Accountability as a virtue in medicine: from theory to practice.

Accountability is a norm basic to several aspects of medical practice. We explore here the benefits of a more explicit focus on the virtue of accountability, which as distinct from the state of being held accountable, entails both welcoming responsibility to others and welcoming input from others. Practicing accountably can limit moral distress caused by institutional pressures on the doctor patient relationship.

Fourfold Improved Odds of a Good First Trimester Outcome Once a Yolk Sac Is Seen in Early Pregnancy.

Objectives: To compare first trimester prognosis when an early pregnancy sonogram demonstrates a gestational sac with yolk sac versus gestational sac without yolk sac.

Methods: Our study comprised 823 transvaginal sonograms without identifiable embryo performed at least 35 days from last menstrual period (LMP), in which mean sac diameter was <16 mm and first trimester outcome (live or early pregnancy loss) was known. We recorded the presence or absence of yolk sac, first trimester outcome, and several clinical features: maternal age, time since LMP, and presence or absence of vaginal bleeding.

Consensus-based classification system for intra-operative management of labral tears during hip arthroscopy-aggregate recommendations from high-volume hip preservation surgeons.

The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey.

Plasmids shape the diverse accessory resistomes of ST131.

The human gut microbiome includes beneficial, commensal and pathogenic bacteria that possess antimicrobial resistance (AMR) genes and exchange these predominantly through conjugative plasmids. is a significant component of the gastrointestinal microbiome and is typically non-pathogenic in this niche. In contrast, extra-intestinal pathogenic (ExPEC) including ST131 may occupy other environments like the urinary tract or bloodstream where they express genes enabling AMR and host cell adhesion like type 1 fimbriae.

Variation Between and Within Hospitals in Single Injection Caudal Local Anesthetic Dose: A Report From the Pediatric Regional Anesthesia Network.

Background: Given that variation exists in health care utilization, expenditure, and medical practice, there is a paucity of data on variation within the practice of anesthesia. The Pediatric Regional Anesthesia Network (PRAN) data lend itself to explore whether different medical practice patterns exist and if there are nerve blocks with more local anesthetic dosing variation than others. The primary aim of this study was to quantify variation in single injection caudal block dosing, and the secondary aim was to explore possible causes for variation (eg, number of blocks performed versus geographic location).

Leveraging Nonhuman Primate Multisensory Neurons and Circuits in Assessing Consciousness Theory.

Both the global neuronal workspace (GNW) and integrated information theory (IIT) posit that highly complex and interconnected networks engender perceptual awareness. GNW specifies that activity recruiting frontoparietal networks will elicit a subjective experience, whereas IIT is more concerned with the functional architecture of networks than with activity within it. Here, we argue that according to IIT mathematics, circuits converging on integrative versus convergent yet non-integrative neurons should support a greater degree of consciousness.

Rac-GTPase promotes fibrotic TGF-β1 signaling and chronic kidney disease EGFR, p53, and Hippo/YAP/TAZ pathways.

Rac-GTPases are major regulators of cytoskeletal remodeling and their deregulation contributes to numerous pathologies. Whether or how Rac promotes tubulointerstitial fibrosis and chronic kidney disease (CKD) is currently unknown. We showed that the major profibrotic cytokine, TGF-β1 promoted rapid Rac1-GTP loading in human kidney 2 (HK-2) human renal epithelial cells.

Cognitive decline after elective and nonelective hospitalizations in older adults.

Objective: To determine whether emergent and urgent (nonelective) hospitalizations are associated with faster acceleration of cognitive decline compared to elective hospitalizations, accounting for prehospital decline.

Methods: Data came from the Rush Memory and Aging Project, a prospective cohort study of community-dwelling older persons without baseline dementia. Annual measures of cognition via a battery of 19 tests were linked to 1999 to 2010 Medicare claims records.

Point-of-Care Ultrasonography (POCUS) in a Community Emergency Department: An Analysis of Decision Making and Cost Savings Associated With POCUS.

Objectives: Point-of-care ultrasonography (POCUS) is an increasingly integral part of emergency medicine. This study investigated community emergency department physicians' choices regarding ultrasonography as a branch point in clinical decision making.

Methods: During shifts covering all days of the week and all time-spans over a 3-month period, emergency department physicians were interviewed whenever POCUS was used.

Smokers' use of electronic cigarettes before, during, and in the month after hospitalization. Findings from the Helping HAND 2 Study.

Introduction: Hospitalization can motivate smokers to attempt cessation, and some smokers might use e-cigarettes to aid quitting after discharge. Little is known about the patterns and predictors of smokers' e-cigarette use immediately before, during, and after hospitalization.

Methods: Secondary data analysis of a multi-site randomized controlled trial that enrolled 1357 hospitalized smokers planning to quit offered two intensities of post-discharge cessation treatment and reached 1100 participants at 1-month follow-up.

Deregulation of Hippo-TAZ pathway during renal injury confers a fibrotic maladaptive phenotype.

Although yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ), nuclear transducers of the Hippo pathway, are mostly silent in adult organs, aberrant activation of YAP/TAZ promotes tumorigenesis and abnormal tissue repair. The extent of involvement of TAZ in chronic kidney disease (CKD) is unknown. In our study, increased TAZ nuclear accumulation and expression in the tubulointerstitium was readily evident in 3 models of renal injury including obstructive, aristolochic acid (AA), and diabetic nephropathy, correlating with fibrosis progression.

Massachusetts Substance Use Disorder Treatment Organizations' Perspectives on the Affordable Care Act: Changes in Payment, Services, and System Design.

The Affordable Care Act (ACA) expanded insurance benefits and coverage for substance use disorder (SUD) treatment and encouraged delivery and payment reforms. Massachusetts passed a similar reform in 2006. This study aims to assess Massachusetts SUD treatment organizations' responses to the ACA.

Identification of 12 new susceptibility loci for different histotypes of epithelial ovarian cancer.

To identify common alleles associated with different histotypes of epithelial ovarian cancer (EOC), we pooled data from multiple genome-wide genotyping projects totaling 25,509 EOC cases and 40,941 controls. We identified nine new susceptibility loci for different EOC histotypes: six for serous EOC histotypes (3q28, 4q32.3, 8q21.

Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Pharmacogenetics-Guided Warfarin Dosing: 2017 Update.

This document is an update to the 2011 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2C9 and VKORC1 genotypes and warfarin dosing. Evidence from the published literature is presented for CYP2C9, VKORC1, CYP4F2, and rs12777823 genotype-guided warfarin dosing to achieve a target international normalized ratio of 2-3 when clinical genotype results are available. In addition, this updated guideline incorporates recommendations for adult and pediatric patients that are specific to continental ancestry.

Loss of expression of protein phosphatase magnesium-dependent 1A during kidney injury promotes fibrotic maladaptive repair.

Protein phosphatase magnesium-dependent-1A (PPM1A) dephosphorylates SMAD2/3, which suppresses TGF-β signaling in keratinocytes and during Xenopus development; however, potential involvement of PPM1A in chronic kidney disease is unknown. PPM1A expression was dramatically decreased in the tubulointerstitium in obstructive and aristolochic acid nephropathy, which correlates with progression of fibrotic disease. Stable silencing of PPM1A in human kidney-2 human renal epithelial cells increased SMAD3 phosphorylation, stimulated expression of fibrotic genes, induced dedifferentiation, and orchestrated epithelial cell-cycle arrest via SMAD3-mediated connective tissue growth factor and plasminogen activator inhibitor-1 up-regulation.

Increased Preoperative Narcotic Use and Its Association With Postoperative Complications and Length of Hospital Stay in Patients Undergoing Spine Surgery.

Study Design: Prospective cohort analysis.

Objective: To assess the effect of preoperative narcotic use on the incidence of 30- and 90-day postoperative complications, as well as length of hospital stay (LOS) in patients undergoing spine surgery.

Summary Of Background Data: Previous work has associated an increased incidence of complications and length of stay following surgery in patients with increased preoperative narcotic use.

Pharmacokinetic and pharmacodynamic study of tariquidar (XR9576), a P-glycoprotein inhibitor, in combination with doxorubicin, vinorelbine, or docetaxel in children and adolescents with refractory solid tumors.

Purpose: P-glycoprotein (Pgp), an ATP-dependent transport protein, confers multidrug resistance in cancer cells. Tariquidar binds and inhibits Pgp. To assess the toxicity, pharmacokinetics (PK), and pharmacodynamics of tariquidar, we conducted a phase I trial of tariquidar in combination with doxorubicin, docetaxel, or vinorelbine in children and adolescents with recurrent or refractory solid tumors.

Peroxisome proliferator-activated receptor δ promotes colonic inflammation and tumor growth.

Although epidemiologic and experimental evidence strongly implicates chronic inflammation and dietary fats as risk factors for cancer, the mechanisms underlying their contribution to carcinogenesis are poorly understood. Here we present genetic evidence demonstrating that deletion of peroxisome proliferator-activated receptor δ (PPARδ) attenuates colonic inflammation and colitis-associated adenoma formation/growth. Importantly, PPARδ is required for dextran sodium sulfate induction of proinflammatory mediators, including chemokines, cytokines, COX-2, and prostaglandin E2 (PGE2), in vivo.

Nephrology quiz and questionnaire: renal replacement therapy.

Presentation of the Nephrology Quiz and Questionnaire has become an annual "tradition" at the meetings of the American Society of Nephrology. It is a very popular session judged by consistently large attendance. Members of the audience test their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts.

Pediatric medical home: foundations, challenges, and future directions.

The medical home concept has been in existence since the late 1960s and has recently been significantly broadened to encompass comprehensive primary care for all patient populations throughout the lifespan. This article provides (1) a review of the foundations and evolution of the medical home concept; (2) an analysis of patient/family, provider, and systemic challenges to developing an effective pediatric medical home particularly in relation to children's mental health needs; and (3) a discussion of future directions for its further adoption and successful implementation.

Physical symptoms and psychosocial correlates of somatization in pediatric primary care.

A group of children, aged 8 to 13 years, presenting to their pediatricians with multiple medically unexplained physical symptoms (MUPS) were compared with a control group of children from the identical age range who were, according to their pediatricians, free of unexplained physical symptoms. The groups were compared on both self-reported and parented-rated scales assessing physical symptoms and psychosocial functioning. The multiple MUPS group, relative to controls, exhibited significantly higher levels of parent-reported emotional/behavioral symptoms and a trend toward higher patient-reported anxiety than controls.