Showing papers in "Cureus in 2017"

A Review on Antibiotic Resistance: Alarm Bells are Ringing

Abstract: Antibiotics are the 'wonder drugs' to combat microbes. For decades, multiple varieties of antibiotics have not only been used for therapeutic purposes but practiced prophylactically across other industries such as agriculture and animal husbandry. Uncertainty has arisen, as microbes have become resistant to common antibiotics while the host remains unaware that antibiotic resistance has emerged. The aim of this review is to explore the origin, development, and the current state of antibiotic resistance, regulation, and challenges by examining available literature. We found that antibiotic resistance is increasing at an alarming rate. A growing list of infections i.e., pneumonia, tuberculosis, and gonorrhea are becoming harder and at times impossible to treat while antibiotics are becoming less effective. Antibiotic-resistant infections correlate with the level of antibiotic consumption. Non-judicial use of antibiotics is mostly responsible for making the microbes resistant. The antibiotic treatment repertoire for existing or emerging hard-to-treat multidrug-resistant bacterial infections is limited, resulting in high morbidity and mortality report. This review article reiterates the optimal use of antimicrobial medicines in human and animal health to reduce antibiotic resistance. Evidence from the literature suggests that the knowledge regarding antibiotic resistance in the population is still scarce. Therefore, the need of educating patients and the public is essential to fight against the antimicrobial resistance battle.

Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review.

Abstract: About 3.5% Americans identify themselves as lesbian, gay, or bisexual while 0.3% identify themselves as transgender. The LGBT (lesbian, gay, bisexual, and transgender) community belongs to almost every race, ethnicity, religion, age, and socioeconomic group. The LGBT youth are at a higher risk for substance use, sexually transmitted diseases (STDs), cancers, cardiovascular diseases, obesity, bullying, isolation, rejection, anxiety, depression, and suicide as compared to the general population. LGBT youth receive poor quality of care due to stigma, lack of healthcare providers' awareness, and insensitivity to the unique needs of this community. The main objective of this literature review is to highlight the challenges faced by the LGBT youth and to enhance the awareness among physicians about the existing disparities in order to provide a more comprehensive, evidence-based, and humane medical care to this community.

Cardiovascular Risk of Nonsteroidal Anti-Inflammatory Drugs: An Under-Recognized Public Health Issue.

Abstract: Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs with analgesic, anti-inflammatory, and antipyretic activity. Their effect is achieved by the reduction in synthesis of prostanoids. Inhibition of prostanoids is responsible for a substantial risk of adverse effects. The risk of side effects affecting the gastrointestinal tract and kidneys has long been known. The possibilities of blood pressure elevation and the development of congestive heart failure are also widely recognized. Increased incidence of acute myocardial infarction in clinical trials with rofecoxib drew attention to the potential cardiotoxicity of selective cyclooxygenase-2 inhibitors, and similarly, concerns have been raised regarding the cardiovascular safety of non-selective NSAIDs. The safety of NSAIDs with regards to cardiovascular events has been studied in recent years in a large number of retrospective and prospective clinical studies and meta-analyses. The results indicate that cardiotoxicity is a class effect, but the magnitude of the risk is widely variable between individual NSAID drugs. This article aims to summarize the available data on the risk of adverse cardiovascular events with NSAIDs, the clinical impact of these events and possible underlying mechanisms.

Recreational Marijuana Use and Acute Myocardial Infarction: Insights from Nationwide Inpatient Sample in the United States.

Abstract: Background Marijuana is a widely used recreational substance. Few cases have been reported of acute myocardial infarction following marijuana use. To our knowledge, this is the first ever study analyzing the lifetime odds of acute myocardial infarction (AMI) with marijuana use and the outcomes in AMI patients with versus without marijuana use. Methods We queried the 2010-2014 National Inpatient Sample (NIS) database for 11-70-year-old AMI patients. Pearson Chi-square test for categorical variables and Student T-test for continuous variables were used to compare the baseline demographic and hospital characteristics between two groups (without vs. with marijuana) of AMI patients. The univariate and multivariate analyses were used to assess and compare the clinical outcomes between two groups. We used Cochran-Armitage test to measure the trends. All statistical analyses were executed by IBM SPSS Statistics 22.0 (IBM Corp., Armonk, NY). We used weighted data to produce national estimates in our study. Results Out of 2,451,933 weighted hospitalized AMI patients, 35,771 patients with a history of marijuana and 2,416,162 patients without a history of marijuana use were identified. The AMI-marijuana group consisted more of younger, male, African American patients. The length of stay and mortality rate were lower in the AMI-marijuana group with more patients being discharged against medical advice. Multivariable analysis showed that marijuana use was a significant risk factor for AMI development when adjusted for age, sex, race (adjusted OR 1.079, 95% CI 1.065-1.093, p<0.001); adjusted for age, female, race, smoking, cocaine abuse (adjusted OR 1.041, 95% CI 1.027-1.054, p<0.001); and also when adjusted for age, female, race, payer status, smoking, cocaine abuse, amphetamine abuse and alcohol abuse (adjusted OR: 1.031, 95% CI: 1.018-1.045, p<0.001). Complications such as respiratory failure (OR 18.9, CI 15.6-23.0, p<0.001), cerebrovascular disease (OR 9.0, CI 7.0-11.7, p<0.001), cardiogenic shock (OR 6.0, CI 4.9-7.4, p<0.001), septicemia (OR 1.8, CI 1.5-2.2, p<0.001), and dysrhythmia (OR 1.8, CI 1.5-2.1, p<0.001) were independent predictors of mortality in AMI-marijuana group. Conclusion The lifetime AMI odds were increased in recreational marijuana users. Overall odds of mortality were not increased significantly in AMI-marijuana group. However, marijuana users showed higher trends of AMI prevalence and related mortality from 2010-2014. It is crucial to assess cardiovascular effects related to marijuana overuse and educate patients for the same.

Crohn's Disease and Ulcerative Colitis Show Unique Cytokine Profiles

Abstract: Introduction Networks of cytokines have been implicated in both forms of inflammatory bowel disease (IBD): Crohn's disease (CD) and ulcerative colitis (UC). While CD has associated with T-helper type 1 (Th1) immune responses, UC shows Th2 patterns. Recent studies reported that the inflamed intestinal regions in both CD and UC are significantly infiltrated with a newly described set of T helper, the Th17 cells. These cells have unique cytokine responses. These findings prompted us to further explore the cytokine profiles of CD and UC with a special focus on the Th2 and Th17 related mediators. Methods Cytokine transcripts were compared using real-time polymerase chain reaction (PCR) in both inflamed and non-inflamed mucosal specimens from patients with active CD (n=35) or UC (n=20) and without CD or UC (Control, n=54). Results In both CD and UC, interleukin (IL)-12 (p40), IL-18, IL-21 and IL-27 transcript levels were higher than in Control. The highest levels of cytokines were found in the diseased areas of CD and UC with only one exception; IL-12 (p40) in CD was more up-regulated in the non-diseased areas compared to diseased CD and Control specimens. CD samples but not UC specimens showed significant IL-17, IL-23, and IL-32 mRNA expression indicating a trend toward Th17 responses. In UC, however, IL-5, IL-13, IL-15 and IL-33 mRNA levels were significantly increased when compared to both CD and Control. Conclusions The unique patterns of cytokine networks can help us to better understand the differential expression of their characteristic pathophysiology. In addition, the pharmacological regulation of these small molecules may hold promise to more effective and personalized therapies.

Fecal Myeloperoxidase as a Biomarker for Inflammatory Bowel Disease.

Abstract: Inflammatory bowel disease (IBD) is a chronic condition involving the inflammation of the colon and small intestine. IBD affects as many as 1.4 million people in the U.S. alone and costs the health care industry over $1.7 billion annually. Managing IBD normally requires invasive and often discomforting diagnostic tests. In an effort to alleviate the painful and costly nature of traditional diagnosis, there has been increasing research initiative focused on noninvasive biomarkers. PubMed, provided by the United States National Library of Medicine (NLM) at the National Institutes of Health, was utilized with the following search terms: 1) myeloperoxidase (MPO) 2), inflammatory bowel disease (IBD), and 3) neutrophils. The following terms were used interchangeably with search terms 1-3: 4) costs, 5) biomarkers, 6) review, and 7) etiology. In the context of IBD, myeloperoxidase (MPO), a lysosomal protein found in neutrophils, may serve as a viable biomarker for assessing disease status. Several studies demonstrated increased levels of neutrophils in patients with active IBD. Furthermore, studies have found significantly higher levels of MPO in patients with active IBD compared to patients without IBD as well as patients with inactive IBD. MPO is also expressed in higher concentrations in patients with more severe forms of IBD. When measuring treatment efficacy, MPO levels are indicative of the quality of response. MPO may serve as an important diagnostic and prognostic tool in assessing IBD status.

Rapid Cycle Deliberate Practice in Medical Education - a Systematic Review.

Abstract: Rapid Cycle Deliberate Practice (RCDP) is a novel simulation-based education model that is currently attracting interest, implementation, exploration and research in medical education. In RCDP, learners rapidly cycle between deliberate practice and directed feedback within the simulation scenario until mastery is achieved. The objective of this systematic review is to examine the literature and summarize the existing knowledge on RCDP in simulation-based medical education. Fifteen resources met inclusion criteria; they were diverse and heterogeneous, such that we did not perform a quantitative synthesis or meta-analysis but rather a narrative review on RCDP. All resources described RCDP in a similar manner. Common RCDP implementation strategies included: splitting simulation cases into segments, micro debriefing in the form of 'pause, debrief, rewind and try again' and providing progressively more challenging scenarios. Variable outcome measures were used by the studies including qualitative assessments, scoring tools, procedural assessment using checklists or video review, time to active skills and clinical reports. Results were limited and inconsistent. There is an absence of data on retention after RCDP teaching, on RCDP, with learners from specialties other than pediatrics, on RCDP for adult resuscitation scenarios and if RCDP teaching translates into practice change in the clinical realm. We have identified important avenues for future research on RCDP.

Health Care in Gulf Cooperation Council Countries: A Review of Challenges and Opportunities.

Abstract: This study was undertaken to review the health care status in the Gulf Cooperation Council (GCC) member states, and explore current challenges and future opportunities. Available data was acquired using databases including PubMed, Embase, and Cochrane Library. The data gathered was then combined and the expert authors in the field discussed and propose strategies to overcome the challenges. There is an increase in both population and health care needs of GCC States citizens and migrant workers. The huge emigrant population challenges the capability of the already limited available health care resources. The region is faced with a quadruple disease burden that includes communicable and non-communicable diseases, mental health issues and accidental injuries. Recent advances in technology have made breakthroughs in diagnosis and treatment modalities but with an increase in overall health care cost. Innovative and cost-effective strategies are required to cater the health care needs of people living in the GCC states. Policy makers should emphasize the need to prioritize and strengthen primary care as a matter of urgency.

Online Adaptive Radiation Therapy: Implementation of a New Process of Care.

Abstract: Onboard magnetic resonance imaging (MRI) guided radiotherapy is now clinically available in nine centers in the world. This technology has facilitated the clinical implementation of online adaptive radiotherapy (OART), or the ability to alter the daily treatment plan based on tumor and anatomical changes in real-time while the patient is on the treatment table. However, due to the time sensitive nature of OART, implementation in a large and busy clinic has many potential obstacles as well as patient-related safety considerations. In this work, we have described the implementation of this new process of care in the Department of Radiation Oncology at the University of California, Los Angeles (UCLA). We describe the rationale, the initial challenges such as treatment time considerations, technical issues during the process of re-contouring, re-optimization, quality assurance, as well as our current solutions to overcome these challenges. In addition, we describe the implementation of a coverage system with a physician of the day as well as online planners (physicists or dosimetrists) to oversee each OART treatment with patient-specific 'hand-off' directives from the patient's treating physician. The purpose of this effort is to streamline the process without compromising treatment quality and patient safety. As more MRI-guided radiotherapy programs come online, we hope that our experience can facilitate successful adoption of OART in a way that maximally benefits the patient.

Gastrointestinal Amyloidosis: Review of the Literature.

Abstract: Gastrointestinal amyloidosis (GIA), a protein deposition disorder, represents a complex common pathway that encompasses multiple etiologies and presentations. It represents a significant diagnostic and treatment challenge. The disease results from the deposition of insoluble extracellular protein fragments that have been rendered resistant to digestion. GIA can be acquired or genetic, and most commonly results from chronic inflammatory disorders (AA amyloidosis), hematologic malignancy (AL amyloidosis), and end-stage renal disease (Beta-2 amyloidosis). The deposition of these abnormal proteins interferes with gastrointestinal tract (GI) organ structure and function, most notably in the liver and small bowel. Presentation from GI involvement includes cirrhotic sequelae, abdominal pain, malabsorption, and GI bleeding. Diagnosis hinges on pathologic examination of affected tissue, with classic green birefringence under polarized light. Abdominal fat pad and rectal mucosal biopsy have been described as sites of higher sensitivity for diagnosis. Serum amyloid P scintigraphy is near 90% sensitive for diagnosis of AA amyloidosis. Patients should be considered for further evaluation to rule out additional organ involvement, notably cardiac and renal. Treatment hinges on an adequate suppression of the predisposing inflammatory disorder, or malignancy, followed by supportive therapy. Prognosis varies depending on the etiology of the disease, with the AL subtype showing worse outcomes, as well as those with hepatic involvement.

Dialysis: A Review of the Mechanisms Underlying Complications in the Management of Chronic Renal Failure.

Abstract: Chronic renal failure (CRF) is the most prevalent, worldwide public health problem of the elderly population. The main cause of CRF is a damaged kidney. There are five stages of CRF based on the glomerular filtration rate (GFR), and stage 5 (GFR < 15 ml/min/1.73m2) is often called an end-stage renal disease (ESRD). In CRF, there is an accumulation of toxins and excess water due to compromised renal function. Dialysis is the preferred way to treat ESRD and remove accumulated toxins from the body. The cardiovascular risk associated with dialysis is 10 to 20 times higher in patients undergoing dialysis than in normal people. The inflamed kidneys and the process of dialysis also affect endothelial function, aggravating the risk of hypertension and cardiac problems. Therefore, both physicians and patients should be aware of the consequences of undergoing dialysis. There is an urgent need to educate CRF patients regarding facts about the disease, medications, dietary habits, and various measures required to manage the condition and lead a normal life. This paper attempts to delineate the mechanisms that could result in cardiovascular and other complications among CRF patients undergoing dialysis.

The Pathophysiology of Perceived Social Isolation: Effects on Health and Mortality.

Abstract: Perceived social isolation (PSI) is a deficit in normal human social interaction, which has been associated with negative health outcomes. However, the precise mechanisms through which PSI influences human health are not fully known. This review aims at bringing out what is known about these pathways through which social isolation affects human health. We searched PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Psychological Information Database (PsycINFO), and Cochrane Library in addition to secondary references from primary journal articles for the most relevant and recent information concerning the research topic. The keywords used were perceived social isolation, loneliness, health outcomes, cardiovascular effects, neuroendocrine effects, depression, and cognitive decline, in animal and human populations. There are clear linkages between PSI and the cardiovascular system, neuroendocrine system, and cognitive functioning. PSI also leads to depression, cognitive decline, and sleep problems. The mechanisms through which PSI causes these effects are neural, hormonal, genetic, emotional, and behavioral. The effects of PSI on health are both direct and indirect. There is a complex interconnected network of pathways through which PSI negatively influences health. These hypothetical pathways using which the effects of PSI have been explained form the base on which further analyses can be carried out.

Pulmonary Vein Thrombosis: A Recent Systematic Review

Abstract: The pulmonary veins (PVs) are the most proximal source of arterial thromboembolism. Pulmonary vein thrombosis (PVT) is a rare but potentially lethal disease; its incidence is unclear, as most of the literature includes case reports. It most commonly occurs as a complica-tion of malignancy, post lung surgery, or atrial fibrillation and can be idiopathic in some cases. Most patients with PVT are commonly asymptomatic or have nonspecific symptoms such as cough, hemoptysis, and dyspnea from pulmonary edema or infarction. The thrombi are typically detected using a variety of imaging modalities including transesophageal echocardiogram (TEE), computed tomography (CT) scanning, magnetic resonance imaging (MRI), or pulmonary angiog-raphy. Treatment should be determined by the obstructing pathological finding and can include antibiotic therapy, anticoagulation, thrombectomy, and/or pulmonary resection. The delay in diagnosing this medical entity can lead to complications including pulmonary infarction, pulmonary edema, right ventricular failure, allograft failure, and peripheral embolism resulting in limb ischemia, stroke, and renal infarction (RI).

The Effectiveness of Internet-Based Cognitive Behavioral Therapy in Treatment of Psychiatric Disorders.

Abstract: This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (ICBT) in the treatment of psychiatric disorders. ICBT’s effectiveness has been investigated in treating and managing conditions like depression, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. ICBT’s role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. Furthermore, this study elaborates on its cost-effectiveness and its impact in rural areas. We conducted a thorough literature search using PubMed and Google Scholar with no restrictions on the date. ICBT's role in treating and controlling psychiatric illnesses has been established in the literature. From the data compiled, we conclude that ICBT is useful in treating mental health and medical illnesses with psychiatric comorbidities. It has also been found to be cost-effective for patients and society. ICBT is a potential tool emerging with modern day technological advancements and is useful in rural and urban settings, across various languages and cultures, and on a global scale. Larger randomized control trials on its use in clinical practice and in reaching rural populations are bound to shed more light on the effectiveness of this tool along with spreading awareness among physician and patient communities.

Stereotactic Body Radiotherapy for Low-Risk Prostate Cancer: A Ten-Year Analysis.

Abstract: Objective This study represents the first 10 year analysis of the efficacy and toxicity of stereotactic body radiotherapy (SBRT) in the treatment of early low-risk prostate cancer. Materials and methods Two hundred and thirty males were treated with Cyberknife SBRT to a dose of 35 Gray (Gy) or 36.25 Gy in five consecutive days. All patients had a Gleason score of six and a PSA < 10ng/ml. Median follow-up is nine years. The median age was 69.5 years and median prostate specific antigen (PSA) was 5.6ng/ml. The treatment was delivered with homogeneous planning with a dose prescription of 82-87% of the maximum dose to cover the planning target volume (PTV). Results Ten-year biochemical disease free survival was 93% with either dose. Local control was 98.4%. Median prostate specific antigen (PSA) dropped to 0.1 by five years and has remained there. Toxicity was mild with 10% of patients having Grade two-three late urinary toxicity and 4% having the late grade two rectal toxicity. Mean Expanded Prostate Cancer Index Composite (EPIC) Quality of Life (QOL) scores declined initially for bowel and urinary domains, but recovered to baseline, where they remain. EPIC sexual scores have declined by 40%. Discussion/Conclusions Stereotactic body radiotherapy to a dose of 35 Gy-36.25 Gy is an effective treatment for early low-risk prostate cancer, with acceptably low toxicity. There appears to be no benefit to increasing the dose beyond 35 Gy. Ten-year biochemical disease free survival appears to be higher than with standard intensity modulated radiotherapy (IMRT).

Correlation of IVC Diameter and Collapsibility Index With Central Venous Pressure in the Assessment of Intravascular Volume in Critically Ill Patients.

Abstract: OBJECTIVE The objective of our study is to assess the correlation between inferior vena cava (IVC) diameters, central venous pressure (CVP) and the IVC collapsibility index for estimating the volume status in critically ill patients. METHODS This cross-sectional study used the convenient sampling of 100 adult medical intensive care unit (ICU) patients for a period of three months. Patients ≥ 18 years of age with an intrathoracic central venous catheter terminating in the distal superior vena cava connected to the transducer to produce a CVP waveform were included in the study. A Mindray diagnostic ultrasound system model Z6 ultrasound machine (Mindray, NJ, USA) was used for all examinations. An Ultrasonic Transducer model 3C5P (Mindray, NJ, USA) for IVC imaging was utilized. A paired sampled t-test was used to compute the p-values. RESULTS A total of 32/100 (32%) females and 68/100 (68%) males were included in the study with a mean age of 50.4 ± 19.3 years. The mean central venous pressure maintained was 10.38 ± 4.14 cmH2O with an inferior vena cava collapsibility index of 30.68 ± 10.93. There was a statistically significant relation among the mean CVP pressure, the IVC collapsibility index, the mean maximum and minimum IVC between groups as determined by one-way analysis of variance (ANOVA) (p < 0.001). There was a strong negative correlation between CVP and IVC collapsibility index (%), which was statistically significant (r = -0.827, n = 100, p < 0.0005). A strong positive correlation between CVP and maximum IVC diameter (r = 0.371, n = 100, p < 0.0005) and minimum IVC diameter (r = 0.572, n = 100, p < 0.0005) was found. CONCLUSION There is a positive relationship of CVP with minimum and maximum IVC diameters but an inverse relationship with the IVC collapsibility index.

Accessory Ossicles of the Foot and Ankle: Disorders and a Review of the Literature.

Abstract: Accessory ossicles of the foot and ankle are normal variants of bone development that usually remain asymptomatic. However, they may be involved in various disorders and become a source of pain such as in fractures, dislocations, degenerative changes, osteonecrosis, osteoarthritis, osteochondral lesions, avascular necrosis, and irritation or impingement of adjacent soft tissues. Hence, during the assessment of the situations above, knowledge about these little-known ossicles could be very important to reach the correct diagnosis. Recent studies in the literature have mostly focused on the most frequent 9-12 accessory bones. In this review, 24 types of accessory ossicle are described. These ossicles are accessory navicular bone, os peroneum, os trigonum, os intermetatarseum, os vesalianum. os subfibulare, os subtibiale, os calcaneus secundarius, os calcanei accessorium, os supratalare, os sustentaculi, os talotibiale, os tali accessorium, talus secundarius, os subcalcis, os cuboideum secundarium, os supranaviculare, os infranaviculare, os paracuneiforme, os intercuneiforme, os cuneometatarsale I tibiale, os cuneometatarsale plantare, os cuneo-I metatarsale-II dorsale, and os aponeurosis plantaris. The clinical importance of these bones should be known thoroughly to reduce unnecessary orthopedic consultations and misdiagnosis. This article describes the clinical importance of the accessory ossicles and their possible pathological conditions. Understanding the possible disorders of the accessory ossicles of the foot and ankle can provide a more accurate diagnostic process.

Pattern and Predictors of Unmet Supportive Care Needs in Cancer Patients.

Abstract: The incidence of cancers is increasing and this is associated with an increase in the burden of the disease. Patients with cancer have to deal with reduced physical functioning, emotional instability, difficulty in concentrating, and an overall diminished feeling of well-being. This creates deficits that have not been well catered for by traditional cancer care, leading to an overall dissatisfaction with care and a reduced quality of life. This review aims at assessing the pattern of unmet needs in cancer patients and to provide information as to the factors that influence the perception of unmet needs. Studies directly focused on unmet needs in cancer patients which were retrieved from Medical Literature Analysis and Retrieval System Online (MEDLINE), Public/Publisher Medline (PubMed), PsychINFO, Excerpta Medica database (EMBASE), and Google Scholar; from the earliest records till 2016. Unmet needs in cancer patients have been measured with a wide variety of tools, with the supportive care needs survey (SCNS) being the most commonly used as a result of its strong psychometric properties, ease of use, responsiveness, and its coverage of the major domains of unmet needs. The most common unmet needs were in the domains of health system and information, psychological, and physical and daily living. These needs are influenced by sociodemographic factors such as age, sex, marital status, income level; and clinical factors such as location of cancer, stage of disease, and tumor size. It is clear that cancer patients experience a wide range of unmet supportive needs, for which solutions need to be devised in order to improve the supportive care services for these patients and their overall quality of life.

The Use of WhatsApp Smartphone Messaging Improves Communication Efficiency within an Orthopaedic Surgery Team.

Abstract: Introduction Effective and timely communication is important for any surgical specialty to function. The use of smartphones is prevalent amongst doctors. Numerous smartphone applications offer the potential for fast and cost-effective communication. WhatsApp is a commonly used application that is free, easy to use, and capable of text and multimedia messaging. We report on the use of WhatsApp over a six month period in our unit. Materials and methods WhatsApp communication between non-consultant members of an orthopaedic team over a six-month period was analysed. Both the phones and the WhatsApp application were password-protected, and patient details were anonymised. A series of 20 communications using the hospital pager system and the telephone system were also analysed. Results A total of 5,492 messages were sent during the six-month period and were part of 1,916 separate communication events. The vast majority of messages, 5,090, were related to patient care. A total of 195 multimedia messages were sent and these included images of radiographs and wounds. When using the hospital telephones, the length of time spent on a communication averaged 5.78 minutes and using the hospital pager system averaged 7.45 minutes. Using the WhatsApp messaging system has potentially saved up to 7,664 minutes over the study period. All participants found WhatsApp easy to use and found it to be more efficient than the traditional pager system Conclusion: Compared to the traditional pager systems, the use of WhatsApp is easy, inexpensive, and reliable and can help improve the efficiency of communication within a surgical team.

Goal-Directed Health Care: Redefining Health and Health Care in the Era of Value-Based Care.

Abstract: Health care reform efforts have increasingly emphasized payment models that reward value (quality/cost). It seems appropriate, therefore, to examine what we value in health care, and that will require that we examine our definition of health. In spite of admonitions from the World Health Organization and others, our current health care system operates under the assumption that health represents the absence of health problems. While that perspective has led to incredible advances in medical science, it now may be adversely affecting value. Problem-oriented care is clearly one of the drivers of rising costs and it could be adversely affecting the quality of care, depending upon how quality is defined. If we redefined health in terms of patient-centered goals, health care could be focused more directly on meaningful outcomes, reducing the number of irrelevant tests and treatments. Greater emphasis would be placed on prevention, meaningful activities, advance directives and personal growth and development. The role of patients within clinician-patient relationships would be elevated, strengthening therapeutic relationships. Reframing health in terms of health-related goals and directing the health care system to help people achieve them, could both improve quality and reduce costs. In the process, it could also make health care less mechanical and more humane.

What Makes the Optimal Wound Healing Material? A Review of Current Science and Introduction of a Synthetic Nanofabricated Wound Care Scaffold

Abstract: Wound matrix materials are used to improve the regeneration of dermal and epidermal layers in both acute and chronic wounds. Contemporary wound matrices are primarily composed of biologic materials such as processed xenogeneic and allogeneic tissues. Unfortunately, existing biologic wound matrices possess multiple limitations including poor longevity, durability, strength, and enzymatic resistance required for persistent support for new tissue formation. A fully-synthetic, resorbable electrospun material (Restrata Wound Matrix, Acera, St.Louis, Missouri ) that exhibits structural similarities to the native extracellular matrix offers a new approach to the treatment of acute and chronic wounds. This novel matrix is the first product to combine the advantages of synthetic construction (e.g. resistance to enzymatic degradation, excellent biocompatibility, strength/durability and controlled degradation) with the positive attributes of biologic materials (e.g. biomimetic architecture similar to human extracellular matrix (ECM), fibrous architecture optimized to support cellular migration and proliferation, engineered porosity to encourage tissue ingrowth and vascularization). These features allow RWM to achieve rapid and complete healing of full-thickness wounds that, in preclinical studies, is comparable to Integra Bilayer Wound Matrix (Integra LifeSciences, Plainsboro, New Jersey), a gold standard biologic material with diverse clinical indications in the wound care. Together, this review suggests that the RWM offers a unique fully-synthetic alternative to existing biologic matrices that is effective, widely available, easy to store, simple to apply and low cost.

Defining Health in the Era of Value-based Care: Lessons from England of Relevance to Other Health Systems.

Abstract: The demand for healthcare is rising due to aging populations, rising chronic disease prevalence, and technological innovations. There are currently more effective and cost-effective interventions available than can be afforded within limited budgets. A new way of thinking about the optimal use of resources is needed. Ensuring that available resources are used for interventions that provide outcomes that patient’s most value, rather than a focus just on effectiveness and cost-effectiveness, may help to ensure that resources are used optimally. Value-based healthcare puts what patients value at the center of healthcare. It helps ensure that they receive the care that can provide them with outcomes they think are important and that limited resources are focused on high-value interventions. In order to do this, we need flexible definitions of ‘health’, personalized and tailored to patient values. We review the current status of value-based health care in England and identify lessons applicable to a variety of health systems. For this, we draw upon the work of the National Institute for Health and Care Excellence (NICE), the National Health Service (NHS), Right Care Initiative, and our local experience in promoting value-based health care for specific conditions in our region. Combining the best available evidence with open and honest dialogue between patients, clinicians, and others, whilst requiring considerable time and resources are essential to building a consensus around the value that allows the best use of limited budgets. Values have been present in healthcare since its beginnings. Placing value and values at the center of healthcare could help to ensure available resources are used to provide the greatest possible benefit to patients.

A Review on the Role of Vitamin D in Asthma.

Abstract: Asthma, a major public health issue, is one of the most common diseases affecting millions of population globally. It is a chronic respiratory disease characterized by increased airway inflammation and hyper-responsiveness. Vitamin D is of particular interest in asthma due to its immunomodulatory effects. Serum 25-hydroxyvitamin D is found to be associated with a wide range of pulmonary diseases, including viral and bacterial respiratory infections, asthma, and cancer. Several researches have reported positive associations between vitamin D and asthma. On the other hand, others have reported contrasting effects of vitamin D on asthma. This review provides an examination of current epidemiologic and experimental evidence of a causal association between vitamin D status and asthma or asthma exacerbations, including its probable protective mechanism. Most of the evidence regarding vitamin D and asthma is reported by observational studies. Therefore, results from the experimental trials of vitamin D supplementation are important as they can provide evidence for future recommendations about the significance of vitamin D for asthma. Moreover, the trials can be effective in assessing the correct dosage and safety of vitamin D supplementation when given in diverse age groups such as children, teenagers, and adults for prevention and treatment of asthma.

Signs and Symptoms of Acoustic Neuroma at Initial Presentation: An Exploratory Analysis

Abstract: Introduction The objective of this study was to describe the most common clinical features associated with an acoustic neuroma diagnosis and to identify those features associated with larger tumour size at initial diagnosis. Methods The clinical information of 945 consecutive patients diagnosed with acoustic neuroma at a single centre between 1992 and 2015 was analysed. Clinical features were examined and the relationship between these features and tumour size (>2.5 cm) was analysed using descriptive statistics and logistic regression analysis. Statistical analysis was performed in R version 3.1.1. Results The most common presenting symptom was a unilateral hearing loss in 752 patients (80%), with a progressive pattern in 90% of these cases. The second most common presenting symptom was unilateral tinnitus, accounting for 6.3%, while ataxia, vertigo and headache accounted for 3.8%, 3.4% and 2%, respectively. The diagnosis of acoustic neuroma was an incidental finding in 20 patients (2.1%). Temporal analysis demonstrated a downward trend in the number of patients presenting with hearing loss and an increased proportion of patients presenting with other symptoms. On multivariate analysis, larger tumour size was associated with abnormal tandem gait (odds ratio 8.9, p=0.02), subjective facial weakness (odds ratio 5.3, p< 0.001), abnormal facial sensation on examination (odds ratio 3.0, p=0.03) and headache (odds ratio 2.6, p< 0.001). Conclusion The majority of patients with acoustic neuroma present with the classic, progressive, unilateral hearing loss. However, the pattern of presentation in acoustic neuroma patients is changing. Features in the history indicative of a larger tumour are headaches and subjective facial weakness, whilst concerning features on examination are abnormal tandem gait and altered facial sensation.

Transradial vs. Transfemoral Approach in Cardiac Catheterization: A Literature Review.

Abstract: The main objective of this review paper is to study the comparison between transradial and transfemoral approach in catheterization Transradial and transfemoral are two main approaches which are used as a diagnostic and therapeutic purpose in catheterization The transradial approach in interventional cardiology is safe, effective, and feasible as compared to the transfemoral approach The aim of this study is to compare pros and cons of transradial vs transfemoral approach in catheterization We conducted this systematic review on the role of transradial vs transfemoral catheterization The articles included real human data on interventional approaches Reviews on these strategies were conducted in PubMed, medical literature analysis and retrieval system online (MEDLINE), Cochrane, Medscape and National Institute of Health To maintain a high standard of review, studies published in all non-famous journals were excluded Data collected from the studies have suggested that transradial approach has less bleeding complications, cost effective, decreased hospital mortality rate, and less access site complications as compared to transfemoral approach However, longer procedural duration and radiation exposure are still concerns regarding transradial approach The findings of the present study show that transradial approach in catheterization is safe, effective, and feasible as compared to the transfemoral approach However, duration and radiation exposure are higher in the transradial access Several studies suggest that the modern approach overweight in benefits with the comparison to the classical approach

Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education

Abstract: Case reports and case series or case study research are descriptive studies that are prepared for illustrating novel, unusual, or atypical features identified in patients in medical practice, and they potentially generate new research questions. They are empirical inquiries or investigations of a patient or a group of patients in a natural, real-world clinical setting. Case study research is a method that focuses on the contextual analysis of a number of events or conditions and their relationships. There is disagreement among physicians on the value of case studies in the medical literature, particularly for educators focused on teaching evidence-based medicine (EBM) for student learners in graduate medical education. Despite their limitations, case study research is a beneficial tool and learning experience in graduate medical education and among novice researchers. The preparation and presentation of case studies can help students and graduate medical education programs evaluate and apply the six American College of Graduate Medical Education (ACGME) competencies in the areas of medical knowledge, patient care, practice-based learning, professionalism, systems-based practice, and communication. A goal in graduate medical education should be to assist residents to expand their critical thinking, problem-solving, and decision-making skills. These attributes are required in the teaching and practice of EBM. In this aspect, case studies provide a platform for developing clinical skills and problem-based learning methods. Hence, graduate medical education programs should encourage, assist, and support residents in the publication of clinical case studies; and clinical teachers should encourage graduate students to publish case reports during their graduate medical education.

The Use of Twitter by the Trauma and Orthopaedic Surgery Journals: Twitter Activity, Impact Factor, and Alternative Metrics.

Abstract: Aim Social media (SoMe) platforms have become leading methods of communication and dissemination of scientific information in the medical community. They allow for immediate discussion and widespread engagement around important topics. It has been hypothesized that the activity on Twitter positively correlates with highly cited articles. The purpose of this study was to analyze the prevalence and activity of Trauma and Orthopaedic Surgery journals on Twitter, with the hypothesis that the impact factor is positively associated with the Twitter usage. Methods The top 50 Trauma and Orthopaedic Surgery journals, ranked by 2016 Impact Factor were analyzed. The Twitter profiles of each journal or affiliated society were identified. Other SoMe platforms used were also recorded. The Twitonomy software (Digonomy Pty Ltd, New South Wales, Australia) was used to analyze the Twitter profiles over a one-year period. The Twitter Klout scores were recorded for each journal to approximate the SoMe influence. The Altmetric scores (the total number of mentions via alternative metrics) were also recorded. The statistical analysis was carried out to identify correlations between journal Impact Factors, SoMe activity, Twitter Klout scores and Altmetric scores. Results Twenty-two journals (44%) changed to 'had dedicated Twitter profiles [corrected]. Fourteen journals (28%) were associated with societies that had profiles and 14 journals (28%) had no Twitter presence. The mean Impact Factor overall was 2.16 +/- 0.14 (range, 1.07-5.16). The journals with dedicated Twitter profiles had higher Impact Factors than those without (mean 2.41 vs. 1.61; P=0.005). A greater number of Twitter followers were associated with higher Impact Factors (R2 0.317, P=0.03). The journals with higher Twitter Klout scores had higher Impact Factors (R2 0.357, P=0.016). The Altmetric score was positively associated with an Impact Factor (R2 0.310, P=0.015). The journals with higher numbers of retweets (virtual citations in the Twittersphere) had higher Altmetric scores (R2 0.463, P=0.015). Conclusion The Trauma and Orthopaedic Surgery journals with dedicated Twitter profiles have higher Impact Factors than those without. The Altmetrics is likely to play a significant role in the literature evaluation going forward along with the traditional metrics. The engagement with the Twitter by Trauma and Orthopaedic surgeons should be encouraged.

Redefining Health: Implication for Value-Based Healthcare Reform.

Abstract: Health definition consists of three domains namely, physical, mental, and social health that should be prioritized in delivering healthcare. The emergence of chronic diseases in aging populations has been a barrier to the realization of a healthier society. The value-based healthcare concept seems in line with the true health objective: increasing value. Value is created from health outcomes which matter to patients relative to the cost of achieving those outcomes. The health outcomes should include all domains of health in a full cycle of care. To implement value-based healthcare, transformations need to be done by both health providers and patients: establishing true health outcomes, strengthening primary care, building integrated health systems, implementing appropriate health payment schemes that promote value and reduce moral hazards, enabling health information technology, and creating a policy that fits well with a community.

Anti-inflammatory and Antioxidant Effects of Sesame Oil on Atherosclerosis: A Descriptive Literature Review.

Abstract: Sesame oil (SO) is a supplement that has been known to have anti-inflammatory and antioxidant properties, which makes it effective for reducing atherosclerosis and the risk of cardiovascular disease. Due to the side effects of statins, the current recommended treatment for atherosclerosis and cardiovascular diseases, the idea of using dietary and nutritional supplementation has been explored. The benefits of a dietary health regime have piqued curiosity because many different cultures have reaped health benefits through the ingredients in their cooking with negligible side effects. The purpose of this literary review is to provide a broad overview of the potential benefits and risks of SO on the development of atherosclerosis and its direction toward human clinical use. Current in vivo and in vitro research has shed light on the effects of SO and its research has shown that SO can decrease low-density lipoprotein (LDL) levels while maintaining high-density lipoprotein (HDL) levels. Current limitations in recent studies include no standardized doses of SO given to subjects and unknown specific mechanisms of the different components of SO. Future studies should explore possible synergistic and adverse effects of SO when combined with current recommended pharmaceutical therapies and other adjunct treatments.

Review of Assessment Scales for Diagnosing and Monitoring Sports-related Concussion

Abstract: Sports-related concussion has emerged as a public health crisis due to increased diagnosis of the condition and increased participation in organized and recreational athletics worldwide. Under-recognition of concussions can lead to premature clearance for athletic participation, leaving athletes vulnerable to repeat injury and subsequent short- and long-term complications. There is overwhelming evidence that assessment and management of sports-related concussions should involve a multifaceted approach. A number of assessment criteria have been developed for this purpose. It is important to understand the available and emerging diagnostic testing modalities for sports-related concussions. The most commonly used tools for evaluating individuals with concussion are the Post-Concussion Symptom Scale (PCSS), Standard Assessment of Concussion (SAC), Standard Concussion Assessment Tool (SCAT3), and the most recognized computerized neurocognitive test, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The strengths and limitations of each of these tools, and the Concussion Resolution Index (CRI), CogSport, and King-Devick tests were evaluated. Based on the data, it appears that the most sensitive and specific of these is the ImPACT test. Additionally, the King-Devick test is an effective adjunct due to its ability to test eye movements and brainstem function.