Notes

Personality Issues in Older Age group.
Learning health systems increasingly welcome embedded researchers as stakeholders poised to inform evidence-based practice. L-NMMA While care systems are potentially familiar with the embedded researcher tools and techniques, care systems may less frequently consider embedded research as a vocation. This insensitivity potentially reduces embedded researchers merely to instruments, as opposed to professional partners in transdisciplinary research. This discussion outlines "general orders" for embedded researchers. The general orders outline embedded researchers' fundamental identity and guide conduct as a means to encourage a shared identity among embedded researchers and clarify embedded researchers' roles in learning health system teams. Students and embedded researchers newly engaging learning health systems may particularly benefit from this rudimentary order list.Introduction and definition of the term Learning Health System (LHS) appears to have occurred initially around 2007. Prior to this and the introduction of electronic health records (EHR), a predecessor could be found in the Clinical Pathways concept as a standard medical care plan and a tool to improve medical quality. Since 1997, Japan's Saiseikai Kumamoto Hospital (SKH) has been studying and implementing Clinical Pathways. In 2010, they implemented EHR, which facilitated the collection of structured data in common templates that aligned with outcome measurements defined through Japan's Society of Clinical Pathways. For each patient at this hospital, variances from the desired outcomes have been recorded, producing volumes of structured data in formats that could readily be aggregated and analyzed. A visualization tool was introduced to display graphs on the home page of the EHR such that each patient can be compared to similar patients. Knowledge learned from patient care is shared regularly through Clinical Pathways meetings that are supported by all staff within the hospital. The SKH experience over the past two decades is worth exploring further in the context of the development of a fully functional LHS and the attributes/characteristics thereof. In this report, the SKH experience and processes are compared with previously published attributes of a fully functional LHS (ie, characteristics of an LHS that can indicate maturity). Specific examples of the SKH system are detailed with respect to leveraging knowledge gained to change performance that improves patient care as prescribed by learning health cycles. The SKH experience and its information infrastructure and culture exemplify a functional LHS, which is now being expanded to additional hospitals with the hope that it can be scaled and serve as a solid platform for measures aimed at improving medical care, thus establishing broader and more global learning health systems.
Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies.

Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories.

Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) smissions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.
Despite the proliferation of pragmatic clinical trials (PCTs) conducted in health care delivery settings, we know relatively little about how practicing clinicians perceive their potential roles in such research. Empirical evidence and practical guidance concerning clinician engagement in research is needed to inform the design and successful implementation of PCTs.

We conducted a two-phase qualitative study to better understand how and to what extent practicing clinicians should be involved in PCTs and to develop guidance for researchers on engaging front-line clinicians in PCTs. In phase one, clinicians who spend the majority of their time providing direct patient care participated in 90-min focus groups. In phase two, we conducted key informant interviews with PCT research teams and clinicians participating in the ADAPTABLE (Aspirin Dosing A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) trial.

Thirty-four physicians, nurses, and other care providers from four health care delivical-to reassure eligible patients that trial participation is a safe alternative for them.
More active involvement by a range of clinical stakeholders in PCT planning may help researchers avoid common barriers to trial implementation. We propose a "medium-touch" approach to involving clinicians in PCT recruitment and enrollment that focuses clinician effort where it is most critical-to reassure eligible patients that trial participation is a safe alternative for them.
We aimed to construct an induction system for polyploid giant cancer cells (PGCCs), as well as to investigate PGCC features and clinical significance.

A laryngeal neoplasm-PGCC induction system was constructed using paclitaxel liposomes (PTX). We used western blots to compare expression of epithelial-mesenchymal transition-related proteins, stem cell interrelated proteins, and cyclin-associated proteins. We then measured PGCC count in tissue samples of patients with laryngeal neoplasms and analyzed its relationship with prognosis. Statistical significance was determined using
-tests.

PTX successfully induced PGCCs. Western blotting showed that CyclinB1, CDC25C, CDK1, E-cadherin, and EIF-4A expression decreased in PGCCs compared with normal cancer cells, whereas vimentin and CD133 expression increased. Number of PGCCs in laryngeal cancer tissues and overall survival time were inversely correlated (
< .05).

PTX successfully induces PGCC formation in laryngeal carcinoma, which may be the cause of poor prognosis in patients with laryngeal cancer.Level of Evidence 4.
PTX successfully induces PGCC formation in laryngeal carcinoma, which may be the cause of poor prognosis in patients with laryngeal cancer.Level of Evidence 4.
Patients with primary hyperparathyroidism (PHPT) treated surgically occasionally have normalized calcium, but persistently high parathyroid hormone (PTH). We hypothesized that a possible explanation for this phenomenon is an underlying hyperplasia rather than adenoma.

Retrospective cohort of patients who underwent parathyroidectomy for PHPT with biopsy of a normal-appearing parathyroid gland were included. Cellularity level of each biopsy and of the adenoma's rim was determined.

Forty-seven patients were included. Of them, 19 (40%) had postoperative normocalcemia but elevated PTH. There was no correlation between cellularity either in the rim or of the normal-appearing parathyroid gland and postoperative PTH. The postoperative high PTH group had higher preoperative PTH (
=0.001) and larger adenomas (
=0.025).

High PTH levels after successful parathyroidectomy in patients with primary hyperparathyroidism do not appear to result from underlying hyperplasia. A possible alternative explanation is that these patients have a higher preoperative burden of disease.
High PTH levels after successful parathyroidectomy in patients with primary hyperparathyroidism do not appear to result from underlying hyperplasia. A possible alternative explanation is that these patients have a higher preoperative burden of disease.
Proper position of an electromyographic (EMG) endotracheal tube within the larynx plays a key role in functional electrophysiologic intraoperative neural monitoring (IONM) in thyroid surgery. The purpose of this study was to determine the feasibility of a portable video-assisted intubation device (UEScope) to verify the optimal placement of an EMG tube.

A retrospective study enrolled 40 consecutive patients who underwent monitored thyroidectomies. After positioning the patient for surgery, an anesthesiologist performed tracheal intubation with UEScope and checked the position of the tube at the proper depth without rotation to the vocal cords. The main outcome measured was the proper EMG tube position, free from further adjustment. The secondary outcomes assessed were the percentage of available initial vagal stimulation (V1) signals.

All tracheal intubations were successful at first attempt. Proper EMG tube placement without position adjustment was found in 97.5% of the patients. Tube withdrawal was required in a male patient. All patients obtained detectable V1 signals; the lowest and median V1 amplitude was 485 and 767 μV as a reference value, respectively.

The UEScope is a valuable and reliable tool for placing an EMG tube and confirming its position during monitored thyroidectomy. In addition, further tube adjustment might be waived in most cases when the anesthesiologist placed the EMG tube after patient positioning for surgery. Routine use of video-assisted intubation devices is highly recommended.

4.
4.
To describe transient and permanent hypocalcaemia following partial and total pharyngolaryngectomy with parathyroid gland preservation or autotransplantation.

Thirty patients underwent partial or total pharyngolaryngectomy by a single surgeon during the period 2009-2020. Intraoperative parathyroid gland preservation or autotransplantation (where the gland appeared devascularized) was routinely performed. Calcium levels performed on day 1, 3months, and at 12 months postoperatively were collected. Rates of transient and permanent hypocalcaemia were calculated.

A total of 13% of patients had transient hypocalcaemia, and 10% permanent hypocalcaemia. Rates of transient and permanent hypocalcaemia in total pharyngolaryngectomy were 14% and 14%, respectively. Partial pharyngectomy hypocalcaemia rates were 13% for transient and 0% for permanent. The majority of patients underwent salvage surgery for oncological resection, often following radiotherapy (63%). Ipsilateral hemithyroidectomy was preferred to total (57% vs 7%), with high rates of concurrent neck dissection (67%) and reconstruction (87%).

This data supports preservation or autotransplantation of parathyroid glands as a means of reducing permanent postoperative hypocalcaemia.

Level IV, case series, retrospective.
Level IV, case series, retrospective.Children with bilateral sensorineural hearing loss (SNHL) should undergo a comprehensive medical evaluation to determine the underlying etiology and help guide treatment and counseling. In this article, we review the indications and rationale for medical evaluation of pediatric bilateral SNHL, including history and physical examination, imaging, genetic testing, specialist referrals, cytomegalovirus (CMV) testing, and other laboratory tests. Workup begins with a history and physical examination, which can provide clues to the etiology of SNHL, particularly with syndromic causes. If SNHL is diagnosed within the first 3 weeks of life, CMV testing should be performed to identify patients that may benefit from antiviral treatment. If SNHL is diagnosed after 3 weeks, testing can be done using dried blood spots samples, if testing capability is available. Genetic testing is oftentimes successful in identifying causes of hearing loss as a result of recent technological advances in testing and an ever-increasing number of identified genes and genetic mutations.
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