Family planning competency following medical school Ob/Gyn clerkships at faith-based and secular sites.

Contraception and abortion topics are variably, but often poorly, addressed in medical school curricula. Restrictions on contraceptive and abortion care at faith-based hospitals may hinder comprehensive family planning training for medical students during Ob/Gyn clerkships. Here we investigated whether medical students at faith-based and non-faith-based clerkships experienced different observations during their Ob/Gyn clerkship and/or differences in self-perceived competency in patient counseling, objective knowledge, and perceived adequacy of training in contraception and abortion topics post-clerkship. A survey was distributed to third- and fourth-year medical students at New York Institute of Technology, College of Osteopathic Medicine. Across all clerkship sites (n = 102 students), observations of, and competency in, contraceptive care was higher than in abortion care. Students at non-faith-based clerkship sites (n = 54) reported the highest levels of observation of contraceptive and abortion care (19.6-90.7%), while those at Catholic sites (n = 26) typically reported the lowest (7.7-34.6%). Students at non-faith-based sites reported significantly higher competency in contraceptive care and some aspects of abortion care, than those at Catholic, and some other faith-based sites (n = 48). Clerkship training at faith-based sites, specifically Catholic sites, resulted in poorer Ob/Gyn training, particularly in contraceptive care. Training outcomes in abortion care were poor at all Ob/Gyn clerkship sites.

Does regular attendance in supplemental virtual near-peer tutoring in anatomy laboratory content improve anatomy performance for medical students?

Near-peer tutoring (NPT) programs are popular vehicles to supplement traditional delivery of medical school curricula, including for anatomy laboratory (AL) content. While NPT programs can result in improved preclinical coursework performance for tutees, little to no data specifically show a benefit of NPT in AL course performance. In 2021, NYIT College of Osteopathic Medicine launched an NPT program where qualified second-year students led group tutoring sessions for first-year students. This study investigated whether participation and level of attendance in AL NPT sessions were associated with greater examination-to-examination improvement in AL performance. Student attendance at AL sessions in the NPT program was categorized as either regular (10 or more sessions), moderate (5-9 sessions), infrequent (1-4 sessions), or never during one semester. For the first 2 years of the NPT program, attendance frequency at AL tutoring sessions had a significant impact on average exam-to-exam improvement (p < 0.05). Overall, students who attended tutoring at any frequency had greater exam-to-exam improvement than students who never attended (p < 0.05). However, this trend was only significant in 1 of 2 years investigated. These data show that NPT programs can, though not uniformly, benefit student outcomes in AL coursework. With these data, this study provides additional details on the level of attendance necessary for expected improvements in AL coursework.

Is Early Extubation Associated with Better Outcomes After Neonatal Congenital Heart Disease Surgery?

Early extubation (EE) of children after surgery (occurring within the operating room or ≤ 6 hours postadmission) for congenital heart disease (CHD) has been advocated to improve postoperative care. The objective of this study is to compare outcomes of neonates undergoing EE following CHD surgical repair with those extubated more than 6 hours after surgery. Retrospective cohort study utilizes data from the Virtual Pediatric Systems database. Data from neonates undergoing surgical repair for six common CHD lesions and admitted to 57 pediatric intensive care units (ICUs) between July 1, 2010, and June 30, 2015, were analyzed. A total of 1,274 neonates were analyzed; 100 (7.8%) had EE, and 146 (11.5%) were extubated > 6 hours but ≤ 24 hours. Most patients (80.4%) were extubated > 24 hours. The EE group had higher ( p < 0.001) failed extubation rate than patients extubated at any other time; a multivariate analysis of linear regression showed no advantage in length of stay (LOS) of EE compared with those subjects who were extubated in the first 24 hours ( p -value: 0.178). Extubation failure was found to impact ICU LOS in this analysis. The ICU LOS was increased by 3.5 days for every failed extubation attempt ( p -value: <0.001, 95% confidence interval: 1.6-5.5 days). EE after CHD surgery is possible. Though it appears as an attractive option to decrease potential mechanical ventilation complications, this study of neonates shows that EE might result in worse outcomes than when performing extubation between 6 and 24 hours postoperatively.

Extended Infusion ß-Lactams for the Treatment of Gram-Negative Bacteremia in Children.

OBJECTIVE: The pharmacokinetics of ß-lactam antibiotics favor administration via an extended infusion. Although literature to support extended infusion ß-lactams exists for adults, few data are available in pediatrics, especially among patients with bacteremia. The purpose of this study was to compare clinical outcomes between extended and standard infusions in children with Gram-negative bacteremia. METHODS: This retrospective chart analysis included hospitalized patients ages 0 to 18 years who received at least 72 hours of cefepime, meropenem, or piperacillin-tazobactam between January 1, 2013 and July 30, 2021. Clinical outcomes included duration of antibiotic therapy, hospital length of stay, readmission within 30 days, all-cause mortality, time to blood culture clearance, and time to normalization of inflammatory markers. RESULTS: A total of 124 patients (51 extended infusion, 73 standard infusion) met criteria for evaluation. Duration of antibiotic therapy was shorter in the extended infusion group (6.6 days versus 10.2 days; p = 0.01). There were no differences in hospital length of stay, readmission rates, all-cause mortality, time to normalization of inflammatory markers, or time to blood culture clearance. CONCLUSIONS: Use of extended infusion ß-lactam antibiotics in children with Gram-negative bacteremia was associated with shorter durations of therapy and should be the preferred method of administration when feasible.

Adaptations for bipedal walking: Musculoskeletal structure and three-dimensional joint mechanics of humans and bipedal chimpanzees (Pan troglodytes).

Humans are unique among apes and other primates in the musculoskeletal design of their lower back, pelvis, and lower limbs. Here, we describe the three-dimensional ground reaction forces and lower/hindlimb joint mechanics of human and bipedal chimpanzees walking over a full stride and test whether: 1) the estimated limb joint work and power during the stance phase, especially the single-support period, is lower in humans than bipedal chimpanzees, 2) the limb joint work and power required for limb swing is lower in humans than in bipedal chimpanzees, and 3) the estimated total mechanical power during walking, accounting for the storage of passive elastic strain energy in humans, is lower in humans than in bipedal chimpanzees. Humans and bipedal chimpanzees were compared at matched dimensionless and dimensional velocities. Our results indicate that humans walk with significantly less work and power output in the first double-support period and the single-support period of stance, but markedly exceed chimpanzees in the second double-support period (i.e., push-off). Humans generate less work and power in limb swing, although the species difference in limb swing power was not statistically significant. We estimated that total mechanical positive 'muscle fiber' work and power were 46.9% and 35.8% lower, respectively, in humans than in bipedal chimpanzees at matched dimensionless speeds. This is due in part to mechanisms for the storage and release of elastic energy at the ankle and hip in humans. Furthermore, these results indicate distinct 'heel strike' and 'lateral balance' mechanics in humans and bipedal chimpanzees and suggest a greater dissipation of mechanical energy through soft tissue deformations in humans. Together, our results document important differences between human and bipedal chimpanzee walking mechanics over a full stride, permitting a more comprehensive understanding of the mechanics and energetics of chimpanzee bipedalism and the evolution of hominin walking.

Using Aggregate Vasoactive-Inotrope Scores to Predict Clinical Outcomes in Pediatric Sepsis.

Objectives: The heterogeneity of sepsis makes it difficult to predict outcomes using existing severity of illness tools. The vasoactive-inotrope score (VIS) is a quantitative measure of the amount of vasoactive support required by patients. We sought to determine if a higher aggregate VIS over the first 96 h of vasoactive medication initiation is associated with increased resource utilization and worsened clinical outcomes in pediatric patients with severe sepsis. Design: Retrospective cohort study. Setting: Single-center at Children's Wisconsin in Milwaukee, WI. Patients: One hundred ninety-nine pediatric patients, age less than 18 years old, diagnosed with severe sepsis, receiving vasoactive medications between January 2017 and July 2019. Interventions: Retrospective data obtained from the electronic medical record, calculating VIS at 2 h intervals from 0-12 h and at 4 h intervals from 12-96 h from Time 0. Measurements: Aggregate VIS derived from the hourly VIS area under the curve (AUC) calculation based on the trapezoidal rule. Data were analyzed using Pearson's correlations, Mann-Whitney test, Wilcoxon signed rank test, and classification, and regression tree (CART) analyses. Main Results: Higher aggregate VIS is associated with longer hospital LOS (p < 0.0001), PICU LOS (p < 0.0001), MV days (p = 0.018), increased in-hospital mortality (p < 0.0001), in-hospital cardiac arrest (p = 0.006), need for ECMO (p < 0.0001), and need for CRRT (p < 0.0001). CART analyses found that aggregate VIS >20 is an independent predictor for in-hospital mortality (p < 0.0001) and aggregate VIS >16 for ECMO use (p < 0.0001). Conclusions: There is a statistically significant association between aggregate VIS and many clinical outcomes, allowing clinicians to utilize aggregate VIS as a physiologic indicator to more accurately predict disease severity/trajectory in pediatric sepsis.

The menisci are not shock absorbers: A biomechanical and comparative perspective.

The lateral and medial menisci are fibrocartilaginous structures in the knee that play a crucial role in normal knee biomechanics. However, one commonly cited role of the menisci is that they function as "shock absorbers." Here we provide a critique of this notion, drawing upon a review of comparative anatomical and biomechanical data from humans and other tetrapods. We first review those commonly, and often exclusively, cited studies in support of a shock absorption function and show that evidence for a shock absorptive function is dubious. We then review the evolutionary and comparative evidence to show that (1) the human menisci are unremarkable in morphology compared with most other tetrapods, and (2) "shock" during locomotion is uncommon, with humans standing out as one of the only tetrapods that regularly experiences high levels of shock during locomotion. A shock-absorption function does not explain the origin of menisci, nor are human menisci specialized in any way that would explain a unique shock-absorbing function during human gait. Finally, we show that (3) the material properties of menisci are distinctly poorly suited for energy dissipation and that (4) estimations of meniscal energy absorption based on published data are negligible, both in their absolute amount and in comparison to other well-accepted structures which mitigate shock during locomotion. The menisci are evolutionarily ancient structures crucial for joint congruity, load distribution, and stress reduction, among a number of other functions. However, the menisci are not meaningful shock absorbers, neither in tetrapods broadly, nor in humans.

Footprint evidence of early hominin locomotor diversity at Laetoli, Tanzania.

Bipedal trackways discovered in 1978 at Laetoli site G, Tanzania and dated to 3.66 million years ago are widely accepted as the oldest unequivocal evidence of obligate bipedalism in the human lineage1-3. Another trackway discovered two years earlier at nearby site A was partially excavated and attributed to a hominin, but curious affinities with bears (ursids) marginalized its importance to the paleoanthropological community, and the location of these footprints fell into obscurity3-5. In 2019, we located, excavated and cleaned the site A trackway, producing a digital archive using 3D photogrammetry and laser scanning. Here we compare the footprints at this site with those of American black bears, chimpanzees and humans, and we show that they resemble those of hominins more than ursids. In fact, the narrow step width corroborates the original interpretation of a small, cross-stepping bipedal hominin. However, the inferred foot proportions, gait parameters and 3D morphologies of footprints at site A are readily distinguished from those at site G, indicating that a minimum of two hominin taxa with different feet and gaits coexisted at Laetoli.

Association of Fluid Balance and Survival of Pediatric Patients Treated With Extracorporeal Membrane Oxygenation.

The effect of positive fluid balance (FB) on extracorporeal membrane oxygenation (ECMO) outcomes in pediatric patients remains unknown. We sought to evaluate if positive FB in pediatric intensive care unit (PICU) patients with respiratory and/or cardiac failure necessitating ECMO was associated with increased morbidity or mortality. This was a multicenter retrospective cohort study of data from the deidentified PEDiatric ECMO Outcomes Registry (PEDECOR). Patients entered into the database from 2014 to 2017, who received ECMO support, were included. A total of 168 subjects met the study criteria. Univariate analysis showed no significant difference in total FB on ECMO days 1-5 between survivors and non-survivors [median 90 ml/kg (IQR 18-208.5) for survivors vs. median 139.7 ml/kg (IQR 11.2-300.6) for non-survivors, p = 0.334]. There was also no difference in total FB on ECMO days 1-5 in patients with no change in functional outcome as reflected by the Pediatric Outcome Performance Category (POPC) score vs. those who had worsening in POPC score ≥2 at hospital discharge [median 98 ml/kg (IQR 18-267) vs. median 130 ml/kg (IQR 13-252), p = 0.91]. Subjects that required 50 ml/kg or more of blood products over the initial 5 days of ECMO support had an increased rate of mortality with an odds ratio of 5.8 (95% confidence interval of 2.7-12.3; p = 0.048). Our study showed no association of the noted FB with survival after ECMO cannulation. This FB trend was also not associated with POPC at hospital discharge, MV duration, or ECMO duration. The amount of blood product administered was found to be a significant predictor of mortality.

The loss of the 'pelvic step' in human evolution.

Human bipedalism entails relatively short strides compared with facultatively bipedal primates. Unique non-sagittal-plane motions associated with bipedalism may account for part of this discrepancy. Pelvic rotation anteriorly translates the hip, contributing to bipedal stride length (i.e. the 'pelvic step'). Facultative bipedalism in non-human primates entails much larger pelvic rotation than in humans, suggesting that a larger pelvic step may contribute to their relatively longer strides. We collected data on the pelvic step in bipedal chimpanzees and over a wide speed range of human walking. At matched dimensionless speeds, humans have 26.7% shorter dimensionless strides, and a pelvic step 5.4 times smaller than bipedal chimpanzees. Differences in pelvic rotation explain 31.8% of the difference in dimensionless stride length between the two species. We suggest that relative stride lengths and the pelvic step have been significantly reduced throughout the course of hominin evolution.

Fossil apes and human evolution.

Humans diverged from apes (chimpanzees, specifically) toward the end of the Miocene ~9.3 million to 6.5 million years ago. Understanding the origins of the human lineage (hominins) requires reconstructing the morphology, behavior, and environment of the chimpanzee-human last common ancestor. Modern hominoids (that is, humans and apes) share multiple features (for example, an orthograde body plan facilitating upright positional behaviors). However, the fossil record indicates that living hominoids constitute narrow representatives of an ancient radiation of more widely distributed, diverse species, none of which exhibit the entire suite of locomotor adaptations present in the extant relatives. Hence, some modern ape similarities might have evolved in parallel in response to similar selection pressures. Current evidence suggests that hominins originated in Africa from Miocene ape ancestors unlike any living species.

Extended Infusion of Beta-Lactams Is Associated With Improved Outcomes in Pediatric Patients.

OBJECTIVE: The pharmacokinetics of beta-lactam antibiotics favor administration via an extended infusion. Although literature supporting extended infusion beta-lactams exists in adults, few data are available to guide the practice in pediatrics. The purpose of this study was to compare clinical outcomes between extended and standard infusions in children. METHODS: This retrospective chart analysis included hospitalized patients 0 to 18 years old who received at least 72 hours of cefepime, piperacillin-tazobactam, or meropenem between October 1, 2017, and March 31, 2019. Clinical outcomes of care included hospital length of stay, readmission within 30 days, and all-cause mortality. RESULTS: A total of 551 patients (258 extended infusion, 293 standard infusion) met criteria for evaluation. Clinical outcomes among the entire population were similar. A subanalysis of select populations demonstrated decreased mortality in critical care patients (2.1% vs 19.6%, p = 0.006) and decreased 30-day readmission rates in bone marrow transplant patients (0% vs 50%, p = 0.012) who received the extended infusion compared with a standard infusion. CONCLUSIONS: Outcomes were similar between extended and standard infusions in children. Subgroup analyses suggest a possible mortality benefit in the critically ill and decreased readmission rate in bone marrow transplant patients.

Comparison of pediatric brain-dead donors to donation after circulatory death donors in the United States.

In pediatrics, an increasing need for transplantable organs exists. This study aimed to describe the epidemiology of pediatric deceased donors in the United States. This retrospective observational study utilized data from the Organ Procurement and Transplantation Network (OPTN) from 2000 to 2015. Patients were stratified based on method of organ donation. Demographic variables and mechanism of death were then compared. A total of 14,481 deceased pediatric organ donors, donation after brain death (DBD) and donation after circulatory death (DCD), were included in the study, of which 8% were DCD donors. A significant difference (p<0.001) existed between the two donor groups with respect to ethnicity and mechanism of death. The annual trend of DCD and DBD donors showed an inverse relationship. During the 15-year study period the number of DBD donors decreased from 985 to 785 per year while DCD donors increased from 15 to 146 per year. As well, overall organs transplanted per year decreased from 3,475 to 3,117 over the 15-year study period. Significant differences exist between pediatric DBD donors and DCD donors, specifically with respect to ethnicity and mechanism of death. The number of pediatric DBD donors is decreasing while the number of pediatric DCD is slowly rising, making it increasingly important to be able to characterize these donors to better identify eligible DCD donors to optimize organ utilization.

Interventions Associated With Treatment of Low Cardiac Output After Stage 1 Norwood Palliation.

BACKGROUND: Mortality after stage 1 palliation of hypoplastic left heart syndrome remains significant. Both cardiac output (CO) and systemic vascular resistance (SVR) contribute to hemodynamic vulnerability. Simultaneous measures of mean arterial pressure and somatic regional near infrared spectroscopy saturation can classify complex hemodynamics into 4 distinct states, with a low-CO state of higher risk. We sought to identify interventions associated with low-CO state occupancy and transition. METHODS: Perioperative data were prospectively collected in an institutional review board-approved database. Hemodynamic state was classified as high CO, high SVR, low SVR, and low CO using bivariate analysis. Associations of static and dynamic support levels and state classifications over 48 postoperative hours were tested between states and across transitions using mixed regression methods in a quasi-experimental design. RESULTS: Data from 10,272 hours in 214 patients were analyzed. A low-CO state was observed in 142 patients for 1107 hours. Both low CO and extracorporeal membrane oxygenation had increased mortality risk. The low-CO state was characterized by lower milrinone but higher catecholamine dose. Successful transition out of low CO was associated with increased milrinone dose and hemoglobin concentration. Increasing milrinone and hemoglobin levels predicted reduced risk of low CO in future states. CONCLUSIONS: Bivariate classification objectively defines hemodynamic states and transitions with distinct support profiles. Maintaining or increasing inodilator and hemoglobin levels were associated with improved hemodynamic conditions and were predictive of successful future transitions from the low-CO state.

Methadone's Effect on Cardiac Repolarization: Safety in the PICU.

OBJECTIVES: Opioids are routinely used in the PICU. Methadone is an effective method of preventing and treating iatrogenic opioid withdrawal; however, it carries an Food and Drug Administration Boxed Warning due to the potential to prolong the corrected QT interval and potentially lead to life-threatening arrhythmias. Guidelines on the safe use of methadone have limited applicability to children since their cardiac intervals differ from those of adults. There is little data on the electrophysiologic effects in the pediatric population. We set out to describe the safety of methadone use in the PICU, hypothesizing that methadone does not cause a significant change in corrected QT interval from baseline. DESIGN: Retrospective cohort study. SETTING: Children's Hospital of Wisconsin, Milwaukee, WI. PATIENTS: Fifty-one patients, age less than or equal to 18 years old, initiated on methadone during PICU admission, over an 11-month period, for the prevention or treatment of opioid withdrawal. INTERVENTIONS: Retrospective data queried from the electronic health record and stored telemetry waveforms obtained from an automated real-time patient data acquisition software system (BedMasterEx; Anandic Medical Systems AG, Feuerthalen, Switzerland). MEASUREMENTS AND MAIN RESULTS: Corrected QT intervals were not significantly different at 12 hours, 96 hours, or PICU discharge (p values: 0.57, 0.54, and 0.34) when compared to baseline. The median change in corrected QT from baseline to 12 hours after the first dose of methadone was 5 ms (interquartile range, -12 to 11 ms), 0 ms to steady state (interquartile range, -18 to 18 ms), and 5 ms from baseline to 12 hours after the highest dose of methadone (interquartile range, -14 to 16 ms). The most common primary diagnosis was structural heart disease (29% of subjects) in our cohort and every subject that experienced an increase in corrected QT interval greater than or equal to 40 ms had some form of structural heart disease. CONCLUSIONS: Methadone did not significantly prolong the corrected QT interval in a population of critically ill children, suggesting that it can be safely used in this population, although patients with structural heart disease may warrant closer monitoring.

Digitization of the Nissen-Riesen chimpanzee radiological growth series.

Longitudinal morphological growth data of apes are incredibly difficult to obtain. Long life histories, combined with practical and ethical issues of obtaining such long-term data have resulted in few longitudinal data sets in chimpanzees of known chronological ages. One classic, long-term growth study of chimpanzees was that of Drs Nissen and Riesen initiated at the Yale Laboratories of Primate Biology in 1939. Through that study, whole-body radiological images were taken on a regular basis from a "normative" group of chimpanzees from birth to adulthood. Here we have digitized the known remaining radiographs from that growth study, many of which are deteriorating, and uploaded the data set to the free, online database MorphoSource. The database comprises 3,568 X-ray images of 15 of the 16 chimpanzee subjects in the normative group and 1 individual from an experimental group. Herein, we briefly review the historical context of this study and specific details of the data set.

The biomechanics of knuckle-walking: 3-D kinematics of the chimpanzee and macaque wrist, hand and fingers.

The origin and evolution of knuckle-walking has long been a key focus in understanding African ape, including human, origins. Yet, despite numerous studies documenting morphological characteristics potentially associated with knuckle-walking, little quantitative three-dimensional (3-D) data exist of forelimb motion during knuckle-walking. Nor do any comparative 3-D data exist for hand postures used during quadrupedalism in monkeys. This lack of data has limited the testability of proposed adaptations for knuckle-walking in African apes. This study presents the first 3-D kinematic data of the wrist, hand and metacarpophalangeal joints during knuckle-walking in chimpanzees and in macaques using digitigrade and palmigrade hand postures. These results clarify the unique characteristics of, and commonalities between, knuckle-walking and digitigrady/palmigrady in multiple planes of motion. Notably, chimpanzees utilized more wrist ulnar deviation than any macaque hand posture. Maximum extension of the chimpanzee wrist was slight (5-20 deg) and generally overlapped with macaque digitigrady. Metacarpophalangeal joint motion displayed distinct differences between digits in both species, likely related to the timing of force application. These data also reveal that maximum metacarpophalangeal extension angles during knuckle-walking (26-59 deg) were generally higher than previously considered. In macaques, maximum metacarpophalangeal extension during digitigrady and palmigrady overlapped for most digits, highlighting additional complexity in the interpretation of skeletal features that may be related to limiting metacarpophalangeal motion. Most importantly, however, these new 3-D data serve as a fundamental dataset with which evaluation of proposed musculoskeletal adaptations for knuckle-walking can be tested.

Is step width decoupled from pelvic motion in human evolution?

Humans are the only primate that walk bipedally with adducted hips, valgus knees, and swing-side pelvic drop. These characteristic frontal-plane aspects of bipedalism likely play a role in balance and energy minimization during walking. Understanding when and why these aspects of bipedalism evolved also requires an understanding of how each of these features are interrelated during walking. Here we investigated the relationship between step width, hip adduction, and pelvic list during bipedalism by altering step widths and pelvic motions in humans in ways that both mimic chimpanzee gait as well as an exaggerated human gait. Our results show that altering either step width or pelvic list to mimic those of chimpanzees affects hip adduction, but neither of these gait parameters dramatically affects the other in ways that lead to a chimpanzee-like gait. These results suggest that the evolution of valgus knees and narrow steps in humans may be decoupled from the evolution of the human-like pattern of pelvic list. While the origin of narrow steps in hominins may be linked to minimizing energetic cost of locomotion, the origin of the human-like pattern of pelvic list remains unresolved.