Biodiversity conservation, human-animal interactions, and zootherapy in ecological knowledge of Indonesian Healers.

We examined the entanglement of biodiversity conservation, human-animal interactions, zootherapy, and local beliefs among Sumatran Healers and their local community by completing an ethnography of 43 Indigenous Healers across 8 tribes in Bengkulu Province, Sumatra, Indonesia. Data collection tools were interviews, observations, videos, photographs, and a researcher journal. Of the 43 Healers, 30 used animals and mentioned 62 species. Of the animals identified, the International Union for Conservation of Nature Red List lists 34% (n = 21) as endangered, decreasing, or vulnerable, including Sumatran tiger (Panthera tigris sumatrae), Sumatran elephant (Elephas maximus sumatranus), and Sumatran rhinoceros (Dicerorhinus sumatrensis). Of the 30 Healers using animals, 50% (n = 15) practiced healing with at least one endangered, decreasing, or vulnerable animal. We defined 3 personas: Healer self-persona, Healer-imposed persona, and community-imposed persona. A persona represented a group's opinions and sentiments related to Healers killing animals for medicinal purposes. Using an iterative data analysis process, we grouped the data across the 3 personas into 5 themes: ease of killing and preparing animals, emotions related to killing animals, animal value, relationship to religion, and Healers are tricksters. The complexity of merging the identities of Healers and the community within an actor-network embodies the relationality of actions, interactions, and feelings among Healers, between Healers and animals, and between Healers and the community. Conservationists should be cognizant of Healers' medicinal use of animals, views of human-animal interactions, and zootherapy from all social and emotional perspectives. The data led to defining Indigenous Healer ecological knowledge components of zootherapy, human-animal interactions, and biodiversity conservation.

Conservación de la biodiversidad, interacciones humano­fauna y zooterapia dentro del conocimiento ecológico de los curanderos indonesios Resumen Analizamos la complejidad de la conservación de la biodiversidad, las interacciones humano­fauna, la zooterapia y las creencias locales de los curanderos y su comunidad local mediante una etnografía de 43 curanderos indígenas de ocho tribus en la provincia de Bengkulu en Sumatra, Indonesia. Usamos entrevistas, observaciones, videos, fotografías y una bitácora de investigador como herramientas de recolección de datos. De los 43 curanderos, 30 usaban animales y mencionaron 62 especies. El 34% (n = 21) de los animales identificados están catalogados como en peligro, en disminución o vulnerables en la Lista Roja de la Unión Internacional para la Conservación de la Naturaleza, incluidos el tigre de Sumatra (Panthera tigris sumatrae), el elefante de Sumatra (Elephas maximus sumatranus) y el rinoceronte de Sumatra (Dicerorhinus sumatrensis). De los 30 curanderos que usan animales, el 50% (n = 15) practica la sanación con al menos una especie en peligro, en disminución o vulnerable. Definimos tres percepciones: autopercepción de curandero, percepción impuesta de curandero y percepción impuesta de comunidad. Cada percepción representó las opiniones y sentimientos de un grupo con respecto a la matanza de animales por cuestiones medicinales. Usamos un proceso de análisis de datos repetitivos para agrupar la información de las tres percepciones en tres temas: facilidad para matar y preparar animales, emociones relacionadas con matar animales, valor del animal, relación con la religión y los curanderos son estafadores. La complejidad de combinar las identidades de los curanderos dentro de una red de actores representa cómo se relacionan las acciones, interacciones y sentimientos dentro de la comunidad de curanderos, entre los curanderos y los animales y entre los curanderos y la comunidad. Los conservacionistas deben ser conscientes desde todas las perspectivas sociales y emocionales del uso medicinal que los curanderos dan a los animales, las percepciones sobre las interacciones humano­fauna y la zooterapia. Esta información nos llevó a definir los componentes del conocimiento ecológico de los curanderos indígenas en materia de zooterapia, interacciones humano­fauna y conservación de la biodiversidad.

Adherence to adhesive patch electrocardiographic monitoring among adults with disabilities.

BACKGROUND: Individuals with developmental and/or intellectual disabilities (I/DD) are at a greater risk for atrial fibrillation (AF), the most common type of cardiac arrhythmia. AF is associated with heart failure, stroke, poor mental health, and reduced quality of life. Management and treatment decisions are based on the ability to detect AF; however, noninvasive, remote cardiac monitoring may not be tolerated by individuals with I/DD. OBJECTIVE: To examine adherence to the placement of an ambulatory cardiac rhythm monitoring patch device by adult patients with I/DD. METHODS: Investigators extracted chart data from a consecutive series of adult patients (18 years+) who received the patch device as part of standard treatment at an adult health center between November 1, 2015 and October 31, 2019. RESULTS: A total of 95 patients were included in data analysis. Average age of subjects was 53.8 ± 13.9 years (range: 20.2-88.5); 66.7% were male. All subjects had intellectual disabilities as follows: mild, 37.9%; moderate, 29.5%; severe, 21.0%; and, profound, 11.6%. With a prescribed duration of 14 days, subjects wore the device a median (interquartile range [IQR]) of 12.2 days (4.1-14.0); total analysis time was a median of 9.5 days (3.4-13.5). A total of 29 subjects (30.5%) received cardiac diagnoses not previously identified (median = 1 new diagnosis; range: 1-5). CONCLUSIONS: This pilot study suggests the possible utility of an ambulatory monitoring patch device in an adult population with I/DD. Investigators recommend larger studies to confirm such preliminary findings to ultimately improve clinical management and patient quality of life.

Challenges to Professional Success for Women Plastic Surgeons: An International Survey.

BACKGROUND: Female plastic surgeons face specific challenges in their careers that impact lifestyle and professional choices. OBJECTIVE: The authors sought to delineate these specific issues further through means of an anonymous survey and to suggest areas for improvement. METHODS: In August 2017, a link to an online email questionnaire via SurveyMonkey.com was sent to 398 women members of the International Society of Aesthetic Plastic Surgery, which included questions on demographics, surgical training, practice characteristics and preferences, leadership and professional activities, marriage and childcare, financial status, workplace sexism and sexual harassment and surgeon attitudes. RESULTS: A total of 138 female plastic surgeons responded to the survey for a response rate of 34.7%. Critical issues most cited by respondents included work-life balance and childcare responsibilities, sexual harassment and the lack of gender parity at meetings. CONCLUSIONS: Plastic surgery training programs, institutions and societies should acknowledge the additional challenges that female surgeons face. The greatest areas for improvement include the balance of work and family responsibilities, addressing the prevalence of sexual harassment and improved representation at scientific meetings. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants.

BACKGROUND: An unsafe sleep environment remains the leading contributor to unexpected infant death. PURPOSE: To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants. METHODS: A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018. RESULTS: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%. IMPLICATIONS FOR PRACTICE: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices. IMPLICATIONS FOR RESEARCH: Future studies on the impact of such an initiative at other hospitals are needed.

Is Earlier Better? The Relationship between Age When Starting Early Intervention and Outcomes for Children with Autism Spectrum Disorder: A Selective Review.

Although the conventional wisdom is that "earlier is better" when it comes to intervention for children with ASD, it is not clear what evidence exists to support this notion. This review examined a group of studies that addressed outcomes for young children with ASD who started early intervention at a range of ages. The review was selective by including only papers that examined the age of initiation of treatment as well as baseline cognitive, language, or adaptive level and, in addition, employed a method to control for the covariance between early ability level and age of beginning intervention. Fourteen studies were identified and then compared on methods and outcomes. The support for "earlier is better" was mixed, but it was clear that complex relationships among predictor variables need to be explored in order to understand the role of age of starting early intervention for later outcomes.

Technology and social media use by adult patients with intellectual and/or developmental disabilities.

BACKGROUND: Technology and social media offer individuals with intellectual and/or developmental disabilities (I/DD) unique and innovative ways to facilitate active participation in their own healthcare process. What remains unclear is the extent to which devices are currently used by this growing patient population. OBJECTIVE: To explore the prevalence of technology and social media use, as well as the possible barriers, among adult patients with I/DD. METHODS: A cross-sectional study utilizing an anonymous, accessible survey was used to obtain data from all adult patients (18 + years of age) with I/DD presenting for primary care services at a healthcare facility in New York between September and December of 2016. RESULTS: A total of 370 individuals completed the survey (529 approached, 69.9% response rate). Less than half (44.6%) of respondents used devices such as a tablet, smartphone or desktop; most (86.8%) did not use social media. Only 21.6% of respondents indicated that they use some type of assistive technology. While some respondents (46.0%) were identified by their caregivers as having a disability that would prevent them from learning/using technology, other respondents reported having no challenges (18.0%), needing training and/or ongoing support (7.4%), or being uncertain as to whether they would experience any challenges (15.5%). CONCLUSIONS: Many adult patients with I/DD do not use technology and social media that could promote self-determination and participation in their healthcare. Continued efforts must be made to promote technology use among adults with I/DD and to ensure that appropriate training is available for both the individual and his/her caregivers to achieve adoption and utilization.

A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale.

BACKGROUND: The ideal management of patients with newly diagnosed symptomatic atrial fibrillation (AF) remains unknown. Current practice guidelines recommend a trial of antiarrhythmic drugs (AAD) prior to considering an invasive ablation procedure. However, earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF, as well as impart other important clinical benefits. OBJECTIVE: The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed, symptomatic atrial fibrillation. METHODS/DESIGN: The EARLY-AF study (ClinicalTrials.govNCT02825979) is a prospective, open label, multicenter, randomized trial with a blinded assessment of outcomes. A total of 298 patients will be randomized in a 1:1 fashion to first-line AAD therapy, or first-line cryoballoon-based pulmonary vein isolation. Patients with symptomatic treatment naïve AF will be included. Arrhythmia outcomes will be assessed by implantable cardiac monitor (ICM). The primary outcome is time to first recurrence of AF, atrial flutter, or atrial tachycardia (AF/AFL/AT) between days 91 and 365 following AAD initiation or AF ablation. Secondary outcomes include arrhythmia burden, quality of life, and healthcare utilization. DISCUSSION: The EARLY-AF study is a randomized trial designed to evaluate the optimal first management approach for patients with AF. We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence.

Intensity of Vasopressor Therapy for Septic Shock and the Risk of In-Hospital Death.

CONTEXT: Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions. OBJECTIVES: To determine if intensity of vasopressor therapy accurately predicts in-hospital death. METHODS: This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship. RESULTS: A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival. CONCLUSION: When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.

Organ Distribution of 13N Following Intravenous Injection of [13N]Ammonia into Portacaval-Shunted Rats.

Ammonia is neurotoxic, and chronic hyperammonemia is thought to be a major contributing factor to hepatic encephalopathy in patients with liver disease. Portacaval shunting of rats is used as an animal model to study the detrimental metabolic effects of elevated ammonia levels on body tissues, particularly brain and testes that are deleteriously targeted by high blood ammonia. In normal adult rats, the initial uptake of label (expressed as relative concentration) in these organs was relatively low following a bolus intravenous injection of [13N]ammonia compared with lungs, kidneys, liver, and some other organs. The objective of the present study was to determine the distribution of label following intravenous administration of [13N]ammonia among 14 organs in portacaval-shunted rats at 12 weeks after shunt construction. At an early time point (12 s) following administration of [13N]ammonia the relative concentration of label was highest in lung with lower, but still appreciable relative concentrations in kidney and heart. Clearance of 13N from blood and kidney tended to be slower in portacaval-shunted rats versus normal rats during the 2-10 min interval after the injection. At later times post injection, brain and testes tended to have higher-than-normal 13N levels, whereas many other tissues had similar levels in both groups. Thus, reduced removal of ammonia from circulating blood by the liver diverts more ammonia to extrahepatic tissues, including brain and testes, and alters the nitrogen homeostasis in these tissues. These results emphasize the importance of treatment paradigms designed to reduce blood ammonia levels in patients with liver disease.

Autism Spectrum Disorder Screening Instruments for Very Young Children: A Systematic Review.

Research on ASD in infancy has provided a rationale for developing screening instruments for children from the first year of life to age of 18 months. A comprehensive literature search identified candidate screening tools. Using methodological probe questions adapted from the Quality Assessment of Diagnostic Accuracy Studies (QUADAS), two Level 1 and three Level 2 screening instruments were reviewed in detail. Research evidence conclusions were that instrument development was in beginning phases, is not yet strong, and requires further development. Clinical recommendations were to continue vigilant developmental and autism surveillance from the first year on but to use the screening instruments per se only for high-risk children rather than for population screening, with considerations regarding feasibility for individual settings, informing caregivers about strengths and weaknesses of the tool, and monitoring new research.

The impact of a hospital-based educational video on maternal perceptions and planned practices of infant safe sleep.

PURPOSE: To evaluate whether an educational video would impact infant sleep practices among new mothers. DESIGN AND METHODS: Survey responses of new mothers who did (n = 43) versus did not (n = 49) watch the educational video were compared to identify differences in observed and planned infant sleep practices. RESULTS: Mothers who watched the video were more likely to observe safe sleep practices while in the hospital (67.4% vs. 46.9%, p < .05). They were also less likely to plan for (unsafe) side positioning (23.9% vs. 7.1%, p < .05). PRACTICE IMPLICATIONS: Given the potentially fatal consequence of unsafe sleep, a brief video provided by nursing staff can be a prudent component of new parent education.

Is fluorescence under an alternate light source sufficient to accurately diagnose subclinical bruising?

This single-blinded, randomized validation study was conducted to evaluate whether fluorescence under alternate light sources (ALS) is sufficient to diagnose subclinical bruising (bruising not visible under white light). Standardized trauma was induced on randomly selected ventral forearms. On days 1, 7, and 14 investigators independently examined case forearms under white light for perceived bruising and under ALS for fluorescence and compared body maps. 56 case and 62 control forearms (n = 118) were examined. Sensitivity of ALS on days 1, 7, and 14 was 76.8%, 69.6%, and 60.7%, respectively, compared to 69.6%, 60.0%, and 32.1% for white light. The specificity of ALS on days 1, 7, and 14 was 51.6%, 59.7%, and 53.2%, respectively, compared to 71.0%, 81.4%, and 86.9% for white light. ALS has increased sensitivity yet low specificity compared to white light in accurately detecting bruises. Fluorescence under ALS is not sufficient to accurately or responsibly diagnose subclinical bruising.

Timely pain management in the emergency department.

BACKGROUND: Delivering timely pain relief remains a challenge for most emergency departments. OBJECTIVE: To evaluate the effectiveness of a policy aimed at delivering analgesics within 30 min to patients presenting to an emergency department with severe pain. METHODS: Subjects were aged ≥19 years, had a principal diagnosis of renal colic, hip fracture, or sickle cell disease, reported a pain score ≥8 on a scale of 0 to 10 at triage, and continued to report a score in this range until receiving analgesia. The study compared proportions of patients receiving analgesics within the 30-min target, median time to analgesic administration, and median time to relief of severe pain (decline in pain level to score <8) during 6 months before vs. 6 months after implementation of the new pain management policy. RESULTS: Paradoxically, the median total waiting time to analgesic administration increased from 64 min (n = 75) to 80 min (n = 70) after policy implementation (p = 0.01), and the proportion of patients receiving analgesics within 30 min declined from 17% (13/75) to 7% (5/70) (p = 0.08). Median time to relief of severe pain did not differ significantly between periods (130.5 vs. 153 min; p = 0.31). CONCLUSIONS: After implementation of the new pain management policy, the proportion of patients with severe pain receiving analgesics within 30 min actually declined. Although a 30-min target may be unrealistic, it seems reasonable to conclude that something is wrong when patients with notoriously painful conditions must typically wait 1-2 h to obtain relief. Given the millions of individuals who receive care in emergency departments nationwide each year, the suffering caused by delays occurs on a large scale, so creative approaches are clearly needed to overcome the obstacles.

Sprint Fidelis lead fractures in patients with cardiac resynchronization therapy devices: insight from the Resynchronization/Defibrillation for Ambulatory Heart Failure (RAFT) study.

BACKGROUND: Using data from the Resynchronization/Defibrillation for Ambulatory Heart Failure (RAFT) study, we examined whether Fidelis lead failure was more common in patients with implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (ICD-CRT) than in patients with an ICD only. METHODS AND RESULTS: All cases of patients who had a right ventricular defibrillation lead revision in the RAFT study were adjudicated for the presence of lead fracture. Criteria for fracture were at least 2 of the following: (1) Impedance rise (>50% or >500 Ω in 1 week), (2) short interval count >10 times per day or 300 times per month, or (3) inappropriate shock caused by noise, verified by stored electrogram. A total of 1798 patients were enrolled into the RAFT study, with a mean follow-up of 40±20 months. There were 818 patients (45.5%) who received a Fidelis lead at the original implantation, 405 with an ICD only and 413 with an ICD-CRT. There were 47 confirmed defibrillation lead fractures; 45 were Fidelis leads (5.5% of Fidelis leads). The overall rate of fracture in the ICD group was 3.2% compared with 7.8% in the ICD-CRT group (P=0.006; hazard ratio, 2.42; 95% confidence interval, 1.27-4.61). Significant correlates of lead fracture in this population were undergoing an ICD-CRT implantation and having ≥2 leads. CONCLUSIONS: In this analysis of the RAFT study, patients with an ICD-CRT were found to have a significantly higher fracture rate than patients with an ICD. This finding needs to be considered when these patients are assessed for possible lead revision at the time of an elective generator replacement.

Vitamin D and retinopathy in adults with diabetes mellitus.

OBJECTIVE To explore a hypothesized association between vitamin D inadequacy and diabetic retinopathy. METHODS This cross-sectional study analyzed data from individuals aged 40 years and older with diabetes mellitus who participated in the interview and medical examination components of the Third National Health and Nutrition Examination Survey conducted from October 1, 1988, through September 30, 1994. The relationship between diabetic retinopathy and serum 25-hydroxyvitamin D concentration was evaluated using regression analysis in the presence of demographic and clinical covariates, such as age, race, obesity, and persistent hyperglycemia. RESULTS On the basis of the 1790 adults with diabetes who met the study's inclusion criteria, the percentage of individuals with vitamin D deficiency increased with severity of retinopathy: no retinopathy, 27.9%; mild, 28.2%; moderate to severe, 43.2%; and proliferative, 64.6% (P = .01). Regression analysis of retinopathy severity vs serum 25-hydroxyvitamin D concentration did not demonstrate a statistically significant relationship between the two variables (P = .07). CONCLUSIONS This study found an association between severity of diabetic retinopathy and prevalence of vitamin D deficiency, but the findings were inconclusive about the existence of a relationship between retinopathy severity and serum 25-hydroxyvitamin D concentration. Given previous research indicating possible anti-inflammatory and antiangiogenic properties of vitamin D, the connection between vitamin D and diabetic retinopathy warrants further study.

The influence of career stage, practice type and location, and physician's sex on surgical practices among board-certified plastic surgeons performing breast augmentation.

BACKGROUND: Breast augmentation is the most commonly performed cosmetic surgical procedure in the United States, but surgeon preferences in terms of technique and postoperative care regimen vary widely. OBJECTIVES: The authors investigated the influence of career stage, practice type and location, and physician's sex on surgical technique preferences among board-certified plastic surgeons performing breast augmentation. METHODS: In October 2009, an online survey was e-mailed to all active members of the American Society of Plastic Surgeons practicing within the United States. Response frequencies were calculated and correlated with surgeon demographics. RESULTS: From the pool of 4737 respondents, 898 responses were received (18.9%). Surgeons performing breast augmentation were more frequently male, between 46 and 65 years old, and had practiced for at least 20 years in solo private practice in a suburban setting. Surgical volume most frequently consisted of 10% to 25% cosmetic surgery, with 10 to 50 breast augmentations performed per year. Surgeons in practice for five years or less were more likely to use smooth, round silicone gel-filled implants, to select implants smaller than 300 cc, to use the dual-plane pocket, and to recommend yearly follow-up. Surgeons in practice for more than 20 years were more likely to select saline implants, utilize the subglandular plane, perform closed capsulotomy, and place drains. Surgeons at academic centers performed fewer breast augmentation surgeries and placed smaller implants than those in private practice, while surgeons in suburban locations performed more breast augmentations than those in urban or rural locations. Surgeons in the West performed the greatest number of augmentations, although the largest-sized implants were placed in the Southwest. Compared with men, women surgeons appeared significantly less likely to use saline implants, were less likely to perform more than 100 breast augmentations per year, and were significantly more likely to place implants less than 300 cc. CONCLUSIONS: Surgical preferences were associated with years in practice and included differences in technique and postoperative care. Practice location was associated with differences in procedural volume, implant size, incision location, and recommended follow-up time, while practice type was related to surgical volume, implant size, implant location, and percentage of cosmetic surgery performed.

Parent education by maternity nurses and prevention of abusive head trauma.

OBJECTIVE: A consortium of the 19 community hospitals and 1 tertiary care children's hospital that provide maternity care in the New York State Hudson Valley region implemented a program to teach parents about the dangers of shaking infants and how to cope safely with an infant's crying. This study evaluated the effectiveness of the program in reducing the frequency of shaking injuries. METHODS: The educational program, which was delivered by maternity nurses, included a leaflet explaining abusive head trauma ("shaken baby syndrome") and how to prevent it, an 8-minute video on the subject, and a statement signed by parents acknowledging receipt of the information and agreeing to share it with others who will care for the infant. Poisson regression analysis was used to compare the frequency of shaking injuries during the 3 years after program implementation with the frequency during a 5-year historical control period. RESULTS: Sixteen infants who were born in the region during the 8-year study period were treated at the children's hospital for shaking injuries sustained during their first year of life. Of those infants, 14 were born during the 5-year control period and 2 during the 3-year postimplementation period. The decrease from 2.8 injuries per year (14 cases in 5 years) to 0.7 injuries per year (2 cases in 3 years) represents a 75.0% reduction (P = .03). CONCLUSIONS: Parent education delivered in the hospital by maternity nurses reduces newborns' risks of sustaining an abusive head injury resulting from shaking during the first year of life.

Impact of AOA status and perceived lifestyle on career choices of medical school graduates.

BACKGROUND: Based upon student ratings of such factors as predictable work hours and personal time, medical specialties have been identified as lifestyle friendly, intermediate, or unfriendly. Lifestyle friendly programs may be more desirable, more competitive, and for students elected to the Alpha Omega Alpha (AOA) Honor Medical Society, more attainable. OBJECTIVE: The objective of this study was to evaluate whether AOA students increasingly entered lifestyle friendly residency programs and whether trends in program selection differed between AOA and non-AOA graduates. DESIGN: This retrospective cohort study examined PGY-2 data from the Association of American Medical Colleges and the 12 allopathic schools in the Associated Medical Schools of New York. PARTICIPANTS: Data on 1987-2006 graduates from participating schools were evaluated. MAIN MEASURES: Residency program selection over the 20-year period served as the main outcome measure. KEY RESULTS: AOA graduates increasingly entered lifestyle-friendly residencies--from 12.9% in 1987 to 32.6% in 2006 (p < 0.01). There was also a significant decrease in AOA graduates entering lifestyle unfriendly residencies, from 31.6% in 1987 to 12.6% in 2006 (p < 0.01). Selection of lifestyle intermediate residencies among AOA graduates remained fairly stable at an average of 53%. Similar trends were found among non-AOA students. However, within these categories, AOA graduates increasingly selected radiology, dermatology, plastic surgery and orthopedics while non-AOA graduates increasingly selected anesthesiology and neurology. CONCLUSIONS: While lifestyle factors appear to influence residency program selection, AOA graduates differentially were more likely to either choose or attain certain competitive, lifestyle-friendly specialties. Health care reform should be targeted to improve lifestyle and decrease income disparities for specialties needed to meet health manpower needs.

Cardiac resynchronization therapy: a meta-analysis of randomized controlled trials.

BACKGROUND: Studies of cardiac resynchronization therapy in addition to an implantable cardioverter defibrillator in patients with mild to moderate congestive heart failure had not been shown to reduce mortality until the recent RAFT trial (Resynchronization/Defibrillation for Ambulatory Heart Failure Trial). We performed a meta-analysis including the RAFT trial to determine the effect of cardiac resynchronization therapy with or without an implantable defibrillator on mortality. METHODS: We searched electronic databases and other sources for reports of randomized trials using a parallel or crossover design. We included studies involving patients with heart failure receiving optimal medical therapy that compared cardiac resynchronization therapy with optimal medical therapy alone, or cardiac resynchronization therapy plus an implantable defibrillator with a standard implantable defibrillator. The primary outcome was mortality. The optimum information size was considered to assess the minimum amount of information required in the literature to reach reliable conclusions about cardiac resynchronization therapy. RESULTS: Of 3071 reports identified, 12 studies (n = 7538) were included in our meta-analysis. Compared with optimal medical therapy alone, cardiac resynchronization therapy plus optimal medical therapy significantly reduced mortality (relative risk [RR] 0.73, 95% confidence interval [CI] 0.62-0.85). Compared with an implantable defibrillator alone, cardiac resynchronization therapy plus an implantable defibrillator significantly reduced mortality (RR 0.83, 95% CI 0.72-0.96). This last finding remained significant among patients with New York Heart Association (NYHA) class I or II disease (RR 0.80, 95% CI 0.67-0.96) but not among those with class III or IV disease (RR 0.84, 95% CI 0.69-1.07). Analysis of the optimum information size showed that the sequential monitoring boundary was crossed, which suggests no need for further clinical trials. INTERPRETATION: The cumulative evidence is now conclusive that the addition of cardiac resynchronization to optimal medical therapy or defibrillator therapy significantly reduces mortality among patients with heart failure.