Workforce studies show shortages of physicians in many areas of the United States. These shortages are especially severe in states such as Kentucky with many rural counties and are predicted to worsen in the future unless there are changes throughout our educational system to build aspirations and prepare students for medical school education. To examine rural-urban differences and community characteristics of applicants and matriculants to Kentucky's two allopathic medical schools and influences on the educational aspirations of young students who wish to become physicians. The number of Kentucky applicants and matriculants to allopathic medical schools was obtained from the Association of American Medical College's data warehouse for the period from 2002-2006. A continuous, multidimensional measure was used to classify counties by degree of rurality. Socio-demographic variables were selected for the counties of residence for applicants and matriculants. Model variables were tested in a least squares multiple regression model for their ability to explain patterns among Kentucky's 120 counties in the number of both resident applicants and matriculants to medical school. Data from a survey of middle school participants in summer health camps were analyzed to help identify important influences on young students aspiring to a career as a health professional, especially becoming a physician, and how these might be supported to increase the supply of rural medical school applicants. The low number of rural applicants to medical school was highly correlated with the relative rurality of their county of residence, a low physician-to-population ratio and a low number of total primary care physicians. The percentage of county residents having a bachelor's degree level of education or higher had a positive impact on the application rate. Respondents became interested in health careers at age 15 or younger, and parents and grandparents, teachers, and close associates stimulated their aspirations, with teachers being the most influential. Prospective students respond to their perception of need for physicians. Rural students are influenced by those who are more highly educated. To overcome the shortage of physicians in rural communities efforts must be made to increase the aspirations for medical education of prospective students from rural counties.
An increasing number of parents are questioning the safety and necessity of routine childhood immunizations. Locally produced vaccine risk communication materials may be effective in reassuring these parents. However, little is known about specific vaccine safety concerns in the state of Kentucky. An Internet-based survey focusing on parental vaccine safety concerns and potential vaccine risk communication strategies was sent to all members of the Kentucky Chapter of the Amerian Academy of Pediatrics. There were 121 respondents who routinely administered childhood vaccines. Of these, 85% reported parental concern about the combined measles-mumps-rubella (MMR) vaccine. Concerns about the influenza and human papillomavirus (HPV) vaccines were also frequent. Of the respondents, 46% noted parental skepticism about all vaccines in general. However, refusal of all vaccines was uncommon in most practices (median 1%, interquartile range 1%-3%). The belief that vaccines cause autism was the most prevalent parental concern, reported by 70% of pediatricians. Physicians also reported that a list of reliable vaccine information Websites and pamphlets addressing common vaccine safety concerns would be the most helpful materials to use during their discussions with concerned parents. These findings suggest that specific information about the MMR, influenza, and HPV vaccines, as well as data refuting the putative link between vaccines and autism would be useful to physicians who administer vaccinations. Respondents were especially interested in reliable vaccine information on the Internet. The Websites listed below offer accurate scientific information about vaccines and the diseases they prevent.
Determine if a new teaching bundle targeting developmental dysplasia of the hip screening improved interns' examination skills across multiple pediatric residency programs. This multicenter prospective cohort study included interns across 6 pediatric residency sites within the Academic Pediatric Association's Better Outcomes through Research for Newborns Network in 2022. Participants underwent a baseline hip examination assessment on models using a checklist derived from textbook descriptions of Galeazzi, Ortolani, and Barlow maneuvers before receiving a teaching bundle. Repeat testing occurred after instruction. Data were analyzed using t-test for continuous and χ2 test for categorical variables. Semistructured focus groups provided qualitative feedback regarding the teaching bundle. We enrolled 117 of 155 interns across 6 sites (76%) for participation in the teaching bundle. Only 2% of participants (n = 2) identified a positive Galeazzi sign at baseline, whereas 88% (n = 103, P < .001) did so on the postinstructional assessment. Although 27% of participants (n = 32) correctly identified a positive Barlow sign at baseline, 69% (n = 81, P < .001) did so on the postinstructional assessment. The ability to correctly detect a positive Ortolani sign increased from 22% (n = 26) to 92% (n = 108, P < .001). Fifteen interns participated in the semistructured focus groups, with resultant themes reinforcing the limited experience of the infant hip examination before this intervention and the positive impact of the teaching bundle. Most participants in this study did not have strong infant hip examination skills at entry into residency. A standardized teaching bundle significantly improved skills in examination technique and identifying abnormalities.
Colonization in the nares with Methicillin Resistant Staphylococcus aureus (MRSA) has been described as a risk factor for eventual MRSA infection. The objective of this report is to describe the outbreak investigation, to identify the risk factors involved, and to evaluate and recommend control measures. This study was a retrospective observational outbreak study carried out in the Intensive Care and Cardiac Unit. Percentages of patients with positive conversions were graphically plotted out and were used to determine expected percentage of conversions versus observed. The case definition was determined to be a patient with a positive culture for MRSA from a nasal swab upon discharge or transfer from the ICCU whose initial swab on admission was negative. The expected number of conversions was 2% per month and the newly observed number of conversions was 6%, which was >3 standard deviations from the mean. Repetitive sequence-based PCR (rep-PCR) was performed for the microbial DNA typing, which discovered genetically identical strains. The main finding in this outbreak investigation was that the common room which housed four of these patients was contaminated with MRSA. A limitation was that some patients who would have been included in the study did not get screened at discharge and their conversion status could not be ascertained and environment cultures were not performed. Active surveillance allowed for the detection of an outbreak of MRSA colonization which led to early intervention that prevented more patients from becoming colonized. Prevention of colonization should be one of the primary goal in the prevention of MRSA.
The rise in cardiovascular disease (CVD) in Sub-Saharan Africa (SSA) reflects a major shift from communicable to noncommunicable diseases as primary health challenges. Consequently, this study aims to explore the burden of CVD and associated risk factors in SSA using data from the Global Burden of Disease (GBD) database. This study utilized data from the GBD 1990 to 2019 to examine CVD prevalence in 46 SSA countries. We employed Bayesian regression models, demographic techniques, and mortality-to-incidence ratios to analyze both prevalence and mortality rates. Additionally, disability-adjusted life years (DALYs) were computed, and various risk factors were examined using the GBD's comparative risk assessment framework. Between 1990 and 2019, CVD raw counts in SSA rose by 131.7 %, with a 2.1 % increase in age-standardized prevalence rates. The most prevalent conditions were ischemic heart disease, stroke, and rheumatic heart disease. During the same period, the age-standardized CVD deaths per 100,000 individuals decreased from 314 (1990) to 269 (2019), reflecting a -14.4 % decline. Age-standardized CVD DALY rates also showed a decrease from 6,755 in 1990 to 5,476 in 2019, with translates to 18.9 % reduction. By 2019, the Central African Republic, Madagascar, and Lesotho were the countries with the highest age-standardized DALY rates for all CVDs. The study highlights a contrasting trend in SSA's CVD landscape: a decrease in age-standardized mortality and DALYs contrasts with increasing CVD prevalence, emphasizing the need for targeted public health strategies that balance treatment advancements with intensified prevention and control measures.
Excessive adiposity is the result of an imbalance in energy homeostasis whereby excessive food intake is not balanced by increased energy utilization. Much has been learned about the physiology of energy expenditure during resting, eating, and physical activity that allows optimal energy utilization that could reduce excessive adiposity. Resting metabolic rate and diet-induced thermogenesis collectively contribute 75% of energy expenditure that is largely based on carbohydrate rather than fat metabolism. Conversely, physical activity, whether active (planned) or spontaneous (non-exercise activity thermogenesis), predominately utilizes fatty acids as sources of energy expenditure. Such enhanced fat-derived thermogenesis most optimally results in weight loss to achieve maintenance of balanced energy homeostasis. While decreased energy expenditure of 100-200 Kcal/day from sedentary activities can cause weight gain, unplanned spontaneous physical activity expenditure of 100-800 Kcal/day from routine activities such as walking and fidgeting is sufficient to prevent weight gain. Furthermore, planned physical activity can be enhanced up to 16-fold, such that additional fat thermogenesis can be optimized. Such physical activity also achieves adaptive conditioning for more efficient energy utilization and weight loss. It is, therefore, necessary that children as well as adults embrace all forms of non-exercise and planned active exercise activities to achieve optimal fat thermogenesis for optimal energy homeostasis including weight loss for either the overweight or obese. Such lifestyles need to be promoted through educational, environmental, and legislative changes that optimize healthy nutrition and physical activity.
We hypothesized that parental perception of their child's weight varies as a function of ethnicity/race, age, and gender. We enrolled parents from three ethnic/race groups of children, 2-18 years of age, attending an inner-city clinic with BMI between 25th and 75th or exceeding 95th percentiles. Parents rated their own and their child's weight and their level of concern about it. A total of 104 Hispanic, 104 African-American, and 102 Caucasian parent/child dyads participated. No ethnic diference in parental perception of child's weight was noted. Analysis restricted to obese children showed parents were less likely to recognize obesity in their younger than in their older girls (P<0.001). This difference was not observed among obese boys. In 80% of parent/child dyads, the parent and child were concordant on the assessment of the child's weight, regardless of race. Both obese and non-obese parents recognized obesity in their child 75% of the time. Parents of obese Hispanic children (81%) were more concerned about their child's weight than were Caucasian (60%) or African-American (65%) (P< or =0.06). Parents of three ethnic/racial groups recognized clinical obesity but were less likely to recognize it in their younger children. Most obese children recognized their obesity, a finding that may facilitate physicians' weight loss interventions.
The American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions strongly recommend that primary Percutaneous Coronary Intervention (PCI) should be performed in facilities that have an experienced cardiovascular surgical team available as emergency backup for all procedures. The current study investigates the medical soundness of allowing select facilities in Kentucky to perform primary PCI despite being devoid of onsite emergency backup capabilities. Two hospitals in the state of Kentucky, currently without emergency backup capabilities, have been allowed to perform primary PCIs for more than three years (beginning in April 2005) by the Kentucky Cabinet for Health and Family Services. The two hospitals selected were of similar size (approximately 200 beds) and similar distances from hospitals with onsite emergency backup capabilities (approximately one hour). We performed an analysis evaluating if hospitals without backup surgical capability have similar outcomes when compared to hospitals with backup surgical capabilities. Outcome variables included: (1) mortality, (2) cardiac arrest as result of PCI, (3) emergency surgery performed as a result of PCI, and (4) door-to-balloon time. Our results suggest that there is no significant difference in any of the outcome variables studied between facilities with and without onsite emergency backup capabilities. Recommendations concerning primary PCI may need to be revisited. The principal outcomes associated with primary PCI were not significantly affected by whether a facility has onsite emergency backup capabilities. Therefore, we recommend that hospitals without backup surgical capabilities be allowed to perform primary PCI (with restrictions based on surgeon experience and the facilities' volume).
The management of the patient with breast cancer has evolved to become a multidisciplinary practice. The role of the surgeon remains important in the diagnosis, staging, and treatment of disease, as well as in educating the patient as to her best options. Herein we review current surgical techniques in the diagnosis, resection, and staging of breast cancer including biopsy techniques, surgical approaches to resection of breast cancer, and breast reconstruction, and issues surrounding axillary staging by sentinel lymph node biopsy.
Thoracic aortic aneurysms (TAA) have remained a formidable operative challenge. Open surgical techniques have been associated with high rates of morbidity and mortality. Thoracic endovascular aneurysm repair (TEVAR) has produced results equal to or better than the traditional open surgical approach. This report presents a patient with a complex thoracic aortic aneurysm involving the ascending, transverse, and proximal descending thoracic aorta. This patient was successfully managed by the creation of Landing Zone-Zero, arch vessel debranching, and endografting the entire aortic arch without the need for hypothermic circulatory arrest or cerebral perfusion strategies. Computer tomographic images demonstrate the repair to be durable at 18 months.
Kentucky has a high incidence of cardiovascular (CV) disease, usually ranking it in the top 5 states of the United States as part of this dubious distinction. The most likely explanation lies in poor health habits with an elevated occurrence of cigarette smoking, diabetes, poor diet, obesity, physical inactivity, and a consistent presence of at least 3 of the 5 major components which define the term Metabolic Syndrome. Since 1980, there has been an explosion in the availability of CV technology and CV care throughout Kentucky, yet the state has maintained its undesirable high ranking for CV disease in the United States. Treating CV disease is clearly not enough; lifestyle habits need to be changed before CV disease develops.
Cornelia de Lange Syndrome is a rare congenital malformation syndrome with typical craniofacial abnormalities and can affect the musculoskeletal, cardiovascular, gastrointestinal, genitourinary, and central nervous systems. Not all the patients look alike as the phenotypic appearance is seen on a spectrum. A classic case of CdLS has been reviewed in this article and we have discussed diagnosis, management, and anticipatory guidance. Maintaining consistent health supervision visits and outpatient therapy is vital for these children. Referring the parents to a genetic counselor is recommended if the family desires to have more children. The CdLS foundation Webpage is www.cdlsusa.org.
The impact of risk-taking behavior among adolescent blunt trauma patients is not fully appreciated. This study examined the relationship between adolescent risk-taking behaviors, the resultant injury severity, and outcome for blunt trauma. Between January 2000 and December 2005, data were collected on adolescent blunt trauma patients (12-18 years) admitted to either a Level I adult trauma center or large urban pediatric hospital. Five groups of risk-taking behavior were examined: ATV riders, drug and alcohol users, unhelmeted motorcyclists, unhelmeted extreme sports participants and unrestrained motor vehicle occupants. Demographic data, mechanism of injury, injury severity, hospital course and outcomes were evaluated for each group. A total of 2030 adolescents were admitted following blunt trauma; 723 adolescents (36%) were engaged in risk-taking behavior at the time of their injury. Most patients were male (68%). Unrestrained MVA occupants were the most frequently encountered risk takers (37%); among this subset, most were unrestrained passengers (74%). Head injuries were frequent (22%) among risk takers. When compared to non-risk-takers, there were no significant age, race, gender, or ISS differences. However, a significantly higher number of positive head CT scans were found among risk-taking adolescents (22%, p < 0.05). Mortality was low (3%). Risk-taking behavior is prevalent among adolescent blunt trauma patients. Improved injury prevention strategies are needed to discourage these behaviors during adolescence.
Type B aortic dissections have remained a difficult management problem. Open surgical techniques have had a very high perioperative mortality, and medical management has not produced satisfactory long-term results. Endovascular grafting techniques may provide a favorable alternative therapy. However, there are currently no endovascular stents approved by the United States Food and Drug Administration for treating Type B aortic dissections. Also, there is very little data from United States centers on the long-term efficacy of endovascular stents used "off-label" to treat aortic dissections. This report discusses the care of a patient with a Type B aortic dissection successfully treated by an endograft in a community hospital. In addition, serial follow-up computerized tomography demonstrates the durability of this repair at three years.
Knowledge of the metastastic status of the regional nodes provides important prognostic information for patients with cutaneous melanoma. Sentinel lymph node (SLN) biopsy has become the standard method for staging the regional nodes of patients with melanoma. The decision algorithm for using SLN biopsy is based upon the primary tumor depth, and utilization of SLN biopsy can spare patients the potential morbidity associated with complete lymph node dissection. Current studies are investigating the possibility of further limiting the need for complete lymph node dissections in patients with positive sentinel nodes.
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