Spartan medical research journal最新文献

Introduction: In the US, ultrasound in Emergency Medicine (EM) is widely considered the standard of care in clinical practice amongst most Emergency Department providers. At the authors' institution and affiliates, there were a variety of health care providers utilizing ultrasound for clinical practice, and their skill levels varied, dependent on training and exposure. As an attempt to standardize credentialing practice and determine need for additional training thresholds, the authors endeavored to perform a skills assessment utilizing both written and clinical based practical assessments.

Methods: A 7 point questionnaire was administered to a convenience sample of providers requesting formal training information, number of ultrasounds performed, and self-assessed competency. A 10 point written assessment with ultrasound knowledge and clinical application questions was also administered. A subsequent clinical assessment on live humans and models was then performed with multiple stations assessing 15 different instrumentation skills and technique, as well as image interpretation and evaluation.

Results: A total of 23 attending EM board-certified physicians, and four advanced practice providers (PA and NP) took the credentialing assessments scoring an average of 7.3 out of 10 (SD 0.83) for the written assessment. Twenty (71%) of the 28 tested passed the clinical evaluation on their initial attempt. Five (17%) passed on a first remediation. Three (10%) required more than one initial revision attempt. All those who did remediate were able to complete the revision with a passing score.

Conclusions: Overall, the testing was considered a successful process. This program appears to have offered a level of standardization that was appealing to the credentialing body at our institution. We were able to assess to a level of competence considered standard of care by national credentialing bodies.

Peritrochanteric hip fractures are most commonly treated with proximal femoral fixation devices, such as a cephalomedullary nail or sliding hip screw. As usage rates increase for these fixation devices, complications from their insertion are becoming more prevalent. Lateral hip pain from proximal locking device insertion and prominence continues to be one of the most frequent complaints regarding hardware irritation following this surgical procedure. Conservative treatment options for this complaint include local corticosteroid injection and physical therapy, although once these treatments have been exhausted, surgical intervention may be recommended. This has generally been managed previously with implant removal, although studies have shown associated femoral neck fractures after removal even with the prescribed protected postoperative weight bearing. Additionally, in certain situations (e.g., when the nail is placed for prophylactic treatment), its removal is contraindicated. The purpose of this manuscript is to describe an alternative treatment option that would limit morbidity, and the need for proximal locking device or implant removal by excising the portion of the iliotibial band causing hip irritation at the level of the proximal locking device, while leaving the retained implant in place. This surgical option would allow most patients to return to their pre-operative weight-bearing status immediately following surgery without the need for additional postoperative precautions.

Introduction to the topic: Previous reports of congenital pharyngeal webs, although rare, have been described in children. Clinical presentation varies, ranging from aspiration to intermittent airway obstruction, and most commonly, dysphagia. In this case report, the authors describe an unusual finding of a hypopharyngeal web in an adult patient. This patient had no prior history of chemoradiotherapy, malignancy, or total laryngectomy, all of which have been associated with acquired pharyngeal stenosis, supporting that this finding was of congenital origin. After a review of the possible embryological developmental abnormalities, the hypothesis is that of gut recanalization failure during development.

Case presentation: We present a case of a woman in her mid-40's with a history of solid food dysphagia resulting in a 20 kg weight loss over three months. The patient denied dysphagia progressing to liquids, pain with swallowing, and a history of alcohol or tobacco use. Upon examination of the larynx via laryngoscope, a congenital hypopharyngeal web was identified. Successful excision of the web via coblation restored proper drainage of the pyriform sinus into the esophagus and resulted in markedly improved swallowing function and weight gain.

Conclusions: Pharyngeal webs are rare findings, particularly in adult patients. These congenital anomalies can be safely and effectively treated endoscopically via coblation.

Context: Cutibacterium acnes (C. Acnes, formerly known as Propionibacterium acnes) are slow growing, gram positive, anaerobic bacilli. C. acnes are found in many locations, both as part of normal skin flora, as well as a contaminant of environmental surfaces. These bacteria have been associated with prosthetic joint infections of the shoulder, and it has been challenging to prevent such infections for a variety of reasons. The purpose of this quality improvement project was to investigate whether the surgical adhesive dressing Ioban could pull subcutaneous C. acnes bacteria from the surgical field.

Methods: During this quality improvement project, a convenience sample of 16 adult volunteers were gathered from other residency departments and from medical students at our hospital. The volunteers were used to take samples from two sites on each shoulder. The shoulder sites were prepped and covered with iodine-impregnated dressings.

Results: There were 26 of 64 (40.6%) samples in the no Ioban group that grew C. acnes. The Ioban group had 37 of 64 (57.8%) samples found to be positive for C. acnes growth. During this project, we identified several key points that could be useful to future researchers working in community hospitals. We describe these lessons concerning ongoing communication with lab and research departments, offering volunteers compensation to participate, interacting with departments unaccustomed to research, and development of a clear methodology.

Conclusions: This was the first time our department had conduct a project utilizing the laboratory as well as volunteers. This came with unforeseen challenges which caused significant time delays. We believe that by highlighting these lessons for future researchers, they might avoid such problems during project activities.

Context: In 2016, the McLaren Oakland Department of Emergency Medicine developed and implemented a Chest Pain Accelerated Diagnostic Protocol (CP-ADP) to identify patients presenting to the emergency department (ED) with chest pain who were at low risk for acute coronary syndrome (ACS) and appropriate for outpatient follow-up. The evaluation of the QI/PS project demonstrated that only 47% of the patients discharged from the ED under the CP-ADP received outpatient follow-up. In response, a second round of the PDSA cycle modified the CP-ADP to add a multidisciplinary provider driven follow-up.

Methods: After ED discharge, patients in the CP-ADP with provider driven follow-up were contacted by a primary care physician to schedule a follow-up appointment. The premise was that this provider driven follow-up would alleviate navigation of the health care system as a barrier to follow-up.

Results: The evaluation of the modified CP-ADP with provider driven follow-up demonstrated that 9 of the 30 patients discharged from the ED were able to be contacted. 21 of the patients were unable to be reached by the phone number they provided. Only 3 patients discharged with provider driven follow-up showed up to follow up appointments.

Conclusions: There were some internal process failures identified that contributed to the low numbers of patients that were successfully contacted. External factors such as patient access to phones and means of communication were also discussed as factors that were originally not considered.

Context: Thermal injury to the larynx and other pharyngeal structures as a result of food ingestion is a rare occurrence, particularly in an adult population. Since the 1970's, only a few cases have been reported in the literature.

Case presentation: We present the case of a male in their early 30's with a history of left sided spastic hemiparesis and unilateral vocal fold paresis who ingested a sweet potato which resulted in supraglottic burns. The patient denied any prior swallowing difficulties. Conservative therapy with steroids, proton pump inhibitors (PPI's) and antibiotics were sufficient for full recovery without any lasting sequelae.

Conclusions: This case demonstrates how careful attention should be paid to food temperature particularly in patients at higher risk of dysphagia. It also demonstrates how prompt diagnosis and implementation of appropriate medications can prevent permanent and debilitating damage.

Context: This study aims to determine whether straw or cup use is superior for the control of a single thin liquid bolus in patients with symptoms of oropharyngeal dysphagia to liquids.

Methods: This is a prospective, randomized, single-blinded study. Patients were studied at a Professional Voice and Swallowing Center by a laryngologist between April 2017 and April 2018. Twenty-five patients, 18 years of age or older, who presented with symptoms of oropharyngeal dysphagia the clinic were included in the study. Each patient complained of difficulty with choking on liquids. Informed consent was obtained from each patient. Patients that were unable to follow one to two step commands and patients with dysphagia that lack oral strength or respiratory strength to facilitate straw or cup usage were not included. Patients with dysphagia that are tracheostomy tube dependent were also not included.

Results: The average PAS for straw versus cup drinking at 10mL was 1.08 and 1.04 respectively with a p-value of 0.33. For straw versus cup at 20mL, the PAS was 1.04 and 1.26 respectively with a p-value of 0.13. For 30mL, the PAS was 1.0 and 1.4 for straw and cup use respectively with a p-value of 0.16. And for 40mL, the PAS was 1.0 and 1.09 with a p-value of 0.27.

Conclusions: No statistical significant difference was demonstrated in risk of penetration or aspiration of thin liquids between cup and straw usage in patients with mild oropharyngeal dysphagia.