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Clinical Rounds

doi: 10.1097/
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Pulse oximetry screening saves lives



The CDC reports that infant deaths from critical congenital heart disease (CCHD) dropped by over 30% in states requiring pulse oximetry screening for all newborns. Low blood oxygen levels can be a sign of CCHD.

In a recently published study, researchers examined birth/infant death data for 2007 through 2013 for 26,546,503 births in the United States. As of June 2013, eight states had implemented mandatory screening policies, five had voluntary screening policies, and nine had adopted but not yet implemented mandates.

In states with mandatory screening policies, early infant deaths from CCHD decreased by 33.4%. No significant decrease was associated with nonmandatory screening policies.

According to the CDC, 25% of infants born with a congenital heart defect have CCHD and will need surgery or other procedures in the first year of life. Currently, 47 states and the District of Columbia mandate bedside pulse oximetry screening, and California requires that it be offered.

Sources: Abouk R, Grosse SD, Ailes EC, Oster ME. Association of US state implementation of newborn screening policies for critical congenital heart disease with early infant cardiac deaths. JAMA. 2017;318(21):2111-2118. Screening for critical congenital heart disease at birth saves lives. Centers for Disease Control and Prevention. News release. December 5, 2017.

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Tracking nurses in real time

Using a combination of in-person or video observation and nonintrusive tracking sensors, a University of Missouri (UM) engineer developed a system for tracking how ICU nurses spend their time. “They're multitaskers,” says Jung Huup Kim, an assistant professor at UM. “We wanted to find ways to streamline their jobs, making them more efficient.”

Because researchers usually can't accompany nurses into patient rooms as they provide care, day-shift nurses wore sensors that are tracked by routers set up throughout the ICU. The nurses' movements were represented as dots on monitors, showing researchers in real time whether nurses were providing patient care or documenting patient care on the bedside computer. With this information, managers can plan more efficient staffing and architects can design work spaces that maximize efficiency. Kim and his team are planning more research to study nurse workflow throughout full 24-hour shifts and intend to extend the research into other ICUs.

Source: New methods of tracking hospital nurses could help make workflow more efficient. University of Missouri-Columbia. News release. December 5, 2017.

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Cataract surgery goes green—in India

In the United States, the healthcare industry emits nearly 10% of greenhouse gases and other pollutants; in the United Kingdom (U.K.), the figure is 3%. By using a system that relies on greater use of reusable instruments, energy-efficient equipment, and low-carbon energy sources, Aravind Eye Care System in India emitted nearly 96% less carbon than that emitted in the U.K. for comparable cataract surgeries.

To find out why, researchers from New York University School of Medicine analyzed surgical materials, energy, and waste from cataract surgery at Aravind in a four-month period and calculated greenhouse emissions and other indicators of environmental pollution. They found that Aravind's emissions were only about 5% of the U.K.'s carbon footprint with clinical outcomes that were comparable or better. The primary reasons for lower emissions were shorter surgery durations, better reuse of surgical gowns and other garments, multiuse pharmaceuticals, and more efficient sterilization of stainless steel instruments so they can be reused the same day.

“Our overuse of disposable materials in surgery is unsustainable,” says lead author Cassandra L. Thiel, PhD. “As healthcare systems and professionals worldwide become more aware of...the public health implications of climate change and excessive resource use, efficient care delivery models must be better understood and promoted.”

Sources: Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: waste and lifestyle assessment of phacoemulsification at a private healthcare facility. J Cataract Refrac Surg. 2017;43(11):1391-1398. “Green” cataract surgery model drastically reduces environmental footprint. NYU Langone Health/NYU School of Medicine. News release. December 6, 2017.

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In February, celebrate

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Smartphones help diagnose skin conditions



Can clinicians rely on parent-provided smartphone photographs to diagnose pediatric skin conditions? In most cases yes, according to the results of a new study.

In a randomized clinical trial of 40 patient-parent dyads from a Philadelphia dermatology clinic, researchers compared diagnoses made by an independent pediatric dermatologist based on in-person examination and those based on parental photographs. Half of the patient-parent dyads received a simple, three-step instruction sheet on how best to take photographs using a smartphone, the other half did not.

Overall concordance between photograph-based versus in-person diagnosis was 83%; concordance was even higher in a subgroup of 37 participants with photographs considered of high enough quality to make a diagnosis. No significant difference was found between participants who received the instruction sheet and those who didn't.

“Our study shows that, for the majority of cases, parents can take photographs of sufficient quality to allow for accurate teledermatology diagnoses in pediatric skin conditions,” said study coauthor Patrick McMahon. Given the prevalence of pediatric skin conditions and the relative shortage of pediatric dermatologists, the authors believe that teledermatology is a promising tool for improving patients' access to care.

Sources: O'Connor DM, Jew OS, Perman MJ, Castelo-Soccio LA, Winston FK, McMahon PJ. Diagnostic accuracy of pediatric teledermatology using parent-submitted photographs: a randomized clinical trial. JAMA Dermatol. 2017;153(12):1243-1248. Mozes A. Smartphone pics help docs ID kids' skin condition. HealthDay. December 4, 2017.

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Chemotherapy for early-stage disease in decline

A study of over 2,900 women with stage-I or stage-II breast cancers diagnosed between 2013 and 2015 showed a significant decline in the use of chemotherapy, despite the lack of any changes in national treatment guidelines in that period. In a study, these women, who were positive for estrogen receptor expression and negative for human epidermal growth factor receptor-2 expression, were categorized based on the involvement of neighboring lymph nodes. Researchers then surveyed them to learn whether their oncologists had recommended chemotherapy and whether they'd received it. The researchers also surveyed 504 of the oncologists treating these patients about how they make decisions about recommending chemotherapy. The findings showed the following:

  • Chemotherapy use in study participants decreased from 34.5% to 21.3%.
  • As reported by participants, chemotherapy recommendations by their oncologists declined from 44.9% to 31.6% in the study period.
  • Chemotherapy use in patients with no lymph node involvement declined from 26.6% to 14.1%.
  • Chemotherapy use in patients with lymph node involvement declined from 81.1% to 64.2%.
  • Among oncologists surveyed, 67.4% said they order tumor genomic testing to estimate a lymph node-positive woman's risk of cancer recurrence if the woman disagreed with their recommendation to receive chemotherapy. In contrast, only 17.5% order the test if the patient and physician agree about the course of treatment.

Researchers say their findings reflect a growing recognition by both oncologists and patients that the harms of chemotherapy may outweigh its benefits for some patients. “We believe this study indicates that physicians are attempting to be more selective in their recommendations and to spare patients toxicity when possible,” says lead researcher Allison Kurian, MD. “As personalized medicine becomes more widely available, doctors are using test results as part of their dialogue with patients about their preferences and overall treatment goals. But the long-term outcomes of these recent changes in chemotherapy use are uncertain.”

Sources: Kurian AW, Bondarenko I, Jagsi R, et al. Recent trends in chemotherapy use and oncologists' treatment recommendations for early-stage breast cancer. J Nat Cancer Instit. [e-pub Dec. 11, 2017]. Use of chemotherapy for early stage breast cancer declines. Stanford University. News release. December 11, 2017.

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Bacteria persist after standard treatment



How to manage signs and symptoms of chronic Lyme disease is controversial. Two new studies by Tulane University researchers may shed light on why some patients experience persistent Lyme disease symptoms despite completing the standard 28-day course of antibiotic treatment.

Researchers evaluated the presence of the causative bacterium, Borrelia burgdorferi, and the antibody immune response it triggers, before and after antibiotic treatment in nonhuman primates. They found living B. burgdorferi spirochetes in ticks that fed on the primates and in multiple organs after treatment with 28 days of oral doxycycline. The immune response to the bacteria varied widely in both treated and untreated subjects.

“It is apparent from these data that B. burgdorferi bacteria, which have had time to adapt to their host, have the ability to escape immune recognition, tolerate the antibiotic doxycycline, and invade vital organs such as the brain and heart,” says lead author Monica Embers, PhD. “In this study, we were able to observe the existence of microscopic disease and low numbers of bacteria, which...could possibly be the cause of the variable and nonspecific symptoms that are characteristic of post-treatment Lyme disease syndrome. Although current antibiotic regimens may cure most patients who are treated early, if the infection is allowed to progress, the 28-day treatment may be insufficient.”

Sources: Embers ME, Hasenkampf NR, Jacobs MB, et al. Variable manifestations, diverse seroreactivity and post-treatment persistence in non-human primates exposed to Borrelia burgdorferi by tick feeding. PLoS One. 2017;12(12):e0189071. Crossland NA, Alvarez X, Embers ME. Late disseminated Lyme disease: associated pathology and spirochete persistence post-treatment in Rhesus macaques. Am J Pathol. [e-pub Dec. 11, 2017]. Study: Lyme bacteria survive 28-day course of antibiotics months after infection. Tulane University. News release. December 13, 2017.

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