Effects of Atrioventricular Optimization on Left Ventricular Reverse Remodeling With Cardiac Resynchronization Therapy: Results of the SMART-CRT Trial.

BACKGROUND: The role of atrioventricular optimization (AVO) to improve cardiac resynchronization therapy outcomes remains controversial. Previous post hoc analyses of a multicenter trial showed that measures of electrical dyssynchrony (right ventricular-left ventricular [LV] or LV electrical delay durations) are associated with patients who benefit from AVO. METHODS: This was a global, multicenter, prospective, randomized trial of de novo cardiac resynchronization therapy implant patients with an right ventricular-LV duration ≥70 ms to determine whether AVO results in greater reverse remodeling. Patients were randomized 1:1 for either an AVO algorithm (SmartDelay) that determines atrioventricular delay and pacing chamber, biventricular or LV only, or a fixed atrioventricular delay of 120 ms with biventricular pacing. Paired echocardiograms performed at baseline and 6 months were evaluated. The primary end point was echocardiographic cardiac resynchronization therapy response, defined dichotomously as a >15% reduction in LV end-systolic volume. RESULTS: A total of 310 patients (n=120 women) were randomized and had completed 6 months of follow-up. The echocardiographic cardiac resynchronization therapy response rate did not statistically differ between the groups (SmartDelay, 74.8%; fixed, 67.7%; P=0.17). Analyses of prespecified secondary end points demonstrated significant improvements in the absolute (median: SmartDelay, -41.0 mL; fixed, -33.0 mL; P=0.01) and relative change in LV end-systolic volume (SmartDelay, -38.3%; fixed, -27.8%; P=0.03) for patients with SmartDelay optimization. Similar results were observed for the relative improvement in LV ejection fraction (SmartDelay, 46.7%; fixed, 32.1%; P=0.050); absolute improvement in LV ejection fraction trended to be higher with SmartDelay (P=0.06). CONCLUSIONS: Analysis of reverse remodeling parameters demonstrated that AVO via SmartDelay, relative to the nonoptimized fixed atrioventricular delay comparator group, improved absolute and relative changes in LV function in patients with longer right ventricular-LV duration. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03089281.

Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains.

PURPOSE: Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain. METHODS: This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy. RESULTS: Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10. CONCLUSIONS: It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Improved Self-Assessed Collaboration Through Interprofessional Education: Midwifery Students and Obstetrics and Gynecology Residents Learning Together.

INTRODUCTION: Research suggests that interprofessional education, bringing learners together to learn about, with, and from each other, improves health professions education and can improve health outcomes. Little research has measured outcomes of interprofessional education between midwifery students and obstetrics and gynecology residents. The purpose of this study was to examine self-assessed interprofessional and collaborative competencies among midwifery students and obstetrics and gynecology residents. METHODS: Baseline self-assessed interprofessional and collaborative competencies were compared with follow-up measurements to evaluate learners' experiences over an 11-month study period. Participants were midwifery students and obstetrics and gynecology residents who experienced interprofessional learning activities. The Interprofessional Education Collaborative Competency Self-Assessment Survey (IPEC Survey) and Interprofessional Collaborative Competency Attainment Survey (ICCAS) were used. RESULTS: Of 256 learners at 4 demonstration sites, 223 (87%) completed the baseline, and 121 of 237 eligible learners (51%) completed the follow-up surveys. The IPEC Survey total score (t = 2.31, P = .02) and interaction subscale (t = 2.85, P = .005) and ICCAS score (t = 4.04, P = .001) increased for midwifery students but not obstetrics and gynecology residents on the IPEC Survey (t = 0.32, P = .75) and ICCAS (t = -0.05, P = .96) measures. Midwifery students (87%) and residents (57%) reported improved overall ability to collaborate. Learners responding to 3 open-ended questions valued team-based experiences, including learning how to communicate with each other; appreciated learning each other's education and scope of practice; and recommended skills development including uncommon clinical events, case discussions, and direct clinical care. DISCUSSION: This study advanced knowledge about interprofessional education between midwifery students and obstetrics and gynecology residents. Midwifery students improved in self-assessed interprofessional and collaborative competencies. Most learners reported better interprofessional collaboration skills and were positive about future interprofessional learning. This evaluation approach is available for other programs implementing or extending interprofessional education.

Forage agronomists are needed in animal science departments.

Ruminants serve a valuable role in sustainable agricultural systems, specifically in the conversion of renewable resources from grasslands, pasture, and other by-products into high-quality human food. Recognizing forage and grasses are grown on 25% of arable land, suitable agronomic practices for management of grazing livestock are necessary for the economic sustainability of the livestock enterprise, whereas at the same time, minimizing water and soil erosion. Demographics of undergraduate animal science students have changed over the last several years with more students from urban backgrounds and with interests other than traditional animal agriculture. Thus, continued emphasis on education programs supporting grazing livestock industries becomes that much more important. In addition, newer technologies to measure production on range and pastureland have emerged, thereby increasing opportunities for further training and education. Based on an email assessment of 10 land grant institutions, typically one MS student/yr and one PhD student/3 to 4 yr graduates with an advanced degree in forage agronomy. Overall budget reductions which impact operational costs, internal funding for research projects and graduate student stipends, force universities to focus in areas with the best chance of monetary return. Challenges with funding faculty positions outside of a department's emphasis area typically result in the question "Should forage agronomy students be trained in Departments of Animal Science or Agronomy/Plant/Soils Sciences?" It could be argued that either department is the best fit. Forage agronomy requires training in the basics of plant and soil science, but the application of those sciences within a Department of Animal Science relates more to animal science/production than to traditional crop production such as cereal grains. Animal science departments must communicate the meaningful context of forage agronomy in an active learning environment developing students' ability to critically think and solve problems. Those providing technical expertise to livestock producers can no longer make recommendations based solely on production efficiency and profitability. Instead, best management practices must include the impact of grazing livestock on the environment and environmental sustainability. Cooperative agreements between departments should be discussed to adequately support student development in this critical subject matter.

Pulmonary Alveolar Proteinosis: A Case of Profound Hypoxemia in a Previously Healthy Teenager.

ABSTRACT: The profoundly hypoxemic child presents an interesting set of diagnostic and management challenges in the pediatric emergency department. While common pathologies including pneumonia, asthma, bronchiolitis, and pneumothoraces are managed using evidence-based algorithms, more enigmatic pathologies may present the treating physician with less diagnostic and therapeutic clarity. We present the case of a profoundly hypoxemic 16-year-old girl who presented in minimal distress, with oxyhemoglobin saturation of 63% on room air.

Wide-Awake Surgery With Local Anesthesia and Epinephrine Is Safe.

Hand and upper extremity surgery performed with the patient wide awake involves the use of a local anesthetic and epinephrine. Controversy persists as to whether epinephrine is safe for use in the hand. The goal of this study was to evaluate the safety of epinephrine in hand and upper extremity surgery. The hypothesis was that epinephrine is safe and can be used for a wide breadth of surgical procedures of the hand and upper extremity. A 4-year retrospective chart review was conducted of consecutive patients undergoing wide-awake surgery performed by 2 surgeons at a single institution. All procedures were performed with local anesthesia and epinephrine. Data collected included patient demographics, procedure volume, procedure type, surgical setting, and complications related to epinephrine use. During the study period, 4054 consecutive patients underwent 4287 wide-awake procedures with local anesthesia and epinephrine. Average patient age was 59 years, and 64% of patients were female. No complications occurred as a result of the use of epinephrine, and no tissue necrosis, phentolamine reversal, anaphylaxis, or readmissions occurred. No patients required conversion to general anesthesia or monitored anesthesia care. This analysis of more than 4000 consecutive patients undergoing wide-awake hand and upper extremity surgery with epinephrine confirmed that epinephrine use is safe, with no reported cases of tissue necrosis, reversal, readmission, anaphylaxis, or anesthetic conversion. Epinephrine is safe for use in the hand and upper extremity for patients undergoing wide-awake hand surgery with a local anesthetic. [Orthopedics. 2020;43(6):e529-e532.].

Cardiac Dysfunction and Shock in Pediatric Patients With COVID-19.

Coronavirus disease-2019 (COVID-19) has been reported to cause significant morbidity in adults, with reportedly a lesser impact on children. Cardiac dysfunction has only been described in adults thus far. We describe 3 cases of previously healthy children presenting with shock and COVID-19-related cardiac inflammation. (Level of Difficulty: Intermediate.).

Frontostriatal Brain Activation Is Associated With the Longitudinal Progression of Cardiometabolic Risk.

OBJECTIVE: Cardiometabolic risk refers to a set of interconnected factors of vascular and metabolic origin associated with both cardiovascular disease and various brain disorders. Although midlife cardiometabolic risk is associated with future brain dysfunction, emerging evidence suggests that alterations in autonomic and central nervous system function may precede increases in cardiometabolic risk. METHODS: The present study tested whether patterns of cerebral blood flow in brain areas associated with autonomic regulation were associated with increases in overall cardiometabolic risk. A community sample of 109 adults with resting systolic blood pressure between 120 and 139 mm Hg, diastolic blood pressure between 80 and 89 mm Hg, or both underwent pseudocontinuous arterial spin labeling to quantify cerebral blood flow responses to cognitively challenging tasks. Cardiometabolic risk and cerebral blood flow measurements were collected at baseline and at a 2-year follow-up. RESULTS: Regression analyses showed that greater frontostriatal cerebral blood flow responses to cognitive challenge were associated with higher cardiometabolic risk at follow-up (ß = 0.26 [95% confidence interval = 0.07 to 0.44], t = 2.81, p = .006, ΔR = 0.04). These findings were specific to frontostriatal brain regions, as frontoparietal, insular-subcortical, and total cerebral blood flow were not associated with progression of cardiometabolic risk. Moreover, cardiometabolic risk was not associated with frontostriatal cerebral blood flow responses 2 years later. CONCLUSIONS: Frontostriatal brain function may precede and possibly forecast the progression of cardiometabolic risk.

Predictors of Septic Wrist: A Dual-Center 10-Year Review of Risk Factors.

Introduction Expeditious and accurate diagnosis of septic wrist arthritis is essential to prevent further cartilage damage, systemic infection, osteomyelitis, and loss of limb. There is limited literature on the incidence and clinical factors that are predictive of septic wrist arthritis. Objective We aimed to investigate the incidence of septic wrist arthritis and identify risk factors and laboratory values associated with septic wrist arthritis. Materials and Methods Data were collected on adult patients presenting with a painful, swollen wrist to two level 1 urban hospitals from 2004 to 2014. Demographics, comorbidities, and laboratory values of patients who had wrist aspiration were collected. Results There was an overall incidence of 0.4%. Increased synovial white blood cells (WBC), being febrile, positive blood cultures, and smoking were significantly associated with septic wrist arthritis on univariate analysis. Synovial WBC was also found to be significant on multivariate analysis. A synovial WBC of 87,750 cells/µL had an optimal sensitivity and specificity of 73% and 86%, respectively, for diagnosing septic wrist arthritis. Conclusion Synovial WBC can be a useful diagnostic tool for septic wrist arthritis. In addition, positive blood cultures, being febrile, and smoking history can help predict septic wrist arthritis in patients with presenting with painful, swollen wrists.

Is the Brain an Early or Late Component of Essential Hypertension?

The brain's relationship to essential hypertension is primarily understood to be that of an end-organ, damaged late in life by stroke or dementia. Emerging evidence, however, shows that heightened blood pressure (BP) early in life and prior to traditionally defined hypertension, relates to altered brain structure, cerebrovascular function, and cognitive processing. Deficits in cognitive function, cerebral blood flow responsivity, volumes of brain areas, and white matter integrity all relate to increased but prehypertensive levels of BP. Such relationships may be observed as early as childhood. In this review, we consider the basis of these relationships by examining the emergence of putative causative factors for hypertension that would impact or involve brain function/structure, e.g., sympathetic nervous system activation and related endocrine and inflammatory activation. Currently, however, available evidence is not sufficient to fully explain the specific pattern of brain deficits related to heightened BP. Despite this uncertainty, the evidence reviewed suggests the value that early intervention may have, not only for reducing BP, but also for maintaining brain function.

Interprofessional Education Between Midwifery Students and Obstetrics and Gynecology Residents: An American College of Nurse-Midwives and American College of Obstetricians and Gynecologists Collaboration.

Despite areas of excellence, US perinatal care outcomes lag behind most developed countries. In addition, a shortage and maldistribution of health care providers exists. The American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists (ACOG) partnered to obtain funding to develop interprofessional education modules and other learning activities for midwifery students and obstetrics and gynecology residents in 4 demonstration sites. The multidisciplinary 2016 ACOG document Collaboration in Practice: Implementing Team-Based Care was adopted as a framework. Core competencies of values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork developed by the Interprofessional Education Collaborative were used to guide the work. Seven modules have been developed including guiding principles, patient-centered care, role clarification, collaborative practice, history and culture, care transition, and difficult conversations. Learners participate in laboratory and simulation activities and work together in clinical care settings. Stakeholder experiences as well as barriers to implementation are discussed. Learning materials and activity descriptions are open resourced and shared on a project website for use by programs interested in implementing an interprofessional curriculum. Ongoing formal evaluation including pilot testing of a program evaluation method is described.

Initial Debridement of Dorsal Hand Abscesses in the Operating Room Does Not Improve Outcomes.

Background: Hand infections frequently involve the dorsal aspect of the hand and often develop secondary to some traumatic mechanism. Although Staphylococcus aureus is most commonly isolated, anaerobic and polymicrobial infections are not uncommon. To date, treatment is largely anecdotal, with some surgeons preferring a formal debridement in the operating room, while others opt for an initial debridement at the bedside. The goals of this study were to compare outcomes between treatment modalities and to identify the most common causative organisms. Methods: A 10-year retrospective chart review was conducted to identify adult patients who presented with a dorsal hand infection to a single, level 1, urban trauma center. Demographic data were collected as well as the abscess size, location, duration of symptoms, treatment administered, number of formal debridements, length of hospital stay, and complications. Results: The number of formal debridements was significantly less in the initial bedside debridement group (P < .01), as was the hospital length of stay (P < .01). There was no significant difference in hospital readmissions, complications, or infection due to methicillin-resistant Staphylococcus aureus. There was also no significant difference in abscess size, duration of symptoms, or demographic data including age, sex, comorbidities, intravenous drug use status, and immunocompromised status. Conclusions: An initial debridement of dorsal hand infections at the bedside is at least as effective as formal debridement in the operating room. This decreases number of formal debridements and days in the hospital, without any increase in complications. This permits safe, expeditious, and cost-effective treatment for this common condition.

Ichnoverruca nom. nov., a replacement name for the genus Verruca Sheng amp; Sun, 2018 (Hymenoptera, Ichneumonidae) non Schumacher, 1817.

The name Verruca was proposed for a new genus of wasps described by Sheng Sun (2018) with the type species Verruca dentia Sheng Sun, 2018 in the family Ichneumonidae (Hymenoptera). However, it cannot be used as a valid generic name due to homonymy as the genus Verruca was established by Schumacher (1817) in the barnacle family Verrucidae (Cirripedia, Verrucomorpha). Verruca Schumacher is a valid generic name in Verrucomorpha.

Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting.

BACKGROUND: Prior research suggests that physician attire has an important effect on patient perceptions, and can influence the patient-physician relationship. Previous studies have established the effect of specialty, location, and setting on patient preferences for physician attire, and the importance of these preferences and perceptions on both the physician-patient relationship and first impressions. To date, no studies have examined the influence of attire in the inpatient orthopaedic surgery setting on these perceptions. QUESTIONS/PURPOSES: (1) Do differences in orthopaedic physician attire influence patient confidence in their surgeon, perception of trustworthiness, safety, how caring their physician is, how smart their surgeon is, how well the surgery would go, and how willing they are to discuss personal information with the surgeon? (2) Do patients perceive physicians who are men and women differently with respect to those endpoints? METHODS: Ninety-three of 110 patients undergoing orthopaedic surgery at an urban academic medical center participated in a three-part survey. In the first part, each patient was randomly presented 10 images of both men and women surgeons, each dressed in five different outfits: business attire (BA), a white coat over business attire (WB), scrubs alone (SA), a white coat over scrubs (WS), and casual attire (CA). Respondents rated each image on a five-point Likert scale regarding how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and the patient's willingness to discuss personal information with the surgeon. In the second part, the respondent ranked all images, by gender, from the most to least confident based on attire. RESULTS: Pair-wise comparisons for women surgeons demonstrated no difference in patient preference between white coat over business attire compared with white coat over scrubs or scrubs alone, though each was preferable to business attire and casual attire (WS versus WB: mean difference [MD], 0.1 ± 0.6; 95% CI, 0.0-0.2; p = 1.0; WS versus SA: MD, 0.2 ± 0.7; 95% CI, 0-0.3; p = 0.7; WB versus SA: 0.1 ± 0.9; 95% CI, -0.1 to 0.2; p = 1.0). The same results were found when rating the surgeon's perceived intelligence, skill, trust, confidentiality, caring, and safety. In the pair-wise comparisons for male surgeons, white coat over scrubs was not preferred to white coat over business attire, scrubs alone, or business attire (WS versus WB: MD, -0.1 ± 0.6; 95% CI, 0-0.1; p = 1.0; WS versus SA: MD, 0 ± 0.4; 95% CI, -0.2 to 0; p = 1.0; WS versus BA: MD, 0.2 ± 0.8; 95% CI, 0-0.4; p = 0.6). WB and SA were not different (MD, 0.0 ± 0.6; 95% CI, -0.1 to 0.2; p = 1.0), though both were preferred to BA and CA (WB versus BA: MD, 0.3 ± 0.8; 95% CI, 0.1-0.5; p = 0.02; WB versus CA: 1.0 ± 1.0; 95% CI, 0.8-1.2; p < 0.01). We found no difference between SA and BA (MD, 0.3 ± 0.7; 95% CI, 0.1-0.4; p = 0.06). We found that each was preferred to CA (SA versus CA: 0.9 ± 1.0; 95% CI, 0.7-1.2; p < 0.01; BA versus CA: 0.7 ± 1.0; 95% CI, 0.5-0.9; p < 0.01), with similar results in all other categories. When asked to rank all types of attire, patients preferred WS or WB for both men and women surgeons, followed by SA, BA, and CA. CONCLUSIONS: Similar to findings in the outpatient orthopaedic setting, in the inpatient setting, we found patients had a moderate overall preference for physicians wearing a white coat, either over scrubs or business attire, and, to some extent, scrubs alone. Respondents did not show any difference in preference based on the gender of the pictured surgeon. For men and women orthopaedic surgeons in the urban inpatient setting, stereotypical physician's attire such as a white coat over either scrubs or business attire, or even scrubs alone may improve numerous components of the patient-physician relationship and should therefore be strongly considered to enhance overall patient care. LEVEL OF EVIDENCE: Level II, therapeutic study.

Orthopaedic Surgery Resident Financial Literacy: An Assessment of Knowledge in Debt, Investment, and Retirement Savings.

Most orthopedic residents carry significant debt and may enter their practice with little knowledge of business management, minimal retirement savings, and overall poor financial literacy. This study aimed to gauge financial literacy, debt, and retirement planning in United States orthopedic surgery residents. Willingness to participate in formalized financial education was also assessed. Eighty-five allopathic orthopedic surgery residents in the United States completed a 14-question anonymous online survey in 2016. The survey assessed demographic data, self-assessed financial knowledge, amount of credit card debt and loans, preparation for retirement, and willingness to participate in formal didactic education on these topics. Most respondents derive their financial knowledge from personal research (51%), whereas only 4 per cent have a formal curriculum. Despite most respondents reporting more than $200,000 in outstanding loans, only 31 per cent create and stick to a budget. Few programs offer retirement advice, and 48 per cent of respondents save $0 toward retirement. Eighty-five per cent of residents expressed interest in learning about personal investment, savings, and retirement planning. Orthopedic surgery residents carry significant debt and do not achieve their high-income potential until disproportionately later in life. Only 4 per cent of residents have formal training in investing, personal finance, or retirement despite a majority who desire such a curriculum. In fact, almost 75 per cent of those surveyed felt less prepared for retirement than their peers outside of medical training. This study suggests a role for formal financial education in the orthopedic curriculum to prepare residents for retirement, improve financial literacy, and enhance debt management.

Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing.

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

A new species of the endemic Australian genus Hyptiogaster Kieffer Hymenoptera: Gasteruptiidae).

Hyptiogaster arafura sp. nov. is described from Arafura Swamp, Northern Territory, Australia, as the eleventh species of Hyptiogaster Kieffer (Hymenoptera: Gasteruptiidae). A revised diagnosis of Hyptiogaster is given based on the new species.

Isolated Compression of the Ulnar Nerve Motor Branch: A Case Series With 3 Unique Etiologies.

BACKGROUND: Although ulnar neuropathies are commonly encountered, isolated involvement of the motor branch is exceedingly rare. Previous reports of this entity describe compression as the deep motor branch passes through the piso-hamate hiatus and the adductor pollicis hiatus. This case series described 3 cases of motor branch compression due to unique etiologies which resolved after surgery. METHODS: A retrospective chart review identified patients with compression of the ulnar nerve motor branch. From these patients, 3 were selected with a unique etiology for compression. Patient demographics, objective and subjective findings, and pathology identified during surgery were recorded and analyzed. RESULTS: Eight patients had compression of the ulnar nerve motor branch and 3 unique etiologies were selected; an intraneural ganglion, a constricting leash of vessels, and a series of compressing fibrous bands. All required surgery, and each patient had full resolution of symptoms by 1 year postoperatively. DISCUSSION: Patients presenting with complaints of weakness with a positive Froment and Egawa signs but a negative Wartenberg sign and no sensory complaints can be a diagnostic dilemma. Compression of the ulnar nerve motor branch must be considered, and here we present 3 unique cases. Activity modification in those presenting early may be curative, although many ultimately require surgery. In the cases presented here, all patients experienced full resolution of their symptoms by 1 year after surgery.