Philadelphia Hospital Research Articles

A knowledge retention strategy for professional nurses in South Africa

This paper explores the existing knowledge retention strategies for professional nurses at Philadelphia hospital, in South Africa, located in one of the previously disadvantaged district municipalities in the country and it develops a strategy for retaining nurses. Design/Methodology/Approach: The study adopted a qualitative research approach and a case-study design. Semi-structured interviews were used to solicit in-depth understanding of the current knowledge retention practices. Out of the 90 professional nurses at Philadelphia hospital, 20 were purposively interviewed to a point of saturation. Data was analysed thematically. Findings: A knowledge retention strategy was developed. It calls for a knowledge retention policy; awareness training programmes; reward systems for effectively encouraging professional nurses to participate in knowledge retention practices; programmes for recovering lost knowledge and conducting knowledge audits. The strategy contributes to the existing body of knowledge-on-knowledge retention in the health care sector. The article is part of the findings from the authors master's dissertation. Conclusion: The loss of critical nursing knowledge remains a challenge in South Africa and to the rest of the globe, as highly skilled and experienced nurses migrate from place to place in search of greener pastures, hence this has affected patient care. Although the country has engaged in several efforts such as educating and training nurses, its knowledge retention strategies have not been prioritised in the country. Limitations: This paper focuses on knowledge retention practices in the nursing profession, which is only one part of the health sector in the former disadvantaged province. It is a qualitative study performed in one out of the nine provinces in South Africa. There is a dire need for a quantitative study, which will explore knowledge retention amongst nurses in the country and the health sector as a whole

African American Males Have More Distress During Cancer Treatment Than White Males.

African American (AA) males have a higher incidence and mortality rate for some cancers than other races and sexes, which could be associated with distress during treatment, medical mistrust, and health disparities. We hypothesize distress in AA males during treatment is higher than in other races and sexes. We assessed effect modification of moderate to severe (≥ 4) distress scores during cancer treatment by race and sex, age, and socioeconomic status (SES). National Comprehensive Cancer Network's distress thermometer (scale 0-10) and characteristics for 770 cancer patients were collected from a Philadelphia hospital. Variables included age, sex, race, smoking status, marital status, SES, comorbidities, mental health, period before and during COVID-19, cancer diagnosis, and stage. Descriptive statistics, chi-square tests, and t-tests were used to compare AA and White patients. Effect modification of ≥ 4 distress by race and sex, age, and SES were analyzed by logistic regression. A p value of ≤ .05 was significant, and 95% confidence intervals (CIs) were reported. On average, AA patients had a non-significant, higher distress score (4.53, SD = 3.0) than White patients (4.22, SD = 2.9) (p = .196). The adjusted odds ratio of ≥4 distress was 2.8 (95% CI [1.4, 5.7]) for AA males compared with White males. There was no significant difference between White and AA females, race and age, or race and SES. There was an effect modification of ≥4 distress by race and sex. AA males in cancer treatment had higher odds of ≥4 distress compared with White males.

1399. Dramatic Increase in Invasive Group A Streptococcal Infection in Persons Who Inject Drugs in an Urban Philadelphia Hospital

Abstract Background Invasive infection from Group A streptococcus (iGAS) is rising nationally, and we report a significant increase in incidence at an urban, quaternary care health center, which serves the Kensington neighborhood, the epicenter of the opioid crisis in Philadelphia, PA. We examined iGAS infection in the Temple University Health System catchment area Methods iGAS was defined as an of streptococcus pyogenes cultured from a previously sterile site. Injection drug use (IDU) is a known risk factor for bacterial infection, including iGAS infection. All blood, sterile fluid, and/or tissue cultures that yielded S. pyogenes were identified using the laboratory information system at Temple University Hospital – Main Campus. Two cohorts were compared: January 1, 2021, to December 31, 2021, and January 1, 2019, to December 31, 2019. Electronic health records were reviewed and data pertaining to age, gender, and injection drug use were abstracted. Descriptive statistics were used to summarize findings. Results 155 cases of iGAS were identified in 2021 (105 of which involved bacteremia) compared to 69 in 2019 (42 of which involved bacteremia), representing a 224% increase overall. Of the cases in 2021, 130 (84%) were Persons Who Inject Drugs (PWID) compared to only 39 (57%) in 2019. PWID with iGAS were younger (median age 35 vs 54 in 2019, 39 vs 53 in 2021) and more likely to be male (57% vs 43% in 2019, 68% vs 32% in 2021). Male patients also had a higher incidence of PWID than female patients (56% vs 44% in 2019 and 64% vs 36% in 2021). Conclusion During this same time period, the COVID-19 pandemic added to the ongoing opioid crisis in Philadelphia. The city of Philadelphia publicly reports opioid data, which shows that hospitalizations related to non-fatal opioid overdose have exponentially risen in the past two decades. This also coincides with an increase in the presence of xylazine, an adulterant in the Philadelphia fentanyl supply. Xylazine has been implicated in worsening wounds. Our data supports a concerning association between iGAS and PWID. Disclosures All Authors: No reported disclosures.

MP54-04 EMERGENCY ROOM PRESENTATIONS OF SYMPTOMATIC UROLITHIASIS DURING THE COVID-19 PANDEMIC: A COMPARISON OF MANAGEMENT AND OUTCOMES

INTRODUCTION AND OBJECTIVE: The lockdowns that ensued during the coronavirus disease 2019 (COVID-19) pandemic saw the reduction of emergency room (ER) visits for many serious medical conditions. Acute stone events often present in the ER setting and can lead to significant morbidity and even mortality especially if infection occurs in the setting of obstruction. However, it is unknown whether patients who presented with symptomatic urolithiasis during the initial months of the pandemic suffered greater morbidity. The clinical presentation and outcomes for patients who presented with symptomatic urolithiasis during the initial months of the COVID-19 pandemic were analyzed. METHODS: We retrospectively reviewed ER presentations from a single urban Philadelphia hospital for symptomatic urolithiasis between March-June 2020 and compared these with presentations for the same time period from the year prior. Patient demographics, stone characteristics, management and clinical outcomes were compared between the two years. RESULTS: 139 patients presented during 2020 compared to 269 in 2019. There were fewer patients who presented during the initial COVID-19 pandemic surge who had obesity (37.41% vs 49.44%, 0 [0.024), hyperlipidemia (18.71% vs 31.60, p=0.006), and asthma (5.76% vs 16.73%, p=0.002). Although overall stone characteristics did not differ between the two groups, a larger proportion of patients in 2020 presented with an obstructing stone (81.16% versus 64.1%, p=0.001). Patients who presented during the COVID-19 pandemic did not have higher rates of infection, acute kidney injury, or complications. Rates of surgical modalities, emergent procedures, and discharges from the ER were similar between the two years. CONCLUSIONS: The COVID-19 pandemic initial surge resulted in fewer ER presentations for symptomatic urolithiasis;however, patients who did present were more likely to have obstructing stones, perhaps due to delaying presentation to avoid COVID-19 exposure in the ER. Despite higher rates of obstruction, clinical outcomes and morbidity were similar.

S0224 Decreasing the Delays in Clostridioides difficile Infection Diagnosis - A Quality Improvement Initiative

INTRODUCTION: Clostridium difficile is the most common cause of healthcare-associated diarrhea in developed countries. Despite the current rapid C. difficile infection (CDI) testing methods, studies have shown that delays in CDI diagnosis still exist due to various factors. Identification and intervention of modifiable factors contributing to delays could possibly lead to early initiation of appropriate infection control measures and treatment. Our objective is to identify the factors causing the delays at various levels from the time of CDI test order to results. METHODS: We conducted a 6-month retrospective study followed by a 3-month prospective interventional study at Mercy Philadelphia Hospital. Chart review was performed to evaluate the time from CDI test orders to stool specimens collection. Interviews were conducted on CDI patients and a subset of nurses and physicians to identify the reasons for delays in diagnosis. A 3-month intervention was performed to address the delays. This included an Electronic medical record (EMR) alert to notify infection control staff and educating nurses and physicians focusing on the importance of timely CDI testing for initiation of treatment. RESULTS: CDI test orders on 140 patients with 80 in the pre- and 60 post-intervention periods were reviewed. No significant difference in patient characteristics and demographics was noted between the 2 groups. The mean time from the test order to test result was significantly lower after the intervention period compared to the pre-intervention period 2 hours vs. 19 hours (P < 0.0001). CONCLUSION: Factors affecting the time from test order to specimen collection accounted for most of the delays. Education of the health care workers at all levels on prompt isolation of suspected CDI patients and the importance of expedited testing significantly reduced the delays in diagnosis. This may reduce the overuse of empirical CDI therapy, reduce delays in initiation of appropriate therapy and finally, decrease C. difficile transmission with timely isolation.

INFLUENCE OF WORK LIFE BALANCE ON PERFORMANCE OF EMPLOYEES IN JORDAN HOSPITALS

This paper examines the impact of WLB on performance of employees in Jordan hospitals. This study is a quantitative research and made use primary data using a research questionnaire as instrument was administered to a total number of 500 respondents selected from four governments and four privates hospitals namely: Al-Bashir hospital (Government), Al Mafraq Government Hospital (Government), Ram Manohar Lohia Hospital (Government),Jawaharlal Nehru Medical College (Government),Philadelphia hospital (private), Haramain Hospital (Private), Jordan hospital (private) and Fortis Hospital (Private) from Jordan. The result of the study reveals that impact of WLB on performance of employees was significant and joint impact of WLB and motivation significantly influence performance of employees. In conclusion, motivation plays an important role in encouraging employees to perform; a well-motivated employee has a possibility of performing better than an employee that is not well motivated.

From the Desk of the Residency Program Director

It has been a historic year for the Nation, City of Philadelphia and teh Jefferson Internal Medicine Residency Program. We have eperienced many health care crises starting with the closure of the historic Philadelphia hospital, Hahnemann. We welcomed residents form this program as part of the Jefferson Family and integrated many patients into our practices.

The Impact of a Mandatory Prescription Drug Monitoring Program (PDMP) on Opioid Prescription Among Sickle Cell Disease Patients By Emergency Medicine Physicians in Community Teaching Hospitals in Philadelphia

Introduction: Although opioids are the recommended treatment for acute pain management in sickle cell disease (SCD) patients, the opioid epidemic may have negatively affected the care of these patients in the emergency care settings. Literature suggested that ED physicians routinely overestimate opioid misuse in patients with SCD. Pennsylvania mandated Prescription drug monitoring programs (PDMP) in August 2016 which may affect ED opioid prescription among SCD patients. We evaluated the impact of that PDMP on opioid prescription in the management of acute pain for patients with SCD. Method: The data collection took place in the two community hospitals (Mercy Fitzgerald and Mercy Philadelphia Hospital) in Philadelphia. Participants were adults (aged ≥18 years) diagnosed with SCD who triaged for pain in the ED was included in the study. We grouped the encounter by year of PDMP implementation: prior to September 2016 (January 2016-August 2016), and after September 2016 (January 2017-August 2017) to collect patient records of a 6-month period and analyzed the data on number of visits, treatment types, opioid dispensing and total morphine milligram equivalents (MMEs) drug prescriptions during the ED visit. Paired t-test and chi square test were used to compare pre- and post-intervention results. Repeat encounters within 7 days period were excluded in the study. Result: The study included 180 qualifying ED visits (92 pre-intervention; 88 post-intervention). PDMP intervention was not significantly associated with reductions in the with opioid prescribing or the amount of prescribed MMEs. The mean age is 32.7 and 58% were male; and all were of African American race/ethnicity. However, prescriptions for non-opioid analgesics increased significantly during the same periods (p&lt;0.012). Conclusion: During January 2017-August 2017, PDMP implementation was not associated with a change in opioid prescription among SCD patients in our community teaching hospitals in Philadelphia. The use of the PDMP would be expected to increase narcotic use by correctly identifying SCD patients as not having opioid misuse. The failure to increase narcotics suggests that the use of PDMP data to adjust prescribing for SCD patients is not adequate. As PDMP is crucial for addressing the opioid crisis, clinicians should also use PDMP data for more tailored care in SCD patients. Integration of palliative care could be more pragmatic approach in balancing opioid abuse and access to opioids for pain management among SCD patients. Disclosures No relevant conflicts of interest to declare.

Abstract A58: Racial disparities in head and neck cancers in an urban hospital

Abstract Introduction: Although head and neck cancer incidence rates are higher for white residents in Philadelphia, PA, related mortality rates are highest for black residents. It is not clear how clinical factors and risk factors like HPV and smoking contribute to these disparities. The goal of this study is to determine which factors are associated with advanced head and neck cancers in a diverse sample of patients from a Philadelphia hospital. Methods: Cancer registry data from Thomas Jefferson University (957 beds, Philadelphia, PA) were used to obtain clinical records from 922 head and neck cancer patients diagnosed from 2011-2015. One patient of other race was removed from these analyses. We examined advanced cancer among the primary racial groups represented in our hospital population. Chi-square tests were used to examine differences in categorical variables. The Kruskal-Wallis test was used to compare continuous variables. Logistic and Cox regression models were designed to examine independent associations with advanced disease and time to mortality. Covariates included age, race, tumor stage, HPV status, smoking status, gender, and treatment type. Results: Our sample included 921 patients (788 white, 96 black, 37 Asian). Our descriptive analysis showed that among the three groups, blacks were more likely to be female (p=0.033). Positive HPV status was most prevalent for white patients (p=0.004). Oral and nasopharyngeal cancers were most common among Asians, and oropharyngeal cancers were most common among whites. In univariate analysis, black patients were most likely to die from their cancer. Multivariable analyses showed that current smoking (compared to never smoking) was associated with T3/T4 stage at diagnosis (OR=6.85, 95% CI=1.11-42.2). Time to death was significantly shorter for older individuals (HR=1.02 95% CI=1.01-1.05), current smokers (HR=2.24, 95% CI=1.25-4.00) and patients receiving radiation only (HR=7.70, 95% CI=1.38-42.95). Positive HPV status was protective (HR=0.29, 95% CI=0.19-0.44). No significant race effects were observed in these models. Conclusions: The results of this study suggest that race is not independently associated with head and neck cancer or associated mortality. These results also suggest that some risk factors for head and neck cancer and related outcomes may be modified by educational and behavioral interventions. Citation Format: Charnita Zeigler-Johnson, Scott Keith, Frances Guiles, David Cognetti, Voichita Bar-Ad, Rita Axelrod. Racial disparities in head and neck cancers in an urban hospital [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A58.

The insight and challenge of reflexive practice in an ethnographic study of black traumatically injured patients in Philadelphia.

The integrity of critical ethnography requires engagement in reflexive practice at all phases of the research process. In this discussion paper, I explore the insights and challenges of reflexive practice in an ethnographic study of the recovery experiences of black trauma patients in a Philadelphia hospital. Observation and interviews were conducted with twelve patients who were admitted to trauma-designated units of the hospital over the course of a year. During fieldwork, I learned the ways that my background as a professional nurse structured my way of being in clinical space and facilitated a particular interpretation of clinical culture. In analysis, reflection on subjectivities through which I designed this ethnographic research allowed me to see beyond my preconceived and theoretically informed perspective to permit unexpected features of the field to emerge. Reflexive practice also guided my reconciliation of key practical and epistemological differences between clinical ethnographic research and the anthropologic tradition in which it is rooted. I conclude that with careful reflection to the subjectivities that influence the research process, interdisciplinary clinically relevant applied interpretations of critical ethnographic work can be used to generate detailed knowledge across contexts in clinical care, nursing practice, and patient experiences.

Criteria Development for Peripherally Inserted Central Venous Catheter Insertion

SESSION TITLE: Education, Research, and Quality Improvement II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Like all central venous catheters, peripherally inserted central catheters (PICC) are associated with excess morbidity. This can be minimized by using PICC lines only when absolutely needed (e.g. for Total parenteral nutrition or long-term intravenous medications), using the smallest diameter catheter possible, and using the right brachial vein when possible. We are yet to see standard criteria for PICC line insertion. Previous studies have demonstrated less thrombotic event with single lumen PICC. PICC inserted by nurses have been found to be more cost effective and associated with less risk of infection. Left sided catheters have also been associated with more thrombotic event. We examined the PICC utilization in two community teaching hospitals. METHODS: We performed a retrospective study of all patients admitted to Mercy Fitzgerald and Mercy Philadelphia hospital from October 2012 - October 2013 who had a PICC line placed. For each patient, we performed a targeted chart review and extracted information regarding PICC insertion. Indication for PICC was identified as well as the type (single vs. double lumen), location (right vs. left) and how it was inserted (nurse vs. interventional radiologist). Descriptive statistics were generated using Microsoft Excel. RESULTS: 446 patients had PICC placement which constituted 2% of the total admissions. PICC lines were placed for poor IV access (237, 53% +- 5%), long-term antibiotics (160, 36% +- 3%), Total parenteral nutrition (47, 11% +- 1%), and chemotherapy (2, 0.4% +- 0.002%). Only 17 (4% +- 0.2%) of patients received a single lumen PICC, the rest received a wider diameter dual lumen PICC. 111 (25% +- 2%) patients had a PICC inserted using the left brachial vein. 71% was placed by Interventional radiologist and 29% by vascular team nurse. 61% of PICC lines were initiated on the floor and 39% in the ICU. No significant differences were seen between the two hospitals. CONCLUSIONS: More than 50% of the patients who had a PICC placed at the two community teaching hospitals required the PICC for poor peripheral IV access, almost all had wider-diameter dual lumen PICCs placed and a very high percentage were placed by the interventional radiologist. This practice potentially exposes patients to unnecessary and/or added risk and cost from PICC use. Strengths of the study are its multi-center design and evaluation of all patients with PICC insertion. Assuming data can be replicated; targeted interventions to use alternate IV access on patients with poor IV access may reduce PICC-related costs and morbidity. Limitation includes reliance on chart review for indication. CLINICAL IMPLICATIONS: Having a poor IV access should not an absolute indication for PICC. A right sided single lumen placement of PICC by a nurse should be given priority unless if there is a contraindication to doing so. DISCLOSURE: The following authors have nothing to disclose: Aasim Mohammed, Bolanle Gbadamosi, Eric Green No Product/Research Disclosure Information

Asylum: Inside the Closed World of State Mental Hospitals

AsylumInside the Closed World of State Mental Hospitals Christopher Payne (bio) asylum, Kirkbride, psychiatric hospital, state mental hospital Photographer Click for larger view View full resolution Figure 1. Administration Building, Buffalo State Hospital, Buffalo, New York, 2003 Almost all nineteenth-century asylums built in the United States were modeled after the Kirkbride plan (named for Dr. Thomas Kirkbride, the superintendent of the Philadelphia Hospital for the Insane), which consisted of a central administration building flanked symmetrically by linked pavilions, each stepping back at right angles. This layout facilitated a hierarchical segregation according to sex, illness, and even social class. At present, only a few Kirkbride asylums still serve their original function. The very qualities that made them appealing in the first place—their enormous size, heavy construction, and distinctive floor plan—have made them difficult to repurpose. Buffalo is one of the few Kirkbrides to be preserved and adaptively reused. Designed by H. H. Richardson, construction began in 1871 and was not completed until 1895, although patients were admitted in 1880. By the 1970s, most of the patients had been moved to a new facility and the original complex was abandoned. Thanks to the efforts of local preservationists, elected officials, and community members, years of neglect have been reversed, and the building is being brought back to life as a hotel and conference center. [End Page 174] For more than half the nation’s history, vast mental hospitals—some of the largest structures ever built in America—were prominent features of the American landscape. From the mid-nineteenth century to the early twentieth, almost three hundred institutions for the insane were built throughout the United States. But in the second half of the twentieth century, after the introduction of psychotropic drugs and policy shifts toward community-based care, patient populations declined dramatically, leaving many of these massive buildings neglected and abandoned. From 2002 to 2008, I visited seventy institutions in thirty states, photographing palatial exteriors designed by famous architects and crumbling interiors that appeared as if the occupants had just left. I also documented how the hospitals functioned as self-contained cities, where almost everything of necessity was produced on site: food, water, power, and even clothing and shoes. Since many of these places have been demolished, my photographs serve as their final, official record. After my book Asylum was published in 2009, I thought I was finished with the project, but it continues to exert a strong emotional pull. Over the years, countless former patients, employees, and their relatives have reached out to thank me for telling this story. As I learn of more hospital closings and impending demolitions, I have been compelled to begin taking pictures again. I realize now that I will probably be working on Asylum, in some form or another, for the rest of my life. [End Page 175] Click for larger view View full resolution Figure 2. Bridge to Infirmary Ward, Taunton State Hospital, Taunton, Massachusetts, 2003 One of the most unique and captivating places I photographed was Taunton State Hospital, a Kirkbride asylum that opened in 1854 and was largely abandoned in 1975. Stepping inside, I felt like I had traveled a century back in time. The interiors were well preserved, with tin ceilings, antique lighting, hardware, furniture, and artifacts, as if the patients had just left. After a fire gutted the central section in 2006, the entire hospital was demolished by 2009. [End Page 176] Click for larger view View full resolution Figure 3. Typical ward, Warren State Hospital, Warren, Pennsylvania, 2003 When I took this picture, the ward was no longer used but patients and staff occupied the rest of the building. Every state hospital had wards like this, and the view down the corridor, with its rigid symmetry and procession of identical bedroom doorways, speaks to the monotony of institutional life. In all the hospitals, the wards were fundamentally the same, sharing a plan driven by the need for efficiency and organization. On their own, they are just hallways, but together they are symbols of a closed and isolated world. [End Page 177] Click for larger view View full resolution Figure 4. Connecting hall, Grafton State Hospital, Grafton, Massachusetts...

Perinatal Depression and Anxiety in Women with and without Human Immunodeficiency Virus Infection

BackgroundUntreated depression and anxiety during the perinatal period have significant consequences on maternal and infant health; however, few studies have examined perinatal depression and perinatal anxiety in women with human immunodeficiency virus (HIV) infection. The current study prospectively examined the prevalence of prenatal and postpartum depression and anxiety, and emotional support from family and friends, as well as childhood sexual abuse in women with and without HIV infection. MethodsBetween July 2009 and January 2013, 258 pregnant women receiving care in a Philadelphia hospital were enrolled, with 162 completing both the prenatal and postpartum portions of the study. The Center for Epidemiological Studies–Depression Scale (CES-D), and the State-Trait Anxiety Inventory for Adults were used to measure depression and anxiety symptoms, respectively. An independent samples t test and multiple linear regressions were used to determine associations among depression, anxiety, and pregnancy-related variables. ResultsForty-nine participants (30%) were living with HIV; 113 (70%) were HIV negative. CES-D scores did not differ prenatally (p = .131) or postpartum (p = .156) between women with and without HIV. Prenatal state anxiety scores were higher in women with HIV (p = .02) but there were no differences postpartum (p = .432). In a multiple linear regression, trait anxiety predicted postpartum anxiety in the full sample (p < .001) and childhood sexual abuse predicted postpartum depression among women with HIV (p = .021). ConclusionsThese findings highlight the importance of identifying and treating perinatal depression and anxiety early in the prenatal period. Results also emphasize the need for providers to be aware of childhood sexual abuse as a potential correlate for depression in women with HIV.

The Reverend Russell H. Conwell, W. Wayne Babcock, and the “soup bone” cranioplasties of 1915

In 1915, faced with 2 patients with large skull defects, W. Wayne Babcock, an obstetrician-gynecologist-turned-general surgeon, operating in a modest North Philadelphia hospital, did something extraordinary: he went to the hospital kitchen to look for a cranial graft. Based heavily on archival and other primary sources, the authors tell the remarkable tale of the "soup bone" cranioplasties of the Samaritan Hospital and place these operations within the context of the early modern American hospital.

The Dercum-Muybridge collaboration for sequential photography of neurologic disorders

To analyze the contributions of American photographer Eadweard Muybridge (1830-1904) and Philadelphia neurologist Francis Dercum (1856-1931) toward creating the first motion-picture sequences of patients with neurologic disorders. In the late 1870s and 1880s, prior to the development of movie cameras or projectors, Muybridge photographed sequential images of people and animals in motion, using arrays of sequentially triggered single-image cameras and multilens cameras. Examination of published writings and photographic sequences by Muybridge and Dercum, and primary source documents, including letters from Dercum. In 1885, Philadelphia neurologist Francis Dercum (1856-1931) collaborated with Muybridge at the University of Pennsylvania to photograph sequential images of patients with various neurologic disorders involving abnormal movements. Subjects were recruited from the neurology services of the University Hospital and the Philadelphia Hospital. Muybridge and Dercum photographed patients with tabes dorsalis, hemiparesis, paraparesis, athetotic cerebral palsy, lead encephalopathy, congenital hydrocephalus with diparesis, poliomyelitis, pseudoseizures, psychogenic movement disorder, and other conditions. These are the first motion-picture sequences of neurologic disorders ever filmed, and provide an important visual archive and teaching resource for neurologic disorders that were prevalent in the late 19th century.

Abstracts fromThe Academy of Breastfeeding Medicine 18th Annual International MeetingPhiladelphia, PennsylvaniaNovember 21–24, 2013

Abstracts fromThe Academy of Breastfeeding Medicine 18th Annual International MeetingPhiladelphia, PennsylvaniaNovember 21–24, 2013

Bilirubin nomogram: A prediction tool or natural history profile?

Bilirubin nomograms have dual functions: (a) to track an individual baby using an evidencebased predictive risk assessment tool; and, (b) to inform the public health perspective on adverse outcome reduction by altering the natural course of the disease through early intervention. The original report that demonstrated the predictive value of a routine predischarge total serum bilirubin (TSB), measured as a universal screen, was simplified for immediate applicability to plot on an hour-specific bilirubin nomogram described for a population of racially diverse, healthy, term and near-term newborns during the first postnatal week in a Philadelphia hospital [1]. Subsequent studies have validated this predictive ability and the usefulness of this nomogram in several regional and multi-national populations [2]. When used with combination of TSB and transcutaneous testing, other centers have effectively promoted universal bilirubin screening [3, 4]. The outcome measure is the likelihood (LR) of TSB >95th percentile for age in hours. Based on the prevalence of “disease”: TSB in the high-risk zone, >95th percentile post-discharge for any population is (present / (present + absent)). One out of 23 infants in this study evidenced “disease”. The LR may calculate a revised or posttest probability of disease: posttest odds = pretest odds × LR where odds = probability ÷ (1 – probability). Because LR is prevalence independent, it can be used to calculate the posttest probability at any site in the world. Alternatively, the revised probability may be obtained for any site by dividing the absent component of the present : absent ratio for the total population by the LR to calculate the revised present : absent ratio for each risk zone (legend for Table 3 in reference 1). The clinical goal for any predictive test is defined by its outcome. We selected an identification of a higher-risk population to ensure a safety margin because of known imprecision of clinical diagnostic tests. Biological risk factors, accuracy as well as precision of bilirubin, pattern of clinical practice and access to healthcare markedly influence the predictive performance of the bilirubin tests. Gestational age, race and ethnicity are also singularly important [4, 5]. Subsequent consensus for TSB thresholds for use phototherapy governed by prematurity, hemolysis and clinical signs of neurotoxicity [2,4] have informed clinical practices similar to those in North America and Europe. However, geography and nationality are poor surrogates for biology, race, ethnicity and prematurity and have yet to be recognized as specific risk factors. Performance of a predictive test is also largely defined, in a research setting, with meticulous attention to study design, definitions, minimization of bias, subsequent validation in diverse cohorts and an anticipation of variable implementation in actual clinical practice. In this issue of Indian Pediatrics, Pathak, et al., [6] have attempted to replicate a predictive study without addressing a precise hypothesis and have expended immense effort without studying the vulnerability (if any) for their specific population cared for at their institution. Their data could be influenced by prevailing clinical practice pattern, race or ethnicity but not geography. Assessment of proven predictive tools for local institutional quality improvement should be benchmarked to best practice models and encouraged. On the other hand, novel questions impact nations with additional clinical or public health burden for bilirubin neurotoxicity that includes sepsis, small for dates, postnatal hypoalbuminemia, unrecognized hemolysis, insufficient breast milk intake or access to healthcare. Here, the risk of neurotoxicity can be altered by natural history of the disease itself. A national endeavor to define thresholds for interventions relevant to the diverse population is an achievable newborn health priority to reduce the prevalence of infants with TSB >95th percentile, use of exchange transfusion or possibly prevent kernicterus in India.

The CHOP Postnatal Weight Gain, Birth Weight, and Gestational Age Retinopathy of Prematurity Risk Model

To develop a birth weight (BW), gestational age (GA), and postnatal-weight gain retinopathy of prematurity (ROP) prediction model in a cohort of infants meeting current screening guidelines. Multivariate logistic regression was applied retrospectively to data from infants born with BW less than 1501 g or GA of 30 weeks or less at a single Philadelphia hospital between January 1, 2004, and December 31, 2009. In the model, BW, GA, and daily weight gain rate were used repeatedly each week to predict risk of Early Treatment of Retinopathy of Prematurity type 1 or 2 ROP. If risk was above a cut-point level, examinations would be indicated. Of 524 infants, 20 (4%) had type 1 ROP and received laser treatment; 28 (5%) had type 2 ROP. The model (Children's Hospital of Philadelphia [CHOP]) accurately predicted all infants with type 1 ROP; missed 1 infant with type 2 ROP, who did not require laser treatment; and would have reduced the number of infants requiring examinations by 49%. Raising the cut point to miss one type 1 ROP case would have reduced the need for examinations by 79%. Using daily weight measurements to calculate weight gain rate resulted in slightly higher examination reduction than weekly measurements. The BW-GA-weight gain CHOP ROP model demonstrated accurate ROP risk assessment and a large reduction in the number of ROP examinations compared with current screening guidelines. As a simple logistic equation, it can be calculated by hand or represented as a nomogram for easy clinical use. However, larger studies are needed to achieve a highly precise estimate of sensitivity prior to clinical application.

Sioban Nelson and Anne Marie Rafferty, Notes on Nightingale: The Influence and Legacy of a Nursing Icon (Ithaca, NY: Cornell University Press, 2010), pp. xi + 172, £12.50/$18.95, paperback, ISBN: 978-0-8014-7611-2.

Sioban Nelson and Anne Marie Rafferty, Notes on Nightingale: The Influence and Legacy of a Nursing Icon (Ithaca, NY: Cornell University Press, 2010), pp. xi + 172, £12.50/$18.95, paperback, ISBN: 978-0-8014-7611-2.

Development of a Marjolin's ulcer within 9 months in a plantar pressure ulcer

Auteur(s) : Arunkumar Baskara, Lovleen Sikka, Farrukh Khan, Nancy Sapanara Mercy Catholic Medical Center, Mercy Philadelphia Hospital, 19143 Philadelphia, USA We report the case of a 72-year-old female who presented with a pressure ulcer in the distal plantar aspect of her foot which eventually progressed to well-differentiated squamous cell carcinoma within nine months of the initial presentation. A 72-year-old African-American female presented with a 6 month history of a non-healing ulcer [...]