• Updating and Improving the Capstone Course Experience for Learners and Teachers

      Bronwyn Cooper; Lin, Ashley; Cooper, Bronwyn (2022-06-30)
      Background:The Capstone Scholarship and Discovery Course (“Capstone course”) is a required four-year course which aims to support students in the design, execution, writing, and presentation of a longitudinal scholarly project. Currently, the Capstone course meets criteria for “underperforming” designation (<75% approval) designationin two areas: Overall, how would you rate this course? | 2.52/4 | 52.77% Feedback on reports supported progress/learning | 2.95/4 | 74.07% The overall medical school curriculum is transitioning to a new curriculum (“Vista”) in which Capstone will fit into the context of student-selected Pathways. As the Capstone student representative responsible for communicating student feedback to Capstone leadership, I became interested in taking advantage of this opportunity to improve the course. I believe that every medical student should feel supported in their Capstone research and finish medical school with a foundational understanding of how to conduct longitudinal scholarly work. Objectives: 1) Identify student and faculty concerns about the Capstone course 2) Propose potential changes to the Capstone course to address the most significant concerns 3) Measure student approval towards these proposed changes 4) Summarize and present the most highly student-approved proposed changes to Capstone Course Leadership Team. Methods: I reviewed all Capstone oasis evaluations from the 2020 – 2021 Academic Year, which included 109 faculty evaluations of students, 133 student evaluations of Capstone faculty (~80% response rate), and 136 student evaluations of the Capstone course (~81% response rate). I also created a pre-survey to assess the most unclear aspects of the Capstone course as well as top barriers to meeting deadlines. I received 44 survey responses from third-year students (~22% response rate) and 47 responses from fourth-year students (~30% response rate). From the oasis evaluations and survey responses, I identified the most significant concerns. I generated twenty-two proposed changes to address these concerns, and created a slideshow that summarizes these proposed changes to the Capstone course. This was distributed to current third- and fourth-year medical students, along with a post-survey where students could vote on the proposed changes and indicate whether these changes addressed the unclear aspects of the Capstone course and top barriers to meeting deadlines. (Terminology note: learning community assigned affiliate = “affiliate”, faculty advisor specific to project = “advisor”). Results: I received 29 post-survey responses from third-year students (~15% response rate) and 37 responses from fourth-year students (~23% response rate). Between the pre- and post-surveys, the average % of students finding certain aspects of Capstone “unclear” decreased by 26.1%, and the average % of students rating certain barriers as significant for meeting Capstone deadlines decreased by 15.5%. Notably, the post-survey found that some students believe the proposed changes would not address their lack of interest in doing a longitudinal project (53.1%), and that certain projects students are interested in would still not meet Capstone requirements (31.3%). An abbreviated summary of the most popular proposed changes (>50% of students agree, and/or >10% of students indicated it as one of their top three changes, highlighted in bold) is below. Proposed Solution | % top 3 | % disagree | % neutral | % agree 1a) Create research project database | 30.4 | 3.1 | 12.3 | 84.6 1b) Create roster of past highly-rated advisors (based on oasis evals) | 7.1 | 4.6 | 24.6 | 70.8 1d) MS1 Capstone curriculum focused on developing research skills | 23.2 | 9.2 | 18.5 | 72.3 1e) Affiliate must give feedback on project feasibility as a Capstone project within a month of project proposal. | 5.4 | 6.2 | 32.3 | 61.5 2a) Add additional, optional Capstone poster presentation session before ERAS deadline so presentation can be on ERAS app | 10.7 | 6.2 | 24.6 | 69.2 2b) Optional workshops (or asynchronous videos) on common issues | 5.4 | 15.4 | 32.3 | 52.3 3a) In place of report submissions, create a live document that can be accessed by affiliate and mentor | 16.1 | 10.8 | 26.2 | 63.1 3b) Flexible format (such as Senior Scholars format: background, objectives, methods, results, conclusion) with no length requirement | 21.4 | 1.5 | 12.3 | 86.2 3c) Rework deadlines to avoid exam dates, Step 1 period, holidays, and flexible range of deadlines provided during clinical rotations | 33.9 | 0 | 3.1 | 96.9 3d) Timeline of deadlines given to affiliates and mentors, with exam dates and Step 1 period marked on timeline | 5.4 | 1.6 | 15.6 | 82.8 3e) No punishment for those who get their work done early | 23.2 | 0 | 4.7 | 95.3 3f) Meeting with affiliate can substitute for an update with affiliate approval | 1.8 | 4.7 | 25 | 70.3 4a) Projects that take place over >1 month should be accepted as “longitudinal” and all affiliates should be on the same page. | 42.9 | 1.5 | 16.9 | 81.5 5a) Students may submit outside project to their affiliate to be approved for Capstone credit as long as they worked on this project during med school | 44.6 | 1.5 | 10.8 | 87.7 5c) Website should be simplified. | 7.1 | 0 | 21.9 | 78.1 Conclusion: Students enter medical school with widely differing levels of experience in conducting scholarly research, and the current Capstone course does not have flexibility for different types of projects, or the resources needed to accommodate student needs. Capstone affiliates and advisors also face difficulties providing optimal assistance to students. Through this work, I have identified solutions that are popular amongst students, which address unclear aspects of the Capstone course and top barriers to meeting deadlines. Bringing these solutions to the Capstone Course Leadership Team is the next step to addressing these concerns. Future goals include asking Capstone affiliates for their input, as this group was not included either in the oasis evaluations or the surveys. Another limitation of this study was the low survey response rates, ranging from 15-30%. I hope that ultimately some of these proposed changes to the Capstone course will be adopted and integrated into the new Vista curriculum.
    • Clinician perspectives on the need for training on caring for pregnant women with intellectual and developmental disabilities

      Tiffany A. Moore Simas; Amir, Nili S.; Smith, Lauren; Valentine, Anne M.; Mitra, Monika; Parish, Susan L.; Moore Simas, Tiffany A. (2021-12-17)
      BACKGROUND: Women with intellectual and developmental disabilities (IDDs) experience disparities in obstetric care access and quality, in addition to communication gaps with healthcare providers. Many obstetric providers are untrained and uneducated about critical aspects of providing care to persons with IDDs. OBJECTIVE: The study was conducted to describe obstetric clinicians' training experiences related to providing obstetric care to women with IDDs, to assess the perceived need for formalized training, and to identify recommendations for training content. METHODS: This study involved qualitative individual interviews (n = 9) and one focus group (n = 8) with obstetric clinicians who self-reported experience caring for women with IDDs during pregnancy. Descriptive coding and content analysis techniques were used to develop an iterative codebook related to education and training; codes were applied to the data. Coded data were analyzed for larger themes and relationships. RESULTS: Analysis revealed three main themes: 1. Need for obstetric training and education: No participant reported receiving any training in caring for pregnant women with IDDs. Participants expressed a need for formal education. 2. Recommendations for formal training: Participants noted the need for training during residency and beyond, and all healthcare staff members should be included in training. 3. Training outcomes should increase knowledge, enhance attitudes, and develop practical skills related to care for pregnant women with IDDs. CONCLUSION: Results indicate a need for systematic training efforts regarding obstetric care for women with IDDs. Improved training and education may decrease health inequities and improve the quality of care, and thus pregnancy outcomes, for women with IDDs. LEVEL OF EVIDENCE: VI.
    • Parent-Reported Symptoms and Perceived Effectiveness of Treatment in Children Hospitalized with Advanced Heart Disease

      Molloy, Meaghan A.; DeWitt, Elizabeth S.; Morell, Emily; Reichman, Jeffrey R.; Brown, David W.; Kobayashi, Ryan; Sleeper, Lynn A.; Elia, Eleni G.; Samsel, Chase; Blume, Elizabeth D. (Mosby, 2021-07-01)
      OBJECTIVE: To characterize parent-reported symptom burden and effectiveness of symptom management in children hospitalized with advanced heart disease. STUDY DESIGN: Prospective survey study of 161 parents whose child was admitted to a single institution with AHD between March 2018 and February 2019 using the Survey about Caring for Children with Heart Disease. RESULTS: Of the 161 patients, 54% were under 2 years old with a diagnosis of single ventricle physiology (39%), pulmonary hypertension (12%), and other congenital heart disease (28%). Over half (56%) of parents reported that their child was experiencing a high degree ('a great deal'/'a lot') of symptoms. The most frequently reported symptoms were pain (68%), fatigue (63%), and breathing difficulties (60%). Of the symptoms that were treated, parents perceived successful treatment to be least likely for their child's sleep disturbance (24%), depression (29%), and fatigue (35%). Parents who reported their child's functional status as NYHA class III/IV were more likely to report that their child was experiencing 'a great deal' of symptoms, compared with those who reported class I/II (51% vs. 19%, p<0.001). Parents who reported their child was experiencing a high degree of suffering from fatigue were also more likely to report a high symptom burden (P < .001). CONCLUSIONS: Parents of children with AHD reported high symptom burden with a broad spectrum of symptoms. Parents reported fatigue and psychiatric symptoms frequently and rarely reported treatment as successful. Parents' view of their child's symptom burden was concordant with their perception of their child's functional status.
    • Neurosteroid and White Matter Correlates of ADHD and Autism Symptoms in Children with ADHD

      Jean A. Frazier, MD; Eichenberg, Tzeidel B.; Frazier, Jean A. (2021-05-12)
      Background: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder (NDD) characterized by inattention, hyperactivity and impulsivity, whereas autism spectrum disorder (ASD) is an NDD characterized by impaired social functioning and restricted interests and behaviors. These two NDD’s often co-occur in individuals—up to 50% of people with ASD may show significant traits of ADHD and approximately 66% of individuals with ADHD exhibit significant traits of ASD. Co-occurring symptoms of both ASD and ADHD are a risk factor for decreased quality of life in the NDD population, and more research on this intersection is needed to better serve these individuals. Study of sex hormone levels and study of brain white matter (WM) have suggested several key differences in sex hormone profiles and WM tracts among individuals with ASD, ADHD, and comorbid ASD and ADHD. People with ASD generally show higher levels of both testosterone (T) and dehydroepiandrosterone (DHEA) when compared to controls, while boys with ADHD have been shown to have lower levels of DHEA, but similar T levels, when compared with controls. Furthermore, altered sex hormone levels have been correlated with symptom severity in both individuals with ADHD and with ASD. For these reasons and more, DHEA and T are often referred to in the neurodevelopment literature as “neurosteroids.” WM tract alterations are typically investigated using diffusion tensor magnetic resonance imaging (DTI) of the head. The measure used as a proxy for WM tract integrity is fractional anisotropy (FA). Both abnormally high and low FA values have been detected in individuals with ADHD, ASD, or features of both, particularly in the tracts connecting the two cerebral hemispheres, tracts connecting multiple cortical areas, and tracts connecting the cortex and the primitive motor control center. Just as with alterations in sex hormone levels, these alterations in FA values are correlated with both ADHD and ASD symptom severity. Although one study on typically developing pubertal boys showed higher rates of increasing T were correlated with lower FA in a WM tract within the brain’s memory and emotion center, there is a gap in the literature around a potential link between neurosteroids and WM integrity in children with ADHD. Better understanding of neurosteroidal regulation of aberrant WM development in ADHD, and its relationship to both ASD and ADHD symptom severity within this population would contribute to our understanding of the ASD-ADHD intersection. Objectives: The goal of this analysis was to elucidate a relationship between the neurosteroids T and DHEA, and integrity of one or more particular WM tracts in children with ADHD. Methods: Four groups of children ages 9-11 years were compiled from the Adolescent Brain Cognitive Development Study (ABCD) via the National Database for Autism Research—males with ADHD, females with ADHD, TD females, and TD males (n=121 per group). Children with ASD, obsessive compulsive disorder, conduct disorder, and schizophrenia diagnoses were excluded. Groups were matched 1:1 by handedness and age. Groups were mean-matched by Parent Pubertal Development Scale (PDMS) item sum within sex. Group status served as the dependent variable, and the independent variables were mean FA within the 23 WM areas examined by ABCD, prepubertal salivary T concentration, prepubertal salivary DHEA concentration, number of ADHD items endorsed on DSM interview (ADHD symptom severity measure), and Parent Short Social Responsiveness Scale (SRS) sum (autistic trait severity measure). All measures were collected at the ABCD baseline visit, except for the SRS, which was conducted at the 1-year follow-up visit. Statistical analysis included two-way ANOVA’s and unpaired, two-way t-tests. The following Pearson linear regression analyses were also conducted: mean FA of each tract over each hormone, symptom severity (both ASD and ADHD) over mean FA of each tract, and symptom severity (both ASD and ADHD) over each hormone. Results: Subjects with ADHD showed significantly higher autistic traits than TD subjects. There were sex-by-diagnosis interaction effects on two tracts: the left inferior fronto-occipital fasciculus (IFOF) and the left cingulate cingulum (CGC). Both autistic trait severity and ADHD symptom severity were negatively correlated with both DHEA and T in males with ADHD, but not in females with ADHD or in TD subjects. ADHD symptom severity was positively correlated with mean FA in the frontal region of the right superior corticostriate (SCS) among all subjects with ADHD pooled (R=0.14, p=.03), whereas analysis of the females and males with ADHD separately showed a positive trend among females (R=0.15, p=.10) and a negative trend among males (R=-0.12, p=.19). TD males showed a negative correlation between DHEA and mean FA in the left SCS (R=-0.21, p=.02), which was notably absent among males with ADHD. TD females showed a positive correlation between T and mean FA in forceps major (FM) (R=0.27, p<.01), while females with ADHD showed a negative correlation between T and mean FA in FM (R=-0.22, p=.02). Conclusion: These findings reinforce the important role of low levels of DHEA in development of ADHD symptoms in boys, while highlighting that T may be a previously unknown mediator. Furthermore, low DHEA and T may play a more significant role in ADHD symptom development in boys than in girls. While higher levels of DHEA and T are linked to higher severity of autistic traits in the ASD population, these results suggest that lower levels of DHEA and T are correlated with higher autistic trait severity in boys with ADHD. This analysis supports the hypothesis that hormonal influence on ADHD symptom severity may take place via neurosteroidal regulation of development of one or more specific WM tracts, and that the anatomy and pathophysiology of this process may be sex-specific. DHEA’s role in the typical development of cortico-basal-ganglia communication may be suppressed in boys with ADHD. Aberrant regulation of interhemispheric communication development by T may be an important factor in the pathogenesis of ADHD in girls. Additionally, the opposing effects of cortico-basal-ganglia WM integrity on ADHD symptom severity in girls versus boys with ADHD, and the presence of sex-by-diagnosis interaction effects in this analysis further reinforce the hypothesis that WM differences in ADHD differ between boys and girls. This was a cross-sectional analysis of prepubescent and early pubescent subjects, therefore it is important to place any sex differences demonstrated here in the context of longitudinal neurodevelopment literature given the disparity in pubertal timing between the sexes.
    • Clinician Perspectives on the Need for Training and Caring for Pregnant Women with Intellectual and Developmental Disabilities [poster]

      Tiffany A. Moore Simas; Amir, Nili S.; Smith, Lauren; Valentine, Anne M.; Mitra, Monika; Parish, Susan L.; Moore Simas, Tiffany A. (2021-04-15)
      Background: Women with intellectual and developmental disabilities (IDD) experience disparities in obstetric care access and quality, in addition to communication gaps with healthcare providers. Many obstetric providers are untrained and uneducated about critical aspects of providing care to persons with IDD. Objectives: The present study was conducted (1) to describe obstetric clinicians’ training experiences related to providing obstetric care to women with IDD, (2) to assess obstetric clinicians’ perceived need for formalized training, and (3) to identify recommendations for training content and dissemination. Methods: This study involved qualitative individual interviews (n=9) and one focus group (n=8) with obstetric clinicians who self-reported experience caring for women with IDD during pregnancy. Descriptive coding and content analysis techniques were used to develop an iterative codebook related to education and training; codes were applied to the data. Coded data were analyzed for larger themes and relationships. Results: Analysis revealed three main themes: 1. Need for obstetric training and education: No participant reported receiving any training in caring for pregnant women with IDD. Participants expressed a need for formal education. 2. Recommendations for formal training: Participants noted a dearth of clinical practice guidelines, the need for pregnancy-specific training during residency and beyond, and all healthcare staff should be included in training opportunities. 3. Training outcomes should increase knowledge, enhance attitudes, and develop practical skills related to communication and care for pregnant women with IDD. Conclusion: Study results indicate a need for and interest in systematic training efforts regarding obstetric care for women with IDD. Improved training and education may decrease health inequities and improve the quality of obstetric care, and thus pregnancy outcomes, for women with IDD.
    • Response to the influence of teledermatology on health care access and equity

      Mehdi Rashighi, MD; Franciosi, Ellen B.; Tan, Alice J.; Kassamali, Bina; O'Connor, Daniel M.; Rashighi, Medhi; LaChance, Avery (2021-04-01)
      To the Editor: We thank Hadeler and his co-authors for their support of our research and for providing additional context regarding telemedicine's impact on health care access and equity.Although we found that teledermatology services performed during the COVID-19 pandemic benefitted minority and Medicaid patients, Hadeler et al highlight previous survey-based studies from 2011 and 2013 to 2016 that demonstrated these patients were the least likely to utilize telemedicine. We believe there are 2 key factors that likely contributed to the increased appointment attendance among minority and Medicaid patients found in our study reflecting the rapidly evolving landscape of telemedicine. These factors are also notable, as they have implications for future access to telemedicine.
    • PAPPA-mediated adipose tissue remodeling mitigates insulin resistance and protects against gestational diabetes in mice and humans

      Silvia Corvera, MD; Rojas-Rodriguez, Raziel; Ziegler, Rachel; DeSouza, Tiffany; Majid, Sana; Madore, Aylin S.; Amir, Nili S.; Pace, Veronica A.; Nachreiner, Daniel; Alfego, David; et al. (2020-11-25)
      Pregnancy is a physiological state of continuous adaptation to changing maternal and fetal nutritional needs, including a reduction of maternal insulin sensitivity allowing for appropriately enhanced glucose availability to the fetus. However, excessive insulin resistance in conjunction with insufficient insulin secretion results in gestational diabetes mellitus (GDM), greatly increasing the risk for pregnancy complications and predisposing both mothers and offspring to future metabolic disease. Here, we report a signaling pathway connecting pregnancy-associated plasma protein A (PAPPA) with adipose tissue expansion in pregnancy. Adipose tissue plays a central role in the regulation of insulin sensitivity, and we show that, in both mice and humans, pregnancy caused remodeling of adipose tissue evidenced by altered adipocyte size, vascularization, and in vitro expansion capacity. PAPPA is known to be a metalloprotease secreted by human placenta that modulates insulin-like growth factor (IGF) bioavailability through prolteolysis of IGF binding proteins (IGFBPs) 2, 4, and 5. We demonstrate that recombinant PAPPA can stimulate ex vivo human adipose tissue expansion in an IGFBP-5- and IGF-1-dependent manner. Moreover, mice lacking PAPPA displayed impaired adipose tissue remodeling, pregnancy-induced insulin resistance, and hepatic steatosis, recapitulating multiple aspects of human GDM. In a cohort of 6361 pregnant women, concentrations of circulating PAPPA are inversely correlated with glycemia and odds of developing GDM. These data identify PAPPA and the IGF signaling pathway as necessary for the regulation of maternal adipose tissue physiology and systemic glucose homeostasis, with consequences for long-term metabolic risk and potential for therapeutic use.
    • The rise and fall of heterologous transfusion

      Manisha Desai; Nguyen, H. Yen; Desai, Manisha S. (2020-09-01)
      Now a routine lifesaving treatment, blood transfusion between humans became a safe procedure only after many early therapeutic disasters. Performed between different species, heterologous transfusions actually succeeded homologous transfusions, those performed between members of the same species. In the early history of transfusion, both homologous and heterologous transfusions were performed in many clinical settings. Early clinicians were unable to distinguish between deaths caused by baseline illness and those resulting from transfusions. This report examines both early experiments with homologous transfusion between animals and later efforts investigating and finally abandoning heterologous transfusion. Topics explored include: 1) contributions and lessons learned from key individuals, 2) how these researchers suggested, performed, advocated, or challenged the practice of heterologous transfusion, and 3) why heterologous transfusions were even considered as a mode of therapy.
    • Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania

      Amna Diwan; Albright, Patrick D.; Ali, Syed H.; Jackson, Hunter; Haonga, Billy T.; Eliezer, Edmund Ndalama; Morshed, Saam; Shearer, David W. (2020-08-01)
      BACKGROUND: Treatment of diaphyseal open tibia fractures often results in reoperation and impaired quality of life. Few studies, particularly in resource-limited settings, have described factors associated with outcomes after these fractures. QUESTIONS/PURPOSES: (1) Which patient demographic, perioperative, and treatment characteristics are associated with an increased risk of reoperation after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? (2) Which patient demographic, perioperative, and treatment characteristics are associated with worse 1-year quality of life after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? METHODS: A prospective study was completed in parallel to a similarly conducted RCT at a tertiary referral center in Tanzania that enrolled adult patients with diaphyseal open tibia fractures from December 2015 to March 2017. Patients were treated with either a statically locked intramedullary nail or external fixator and examined at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. The primary outcome, reoperation, was any deep infection or nonunion treated with a secondary intervention. The secondary outcome was the 1-year EuroQol-5D (EQ-5D) index score. There were 394 patients screened and ultimately, 267 patients enrolled in the study (240 from the primary RCT and 27 followed for the purposes of this study). Of these, 90% (240 of 267) completed 1-year follow-up and were included in the final analysis. This group comprised 110 patients who underwent IMN and 130 who had external fixation; follow-up was similar between study groups. Patients were an average of 33 years old and were primarily males who sustained road traffic injuries resulting in AO/Orthopaedic Trauma Association (OTA) classification type A or B fractures. There were 51 reoperations. For the purposes of analysis, all patients were pooled to identify all other factors, in addition to treatment type, associated with increased risk of reoperation and 1-year quality of life. An exploratory bivariable analysis identifying various factors associated with reoperation risk and EQ-5D was subsequently included in a multivariate modeling procedure to control for confounding of effect on our primary outcome. Multivariable modeling was performed using standard hierarchical modeling simplification procedures with log-likelihood ratios. Alpha levels were set to 0.05. RESULTS: After controlling for potentially confounding variables such as gender, smoking status, mechanism of injury, and treatment type, the following factors were independently associated with reoperation: Time from hospital presentation to surgery more than 24 hours (odds ratio 7.7 [95% confidence interval 2.1 to 27.8; p = 0.002), AO/OTA fracture classification Type 42C fracture (OR 4.2 [95% CI 1.2 to 14.0]; p = 0.02), OTA-Open Fracture Classification muscle loss (OR 7.5 [95% CI 1.3 to 42.2]; p = 0.02), and varus coronal angle on an immediate postoperative AP radiograph (OR 4.8 [95% CI 1.2 to 14.0]; p = 0.002). After again controlling for confounding variables such as gender, smoking status, mechanism of injury, and treatment type factors independently associated with worse 1-year EQ-5D scores included: Wound length > /= 10 cm (ss = [change in EQ-5D score] -0.081 [95% CI -0.139 to -0.023]; p = 0.006), OTA-Open Fracture Classification muscle loss (ss = -0.133 [95% CI -0.215 to -0.051]; p = 0.002), and OTA-Open Fracture Classification bone loss (ss = -0.111 [95% CI -0.208 to -0.013]; p = 0.03). We observed a modest, but independent association between reoperation and worse 1-year EQ-5D scores (ss = -0.113 [95% CI -0.150 to -0.077]; p < 0.001). CONCLUSIONS: We found two potentially modifiable factors associated with the risk of reoperation: reducing time to surgical treatment and avoiding varus coronal angulation during definitive stabilization. Hospitals may be able to minimize time to surgery, and thus, reoperation, by increasing the number of available operative personnel and space and emphasizing the importance of open tibia fractures as an injury requiring emergent orthopaedic management. Given the lack of fluoroscopy in the study setting and similar settings, surgeons should emphasize appropriate fracture alignment, even into slight valgus, to avoid varus angulation and subsequent reoperation risk. LEVEL OF EVIDENCE: Level II, therapeutic study.
    • Impact of acute kidney injury on long-term outcomes after fenestrated and branched endovascular aortic aneurysm repair

      Andres Schanzer; Dossabhoy, Shernaz S.; Simons, Jessica P.; Crawford, Allison S.; Aiello, Francesco A.; Judelson, Dejah R.; Arous, Edward J.; Messina, Louis M.; Schanzer, Andres (2020-07-01)
      OBJECTIVE: Acute kidney injury (AKI) has been identified as a common complication after fenestrated and branched endovascular aneurysm repair (F/BEVAR), occurring in 5% to 29% of patients. Predictors of AKI and its impact on long-term outcomes remain unknown. We sought to identify independent predictors of AKI and its effect on long-term survival after F/BEVAR. METHODS: A single-institution retrospective review of all consecutive F/BEVAR procedures was performed (November 2010-September 2018). Data were collected prospectively through an Institutional Review Board-approved registry and a physician-sponsored investigational device exemption clinical trial (G130210). AKI was defined as a decrease in estimated glomerular filtration rate by > 30% from baseline, within 30 days postoperatively. The cohort was stratified according to whether a patient experienced AKI. Demographics, operative details, perioperative complications, and length of stay between groups were compared. The primary outcome, long-term survival, was assessed with Kaplan-Meier analysis and Cox proportional hazards modeling. Independent predictors of AKI were identified using logistic regression. RESULTS: Among 219 consecutive F/BEVAR patients, AKI occurred in 41 patients (19%) and was the most common 30-day complication observed. Whereas preoperative creatinine concentration, estimated glomerular filtration rate, and target renal artery stenosis > 50% did not predict AKI, the occurrence of intraoperative complications did correlate with AKI (37% vs 7.3%; P < .01). By 30 days, AKI resolved in 7 (17%) patients, persisted without need for dialysis in 26 (64%), and progressed to dialysis in 5 (12%); the remaining 3 (7%) patients died. Survival at 30 days was significantly lower in the AKI group (92.7% vs 98.9%; P = .047), and this difference persisted at 1 year (68% vs 87%; log-rank, P < .01) and 3 years (44% vs 60%; log-rank, P = .04). On multivariable modeling, AKI increased the hazard of death nearly twofold (hazard ratio, 1.92; 95% confidence interval [CI], 1.11-3.23; P = .019). Independent predictors of AKI on multivariable logistic regression were intraoperative complications (odds ratio, 4.10; 95% CI, 1.61-10.42; P < .01) and increased operating room time (odds ratio, 1.56; 95% CI, 1.22-2.00; P < .01). CONCLUSIONS: In our 8-year experience of F/BEVAR, AKI was the most common postoperative complication observed in nearly 20% of patients. AKI after F/BEVAR is associated with decreased short- and long-term survival. Whether AKI is causative or just associated with decreased survival remains to be elucidated. Further study is needed to determine whether the independent predictors of AKI, including intraoperative complications and operating room time, are generalizable across all centers performing F/BEVAR and to investigate how we might further mitigate this common and serious complication.
    • Goals-of-care decision aid for critically ill patients with TBI: Development and feasibility testing

      Susanne Muehlschlegal; Muehlschlegel, Susanne; Hwang, David Y.; Flahive, Julie M.; Quinn, Thomas; Lee, Christopher; Moskowitz, Jesse; Goostrey, Kelsey; Jones, Kelsey; Pach, Jolanta J.; et al. (2020-06-17)
      OBJECTIVE: To develop and demonstrate early feasibility of a goals-of-care decision aid for surrogates of patients who are critically ill with traumatic brain injury (ciTBI) that meets accepted international decision aid guidelines. METHODS: We developed the decision aid in 4 stages: (1) qualitative study of goals-of-care communication and decision needs of 36 stakeholders of ciTBI (surrogates and physicians), which informed (2) development of paper-based decision aid with iterative revisions after feedback from 52 stakeholders; (3) acceptability and usability testing in 18 neurologic intensive care unit (neuroICU) family members recruited from 2 neuroICU waiting rooms using validated scales; and (4) open-label, randomized controlled feasibility trial in surrogates of ciTBI. We performed an interim analysis of 16 surrogates of 12 consecutive patients who are ciTBI to confirm early feasibility of the study protocol and report recruitment, participation, and retention rates to date. RESULTS: The resultant goals-of-care decision aid achieved excellent usability (median System Usability Scale 87.5 [possible range 0-100]) and acceptability (97% graded the tool's content as "good" or "excellent"). Early feasibility of the decision aid and the feasibility trial protocol was demonstrated by high rates of recruitment (73% consented), participation (100%), and retention (100% both after the goals-of-care clinician-family meeting and at 3 months) and complete data for the measurements of all secondary decision-related and behavioral outcomes to date. CONCLUSIONS: Our systematic development process resulted in a novel goals-of-care decision aid for surrogates of patients who are ciTBI with excellent usability, acceptability, and early feasibility in the neuroICU environment, and meets international decision aid standards. This methodology may be a development model for other decision aids in neurology to promote shared decision-making.
    • Intramedullary Nailing Versus External Fixation in the Treatment of Open Tibial Fractures in Tanzania: Results of a Randomized Clinical Trial

      Amna Diwan; Haonga, Billy T.; Liu, Max; Albright, Patrick; Challa, Sravya T.; Ali, Syed H.; Lazar, Ann A.; Eliezer, Edmund N.; Shearer, David W.; Morshed, Saam (2020-05-20)
      BACKGROUND: Open tibial fractures are common injuries in low and middle-income countries, but there is no consensus regarding treatment with intramedullary nailing versus external fixation. The purpose of the present study was to compare the outcomes of initial treatment with intramedullary nailing or external fixation in adults with open tibial fractures. METHODS: We conducted a randomized clinical trial (RCT) at a tertiary orthopaedic center in Tanzania. Adults with acute diaphyseal open tibial fractures were randomly assigned to statically locked, hand-reamed intramedullary nailing or uniplanar external fixation. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Secondary outcomes included quality of life as measured with the EuroQol-5 Dimensions (EQ-5D) questionnaire, radiographic alignment, and healing as measured with the modified Radiographic Union Scale for Tibial fractures (mRUST). RESULTS: Of the 240 patients who were enrolled, 221 (92.1%) (including 111 managed with intramedullary nailing and 110 managed with external fixation) completed 1-year follow-up. There were 44 primary outcome events (with rates of 18.0% and 21.9% in the intramedullary nailing and external fixation groups, respectively) (relative risk [RR] = 0.83 [95% confidence interval (CI), 0.49 to 1.41]; p = 0.505). There was no significant difference between the groups in terms of the rate of deep infection. Intramedullary nailing was associated with a lower risk of coronal malalignment (RR = 0.11 [95% CI, 0.01 to 0.85]; p = 0.01) and sagittal malalignment (RR = 0.17 [95% CI, 0.02 to 1.35]; p = 0.065) at 1 year. The EQ-5D index favored intramedullary nailing at 6 weeks (mean difference [MD] = 0.07 [95% CI = 0.03 to 0.11]; p < 0.001), but this difference dissipated by 1 year. Radiographic healing (mRUST) favored intramedullary nailing at 6 weeks (MD = 1.2 [95% CI = 0.4 to 2.0]; p = 0.005), 12 weeks (MD = 1.0 [95% CI = 0.3 to 1.7]; p = 0.005), and 1 year (MD = 0.8 [95% CI = 0.2 to 1.5]; p = 0.013). CONCLUSIONS: To our knowledge, the present study is the first RCT assessing intramedullary nailing versus external fixation for the treatment of open tibial fractures in sub-Saharan Africa. Differences in primary events were not detected, and only coronal alignment significantly favored the use of intramedullary nailing. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
    • Senior Scholars Day Slide Presentation, May 2020

      Savageau, Judith A. (2020-05-17)
      The fundamental goal of the Senior Scholars Program at the University of Massachusetts Medical School is to increase the medical student’s understanding of scientific methods that can be applied directly to problem-solving skills development and critical thinking. Specific goals of the program include: 1) providing a structured research experience; 2) developing students’ hypothesis-generating skills; 3) providing an opportunity for students considering academic careers; and 4) fostering student-mentor relationships. The 23 students highlighted on the following slides represent those who completed their project in Academic Year (AY) 2019-2020. For 6 of these students, this work also completes their participation in the 4-year Clinical and Translational Research Pathway (CTRP). An additional 3 students were Senior Scholars in AY20 but will present their work in the Spring of AY21. This presentation was prepared for Senior Scholars Day to highlight the individual work of all 23 students and their faculty mentors.
    • Prehospital Intubations Are Associated With Elevated Cuff Pressures: A Cross-Sectional Study Characterizing ETT Cuff Pressures at the UMMMC University Emergency Department

      Matthew R. Rebesco; Chen, Ruo S.; Rebesco, Matthew R.; O'Connor, Laurel C.; LaBarge, Kara L.; Remotti, Edgar J.; Tennyson, Joseph C. (2020-05-15)
      Abstract will be available upon expiration of embargo.
    • Penile calciphylaxis: A retrospective case-control study

      Daniela Kroshinsky; Gabel, Colleen; Chakrala, Teja; Shah, Radhika; Danesh, Melissa J.; Dobry, Allison S.; Garza-Mayers, Anna Cristina.; Ko, Lauren N.; Nguyen, Emily; St. John, Jessica; et al. (2020-05-15)
      BACKGROUND: Calciphylaxis is a rare disorder characterized by skin necrosis caused by calcium deposition within vessels, thrombosis, and subsequent tissue ischemia. Penile involvement may rarely occur. OBJECTIVE: To identify risk factors, diagnosis, management, and mortality of patients with penile calciphylaxis. METHODS: A retrospective medical record review was conducted of 16 patients with penile calciphylaxis treated at 2 large urban tertiary care centers between January 2001 and December 2019. A control group of 44 male patients with nonpenile calciphylaxis at the same institution was included. RESULTS: The median survival of patients with penile calciphylaxis was 3.8 months (interquartile range, 27.0 months). Mortality was 50% at 3 months and 62.5% at 6 months for penile calciphylaxis, and 13.6% at 3 months and 29.5% at 6 months for controls (P = .008). Patients with penile calciphylaxis were less likely to be obese (P = .04) but more likely to have hyperparathyroidism (P = .0003) and end-stage renal disease (P = .049). LIMITATIONS: Retrospective study design and small sample size. CONCLUSIONS: This study further defines the disease course of penile calciphylaxis, which has high mortality. Imaging may be used to aid diagnosis. Risk factors include end-stage renal disease, hyperparathyroidism, and normal body mass index.
    • Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries

      Amna Diwan; Curran, Patrick F.; Albright, Patrick; Ibrahim, John M.; Ali, Syed H.; Shearer, David W.; Sabatini, Coleen S. (2020-05-01)
      BACKGROUND: Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. METHODS: Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and chi test for continuous and categorical variables, respectively, and weighted Pearson correlation (P < 0.05). RESULTS: Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated > 10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P < 0.001; UMIC vs. LIC P < 0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P < 0.05 between UMIC-LMIC and UMIC-LIC). CONCLUSION: This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. LEVEL OF EVIDENCE: Level II-prospective comparative study.
    • The Presence of Hurthle Cells Does Not Increase the Risk of Malignancy in Most Bethesda Categories in Thyroid Fine-Needle Aspirates

      Gregory Randolph; Ren, Yin; Kyriazidis, Natalia; Faquin, William C.; Soylu, Selen; Kamani, Dipti; Saade, Rayan; Torchia, Nicole; Lubitz, Carrie; Davies, Louise; et al. (2020-03-11)
      Background: Hurthle cell/oncocytic change is commonly reported on thyroid fine-needle aspiration (FNA) and may be considered an "atypical cell" by clinicians. This study aims to delineate the association between Hurthle cells in preoperative cytology and subsequent pathology of the indexed thyroid nodule and to report rates of malignancy. Methods: Retrospective review of records of 300 patients with Hurthle cell/oncocytic change on FNA and final surgical pathology at a tertiary referral center between 2000 and 2013 was performed and compared with a multi-institutional FNA cohort. The degree of Hurthle cell presence was correlated with histopathologic diagnoses. Results: In the Hurthle cell FNA group, Bethesda System for Reporting Thyroid Cytopathology (BSRTC) categories were as follows: I (nondiagnostic) 14 (4.7%); II (benign) 113 (37.7%); III (atypia of undetermined significance/follicular lesion of undetermined significance) 33 (11%); IV (follicular neoplasm/suspicious for a follicular neoplasm) 125 (41.6%); V (suspicious for malignancy) 12 (4%); and VI (malignant) 3 (1%). When categorized based on the degree of Hurthle cell change, 59 (29%) were classified as mild, 13 (6%) moderate, and 131 (65%) as predominant. When comparing the results with a multi-institutional FNA cohort (all with surgical confirmation), the presence of Hurthle cells was found to be associated with a lower risk of malignancy in all BSRTC categories, with a statistically significant difference in the BSRTC IV and V groups. The sole exception was when Hurthle cell presence was classified as predominant (defined as > 75% of the cellular population); the rate of malignancy was significantly elevated in FNAs interpreted as benign/Bethesda II. Conclusions: Although Hurthle cells have been considered by clinicians as an "atypical cell," their presence does not increase the risk of malignancy within BSRTC categories overall. However, when predominant Hurthle cell change is present, the risk of malignancy is increased in the benign cytology/BSRTC category II.
    • Increasing Fat Graft Retention in Irradiated Tissue after Preconditioning with External Volume Expansion

      Janice Lalikos; Lujan-Hernandez, Jorge; Chin, Michael S.; Perry, Dylan J.; Chappell, Ava G.; Lancerotto, Luca; Yu, Nanze; Slamin, Robert P.; Bannon, Elizabeth; Fitzgerald, Thomas J.; et al. (2020-01-01)
      BACKGROUND: Fat grafting is an adjuvant that may improve the quality of radiation-damaged tissue. However, fat grafting for volume restoration in irradiated sites may be less effective because of a poorly vascularized fibrotic recipient bed. External volume expansion has emerged as a potential technique to prepare the recipient sites for improved survival of grafted fat. The authors previously demonstrated increased vasculature with external volume expansion stimulation of irradiated tissues. The authors now hypothesize that external volume expansion's improvements in recipient-site vascularity will increase the volume retention and quality of fat grafts in fibrotic irradiated sites. METHODS: Athymic mice were irradiated until development of chronic radiation injury. Then, the irradiated site was stimulated by external volume expansion (external volume expansion group), followed by subcutaneous fat grafting. Grafts in an irradiated site without external volume expansion stimulation (irradiated control group) and grafts in a healthy nonirradiated (nonirradiated control group) site were used as controls. All grafts were monitored for 8 weeks and evaluated both histologically and by micro-computed tomography for analysis of volume retention. RESULTS: Hyperspectral imaging confirmed a 25 percent decrease in vascularity of irradiated tissue (irradiated control group) compared with nonirradiated tissue (nonirradiated control group). Grafts in the irradiated control group retained 11 percent less volume than grafts in the nonirradiated control group. The experimental external volume expansion group achieved a 20 percent (p = 0.01) increase in retained graft volume compared with the irradiated control group. CONCLUSIONS: External volume expansion stimulation can mitigate the effects of irradiation at the recipient site and in turn help preserve fat graft volume retention. Possible mechanisms include increased vascularity, adipogenic conversion, and increased compliance of a fibrotic recipient site.
    • Applying Machine Learning Algorithms for Automatic Detection of Swallowing from Sound

      David Paydarfar; Santoso, Laura F.; Baqai, Faiz; Gwozdz, Mary; Lange, Justina; Rosenberger, Matthew G.; Sulzer, James; Paydarfar, David (2019-07-23)
      Despite the severe consequences of dysfunctional swallowing, there is no simple method of monitoring swallowing outside of clinical settings. People who cannot swallow cannot eat safely, resulting in profound changes in quality of life and risk of death from aspiration pneumonia. A non-invasive swallowing detector may have widespread impact in both clinical care and research. Detection of swallowing from laryngeal sounds could become an ideal assessment tool because sounds are simple to record, quantifiable, and amenable to software analysis. The focus of this paper is to achieve high accuracy binary swallowing detection from sound recordings. A dataset with 2500 swallow sound samples and 1700 mixed laryngeal noise samples from 15 healthy adults was used to train and test three supervised machine learning algorithms. A decision tree, support vector machine (SVM), and neural network trained with the scaled conjugate gradient (SCG) method had areas under the receiver operating characteristic (ROC) curve of 0.970, 0.961, and 0.971 and average accuracies of 93.2 percent, 86.2 percent, and 93.7 percent respectively. While further work needs to be done to further optimize these algorithms and validate their efficacy, these initial results suggest machine learning strategies may be helpful to improve accuracy of swallowing detection.
    • Knowledge of and Attitudes Towards Mental Illness Among ASHA and Anganwadi Workers in Vadodara District, Gujarat State, India

      Xiaoduo Fan, MD; Shah, Qainat N.; Dave, Pooja A.; Loh, Daniella A.; Appasani, Raghu; Katz, Craig L. (2019-06-01)
      Unmet needs in mental health care are high in low and middle-income countries like India. We propose recruiting community health workers (CHWs) to provide mental health services and address the treatment gap, but there is limited data available on the training needs for this potential role. The aim of this study is to help determine what type of formal mental health training and programming could most benefit CHWs in India. This was a cross sectional study design. Self-administered surveys were conducted amongst CHWs in the villages of Vadodara District, Gujarat, India. Statistical analyses included two tailed t-tests using Microsoft Excel 2011. The most common causes for mental illness were attributed to anxiety (61%) and brain disease (61%) followed by stress (45%) and alcohol use disorder (38%). CHWs were dismissive of faith healers ability to treat mental illness (72.9%) showing a strong approval for recommending psychiatric care for the mentally ill (84.4%). Over 50% of participants believed that mentally ill have a lower IQ and that they were unpredictable, but at the same time asserted that people with mental illness can live in the community (80.8%), and recover if given treatment and support (91.8%). Results are promising with CHWs displaying basic knowledge of the etiology and treatment of disease harboring positive attitudes towards psychiatrist's ability to treat mental illness. Future direction should focus on training CHWs towards minimizing stigmatizing views and increasing their knowledge of mental illness in order to scale up mental health services in these low resource communities.