Medicine and Health Sciences Commons^™

Development Of A Health Care Systems Curriculum., Zachary Pruitt, Rahul Mhaskar, Bryan G. Kane Md, Robert D. Barraco Md, Mph, Deborah J Dewaay, Alexander M. Rosenau Do, Kristin A. Bresnan Md, Marna R. Greenberg Do, Mph, Facep

Marna R Greenberg DO, MPH, FACEP

Background: There is currently no gold standard for delivery of systems-based practice in medical education, and it is challenging to incorporate into medical education. Health systems competence requires physicians to understand patient care within the broader health care system and is vital to improving the quality of care clinicians provide. We describe a health systems curriculum that utilizes problem-based learning across 4 years of systems-based practice medical education at a single institution.

Methods: This case study describes the application of a problem-based learning approach to system-based practice medical education. A series of behavioral statements, called entrustable professional activities, was created …

10-Year Outcome Of The Thoracic Endovascular Aortic Repair (Tevar) Procedure, James K. Wu Md, Tim S. Misselbeck Md, Jacob Fink, Youssef Zaki

James K. Wu, M.D.

No abstract provided.

Development Of A Health Care Systems Curriculum., Zachary Pruitt, Rahul Mhaskar, Bryan G. Kane Md, Robert D. Barraco Md, Mph, Deborah J Dewaay, Alexander M. Rosenau Do, Kristin A. Bresnan Md, Marna R. Greenberg Do, Mph, Facep

Bryan G Kane MD

Background: There is currently no gold standard for delivery of systems-based practice in medical education, and it is challenging to incorporate into medical education. Health systems competence requires physicians to understand patient care within the broader health care system and is vital to improving the quality of care clinicians provide. We describe a health systems curriculum that utilizes problem-based learning across 4 years of systems-based practice medical education at a single institution.

Methods: This case study describes the application of a problem-based learning approach to system-based practice medical education. A series of behavioral statements, called entrustable professional activities, was created …

Ependymomas Overexpress Chemoresistance And Dna Repairrelated Proteins, Sherise D. Ferguson, Shouhao Zhou, Joanne Xiu, Yuuri Hashimoto, Nader Sanai, Lyndon Kim, Santosh Kesari, John De Groot, David Spetzler, Amy B. Heimberger

Department of Neurosurgery Faculty Papers

Background: After surgery and radiation, treatment options for ependymoma are few making recurrence a challenging issue. Specifically, the efficacy of chemotherapy at recurrence is limited. We performed molecular profiling on a cohort of ependymoma cases in order to uncover therapeutic targets and to elucidate the molecular mechanisms contributing to treatment resistance. Results: This ependymoma cohort showed minimal alterations in gene amplifications and mutations but had high expression rates of DNA synthesis and repair enzymes such as RRM1 (47%), ERCC1 (48%), TOPO1 (62%) and class III β-tublin (TUBB3) (57%), which are also all associated with chemoresistance. This cohort also had high …

The Gift That Keeps One Living, Scott R. Axelrod

Capstones

This long-form narrative feature article reports on the shortage of living kidney donors and those in desperate need of kidney transplants. It features interviews with doctors, transplant coordinators, patients, living kidney donors, and kidney recipients. The story culminates with my own personal experience as a kidney donor to my late dad over a decade ago. The presentation includes an extensive photo component capturing characters and elements from the story through a series of detailed portraits, photo essays, and infographics.

https://saxelrod718.wixsite.com/livingkidneydonors

Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment And Worse Outcome In The Stratis Registry (Systematic Evaluation Of Patients Treated With Neurothrombectomy Devices For Acute Ischemic Stroke)., Michael T Froehler, Jeffrey L Saver, Osama O Zaidat, Reza Jahan, Mohammad Ali Aziz-Sultan, Richard P Klucznik, Diogo C Haussen, Frank R Hellinger, Dileep R Yavagal, Tom L Yao, David S Liebeskind, Ashutosh P Jadhav, Rishi Gupta, Ameer E Hassan, Coleman O Martin, Hormozd Bozorgchami, Ritesh Kaushal, Raul G Nogueira, Ravi H Gandhi, Eric C Peterson, Shervin R Dashti, Curtis A Given, Brijesh P Mehta, Vivek Deshmukh, Sidney Starkman, Italo Linfante, Scott H Mcpherson, Peter Kvamme, Thomas J Grobelny, Muhammad S Hussain, Ike Thacker, Nirav Vora, Peng Roc Chen, Stephen J Monteith, Robert D Ecker, Clemens M Schirmer, Eric Sauvageau, Alex Abou-Chebl, Colin P Derdeyn, Lucian Maidan, Aamir Badruddin, Adnan H Siddiqui, Travis M Dumont, Abdulnasser Alhajeri, M Asif Taqi, Khaled Asi, Jeffrey Carpenter, Alan Boulos, Gaurav Jindal, Ajit S Puri, Rohan Chitale, Eric M Deshaies, David H Robinson, David F Kallmes, Blaise W Baxter, Mouhammad A Jumaa, Peter Sunenshine, Aniel Majjhoo, Joey D English, Shuichi Suzuki, Richard D Fessler, Josser E Delgado Almandoz, Jerry C Martin, Nils H Mueller-Kronast

Articles, Abstracts, and Reports

BACKGROUND: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.

METHODS: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or …

Optimal Management Of Post-Traumatic Radioulnar Synostosis, Arthur Lee Osterman, Melissa S. Arief

Department of Orthopaedic Surgery Faculty Papers

Post-traumatic radioulnar synostosis is a rare complication after forearm or elbow injury that can result in loss of motion and significant disability. Risk factors include aspects of the initial trauma and of the surgical treatment of that trauma. Surgical intervention for synostosis is the standard of care and is determined based on the location of the bony bridge. Surgical timing is recommended between 6 months and 2 years with recent advocacy for the 6- to 12-month period after radiographs demonstrate bony maturation but early enough to prevent further stiffness and contractures. For most types of synostosis, surgical resection with interposition …

Reorganization Of Thalamic Intrinsic Connectivity Following Anterior Temporal Lobectomy, Xiaosong He, Chaitanya Ganne, Michael R. Sperling, Ashwini Sharan, Joseph I. Tracy

Department of Neurosurgery Posters

The thalamus has played a crucial role in determining surgical outcome following anterior temporal lobectomy (ATL) in temporal lobe epilepsy (TLE) (He, et al., 2017). Before successfully quantifying the impact of the thalamus on ATL outcomes, this structure’s own intrinsic connectivity must be understood. Accordingly, we characterize thalamic intrinsic connectivity through resting-state fMRI (rsfMRI) longitudinally, exploring its change pre- to post-surgery.

Telesurgery: Surgery In The Digital Age, Dylan J. Cahill

Dartmouth Undergraduate Journal of Science

The dawn of the digital age has transformed the way we now receive and provide healthcare. Today, providers have instant access to all of their patients’ information, just as patients can connect with their providers on their smartphones in minutes from nearly anywhere in the world.

Retrieval Analysis Of Necropsy Total Hip Replacements: Considerations Beyond The Implant, Julie Alyse Lowell

Theses and Dissertations (ETD)

Introduction. Total hip arthroplasty (THA) surgery is one of the most commonly performed and successful orthopedic procedures in the United States. More than 300,000 primary THAs and 40,000 revision THAs performed in the United States every year. While the need for revision surgeries can stem from a variety of causes, there have been, to the author’s knowledge, no studies attempting to correlate the concentrations of certain inflammatory cytokines to metal ion concentrations found in the tissue surrounding the implant, amount of polyethylene wear, or strength of the interface of the modular taper. The purpose of this study was to begin …

The Technique Of S2-Alar-Iliac Screw Fixation: A Literature Review, Ai-Min Wu, Dong Chen, Chun-Hui Chen, Yu-Zhe Li, Li Tan Li Tang, Kevin Phan, Kern Singh, Brittany E. Haws, Daniele Vanni, Yusef I. Mosley, Srinivas K. Prasad, James Harrop, Zhong-Ke Lin, Yan Lin, Wen-Fei Ni, Xiang-Yang Wang

Department of Neurosurgery Faculty Papers

The distal fixation in thoracolumbar deformity surgery can be challenging for spine surgeons. When isolated S1-pedicle screws are utilized as the sole distal fixation in long thoracolumbar posterior constructs, there is a high rate of failure, due to loosening, breakage, and pseudarthrosis. Unfortunately, with iliac screw fixation the entry point at the posterior superior iliac spine requires considerable soft tissue dissection and may potentially increase the likelihood of wound complications. S2-alar-iliac (S2AI) screw fixation technique was developed recently to provide increased fixation with a lower profile screw and rod construct. These screws can be inserted with percutaneous or free hand …

Emergency Department Repair Of Blunt Right Atrial Rupture Utilizing Cardiopulmonary Bypass, Samuel P. Carmichael, Michael C. Bounds, Alexis E. Shafii, Phillip K. Chang

Internal Medicine Faculty Publications

Blunt cardiac injury (BCI) with free wall rupture carries a high risk of pre-hospital death. Cardiopulmonary bypass (CPB) has been utilized as a bridge to repair of cardiac lesions in select patients. We present an interesting case of emergency department repair of right atrial rupture with cardiopulmonary bypass.

Surgical Plume And Its Implications: A Review Of The Risk And Barriers To A Safe Work Place, Eunice Tan, Kylie P. Russell

Journal of Perioperative Nursing

Every year thousands of health care professionals worldwide are exposed to surgical smoke. There is evidence that this smoke consists of toxic gases, pathogens and particulate matter that is a hazard for patients and the perioperative team. Past research indicates that perioperative staff inconsistently comply with smoke evacuation recommendations. The aim of this study was to identify, review and discuss the issues related to surgical plume and its implications for patients and perioperative staff. The findings of this review relate to: surgical smoke content, its risks to the health of the perioperative staff, preventative measures, infection control measures, compliance with …

A Review Of Suspected Intraoperative Antiseptic Burns: A Quality Improvement Review, Monica Stankiewicz, Michele Wyland

Journal of Perioperative Nursing

No abstract provided.

Survival Benefit Of Surgery In Recurrent Glioblastoma Multiforme, Usama Khalid Choudry, Saad Akhtar Khan, Muhammad Shahzad Shamim

Section of Neurosurgery

There is an ongoing debate regarding role of surgery for recurrent glioblastoma multiforme (GBM). Older literature hinted at only modest survival benefits with surgery and a high rate of morbidity. However, more recent literature suggests better survival that may be attributed to better surgical techniques and better options in adjuvant treatment. Herein the authors review recent literature with regards to the possible role of surgery in recurrent GBM and also look into the key factors impacting second surgery.

Surgical Approaches To Adenocarcinoma Of The Gastroesophageal Junction: The Siewert Ii Conundrum., Andrew M. Brown, Danica N. Giugliano, Adam C. Berger, Michael J. Pucci, Francesco Palazzo

Department of Surgery Faculty Papers

BACKGROUND: The Siewert classification system for gastroesophageal junction adenocarcinoma has provided morphological and topographical information to help guide surgical decision-making. Evidence has shown that Siewert I and III tumors are distinct entities with differing epidemiologic and histologic characteristics and distinct patterns of disease progression, requiring different treatment. Siewert II tumors share some of the characteristics of type I and III lesions, and the surgical approach is not universally agreed upon. Appropriate surgical options include transthoracic esophagogastrectomy, transhiatal esophagectomy, and transabdominal extended total gastrectomy.

PURPOSE: A review of the available evidence of the surgical management of Siewert II tumors is presented. …

Silent Sentence Completion Shows Superiority Localizing Wernicke's Area And Activation Patterns Of Distinct Language Paradigms Correlate With Genomics: Prospective Study., Kamel El Salek, Islam S. Hassan, Aikaterini Kotrotsou, Srishti Abrol, Scott H. Faro, Feroze B. Mohamed, Pascal O. Zinn, Wei Wei, Nan Li, Ashok J. Kumar, Jeffrey S. Weinberg, Jeffrey S. Wefel, Shelli R. Kesler, Ho-Ling Anthony Liu, Ping Hou, R. Jason Stafford, Sujit Prabhu, Raymond Sawaya, Rivka R. Colen

Department of Radiology Faculty Papers

Preoperative mapping of language areas using fMRI greatly depends on the paradigms used, as different tasks harness distinct capabilities to activate speech processing areas. In this study, we compared the ability of 3 covert speech paradigms: Silent Sentence Completion (SSC), category naming (CAT) and verbal fluency (FAS), in localizing the Wernicke's area and studied the association between genomic markers and functional activation. Fifteen right-handed healthy volunteers and 35 mixed-handed patients were included. We focused on the anatomical areas of posterosuperior, middle temporal and angular gyri corresponding to Wernicke's area. Activity was deemed significant in a region of interest if P < 0.05. Association between fMRI activation and genomic mutation status was obtained. Results demonstrated SSC's superiority at localizing Wernicke's area. SSC demonstrated functional activity in 100% of cancer patients and healthy volunteers; which was significantly higher than those for FAS and CAT. Patients with 1p/19q non-co-deleted had higher extent of activation on SSC (P < 0.02). Those with IDH-1 wild-type were more likely to show no activity on CAT (P < 0.05). SSC is a robust paradigm for localizing Wernicke's area, making it an important clinical tool for function-preserving surgeries. We also found a correlation between tumor genomics and functional activation, which deserves more comprehensive study.

Trends In Spinal Surgery For Pott's Disease (2000-2016): An Overview And Bibliometric Study., Christian Fisahn, Fernando Alonso, Ghazwan A Hasan, R Shane Tubbs, Joseph R Dettori, Thomas A Schildhauer, Tarush Rustagi

Articles, Abstracts, and Reports

Study Design: Systematic review.

Objectives: (1) What are the surgical indications? Have they changed over time since the year 2000? (2) What is the current surgical approaches of choice? Have they changed over time since the year 2000? Do they vary by geographical region? (3) What are the most common outcome measures following surgery?

Methods: Electronic databases and reference lists of key articles were searched from database inception from January 1, 2000 to December 31, 2016 to identify studies specifically evaluating surgical indications, current surgical approaches, and outcome measures for spinal tuberculosis.

Results: Six randomized controlled trials were identified from …

Critical Event Review Team (Cert), Jeffrey Kuhlman, Thomas Looke, Louis Barr, Jeanette Bartos, Gengie Nail, Brittany Almon, Joseph Keebler, Elizabeth Lazzara, Elizabeth Blickensderfer

Publications

The culture of medicine is shifting from placing blame on providers to a systems-minded culture of trying to understand human error as a symptom of deeper rooted systemic issues. The goal is to reduce harm by redesigning the systems in which humans work.

Remaining Dentine Thickness Of Root Canals Prepared With K-3 And Protaper Rotary Systems, Sana Ehsen Nagi, Farhan Raza Khan, Munawar Rahman

Section of Dental-Oral Maxillofacial Surgery

Objective: To compare the remaining dentine thickness of root canals prepared with K-3 and ProTaper files..Methods: This in-vitro experimental study was conducted from 1st April-30th September 2015 at the dental clinics of Aga Khan University Hospital, Karachi, and comprised human teeth. Extracted human premolars and molars were included in the study using non-probability consecutive sampling. Canals were randomly allocated into two groups i.e. K-3 and ProTaper. Changes in inner and outer walls of canals were measured using Vixwin software at 1mm, 4mm, 7mm and 10mm from the apex. SPSS 20 was used for data analysis.Results: Of the 214 canals, 107(50%) …

Widespread Theta Synchrony And High-Frequency Desynchronization Underlies Enhanced Cognition., E. A. Solomon, J. E. Kragel, Michael R. Sperling, Ashwini Sharan, G. Worrell, M. Kucewicz, C. S. Inman, B. Lega, K. A. Davis, J. M. Stein, B. C. Jobst, K. A. Zaghloul, S. A. Sheth, D. S. Rizzuto, M. J. Kahana

Department of Neurology Faculty Papers

The idea that synchronous neural activity underlies cognition has driven an extensive body of research in human and animal neuroscience. Yet, insufficient data on intracranial electrical connectivity has precluded a direct test of this hypothesis in a whole-brain setting. Through the lens of memory encoding and retrieval processes, we construct whole-brain connectivity maps of fast gamma (30-100 Hz) and slow theta (3-8 Hz) spectral neural activity, based on data from 294 neurosurgical patients fitted with indwelling electrodes. Here we report that gamma networks desynchronize and theta networks synchronize during encoding and retrieval. Furthermore, for nearly all brain regions we studied, …

Anaesthetic Management Of Supratentorial Tumor Craniotomy Using Awake-Throughout Approach, Faraz Shafiq, Fahad Salim, Ather Enam, Jai Parkash, Mohammad Faheem

Department of Anaesthesia

The authors are reporting an anaesthetic management of patient presenting with left parietal lobe space occupying lesion and scheduled for Awake-craniotomy. Awake-throughout approach using scalp block was planned. Among techniques reported for keeping patient awake during the surgery, this one is really underutilized. The successful conduct requires thorough preoperative assessment and psychological preparation. We used powerpoint presentation as a preoperative teaching tool. The anatomical landmark technique was used to institute scalp block, where individual nerves were targeted bilaterally. Patient remained stable throughout and participated actively in intraoperative neurological monitoring. Postoperative period showed remarkable recovery, better pain control, and shorter length …

Editorial Perspective., Jens R Chapman

Articles, Abstracts, and Reports

No abstract provided.

Psoas Abscess Masquerading As A Prosthetic Hip Infection: A Case Report, Muhammad Atif, Azeem Tariq Malik, Shahryar Noordin

Section of Orthopaedic Surgery

Introduction: Psoas abscess is an unusual condition and is defined as a collection of pus in the iliopsoas compartment. Due to the unique anatomy of psoas muscle it forms a conduit for spread of infection from upper part of body to hip joint in neglected cases.
Case Presentation: A 67year old lady presented with left groin pain for three weeks. She underwent an uncemented unipolar hemiarthoplasty eight years back. Currently, she developed fever and was unable to do any active left hip range of motion. Passive motion of the left hip was restricted to 30° flexion, no internal rotation, 5° …

Recurrent Renal Cancer In Birt-Hogg-Dube Syndrome: A Case Report, Hammad Ather, Nida Zahid

Department of Surgery

Introduction: Birt-Hogg-Dube syndrome (BHDS) is a rare autosomal dominant disease. It is caused by constitutional mutations in the FLCN gene. Since BHDS is a rare syndrome therefore it is unknown to many physicians. However, it is important to identify this rare syndrome at early stages because incidence of renal cancer in BHD patients is very high and its detection at early stages can prevent its metastasis. Hence, we want to present a case of BHDS and draw the attention of the treating physician to this rare inherited disorder and discuss its appropriate diagnosis and management.CASE PRESENTATION: We present a case …

A Case Report Of Successful Management Of Clostridium Difficile Colitis With Antegrade Fidaxomicin Through A Mucous Fistula Obviating The Need For Subtotal Colectomy., Suzanne Arnott, Matthew Skancke, Sheena Chen, Bruce Abell

Surgery Faculty Publications

Introduction

Clostridium difficile is the most common cause of healthcare-associated infections and can have devastating morbidity and mortality. Traditional treatment algorithms involve intravenous metronidazole and enteric metronidazole or vancomycin. Fidaxomicin (DificidR) targets “switch regions” within RNA polymerases and effectively kills clostridium difficile bacteria and is typically administered orally primarily or through a naso/oro-gastric conduit.

Presentation of case

55-year-old with a recent elective surgical procedure was hospitalized with multifocal pneumonia and subsequently developed clostridium difficile colitis. This patient failed the standard medical therapy for clostridium difficile colitis, decompensated and required surgical exploration, partial colectomy and mucous fistula creation. Following her surgery, …

Transcriptional Alterations In Hereditary And Sporadic Nonfunctioning Pancreatic Neuroendocrine Tumors According To Genotype., Xavier M Keutgen, Suresh Kumar, Sudheer Gara, Myriem Boufraqech, Sunita Agarwal, Ralph H Hruban, Naris Nilubol, Martha Quezado, Richard Finney, Maggie Cam, Electron Kebebew

Surgery Faculty Publications

BACKGROUND

Nonfunctioning pancreatic neuroendocrine tumors (NFPanNETs) may be sporadic or inherited because of germline mutations associated with von Hippel-Lindau disease (VHL) or multiple endocrine neoplasia type 1 (MEN1). The clinical behavior of NFPanNETs is difficult to predict, even in tumors of the same stage and grade. The authors analyzed genotype-specific patterns of transcriptional messenger RNA (mRNA) levels of NFPanNETs to understand the molecular features that determine PanNET phenotype.

METHODS

Thirty-two samples were included for genome-wide mRNA gene expression analysis (9 VHL-associated, 10 MEN1-associated, and 9 sporadic NFPanNETs and 4 purified normal islet cell [NIC] samples). Validation of genes was performed …

Comparison Of Outcomes Of Antibiotic Drugs And Appendectomy (Coda) Trial: A Protocol For The Pragmatic Randomised Study Of Appendicitis Treatment., Giana H Davidson, David R Flum, David A Talan, Larry G Kessler, Danielle C Lavallee, Bonnie J Bizzell, Farhood Farjah, Skye D Stewart, Anusha Krishnadasan, Erin E Carney, Erika M Wolff, Bryan A Comstock, Sarah E Monsell, Patrick J Heagerty, Annie P Ehlers, Daniel A Deugarte, Amy H Kaji, Heather L Evans, Julianna T Yu, Katherine Mandell, Ian C Doten, Kevin S Clive, Karen M Mcgrane, Brandon C Tudor, Careen S Foster, Darin J Saltzman, Richard C Thirlby, Erin O Lange, Amber K Sabbatini, Gregory J Moran

Articles, Abstracts, and Reports

INTRODUCTION: Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%-15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy.

OBJECTIVES: The Comparing Outcomes of …

Genetic And Genomic Characterization Of 462 Melanoma Patient-Derived Xenografts, Tumor Biopsies, And Cell Lines., Bradley Garman, Ioannis N. Anastopoulos, Clemens Krepler, Patricia Brafford, Katrin Sproesser, Yuchao Jiang, Bradley Wubbenhorst, Ravi Amaravadi, Joseph Bennett, Marilda Beqiri, David Elder, Keith T. Flaherty, Dennie T. Frederick, Tara C. Gangadhar, Michael Guarino, David Hoon, Giorgos Karakousis, Qin Liu, Nandita Mitra, Nicholas J. Petrelli, Lynn Schuchter, Batool Shannan, Carol L. Shields, Jennifer Wargo, Brandon Wenz, Melissa A. Wilson, Min Xiao, Wei Xu, Xaiowei Xu, Xiangfan Yin, Nancy R. Zhang, Michael A. Davies, Meenhard Herlyn, Katherine L. Nathanson

Wills Eye Hospital Papers

Tumor-sequencing studies have revealed the widespread genetic diversity of melanoma. Sequencing of 108 genes previously implicated in melanomagenesis was performed on 462 patient-derived xenografts (PDXs), cell lines, and tumors to identify mutational and copy number aberrations. Samples came from 371 unique individuals: 263 were naive to treatment, and 108 were previously treated with targeted therapy (34), immunotherapy (54), or both (20). Models of all previously reported major melanoma subtypes (BRAF, NRAS, NF1, KIT, and WT/WT/WT) were identified. Multiple minor melanoma subtypes were also recapitulated, including melanomas with multiple activating mutations in the MAPK-signaling pathway and chromatin-remodeling gene mutations. These well-characterized …

Diverticulitis Resulting In Brain Abscess: A Case Report (Poster)., Sean J. Wallace Md, David Deisher Do, Thomas Daniel Harrison Do

Department of Surgery

No abstract provided.