Utilizing Zoom Breakout Rooms to Expose Preclerkship Medical Students to TeleMedicine Encounters.

Emergency Remote Teaching (ERT) presented various challenges as the Oklahoma State University Center for Health Sciences (OSU-CHS) campus closed to students in response to COVID-19 mitigation efforts in late March 2020. While some classes transitioned easily to virtual platforms already in place, such as learning management systems and the lecture recording software, other classes that involved coordinated group activities did not have as many suitable alternatives. One College of Osteopathic Medicine (COM) class utilized the teleconferencing tool Zoom. Zoom's breakout rooms and waiting room features were used to facilitate a clinical interviewing skills lab and telemedicine-type encounter with standardized patients. We were able to successfully designate groups of approximately 10 students into three rooms, amongst which the standardized patients moved at set intervals. Faculty facilitators participated in each room to guide students, and one support staff member served as host to manage the technical aspects of the overall meeting. We found this approach to be a successful alternative to live group activities and a worthwhile opportunity to expose preclerkship students to telemedicine.

Respiratory syncytial virus prophylaxis in children with cardiac disease: a retrospective single-centre study.

OBJECTIVES: To examine the characteristics of congenital heart disease patients hospitalised with respiratory syncytial virus infection after prophylaxis and determine the associated comorbidities and the incidence of breakthrough respiratory syncytial virus infections. STUDY DESIGN: This is a retrospective, single-centre study that was conducted over a period of 7 years. Respiratory syncytial virus infection was identified by classification codes and confirmed by virological tests. Data on baseline demographics, cardiac anomalies, other underlying disease, criteria for hospitalisation, type of respiratory illness and management, complications, and palivizumab prophylaxis were analysed by standard descriptive methods and comparative statistics. RESULTS: A total of 30 patients were enrolled. The majority were ≤ 2 years (n = 24). The mean admission age was 15.1 months (standard deviation = 18.3). In all, 90% were acyanotic, 40% had haemodynamically significant disease, and 60% had ≥ 1 underlying medical illness. Patients were admitted with: respiratory distress (86.7%), hypoxaemia (66.7%), fever (60%), inability to maintain oral intake (36.7%), and apnoea (16.7%). More than 50% required mechanical ventilation and intensive care with a median stay of 11 days (range: 1-43); the length of hospital stay for all children was 10 days (range: 1-65). Complications included: concurrent bacterial sepsis (20%), electrolyte abnormalities (16.7%), and worsening pulmonary hypertension (13.3%). Of 10 infants ≤ 2 years with haemodynamically significant heart disease, four had received prophylaxis. There was one death, which was attributed to respiratory syncytial virus infection. CONCLUSIONS: Overall, 185 infants ≤ 2 years with haemodynamically significant cardiac disease received prophylaxis. In all, six qualifying infants missed immunisation and were hospitalised. Breakthrough respiratory syncytial virus infections occurred in 2.2%, demonstrating good efficacy of palivizumab in this population compared with the original, multi-centre, randomised trial.

Establishment of reference intervals for bone markers in children and adolescents.

OBJECTIVES: To determine age and gender specific reference intervals for bone markers. DESIGN AND METHODS: Morning blood samples were collected after overnight fast from 356 healthy children (6 to 18 year-old) for the determination of bone marker levels, PTH and vitamin D(3). Multiple regression analysis was done to assess the effect of factors that could influence the bone marker levels; the central 95% reference interval and their 90% CI were calculated. RESULTS: After excluding samples when BMI-z -scores were <-2 or >+2, both vitamin D(3) and PTH levels were abnormal and from children who used steroids the remainder were partitioned using Tanner stage based chronological age. As expected the reference intervals show a significant variation with age and gender. All the bone marker levels, except total alkaline phosphatase, were significantly higher in puberty with vitamin D(3) >75nmol/L. CONCLUSION: Vitamin D status, age and gender are important for establishing reference intervals of bone markers in healthy children.

The impact of prophylaxis on paediatric intensive care unit admissions for RSV infection: a retrospective, single-centre study.

Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections and hospitalizations in children aged < 2 years. The aim of this retrospective, single-centre study was to examine the characteristics of patients admitted to a paediatric intensive care unit (PICU) with RSV infection following the implementation of a RSV prophylaxis programme. Electronic hospital medical records of all PICU admissions for RSV infection were searched from 2003 to 2009. Data on baseline demographics, underlying disease, criteria for hospitalization, respiratory diagnosis and management, complications and palivizumab prophylaxis were collected. A total of 181 patients were admitted with RSV infection, accounting for 5.7% of all admissions. Eighty-four percent were ≤ 2 years of age. Majority (70.2%) had no underlying medical illness, and 79.6% received antibiotics as part of their medical treatment. Comparison of children aged ≤ 2 years and those >2 years revealed that fewer of the younger cohort (20.4% versus 79.3%; p < 0.001) had an underlying medical condition. RSV infection occurred in 3.3% (n = 6) children who had received palivizumab prophylaxis, and there were two deaths. The results indicate that > 88% of all PICU admissions would not qualify for RSV prophylaxis under our established guidelines and 66% of the children aged ≤ 2 years were > 36 weeks gestation and are not currently targeted for prophylaxis. The number of high-risk infants admitted to PICU with RSV infection has likely plateaued, and further reductions in admission rates may only be realised with the use of universal, vaccine immunization programmes.

Risk-Scoring Tool for respiratory syncytial virus prophylaxis in premature infants born at 33-35 completed weeks' gestational age in Canada.

OBJECTIVE: To study the impact of the Risk-Scoring Tool (RST) as a strategy for targeting prophylaxis effectively in 33-35-week gestational age (GA) Canadian infants who range from low to high risk by evaluating the subsequent incidence of respiratory syncytial virus (RSV) infections resulting in emergency room (ER) visits and hospitalization. DESIGN: Prospective, descriptive study. SETTING: McMaster Children's Hospital and St Joseph's Healthcare in Hamilton, Ontario. PARTICIPANTS: Premature infants between 33 and 35 weeks' completed gestation who were less than 6 months' chronological age at the start of, or during, the local 2005-2008 RSV winter seasons. METHODS: A validated, Canadian RST was used to calculate a total risk score based on seven risk factors. Only infants at moderate (RST score 49-64) and high risk (RST score 65-100) received palivizumab at monthly intervals from November to April and were followed during the respective RSV seasons. All parents received information on RSV prevention at hospital discharge. Parents of all recruited infants were contacted by telephone in May at the end of each season, and medical records were checked to determine ER visits for RSV-related respiratory tract infections and RSV hospitalization. Means, standard deviations, ranges, and percents were used to describe the variables for patients enrolled in the study. RESULTS: Over 3 years, 430 infants were recruited. Of these, 346 (81%), 57 (13%), and 27 (6%) were in the low-, moderate- and high-risk categories, respectively, based on their risk scores. A total of 78 (18.1%) infants received full courses of palivizumab. Six out of 57 (10.5%) infants in the moderate-risk group did not receive prophylaxis, while all 27 high-risk group infants received palivizumab. Seven (1.6%) infants were RSV-positive and five (low-risk) infants were hospitalized. One high-risk, RSV-positive infant, was seen in the ER, and discharged home. There were no statistical differences in the number of infants with RSV-related ER visits and hospitalizations within the risk category groups (p = 0.43). The limitations of this study include the observational design and the relatively small sample size. CONCLUSIONS: The RST is a practical, easy-to-use instrument to guide judicious RSV prophylaxis for moderate-high-risk, 33-35-week GA infants. It is cost-effective, reducing hospitalization in infants who are most 'at-risk', while avoiding prophylaxis in a large segment (81.9%) of this GA cohort who are considered low risk for RSV infection.

Interscalene brachial plexus block for outpatient shoulder arthroplasty: Postoperative analgesia, patient satisfaction and complications.

BACKGROUND: Shoulder arthroplasty procedures are seldom performed on an ambulatory basis. Our objective was to examine postoperative analgesia, nausea and vomiting, patient satisfaction and complications of ambulatory shoulder arthroplasty performed using interscalene brachial plexus block (ISB). MATERIALS AND METHODS: We prospectively examined 82 consecutive patients undergoing total and hemi-shoulder arthroplasty under ISB. Eighty-nine per cent (n=73) of patients received a continuous ISB; 11% (n=9) received a single-injection ISB. The blocks were performed using a nerve stimulator technique. Thirty to 40 mL of 0.5% ropivacaine with 1:400,000 epinephrine was injected perineurally after appropriate muscle twitches were elicited at a current of less than 0.5% mA. Data were collected in the preoperative holding area, intraoperatively and postoperatively including the postanesthesia care unit (PACU), at 24h and at seven days. RESULTS: Mean postoperative pain scores at rest were 0.8 ± 2.3 in PACU (with movement, 0.9 ± 2.5), 2.5 ± 3.1 at 24h and 2.8 ± 2.1 at seven days. Mean postoperative nausea and vomiting (PONV) scores were 0.2 ± 1.2 in the PACU and 0.4 ± 1.4 at 24h. Satisfaction scores were 4.8 ± 0.6 and 4.8 ± 0.7, respectively, at 24h and seven days. Minimal complications were noted postoperatively at 30 days. CONCLUSIONS: Regional anesthesia offers sufficient analgesia during the hospital stay for shoulder arthroplasty procedures while adhering to high patient comfort and satisfaction, with low complications.

When trauma means a stoma.

Trauma is a leading cause of death and disability. When traumatic injuries require ostomy surgery, the wound, ostomy, and continence nurse acts as a crucial part of the trauma team. This literature review describes mechanisms of injury associated with creation of a stoma, key aspects of wound, ostomy, and continence nursing care in trauma populations and presents suggestions for future research.

Combined lumbar-plexus and sciatic-nerve blocks: an analysis of plasma ropivacaine concentrations.

BACKGROUND AND OBJECTIVES: Lumbar-plexus and sciatic-nerve blocks are commonly combined for lower-extremity anesthesia using large doses of ropivacaine. Limited information is available about the pharmacokinetics of this practice. We analyzed plasma ropivacaine concentrations after single-injection lumbar-plexus blocks with and without sciatic-nerve blocks. METHODS: Twenty patients having lower-extremity surgery using a lumbar-plexus block with 0.5% ropivacaine with 1:400,000 epinephrine (35 mL, n = 10) or the same lumbar-plexus block with the addition of a sciatic-nerve block (25 mL, n = 10, 60 mL total) using the same solution were enrolled. Venous blood samples were collected at 5, 15, 30, 45, 60, 120, and 240 minutes after block placement and analyzed for total ropivacaine concentration by use of gas chromatography. Individual timepoints, maximum concentrations (C(max)), and time to C(max) (T(max)) were compared. Values are mean +/- SD. RESULTS: Both groups demonstrated a rapid increase in plasma concentration over the first 30 to 45 minutes. Concentrations were greater for those who received both blocks (P = .0005) at all timepoints. The lumbar-plexus block C(max) was less (986 +/- 221 ng/mL) than for the combined blocks (1,560 +/- 351 ng/mL, P = .0004). The T(max) was greater for the lumbar plexus (80 +/- 49 min) than for the combined blocks (38 +/- 22 min, P = .03). There was no relationship between the C(max) and patient age, weight, or body mass index. CONCLUSIONS: The results of this study demonstrate that the plasma ropivacaine concentrations increase quicker when a sciatic-nerve block is added to a lumbar-plexus block, but C(max) remains below the toxicity threshold.

The effect of age on sciatic nerve block duration.

The physiologic changes that occur with advancing age and their effect on the duration of peripheral nerve blocks have yet to be defined. We prospectively studied the duration of sciatic nerve block using mepivacaine in younger and older patients. Eighty ASA physical status I-III patients, aged 18-35 (n = 40) or 55-80 (n = 40) yr, having outpatient knee arthroscopy with a femoral block and a standardized sciatic nerve block were enrolled; 37 in each group completed the study. All patients received a Labat sciatic nerve block using 20 mL of 1.0% mepivacaine with 0.1 mEq/mL sodium bicarbonate and 1:400,000 (2.5 microg/mL) epinephrine and a femoral nerve block. The duration of sensory block (sensation of pinprick, temperature, and vibration), motor block (plantar and dorsi flexion), and complete sensory and motor block in the sciatic nerve distribution of the operative extremity were measured. The time for complete return of both sensory and motor function was longer in the older group, 329 +/- 47 min compared with 306 +/- 46 min (mean +/- sd) in the younger group (P = 0.04). The difference was small under the conditions of this study and would not be perceived clinically. Age also increased the time to return of vibratory sensation (younger = 292 +/- 58 min, older = 257 +/- 50 min; P = 0.007). The other measurements did not differ between groups. We conclude that age may affect peripheral nerve blocks and that more investigation is needed to determine the pharmacologic, physiologic, and chronologic factors behind these findings.

Questionnaire development to predict mammography intention among women in southeastern Louisiana.

This article summarizes the development and psychometric analysis of the Thoughts About Mammography (TAM) questionnaire to predict mammography intention using the Theory of Planned Behavior (TPB). Key themes, obtained from elicitation interviews (N = 45), were categorized, ranked and extracted for item construction. Initial pilot testing supported test-retest reliability (alpha = .85 to .97), internal consistency (alpha = .67 to .91), and content validity (0.86-1.00). After pilot testing, the TAM was administered to 302 rural women in southeastern (SE) Louisiana. The instrument was internally consistent (alpha = 0.77 to 0.92), construct valid (alpha = .18 to .64), and predicted 24% of the variance of mammography intention. The TAM adequately demonstrated reliability and validity to measure mammography intention in rural southeastern Louisiana women.

Peripheral nerve block techniques for ambulatory surgery.

Peripheral nerve blocks (PNBs) have an increasingly important role in ambulatory anesthesia and have many characteristics of the ideal outpatient anesthetic: surgical anesthesia, prolonged postoperative analgesia, and facilitated discharge. Critically evaluating the potential benefits and supporting evidence is essential to appropriate technique selection. When PNBs are used for upper extremity procedures, there is consistent opioid sparing and fewer treatment-related side effects when compared with general anesthesia. This has been demonstrated in the immediate perioperative period but has not been extensively investigated after discharge. Lower extremity PNBs are particularly useful for procedures resulting in greater tissue trauma when the benefits of dense analgesia appear to be magnified, as evidenced by less hospital readmission. The majority of current studies do not support the concept that a patient will have difficulty coping with pain when their block resolves at home. Initial investigations of outpatient continuous peripheral nerve blocks demonstrate analgesic potential beyond that obtained with single-injection blocks and offer promise for extending the duration of postoperative analgesia. The encouraging results of these studies will have to be balanced with the resources needed to safely manage catheters at home. Despite supportive data for ambulatory PNBs, most studies have been either case series or relatively small prospective trials, with a narrow focus on analgesia, opioids, and immediate side effects. Ultimately, having larger prospective data with a broader focus on outcome benefits would be more persuasive for anesthesiologists to perform procedures that are still viewed by many as technically challenging.

Testing the theory of planned behavior to predict mammography intention.

BACKGROUND: Louisiana ranks 50th as the least healthy state in the United States. Although limited healthcare access may explain part of the health disparity related to mammography utilization, there is no research to elucidate mammography intention among rural Southeastern Louisiana women. OBJECTIVE: To test the Theory of Planned Behavior to predict mammography intention among rural women in Southeastern Louisiana. METHODS: A correlation study design with multiple regression and path analysis was used. The sample consisted of 302 women, between the ages of 40-74 who were without a prior history of breast cancer, able to read English, and able to respond to a written questionnaire. RESULTS: Path analysis confirmed the direct and indirect relationships of mammography intention (chi2 = 26.2, p > .10, Comparative Fit Index =.968). Regression analysis computed the model path coefficients ranging from beta .176 to .640. Overall, the Theory of Planned Behavior explained 24% of the variance. DISCUSSION: Perceived behavioral control was the strongest predictor of mammography intention. A woman's attitude towards mammography and referent motivation needs further explanation prior to the development of an intervention to increase mammography intention and use.

Manuscript Architect: a Web application for scientific writing in virtual interdisciplinary groups.

BACKGROUND: Although scientific writing plays a central role in the communication of clinical research findings and consumes a significant amount of time from clinical researchers, few Web applications have been designed to systematically improve the writing process. This application had as its main objective the separation of the multiple tasks associated with scientific writing into smaller components. It was also aimed at providing a mechanism where sections of the manuscript (text blocks) could be assigned to different specialists. Manuscript Architect was built using Java language in conjunction with the classic lifecycle development method. The interface was designed for simplicity and economy of movements. Manuscripts are divided into multiple text blocks that can be assigned to different co-authors by the first author. Each text block contains notes to guide co-authors regarding the central focus of each text block, previous examples, and an additional field for translation when the initial text is written in a language different from the one used by the target journal. Usability was evaluated using formal usability tests and field observations. RESULTS: The application presented excellent usability and integration with the regular writing habits of experienced researchers. Workshops were developed to train novice researchers, presenting an accelerated learning curve. The application has been used in over 20 different scientific articles and grant proposals. CONCLUSION: The current version of Manuscript Architect has proven to be very useful in the writing of multiple scientific texts, suggesting that virtual writing by interdisciplinary groups is an effective manner of scientific writing when interdisciplinary work is required.

Peripheral nerve blocks and continuous catheter techniques.

Peripheral nerve blocks provide intense, site-specific analgesia and are associated with a lower incidence of side effects when compared with many other modalities of postoperative analgesia. Continuous catheter techniques further prolong these benefits. These advantages can facilitate a prompt recovery and discharge and achieve significant perioperative cost savings. This is of tremendous value in a modern health care system that stresses cost-effective use of resources and a continued shift toward shorter hospital stay as well as outpatient surgery.

Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks.

BACKGROUND: Regional anesthesia is increasing in popularity for ambulatory surgical procedures. Concomitantly, the prevalence of obesity in the United States population is increasing. The objective of the present investigation was to assess the impact of body mass index (BMI) on patient outcomes after ambulatory regional anesthesia. METHODS: This study was based on prospectively collected data including 9,038 blocks performed on 6,920 patients in a single ambulatory surgery center. Patients were categorized into three groups according to their BMI (<25 kg/m2, 25-29 kg/m2, > or =30 kg/m2). Block efficacy, rate of acute complications, postoperative pain (at rest and with movement), postoperative nausea and vomiting, rate of unscheduled hospital admissions, and overall patient satisfaction were assessed. Linear and logistic multivariable analyses were used to obtain the risk-adjusted effect of BMI on these outcomes. RESULTS: Of all patients 34.8% had a BMI <25 kg/m2, 34.0% were overweight (BMI 25-29 kg/m2), and 31.3% were obese (BMI > or = 30 kg/m2). Patients with BMI > or =30 kg/m2 were 1.62 times more likely to have a failed block (P = 0.04). The unadjusted rate of acute complications was higher in obese patients (P = 0.001). However, when compared with patients with a normal BMI, postoperative pain at rest, unanticipated admissions, and overall satisfaction were similar in overweight and obese patients. CONCLUSIONS: The present investigation shows that obesity is associated with higher block failure and complication rates in surgical regional anesthesia in the ambulatory setting. Nonetheless, the rate of successful blocks and overall satisfaction remained high in patients with increased BMI. Therefore, overweight and obese patients should not be excluded from regional anesthesia procedures in the ambulatory setting.