Medical Specialties Commons^™

Implementation Of Trauma Service Guideline For The Use Of Phenobarbital In The Management Of The Non-Icu Trauma Patient At Risk Or Experiencing Severe Alcohol Withdrawal, Joseph Rappold, Julianne Ontengco, Stephen Tyzik, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operations Transformation

The trauma service in a large academic tertiary medical center admits a large proportion of patients with the secondary diagnosis of alcohol use disorder. Given the successful use of phenobarbital in the critical care unit for withdrawal prophylaxis and treatment of acute withdrawal, a quality improvement project was established to create and implement guidelines for the non ICU patient.

A root cause analysis demonstrated several issues to include inconsistent clinical decision documentation. As a result, several countermeasures were initiated to address the various issues.

Post implementation of countermeasures, a decrease in the amount of severe alcohol withdrawal as well as …

Factors Leading To Meconium Aspiration Syndrome In Term- And Post-Term Neonates, Saroop Chand, Aamna Salman, Razia Mustafa Abbassi, Abdul Rehman Siyal, Fayaz Ahmed Memon, Abdul Lateef Leghari, Ashmal Sami Kabani, Sajid Ali

Department of Pathology and Laboratory Medicine

Background:
Meconium aspiration syndrome (MAS) is considered a major cause of respiratory morbidity. It is a common issue encountered in the delivery room and newborn nursery. There is a need to identify the factors that lead to MAS to develop strategies to screen such patients at an early stage to decrease the mortality and morbidity. The objective of this study was to determine the factors leading to MAS in neonates delivered at ≥37 weeks of gestational age.
Methods:
A cross-sectional study was conducted through non-probability consecutive sampling technique at Liaquat University Hospital, Hyderabad from August 2016 to February 2017. All …

Yearly Trend Of Acute Venous Thromboembolism In Patients Admitted With Heart Failure In The United States., Sijan Basnet, Rashmi Dhital, Biswaraj Tharu, Dilli Ram Poudel, Anthony Donato

Reading Hospital Internal Medicine Residency

Introduction: Heart failure (HF) patients are at risk for venous thromboembolism (VTE) during the hospital stay. We aim to study the recent trend of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE in heart failure patients from years 2000-2013. Methods: We utilized the National (Nationwide) Inpatient Sample database and selected non-pregnant patients over the age of 18 years for this purpose. We selected HF, DVT, PE, and VTE based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We used STATA for analysis. Results: We noted an increase in prevalence of DVT, PE and composite …

Effect Of 3-Dimensional Virtual Reality Models For Surgical Planning Of Robotic-Assisted Partial Nephrectomy On Surgical Outcomes: A Randomized Clinical Trial., Joseph D Shirk, David D Thiel, Eric M Wallen, Jennifer M Linehan, Wesley M White, Ketan K Badani, James R Porter

Articles, Abstracts, and Reports

Importance: Planning complex operations such as robotic-assisted partial nephrectomy requires surgeons to review 2-dimensional computed tomography or magnetic resonance images to understand 3-dimensional (3-D), patient-specific anatomy.

Objective: To determine surgical outcomes for robotic-assisted partial nephrectomy when surgeons reviewed 3-D virtual reality (VR) models during operative planning.

Design, Setting, and Participants: A single-blind randomized clinical trial was performed. Ninety-two patients undergoing robotic-assisted partial nephrectomy performed by 1 of 11 surgeons at 6 large teaching hospitals were prospectively enrolled and randomized. Enrollment and data collection occurred from October 2017 through December 2018, and data analysis was performed from December 2018 through March …

A Comparison Of Opioid Abuse Screening Tools Of Detection Of High Risk Patients In The Inpatient Setting, Grace Gu Md, Albert Cheng Md, Darren Rahaman Md, Shyh-Jeun Wang Md, Maureen Strohm Md, Napatkamon Ayutyanont

Family Medicine

• The United States is currently experiencing an opioid epidemic, which claims 115 lives daily by overdose.
• Tools for identifying patients at increased risk for abuse include: Screener and Opioid Assessment for Patients with Pain (SOAPP-R) and Opioid Risk Tool (ORT).
• However, data is lacking for the comparison of the two most commonly used opioid screen tools (SOAPP-R and ORT).
• We are comparing the effectiveness of these screening tools for patients being discharged from the hospital who have no "red flags" for abuse.

Factors Leading To Meconium Aspiration Syndrome In Term- And Post-Term Neonates, Saroop Chand, Aamna Salman, Razia Mustafa Abbassi, Abdul Rehman Siyal, Fayaz Ahmed Memon, Abdul Lateef Leghari, Ashmal Sami Kabani, Sajid Ali

Department of Paediatrics and Child Health

Background: Meconium aspiration syndrome (MAS) is considered a major cause of respiratory morbidity. It is a common issue encountered in the delivery room and newborn nursery. There is a need to identify the factors that lead to MAS to develop strategies to screen such patients at an early stage to decrease the mortality and morbidity. The objective of this study was to determine the factors leading to MAS in neonates delivered at ≥37 weeks of gestational age.
Methods: A cross-sectional study was conducted through non-probability consecutive sampling technique at Liaquat University Hospital, Hyderabad from August 2016 to February 2017. All …

Irisin Functions To Inhibit Malignant Growth Of Human Pancreatic Cancer Cells Via Downregulation Of The Pi3k/Akt Signaling Pathway., Deguo Zhang, Ping Zhang, Luan Li, Nan Tang, Fei Huang, Xianguo Kong, Xueying Tan, Guangjun Shi

Department of Medicine Faculty Papers

Introduction: Irisin is a newly identified cytokine that has gained increasing attention because of its potential therapeutic applications in metabolic diseases and human cancers. Recently, accumulating evidence indicates that irisin plays an important role in the development and metastasis of various tumors. The aim of this study was to evaluate the effects and underlying mechanisms of irisin on malignant growth of pancreatic cancer cells.

Materials and methods: The anti-proliferative effect of irisin was examined using the CCK-8 assay. Irisin-induced apoptosis was determined by the annexin V-FITC/PI staining assay. The effects of irisin on cell migration and invasion were assessed using …

Geriatric Hepatology: The Hepatic Diseases Of The Elderly And Liver Transplant, Shima Ghavimi, Hamed Azimi, Neel Patel, Oleg Shulik

Internal Medicine

Introduction: With the aging US population, chronic liver diseases are becoming more commonly diagnosed in the geriatric population. Advanced age leads to changes in liver blood flow, volume, morphology and normal physiology. This predisposes elderly patients to develop certain chronic liver diseases. Also, the clinical course and management differ in an older patient when compared to a younger patient. Some causes of chronic liver disease in the geriatric population include Hepatitis A, B, C, Non-Alcoholic Fatty liver disease, prolonged alcohol use and inflammation. Many chronic liver diseases are characterized by a slow, indolent course of progression with non-specific symptoms and …

Management And Outcomes Of Gastrointestinal Congenital Anomalies In Low, Middle And High Income Countries: Protocol For A Multicentre, International, Prospective Cohort Study, Naomi Jane Wright, Andrew Leather, Nick Sevdalis, Niyi Ade-Ajayi, Adesoji O. Ademuyiwa, Emmanuel A. Ameh, Justine Davies, Kokila Lakhoo, Samuel Parker, Muhammad Arshad

Section of Paediatric Surgery

Introduction: Congenital anomalies are the fifth leading cause of death in children globally, contributing an estimated half a million deaths per year. Very limited literature exists from low and middle income countries (LMICs) where most of these deaths occur. The Global PaedSurg Research Collaboration aims to undertake the first multicentre, international, prospective cohort study of a selection of common congenital anomalies comparing management and outcomes between low, middle and high income countries (HICs) globally.
Methods and Analysis: The Global PaedSurg Research Collaboration consists of surgeons, paediatricians, anaesthetists and allied healthcare professionals involved in the surgical care of children globally. Collaborators …

Preliminary Observations On Soluble Programmed Cell Death Protein-1 As A Prognostic And Predictive Biomarker In Patients With Metastatic Melanoma Treated With Patient-Specific Autologous Vaccines., Robert O Dillman, Gabriel I Nistor, Bryce T Mclelland, Candace Hsieh, Aleksandra J Poole, Andrew N Cornforth, Hans S Keirstead

Articles, Abstracts, and Reports

Because of its role as an immune checkpoint, levels of soluble programmed cell death protein-1 (sPD-1) could be useful as a prognostic biomarker or predictive biomarker in cancer patients treated with vaccines. Very low levels of sPD-1 may indicate lack of an existing anti-cancer immune response; very high levels may indicate an active immune response that is suppressed. In between these extremes, a decrease in PD-1 following injections of an anti-cancer vaccine may indicate an enhanced immune response that has not been suppressed. Blood samples obtained during a randomized trial in patients with metastatic melanoma were tested from 22 patients …

Identification Of Monocyte-Like Precursors Of Granulocytes In Cancer As A Mechanism For Accumulation Of Pmn-Mdscs., Jérôme Mastio, Thomas Condamine, George Dominguez, Andrew V Kossenkov, Laxminarasimha Donthireddy, Filippo Veglia, Cindy Lin, Fang Wang, Shuyu Fu, Jie Zhou, Patrick Viatour, Sergio Lavilla-Alonso, Alexander T. Polo, Evgenii N. Tcyganov, Charles Mulligan, Brian Nam, Joseph Bennett, Gregory Masters, Michael Guarino, Amit Kumar, Yulia Nefedova, Robert H. Vonderheide, Lucia R. Languino, Scott I. Abrams, Dmitry I. Gabrilovich

Department of Cancer Biology Faculty Papers

We have identified a precursor that differentiates into granulocytes in vitro and in vivo yet belongs to the monocytic lineage. We have termed these cells monocyte-like precursors of granulocytes (MLPGs). Under steady state conditions, MLPGs were absent in the spleen and barely detectable in the bone marrow (BM). In contrast, these cells significantly expanded in tumor-bearing mice and differentiated to polymorphonuclear myeloid-derived suppressor cells (PMN-MDSCs). Selective depletion of monocytic cells had no effect on the number of granulocytes in naive mice but decreased the population of PMN-MDSCs in tumor-bearing mice by 50%. The expansion of MLPGs was found to be …

Surgical Stress And Cancer Progression: The Twisted Tango., Zhiwei Chen, Peidong Zhang, Ya Xu, Jiahui Yan, Zixuan Liu, Wayne Bond Lau, Bonnie Lau, Ying Li, Xia Zhao, Yuquan Wei, Shengtao Zhou

Department of Emergency Medicine Faculty Papers

Surgical resection is an important avenue for cancer treatment, which, in most cases, can effectively alleviate the patient symptoms. However, accumulating evidence has documented that surgical resection potentially enhances metastatic seeding of tumor cells. In this review, we revisit the literature on surgical stress, and outline the mechanisms by which surgical stress, including ischemia/reperfusion injury, activation of sympathetic nervous system, inflammation, systemically hypercoagulable state, immune suppression and effects of anesthetic agents, promotes tumor metastasis. We also propose preventive strategies or resolution of tumor metastasis caused by surgical stress.

A Case Of Essential Thrombocythemia And Iga Nephropathy With Literature Review Of The Concurrence., Shoja Rahimian, Timothy Johnson, Ronald Herb

Reading Hospital Internal Medicine Residency

Myeloproliferative neoplasms such as essential thrombocythemia (ET) have been associated with glomerular disease on rare instances. A case of ET associated with immunoglobulin A nephropathy (IgAN) is described in a 57-year-old man with a history of hypertension. Progressively worsening renal function was noted in the patient along with unexplained mild thrombocytosis. Pathological review of renal biopsy identified IgAN concurrently with newly diagnosed JAK2-mutated ET. The patient was started on aspirin therapy and closely monitored for his renal function. A literature review of the association of ET and renal disease revealed nine cases of ET associated with IgAN, focal segmental glomerulosclerosis, …

Asthma Exacerbation Trajectories And Their Predictors In Children With Incident Asthma., Sharifa Nasreen, Piotr Wilk, Tara Mullowney, Igor Karp

Paediatrics Publications

BACKGROUND:
Asthma exacerbation trajectories in children after incident asthma diagnosis are understudied.

OBJECTIVE:
To identify trajectories of asthma exacerbation and predictors of these trajectories in children with incident asthma.

METHODS:
Children from the National Longitudinal Survey of Children and Youth, Canada, with incident asthma were followed-up for up to 12 years during childhood. Latent class growth modeling was used to identify distinct asthma exacerbation trajectory groups. Multinomial logistic regression was performed to identify predictors of trajectory group membership.

RESULTS:
The mean age at asthma diagnosis among 403 children was 5.9 years. Three distinct trajectories were identified: low increasing (21.3% of …

Surgical Configurations Of The Pectoralis Major Flap For Reconstruction Of Sternoclavicular Defects: A Systematic Review And New Classification Of Described Techniques, Jude Opoku-Agyeman, David Matera, Jamee Simone

Plastic Surgery Resident Research

The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction.

METHODS:

EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August …

Phase 1 Trial Of Fruquintinib In Patients With Advanced Solid Tumors: Results Of The Dose Escalation Phase., A Wang-Gillam, H Park, H Yeckes-Rodin, Thomas Stanton, M Kosmo, S Fan, N Sauter, M Kanie

Articles, Abstracts, and Reports

Background: Fruquintinib (Fruq) is a potent, highly selective, novel vascular endothelial growth factor receptor (VEGFR) -1, -2, and -3 tyrosine kinase inhibitor. In the Phase III FRESCO trial¹ that led to the drug approval in China, Fruq improved the median overall survival in patients with metastatic colorectal cancer (mCRC) in the third line or later setting when compared to placebo (9.3 vs 6.6 months); hazard ratio 0.65 (95% CI, 0.51-0.83; P < .001),

Methods: This is a Phase 1 open-label, dose escalation/dose expansion study conducted in the US (NCT03251378). The primary objectives are to evaluate the safety and tolerability of Fruq …

Gbs With Non-Hodgkin Lymphoma, A Rarity, Javaria Munir, Umer Aziz Qazi

Pakistan Journal of Neurological Sciences (PJNS)

Patients of Non-Hodgkin’s lymphomas may develop neurological signs and symptoms. This case is of a 76 year old male recently diagnosed with Non-Hodgkin’s lymphoma and on chemotherapy who presented with sudden bilateral leg weakness and inability to walk. The signs and symptoms, neurological examinations and Nerve conduction studies revealed a polyneuropathy which was consistent with Guillain-Barré syndrome (GBS). This has been seen in patients with Hodgkin's lymphoma but is rare in NHL.

Neurotoxicity In A Young Patient With Diffuse Large B-Cell Lymphoma After First Dose Of Intrathecal Triple Therapy., Ali Sajjad, Sajid Hameed, Sara Khan

Pakistan Journal of Neurological Sciences (PJNS)

Intrathecal triple chemotherapy (ITT) including cytarabine arabinoside, methotrexate and glucocorticoids is a standard regimen for prophylaxis and treatment of hematological malignancies, owing to their high proclivity for invasion of the neuraxis. Unfortunately, intrathecal chemotherapy is associated with various neurological adverse effects including seizures, encephalopathy, myelopathy, arachnoiditis and cauda/conus syndrome. We present a case of 33-year-old lady with primary bone diffuse large B-cell lymphoma. She had received 4 cycles of R-CHOP* and later 2 cycles of R-DHAP**. The first dose of ITT was administered along with the last cycle of R-DHAP. On the third day post-ITT, she developed acute bilateral lower …

Extended Window Intravenous Thrombolysis: Is Conventional Window Of 4.5 Hours Coming To An End?, Malik Muhammad Adil, Narmeen Masood

Pakistan Journal of Neurological Sciences (PJNS)

The current standard of care to treat acute stroke patients presenting within 4.5 hours of stroke symptom onset is intravenous (IV) Alteplase.1 Over the past decade, tremendous efforts have been made to challenge the conventional window of 4.5 hours for the administration of Alteplase to expand the patient population which can benefit from thrombolysis. Based on the recent meta-analysis, 2 we have strong evidence supporting the use of IV thrombolysis in patients presenting between 4.5 to 9 hours of symptom onset with favorable perfusion imaging and it appears that the era of the conventional 4.5 hours window may be coming …

Children With Strabismus: Is There Psychological Impact On Mothers?, Syed Usman Bin Mehmood, Sidra Zafar, Azhar Hussain, Zafar Iqbal

Section of Ophthalmology

No abstract provided.

No Difference In Quality Of Life (Qol) Among People Who Switched From Injectable To Oral Disease Modifying Treatment (Dmt) Compared To Those Who Stayed On Injectable In A Community Cohort: A Propensity Score Matched (Psm) Analysis, Tamela Stuchiner, Lindsay Lucas, Elizabeth Baraban, Chiayi Chen, Stanley Cohan

Articles, Abstracts, and Reports

Introduction: Since the emergence of oral DMT to the market, few studies have examined patient reported outcomes of quality of life (QoL) after switching to oral DMT.

Objective: The aim of this study was to evaluate the impact of switching from injectable to oral disease modifying treatment (DMT) on QoL among relapsing multiple sclerosis (MS) participants.

Methods: Participants registered in the Pacific Northwest Multiple Sclerosis Registry who completed at least two annual surveys between 2012 and 2018 were included. Two cohorts were identified: “switchers”, those who switched from injectable to oral DMT, and “stayers”, those who stayed on injectable DMT. …

The Art Of Surgery: The Strange World Of The Placebo Response., Joseph R Dettori, Daniel C Norvell, Jens R Chapman

Articles, Abstracts, and Reports

No abstract provided.

Colostrum And Mature Breast Milk Analysis Of Serum Irisin And Sterol Regulatory Element-Binding Proteins-1c In Gestational Diabetes Mellitus, Syeda Sadia Fatima, Erum Khalid, Asma Akbar Ladak, Syed Adnan Ali

Department of Biological & Biomedical Sciences

Background: We aimed to evaluate irisin and SREBP-1c levels in serum, colostrum and mature breast milk in women with and without gestational diabetes (GDM); and to relate them with maternal glucose, lipid profile and weight status of babies.
Methods: GDM positive women (n = 33) and normal glucose tolerant women (NGT) (n = 33) were recruited. Maternal blood samples were collected at 28th week of gestation and later at 6-week post-partum while breast milk samples of the lactating mothers were collected within 72 hours of birth (colostrum) and at 6 weeks post-partum (mature milk). Irisin and SREBP-1c levels were analyzed …

Illegal Motorcycle Street Racing- A Growing Threat To Public Safety, Madiha Mumshad, Aisha Ashraf

Department of Emergency Medicine

No abstract provided.

Collaborative International Research In Clinical And Longitudinal Experience Study In Nmosd., Lawrence J Cook, John W Rose, Jessica S Alvey, Anna Marie Jolley, Renee Kuhn, Brie Marron, Melissa Pederson, Rene Enriquez, Jeff Yearley, Stephen Mckechnie, May H Han, Anna J Tomczak, Michael Levy, Maureen A Mealy, Jessica Coleman, Jeffrey L Bennett, Ruth Johnson, Myka Barnes-Garcia, Anthony L Traboulsee, Robert L Carruthers, Lisa Eunyoung Lee, Julia J Schubert, Katrina Mcmullen, Ilya Kister, Zoe Rimler, Allyson Reid, Nancy L Sicotte, Sarah M Planchon, Jeffrey A Cohen, Diane Ivancic, Jennifer L Sedlak, Ilana Katz Sand, Pavle Repovic, Lilyana Amezcua, Ana Pruitt, Erika Amundson, Tanuja Chitnis, Devin S Mullin, Eric C Klawiter, Andrew W Russo, Claire S Riley, Kaho B Onomichi, Libby Levine, Katherine E Nelson, Nancy M Nealon, Casey Engel, Mason Kruse-Hoyer, Melanie Marcille, Leticia Tornes, Anne Rumpf, Angela Greer, Megan Kenneally Behne, Renee R Rodriguez, Daniel W Behne, Derek W Blackway, Brian Coords, Terrence F Blaschke, Judy Sheard, Terry J Smith, Jacinta M Behne, Michael R Yeaman

Articles, Abstracts, and Reports

Objective: To develop a resource of systematically collected, longitudinal clinical data and biospecimens for assisting in the investigation into neuromyelitis optica spectrum disorder (NMOSD) epidemiology, pathogenesis, and treatment.

Methods: To illustrate its research-enabling purpose, epidemiologic patterns and disease phenotypes were assessed among enrolled subjects, including age at disease onset, annualized relapse rate (ARR), and time between the first and second attacks.

Results: As of December 2017, the Collaborative International Research in Clinical and Longitudinal Experience Study (CIRCLES) had enrolled more than 1,000 participants, of whom 77.5% of the NMOSD cases and 71.7% of the controls continue in active follow-up. Consanguineous …

An Unusual Presentation Of Subglottic Stenosis Necessitating Urgent Tracheostomy, Jacob Burdett, Alexander Manteghi

Otolaryngology (ENT) Resident Research

By definition, the subglottis is the area of the larynx immediately below the vocal folds extending to the level of the inferior border of the cricoid cartilage. This area represents the narrowest portion of the pediatric airway and is the most common site of iatrogenic stenosis. This stenosis is generally secondary to increased rates of intubation in infants of prematurity. Evaluation and treatment for subglottic stenosis represents one of the most common airway consultations within pediatric otolaryngology. Goals of therapy include securing a safe airway and restoring subglottic patency. In this clinical case, we present a unique pattern and presentation …

An Interesting Secondary Airway Lesion In An Infant With Laryngomalacia, William L. Valentino, David Lafferty, Alexander Manteghi

Otolaryngology (ENT) Resident Research

A 2-month-old male with a prior diagnosis of laryngomalacia (LM) presented to the emergency department in respiratory distress with worsening inspiratory stridor, suprasternal retractions, and a dry cough. A chest X-ray and lateral neck radiograph were performed and demonstrated no abnormalities. Flexible laryngoscopy revealed the same, previously observed moderately prolapsed arytenoids and an omega-shaped epiglottis with shortened aryepiglottic (AE) folds. He also had a right lower neck mass. He was scheduled for a direct laryngoscopy and bronchoscopy (DLB) and supraglottoplasty. During the DLB, LM and anterior compression of the midtrachea was noted. Lysis of the AE folds was performed in …

Reported Quality Of Life In Those On High Efficacy Compared To First Line Disease Modifying Therapies In A Community Cohort, Tamela Stuchiner, Lindsay Lucas, Elizabeth Baraban, Chiayi Chen, Stanley Cohan

Articles, Abstracts, and Reports

Introduction: In recent years, more high efficacy disease modifying treatments (DMT) have been approved and patients are placed on high efficacy DMT earlier in their disease course. Few studies have assessed the impact of high efficacy DMT on patients’ quality of life (QoL).

Objective: The study objective was to determine whether participants on high efficacy DMT reported greater impact of MS on their physical and psychological QoL than those on first line DMT using survey data from the Pacific Northwest Multiple Sclerosis Registry (PNWMSR).

Methods: This was a cross-sectional study using participants’ last annual follow up survey submitted between 2013 …

Medical Evaluation And Management Of Male And Female Voiding Dysfunction: A Review., Alana Murphy, Seth Teplitsky, Akhil K. Das, Joon Yau Leong, Andrew Margules, Costas D. Lallas

Department of Urology Faculty Papers

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients …

Learning From Experience: Avoiding Common Pitfalls In Multicenter Quality Improvement Collaboratives, Jonathan D. Thackeray, Carrie A. Baker, Rachel P. Berger

Pediatrics Faculty Publications

Clinicians and researchers often tout the newest breakthrough or latest successful intervention. Sharing wins, however, is often done at the expense of sharing obstacles, failures, and subsequent adjustments, which are the cornerstone of quality improvement (QI).^1–3 Here, we share 3 key lessons from 2 hospital-based QI initiatives—the Ohio Timely Recognition of Abuse Injuries (TRAIN) Collaborative and the University of Pittsburgh Medical Center (UPMC) Child Abuse Initiative (UPMC-CAI). Both focus on early identification, proper evaluation, and accurate reporting of child maltreatment. These are important clinical issues because many children who die or nearly die from maltreatment had been …