In a sea of competition, putting the patient first

Although Hoag Memorial is in a county with more than 30 other hospitals, a unique branding campaign has helped to establish its facility as one that considers patients a top priority. With creative guidance from the Larson Group, Hoag developed the "Always First" campaign.     

Reoperative surgery for nonresponders and complicated sleeve gastrectomy operations in patients with severe obesity. An international expert panel consensus statement to define best practice guidelines

Background

Laparoscopic sleeve gastrectomy (SG) has rapidly become the most commonly performed bariatric procedure in the United States as well as other countries, with approximately 120,000 procedures being performed annually in the United States. Reoperative interventions after SG have become more prevalent in the past few years since the initial development of SG as a primary operation. Given the expected rapid growth of these reinterventions, an expert consensus conference was held with some of the most experienced bariatric surgeons in the world to better understand, discuss, and provide consensus on the reasons, indications, contraindications, and surgical options for nonresponders and complicated SG operations.

Symbolic Play of Preschoolers with Severe Communication Impairments with Autism and Other Developmental Delays: More Similarities than Differences

Children with autism are often described as having deficient play skills, particularly symbolic play. We compared the play of 35 children with autism to 38 children with other developmental delays. All children were preschool-age and produced less than 20 different words. Results indicated no significant differences across the two groups in their play. Children with autism engaged in more conventional play, that is, putting objects together according to how the toys were constructed (e.g., pieces in a puzzle, lid on a teapot). Results also indicated high correlations between play, language, and cognitive measures. Findings indicate that play relates to language and cognitive levels yet may not discriminate children with autism and children with other developmental delays early in their development.     

Magnetic resonance imaging as a predictor of pathologic response in patients treated with neoadjuvant systemic treatment for operable breast cancer

BACKGROUND:

Increased pathologic complete response (pCR) rates observed with neoadjuvant chemotherapy (NCT) for some subsets of patients with invasive breast cancer have prompted interest in whether patients who achieved a pCR can be identified preoperatively and potentially spared the morbidity of surgery. The objective of this multicenter, retrospective study was to estimate the accuracy of preoperative magnetic resonance imaging (MRI) in predicting a pCR in the breast.

METHODS:

MRI studies at baseline and after the completion of NCT plus data regarding pathologic response were collected retrospectively from 746 women who received treatment at 8 institutions between 2002 and 2011. Tumors were characterized by immunohistochemical phenotype into 4 categories based on receptor expression: hormone (estrogen and progesterone) receptor (HR)‐positive/human epidermal growth factor receptor 2 (HER2)‐negative (n = 327), HR‐positive/HER2‐positive, (n = 148), HR‐negative/HER2‐positive, (n = 101), and triple‐negative (HR‐negative/HER2 negative; n = 155). In all, 194 of 249 patients (78%) with HER2‐positive tumors received trastuzumab. Univariate and multivariate analyses of factors associated with radiographic complete response (rCR) and pCR were performed.

RESULT:

For the total group, the rCR and pCR rates were 182 of 746 patients (24%) and 179 of 746 patients (24%), respectively, and the highest pCR rate was observed for the triple‐negative subtype (57 of 155 patients; 37%) and the HER2‐positive subtype (38 of 101 patients; 38%). The overall accuracy of MRI for predicting pCR was 74%. The variables sensitivity, negative predictive value, positive predictive value, and accuracy differed significantly among tumor subtypes, and the greatest negative predictive value was observed in the triple‐negative (60%) and HER2‐positive (62%) subtypes.

CONCLUSIONS:

The overall accuracy of MRI for predicting pCR in invasive breast cancer patients who were receiving NCT was 74%. The performance of MRI differed between subtypes, possibly influenced by differences in pCR rates between groups. Future studies will determine whether MRI in combination with directed core biopsy improves the predictive value of MRI for pathologic response. Cancer 2013. © 2013 American Cancer Society.     

Parenting young children with and without Fragile X syndrome

The purpose of this study was to examine maternal parenting styles across age-matched siblings using a within-family design, in which one child has Fragile X syndrome. Thirteen families participated; children were aged 16 to 71 months. Mothers completed several videotaped activities with each child separately as well as an interview. Mothers used a consistent, responsive style with both children, using the same degree of positive affect and warmth. Differences included using more behavior management strategies with the child with Fragile X and a conversational style of interaction with the sibling. Differences in approaches suggest the mothers adapted to the developmental differences between the children. The interview data supported these findings; mothers were aware of the changes made to accommodate the developmental differences.     

Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees?

BACKGROUND: The aim of this study was to quantify the changes over time in general surgical residents' operative experience as surgeon, first assistant, and teaching assistant. The introduction of work hour restrictions in July 2003 raised concern that residents' operative experience might decline. Early studies evaluating the mean number of operations performed as surgeon reported no major change. The experiences of residents as first assistant and teaching assistant have not been closely examined. STUDY DESIGN: The Accreditation Council for Graduate Medical Education Resident Statistics Summary reports from academic year 1992 to 1993 through the present were reviewed. The mean number of cases reported as total surgeon, surgeon chief, and surgeon junior for academic year 2001 to 2002 through 2005 to 2006 were analyzed for total major operations. The median number of cases reported as total surgeon, first assistant, and teaching assistant for academic year 1992 to 1993 through 2005 to 2006 were analyzed for total major operations. RESULTS: Since the implementation of the 80-hour work duty restrictions, the number of total major operations reported by residents as surgeon decreased from 930 to 909 (2.3% decrease, p < 0.0001), surgeon chief operations decreased from 252 to 231 (8.3% decrease, p <0.0001), and surgeon junior operations remained essentially unchanged, from 677 to 678. From academic year 1992 to 1993 through 2005 to 2006, the median number of first assistant and teaching assistant cases declined from 231 to 49 (79% decrease) and from 67 to 23 (66% decrease), respectively. CONCLUSIONS: Since duty hour restrictions were introduced, there have been small but notable declines in the number of total surgeon and surgeon chief operative cases reported by graduating residents. Over a longer time period, operative cases reported by graduating residents in the roles of first assistant and teaching assistant declined dramatically. Although some of these declines were gradual, recent declines may have been accelerated by the 80-hour duty hour restrictions. These trends must be considered as we plan the education of present and future surgical residents.     

Bivalirudin with planned or provisional abciximab versus low-dose heparin and abciximab during percutaneous coronary revascularization: results of the Comparison of Abciximab Complications with Hirulog for Ischemic Events Trial (CACHET)

Background The direct thrombin inhibitor bivalirudin has previously been associated with better efficacy and lower hemorrhage risk than heparin during balloon angioplasty. This agent has not yet been tested with stenting or in combination with platelet glycoprotein IIb/IIIa antagonists. Methods and Results In a pilot trial, 268 patients who underwent coronary intervention were randomized in 3 sequential phases to treatment with bivalirudin (with or without abciximab) or the control regimen of low-dose weight-adjusted heparin with abciximab. Patients in the bivalirudin arms received bivalirudin (1.0 mg/kg bolus, infusion of 2.5 mg/kg/h for 4 hours) plus abciximab in phase A, bivalirudin (0.5 mg/kg bolus, infusion of 1.75 mg/kg/h for the procedure duration) plus provisional (“rescue”) abciximab in phase B, or bivalirudin (0.75 mg/kg bolus, infusion of 1.75 mg/kg/h for the procedure duration) plus provisional abciximab in phase C. Abciximab was necessitated on a provisional basis in 24% of the patients in the bivalirudin arms of phases B and C. A composite clinical endpoint of death, myocardial infarction, repeat revascularization, or major bleeding by 7 days occurred in 3.3%, 5.9%, 0, and 10.6% of the patients in the bivalirudin phase A, bivalirudin phase B, bivalirudin phase C, and heparin plus planned abciximab arms, respectively (P = .018 for the pooled bivalirudin groups versus the heparin group). Conclusion Bivalirudin with planned or provisional abciximab may be at least as safe and effective as low-dose heparin plus abciximab during percutaneous coronary intervention. (Am Heart J 2002;143:847-53.)     

Prelinguistic predictors of language growth in children with developmental disabilities.

This study followed 18 children with developmental disabilities, whose chronological ages were between 3 years and 6 years at the start of the study, over a 2-year period. At initial observation, children communicated primarily through prelinguistic gestures, vocalizations, and single-word utterances. Children's language skills were measured every 6 months with the Sequenced Inventory of Communication Development-Revised (D. E. Hedrick, E. M. Prather, and A. R. Tobin, 1984). Prelinguistic communication rate and parental responsiveness were also measured at each observation. Development of language over time differed between participants in accordance with their entry-level communication. Hierarchical linear modeling indicated that children's level of gestural attainment, rate of communication, and parent response contingency were significant predictors of language outcome.