Mario A. Davidson

Is early venous thromboembolism prophylaxis safe in trauma patients with intracranial hemorrhage.

BACKGROUND Patients with traumatic brain injuries (TBIs) are at high risk for venous thromboembolic sequelae; however, prophylaxis is often delayed because of the perceived risk of intracranial hemorrhagic exacerbation. The goal of this study was to determine whether enoxaparin for early venous thromboembolism (VTE) prophylaxis is safe for hemodynamically stable patients with TBIs. METHODS This is a retrospective cohort study from a Level I Trauma Center of patients with TBIs receiving early (0-72 hours) or late (>72 hours) VTE prophylaxis. Inclusion criteria included evidence of acute intracranial hemorrhagic injury (IHI) on admission computed tomography, head/neck abbreviated injury score≥3, age≥16 years, and hospital length of stay≥72 hours. Exclusion criteria included intracranial pressure monitor/ventriculostomy, current systemic anticoagulation, pregnancy, coagulopathy, history of DVT, ongoing intra-abdominal hemorrhage 24 hours postadmission, and preexisting inferior vena cava filter. Progression of IHI defined as lesion expansion/new IHI on repeat computed tomography. RESULTS Totally, 669 patients were identified: 268 early (40.1%) and 401 late (59.9%), with a mean injury severity score of 27.8±10.2 and 29.4±11, respectively. Head neck abbreviated injury score of 3 (47% vs. 34%), 4 (42% vs. 46%), 5 (11% vs. 19%), and 6 (0% vs. 1%) were reported for the early and late treatment groups, respectively. Mean time to prophylaxis was 2.77 days±0.49 days and 5.31 days±1.97 days. IHI progression before prophylaxis was 9.38% versus 17.41% (p<0.001) and after prophylaxis was 1.46% versus 1.54% (p>0.9). Proportions of proximal DVT were 1.5% versus 3.5% (p=0.117) and pulmonary embolism were 1.5% versus 2.2% (p=0.49). There were no differences in injury severity score, age, and pelvic and/or long bone fractures. CONCLUSIONS We found no evidence that early VTE prophylaxis increases the rate of IHI progression in hemodynamically stable patients with TBIs. The natural rate of IHI progression observed is comparable with previous studies. Although not powered to detect differences in the incidence of DVT and pulmonary embolism, the data trend toward increased proportions of both VTE outcomes in the late group.

Assessing Student Mental Health at the Vanderbilt University School of Medicine

Purpose To determine the prevalence rates of four major categories of mental illness among medical students and to examine associations between these illnesses and a range of demographic variables. Method The authors invited all 330 first-, second-, and third-year medical students at Vanderbilt University School of Medicine to participate in a survey during winter 2008–2009. Students completed an anonymous written questionnaire assessing the prevalence of depression, anxiety, eating disorders, and alcohol and drug use disorders. Additionally, the authors obtained student demographic information to investigate variations in rates of illness based on interindividual differences. Results Most students (301; response rate: 91.2%) completed the survey. The authors found that depression and anxiety were more prevalent in the Vanderbilt medical student population than in their nonmedical peer group. The authors found that 37 (12%) of the students were borderline for possible alcohol abuse and 3 (1%) were problem drinkers, 1 (0.3%) had a possible drug abuse disorder, and 3 (1%) had possible eating disorders. Whereas exercising one to three times per week was associated with lower rates of both depression and anxiety, having a family history of mental illness was associated with higher eating disorder scores and anxiety. There was an association between gender and all disorders. Conclusions Insight into the prevalence of mental health disorders in the medical student population and the variables that may influence them provides important information for medical schools as they develop more robust and effective wellness programs to help students in these very stressful learning environments.

Burst suppression on processed electroencephalography as a predictor of postcoma delirium in mechanically ventilated ICU patients.

Objectives:Many patients, due to a combination of illness and sedatives, spend a considerable amount of time in a comatose state that can include time in burst suppression. We sought to determine if burst suppression measured by processed electroencephalography during coma in sedative-exposed patients is a predictor of post-coma delirium during critical illness. Design:Observational convenience sample cohort. Setting:Medical and surgical ICUs in a tertiary care medical center. Patients:Cohort of 124 mechanically ventilated ICU patients. Interventions:None. Measurements and Main Results:Depth of sedation was monitored twice daily using the Richmond Agitation-Sedation Scale and continuously monitored by processed electroencephalography. When noncomatose, patients were assessed for delirium twice daily using Confusion Assessment Method for the ICU. Multiple logistic regression and Cox proportional hazards regression were used to assess associations between time in burst suppression and both prevalence and time to resolution of delirium, respectively, adjusting for time in deep sedation and a principal component score consisting of Acute Physiology and Chronic Health Evaluation II score and cumulative doses of sedatives while comatose. Of the 124 patients enrolled and monitored, 55 patients either never had coma or never emerged from coma, yielding 69 patients for whom we performed these analyses; 42 of these 69 (61%) had post-coma delirium. Most patients had burst suppression during coma, although often short-lived (median [interquartile range] time in burst suppression, 6.4 [1–58] min). After adjusting for covariates, even this short time in burst suppression independently predicted a higher prevalence of post-coma delirium (odds ratio, 4.16; 95% CI, 1.27–13.62; p = 0.02) and a lower likelihood (delayed) resolution of delirium (hazard ratio, 0.78; 95% CI, 0.53–0.98; p = 0.04). Conclusions:Time in burst suppression during coma, as measured by processed electroencephalography, was an independent predictor of prevalence and time to resolution of postcoma/post–deep sedation delirium. These findings of this single-center investigation support lighter sedation strategies.

Factors that influence parental attitudes toward enrollment in type 1 diabetes trials.

Aims To assess parental attitudes towards type 1 diabetes clinical trials (T1DCTs) and factors that impact willingness to enroll their children with and without diabetes. Methods A cross-sectional survey of parents of children with type 1 diabetes was administered at an academic clinic and a diabetes educational event. Results Survey response rate was 36%. Of 166 participating parents, 76% were aware of T1DCTs. More parents reported willingness to enroll children with diabetes (47%) than unaffected children (36%). Only 18% recalled being asked to enroll their children, and of these, 60% agreed to enroll at least some of those times. Less than 30% were comfortable with placebos. Factors predicting willingness to enroll children with diabetes included healthcare provider trust, comfort with consent by proxy, low fear of child being a “guinea pig,” and comfort with placebo. Factors predicting willingness to enroll unaffected children were provider trust, comfort with consent by proxy, comfort with placebo, and perceived ease of understanding T1DCT information. Conclusions Parents report moderate willingness to enroll children in T1DCTs. Willingness is diminished by common trial methodologies. Although most parents recalled receiving trial-related information, significantly fewer recalled being asked to participate. Efforts to optimize effective communication around identified areas of parental concern may increase T1DCT participation.

Improvements in medical school wellness and career counseling: A comparison of one-on-one advising to an Advisory College Program.

Background: Medical students have unmet needs in the areas of career and wellness advising. Aims: The goal of this study is to describe the development of an Advisory College Program (ACP) and assess its effectiveness compared to a traditional one-on-one faculty advisor system. Methods: The ACP, consisting of four colleges co-led by Advisory College Directors and supported by key Faculty, was developed to provide structured career and wellness advising. The authors compared the ACP to the former Faculty Advisory Program (FAP) using two parallel questionnaires. Results: Surveys were completed by 74% of first-year students, 60% of second-year students, and 88% of third-year students. Survey data demonstrated a significant increase in the number of students who could identify their advisor, the frequency of student–advisor contacts, and the perceived accessibility of advisors in the ACP compared to the FAP. While an ordinal logistic regression model did not demonstrate a significant effect of the new advising system on overall satisfaction, univariate analysis demonstrated a significant increase in student satisfaction with wellness and career counseling. Conclusions: The ACP was more effective in promoting student wellness and career counseling than the traditional one-on-one faculty advisor system. Similar college-based programs may be beneficial to students at other medical school programs.

Exostoses of the external auditory canal in white-water kayakers†

Exostoses of the external auditory canal are benign bony tumors associated with frequent cold‐water exposure. Obstruction may lead to conductive hearing loss and recurrent otitis externa, requiring surgical correction when symptoms become intolerable. This study aimed to characterize the prevalence of exostoses in white‐water kayakers and identify associated risk factors and protective measures.

Use of individualized learning plans among fourth-year sub-interns in pediatrics and internal medicine

Background: Individualized Learning Plans (ILPs) are an effective tool for promoting self-directed learning among residents. However, no literature details ILP use among medical students. Methods: Fifty fourth-year sub-interns in pediatrics and internal medicine created ILPs, including a self-assessment of strengths and weaknesses based on ACGME core competencies and the setting of learning objectives. During weekly follow-up meetings with faculty mentors and peers, students discussed challenges and revised goals. Upon completion of the rotation, students completed a survey of Likert-scale questions addressing satisfaction with and perceived utility of ILP components. Results: Students most often self-identified strengths in the areas of Professionalism and Interpersonal and Communication Skills and weaknesses in Patient Care and Systems-Based Practice. Eighty-two percent set at least one learning objective in an identified area of weakness. Students expressed high confidence in their abilities to create achievable learning objectives and to generate strategies to meet those objectives. Students agreed that discussions during group meetings were meaningful, and they identified the setting learning objectives and weekly meetings as the most important elements of the exercise. Conclusions: Fourth-year sub-interns reported that ILPs helped them to accomplish rotation goals, with the setting of learning objectives and weekly discussions being the most useful elements.

High Prevalence of Soil-transmitted Helminths in Western Kenya: Failure to Implement Deworming Guidelines in Rural Nyanza Province

Soil-transmitted helminth (STH) infections affect an estimated 2 billion people world wide. Children experience the greatest morbidity, limiting their potential in academic and physical endeavors. Our study assessed the prevalence of STH infections in primary school-aged children in a rural village in the Nyanza Province of Kenya. Over two-thirds (68%) of the sampled population tested positive using a direct smear microscopic analysis of single stool samples. Only heavy worm infections would be detected with this technique; thus 68% is a minimum estimate of prevalence. Prior to our study, there were no deworming programs in this village, despite WHO and Kenyan government guidelines supporting regular deworming programs. Our study demonstrates the significant burden of STH infections in a rural Kenyan village and highlights the need for deworming programs in similar venues. We also demonstrate that with basic infrastructure and community involvement, regular deworming can be implemented effectively in remote, rural communities.

Long‐term mortality associated with acute kidney injury in children following congenital cardiac surgery

Children undergoing congenital cardiac surgery (CCS) are at increased risk for acute kidney injury (AKI) due to a number of factors. Recent evidence suggests AKI may influence mortality beyond the immediate postoperative period and hospitalization. We sought to determine the association between renal failure and longer‐term mortality in children following CCS.

Vitamin D Deficiency among Newborns in Amman, Jordan

Objective: Vitamin D deficiency is well recognized in selected Middle Eastern countries, but neonatal vitamin D status is not well studied in Jordan and other nearby countries. The aim of this study is to determine the prevalence of vitamin D deficiency in Jordanian newborns and risk factors associated with low levels. Methods: This is a prospective cohort study of newborn infants who were delivered at the Al Bashir Government Hospital in Amman, Jordan, from January 31, 2010, to January 27, 2011. Heel stick blood samples for 25-hydroxyvitamin D [25(OH)D] levels were obtained within 96 hours of birth. Maternal dress pattern, vitamin supplementation, smoke exposure during pregnancy, mode of delivery, gestational age, and birth weight were documented. Results: Samples were obtained from 3,731 newborns. Median gestational age was 39 weeks, median birth weight was 3.1 kilograms, median maternal age was 27 years, and median newborn 25(OH)D level was 8.6nmol/L. A total of 3,512 newborns (94.1%) in this study were vitamin D deficient (< 50 nmol/L). Lower gestational age, maternal smoke exposure, and birth during winter months were associated with lower infant vitamin D levels, while vitamin D supplementation and time spent outside during pregnancy were associated with higher vitamin D levels. Conclusions: The prevalence of severely low vitamin D levels in newborn infants in Amman, Jordan, is substantial, even in newborns born during the spring and summer months. Vitamin D supplementation is needed in this population.