A multi-source feedback tool for measuring a subset of Pediatrics Milestones

Background: The Pediatrics Milestones Assessment Pilot employed a new multisource feedback (MSF) instrument to assess nine Pediatrics Milestones among interns and subinterns in the inpatient context.

Objective: To report validity evidence for the MSF tool for informing milestone classification decisions.

Methods: We obtained MSF instruments by different raters per learner per rotation. We present evidence for validity based on the unified validity framework.

Results: One hundred and ninety two interns and 41 subinterns at 18 Pediatrics residency programs received a total of 1084 MSF forms from faculty (40%), senior residents (34%), nurses (22%), and other staff (4%). Variance in ratings was associated primarily with rater (32%) and learner (22%). The milestone factor structure fit data better than simpler structures. In domains except professionalism, ratings by nurses were significantly lower than those by faculty and ratings by other staff were significantly higher. Ratings were higher when the rater observed the learner for longer periods and had a positive global opinion of the learner. Ratings of interns and subinterns did not differ, except for ratings by senior residents. MSF-based scales correlated with summative milestone scores.

Conclusion: We obtain moderately reliable MSF ratings of interns and subinterns in the inpatient context to inform some milestone assignments.     

Mortality-Related Factors in 1056 Radioiodine-Treated Patients with Well-Differentiated Thyroid Cancer in Southern Thailand

Background  

Reported risk factors for death related to well differentiated thyroid cancer vary, possibly depending on the methods and geographical site of data collection.     

Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer.

Major surgery is immunosuppressive, and this could have an impact on postoperative tumor immunosurveillance and, therefore, long-term survival in cancer patients. Video-assisted thoracic surgery (VATS) lung resection is a new alternative surgical approach to thoracotomy for patients with early lung cancer. This is a pilot study to examine the postoperative changes in leukocytes, lymphocyte subsets, B cells, T cells, and natural killer (NK) cells in non-small-cell lung cancer (NSCLC) patients undergoing lung resection with VATS versus thoracotomy approaches. Twenty-one consecutive patients with resectable primary NSCLC were assigned to VATS or thoracotomy approach over a 3-month period. Blood samples were collected preoperatively and at postoperative days (POD) 1, 3, and 7 for flow cytometry determination of total leucocytes, B cells, NK cells, lymphocytes, total T cells, and T4 and T8 cell numbers. There were no demographic differences between the two groups. Compared with the preoperative values, significantly increased total white cell numbers were detected at POD 1, 3, and 7 in all patients. At POD 1, although T8 cells and NK cells were reduced in both groups, total T cell, T4 cell, and lymphocyte numbers were significantly reduced only in the thoracotomy group. At POD 7, NK cell numbers were significantly lower in the thoracotomy group than that in the VATS group. No significant intra- or intergroup differences were seen with B cells. No significant differences in survival or disease-free survival were found between the two groups. Thus, VATS major lung resection for NSCLC is associated with less, as well as quicker recovery from, postoperative immunosuppression compared with the thoracotomy approach. The clinical relevance of better preserved cellular immunity in the early postoperative period warrants confirmation from large randomized trials.     

Pravastatin attenuates tourniquet-induced skeletal muscle ischemia reperfusion injury

Background Revascularization of a limb following prolonged ischemia results in substantial skeletal muscle injury. Statins play a well-understood role in the treatment of hypercholesterolemia but are also known to have anti-inflammatory properties. The purpose of this study was to examine the effects of pravastatin pre-treatment in the setting of skeletal muscle ischemia reperfusion injury (IRI).

Methods Adult male Sprague Dawley rats (n = 27) were randomized into 3 groups: control group, I/R group, IR group pre-treated with pravastatin. Bilateral hind-limb ischemia was induced by rubber band application proximal to the level of the greater trochanters for 2.5 h. Treatment groups received normal saline in equal volumes prior to tourniquet release. Following 12 h reperfusion, the tibialis anterior muscle was dissected and muscle function assessed electrophysiologically by electrical field stimulation. The animals were then killed and skeletal muscle harvested for evaluation.

Results We found that pre-treatment with pravastatin reduces the tissue oxidative damage and edema associated with skeletal muscle reperfusion injury. Skeletal muscle injury, measured by edema, leucose-questration and electrical properties were significantly lower with pravastatin pre-treatment compared to the non-treated group.

Interpretation We feel that pravastatin pre-treatment may be a potential therapeutic intervention for skeletal muscle ischemia reperfusion injury in the clinical setting. ▪     

Timely bolus insulin for glucose control during cardiopulmonary bypass

Hyperglycemia during cardiopulmonary bypass (CPB) with glucose containing cardioplegia is common; normoglycemia is difficult to maintain and failure to do so may result in worse outcomes. The purpose of this quality improvement initiative was to show that a simple timely insulin bolus is more effective for glucose control during CPB with glucose containing cardioplegia than conventional (not standardized) glucose management in historical case-matched controls. A single bolus of insulin (.2 international units per kilogram; iu/kg) was administered, at the time of aortic cannulation, to 211 consecutive patients undergoing cardiac surgery with CPB and glucose containing cardioplegia. A further .1 iu/kg bolus of insulin was given for blood glucose (BG) measurements greater than 10.0 mmol/L (180 mg/dL) during CPB. The control group of 211 historical case-matched patients had glucose management according to anesthesiologist preference (insulin as a bolus, bolus plus infusion, infusion only, or no insulin). The frequency of hyperglycemia (BG > 11.0 mmol/L; 198 mg/dL) during CPB was significantly less in the study group (22; 10.5%) than in the control group (117; 55.5%) (p < .0001). Hyperglycemia in the first 6 hours in the intensive care unit was also significantly less frequent in the study group (5; 2.4%) than in the control group (14; 6.6%) (p = .03). Severe hypoglycemia (BG < 2.8 mmol/L; 50.4 mg/dL) occurred in one patient (.47%) in the timely bolus insulin group and five patients (2.3%) in the control group (p = .09). The timely bolus insulin method is more efficacious, but equally safe, in preventing hyperglycemia during CPB with glucose containing cardioplegia, compared with conventional (not standardized) insulin treatment in historical case-matched controls.     

Solid-pseudopapillary tumor of the pancreas: two cases in male patients

Solid-pseudopapillary tumor (SPT) of the pancreas is a rare lesion with low malignant potential occurring predominantly in young women. This is a report of two cases in young male patients. Clinical data were retrieved retrospectively from a prospective database of patients with pancreatic tumors. The two patients were caucasian males, ages 34 years (Pt1) and 41 years (Pt2) at the time of diagnosis. Pt1 presented with intermittent epigastric pain, nausea, and vomiting. Computed tomography (CT) scan showed a 9-cm mass involving the pancreatic head. He underwent pancreaticoduodenectomy, with en bloc segmental colectomy due to mesocolon involvement. Pt2 was asymptomatic, diagnosed with abdominal mass by screening ultrasound. He had an 11-cm tumor involving the pancreatic tail encasing the splenic vessels on CT. He underwent distal pancreatectomy with splenectomy en bloc. Pathology in both cases was reviewed by staff pathologists as well as outside consultants. SPT is a rare tumor of the pancreas that is diagnosed primarily in young women. The cases presented here demonstrate SPT of the pancreas in two men. In both cases, the clinical presentation was relatively unremarkable. Both have had benign late postoperative courses, consistent with the low malignant potential of this lesion.     

Ex vivo extended left hepatectomy with caval preservation, temporary portacaval shunt, and reconstruction of the right hepatic vein outflow using a reversed portal vein bifurcation graft

Liver resections that require ex vivo techniques occur rarely, but when done are generally performed on veno-veno bypass to maintain venous return and decompress the portal circulation during the anhepatic phase of the procedure. We describe an ex vivo extended left hepatectomy that was performed with preservation of the inferior vena cava and the use of a temporary portacaval shunt to eliminate the need for veno-venous bypass. Ex vivo resection allowed reconstruction of right hepatic vein branches, using the patient's reversed portal vein bifurcation as a graft to provide venous outflow.     

Functional-anatomical validation and individual variation of diffusion tractography-based segmentation of the human thalamus

Parcellation of the human thalamus based on cortical connectivity information inferred from non-invasive diffusion-weighted images identifies sub-regions that we have proposed correspond to nuclei. Here we test the functional and anatomical validity of this proposal by comparing data from diffusion tractography, cytoarchitecture and functional imaging. We acquired diffusion imaging data in eleven healthy subjects and performed probabilistic tractography from voxels within the thalamus. Cortical connectivity information was used to divide the thalamus into sub-regions with highest probability of connectivity to distinct cortical areas. The relative volumes of these connectivity-defined sub-regions correlate well with volumetric predictions based on a histological atlas. Previously reported centres of functional activation within the thalamus during motor or executive tasks co-localize within atlas regions showing high probabilities of connection to motor or prefrontal cortices, respectively. This work provides a powerful validation of quantitative grey matter segmentation using diffusion tractography in humans. Co-registering thalamic sub-regions from 11 healthy individuals characterizes inter-individual variation in segmentation and results in a population-based atlas of the human thalamus that can be used to assign likely anatomical labels to thalamic locations in standard brain space. This provides a tool for specific localization of functional activations or lesions to putative thalamic nuclei.