Assessing the Necessity for the "Joint Above and Below" Radiography Approach for Lower-extremity Long Bone Fractures in Children

OBJECTIVES

A common strategy for evaluation of extremity fractures is the "joint above and below" (JAB) radiograph approach, which includes dedicated imaging of the joint proximal and distal to a fracture independent of clinical suspicion for an injury involving the joint. The incidence of concomitant ipsilateral lower-extremity fractures or dislocations associated with lower-extremity long bone fractures in children has not been commonly reported and represents an evidential gap for determining a radiograph approach. Our purpose was to determine the frequency of and risk factors for concomitant ipsilateral lower-extremity fractures or dislocations.

METHODS

A retrospective study of children aged 1 to 17 years treated at an academic medical center emergency department from 2015 to 2018 with any fracture involving the tibia, fibula, or femur. Children with pathologic fractures, transferred from another facility, and/or designated as a level I trauma were excluded. The primary outcome was the prevalence of a concomitant bony injury (fracture or dislocation) at a distinct site in the same extremity. Differences between the concomitant bony injury group and single injury group were characterized using Fisher exact tests. Regression analysis was used to determine predictors of concomitant bony injuries, including age, sex, and mechanism of injury (with injuries requiring level II or III trauma activation classified as high risk).

RESULTS

During the study period, 241 patients with lower-extremity long bone fractures were included. Complete JAB radiographs, defined as dedicated orthogonal radiographs of the joint proximal to and distal to the fracture site, were taken in 85 (35.3%) of 241 patients. Concomitant bony injuries were found in 9 (3.73%) of 241 patients (95% confidence interval, 1.7-7.0%). No additional concomitant bony injuries were identified at follow-up. When comparing patients with and without concomitant bony injuries, there was no significant difference in age (P = 0.34) and sex (P = 0.73). However, patients with a high-risk injury were more likely to have a concomitant bony injury (P < 0.01; odds ratio, 21.9; 95% confidence interval, 3.6-131.5).

CONCLUSIONS

Concomitant ipsilateral lower-extremity fractures or dislocations are uncommon in children sustaining tibia, fibula, and/or femur fractures. Although the JAB approach to radiographs may be useful in identifying additional injuries in children with lower-extremity injuries resulting from a "high-risk" mechanisms, its overall yield is low. To provide safe, cost-effective care, providers should continue to value clinical suspicion, history, and physical examination findings to guide selection of radiographs in those with lower-extremity long bone fractures as significant fractures can typically be identified with limited imaging in patients with low-risk injury mechanisms.

Are pediatric surgery clinics LGBTQ+ inclusive?

PURPOSE

Creating inclusive LGBTQ+ environments is important in the provision of inclusive care. This cross sectional study assessed whether patient intake forms in pediatric surgery departments were LGBTQ+ inclusive (L-I).

METHODS

North American pediatric surgery departments affiliated with pediatric surgery fellowships or general surgery residencies were contacted to retrieve patient intake forms. Forms were assessed for LGBTQ+ inclusivity using a novel L-I scoring system consisting of 6 criteria: preferred name, pronouns, preferred language, gender identity, sex assigned at birth, and l-I guardianship. Institutions without intake forms were invited to comment on their use of l-I intake questions.

RESULTS

59/125 programs responded to our query, 10 of which provided intake forms. Median l-I score was 2/6 points (range 1-4). l-I guardianship was the most common question asked. No intake form asked for pronouns. Of the 49 institutions without forms, 30.5% reported asking l-I questions during initial visits. Narratives from these institutions varied widely. Some institutions supported routine l-I questions while others stated l-I questions were unnecessary, irrelevant, and/or offensive.

CONCLUSIONS

Few North American pediatric surgery departments consistently ask l-I questions during the intake process. Comments questioning the appropriateness and necessity of l-I questions highlight the need for LGBTQ+ education.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Cross sectional study.

A rare case of diabetic ketoacidosis presenting with severe hypertriglyceridemia requiring plasmapheresis in an adult with type-2 diabetes mellitus: Case report

INTRODUCTION

Severe hypertriglyceridemia (HTG) is a rare complication of insulin resistance. Its presentation with diabetic ketoacidosis (DKA) has been reported in a few cases, where most patients have type-1 diabetes mellitus (DM). Our case represents a unique presentation of DKA associated with severe HTG above 10,000 mg/dL in an adult with type-2 DM.

PATIENT CONCERNS AND DIAGNOSIS

Case Report: A 51-year-old man with no prior illnesses presented to the emergency department with abdominal pain and nausea. He was found to have DKA with a blood glucose level of 337 mg/dL, pH of 7.17, beta-hydroxybutyrate of 7.93 mmol/L, and anion gap of 20 mmol/L. His triglyceride levels were >10,000 mg/dL. His serum was found to be lipemic. Computerized tomography scan of the abdomen demonstrated mild acute pancreatitis. Negative GAD65 antibodies supported the diagnosis of type-2 DM.

INTERVENTIONS AND OUTCOMES

Endocrinology was consulted and one cycle of albumin-bound plasmapheresis was administered. This therapy significantly improved his HTG. DKA gradually resolved with insulin therapy as well. He was discharged home with endocrinology follow-up.

CONCLUSION

This unique case highlights an uncommon but critical consequence of uncontrolled DM. It brings forth the possibility of severe HTG presenting as a complication of uncontrolled type-2 DM. Severe HTG commonly presents with acute pancreatitis, which can be debilitating if not managed promptly. Most patients with this presentation are managed with insulin infusion. The use of plasmapheresis for management of severe HTG has not been well studied. Our case supports the use of plasmapheresis as an effective and rapid treatment for severe HTG.

Blindfolding Improves Communication in Inexperienced Residents Undergoing ACLS Training

BACKGROUND

Closed-loop communication (CLC) is associated with decreased medical errors and improved time-to-task completion during resuscitations. Depriving team leaders of sight during training may accelerate the acquisition of favorable communication skills; however, its effect on the frequency of CLC is unclear, especially with trainees.

OBJECTIVE

We assessed the effect of depriving interns of sight during advanced cardiovascular life support (ACLS) on verbal communication patterns and resuscitation confidence.

METHODS

All interns undergoing ACLS training in June 2019 at a single center were eligible. Interns were randomized to blindfolded training (BT) or standard training (ST). BT team leaders were blindfolded during practice sessions and permitted to use sight during testing. Testing scenarios were video- and audio-recorded. Recordings were assessed for teams' performance and communication patterns. Participants were surveyed for confidence with resuscitation skills before and after ACLS training.

RESULTS

All 87 eligible interns participated in the study (100% participation). Eighty-five of 87 (98%) interns were included for analysis; 46 were randomized to BT and 39 to ST. Interns in the BT group were significantly more likely to exhibit CLC (mean: BT 20.3, ST 16.6; P = .003), directed communication (mean: BT 4.3, ST 1.5; P < .001), and follower-initiated communication (mean: BT 12.8, ST 10.2; P = .028). There was no significant difference in clinical performance measures or self-reported confidence with resuscitation between BT and ST groups.

CONCLUSIONS

Blindfolding trainees results in greater instances of CLC, directed communication, and follower-initiated communication during ACLS training.

Implementation and Process of a COVID-19 Contact Tracing Initiative: Leveraging Health Professional Students to Extend the Workforce During a Pandemic

Background

The Centers for Disease Control and Prevention recommends aggressive contact tracing to control the COVID-19 pandemic. In this work, we (1) describe the development of a COVID-19 contact tracing initiative that includes medical, nursing, and public health students, and is led by clinicians and infectious disease epidemiologists within our health system, and, (2) articulate process steps for contact tracing including workflows and telephone scripts, and, (3) highlight the key challenges and strategies to overcome these challenges.

Methods

A single academic institution-based contact tracing initiative was rapidly scaled to 110 health professional students, four physicians, two epidemiologists, and a research team. Following training, students called patients who were COVID-19 positive and the individuals they were in contact with to ensure proper isolation and quarantine measures. Students also assisted those who faced barriers to quarantine.

Implications

In total, between March 24 and May 28 – this initiative completed contact tracing for 536 confirmed cases, which resulted in the identification of 953 contacts. We aim to disseminate this process, including telephone scripts and workflow, to other health systems for use in their initiatives to respond to the COVID-19 pandemic and future public health emergencies.

Contributions of Health Professions Students to Health System Needs During the COVID-19 Pandemic: Potential Strategies and Process for U.S. Medical Schools

The COVID-19 pandemic poses an unprecedented challenge to U.S. health systems, particularly academic health centers (AHCs) that lead in providing advanced clinical care and medical education. No phase of AHC efforts is untouched by the crisis, and medical schools, prioritizing learner welfare, are in the throes of adjusting to suspended clinical activities and virtual classrooms. While health professions students are currently limited in their contributions to direct clinical care, they remain the same smart, innovative, and motivated individuals who chose a career in health care and who are passionate about contributing to the needs of people in troubled times. The groundwork for operationalizing their commitment has already been established through the identification of value-added, participatory roles that support learning and professional development in health systems science (HSS) and clinical skills. This pandemic, with rapidly expanding workforce and patient care needs, has prompted a new look at how students can contribute. At the Penn State College of Medicine, staff and student leaders formed the COVID-19 Response Team to prioritize and align student work with health system needs. Starting in mid-March 2020, the authors used qualitative methods and content analysis of data collated from several sources to identify 4 categories for student contributions: the community, the health care delivery system, the workforce, and the medical school. The authors describe a nimble coproduction process that brings together all stakeholders to facilitate work. The learning agenda for these roles maps to HSS competencies, an evolving requirement for all students. The COVID-19 pandemic has provided a unique opportunity to harness the capability of students to improve health.Other AHCs may find this operational framework useful both during the COVID-19 pandemic and as a blueprint for responding to future challenges that disrupt systems of education and health care in the United States.

The complete genome sequence of the gram-positive bacterium Bacillus subtilis

Bacillus subtilis is the best-characterized member of the Gram-positive bacteria. Its genome of 4,214,810 base pairs comprises 4,100 protein-coding genes. Of these protein-coding genes, 53% are represented once, while a quarter of the genome corresponds to several gene families that have been greatly expanded by gene duplication, the largest family containing 77 putative ATP-binding transport proteins. In addition, a large proportion of the genetic capacity is devoted to the utilization of a variety of carbon sources, including many plant-derived molecules. The identification of five signal peptidase genes, as well as several genes for components of the secretion apparatus, is important given the capacity of Bacillus strains to secrete large amounts of industrially important enzymes. Many of the genes are involved in the synthesis of secondary metabolites, including antibiotics, that are more typically associated with Streptomyces species. The genome contains at least ten prophages or remnants of prophages, indicating that bacteriophage infection has played an important evolutionary role in horizontal gene transfer, in particular in the propagation of bacterial pathogenesis.