Multiple organizations recommend that individualized end-of-life (EOL) care should be standard practice. However, a standardized approach does not exist because EOL care should be individually ...tailored. The 3 Wishes Project is an EOL intervention that provides direction for individualized care with 3 goals: dignify death, celebrate the patient's life, and support family members and the intensive care unit clinicians caring for the patient. Patients and families are given the opportunity to choose 3 wishes during the dying process.
To ascertain if the implementation of the 3 Wishes Project allowed the medical team to provide individualized EOL care.
The Iowa Model was used for this evidence-based project. The project was implemented in the medical intensive care unit at an academic medical center. Outcomes were evaluated by the collection and analysis of qualitative and quantitative data.
From the 57 patients who died during the 2-month implementation period, 32 wish forms were collected; 31 patients participated and 1 declined. Overall participation among patients was 56%. The top 5 wishes were cloth hearts, blankets, heartbeat printouts, fingerprints and handprints, and music. The total cost was $992, and the average cost per wish was $6.98. Eighty-five percent (33 of 39) of the respondents to the medical team survey indicated that they either agreed or strongly agreed that the project allowed the medical team to consistently provide individualized EOL care.
The survey data support the 3 Wishes Project as a method that allowed the medical team to individualize EOL care and as a valuable tool for incorporation at the bedside.
The Affordable Care Act of 2010 increased dental coverage for children in the United States, (U.S.) but not for adults. Few studies in current scholarship make use of up-to-date, nationally ...representative data to examine oral health disparities in the U.S.
The purpose of this study is to use nationally representative data to determine the prevalence of untreated caries among children and adults of different socioeconomic and racial/ethnic groups and to examine the factors associated with untreated caries among children and adults.
This study used the 2011-2014 National Health and Nutrition Examination Survey (NHANES) demographic, oral health questionnaire, and oral health dentition examination data (n = 7008 for children; n = 9673 for adults). Participants that had a standardized oral health examination and at least one natural primary or permanent tooth considering 28 tooth spaces were included in this study. Our main outcome measure was untreated coronal caries defined as decay on the crown or enamel surface of a tooth that had not been treated or filled. Population estimates were calculated to determine the prevalence of untreated caries among children and adults in the United States. Frequencies and Pearson's chi-square tests were used to compare those with and without untreated caries. Multivariate logistic regression models were used to evaluate the factors associated with untreated caries. We conducted analyses among children and adults separately.
From 2011 to 2014, 12.4 million children and 57.6 million adults in the United States had untreated caries. Age, family income level, recent dental visit, and financial and non-financial barriers were significantly associated with untreated caries in both children and adults. Race/ethnicity, gender and education level were also significantly associated with untreated caries among adults. The odds of untreated caries associated with financial barriers were 2.06 for children and 2.84 for adults while the odds of untreated caries associated with non-financial barriers were 2.86 for children and 1.67 for adults.
Demographic and socio-economic disparities in untreated caries exist among children and adults.
Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed ...via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, 0.29, 3.24,
p
= 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, 0.72, 3.34,
p
= 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, 0.93, 3.98,
p
= 0.08), need for fundoplication following EA repair (OR 1.22, 0.39, 3.75,
p
= 0.73)—with the exception of operative time (MD 30.68, 4.35, 57.01,
p
= 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.
Level of evidence
3a systematic review of case–control studies.
Extreme prematurity is the leading cause of death among children under 5 years of age. Currently, there is no treatment for bronchopulmonary dysplasia (BPD), the most common complication of extreme ...prematurity. Experimental studies in animal models of BPD suggest that mesenchymal stromal cells (MSCs) are lung protective. To date, no systematic review and meta‐analysis has evaluated the preclinical evidence of this promising therapy. Our protocol was registered with Collaborative Approach to Meta‐Analysis and Review of Animal Data from Experimental Studies prior to searching MEDLINE (1946 to June 1, 2015), Embase (1947 to 2015 Week 22), Pubmed, Web of Science, and conference proceedings (1990 to present) for controlled comparative studies of neonatal animal models that received MSCs or cell free MSC‐derived conditioned media (MSC‐CM). Lung alveolarization was the primary outcome. We used random effects models for data analysis and followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses reporting guidelines. We screened 990 citations; 25 met inclusion criteria. All used hyperoxia‐exposed neonatal rodents to model BPD. MSCs significantly improved alveolarization (Standardized mean difference of −1.330, 95% confidence interval CI −1.724, −0.94, I2 69%), irrespective of timing of treatment, source, dose, or route of administration. MSCs also significantly ameliorated pulmonary hypertension, lung inflammation, fibrosis, angiogenesis, and apoptosis. Similarly, MSC‐CM significantly improved alveolarization, angiogenesis, and pulmonary artery remodeling. MSCs, tested exclusively in hyperoxic rodent models of BPD, show significant therapeutic benefit. Unclear risk of bias and incomplete reporting in the primary studies highlights nonadherence to reporting standards. Overall, safety and efficacy in other species/large animal models may provide useful information for guiding the design of clinical trials. Stem Cells Translational Medicine 2017;6:2079–2093
MSCs in pre‐clinical bronchopulmonary dysplasia (BPD). In this first‐ever systematic review and meta‐analysis, when tested exclusively in hyperoxic rodent models of BPD, mesenchymal stromal cells significantly improved several outcome measures, although with a high degree of heterogeneity, unclear risk of bias, poor reporting and potential publication bias; underscoring the need to fix methodological flaws by rigorously implementing reporting standards such as Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines, thereby ensuring successful clinical translation of this promising therapy.
Background
Shortened courses of radiation therapy have been shown to be similarly effective to whole-breast external-beam radiation therapy (WB-EBRT) in terms of local control. We sought to analyze, ...from a societal perspective, the cost-effectiveness of two radiation strategies for early-stage invasive breast cancer: single-dose intraoperative radiation therapy (IORT) and the standard 6-week course of WB-EBRT.
Methods
We developed a Markov decision-analytic model to evaluate these treatment strategies in terms of life expectancy, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio over 10 years.
Results
IORT single-dose intraoperative radiation therapy was the dominant, more cost-effective strategy, providing greater quality-adjusted life years at a decreased cost compared with 6-week WB-EBRT. The model was sensitive to health state utilities and recurrence rates, but not costs. IORT was either the preferred or dominant strategy across all sensitivity analyses. The two-way sensitivity analyses demonstrate the need to accurately determine utility values for the two forms of radiation treatment and to avoid indiscriminate use of IORT.
Conclusions
With less cost and greater QALYs than WB-EBRT, IORT is the more valuable strategy. IORT offers a unique example of new technology that is less costly than the current standard of care option but offers similar efficacy. Even when considering the capital investment for the equipment ($425 K, low when compared with the investments required for robotic surgery or high-dose-rate brachytherapy), which could be recouped after 3–4 years conservatively, these results support IORT as a change in practice for treating early-stage invasive breast cancer.
Abstract Objective To examine the cost factors associated with ultrasound and fluoroscopic guidance for percutaneous nephrolithotomy (PCNL) and determine which method can be performed at a lower cost ...per case. Methods A cost comparison study was performed utilizing clinical data from a prospectively maintained research database. We included the most recent 33 consecutive ultrasound-guided PCNL cases in 2016 and the most recent 40 consecutive fluoroscopy-guided PCNL cases before the operative surgeon transitioned to ultrasound guidance in May 2014. Total operative time and clinical outcomes were examined. Costs were extracted from the institution accounting systems and given a uniform multiplier to protect institutional financial reporting confidentiality. Comparisons were made using Student's t-test and Chi-squared. Results After excluding outliers, 71 PCNL procedures were included in the analysis. Demographic data and stone characteristics were not different between ultrasound-guided and fluoroscopy-guided groups. However, mean operative time for ultrasound-guided PCNL was significantly shorter (99.8±27.0 vs. 144.9±55.1 minutes, p <0.05). Including capital equipment costs, the mean total cost per case of ultrasound-guided PCNL was approximately 30% less than fluoroscopy-guided PCNL (simulated costs with a uniform multiplier; $5,258.90±957.12 vs. $7,508.60±1,163.83, p <0.05). Postoperative clinical outcomes were comparable between the two groups. Conclusion Including capital costs, ultrasound-guided PCNL can produce comparable clinical outcomes to fluoroscopy-guided procedures at a lower cost to the institution. Shorter operative time drives significant savings with the adoption of ultrasound guidance, which may be magnified with increasing case volume. Using ultrasound imaging during PCNL may be more cost-effective compared to fluoroscopy and warrants further study.
The TARGIT-A Trial is an international randomized, prospective trial comparing intraoperative radiotherapy (IORT) for equivalence to external beam radiotherapy (EBRT) following lumpectomy for ...invasive breast cancer in selected low-risk patients; early results suggest that outcomes are similar. In addition to effectiveness data and cost considerations, the preferences of patients should help inform practice. This study was undertaken to explore and quantify preference in choosing between IORT and the current standard, EBRT. Eligible subjects were current or past candidates for breast-conserving surgery and radiation being seen at the University of California, San Francisco Breast Care Center. A trade-off technique varying the risk of local recurrence for IORT was used to quantify any additional accepted risk that these patients would accept to receive either treatment. Patients were first presented with a slideshow comparing EBRT with the experimental IORT option before being asked their preferences given hypothetical 10-year local recurrence risks. Patients were then given a questionnaire on demographic, social and clinical factors. Data from 81 patients were analyzed. The median additional accepted risk to have IORT was 2.3 % (−9 to 39 %), mean 3.2 %. Only 7 patients chose to accept additional risk for EBRT; 22 accepted IORT at no additional risk; and the remaining 52 chose IORT with some additional risk. Patients weigh trade-offs of risks and benefits when presented with medical treatment choices. Our results show that the majority of breast cancer patients will accept a small increment of local risk for a simpler delivery of radiation. Further studies that incorporate outcome and side effect data from the TARGIT-A trial clarify the expected consequences of a local recurrence, and include an expanded range of radiation options that could help guide clinical decision making in this area.
This review explores the ethical and medical challenges faced by women of advanced maternal age who decide to have children. Assisted reproductive technologies (ARTs) make post-menopausal pregnancy ...physiologically plausible, however, one must consider the associated physical, psychological, and sociological factors involved.
A quasi-systematic review was conducted in PubMed and Ovid using the key terms post-menopause, pregnancy + MeSH terms donations, hormone replacement therapy, assisted reproductive technologies, embryo donation, donor artificial insemination, cryopreservation. Overall, 28 papers encompassing two major themes (ethical and medical) were included in the review.
There are significant ethical considerations and medical (maternal and fetal) complications related to pregnancy in peri- and post-menopausal women. When examining the ethical and sociological perspective, the literature portrays an overall positive attitude toward pregnancy in advanced maternal age. With respect to the medical complications, the general consensus in the evaluated studies suggests that there is greater risk of complication for spontaneous pregnancy when the mother is older (eg, >35 years old). This risk can be mitigated by careful medical screening of the mother and the use of ARTs in healthy women. In these instances, a woman of advanced maternal age who is otherwise healthy can carry a pregnancy with a similar risk profile to that of her younger counterparts when using donated oocytes.
Objectives/Hypothesis:
Long term taste dysfunction after otologic surgery has never been characterized in children. The aim of this study is to determine the rates of gustatory dysfunction in normal ...and postotologic surgery in children.
Study Design:
Cross‐sectional study.
Methods:
One hundred sixty children visiting a tertiary pediatric otolaryngology clinic, 4 to 18 years of age, were recruited. Surgical groups included patients who had undergone tympanoplasty, combined approach mastoidectomy, modified radical mastoidectomy, and unilateral and bilateral cochlear implantation. They were then tested using a Rion TR‐06 electrogustometer (Sensonics, Inc., Haddon Heights, NJ) using a standardized protocol to assess chorda tympani nerve function. An abnormal gustometry result was defined as any recording of ≥16 dB or a difference of 6 dB between ears.
Results:
The control group had a 9% (5/61) abnormal electrogustometric threshold rate. Rates of dysfunction after surgery were: tympanoplasty (27%, 4/15), combined approach mastoidectomy (30%, 11/29), modified radical mastoidectomy (50%, 4/8). Unilateral cochlear implantation yielded a 26% (7/27) per ear risk of dysfunction, whereas bilateral cochlear implantation had a 5% (2/40) per ear risk.
Conclusions:
There is a 9% baseline level of electrogustometric abnormality in the pediatric population, which suggests a subclinical level of gustatory dysfunction. Normal electrogustometry was found in 50% of children after modified radical mastoidectomy, suggesting a degree of neural regenerative capacity. Finally, cochlear implantation, using newer surgical techniques (in the bilateral cochlear implant group) has a low risk for causing gustatory dysfunction, reducing concerns over the safety profile of bilateral cochlear implantation. Laryngoscope, 2009
Most medical students worldwide are using some form of social media platform to supplement their learning via file sharing and to stay up-to-date on medical events. Often, social media may blur the ...line between socialization and educational use, so it is important to be aware of how one is utilizing social media and how to remain professional. Research has yielded some troublesome themes of misconduct: drunken behaviour, violations of confidentiality and defamation of institutions. Because there is no universal policy to monitor online professionalism, there exists the potential for indiscretions to occur. It has been reported that misdemeanours can affect future residency placements and employment for medical students. Accordingly, studies suggest that educators need to recognize this new era of professionalism and adapt policies and reprimands to meet modern outlets where professionalism may be violated.
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