and potential comprehension challenges. After thematic saturation was reached in one cycle, the tool was changed per participant input; cycles were completed until thematic saturation was reached overall.ResultsA total of 16 participants (six patient guardians and 10 patients) completed cognitive interviews throughout three cycles. Participant feedback included suggestions for further clarification and simplification of survey questions for improved comprehension. The survey was thus reduced and simplified from 16 questions concerning five domains to 10 questions concerning four domains.ConclusionWe used an iterative cognitive interviewing process to develop a social screening tool for use in EDs. This process demonstrates the importance of patient input to refine questionnaires, and provides a brief screening tool for ED use.

Incidence of Down's Syndrome by Maternal Age of Asian Population

Objectives: To study the incidence of Down's syndrome by maternal age of the Asian population. Setting and Design: Data on prenatal serum screening between 2008-2017 was obtained from the Maternal and Child Hospital of Hubei Province. Cases were classified into three groups: ≤26-year-old, 27-33-year-old, and ≥34-year-old. The prevalence of Down's Syndrome was calculated for each age and age bracket separately, and the difference between different groups was analyzed with the chi-square test. Results: The incidence of Down’s syndrome in maternal age of ≤26-year-old, 27-33-year-old, and ≥34-year-old was 0.67 ‰, 0.29 ‰, and 2.07 ‰, respectively. There were significant differences among different age groups (χ 2 = 79.748, P < 0.05). Conclusion: In the population investigated, the incidence of Down’s syndrome in maternal age over 34 is much higher than that of the 27-33-year-old group, while younger women aged under 26 are also subject to a higher risk. Funding Statement: This work was supported by Hubei Provincial Health and Family Planning Scientific Research Project [Grant # WJ2018H0137]. Declaration of Interests: The authors have no conflicts of interest relevant to this article. Ethics Approval Statement: The research was approved by the Ethics Committee of Maternal and Child Health Hospital of Hubei Province. All patient guardians gave informed consent to the study.

Beware the Alar Base Optical Illusion in Assessment of Unilateral Cleft Lip Nasal Deformity

Sir: Dr. Mulliken has once again illustrated his vast experience and expertise in a simple yet elegant study.1 Incorrectly diagnosing a lateralized cleft alar base position can lead to medial repositioning during secondary revision, thereby worsening an existing deformity. The study by Mulliken et al. demonstrates how commonly the mistake is made and provides a simple maneuver to avoid this pitfall. The article will no doubt have an important impact on cleft care. What we find interesting is the etiology of the “optical illusion.” While aberrations of form may prompt innate human perceptions that result in an “illusion,” it is also possible that bias from surgical dogma may be at play. Our literature commonly attributes the unilateral cleft lip nasal deformity to lateral displacement of the cleft alar base and considers medial repositioning as a key component of reconstruction.2–4 As such, the medical professionals who served as raters in this study may have attributed less favorable form to “undercorrection” of the cleft alar base, resulting in more frequent ratings that the alar base was too wide. We have recently analyzed three-dimensional images of infants with unrepaired cleft lip and found that, if a vertical midway through the intercanthal line is used as reference, the medial-lateral position of the cleft alar base is normal relative to control (infants without cleft) and the cleft alar base is much closer to midline than the noncleft alar base (Fig. 1).5 After repair, medial movement of the noncleft alar base and anterior movement of the cleft alar base produced nasal base positions that matched those of normal controls. Given those findings, the current dogma is wrong: the unilateral cleft lip nasal deformity does not occur because of lateral displacement of the cleft alar base. Rather, it is the columella and noncleft alar base that are displaced laterally. Therefore, the cleft alar base should not be moved medially, otherwise the distance from alare to midline would be too narrow and the underlying etiology of the nasal tip derangement would remain (Fig. 2).Fig. 1.: Current dogma dictates that the cleft alar base is laterally displaced and needs to move medial to correct the unilateral cleft lip nasal deformity. If focused on the lower nose, the collapse and resulting deformity of the cleft alar dome captures our attention, leading us to perceive that the cleft side is displaced laterally, relative to the rest of the more normal-appearing nose. Based on three-dimensional image analysis and photographs that use medial canthi to define the facial midline, it is actually the noncleft alar base and columella that are displaced laterally. The cleft alar base is retropositioned but similar in medial-lateral position relative to that of control subjects without clefts. In order to improve symmetry, the noncleft alar base needs to move medial, the columella needs to be centralized, and the cleft alar base needs to move anteriorly.Fig. 2.: The uncorrected or inadequately corrected nasal base becomes apparent when using the full face as reference. The noncleft alar base is lateral, the columella is off midline, and cleft alar base is posterior (and not lateral). While the distance from the cleft alare to subnasale (al-sn) may be wider than the noncleft side, the distance from cleft alar base to midline is less than that on the noncleft side. Medial repositioning of the cleft alar base should be avoided, as it would make the deformity worse.It would be interesting to see if the results of Mulliken et al.’s study would be reproduced with raters who are naive to existing surgical dogma. Repetition of the study utilizing a layperson rating group or crowdsourced rating system could be utilized to this end. If the same outcome is not reproduced, the phenomenon that the authors describe may be more of a bias from erroneous surgical dogma rather than a true optical illusion (i.e., an innate misperception influenced by visual cues). Regardless of optical illusion or bias, accurate assessment of alar base position is critical. The maneuver that Dr. Mulliken’s group describes and objective analysis of three-dimensional stereophotogrammetry are valuable in avoiding a cleft alar base that is too medial. Once an alar base has been placed too medially, it is very difficult to reverse. “The eye sees what the mind knows,” and by uncovering our misperceptions, we may improve the care that we provide. PATIENT CONSENT Parents or guardians provided written consent for use of the patient’s image. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding support was received for this work. Chad A. Purnell, M.D.Russell E. Ettinger, M.D.Raymond W. Tse, M.D.Division of Craniofacial and Plastic SurgerySeattle Children’s HospitalDivision of Plastic SurgeryUniversity of WashingtonSeattle, Wash.

Improving the Pediatric Hospital Experience Using Telepresence Robotics

Background In a hospital setting, pediatric patients miss out on routine stress coping mechanisms, such as normative play, socialization, and exploration. Previous work has established that a lack of healthy coping mechanisms negatively impacts the psychosocial development and well-being of hospitalized children. To help alleviate the stress of hospitalization, we created a novel, normative play robotics program that utilizes telepresence technology to give children live, virtual tours of museums and cultural attractions. Objective The objective was to 1) demonstrate feasibility, and 2) assess quality and impact on mood of telepresence tours as a new normative play intervention. Methods A prospective, cross-sectional study was conducted on inpatients at the Johns Hopkins Children's Center and the University of Maryland Children's Hospital from the ages of 3 to 19. Subjects were selected through convenience sampling by Child Life Specialists. The intervention consisted of a 30-minute session in which a volunteer: 1) remotely connected a laptop in the hospital room to a telepresence robot at the Maryland Science Center or the National Aquarium; 2) introduced the child to their venue tour guide and taught the child how to drive the robot, and 3) facilitated a tour in conjunction with the venue tour guide on site with the robot. Feasibility was assessed by the rate of completed tours. Quality of the experience and mood were evaluated with surveys answered with a 5 or 7-point Likert scale. Surveys were administered in 2 phases: phase 1 evaluated quality of the experience after the tour, and phase 2 included the phase 1 survey plus mood assessment before and after the tour. The two-tailed Wilcoxon signed-rank test was used to determine statistical significance in difference in mood before and after the tour. Verbal consent was obtained from patient guardians and assent was obtained from the patient. Results 77 tours were conducted with pediatric inpatients, and no tours were terminated due to technical difficulty. Out of 77 children, 68 completed surveys. In phase 1 (n=40) participants’ average age was 7.8 years. On average, patients rated their overall experience a 4.8/5, ease of driving 4.1/5, ease of communicating with other guests at the venues a 4.3/5, and their tour guides a 4.7/5. In phase 2 (n=37), average age was 10.1 years. Children’s self-reported mood improved from pre-visit (3.7/5) to post visit (4.4/5) (P&lt;.001). Additionally, patients rated their overall ease of driving 5.8/7, ease of communicating with other guests at the venues 5.3/7, and their tour guides 6.8/7. Conclusions Patients reported positive assessments of their overall experience, ease of driving, communication with tour guides and guests at the venues, and elevated mood after the tour. This study demonstrates that telepresence tours are a feasible and enjoyable intervention for hospitalized pediatric patients, and significantly improve mood. This unique program adds to existing child life specialist strategies by allowing children to engage in normative behaviors outside of the hospital. This novel use of telepresence robotics as a normative play intervention warrants future studies to further characterize the improvement in mood and impact on the patient’s overall hospital satisfaction.

SATB2-associated syndrome (SAS) and associated dental findings.

Identify, diagnose, and document oral clinical and radiographic evidence associated with the genetic condition known as special AT-rich sequence-binding protein 2 (SATB2)-associated syndrome. Through identifying and publishing these common dental and behavioral findings, we hope to educate oral and medical healthcare providers to identify this condition in an attempt to develop meaningful comprehensive care to this patient population. A total of 37 patients (19 female), ranging from ages 2 to 20 were evaluated at Arkansas Children's Hospital in Little Rock, Arkansas. Patient geographic distribution included: the United States, Canada, Portugal, Spain, and the Netherlands. Patients were clinically and radiographically examined for oral findings. Panoramic radiographs were obtained when patient's behavior allowed. Patient's parents or guardians were also interviewed concerning dental, medical, and behavioral histories. Clinical findings included delayed tooth eruption, bruxism, sialorrhea, larger than normal teeth with an increased propensity for maxillary anterior tooth trauma due to unsteady ambulation. Radiographic findings included delayed permanent root formation, significantly delayed or missing second bicuspids, malformed teeth, and taurodontism. Medical and behavioral issues included: insomnia, hyperphagia, cognitive delays, and an extremely high pain threshold. Patients with SATB2-associated syndrome have shown to have a consistent and unique set of dental findings both clinically and radiographically. A thorough health and dental history along with the aforementioned results of the study may facilitate a diagnosis of this syndrome. Due to the complexity of the patient's dental needs and behavior, a health practitioner with special needs care experience on a comprehensive craniofacial team would be optimal.

Helix free otoplasty for correction of prominent ear

Prominent or bat ear is not uncommon deformity as it affecting 5% of population. Plenty of procedures were reported for its correction. Being plenty means it is still a subject of research. The current procedures could be summarized as cartilage sparing and cartilage splitting ones. During a period of 35 months a total of 31 patients were presented with bilateral prominent ears so the included a total of 62 ears. Their average age was 8 years (ranging from five to 18 years). All deformities were corrected using helix free otoplasty technique which included skin paddle excision, separation of helical cartilage (hence the name helix free), anterior scoring, backward folding, mattress and simple suturing of the folded cartilage, proper definition of antitragus and earlobe and concha-mastoid sutures. Outcomes including patient's and/or guardians' satisfaction were determined. The postoperative period was uneventful except two cases that developed early postoperative hematomas, one case shows late postoperative antihelical fold irregularity in one ear and other case developed ill defined superior helix in one ear. The average follow up period of two years shows no recurrences. Almost all patients (96.85%) and their guardians were satisfied with the aesthetic results while only one (3.2%) was dissatisfied. Helical free otoplasty technique addresses the deformity through a posterior approach with under vision correction. It has very low incidence of complications, high patient's satisfactions, no visible scars and no recurrences. It is a simple, short duration procedure, reliable and good option for correction of prominent ear.

Parent reported long-term quality of life outcomes in children after congenital diaphragmatic hernia repair

PurposeThe aim of this study was to determine long-term outcomes for congenital diaphragmatic hernia (CDH) patients including quality of life (QoL), symptom burden, reoperation rates, and health status. MethodsA chart review and phone QoL survey were performed for patients who underwent CDH repair between 2007 and 2014 at a tertiary free-standing children’s hospital. Comprehensive outcomes were collected including subsequent operations and health status. Associations with QoL were tested using Wilcoxon Rank-Sum tests and Pearson correlation coefficients. ResultsOf 102 CDH patients identified, 46 (45.1%) patient guardians agreed to participate with mean patient age of 5.8 (SD, 2.2) years at time of follow-up. Median PedsQLTM and PedsQLTM Gastrointestinal scores were 91.8 (IQR, 84.8–95.8) and 95.8 (IQR, 93.0–98.2), out of 100. Thoracoscopic repair was associated with higher PedsQLTM scores while defects with an intrathoracic stomach were associated with increased gas and bloating. No difference in QoL was found when comparing defect side, patch vs primary repair, prenatal diagnosis, extracorporeal membrane oxygenation, or recurrence. Older age weakly correlated with worse school functioning and heartburn. ConclusionChildren with CDH have reassuring QoL scores. Given the correlation between older age and poor school function, longer follow-up of patients with CDH may be warranted. Level of EvidenceIII (Retrospective comparative study).

Characteristics and Long-term Follow-up of Isolated Vertical Nystagmus in Infancy.

To determine the clinical characteristics and long-term outcomes of infants who presented with isolated vertical nystagmus. The medical records of 114 infants who were diagnosed as having nystagmus from 1996 to 2016 were screened. Patients with vertical nystagmus within the first year of life who had unremarkable magnetic resonance imaging of the brain and demonstrated age-appropriate visual behavior were included. The parents of patients in the final study cohort were contacted by telephone to obtain long-term follow-up information. Eight patients comprised the final cohort. Vertical nystagmus was first observed at a mean age of 1.4 months (range: 1 to 2.5 months) and resolved in 87.5% of patients at a mean age of 3.8 months (range: 2 to 10 months). Vertical nystagmus was intermittent in 62.5%, upbeat in 62.5%, and pendular in 37.5% of patients. One patient's nystagmus did not resolve. Seventy-five percent of patient guardians participated in the telephone questionnaire. The mean age of patients at follow-up was 3.5 years (range: 0.5 to 8.1 years). Isolated iris transillumination was discovered in one patient without other features of albinism. Fifty percent of patients had speech delay requiring intervention. No other developmental delays or general medical conditions were identified. Nystagmus resolved in 87.5% of patients, all before the first year of life, and speech delay was later identified in half of the patients. [J Pediatr Ophthalmol Strabismus. 2018;55(3):159-163.].

Patient Guardian: Concept Analysis

Shortage of healthcare personnel in Malawi has posed great challenges to the health care delivery system. It is not possible for a few nurses to provide quality care to a large number of hospitalised patients. Patient guardians provide care to inpatients without the support of nurses. The purpose of this concept analysis was to clarify the concept of patient guardian in relation to their role in the healthcare delivery system. Walker and Avant’s strategic method of concept analysis was used to analyse patient guardian concept. In this paper, a patient guardian has been defined as; usually a female family member or close friend, who is legally responsible for the intimate care of a patient who is unable to look after him or herself, by performing a wide range of activities of daily living for the patient and is recognised by the healthcare providers as an extension of the hospital support system but is not supported by the healthcare providers and lives on the hospital premises during the entire period of patient’s hospitalisation. The empirical referents for a patient guardian are, a patient must be hospitalised and a family member who is legally capable of caring for the patient and willingly stays on the hospital premises during the entire period of hospitalisation. The role of patient guardians in the care of hospitalised patients needs to be clearly stipulated in order to bring a meaningful collaboration and partnership that will improve delivery of quality healthcare services in Malawi despite the shortage of nurses.

Effects of dexmedetomidine combined with sodium creatine phosphate on inflammation, oxidative stress, and neurological function recovery in patients undergoing intracranial hematoma evacuation: study protocol for a multi-center, prospective randomized parallel-cohort controlled trial

Background: In treating intracranial hematoma, dexmedetomidine (Dex) exhibits neuroprotective effects by preventing cognitive decline, and sodium creatine phosphate (SCP) exhibits neuroprotective effects by reducing cell death, maintaining the blood-brain barrier and improving interstitial cerebral edema. Few studies have examined the effects of Dex combined with SCP on perioperative inflammation and oxidative stress response, or recovery of neurological function. Methods/Design: Here we propose a multi-center, prospective randomized parallel-cohort controlled trial, to be performed at Anhui Provincial Hospital and Renmin Hospital of Wuhan University, China. After screening against inclusion and exclusion criteria, 80 patients scheduled to receive intracranial hematoma evacuation will be randomly divided into control, Dex, SCP, and Dex + SCP groups, with 20 patients per group. Under general anesthesia, all patients will undergo craniotomy for hematoma removal. In the Dex and Dex + SCP groups, an intravenous bolus of Dex (0.6 μg/kg) will be administered 10 minutes before anesthesia induction and thereafter intravenous administration of Dex (0.4 μg/kg/h) will be given. In the SCP, and Dex + SCP groups, 1.0 g SCP will be administered 10 minutes before anesthesia induction. The primary outcome measure is the difference in postoperative 72-hour Glasgow Coma Scale (GCS) score and postoperative 12-hour GCS score. The secondary outcome measures include differences in postoperative 48-hour and 24-hour GCS scores and postoperative 12-hour GCS score; plasma levels of inflammatory and oxidative stress markers, and pathological changes in brain tissue before anesthesia induction and at the end of surgery; and physiological indices during surgery. Discussion: We evaluate whether results from the proposed study protocol will provide evidence that the use of Dex combined with SCP in patients undergoing intracranial hematoma evacuation is feasible. Trial registration: The study protocol was registered at Chinese Clinical Trial Registry ( http://www.chictr.org.cn/ ) on 11 December 2014 (registration number: ChiCTR-IPR-14005656). Ethics: The study protocol was approved by Ethics Committee, Anhui Provincial Hospital, China on 25 November 2014 (approval No. 2014-ethics-39) and will be performed in accordance with the Declaration of Helsinki formulated by the World Medical Association. Informed consent: Written informed consent will be obtained from patient's guardians or clients prior to enrollment in the clinical trial.

Early treatment of patient with Class III skeletal and dental patterns.

Class III skeletal pattern is characterized by disharmony between maxillary and mandibular basal bones anteroposteriorly, and might or might not be associated with dental changes. In general, facial esthetics is hindered significantly, which most of times is the reason why patients or patient's guardians seek treatment. This case was presented to the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO) in partial fulfillment of the requirements for Diplomate recertification and revalidation.

Primary Packaging Considerations in Developing Medicines for Children: Oral Liquid and Powder for Constitution

The packaging presentation of oral liquid pediatric medicines is a critical step in maintaining chemical and physical stability, compliance, adherence, and proper handling by the target patient population, guardians, caregivers, and health-care professionals. The common packaging presentations for commercial oral liquid pediatric drug products are glass bottle, plastic bottle, sachet, and stick pack configurations. The type of pack presentation selected is driven by the quality target product profile (QTPP) that is designed around the physicochemical properties of the drug substance and the desired drug product suitability for the target population. The QTPP defines the intended use of the drug product, drug product quality criteria, dose strength, dosage form, container closure system, storage conditions, stability criteria, dosing device, shelf life, and attributes affecting the pharmacokinetic characteristics. Oral liquid pediatric formulations are typically prepared from a powder that is constituted at the time of use as a suspension or a solution for single or multiple use depending on the stability of the constituted formulation. Active ingredients with high aqueous solubility can be developed as a powder for oral solution and presented in a bottle for multiple use product and a stick pack, packet, or sachet for single-use product. Active ingredients with low aqueous solubility can be developed as a powder for oral suspension and presented in a bottle for multiple use product and a stick pack or sachet for single-use product. A secondary package may be used in cases where the primary pack failed to provide adequate protection against light degradation. This work will help formulation scientists select the most appropriate pack presentation in the early stages of pediatric clinical development.

The "adorability" of the ipsilateral oblique view in unicoronal craniosynostosis: a silver lining for families.

Sir: Infants with unicoronal craniosynostosis demonstrate classic phenotypic findings of the anterior cranium and facial skeleton. These include ipsilateral forehead retrusion, brow elevation, and peaking of the lateral orbit. The palpebral fissure is rounded and shortened transversely on the affected side. The nasal root deviates toward the synostotic half, whereas the contralateral forehead and midface demonstrate increased compensatory projection (Fig. 1).1,2 Modern ultrasonography now identifies premature in utero fusion of the coronal suture with increasing reliability.3 Although this permits obstetricians and pediatricians to direct families to multidisciplinary craniofacial centers for prenatal and neonatal counseling, it can induce parental anxiety during an otherwise joyous time.Fig. 1: Anterior (left) and superior (right) views of an infant with left unicoronal craniosynostosis demonstrate classic craniofacial asymmetries. Note mild superior oblique palsy and contralateral head tilt.At our institution, every attempt is made to educate and reassure families about all available treatment options. With this in mind, parents meet our craniofacial surgeon, pediatric neurosurgeon, pediatric anesthesiologist, pediatric ophthalmologist, geneticist, pediatric nurse practitioner, social worker, and psychologist. However, before meeting any of these health professionals, parents first meet our full-time expert medical photographer (M.S.). Using a combination of automated stuffed animals and state-of-the-art cameras, two- and three-dimensional images of the infant’s head and face are taken in all standard views: anterior, lateral, oblique, posterior, superior, and submental. In reviewing these photographs—with parents and the surgical team—one consistent finding has been, for lack of a better word, the “adorability” of the ipsilateral oblique view. This view does more than simply mask inherent craniofacial asymmetries. The retruded forehead and elevated brow create the illusion of an engaged and inquisitive child (Fig. 2). The ipsilateral nasal root deviation and contralateral midfacial projection provide rare facial fullness for an oblique view and can suggest a “half-smiling” infant. Children with unicoronal craniosynostosis also often demonstrate ipsilateral strabismus (superior oblique palsy) with contralateral head tilt (Fig. 1).4,5 At the very least, the lateral oblique view hides these asymmetries; in our opinion, these ocular and positional findings actually increase the viewer’s perception of an engaged, playful infant (Fig. 2).Fig. 2: Contralateral (left) and ipsilateral (right) oblique views of the same infant. Ipsilateral oblique view masks craniofacial asymmetries, highlights “adorable” skeletal and soft-tissue differences, and creates the illusion of a playful, engaged infant.As owners of their child’s medical records, parents receive digitized copies of all professional photographs taken at our institution. In keeping with our team’s mission to educate, reassure, and guide anxious parents of children with unicoronal craniosynostosis, we find that it is useful to specifically share with young families the adorability of their child’s ipsilateral oblique image. While awaiting definitive reconstruction, anxious parents can enjoy a light-hearted moment with their new craniofacial team and selectively share their child’s ipsilateral oblique photograph with supportive friends and family. PATIENT CONSENT Parents or guardians provided written consent of use of the patient’s images. DISCLOSURE The authors have no financial interests or commercial associations to disclose. Raj M. Vyas, M.D. Michael Alperovich, M.D. Mary Spano David A. Staffenberg, M.D. Institute of Reconstructive Plastic Surgery New York University School of Medicine New York, N.Y.

소아 방사선 검사 시 보호자 참여에 대한 인식도 조사

The purpose of this study was to survey guardian‘s opinion on assisting pediatric radiography and their level of awareness of radiation, improving the quality of pediatric radiography. In this study, the recognition was analyzed for 210 parents of child patients in Pusan National University Hospital from August 20 to September 15, 2013. total of 66.2 percent of the respondents said they had participated in pediatric radiography in the past. The reason why they did is “Radiologist's request”, the highest. According to the survey, 84.3 percent said they thought it is necessary to attending patient in pediatric radiography. “The stability of the child” is the reason for it. And respondents who thought there’s no need to do that answered back, the reason for this is “Radiologist's work.” There was a significant difference on the psychological state for the medical radiation by gender and child age. (p<0.05) In the analysis of recognition for the radiation, there was the significance by gender and education. (p<0.05) Regarding the awareness of the radiation protector, there was a statistical significance in age, gender, child age and education. (p<0.05) Considering the results, pediatric patient's guardians recognized that it is necessary to attend a child on X-ray for their child's stability and accurate exam above all. It must make guardians wear X-ray protector and radiologist should let the guardians recognize the X-ray examination method, before starting pediatric x-ray. It needs to improve the atmosphere of the examination room and to be considered to take visual and auditory approaches in comfort for reducing the children’s fear and anxiety. Key word : Pediatric Radiography, Guardian, Attending Patient, Perceptions 요 약 소아 방사선 검사 시 참여 여부와 방사선에 대한 인식도를 파악하여 검사의 질을 향상시키기 위해 부산 P대학병원 에 내원한, 소아 아동이 있는 보호자 210명을 대상으로 2013년 8월 20일부터 2013년 9월 15일까지 설문조사하였으 http://dx.doi.org/10.7742/jksr.2014.8.4.189 Corresponding Author: Jonghyeok Kwak E-mail:ikwark9476@naver.com Tel: +82-51-515-4937 No. Depart of Radiology , Pusan National University Hospital, korea Received : April 28, 2014 Revised :June 05, 2014 Accepted : June 25, 2014 A Study on the Guardian’s Perception of Attending Patient in Pediatric Radiography 190 며 “과거에 소아 방사선 검사에 참여 해본 적이 있는가?” 라는 질문에 “그렇다”(66.2%)로 나타났고 참여한 이유는 “방 사선사의 요청”(66.0%)로 가장 높게 나타났으며 “소아 방사선 검사 시 보호자의 참여가 필요하다고 생각하는가?” 라 는 질문에 “그렇다”(84.3%)로 나타났으며 그 이유는 “아이의 안정을 위해”(80.8%)였으며 “참여할 생각이 없다면 그 이유는 무엇인가?” 라는 질문에는 “방사선사의 업무이기 때문에”(54.8%)로 나타났다. 보호자의 심리상태 인식도 분석 에서는 성별 분석을 보면 여성(3.40)이 남성(3.23)보다 평균이 높게 나타났으며, 소아 연령 분석을 보면 평균이 영아 기(3.62)가 다른 소아 연령대보다 높은 것으로 나타났고 학령기(3.34), 유아기(3.25)순으로 나타났으며 통계적으로 유의한 차이가 있었다.(p<0.05) 보호자의 방사선 인식도 분석에서는 성별 분석을 보면 평균이 남성(3.09)이 여성 (2.78)보다 높게 나타났으며, 학력별 분석을 보면 평균은 대학원 (3.36)이 가장 높게 나타났고 전문대졸(2.90), 대졸 (2.80), 고졸(2.77) 순서로 나타났으며 통계적으로 유의한 차이가 나타났다.(p<0.05) 보호자의 방사선 피폭 방지에 대한 인식도 분석에서는 연령별로 살펴보면 평균이 20대(3.60)가 가장 높게 나타났으며 50대(3.33), 30대(3.04)의 순으로 나타났고 40대(2.94)가 가장 낮게 나타났으며 성별 분석을 보면 평균이 남성(3.12)은 여성(2.96)보다 높게 나 타났고, 소아 연령별 분석을 보면 평균이 영아기(3.27)가 가장 높게 나타났으며 유아기 (2.98), 학령기(2.98)로 나타 났고, 학력별 분석을 해보면 평균이 대학원(3.31)이 가장 높게 나타났으며 고졸(2.99), 대졸(2.99) 순으로 나타났고 전문대졸(2.94)이 가장 낮게 나타났으며 통계적으로 유의한 차이가 있었다.(p<0.05) 보호자들은 우선적으로 아이의 안정과 정확한 검사를 위해 방사선사와 동반검사가 필요하다고 인식하고 있었으며, 동반검사 전에 검사방법에 대해 숙 지를 시키고 보호자에게 보호 장구를 필히 착용시키며 소아의 심리적 불안감을 없애기 위해 검사실의 환경 등을 개선 하고 시각적, 청각적으로 편안하게 다가갈 수 있는 방안이 필요할 것으로 사료된다. 중심단어: 소아 방사선검사, 보호자, 참여, 인식도

Patient guardians as an instrument for person centered care.

Person-centered care involves keeping the person at the center of the care planning and decision-making process. While the theory behind person-centered care is commonly shared, its application in healthcare settings is more challenging. In a number of African countries, a lesson emerges involving the application of person-centered care through the use of patient guardians. Patient guardians, often family or close friends, act as an extension of the patient’s hospital care team. Medical teams engage with these self-designated individuals who invest their time and efforts in the care of the patient. More importantly, the guardian continues this role and relationship when the patient is released from the hospital to return home. Healthcare workers view patient guardians as a valuable resource. In a structured manner, guardians become stewards of information regarding topics such as hand hygiene and infection control. The knowledge gained can help the recovering patient upon discharge and potentially spread the information to others in the community. Further study of this model may show clear applicability to help improve health literacy in underserved settings in both low-income and high-income countries.

증례를 통해 본 치매의 한양방 협진 모델 연구

Objectives : This report describes the diagnostic and therapeutic procedures of Collaborative Practice between Korean Traditional Medicine and Western Medicine for two dementia patients. Furthermore, through these cases, we suggest a model of collaborative practice between Korean traditional medicine and western medicine for the treatment of dementia. Methods : Two patients suffering from several symptoms related to dementia received collaborative practice between Korean traditional medicine and western medicine. Physicians of deparment which paient first visit interviewed patient and patient's guardians, discussed the symptoms and the status of the patient. Since then, the medical team made a differential diagnosis based on the results of brain imaging, hematology, urine test. and apprehended the status of dementia by the neuropsychological test. Korean traditional physicians examined the physical symptoms and identified the pattern of dementia in Korean traditional medicine. Following this, they decided on the method of acupuncture, moxibustion, cupping and herbal treatment. Western physicians decided on the type of medication after consideration of the patient's other medical conditions. Every intervention was decided by both Korean traditional physicians and western physicians after discussion. The medical team provided education on dementia and counseled the guardians. They also wrote the paper for using the long-term care insurance for the aged. Results : Two patients showed no improvement on the neuropsychologic and activity of daily living tests. However, the patients' subjective physical symptoms were improved. The collaborative practice between Korean traditional medicine and western medicine improved the patients' and guardians' satisfaction. Conclusions : Through these cases, we propose a model of collaborative practice between Korean traditional medicine and western medicine for dementia categorized diagnosis-test, treatment, prevention, management. More specifically, we supplement qigong and psychotherapy which was inadequate in these cases.

Composite Facial Part Replantation

Sir:FigureWe report two cases involving tissue loss of varying magnitudes on the face that were replanted successfully. Replantation is the ideal method of reconstructing amputated small facial parts. However, the small-caliber vessels in this region make such replantation challenging. The 6-year-old boy in our series, who had avulsion of the entire nose with nasal cartilages, part of the cheek, and the upper lip, is the recipient of the largest successful composite facial replantation thus far published. In the first case, a 6-year-old boy was injured in a road traffic accident and suffered avulsion of the entire midface, including the nose, with nasal cartilages, upper lips, and part of the cheek, with palatal disruption (Fig. 1). Warm ischemia time was 9.5 hours. The amputated part (Fig. 2) was grossly contaminated. This was cleansed thoroughly and the angular vessels were identified.Fig. 1: Case 1. Preoperative photograph shows loss of the entire nose with nasal cartilages, upper lip, and part of the cheek.Fig. 2: Case 1. The amputated part.The palate was repaired first. The angular vessels were identified, and the amputated part was replaced anatomically. The angular and supratrochlear veins were first anastomosed end-to-end with 11-0 Ethilon (Ethicon, Inc., Somerville, N.J.) followed by the angular artery. Dextran 40 infusion was administered postoperatively. The child was ventilated overnight. By the tenth day, he was back on a normal diet. The entire replant survived. His 6-month follow-up was uneventful (Fig. 3). He has no problems with regard to speech, breathing, or deglutition.Fig. 3: Case 1. The patient is shown at 6-month follow-up.In the second case, a 35-year old man suffered a nose amputation in an assault, and had an ischemia time of 18 hours. The right angular vessels were revascularized and dextran 40 was infused. The patient had epidermal loss over the nasal dorsum in the postoperative period, which epithelialized with conservative measures. There are several reports of successful replantation of the scalp, and fewer reports for small part composite replantation of the face.1–7 The problems peculiar to this area are the small caliber of the facial vessels, venous congestion, and a paucity of reports in the literature to guide the approach. Several authors have suggested tips for circumventing these problems. Newer techniques involve artery-to-vein anastomosis for improved venous return and consequent survivability.1,3,4 We used several points in our surgical plan that facilitated an uneventful and successful postoperative result. The venous anastomosis was planned intentionally first to reduce troublesome bleeding that would have ensued with an initial arterial anastomosis. This would have obscured the surgical field and added significant difficulty to working in this region. An additional vein reduced venous congestion. We report two successful cases of composite facial replantation (Table 1). End-to-end anastomosis of small-caliber vessels was achieved, with a smooth postoperative course. The cosmetic and functional recovery was excellent. The young boy who had successful replantation of his nose, upper lip, and most of the cheek represents the largest successful replantation attempt reported in the medical literature.Table 1: Comparative Analysis of the Patients Who Had Composite Facial ReplantationsNo amount of reconstruction can compare with the functional and cosmetic outcome of a composite facial replantation. Thus, it is worthwhile to attempt a replantation in every case of small facial parts amputation, irrespective of the ischemia time. The survival rates are likely to be high, because the muscle mass is less, with greater vascularity on the face. R. Jayakumar, M.S., M.Ch.Plast.Surg. Jewel Raj Zachariah, M.S., M.Ch.Plast.Surg. M. Senthilkumar, M.S., M.Ch.Plast.Surg. A. J. Guild, M.B.B.S. Asha Cyriac, M.S., M.Ch.Plast.Surg. Girija Nair, M.S., M.Ch.Plast.Surg. Department of Plastic Surgery, Specialists'Hospital, Kaloor, Ernakulam, Kerala PATIENT CONSENT Parents or guardians provided written consent for use of the patient's images. DISCLOSURE None of the authors have any financial interests in the cases presented. ACKNOWLEDGMENTS The authors thank Dr. Nisheed Joseph and Dr. J. Shina, who were the anesthetists, and Dr. George K. Joseph, the maxillofacial surgeon involved in performing the cases.

Circumcision in the United States: Where Are We?

Circumcision is one of the most common surgical procedures performed on males in the United States. Ethical considerations of the procedure have been considered for many years and, recently, research on the topic has shed more light on the debate. The purpose of this study was to review the history and emergence, current demographics, and practices of male circumcision, specifically, nonreligious, nonmedically indicated routine neonatal circumcision. A review of the current literature was conducted using PubMed and current practices from guidelines of major professional societies. Physicians should consider the various ethical concerns and provide the patient's guardians with unbiased counsel. There is a lack of evidence both in favor of and against recommending routine neonatal circumcisions in the United States. The question remains whether we should continue unwarranted male circumcisions, especially when the major tenet of medical ethics is "do no harm."

Attitudes towards oxygen: exploring barriers to acceptance of oxygen therapy in Malawi

<h3>Aims</h3> Malawian clinicians recognise that oxygen therapy is important for sick patients. Availability has recently increased through introduction of oxygen concentrators to hospitals. Many patients and parents of sick children are unwilling to accept oxygen. We aimed to evaluate reasons for this. <h3>Study objectives</h3> Document understanding of oxygen usage; Explore barriers to acceptance of oxygen therapy <h3>Methods</h3> A prospective qualitative exploratory study using framework analysis of data. Nine focus groups were held involving patient guardians, urban and rural communities, using a Chichewa speaking facilitator. In depth interviews were undertaken with fifteen staff from paediatrics and medicine at a central hospital. Written consent was obtained. Focus groups and interviews were audio-recorded then transcribed. <h3>Results</h3> Data analysis revealed common themes: <h3>Focus groups</h3> Malawians understand oxygen is used for breathing problems, illness and low oxygen levels. They do not understand how oxygen works. It is accepted because of medical advice “you will obey whatever the doctor says regardless of its consequences”. People fear oxygen and associate it with death “we believe that once the patient goes for the machine, he is going to die right away”. Beliefs stem from personal and family experiences “for those afraid of the machine it9s because they previously lost a child”. Some believe doctors seek to harm. People are keen to know more about oxygen recommending community based strategies and information provision through radio and hospitals. <h3>Interviews</h3> Staff had experienced patients or parents of sick children refusing oxygen. Sick patients receive oxygen before they die leading to belief that oxygen contributes to death. Communities discuss medical treatments so even those with no experience of oxygen may become wary. They lack understanding about oxygen therapy. <h3>Conclusion</h3> There is a strong belief that oxygen kills. Whilst it remains a relatively scarce commodity in Malawi, it will only be given to the sickest, therefore this misconception will prevail. Patients and guardians recognise they have a lack of understanding about oxygen and are keen to learn more. Education aimed at community level may improve acceptance of oxygen therapy in Malawi.

The Question Mark Ear in Patients with Mandibular Hypoplasia

Sir:FigureThe question mark ear is characterized by a cleft between the lower part of the helix and the earlobe, sometimes with a prominent upper pole of the pinna, and was first described in 1961.1 The term “question mark ear” was coined in 1970.2 Ear malformations and mandibular hypoplasia can occur together in oculoauriculovertebral spectrum (Online Mendelian Inheritance in Man no. 164210) (including craniofacial microsomia and Goldenhar syndrome), Treacher Collins syndrome (Online Mendelian Inheritance in Man no. 154500), Pierre Robin sequence, and auriculocondylar syndrome (Online Mendelian Inheritance in Man no. 602483). Auricular malformations in four patients with mandibular hypoplasia were reviewed. In case 1, an 11-year-old girl presented with bilateral question mark ears and micrognathia (Fig. 1). Her mother and sister both had a unilateral question mark ear. The patient underwent bilateral mandibular distraction and later ear reconstruction.Fig. 1: Case 1. An 11-year-old girl with bilateral question mark ears and micrognathia.In case 2, a 2-year-old boy presented with a left question mark ear, Pierre Robin sequence, micrognathia, and severe obstructive sleep apnea (Fig. 2). He successfully underwent bilateral mandibular distraction osteogenesis to improve his airway.Fig. 2: Case 2. A 2-year-old boy with Pierre Robin sequence, micrognathia, and a unilateral question mark ear.In case 3, a 3-month-old boy was referred with bilateral question mark ears and severe micrognathia requiring emergency tracheostomy at birth. He had macrostomia with a trifurcated, hypoplastic tongue and gingival hypertrophy. He required bilateral hearing aids. He underwent approximately 20 operations, including mandibular distraction osteogenesis, free fibula mandibular reconstruction, release of jaw ankylosis, temporomandibular joint reconstructions, tongue Z-plasty, release of floor-of-mouth adhesions, iliac bone graft to the anterior mandible, and further bilateral mandibular distraction. In case 4, a 14-year-old boy presented with a left question mark ear and micrognathia. He underwent bilateral vertical L-osteotomies of the mandible with interpositional iliac bone grafts, bilateral coronoidectomies, and alloplastic genioplasty. The question mark ear is rare. It can arise spontaneously or by means of autosomal dominant inheritance, with high intrafamilial variability.3 The cleft associated with the question mark ear can be explained as an arrest of fusion of the fifth (helical) and sixth (lobular) hillocks.4 The reason for any accompanying mandibular or condylar hypoplasia is unknown, but both structures arise from the first pharyngeal arch. The question mark ear is thought to be a diagnostic trait for auriculocondylar syndrome, described in 1978 in a mother and two sons with bilateral external ear malformations and mandibular hypoplasia.5 Condylar hypoplasia, temporomandibular joint abnormalities, microstomia, stenotic ear canals, and hearing loss are associated. Auriculocondylar syndrome has features that overlap with other first and second pharyngeal arch disorders, especially oculoauriculovertebral spectrum. The heart, kidneys, and spine should be evaluated: auriculocondylar syndrome is thought to be similar to Goldenhar syndrome but lacks vertebral anomalies. Expression of auriculocondylar syndrome is variable. Surgery aims to reduce size and prominence of the upper pole of the ear and to correct the cleft.3 The anomaly has been classified as moderate and severe.3 Rib or contralateral conchal cartilage grafts are used to correct cartilage deficiency.4 A V-Y flap from the posterior surface of the ear can be advanced to correct the skin deficiency.4 If a notch remains, a Z-plasty can realign tissue but makes the ear smaller.4 Transposition flaps with cartilage grafts are an alternative. Ear reconstruction should be delayed until after the mandibular deficiency has been corrected, especially if there are associated respiratory problems. Aina V. H. Greig, Ph.D., F.R.C.S.(Plast.) Silvio Podda, M.D. Charles H. Thorne, M.D. Joseph G. McCarthy, M.D. Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, N.Y. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. PATIENT CONSENT Parents or guardians provided written consent for the use of the patient images.