Health Care Surrogacy Laws Do Not Adequately Address the Needs of Minors

A couple and their five-year-old daughter are in a car accident. The parents are not expected to survive. The child is transported to a children's hospital, and urgent treatment decisions must be made. Whom should the attending physician approach to make decisions for the child? When such cases arise in, for example, the hospitals where we work, the social worker or chaplain is instructed to use the Illinois Health Care Surrogacy Act as a guidepost to identify a decision-maker. But in our state and the country overall, the limitations of such statutes leave hospital workers to make a judgment call among friends, family, and clergy who may come forward. While surrogate decision-making statutes comprehensively address surrogate decision-makers for adults, a patchwork of laws—permanency statutes, kinship provider statutes, standby guardianship statutes, and, in some cases, surrogate decision-making statutes—provide variable decision-making pathways for children.     

ASO Author Reflections: Is Surgical Excision Necessary in Lobular Neoplasia with Synchronous Breast Carcinoma?

Annals of Surgical Oncology -     

Case Report of Lichen Planopilaris Occurring in a Pediatric Patient Receiving a Tumor Necrosis Factor α Inhibitor and a Review of the Literature

A 12‐year‐old girl with extended oligoarthritis treated with adalimumab presented with a short history of a progressive cutaneous eruption involving the legs and scalp. Physical examination and histologic results were consistent with lichen planopilaris. The adalimumab was discontinued. She received treatment with topical clobetasol propionate and the majority of the lesions resolved. Residual lesions and the extended oligoarthritis were then treated with sulfasalazine. Adalimumab is a tumor necrosis factor α (TNF‐α) inhibitor used for the treatment of a variety of immunologically mediated conditions, including lichen planus and lichen planopilaris. TNF‐α antagonists have been associated with paradoxical psoriasiform, lichenoid, eczematous, granulomatous, and acneiform eruptions. We detail this case and review the literature of lichenoid reactions secondary to TNF‐α inhibitors.     

Process Redesign to Improve First Case Surgical Starts in an Academic Institution

Purpose: On time start of the first surgical case improves operating room (OR) utilization, physician, and patient satisfaction and decreases delays in subsequent cases. The goal of our study was to evaluate the effect of a multidisciplinary initiative to improve first patient in the room (FPIR) and first case on time start (FCOTS) metrics in a tertiary care setting. Materials and Methods: A multidisciplinary committee focused on first case start data collection. Reasons for both anesthesia and surgical delays were analyzed. Improvement efforts focused on the timely completion of surgical consent, a requirement of a surgical, anesthesia, and nurse team member presence at the patient's bedside by specific time, and parallel processing in the OR. Results: Over 65,100 OR cases were analyzed between 2007 and 2014. There was a statistically significant improvement in FPIR (82.80% versus 69.60%, p < .0001) and FCOTS (66.60% versus 55.90%, p < .0001). Surgical consent completion rate increased from 35% baseline to 68%–100%, depending on the surgical subspecialty. Improvements appeared sustainable several years following process implementation for both FPIR (84.60% versus 69.60%, p < .0001) and FCOTS (67.60% versus 55.90%, p < .0001). Conclusions: Our study demonstrates a successful targeted, multidisciplinary initiative to improve first case surgical starts in an academic setting. Our approach was organizational rather than punitive or rewarding on an individual basis. Strategies included establishing concrete, time-specific goals and posting them visibly, empowering individuals to fulfill them, and ensuring no compromise in patient safety. In the complex environment of academic medicine including research protocols and teaching in the ORs, our organizational approach proved sustainable over several years.     

Affective School Engagement and Self-Concept: How are Irish Boys and Girls Faring?

Internationally and in Ireland, much of the research around gender and educational engagement has centred on the academic differences between boys and girls (Warrington and Younger 2000; Francis 2009; O’Connor 2007). Less is known however about the factors shaping affective school engagement and student self-concept and how this can affect participation in learning. Children and young people emphasise the affective or emotional as much as the learning aspects of school life (Alexander 2008). Drawing on data from the 9-year cohort of the Growing Up in Ireland study, this paper examines self-concept among boys and girls in Irish primary schools. The findings show important differences in terms of the affective elements of school engagement, with boys more likely than girls to score significantly lower levels on measures of ‘good’ behaviour and intellectual school status, while girls score significantly lower on freedom from anxiety than boys. The findings also illustrate that predictors of disengagement are about more than the child’s gender – in that working class children and students with special educational needs are faring less well in terms of affective engagement in school.     

Avoiding osseous grafting in the atrophic posterior mandible for implant-supported fixed partial dentures: a report of 2 cases

Bone atrophy occurs after tooth extraction in the posterior mandible, placing the mandibular canal and its neural, arterial, and venous contents closer to the osseous facial aspect and the coronal crest. This proximity places the structure in danger of damage when dental implants are surgically placed to support fixed or removable prostheses. Several options are available to treat these areas for implant-supported fixed and removable complete or partial dentures. Osseous grafting and ridge expansion are surgical options that enable acceptance of standard sized dental implants but have serious morbidities. Additionally, vertical osseous augmentation is not predictable at this time. Narrow diameter dental implants can be placed to avoid the mandibular canal, but some bone volume situations preclude this. Very wide and very short (6.5 × 5 mm) dental implants may be placed at an angle in atrophic sites to successfully support fixed partial dentures. An anterior guidance occlusal scheme may be used in maxillary dentate patients or group function in maxillary complete denture patients. A 100 micron occlusal relief in fixed partial dentures in dentate patients may be required to account for natural tooth intrusion and to prevent occlusal overload of the implant-supported partial denture.