The Accuracy of Incident Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

Vertebral fractures are clinically important sequelae of a wide array of pediatric diseases. In this study, we examined the accuracy of case-finding strategies for detecting incident vertebral fractures (IVF) over 2 years in glucocorticoid-treated children (n = 343) with leukemia, rheumatic disorders, or nephrotic syndrome. Two clinical situations were addressed: the prevalent vertebral fracture (PVF) scenario (when baseline PVF status was known), which assessed the utility of PVF and low lumbar spine bone mineral density (LS BMD; Z-score <−1.4), and the non-PVF scenario (when PVF status was unknown), which evaluated low LS BMD and back pain. LS BMD was measured by dual-energy X-ray absorptiometry, vertebral fractures were quantified on spine radiographs using the modified Genant semiquantitative method, and back pain was assessed by patient report. Forty-four patients (12.8%) had IVF. In the PVF scenario, both low LS BMD and PVF were significant predictors of IVF. Using PVF to determine which patients should have radiographs, 11% would undergo radiography (95% confidence interval [CI] 8–15) with 46% of IVF (95% CI 30–61) detected. Sensitivity would be higher with a strategy of PVF or low LS BMD at baseline (73%; 95% CI 57–85) but would require radiographs in 37% of children (95% CI 32–42). In the non-PVF scenario, the strategy of low LS BMD and back pain produced the highest specificity of any non-PVF model at 87% (95% CI 83–91), the greatest overall accuracy at 82% (95% CI 78–86), and the lowest radiography rate at 17% (95% CI 14–22). Low LS BMD or back pain in the non-PVF scenario produced the highest sensitivity at 82% (95% CI 67–92), but required radiographs in 65% (95% CI 60–70). These results provide guidance for targeting spine radiography in children at risk for IVF. © 2021 American Society for Bone and Mineral Research (ASBMR).     

Child participation in research: reflections on ethical challenges in the southern African context

This article reflects on several challenges that particular cultural, socio-economic and catastrophic factors (such as the HIV epidemic) pose to ethical practice in research involving child participation in a region such as southern Africa. With reference to concrete situations, we discuss research practices in relation to: countering the widespread power disparity between adults and children; ensuring the authenticity of children's evidence; obtaining informed consent; ensuring non-malfeasance and beneficence; and preserving the anonymity of participants and their sources. Within the authors' own research experience, selected elements of practice that have been helpful in addressing these issues are offered. It is hoped that the article may have relevance not only in the southern African context, but also for developing countries elsewhere.     

Rivaroxaban: future in anticoagulation practice?

Abstract

Objective: To summarise and critically evaluate the evidence from randomised clinical trials for the effectiveness of rivaroxaban against standard anticoagulation practice.

Methods: The implementation of a search strategy in the Journal of Thrombosis and Haemostasis and the American Heart Association. The search identified randomised, controlled trials investigating the efficacy and safety of rivaroxaban against standard anticoagulation practice in the prevention and treatment of venous thromboembolism, which were then reviewed.

Results: Rivaroxaban in phase II studies has shown comparable rates of efficacy and safety with enoxaparin in the prevention of venous thromboembolism. Rivaroxban given once or twice daily over a wide dose range was as effective and safe as standard therapy for the treatment of acute, symptomatic DVT. Preliminary data in phase III studies show rivaroxaban 10 mg administered once daily is superior to enoxaparin in the prevention of venous thromboembolism.

Conclusions: Results from phase II trials and current on-going research demonstrates that rivaroxban has the potential to replace standard anticoagulation practice for the prevention of venous thromboembolism.     

Economic Impact of Bariatrics on a General Surgery Practice

Bariatric surgery is currently a rapidly growing subsection of general surgery, with exponential expansion over the past decade. Many residency programs lacked sufficient experience in bariatrics, necessitating established surgeons to consider re-training and re-vamping of their practice to enter the field. The addition of bariatric surgery to a general surgery practice can present economic consequences, which are both positive and negative. Positive consequences include a potential new revenue source with a large population base. Negative consequences include increased employees, required paper-work and office resources, increased malpractice premiums, difficulties with appropriate re-imbursement, and limitations on access to appointment time for non-bariatric cases. This paper reviews the potential economic impact of bariatric surgery on a general surgery practice and possible alternatives to manage these efficiently.     

The reform of medical education: a Canadian model †

The Flexner reforms of the early 20th century were successful in correcting a mismatch between medical education and the newly available knowledge from the laboratory sciences. At the same time, they set in motion changes which have resulted in another mismatch, this time between medical education and society's needs. Five major corrective changes are described, with particular reference to the role of family medicine (general practice) in attaining them: (1) a change in the environment of learning, (2) a reawakening of concern with the subjective aspects of medicine, (3) a shift of emphasis from content to process, (4) a change in our concept of health and (5) a rapprochement between personal and population medicine. New medical schools have had an important influence on the reform of medical education. However, it is important also to study examples of successful adaptive change in older institutions. Changes at the University of Western Ontario are described as an example of successful adaptation. Some reasons are given for the failure of many institutions to adapt. Five conditions are necessary if a medical school is to adapt successfully to change: (1) the school should penetrate the entire health care system, (2) all sections of the profession should be represented on the faculty, (3) the school should be strongly rooted in its region, (4) it should have a flow of information from the ‘grass roots’ and (5) society should have some means of ensuring that its needs are met.     

Opportunistic Osteoporosis Screening Using Chest Radiographs With Deep Learning: Development and External Validation With a Cohort Dataset

Osteoporosis is a common, but silent disease until it is complicated by fractures that are associated with morbidity and mortality. Over the past few years, although deep learning-based disease diagnosis on chest radiographs has yielded promising results, osteoporosis screening remains unexplored. Paired data with 13,026 chest radiographs and dual-energy X-ray absorptiometry (DXA) results from the Health Screening and Promotion Center of Asan Medical Center, between 2012 and 2019, were used as the primary dataset in this study. For the external test, we additionally used the Asan osteoporosis cohort dataset (1089 chest radiographs, 2010 and 2017). Using a well-performed deep learning model, we trained the OsPor-screen model with labels defined by DXA based diagnosis of osteoporosis (lumbar spine, femoral neck, or total hip T-score ≤ −2.5) in a supervised learning manner. The OsPor-screen model was assessed in the internal and external test sets. We performed substudies for evaluating the effect of various anatomical subregions and image sizes of input images. OsPor-screen model performances including sensitivity, specificity, and area under the curve (AUC) were measured in the internal and external test sets. In addition, visual explanations of the model to predict each class were expressed in gradient-weighted class activation maps (Grad-CAMs). The OsPor-screen model showed promising performances. Osteoporosis screening with the OsPor-screen model achieved an AUC of 0.91 (95% confidence interval [CI], 0.90–0.92) and an AUC of 0.88 (95% CI, 0.85–0.90) in the internal and external test set, respectively. Even though the medical relevance of these average Grad-CAMs is unclear, these results suggest that a deep learning-based model using chest radiographs could have the potential to be used for opportunistic automated screening of patients with osteoporosis in clinical settings. © 2021 American Society for Bone and Mineral Research (ASBMR).     

主带教老师模式在手术室带教中的应用

目的探讨手术室实行主带教老师模式在护理专业学生实习带教工作中的作用。方法由手术室护士长推荐后经护理部教学组考核双结合的方法确立主带教老师1名,负责统筹协调年度教学的各项工作,全程监控教学质量。学生出科时,由主带教老师对手术医生、麻醉医生发放调查问卷评价了143名学生的综合表现。学生出科后,由教学组对每批次出科学生每人发放3种关于手术室实习教学质量的评价表。结果143名学生均顺利完成手术室的实习,各项实习成绩优良率（≥85分）在89．5％-96．5％之间：医生对学生的满意度在87．0％-97．0％之间;学生对手术室教学质量的满意度在95．0％-98．5％之间。结论手术室主带教老师模式的实施,减少了带教误差,有利于因材施教和各环节的沟通,使手术室的带教工作条理化、规范化。     

大专实习学生身心体验的现象学研究

目的探讨大专学生实习的身心体验。方法采用质性研究的方法对13名大专实习学生进行观察、深入访谈和现场笔录,运用Colaizzi的分析程序对资料进行分析。结果大专实习学生的身心体验包括4个主题：职业认可度低、与患者的消极互动、学习热情的逐渐消退和对前途的喜忧参半。结论大专实习学生的身心体验负面情绪居多,护理教育者应有针对性地采取措施优化实习过程,培养出身心健康的护理工作者。     

Population‐Wide Impact of Non‐Hip Non‐Vertebral Fractures on Mortality

Data on long‐term consequences of non‐hip non‐vertebral (NHNV) fractures, accounting for approximately two‐thirds of all fragility fractures, are scanty. Our study aimed to quantify the population‐wide impact of NHNV fractures on mortality. The national population‐based prospective cohort study (Canadian Multicentre Osteoporosis Study) included 5526 community dwelling women and 2163 men aged 50 years or older followed from July 1995 to September 2013. Population impact number was used to quantify the average number of people for whom one death would be attributable to fracture and case impact number to quantify the number of deaths out of which one would be attributable to a fracture. There were 1370 fragility fractures followed by 296 deaths in women (mortality rate: 3.49; 95% CI, 3.11 to 3.91), and 302 fractures with 92 deaths in men (5.05; 95% CI, 4.12 to 6.20). NHNV fractures accounted for three‐quarters of fractures. In women, the population‐wide impact of NHNV fractures on mortality was greater than that of hip and vertebral fractures because of the greater number of NHNV fractures. Out of 800 women, one death was estimated to be attributable to a NHNV fracture, compared with one death in 2000 women attributable to hip or vertebral fracture. Similarly, out of 15 deaths in women, one was estimated to be attributable to a NHNV fracture, compared with one in over 40 deaths for hip or vertebral fracture. The impact of forearm fractures (ie, one death in 2400 women and one out of 42 deaths in women attributable to forearm fracture) was similar to that of hip, vertebral, or rib fractures. Similar, albeit not significant, results were noted for men. The study highlights the important contribution of NHNV fractures on mortality because many NHNV fracture types, except for the most distal fractures, have serious adverse consequences that affect a significant proportion of the population. © 2017 American Society for Bone and Mineral Research.