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Background Ectopic deciduosis is a benign presence of endometrial tissue outside of the uterus during pregnancy that rarely presents with pleuropulmonary manifestations and recurrent pneumothorax. Case Description We report a 35-year-old woman at 15 weeks' gestation with a history of recurrent intrapartum right pneumothorax found to have pleural, pulmonary, and diaphragmatic lesions and a middle lobe air leak. Wedge resection of the middle lobe and mechanical pleurodesis was performed. Histopathological analysis was progesterone receptor and PAX8 positive consistent with ectopic deciduosis. Conclusion Ectopic deciduosis is a rare cause of recurrent pneumothorax in pregnancy and should be considered when evaluating these patients.
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OBJECTIVE: To determine whether outcomes achieved by new surgeons are attributable to inexperience or to differences in the context in which care is delivered and patient complexity. BACKGROUND: Although prior studies suggest that new surgeon outcomes are worse than those of experienced surgeons, factors that underlie these phenomena are poorly understood. METHODS: A nationwide observational tapered matching study of outcomes of Medicare patients treated by new and experienced surgeons in 1221 US hospitals (2009-2013). The primary outcome studied is 30-day mortality. Secondary outcomes were examined. RESULTS: In total, 694,165 patients treated by 8503 experienced surgeons were matched to 68,036 patients treated by 2119 new surgeons working in the same hospitals. New surgeons' patients were older (25.8% aged ≥85 vs 16.3%,P<0.0001) with more emergency admissions (53.9% vs 25.8%,P<0.0001) than experienced surgeons' patients. Patients of new surgeons had a significantly higher baseline 30-day mortality rate compared with patients of experienced surgeons (6.2% vs 4.5%,P<0.0001;OR 1.42 (1.33, 1.52)). The difference remained significant after matching the types of operations performed (6.2% vs 5.1%, P<0.0001; OR 1.24 (1.16, 1.32)) and after further matching on a combination of operation type and emergency admission status (6.2% vs 5.6%, P=0.0007; OR 1.12 (1.05, 1.19)). After matching on operation type, emergency admission status, and patient complexity, the difference between new and experienced surgeons' patients' 30-day mortality became indistinguishable (6.2% vs 5.9%,P=0.2391;OR 1.06 (0.97, 1.16)). CONCLUSIONS: Among Medicare beneficiaries, the majority of the differences in outcomes between new and experienced surgeons are related to the context in which care is delivered and patient complexity rather than new surgeon inexperience.
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Competência Clínica , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Medicare , Avaliação de Resultados em Cuidados de Saúde , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade , Estados UnidosRESUMO
Anxiety disorders affect up to 50% of individuals with autism spectrum disorder (ASD) and are significantly impairing to the person affected, as well as to their loved ones. Cognitive-behavioral therapy (CBT) has been established as the gold-standard treatment for anxiety disorders among typically developing youth and adults, and demonstrates similar efficacy among youth with high-functioning autism (HFA). Many CBT interventions utilize a "full-package" treatment approach to treat co-occurring anxiety in youth with ASD. However, these service delivery systems are often therapist-intensive, costly, and impractical, thereby compromising full engagement and treatment adherence. This paper describes the design, rationale, and methodology of a study examining stepped-care CBT for youth with HFA and co-occurring anxiety - a clinical trial examining the efficacy of low-intensity, parent-led CBT as the first line of treatment and utilizing a more intensive, therapist-led intervention for nonresponders. The study will evaluate the potential benefits of stepped-care and parent-led therapist-assisted interventions, predictors of treatment response, and the economic value of using a stepped-care model. Implications for practice will be discussed.
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Humanos , Adolescente , Adulto , Transtorno Autístico , Transtorno do Espectro Autista , Ansiedade/terapia , Transtornos de Ansiedade/terapia , Pais , Resultado do Tratamento , CogniçãoRESUMO
Anxiety disorders affect up to 50% of individuals with autism spectrum disorder (ASD) and are significantly impairing to the person affected, as well as to their loved ones. Cognitive-behavioral therapy (CBT) has been established as the gold-standard treatment for anxiety disorders among typically developing youth and adults, and demonstrates similar efficacy among youth with high-functioning autism (HFA). Many CBT interventions utilize a "full-package" treatment approach to treat co-occurring anxiety in youth with ASD. However, these service delivery systems are often therapist-intensive, costly, and impractical, thereby compromising full engagement and treatment adherence. This paper describes the design, rationale, and methodology of a study examining stepped-care CBT for youth with HFA and co-occurring anxiety - a clinical trial examining the efficacy of low-intensity, parent-led CBT as the first line of treatment and utilizing a more intensive, therapist-led intervention for nonresponders. The study will evaluate the potential benefits of stepped-care and parent-led therapist-assisted interventions, predictors of treatment response, and the economic value of using a stepped-care model. Implications for practice will be discussed.
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Transtorno do Espectro Autista , Transtorno Autístico , Adolescente , Adulto , Ansiedade/terapia , Transtornos de Ansiedade/terapia , Cognição , Humanos , Pais , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice. SUMMARY BACKGROUND DATA: In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied. METHODS: We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors. RESULTS: Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9âmin; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049]. CONCLUSIONS: Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.
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Competência Clínica , Admissão e Escalonamento de Pessoal/tendências , Procedimentos Cirúrgicos Operatórios/educação , Procedimentos Cirúrgicos Operatórios/mortalidade , Tolerância ao Trabalho Programado , Algoritmos , Educação de Pós-Graduação em Medicina , Feminino , Mortalidade Hospitalar/tendências , Humanos , Internato e Residência , Masculino , Medicare , Estados UnidosRESUMO
Laccases are multicopper oxidases that are being studied for their potential application in pretreatment strategies of lignocellulosic feedstocks for bioethanol production. Here, we report the expression and characterization of a predicted laccase (LAC_2.9) from the thermophilic bacterial strain Thermus sp. 2.9 and investigate its capacity to delignify lignocellulosic biomass. The purified enzyme displayed a blue color typical of laccases, showed strict copper dependence and retained 80% of its activity after 16 h at 70 °C. At 60 °C, the enzyme oxidized 2,2'-azino-di-(3-ethylbenzthiazoline sulfonate) (ABTS) and 2,6-dimethoxyphenol (DMP) at optimal pH of 5 and 6, respectively. LAC_2.9 had higher substrate specificity (kcat/KM) for DMP with a calculated value that accounts for one of the highest reported for laccases. Further, the enzyme oxidized a phenolic lignin model dimer. The incubation of steam-exploded eucalyptus biomass with LAC_2.9 and 1-hydroxybenzotriazole (HBT) as mediator changed the structural properties of the lignocellulose as evidenced by Fourier transform infrared (FTIR) spectroscopy and thermo-gravimetric analysis (TGA). However, this did not increase the yield of sugars released by enzymatic saccharification. In conclusion, LAC_2.9 is a thermostable laccase with potential application in the delignification of lignocellulosic biomass.
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OBJECTIVE: We sought to compare postoperative outcomes of female surgeons (FS) and male surgeons (MS) within general surgery. SUMMARY OF BACKGROUND DATA: FS in the workforce are increasing in number. Female physicians provide exceptional care in other specialties. Differences in surgical outcomes of FS and MS have not been examined. METHODS: We linked the AMA Physician Masterfile to discharge claims from New York, Florida, and Pennsylvania (2012 to 2013) to examine practice patterns and to compare surgical outcomes of FS and MS. We paired FS and MS operating at the same hospital using cardinality matching with refined balance and compared inpatient mortality, any postoperative complication, and prolonged length of stay (pLOS) in FS and MS. RESULTS: Overall practice patterns differed between the 663 FS and 3219 MS. We identified 2462 surgeons (19% FS, 81% MS) at 429 hospitals who met inclusion criteria for outcomes analysis. FS were younger (mean ageâ±âSD FS: 48.5â±â8.4 years, MS: 54.3â±â9.4y; P < 0.001) with less clinical experience (mean yearsâ±âSD FS: 11.6â±â8.3 y, MS: 17.6â±â10.0 years; P < 0.001) than MS before matching. FS had lower rates of inpatient mortality (FS: 1.51%, MS: 2.30%; P < 0.001), any postoperative complication (FS: 12.6%, MS: 16.1%; P < 0.001), and pLOS (FS: 18.4%, MS: 20.7%; P < 0.001) before matching. After matching, FS and MS outcomes were equivalent. CONCLUSION: Surgeon practice patterns vary by sex and experience. FS and MS with similar characteristics who treat similar patients at the same hospital have equivalent rates of inpatient morality, postoperative complications, and prolonged length of hospital stay. Patients should select the surgeon who is the best fit for them regardless of sex.
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Competência Clínica , Avaliação de Resultados em Cuidados de Saúde , Padrões de Prática Médica , Cirurgiões/normas , Procedimentos Cirúrgicos Operatórios/normas , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Médicas , Estudos Retrospectivos , Fatores Sexuais , Resultado do TratamentoRESUMO
In this paper, we discuss how life history drawings can serve as a valuable method for global health research. The introduction discusses qualitative approaches to concepts such as reliability, validity and triangulation, and situates the use of participatory visual methods within the broader field of participatory research. The paper reports on an experience using life history drawings as part of extended ethnographic research in rural Mexico and among Mexican migrants living in Atlanta. The primary method for that parent project was comparative ethnographic research, which included life histories collected from 13 pairs of women over 15 months of participant observation. Early in the research, the drawings contributed to a major reorientation in the direction of the research project. The insights generated through analysis of the life history drawings exemplify how this participatory research technique can direct attention to social processes that feel salient to community members. In this case, they called attention to the enormity of social change in this community over one generation, reorienting the study from one focused on change causes by migration to one that focused on two trajectories of change: generational and migration-related.
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Pesquisa Participativa Baseada na Comunidade/métodos , Americanos Mexicanos/psicologia , Sexualidade/etnologia , Mobilidade Social , Migrantes/psicologia , Saúde da Mulher/etnologia , Direitos da Mulher , Fatores Etários , Antropologia Cultural/métodos , Arte , Comparação Transcultural , Feminino , Georgia , Humanos , México , Narrativas Pessoais como Assunto , Pesquisa Qualitativa , População Rural , Sexualidade/psicologiaRESUMO
PURPOSE: The Down syndrome cell adhesion molecule (Dscam) gene is required for normal dendrite arborization and lamination in the mouse retina. In this study, we characterized the developmental localization of the DSCAM protein to better understand the postnatal stages of retinal development during which laminar disorganization occur in the absence of the protein. METHODS: Immunohistochemistry and colocalization analysis software were used to assay the localization of the DSCAM protein during development of the retina. RESULTS: We found that DSCAM was initially localized diffusely throughout mouse retinal neurites but then adopted a punctate distribution. DSCAM colocalized with catenins in the adult retina but was not detected at the active zone of chemical synapses, electrical synapses, and tight junctions. Further analysis identified a wave of colocalization between DSCAM and numerous synaptic and junction proteins coinciding with synaptogenesis between bipolar and retinal ganglion cells. CONCLUSIONS: Research presented in this study expands our understanding of DSCAM function by characterizing its location during the development of the retina and identifies temporally regulated localization patterns as an important consideration in understanding the function of adhesion molecules in neural development.