Written Versus Simulation-Based Evaluation Methods to Assess Competency and Confidence in the Use of Electronic Medical Records.

BACKGROUND: This study compares data on the use of written versus patient simulator methods to evaluate the competence and confidence of RNs after electronic medical record training. METHOD: A randomized controlled trial compared evaluations of the competence and confidence of newly hired nurses using a written patient admission and discharge versus a high-fidelity simulation manikin. Trained observers evaluated nurses' competence, and the nurses rated their own levels of confidence in their performance. RESULTS: No differences were found in confidence or competence. CONCLUSION: Evaluating nurse training on electronic medical records via simulation is as good as evaluating them using the traditional written method. J Contin Educ Nurs. 2018;49(6):262-268.

Bi-allelic inactivation is more prevalent at relapse in multiple myeloma, identifying RB1 as an independent prognostic marker.

The purpose of this study is to identify prognostic markers and treatment targets using a clinically certified sequencing panel in multiple myeloma. We performed targeted sequencing of 578 individuals with plasma cell neoplasms using the FoundationOne Heme panel and identified clinically relevant abnormalities and novel prognostic markers. Mutational burden was associated with maf and proliferation gene expression groups, and a high-mutational burden was associated with a poor prognosis. We identified homozygous deletions that were present in multiple myeloma within key genes, including CDKN2C, RB1, TRAF3, BIRC3 and TP53, and that bi-allelic inactivation was significantly enriched at relapse. Alterations in CDKN2C, TP53, RB1 and the t(4;14) were associated with poor prognosis. Alterations in RB1 were predominantly homozygous deletions and were associated with relapse and a poor prognosis which was independent of other genetic markers, including t(4;14), after multivariate analysis. Bi-allelic inactivation of key tumor suppressor genes in myeloma was enriched at relapse, especially in RB1, CDKN2C and TP53 where they have prognostic significance.

Dose-dense and less dose-intense Total Therapy 5 for gene expression profiling-defined high-risk multiple myeloma.

Multiple myeloma (MM) is a heterogeneous disease with high-risk patients progressing rapidly despite treatment. Various definitions of high-risk MM are used and we reported that gene expression profile (GEP)-defined high risk was a major predictor of relapse. In spite of our best efforts, the majority of GEP70 high-risk patients relapse and we have noted higher relapse rates during drug-free intervals. This prompted us to explore the concept of less intense drug dosing with shorter intervals between courses with the aim of preventing inter-course relapse. Here we report the outcome of the Total Therapy 5 trial, where this concept was tested. This regimen effectively reduced early mortality and relapse but failed to improve progression-free survival and overall survival due to relapse early during maintenance.

The impact of age and gender on papillary thyroid cancer survival.

CONTEXT: Thyroid cancer predominately affects women, carries a worse prognosis in older age, and may have higher mortality in men. Superimposed on these observations is the fact that most women have attained menopause by age 55 yr. OBJECTIVE: The objective of the study was to determine whether men contribute disproportionately to papillary thyroid cancer (PTC) mortality or whether menopause affects PTC prognosis. DESIGN: Gender-specific mortality was normalized using age-matched subjects from the U.S. population. Multivariate Cox proportional hazard regression models incorporating gender, age, and National Thyroid Cancer Treatment Cooperative Study Group stage were used to model disease-specific survival (DSS). PARTICIPANTS AND SETTING: Patients were followed in a prospective registry. MAIN OUTCOME MEASURE: The relationships between gender, age, and PTC outcomes were analyzed. RESULTS: The unadjusted hazard ratio (HR) for DSS for women was 0.40 [confidence interval (CI) 0.24-0.65]. This female advantage diminished when DSS was adjusted for age at diagnosis and stage with a HR encompassing unity (HR 0.72, CI 0.44-1.19). Additional multivariate models of DSS considering gender, disease stage, and various age groupings showed that the DSS for women diagnosed at under 55 yr was improved over men (HR 0.33, CI 0.13-0.81). However, the HR for DSS increased to become similar to men for women diagnosed at 55-69 yr (HR 1.01, CI 0.42-2.37) and at 70 yr or greater (HR 1.17, CI 0.48-2.85). CONCLUSIONS: Although the overall outcome of women with PTC is similar to men, subgroup analysis showed that this composite outcome is composed of two periods with different outcomes. The first period is a period with better outcomes for women than men when the diagnosis occurs at younger than 55 yr; the second is a period with similar outcomes for both women and men diagnosed at ages greater than 55 yr. These data raise the question of whether an older age cutoff would improve current staging systems. We hypothesize that older age modifies the effect of gender on outcomes due to menopause-associated hormonal alterations.

Effects of a stannous fluoride-impregnated dental floss on in vivo salivary fluoride levels.

PURPOSE: The aim of this in vivo pilot study was to determine the concentration of fluoride retained intra-orally in saliva after flossing with dental floss impregnated with stannous fluoride (SnF(2)). METHODS: Participants flossed their teeth ad libitum with 2 premeasured lengths of fluoridated dental floss. Expectorated saliva samples were collected in vials before flossing (PF), immediately postflossing(IPF), at 30 minutes (30), and 1 hour (60) after flossing for analysis with a fluoride-specific electrode and an Orion millivoltmeter. Postflossing samples were compared to the preflossing samples using ANOVA and Tukey's HSD. RESULTS: Differences between the PF and IPF group means were found to be statistically significant at p<0.01. No other significant differences were found between or among any of the groups. Salivary fluoride levels at 60 minutes (60) were similar to those prior to flossing (PF). CONCLUSIONS: It can be concluded that fluoride can be released from flossing with the tested SnF(2)-impregnated dental floss elevating salivary fluoride levels for at least 30 minutes. Use of this fluoride-containing dental floss offers an option for delivery of fluoride to individuals at risk for dental caries.

A comparison between portable ultrasound (MIDUS) and nocturnal RigiScan when confirming the diagnosis of vascular organic erectile disorder.

In recent years, the use of RigiScan and ultrasound to assess erectile dysfunction has fallen from favour. However, in a small minority of specialist cases, where a vascular, neurogenic or psychogenic aetiology requires confirmation, there remains a need for further investigation. To establish if in a preliminary assessment the use of nocturnal RigiScan or male impotence diagnostic ultrasound system (MIDUS) represents best practice as a diagnostic investigation in patients with a history suggestive of vascular organic erectile disorder. Men attending both urological and psychosexual therapy clinics with erectile dysfunction were assessed using a generic assessment schedule. Patients with a history suggestive of vascular erectile disorder were offered the opportunity of dual investigation of their condition. After screening using a provocative RigiScan using visual stimuli that gleaned inconclusive results, patients were offered the chance to enter a study with both nocturnal RigiScan and MIDUS investigation. These were confined for the purposes of this study to RigiScan events, peak systolic flow velocity (PSV) and end-diastolic flow velocity (EDV) from ultrasound examination where an abnormal EDV is defined as in excess of 4.5 cm/s and a normal PSV is variously defined as being greater than 35 cm/s. In all, 38/43 (88%, 95% CI: 76-95%) of men had a nocturnal event exceeding 3 min on the RigiScan investigation. This compares with 17/43 (40%, 95% CI: 26-54%) of men with a normal EDV blood flow of less than 4.5 cm/s (P<0.017) and 32/43 (74%, CI: 60-85%) of men with a normal PSV flow greater than 35 cm/s (NS). Rigiscan and ultrasonography of the cavernosal vessels are of equal usefulness in suspected arterial penile disease although where veno-occlusive disease is suspected, ultrasonography is more specific.

Steroids for improving recovery following tonsillectomy in children.

BACKGROUND: Tonsillectomy continues to be one of the most common surgical procedures performed worldwide. Despite advances in anesthetic and surgical techniques, post-tonsillectomy morbidity remains a significant clinical problem. OBJECTIVES: To assess the clinical efficacy of a single intra-operative dose of dexamethasone in reducing post-tonsillectomy morbidity. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Issue 1, 2002), MEDLINE (from 1966 - February 2002), EMBASE (from 1974 - February 2002) and reference lists of relevant articles. We contacted leading experts for information on any relevant unpublished data. SELECTION CRITERIA: Randomized, double-blind, placebo-controlled trials of a single dose of intravenous, intra-operative corticosteroid for pediatric patients (age < 18 years) who underwent tonsillectomy or adenotonsillectomy were included. DATA COLLECTION AND ANALYSIS: Data regarding the primary outcome measures and measurement tools were extracted by the first author from the published studies. Data regarding study design, patient ages, procedures performed, dose of corticosteroid and method of delivery, as well as methodologic quality were also recorded by the first author. When data were missing from the original publications, the authors were contacted for more information. Data analysis was performed with a random effects model, using the RevMan 4.1 software developed by the Cochrane Collaboration. MAIN RESULTS: Children receiving a single intra-operative dose of dexamethasone (dose range = 0.15 to 1.0 mg/kg; maximum dose range = 8 to 25 mg) were two times less likely to vomit in the first 24 hours than children receiving placebo (RR = 0.54, CI95 = 0.42, 0.69; p < 0.00001). Routine use in four children would be expected to result in one less patient experiencing post-tonsillectomy emesis (RD = -0.25, CI95 = -0.37, -0.13; p = 0.00004). Additionally, children receiving dexamethasone were more likely to advance to a soft/solid diet on post-tonsillectomy day 1 (RR = 1.69, CI95 = 1.02, 2.79; p = 0.04) than those receiving placebo. Due to missing data and varied outcome measurement tools, pain could not be meaningfully analyzed as a distinct outcome measure. REVIEWER'S CONCLUSIONS: The evidence suggests that a single intravenous dose of dexamethasone is an effective, relatively safe and inexpensive treatment for reducing morbidity from pediatric tonsillectomy. No adverse events attributable to dexamethasone were reported in these trials. Additionally, in our 10-year experience of routine use of a single intravenous dose of dexamethasone during pediatric tonsillectomy, there have been no attributable, adverse events. Lastly, we found no reports in the literature of complications from use of a single intravenous dose of corticosteroid during pediatric tonsillectomy.

Biological vulnerability in infants with failure to thrive: the association with birthweight.

The development of failure to thrive (FTT) is hypothesized to be caused by the interaction between biological and environmental factors. Birthweight is one biological variable thought to play a role in the infant's growth failure. In studies that enrolled infants with FTT who were full-term at birth, the reported birthweights of these infants were significantly less than healthy control infants (M = 2959 g vs. M = 3364 g), t(14) = -4.597, P < 0.000. There is growing evidence that there is a subgroup of full-term newborn infants who actually may have experienced some degree of intrauterine growth retardation but their birthweights remain above the traditional cut-off of 2500 g so that they go unrecognized. The question to consider is whether these infants are as behaviourally vulnerable as full-term infants with classic intrauterine growth retardation. It may be that this unrecognized group is at a higher risk of developing FTT. The purpose of this manuscript is to discuss birthweight as a possible precursor to the development of FTT.

Stability of respiratory quotient and growth outcomes of very low birth weight infants.

Nutritional management of very low birth weight (VLBW) infants involves promoting growth at rates that mimic intrauterine rates. Nutritional intake at the recommended energy level to promote growth results in fat accretion at levels that exceed intrauterine rates for fat accretion. The respiratory quotient (RQ), the ratio of carbon dioxide produced to oxygen consumed during oxidation, provides a measure of the percentage of substrates used for energy. An RQ of greater than 0.9 indicates carbohydrate is used to meet energy needs, allowing the majority of fat intake to be stored as new tissue. The purpose of this study was to examine the stability of the RQ across time in relation to nutritional intake and growth in VLBW infants. Subjects were 9 enterally fed VLBW infants. Measurements to determine the RQ were obtained weekly for 3 weeks by indirect calorimetry. Nutritional intake and growth velocity were examined. There was no significant difference in the RQ across 3 weeks. The mean (+/- SD) RQs for each of the 3 weeks were 1.08 (+/- 0.04), 1.06 (+/- 0.05), and 1.06 (+/- 0.07), respectively. No significant differences were found across the 3 weeks for any of the macronutrient variables. Growth velocity for the period was 15.7 g/kg/day. By discharge from the NICU, 66% of the infants had weights less than the 10th percentile on an intrauterine growth reference. An RQ greater than 1.0 indicates VLBW infants are depositing excess fat. However, increased accretion rates of fat did not improve the growth outcomes of these VLBW infants.

Biobehavioral characteristics of infants with failure to thrive.

Failure to thrive (FTT) is a syndrome of growth failure that results in an infant who is behaviorally difficult. The current thinking is that FTT results from a problematic infant-mother interaction, with the infant making a significant contribution to the interactional process. It is possible that the behavioral characteristics of the infant with FTT may be related to underlying physiologic response patterns, specifically, activity of the autonomic nervous system. The purpose of this study is to examine the relationships among behavioral responsiveness, heart rate variability as a marker of autonomic nervous system activity, and nutritional status in infants with FTT. Infants with FTT were matched with healthy growing infants (n = 14 pairs). Results from the study indicated that infants with FTT exhibited considerably more negative behaviors and exhibited low heart rate variability. It appears that there may be a physiologic basis to the behaviors that are exhibited by infants with FTT. Prospective research is needed to further clarify this relationship.

Behavioral characteristics of infants with nonorganic failure to thrive during a play interaction.

PURPOSE: To examine the behavioral responses of infants with nonorganic failure to thrive (NOFTT) during play interactions with their mothers. DESIGN: Comparative descriptive. METHODS: The sample consisted of 31 infants; 17 with nonorganic failure to thrive (NOFTT) and 16 matched healthy controls. The infants were videotaped during a play interaction with their mothers. The behaviors exhibited by the infants were scored with the Parent-Child Early Relational Assessment. The environmental context of the play interaction was also rated for how play was initiated, maternal involvement, and the presence of chaos. RESULTS: Infants with NOFTT exhibited more difficult behaviors during play such as more negative affect, less vocalizing, and more gaze aversion. Mothers of the infants with NOFTT were less likely to remain involved during the play interaction. The environments of the infants with NOFTT were also found to be more chaotic during play. CLINICAL IMPLICATIONS: Assessment of the infant-mother interaction during play may provide insight into the interactions that occur during other caretaking activities. Strategies could be developed to assist the mother with interacting with her difficult infant. Future research could lead to interventions that could help improve the dynamics of the infant-mother interaction in infants with NOFTT.

Does vibration offer any advantage over visual stimulation studies (VSS) in the assessment of erectile capacity?

The purpose of this work was to determine whether vibration stimulation or erotic videotape material can provide an acceptable diagnostic yield for patients with erectile dysfunction (ED) without the patient needing to endure more explicit erotic films, which may be distasteful to some patients, or intracavernous injections, to which there may be a high inhibitory response. Ninety-five subjects were randomly exposed to either vibration or videotape alone and erectile response monitored by the RigiScan. Where no clinical response was recorded by the RigiScan or by self-report by the patient, both stimuli were presented to the subject. Forty-nine subjects received vibration first and 46 received videotape first. Use of clinically based standardised measures revealed neither group achieving above threshold responses to the first stimulation and there were no differences between the two groups. Eight subjects (8%) between both groups exceeded the tip threshold during combination stimulation. Single stimulation with vibration or erotic videotape with provocative RigiScan monitoring is unhelpful in the assessment of ED in any of the diagnostic subgroups of ED. In comparison to previous provocative studies, combination of stimuli sets, whilst increasing penile response (circumferential change and rigidity) did not lead to significant evidence of clinically relevant responses using current RigiScan measures or patient self-report of change. Further studies are necessary to determine the most useful set of stimuli for provocation studies with the RigiScan.

Do steroids reduce morbidity of tonsillectomy? Meta-analysis of randomized trials.

OBJECTIVES/HYPOTHESIS: The study aims to reconcile conflicting published reports regarding the clinical efficacy of a single intraoperative dose of dexamethasone in reducing post-tonsillectomy morbidity. STUDY DESIGN: Systematic overview (meta-analysis). METHODS: To critically evaluate the existing evidence, we performed a formal meta-analysis of eight double-blinded, randomized, placebo-controlled studies of dexamethasone in pediatric patients undergoing tonsillectomy or adenotonsillectomy. Reduction in postoperative emesis and pain, as well as early return to soft or solid diet, were studied as distinct end points. RESULTS: Children being given a single intraoperative dose of dexamethasone (dosing, 0.15-1.0 mg/kg; maximum dose, 8-25 mg) were two times less likely to vomit in the first 24 hours than children being given placebo (relative risk [RR] = 0.55; 95% confidence interval [CI], 0.41-0.74; P < .0001). Routine use in four children would be expected to result in one less patient having post-tonsillectomy emesis (risk difference [RD] = -0.24; 95% CI, -0.38 to -0.10; P = .0006). In addition, children being given dexamethasone were more likely to advance to a soft or solid diet on post-tonsillectomy day 1 (RR = 1.69; 95% CI, 1.02-2.79; P = .04) than those being given placebo. Because of missing data and varied outcome measures, pain could not be meaningfully analyzed as a distinct end point. CONCLUSION: Given the frequency of tonsillectomy, relative safety and low cost of dexamethasone, and the reduction in postoperative morbidity, we recommend routine use of a single intravenous dose during pediatric tonsillectomy.

Selective indications for the management of extensive anterior epitympanic cholesteatoma via combined transmastoid/middle fossa approach.

OBJECTIVES/HYPOTHESIS: Cholesteatoma that is present in the anterior epitympanic space may extend medially along the supralabyrinthine route to the geniculate ganglion, labyrinth, and cochlea and medially toward Kawase's triangle and the anterior petrous apex. Superiorly it may erode into the middle fossa. Contemporary microsurgical techniques allow for optimal management of these lesions with minimal morbidity, provided that the irregular and complex osteology of the petrous base is understood. The objective of the study was to review the relevant regional anatomy, pathobiology, and current algorithm used in treatment of this select patient population using a combined transmastoid/middle fossa (TM/MF) approach. METHODS: A retrospective review was performed of all clinical and radiographic data from patients undergoing combined TM/MF management of extensive anterior epitympanic cholesteatoma between July 1984 and June 1998. Data from physical examinations, preoperative imaging studies, and operative findings and other relevant data were tabulated and analyzed for patients undergoing TM/MF management of cholesteatoma. RESULTS: Of 488 patients with cholesteatoma treated by the otological service between 1984 and 1998, 11 patients underwent TM/MF exposure and removal of anterior epitympanic cholesteatoma. Total cholesteatoma removal was accomplished in six patients. In three patients, because of facial nerve involvement, labyrinthine fistulae, or internal carotid artery involvement, open-cavity surgery was performed. In two patients, residual or recurrent cholesteatoma was exteriorized at "second-look" procedures. In this small cohort of patients the majority had extension to the arcuate eminence, geniculate ganglion, or Kawase's triangle or had "blue-lining" of the cochlea or labyrinth. To a lesser degree, the middle ear and mastoid contents were involved. Further facial nerve dysfunction or sensorineural hearing loss was not noted after surgery. CONCLUSIONS: Selective TM/MF removal of cholesteatoma provides an optimal route for removing complex cholesteatoma in patients with intact sensorineural function and medial cholesteatoma extension.