Use of a midstream clean catch mobile application did not lower urine contamination rates in an ED.

OBJECTIVES: Urine microscopy is a common test performed in emergency departments (EDs). Urine specimens can easily become contaminated by different factors, including the collection method. The midstream clean-catch (MSCC) collection technique is commonly used to reduce urine contamination. The urine culture contamination rate from specimens collected in our ED is 30%. We developed an instructional application (app) to show ED patients how to provide a MSCC urine sample. We hypothesized that ED patients who viewed our instructional app would have significantly lower urine contamination rates compared to patients who did not. METHODS: We prospectively enrolled 257 subjects with a urinalysis and/or urine culture test ordered in the ED and asked them to watch our MSCC instructional app. After prospective enrollment was complete, we retrospectively matched each enrolled subject to an ED patient who did not watch the instructional app. Controls were matched to cases based on gender, type of urine specimen provided, ED visit date and shift. Urinalysis and urine culture contamination results were compared between the matched pairs using McNemar's test. RESULTS: The overall urine culture contamination rate of the 514 subjects was 38%. The majority of the matched pairs had a urinalysis (63%) or urinalysis plus urine culture (35%) test done. There were no significant differences in our urine contamination rates between the matched pairs overall or when stratified by gender, by prior knowledge of the clean catch process or by type of urine specimen. CONCLUSION: We did not see a lower contamination rate for patients who viewed our instructional app compared to patients who did not. It is possible that MSCC is not effective for decreasing urine specimen contamination.

An Echocardiography Training Program for Improving the Left Ventricular Function Interpretation in Emergency Department; a Brief Report.

INTRODUCTION: Focused training in transthoracic echocardiography enables emergency physicians (EPs) to accurately estimate the left ventricular function. This study aimed to evaluate the efficacy of a brief training program utilizing standardized echocardiography video clips in this regard. METHODS: A before and after design was used to determine the efficacy of a 1 hour echocardiography training program using PowerPoint presentation and standardized echocardiography video clips illustrating normal and abnormal left ventricular ejection fraction (LVEF) as well as video clips emphasizing the measurement of mitral valve E-point septal separation (EPSS). Pre- and post-test evaluation used unique video clips and asked trainees to estimate LVEF and EPSS based on the viewed video clips. RESULTS: 21 EPs with no prior experience with the echocardiographic technical methods completed this study. The EPs had very limited prior echocardiographic training. The mean score on the categorization of LVEF estimation improved from 4.9 (95% CI: 4.1-5.6) to 7.6 (95%CI: 7-8.3) out of a possible 10 score (p<0.0001). Categorization of EPSS improved from 4.1 (95% CI: 3.1-5.1) to 8.1 (95% CI: 7.6- 8.7) after education (p<0.0001). CONCLUSIONS: The results of this study demonstrate a statistically significant improvement of EPs' ability to categorize left ventricular function as normal or depressed, after a short lecture utilizing a commercially available DVD of standardized echocardiography clips.

Utilization of fertility treatment and reproductive choices by lesbian couples.

OBJECTIVE: To describe intentions and outcomes of lesbian couples requesting reproductive assistance; and report number of cycles needed to achieve a live birth. DESIGN: Retrospective chart review. SETTING: University-based fertility center. PATIENT(S): A total of 306 lesbian couples who sought reproductive assistance between 2004 and 2015. INTERVENTION(S): Intrauterine insemination or IVF using donor sperm. MAIN OUTCOME MEASURE(S): Mean age, relationship status, family size, preconception goals, conception attempts, number of cycles to achieve a live birth. RESULT(S): Preconception plans were available for 233 couples: 76.4% planned for one partner to conceive and carry (single partner conception); 23.6% planned for both partners to eventually conceive and carry (dual partner conception). Of 306 couples who presented, 85.1% attempted single partner conception, and 68% of these achieved a live birth. Dual partner conception was attempted by 14.9% of couples, and 88.9% achieved a live birth. Of those who conceived with IUI, a mean (±SD) of 3 ± 1.1 cycles were completed. Of those who conceived with IVF, a mean of 6 ± 1.4 IUI and 1.7 ± 0.3 IVF cycles were completed. CONCLUSION(S): Lesbian couples may improve their likelihood of a live birth if both partners attempt conception. Further studies are needed to understand why one-fifth of patients did not pursue treatment.

Validation of the existing modified screening criteria for detection of all cases of Retinopathy of Prematurity in preterm babies - 11 year study from a governorate referral hospital in Oman.

PURPOSE: To study appropriateness of our modified screening criteria for detection of all cases of Retinopathy of Prematurity (ROP) among preterm babies. METHOD: Retrospective observational cohort study among preterm neonates who underwent ROP screening as per set protocol for 11 years at Nizwa Hospital, Al Dhakilya Governorate, Oman. We screened all babies with gestational age ⩽32 weeks or BW â©½ 1500 g. Preterm babies >32 weeks of GA or BW > 1500 g with unstable clinical course believed to be at high risk by the attending neonatologist also were screened. RESULTS: During the study period 528 babies were screened for ROP of which 76 babies were excluded due to death, associated congenital ocular malformation and loss for follow-up either due to transfer to other institution or defaulting. Thus 452 babies were included in the final analysis. Incidence of ROP was 46.4% of which 27.9% had mild ROP, 11.3% had severe ROP which regressed and 7.3% had severe ROP who were treated. The incidence of ROP among infants with GA < 26 wks, 26-28 wks, 29-30 wks, 31-32 wks and above 32 weeks was 100.0%, 80.0%, 59.3%, 34.4% and 19.4% respectively. 56 babies of this cohort belonged to Extended (modified) criteria group. Among these 12 babies had ROP out of which 9 had mild ROP and 3 had severe ROP. Among cases with severe ROP, two cases regressed spontaneously and one case needed treatment. Multivariate analysis using stepwise regression model showed statistically significant association of GA and BW to development of ROP. We would have missed few babies with ROP if we had followed other criteria. CONCLUSION: Our modified screening criteria seem to be appropriate as no infant with severe ROP was missed during the study period. Incidence of severe ROP among babies in the extended criteria group (5.4%) is low but significant compared to lower gestational age. We plan to formulate a scoring system following all risk factor analysis to enable us to optimize the number of infants screened. Detection of all babies with ROP is important as they need long-term follow-up for the timely detection and management of associated ocular comorbidities.

Colloid cyst of the third ventricle presenting with features of Terson's syndrome.

This report describes a middle-aged man presenting to the ophthalmologist with history of seeing floaters before both eyes since 2-weeks duration. A history of intermittent headache and dizziness of recent onset was elicited on questioning. Ocular examination showed bilateral early papilloedema and mild vitreous hemorrhage. Brain computed tomography (CT) disclosed features suggestive of colloid cyst of the third ventricle in the region of foramen of Monro with moderate hydrocephalus. Emergency craniotomy and excision of the cyst was done, and the patient is doing well for the last 18 months after the surgical intervention. The mechanism of this presentation, importance of early investigations, and timely intervention are highlighted in order to avoid serious neurological sequelae. The literature was extensively reviewed for atypical presentations of intraventricular colloid cyst.

Blurred vision as the sole initial presentation of disseminated lung malignancy.

Symptomatic choroidal metastasis (CM) is a rare presenting feature of disseminated lung malignancy. Detection of the primary malignancy usually precedes ocular findings. We report a rare case of blurred vision secondary to bilateral CM as the sole initial manifestation of disseminated lung malignancy in a female patient. Pulmonary symptoms appeared 2 months later. She received radiotherapy and palliative chemotherapy and survived for 7 months after the initial presentation.

X-ray-negative posterior sternoclavicular dislocation after minor trauma.

Posterior sternoclavicular dislocation is a rare injury that must be recognized by the emergency physician because failure to rapidly reduce can lead to serious vascular complications. A high index of suspicion must be maintained in the appropriate setting because these injuries are difficult to detect on physical examination as well as on plain radiography. We present a case of a 19-year-old man with an isolated posterior sternoclavicular dislocation, in the setting of minor blunt trauma. The correct diagnosis required multiple imaging modalities over 2 emergency department visits and was ultimately successfully managed with intraoperative reduction.

Impact of an educational intervention and insurance coverage on patients' preferences to transfer multiple embryos.

Multiple gestations resulting from IVF continue to be a major problem associated with maternal/neonatal morbidity and mortality including preterm labour/delivery, pre-eclampsia and post-partum haemorrhage. A prospective survey at a university IVF clinic evaluated the effect of education and insurance coverage on patients' preferences for single-embryo transfer (SET) versus double-embryo transfer (DET). Patients undergoing IVF treatment from September 2008 to October 2009 were included. The main outcome measure was patients' preference of SET versus DET. Patients were sent an educational handout describing maternal and fetal risks of twin gestation. A total of 163 patients (32.6% response rate) returned the pre- and post-education surveys regarding preferences for SET versus DET based on three different IVF insurance coverage scenarios (no coverage, two cycles covered and unlimited coverage). There were statistically significant differences in the preference for SET before and after education across all insurance scenarios (scenario 1, 42.0% versus 61.1%; scenario 2, 50.6% versus 71.0%; and scenario 3, 61.7% versus 79.6%; P<0.001 for all scenarios). Before education, patients preferred SET more in the unlimited coverage scenario (61.7%) versus no coverage (42.0%; P<0.001). An educational handout and increasing the amount of insurance coverage significantly increased a patient's preference for SET.

Characteristics of nulliparous women who would consider cesarean delivery on maternal request.

INTRODUCTION/HYPOTHESIS: To identify factors that influence nulliparous women to choose cesarean delivery on maternal request (CDMR). METHODS: Nulliparous women at > or = 34 weeks completed a 76-item survey about concerns during labor, delivery and postpartum. RESULTS: Mean age of the 294 respondents was 28.4 years (+/- 6.13 years SD) and mean gestational age was 35.4 weeks (+/- 2.8 weeks). Sixteen patients (5.4%) would request CDMR if offered. Women who would request CDMR were more likely to plan breastfeeding (OR 5.1, P=0.02), have a mother who delivered by C-section (OR 5.1, P= 0.01), and be concerned about the number of family members present (OR 1.75, P=0.002). Pelvic muscle damage, urinary incontinence, fecal incontinence, or need for prolapse surgery were notcited by any patient as her top concern. CONCLUSIONS: Few women in our sample desire CDMR. Concern for pelvic-floor problems was low.

Temporary Anchorage Device: An Epitome of Anchorage in Orthodontic Treatment.

One of the most important phases of oral health is the form and function of the oral mechanism. Recently, pediatric dentists are concerned with the obvious esthetic disabilities and the pathologic implications of the malposed teeth. Interceptive and functional orthodontic treatment is playing a major role in these discrepancies. Anchorage is an important consideration in orthodontics, particularly if force is applied entirely to the teeth. For many years, clinicians have searched for a form of anchorage that does not rely on patient cooperation. During the last few decades, a wealth of new information has accumulated to such an extent that the present authors thought it appropriate to let these advances make an impact by suggesting a revised definition and classification of anchorage. This paper also gives a brief insight on evolution of anchorage and its application in pediatric dentistry.

Effect of molecule branching and glycosidic linkage on the degradation of polydextrose by gut microbiota.

Polydextrose is a randomly linked complex glucose oligomer that is widely used as a sugar replacer, bulking agent, dietary fiber and prebiotic. Polydextrose is poorly utilized by the host and, during gastrointestinal transit, it is slowly degraded by intestinal microbes, although it is not known which parts of the complex molecule are preferred by the microbes. The microbial degradation of polydextrose was assessed by using a simulated model of colonic fermentation. The degradation products and their glycosidic linkages were measured by combined gas chromatography and mass spectrometry, and compared to those of intact polydextrose. Fermentation resulted in an increase in the relative abundance of non-branched molecules with a concomitant decrease in single-branched glucose molecules and a reduced total number of branching points. A detailed analysis showed a preponderance of 1,6 pyranose linkages. The results of this study demonstrate how intestinal microbes selectively degrade polydextrose, and provide an insight into the preferences of gut microbiota in the presence of different glycosidic linkages.

A prospective, randomised, placebo-controlled trial of postoperative oral steroid in allergic fungal sinusitis.

The aim of this study is to determine the effectiveness of postoperative oral steroid in controlling disease in patients with allergic fungal sinusitis (AFS). The study design includes prospective, randomised, double blind,placebo-controlled trial using oral prednisolone.Twenty-four patients diagnosed with AFS underwent sinus surgery (endoscopic sinus surgery with or without open surgery) to completely excise disease. Patients were randomised to receive either oral steroid (n = 12) or placebo(n = 12) soon after surgery. All patients were also administered itraconazole and steroid nasal spray in the postoperative period. Subjective evaluation of symptom relief and objective evaluation by rigid nasal endoscopy at 6 and 12 weeks following surgery was performed. After12 weeks, the code was broken and the two groups of patients were identified to note their response to treatment.At 6 weeks, complete relief of preoperative symptoms was obtained in eight patients who had received oral steroid and none who had received placebo (p = 0.001). Partial relief of preoperative symptoms was obtained in four who had received oral steroid and eight who had received placebo.Nasal endoscopy revealed that 8 of 12 patients who had received oral steroid and 1 patient who had received placebo were disease free (p = 0.009). At 12 weeks, complete symptom relief was obtained by all patients who received oral steroid but only one who received placebo(p = 0.0001). Nasal endoscopy at 12 weeks revealed that all 12 patients who had received oral steroid and only 1 patient (the same patient) who had received placebo were disease free (p = 0.0001). In conclusion, postoperative oral steroid in a tapering dose produces significant subjective and objective improvement of patients with AFS. It is also effective in preventing early recurrence. Inclusion of post operative oral steroid therapy for at least 12 weeks is recommended in all patients who undergo excisive surgery for AFS.

High-dose chemotherapy and autologous hematopoietic progenitor cell rescue in children with recurrent medulloblastoma and supratentorial primitive neuroectodermal tumors: the impact of prior radiotherapy on outcome.

BACKGROUND: The role of myeloablative chemotherapy in children with recurrent medulloblastoma and supratentorial primitive neuroectodermal tumors (MB/ST-PNET) is controversial, in particular in patients who develop recurrent disease after craniospinal radiotherapy. METHODS: In this retrospective analysis, the authors investigated the outcome of children with recurrent MB/ST-PNET who were referred for myeloablative chemotherapy and autologous hematopoietic progenitor cell rescue at Childrens Hospital Los Angeles. RESULTS: Thirty-three children were referred for myeloablative chemotherapy: Fourteen of those children were never transplanted because of pre-transplant adverse events, and 19, including 6 without and 13 with previous irradiation, underwent transplant. Conditioning regimens included a backbone of thiotepa, which was given either in a single cycle or in multiple sequential cycles. The 3-year post-transplant event-free survival rate in unirradiated versus previously irradiated children was 83% +/- 15% versus 20% +/- 12%, respectively (P = .04). One child who had never been exposed to radiotherapy died of toxicity; the other children received post-transplant radiotherapy and remained disease free. Nine previously irradiated children experienced 4 toxic deaths and 6 tumor recurrences (1 patient had both): An interval of <1 year between initial radiotherapy and myeloablative chemotherapy predicted a greater risk of toxic death (P = .02), whereas a history of meningeal metastases at diagnosis and a poor response to the initial rescue therapy predicted a greater risk of post-transplant recurrence (P = .03 and P = .08, respectively). CONCLUSIONS: Myeloablative doses of thiotepa-based chemotherapy and radiotherapy were able to cure most children who had radiotherapy-naive, chemoresponsive recurrences. Children who developed recurrences after craniospinal radiotherapy had poorer outcomes; however, cure was possible in those who had good prognostic features at presentation, chemoresponsive recurrences, and a long interval between initial radiotherapy and myeloablative chemotherapy.

Effect of macular photocoagulation on visual acuity of Omani patients with clinically significant macular edema.

BACKGROUND: The aim of this study was to determine the effect of macular laser treatment on the visual acuity (VA) of Omani diabetic patients with clinically significant macular edema (CSME). Visual outcome was also correlated with duration and control of diabetes and presence or absence of hypertension and hyperlipidemia. MATERIALS AND METHODS: This is a retrospective noncomparative cohort study involving 101 eyes of 72 Omani diabetic patients. Change in VA was determined using Snellen's VA chart. The mean duration of follow-up was approximately 21 months (range, 16-24 months). RESULTS: 29.7% of the patients maintained their vision, 35.6% showed improvement, whereas 34.7% showed a decrease in their vision. Positive visual outcome showed a statistically significant direct relationship with tight control of diabetes and absence of hypertension and an inverse relationship with the duration of diabetes. Presence of hyperlipedemia did not show a statistically significant relationship with positive visual outcome. However, it showed a trend to better visual outcome in the absence of hyperlipedemia. Peak incidence of macular edema was seen at the age of 52.3 years. CONCLUSION: Macular photocoagulation was found to be an effective method of treatment for CSME among Omani diabetic patients, which has resulted in a positive visual outcome in 65.3% of the patients (stable and improved vision). Effective control of diabetes, duration of diabetes, and hypertension are the factors which influence the postlaser visual outcome.

The clinical profile of children in India with pigmentary anomalies along the lines of Blaschko and central nervous system manifestations.

The aim of this study was to describe the clinical profile of children with congenital pigmentary anomalies along Blaschko lines and the associated manifestations in the central nervous system. Twenty-six children aged 12 years or less (14 boys and 12 girls), with hypopigmentation and hyperpigmentation along Blaschko lines and central nervous system manifestations were included during the period June 2001 to December 2003. Detailed physical, cutaneous, and systemic examinations were carried out. Relevant investigations included histopathology, karyotyping, electroencephalogram, computerized tomography scans, and magnetic resonance imaging of the brain whenever possible. Twenty children had hyperpigmentation along the lines of Blaschko, four had hypopigmentation, and two had a combination of the two. Eight children had diffuse involvement. Of these, two each had hypomelanosis of Ito, incontinentia pigmenti and linear and whorled nevoid hypermelanosis. The remaining 20 patients could not be categorized as any of the described entities. The majority (92.3%) of patients manifested skin and central nervous system disorders before the age of 2 years. Hyperpigmentation along Blaschko lines was significantly higher in patients with central nervous system manifestations (p = 0.01). Developmental delay was the most frequent central nervous system presentation. Multiple systems were affected, including the eyes. Histology was useful to distinguish incontinentia pigmenti from other types of nevoid hyperpigmentation.

Psychological distress by type of fertility barrier.

BACKGROUND: We examined fertility-specific distress (FSD) and general distress by type of fertility barrier (FB). METHODS: In a random sample telephone survey, 580 US women reported their fertility intentions and histories. Six groups of women were identified: (i) no FBs, (ii) infertile with intent, (iii) infertile without intent, (iv) other fertility problems, (v) miscarriages and (vi) situational barriers. Multiple regression analyses were used to compare groups with FBs. RESULTS: Sixty-one percent reported FBs and 28% reported an inability to conceive for at least 12 months. The infertile with intent group had the highest FSD, which was largely explained by (a) self-identification as infertile and (b) seeking medical help for fertility. The no FB group had a mean Center for Epidemiological Studies Depression scale score above the commonly used cut-off of 16, although 23% of the women with FBs did score above 16. CONCLUSIONS: FBs are common. Self-identification as infertile is the largest source of FSD. More women with FBs had elevated general distress than women without FBs; mean general distress was below 16 for all FB groups. It may be that, for some women (even those with children), FBs can have lasting emotional consequences, but many women do heal from the emotional distress that may accompany fertility difficulties.