Five-Year Breast Surgeon Experience in LYMPHA at Time of ALND for Treatment of Clinical T1–4N1–3M0 Breast Cancer

Annals of Surgical Oncology - Breast cancer-related lymphedema (BCRL) is a source of postoperative morbidity for breast cancer survivors. Lymphatic microsurgical preventive healing approach...     

Variability in cesarean delivery rates among individual labor and delivery nurses compared to physicians at three attribution time points

ObjectiveTo examine the variability in the cesarean delivery (CD) rates of individual labor and delivery nurses compared with physicians at three attribution time points.Data SourcesMedical record data from nine hospitals in Washington State from January 2016 through September 2018.Study DesignRetrospective, observational cohort design using an aggregated database of birth records.Data Collection/Extraction MethodsChart‐abstracted clinical data from a subset of nulliparous, term, singleton, vertex births attributed at admission, labor management, and delivery to nurses and physicians. Two classification methods were used to categorize nurse‐ and physician‐level CD rates at three attribution time points and the reliability of these methods compared.Principal FindingsThe sample included 12 556 births, 319 nurses, and 126 physicians. Overall, variation in nurse‐level CD rates did not differ significantly across the three attribution time points, and the extent of variation was similar to that observed in physicians. However, agreement between attribution time points varied between 35 percent and 65 percent when classifying individual nurses into the top and bottom deciles. The average reliability of nurse‐level CD rates was 32 percent at admission (IQR 22.0 percent to 38.7 percent), 32.6 percent at labor (IQR 23.1 percent to 40.9 percent), and 29.3 percent (IQR 20.9 percent to 35.8 percent) at delivery. The average reliability of physician‐level CD rates was higher: 54.2 percent (IQR 38.7 percent to 71.4 percent) at admission, 62.5 percent (IQR 49.0 percent to 79.6 percent) at labor management, and 66.1 percent (IQR 53.7 percent to 81.2 percent) at delivery.ConclusionFeedback on nurse‐level CD rates as part of routine clinical quality audits can provide insight into nurse performance in the context of other individual‐level and unit‐level information. To reliably distinguish individual nurse performance, larger sample sizes are needed.     

Social HMOs and Other Capitated Arrangements for Children with Special Health Care Needs

Objective: Children with special health care needs are increasingly enrolling in managed care arrangements. However, existing managed care organizations, including traditional HMOs, are often poorly suited for caring for this population. In the adult health care area, new managed care entities, called Social HMOs (S/HMO) and Programs for the All-inclusive Care for the Elderly (PACE), have been created to integrate health and health-related services for chronically ill and disabled adults. We describe these models and assess their potential for serving children with special health care needs. Method: We reviewed the literature on managed care for children with special health care needs and evaluation findings from the S/HMO and PACE models for the elderly. Results: Evaluations of the S/HMO and PACE models have yielded mixed findings. Some of the more positive accomplishments include lower use and expenditures for long-term care services compared to other demonstration projects, greater integration of primary care physicians in decision making concerning long-term care, and improved management of transitions between care levels. On the negative side, start-up has been slow, prospective members have been hesitant to enroll, intermittent and sometimes frequent operating deficits have emerged, no discernible positive effects on health or social outcomes are apparent, and no significant overall savings have emerged. Conclusions: With mixed results so far, caution is required in applying these or similar models for vulnerable child populations. However, given the inadequacies of traditional managed care for this population, we believe experimentation with new models of care that integrate health and health-related services is important. Such experimentation should be fostered only to the extent that the models are carefully designed and then implemented in a manner that protects the interests of children with special health care needs.     

Knee joint kinematics during the sidestep cutting maneuver: potential for injury in women.

PURPOSE: There is a paucity of data describing female lower limb biomechanics during "high risk" movements linked to noncontact ACL injury. This study compared, across gender, knee kinematics associated with sidestepping maneuvers to provide insight into why women display a significantly higher incidence of this injury than do men. METHODS: Thirty participants (16 men, 14 women) had bilateral knee joint kinematic data recorded while sidestepping. A custom software package (JTMOTION) quantified maximum, minimum, and range of motion during stance for each of the three clinical knee joint rotations (flexion/extension, adduction/abduction and external/internal rotation) over 20 (leg x condition x trial (5)) trials. RESULTS: Gender differences possessed limited clinical significance with all maximum values well within safe ranges of knee motion. Women did, however, display increased intertrial variability for axial rotation patterns during cutting compared with men. This variability was thought to be unaffected by gender, with experience level found statistically (P < 0.01) to be the major determinant of knee kinematic variability during sidestepping. Hence, the level of exposure to sidestep cutting may have a large impact on the subsequent risk of ACL injury when when one performs these maneuvers. CONCLUSIONS: Gender differences in knee motions during cutting did not contribute to the increased risk of noncontact ACL injury in women compared with men. The reasons for this increased incidence, therefore, remain unclear. The potential relationship between gender and other parameters linked to ACL injury such as joint geometry, ligament morphology, and physical conditioning requires further investigation.     

Host defense mechanisms in urinary tract infections

The host response to urinary tract infections is directed against both bacterial surface antigens, as well as bacterial products. The local response is perhaps the most important, with prevention of binding and tissue invasion as the hallmarks. Once an infection is established, the humoral immune system is most active in curtailing the damage and clearing the infecting organism. The prostate has a specialized complex of defenses that serves to reduce the incidence of infections in males.     

Sources of job satisfaction and psychological distress in GPs and medical house officers

The psychological health and job satisfaction of 285 GPs and 89 medical house officers from Leeds was compared using standardized self-report measures. Forty-eight per cent of the GPs and 20% of the house officers scored as 'cases' of psychiatric disorder. The GPs were less satisfied with the recognition they received for their work and their hours of work, but more satisfied with their job variety and job autonomy. Further research examining the sources of work-related distress in different medical settings could help inform future organizational changes.     

Seven-week interval between acquisition of a meningococcus and the onset of invasive disease. A case report

Invasive meningococcal disease (IMD) is thought to occur within a few days of pharyngeal acquisition of Neisseria meningitidis. During a longitudinal study of carriage and acquisition among 2453 first-year undergraduates we identified a male student from whom N. lactamica was isolated in October 1997 followed by N. meningitidis in December 1997. In mid-January 1998 this student suffered a mild episode of IMD (meningitis) during which N. meningitidis was isolated from his CSF. The meningococcus carried in December 1997 was phenotypically and genotypically indistinguishable from the invading organism, suggesting the possibility that the organism may have been carried for 7 weeks prior to the onset of invasive disease. Further studies are needed to assess more accurately the range of asymptomatic carriage prior to disease onset.     

Emboli and Neuropsychological Outcome Following Cardiopulmonary Bypass

The dramatic decline in mortality related to cardiac surgery has resulted in over 330,000 surgeries involving cardiopulmonary bypass (CPB) being performed yearly in the United States. Although few patients die as a result of cardiac surgery, over two thirds of the patients demonstrate evidence of acute neuropsychological dysfunction postoperatively. The potential mechanisms contributing to post-CPB neuropsychological deficits are many, but two major inter-related etiologic factors, hypoperfusion and emboli, are suggested as the probable culprits. If embolism is the cause of the deficits, increasing cerebral perfusion would deliver more emboli and increase the amount and severity of injury. Conversely, if hypoperfusion is the cause of the injury, then decreasing brain blood flow to minimize embolic delivery would increase the likelihood of perfusion injury. By monitoring the carotid arteries of patients undergoing coronary artery bypass graft surgery, we have determined the frequency and quantity of embolic signals that occur during CPB. Although we have not been able to determine the nature of the embolus, gaseous or solid, we have demonstrated a relationship between the overall embolic load and the probability of having NP dysfunction.